Every finding on record at Livingston Manor Care Center

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care. When the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for three (Resident #01, Resident #02, and Resident #03) of the four sampled residents. The facility census was 26.Review of facility's Psychotropic Medication Use policy, reviewed February 2025, showed: - Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior;- These drugs include but are not limited to drugs in the following categories: Antipsychotic, Antidepressant, Anxiolytic, and Hypnotic;- Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative;- Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review 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, with the resident/representative prior to obtaining documented consent or refusal.1. Review of Resident #01's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 08/18/26, showed:- The resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS - is a standardized cognitive assessment tool required by the Centers for Medicare & Medicaid Services (CMS) for patients and residents in settings like skilled nursing facilities and home health) of 05;- The resident was taking antianxiety medication;- Diagnosis of dementia. Review of the resident's care plan, revised on 08/11/26, showed: - The resident has impaired cognitive function related to frontotemporal neurocognitive disorder (a group of progressive brain disorders that damage the frontal and temporal lobes, affecting personality, behavior, and language rather than early memory);- Staff are to communicate with the resident, family, and caregivers regarding the residents capabilities and needs;- Staff are to discuss concerns about confusion and disease process with resident, family, and caregivers. Review of the resident's Physician's Order Sheet, dated August 2026, showed:- Buspirone (a prescription anti-anxiety medication used to treat anxiety disorders) 5 milligrams (mg) by mouth every morning and bedtime beginning on 07/28/26 and ending 08/19/26;- Buspirone 5mg by mouth one time a day for anxiety, for three days, beginning on 08/20/26 and ending on 08/23/26. Review of the resident's medical record on 09/24/26, showed no consent form for the resident regarding the use of Buspirone. During an Interview on 09/24/26 at 10:48 A.M., the resident's family member/responsible party said: - The facility did not have him/her sign a psychotropic consent nor discuss the buspirone medication with him/her;- He/She had told the Director of Nursing (DON) prior that he/she did not want to have to do psychotropic medications for his/her family member unless they really had to;- He/She found out the resident was on the medication when he/she received the bill for the medication which led him/her to believe the resident had to have been on the medication for a little over a month before he/she found out;- He/She had told the facility he/she wanted to speak to Resident #01's neurologist first to ensure the medication was okay to take with his/her diagnosis, two to three months ago;- The Nurse Practitioner (NP) had informed him/her that he/she doesn't contact the family directly regarding prescriptions. It was the facility's job to do it. 2. Review of Resident #02's Quarterly MDS, dated [DATE], showed:- The resident had mild cognitive impairment with a BIMS of 13;- The resident was taking antidepressant and antianxiety medication;- Diagnoses: dementia, anxiety disorder, and depression.Review of the resident's care plan, revised on 07/15/26, showed:- The resident uses anti-anxiety medication Buspirone related to anxiety disorder and staff were to monitor, document, and report as needed and adverse reactions to the anti-anxiety therapy;- The resident used antidepressant medication Escitalopram and Trazodone (medications used to treat depression) and staff are to monitor, document, and report as needed and adverse reactions to the antidepressant therapy. Review of the resident's Physician's Order Sheet, dated September 2026, showed:- Auvelity 45-105mg (Dextromethorphan Hydrobromide-Bupropion Hydrochloride) by mouth one time a day (a prescription oral tablet made of dextromethorphan and bupropion used to treat major depressive disorder and agitation linked to Alzheimer's disease dementia) began on 09/02/26;- Buspirone 30mg two tablets (60mg) by mouth two times a day (a prescription anti-anxiety medication used to treat anxiety disorders) began on 05/01/26 and ended 09/15/26;- Buspirone 30mg by mouth one time a day beginning on 09/17/26 and ending 09/22/26;- Buspirone 30mg two tablets by mouth at bedtime began on 09/16/26 and ended 09/22/26;- Buspirone 30mg by mouth two times a day began on 09/22/26;- Escitalopram 10mg one and a half tablets (15mg) by mouth one time a day (a prescription antidepressant used to treat depression) began on 06/20/26 and ended on 09/10/26;- Escitalopram 10mg by mouth one time a day began on 09/11/26 and ended on 09/14/26;- Escitalopram 10mg half tablet (5mg) by mouth one time a day for one day began on 09/14/26;- Trazodone 100mg by mouth at bedtime (a prescription medication to treat major depressive disorder) began on 03/27/26.Review of the resident's medical record on 09/24/26 showed:- The facility did not have a consent form for the resident regarding the use of Auvelity;- One multi-consent form, signed by the DON for the resident's representative, regarding the use of Trazodone and Buspirone (along with four other medications) dated 02/17/26.During an Interview on 09/24/26 at 10:10 A.M., the resident's family member/responsible party said:- He/She had not signed anything regarding the resident's medication consents and only spoke with the NP while she was at the facility one day regarding the resident's new Avuelity medication;- He/She would like the facility to notify him/her more regarding the medications benefits or side effects;- He/She was not happy with the facility not communicating with him/her as much as he/she would like.3. Review of Resident #03's Quarterly MDS, dated [DATE], showed:- The resident had mild cognitive impairment with a BIMS of 13;- The resident was taking antidepressant and antianxiety medication;- Diagnoses: psychotic disorder and depression.Review of the resident's care plan, dated 07/15/26, showed:- The resident uses antidepressant medication Celexa (a medication used to treat psychotic disorder) and staff are to monitor, document, and report as needed and adverse reactions to the antidepressant therapy.Review of the resident's Physician's Order Sheet, dated September 2026, showed:- Citalopram Hydrobromide (Celexa) 20mg by mouth one time a day (a prescription antidepressant used to treat major depressive disorder) began on 08/11/26;- Quetiapine Fumarate 50mg by mouth two times a day (an antipsychotic medicine) began on 07/05/26.Review of the resident's medical record on 09/24/26 showed:- One multi-consent form, signed by the DON for the resident's representative, regarding the use of Citalopram and Quetiapine dated 02/08/26.During an Interview on 09/24/26 at 12:47 P.M., the resident's family member/responsible party said:- The facility had not reviewed the resident's psychotropic medications with him/her and he/she would like them to since he/she didn't even know what all medications the resident was taking;- He/She had signed nothing since the resident had been admitted and he/she did not remember the facility calling in February regarding the resident's medications and had not been informed regarding the psychotropic consent information;- He/She used to know what all meds the resident was taking when the resident was with the Veteran's Administration (VA), but not at the Nursing Home, and he/she would like to know.During an Interview on 09/24/26 at 11:00 A.M., the DON said:- Residents and representatives should be informed regarding medications, medication changes, side effects and pro's and con's, because certain medications have contraindications with other medications and disease processes, that we have to be aware of and also so the family can be aware;- The Minimum Data Set coordinator (MDS), charge nurses, herself (DON), and physicians are responsible for completing the psychotropic consents. Charge nurses have the ability due to getting consents when the medication comes in from the family. The physician can get it when they prescribe the medication. On a normal basis though, the MDS coordinator and myself do them;- There should be a signed record of consent by the resident or their representative and it would be best to have it signed by the person, if possible, to avoid confusion;- The last audit of the psychotropic consents she had done was in February. - Ideally she would review the psychotropic consents every six months with the residents and their representatives.During an Interview on 09/24/26 at 11:05 A.M., the Administrator said:- A verbal psychotropic consent, as long as there was documentation, would be best practice;- She would then send that documentation to the representative to review, sign, and return to the facility;- She believes it is the facility's responsibility to get the psychotropic consents, not the NP or provider;- The NP or provider gets the verbal consent first, then the nursing staff would get the paper/physical documentation and signatures. Intake #3169439

Based on observations, interviews, and record review, the facility failed to lock the medication room narcotics cabinet, dispose of discharged resident's medications including narcotics, enter into inventory a controlled medication into the secure, computer-controlled medication dispensing cabinet, and ensure nursing staff accounted for and signed log sheets for medication room, controlled medications. The facility census was 24.Review of the facility policy, Medication Labeling and Storage, dated February 2023, showed:-If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items;-Compartments containing medications and biologicals are locked when not in use;-Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems;-Controlled substances and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.Review of the facility policy, Discarding and Destroying Medications, dated [DATE], showed:-Medications that cannot be returned to the dispensing pharmacy including medications left by residents upon discharge are disposed of in accordance with federal, state, and local governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substances;-All unused controlled substances are retained in a securely locked area with restricted access until disposed of. 1.Review of the facility Change of Shift Narcotic Count sheet for the medication room, on [DATE], showed: i-Entry on [DATE] - the day shift nurse signed on duty and off duty with no night shift nurse signatures listed;-Entry on [DATE] - the night shift nurse signed on duty with no other signatures listed;-Entry on [DATE] - both day shift and night shift nurses signed on duty and off duty properly;-Entry on [DATE] - the night shift nurse signed off duty with no other signatures listed;-Entry on [DATE] - the day shift nurse signed on and off duty and the night shift nurse signed off duty;-Entry on [DATE] - the day shift nurse signed on duty with no other signatures listed;-No other entries and no other count sheets available or provided.2.Observation of the medication room on [DATE] at 1:30 P.M., showed:-A large black lock box sitting on the counter, open, and contained 12 bottled prescription medications for a former resident who had been discharged over four months ago and Registered Nurse (RN) A said, he/she hasn't been here for a long time.; -A cartridge for the secure, computer-controlled medication dispensing cabinet, containing eight tablets of the controlled anti-anxiety medication Clonazepam 0.5 milligrams (mg) with the issued date of [DATE], in a large plastic bag, sitting on the counter. RN A said it has been sitting there since it came from the pharmacy. It goes in the secure, computer-controlled medication dispensing cabinet and doesn't have a count sheet.;-The medication narcotic count sheet had only seven dates with nurse activity noted and RN A said, you can tell we don't use it. We don't generally check the fridge and count because we don't get into it.;-The padlock for the controlled medication cabinet was unlocked;-A sealed bottle of liquid Lorazepam (a highly addictive medication to treat anxiety) and a sealed bottle of liquid Morphine (a highly addictive medication to treat pain) that belonged to a resident who had passed away two months ago;-A sealed bottle of liquid Haloperidol (a medication to treat psychosis) 15 milliliters (ml), a packet of 18 Zofran (medication used to treat nausea and vomiting) 4mg sublingual tablets, and a packed of six 650mg acetaminophen suppositories (medication used to treat mild pain and fever) that belonged to a resident who had discharge to another facility three weeks ago;-A card of seven Oxycodone (a highly addictive medication to treat severe pain) 5mg tablets and a card of 56 Immediate Release oxycodone 5mg tablets that belonged to a discharged resident;-A card of 14 Clonazepam sublingual 0.25mg tablets that belonged to a current resident but the order had been discontinued. During an Interview on [DATE] at 2:00 P.M., RN A said:-Nursing staff should check and sign the narcotic count sheet daily when going on and off shift;-The expired or discontinued medications should have been destroyed by now and it was a risk for diversion. 3.During an Interview on [DATE] at 2:20 P.M., the Director of Nursing (DON) said:-Nurses were supposed to check with oncoming and off going nurses to make sure the medication room narcotics and refrigerator narcotics are within time frames and dispose of, if necessary, together;-She would expect the nurses to complete narcotics counts and it would be a good idea to sign the sheet in the medication cart for the narcotics in the cart and sign the sheet in the medication room for the narcotics in the medication room/refrigerator;-The clonazepam cartridge should have been put in the secure, computer-controlled medication dispensing cabinet; -The medication box with the 16 prescription medications belonging to a discharged resident were expired and need to be destroyed;- Narcotic's should be destroyed after a resident passed away or was discharged , the narcotic count sheets should be signed by both staff. During an Interview on [DATE] at 3:16 P.M., the Administrator said:-The nursing staff should be signing the count sheets for controlled medications and narcotics in the medication room, both ongoing and off going nurses;-The narcotics should be disposed of properly;-Medications should be put in the secure, computer-controlled medication dispensing cabinet when delivered by the pharmacy and the receiving nurse should verify the count with the delivery person;-The cartridge of Clonazepam should be locked up if not inserted into the cabinet;-The locks on the cabinets and refrigerator should be locked at all times when not being utilized. Intake 3075430

Based on interview and record review the facility failed to ensure one resident (Resident #1) was free from abuse when Resident #1 was pushed onto the floor by Resident #2 which caused two skin tears on Resident #1's left arm after Resident #1 went into Resident #2's room due to confusion. This affected one of four sampled residents. The facility census was 28.Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, showed residents had the right to be free from abuse. This included by was not limited to freedom from corporal punishment, verbal, mental, or physical abuse. The facility would protect residents from abuse by anyone including other residents.Review of the facility policy titled, Resident-to-Resident Altercations, dated 2001, showed facility staff were supposed monitor residents for aggressive/inappropriate behaviors towards other residents. Behaviors that may provoke a reaction by residents to others included wandering into others' rooms/space. 1.Review of Resident #1's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 03/19/26, showed:-The resident was not cognitively intact;-The resident required assistance from staff to perform activities of daily living;-The resident's diagnoses included: Insomnia (a sleep disorder causing difficulty falling asleep or staying asleep), Alzheimer's Disease (an irreversible brain disorder that affects memory and the ability to carry out activities of daily living), and muscle weakness.Review of Resident #1's care plan, dated 03/19/26, showed the resident had impaired cognitive function due to Alzheimer's disease. Review of Resident #1's progress note, dated 04/22/2026, showed the facility staff noticed Resident #1 was not in his/her room and went to look for him/her. When facility staff found Resident #1 he/she had been thrown out of another resident's room which caused a skin tear to the resident's left elbow and left wrist.Review of Resident #2's Comprehensive MDS, dated [DATE], showed:-The resident was not cognitively intact;-The resident was able to perform activities of daily living without assistance from staff;-The resident diagnoses included: Dementia and repeated falls. The resident's #2's care plan, dated 04/30/26, showed:-The resident was independent for meeting emotional, intellectual, physical, and social needs;-The resident had the potential for impaired cognitive function or impaired thought process related to dementia;-The resident had a potential psychosocial wellbeing problem related to social isolation.Review of Resident #2's progress note, dated 4/22/26, showed resident #2 was interviewed by the Administrator. Resident #2 told the Administrator that a big ole son of a bitch came into my room and turned on all the lights and shut my door. That's all I'm saying. Review of the facility investigation, dated 04/28/26, showed:-Review of video surveillance showed that Resident #1 fell out of Resident #2's room;-Resident #1 acquired two small skin abrasions from making contact with the floor when he/she fell;-Resident #2 was interview able and had said that someone had come into his/her room, turned the lights off and shut the door;-Resident #2 told Resident #1 to get out and Resident #1 did not move so Resident #2 pushed Resident #1 out of his/her room. Observation on 05/01/26 at 11:47 A.M., showed resident #1 had a quarter sized skin tear on his/her left elbow that was scabbed over and a dime sized skin tear to his/her left wrist that was scabbed over. During an interview on 05/01/26 at 10:58 A.M., Resident #1's responsible party said the resident gets confused sometimes, which was probably why he/she went into the wrong room. He/She wished that the facility had more staff to keep a closer eye on all the resident's, especially the resident's that have memory problems. During an Interview on 05/01/26 at 11:23 A.M., the Administrator said:-She watched the camera footage and it showed Resident #1 going into Resident #2's room, then showed Resident #2 pushed Resident #1 out of his/her room, Resident #1 fell on his/her side and obtained two skin tears to his/her arm;-Resident #2 was woken up from his/her sleep by Resident #1 going into his/her room and was startled by someone being in his/her room;-She did not believe that Resident #2 intended to hurt Resident #1. During an interview on 05/01/26 at 11:09 A.M., Resident #2 said:-Some big son of a bitch came into my room early in the morning and woke me up;-Resident #2 told Resident #1 to get out of his/her room three times and Resident #1 did not move so Resident #2 pushed Resident #1 out of his/her room and Resident #1 fell down on the floor;During an interview on 05/01/26 at 1:09 P.M., Certified Nursing Assistant (CNA) A said:-He/She noticed that Resident #1 was not in his/her room around 5:00 A.M. on 04/22/26 and he/she went to looking for the resident when another resident had asked CNA A assist him/her;-While CNA A was assisting another resident he/she heard another room door open;-He/She stepped out of the other resident's room and saw Resident #1 on the floor outside of Resident #2's room;-He/She got Registered Nurse (RN) A to assess the resident for any injuries. During an interview on 05/01/26 at 1:57 P.M., RN A said:-He/She did not witness Resident #2 push Resident #1 onto the floor, he/she was notified by CNA A;-Resident #1 had two skin tears to his/her arm;-Resident #1 abused Resident #2 when he/she pushed Resident #1 to the floor. During an interview on 05/01/26 at 3:25 P.M., the Director of Nursing (DON) said:-She had spoken with Resident #2 who said that he/she understood he/she couldn't physically push another resident out of his/her room;-Resident #2 pushing Resident #1 onto the floor was considered abuse. During a follow up interview on 05/01/26 at 4:08 P.M., the Administrator said:-She did not believe that Resident #2 pushing Resident #1 onto the floor was abuse since Resident #2 did not intend to harm Resident #1, Resident #2 just wanted Resident #1 out of his/her room;-Abuse was if a resident intended to deliberately harm another resident. Intake 2990685.

Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse when C.N.A. A slapped Resident #1 on the hand with his/her open hand and forced the residents' hands down into his/her lap twice while in the dining room for a meal. This effected one of three sampled residents. The facility census was 25. Review of the facilities Abuse, Neglect, and Exploitation policy, dated 1/31/24, showed:-Abuse means the willful infliction injury, intimidation, or punishment resulting in physical harm, pain or mental anguish, which can include staff to resident abuse;-New employees will be educated on abuse during initial orientation and existing staff will receive annual education through planned in-services and as needed;-Training topics will include: prohibiting and preventing all forms of abuse, understanding behavioral symptoms of residents that may increase the risk of abuse such as aggressive reactions of resident's, resistance to care, outbursts or yelling, and difficulty in adjusting to new routines or staff;-The facility will implement policies and procedures to prevent and prohibit all types of abuse;-Report all alleged violations to the Administrator. Review of CNA A's employee file, dated 1/26/26, showed:-CNA A was hired on 1/26/26;-CNA A did not complete the quiz that was provided after watching the Hand-In-Hand- Module two: What is Abuse video;-CNA A did not complete the quiz that was provided after watching the Hand-In-Hand- Module three: Being with a person with Dementia: Listening and Speaking video;-CNA A did not complete the quiz that was provided after watching the Hand-In-Hand- Module five: Preventing Abuse video;-CNA A did not complete the quiz that was provided after watching the Hand-In-Hand- Module six: Being with a Person with Dementia video. Review of the resident's care plan, dated 2/16/26, showed: -The resident had the potential to be verbally aggressive related to dementia, staff were to analyze triggers and what de-escalated the behavior and anticipate the resident's needs;-The resident had the potential to be physically aggressive hitting/swatting related to dementia, staff were to engage calmly in conversation or walk away calmly if resident became agitated. Review of Resident #1's Comprehensive Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 2/17/26, showed:-The resident was not cognitively intact; -The resident was dependent on staff for carrying out activities of daily living;-The resident used a wheelchair for mobility;-The resident had diagnoses of lack of coordination, generalized muscle weakness, and dementia (a decline in mental ability severe enough to interfere with daily life).Review of the security camera footage provided by the Administrator, dated 4/14/26, showed the resident was sitting at a table in the dining room. CNA A delivered Resident #1's meal tray and the resident reached up and slapped CNA A on the arm. CNA A hit the resident with an open hand on the back of the resident's right hand. Resident #1 then reached up towards CNA A and CNA A grabbed the resident's hand and forcibly shoved his/her hand towards the resident's lap. Resident #1 reached up towards CNA A again, and CNA A grabbed the resident's hand again and forcibly shoved the resident's hand towards the resident's lap. CNA A then threw a bowl of food from the resident's tray onto the table in front of the resident. During an interview on 04/16/2026 at 10:44 A.M. Nurse's Aide (NA) A said:-On 4/14/26 NA A was on the opposite side of the dining room from where Resident #1 was sitting when NA A heard a slapping sound coming from the area Resident #1 was sitting at. NA A turned around and observed CNA A standing near Resident #1 -NA A did not witness CNA A slap the resident;-NA A had a suspicion that CNA A had hit Resident #1 but was unsure since he/she did not actually witness what had occurred;-The next morning on 4/15/26, NA A overheard some of the dietary staff say that they had heard CNA A say that he/she would defend him/herself if necessary, overhearing this remark made NA A feel like he/she should report his/her suspicion that CNA A hit Resident #1 to the Administrator. During an interview on 04/16/2026 at 11:41 A.M. Registered Nurse (RN) A said:-He/she was working on 4/14/26 at 6:08 P.M. -He/she did not witness CNA A hit Resident #1;-He/she was not notified by NA A or dietary staff that CNA A had hit Resident #1;-He/she would expect staff to notify him/her or the Administrator or Director of Nursing (DON) of any suspicion of abuse immediately. During an interview on 04/16/2026 at 11:46 A.M. CNA B said:-He/she was in the dining room assisting another resident with their meal when he/she had heard two slapping sounds;-He/she did not see CNA A hit Resident #1;-He/she had just assumed the sound was Resident #1 hitting CNA A since Resident #1 did do that occasionally;-He/she should have went to check on Resident #1 when he/she heard the slapping sounds;-He/she had heard CNA A make the comment that CNA A would defend him/herself if necessary multiple times before while working. -CNA B thought that CNA A was joking when saying this and that CNA A liked to joke around often. During an interview on 04/16/2026 at 2:44 P.M. NA B said:-He/she should have reported suspicion of abuse to the charge nurse immediately;-Resident #1 could become agitated and the best way to handle Resident #1 when agitated was to ensure the environment around him/her was calm and determine what could have been triggering him/her and remove that trigger if possible.CNA A did not return a call to the state survey agency as requested. During an interview on 04/16/2026 at 3:28 P.M. the Administrator said CNA A hitting Resident #1 is physical abuse. Residents have the right to be free from abuse. During an interview on 04/16/2026 at 3:46 P.M. the DON said CNA A hitting Resident #1 is physical abuse. Residents have the right to be free from abuse. Review of the facility investigation dated 4/20/26 showed: -On 04/15/2026 at ap 1230, NA A reported an allegation of suspicion of physical abuse to the administrator. NA A reported that during supper on 04/14/26 she overheard a slap sound that made her and another employee turn around and look in the direction of Resident#1s table.-Due to NA As location across the room she did not see what had occurred.-An investigation was immediately initiated and included review of the video surveillance of area at approximately 6:08P.M. -It was confirmed that Resident #1 slapped at CNA A and CNA A slapped Resident #1 on the hand and forcefully subdued her hand twice. -A second employee, CNA B also heard the slap and was witnessed walking by the incident and looking at Resident#1 within seconds of the action. CNA B that she had heard two slaps, did not know if it was the resident slapping at staff (which is a common occurrence with this resident), and walked by to see that everything was ok. CNA B did not see what had occurred. - It was confirmed through review of the video that Resident #1 grimaced, but no confirmation of (physical) injury was found upon assessment. -Resident#1 is nonverbal and not able to provide information.-Based on the findings from the video CNA A was suspended pending notification of termination due to substantiated abuse. -On 4/16/26 the administrator terminated CNA A. Intake 2984683

Based on interview and record review, the facility failed to follow facility policy to notify law enforcement of an allegation of staff to resident physical abuse. This affected one of four sampled residents. The facility census was 25.Review of the facilities Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, dated 2001, showed:-If resident abuse was suspected the suspicion must be reported immediately to the administrator and to other officials according to state law;-The administrator or the individual making the allegation immediately reports his or her suspicion to law enforcement officials.Review of Resident #1's Comprehensive Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 2/17/26, showed:-The resident was not cognitively intact; -The resident was dependent on staff for carrying out activities of daily living;-The resident used a wheelchair for mobility;-The resident had diagnoses of lack of coordination, generalized muscle weakness, and dementia (a decline in mental ability severe enough to interfere with daily life)Review of the facilities security camera footage of the dining room, dated 4/14/26, showed:-The resident sat at a table in the diningroom;-The CNA A delivered Resident #1 his/her meal tray. The resident reached up and slapped CNA A on the arm, CNA A then hit the resident with an open hand on the back of his/her right hand, Resident #1 reached up towards CNA A again and CNA A then grabbed the resident's hand and forcibly shoved his/her hand towards the resident's lap. Resident #1 reached up towards CNA A again and CNA A again grabbed the resident's hand and forcibly shoved his/her hand towards the resident's lap.-CNA A then threw a bowl of food from the resident's tray onto the table in front of the resident.During an interview on 04/16/2026 at 10:44 A.M. Nurse's Aide (NA) A said:-On 4/14/26 NA A was on the opposite side of the dining room from where Resident #1 was sitting and NA A heard a slapping sound coming from the area where Resident #1 was sitting. When NA A turned around to see what happened, CNA A was standing near Resident #1. -NA A did not witness CNA A slap the resident;-NA A had a suspicion that CNA A had hit Resident #1 but was unsure since he/she did not witness CNA A hit Resident #1;-The next morning on 4/15/26, NA A had overheard some of the dietary staff say that they had heard CNA A say that he/she would defend him/herself from residents if necessary and overhearing this remark, made NA A feel like he/she should report her suspicion that CNA A hit Resident #1 to the Administrator so he/she did.During an interview on 4/13/2026 at 3:28 P.M. the Administrator said she did not notify law enforcement of the situation. She thought she should have notified law enforcement when the allegation of abuse was brought to her attention however, she did not because the facilities [NAME] administrator had told her she did not need to because the resident did not have injury after CNA A hit the resident. Review of the facility investigation dated 4/20/26 showed: -On 04/15/2026 at ap 1230, NA A reported an allegation of suspicion of physical abuse to the administrator. NA A reported that during supper on 04/14/26 she overheard a slap sound that made her and another employee turn around and look in the direction of Resident#1s table.-Due to NA As location across the room she did not see what had occurred.-An investigation was immediately initiated and included review of the video surveillance of area at approximately 6:08P.M. -It was confirmed that Resident #1 slapped at CNA A and CNA A slapped Resident #1 on the hand and forcefully subdued her hand twice. -A second employee, CNA B also heard the slap and was witnessed walking by the incident and looking at Resident#1 within seconds of the action. CNA B that she had heard two slaps, did not know if it was the resident slapping at staff (which is a common occurrence with this resident), and walked by to see that everything was ok. CNA B did not see what had occurred. - It was confirmed through review of the video that Resident #1 grimaced but no confirmation of injury was found upon assessment. -Resident#1 is nonverbal and not able to provide information. -The investigation showed the administrator contacted law enforcement on 4/16 for presence at the facility for the termination notification to CNA A for physical abuse of a resident. Intake 2984683

Based on interviews and record review, the facility failed to ensure they employed a Registered Nurse (RN) for eight consecutive hours per day, seven days per week. The facility census was 31. The facility did not provide the requested nurse staffing policy.Review of the staffing sheets for January 2025 showed:- No RN scheduled for eight consecutive hours 01/01, 01/04, 01/05, 01/11,01/12, 01/18 and 01/19;Review of the staffing sheets for February 2025 showed:- No RN scheduled for eight consecutive hours 02/01, 02/02,02/08,02/09,02/15 and,02/23;Review of the staffing sheets for March 2025 showed:- No RN scheduled for eight consecutive hours 03/08,03/09,03/22,03/23.During an interview on 08/21/2025 at 11:46 A.M., the Administrator and the Director of Nursing (DON) said:- They should have an RN coverage eight hours a day, seven days a week.

Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. The facility census was 31.Review of the facility's Sanitation of Dining and Food Service Areas, undated., showed: The dining services manager will be responsible for ensuring the cleaning and sanitation is maintained in the kitchen and dining areas.- All staff will be trained on the frequency of cleaning.- A cleaning schedule will be posted for all cleaning tasks. - Observation of the kitchen on 08/18/25 at 10:46 A.M., showed: - Area under the three compartment sink covered with food debris;-The floor under the prep table covered with dirt and debris;-A metal storage rack above the prep table covered in dirt and dust;-A cake uncovered sat under the dirty and dusty metal storage rack;-The handles of the refrigerator covered with a sticky substance;- A black substance along the drain on the floor in the dish room;-A fan covered with dust and debris blew across a tray with open glasses with ice in them;-The trash can by the prep table with no lid;-A window by the prep table covered in dirt and debris; Dry storage:-A box containing 4 large cans of baked beans sat on the floor; The freezer:-An undated, opened package of sausage patties;-An undated opened package of chicken patties;-An undated opened package of French toast sticks. During an interview on 08/20/25 at 12:45 P.M., [NAME] A said:-Food should be dated and stored in a closed container;-The kitchen should be kept clean;-The kitchen staff try to work together to keep the kitchen clean;-Sometimes things fall through the cracks.During an interview on 08/20/25 at 01:45 P.M., the Dietary Manager said:-Food should be closed and dated;-The kitchen should be clean and sanitary;-The kitchen staff was responsible for cleaning the kitchen.During an interview on 08/20/25 at 02:15 P.M., the Registered Dietitian said:-Food should be stored in a safe and sanitary manner;-Food should be dated and kept in a closed container;-The kitchen should be kept clean and sanitary.During an interview on 08/20/25, at 02:26 P.M., the Administrator said:-She expected the dietary department to keep the kitchen clean;-She expected food to be stored properly;-She expected the dietary staff to take care of needs of the kitchen.

