Every finding on record at Hubble Creek

Based on interview and record review, the facility failed to provide abuse/neglect training for three Certified Nursing Assistants (CNAs) and one Licensed Practical Nurse (LPN) of four sampled staff hired since September 2025. The facility census was 64.Review of the facility's policy titled, In-Service Training, All Staff, dated 2001, showed:- The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training;- Required training topics include preventing abuse, neglect, exploitation and misappropriation of resident property;- Completed training is documented by the staff development coordinator, or his/her designee. 1. Review of CNA B's employee file showed:- A hire date of 12/27/25;- No documentation of abuse/neglect training. 2. Review of CNA H's employee file showed:- A hire date of 01/07/26;- No documentation of abuse/neglect training. 3. Review of CNA I's employee file showed:- A hire date of 01/19/26;- No documentation of abuse/neglect training. 4. Review of LPN D's employee file showed:- A hire date of 12/28/25;- No documentation of abuse/neglect training. During an interview on 02/10/26 at 3:53 P.M., CNA B said he/she did not remember getting abuse/neglect training since being employed at the facility. During an interview on 02/10/26 at 5:00 P.M., the Administrator said he took over as the Administrator in December after the facility was bought in September. The facility had just gotten all of their staff signed up through the contracted training company last week so the staff could do the required trainings. During an interview on 02/12/26 at 6:35 P.M., the Administrator and Director of Nursing (DON) said they would expect all nursing staff to have abuse/neglect training upon hire and before working with residents.

Based on interview and record review, the facility staff failed to allow residents or their representatives to make informed decisions about their care by not providing psychotropic (medications that affect behavior, mood, thoughts, or perception) medication consents for seven residents (Residents #1, #2, #4, #6, #12, #35, and #64) out of 11 sampled residents and one resident (Resident #13) outside the sample. The facility census was 64.Review of the facility's policy titled, Psychotropic Medication Use, revised February 2025, showed: - Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: non-pharmacological alternatives; the indications and rationale for the recommendation; the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings) and; the resident's/representative's right to accept or decline the treatment. 1. Review of Resident #1's medical record showed: - admitted on [DATE]; - Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning) with behavioral disturbance, dementia with agitation, anxiety (persistent worry and fear about everyday situations), insomnia (difficulty sleeping), restlessness, and agitation; - An order for divalproex sodium (anticonvulsant medication and also used as a mood-stabilizer medication) 24-hour extended release (ER) 500 milligrams (mg) by mouth one time a day for restlessness and agitation per hospital physician, dated 01/20/26; - An order for melatonin (a hormone that helps regulate the sleep cycle) 3 mg two tablets by mouth at bedtime related to insomnia, dated 09/05/25; - An order for donepezil (a medication to help memory) 24 hour-extended release 28-10 mg by mouth one time a day related to unspecified dementia with behavioral disturbance, dated 09/06/25; - An order for mirtazapine (an antidepressant medication) 15 mg by mouth at bedtime for restlessness and agitation and insomnia per hospital physician, dated 09/05/25; - An order for quetiapine (an antipsychotic (psychiatric medications that treat symptoms of psychosis – such as hallucinations, delusions, and severe paranoia) medication) 300 mg by mouth at bedtime for dementia with agitation per hospital physician, dated 09/05/25; - No documentation of consents or education of risks and benefits for the psychotropic medication use were provided to the resident and/or their representative. 2. Review of Resident #2's medical record showed: - admitted on [DATE]; - Diagnoses of dementia with agitation, anxiety, mood disturbance, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); - An order for olanzapine (an antipsychotic medication) 5 mg by mouth at bedtime related to restlessness and agitation, dated 01/20/26; - An order for escitalopram (an antidepressant medication) 20 mg by mouth one time a day related to generalized anxiety disorder, dated 11/05/25; - No documentation of consents or education of risks and benefits for the psychotropic medication use were provided to the resident and/or their representative. 3. Review of Resident #4's medical record showed: - An admission date of 10/14/25; - Diagnosis of dementia; - An order for risperidone (an antipsychotic medication) 0.5 mg by mouth one time a day for dementia, dated 10/14/25; - An order for quetiapine 25 mg by mouth one time a day for depression, dated 10/14/25; - No documentation of consents or education of risks and benefits for the psychotropic medication use were provided to the resident and/or their representative. 4. Review of Resident #6's medical record showed: - An admission date of 04/18/25; - Diagnoses of anxiety disorder, auditory hallucinations (the perception of sounds, such as voices, music, or noises, without an external source), schizoaffective disorder (a chronic mental health condition combining hallucinations, delusions, and disorganized thinking with mood disorder symptoms like mania, depression), and unspecified intellectual disability (a diagnosis for individuals over age five with clear, significant limitations in intellectual and adaptive functioning, but whose impairment cannot be formally assessed or categorized due to severe co-occurring conditions); - An order for Seroquel (an antipsychotic medication) 300 mg by mouth at bedtime for schizoaffective disorder, dated 12/06/25; - No documentation of consent or education of risks and benefits for the psychotropic medication use was provided to the resident and/or their representative. 5. Review of Resident #12's medical record showed: - admitted on [DATE]; - Diagnoses of Alzheimer's disease (brain disorder with progressive mental deterioration), dementia with mood disturbance, and depression; - An order for citalopram (an antidepressant medication) 20 mg by mouth one time a day related to depression, dated 10/18/25; - An order for Seroquel 25 mg 0.5 tablet by mouth at bedtime related to Alzheimer's disease, dated 01/19/26; - An order for buspirone (an anxiety medication) 5 mg by mouth two times a day related to dementia with mood disturbance, dated 10/17/25; - No documentation of consents or education of risks and benefits for the psychotropic medication use were provided to the resident and/or their representative. 6. Review of Resident #13's medical record showed: - An admission date of 04/10/25; - Diagnoses of unspecified mood disorder, bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), generalized anxiety disorder, and unspecified dementia without behavioral disturbance; - An order for aripiprazole (an antipsychotic medication) 5 mg by mouth at bedtime for unspecified mood disorder, dated 11/05/25; - No documentation of a consent or education of risks and benefits for the psychotropic medication use was provided to the resident and/or their representative. 7. Review of Resident #35's medical record showed: - An admission date of 10/01/25; - Diagnoses of Alzheimer's disease with late onset, anxiety disorder, and dementia with mood disturbance; - An order for quetiapine 75 mg by mouth two times a day for dementia with behaviors, dated 02/05/26; - No documentation of consent or education of risks and benefits for the psychotropic medication use was provided to the resident and/or their representative. 8. Review of Resident #64's medical record showed: - admitted on [DATE]; - Diagnoses of dementia with agitation and insomnia; - An order for sertraline (an antidepressant medication) 25 mg by mouth at bedtime for mood, dated 01/16/26, and discontinued on 01/22/26; - An order for haloperidol (an antipsychotic medication) 2 mg by mouth two times a day for restlessness/agitation, dated 01/28/26; - An order for memantine (a medication for memory) 10 mg by mouth two times a day for memory, dated 01/17/26, and discontinued 01/22/26; - An order for morphine sulfate (an opioid pain medication) 100 mg/5 milliliters (ml) 0.5 ml by mouth every 1 hour as needed for pain and shortness of breath, dated 01/22/26; - An order for ondansetron (a nausea medication) 4 mg by mouth every 6 hours as needed for nausea and vomiting, dated 01/22/26; - An order for haloperidol inject 0.2 ml intramuscularly (IM – injection into the muscle) at bedtime for behavior/ mood, dated 01/22/26, and discontinued 01/28/26; - An order for haloperidol 2 mg/ml 0.5 ml orally every 6 hours as needed for agitation/restlessness, dated 01/30/26; - No documentation of consents or education of risks and benefits for the psychotropic medication use were provided to the resident and/or their representative. During an interview on 02/11/25 at 9:15 A.M., the Corporate Compliance Officer said psychotropic medication consent forms were discussed during a meeting with the administration and had not yet been initiated. During an interview on 02/12/26 at 6:37 P.M., the Administrator and Director of Nursing (DON) said they would expect residents or their representatives to be given informed consents for the use of psychotropic medications.

