Every finding on record at Glendale Gardens Nursing & Rehab

Based on record review and interview, the facility failed to ensure all residents were treated with respect and dignity when one staff (Certified Nurse Aide CNA) A spoke to one resident (Resident #1) in a rude manner while using profane language. The facility census was 92.Review of the Resident Rights, undated, shows residents should be treated with consideration, and respect, with full recognition of their dignity and individuality.1. Review of Resident #1's face sheet showed the following:-readmission date of 10/21/24;-Diagnoses included metabolic encephalopathy (a problem in the brain), chronic kidney disease (kidneys are damaged and have a hard time removing fluid), Type 2 diabetes with neuropathy (body doesn't produce enough insulin, poor blood circulation), unspecified dementia without behavioral disturbances (memory loss), and major depressive disorder (feelings of sadness and hopelessness).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/14/22, showed the following:-Moderate cognitive impairment;-Supervision with toileting hygiene, upper and lower body dressing and personal hygiene;-Partial assistance with showers.Review of the resident's care plan, revised on 03/20/26, showed the following information:-Resident at risk for pain/discomfort related to the diagnosis and process of limited mobility;-Resident required one to two assist with all adult daily living skills due to weakness.Review of a witness statement from Certified Medication Technician (CMT) B, dated 04/23/26, showed the resident asked CNA A to get something for him/her. CNA A proceeded to tell the resident he/she was on f***ing A and D, and he/she didn't have time. The resident came out into the hall and said CNA A was talking so he/she should have time to do it.During an interview on 04/24/26, at 10:45 A.M., CMT B said the following:-It was close to 6:00 A.M. on 04/23/26 and he/she was on C hall in front of the resident's room;-He/she heard CNA A saying I'm f***ing working C and D hall, and don't have time for you;-Cursing at or around a resident was disrespectful.Review of Registered Nurse (RN) F's written statement, dated 04/23/26, showed resident reported he/she asked CNA A for a water pitcher, toothpaste, and something else. CNA A said he/she could get the new water pitcher now, but everything else would have to wait because CNA A was busy. Resident said CNA A then stormed out of the room. Resident then said he/she walked to his/her doorway and saw CNA A standing in the hallway talking to another coworker. The resident said he/she asked CNA A if you can stand in the hallway talking why can't he/she get the resident's things. Resident reports CNA A then said it is none of your f***ing business what he/she is doing. Go to your room and shut up;-Resident said he/she went back to his/her room.During an interview on 04/24/26, at 11:45 A.M., RN F said the following:-It would be disrespectful to curse around or at a resident;-CNA E said the resident was upset because CNA A had cussed at the resident;-He/she spoke to the resident and the resident said he/she asked CNA A for supplies and CNA A said he/she didn't have time. The resident saw the aide talking to another aide and the resident asked why CNA A couldn't get the resident's things he/she asked for. CNA A told the resident to go to his/her f***ing room and shut up;-The resident was upset. The resident didn't expect the CNA's response.Review of the Social Services Director (SSD)'s written statement, dated 04/23/26, showed the following:-Resident said that he/she pushed his/her call light and CNA A answered. Resident asked for another cup with ice and water, as his/her cup was leaking, a toothbrush and something else but the resident could not remember what;-CNA A said he/she would get the cup with ice water, but the resident would need to wait for the other things;-Resident felt like CNA A was being hateful so the resident went to the door and CNA A was talking to another aide;-Resident said he/she told CNA A that if he/she had time to stand around and talk, he/she had time to not be hateful and get the resident the things the resident needs;-Resident stated CNA A then told the resident that he/she would f***ing wait and for the resident to go back to his/her room and shut up;-Resident told CNA A that he/she is a resident and he/she paid to be at the facility, and the resident was not going to be talked to that way, and then returned to his/her bed;-CNA A then went to the room across the hall and slammed the door;-The resident said this hurt the resident's feelingsReview of the Director of Nursing (DON)'s text message dated 04/23/26, at 9:39 A.M., from CNA A showed the following:-Staff were very busy. The Resident's light was on, so we went in and answered it;-CNA A was standing by the resident's tv so he/she couldn't really hear the resident;-The resident became agitated when CNA A asked the resident to repeat him/herself. The resident wanted toothbrushes, water and a pain pill. CNA A said he/she can help with the pain pill, because the med tech was right outside the room, but the other stuff would have to wait because he/she is very busy on two halls;-CNA A turned to go to the hallway and tell the med tech the resident would like a pain pill and the resident came out of his/her room and said if you're so busy, why are you out there talking;-CNA A told the resident he/she was telling the med tech the resident wanted a pain pill;-The resident said something to CNA A and he/she was already upset and overwhelmed and trying to make sure everything got done. CNA A said he/she told the resident to leave him/her the f*** alone, he/she was just trying to get finished;-CNA A said he/she should not have cussed.During an interview on 04/27/26, at 8:25 A.M., CNA A said the following:-He/she was overwhelmed on 04/22/26, as one of the aides had gone home and he/she was responsible for their hall;-On 04/23/26 around 6:00 A.M., he/she answered the resident's call light;-Once in the resident's room he/she could not hear the resident as the tv was loud, so he/she asked the resident to repeat him/herself. The resident wanted water, toothbrush and a pain pill;-CNA A told the resident he/she would need to wait for the toothbrush and water, but he/she would tell the med tech outside the door the resident wanted a pain pill;-The resident came to the door and yelled at CNA A, and said why are you talking if you're so busy;-He/she turned and looked at the resident and said leave me the f*** alone;- He/she knew it was not appropriate to say that to the resident;- It was disrespectful to cuss at a resident.During an interview on 04/24/26, at 9:42 A.M., the resident said the following:-The resident pushed his/her light as he/she needed a new glass as his/hers was leaking;-CNA A was busy and the facility was short-staffed. Resident said this is his/her home and he/she told CNA A, he/she would be treated with respect;-Resident said sometimes he/she is not the sweetest and can be crotchety;-He/she did not want to discuss the issues anymore.During an interview on 04/24/26, at 11:20 A.M., Nurse's Aide (NA) C said it was not appropriate to cuss at or around a resident, it's against their rights.During an interview on 04/24/26, at 11:30 A.M., Licensed Practical Nurse (LPN) D said the following:-If he/she heard a staff cursing at or around a resident, he/she would report to the DON right way;-Cursing at a resident was disrespectful.During an interview on 04/24/26, at 11:40 A.M., CNA E said the following:-It is against the resident's rights to curse at or around them, as this is their home;-Saying cursing words around a resident could was disrespectful.During an interview on 04/24/26, at 11:50 A.M., LPN G said cursing at or around a resident would be disrespectful.During an interview on 04/24/26, at 12:05 P.M., CNA H it would be disrespectful to curse at a resident, and against their rights to curse around the resident.During an interview on 04/24/26, at 12:13 P.M., NA I said he/she would consider cussing at or around a resident disrespectful and against their rights.During an interview on 04/24/26, at 1:20 P.M., the DON said it was not appropriate to curse around residents. It was disrespectful and against their rights. The f word is offensive.During an interview on 04/24/26 at 1:40 P.M., the Administrator said he/she would consider cursing at a resident to be disrespectful and against their rights. Complaint #2992998

Based on interview and record review, the facility failed ensure all allegations of possible abuse were reported to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) within two hours of staff becoming aware of the allegation when the facility failed to report an allegation of staff to resident abuse involving one resident (Resident #1) until two days after the facility staff became aware of the allegation. The facility census was 99. Review of the facility policy titled Response and Reporting Guidelines, dated March 2016, showed the following:-It is the purpose of the facility to report all substantiated incidents of abuse or neglect to the appropriate state agencies and the designated individuals at the facility's consultant office;-Report any and all cases of alleged resident neglect, abuse and misappropriation of resident property by facility employees, contract employees, volunteers, contract services, consultants, physicians, visitors, family members, or other individuals;-Report immediately, but not later than two hours after forming the suspicion;-This report will be to the hot-line number and or DHSS.1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following information:-admission date of 02/05/26;-Diagnoses included Parkinson's Disease (a movement disorder of the nervous system), chronic obstructive pulmonary disease (progressive lung disease that blocks air flow making breathing difficult), atrial fibrillation (a rapid irregular heartbeat), and dementia.Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/17/26, showed the following information:-Moderate cognitive impairment;-Utilized a wheelchair for mobility;-Frequently incontinent of bowel and bladder.Review of the resident's care plan, revised 02/17/26, showed the following information:-Resident had cognitive impairments related to the use of psychotropic medications;-Resident was at risk for falls due to weakness, medications and gait disturbance.Review of the facility's investigation summary documentation, dated 03/02/26 , showed the following information:-The resident alleged that a male was calling the resident names and threw him/her in the bed;-On 02/28/26, facility staff became aware of the incident;-On 02/28/26, facility staff notified the Director of Nursing (DON) of the allegation;-On 03/01/26, the DON notified the Administrator of the incident;-On 03/02/26, the Administrator interviewed the resident regarding the allegation;-On 03/02/26, at 10:00 A.M., the Administrator notified DHSS, the Ombudsman and the Police Department of the incident.-On 03/02/26, the Administrator notified the resident's daughter of the incident;-On 03/02/26, the Administrator instructed the DON to notify the Physician of the incident.Review of DHSS records showed the facility self-report the allegation of abuse on 03/02/26, at 10:19 A.M.Review of a handwritten statement date 02/28/26, at 5:00 P.M., showed Licensed Practical Nurse (LPN) B's noted the following: -On 02/28/26, between 3:00 P.M. and 4:00 P.M., the resident's family member expressed concerns to LPN B, witnessed by LPN A;-The family member reported that the resident said that he/she was tossed roughly into bed by a male CNA who worked the night shift;-The family member also said that the same male CNA also cursed at the resident;-The family member immediately demanded that the male CNA not provide care to the resident.During an interview on 03/04/26, at 2:17 P.M., LPN B confirmed his/her written statement and said the following: -LPN B confirmed that the resident's family member reported to him/her that a male CNA who worked the night shift had thrown the resident in the bed and cursed at the resident;-He/she immediately called and reported the allegation to the DON;-The allegation was considered physical and verbal abuse and should be reported to the DON immediately;-The facility had two hours to report abuse to the State.During an interview on 03/04/26, at 2:25 P.M., LPN A said the following: -On 02/28/26, between 3:00 P.M. and 4:00 P.M., he/she overheard the resident's family member at the desk telling LPN B that the resident reported to him/her that a male aide had been rough with cares;-The family member reported to LPN B that he/she did not know the CNA's name, only that he/she was male and worked the night shift;-LPN B immediately called the DON and reported the allegation;-The facility has two hours to report abuse to State.During an interview on 03/04/26, at 9:10 A.M., LPN D said the following: -Any allegation of abuse should be reported immediately to the charge nurse or the DON;-The facility had two hours to report abuse allegations to the State. During an interview on 03/04/26, at 10:15 A.M., CNA E said the following: -The facility had two hours to report to State;-He/she considered cursing and rough cares abuse and would report that immediately. During an interview on 03/04/25, at 10:20 A.M., CNA F said the following:-He/she would notify his/her charge nurse of the DON immediately of any allegation of abuse;-The facility had two hours to report abuse to State;-Rough cares and cursing should be reported immediately. During an interview on 03/04/26, at 2:45 P.M., the ADON said the following: -She was not notified of any abuse allegation regarding the resident;-Staff should notify the DON immediately of any abuse allegation;-The facility had two hours to report abuse to the state;-Rough cares and cursing would be considered abuse and should be reported immediately.During an interview on 03/04/26, at 4:00 P.M, the DON said the following information:-On 02/28/26, the resident's family member came to the facility complaining that the resident got thrown into bed;-The DON said he/she felt like the family was complaining to complain;-He/she should have called the Administrator immediately;-The DON called the Administrator the next night, on 03/01/26 and reported what the family member said;-On 03/02/26, the Administrator came to the facility to start the investigation and said it should have been reported to DHSS immediately. During an interview on 03/04/26, at 4:30 P.M., the Administrator said the following information:-On 03/01/26, at 10:28 P.M., the DON called the Administrator and informed him of an allegation of abuse;-On 03/02/26, at 10:00 A.M., the Administrator reported the allegation to DHSS and started an investigation;-An allegation of rough cares and cursing was physical and verbal abuse;-The facility had two hours to report abuse allegations to DHSS;-The allegation should had been reported immediately, and the facility failed to report the allegation within the two-hour time frame.Complaint #2791690

Based on observation, interview, and record review, the facility failed ensure an environment as free from accident hazards as possible when staff failed to analyze and identify the risks for falls, failed to implement new intervention to prevent future falls, and failed to care plan regarding new falls for three residents (Resident #1, #3, and #4) that sustained falls. The facility census was 93. Review showed the facility did not provide a policy regarding falls. Review of the facility policy titled Care Plan Comprehensive, undated, showed the following:-An individual comprehensive care plan should include measurable goals and timeframes;-The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to the Minimum Data Sheet (MDS - a federally mandated assessment instrument completed by facility staff);-A well-developed care plan will be oriented to preventing avoidable declines in functioning or functional levels; managing risk factors to the extent possible; applying current standards of practice in the care planning process; evaluating treatment of goals, timetables, and outcomes of care; and assessing and planning for care to meet the resident's medical, nursing, mental, and psychosocial needs.-The interdisciplinary care team is responsible for reviewing and updating the care plan when a significant change has occurred, quarterly, and when changes that impact resident care occur. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 03/27/25; -Diagnoses included non-Hodgkin lymphoma (cancer that is in the lymphocytes (white blood cells - a component of the immune system) and osteoarthritis (joint disease that causes pain, stiffness, and loss of function). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/01/25, showed the resident was cognitively intact and required moderate staff assistance with dressing and shower and supervision with toileting.Review of the resident's care plan, revised on 04/04/25, showed the following:-Resident at risk for falls related to decreased mobility and disease process;-Assess comfort and provide interventions during periods of restlessness;-Assist to the restroom before and after meals, bedtime, and as needed;-Assure resident wears eyeglasses;-Call light and personal items within reach;-Encourage resident to use environmental devices as needed;-Ensure proper footwear;-Bed in low position;-Obtain physical therapy consult as needed. Review of the resident's nursing progress note dated 05/07/25, at 1:00 A.M. showed the resident had an unwitnessed fall in the restroom while a certified nurse aide (CAN) was in the room. The CNA turned to obtain supplies for the resident and resident fell toward the right and hit his/her head on the wall next to the shower. Resident remained conscious and was able to follow commands. No red drainage noted. No bruise noted on head. Turned resident over to back and range of motion performed on right arm without difficulty. Faint lavender bruise noted on right side. Assisted up to toilet with one person assist. Resident complained of headache, rated at a 10 out of 10 on pain scale and pain medication administered. Vital signs and neurological monitoring started. Review of the resident care plan, revised 11/05/25, showed staff did not update the care plan with the fall on 05/07/25 or any new interventions to prevent future falls. Review of the resident's record showed staff did not document an investigation into the fall, the cause of the fall, and any new interventions to prevent future falls. Review of the resident's nursing progress note, dated 06/01/25, showed the certified medication technician (CMT) reported the resident was on the floor. Resident reported he/she went to the restroom without a walker and on the way out lost his/her balance. Resident reported hitting right side of breast hard on the arm of a wheelchair nearby. Resident denied hitting head or pain. Resident able to move all extremities with good range of motion. Right side of breast noted to be red. Will monitor breast for any changes. Family notified of fall. Neurological assessment started. Review of the resident care plan, revised 11/05/25, showed staff did not update the care plan with the fall on 06/01/25 or any new interventions to prevent future falls. Review of the resident's record showed staff did not document an investigation into the fall, the cause of the fall, and any new interventions to prevent future falls. Review of the resident's nursing progress note, dated 09/22/25, showed resident continued fall follow up due to a fall on 09/21/25 with no complaint of any discomfort at this time.Review of the resident care plan, revised 11/05/25, showed staff did not update the care plan with the fall on 09/21/25 or any new interventions to prevent future falls. Review of the resident's record showed staff did not document an investigation into the fall, the cause of the fall, and any new interventions to prevent future falls. Review of the resident's nursing progress note dated 11/01/25, at 6:49 P.M., showed resident looked tired and reported he/she was very tired and weak. He/she slid from the recliner due to legs giving out and no energy. He/she again slid from bed but denies falling. Resident reported sliding from the bed due to very weak legs. Review of the resident care plan, revised 11/05/25, showed staff did not update the care plan with the fall on 11/01/25 or any new interventions to prevent future falls. Review of the resident's record showed staff did not document an investigation into the fall, the cause of the fall, and any new interventions to prevent future falls. Review of the resident's nursing note dated 11/02/25, at 1:12 P.M. showed a late entry indicating a report from the CNA this morning that the resident slipped on the floor while standing and landed on his/her back. Nurse checked resident and no injury or bruise noted. Resident denied any pain and stated his/her legs gave out and became very weak. Review of the resident care plan, revised 11/05/25, showed staff did not update the care plan with the fall on 11/02/25 or any new interventions to prevent future falls. Review of the resident's record showed staff did not document an investigation into the fall, the cause of the fall, and any new interventions to prevent future falls. Review of the resident's nursing progress note dated 11/03/25, at 11:31 P.M., showed at 6:00 P.M. the resident fell on the way out of the bathroom. Resident was utilizing a walker and turned, lost balance, and landed on the floor. Resident found lying on his/her back. Resident complained of back pain which is not new to him/her. X-ray results negative on his/her back today before this fall. Roommate witnessed the fall. Resident able to move all extremities with no pain and denies hitting his/her head.Review of the resident care plan, revised 11/05/25, showed staff did not update the care plan with the fall on 11/03/25 or any new interventions to prevent future falls. Review of the resident's record showed staff did not document an investigation into the fall, the cause of the fall, and any new interventions to prevent future falls. 2. Review of the resident #3's face sheet showed the following:-admission date of 09/10/25; -Diagnoses included high blood pressure and lung cancer. Review of the resident's annual MDS, dated [DATE], showed the resident was cognitively intact and required supervision with ADL's. Resident utilized both a walker and a wheelchair. Review of the resident's care plan, revised on 09/17/25, showed the following:-Resident required one-to-two-person assistance with ADL's due to weakness;-Required one to two staff assistance with transfer and positioning;-Resident at risk for falls related to the disease process and weakness;-Staff should remind resident to be mindful of tubing as it can be a fall hazard;-Assess and treat orthostatic hypertension;-Implement exercise program for strength, balance, and gait;-Staff supervision based on resident need;-Offer comprehensive medication review;-Provide toileting interventions based on needs. Review of the resident's nursing progress note dated 10/06/25, at 12:30 A.M., showed resident turned on the call light and reported he/she was reaching for a pen on the floor and rolled out of bed. Resident sitting up with head above mattress. No marks seen on head, hand grip and feet push pulls equally strong. Resident helped to her feet without difficulty. Neurological assessment and vital signs started.Review of the resident current care plan showed staff did not update the care plan with the fall 10/06/25 or any new interventions to prevent future falls. Review of the resident's record showed staff did not document an investigation into the fall, the cause of the fall, and any new interventions to prevent future falls. Review of a nursing progress note dated 10/21/25, at 11:33 A.M,. showed a fall reported by the nurse at shift change and happened at 5:45 A.M Fall caused by patient trying to get a soda and fell. No abnormalities reported. Review of the resident current care plan showed staff did not update the care plan with the fall on 10/21/25 or any new interventions to prevent future falls. Review of the resident's record showed staff did not document an investigation into the fall, the cause of the fall, and any new interventions to prevent future falls. 3. Review of the resident #3's face sheet showed the following:-admission date of 11/12/24; -Diagnoses included chronic obstructive pulmonary disease (COPD- group of lung diseases that cause persistent airflow obstruction and breathing problems) and heart failure. Review of the resident's annual MDS, dated [DATE], showed the resident was cognitively intact and required supervision with ADL's. Resident utilized both a walker and a wheelchair. Review of the resident's care plan, revised on 12/13/24, showed the following:-Resident at risk for falls related to the weakness, gait and balance concerns, and tethering of oxygen tubing;-Implement exercise program for strength, gait, and balance;-Increased staff supervision based on resident need;-Order comprehensive medication review;-Provide individualized toiling interventions. Review of the resident's nursing progress note dated 06/03/25, at 7:00 P.M., showed the resident found lying in the bathroom by the CNA. Resident stated he/she fell due to being lightheaded and hit head on the toilet paper holder. Resident left ankle was underneath him/her when fell. Head to toe assessment completed. Resident reported having a lot of pain. Scheduled pain medication is due. Family, nurse practitioner, and DON notified. X-ray is pending. Area wrapped, elevated, and ice applied. Review of the resident current care plan, updated 09/29/25, showed staff did not update the care plan with the fall 16/03/25 or any new interventions to prevent future falls. Review of the resident's record showed staff did not document an investigation into the fall, the cause of the fall, and any new interventions to prevent future falls. 4. During an interview on 11/05/25, at 12:45 P.M., CNA F said a resident care plan should include actual falls or if a resident is at risk for falls. Interventions for falls could include clear area or path for resident and ensure use of grippy socks. During an interview on 11/05/25, at 12:45 P.M., CNA B said he/she would check on the resident, call for help, and tell the nurse right away if a resident had a fall. Fall interventions could include call light within reach, bed rails, and keeping bed in a low position.During an interview on 11/05/25, at 3:35 P.M., CNA A said falls should be included in the care plan and interventions should be included after falls. Fall interventions could include grippy socks, bed alarms, call lights within reach, and ensuring use of adaptive equipment. During an interview on 11/05/25, at 1:10 P.M., Licensed Practical Nurse (LPN) C said new interventions should be included on the fall event form. During an interview on 11/05/25, at 1:20 P.M., LPN G said any new interventions should be entered in the event form. Falls should be included on a resident care plan and reviewed and updated after a fall. During an interview on 11/05/25, at 3:45 P.M., LPN D said residents at risk for falls should have it included in the care plan. He/she did not know if the care plan should be updated or reviewed after a fall. Fall interventions include bed in the lowest position and call light within reach. During an interview on 11/05/25, at 2:40 P.M., the MDS Coordinator said falls should be included in the care plan and have a template to include it. Falls are reviewed in morning meeting and new interventions are implemented and should be included in the care plan. He/she updates the care plan based upon information obtained from nurses and in the morning meetings. Interventions for falls could include use of grippy socks and keeping the bed in a low position. During an interview on 11/05/25, at 4:15 P.M., the Director of Nursing (DON) said care plans should be updated after a fall if a new intervention is needed. Care plan changes are discussed in stand-up meeting daily with the DON, Assistant Director of Nursing (ADON), and the MDS Coordinator. New orders and progress notes are reviewed for the last 24 hours for updates. During an interview on 11/05/25, at 5:05 P.M., the Administrator said falls and prevention are discussed in the morning stand up meeting. Care plans should be updated with any interventions that apply to a fall and what the fall was related to. Complaint #2659996