Based on record review and interviews, the facility failed to ensure they maintained a surety bond in an amount to cover any loss of theft to residents' money held in the facility's Resident Trust Fund (RTF) account which affected all residents who had money held in their RTF account. The facility census was 31. Review of the facility's Surety Bond Policy dated March 2021 showed:-This facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf its residents;-All funds entrusted to the facility for a resident are covered by the surety bond. Review of the RTF worksheet, completed on 08/21/2025, showed:-The average monthly balance for the facility's interest-bearing account was $36673.99;-The facility still held funds in the operating account for Resident #45 who was discharged from the facility on 10/20/24; -The approved bond amount for this average monthly balance (Grand Total rounded to the nearest thousand x 1.5 + $850.00 = required bond amount) should be at least $56,775.00. Review of the facility's surety bond rider dated August 21, 2025 showed:-An increase certificate to increase the bond amount from $55,000.00 to $60,000.00.-No approval letter from Department and Senior Services (DHSS) to increase the bond amount was found. During an interview on 08/21/25, at 1:05 P.M, the Corporate Administrator said:-The resident trust fund account was reconciled on 8/18/25:-She realized the bond amount needed to be increased;-She was aware 8/18/25 was the day the annual survey was started;-She sent the bond increase to the state on 8/18/25;-She could not find the email where she sent the bond increase to the state;-She did not have an approval letter for the bond increase. During an interview on 08/21/25, at1;10 P.M. the Administrator said she expects the bond amount to be sufficient.

Based on interview and record review, the facility staff failed to implement their Abuse and Neglect policy when they failed to complete employee background checks prior to staff working with residents, failed to complete employee disqualification list (EDL) check for one employee, and failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected eight of eight sampled staff (Licensed Practical Nurse (LPN) A, The Dietary Manager, Registered Nurse (RN) A, CNA A, Housekeeper A, [NAME] B, CNA B, and RN B). The facility census was 31.Review of facility Background Screening Investigations policy, revised March 2019, showed: -For any individual applying for a position as a certified nursing assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file; -The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment. Review of LPN A employee file, showed: Employee hired on 5/22/25. Certified Nurse Aide Registry was not checked.2. Review of the Dietary Manager's employee file, showed:Employee hired on 6/1/25;Certified Nurse Aide Registry was not checked.3. Review of RN A employee file, showed:Employee hired on 4/30/25;Certified Nurse Aide Registry was not checked.4. Review of CNA A employee file, showed:Employee hired 9/11/24;Family Care Registry was not completed;Certified Nurse Aide Registry was not checked.5. Review of Housekeeper A employee file, showed:Employee hired on 1/10/25;Certified Nurse Aide Registry was not checked.6. Review of [NAME] B employee file, showed:Employee hired on 6/9/25;Certified Nurse Aide Registry was not checked.7. Review of CNA B employee file, showed:Employee hired on 6/10/25;EDL check completed on 7/29/25, after date of hire;Certified Nurse Aide Registry was not checked.8. Review of RN B employee file, showed:Employee hired on 2/5/25;Certified Nurse Aide Registry was not checked. During an interview on 08/21/2025 at 11:25 A.M. The Cooperate Administrator said she was unaware that the Certified Nurse Aide Registry needed to be checked for all employees. She was unable to find any documentation from the highway patrol for CNA A's background screening. CNA B did not have an initial EDL check completed upon his/her hire, just the quarterly EDL check.During an interview on 08/21/2025 at 11:18 A.M. the facility Administrator said if an employee is not in the family care safety registry she would call the employee to notify them that they need to register for the family care safety registry before they can begin working.

Based on interviews and record review, the facility failed to complete a discharge summary for two of 12 sampled residents, (Resident #39 and Resident #41). The facility census was 31. Review of the facility's policy for discharge summary and plan, revised December 2016, showed:- When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment;- The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. The discharge summary shall include: current diagnosis medical history (including any history of mental disorders and intellectual disabilities); course of illness, treatment and/or therapy since entering the facility; current laboratory, radiology, consultation, and diagnostic test results; physical and mental functional status; Ability to perform activities of daily living (ADLs) including: bathing, dressing and grooming, transferring and ambulating, toilet use, eating and using speech, language and other communication systems; the need for staff assistance and assistive devices or equipment to maintain or improve functional abilities and the ability to form relationships, make decisions including health care decisions, and participate (to the extent physically able) in the day- to- day activities of the facility; sensory and physical impairments (neurological, or muscular deficits); nutritional status and requirements: weight and height, nutritional intake, eating habits, preferences and dietary restrictions; special treatments or procedures (treatments and procedures that are not part of basic services provided); metal and psychosocial status (ability to deal with life, interpersonal relationships and goals, make health care decisions, and indicators of resident behavior and mood); discharge potential (the expectation of discharging the resident from the facility within the next three months); dental condition (the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's national status, communications abilities, quality of life and the need for and use of dentures or other dental appliances); activities potential (the ability and desire to take part in activity pursuits which maintain or improve physical, mental, and psychosocial well-being); rehabilitation potential (the ability to improve independence in functional status through restorative care programs); cognitive status (the ability to problem solve, decide, remember , and be aware of and respond to safety hazards); and medication therapy (all prescription and over- the - counter (OTC) medications taken by the resident including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident);- As part of the discharge summary, the nurse will reconcile all pre-discharge medication with the resident's post-discharge medications. The medication reconciliation will be documented;- Every resident will be evaluated for his/her discharge needs and will have an individualized post-discharge plan. 1. Review of Resident #39's admission Record dated 06/13/25 showed diagnoses included high blood pressure, diabetes, and impaired cognition. The facility did not provide the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff. The facility did not provide the resident's care plan. Review of the resident's medical record showed:- 06/13/25 - the resident was admitted to the facility;- 06/13/25 - the resident was sent to the hospital due to safety risk to self, residents, and staff;- 06/14/25 - the resident returned to the facility;- 06/16/25 - the resident was sent to the hospital, discharged , and ultimately sent to a facility in another town;- There was no full assessment;- There was no discharge summary. During an interview on 08/20/2025 at 10:50 A.M., the Social Services Director said:- There were no extra files or paperwork related to this resident;- The facility would normally send a bed hold policy and all other information with hospitalizations or discharges, but this hadn't been a typical situation;- The Resident had been onsite maybe 36 hours total and returned twice;- He/She would notify the ombudsman every month regarding discharges. During an interview on 08/21/2025 at 09:00 A.M., the Director of Nursing said: - If a resident went to the emergency room (ER), the facility would send a face sheet, physician orders, the bed hold policy, and it would be documented via an electronic discharge assessment;- If a resident was discharged , the facility would do a full skin assessment and a list of meds and send the meds with them, send all belongings, and a recapitulation which should be documented under nurse's notes. During an interview on 08/21/2025 at 11:00 A.M., the Administrator said:- Residents going to ER, the facility should send an ER transfer form, physician order sheets, the bed hold policy, and some other clinical items;- Information should be documented in narrative in notes and report called to hospital;- Residents going to discharge would include a copy of orders, discharge papers and assessment in point click care, follow up appointments for home health if needed, and the facility would meet with the resident to identify needs;- All information would be entered in the discharge paperwork and recapitulation which should be documented in section of nursing's charting that has recapitulation in the medical record. 2. Review of Resident's 41's discharge medical record showed: -The resident was admitted on [DATE] and discharged to a group home on 7/1/25; -No recapitulation of the resident's stay was completed; -Resident was being discharged from the facility to a group home; -There was no continuance of care or medications listed for the resident in the discharge chart; -There was no inventory sheet listed in the resident's discharge record. During an interview on 08/20/2025 at 10:58 A.M. the social service director (SSD) said since resident #41 was going to a different facility he did not think to send a discharge packet. During an interview on 08/21/2025 at 12:37 P.M. the DON said: -Resident's are to have a recapitulation of their stay completed upon discharge; -discharged residents are to be sent with a medication list, medications, full assessment, and their inventory sheet.

Based on observation, interview, and record review, the facility failed to assure staff provided proper respiratory care when oxygen or nebulizer tubing was not dated for four residents (Residents #4, #7, #18, and #32)., and additionally failed to ensure Continuous Positive Airway Pressure (CPAP) orders were initiated for Resident #9. The facility census was 31. Review of the facility's policy for CPAP/Bi-level Positive Airway Pressure (BiPAP) support, revised March 2015, showed:- The purpose is to provide the spontaneously breathing resident with continuous positive airway pressure, to improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease, and to promote resident comfort and safety.Review of the facility's policy for oxygen administration, reviewed 01/01/24, showed:- Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences;- Oxygen is administered under orders of a physician;- Change oxygen tubing and cannula weekly and as needed if it becomes soiled or contaminated;- Change humidifier bottle when empty, every 72 hours or per facility policy. Use only sterile water for humidification;- Keep delivery devices covered in plastic bag when not in use.1. Review of Resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 07/01/25 showed:- Cognitive skills severely impaired;- Dependent on the staff for oral hygiene, toilet use, showers, dressing, personal hygiene and transfers;- Diagnoses included: non-traumatic spinal cord dysfunction (any damage to the spinal cord that has not been caused by a major trauma) and cerebral palsy (CP, a neurological disorder caused by a non - progressive brain injury or malformation that occurs while the child's brain is under development) and anxiety. Review of Resident #4's care plan, dated 09/14/23 showed:- The resident had oxygen therapy as needed at night;- Change tubing weekly;- Oxygen settings: Oxygen at one to four liters via nasal cannula (1-4L/NC) as needed to keep oxygen saturation (O2 sats) above 90%;- Provide oxygen with humidification bottle;Review of Resident's physician order sheet (POS), dated 08/20/25, showed:- Start date: 11/09/23 - Change oxygen tubing weekly on Thursday nights and as needed;- Start date: 11/08/23 - Check O2 saturations during night shift and administer as needed oxygen for saturations less than 94%. Observation on 08/18/2025 at 12:28 P.M., showed: - Oxygen humidifier bottle and tubing not labeled; - Bag tied to concentrator to hold tubing dated 07/13/25.Observation on 08/20/2025 at 11:30 A.M., showed:- O2 concentrator and tubing have been removed from resident room.2. Review of Resident #7's care plan, dated 02/18/25 showed:- The resident had Emphysema (progressive lung disease where the air sacs (alveoli) in the lungs are damaged and destroyed, leading to shortness of breath, coughing, and wheezing an accumulation of fluid in the lungs);- Oxygen settings: O2 via nasal cannula at 2L per minute. Review of Resident's Quarterly MDS, dated [DATE] showed:- Cognitive skills intact;- Required substantial assistance from staff for toilet use, showers, dressing and transfers;- Diagnoses included: high blood pressure, diabetes, and respiratory failure.Review of Resident's POS, dated 08/20/25, showed:- Start date: 02/18/25 - Oxygen at 2L/NC every shift;- Start date: 04/02/25 - Clean residents CPAP machine weekly, every Monday.Observation on 08/18/25 at 09:52 A.M., showed:- The resident not in room at this time;- The resident had oxygen tubing undated and in contact with the floor and humidifier bottle undated. Observation on 08/18/25 at 02:42 P.M., showed:- The resident sat in his/her wheelchair;- The resident had oxygen on at 2L/NC and the oxygen tubing was not dated. During an interview on 08/18/25 at 02:42 P.M., the Resident said:- The oxygen tubing had been on there awhile and when the tubing plastic gets hard he/she had nursing staff change it;- Didn't like it and made him/her want to get sick because of all the germs;- His/her spouse had been at the hospital since Sunday with pneumonia; - Nursing staff would clean his/her CPAP and change the hose every four to six months;- It pissed him/her off.Observation on 08/19/2025 at 08:03 A.M., showed:- The resident sat in the dining room with oxygen concentrator plugged in and running with oxygen tubing and humidifier bottle still undated. Observation on 08/20/2025 at 11:30 A.M., showed:- The resident sat in recliner with oxygen concentrator running with oxygen tubing and humidifier bottle still undated;- Nebulizer tubing dated 06/25.3. Review of Resident #18's care plan, dated 06/20/25, showed:- The resident had oxygen therapy related to Congestive Heart Failure (CHF, condition where the heart can't pump enough blood to meet the body's needs, causing fluid to build up in various organs like the lungs and legs, leading to symptoms such as shortness of breath and swelling);- Oxygen settings: O2 via nasal cannula at 2L per minute as needed.Review of Resident's Comprehensive MDS, dated [DATE], showed:- Cognitive skills intact;- Dependent on the staff for oral hygiene, toilet use, showers, dressing, personal hygiene and transfers;- Diagnoses included: high blood pressure, heart failure, and diabetes.Review of Resident's POS, dated 08/21/25, showed:- Start date: 06/20/25 - Oxygen therapy 2L per minute daily as needed.Observation on 08/18/25 at 11:17 A.M., showed: - The resident not in room at this time;- The resident had oxygen tubing undated and in contact with the floor and humidifier bottle undated.Observation on 08/19/2025 at 07:53 A.M., showed: - The resident not in room at this time;- The resident had oxygen tubing undated and in contact with the floor and humidifier bottle undated.4. Review of Resident #32's care plan, dated 02/11/23, showed:- The resident had Hospice Care related to diagnosis of lung cancer;- The resident had Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease that includes emphysema and chronic bronchitis, making it difficult to breathe) related to history of smoking;- Nursing staff should monitor for signs and symptoms of acute respiratory insufficiency;- Nursing staff should give aerosol or bronchodilators as ordered.Review of Resident's Comprehensive MDS, dated [DATE], showed:- Mild cognitive impairment;- Required substantial assistance from staff for toilet use, showers, dressing and transfers;- Diagnoses included: COPD, depression, and high blood pressure.Review of Resident's POS, dated 08/20/25, showed:- Start date: 09/28/23 - Change nebulizer tubing as needed if used and clean machine on Thursday;- Start date: 01/17/24 - Monitor oxygen saturation every shift related to COPD.Observation on 08/18/25 at 10:00 A.M., showed:- The resident sat in wheelchair with nebulizer tubing dated 07/13/25 and in contact with the floor. 5. Review of Resident #9's care plan, dated 05/08/24, showed:- The resident had Emphysema related to smoking;- Nursing staff should monitor for signs and symptoms of acute respiratory insufficiency;- Nursing staff should give aerosol or bronchodilators as ordered;- No care plan interventions related to CPAP.Review of Resident's Comprehensive MDS dated [DATE], showed:- Cognitive skills intact;- Shortness of breath or trouble breathing when lying flat;- Required substantial assistance from staff for toilet use, showers, dressing and transfers;- Diagnoses included: COPD, seizures, and high blood pressure.Review of Resident's POS, dated 08/19/25, showed:- No order entered for CPAP;- No order entered for CPAP machine or tubing care.Review of Resident's after visit hospital notes, dated 04/30/24, showed:- Resident was seen related to COPD and sleep apnea;- Specialist verified resident had COPD and sleep apnea;- Resident to continue using CPAP and began a new inhaler.Review of Resident's provider progress notes, dated 10/31/24, showed:- Severe COPD;- Patient to use CPAP.Observation on 08/19/25 at 08:30 A.M., showed:- The resident sat up in recliner with feet elevated;- The resident had CPAP machine sitting on dresser with no date on tubing and no water in reservoir.During an interview on 08/19/2025 at 08:30 A.M., the Resident said:- His/her CPAP machine leaks water and was broken during the move to the facility and hasn't worked since arriving;- He/She can't use the CPAP due to it being broken and the facility hasn't mentioned fixing or replacing it; - He/She had trouble breathing at night due to sleep apnea and will stop breathing at night for a long time; - Not having the CPAP makes him/her feel not very good and would like it fixed so he/she can use it.During an interview on 08/20/25 at 08:10 A.M., the Resident said:- Nursing staff tried to use the CPAP last night and it's a death trap, water went everywhere;- Nursing staff just shut it down and decided not to use it and just left it in the room;- He/She was upset about not being able to use it since being at the facility.During an interview on 08/21/2025 at 08:30 A.M., Registered Nurse (RN) B said: - Night shift nurses are responsible for changing the oxygen and nebulizer tubing every Thursday night;- Nursing staff know to do this from orientation;- All tubing should have tape on it with the date written on it;- All tubing should be changed weekly, dated, and stored in dated bags;- If a CPAP machine wasn't working properly, he/she would tag it and check the water level;- Regarding Resident #9, he/she moved and tagged it because there was no order in the POS but there must have been an order sometime;- He/She called the company listed on the machine and found they had orders for the settings so, he/she faxed the provider. - He/She would look up orders for oxygen or CPAP on the POS;- Orders brought in on progress notes should absolutely be entered on the POS as soon as nursing staff get the notes;- Residents with as needed oxygen orders don't usually have a concentrator in their room unless they need it. The facility will keep the concentrators in the oxygen room;- He/She pulled Resident #4's concentrator out because the resident hasn't used it in about 6 months (had undated tubing on it first day onsite).During an interview on 08/21/2025 at 09:00 A.M., the Director of Nursing (DON) said: - The night shift nurses are responsible for changing oxygen and nebulizer tubing every Thursday. It will pop up on the treatment administration record (TAR); - There should be an order on the POS to change the tubing;- The tubing should be changed weekly and should be dated, initialed by the nurse, and stored in bags;- A broken CPAP machine should be tagged out and removed from the room. The supplier needs called and we can get replacement through a local pharmacy if not local to make sure the resident doesn't go too long without it.- There should be an order in the POS if a resident has an order for oxygen, nebulizer, or CPAP;- An order in provider progress notes should be entered on the resident POS. There is a two-step verification by nurses that the order is put in;- Residents with as needed oxygen orders don't have concentrators kept in their rooms all the time. The facility would keep the concentrator in the oxygen storage room.During an interview on 08/21/2025 at 11:00 A.M., the Administrator said:- Night shift nurses are responsible for changing oxygen and nebulizer tubing. The order should pop up on their TAR because there should be an order on the POS;- All tubing should be changed monthly, but don't hold me to that, and it should be dated;- If a resident's CPAP was not working staff should notify the DON and myself along with provider of machine and remove from the resident's room;- There should be an order for CPAP, oxygen, and nebulizer on the POS;- Any orders from providers should go on the POS and there should be feedback from providers on rounds to ensure orders were put in;- Providers should meet with us after rounds and ideally they will enter their orders into PCC;- As needed oxygen concentrators in a resident's room depends on if they use it frequently. Oxygen storage room otherwise.