Based on observation, interview, and record review, the facility failed to provide adequate supervision when leaving residents unattended with an unlabeled, unknown liquid material, and failed to provide adequate supervision when leaving the locked unit without staff for 14 residents out of 14 residents. The facility census was 64.The facility did not provide a policy regarding adequate supervision. Observation of the facility during the initial tour on 02/09/26, showed a locked unit with 14 residents. Review of the facility's Matrix (information used to identify pertinent care categories for residents in long-term care facilities) showed:- The 14 cognitively impaired residents that resided on the locked unit had a diagnosis of Alzheimer's (brain disorder with progressive mental deterioration)/dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), exhibited behaviors, and needed increased monitoring. 1. Observation of the locked unit on 02/09/26 at 11:50 A.M., showed:- One unknown Certified Nurse Assistant (CNA) worked on the unit;- The CNA brought residents to the dining room one at a time, leaving those in the dining room unsupervised while he/she went to get the next resident;- A cart with 15 uncovered cups sat in the dining room. On the cart next to the cups was an unlabeled bucket of an unknown liquid substance which smelled strongly of bleach;- A resident stood next to the cart and other residents passed back and forth in front of the cart with no staff monitoring in the dining area. Observation of the dining room on the locked unit on 02/11/26 at 11:55 A.M., showed:- A cart in the dining room with an unlabeled bucket of an unknown liquid substance which smelled strongly of bleach. A rag floated in the bucket;- CNA F washed the hands of each resident in the dining room with the rag from the bucket;- Resident #10 and Resident #15 complained of his/her hands burning. During an interview on 02/11/26 at 12:01 P.M., CNA F said he/she did not know what was in the bucket. Kitchen staff delivered it every day before each meal, and he/she wiped the resident's hands with it. CNA F said he/she thought it was soap and water, but it wasn't labeled. Observation of the dining room on the locked unit on 02/12/26 at 11:45 A.M., showed:- A cart in the dining room with an unlabeled bucket of an unknown liquid substance which smelled strongly of bleach. A rag floated in the bucket;- CNA G wiped the dining room tables with the rag from the unknown substance in the bucket. During an interview on 02/12/26 at 11:50 A.M., CNA G said the bucket was filled with soap and water to wipe the dining room tables down before and after each meal. The bucket came from the kitchen before each meal. During an interview on 02/12/26 at 2:00 P.M., the Dietary Services Manager (DSM) said the liquid in the bucket was bleach water for wiping the tables down before and after the meals. It was plain water with a couple of capfuls of bleach. The bucket was sent with each meal. The CNAs should be aware of what the bucket held and how to use it. The mixture was not supposed to be used on a resident's skin. 2. Observation on 02/10/26 at 5:30 P.M. to 5:32 P.M., showed no staff on the locked unit. Observation on 02/11/26 from 11:55 A.M. until 12:10 P.M., of the locked unit showed:- CNA F went from resident to resident and attempted to redirect the residents to the dining room tables to prepare for lunch;- The residents got up and walked off from the dining room tables;- Certified Medication Technician (CMT) J tried to assist with the residents. During an interview on 02/11/26 at 12:01 P.M., CNA F said the facility regularly staffed only one CNA on the locked unit. It was very difficult to monitor all the residents when the CNA was providing care to a resident in his/her room. Every resident on the unit had dementia and/or behaviors and was constantly on the move. CNA F said mealtimes were very difficult for one staff. During meals, he/she was constantly redirecting residents one after another. Today he/she was very thankful for CMT J for helping, but that was not the norm. If a resident should require more than one person for assistance, he/she had to call the float staff. Sometimes help came, and sometimes it took a long time, or no one came. Observation of the dining room on the locked unit on 02/12/26 at 11:54 A.M., showed:- CNA G assisted Resident #64 to the bathroom in the resident's room;- The dining room was left unsupervised for four minutes while Resident #64 and CNA G were in the resident's room. During an interview on 02/12/26 at 11:50 A.M., CNA G said there was usually only one CNA assigned to the locked unit. He/She said it would be good to have a second person working the unit. It got really busy at lunch times and if the only CNA was in a resident's room, there was no way staff knew what was going on outside the room. During an interview on 02/10/26 at 5:45 P.M., the Director of Nursing (DON) said there was usually one staff member assigned to the locked unit. There was usually a float staff member that could work where needed, and there was always a nurse that could assist if needed, but neither stayed on the locked unit. She was not aware of any instances when the single staff member left the unit unsupervised. There should always be staff on the unit with the residents. If the unit staff member needed a break, then they were expected to find another staff member to take over prior to leaving.

Based on interview and record review, the facility failed to provide routine and emergency medications and biologicals for one resident (Resident #12) out of 16 sampled residents. The facility census was 64.Review of the facility policy titled, Medication and Treatment Orders, revised July 2016, showed:- Medications and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three days prior to the last dosage being administered to ensure that refills are readily available;- Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders;- Medications not specifically limited to duration of use and number of doses when ordered will be controlled by automatic stop orders. 1. Review of Resident #12's medical record showed:- admitted on [DATE];- Diagnoses of Alzheimer's disease (brain disorder with progressive mental deterioration), dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with mood disturbance, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest);- An order for Seroquel (an antipsychotic (psychiatric medications that treat symptoms of psychosis - such as hallucinations, delusions, and severe paranoia) medication) 25 milligram (mg) 0.5 tablet by mouth two times a day related to dementia with mood disturbance, dated 10/07/25, and discontinued 01/19/26;- An order for buspirone (an anxiety medication) 5 mg by mouth two times a day related to dementia with mood disturbance, dated 10/17/25;- An order for memantine (a medication for memory) 5 mg by mouth two times a day related to Alzheimer's disease, dated 10/17/25, and discontinued date 01/19/26. Review of the resident's Medication Administration Record (MAR) for November 2025 - January 2026, showed:- Seroquel not administered the morning of 11/03/25, the night of 11/05/25, the morning and night of 11/07/25, and the morning and night of 11/08/25, the night of 12/12/25, the morning and the night of 12/13/25;- Buspirone not administered the morning of 11/02/25, the morning of 11/03/25, the night of 01/06/26, the morning and the night of 01/07/26, and the night of 01/08/26;- Memantine not administered the morning and the night of 01/06/26, the morning and night of 01/07/26, and the morning of 01/08/26. Review of the resident's progress Notes showed:- On 11/02/25 at 09:45 A.M., buspirone medication on order;- On 11/03/25 at 7:00 A.M., buspirone medication out and on order;- On 11/03/25 at 7:01 A.M., Seroquel medication out on order;- On 11/05/25 at 3:57 P.M., Seroquel medication ordered;- On 11/07/25 at 6:57 A.M., Seroquel medication on order;- On 11/07/25 at 9:12 P.M., Seroquel medication ordered;- On 11/08/25 at 7:01 A.M., Seroquel medication out and ordered;- On 11/08/25 at 3:06 P.M., Seroquel medication ordered and waiting on pharmacy;- On 12/12/25 at 2:24 P.M., Seroquel medication out and waiting on pharmacy;- On 12/13/25 at 8:26 A.M., Seroquel medication unavailable;- On 12/13/25 at 4:54 P.M., Seroquel medication on order;- On 01/06/26 at 2:42 P.M., memantine and buspirone medications on order;- On 01/07/26 at 6:42 A.M., memantine medication on order;- On 01/07/26 at 6:43 A.M., buspirone medication on order;- On 01/07/26 at 2:48 P.M., memantine and buspirone medication on order;- On 01/08/26 at 7:02 A.M., memantine medication on order;- On 01/08/26 at 2:30 P.M., buspirone on order. During an interview on 02/12/26 at 2:40 P.M., Licensed Practical Nurse (LPN) E said if a resident ran out of a medication or it wasn't in the medication cart, there was a locked medication stock supply that had certain medications in it. The paper list of locked medications might not be accurate, so he/she did not go by that. He/She looked up Resident #12's Seroquel and it was not in the locked medication stock supply. If the medication was not in there, then the nurse would call the physician and/or pharmacy for further instructions. During an interview on 02/12/26 at 5:40 P.M., the Director of Nursing (DON) said medications should be ordered before they ran out and the pharmacy delivered medications daily except on the weekend. If medications ran out, the facility had a locked medication stock supply the nursing staff could access for certain medications. If that option did not work, then he/she did not know what the next step was. During a phone interview on 02/24/26 at 11:47 A.M., the Pharmacist said they did daily deliveries to the facility. If a medication was ordered before 1:00 P.M., then a medication would likely be delivered the same day, and if ordered after 1:00 P.M., then it would be delivered the next day. The pharmacy always had an on-call pharmacist that could be called. If it was an important medication, such as a seizure medication, then the pharmacy would send it as soon as possible as a high priority. The facility had a locked medication supply with a lot of different medications that could be utilized if a resident's medication supply was out. Seroquel should be in the locked medication supply. The facility should document the reason for not administering a medication and call the pharmacy if they were out of a medication and needed it as soon as possible. The facility should not document a medication was not given because it was ordered or out. During a phone interview on 02/24/26 at 3:55 P.M., the Pharmacist said the facility had staff issues because they weren't following through with the ordering of medications. For example, on 11/07/25, a resident's Seroquel medication was requested and delivered, but staff still marked it as not administered on 11/08/25, even though the facility had it. The Pharmacist said he/she talked to the Administrator about the staff not ordering the resident medications in a timely manner. During a phone interview on 02/25/26 at 1:29 P.M., the Pharmacist said Resident #12's buspirone medication was ordered and delivered on 11/11/25, ordered and delivered on 01/06/26, ordered on 01/22/26 and not delivered because it was ordered too soon, ordered and delivered on 02/03/26, and ordered on 02/09/26 and not delivered because it was ordered too soon. The resident's memantine medication was ordered and delivered on 12/05/25, ordered and delivered on 01/06/26, and ordered on 01/07/26 and not delivered because the medication was delivered the day before on 01/06/26. The resident's Seroquel medication was ordered and delivered on 11/07/25, ordered and delivered on 12/11/25, ordered and delivered on 01/12/26, and ordered and delivered on 02/03/26. There should be no reason the facility documented the resident's medications weren't administered because they were out or on order.