Based on interview, and record review, the facility failed to notify all residents' families and physicians of all changes in condition and incidents when staff did not notify the physician and family of falls in a timely manner for two residents (Resident #1and #3). The facility census was 93. Review showed the facility did not provide a policy regarding falls or physician notification. Review of the facility policy titled Charting and Documentation, undated, showed the following:-The purpose of these guidelines is to provide a complete account of the resident's care, treatment, response to care and progress; guidance to the physician in prescribing appropriate medications and treatments; assistance in the plan of care for each resident; and an information source for resident changes;-Accidents/Incidents documentation does not take the place of the Event Report Form. Documentation should include circumstances surrounding the accident or incident; where the accident or incident took place; date and time the incident occurred; name of the witness and their account of the accident or incident; resident's account of accident or incident; time the physician was notified as well as the time the physician responded; the date and time the family was notified; the condition of the resident, to include vital signs; disposition of the resident; and all pertinent observations. 1. Review of the Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 03/27/25; -Diagnoses included non-Hodgkin lymphoma (cancer that is in the lymphocytes (white blood cells - a component of the immune system) and osteoarthritis (joint disease that causes pain, stiffness, and loss of function). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/01/25, showed the resident was cognitively intact and required moderate staff assistance with dressing and shower and supervision with toileting. Review of the resident's care plan, revised on 11/05/25, showed the following:-Resident required one-to-two-person assistance with activities of daily living (ADL-basic tasks done regularly to care for the body) due to weakness;-Required one staff assistance with transfer, positioning, and hygiene;-Resident at risk for falls related to decreased mobility.Review of the resident's nursing progress note, dated 06/01/2025, showed the certified medication technician (CMT) reported the resident was on the floor. Resident reported he/she went to the restroom without a walker and on the way out lost his/her balance. Resident reported hitting right side of breast hard on the arm of a wheelchair nearby. Resident denied hitting head or pain. Resident able to move all extremities with good range of motion. Right side of breast noted to be red. Staff will monitor breast for any changes. Staff notified family of fall. Neurological assessment started. (Staff did not document notification of the resident's physician regarding the fall). Review of the resident's nursing progress note, dated 09/22/25, showed resident continued fall follow up due to a fall on 09/21/25 with no complaint of any discomfort at this time. Review of the resident's progress notes showed staff did not document a fall on 09/21/25 or family and physician notification of the fall. Review of the resident's nursing progress note dated 11/01/25, at 6:49 P.M., and recorded as late entry on 11/02/25 at 4:53 P.M., showed resident looked tired and reported he/she was very tired and weak. He/she slid from the recliner due to legs giving out and no energy. He/she again slid from bed, but denied falling. Resident reported sliding from the bed due to very weak legs. (Staff did not document physician or family notification of the resident's falls.) Review of the resident's nursing progress note dated 11/03/25, at 11:31 P.M., showed at 6:00 P.M. the resident fell on the way out of the bathroom. Resident was utilizing a walker and turned, lost balance, and landed on the floor. Resident found lying on his/her back. Resident complained of back pain which was not new to him/her. X-ray results negative on his/her back today before this fall. Roommate witnessed the fall. Resident able to move all extremities with no pain and denies hitting his/her head. (Staff did not document notification of the resident's physician or family of the fall.) During an observation and interview on 11/05/25 at 10:15 A.M. with resident #1 showed the resident in room sitting in a recliner with walker sitting next to resident. Resident reports he/she had four falls in the last week. During an interview on 11/05/25, at 3:45 P.M., Licensed Practical Nurse (LPN) D said the resident slipped out of the recliner and bed one night. He/she did not notify the physician because he/she did not consider sliding from the bed or a chair a fall. The resident had a fall on the way to the bathroom the day after he/she slid from the chair and bed. He/she notified the family but did not notify the physician. The resident had an x-ray to the back due to complaint of back pain before the fall. 2. Review of the Resident #3's face sheet showed the following:-admission date of 09/10/25; -Diagnoses included high blood pressure and lung cancer. Review of the resident's annual MDS, dated [DATE], showed the resident was cognitively intact and required supervision with ADL's. Resident utilized both a walker and a wheelchair. Review of the resident's care plan, revised on 09/17/25, showed the following:-Resident required one-to-two-person assistance with ADL's due to weakness;-Required one to two staff assistance with transfer and positioning;-Resident at risk for falls related to the disease process and weakness;-Staff should remind resident to be mindful of tubing as it can be a fall hazard. Review of the resident's nursing progress note dated 10/21/25, at 11:33 A.M., showed a fall reported by the nurse at shift change and happened at 5:45 A.M. Fall caused by patient trying to get a soda and fell. No abnormalities reported. (Staff did not document notification of the resident's physician or family of the fall.) 3. During an interview on 11/05/25, at 1:10 P.M., LPN C said the family and physician should be notified after a resident fall. All information should be documented in the progress note and on an event form. During an interview on 11/05/25, at 1:20 P.M., LPN G said he/she would notify the Director of Nursing (DON), physician, and family after a resident fall. All information should be documented in the progress note. The physician should be notified of any fall regardless of injuries. During an interview on 11/05/25, at 2:40 P.M., the MDS Coordinator said the nurse should assess the resident, start neurological checks, obtain vital signs, and notify the physician and family if a resident had a fall. Nurses should document in the progress note after a fall. During an interview on 11/05/25, at 3:45 P.M., LPN D said the resident's family should be notified after a fall but most of the time the resident calls the family. Night shift nurses do not usually call the physician if there are no injuries but will call the family. The facility had a policy to not call the physician if there are no injuries after a fall. During an interview on 11/05/25, at 4:15 P.M., the DON said nurses should assess a resident and notify the physician and family after a fall. Some physicians do not want to be notified of a fall during the night. Staff will notify the physician or nurse practitioner in the morning. During an interview on 11/05/25, at 5:05 P.M., the Administrator said nurses should assess the resident, notify the physician and family, and follow any orders after a resident fall. Physician should be notified anytime a resident sustains a fall. Complaint #2659996

Based on observation, interview, and record review, the facility failed to provide care per standard of practice when staff failed to document follow-up regarding edema (swelling/fluid retention), failed to obtain orders for the use of Tubi grips (a reuseable tubular elastic bandage used to provide support and compression,) and failed to care plan related to edema for one resident (Resident #1) and when staff failed to complete ordered daily weights and update the care plan related to edema for one resident (Resident #2). The facility census was 93. Review of the facility policy titled Physician Orders, undated, showed the following:-Current list of orders must be maintained in the clinical record of each resident to avoid confusion and errors;-Physician orders must be reviewed and renewed;-Treatment orders should specify what is done, location and frequency, and duration of the treatment. Review of the facility policy titled Care Plan Comprehensive, undated, showed the following:-An individual comprehensive care plan should include measurable goals and timeframes;-The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to the Minimum Data Sheet (MDS - a federally mandated assessment instrument completed by facility staff);-A well-developed care plan will be oriented to preventing avoidable declines in functioning or functional levels; managing risk factors to the extent possible; applying current standards of practice in the care planning process; evaluating treatment of goals, timetables, and outcomes of care; and assessing and planning for care to meet the resident's medical, nursing, mental, and psychosocial needs;-The interdisciplinary care team is responsible for reviewing and updating the care plan when a significant change has occurred, quarterly, and when changes that impact resident care occur. 1. Review of the Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 03/27/25; -Diagnoses included non-Hodgkin lymphoma (cancer that is in the lymphocytes (white blood cells - a component of the immune system), varicose veins of lower extremities (swollen, and twisted veins), high blood pressure, and cardiovascular disease (group of diseases that affect the heart and blood vessels). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Required moderate staff assistance with dressing and shower and supervision with toileting;-Utilized a walker.Review of the resident's nursing progress note, dated 04/01/25, showed resident had some swelling to feet, ankles, and legs. Staff contacted the physician contacted and nurse practitioner (NP) will look at tomorrow. Review of the resident's progress notes showed staff did not document monitoring or the resident swelling or physician/NP response to swelling. Observation and interview on 11/05/25, at 10:15 A.M., showed the resident sitting in a recliner with Tubi grips in place to both lower extremities. He/she reported swelling to the legs on and off. Observation and interview on 11/05/25, at 4:05 P.M., showed the resident observed sitting in a recliner wearing Tubi grips on both legs. Resident reported the certified nurse assistant (CNA) applied the Tubi grips in the morning and removed them at night. Resident reported that he/she also applied them at times. Review of the resident's care plan, revised on 11/05/25, showed the following:-Resident required one-to-two-person assistance with activities of daily living (ADL-basic tasks done regularly to care for the body) due to weakness;-Required one staff assistance with transfer, positioning, and hygiene.(Staff did not care plan related to the use of Tubi grips.) Review of resident's current Physician Order Sheet (POS) showed staff did not document an order for use of Tubi grips.During an interview on 11/05/25, at 3:35 P.M., Certified Nurse Aide (CNA) A said the resident wore Tubi grips. The CNA that gets him/her up in the morning puts them on and they are removed at night. During an interview on 11/05/25, at 3:45 P.M., Licensed Practical Nurse (LPN) D the resident does not wear Tubi grips and does not have an order. During interviews on 11/05/25, at 2:40 P.M. and 3:40 P.M., the MDS Coordinator said he/she was unsure if the resident wore Tubi grips, but the resident does not have an order in the chart. During an interview on 11/05/25, at 4:15 P.M., the Director of Nursing (DON) said the resident does not have an order for Tubi grips to be applied. 2. Review of the Resident #2's face sheet showed the following:-admission date of 05/13/24;-Diagnoses included edema, high blood pressure, and chronic respiratory failure (condition where the lungs are unable to exchange oxygen and carbon dioxide between the body and the environment). Review of the resident's care plan, revised on 06/13/24, showed the following:-Required one staff assistance with ADL's due to weakness;-Monitor weights per physician orders. Notify physician and responsible party of significant weight changes. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Dependent on staff for transfers, mobility, dressing, and showering;-Wheelchair used for mobility;-Resident taking a diuretic. Review of resident's current POS showed the following:-An order, dated 03/11/25, for fluid restriction of 1500 milliliters (ml) in 24 hours for a diagnosis of hypoosmolality (condition where there is an excess of water in relation to the amount of sodium in the body); -An order, dated 03/11/25, for Tubi grips size F in morning and off in the evening;-An order, dated 05/16/25, for daily weight check and notify provider for a weight gain of 3 pounds in one day or 5 pounds in a week;-An order, dated 06/15/25, for Lasix (used to treat edema) 20 milligram (mg) tablet take two tablets daily.Review of the resident's care plan, revised on 06/13/24, showed staff did not update the care plan to reflect the new orders including fluid restriction, Tubi grips, and Lasix. Review of resident's September 2025 Medication Administration Report (MAR) showed the following:-An order, dated 05/16/25, for a daily weight check - notify provider of weight gain of 3 pounds in one day or 5 pounds in a week;-On 09/01/25, weight of 189.8 pounds;-On 09/02/25, weight of 190.2 pounds;-On 09/03/25, staff did not document a weight or refusal; -On 09/04/25, staff did not document a weight or refusal; -On 09/05/25, weight of 191.3 pounds;-On 09/06/25 - staff did not document a weight or refusal; -On 09/07/25, resident refused; -On 09/08/25, resident refused; -On 09/09/25, weight of 190.2 pounds;-On 09/10/25, resident refused; -On 09/11/25, staff did not document a weight or refusal; -On 09/12/25, resident refused; -On 09/13/25, staff did not document a weight or refusal; -On 09/14/25, staff did not document a weight or refusal; -On 09/15/25, staff did not document a weight or refusal; -On 09/16/25, staff did not document a weight or refusal; -On 09/17/25, resident refused; -On 09/18/25, staff did not document a weight or refusal; -On 09/19/25 - staff did not document a weight or refusal; -On 09/20/25, weight of 194.2 pounds;-On 09/21/25, weight of 194 pounds;-On 09/22/25, weight of 193 pounds;-On 09/23/25, staff did not document a weight or refusal; -On 09/24/25, weight of 149 pounds. Staff did not document recheck of weight or documentation of physician notification;-On 09/25/25, weight of 194 pounds;-On 09/26/25, weight of 192 pounds;-On 09/27/25, weight of 192 pounds;-On 09/28/25, weight of 192 pounds;-On 09/29/25, staff did not document a weight or refusal; -On 09/30/25, staff did not document a weight or refusal. Review of resident's October 2025 MAR showed the following:-An order, dated 05/16/25, for a daily weight check and notify provider of weight gain of 3 pounds in one day or 5 pounds in a week;-On 10/01/25, staff did not document a weight or refusal; -On 10/02/25, weight of 193 pounds;-On 10/03/25, weight of 193 pounds;-On 10/04/25, staff did not document a weight or refusal; -On 10/05/25, staff did not document a weight or refusal; -On 10/06/25, resident refused; -On 10/07/25, staff did not document a weight or refusal; -On 10/08/25, weight of 196.4 pounds; -On 10/09/25, staff did not document a weight or refusal; -On 10/10/25, resident refused; -On 10/11/25, staff did not document a weight or refusal; -On 10/12/25, resident refused; -On 10/13/25, staff did not document a weight or refusal; -On 10/14/25, staff did not document a weight or refusal; -On 10/15/25, staff did not document a weight or refusal; -On 10/16/25, staff did not document a weight or refusal; -On 10/17/25, resident refused; -On 10/18/25, staff did not document a weight or refusal; -On 10/19/25, staff did not document a weight or refusal; -On 10/20/25, resident refused; -On 10/21/25, staff did not document a weight or refusal; -On 10/22/25, staff did not document a weight or refusal; -On 10/23/25, weight of 195.6 pounds; -On 10/24/25, staff did not document a weight or refusal; -On 10/25/25, weight of 195 pounds; -On 10/26/25, weight of 194 pounds; -On 10/27/25, staff did not document a weight or refusal; -On 10/28/25, staff did not document a weight or refusal; -On 10/29/25, staff did not document a weight or refusal; -On 10/30/25, staff did not document a weight or refusal; -On 10/31/25, staff did not document a weight or refusal. Observation and interview on 11/05/25, at 12:35 P.M., showed the resident sat in a wheelchair wearing Tubi grips to both lower extremities. The resident reported he/she needed tighter Tubi grips due to leg swelling. The resident said he/she had a hard time walking due to his/her legs being so swollen. Resident thinks he/she should be weighted daily but staff are not doing it. He/she reported weight gain since admitted to the facility. During an interview on 11/05/25, at 3:35 P.M., CNA A said the resident gets weighted by the CNA's but he/she was unsure if it is done daily. The resident complained about having trouble walking with edema to legs. He/she wears Tubi grips and elevated legs. Resident reported having trouble wearing shoes due to swelling.During an interview on 11/05/25, at 3:45 P.M., LPN D said the resident is on daily weights and fluid restriction due to edema. During interviews on 11/05/25, at 2:40 P.M. and 3:40 P.M., the MDS Coordinator said the resident had edema that comes and goes. During an interview on 11/05/25, at 4:15 P.M., the DON said the resident had an order for daily weights. 3. During an interview on 11/05/25, at 12:45 P.M., CNA B said he/she would report a resident with new or increased leg swelling to the charge nurse. During an interview on 11/05/25, at 3:30 P.M., LPN C said the following:-He/she would contact the physician for any new onset or worsening of edema;-Residents should have a physician order for Tubi grips;-Tubi grips and edema should be included in the care plan;-CNA's are responsible for obtaining resident weights;-Weights should be obtained daily if a resident has an order. During an interview on 11/05/25, at 3:35 P.M., CNA A said the charge nurse tells the CNA's which residents wear Tubi grips. The CNA's are responsible for putting Tubi grips on residents. Tubi grips should be included in the care plan. Day shift CNA's should complete daily weight by 10:00 A.M The charge nurse provides a list with residents that need to be weighed in the morning. During an interview on 11/05/25, at 3:45 P.M., LPN D said a resident should have an order to use Tubi grips. The order should include the size and when to wear. A resident with edema or Tubi grip use should have the information included on the care plan. The morning aides complete daily weights. The nurse provides the CNA's with a list of weights to be done every day.During an interview on 11/05/25, at 4:00 P.M., Certified Medication Technician (CMT) E said Tubi grips require a physician order. He/she does not apply Tubi grip. Tubi grips and edema should be included on the care plan. Daily weights are completed by day shift CNA's. During interviews on 11/05/25, at 2:40 P.M. and 3:40 P.M., the MDS Coordinator said he/she updates the care plan based upon information obtained from nurses and in the morning meetings. Edema and Tubi grips should be included on residents' care plans. Tubi grips should have an order. During an interview on 11/05/25, at 4:15 P.M., the DON said edema, Lasix use, and Tubi grips should be included on the care plan. Care plan changes are discussed in stand-up meeting daily with the DON, Assistant Director of Nursing (ADON), and the MDS Coordinator. New orders and progress notes are reviewed for the last 24 hours for updates. The nurse and CNA's are responsible for daily weights. The CNA's are responsible for completing monthly weights. The charge nurse should make a list of daily weights and provide it to the aides. During an interview on 11/05/25, at 5:05 P.M., the Administrator said staff should follow physician orders for daily weights. Tubi grips should have an order and be included on the care plan. Edema should be included on a resident's care plan. Complaint #2659996