Based on observation, interview, and record review, the facility failed to ensure follow policy and ensure medications were stored at the proper temperatures and conditions to preserve their integrity when nursing staff did not check the medication room refrigerator temperature daily. The facility census was 31.Review of the facility's policy for storage of medications, revised November 2020 showed:- The facility stores all drugs and biologicals in a safe, secure and orderly manner;- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Observation of the medication refrigerator in the medication room on 08/20/2025 at 09:45 A.M., showed: - No refrigerator temperature log sheet on refrigerator and no log book available in medication room;- No thermometer in the refrigerator;- Freezer was a block of ice and needed defrosted;- Contents of the refrigerator included: four bottles of liquid lorazepam, one bottle of suppositories, one box of Performist inhalation vials, one box of Ozempic injectors, one box of Prolia injectors, two boxes of influenza vaccine prefilled syringes, three Lantus injectors, one Humalog injector, two Humulin injectors, five boxes of tuberculin vials, and three bottles of opened wine.During an interview on 08/20/2025 at 09:45 A.M., Registered Nurse (RN) B said:- He/She wasn't sure where the temperature log was and wasn't sure who was supposed to check the refrigerator temperature;- He/She was told that housekeeping would be responsible for checking the medication room refrigerator temperature;During an interview on 08/20/2025 at 10:26 A.M., Certified Medication Technician (CMT) A said: - He/She believed housekeeping checked the temperature of the medication room refrigerator but was corrected by RN B who said nurses are to check the temperature at shift change;Observation of the medication room refrigerator on 08/21/2025 at 07:15 A.M., showed:- Temperature log had been placed on the refrigerator dated as starting on 08/20/25;- Thermometer had been placed in refrigerator reading 48 degrees;- Freezer remained frozen over to almost a block of ice.During an interview on 08/21/2025 at 08:30 A.M., RN B said:- Now it's the nurse coming on who is responsible for checking the medication room refrigerator temperature;- The refrigerator temperature should be checked daily and there is a sheet on the refrigerator now;- The Director of Nursing would keep the finished sheets in his/her office.During an interview on 08/21/2025 at 09:00 A.M., the DON said: - The nurses and medication technicians were responsible for checking the medication room refrigerator temperature;- The refrigerator temperature should be checked daily.During an interview on 08/21/2025 at 11:00 A.M., the Administrator said:- Charge nurses and CMT's would be responsible for checking refrigerator temperature and signing the temperature log; - The refrigerator temperature should be checked daily.

Based on observation, interview and record review the facility failed to ensure that menus were posted in advance and followed. This effected three out of 12 sampled residents (Resident #5, #28 and #34). The facility census was 31. Review of the facility's Menu Planning policy, dated 2020, showed:-Meals are planned in advance;-Planned menus take into consideration the food habits of all residents.Review of the Resident Self Determination and Participation policy, dated 2020, showed:-Residents have the right to choose activities, schedules, health care, and providers of health care services consistent with his or her interests, assessments, and plan of care;-Residents have the right to make choices about aspects of his or her life in the facility that are significant to the resident. 1.Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/12/25, showed:-Severe cognitive impairment;-Minimal assistance for transfers, bathing, locomotion, toileting and eating;-Diagnoses included: Alzheimer's Disease, atrial fibrillation (an irregular heart beat) and depression.Review of the resident's updated care plan showed:-Self care deficit related to Alzheimer's Disease;-Impaired decision making.2. Review of Resident #28's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Minimal assistance for transfers, bathing, locomotion, toileting and eating;-Diagnoses included Alzheimer's Disease, cancer and anemia.Review of the resident's updated care plan showed:-Self care deficit related to Alzheimer's Disease;-Impaired decision making.3. Review of Resident #28's annual MDS, dated [DATE], showed:-Severe cognitive impairment;-Minimal assistance for transfers, bathing, toileting and eating;-Diagnoses included dementia and anxiety. Review of the resident's updated care plan showed:-Self care deficit related to dementia;-Impaired decision making.Observation of the memory care unit on 08/18/2025 at 12:23 P.M., showed:-Lunch Menu, breaded pork chop, au gratin potatoes, zucchini and tomatoes, cornbread and frosted poke cake;-No alternates were listed on the menu board.Observation of Lunch on the memory care unit on 08/18/25 at 12:35 P.M., showed:-Residents #5, #28 #34 were served, ham, cauliflower and Jello with fruit.Observation of lunch on the memory care unit on 08/18/25 at 12:35 P.M., showed:-Residents #5, #28 #34 were served, ham, cauliflower and Jello with fruit. During an interview on 08/18/25 at 1:37 P.M., Resident #5's family member said:-He/She is with the resident at the facility daily for meals; -The resident never gets a menu;-No staff have asked the resident if he/she likes what is on the menu;-No staff have asked the resident's family member what the resident's likes and dislikes are.-He/She has told the aides what the resident would like for the meal;-The kitchen did not bring what was ordered for the resident;-The staff said they did not know why the resident did not get what he/she ordered.During an interview on 08/18/2025 at 2:02 P.M. the Dietary Manager (DM) said:-The resident's have a choice of what they eat;-The activity director asks the residents what they would like to eat;-If the residents are unable to tell us what they want staff will contact family.-She was not sure who was in charge of talking to family members about food choices;-The wrong menu was posted in the memory care unit;-The menu should be changed every day;-The dietary department is responsible for changing the menus;-An alternate menu should be posted.During an interview on 08/18/2025 at 2302 P.M. the Activities Director said:-The resident's have a choice of what they eat;-She does not ask the resident's on the memory care unit what they would like to eat for meals;-The kitchen staff were responsible for that.Intake #2586257

Based on observations, record review, and interviews, the facility failed to ensure staff prepared foods designed in a way to meet the needs of individual residents when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency. This affected one resident (Resident #15) identified by the facility as having orders for a pureed diet. The facility census was 31. Review of the facility's Purred Food Preparation Policy, dated 2020, showed:-Pureed foods will be prepared using standardized recipes to ensure quality, flavor and palatability;Pureed foods will be the consistency of applesauce or mashed potatoes.1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/18/25, showed:-Severe cognitive impairment;-Extensive assistance of two staff for transfers, bathing, locomotion, toileting and eating;-Coughing and pain while swallowing;-Diagnoses included seizure disorder, diabetes and high blood cholesterol.A review of the resident's care plan, revised 06/29/25, showed:-The resident was on a pureed diet.A review of the resident's Physician Order Sheet (POS), dated August 2025, showed the resident had an order for a pureed diet.Review of the purred meal recipe for 08/20/25 showed:-3 ounces (oz) pureed beef roast;-3 oz pureed mashed potatoes;-3 oz pureed spinach.Observation of meal preparation for lunch on 08/20/24, at 11:41, A.M., showed:- [NAME] A began preparing the pureed lunch meal; - He/she placed 3 oz of cooked potatoes into the food processor;- He/she then turned on the food processor and began adding gravy and blended until it was the desired consistency;- The mixture was thick with visible pea sized chunks in it.Observation of lunch service on 08/20/25, at 12:55 P.M., showed:-Resident #15 served his/her pureed meal that were thick and had chunks in it;-Resident #15 did not eat the spinach;-Resident #15 was having difficulty chewing the potatoes.Observation of pureed lunch meal on 08/20/25, at 1:08 P.M., showed:- Pureed potatoes were very thick and allowed a spoon to remain standing with particles of food of the that required chewing and were hard to swallow.During an interview on 08/20/25 at 01:36 P.M., [NAME] A said:- Pureed food should be a smooth, pudding-like consistency with no chunks or particles; - He/she had not realized the pureed food was chunky;- Pureed food should be easy to swallow.During an interview on 08/20/25 at 01:45 P.M., the Dietary Manager said:- Pureed food should be a smooth, pudding-like consistency with no chunks or particles; - Pureed food should be easy to swallow.During an interview on 08/20/25 at 02:15 P.M., the Registered Dietitian said:-Pureed diet should be easy to chew;-Pureed diet should not contain hard, touch, chewy, fibrous, seeds, husks, or food particles;-Pureed diet should be a smooth texture.During an interview on 08/20/25, at 02:26 P.M., the Administrator said:- There should not be chunks of food in the pureed food;- Pureed food should not be lumpy;- Pureed food should not be hard to swallow.

Based on record review and interview, the facility failed to establish and maintain a system that assured a full and complete, separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf when monthly personal funds reconciliation showed a negative balance and when the facility failed to reimburse the residents and/or their responsible party after the resident was discharged .This affected one of 12 sampled residents (Resident #45). The facility census was 31. Review of the facility's Conveyance of Resident Funds policy dated March 2021 showed:-Any funds on deposit with the facility are refunded to the resident, the resident representative, or the resident's estate, upon discharge, eviction or death as applicable;-The resident's personal funds and a final accounting of funds are returned to the resident, the resident's representative or to the resident's estate as, applicable, with in 30 days from the date of the resident' discharge from the facility or death.Review of Interim Aged Analysis Summary, dated July 2025 showed:-Resident #45 (discharged [DATE]), had an owed balance of $850.00 in facility's operating account.During an interview on 08/21/2025 at 12:19 P.M, the Business Office Manager (BOM) said:-There should be no owed balance in the residents account;-Funds should be returned within 30 days of discharge from the facility.During an interview on 08/21/25 at 12:48 P.M. Administrator said:-There should be no owed balance in the residents account;-Funds should be returned within 30 days of discharge from the facility.