Based on observation, interview and record review, the facility failed to ensure medications and biologicals were labeled and stored in accordance with currently accepted practices for one medication cart out of two medication carts and one medication storage room out of one medication storage room which affected five residents (Residents #9, #19, #37, #39, and #58). This had the potential to affect all residents. The facility census was 64. Review of the facility policy titled, Medication Labeling and Storage, undated, showed:- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner;- If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items;- Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices;- The medication label includes, at a minimum, the medication name (generic and/or brand), prescribed dose, strength, expiration date, when applicable, resident's name, route of administration, and appropriate instructions and precautions;- For over the counter (OTC) medications in bulk containers (if permitted by state law) the label contains the medication name, strength, quantity, accessory instructions, lot number, and expiration date (if applicable);- Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial;- Multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date;- If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items. Observation of the 100 Hall medication cart on 02/12/26 at 10:20 A.M., showed:- Resident #39's hydralazine (blood pressure medication) 25 mg with 18 tablets expired on 06/30/25;- Resident #9's furosemide (medication to get rid of excess fluid) 20 mg as needed with 12 tablets expired 07/08/25. Review of Resident #9's Medication Administration Record (MAR), dated February 2026, showed:- The resident received one dose of furosemide on 02/01/26, 177 days after the expiration date. Review of the Resident #9's medical record showed:- No documentation of any adverse reactions to the expired furosemide dose. Observation of the medication room on 02/12/26 at 10:45 A.M., showed: - Three bottles of Vitamin E (a supplement medication) 180 mg expired 09/2025;- One bottle of Geri-Dryl (an antihistamine medication) 25 mg expired 11/2025;- Three bottles of Alkums Antacid regular strength Calcium Carbonate 500 (heart burn medication) mg expired 11/25;- Nine boxes of Alginaid arginine (medication for wound management) powder expired 12/14/25;- One bottle of Thiamine B1 (vitamin medication) 100 mg expired 11/25;- One bottle of Zinc (mineral medication) 50 mg expired 01/26;- Two boxes of Bisacodyl (stool softener) 5 mg expired 12/25;- Resident #37's divalproex (an anticonvulsant medication) 500 mg delayed release with 56 tablets, expired 10/01/25;- Resident #58's one bottle of cholecalciferol (Vitamin D supplement) 50 mcg expired 01/26;- A discharged resident's amiodarone (medication to control heart rhythm and rate) 200 mg tablets with no expiration date; - A discharged resident's pantoprazole (heart burn medication) 40 mg delayed release tablets with no expiration date;- Resident #19's undated lorazepam (antianxiety medication) 2.1mg/milliliter (ml) open bottle with 28 ml left in the bottle;- Two vials of Afluria (flu vaccine) 5 ml multidose vial, opened and undated, expired 06/30/24;- Four vials of stock Aplisol tuberculin (purified protein derivative to test for tuberculosis infection) one ml vial, opened and undated;- One vial of Afluria 5 mg, opened and undated, expired 06/30/25;- Five vials of Afluria 5 mg multidose vial, unopened, expired 06/30/25. During an interview on 02/12/26 at 10:25 A.M., Certified Medication Technician (CMT) J said the pharmacy was here last week and there was no schedule for the nurses and CMTs to check the medication carts for expired medications, but they did look at the medication carts when possible, for expired medications. During an interview on 02/12/26 at 11:00 A.M, Licensed Practical Nurse (LPN) D said multidose medications should be labeled with the date it was opened. During an interview on 02/12/26 at 2:40 P.M., LPN E said nursing staff looked at the medication carts for expired medications when they could, but it was not a scheduled task. CMTs were usually good about finding expired medications and letting the nurses know. During an interview on 02/12/26 at 5:40 P.M., the Director of Nursing (DON) said nursing staff looked at the medication carts and room for expired medications, but it was not on a scheduled time frame. The pharmacy rounded once a month and delivered medications to the facility every day except the weekends. Expired medications should not be administered to the residents and staff should be checking the medications before administering. Medications should be labeled with the date it was opened.

Based on observation, interview, and record review, the facility failed to follow infection control precautions by not changing gloves, performing hand hygiene, and by not following enhanced barrier precautions (EBP - an infection control intervention for nursing homes designed to reduce the transmission of multidrug-resistant organisms (MDROs)) for one resident (Resident #54) out of two sampled residents. The facility also failed to use proper infection control techniques to wash residents' hands during a lunch service. The facility census was 64.Review of the facility policy titled, Urinary Catheter (a flexible tube inserted into the bladder to drain urine) Care, dated August 2022, showed: - Use a clean washcloth with warm water and soap or a bathing wipe to cleanse and rinse the catheter from the insertion site to approximately four inches outward. Review of the facility policy titled, Enhanced Barrier Precautions, dated December 2024, showed: - EBP apply when a resident is infected or colonized with a Centers for Disease Control (CDC) targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained; - EBP apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; - Indwelling medical devices include central lines, urinary catheter, feeding tubes, and tracheotomies; - Examples of secretions or excretions include wound drainage, fecal incontinences or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen; - EBPs employ targeted gown and glove use during high contact resident care activities; - Examples of high-contact resident care activities requiring the use of a gown and gloves include dressing, bathing, showering, providing hygiene or grooming, changing briefs, assisting with toileting, transferring, providing bed mobility, changing linens, device care, and wound care. Review of the facility policy titled, Handwashing/Hand Hygiene, undated, showed hand hygiene is indicated: - Immediately before touching a resident: - Before performing an aseptic technique (procedure that healthcare providers use to prevent the spread of germs that cause infection) task; - After contact with blood, body fluids, or contaminated surfaces; - After touching a resident's environment; - Before moving from work on a soiled body site to a clean body site on the same resident; - Immediately after glove removal; - Did not address resident hand hygiene. 1. Review of Resident #54's medical record showed: - An admission date of 02/09/23; - Diagnoses of neuromuscular dysfunction of the bladder (refers to what happens when an injury or disease interrupts the electrical signals between the nervous system and bladder function) and obstructive and reflux uropathy (a blockage in the urinary tract causing urine to back up and flow backward from the bladder to the kidneys); - An order to change the catheter every month starting on the 22nd of each month related to neuromuscular dysfunction of the bladder, dated 09/22/25; - An order for EBP related to Foley catheter (a type of catheter), dated 01/23/26; - An order to perform catheter care every shift for prevention, dated 09/03/25. Observation on 02/09/26 at 2:13 P.M., of Resident #54's incontinent and catheter care showed: - EBP signage on the door and PPE hung on the door; - Certified Nurse Assistant (CNA) L and CNA M put on gloves, did not perform hand hygiene, did not put on a gown, and entered the room; - CNA M pulled wipes from the container and handed them to CNA L; - CNA L cleaned the resident's front peri area, did not change gloves, and did not perform hand hygiene; - CNA L rolled the resident onto his/her right side facing CNA L; - CNA L did not change gloves, did not perform hand hygiene, pulled wipes from the container, and handed them to CNA M; - CNA M cleaned the resident's buttocks and rectal area, changed gloves, and did not perform hand hygiene; - CNA L and CNA M changed the bed linens and rolled the resident side-to-side; - CNA M did not change gloves, did not perform hand hygiene, cleaned the insertion site of the catheter, and cleaned the catheter by wiping toward the insertion site; - CNA L and CNA M changed gloves, did not perform hand hygiene, assisted the resident with putting clothes on, and pulled the resident up in the bed; - CNA M did not remove gloves, did not perform hand hygiene, and exited the resident's room with the bagged up trash and soiled linens from the room; - CNA L did not change gloves, did not perform hand hygiene, adjusted the resident's blanket, and hung the catheter bag on the bedframe; - CNA L did not change gloves, did not perform hand hygiene, picked up the resident's cup from the bedside table and exited the resident's room; - CNA L did not change gloves, did not perform hand hygiene, and entered the resident's room with the resident's cup full of ice; - CNA L did not change gloves, did not perform hand hygiene, poured tea into the resident's cup, and placed the lid on the cup; - CNA L removed gloves, did not perform hand hygiene, and exited the resident's room. During an interview on 02/12/26 at 4:55 P.M., CNA H said hand hygiene should be performed prior to putting on gloves. He/She the catheter should be cleaned by wiping around the insertion site and then wiping from the insertion site and away. He/She knew which residents were on EBP by the sign on the door, the PPE hanging on the door, and staff were told during report at the start of the shift. During an interview on 02/12/26 at 5:01 P.M., CNA N said hand hygiene should be performed when entering and leaving residents' rooms and when changing gloves. He/She knew what residents were on EBP by the sign on the door, the PPE hanging on the door, and any of his/her residents with wounds or catheters. During an interview on 02/12/26 at 5:06 P.M., Licensed Practical Nurse (LPN) C said residents on EBP had signs on the door and it was told in shift change report. Hand hygiene should be performed when entering residents' room and after removing gloves. Catheters should be cleaned by wiping around the insertion site and then down the catheter. During an interview on 02/12/26 at 6:30 P.M., the Administrator and the Director of Nursing (DON) said they would expect staff to wear gowns and gloves while performing high-contact care on residents with EBP. During an interview on 02/12/26 at 6:30 P.M., the DON said she would expect staff to change gloves and perform hand hygiene when going from dirty to clean care. She would expect staff to clean the urinary catheter from the insertion site and away from the body. During an interview on 02/12/26 at 6:30 P.M., the Corporate Compliance Officer said residents with MDROs, indwelling medical devices, and wounds should be on EBP. 2. Observations during the lunch service in the main dining room on 02/09/26 from 11:49 A.M. - 12:10 P.M., showed: - CNA T removed a rag from a bucket of soapy water, and washed a resident's hands with the rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag. Observation during the lunch service in the main dining room on 02/10/26 from 11:50 A.M. - 12:05 P.M., showed: - CNA T removed a rag from a bucket of soapy water and washed a resident's hands with the rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag. Observation during the lunch service in the main dining room on 02/11/26 from 11:46 A.M. - 12:00 P.M., showed: - CNA T removed a rag from a bucket of soapy water and washed a resident's hands with the rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket rag and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag; - CNA T placed the rag in the bucket and washed another resident's hands with the same rag. During an interview on 02/11/26 at 1:38 P.M., CNA T said that he/she used a rag in a bucket of soap and water to wash the residents' hands before meals. He/She used the same rag on each resident but washed it in the bucket of soapy water between each resident. During an interview on 02/12/26 at 6:40 P.M., the Administrator and Corporate Compliance Officer said that it was not appropriate for staff to use the same rag to clean multiple residents' hands.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 45. The facility did not provide an environment policy. 1. Observation on 11/05/24 at 10:35 A.M., showed room [ROOM NUMBER] with a one foot (ft) by six inches (in) hole in the dry wall on the right side of the window. 2. Observation on 11/05/24 at 10:48 A.M., of room [ROOM NUMBER] showed: - A hole in the dry wall at the foot of the bed three in by six in; - A hole in the dry wall under the bathroom sink three in by six in; - Missing dry wall which exposed the metal corner mold along the wall by the bathroom door; - Multiple scraped areas of the dry wall along the wall by the room exit door. During an interview on 11/05/24 at 10:49 A.M., the resident in room [ROOM NUMBER] said he/she was unsure how long the walls had been like this but at least a few months. 3. Observation on 11/05/24 at 10:50 A.M., showed a two ft missing section of base cove around the corner of room [ROOM NUMBER]. During an interview on 11/08/24 at 12:30 P.M., the Maintenance Director said he/she had forms to fill out if something needed fixed but most of the time, everyone just told him/her if something needed fixed or looked at. During an interview on 11/08/24 at 1:33 P.M., the Administrator said she would expect the building to be in good repair. 49152