Based on observation, interview, and record review, the facility failed to promote and facilitate each resident's right of self-determination in support of resident choice when staff failed to honor resident preferences for shower frequency for four residents (Resident #6, #11, #23, and #33). The facility census was 91.Review of the facility procedure for Bath/Shower, undated, the purpose of a shower is to maintain the resident's skin integrity, comfort, and cleanliness.1.Review of Resident #6's face sheet showed the following:-admission date of 02/23/14;-readmission date of 02/23/23;-Diagnoses included cerebral palsy (a group of conditions that affect movement and posture), spastic hemiplegia (a neuromuscular condition that results in the muscles on one side of the body being contracted) affecting his/her right side, anxiety, major recurrent depression, open wounds to his/her right thigh and lower back, and reduced mobility.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 09/04/25, showed the following:-Moderate cognitive impairment;-No rejection of care;-Functional limitation in range of motion to one side of his/her upper and one side of his/her lower body;-Motorized wheelchair for mobility;-Dependent on staff assistance for toileting hygiene, transfers, and showering;-Required substantial/maximal staff assistance with upper and lower body dressing and personal hygiene;-Always incontinent of bowel and bladder;-Risk of pressure ulcer development and presence of one pressure ulcer.Review of the resident's current care plan showed the following:-Required extensive assistance for all his/her activities of daily living (ADLs - dressing, toileting, showering, grooming, etc.) related to mobility issues, weakness, and disease process;-Resident will be offered two baths per week and have the right to refuse or request additional baths. Please encourage the resident if needed;-Two staff to assist the resident with positioning and Hoyer (a mechanical transfer lift) for transfers.Review of the July 2025 Shower Schedule showed the following: -The resident received a shower on 07/03/25, 07/10/25, and 07/22/25;-Staff did not document any resident refusals.Review of the August 2025 Shower Schedule showed the following: -The resident received a shower on 08/08/25 and 08/12/25;-Staff did not document any resident refusals.Review of the resident's electronic medical record, dated 09/01/25 to 09/09/25, showed staff did not document any showers received by the resident.Observation and interview on 09/10/25, at 11:20 A.M., showed the following:-The resident said he/she would like to have a shower three times per week, but he/she was lucky to get one shower per week;-The resident said it makes him/her feel yucky when he/she does not receive a shower;-The resident said his/her head gets, itchy when he/she does not get assistance with shampooing his/her hair;-Observation showed the resident's hair appeared greasy;-The resident said he/she had not received a shower so far this week.2. Review of Resident #11's face sheet showed the following:-admission date of 07/20/22;-re-admission date of 08/03/24;-Diagnoses included of congestive heart failure, diabetes, anxiety, and major recurrent depression.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-No rejection of care;-Utilized walker or wheelchair for mobility;-Partial/moderate staff assistance for toileting hygiene and showering;-Required substantial/maximal staff assistance with lower body dressing;-At risk of pressure ulcer development and presence of moisture associated skin damage (MASD, skin breakdown from prolonged exposure to moisture).Review of the resident's current care plan showed;-Required assistance of one to two staff for all his/her ADLs related to weakness and rhabdomyolysis (a condition in which the skeletal muscles break down quickly);-Resident will be offered two baths per week and have the right to refuse or request additional baths. Please encourage the resident if needed. Review of the resident's July 2025 Shower Schedule showed the following:-On 07/08/25, the resident refused a shower;-On 07/17/25 and 07/30/25, the resident received a shower. Review of the resident's August 2025 Shower Schedule showed the following: -The resident received a shower on 08/19/25;-Staff did not document any resident refusals.Observation and interview on 09/03/25, at 11:25 A.M., showed the following:-Resident sat up in his/her recliner with his/her walker nearby;-The resident said his/her main concern was showers because staff have not assisted him/her with a shower for a few weeks;-The resident said staff came in earlier that morning on 09/03/25 and said he/she would get a shower tomorrow on 09/04/25;-The resident said his/her head was itching and hair was greasy because of no shower or shampoo.Review of the resident's electronic medical record, dated 09/01/25 to 09/09/25, showed the resident received a shower on 09/04/25.3. Review of Resident #23's face sheet showed the following:-admission date of 12/05/23;-Diagnoses included stroke, diabetes, general anxiety disorder, and depression.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-No rejection of care;-Utilized walker or wheelchair for mobility;-Supervision/touching assistance of staff for toileting hygiene, transfers, and showering;-Occasionally incontinent of bladder;-At risk of pressure ulcer development.Review of the resident's current care plan showed the following:-Required supervision or assistance of one staff for all his/her ADLs related to weakness and disease process;-Resident will be offered two baths per week and have the right to refuse or request additional baths. Please encourage the resident if needed.Review of the July 2025 Shower Schedule showed the resident received one shower for the month on 07/08/25. Staff did not document any resident refusals.Review of the August 2025 Shower Schedule showed the resident received one shower for the month on 08/04/25. Staff documented two refusals on 08/20/25 and 08/22/25.Review of the resident's electronic medical record, dated 09/01/25 to 09/09/25, showed staff did not document any showers received by the resident.During an interview on 09/03/25, at 1:50 P.M., the resident said he/she has not had assistance with a shower for 2 weeks.Observation on 09/10/25, showed the resident participating in activities. The resident's hair was visibly oily and stringy.4. Review of Resident #33's face sheet showed the following:-admission date of 05/13/24;-re-admission date of 03/11/25;-Diagnoses included of chronic respiratory failure and generalized anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-No rejection of care;-Utilized wheelchair for mobility;-Substantial/maximal staff assistance for toileting hygiene, transfers, showering, and upper and lower body dressing;-Occasionally incontinent of bladder;-At risk of pressure ulcer development.Review of the resident's care plan showed the following:-Required assistance of one staff for all his/her ADLs related to weakness, and disease process (respiratory failure); -Resident will be offered two baths per week and has the right to refuse or request additional baths. Please encourage the resident if needed.Review of the July 2025 Shower Schedule showed the following: -The resident received showers on 07/04/25, 07/09/25, 07/16/25, 07/23/25, and 07/30/25;-Staff did not document any resident refusals.Review of the August 2025 Shower Schedule showed the following: -The resident received showers on 08/06/25, 08/13/25, 08/20/25, and 08/27/25;-Staff did not document any refusals.Observation and interview of Resident #33 on 09/03/25 at 9:38 A.M., showed:-Staff propelled the resident to his/her room in his/her wheelchair;-The resident stated he/she just came from a shower, but the facility had an issue with not providing residents with enough showers at times;-He/she felt dirty when he/she did not get a shower.Review of the resident's electronic medical record, dated 09/01/25 to 09/09/25, showed the resident received one shower on 09/03/25.During an interview on 09/10/25 11:05 A.M., the resident said the following:-During the summer, he/she wanted two showers per week, but only received one shower per week at times, because the facility pulled the shower aides to work the floor;-When at home, he/she took a shower every morning;-In the summer, he/she would sweat and liked a shower twice per week.5. During an interview on 09/08/25, at 1:49 P.M., Restorative Aide G said the following:-He/she worked at the facility for approximately the last six years-The facility was having a rough time completing all resident showers;-The facility used to have four shower aides;-One of the shower aides quit working at the facility and another stepped into a different role;-The two remaining shower aides each work part-time at the facility and the facility did not have anyone on evening helping to complete showers;-Staff are not able to assist some of the residents with showers weekly;-He/she was unsure how the facility was keeping track of showers, but he/she did not think the shower aides had a clear idea of when residents were last showered. During an interview on 09/09/25, at 11:26 A.M., Certified Nurse Assistant (CNA) F said the following:-He/she worked at the facility as a shower aide for approximately three years;-He/she worked Monday through Friday, 8:00 A.M. to 1:00 P.M.;-The other shower aide worked as needed;-The facility did not have anyone else helping with resident showers;-He/she showered four to six residents per day on average;-A few residents were independent with showering but not a lot of them were;-It was possible that residents were going over a week without showers;-The Director of Nursing (DON) or Assistant Director of Nursing (ADON0 gave him/her a list of showers for the day, The list usually had 6 to 8 residents each day;-He/she tried to complete as many showers as he/she could each day;-He/she gave a list of completed showers and showers that were not completed to the DON each day;-He/she completed an estimated 25 resident showers per week;-He/she did not realize that some of the residents were having to wait longer than a week for showers.During an interview on 09/10/25 at 10:14 A.M., Licensed Practical Nurse (LPN) D said the following:-He/she thought the DON or ADON made out the resident shower lists for the shower aide each day;-He/she was unsure if staff were completing all resident showers or not;-Some of the residents and families had complained about the staff not completing resident showers;-The shower aides do not report to the nurse which showers were not completed;-If a shower aide came to the nurse and said the resident was refusing his/her shower, the nurse would try to convince the resident to shower;-Staff was supposed to assist residents with two showers per week.During an interview on 09/09/25, at 1:00 P.M., Registered Nurse (RN) C said the following:-He/she was unsure if the showers aides were completing all the resident showers or not;-The DON made a list of residents for the shower aide;-He/she thought the shower aide would inform the DON if a resident refused a shower.During an interview on 09/10/25, at 2:30 P.M., the Long-Term Care (LTC) Case Manager said the following:-He/she was not aware of any issues with staff not completing resident showers, but the DON and former ADON were tracking the showers;-The shower aides should try to offer the resident a shower three times and if the resident refused, the aide should notify the nurse, and the nurse would try to convince the resident.-If the nurse could not get the resident to take a shower, the nurse should contact the resident's family or responsible person and document in the resident's progress notes. During an interview on 09/09/25, at 2:13 P.M., the DON said the following:-The facility currently had two shower aides working and each worked five hours per day and typically completed four to five showers per day;-The DON gave the shower aides a list of which residents to shower each day;-The DON tracked the shower on a monthly schedule and would mark an X on the days staff gave each resident a shower;-Based on the showers completed and a list of resident preferred shower days, he/she made the list for the following day;-There are residents going longer than a week without with showers due to not enough shower aides;-The facility goal is to provide each resident with two showers per week;-He/she did not have anyone asking for more than two showers per week and the residents were care planned for showers based on their preference.During an interview on 09/10/25, at 5:42 P.M., the Administrator said facility staff should provide residents with showers assistance per each resident's preference and per each resident's care plan.

Based on record review and interview, the facility failed to ensure that staff notified the resident and/or the resident's representative in writing of a transfer at the time of transfer for two residents (Residents #8 and 104). The facility census was 91.Review of the facility's policy titled Discharge/Transfer of Resident, undated, showed the following:-Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person responsible for care.-If emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible.1. Review of Resident #41's face sheet (gives basic profile information at a glance) showed an admission date of 09/08/23.Review of the resident's nurse progress notes, dated 08/03/25, showed the following:-An aide informed a nurse that the resident was unresponsive;-The nurse tried to arouse the resident with no response;-The nurse called for two nurses to help;-Resident was placed on the floor for chest compressions to be administered;-Staff contacted 911 and emergency medical services (EMS) arrived;-Staff provided report and medical records;-Staff notified Director of Nursing (DON), physician, and next of kin (NOK).Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 08/03/25.2. Review of Resident #104's face sheet showed an admission date of 04/05/24.Review of the resident's nurses' progress notes, dated 07/10/25, showed the following:-Registered Nurse (RN) assessed resident after report and vital stats taken;-Resident grunting and not responding to nurse when talking to him/her;-Breath sounds were diminished;-Contacted Nurse Practitioner (NP) with condition update, labs and stats;-Order received to send resident to the emergency room (ER) for evaluation and treatment;-NP will contact NOK, physician, and ER;-Staff gathered paperwork gathered and contacted emergency medical services;-EMS arrived and report given. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 07/10/25.3. During an interview on 09/09/25, at 1:07 P.M., Licensed Practical Nurse (LPN) D said the following:-Nurses notify the resident's family as soon as possible if a resident is transferred or discharged ;-LPN D does not issue a letter to family regarding the discharge.During an interview on 09/09/25, at 1:09 P.M., Social Services (SS) said the following:-Nurses notify family and put note in record if a resident is transferred to the hospital;-SS will occasionally contact the family regarding the transfer if the nurse requests;-Nurses send paperwork including the face sheet and physician's orders with resident to hospital;-SS does not send written notification to family or the resident explaining the transfer;-SS does not believe the facility provides written notification of transfer. During an interview on 09/09/25, at 1:24 P.M., the Business Office Manager (BM), said the following:-When a resident is transferred to the hospital, the nurses enter a note in the resident's chart documenting where the resident was transferred to and who was notified of the transfer; -No written notification is issued to the resident or their family. During an interview on 09/09/25, at 1:42 P.M., Long-Term Care Case Manager (LTC CM) said the following:-Nurses will notify a resident's family when they are transferred out of the facility;-LTC CM does not know if written notification of the transfer is provided to the resident or their family. During an interview on 09/10/25, at 12:31 P.M., the Director of Nursing (DON) said the following:-The charge nurse is responsible for notifying the resident's family when a resident is transferred to the hospital;-No written notification is provided to the resident or their family. During an interview on 09/10/25, at 12:33 P.M, the Administrator said the following:-The nurse will verbally notify the resident's family when a resident transfers out to a hospital;-No written notification is provided to the family or resident.

Based on interview and record review, the facility failed to maintain a system an effective system to make code status (whether or not the resident wished to receive cardiopulmonary resuscitation (CPR - an emergency procedure used during cardiac or respiratory arrest)) of each resident available to staff at all times when staff failed to maintain accurate, current, and accessible code status information for nine resident (Resident #2, #10, #27, #30, #7, #8, #42, #33, and #68). The facility had a census of 91.Review of the facility policy titled, Advanced Directives, undated, showed Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 1. Review of Resident #2's face sheet (brief look at resident information) showed the following information:-admission date of [DATE];-Code status of do not resuscitate (DNR – does not wish to receive CPR). Review of the resident's current physician order sheet showed an order, dated [DATE], for code status of DNR. Review of the resident's care plan, dated [DATE], showed code status of DNR. Review of the facility's Resident Face Sheet book, on [DATE], showed the resident as a full code (to receive CPR). Review of the facility's Certified Nursing Assistant (CNA) quick reference book, on [DATE], showed the resident's information absent from the book. 2. Review of Resident #10's face sheet showed the following information:-Current admission date of [DATE];-Code status of DNR. Review of the resident's current physician order sheet showed an order, dated [DATE], for code status of DNR. Review of the resident's care plan, dated [DATE], showed code status of DNR. Review of the facility's Resident Face Sheet book, on [DATE], showed the resident's face sheet and code preference absent from the book. Review of the facility's CNA quick reference book, on [DATE], showed the resident's information absent from the book. 3. Review of Resident #27's face sheet showed the following information:-admission date of [DATE];-Code status of DNR. Review of the resident's current physician order sheet showed an order, dated [DATE], for code status of DNR. Review of the resident's care plan, dated [DATE], showed code status of DNR. Review of the facility's Resident Face Sheet book, on [DATE], showed the resident's face sheet and code preference absent from the book. Review of the facility's CNA quick reference book, on [DATE], showed the resident's information absent from the book. 4. Review of Resident #30's face sheet showed the following information:-admission date of [DATE];-Code status of DNR. Review of the resident's current physician order sheet showed an order, dated [DATE], for code status of DNR. Review of the resident's care plan, last reviewed/revised [DATE], showed code status of DNR. Review of the facility's Resident Face Sheet book, on [DATE], showed the resident's face sheet and code preference absent from the book. Review of the facility's CNA quick reference book, on [DATE], showed the resident's information absent from the book. 5. Review of Resident #7's face sheet showed the following information:-readmission date of [DATE];-Code status of DNR. Review of the resident's Physician Order Sheet (POS), current as of [DATE], showed an order, dated [DATE], for resident to be a DNR. Review of resident's care plan, dated [DATE], showed the resident was a DNR. Review of the facility's Resident Face Sheet book, on [DATE], showed the resident's face sheet and code preference absent from the book. Review of the facility's CNA quick reference book, on [DATE], showed the resident's information absent from the book. 6. Review of Resident #8's face sheet showed the following information:-readmission date of [DATE];-Code status of full code (wished to receive CPR). Review of the resident's POS, current as of [DATE], showed an order, dated [DATE], for full code. Review of resident's care plan, dated [DATE], showed the resident to be full code. Review of the facility's Resident Face Sheet book, on [DATE], showed the resident's face sheet and code preference absent from the book. Review of the facility's CNA quick reference book, on [DATE], showed the resident's information absent from the book. 7. Review of Resident #42's face sheet showed the following information:-admission date [DATE];-Code status of DNR. Review of the resident's POS, current as of [DATE], showed an order, dated [DATE], for resident to be a DNR. Review of resident's care plan, dated [DATE], showed the resident was a DNR. Review of the facility's Resident Face Sheet book, on [DATE], showed the resident's face sheet and code preference absent from the book. Review of the facility's CNA quick reference book, on [DATE], showed the resident's information absent from the book. 8. Review of Resident #33's face sheet showed:-admission date of [DATE];-Code status of DNR. Review of the resident's current physician order sheet showed an order, dated [DATE], for code status of DNR. Review of the resident's care plan, dated [DATE], showed code status of DNR. Review of the D hall binder titled, Resident Face Sheet, on [DATE] at 12:06 P.M., showed it contained the face sheets and code status information for several residents, but did not contain a face sheet or any information for Resident #33. 9. Review of Resident #68's face sheet showed:-admission date of [DATE];-Code status of full code. Review of the resident's current physician order sheet showed code status of full code. -Full code. Review of the resident's care plan, dated [DATE], showed code status of DNR. Review of the D hall binder titled, :Resident Face Sheet, on [DATE] at 12:06 P.M., showed it contained the face sheets and code status information for several residents, but did not contain a face sheet or any information for Resident #68. 10. During an interview on [DATE], at 9:21 A.M., Registered Nurse (RN) C said the following:-Resident code status can be located in the Face Sheet book located at the nurses' stations;-The Face Sheet book is updated periodically or when code status changes. During an interview on [DATE], at 10:14 A.M., Licensed Practical Nurse (LPN) D said the following:-He/she would look for a resident's advanced directives on his/her face sheet in the electronic medical record or check for the DNR in the document section in the electronic medical record;-One of the evening nurses also placed a list of resident code status for C and D hall residents in the C/D medication room. During an interview on [DATE], at 1:43 PM, the Skilled Case Manager (CM) said the following:-Upon admission, he/she will obtain the resident's code status preference;-He/she will place the form in the physician folder to obtain a signature;-Code status is entered into the computer, but he/she is unsure who enters the information;-He/she would ask medical records if he/she needed to know a resident's code status. During an interview on [DATE], at 12:06 P.M., the Long-Term Care (LTC) Case Manager/ MDS Coordinator said the following:-If he/she needed to check a resident code status, he/she would look in the electronic health record (EHR) system on the resident's face sheet or the physician orders;-If a staff member could not access the electric health record, he/she should look in the face sheet binder for that hall located at the nurse desk;-He/she thought the Director of Nursing (DON) or Medical Records person was in charge of keeping the binder up to date, but was unsure when they completed updates;-He/she updated each resident's code status in the electronic medical record when he/she completed a care plan for that resident;-If a resident's code status changed, the nurse should update the code status in the EHR and pass the change on to the next shift nurse in report;-As far as he/she knew, the face sheet book was up to date with current resident code statuses. During an interview on [DATE], at 12:48 P.M., the LTC Social Service Director (SSD) said the following:-He/she completed admission paperwork with LTC admissions at the facility;-He/she goes over the admission packet which included a DNR form;-He/she educated residents and families about the DNR form and the resident or his/her responsible parties had an option to sign the form.-If the resident decided to sign the form, he/she notified the nurse on duty and the nurse would contact the resident's physician for a DNR order and place the order in electronic medical record;-He/she then placed the paper copy of the signed DNR form into the physician's box located at the nurse desk for signature or fax the physician for signature;-If he/she obtained a physician signature for the DNR, he/she then gave the form to the DON;-The DON ensured the order the nurse updated the order in electronic medical record and then the DON gave the form to Medical Records;-When Medical Records person was not at work, he/she was unsure if the nurses would have access to the original DNR order form or not;-If the nurse asked the SSD a resident's code status, he/she would run to a computer and look in the electronic medical record;-He/she thought each resident was supposed to have a code status sheet inside each closet with all that information. He/she remembered discussion about that one day in the morning meeting. During an interview on [DATE], at 12:16 P.M., Medical Records said the following: -When admitting a new resident, he/she scanned in the resident's hospital records and hospital discharge orders into electronic medical records;-He/she checked the Medical Records mailbox located at each nurses' station and if there was a resident DNR order form in the box, he/she delivered the form to the DON and the DON updated the resident's physician order for code status in the electronic medical record;-He/she kept the original DNR forms in a file cabinet in his/her office;-He/she locked the office when he/she left work;-He/she did not think the nurses had access or a key to the office in the evenings or on weekends; -Each resident's code status is in the electronic medical record. It should either read full code or DNR, but he/she was unaware the nurses needed to have a hard copy of each resident's code status;-He/she was unsure if anyone in the facility had access to resident code status information in the event of an emergency. During an interview on [DATE], at 2:50 P.M., the DON said the following:-If staff were unable to access code status from the computer, it could be obtained by accessing the offline electronic medication administration record (eMAR);-To access the offline eMAR, staff would contact the DON and he/she could give staff instructions to print off the eMAR. During an interview on [DATE], at 5:43 P.M., the Administrator said the following:-The computers should not be affected as they have generator power;-There is an offline eMAR available that nurses should be able to access;-If staff cannot access the eMAR, they should contact the DON or Administrator.