Based on record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when the facility failed to have a documented water management program. The facility census was 31. Review of the monitoring water supply to minimize outbreaks of Legionella Bacteria Contamination policy, dated 12/12/2019, showed:-It is the policy of the facility to maintain water management controls through the use of risk assessments, water management program and water management program team meetings so as to minimize the possibility of a Legionella outbreak in residents through contamination of the facility water system. During an interview on 08/20/2025 at 11:35 A.M. The Maintenance Supervisor said: - He tests the waters PH monthly;- He does not perform Legionella testing;- He does not document a water management plan with interventions or risk assessments;

Based on interview and record review, the facility failed protect one sampled residents (Resident #1) right to be free from physical abuse when resident (Resident #2) hit Resident #1 in the head. The facility staff did not place Resident #2 on increased monitoring until the resident was moved to the secured unit six days after the event. The facility census was 37. Review of the facility's abuse policy, titled Abuse, Neglect and Exploitation Policy, dated 1/31/24 showed: -It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. -Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. -The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: Increased supervision of the alleged victim and residents, room or staffing changes to protect the resident from the alleged perpetrator. 1. Review of Resident #1's medical record on 6/2/25 showed: - Diagnoses included: Palliative care (specialized medical care that focuses on relieving the symptoms and stress of a serious illness), lung cancer, dementia ( a group of thinking and social symptoms that interferes with daily functioning), chronic kidney disease (a progressive, irreversible condition where the kidneys are damaged and lose their ability to filter waste and fluids from the blood), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), cellulitus (a bacterial skin infection affecting the deeper layers of the skin and underlying tissue, often caused by bacteria like Streptococcus or Staphylococcus entering through a break in the skin), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) showed: -The resident has adequate hearing, clear speech, understands others and is able to make self understood; -He/She scored 8 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates moderately impaired cognitive impairment; -The resident has displayed no behaviors. Review of the resident's comprehensive care plan, dated 5/25/25, showed: - Interventions related to hospice care, activities of daily living, weakness, occasional verbal aggression, cognitive decline, risk for falls, nutrition, incontinence, pain related to lung cancer, and COPD. 2. Review of Resident #2's medical record on 6/2/25 showed: -The resident's diagnoses included: Dementia, age related physical debility, psychosis (a state where a person experiences a loss of contact with reality, often involving hallucinations and delusions, which are false perceptions and beliefs), anemia, pain, malnutrition, heart disease, osteoarthritis (a chronic degenerative joint disease that causes cartilage in the joints to break down over time). Review of the resident's annual MDS, dated [DATE], showed: -The resident has moderate difficulty hearing, clear speech, usually understands others and usually makes self understood; -He/She scored 6 on the BIMS, indicating severely impaired cognitive impairment; -He/She displayed verbal and physical behaviors. Review of the resident's comprehensive care plan, dated 5/25/25, showed: -Interventions related to verbal and physical behaviors toward staff, altercations with another resident; -The resident doesn't like others touching him/her; -When the resident is in the dining room keep other resident's away; -Monitor the resident at meal times to keep from eating and drinking other resident's foods. Review of the facility investigation on 6/2/25 showed: -On 5/23/25 at 3:18 P.M., dietary staff notified nursing staff that Resident #2 had poured milk on and hit resident #1. The dietary aide heard Resident #1 yell out and and turned to see Resident #2 pour milk on Resident #1, and moved to intervene. Before the staff could reach the residents, Resident #2 hit Resident #1 in the head. The dietary staff member separated the residents and notified nursing staff. The charge nurse assessed the residents and no injuries were noted. The physician, administrator, director of nursing and responsible parties were notified of the incident. Resident #2 was moved to the memory care unit on 5/29/25, as it was determined the structured environment would be beneficial for the resident. During an interview on 6/2/25 at 12:56 P.M., the Administrator said: -He/She reviewed the camera footage from the dining room of the incident on 5/23/25. Resident #1 was sitting at the dining table, sleeping in his/her wheelchair. Resident #2 propelled him/herself in his/her wheelchair to the table, and took a drink of the glass of milk in front of Resident #1. Resident #1 awoke, reached out and bumped Resident #2's arm, causing Resident #2 to spill some milk. Resident #2 became upset and poured the milk on Resident #1. Resident #1 then became upset and yelled out. The dietary staff member heard the resident yell and headed to the residents' table. Before the staff member could reach the residents, Resident #2 hit Resident #1 in the head. The dietary staff separated the residents and informed the charge nurse of the incident. -The administrator instructed the staff to keep a close eye on Resident #2. On 5/27/25, the physician reviewed and adjusted Resident #2's medication. The physician also ordered a urine analysis (UA) for resident #2. On 5/28/25, the resident's UA was positive for infection and he/she was started on antibiotics. The charge nurse also spoke with Resident #2's responsible party, who approved the resident's move to the memory care unit, has he/she would benefit from the quiet, structured environment. The resident was moved to the secure unit on 5/29/25. -Staff were not instructed to place Resident #2 on closer supervision, such as 15 minute checks or one on one supervision, as neither resident recalled the incident or were targeting the other. -Resident #2 was not moved to the memory care unit until 5/29/25 as the facility was waiting for approval from the resident's responsible party. MO254735

Based on observation, interview and record review, the facilty staff failed to maintain standard infection control precautions when staff did not perform hand hygiene with glove changes during wound care for two residents (Resident #1 and #2). Additionally, staff did not wear a personal protective gown when assisting with wound care for Resident #2 when the resident was on Enhanced Barrier Precautions (EBP). The facility did not have gowns near or outside of the resident rooms. The facility did not obtain a physicians order to implement EBP when Resident #1 and #2 had wounds. This deficient practice affected two of two sampled residents. The facility census was 33. Review of the facility policy titled, Hand Hygiene, dated 1/1/24 showed: - Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of Practice; - The use of gloves does not replace hand hygiene; - Perform hand hygiene prior to putting on gloves, and immediately after removing gloves. Review of the facility policy titled, Infection Prevention and Control Program, dated 1/124 showed: - Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures; - All staff shall use personal protective equipment (PPE) according to established facility policy. Review of the facility policy titled, Enhanced Barrier Precautions, dated 3/23/24 showed: - EBP refers to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities; - Make gowns and gloves available immediately near or outside of the resident's room; - High contact resident care activities include wound care; - The facility staff with obtain a physician's order when a resident is placed on EBP precautions. 1. Review of Resident #1's admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 3/12/25 showed: - He/She had a Brief Interview for Mental status score of 10, indicating moderate cognitive impairment; - Diagnoses included: Heart Failure (HF), urinary tract infection (UTI), stroke, and anxiety; - He/She was dependent on the staff to toilet, get dressed and shower; - He/She was at risk for the development of pressure ulcers; - He/She did not have any pressure ulcers. Review of the resident's comprehensive care plan dated 3/8/25 showed the resident's wounds were not addressed. Review of the Physicians Order Sheet (POS) dated 4/2025 showed: - 3/24/25 Left 1st toe, cleanse the area with wound cleanser (WC), apply silver sulfadiazine (a wound treatment to promote healing) and calcium alginate, cover with a non stick pad, wrap in kerlix (a gauze that is wrapped around the area) and an elastic bandage. Change every Monday, Wednesday and Friday; - 3/24/25 Left toes, apply anti-fungal powder in between each toe before wrapping in kerlix and elastic bandage; - 3/24/25 Left and right heels, apply betadine (a liquid that cleans) and foam to both heals, cover with a border gauze dressing one time daily; - The orders did not include an order for EBP. Observation on 4/5/25 at 11:0 A.M. showed: - There was no PPE cart in or near the resident's room; - There was no signage in or near the resident's room indicating staff were to adhere to EBP precautions; - Licensed Practical Nurse (LPN) A and Certified Nurse Aide (CNA) A entered the resident's room; - LPN A pushed the treatment cart into the room; - CNA A did not wash his/her hands prior to putting on gloves; - LPN A washed his/her hands and put on gloves; - LPN A pushed his/her glasses up on his/her face with his/her gloved fingers and the finger of the gloves touched his/her side of nose; - CNA A lifted the resident's leg up and LPN A began cutting the dressing from the resident's right foot; - LPN A removed the dressing and grabbed cleaning gauze pads from the top of the cart with the same gloves on; - LPN A opened the cart and dug through it to get the wound cleanser with the same gloves on; - LPN A cleaned the resident's open wound with the same gloves on; - LPN A removed the used gloved and put on clean ones, he/she did not perform hand hygiene before putting on clean gloves; - LPN A applied the ordered treatment and replaced the dressing to the resident's right foot; - CNA A set the resident's right foot down and lifted the resident's left foot; - LPN A removed the dressing from the resident's left foot, cleaned the wounds with wound cleanser and did not put on clean gloves; - LPN A touched his/her nostril area of his/her nose with his/her gloved right hand; - LPN A placed a clean dressing to the reisdent's wounds and did not change his/her gloves; - LPN A pushed his/her glasses up onto his/her face wearing the same gloves; - LPN A then took off the used gloves and washed his/her hands before exiting the room; - CNA A removed his/her PPE and did not was his/her hands before leaving the resident's room. During an interview on 4/5/25 at 11:17 A.M. CNA A said: - He/She did not know the staff were supposed to adhere to EBP precautions; - He/She had not received educations regarding EBP; - He/She put a protective gown on because LPN A told him/her to; - He/She knew he/she was supposed to wash his/her hands when entering and exiting the resident's room. During an interview on 4/5/25 at 11:27 A.M. LPN A said: - The staff were supposed to adhere to EBP precautions because the resident had a wound; - He/She should have washed his/her hands upon entering and exiting the reisdent's room; - HE/She should have changed his/her gloves and performed hand hygiene before putting on clean gloves prior to cleaning the reisdent's wounds, and prior to completing the wound treatment; - He/She should have changed his/her gloves and performed hand hygiene when he/she touched his/her face and nostrils; - He/She should not have dug in the treatment cart with contaminated gloves on. 2. Review of Resident #2's quarterly MDS dated [DATE] showed: - He/She had a BIMS score of 15, indicating no cognitive impairment; - Diagnoses included: multi-drug resistant organism and anxiety; - The resident was dependent on staff assistance to toilet, get dressed and bathe; - The resident was at risk for the development of pressure ulcers; - The resident had one stage 4 (a pressure ulcer with exposed tendons and bone), and six stage 2 (pressure ulcer characterized by the top layer of skin opened). The reisdent's wound care plan dated 1/30/25 showed: - The staff were supposed to complete wound treatments as ordered by the physician; - Resident was to be monitored for signs and symptoms of infection; - The resident's care plan did not address EBP. Review of the resident's POS dated 4/2025 showed: - 4/4/25 Cleanse the area with Vashe cleanser (wound cleanser), apply betadine to the edges of the wound, calcium alginate with silver to the wound bed, cover with a foam border dressing. Change three times per week on Monday, Wednesday and Friday; - There was no order for EBP. Observation on 4/5/25 at 9:54 A.M. showed: - There was no PPE cart in or near the resident's room; - There was no signage in or near the resident's room indicating EBP precautions; - LPN A placed the resident's treatment items on top of the treatment cart; - LPN A put on a protective gown and entered the resident's room with the treatment cart; - CNA A entered the resident's room and did not put on a protective gown; - LPN A and CNA A did not wash their hands upon entering the residents room; - Both staff put on gloves; - CNA A rolled the resident's to his/her side; - LPN A removed the old dressing from the resident's wound; - LPN A pushed his/her glasses up onto his/her nose with the back of his/her gloved hand; - LPN A did not change his/her gloves after touching his/her glasses; - LPN A cleaned the resident's wound and did not change his/her gloves; - LPN A applied a new wound dressing with his/her contaminated gloves; - LPN A took his/her dirty gloves off and put on clean gloves, LPN A did not perform hand hygiene with the glove change; - LPN A touched his/her face and nostril with his/her gloved fingers; - LPN A dug through his/her pocket and pulled out a pen; - LPN A wrote the date on the resident's wound dressing; - LPN A and CNA A removed his/her gloves and left the residents room with out performing hand hygiene. 3. During an interview on 4/5/25 at 11:52 A.M. the Director of Nursing (DON) said: - She expected all staff to wear protective gowns when they are assisting with wound care; - She expected hand hygiene to be completed between glove changes; - She expected staff to wash their hands when entering a resident's room and exiting; - She expected staff to change their gloves and perform hand hygiene when they have touched their face, nostril, and glasses; - She expected staff to change their gloves and perform hand hygiene when they remove an old wound dressing, again when cleaning the wound, again when applying a new treatment and dressing, and if visibly soiled; - Staff should not dig in their pockets or the treatment cart with gloved hands; she expects staff to have all of the materials needed for the treatment prepared and easily accessible; - There should be a PPE cart in or near the resident's room, so that staff have easy access to PPE; - There should by signage in or near the resident's room to alert staff the resident's was receiving EBP precautions; - She expected EBP to be care planned and a physician's order obtained. MO252238