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility initiated transfer when two residents (Residents #6 and #30) out of five sampled residents transferred to the hospital. The facility's census was 45. Review of facility policy titled, Discharge/Transfer of Resident, undated, showed: - Give copy of a signed transfer or discharge notice to the resident and/or representative or person responsible for care; - If an emergency transfer, a transfer or discharge notice form may be completed later, but as soon as possible. 1. Review of Resident #6's medical record showed: - The resident transferred to the hospital on 04/09/24, and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on 04/09/24. 2. Review of Resident #30's medical record showed: - The resident transferred to the hospital on 03/08/24, and readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on 03/08/24. During an interview on 11/08/24 at 11:28 A.M., the Director of Nursing (DON) said they had not been able to find any transfer/discharge notices. During an interview on 11/08/24 at 1:33 P.M., the Administrator said she would expect transfer/discharge notices to be given when residents transfer to the hospital. 49152 49999

Based on interview and record view, the facility failed to inform the resident and/or the resident's representative of the facility bed hold policy at the time of transfer to the hospital for two residents (Residents #6 and #30) out of five sampled residents. The facility's census was 45. Review of facility policy titled, Discharge/Transfer of Resident, undated, showed: - Explain and give a copy of the bed hold form to the resident and/or representative. 1. Review of Resident #6's medical record showed: - The resident transferred to the hospital on 04/09/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer. 2. Review of Resident #30's medical record showed: - The resident transferred to the hospital on 03/08/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer. During an interview on 11/08/24 at 11:28 A.M., the Director of Nursing (DON) said bed hold policies prior to her and the Administrator starting at the facility were not found. During an interview on 11/08/24 at 1:33 P.M., the Administrator said she would expect bed hold policies were to be given when residents transfer to the hospital. 49999

Based on observation, interview, and record review, the facility failed to ensure the environment remained free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in seven occupied resident room sinks and two community showers, which put the residents at an increased risk of injuries from exposure to the hot water. These practices had the potential to affect all the residents at the facility. The facility census was 45. The facility did not provide a policy regarding water temperatures. Review of the Burn Foundation website showed hot water caused third degree burns (full thickness burns which go through the skin and affect deeper tissue resulting in white or blackened, charred skin) at the following temperatures and time parameters: - In one second at 156 degrees F; - In two seconds at 149 degrees F; - In five seconds at 140 degrees F; - In 15 seconds at 133 degrees F; - In one minute at 127 degrees F. Observation on 11/05/24 at 12:15 P.M. through 12:33 P.M., of water temperatures taken at 60 seconds with a digital thermometer showed: - room [ROOM NUMBER] hot water temperature recorded at 128 degrees F; - room [ROOM NUMBER] hot water temperature recorded at 132 degrees F; - room [ROOM NUMBER] hot water temperature recorded at 124 degrees F; - room [ROOM NUMBER] hot water temperature recorded at 129 degrees F; - The 400 Hall shower room water temperature recorded at 122 degrees F. Observation on 11/08/24 at 10:04 A.M. through 10:15 A.M., of water temperatures taken at 60 seconds with a digital thermometer showed: - room [ROOM NUMBER] water temperature recorded at 141 degrees F; - room [ROOM NUMBER] water temperature recorded at 129 degrees F; - room [ROOM NUMBER] water temperature recorded at 129 degrees F; - room [ROOM NUMBER] water temperature recorded at 131 degrees F; - The 500 Hall shower room water temperature recorded at 124 degrees F. Observation on 11/08/24 at 10:18 A.M., of the mechanical room on the 200 Hall showed one hot water heater with two non-digital external thermometers for monitoring and setting the temperatures. Both thermometers showed temperatures of 122 degrees F. Observation on 11/08/24 at 10:20 A.M., of the mechanical room on the 100 Hall showed one hot water heater with two non-digital external thermometers for monitoring and setting the temperatures. The first thermometer showed 140 degrees F and the second thermometer showed 130 degrees F. Observation on 11/08/24 at 10:22 A.M., of the mechanical room on the 400 Hall showed one hot water heater with two non-digital external thermometers for monitoring and setting the temperatures. Both thermometers showed temperatures of 132 degrees F. During an interview on 11/05/24 at 2:34 P.M., Certified Nurse Assistant (CNA) F said no residents had reported the water being too hot or being scalded by the water on the 400 Hall. During an interview on 11/08/24 at 10:50 A.M., the resident in room [ROOM NUMBER] said the water had been really cold but today it was scalding hot. During an interview on 11/08/24 at 10:00 A.M., the Maintenance Supervisor said the plumber was at the facility yesterday and fixed the water heater pump for the 100 Hall. The plumber set the the hot water heater thermometer at 125 degrees F. During an interview on 11/20/24 at 10:30 A.M., the Administrator said she expected the water temperatures in the resident rooms and resident care areas to be between 105 and 120 degrees F.

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing was dated when changed for one resident (Resident #12) and failed to ensure a physician's order for oxygen with the use of a bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) was followed for one resident (Resident #195) out of two sampled residents. The facility census was 45. Review of the facility's policy titled, Oxygen Administration, undated, showed: - The purpose is to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues; - Prefilled disposable humidifiers may be changed when empty; - Set the flow meter to the rate ordered by the physician; - Label the humidifier with the date and time opened; - Change humidifier and tubing per cleaning guidelines; - At regular intervals, check and clean the oxygen equipment, masks, tubing and cannulas; - At regular intervals, check the liter flow contents of the oxygen cylinder, fluid level in the humidifier, and assess the resident's respiration. Review of the facility policy titled, Physician Orders, undated, showed oxygen orders must specify the rate of flow, route, and rationale for use. 1. Review of Resident #12's medical record showed: - admitted [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD - a group of lung diseases that causes restricted airflow and breathing problems) and chronic kidney disease (kidneys do not filter waste and fluid like they should). Review of the resident's Physician Order Sheet (POS), dated October 2024, showed: - An order for oxygen at 2 liters per minute (LPM) by nasal cannula (NC - a flexible tube inserted into the nose to administer supplemental oxygen) as needed for shortness of breath, dated 08/13/24; - An order to change oxygen tubing monthly on the first of the month, dated 08/13/24. Observation of the resident on 11/06/24 at 2:42 P.M., showed the resident sat on the side of the bed with oxygen on at 2 LPM via NC and the oxygen tubing was not dated. Observation of the resident on 11/08/24 at 9:29 A.M., showed the resident sat in the wheelchair with oxygen on at 2 LPM via NC and the oxygen tubing was not dated. During an interview on 11/06/24 at 2:43 P.M., Resident #12 said the nurses changed the tubing but was unsure when it was changed last. 2. Review of Resident #195's medical record showed: - admitted [DATE]; - Diagnoses of acute respiratory failure, heart failure (heart not pumping as it should), and chronic kidney disease. Review of the resident's POS, dated October 2024, showed: - An order for oxygen at 2 LPM by NC continuous, dated 10/18/24; - No order for BIPAP. Review of the resident's care plan, revised 10/23/24, showed: - Administer oxygen as prescribed; - Did not address the BIPAP. Observation on 11/06/24 at 10:15 A.M., showed Resident #195 lay in bed sleeping on his/her left side with a BIPAP and 2 LPM of oxygen bled in. Observation on 11/06/24 at 11:55 A.M., showed the resident sat on the side of the bed and did not wear oxygen. Observation on 11/07/24 at 10:28 A.M., showed the resident sat on the side of the bed and did not wear oxygen. Two staff were assisting the resident with a dressing change. Observation on 11/08/24 at 10:45 A.M., showed the resident sat in a wheelchair, did not wear oxygen, and one staff in the room. During an interview on 11/08/24 at 8:20 A.M., Registered Nurse (RN) I said he/she thought Resident #195 was supposed to have oxygen 2 LPM bled into the BIPAP. He/She couldn't find an order for the resident's BIPAP with the settings. During an interview on 11/08/24 at 12:02 P.M., RN G said nurses were responsible for BIPAP equipment and changing the tubing monthly. During an interview on 11/08/24 at 12:35 P.M., the Director of Nursing (DON) said nurses were responsible for managing the BIPAP and for changing the tubing monthly. There should be an order for the BIPAP with the settings. During an interview on 11/08/24 at 1:33 P.M., the DON and Administrator said they would expect the resident to have an order for the BIPAP use including the settings. 49152

Based on interview and record review, the facility failed to ensure two nurse aides (NAs) (NA B and NA C) completed a nurse aide training program within four months of his/her employment in the facility out of two sampled NAs. This deficient practice had the potential to affect all residents in the facility. The facility census was 45. The facility did not provide a policy on the nurse aide training program. 1. Review of NA B's Training Record showed: - Hire date of 06/12/24; - NA B attended an online nurse aide program; - The facility failed to ensure the completion of the program within four months of the hire date. 2. Record review of NA C's Training Record showed: - Hire date of 06/25/24; - NA C attended an online nurse aide program; - The facility failed to ensure the completion of the program within four months of the hire date. During an interview on 11/07/24 at 9:30 A.M., the Director of Nursing (DON) said the currently employed NAs were taking nurse aide training through an online program. She thinks NA B and NA C had completed the program and were waiting on permission to take their tests. During an interview on 11/07/24 at 9:45 A.M., the Administrator said she would expect NAs to complete a nurse aide training program within four months of their hire date.