Based on observation, record review, and interview, the facility failed to provide care respiratory care per standards of practice when staff failed to administer oxygen per physician orders for one resident (Resident #110) and failed to obtain complete oxygen administration orders for three residents (Resident #2, #30, and #8). The facility census was 91. Review of the facility's policy titled Oxygen Administration, undated, showed the following:-The purpose is to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues;-Check physician's order for liter flow and method of administration;-For oxygen per nasal cannula, connect the tubing to the humidifier outlet and adjust the flow as ordered;-Place prongs of cannula into the resident's nares;-Adjust elastic loosely around head above the ears;-If cannula does not have elastic adjustment, loop the plastic around the ears and under the chin;-Adjust the plastic slide to hold cannula in place;-Constant flow of oxygen can cause drying and thickening of normal secretions resulting in laryngeal ulceration. 1. Review of Resident #110's face sheet (brief look at resident information) showed the following information:-admission date of 10/21/24;-Diagnoses included chronic obstructive pulmonary disease (COPD-a lung disease that causes airflow obstruction and breathing problems, anxiety (mental health condition that causes excessive worry, fear, and nervousness), and dementia (progressive decline in memory, thinking, reasoning, and judgment). Review of the resident's quarterly Minimum Data Set (MDS – a federally mandated assessment tool completed by facility staff), dated 05/13/25, showed the following:-Resident was cognitively intact;-No indication of oxygen administration;-Health conditions include shortness of breath or trouble breathing with exertion (e.g. walking, bathing, transferring) and shortness of breath or trouble breathing when lying. Review of the resident's care plan, revised 09/10/25, showed the following:-Monitor for respiratory difficulties and intervene as needed;-Apply oxygen as ordered for comfort and assess for signs and symptoms of activity intolerance as evidenced by fatigue, pain. and/or shortness of breath;-Resident required oxygen therapy per orders and oxygen stats;-Administer oxygen as ordered 2 liters per minute via nasal cannula, change tubing per protocol, ensure oxygen supply is available at all times, monitor for changes in symptoms that may indicate worsening respiratory status, and report to physician. Review of the resident's current Physician's Orders Sheet (POS) showed an order, dated 09/05/25, for oxygen 2 liters per minute per nasal cannula continuous, every shift- day, evening, and night. Review of the resident's Treatment Administration Record (TAR), dated 09/01/25 to 09/10/25, showed an order, dated 09/05/25, for oxygen at two liters per minute per nasal cannula continuous every shift. Observation on 09/8/25, at 10:27 A.M., showed the resident lying in bed with eyes closed. The oxygen tubing was lying on his/her stomach and not in his/her nose. The oxygen concentrator was set on three liters per minute. During an interview and observation on 09/08/25, at 11:21 A.M., the resident stated, he/she was not on oxygen prior to coming to the facility. He/she was supposed to be on two liters of oxygen all the time. He/she does not do any adjustments on the oxygen concentrator, he/she lets staff do that. He/she puts on and takes off his or her own oxygen tubing. The oxygen concentrator was set on three liters per minute per nasal cannula. Observation on 09/09/25, at 12:07 P.M., showed the resident in the dining room with a portable oxygen tank on the back of his/her wheelchair. The oxygen concentrator was set at three liters per minute. Certified Nurse Aide (CNA) M came to attend to the resident, and he/she confirmed that the resident's oxygen concentrator was set on three liters per minute. The resident asked the CNA to turn his/her oxygen off while she ate lunch. The CNA turned the resident's oxygen concentrator off per the resident's request. During an interview on 09/09/25, at 10:31 A.M., CNA M said the resident had oxygen set at three liters per minute. He/she checked the CNA quick reference book and stated that he/she did not see any information regarding oxygen or the prescribed amount, but he/she just knew his/her residents on the hall. During an interview on 09/09/25, at 10:51 A.M., CNA N said the resident was put on oxygen at the hospital approximately a week ago and he/she was still on it. The resident was supposed to wear oxygen all the time, but sometimes the resident took it off. He/she thought the resident should be on two liters of oxygen per minute. 2. Review of the Resident # 2's face sheet showed the following information:-admission date of 03/20/23;-Diagnoses included COPD and congestive heart failure (CHF - condition where the heart muscle becomes weak and cannot pump blood effectively). Review of the resident's quarterly MDS, dated [DATE], showed the following:-No indication of oxygen administration;-Health conditions included shortness of breath or trouble breathing when lying flat. Review of the resident's care plan, dated 07/29/25, showed staff should monitor for respiratory difficulties, intervene as needed, and apply oxygen as ordered for comfort. Review of the resident's Medication Administration Record (MAR) and TAR, dated 06/01/25 to 09/09/25, showed staff did not document orders for oxygen usage. Review of the resident's nurse's note on 08/11/25, at 12:49 A.M., showed the resident reported he/she could not breathe, so staff obtained an oxygen concentrator and placed the resident on oxygen per nasal cannula at 2.5 liters per minute. Review of the resident's nurses note on 08/21/25, at 3:20 P.M., showed the resident was lethargic and on two liters of oxygen due to the resident breathing heavily. Review of the resident's nurses note on 08/23/25, at 3:22 P.M., showed oxygen was placed after the resident received a shower. Review of the resident's nurses note on 08/24/25, at 1:10 A.M., showed staff placed oxygen per nasal cannula for comfort. During an interview on 09/09/25, at 10:31 A.M., CNA M said the resident was not on oxygen that he/she was aware of. During an interview on 09/09/25, at 10:51 A.M., CNA N said the resident was only on oxygen as needed for anxiety, but he/she did not know how much oxygen was ordered for the resident. He/she did not need it all the time. The oxygen made him/her feel better. During an interview on 09/09/25, at 2:06 P.M., LPN D said he/she looked in the electronic health record for the resident and did not see an order for the resident to have oxygen. The resident did wear oxygen, but he/she thought the resident only wore it as needed. He/she puts two liters of oxygen on the resident when the resident complained of anxiety or shortness of breath. The resident wore his/her oxygen off and on. During an interview on 09/09/25, at 1:42 P.M, the Long-Term Care (LTC) Case Manager (LTC-CM) looked in the electronic health record for the resident and said he/she did not find an order for him/her to receive oxygen. During an interview on 09/10/25, at 4:56 P.M., the Director of Nursing (DON) said the resident had an oxygen tank in his/her room from Hospice. He/she was not sure if the resident has an order for oxygen. 3. Review of the Resident #30's face sheet (brief look at resident information) showed the following information:-admission date of 12/05/15;-Diagnoses included anxiety (mental health condition that causes excessive worry, fear, and nervousness). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-No indication of oxygen administration;-Health conditions include dyspnea (shortness of breath). Review of the resident's progress notes, dated 06/01/25 through 09/09/25, showed staff did not document the resident use of oxygen. Review of the resident's physician order report, dated 06/01/25 through 09/09/25, did not include an order for oxygen administration. Review of the resident's care plan, revised 06/24/25, showed short apneic periods may occur during or immediately following generalized seizure activity. Staff should provide oxygen as necessary to maintain saturations greater than 90 percent. Observation on 09/03/25, at10:42 A.M., showed the resident in bed covered up with blanket, awake, and in no distress. Oxygen tubing near the resident's mouth. Oxygen concentrator set on three liters per nasal cannula. Observation on 09/03/25, at 11:22 A.M., showed the resident's oxygen tubing was below his/her nose, near his/her mouth. Observation on 09/04/25, at 11:27 A.M., showed CNA N and CNA O assisted the resident from the bed into a wheelchair with the use of a Hoyer lift (mechanical lift). CNA O removed the resident's oxygen and left it off once the resident was in the wheelchair. Observation on 09/08/25, 11:37 A.M., showed the resident lying in bed asleep with oxygen on at three liters per nasal cannula. During an interview on 09/09/25, at 10:31 A.M., CNA M said the resident was on oxygen, but he/she did not know how many liters. He/she looked in the CNA quick reference book, located at the nurses' station and did not find any information regarding the resident being on oxygen or the number of liters per minute ordered. During an interview on 09/09/25, at 10:51 A.M., CNA N said the resident was on two liters of oxygen the last time he/she checked. The resident was not on oxygen all the time and usually only when he/she was in bed. He/she does not usually need oxygen while he/she was up in a chair. Observation on 09/09/25, at 11:25 A.M., showed the resident lying in bed with his/her eyes closed. No oxygen on and the tubing was rolled up inside a clear bag on top of the oxygen concentrator. During an interview on 09/09/25, at 1:42 P.M, the LTC-CM looked in the electronic health record for the resident and said he/she did not find an order for him/her to receive oxygen. During an interview on 09/09/25, at 2:06 P.M., Licensed Practical Nurse (LPN) D said the resident had oxygen on and off quite a bit. The resident has an order for pulse ox checks every shift, but he/she did not find an order in the chart for oxygen. The resident wore his/her oxygen more in bed, not when he/she is up in his/her wheelchair. The resident received anywhere between two to three liters of oxygen per minute. During an interview on 09/10/25, at 4:56 P.M., the said he/she was not sure if the resident hac an order for oxygen. He/she did not always wear oxygen, but he/she should have an as needed order. 4. Review of Resident #8's face sheet showed the following information:-readmission date of 08/21/22;-Diagnoses included atrial fibrillation (irregular heartbeat) and anxiety. Review of the resident's POS, current as of 09/09/25, showed an order, dated 05/20/25, for oxygen saturation (SPO2 - a measure of how much oxygen is in your blood) every shift to keep stats above 90% for shortness of breath. (The record did not reflect a liter amount of oxygen.) Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident was cognitively intact;-No indication of oxygen administration. Review of resident's care plan, dated 07/07/25, showed staff did not document regarding the resident receiving oxygen. Observation on 09/04/25, at 1:30 P.M., showed the resident lying in bed with oxygen canula on. Oxygen was set at 3 liters. Observation and interview on 09/09/25, at 10:39 A.M., showed the following:-Resident lying in bed with oxygen canula on;-Oxygen set at 3.5 liters;-He/she wore his/her oxygen all the time. During an interview on 09/09/25, at 1:42 P.M., LTC CM said the following:-The resident's order only stated to check pulse ox;-No orders for oxygen were present; During an interview on 09/10/25, at 8:56 A.M., Registered Nurse (RN) B said the following:-An oxygen order for Resident #8 was entered on 09/09/25;-No tube changing order is listed in the resident's orders. During an interview on 09/10/25, at 4:56 P.M., the DON said he/she is unsure of the resident's order for oxygen. 5. During an interview on 09/09/25, at 10:31 A.M., CNA M said the nurses let him/her know which residents were on oxygen or he/she looked at the resident's care plan in the physical record located at the nurses' station. He/she was not sure where to find that information in the electronic health record. The nurses were responsible for monitoring and adjusting the oxygen concentrators. The CNA's do not make any adjustments with oxygen. He/she would get a nurse to adjust the oxygen, if needed. The nurses get the oxygen order from the DON or Assistant Director of Nursing (ADON). During an interview on 09/09/25, at 10:51 A.M., CNA N said he/she just knows the residents and how much oxygen they should be on. If he/she cares for a new resident, he/she can look at the computer profile for the resident or look in the physical binder located at the nurses' station to see how much oxygen a resident is on, but it is easier to look at the computer for that information. The nurses were responsible for monitoring and adjusting the oxygen concentrators. He/she would only adjust the oxygen concentration if the nurse was in the room and told him/her to adjust it. If he/she was in the room alone and noticed that the oxygen needed to be adjusted, he/she would get a nurse to adjust the oxygen. There should be an order for oxygen, but he/she does not know what the order should include. The nurses get the oxygen order from the physician. During an interview on 09/09/25, at 2:06 P.M., LPN D said nurses can give oxygen as needed without a physician's order, but they should let the physician know. If a resident is on continuous oxygen there would be an order. During an interview on 09/09/25, at 1:42 P.M., LTC-CM said the following:-Residents who require oxygen should have a physician's order;-Oxygen orders should indicate if it is continuous or PRN (as needed), how many liters, and the oxygen saturation level. During an interview on 09/10/25, at 8:56 A.M., Registered Nurse (RN) B said the following:-Residents requiring oxygen should have a physician's order;-Oxygen orders should indicate how many liters to be administered. During an interview on 09/10/25, at 4:56 P.M., the DON said the following:-Residents receiving oxygen should have a physician's order;-Continuous orders should state how many liters to administer;-PRN orders should state oxygen levels to be greater than 90%, and staff would assess how many liters are needed;- Oxygen orders are documented in the care plan. During an interview on 09/10/25, at 5:43 P.M., the Administrator said resident's receiving oxygen should have an order for the amount (liters) and for scheduled tube changing.

Based on observations, interview, and record review, the facility failed to provide pharmaceutical services that provided a consistent system of reconciliation for all controlled substances, when staff failed to consistently sign the controlled medication count sheets at change of shift for two of seven medication/treatment carts in the facility. The facility census was 91. Review of the facility policy titled, Narcotic Count, undate, showed the following:-Purpose to complete a physical inventory of narcotics at each shift change to identify discrepancies;-The narcotic supply is to be kept under two locks at all times. The lock on the medication cart and the lock on the narcotics. These two locks and the medication room are to be locked at all times; -One registered nurse (RN), licensed practical nurse (LPN) or certified medication technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift;-Narcotics records are reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse. Records are to be retained for a least one year. Emergency kits containing narcotics will be checked at the same time to be sure the seal has not been broken or will be reconciled if the seal is broken;-One prescription for a controlled substance is entered on one individual narcotic sheet;-After the supply is counted and justified, the nurse/CMT records the date and his/her signature, verifying that the count is correct.1. Review of the August 2025 A/B Nurse Controlled Drugs-Count Record showed staff failed to sign a reconciliation count completed on the following dates and times:-On 08/02/25, 3-11 shift, the oncoming and off going nurses failed to sign;-On 08/04/25, 7-3 shift, the oncoming nurse failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 08/05/25, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/06/25, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/07/25, 11-7 shift, the oncoming nurse failed to sign;-On 08/08/25, 11-7 shift, the off going nurse failed to sign;-On 08/12/25, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/17/25, 7-3 shift, the oncoming nurse failed to sign;-On 08/19/25,1 1-7 shift, the oncoming nurse failed to sign;-On 08/20/25; 11-7 shift, the off going nurse failed to sign;-On 08/25/25, 3-11 shift, the oncoming and off going nurses failed to sign and 11-7 shift, the oncoming nurse failed to sign;-On 08/26/25, 11-7 shift, the off going nurse failed to sign and 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 08/27/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 08/28/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 08/29/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 08/30/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 08/31/25, 7-3 shift, the oncoming nurse and off going failed to sign.Review of the September 2025 A/B Nurse Controlled Drugs-Count Record showed staff failed to sign a reconciliation count completed on the following dates and times:-On 09/01/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 09/02/25, 7-3 shift, the oncoming nurse and off going failed to sign, 3-11 shift, the oncoming and off going nurses failed to sign, and 11-7 shift, the oncoming nurse failed to sign;-On 09/03/25, 11-7 shift, the off going nurse failed to sign, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 09/04/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 09/05/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 09/06/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 09/07/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-09/08/25, 7-3 shift, the oncoming nurse and off going failed to sign, and 3-11 shift, the oncoming and off going nurses failed to sign;-On 09/09/25, 7-3 shift, the oncoming nurse and off going failed to sign, 3-11 shift, the oncoming and off going nurses failed to sign; and 11-7 shift, the oncoming nurse failed to sign.During interviews on 09/10/25, at 9:50 A.M. and at 10:50 A.M., RN C said the following:-At the beginning and end of each shift the oncoming and off going nurse or CMT should count all the controlled medications and both should sign the count sheet;-Some of the nurses were not signing the controlled medication count sheets at the change of shift.Observation on 09/10/25, at 9:50 A.M., of the A/B hall nurse cart narcotic book showed RN C showed the surveyor the A/B hall-controlled medication book which contained several blank spaces where nurses had failed to sign in September 2025 at the change of shift count.2.Review of the August 2025 C/D Nurse Controlled Drugs-Count Record showed staff failed to sign a reconciliation count completed on the following dates and times:-On 08/01/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/02/25, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/03/25, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/08/25, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/09/25, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/10/25, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/12/25, 3-11 shift, the oncoming and off going nurse failed to sign and the 11-7 oncoming nurse failed to sign;-On 08/13/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign and the 11-7 oncoming nurse failed to sign;-On 08/14/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/15/25, 3-11 shift, the oncoming and off going nurse failed to sign and the 11-7 oncoming nurse failed to sign;-On 08/16/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/17/25, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/18/25, 3-11 shift, the oncoming and off going nurse failed to sign and the 11-7 oncoming nurse failed to sign;-On 08/19/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign and the 11-7 oncoming nurse failed to sign;-On 08/20/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign and the 11-7 oncoming nurse failed to sign;-On 08/21/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign and the 11-7 oncoming nurse failed to sign;-On 08/22/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign and the 11-7 oncoming nurse failed to sign;-On 08/23/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/26/25, 7-3 shift, the oncoming and off going nurse failed to sign;-On 08/27/25, 7-3 shift, the oncoming and off going nurse failed to sign;-On 08/28/25, 7-3 shift, the oncoming and off going nurse failed to sign, and 3-11 shift, the oncoming and off going nurse failed to sign;-On 08/29/25, 3-11 shift, the oncoming and off going nurse failed to sign, and the 11-7 oncoming nurse failed to sign;-On 08/30/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign and the 11-7 oncoming nurse failed to sign;-On 08/31/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign.Review of the September 2025 C/D Nurse Controlled Drugs-Count Record showed staff failed to sign a reconciliation count completed on the following dates and times:-On 09/04/25, 11-7 shift, the off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign;-On 09/05/25, 3-11 shift, the off going nurse failed to sign, and the 11-7 oncoming nurse failed to sign;-On 09/06/25, 11-7 shift, the off going nurse, 3-11 shift, the oncoming and off going nurse failed to sign, and the 11-7 oncoming nurse failed to sign;-On 09/07/25, no nurses signed the count;-On 09/08/25, 11-7 shift, the off going nurse, 7-3 shift, the oncoming and off going nurse failed to sign, 3-11 shift, the oncoming and off going nurse failed to sign, and the 11-7 oncoming nurse failed to sign;-On 09/09/25, 3-11 shift, the oncoming and off going nurse failed to sign.During an interview on 09/10/25, at 10:00 A.M., LPN D said not all nurses were signing the C/D hall nurse cart narcotic book.Observation on 09/10/25, at 9:50 A.M., of the C/D hall nurse cart narcotic book showed RN C showed the surveyor the C/D hall-controlled medication book which contained several blank spaces where nurses had failed to sign in September 2025 at the change of shift count.3. During an interview on 09/10/25, at 4:38 P.M., LPN A said he/she sometimes forgot to sign the control count sheet at the beginning and end of each shift, but he/she did count the controlled medications.During an interview on 09/10/25, at 2:30 P.M., the Long-Term Care (LTC) Case Manager, a RN, said the off going and oncoming nurse or CMT should count all narcotics/controlled medications, and both staff should sign the narcotic count record.During an interview 09/10/25, at 10:10 A.M., the Director of Nursing (DON) said the following: -The oncoming and off going nurses should count and sign the controlled medication sheet and the change of each shift;-He/she thought the nurses were counting but were just forgetting to sign the sheet.During an interview on 09/10/25, at 5:42 P.M., the Administrator said the off going and oncoming nurses and/or CMTs should count all the controlled medications at the beginning and end of each shift, and both should sign the narcotic count record.