Based on observation, record review, and interview the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to use sanitary practice of washing hands and turning off faucet handle with same towel, failed to date food items, failed to check and record temperatures of the refrigerator and freezer units daily, failed to check the dishwasher twice daily prior to washing dishes, failed to temperature check all foods being served to residents, failed to store personal items away from food, and failed to complete daily food temperature log prior to meal service. The facility census was 29. 1. Review of facility policy, proper hand washing and glove use, dated 2020, showed: -All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines. -Proper procedure for washing hands is as following: a. Turn on water as hot as comfortable. b. Wet hands and apply soap. c. Scrub 15 to 20 seconds or more: getting under nails, between fingers, and all exposed areas, such as back of hands and forearms. d. Rinse hands thoroughly. e. Dry hands with paper towel or air dryer. f. Turn off faucet with paper towel. -All employees will wash hands upon entering the kitchen from any other location, after all breaks (including bathroom and smoking breaks), and between all tasks. Hand washing should occur at a minimum of every hour. -Employees will wash hands before and after handling food, after touching any part of the uniform, face, or hair, and before and after working with an individual resident. -Gloves are to be used whenever direct food contact is required. -Hands are washed before donning gloves and after removing gloves. Continuous observation on 5/29/24 starting at 11:15 A.M., showed: -11:38 A.M., Dietary manager washed hands, turned faucet off with paper towel, then used same paper towel to dry his/her hands; -11:43 A.M., Dietary manager washed hands, used paper towel to turn off faucet handle, then used same paper towel to dry his/her hands; -11:59 A.M., Dietary manager washed hands, used paper towel to turn off faucet handle, then used same paper towel to dry his/her hands; -12:00 P.M., Dietary Aide B washed hands, used paper towel to turn off faucet handle, then used same paper towel to dry his/her hands; -12:03 P.M., Dietary Manager washed hands, turned off faucet handle with paper towel and then dried hands with same paper towel; -12:14 P.M., Dietary Manager washed hands, turned off faucet handle with paper towel and then dried hands with same paper towel; -12:27 P.M., Dietary Manager washed hands, turned off faucet handle with paper towel and used same paper towel to dry his/her hands. During an interview on 5/29/24 at 12:20 P.M., Dietary Aide B said: -He/She should wash his/her hands every time he/she opened and closed doors, every time he leaves and re-enters kitchen, anytime he/she touched his/her face; -He/She had training on hand washing; -It was not sanitary to turn off faucet handle with paper towel and use the same paper towel to dry his/her hands; -He/She did use the same paper towel to dry his/her hands with that he/she used to turn off faucet. During an interview on 5/29/24 at 12:33 P.M., Dietary Manager said: -It was not sanitary to use a paper towel to turn off faucet handle and then use same paper towel to dry his/her hands. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -The same towel should not be used to turn off faucet handle and then dry staff's hands, he/she expected staff to use different towel. 2. Review of facility policy, monitoring food temperatures for meal service, dated 2020, showed: -Food temperatures will be monitored to prevent food borne illness and ensure foods are served at a palatable temperature. -Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. -The temperature of each food item will be recorded on the food temperature log. Observation on 5/27/24 at 8:48 A.M., showed weekly food temperature log dated 5/26/24 to 6/1/24, showed: -No temperatures recorded for breakfast on 5/27/24, breakfast had already been served for the day. Observation on 5/29/24 at 11:45 A.M., in the kitchen of [NAME] A showed he/she temperature checked foods on the steam table and drinks on drink cart. The chicken temperature was 202.1 Fahrenheit (F), mechanical soft chicken 200.0 degrees F, peas showed 190.4 degrees F, pureed pees 180.9 degrees F, gravy 188.0 degrees F, penee pasta 166.6 degrees F, puree pasta 191.8 degrees F. He/She did not temperature check the hamburger patties and carrots which were located on the steam table. He/She did not temperature check the peach crisp which was located on a food cart. [NAME] A recorded temperatures immediately on Food Temperature log. Observation on 5/29/24 at 12:01 P.M. showed [NAME] A added tomato soup to the microwave and turned on two minutes. Observation on 5/29/24 at 12:02 P.M. showed [NAME] A stirred tomato soup with a plastic spoon. Observation on 5/29/24 at 12:04 P.M. showed [NAME] A added a cooked hamburger patty to residents plate to be served. Hamburger patty was not temperature checked before being served. Observation on 5/29/24 at 12:07 P.M., showed [NAME] A obtained tomato soup from microwave, was not temperature checked, and was served to a resident. Observation on 5/29/24 at 12:17 P.M., showed [NAME] A added second bowl of tomato soup to microwave, tomato soup pulled out of microwave and was not temperature checked and served to a resident in the dining room. During an interview on 5/29/24 at 12:28 P.M., Dietary Manager said: -All foods should be temperature checked; -Tomato soup should be temperature checked when removed from the microwave. During an interview on 5/29/24 at 12:34 P.M., [NAME] A said: -He/She did not temperature check the hamburger patties and carrots; -He/She did not think to temperature check the tomato soup coming from the microwave. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -Food temperatures should be tested before meal service to ensure appropriate temperature. 3. Facility did not provide a policy on sanitation buckets. Observation on 5/27/24 at 9:31 A.M. of Dietary Aide A completing sanitizer bucket test strip showed bucket was at 200 parts per million. Review of sanitizing bucket chemical log, dated April 2024, showed: -The log had no recorded entries for breakfast on 4/20, 4/23, 4/24, and 4/30; -The log had no recorded entries for lunch for entire month; -The log had no recorded entries for dinner on 4/20, 4/27, 4/29, and 4/30. Review of sanitizing bucket chemical log, dated May 2024, showed: -The log had no recorded entries for breakfast on 5/4, 5/5, 5/10, 5/15, 5/22, and 5/27; -The log had no recorded entries for lunch for the entire month; -The log had no recorded entries for dinner on 5/2, 5/12, 5/16, 5/25, 5/26. During an interview on 5/30/24 at 12:58 P.M., Dietary Manager said: -He/She expected logs to be completed daily; -Sanitizer bucket solution should be tested every two hours. 4. Review of facility policy, food storage (dry, refrigerated, and frozen, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. -All food items will be labeled. The label must include the name of the food and the date by which it should be consumed or discarded. -Keep potentially hazardous foods out of the temperature danger zone (41 degrees F to 135 degrees F, or per state specific regulations). -Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41 degrees F or lower. Place a thermometer in the warmest part of the refrigerator to monitor the air temperature in the refrigerator. -Conduct random temperature checks of food items. -Check freezer temperatures regularly. Review of facility policy, labeling and dating foods, dated 2020, showed: -Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. Observation on 5/27/24 at 8:44 A.M. showed: -Single door refrigerator had: -Two Opened and undated one gallon containers of milk; -Opened and undated 5 pound (lb) container of sour cream; -Opened and undated chocolate syrup; -Dry storage room: -Ear buds in a case was sitting on dry storage rack next to the food; -Cell phone and charger was laying on top of a box of pudding on the dry storage rack and plugged into the outlet behind the dry storage food rack; -Styrofoam cup filled with ice sitting on wire dry storage food rack; -Spice rack: -Opened onion powder dated 2/9, no year; -Opened parsley, tape showed refilled 2/2, no year; -Opened 10 oz oregano, showed received 1/12, no opened date; -Unclear labeling when a container labeled with masking tape had salt written on it, red marker writing showed 10/25, black marker writing was written over top of red marker showed 3/11/24; -Opened black pepper dated 2/13, do not have year; -Opened chopped onion, 3 lb, dated 4/9 did not have year. Review of Refrigerator/Freezer temperature log, dated April and May 2024 ,showed: Upstairs Freezer: -No temperature recorded for morning readings on 4/3, 4/8, 4/14, 4/20, 4/23, 4/24, 4/30, 5/5, 5/22, 5/27; -No temperature recorded for evening readings on 4/6, 4/7, 4/13, 4/20, 4/26, 4/27, 4/29, 4/30, 5/2, 5/6, 5/11, 5/12, 5/16, 5/21, 5/25, and 5/26; Reach in refrigerator: -No temperature recorded for morning readings on 4/3, 4/8, 4/11, 4/14, 4/20, 4/23, 4/24, 4/30, 5/4, 5/5, 5/10, 5/15, 5/22, 5/27; -No temperature recorded for evening readings on 4/3, 4/6, 4/7, 4/13, 4/20, 4/26, 4/27, 4/29, 4/30, 5/2, 5/6, 5/11, 5/12, 5/16, 5/20, 5/21, 5/25, and 5/26; Milk Refrigerate: -No temperature recorded for morning readings on 4/3, 4/8, 4/11, 4/14, 4/20, 4/23, 4/24, 4/30, 5/4, 5/5, 5/10, 5/22, and 5/27; -No temperature recorded for evening readings on 4/3, 4/6, 4/7, 4/10, 4/13, 4/20, 4/26, 4/27, 4/29, 4/30, 5/2, 5/6, 5/11, 5/12, 5/20, 5/21, 5/25, and 5/26; Downstairs Freezer: -No temperature recorded for morning readings on 4/3, 4/8, 4/11, 4/14, 4/20, 4/23, 4/24, 4/30, 5/15, and 5/27; No temperature recorded for evening readings on 4/3, 4/6, 4/7, 4/10, 4/13, 4/20, 4/21, 4/27, 4/29, 4/30, 5/2, 5/6, 5/11, 5/12, 5/16, 5/20, 5/21, 5/25, and 5/26; During an interview on 5/30/24 at 12:58 P.M., Dietary Manager said: -Logs should be completed daily; -Food should be dated when opened; -Opened milk should have an opened date written on it; -Spices should be dated when opened; -Spices should include a year on the date it was opened; -He/She expected packages to have two dates, one date written when item was received in kitchen and a second date written when item package was opened; -Employee personal items should not be stored in dry storage room. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -Expected food to be dated when it was opened; -Spices should be labeled with the years; -Temperatures of refrigerators and freezers should be tested every day; -Personal items should not be stored near food; -Phone resting on food on dry storage rack is not appropriate storage. During an interview on 5/30/24 at 3:03 P.M., Administrator said: -He/She expected spices to be dated with year; -Food should be dated when opened. 5. Review of facility policy, Dishwashing: Machine Operation, dated 2020, showed: -Check the dishwashing machine before first use. If the dishwashing machine has not been used for several hours, it is recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper functions. -Record log documents twice daily for either final rinse temperature or sanitizer concentration (low-temperature dishwashing machine with chemical sanitizer) Observation on 5/27/24 at 8:44 A.M. showed Dietary Aide A was running dishes through the low temperature dishwasher. Wash cycle observed showed temperature was at 120 degrees. Dietary Aide A ran a test strip which showed 100 parts per million (PPM) which was appropriate sanitation. Dietary Aide A then wrote test strip down on dishwasher machine log. Several cycles of dishes had already been washed and no test had been recorded in log book for 5/27/24 until requested observation was completed. During an interview on 5/27/24 at 8:48 A.M., Dietary Aide A said: -He/She recorded tests of dishwasher once per shift; -There were two shifts daily that recorded temperatures of low temperature dish washer; -He/She ran test strip any time during his/her shift. Review of dishwasher machine log, dated May 2024, showed: -No reading 5/2/24, 5/12/24, 5/16/24, 5/25/24, 5/26/24, 5/27/24 for P.M. shift; -No reading on 5/4/24, 5/5/24, 5/10/24, 5/15/24 for day shift. During an interview on 5/30/24 at 12:58 P.M., Dietary Manager said: -Logs needed to be completed daily; -Dishwasher should be tested twice daily; -Testing should be done when staff arrive in the morning before 7:00 A.M. and around 3:00 P.M.; -The dishwasher should have run a couple of cycles before it was first tested to ensure the unit was heated up to proper sanitation temperatures; -He/She expected to complete log book right after testing was completed. During an interview on 5/30/24 at 3:03 P.M., Corporate Administrator said: -Dishwasher sanitizer should be tested weekly to monthly, whatever the policy read.

Based on observation, interview, and record review, the facility failed to ensure staff treated residents with dignity and respect when staff did not ask each resident before applying clothing protectors to them in North and South dining rooms, stood while assisting four sampled residents with eating (Residents #14, #7, and #29), when staff left a clothing protector on resident before and after meals (Resident #14) and when staff did not provide privacy when was left exposed to hallway while only wearing a brief and T-shirt. (Residents #3). Additionally, the facility failed to ensure staff cared for residents in a dignified manner when they obtained blood sugars and administered insulin in the dining room which affected Resident #12 and #24. The facility census was 29. Review of facility policy, promoting/maintaining resident dignity, updated 1/1/24, showed: -It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality; -All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights; -Groom and dress residents according to resident preference; -Maintain resident privacy; -Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source. Review of facility policy, assistance with meals, updated 1/1/24, showed: -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity; - Staff will not stand over residents while assisting them with meals; -Avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident. 1. Observation on 5/27/24 at 11:51 A.M. showed housekeeping Aide (HA) A applying clothing protectors to all residents in south dining room. He/She did not ask residents if they wanted clothing protector applied before putting them on residents. Observation on 5/27/24 at 12:10 P.M. showed maintenance supervisor placed clothing protector on residents in south dining room did not ask him/her if he/she wanted one applied. 2. Review of Resident #3's annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/14/24, showed: -He/She was severely impaired and never/rarely made decisions; -He/She was dependent on staff for all personal hygiene and dressing; -Diagnoses included cerebral palsy (a disorder that affects movement, muscle tone and posture). Review of care plan, dated 5/4/23, showed: -Resident was dependent on staff for completion of all ADL's; -When resident was in bed, keep a brief on him/her so he/she did not expose self or dirty his/her hands with urine or feces; -Resident was totally depend on two staff for dressing; -Resident had impaired cognitive function, difficulty communication and impaired thought processes; -Resident is dependent on staff with toileting and hygiene. Observation on 5/27/24 10:00 A.M. showed Resident was lying in bed exposed to the hallway wearing only a brief and T-shirt. No privacy curtain pulled. Observation on 5/28/24 at 8:58 A.M. showed resident asleep in bed with no pants on, wearing a brief and T-shirt, exposed to hallway. No privacy curtain pulled. Observation on 5/28/24 at 10:41 A.M. showed resident remained in bed exposed from hallway wearing only a brief and T-shirt, no privacy curtain pulled. Observation on 5/28/24 at 3:28 P.M., showed resident asleep in bed wearing only brief and T-shirt, no privacy curtain pulled. During an interview on 5/30/24 at 12:05 P.M., Activity Director said: -Resident should have his/her privacy curtain pulled when laying in bed with a brief on. During an interview on 5/30/24 at 12:10 P.M., Certified Nurse Aid (CNA) C said: -Privacy curtain should be pulled if a resident is laying in bed wearing a brief and was uncovered. During an interview on 5/30/24 at 12:13 P.M. CNA D said: -He/She should pull resident's privacy curtain or close the door if resident was lying in bed with a brief on and no cover. 3. Review of Resident #14's annual MDS, dated [DATE], showed: -He/She had severely impaired cognition; -He/She exhibited wandering behaviors daily; -He/She required partial/moderate assistance with eating; -He/She was dependent for personal hygiene; -Diagnoses included dementia (condition characterized by impairment of at least two brain functions such as memory loss and judgement), schizophrenia (a disorder that affects a person's ability to think, feel, or behave clearly), need for assistance with personal care, unsteadiness on feet, and generalized muscle weakness. Review of care plan, dated 3/17/23, showed: -He/She was able to feed self after tray is set up. Supervise or encourage and assist him/her with meals as needed; -He/She was assisted by one staff with personal hygiene; -He/She ambulates independently throughout the unit. Supervise/assist him/her as needed. -He/She was at risk for falls due to confusion. Observation on 5/27/24 at 11:05 A.M., showed the resident was laying in bed with a clothing protector tied around his/her neck. Observation on 5/27/24 at 1:57 P.M., showed resident assisted with walking by holding CNA B's hand. Resident was wearing a clothing protector around his/her neck as he/she walked around the facility. Observation on 5/28/24 at 12:16 P.M. showed CNA B standing to assist resident take bites of his/her food. Observation on 5/29/24 at 7:07 A.M., showed CNA D assisted the resident to take a bite of food while leaning over him/her in a standing position. 4. Review of Resident #7's quarterly MDS, dated [DATE], showed: -His/Her cognitive status was untestable; -He/She required touching assistance with eating; -He/She required substantial/maximal assistance with oral care, toileting, upper and lower body dressing, personal hygiene; -Diagnoses included: non-traumatic brain dysfunction; diabetes (a condition resulting into much sugar in the blood), dementia (a group of conditions characterized by impairment of at least two brain functions such as memory loss and judgment that interfered with daily function), anxiety, depression, lack of coordination, and pain. Review of care plan, dated 3/9/23, showed: -Provide verbal encouragement and cueing during meals; -He/She was able to feed self. Sometimes, he/she had a hard time sitting down at the table for whole meal. See if he/she will sit with you and encourage him/her to finish eating. Observation on 5/28/24 at 12:16 P.M., showed CNA C standing and leaning over the resident to assist to with taking bites of his/her food. Observation on 5/28/24 at 12:20 P.M. showed CNA C continued standing to assist the resident to eat his/her food. 5. Review of Resident #29's MDS, dated [DATE], showed: -He/She had severe cognitive impairment; -He/She had impairments to both sides of upper extremities; -He/She was dependent on a walker; -He/She required set up or clean up assistance with eating; -He/She required substantial/maximal assistance with oral hygiene; -He/She was dependent for toileting, putting on shoes, and personal hygiene; -Diagnoses included Alzheimer's Disease (a progressive disease that destroys memory and thinking skills), repeated falls, generalized muscle weakness, need for assistance with personal care, and difficulty in walking. Review of care plan, dated 5/4/24, showed: -Resident was able to eat independently after set up assistance; -Keep resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion; -Resident had impaired cognitive function or impaired thought processes due to dementia. Observation on 5/29/24 at 7:31 A.M. showed CNA C standing next to the resident and offering the resident a bite of breakfast. 6. During an interview on 5/30/24 at 11:58 A.M., Housekeeping Supervisor said: -He/She took feeding course; -He/She thought he/she should stand to feed residents; -He/She should ask residents if they want clothing protectors before applying them; -He/She did not ask residents if they wanted a clothing protector before putting them on residents. During an interview on 5/30/24 at 12:05 P.M., Activity Director said: -Staff should sit beside residents when assisting to feed. During an interview on 5/30/24 at 12:10 P.M., Certified Nurse Aide (CNA) C said: -He/She should sit to assist resident to eat their meals; -It was intimidating when standing next to a resident during meal assistance. During an interview on 5/30/24 at 12:13 P.M., CNA D said: -Staff should not stand to assist residents to eat their meals. During an interview on 5/30/24 at 3:03 P.M., Director of Nursing said: -He/She expected staff to sit when assisting residents to eat during meals; -He/She expected staff to ask resident's if they wanted a clothing protector before one was applied to each resident; -He/She expected staff to pull a privacy curtain when a resident was laying in bed wearing only a brief. 31102 7. Review of Resident #12's admission MDS, dated [DATE] showed:- Cognitive skills moderately impaired; - Lower extremities impaired on both sides; - Required assistance with set up and clean up when eating; - Dependent on the assistance of staff for dressing and transfers; - Diagnoses included depression, anxiety, psychotic disorder ( severe mental disorders that cause abnormal thinking and perceptions), diabetes mellitus and urinary tract infection (UTI, an infection in any part of the urinary system). Observation on 5/28/24 at 7:57 A.M., showed: - The resident sat in his/her wheelchair at the dining room table and had finished eating his/her breakfast; - Licensed Practical Nurse (LPN) B obtained the resident's blood sugar after the resident had completed his/her meal and in the presence of two other residents. Observation and interview on 5/28/24 at 12:09 P.M., showed: - The resident sat in his/her wheelchair at the dining room table; - The staff brought the resident his/her meal; - LPN B obtained the resident's blood sugar in the presence of three other residents at the table; -The resident's blood sugar was 128 and LPN B said the resident would not get any insulin. Review of the resident's physician order sheet (POS), dated May 2024 showed: - Start date: 4/17/24 - Humalog (fast acting) insulin per sliding scale, for blood sugar 0 - 150 - no units of insulin. Review of the resident's medication administration record (MAR), dated May 2024 showed: - Humalog insulin per sliding scale, for blood sugar 0 - 150- no units of insulin. 8. Review of Resident #24's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required assistance with set up and clean up when eating; - Dependent on the assistance of staff for dressing and transfers; - Diagnoses included diabetes mellitus, dementia (inability to think), anxiety, depression and psychotic disorder. Observation on 5/28/24 at 11:49 A.M., showed: - The resident sat in his/her wheelchair at the dining room table; - LPN B obtained the resident's blood sugar in the dining room in the presence of three other residents; - The resident's blood sugar was 292; - LPN B administered the resident's insulin at the dining room table in the presence of three other residents. Review of the resident's POS, dated May 2024 showed: - Start date: 3/1/24 - Novolog (fast acting) insulin, 14 units three times daily related to diabetes mellitus. Review of the resident's MAR, dated May 2024 showed: - Novolog insulin, 14 units three times daily related to diabetes mellitus. During an interview on 5/30/24 at 10:14 A.M., LPN B said: - Part of his/her routine is obtaining blood sugars and administering insulin in the dining room; - He/She should obtain the blood sugars before the resident had their meal; - He/She should not check the blood sugars in the dining room or give the insulin in the dining room, should do it in the residents' rooms. During an interview on 5/30/24 at 3:03 P.M., the Director of Nursing (DON) said: - Staff should not obtain blood sugars in the dining room; - Staff should not administer insulin in the dining room.