Based on interview and record review, the facility failed to provide nurse aide's annual individual performance review or evaluation, and failed to provide annual in-service training based on the outcome of performance reviews for two Certified Nurse Assistants (CNAs) (CNA D and CNA E) out of two sampled CNAs. The facility census was 45. The facility did not provide a policy on CNA performance review and training requirements. 1. Review of CNA D's in-service record showed: - CNA D with a hire date of 02/22/22; - CNA D did not receive an annual individual performance review or evaluation; - No annual in-service training for February 2023 through February 2024. 2. Review of the CNA E's in-service record showed: - CNA E with a hire date of 02/18/15; - CNA E did not receive an annual individual performance review or evaluation; - No annual in-service training for February 2023 through February 2024. During an interview on 11/07/24 at 9:00 A.M., the Administrator said no employee performance reviews or evaluations had been done since she started in May 2024, and there was no documentation they had been done prior to her employment either.

Based on interview and record review, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic (medications that treat psychosis-related conditions and symptoms) medication for one resident (Resident #37) out of five sampled residents. The facility census was 45. Review of the facility's policy titled, Antipsychotic Medication Use, not dated, showed: - Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; - Antipsychotic medications shall only be used for the following conditions/diagnoses as documented in the record: schizo-affective disorder (a chronic mental illness that combines symptoms of schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors) and a mood disorder (a mental health condition that involves a persistent change in a person's emotional state)), mood disorders, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) with psychotic (a severe mental disorder that causes a person to lose touch with reality) features, psychosis not otherwise specified, brief psychotic disorder, schizophrenia , delusional disorder (a psychiatric condition characterized by a person having one or more fixed false beliefs), schizophreniform disorder (a mental health condition that causes symptoms similar to schizophrenia, but for a shorter period of time), atypical psychosis, dementing (causing or characterized by dementia, a disease that can cause memory loss, confusion, and disorientation) illness with associated behavioral symptoms. 1. Review of Resident #37's medical record showed: - admitted to the facility on [DATE]; - Diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), generalized anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression, and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep); - An order for olanzapine (an antipsychotic medication) 2.5 milligrams (mg) at bedtime for insomnia, dated 08/21/24; - No documentation for an appropriate diagnosis for the olanzapine. Review of the resident's Pharmacist monthly Medication Regimen Review (MRR) for September and October 2024 showed: - No recommendation for an appropriate diagnosis for the olanzapine. During an interview on 11/07/24 at 2:30 P.M., the Director of Nursing (DON) said insomnia was not an appropriate diagnosis for an antipsychotic medication. During an interview on 11/19/24 at 12:38 P.M., Pharmacist N said insomnia was not an appropriate diagnosis for an antipsychotic medication. Physician orders were reviewed on a monthly basis, but Resident #37's olanzapine was not due for a gradual dose reduction yet, so it may not have been reviewed during the MRR.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 32 opportunities with two errors made, for an error rate of 6.25%, which affected two residents (Residents #33 and #195) out of six sampled residents. The facility census was 45. The facility did not provide a medication error policy. Review of the insulin aspart manufacture guidelines for giving the airshot (prime) before each injection and administration, revised 02/2023, showed: - Turn the dose selector to select 2 units; - Hold the pen with the needle pointing up; - Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge; - Keep the needle pointing upwards, press the push-button all the way in; - The dose selector returns to zero; - A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times; - Select your dose. 1. Review of Resident #33's Physician Order Sheet (POS), dated November 2024, showed an order for insulin aspart 18 units subcutaneous (an injection under the skin) at 7:00 A.M., 12:00 P.M., and 5:00 P.M., with meals every day, dated 09/30/24. Observation on 11/06/24 at 11:45 A.M., of the resident's insulin aspart administration showed Registered Nurse (RN) G failed to prime the insulin aspart pen before administering the 18 units. 2. Review of Resident #195's POS, dated November 2024, showed an order for insulin aspart 10 units subcutaneous at 7:00 A.M., 12:00 P.M., and 5:00 P.M., with meals every day, dated 10/16/24. Observation on 11/06/24 at 11:59 A.M., of the resident's insulin aspart administration showed RN G failed to prime the insulin aspart pen before administering the 10 units. During an interview on 11/06/24 at 11:46 A.M., RN G said he/she primed the insulin pens the first time they were used. The insulin pens didn't require priming after the first use. During an interview on 11/08/24 at 1:35 P.M., the Director of Nursing (DON) and the Administrator said they would expect staff to administer medications according to the manufacturer's guidelines.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect the thirteen residents who were served food from the 400 Hall refrigerator. The facility census was 45. Review of facility policy titled, Receiving and Storage of Food, dated May 2015, showed: - All perishable items are stored in either refrigerators at a temperature of 40 degrees Fahrenheit (F) or below or freezers at a temperature of 0 degrees F or below. The facility did not provide refrigerator temperatures for the 400 Hall. 1. Observation on 11/07/24 at 12:10 P.M., of the 400 Hall unit refrigerator showed: - A temperature of 50 degrees F; - An opened container of milk, unlabeled and undated; - A pitcher of a purple liquid, unlabeled and undated; - An unopened container of yogurt. 2. Observation on 11/07/24 at 2:00 P.M., of the 400 Hall unit refrigerator showed: - A temperature of 50 degrees; - An opened container of milk, unlabeled and undated; - An unopened container of yogurt. 3. Observation on 11/08/24 at 8:56 A.M., of the 400 Hall unit refrigerator showed: - A temperature of 50 degrees; - An opened container of milk, unlabeled and undated; - A pitcher of yellow liquid, unlabeled and undated; - A pitcher of red liquid, unlabeled and undated. During an interview on 11/07/24 at 12:19 P.M., Nurse Aide (NA) B said the refrigerator on the 400 Hall was mainly used for employee's food but it was also used to store the residents' leftover drinks from meals. Maintenance monitored the refrigerator temperatures. During an interview on 11/07/24 at 12:19 P.M., Certified Nurse Aide (CNA) A said he/she brought the opened milk container over from the kitchen, but did not date the container when it was opened. During an interview on 11/07/24 at 3:50 P.M., the Maintenance Supervisor said he/she monitored the temperatures for the unit refrigerators and keeps a log which was kept in the kitchen. During an interview on 11/08/24 at 9:19 A.M., the Dietary Manager said he/she did not keep logs of the unit refrigerators and staff should be dating the milk when the containers were opened. During an interview on 11/8/24 at 1:33 P.M., the Administrator said she would expect unit refrigerator temperatures to be checked regularly and to be maintained below 41 degrees F.

Based on interview and record review, the facility failed to ensure the quality assessment and assurance (QAA) committee attendees included an Infection Preventionist (IP). This failure had the potential to affect all 45 residents who reside at the facility. The facility's census was 45. The facility did not provide a policy regarding the QAA Committee. The facility did not provide QAA Committee Attendance records prior to September 2024. Review of the QAA Committee Attendance record, dated September 2024, showed the IP did not attend the meeting as required. During an interview on 11/06/24 at 8:50 A.M., the Administrator said the IP did not attend the QAA meeting because he/she had been working as the charge nurse on the night shift. She did not have the QAA Committee Attendance records prior to September 2024.