Based on observation, interview, and record review, the facility failed to ensure all resident medications were secure, when a staff member failed to lock 1 of 7 carts containing resident medications while out of his/her line of sight. The facility census was 91.Review of the facility policy titled, Storage of Medication, undated showed the following:-All medications for residents must be stored at or near the nurses' station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts;-All mobile medication carts must be under visual control of the staff at all times when not stored safely and securely. Carts must be either in a locked room of otherwise made immobile;-All controlled substances must be stored under double lock and key;-An unattended medication cart must remain locked at all times. In the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it or secured in a locked medication room.1. Observation on 09/05/25, at 9:04 A.M., of Certified Medication Technician (CMT) K showed the following:-CMT K stood at a medication cart preparing medications. The medication cart was located on the B resident hall, midway down the hall;-CMT K prepared a resident's medications while standing at the B hall medication cart;-The CMT placed the medications in a medicine cup-The CMT pressed in slightly on the medication cart lock. The lock was protruding approximately one inch from the front of the cart with a visible red dot on the side of the lock;-The CMT walked away from the cart, down the hall, and into a resident's room, out of sight line of the cart;-When the CMT returned to the medication cart, he/she pulled the lock out with his/her fingers, without the use of a key, and opened the cart drawers to prepare another resident's medications;-After preparing the medications and placing in a medication cup the CMT again pressed in slightly on the medication cart lock. The lock was protruding approximately one inch from the front of the cart with a visible red dot on the side of the lock;-The CMT walked away from the cart, down the hall, and into the resident's room, out of line of sight of the cart;-The CMT checked the resident's blood pressure and administered the resident medications and offered the resident a drink of water;-When the CMT returned to the cart, he/she pulled the lock with his/her fingers, without the use of a key and opened the cart drawers.During an interview on 09/05/25, at 9:15 A.M., CMT K said the following:-The B hall medication cart did not lock properly;-He/she did not compress the lock entirely, because sometimes the lock would stick and when that occurred, he/she was unable to access the resident medications;-He/she was able to access the medications without the use of a key, by pulling on the lock;-When he/she started working for the facility other CMTs told him/her not to lock the B hall medication cart due to the cart lock sticking.During an interview on 09/05/25, at 9:25 A.M., CMT L said the following:-If the B hall cart drawers were not lined up correctly, he/she was unable to push the cart lock in all the way;-He/she had not spoken to anyone about the issue;-He/she had a similar problem with the C Hall medication cart as it was hard for him/her to get the medication cart drawers shut and he/she had to ensure all the drawers were lined up in order to lock the car;-He/she did not leave the unlocked cart unattended.During an interview on 09/10/25, at 2:30 P.M., the Long-Term Care (LTC) Case Manager, a Registered Nurse (RN), said the nurse and/or CMT should keep the medication carts locked when not in use or if the cart was not in the staff member's direct line of sight.During an interview on 09/09/25, at 2:13 P.M., the Director of Nursing said the following:-He/she was not aware staff were leaving B hall medication cart unlocked or that the lock would stick;-If staff were going out of line of sight of the medication cart, then the cart needed to be fully locked where it required a key to access, and the narcotic drawer should be locked as well.During an interview on 09/10/25, at 5:42 P.M., the Administrator said nurses/CMTs should keep their medication cart locked if not in line of their sight.

Based on observation, interview, and record review, the facility failed to ensure food was stored in a manner to protect the food from possible contamination when staff failed to store food in sealed containers and failed to dispose of expired food items. The facility had a census of 91 residents.Review of the facility's policy titled, Safe Food Handling, dated April 2011, showed the following:-Food items are to be labeled and dated when removed from the freezer to be thawed;-No potentially hazardous food should be refrigerated over three days or per state regulation;-All food, including bulk items, should be tightly sealed with an identifying label and date. Review of the facility's policy titled, Receiving and Storage of Food, dated April 2011, showed the following:-The Dining Services Manager (DM) is responsible for receiving and storing food and nonfood items;-Follow the rule of First in, First Out.Review of the Missouri Food Code, published 2013, regarding refrigerator food storage, showed the following:-Refrigerated, ready-to-eat, potentially hazardous food, prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of forty-one degrees Fahrenheit (41F) or less for a maximum of seven days or when held at a temperature of forty-five degrees Fahrenheit (45 F) or less for a maximum of four days.-Refrigerated, ready-to-eat, potentially hazardous food, prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified:-The day the original container is opened in the food establishment shall be counted as day 1;-The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety;-Food shall be protected from cross contamination by storing the food in packages, covered containers, or wrappings.1. Observation on 09/03/25, at 9:38 A.M., of the walk-in refrigerator in the kitchen showed the following:-Three slices of bread in a bag, twisted, and folded over with best by date 08/07/25;-An icing package, thawed, with directions that read to store at 0 degrees and thaw overnight in fridge. The package had no date noted;-Orange sauce in a reusable container, covered in saran wrap, with no label or date;-Chopped tomato and onion in a metal bowl covered with saran wrap with no date;-Ham in a metal pan, wrapped in saran wrap, dated 08/28 and use by 08/31.Observation on 09/05/25, at 12:00 P.M., of the double-door refrigerator in the kitchen showed the following:-Two open cartons of prune juice marked 06/17/25;-Four open cartons of grape juice, marked 08/12/25;-One cup of macaroni salad, covered in saran wrap, at back of fridge tilted over with no date. Observation on 09/05/25, at 12:09 A.M., of the walk-in refrigerator in the kitchen showed the following:-A brown liquid in a reusable container, covered in saran wrap, with no label or date;-Two plastic bins with raw chicken in plastic bags, on the bottom shelf, with no date;-Sliced cheese wrapped in saran wrap, dated 08/25, and use by 08/28;-Sliced cheese wrapped in saran wrap, dated 08/28 and use by 08/31;-Two 1 quart jugs of half and half creamer with expiration date 09/02/25.Observation on 09/09/25, at 10:44 A.M., of the activities area refrigerator showed the following:-On the outside of the refrigerator, signage indicated all items must be covered and labeled with name and date;-An open bottle of apple juice with no open date;-An open bottle of sparkling cider with no open date;-Ten individual servings of salad dressing with no label or open date;-An open bottle of mustard with expiration date of 01/01/25;-An open bag of flour, folded open, with no date;-An open large bottle of flavored creamer with no date.Observation on 09/10/25, at 1:00 P.M., of the double-door refrigerator in the kitchen showed the following:-An open container of cottage cheese with no open date;-Two open cartons of prune juice marked 06/17/25;-Three open cartons of grape juice, marked 08/12/25;-Two pitchers of an unknown liquid with no date;-One pitcher of lemonade with no date;-Three pitchers of orange juice with no date;-Three pitchers of tea with no date;-An open carton of orange juice concentrate with no open date;-An open carton of cranberry juice marked 08/12/25.During an interview on 09/09/25, at 11:36 A.M., the Activities Director (AD) said the following:-The activity staff checked the refrigerator periodically for expired items;-Staff use the manufacturer expiration date on the item to determine which items need to be disposed of, not the date the item is opened;-The DM also checked the refrigerator and records the temperatures;-Only items used for resident use were stored in the refrigerator.During an interview on 09/10/25, at 1:09 P.M., the Dietary Aide (DA) H said the following:-Opened items need to be labeled with the date the item is opened and the dispose date;-Open items can be kept for five days;-Cooks check the refrigerators daily for expired items;-He/she was unsure who recorded refrigerator temperatures.During an interview on 09/10/25, at 1:14 P.M., Dietary Aide (DA) said the following:-Opened items are dated with the day open, and the dispose date which is three days out;-The DA's check the refrigerators in the kitchen daily for expired items, and the cooks oversee;-Any expired item is thrown out;-The refrigerators in the kitchen are temped daily;-DA I believed activity staff temps the refrigerator in the activities room. During an interview on 09/10/25, at 1:19 P.M., DA J said the following:-All open items are dated, and kept for three days;-The cooks clean out the refrigerator daily and throw out all expired items;-The refrigerators are checked daily;-Activity staff are responsible for cleaning out the refrigerator in the activity room, but the DM temps the refrigerator daily.During an interview on 09/10/25, at 1:30 P.M., the DM said the following:-All items placed in the refrigerators should be covered securely and dated;-Items should be marked with the open date, and a dispose date which is three days after the open date;-Dry goods should be dated;-The DM pulls expired items from the refrigerators in the kitchen on Monday, Tuesday, and Friday;-All open juices should be disposed of after three days;-Coffee and tea is made fresh every shift;-Items placed in the refrigerator to thaw are used within the week;-Activity staff is responsible for the refrigerator in the activity room;-Activity staff should be labeling all items, disposing of expired items and temping the refrigerator and logging the temp daily. During an interview on 09/10/25, at 5:43 P.M., the Administrator said the following:-The DM was responsible for overseeing food storage and disposal of expired food items;-The rules that applied to the refrigerators in the kitchen, should also apply to the refrigerator in the activity room;-The DM iwas responsible for checking the activity room refrigerator and temping it as required.

Based on record review and interview, the facility failed to implement a complaint infection prevention and control program when the home failed to have processes in place to ensure each resident was screened annually for tuberculosis when staff failed to screen four residents (Residents #1, #42, #22, and #30) and when the facility failed to review and update their infection prevention and control program policies and procedures manual annually as required. The facility census was 91. 1. Record review of the facility Infection Prevention and Control Policy (IPCP) manual showed the policy dates in the manual included 04/23/20, 08/11/20, 05/15/23, and 05/18/23. There was no documentation included in the manual showing staff reviewed and revised the manual on an annual basis. During an interview on 09/10/25, at 10:45 A.M., the Registered Nurse/Quality Assurance Consultant said he/she was not aware of the infection control policies and procedures or the manual being reviewed or updated annually. He/she is not doing an annual review During an interview on 09/10/25, at 10:40 A.M, the Director of Nursing (DON) said he/she does not do an annual review of the IPCP policies and procedures, but the Administrator may review it. During an interview on 09/10/25, at 10:43 A.M, the Administrator said he/she does not do an annual review of the infection prevention and control policies and procedures. 2. Review of the facility's policy entitled Tuberculosis Control, undated, showed the following:-Annual skin tests for residents with documented results under 10 millimeters (mm) are not required, nor are annual chest x-rays for resident with documented skin test results greater than 10 mm;-Staff person must be constantly vigilant for signs and symptoms of TB in residents, and obtain a chest x-ray and sputum specimens should such signs and symptoms appear;-In addition, residents are to be evaluated, at least annually, to assure absence of signs and symptoms for TB disease. 3. Review of Resident #22's face sheet (gives basic profile information at a glance) showed the following:-admission date of 02/24/22;-Diagnoses included chronic obstructive pulmonary disease (COPD-a lung disease that causes airflow obstruction and breathing problems). Review of the resident's preventative health records showed the following:-Annual TB screening form completed on 02/18/24 indicating no TB symptoms, no current/recent respiratory infection;-No annual TB screening form completed or documented for 2025. During an interview on 09/10/25, at 4:56 P.M., the DON said the resident did not have documentation in his/her records regarding the annual TB screening form being completed in 2025. 4. Review of Resident #30's face sheet showed an admission date of 12/05/15. Review of the resident's Physician's Order Sheet (POS), current as of 9/10/25, showed an order, dated 08/07/17, for permission to administer 2 step PPD upon admission and then TB screen annually. Review of the resident's preventative care records showed the following:-TB screening form completed on 05/01/24, indicating no TB symptoms, no current/recent respiratory infection, no further action needed at this time;-No annual TB screening form completed or documented for 2025. During an interview on 09/10/25, at 4:56 P.M., the DON said the resident did not have documentation in his/her records regarding the annual TB screening form being completed in 2025. 5. Review of Resident #1's face sheet showed an admission date of 06/12/22. Review of the resident's POS, current as of 09/10/25, showed an order, dated 06/11/22, for permission to administer 2 step PPD (purified protein derivative, a substance used in a skin test to determine if a person has been infected with Mycobacterium tuberculosis, the bacteria that causes TB or resident to be screened annually for tuberculosis) upon admission and then TB screen annually. Review of the resident's preventative health records showed staff did not document information pertaining to TB annual screening for 2023, 2024, and 2025. During an interview on 09/11/25, at 4:56 P.M., the DON said the resident did not have documentation in his/her records regarding annual TB screenings being administered. 6. Review of Resident #42's face sheet showed admission date of 06/13/22.-Diagnoses included Huntington's disease, protein-calorie malnutrition, and anxiety. Review of the resident's POS, current as of 9/10/25, showed an order, dated 06/13/22, Review of the resident's preventative care records showed the following:-An annual screening was complete on 06/18/23;-Staff did not document information pertaining to TB annual screening for 2024 and 2025. During an interview on 09/11/25, at 4:56 P.M., DON said the resident did not have documentation in his/her records regarding annual TB screenings being administered in 2024 or 2025. 7. During an interview on 09/10/25, at 4:38 P.M., Licensed Practical Nurse (LPN) A said the registered nurses (RN) complete the annual TB screening. During an interview on 09/10/25, at 4:41 P.M., RN B said the following:-The RN on the floor completed the annual TB screening;-The Treatment Administration Record (TAR) alerts the RN that a screening is due. During an interview on 09/10/25, at 4:56 P.M., the DON said the following:-All residents should have a physician's order for an annual TB screening;-Resident TB screenings are completed by an RN;-The TAR triggers nurses to conduct the screening. During an interview on 09/10/25, at 5:43, the Administrator said RN's are responsible for completing annual resident TB screenings.