Based on interview and record review, facility staff failed to protect two sampled residents (Resident #2 and Resident #3) from resident to resident sexual abuse. Resident #1 was identified to have sexual behaviors towards others. Facility staff found Resident #1 alone and fully naked sitting on an empty bed with Resident #3's hands on Resident #1's genitals, and staff failed to report this to the facility Administrator or Director of Nursing. The following day, Resident #1 lead Resident #2 into a room, removed his/her pants and was seen by facility staff, holding Resident #2's hand on Resident#1's genitals. The facility census was 29. The administrator was notified on 2/22/24 at 10:30 A.M. of an Immediate Jeopardy (IJ) which began on 1/19/24. The IJ was removed on 2/22/24 as confirmed by surveyor on-site. Review of the facility's Abuse and Neglect Policy, dated 2/21/17, showed: -All residents shall be free from any and all abuse. -All staff are to report any and all concerns related to possible resident abuse to administrative staff. -The facility staff will help identify risk factors for abuse in the facility, for residents with unmanaged problematic behaviors, and staff training that is lacking in knowledge of management in behaviors. -The facility management team will institute measures to address the needs of residents to minimize the possibility of resident abuse. 1. Review of Resident #1's Annual Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 11/8/23, showed staff assessed the resident as: - Moderate cognitive impairment; - Independent with mobility, transfers, walking, and eating; - Required 1 person for oversight with bathing, dressing, personal hygiene, and wandering; - Diagnoses of dementia and depression. Review of the resident's care plan, dated 11/17/23, showed: - One person physical assistance for personal hygiene, showers, and dressing; - Independent with walking, transfers, and mobility; - Takes medication for depression and administered by facility staff; - At risk for elopement, requires a secured unit. - No behaviors or staff interventions were care planned. Review of the resident's Nursing Progress/Behavioral Notes for the month of January 2024, showed: - On 1/6/24, resident was observed walking into another resident's room and became verbally abusive with staff when they attempted to redirect the resident; - On 1/9/24, resident wandered into three different resident rooms, staff redirected each time and resident was verbally abusive with the staff. Resident also displayed sexual inappropriateness towards residents. Physician was notified and a urine culture was ordered; - On 1/20/24, resident displaying sexual behaviors towards another resident, was re-directed away from the residents. Physician and family notified. Review of nursing notes for the resident, dated 2/1/24, showed the resident's guardian was notified by phone that behaviors of sexual nature required the resident be evaluated at a behavioral health facility, and the resident was discharged from the facility on 2/1/24 (a 13 day delay in management of the resident's sexual behavior with other residents). 2. Review of Resident #2's Annual MDS, dated [DATE], showed staff assessed the resident as: - Cognitively impaired; - Independent with ambulation and eating; - Required staff assistance for all personal hygiene, grooming, dressing, and decision-making; - Diagnoses of dementia, anxiety, depression, and wandering. Review of the resident's Care Plan, dated 12/20/23, showed: - Required assist of one nursing staff for personal hygiene, grooming, and decision-making related to impaired cognition; - An elopement risk and often wanders; - No behaviors or staff interventions were care planned. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as: - Severe cognitive impairment; - Required one person physical assist for all personal hygiene, grooming, dressing, and decision-making; - Independent of mobility, ambulation, transfers, walking, and eating; - Diagnoses of dementia, depression, and elopement risk. Review of the resident's care plan, dated 12/6/23, showed: - Resident required supervision on the secured unit; - Anticipate and meet all needs of the resident; - No information regarding behaviors or the interventions for the resident residing on the secured unit; - No behaviors were care planed. 4. During an interview on 2/2/24 at 10:05 A.M., the facility transportation aide said: - On 1/19/24, he/she and Licensed Practical Nurse (LPN) B were searching for Resident #3, as the resident had a doctor's appointment. After searching every room on the hall, the transportation aide and LPN B saw a bathroom door open going into a non-occupied resident room. - Upon entry through the bathroom into the empty room, both the transport aide and LPN B saw Resident #1 completely naked, sitting on the bed with Resident #3, who was clothed. Resident #1 guided Resident #3's hand onto Resident #1's genitalia and encouraged Resident #3 to manually stimulate Resident #1. - He/she did not report it to anyone because LPN B was in the room and witnessed the activity as well. - He/she removed Resident #3 from the room and helped the resident get ready for her/his doctor's appointment. - It wasn't until a week later when he/she overheard staff talking about Resident #1 with another resident that it triggered him/her to report what he/she witnessed to the Administrator. - He/she believed that Resident #3 was completely unaware of what was happening, and that Resident #1 knew what he/she wanted Resident #3 to do to him/her with the way he/she was guiding Resident #3's hand. - There were no other interventions or direction from the charge nurse put into place on 1/19/24. During an interview on 2/2/23 at 2:15 P.M., LPN B said: - On 1/19/24, he/she witnessed Resident #1 naked and alone sitting on the bed with Resident #3, who was clothed. Resident #1 had his/her hand on Resident #3's hand on top of Resident #1's genitals. - He/She and the transportation aid immediately separated the residents. - He/She reported the inappropriate behavior and resident to resident interaction to the charge nurse on duty, who was LPN A. - He/She did not report it the Administrator and did not know that he/she needed to. During an interview on 2/22/24 at 4:05 P.M., LPN A said: - He/She did not realize initially that there had been physical sexual touching between Resident #1 and Resident #3 during the incident on 1/19/24 . - Staff separated Resident #1 and Resident #3 immediately, Resident #1 put his/her clothing back on and returned to his/her room, and Resident #3 was taken to a scheduled doctor's appointment that day. - No new interventions were put into place on 1/19/24 or on 1/20/24 regarding Resident # 1's behavior. - He/She did not remember who had reported it to the Director of Nursing (DON). - He/She believed interventions should have been care planned and put into place for the resident. - He/She does not complete care plans for residents. - He/She should have started 15 minute checks on Resident #1. 5. During an interview on 1/25/24 at 1:31 P.M., Certified Medication Technician (CMT) A, said: - On 1/20/24, he/she saw Resident #1 take Resident #2 by the hand and walk into an empty room together at the end of the hall. - The door was closed and CMT A opened the door and saw Resident #1 with his/her pants down to his/her ankles and observed Resident #2 standing in front of Resident #1 with Resident #1's genitalia in the hands of Resident #2. - He/She immediately separated both residents, and Resident #1 pulled up his/her pants and rushed out of the room quickly. - He/She immediately reported the interaction between the two residents to the nurse on duty, LPN A. During an interview on 1/25/24 at 2:05 P.M., LPN A said: - He/She did not remember which staff member had reported to him/her about the inappropriate interaction between Resident #1 and Resident #2. - He/She did not remember if he/she reported it to the DON or if he/she documented it in Resident #2's chart, but said he/she would expect to have done that considering the inappropriateness between Resident #1 and Resident #2. - He/She went into the secured unit to ensure Resident #1 and Resident #2 were separated. During an interview on 1/25/24 at 3:05 P.M., the Administrator said: - She was not aware that physical contact had occurred between Resident #1 and Resident #2. - She was not aware that known behaviors between the two residents had not been care planned with staff interventions put into place. - She would expect that all behaviors be care planned. During an interview on 1/26/24 at 9:30 A.M., the family/guardian of Resident #2, said: - Resident #2 had a history of sexually inappropriate behavior at the current facility and other facilities. - He/She was notified of the most recent encounter between Resident #2 and Resident #1 on the morning of 1/26/24, approximately 6 days after the event occurred. 6. During an interview on 2/2/23 at 11:45 A.M., the Administrator said: -She was unaware of any incident between Resident #1 and Resident #3 until it was reported to her by the transportation aide on 2/1/24 and then a facility self-report was completed and an investigation started. - She would expect any staff member concerned with abuse or who has witnessed abuse or inappropriate behavior between residents to report immediately to the Administrator and/or DON, in addition to the charge nurse on duty. During an interview on 2/2/23 at 1:35 P.M., the DON said: - All witnessed and reported concerns with abuse or residents behaviors should be reported immediately to her, the Administrator, and the charge nurse. - All events surrounding such events are to be documented in the clinical record, and physician and guardian/family notified. At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO00231173 MO00230744