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment by not wearing source control (facemasks) during a Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 - a member of a large family of viruses called coronaviruses) outbreak. This deficient practice had the potential to affect all residents in the facility. The facility's census was 45. Review of the Infection Control Guidance, provided by the Centers for Disease Control and Prevention (CDC), updated on 05/08/23, showed: - Source control is recommended for those working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of a respiratory infection; - Universal use of source control could be discontinued once the outbreak is over; - Visitors should be counseled about their potential to be exposed to SARS-CoV-2 in the facility. Review of the facility's policy titled, Outbreak Management, SARS-CoV-2 for Long Term Care Facilities, last revised 05/15/23, showed: - The strategies CDC recommends to prevent the spread of SARS-CoV-2 in long term care communities are the same strategies used every day to detect and prevent the spread of other respiratory viruses like influenza; - Ensure facility staff are educated, trained, and have practiced the appropriate use of personal protective equipment (PPE) prior to caring for a resident; - Source control refers to the use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; - Source control is recommended for those working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection. 1. Observations on 11/05/24 showed: - At 9:55 A.M., no sign posted on the entry door indicating the facility in COVID 19 outbreak status; - At 9:57 A.M., no signs indicating isolation on the rooms of the COVID 19 positive residents; - At 9:58 A.M., Licensed Practical Nurse, (LPN) L sat at the desk without a face covering or mask; - At 10:00 A.M., LPN M placed isolation gowns on the isolation cart outside of the COVID 19 positive rooms, and returned to the common area with other residents present, without a face covering or mask; - At 12:23 P.M., staff assisted residents in the dining room without face coverings or masks. 2. Observations on 11/06/24 showed: - At 8:46 A.M., Certified Medication Technician (CMT) H failed to wear a mask when administering medications to residents in the common area; - At 8:58 A.M., CMT H failed to wear a mask when administering medications to residents in the common area; - At 9:16 A.M., CMT H failed to wear a mask when administering medications in room [ROOM NUMBER]; - At 9:20 A.M., CMT H failed to wear a mask when administering medications to residents in the common area on the locked unit; - At 11:32 A.M., Registered Nurse (RN) G failed to wear a mask when checking a blood sugar in room [ROOM NUMBER]; - At 11:37 A.M., RN G failed to wear a mask when checking a blood sugar in room [ROOM NUMBER]; - At 11:40 A.M., RN G failed to wear a mask when checking a blood sugar in room [ROOM NUMBER]; - At 11:45 A.M., RN G failed to wear a mask when checking blood sugar and administering insulin in room [ROOM NUMBER]; - At 11:59 A.M., RN G failed to wear a mask when administering insulin in room [ROOM NUMBER]. During an interview on 11/05/24 at 10:45 A.M., Housekeeper J said staff had to dress up with the PPE outside the COVID rooms before going in, but no one had said anything about wearing a mask outside the COVID rooms. During an interview on 11/08/24 at 9:10 A.M., CNA K said no one had said anything about wearing a mask outside the COVID rooms. If he/she needed to go into a COVID room, then needed to wear a faceshield, gown, gloves, and a N95 mask. During an interview on 11/05/24 at 2:30 P.M., the Director of Nursing (DON) said the facility's protocol at this time was for staff to wear face masks in the isolation rooms only. During an interview on 11/08/24 at 1:33 P.M., the Administrator and the DON said they expect staff to follow the CDC guidelines during a COVID-19 outbreak.

Based on interview and record review, the facility failed to conduct at least twelve hours of certified nurse assistant (CNA) in-service education per year and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) for two CNAs (CNA D and CNA E) out of two sampled CNAs. The facility census was 45. The facility did not provide a policy on nurse aide training requirements. 1. Review of Certified Nursing Assistant (CNA) D's in-service record showed: - A hire date of 02/22/22; - Did not attend an annual competency in-service training on Dementia Care; - No annual in-service training for February 2023 through February 2024; - Less than twelve hours of in-service education for February 2023 through February 2024. 2. Review of CNA E's in-service record showed: - A hire date of 0218/15; - Did not attend an annual competency in-service training on Dementia Care; - No annual in-service training for February 2023 through February 2024; - Less than twelve hours of in-service education for February 2023 through February 2024. During an interview on 11/07/24 at 11:30 A.M., the Director of Nursing (DON) said she had started as DON in May 2024, and had been trying to catch staff up on the required training. During an interview on 11/08/24 at 1:45 A.M., the Administrator said she expects all CNAs to have at least 12 hours of continuing in-service training annually and the training should include training on Dementia Care.

Based on interview and record review, the facility failed to provide resident care for activities of daily living (ADLs) when residents did not receive scheduled showers for three residents (Residents #1, #2, and #3) out of three sampled residents. The facility census was 38. The facility did not provide a policy regarding shower frequency. 1. Review of Resident #1's medical record showed: - admitted [DATE]; - Diagnoses of osteoporosis (a decrease in bone mass and density) with fracture, muscle weakness, disc degeneration (a condition in which damaged disc causes pain), history of falling, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), lack of coordination, and frontotemporal neurocognitive disorder (a disorder when nerve cells of parts of the brain are lost, which can affect behavior, personality, language and movement). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 01/26/24, showed: - Moderate cognitive impairment; - Set up and clean up assistance from staff for upper body dressing and personal hygiene; - Moderate assistance for lower body dressing, toileting, and shower/bath. Review of the resident's comprehensive care plan, last revised 11/27/23, showed: - Resident requires assistance from staff with activities of daily living, incontinent care, and transfers. Review of the facility's shower schedule showed the resident was scheduled for showers on Mondays and Thursdays. Review of the resident's shower sheets from 01/01/24 through 02/21/24, showed seven out of 15 opportunities for showers missed. During an interview on 01/21/23 at 10:55 A.M., the resident said he/she has gone a week at a time without a shower and had to request to get those. 2. Review of Resident #2's medical record showed: - admitted [DATE]; - Diagnoses of dementia, compression fracture (a type of break in a bone caused by pressure) of the lower back, repeated falls, weakness, high blood pressure, and depressive episodes (a mood disorder that causes a periodic feeling of sadness and loss of interest in activities, causing significant impairment in daily life). Review of the resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Maximal assistance of staff for lower body dressing, toileting and shower/bath; - Moderate assistance for upper body dressing, and personal hygiene. Review of the resident's comprehensive care plan, last revised on 01/15/24, showed: - Resident requires assistance from staff with activities of daily living, incontinent care, and transfers. Review of the facility's shower schedule showed the resident was scheduled for showers on Mondays and Thursdays. Review of the resident's shower sheets from 01/01/24 through 02/21/24 showed 10 out of 15 opportunities for showers missed. During an interview on 02/21/24 at 11:10 A.M., the resident said he/she rarely gets a shower, for sure not twice a week. 3. Review of Resident #3's medical record showed: - admitted [DATE]; - Diagnoses of heart failure, unsteadiness on feet, history of falling, lack of coordination, high blood pressure, and depressive episodes. Review of the resident's annual MDS, dated [DATE], showed: - No cognitive impairment; - Independent for upper and lower dressing, personal hygiene, and toileting; - Supervisory or touching assistance from staff for shower/bath. Review of the resident's comprehensive care plan, dated 11/27/23, showed: - Assistance with activities of daily living was not addressed. Review of the facility's shower schedule showed the resident was scheduled for showers on Tuesdays and Fridays. Review of the resident's shower sheets from 02/09/24 through 02/21/24 showed four out of four opportunities for showers missed. During an interview on 02/21/24 at 11:24 A.M., the resident said he/she has not had a shower since moving to this side of the building, needs assistance from staff with showers since breaking wrist during a fall, and is concerned he/she may have a bad odor due to not having a shower. During an interview on 01/21/24 at 11:45 A.M., Registered Nurse (RN) A said residents should have a shower twice per week per the shower schedule and aides fill out shower sheets when done. During an interview on 01/21/24 at 11:48 A.M., Certified Nursing Assistant (CNA) B said residents should have two showers a week, and if they didn't, it was due to low staffing. During an interview on 01/21/24 at 11:49 A.M., CNA C said they did have a shower aide that performed showers, but due to low staffing, there isn't one now, and if a resident refuses a shower, CNAs fill out a shower sheet, mark refused, and tell the charge nurse. During an interview on 01/21/24 at 12:30 P.M., the Administrator said the prior shower aide did not work out, and a new shower aide will be assigned to ensure residents will receive showers twice per week. CMP #MO232039