Based on observation, interview, and record review, the facility failed to have a process in place for periodic bed rail safety checks, to include measurements of the bed frame and bed rails for risk of entrapment, for seven residents (Residents #22, #30, #91, #1, #5, #8, and #21) out of a sample of 24 residents. The facility census was 91.Review of the facility policy, Bed Rails, undated, showed the following information:-Prior to use of bed rails the facility should complete the Bed Rail Observation including the following observation detail, clinical assessment, alternatives attempted prior to bed rail implementation, bed rail details, assessment of potential entrapment zones, review the risk and benefits with resident and resident representative, obtain informed consent with resident and/or resident representative signature, and obtain physician order for medical symptom assessed requiring bed rail use;-Develop a care plan that outlines the medical factors necessitating bed rails and an explanation of how the use of a bed rail is intended to treat the specific resident's condition;-Staff will conduct regular inspections of all bedframes, mattresses, and bed rails, to identify areas of possible entrapment. Review of the Owner's Operator and Maintenance Manual for the IVC bed series, dated 2007, showed the following:-A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety;-Reassess the need for using bed rails on a frequent, regular basis. 1. Review of Resident #22's face sheet (gives basic profile information at a glance) showed the following:-admission date of 02/24/22;-Diagnoses included chronic obstructive pulmonary disease (COPD-a lung disease that causes airflow obstruction and breathing problems), chronic kidney disease (condition where the kidneys lose their ability to filter waste products from the blood), anxiety (mental health condition that causes excessive worry, fear, and nervousness), and depression (mental health condition that causes persistent feelings of sadness, loss of interest, and other symptoms that can significantly impact daily life). Review showed a bed rail assessment and consent signed by the resident on 04/22/22. Review of the resident's Physician Order Sheet (POS), current as of 09/10/25, showed an order, dated 11/11/22, for bilateral half side rails for repositioning and transfers. Review of the resident's comprehensive Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/05/25, showed the following:-Moderate cognitive impairment;-Substantial/maximal assistance for shower/bathing, lower body dressing, putting on and taking off footwear, rolling left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer;-Partial/moderate assistance for upper body dressing, personal hygiene, and sit to lying. Review of the resident's care plan, revised 06/23/25, showed the following:-Required one person assist for all activities of daily living (ADL – dressing, toileting, grooming, etc.) due to weakness and disease process;-Bilateral half side rails for repositioning and transfers. Review of the resident and facility records showed staff did not provide documentation of periodic assessment and measurements of the rails to ensure they placed appropriately and were not loose. Observation on 09/03/25, at 11:00 A.M., showed the following;-Bilateral half size side rails in the upright position on the resident's bed;-Right bed rail was loose to touch and wiggled from top to bottom with twice as much movement at the bottom of the rail near the middle of the bed compared to the movement at the top of the rail near the head of the bed. Observation on 09/08/25, at 11:40 A.M., showed the right siderail loose. It moved top to bottom with it moving twice as much at the bottom of the rail near the middle of the bed compared to the movement at the top of the rail near the head of the bed. It also pushed all the way in to touch the mattress on the bed. Observation on 09/09/25, at 11:22 A.M., showed the following:-Resident resting in bed awake;-Right side rail with a two to three inch gap moving away from mattress when touched;-Right side rail also with an approximate six inch back and forth, up and down play from the top of the rail (head of the bed) to the bottom of the rail (middle of the bed). During an interview on 09/10/25, at 4:56 P.M., the Director of Nursing (DON) said the resident used the side rails to set on the side of the bed. 2. Review of Resident #30's face sheet showed the following:-admission date of 12/05/15;-Diagnoses included Down Syndrome (a genetic disorder that causes physical, ability to think and understand, and developmental disabilities), chronic kidney disease, anxiety, depression, and epilepsy (seizures). Review showed a bed rail assessment and verbal consent was provided by the resident's power of attorney on 08/03/21 via telephone due to COVID-19. Review of the resident's POS, current as of 09/10/25, showed an order, dated 11/11/22, for half side rails for purpose of assisting with repositioning/transferring. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Substantial/maximal assistance for toileting hygiene, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed;-Dependent for lower body dressing, putting on and taking off footwear, chair/bed-to-chair transfer, tub/shower transfer;-Partial/moderate assistance for rolling left and right. Review of the resident's care plan, revised 06/24/25, showed the following:-Required one or two persons assist for all ADLs due to weakness and disease process;-Half side rails for purpose of assisting with repositioning and transfers;-During seizure activity, ensure that the head is protected to prevent injury and do not attempt to restrain the resident;-If the seizure occurs in bed remove all pillows and ensure the side rails are raised bilaterally. Review of the resident and facility records showed staff did not provide documentation of periodic assessment and measurements of the rails to ensure they placed appropriately and were not loose. Observation on 09/08/25, at 10:14 A.M., showed staff provided peri care to the resident. The resident unable to assist staff with rolling in bed. Observation on 09/09/25, at 11:16 A.M., showed the resident's left bed rail had an approximate four-inch gap at the bottom side of the rail (middle of the bed) that moved back and forth from the rail to the mattress. The left bed rail also moved approximately two to three inches up and down lengthwise to the bed. During an interview on 09/09/25, at 10:51 A.M., Certified Nurse Aide (CAN) N said the following:-The resident was not able to use his/her side rails;-The resident was moving a lot a few years back, but he/she cannot pull himself/herself to his/her side by himself/herself anymore;-He/she thought the facility kept the bed rails on the resident's bed for the safety of rolling the resident during care. During an interview on 09/09/25, at 1:42 P.M., the Long-Term Care Case Manager (LTC CM) said he/she thought the resident had his/her bed rails for comfort and repositioning in bed when being changed. During an interview on 09/10/25, at 4:56 P.M., the Director of Nursing (DON) said the resident used the bed rails to hold on to when staff changed him/her. He/she thought the resident could move his/her arms and hands and hold on to the rail. 3. Review of Resident #91's face sheet showed the following:-admission date of 05/24/21;-Diagnoses included Alzheimer's disease (progressive brain disorder that causes memory loss, confusion, and cognitive decline) and anxiety. Review showed a bed rail assessment and consent signed by the resident on 08/06/21. Review of the resident's (POS, current as of 09/10/25, showed an order, dated 11/11/22, for half side rails bilaterally for purpose of assisting with repositioning/transferring. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Substantial/maximal assistance for toileting hygiene, shower/bathing, lower body dressing, putting on and taking off footwear, going from sit to stand, chair/bed-to/chair transfer, tub/shower transfer, and toilet transfer;-Partial/moderated assistance for upper body dressing, personal hygiene, sit to lying, and lying to sitting on the side of the bed;-Supervision or touching assistance for rolling left and right. Review of the resident's care plan, dated 08/02/21, showed the following:-Required one to two persons assist for all ADLs due to weakness and disease process;-Half side rails bilaterally for turning, repositioning, and transferring. Review of the resident and facility records showed staff did not provide documentation of periodic assessment and measurements of the rails to ensure they placed appropriately and were not loose. During an observation and interview on 09/03/25, at 10:00 A.M., the resident said the right bed rail was loose and had been loose for three to four months. He/she told staff the bed rail is loose. He/she did not feel like the bed rail is safe for him/her to use. Observations showed the right bed rail wiggled up and down from the top of the rail (head of the bed) to the bottom of the rail (middle of the bed). During an interview and observation on 09/9/25, at 11:22 A.M., the resident said the following:-His/her right bed rail fell to the floor yesterday and he/she was glad his/her hand was not in it because he/she felt like he/she would have been injured;-The resident's right bed rail had approximately a five-inch movement back and forth from the top of the rail (at the head of the bed) to the bottom of the rail (at the middle of the bed). During an interview on 09/10/25, at 10:51 A.M., CNA N said the resident used his/her bed rails for rolling. During an interview on 09/10/25, at 4:56 P.M., the DON said the resident can hold on to the rail and position himself/herself in bed. 4. Review of Resident #1's face sheet showed the following:-admission date of 06/12/22;-Diagnoses included senile degeneration of the brain and anxiety. Review showed a bed rail assessment and consent signed by the resident on 06/22/22. Review of the resident's POS, current as of 09/10/25, showed an order, dated 11/14/22, for bilateral half side rails for transfers and repositioning. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Cognitively impaired;-Substantial/maximal assistance with toileting;-Substantial/maximal assistance with personal hygiene;-Substantial/maximal assistance with lying to sitting;-Dependent with bed to chair transfer. Review of the resident's care plan, dated 07/07/25, showed the following:-Required one person assist for all ADLs due to weakness and disease process;-Half bilateral side rails for transfers and repositioning. Review of the resident and facility records showed staff did not provide documentation of periodic assessment and measurements of the rails to ensure they placed appropriately and were not loose. Observation on 09/05/25, at 10:36 A.M. showed the following;-Bilateral half size side rails in the upright position;-Resident in bed with hand gripped on rail and rail leaning over at approximately 120 degrees. Observation on 09/09/25, at 10:18 A.M., showed the following:-Resident rested in bed with eyes closed;-Both side rails loose to the touch. During an interview on 09/10/25, at 4:56 P.M., the DON said the resident had used to use the rail to assist with getting up. 5. Review of Resident #5's face sheet, showed the following:-readmit date of 12/31/24;-Diagnoses included dementia without behavioral disturbance, major depressive disorder, and anxiety disorder. Review showed a bed rail assessment and consent signed by the resident on 10/27/23. Review of the resident's POS, current as of 09/10/25, showed and order, dated 01/26/24, for half side rails bilaterally for assistance with bed mobility and transfers. Review of the resident's quarterly MDS, dated [DATE], shows the following:-Cognitively impaired;- Dependent with toileting;- Substantial/maximal assistance with personal hygiene;- Dependent with lying to sitting;-Dependent with bed to chair transfer. Review of the resident's care plan, dated 06/23/25, showed the following:-Resident required assist of one to two staff for all ADLs due to weakness and lack of mobility;-Resident would like half side rails bilaterally for purpose of assistance with bed mobility and transfers. Review of the resident and facility records showed staff did not provide documentation of periodic assessment and measurements of the rails to ensure they placed appropriately and were not loose. 6. Review of Resident #8's face sheet showed the following information:-readmission date of 08/21/22;-Diagnoses included coagulation defect (impairment to body's ability to form blood clots), major depression disorder, and anxiety. Review showed a bed rail assessment and consent completed on 11/07/23 and signed by the resident on 12/24/24. Review of the resident's POS, current as of 09/10/25, showed and order, dated 11/07/23, for half side rails right and left for purpose of bed mobility per resident request. Review of the resident's quarterly MDS, dated [DATE], showed the following:- Cognitively intact;- Substantial/maximal assistance with toileting;- Partial/moderate assistance with personal hygiene;- Partial/moderate assistance with lying to sitting;-Dependent with bed to chair transfer. Review of the resident's care plan, dated 08/07/25, showed the following:-Resident required assist of one to two staff for all ADL due to weakness and disease process;-Resident required bilateral half rails for purpose of assistance with bed mobility. Review of the resident and facility records showed staff did not provide documentation of periodic assessment and measurements of the rails to ensure they placed appropriately and were not loose. Observation and interview with resident on 09/09/25, at 10:19 A.M., showed the following:-Both side rails loose to the touch;-Resident used the rails to assist with positioning. 7. Record review of Resident #21's face sheet showed the following information:-readmit date of 11/26/24;-Diagnoses include cerebral infarction due to occlusion or stenosis of small artery (a stroke caused by a blockage or narrowing of a small blood vessel in the brain), amputation, hemiplegia (paralysis to one side of the body), and seizures. Review showed a bed rail assessment and consent completed on 08/27/21 and signed by the resident representative on 08/30/21. Review of the resident's POS, current as of 09/10/25, showed and order, dated 04/02/25, for half side rails bilaterally for assistance with bed mobility and transfers. Review of the resident's care plan, dated 07/30/25, showed the following:-Resident has potential for seizure activity;-If the seizure occurred in bed remove all pillows and ensure the side rails are raised bilaterally. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-Cognitively impaired;-Dependent with toileting;-Dependent with personal hygiene;-Dependent with lying to sitting;-Dependent with bed to chair transfer. Review of the resident and facility records showed staff did not provide documentation of periodic assessment and measurements of the rails to ensure they placed appropriately and were not loose. Observation on 09/09/25, at 10:16 A.M., showed the following:-Resident resting in bed;-Both rails secure to the touch. During an interview on 9/09/25, at 10:16 A.M., Nursing Assistant (NA) E said the resident did not use the bed rails for positioning, as they are in place for safety if the resident has seizure. During an interview on 09/09/25, at 1:42 P.M., LTC CM said he/she believed the resident had bed rails to prevent the resident from falling out of bed while being changed. During an interview on 09/10/25, at 4:56 P.M., the DON said the resident can use his/her rail with his/her one arm. 8. During an interview on 09/09/25. at 10:31 A.M., CNA M said the following:-He/she was not aware of any bed rails being loose;-If he/she was aware of a loose bed rail he/she would verbally notify the charge nurse and the maintenance staff;-If the maintenance department determined that a bed rail needed to be replaced, they would fill out a form and provide it to the nurse for notification that the bed rail was looked at. The nurse gives the notification to the DON or Assistant Director of Nursing (ADON), so they will know to order a new bed rail;-Bed rail assessments are completed one time per week, but he/she did not know who was responsible for completing them;-The older black bed rails like to come loose;-The main maintenance staff who does the work inside the facility does the maintenance on the bed rails;-He/she was unsure what the facility policy or process is for checking bed rails was since maintenance staff was responsible for that;-When bed rails are loose, it scares the residents. During an interview on 09/09/25, at 10:51 A.M., CNA N said the following:-He/she was not aware of any bed rails being loose;-If he/she was aware of a loose bed rail, he/she would notify the maintenance staff or the housekeeping supervisor;-The nurses and therapy department check bed rails, but he/she was not sure how often. They check for loose and broken rails and to see if they move up and down;-He/she was unsure what the facility policy or process is for checking bed rails since maintenance staff is responsible for that. During an interview on 09/10/25, at 8:56 A.M., Registered Nurse (RN) C said the following:-He/she was not aware of any loose bed rails;-Staff can notify the charge nurse or maintenance if they observe a loose bed rail;-He/she was unsure if a protocol is in place to regularly check the bed rails for safety issues. During an interview on 09/09/25, at 1:42 P.M., LTC CM said the following: -He/she reviewed the bed rail assessment with the resident and the family;-Maintenance provided the measurement numbers to LTC CM to enter into the form;-LTC CM obtained the order from the physician and added the information to the care plan;-LTC CM is not aware of any procedures in place to regularly check the rails. During an interview on 09/09/25, at 1:56 P.M., the Maintenance Worker (MW) said the following:-The LTC CM notified him/her which residents need a bed rail;-Measurements are obtained during installation, and he/she provided the measurements to the LTC CM;-Staff will verbally notify MW if a resident has a loose rail;-MW regularly tightens bed rails as they often come loose from residents pulling on the rails;-MW does not document which rails he/she tightens;-There is no regular assessment or maintenance schedule. During an interview on 09/10/25, at 4:56 P.M., the DON said the following:-The side rail assessment was only completed once;-The LTC CM completed the side rail assessment with the resident and/or family;-Maintenance took measurements and installed the side rails;-Staff should try to tighten loose side rails or notify maintenance;-Maintenance checks side rails weekly. During an interview on 09/10/25, at 5:43 P.M., the Administrator said the following:-He/she was not aware of any additional assessments after the initial assessment is complete;-Maintenance checks the rails once a week;-He/she was unsure if the maintenance checks are documented;-Staff notify maintenance if a side rail is loose.

Based on interview and record review, the facility failed to provide care per standards of practice and care plan when staff failed to complete accurate and timely skin assessment for two residents (Resident #27 and #23) with identified skin concerns and skin treatments in place. The facility census was 91. Review of facility policy titled, Wound Care and Treatment, undated, showed the following:-It is the purpose of the facility to prevent and treat all wounds;-On-going skin assessment with weekly documentation of status. Review showed the facility did not provide a policy regarding skin assessments. 1. Review of Resident #27's face sheet (give basic profile information at a glance) showed the following information:-admission date of 03/25/25;-Diagnoses included dementia (progressive decline in memory, thinking, reasoning, and judgment), spondylolisthesis (a condition where one bone in the spine slips forward over the bone below it) anxiety (mental health condition that causes excessive worry, fear, and nervousness), type 2 diabetes mellitus (the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), hypertension (high blood pressure), heart failure, chronic kidney disease, and cellulitis, unspecified (a bacterial skin infection that affects the deeper layers of the skin). Review of the resident's care plan, dated 03/31/25, showed the following:-Skin will remain intact;-Assess for presence of risk factors and treat, reduce, eliminate risk factors to extent possible;-Report any signs of skin breakdown (sore, tender, read, or broken areas). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/01/25, showed the following information:-Resident was cognitively intact;-Application of ointments/medications other than to feet. Review of the resident's progress note, dated 07/01/25, showed the following:-Resident bilateral (both sides) lower extremities weeping (with drainage) slightly, showered self in personal shower and re-wrapped bilateral lower extremities and placed tubi-grips (compression bandage) on;-Staff notified provider of weeping;-No new orders at this time. Review of the resident's progress note, dated 07/02/25, showed the following:-A few scratches on outer right forearm;-Tubi-grip change on right lower leg due to weeping clear fluid;-Encouraged to get legs elevated. Review of the resident's progress note, dated 07/03/25, showed the following:-New order for tubi-grips to remain on in A.M. and off in P.M.;-May have gauze to bilateral lower extremities as needed if has weeping edema (swelling). Review of the resident's Physician Order Sheet (POS), current as of 09/10/25, showed an order, dated 07/03/25, for may have gauze to bilateral lower extremities as needed if resident has weeping edema. Review of resident's July 2025 Weekly Skin Assessments showed a skin assessment, dated 07/04/25, showed staff noted skin intact (excluding feet), with no interventions or treatments. (Staff did not document regarding the bilateral lower extremity weeping or dressing ordered.) Review of resident's July 2025 Weekly Skin Assessments, dated 07/11/25, showed staff noted skin intact (excluding feet), with no interventions and treatments in place. (Staff did not document regarding the bilateral lower extremity weeping or dressing ordered.) Review of the resident's progress note's, dated 07/13/25, showed the following:-Observed resident's bilateral lower extremities which are swollen and red;-The left leg is weeping yellow fluid;-The left leg also has an open area where resident scraped on something in his/her room. It is on the anterior (front) shin, raw, and larger than a quarter;-Resident was using soaker pads to wrap the left leg every two hours and he/she has filled a white large trash sack half full of soaker pads used during this night;-Resident is on torsemide (a medication used to remove excess water and salt from the body) 3 time a week for a week and then daily, 10 milligrams (mg);-Resident has some clear liquid weeping from right upper leg and left lower leg;-Placed absorbent bandage and wrapped in kerlix (stretch, self-adhesive bandage);-Resident has bed pad wrapped around his/her leg;-Kerlix has held up this shift;-Resident continuously weeping to bilateral lower extremities;-Staff called nurse practitioner to update. Review of the resident's Physician Order Sheet (POS), current as of 09/10/25, showed, showed the following: -An order, dated 07/15/25, to check resident room for extra wound supply and check resident for putting his/her own dressing on twice daily for safety measures;-An order, dated 07/15/25, for treatment order for left inner thigh, to cover with band aid and piece of gauze two times per day and as needed for weeping;-An order, dated 07/15/25, for treatment order for right ankle band aid and piece of gauze two times per day and as needed;-Order, dated 07/15/25, for treatment order for left shin apply two ABD pads (highly absorbent wound dressing) ace wrap lightly. Review of the resident's July 2025 Weekly Skin Assessments showed an assessment, dated 07/18/25. Staff noted skin intact (excluding feet), no interventions and treatments. (Staff did not document regarding the bilateral lower extremity weeping or dressing ordered.) Review of the resident's progress notes, dated 07/21/25 and 07/23/25, showed the resident continued antibiotic for legs with no adverse effects. Review of the resident's progress note, dated 07/24/25, showed the following:-No adverse reaction from antibiotic/lower legs;-Leg is wrapped and resident refused to let nurse do anything with it. Review of the resident's progress note, dated 07/26/25, showed the following:-Treatments completed;-Resident did have blister on right lower inner calf;-Area on left shin open;-Excess treatment supplies removed from room. Review of the resident's POS, current as of 09/10/25, showed a new order, dated 07/26/25, for treatment order for left inner thigh, to cover with band aid and piece of gauze two times per day and as needed for weeping. Review of the resident's progress note, dated 07/29/25, showed the following:-Resident alerted this nurse to having what he/she described as a blister to his/her inner right calf/ankle area;-Resident stated that he/she had already cleansed and bandaged the area;-Area noted to be wrapped with washcloth and tape securing with writing on tape describing wound;-This nurse removed resident's bandage and observed an area that was approximately the size of a half dollar with no skin intact and scant sanguineous (containing blood) drainage noted;-New order placed for daily treatment;-Healthcare provider registered nurse (RN) in facility and will be updated. Review of the resident's POS, current as of 09/10/25, showed, showed an order, dated 07/29/25, to cleanse area to right inner ankle/calf with wound cleanser, pat dry, apply xeroform (specialized dressing) and cover with gauze, wrap with ace wrap daily, and as needed until resolved. Review of the resident's July 2025 Weekly Skin Assessments showed staff did not document complete skin assessment completed between 07/19/25 and 07/31/25. Review of the resident's August 2025 Weekly Skin Assessments showed the following:-On 08/01/25, staff completed a skin assessment. Staff noted skin intact (excluding feet), with no interventions and no treatments. (Staff did not address the current identified areas and current ordered treatments.);-On 08/08/25, staff completed a skin assessment. Staff noted skin intact (excluding feet), with no interventions and not. (Staff did not address the current identified areas and current ordered treatments.);On 08/15/25, staff completed a skin assessment. Staff noted skin intact (excluding feet) with no interventions and no treatments. (Staff did not address the current identified areas and current ordered treatments.) Review of the resident's progress note, dated 08/19/25, showed the following:-Resident approached this nurse this A.M. requesting that her wraps be cut off to shower;-Bilateral lower extremities noted to be wrapped tightly with kerlix and wrapped with paper tape;-This nurse noted edema proximal and distal to wraps. Resident stated, yea, that's my fault indicating that she wrapped her legs. Tubi-grips noted to be off at that time too;-Education provided as to not be doing the treatment him/herself and to allow nursing staff to do treatments;-Asked where supplies were coming from, resident acknowledged and shrugged his/her shoulders;-This nurse informed resident of needing to perform bilateral lower extremity treatment. Review of weekly skin assessments for August 2025 showed the following:-On 08/22/25, staff completed a skin assessment. Staff noted skin intact (excluding feet), with no interventions and no treatments. (Staff did not address the current identified areas and current ordered treatments.);-On 08/29/25, staff completed a skin assessment. Staff noted skin intact (excluding feet), with no interventions and no treatments. (Staff did not address the current identified areas and current ordered treatments.) Review of the resident's September 2025 Weekly Skin Assessments for September 2025 showed the skin assessment dated [DATE] was still pending on 09/10/25. Review of the resident's progress note, dated 09/09/25, showed the following:-Completed daily dressing change to bilateral lower extremities;-On the left lower leg noted three to four areas that are seeping with clear liquid, about 0.1centimeter (cm) x 0.1 cm size and on the right three areas about 0.1 cm x 0.1 cm with one of them noted brown color scab over no drainage;-Tolerated procedure well and was very cooperative during procedure. During an interview on 09/09/25, at 2:52 P.M., the resident said the following:-He/she has had fluid leaking from both lower extremities since March 2025;-The leaking is not any better or worse;-The black scabbed area was a new because it was not there during the dressing change on 09/08/25. During an interview on 09/09/25, at 10:11 A.M., Licensed Practical Nurse (LPN) D said the following:-The resident came to the facility with his/her leg wounds;-The resident had an order to make sure no dressing supplies were left in his/her room. He/she was not sure who was bring the dressing supplies to the resident;-The resident had taken off some of the dressing that staff apply. During an interview on 09/09/25, at 2:52 P.M., LPN P said the following:-The resident's left lower extremity oozed more than the right lower extremity;-The oozing was on and off. 2. Review of Resident #23's face sheet showed the following information:-readmission date of 11/26/24;-Diagnoses include cerebral infarction due to occlusion or stenosis of small artery (a stroke caused by a blockage or narrowing of a small blood vessel in the brain), amputation, hemiplegia (paralysis to one side of the body), type II diabetes, and seizures. Review of the resident's care plan, dated 06/12/25, showed the following:-Resident at risk for alteration in skin integrity due to decreased mobility and incontinence issues;-Report any signs of skin breakdown (sore, tender, read, or broken areas). Review of the resident's quarterly MDS, dated [DATE], showed the following information:-At risk of developing pressure ulcers;-Applications of ointments/medications other than to feet. Review of the resident's POS, current as of 09/10/25, showed, showed an order, dated 08/15/25, to cleanse area to right shoulder with wound cleanser, pat try, cover with TAO (antibacterial ointment) and telfa (non-stick bandage), secure with tape QOD (every other day). Review of the resident's progress notes, dated 08/23/25, showed the following:-While performing treatment order to cleanse resident's right shoulder, purulent drainage (a thick, cloudy, and often foul-smelling fluid that can exude from an infected wound) noted with some redness around wound;- Slightly warm to touch;-Physician contacted and new orders received Review of the resident's POS, current as of 09/10/25, showed the following:-An order, dated 08/23/25, for amoxicillin (antibiotic), 1 tablet, 500 milligrams, for diagnosis rash and other nonspecific skin eruption;-An order, dated 08/24/25, to cleanse area to right shoulder with would cleanser, pat dry cover with Bactroban (topical antibiotic) and telfa, secure with tape, daily. Review of the resident's medical record showed staff did not document routine skin assessments for the resident for August 2025. Review of the resident's progress notes, dated 09/02/25, showed the following:-Right shoulder had wound measuring 1.2cm x 1.5cm with serous drainage (a clear, watery fluid) noted with some erythema (reddening of the skin) around wound;-Completed amoxicillin for possible wound infection;-Continue treatment order daily. Review of the resident's POS, current as of 09/10/25, showed an order, dated 09/09/25, to cleanse area to right shoulder with wound cleanser, pat dry, cover with Bactroban and cover with a band-aid daily. Review of the resident's medical record showed staff did not document routine skin assessments for the resident the week of 09/01/25 to 09/07/25. 2. During an interview on 09/09/25, at 11:13 A.M., Nursing Assistant (NA) E said the following:-Nurses conduct weekly skin assessments;-NA E was unsure where the skin assessment is documented. During an interview on 09/09/25, at 11:19 A.M., Certified Nursing Assistant (CNA) F said the following:-CNA F believed nurses conducted resident skin assessments;-He/she did not know the frequency of the assessments. During an interview on 09/10/25. at 10:14 A.M., Licensed Practical Nurse (LPN) D said the following:-When he/she was the only nurse assigned to the C/D side, he/she had to oversee approximately 58 residents and was not always able to complete the assigned skin assessments;-The facility had a skin assessment form;-He/she told the Director of Nursing (DON) in the past, when he/she was not able to complete all the assigned resident skin assessments. During an interview on 09/10/25, at 8:56 A.M., Registered Nurse (RN) C said the following;-Nurses conduct weekly skin assessments on all residents;-The skin assessments should be documented in the electronic record. During an interview on 09/09/25, at 1:42 P.M., the Long-Term Care Case Manager (LTC CM) said the following:-Hall nurses conduct weekly skin assessments of residents;-The computer notifies the nurses when to conduct the weekly assessments. During an interview on 09/09/25 at 2:13 P.M., the Director of Nursing (DON) said the following:-Nurses were doing the resident weekly skin assessment and the wound treatments;-The nurses should initial completion of each resident's weekly skin assessments form on the treatment administration record (TAR);-At times, the nurse on duty might get busy and miss a week of completing resident skin assessments. During an interview on 09/10/25, at 4:56 P.M., the DON said the following:-Nurses should be completing skin assessments weekly;-The TAR should prompt the nurses to complete the assessment;-A skin assessment form in the electronic chart should be completed;-Skin assessments might not be complete on busier days;-An audit of skin assessments has not been complete in two months. During an interview on 09/10/25, at 5:43 P.M., the Administrator said nurses should be conducting weekly skin assessments on all residents and documenting their findings.

Based on interview and record review, the facility failed to ensure all allegation of verbal abuse were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services; DHSS) within the required time frame when staff failed to report an allegation of verbal abuse involving one resident (Resident #1) until the following afternoon. The facility census was 99.Review of the facility policy entitled Abuse Prohibition, dated November 2016, showed the following:-It is the purpose of the facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property, and exploitation of any resident;-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. It includes verbal abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm;-Mistreatment means inappropriate treatment or exploitation of a resident;-To assure that everything possible is being done to prevent abuse, the facility has implemented component processes including training, initial and ongoing of employees; prevention of abuse, neglect or mistreatment or any of the types of abuse; identification of suspicious events; protection of residents during an investigation; investigation of all alleged violations; and response and reporting of an abusive situation to necessary agencies. 1. Review of Resident #1's face sheet (gives basic profile information) showed the following:-admission date of 01/09/17;-Diagnoses included anxiety, insomnia, generalized muscle weakness, pain, diarrhea, abnormalities of gait and mobility, and limitation of activities due to disability. Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 05/09/25, showed the following information:-Cognition intact;-Adequate hearing without assistive devices;-Required moderate assist with upper body dressing, personal hygiene, and bed mobility;-Required substantial assist with showers/bathing, sitting/lying;-Dependent on others for assistance with toileting hygiene, lower body dressing and footwear, sit to stand, and transfers. Review of the resident's care plan, updated 05/27/25, showed the following:-Required assistance of 1 to 2 staff for all activities of daily living (ADLs) including transfers and positioning, hygiene, long distance mobility, incontinence care, bathing;-At risk for complications due to use of psychoactive medications to treat/manage depression. During an interview on 06/21/25, at 4:40 P.M., Licensed Practical Nurse (LPN) A said the following:-During the evening on 06/20/25, Certified Medication Technician (CMT) B told LPN A that Certified Nursing Assistant (CNA) C was rude and verbally abusive to the resident;-LPN A said around 11:00 P.M. he/she went to interview the resident, but the resident was asleep. He/she did not notify the Director of Nursing (DON) or Administrator of the allegation at that time, because he/she had not yet interviewed the resident to confirm or clarify the allegation;-LPN A said he/she spoke with the resident that morning, and the resident said CNA C was short with him/her the previous evening;-LPN A said he/she did not inform the DON of the abuse allegation until 06/21/25, when the LPN called the DON to inform her that a State Surveyor was in the building to investigate a reported complaint. Review of DHSS facility records showed no self report received regarding the allegation of abuse. During an interview on 06/21/25, at 4:52 P.M., CMT B said the following: -On 06/20/25, while he/she was doing his/her last medication pass of the shift, CNA C stood in the hallway approximately five feet from the resident's doorway. CNA C was complaining about the resident having diarrhea and having to change him/her again. The CNA loudly said, What the hell does he/she want now?! I don't know how the fuck he/she could have that much diarrhea! -CMT B went into the resident's room to talk to him/her. The resident looked tearful and said CNA C told him/her he/she would just have to wait for assistance;- CMT B said residents could probably hear the CNA's comments;-CMT B said he/she reported the incident to LPN A and believed the nurse would report the allegation to the DON. During an interview on 07/01/25, at 11:15 A.M., CNA D said staff should tell the charge nurse or the DON if they witnessed or were told allegations of abuse, neglect, or rude staff behavior. The facility has two hours to report abuse allegations to the State. During an interview on 07/01/25, at 11:55 A.M., LPN E said any witnessed or reported abuse should be reported to the State within two hours. During an interview on 07/01/25, at 12:02 P.M., Registered Nurse (RN) F said an allegation of abuse should be reported to the State within two hours. During an interview on 07/01/24, at 11:37 A.M., the Activities Director said staff should report any witnessed or verbalized allegation of abuse so the facility management can report the allegation to the State. During an interview on 06/21/25, at 5:04 P.M., the DON said he/she was not notified on the previous evening regarding the abuse allegation. LPN A called the DON to notify him/her that a surveyor was onsite and informed the DON of the allegation at that time. During an interview on 07/01/25, at 1:25 P.M., the DON said staff should report anything they witness that they feel is abuse or even makes them uncomfortable. Reports should be made to the charge nurse, who is to report immediately to the DON or Assistant Director of Nursing (ADON), who would then report the allegation to the Administrator. MO00256220

Based on interview and record review, the facility failed to document a timely and thorough investigation, to include interviews with multiple staff and other residents, and steps taken to protect all residents during the investigation for an allegation of possible verbal abuse involving one resident (Resident #1). The facility census was 99.Review of the facility policy entitled Abuse Prohibition, November 2016, showed the following:-It is the purpose of the facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property, and exploitation of any resident;-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. It includes verbal abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm;-Mistreatment means inappropriate treatment or exploitation of a resident;-To assure that everything possible is being done to prevent abuse, the facility has implemented component processes including -training, initial and ongoing of employees; -prevention of abuse, neglect or mistreatment or any of the types of abuse; identification of suspicious events; protection of residents during an investigation; investigation of all alleged violations; and response and reporting of an abusive situation to necessary agencies. 1. Review of Resident #1's face sheet (gives basic profile information) showed the following:-admission date of 01/09/17;-Diagnoses included anxiety, insomnia, generalized muscle weakness, pain, diarrhea, abnormalities of gait and mobility, and limitation of activities due to disability. Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 05/09/25, showed the following information:-Cognition intact;-Adequate hearing without assistive devices;-Required moderate assist with upper body dressing, personal hygiene, and bed mobility;-Required substantial assist with showers/bathing, sitting/lying;-Dependent on others for assistance with toileting hygiene, lower body dressing and footwear, sit to stand, and transfers. Review of the resident's care plan, updated 05/27/25, showed the following:-Required assistance of 1 to 2 staff for all activities of daily living (ADLs) including transfers and positioning, hygiene, long distance mobility, incontinence care, and bathing;-At risk for complications due to use of psychoactive medications to treat/manage depression. During an interview on 06/21/25, at 4:40 P.M., Licensed Practical Nurse (LPN) A said the following:-During the evening on 06/20/25, Certified Medication Technician (CMT) B told LPN A that Certified Nursing Assistant (CNA) C was rude and verbally abusive to the resident;-Around 11:00 P.M., LPN A went to interview the resident, but the resident was asleep. He/she did not notify the Director of Nursing (DON) or Administrator of the allegation at that time, because he/she had not yet interviewed the resident to confirm or clarify the allegation;- LPN A said he/she spoke with the resident that morning, and the resident said CNA C was short with him/her the previous evening. LPN A did not inform the DON of the abuse allegation until 06/21/25, when the LPN called the DON to inform her that a State Surveyor was in the building to investigate a reported complaint;-LPN A said he/she did not remove CNA C from the worksite the previous evening. CNA C worked through his/her shift (2:00 P.M. - 10:00 P.M.). Review of facility provided records showed no documentation of a timely and complete investigation or staff taken to protect all residents during the investigation of the allegation of abuse. During an interview on 06/21/25, at 4:52 P.M., CMT B said the following:-On 06/20/25, while he/she was doing his/her last medication pass of the shift, CNA C stood in the hallway approximately five feet from the resident's doorway. CNA C was complaining about the resident having diarrhea and having to change him/her again. The CNA loudly said, What the hell does he want now?! I don't know how the fuck he/she could have that much diarrhea! -CMT B went into the resident's room to talk to him/her. The resident looked tearful and said CNA C told him/her he/she would just have to wait for assistance;-CMT B said CNA C had at other times come out of other resident rooms complaining;-The CMT said residents could probably hear the CNA's comments. CMT B reported the incident to the charge nurse, LPN A. During an interview on 07/01/25, at 11:15 A.M., CNA D said staff should tell the charge nurse or the DON if they witnessed or were told allegations of abuse, neglect, or rude staff behavior. The alleged abuser should be separated from the residents. The facility management would begin an investigation. During an interview on 07/01/25, at 11:55 A.M., LPN E said after any witnessed or reported abuse the alleged perpetrator should be walked out of the building, and the charge nurse or management should begin an investigation immediately. During an interview on 07/01/24, at 11:37 A.M., the Activities Director said staff should report any witnessed or verbalized allegation of abuse so the facility management can do an investigation. During an interview on 07/01/25, at 12:02 P.M., Registered Nurse (RN) F said an alleged perpetrator should be pulled away from residents and the situation reported immediately to the DON. During an interview on 06/21/25, at 5:04 P.M., the DON said the following:-He/she was not notified on the previous evening regarding the abuse allegation. LPN A called the DON to notify him/her that a surveyor was onsite and informed the DON of the allegation at that time;-The DON then notified CNA C by phone of the allegation and suspended CNA C pending the facility's investigation;-CMT B should have called the DON if he/she wasn't sure if the nurse had notified the DON/Administrator. During an interview on 07/01/25, at 1:25 P.M., the DON said staff should report anything they witness that they feel is abuse or even makes them uncomfortable. Reports should be made to the charge nurse, who is to report immediately to the DON or Assistant Director of Nursing (ADON), who would then report the allegation to the Administrator. The alleged abuser should be immediately clocked out of the building pending an investigation. MO00256220

Based on interview and record review, the facility failed to protect each resident's right to be free from physical abuse when Registered Nurse (RN) C slapped one resident's (Resident #1) face in retaliation for the resident biting the RN's finger. The facility census was 89. Review of the facility's policy titled, Abuse Prohibition, dated 2016, showed the following: -It is the purpose of the facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property, and exploitation of any resident. To assist the facility staff members in recognizing incidents of abuse, the following definitions of abuse are provided; -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. Review of the facility's policy titled, Resident's Rights, undated, showed the following: -Long-term care residents have a right to care which maintains or enhances the quality of life; -A resident has the right to be free from abuse. Residents shall not be subjected to physical, sexual, or emotional injury or harm. 1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included of anxiety (a feeling of fear, dread, and uneasiness), unspecified dementia (dementia without a specific diagnosis, multiple types of mental and physical conditions present at once), and major depressive disorder (a mental health disorder characterized by persistently depressed mood). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/14/24, showed the following: -The resident was severely cognitively impaired. -The resident used a wheelchair. -The resident required supervision when eating. -The resident required a therapeutic diet. Review of the resident's care plan, dated 06/20/24, showed the following: -The resident required assistance with eating; -Provide the resident with encouragement and gentle verbal cues with cares. Review of the facility's investigation, dated 07/30/24, showed the following: -At 9:47 P.M., on 07/28/24, the Administrator was contacted by the Director of Nursing (DON); -The DON said Nurse Aide (NA) A and NA B witnessed RN C slap the resident on his/her left cheek; -RN C said the resident had something in his/her mouth that could cause him/her to choke; -The resident refused to open his/her mouth and spit out the object in his/her mouth; -RN C said he/she used his/her thumb and index finger to open the resident's mouth; -RN C said he/she placed his/her finger in the resident's mouth once it opened and the resident bit RN C's finger; -RN C said he/she pulled his/her hand away and in a reactive response very lightly tapped the resident's left cheek; -RN C said the tap was very slight and an automatic response to being bit; -RN C was removed from the facility and sent home. Review of the incident report (written statement), undated, completed by NA A showed the following: -NA A went to the resident's room to get the resident up for dinner; -The resident was chewing on something, but would not spit it out; -NA B and RN C helped remove the item from the resident's mouth; -NA A was completing last rounds when NA A noticed the resident chewing on something again; -The resident refused to spit the item out; -RN C was trying to get the item out of the resident's mouth and the resident refused to spit it out; -The resident chopped down on RN C's finger; -RN C got upset and slapped the resident on the left side of the resident's face; -RN C said he/she was sorry and that was a reaction; -RN C had NA A and NA B remove everything from the residents room. During an interview on 08/01/24, at 2:04 P.M., NA A said the following: -The resident had choked on a straw earlier in the day; -NA A checked on the resident and he/she was chewing on something and would not spit it out when asked; -NA A asked NA B and RN C for help getting the object out of the resident's mouth; -RN C put her finger in the resident's mouth to remove the item; -The resident bit down on RN C's finger and RN C slapped the resident on the left of side of the resident's face; -RN C apologized to the resident and said the slap was a reaction to the bite; -RN C's action of slapping the resident was not appropriate; -NA B left the resident's room and reported the incident to the DON. Review of the incident report (written statement), undated, completed by NA B, showed the following: -NA A had come and got RN C and myself and said the resident have been chewing on something and refused to spit it out; -NA B said all three of them went to the resident's room to remove the item the resident was chewing on; -RN C claimed that the resident bit him/her; -NA B said he/she did not physically see the resident bite RN C; -NA B said he/she saw RN C love tap (smacked the resident) then RN C said he/she was sorry and that it was a reaction; -NA B said that RN C seemed a little upset in his/her voice; -This happened about 9:30 P.M. During an interview on 08/01/24, at 2:14 P.M., NA B said the following: -NA A had checked on the resident and the resident was chewing on something and would not spit it out; -NA A asked him/her and RN C to help NA A get the item out of the resident's mouth; -RN C opened the resident's mouth to remove the item; -From his/her position in the room he/she did not see the resident bite RN C's finger; -He/she saw RN C love tap the resident on the left cheek; -RN C said the hit was a reaction to the resident biting his/her finger; -RN C's reaction to being bit by the resident was not appropriate; -He/she and NA A left the resident's room and reported the incident to the DON. Review of RN C's written statement, dated 07/28/24, showed the following: -RN C was called to the resident's room around 9:30 P.M., for the second time on this shift; -The resident was chewing on a plastic straw and was not spitting the straw out of his/her mouth; -NA A and NA B asked the RN to come to the resident's room because they thought the resident was chewing on a rubber band; -RN C asked a medical technician (med tech) who often works the hall to accompany him/her to assist in getting the rubber band out of the resident's mouth; -The resident was asked several times and the med tech then used his/her thumb and index finger to open her mouth; -The resident finally opened his/her mouth slightly and the med tech was able to get the item which was a plastic straw; -RN C said the second time he/she did the same; -RN C asked the resident several times to open his/her mouth and the resident did not follow command; -RN C said he/she was concerned that the resident could choke on the straw; -RN C said that he/she did as the med tech and placed his/her thumb and index finger on the resident's cheeks; -RN C said the resident opened his/her mouth slightly and RN C put his/her index finger in the residents mouth to retrieve the straw and the resident bit down on RN C's finger; -RN C pulled his/her hand away and in a reactive response very lightly taped the resident left cheek; -RN C said the tap was very very slight and an automatic response to being bit; -RN C said the resident continued to keep his/her mouth tightly closed; -RN C tried the thumb and index finger again and the resident opened his/her mouth slightly more and RN C was able to retrieve the straw; -RN C said he/she was unsure if NA A and NA B were in the room and saw the resident bite RN C; -RN C said he/she did say the resident bit him/her; -RN C said that his/her finger stung from the bite; -RN C said he/she then instructed NA A and NA B to remove all straws and paper products from the residents table and make sure the resident's water pitcher was in reach without a straw; -RN C said that after the NA's left the resident's room he/she told the resident he/she was sorry for doing what he/she did; -RN C said she told the resident he/she was afraid the resident would choke on the straw; -RN C said the resident looked at him/her in the eye, smiled and RN C and said he/she wouldn't have choked; -RN C said she told the resident they did not know that for sure and gave the resident a kiss on the forehead and the resident smiled bigger; -RN C said the med tech he/she lightly pushed on her cheeks. During an interview on 08/02/24, at 3:21 P.M., RN C said the following: -NA A came to him/her and reported the resident was chewing on something and refused to spit it out; -The resident had been chewing on a straw earlier in the evening and had choked on it; -He/she, NA A, and NA B went into the resident's room; -He/she asked the resident several times to spit out what he/she was chewing on; -The resident refused to spit out the item; -She used his/her thumb and index finger to get the resident to open his/her mouth; -The resident opened his/her mouth RN C used his/her index finger to sweep the resident's mouth; -The resident bit down on RN C's finger and let go; -He/she tapped the resident's left cheek lightly; -The tap was a knee jerk reaction to being bit by the resident; -His/her reaction to the resident biting him/her was not appropriate. During an interview on 08/01/24, at 2:43 P.M., the DON said the following: -The DON was contacted by NA A and NA B; -NA A and NA B told the DON that RN C had tried to remove an item from the resident's mouth by putting his/her finger in the resident's mouth and the resident bit RN C's finger; -NA A and NA B told the DON that RN C slapped the resident on the left cheek; -The DON said she reported the incident to the Administrator; -The DON and Administrator spoke with RN C and instructed RN C to leave the facility and he/she was suspended pending the investigation of the incident; -The DON said that RN C's reaction to being bit by the resident was not appropriate. During an interview on 08/01/24, at 3:05 P.M., the Administrator said the following: -The Administrator was contacted by the DON; -The Administrator spoke with NA A and NA B about the incident; -The Administrator spoke with RN C regarding the incident; -RN C was sent home and suspended pending the investigation; -RN C's reaction to being bit by the resident was not appropriate. Complaint MO00239672