Based on interview and record review, the facility failed to follow the resident's risk assessment dated [DATE] to ensure staff utilized safe transfer techniques for one resident (Resident #5) when staff failed to transfer the resident via mechanical lift. The resident sustained a right mid shaft femur fracture (the long, straight part of the thighbone). The facility census was 39. Review of the facility's policy titled, Transfer Activities, not dated, showed: - The purpose is to transfer the resident from bed to chair safely; - Gather equipment, mechanical lift, if necessary. 1. Review of Resident #5's medical chart showed: - An admitted [DATE]; - Diagnoses of thyroid disorder, malnutrition (lack of proper nutrition), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and act); - Cognitively impaired; - Received hospice services; - Weight of 67 pounds (lbs.). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 07/26/23, showed: - Cognitively impaired; - Total dependence of one staff for bed mobility, dressing, personal hygiene and bathing; - Total dependence of two staff for transfers and toilet use; - Always incontinent of bowel and bladder. Review of the resident's Lift Assessment, dated 08/09/23, showed: - Weight less than 99 lbs.; - Able to bear partial weight, extreme weakness; - Impaired sensory perception; - Required a minimum of two staff to lift/transfer; - Transfer the resident via mechanical lift. Review of the resident's care plan, last revised 08/22/23, showed: - The resident required assist of staff with activities of daily living (ADL's), incontinent care and transfers; - Required a minimum of two staff to lift/transfer, dated 08/22/23; - Did not address how to transfer the resident. Review of the resident's hospital records, dated 8/24/23, showed: - The resident presented to the emergency room with an extensive right thigh deformity with bone tenting (bone protruding out to the skin) in two places; - The resident sustained a horrific closed right mid shaft femur fracture; - It was reported the staff at the facility turned him/her and caused the thigh to snap. - The resident was severely frail. - Orthopedic surgeon consulted and only recommended traction (the action of pulling of on part of the body). During an interview on 08/29/23 at 9:30 A.M., the Director of Nursing (DON) said the Certified Nurse Aide (CNA) D and G put the resident to bed after breakfast. The hospice staff showed up to care for the resident and at 9:45 A.M., at the request of the hospice nurse, the DON gave the resident a dose of Tylenol pain medication. At 10:00 A.M., the hospice nurse notified her of the resident's leg being abnormal. She went and assessed the resident's leg and the right knee was inverted inward and with the bone pushed against the skin of the right lateral (most outer side) thigh. The resident complained of pain. The physician was called and gave a new order to send the resident to the emergency room . During a phone interview on 08/29/23 at 2:03 P.M., CNA D said the the resident made a face when the wheelchair was bumped after he/she propelled the chair back to the room. The resident complained of pain. CNA D said the mechanical lift pad was not positioned under the resident safely, so CNA D and CNA G used a bed/incontinent pad to transfer the resident from the chair to the bed by holding on to opposite sides of the pad and lifted the resident from the chair to the bed. During an interview on 08/29/23 at 3:07 P.M., the DON said CNA D and CNA G told her they transferred the resident with a bed/incontinent pad from the chair to the bed. During an interview on 08/29/23 at 3:43 P.M., the Physician said if the resident's medical record showed they should be transferred with a mechanical lift, then that was what he/she would expect. During an interview on 08/29/23 at 3:56 P.M., CNA E said if he/she wasn't sure how to transfer a resident, then he/she should look at the care plan. If it's not on the care plan, then he/she would ask the charge nurse. He/She would absolutely never use an incontinent pad/bed pad to transfer a resident. If the resident's medical record showed a gait belt transfer, then the gait belt should be used, and if it showed a mechanical lift, then that was what should be used. During an interview on 08/29/23 at 4:00 P.M., Nurse Aide (NA) F said he/she would look at the care plan, if not there, then he/she would ask the charge nurse, then the DON. He/she said the facility had ordered a smaller mechanical lift pad for the resident. During an interview on 08/29/23 at 4:35 P.M., the Administrator said there had been an in-service completed 08/02/23 regarding the correct way to transfer this resident. The staff knew they should be transferring the resident by the mechanical lift. The two CNA's that improperly transferred the resident had been re-educated. During a phone interview on 08/31/23 at 10:32 A.M., CNA H said on the early morning of 08/24/23, he/she transferred the resident by him/herself with the mechanical lift. The resident did not have any abnormalities of any kind at that time and no facial grimace or anything. During a phone interview on 08/31/23 at 10:58 A.M., CNA G said he/she assisted CNA D in transferring the resident with the bed/incontinent pad due to the mechanical lift pad not being correctly positioned under the resident. He/She was never told or inserviced on how to transfer the resident. Complaint #MO223432 and MO223559

Based on interview and record review, the facility failed to assess a resident after a fall and failed to investigate, document, assess and treat in a timely manner one resident (Resident #1) of three sampled residents. On [DATE] at 4:00 A.M., the resident fell to the floor and no notifications, interventions or assessment took place until 1:30 P.M. that afternoon, seven hours later, when Resident #1 was sent to the hospital and diagnosed with a displaced hip fracture. The facility census was 41. The facility did not provide a policy regarding falls or post fall protocol. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated [DATE] showed: - Admission to facility on [DATE]; - Diagnoses of Alzheimer's disease ( a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, the disease involves parts of the brain that control thought, memory, and language), dementia with behavioral disturbances (Behavioral disturbances in dementia are often globally described as agitation including verbal and physical aggression, excessive wandering, and sleep disturbance), anxiety, major depressive disorder (Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily living), lack of coordination (lost of balance); - Cognition impaired; - Delirium with fluctuating behaviors of inattention and disorganized thinking, comes and goes and changes in severity; - Behaviors of wondering daily; - Requires supervision of one staff member for exiting secure unit; - Occasionally incontinent of bowel and bladder; - Receives antipsychotic ( medication that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking) and antidepressant medications seven days a week on a routine basis; - Guardian in place. Review of the Resident #1's Care Plan, showed: - At risk for falls related to diagnosis of Alzheimer's and overestimates abilities at times; - Resident resides on the special care unit due to diagnosis of Alzheimer's; - The resident has difficulty making safe decisions related to a history of dementia; Review of the resident's [DATE] Physician Order Sheet (POS), showed: - No order for pain/fever reducing medications; - No order to send resident to emergency room for evaluation; - No orders or instructions for post-fall monitoring such as neuro-checks. Review of the progress notes showed: - On [DATE] at 4:10 A.M., resident entered other resident rooms, when told not to enter the room resident became combative with the staff and attempted to hit staff. The resident then threw self into floor and started screaming and hollering for help and saying she hit me, staff assisted the resident back to his/her room, will continue to monitor; - On [DATE] at 2:06 P.M., the resident complained of severe pain to the right pelvic area due to a fall this morning. Contacted the resident Power of Attorney (POA) (a legal document allowing a person to act on your behalf), ambulance responding to facility to transport resident to hospital. Review of Resident #1 hospital report dated [DATE] through [DATE] showed: - Resident #1 admitted with displaced right hip fracture; - Resident expired on 0 [DATE] with cause of death listed as Alzheimer's disease and right hip fracture. The facility did not provide any investigation of the fall or post fall assessment of the resident. During a interview on [DATE] at 10:45 A.M., Registered Nurse (RN) A said on [DATE] during shift report, the previous nurse, RN B, did not give any report on Resident #1's behaviors or changes in condition. RN A said his/her shift began as usual, going to the special care unit at approximately 6:30 A.M. Upon entering the unit a staff member informed him/her Resident #1 had thrown him/herself in the floor on the prior shift. RN A said he/she went to the resident's room to assess and found the resident's right leg bent at the knee with rotation (indicating a fracture). The resident cried out in pain when touching the knee/pelvic/hip area. RN A said he/she was surprised the night shift nurse did not notice the rotation in the right leg due to it was very obvious. RN A said he/she did not notify the physician or family, and did not administer any pain medications to the resident. RN A said he/she waited for the Administrator to come to work and assess the resident. At approximately 1:30 P.M. (seven hours later) the Administrator came in and they both decided to notify the family and call an ambulance to transfer the resident to the emergency room . RN A said time got away from him/her with other duties and the Administrator had left the building, so he/she did not remember to inform her (administrator) he/she needed her to look at Resident #1 until later that afternoon. When asked if the resident was in pain that entire time, RN A did not respond. When asked why no pain medications were administered upon the initial observation of the injury, RN A did not respond. When asked why the doctor and family were not contacted upon discovery, RN A did not respond. When asked what the facility's policy on post-fall monitoring was, RN A did not respond. When asked why he/she felt the resident needed the Administrator's assessment prior to any interventions, RN A did not respond. During an interview on [DATE] at 1:25 P.M., Certified Nurse Aide (CNA) C said he/she was working the special needs unit during the night shift on [DATE]. At approximately 4:00 A.M., CNA C went to the employee rest room on the unit. When CNA C came out, Resident #1 was standing at the door attempting to get past him/her to get into the bathroom. CNA C said he/she tried to assist the resident to turn around when the resident suddenly went to the floor, landed on his/her knees, screamed and slapped the floor and rolled around. RN B heard the commotion and came onto the unit along with CNA D. RN B checked the resident's vital signs while the resident was holding his/her right knee. RN B directed CNA C and CNA D to get the resident off the floor and assist Resident #1 to his/her room. The resident limped on the right leg from where he/she fell to his/her room at the opposite end of the hall. The resident then remained in his/her room screaming for an unknown person and her spouse. No other interventions were done that he/she is aware of. CNA C said Resident #1 had been limping prior to the fall due to a blister on the right foot, but had not appeared to be in the extreme pain he/she was exhibiting after the incident. During an interview on [DATE] at 2:35 P.M., CNA D said RN B ask him/her to assist on the special needs unit on [DATE] at 4:00 A.M. to help get Resident #1 off the floor. Upon entering the unit CNA D observed Resident #1 on the floor on his/her left side crying out and asking for his/her spouse. When RN B attempted to move the resident's right leg Resident #1 screamed out with pain, the staff attempted to get the resident to sit in a wheelchair but he/she refused, so he/she and CNA C walked Resident #1 to his/her room while the resident limped and cried. CNA D said the resident was obviously in a great deal of pain. During a telephone interview on [DATE] at 2:45 P.M., RN B said CNA C had called him/her to the unit saying Resident #1 put him/herself on the floor. Upon arrival, RN B saw Resident #1 on the floor yelling he/she pushed me and broke my leg referring to CNA C. The resident was holding his/her right leg. RN B said he/she knew Resident #1 had previously had a blister on his/her right foot, and thought that was why he/she held the right leg. The staff assisted the resident to his/her room. The resident limped and cried during the walk to his/her room. The resident continued to cry as staff assisted him/her to lay on the bed. RN B said he/she looked at the resident legs and did not notice any deformities. RN B said he/she asked the resident if he/she was in pain and the resident would point at his/her lower leg. RN B said he/she did not administer any pain medication at that time because the resident denied being in pain. When asked why he/she thought the resident would respond to being asked about pain by pointing at his/her right leg was not an indication of pain, RN B did not respond. RN B said he/she went back about an hour later and the resident was still crying and yelling out for his/her spouse. At that time, he/she administered an antianxiety medication to calm the resident. RN B said he/she did not go back and check the resident again. RN B said neither the family, nor the physician was notified. When asked why no pain medications were given when the resident indicated her leg hurt during the initial incident, RN B did not answer. When asked why after waiting an hour and finding the resident still crying, no pain medications were given or pain assessment completed, RN B did not answer. When asked what the facility's policy for post fall assessment was, RN B said he/she did not consider the resident dropping to the floor a fall, he/she felt it was a behavior. RN B believed he/she did share the condition of the resident with the oncoming shift as is the policy. During an interview on [DATE] at 3:15 P.M., the Administrator said on [DATE] at 1:30 P.M., RN A notified her of Resident #1 having thrown him/herself in the floor during the night shift and had visible rotation on the right lower leg. She accompanied RN A and assessed the resident. Resident #1 had rotation noted on the right leg. She then advised RN A to call the family and ask if they wanted a portable X-ray or have the resident sent to the emergency room . The family chose to have Resident #1 sent to the emergency room at that time. RN A notified emergency medical services for a transfer. The Administrator said any time any resident is in the floor, she expected staff to assess the resident, document the situation and notify the physician and family. The Administrator said she considered this incident to be a fall and should have been treated as one. The Administrator said RN B should have investigated and assessed the resident's pain when the resident was still in the floor. The physician should have been called for further instruction at that time as well. The Administrator said when she arrived at work on [DATE] she was notified the resident had experienced a behavior, but was not informed of any potential injuries. The Administrator said, after she got to the facility she was scheduled to go shopping for residents. Had she known the resident had any complaints of pain, or that he/she had dropped to the floor, she would have gone and assessed the resident immediately. RN A or RN B could have contacted her at any time prior to her return to the facility and she would have come back or giving direction to contact the doctor. The Administrator said she expected the licensed staff, including RN A and RN B to call a resident's family, a resident's physician and/or emergency services without her consent. During an interview on [DATE] at 4:10 P.M., the Primary Care Physician (PCP) said he/she would have expected the staff to fully assess resident #1 after a fall regardless of putting self in floor or not and to notify him/herself of the incident in a timely manner. The PCP said they should have given the resident at least Tylenol for pain after such an event and definitely would have been expected to be notified immediately when assessed to have a rotation in the lower extremities indicating a fracture which is very painful. Complaint #MO218205