Based on interview and record review, the facility failed to report all allegations of abuse immediately to management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required time two hour frame when an allegation of one staff member staff member (Certified Nursing Assistant (CNA) B) being physically abusive to one resident (Resident #1), out of five sampled residents, was made and not reported in a timely manner. The facility census was 96. Review of the facility's policy titled New Abuse/Neglect Report Regulations - Effective 11/28/16, revised 01/2017, showed the following: -With recent changes to Federal & State Regulations, one important change requiring immediate action involves Abuse Prohibition Protocol; -Immediately educate all staff to report to the Administrator and/or Designees any alleged (all allegations) violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property; -Per regulation 483.12 (c), the Administrator or designee must report to the State Survey agency no later than two hours after the allegation is made if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the event that caused the allegation did not involve abuse and did not result in serious bodily injury. Review of the facility's policy titled, Guidelines for Facility Self-Reporting Effective November 28, 2016, revised 01/2017, showed the following: -The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures. Review of the facility's policy titled Response and Reporting Guidelines, dated 05/2016, showed the following: -It is the purpose of the facility to report all substantiated incidents of abuse or neglect to the appropriate state agencies and the designated individuals at the facility's consultant office; -If the events that cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than two hours after forming the suspicion. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -The resident had a responsible party; -Diagnoses included dementia, depression, hemiplegia (paralysis affecting one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems) affecting the right side, and reduced mobility. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 11/01/23, showed the following: -Mild cognitive impairment; -No behaviors; -Functional limitation in range of motion of the upper extremity on one side; -Used a wheelchair and walker for locomotion; -Required moderate assistance of one staff member to roll left and right, move from sit to lying, and move from lying to sitting on the side of the bed; -Required substantial assistance of one staff member to transfer from sitting to standing, from chair or bed to chair, toilet transfers, tub and shower transfers and to walk ten feet. Review of the resident's care plan, revised 11/22/23, showed the following: -Staff to develop a trusting relationship through frequent contact being honest and non-judgmental while projecting an accepting attitude toward the resident; -Staff to explain all cares, procedures, and medications before beginning; -Include the resident in the planning process, giving them choices whenever possible to enhance a sense of trust and respect for the resident; -Resident was at risk for falls; -Resident required a walker for short distances with supervision to set-up assist for safe ambulation; -Resident used a wheelchair for long distance mobility; -Staff to assist resident as needed or requested; -Staff to observe, document, and report any functional decline and provide assistance as needed; -Provide increased activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) assistance as needed and appropriate due to weakness or unsteady gait; -The resident did transfer self, but provide assistance as needed and requested. Always use a gait belt for all assisted transfers for safety; -Resident required assist of one for all his/her ADL's related to weakness and decreased mobility; -Resident was stand-by assistance to one person assistance with transfers and positioning. Review the facility's investigation, dated 02/06/24, showed the following: -On 02/05/24, at 6:19 A.M., the Administrator received a call from the Director of Nursing (DON) concerning an allegation of possible abuse on involving the resident; -The DON said Registered Nurse (RN) A text her at 4:30 A.M. and the RN called her back at 4:40 A.M.; -The DON said that RN A reported that CNA K responded to the resident's call light around 1:50 A.M. The CNA reported that the resident was hurting because CNA B made the resident go back to bed; -The RN went to the resident's room and asked him/her questions regarding the event. The resident told the RN that CNA B took him/her by the wrist and slammed him/her down hard onto the bed (he/she clarified into a sitting position). The resident said it wasn't necessary and it was uncalled for. CNA B was out of control, almost; -The RN noticed a small bruise to the palm-side of the left thumb proximal (close) to the base on the [NAME] surface (fatty part of the thumb). It measured 0.7 centimeters (cm); -The RN asked when CNA B slammed him/her down onto the bed. The resident stated nine o' clock. The resident said that he/she went to bed and woke up in pain and told CNA K; -The Administrator completed an online, after hours abuse and neglect report with DHSS at 7:00 A.M. (five hours after the allegation of abuse was received by staff); -The Administrator reported incident to DHSS, ombudsman, and the resident's doctor. Review of the resident's nurse's progress note dated 02/05/24, at 7:09 A.M. showed the following: -A CNA reported to the RN at approximately 1:50 A.M., the resident was complaining of wrist pain and reported the events leading to this pain. The RN spent the next half to one hour talking with the resident and staff regarding the events and assessing for facts. At approximately 4:28 A.M., RN was able to get a text to the DON regarding the events. RN then spoke on the phone with the DON. RN provided CNAs with required paperwork for event follow up. During an interview on 02/09/24, at 2:05 P.M., CNA K said the following: -If a resident reported abuse to him/her, he/she reported to the charge nurse immediately; -The charge nurse reported to DHSS within two hours; -On 02/05/24, at approximately 1:30 A.M. to 1:40 A.M., he/she answered the resident's call light and the resident reported that CNA B told the resident he/she had to go to bed, grabbed his/her arm, threw him/her in bed, and told him/her to stay in bed. The resident said his/her arm hurt and when the CNA looked at it, the CNA did not see any marks; -He/she left the room approximately five minutes after answering the resident's call light and reported this the RN A. During an interview on 02/08/24, at 11:54 A.M., RN A said the following: -If a resident reported abuse to a CNA or CMT, they reported to the charge nurse immediately. The charge nurse then reported to the DON immediately; -The Administrator reported to DHSS within two hours; -On 02/05/24, at approximately 1:50 A.M., CNA K reported to him/her that the resident complained of wrist pain and stated that CNA B grabbed the resident by the wrists and slammed him/her down; -The RN spoke with the resident after CNA K reported to the RN and the resident said that he/she hurt his/her wrist. CNA B told him/her to go to bed, grabbed him/her by the wrists, and slammed him/her down on the bed onto his/her bottom; -At 4:28 A.M., the RN reported the allegation to the DON; -He/she should have reported to the DON sooner. During an interview on 02/08/24, at 9:06 A.M., the resident said approximately one week ago, CNA B put him/her in bed strongly. It hurt and the CNA handled her in an inappropriate way. During an interview on 02/08/24, at 9:18 A.M., Housekeeper E said if a resident reported abuse to him/her, he/she reported to his/her supervisor immediately. The DON reported to DHSS within four hours. During an interview on 02/08/24, at 9:25 A.M., Certified Medication Technician (CMT) F said if a resident reported abuse to him/her, he/she reported to the charge nurse immediately. The DON or Administrator reported to DHSS within two hours. During an interview on 02/08/24, at 9:29 A.M., CNA G said if a resident reported abuse to him/her, he/she reported to the charge nurse immediately. The DON or Administrator reported to DHSS within 24 to 48 hours. During an interview on 02/08/24, at 9:31 A.M., RN H said if a resident reported abuse to a CNA or CMT, they reported to him/her immediately after they ensured the resident was safe. He/she assessed the resident then reported to the Assistant Director of Nursing (ADON) or DON. The ADON or DON reported to DHSS immediately but within two hours. During an interview on 02/08/24, at 9:37 A.M., CNA D said if a resident reported abuse to him/her, he/she reported to the charge nurse immediately. The DON reported to DHSS. During an interview on 02/08/24, at 9:39 A.M., Licensed Practical Nurse (LPN) I said if a resident reported abuse to a CNA or CMT, they reported this to the charge nurse immediately. The charge nurse reported to the DON immediately. Reports of abuse in the middle of the night still required to be reported to the DON immediately. The DON reported to DHSS within two hours. During an interview on 02/08/24, at 9:46 A.M., CNA J if a resident reported abuse to him/her, he/she reported to the charge nurse immediately. The charge nurse reported to the DON and the DON reported to DHSS immediately. During an interview on 02/08/24, at 12:35 P.M., the DON said the following: -If a resident reported abuse to a CNA or CMT, they should report to the charge nurse immediately; -The charge nurse interviewed and assessed the resident and then contacted the DON or Administrator immediately; -He/she or the Administrator reported to DHSS within two hours; -On 02/05/24, between 1:45 A.M. and 2:00 A.M., CNA K reported to RN A that the resident stated CNA B slammed him/her down on the bed and told the resident to get to bed; -He/she considered that an allegation of abuse; -RN A texted him/her around 4:30 A.M. and he/she called the RN around 4:40 A.M. and the RN reported the allegation of abuse at that time to him/her; -He/she reported the allegation to the Administrator after 6:00 A.M. but he/she should have reported to the Administrator immediately. During an interview on 02/08/24, at 1:10 P.M., the Administrator said the following: -He/she reported allegations of abuse to DHSS within two hours; -CNA K reported to RN A on 02/05/24, at 1:50 A.M.; -RN A reported to the DON on 02/05/24, at approximately 4:30 A.M.; -The DON reported to him/her at 6:19 A.M. and he/she reported to DHSS at approximately 7:00 A.M.; -The allegation should have been reported to DHSS by 3:50 A.M. MO00231374

Based on interview and record review, the facility failed following their abuse policy and take steps to protect all residents during an investigation of alleged abuse after staff reported that one resident (Resident #1) alleged a staff member (Certified Nursing Assistant (CNA) B) physically abused him/her and the CNA continued to work independently with residents. Five residents were sampled in a facility with a census of 96. Review of the facility's policy titled Abuse Prohibition, dated 11/2016, showed the following: -It is the purpose of this facility to prohibit mistreatment, neglect, abuse, misappropriation of resident's property and exploitation of any resident; -To assure that everything possible is being done to prevent abuse, the facility has implemented the following seven component processes: Screening of potential employees, training, initial and ongoing of employees, prevention of abuse, neglect or mistreatment or any of the types of abuse, identification of suspicious events, protection of residents during an investigation, investigation of all alleged violations, and response and reporting of an abusive situation to necessary agencies. Review of the facility's policy titled Guidelines for Facility Self-Reporting, Effective November 28, 2016, revised 01/2017, showed the following: - The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse, neglect or exploitation or mistreatment while the investigation is in progress. Review of the facility's policy titled Protection Guidelines, dated 03/2012, showed the following: -It is the purpose of the facility to protect the resident from harm during an abuse investigation; -To protect the resident from an employee during an abuse investigation, the employee will be suspended without pay during the investigation process. Review of the facility's policy titled Response and Reporting Guidelines, dated 05/2016, showed the following: -All alleged persons (employees) suspicious of a crime (any resident injury-serious or not) will be immediately suspended during the investigation. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -The resident had a responsible party; -Diagnoses included dementia, depression, hemiplegia (paralysis affecting one side of the body) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems) affecting the right side, and reduced mobility. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 11/01/23, showed the following: -Mild cognitive impairment; -No behaviors; -Functional limitation in range of motion of the upper extremity on one side; -Used a wheelchair and walker for locomotion; -Required moderate assistance of one staff member to roll left and right, move from sit to lying, and move from lying to sitting on the side of the bed; -Required substantial assistance of one staff member to transfer from sitting to standing, from chair or bed to chair, toilet transfers, tub and shower transfers and to walk ten feet. Review of the resident's care plan, revised 11/22/23, showed the following: -Staff to develop a trusting relationship through frequent contact being honest and non-judgmental while projecting an accepting attitude toward the resident; -Staff to explain all cares, procedures, and medications before beginning; -Include the resident in the planning process, giving them choices whenever possible to enhance a sense of trust and respect for the resident; -Resident was at risk for falls; -Resident required a walker for short distances with supervision to set-up assist for safe ambulation; -Resident used a wheelchair for long distance mobility; -Staff to assist resident as needed or requested; -Staff to observe, document, and report any functional decline and provide assistance as needed; -Provide increased activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) assistance as needed and appropriate due to weakness or unsteady gait; -The resident did transfer self, but provide assistance as needed and requested. Always use a gait belt for all assisted transfers for safety; -Resident required assist of one for all his/her ADL's related to weakness and decreased mobility; -Resident was stand-by assistance to one person assistance with transfers and positioning. Review the facility's investigation, dated 02/06/24, showed the following: -On 01/05/24, at 6:19 A.M., the Administrator received a call from the Director of Nursing (DON) concerning an allegations of possible abuse from the resident; -The DON said Registered Nurse (RN) A texted her at 4:30 A.M. and the RN called her back at 4:40 A.M.; -The DON said RN A reported that Certified Nursing Assistant (CNA) K responded to the resident's call light around 1:50 A.M. The CNA reported that the resident was hurting because CNA B made the resident go back to bed; -The RN went to the resident's room and asked him/her questions regarding the event. The resident told the RN that CNA B took him/her by the wrist and slammed him/her down hard onto the bed (he/she clarified into a sitting position). The resident said it wasn't necessary and it was uncalled for. CNA B was out of control, almost; -The RN noticed a small bruise to the palm-side of the left thumb proximal (near) to the base on the [NAME] surface (fatty part of the thumb). It measured 0.7 centimeters (cm); -The RN asked when CNA B slammed him/her down onto the bed. The resident stated nine o' clock. The resident said that he/she went to bed and woke up in pain and told the CNA K; -The Administrator completed an online, after hours abuse and neglect report with DHSS at 7:00 A.M.; -CNA B was not in the building when this writer was called due to the CNA's shift ending at 6:00 A.M.; -RN A stated in his/her report that CNA B was not going back into the resident's room and he/she would have CNA K answer the resident's call light until shift change. During interviews on 02/08/24, at 10:36 A.M. and 11:35 A.M., CNA B said the following: -On 02/05/24, when he/she returned from lunch, the charge nurse told him/her not to go back into the resident's room due to the resident reported he/she slammed the resident on the bed; -He/she worked the rest of his/her shift and left the facility around 6:00 A.M.; -He/she did not have to have another staff member with him/her when he/she entered other residents' rooms that night. During an interview of 02/09/24, at 2:05 P.M., CNA K said the following: -After he/she reported the allegations of abuse made by the resident to RN A, CNA B worked the rest of his/her shift and was not required to have another staff member with him/her; -He/she worked C hall so he/she did not know if CNA B entered the resident's room again during their shift; -The RN did tell him/her to answer the resident's call light for the rest of the shift. During an interview on 02/08/24, at 11:54 A.M., RN A said the following: -On 02/05/24, when CNA B returned from lunch, he/she spoke with the CNA within fifteen minutes of the CNAs return to work about the resident's allegation; -He/she told CNA B to not go in the resident's room the rest of his/her shift; -CNA B worked the rest of his/her shift and the RN did not make the resident work alongside another aide when entering other residents' rooms; -If he/she would have deemed the CNA a threat, he/she would have treated the situation differently, but felt keeping him/her away from the resident was sufficient; -When he/she notified the DON of the allegations, he/she did not receive any further guidance of what to do with the CNA; -He/she believed that a staff member would be sent home pending investigation, depended on the accusation. During an interview on 02/08/24, at 11:17 A.M., RN H said the following: -If a staff member was accused of abuse, he/she had the staff member stay where he/she could monitor them until he/she received further direction from the Administrator; -That staff member should not work until the investigation was completed. During an interview on 02/08/24, at 11:25 A.M., Licensed Practical Nurse (LPN) I said the following: -If a staff member was accused of abuse, he/she made that staff member stay with him/her until he/she received further direction from the DON; -He/she did not believe a staff member accused of abuse should be allowed to come back to work until the investigation was completed. During an interview on 02/08/24, at 12:35 P.M., the DON said the following: -If a staff member was accused of abuse, they would be removed from that resident and normally he/she had them leave the building until the investigation was completed; -When RN A reported the allegation of abuse to him/her, the RN said CNA B was not caring for the resident for the rest of the CNA's shift; -The CNA did care for other residents that night after the allegation was made and was not required to have another staff member with him/her; -He/she felt the other residents were protected from the CNA because there was a charge nurse and other aides in the building; -The Administrator suspended the CNA after his/her shift ended until the investigation was completed. During an interview on 02/08/24, at 1:10 P.M., the Administrator said the following: -If a resident made an allegation of abuse against a staff member, the staff member should be suspended until the investigation was completed; -On 02/05/24, the resident was protected from CNA B, but the other residents were not; -If RN A would have reported immediately, CNA B would have been suspended immediately. MO00231374