Based on interview and record review, the facility failed to assess and treat one resident (Resident #1) of three sampled residents, in a timely manner after Resident #1 fell to to the floor on [DATE]. The fall occurred at 4:00 A.M., at 6:30 A.M., a nurse noted the resident was in pain and had marked rotation to the right leg, no interventions for pain or post fall procedures were put in place until seven hours later at 1:30 P.M., when the resident was sent to the hospital. Resident #1 was diagnosed with a displaced right hip fracture. The facility census was 41. The facility did not provide a policy regarding falls, post fall assessment or pain managment. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated [DATE] showed: - Admission to facility on [DATE]; - Diagnoses of Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, the disease involves parts of the brain that control thought, memory, and language), dementia with behavioral disturbances (Behavioral disturbances in dementia are often globally described as agitation including verbal and physical aggression, excessive wandering, and sleep disturbance), anxiety, major depressive disorder (Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily living), lack of coordination (lost of balance); - Cognition impaired; - Delirium with fluctuating behaviors of inattention and disorganized thinking, comes and goes and changes in severity; - Requires supervision of one staff member for exiting secure unit; - Guardian in place. Review of the resident Care Plan, showed: - At risk for falls related to diagnosis of Alzheimer's and overestimates abilities at times; - The resident has difficulty making safe decisions related to a history of dementia; The Care Plan did not address pain or pain management. Review of the [DATE] Physician Order Sheet (POS), showed: - No order for pain/fever reducing medications; - No order to send resident to emergency room for evaluation. Review of the progress notes showed: - On [DATE] at 4:10 A.M., Resident #1 threw self into floor and started screaming and hollering for help and saying she hit me, staff assisted the resident back to his/her room, will continue to monitor; - On [DATE] at 2:06 P.M., the resident complained of severe pain to the right pelvic area due to a fall this morning. Contacted the resident Power of Attorney (POA) (a legal document allowing a person to act on your behalf), ambulance responded to facility to transport resident to hospital. Review of Resident #1 hospital report dated [DATE] through [DATE] showed: - Resident #1 admitted with displaced right hip fracture; - Resident expired on [DATE] with cause of death listed as Alzheimer's disease and right hip fracture. The facility did not provide any investigation of the fall, post fall or pain assessment of the resident. During a interview on [DATE] at 10:45 A.M., Registered Nurse (RN) A said on [DATE] during shift report, the previous nurse, RN B, did not give any report on Resident #1's behaviors or changes in condition. RN A said his/her shift began as usual, going to the special care unit at approximately 6:30 A.M. Upon entering the unit a staff member informed him/her Resident #1 had thrown him/herself in the floor on the prior shift. RN A said he/she went to the resident's room to assess and found the resident's right leg bent at the knee with rotation (indicating a fracture). The resident cried out in pain when touching the knee/pelvic/hip area. RN A said he/she was surprised the night shift nurse did not notice the rotation in the right leg due to it was very obvious. RN A said he/she did not notify the physician or family, and did not administer any pain medications to the resident. RN A said he/she waited for the Administrator to come to work and assess the resident. At approximately 1:30 P.M. (seven hours later) the Administrator came in and they both decided to notify the family and call an ambulance to transfer the resident to the emergency room . RN A said time got away from him/her with other duties and the Administrator had left the building, so he/she did not remember to inform her (administrator) he/she needed her to look at Resident #1 until later that afternoon. When asked if the resident was in pain that entire time, RN A did not respond. When asked why no pain medications were administered upon the initial observation of the injury, RN A did not respond. When asked why the doctor and family were not contacted upon discovery, RN A did not respond. During an interview on [DATE] at 1:25 P.M., Certified Nurse Aide (CNA) C said he/she was working the special needs unit during the night shift on [DATE]. At approximately 4:00 A.M., CNA C went to the employee rest room on the unit. When CNA C came out, Resident #1 was standing at the door attempting to get past him/her to get into the bathroom. CNA C said he/she tried to assist the resident to turn around when the resident suddenly went to the floor, landed on his/her knees, screamed and slapped the floor and rolled around. RN B heard the commotion and came onto the unit along with CNA D. RN B checked the resident's vital signs while the resident was holding his/her right knee. RN B directed CNA C and CNA D to get the resident off the floor and assist Resident #1 to his/her room. The resident limped on the right leg from where he/she fell to his/her room at the opposite end of the hall. The resident then remained in his/her room screaming for an unknown person and her spouse. No other interventions were done that he/she is aware of. CNA C said Resident #1 had been limping prior to the fall due to a blister on the right foot, but had not appeared to be in the extreme pain he/she was exhibiting after the incident. During an interview on [DATE] at 2:35 P.M., CNA D said RN B ask him/her to assist on the special needs unit on [DATE] to help in get Resident #1 off the floor. Upon entering the unit CNA D observed Resident #1 on the floor on his/her left side crying out and asking for his/her spouse. When RN B attempted to move the residents right leg Resident #1 screamed out with pain, the staff attempted to get the resident to sit in a wheelchair but he/she refused so he/she and CNA C walked Resident #1 to his/her room while the resident limped and cried. CNA D said the resident was in obviously in a great deal of pain. During a telephone interview on [DATE] at 2:45 P.M., RN B said CNA C had called him/her to the unit saying Resident #1 put him/herself on the floor. Upon arrival, RN B saw Resident #1 on the floor yelling she pushed me and broke my leg referring to CNA C. The resident was holding his/her right leg. RN B said he/she knew Resident #1 had previously had a blister on his/her right foot, and thought that was why he/she held the right leg. The staff assisted the resident to his/her room. The resident limped and cried during the walk to his/her room. The resident continued to cry as staff assisted him/her to lay on the bed. RN B said he/she looked at the resident legs and did not notice any deformities. RN B said he/she asked the resident if he/she was in pain and the resident would point at his/her lower leg. RN B said he/she went back about an hour later and the resident was still crying and yelling out for his/her spouse. At that time the he/she administered a antianxiety medication to calm the resident. RN B said he/she gave the resident antianxiety medication because he/she felt like the resident denied having pain. When asked why no pain medications were given when the resident indicated her leg hurt during the initial incident, RN B did not answer. When asked why after waiting an hour and finding the resident still crying, no pain medications were given or pain assessment completed, RN B did not answer. When asked what the facility's policy for post fall assessment was, RN B said he/she did not consider the resident dropping to the floor a fall, he/she felt it was a behavior. During an interview on [DATE] at 3:15 P.M., the Administrator said on [DATE] at 1:30 P.M., RN A notified her of Resident #1 having thrown him/herself in the floor during the night shift and had visible rotation on the right lower leg. She accompanied RN A and assessed the resident. Resident #1 had rotation noted on the right leg. She then advised RN A to call the family and ask if they wanted a portable X-ray or have the resident sent to the emergency room . The family chose to have Resident #1 sent to the emergency room at that time. RN A notified emergency medical services for a transfer. The Administrator said she would have expected the staff to assess the resident, document any incident of the resident being in the floor, and notify the physician and family. The Administrator said she considered this incident to be a fall and should have been treated as one. The Administrator said when she arrived at work on [DATE] she was notified the resident had experienced a behavior, but was not informed of any potential injuries. The Administrator said, had she known of any injury or complaints of pain she would have assessed the resident immediately. During an interview on [DATE] at 4:10 P.M., the Primary Care Physician (PCP) said he/she would have expected the staff to fully assess resident #1 after a fall regardless of putting self in floor or not and to notify him/herself of the incident in a timely manner. The PCP said it would be difficult to evaluate pain in Resident #1 but the staff should have given the resident tat least Tylenol for pain after such an event and definitely would have been expected to be notified immediately when assessed to have a rotation in the lower extremities indicating a fracture which is very painful. Complaint #MO218205