Based on observation, interview, and record review, facility staff failed to assess one resident (Resident #140) thoroughly and notify the resident's physician when he/she had a change in condition and [CONDITION(S)]-like activity. The facility failed to assess thoroughly, notify the physician, and transport the resident using Emergency Medical Services (EMS) after the resident had another [CONDITION(S)]-like activity and became unresponsive with agonal (labored and loud with long pauses) respirations. Facility staff further failed to properly assess, notify physician, and attempt to remove the resident's indwelling urinary catheter appropriately that became dislodge and stuck in his/her urethra. The resident was pronounced deceased at 12:06 P.M. on [DATE], approximately 16 minutes after leaving the facility. The facility census was 39. The administrator was notified on [DATE] at 4:23 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site. Review of the Resident Assessment policy, dated February 2014, showed: - Notify the resident's physician of any change in condition or change of neurological status from baseline. - Notify the physician of labored breathing or breath sounds that are not clear. Review of the Change in Condition policy, dated [DATE], showed: - The facility staff shall promptly notify the Primary Care Physician (PCP) and resident representative of the resident's medical condition. - The nurse will notify the PCP when there is a significant change in the resident's condition. - The nurse will notify the PCP when there has been a change in condition that required the resident to be transferred the to the hospital. Review of the Urinary Catheter (A tube that enters the bladder from the urethra and drains urine from the body) Care policy, dated [DATE], showed: - If the resident indicates that his/her bladder is full and unable to urinate, notify the PCP or supervisor. - The nurse is to notify the PCP or supervisor in the event that the resident's catheter is bleeding or accidentally removed. - If the catheter material is contributing to the catheter obstruction, notify the PCP and change the catheter if instructed to. Review of undated Bard Comprehensive Care and Management of Catheters education material showed: - In the event that an anchoring balloon does not deflate the nurse is to remove the syringe and try a different one. - Leave the syringe attached for 15 to 20 minutes. - Do not cut the catheter during removal. - The inflation tunnel should remain intact. 1. Review of Resident #140's medical record showed: - He/she was admitted to the facility on [DATE] and was discharged on [DATE]. - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - Activities of Daily Living (ADL) care plan, dated [DATE], showed he/she was dependent on staff to transfer, dress, turn while in bed, and incontinent of bowel and bladder. - physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - The facility staff did not document a urinary catheter care plan. Review of the facility surveillance video, dated [DATE], showed the following: - 7:37 A.M. The resident sitting at his/her dining table, his/her body partially obscured by a wooden column. The video showed his/her face and he/she had both legs amputated below both knees. His/her upper body made a rhythmic twisting while in his/her wheel chair, leaning forward and sitting back. He/she made a sudden movement with his/her left hand and knocked his/her bowl onto the floor. - 7:39 A.M. The resident continued with upper body jerking forward and backward. Video did not show staff in the dining room. - 7:42 A.M. He/she was resting his/her head on his/her left hand. - 7:47 A.M. His/her upper body stiffens, then relaxes, and then he/she rests his/her head on his/her hand. Video did not show staff in the dining room. - 7:53 A.M. Licensed Practical Nurse (LPN) A was seen attempting to give the resident a medication. The resident's head was down, chin to chest and rolling from side to side. - 7:55 A.M. LPN A removes the resident from the dining room, resident remains with his/her head in a downward position with chin resting on his/her chest, LPN A and Certified Nurse's Aide (CNA) A wheeled the resident down the hall where he/she resided. Review of the resident's nurses note dated, [DATE] at 8:27 A.M., showed: - LPN A documented the resident was observed at the breakfast table moving his/her body back and forth and calling for mama spilling his/her cereal on the floor. The resident was unable to answer questions and appeared to be staring off into the distance continuing to thrash about. LPN A and another staff member assisted the resident back to his/her bed using the mechanical lift. The resident acknowledged LPN A after being in bed for two minutes. The resident asked for a blanket. His/her blood pressure was ,d+[DATE] within normal range, pulse 114 indicating an elevated heart rate, respirations were 20 and within normal range, oxygen saturation was 98% on room air and within normal range, temperature 98 degrees Fahrenheit and within normal range. The resident was unable to recall what happened. The Primary Care Provider (PCP) was notified by fax and responsible party was notified by phone. During an interview on [DATE] at 10:45 A.M., CNA G said: - He/she saw the resident acting like he/she was having a [CONDITION(S)] at the breakfast table. - He/she described the [CONDITION(S)] activity as the resident was rocking back and forth in his/her wheelchair and was lethargic. - The resident knocked his/her oatmeal off of the table during the [CONDITION(S)] activity. - LPN A and CNA G laid the resident in bed and he/she began responding verbally. During an interview on [DATE] at 11:10 A.M., LPN A said: - He/she was in the dining room at breakfast, the resident was yelling for mama. - The resident stared off into space and he/she thought the resident was having a [CONDITION(S)]. - The resident did not make eye contact with him/her and did not respond verbally. - He/she asked CNA G to help lay the resident in bed, once in bed, the resident became responsive verbally. - He/she assessed the resident was cold to the touch, temperature 98 Fahrenheit, pulse 114 (elevated), blood pressure ,d+[DATE], and respirations were 20 per minute after transferring him/her to bed. - He/she notified the Primary Care Physician (PCP) via fax. - He/she was supposed to notify the physician by fax with non- emergencies. - He/she thought that since the resident returned to baseline and was alert, notifying the PCP by fax was appropriate. - He/she was supposed to notify the PCP by phone in the case of an emergency. Review of the facility surveillance video, dated [DATE], showed the following: - 10:47 A.M., LPN A and CNA A entered the resident's room. - 10:50 A.M., LPN A returned to the nurses' desk and gathered vital sign equipment. - 11:04 A.M., LPN A and the Administrator walked down the resident's hall. - 11:12 A.M., the Administrator walked up the hall towards the nurses' desk. - 11:14 A.M., LPN A was at the nurses' desk on the telephone and gathering papers. - 11:46 A.M., the resident sat in his/her wheelchair and Transportation Staff (TS) A and CNA C wheeled the resident's wheelchair up the hall toward the lobby. The resident's eyes were closed, his/her mouth was open, and his/her face appeared very pale. His/her head was resting against the back rest of the wheelchair. -11:47 A.M., TS A and CNA C wheeled the resident out the front door. TS A stopped just outside the front door. The resident was not moving. CNA C said something to the resident, the resident did not appear to respond. TS A touched the resident's shoulder and rubbed his/her chest with his/her flat hand; the resident did not appear to respond. TS A and CNA C talked to one another. CNA C then quickly returned to the desk and spoke to LPN A. - 11:48 A.M., LPN A sat at the nurses' desk, CNA C talked to LPN A. LPN A then ran from the nurses' desk to the resident sitting outside the front door. LPN A touched the resident's shoulder and spoke to the resident. The resident did not appear to respond. His/her body did not move. TS A, CNA C, and LPN A hurriedly wheeled the resident to the van. CNA C entered the facility transportation van through the side door. TS A and LPN A loaded the resident into the back of the van. - 11:50 A.M., the facility van left the facility parking lot with the resident inside. Review of the resident's September Nurses Notes showed: - [DATE] 10:45 A.M. LPN A documented Physical Therapy Assistant (PTA) A reported to him/her that the resident was lying on the fall mat in his/her room. The resident was positioned on his/her fall mat, in front of the bed with his/her head resting on the fall mat. The resident was not able to talk, but was able to make eye contact. Four facility staff members picked the resident up from the floor using a bed sheet and placed him/her in bed. There were no apparent injuries. LPN A saw that there was no urine output in the urine bedside drainage bag and the indwelling urinary catheter appeared longer than usual. The resident's penis appeared to be swollen mid-way. He/she attempted to deflate the anchoring balloon of the urinary catheter by using a syringe to remove the fluid from the balloon, but no fluid came out of the anchoring balloon. He/she cut the urinary catheter above the Y junction in an attempt to deflate the anchoring balloon, but no fluid drained from the bulb. He/she called the PCP and obtained an order to send the resident to the emergency department (ED). The resident's Durable Power of Attorney (DPOA) was at the resident's bedside. - [DATE] 11:28 A.M., LPN A documented he/she called the ED to give report to them about why the resident was going to the ED. - [DATE] 11:45 A.M., LPN A documented the resident left the facility using the facility transportation van. During an interview on [DATE] at 11:10 A.M., LPN A said: - PTA A saw the resident lying on his/her fall mat next to his/her bed and alerted LPN A. - He/she saw the resident lying on his/her fall mat, the resident made eye contact with him/her, but was nonverbal and out of character for the resident. - LPN A and three other staff members lifted the resident into bed using a bed sheet. - He/she saw the bedside drainage bag did not have urine in it and the resident's penis was swollen half way down and the catheter appeared longer than it should have been. - He/she attempted to deflate the anchoring balloon by removing the fluid with a syringe and was unsuccessful. - He/she then cut the urinary catheter above the Y junction in an attempt to drain the fluid from the anchoring balloon and was unsuccessful. - He/she should not have cut the urinary catheter in an attempt to deflate the anchoring balloon. - He/she summoned the Administrator who tried to remove the catheter and was unsuccessful and the resident's penis began to bleed. - The administrator advised LPN A to send the resident to the ED to have the catheter removed. She told LPN A to use the facility van, because it was not an emergency. - LPN A sent a fax notifying the physician of the change in condition. - LPN A and CNA G used the mechanical lift and placed the resident in his/her wheelchair. - TS A and CNA C took the resident outside the front door. - CNA C came back inside and said the resident was not acting right and was very sleepy with a faraway look in his/her eyes. - LPN A went outside and tried to speak to the resident, but he/she would not speak. - LPN A told TS A and CNA C to get the resident to the hospital as soon as possible and tell the hospital nurse about the resident's current condition. - He/she did not call the hospital to report the resident's second change in condition, but instead told TS A and CNA C to tell the hospital nurse about the resident's change in condition. - He/she should have called the hospital to report on the second change in condition. - The hospital called the facility a short time later and reported that the resident had died . During an interview on [DATE] at 10:45 A.M., CNA G said: - Later in the morning LPN A requested help from CNA G, because the resident's urinary catheter had become dislodged. - The resident was in bed, had facial grimaces and appeared to be in pain. - The resident's penis was swollen. LPN A tried to get the resident's urinary catheter out and was not able to. - LPN A and CNA G transferred the resident to his/her wheelchair using the mechanical lift. - The resident was alert when he/she was placed in his/her wheelchair. During an interview on [DATE] at 11:50 A.M., PTA A said: - He/she did not provide therapy services the morning of [DATE] because LPN A reported that the resident was having seizures that morning. - He/she was walking up the hallway and saw the resident lying on his/her fall mat next to his/her bed. - There were several staff members in the room. - He/she then saw TS A and CNA C wheeling the resident up the hall in his/her wheelchair. - The resident had his/her head back and was snoring very loud with pauses [MEDICATION(S)] several seconds between the snoring sounds. - The resident was not breathing normally. - He/she looked very pale. During an interview on [DATE] at 11:56 A.M., TS A said: - LPN A told him/her the resident needed to go to the ED. - CNA C and he/she wheeled the resident outside the front door. - The resident had wheezy breathing with long pauses, he/she was very pale, eyes were closed and he/she would not respond. - The resident was not breathing normally. - He/she looked like he/she had a [CONDITION(S)] with his/her hands shaking, head leaned back. - CNA C went inside the facility and got LPN A to assess the resident. - LPN A looked at the resident, tried to talk to him/her and the resident did not respond. - LPN A said to get the resident to the hospital as soon as possible. - He/she did not feel comfortable transporting the resident in the facility van, because the resident looked like he/she needed to be transported by an ambulance. - He/she told LPN A that he/she did not feel comfortable transporting the resident and asked if LPN A would call an ambulance to take the resident to the hospital. LPN A said to get to the hospital as fast as possible. - The transportation took 15 minutes. - The resident was in the back with CNA C. - The facility van arrived at the hospital at approximately 12:05 P.M. - TS A and CNA C waited with the resident in the waiting room, the resident's face and skin was gray, he/she had labored breathing with longs pauses between breaths. - TS A told the hospital nurse about the resident's change in condition and then left the hospital. During an interview on [DATE] at 12:59 P.M., the Administrator said: - LPN A asked her to help with the resident's catheter because it was stuck. - The resident's penis was swollen. - LPN A cut the urinary catheter before her arrival to the room. - She attempted to wiggle the remainder of the catheter around in an attempt to dislodge the anchoring balloon. - The resident's penis began to bleed and she advised LPN A to get an order to send the resident to the ED for catheter removal. - Her expectation was that LPN A not cut the catheter. - The resident appeared to be at his/her baseline and alert, he/she did not appear to be in pain. - She expected LPN A to send the resident to the ED for catheter removal. - Facility transportation was appropriate, because this was not a life-threatening emergency. - TS A and CNA G told her that the resident was gasping for air on the way to the hospital. - LPN A told her after the resident died and that he/she had a second episode of becoming unresponsive before he/she was loaded on the facility van. - She expected LPN A to call an ambulance at that point. During an interview on [DATE] at 12:50 P.M., CNA C said: - He/she got LPN A and reported that the resident was not talking or opening his/her eyes. - LPN A went outside and tried to wake the resident, then told him/her and TS A to get the resident to the hospital as fast as possible. - He/she and TS A loaded the resident in the back of the facility van and the resident was breathing funny, taking loud deep breaths and holding it for several seconds. - He/she was not talking and did not open his/her eyes. - TS A was driving and rushed him/her to the ED because he/she was breathing funny. During an interview on [DATE] at 11:01 A.M., Family Member A said: - He/she arrived at the facility after breakfast, LPN A called him/her and said the resident had a [CONDITION(S)] that morning. - He/she was awake when he/she arrived, but was not acting normal and was not able to talk. - The resident's penis was very swollen and red. The staff told him/her the resident's urinary catheter was stuck. - The nurse had cut off his/her catheter before he/she arrived to the facility. - The resident was in pain, his/her face was grimacing with a frown on his/her face and a wrinkle in his/her forehead. - LPN A said he/she was being sent to the hospital to have his/her catheter removed. - He/she was loaded on the facility van. - He/she wishes that the facility had sent the resident to the ED by ambulance, but did not say so at the time. - The hospital called him/her 20 minutes after leaving the facility and told him/her that the resident had died . Review of the hospital records, dated [DATE] 12:05 P.M., showed: - The resident arrived to the hospital unresponsive, skin was pale, cool and mottled (purple coloration of the skin when the blood circulation was decreased), agonal (very labored breathing with long pauses) respirations. - There was no palpable pulse. - Three nurses lifted the resident to the ED cart. - Heart monitor showed initially ventricular fibrillation (the lower chambers of the heart not beating in an effective rhythm), and then asystole (no heart beat). - Cardiopulmonary resuscitation (CPR) was initiated upon arrival until it was discovered the resident did not want CPR when his/her heart and breathing stopped. - The resident was pronounced dead on [DATE] at 12:06 P.M. During an interview on [DATE] at 2:20 P.M., Hospital Nurse A said: - LPN A called the hospital to report the resident's urinary catheter had been pulled and the bulb was stuck in his penis. - The facility transportation drove the resident to the hospital. - He/she was called to the waiting area to triage (assess to see how quickly the resident needs to see a physician), and the resident did not have respirations or a pulse. - He/she said the facility staff was not with the resident and the resident's change in condition was not reported to him/her until he/she found the resident to triage. - The resident's skin was mottling. - He/she and other nurses lifted the resident from the wheel chair to the ED gurney and initiated CPR. - CPR was performed until it was determined the resident signed a do not resuscitate (DNR) form. - He/she called the facility and spoke with LPN A reporting the resident was pronounced dead at 12:06 P.M. - LPN A said the resident may have had a [CONDITION(S)] earlier in the morning. During an interview on [DATE] at 4:36 P.M. PCP A said: - He/she found out about the resident's change in condition after the resident died on [DATE]. - He/she expected the facility nurse to call an ambulance to have the resident evaluated at the ED after his/her first [CONDITION(S)] activity of the morning. - He/she expected the facility nurse to send the resident to the hospital to have the urinary catheter removed that was stuck in the resident's penis. - He/she expected the facility nurse not to cut the urinary catheter to deflate the anchor bulb. - He/she expected the facility nurse to call him/her when the resident had [CONDITION(S)] activity earlier in the morning and not send a fax because he/she usually does not look at his/her faxes until the end of the day. - The facility staff know to call him/her with any changes in his/her patients condition. - He/she expected the facility nurse to assess the resident after his/her second episode of [CONDITION(S)] activity and difficulty breathing and send the resident to the ED by ambulance. - He/she found out that the resident was in the ED and died from the ED physician shortly after the resident died . - He/she called the facility and spoke with LPN A to find out what happened to the resident after the resident died . - LPN A told him/her that the reason the facility sent the resident to the hospital was because the resident's urinary catheter was stuck. - He found a fax late in the day telling him/her of the [CONDITION(S)] activity. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO 7

Based on observations, interviews and record review, the facility failed to ensure they protected one sampled resident (Resident #1) from injuries when staff allowed the resident to sit on a large pillow in his/her wheelchair during transport to [CONDITION(S)]. The transportationist (TA) became distracted by the resident when he/she complained of pain, which caused him/her to have to slam on the brakes of the facility van. The resident slid out of the wheelchair and was injured. Medical records showed the resident was diagnosed with a compression fracture of the T4 vertebrae and a rib fracture. The facility census was 37. Review of the undated Positioning Techniques Sitting policy showed two images of a person sitting in a wheelchair. The policy was included in the facility's investigation, had a date handwritten at the top of [DATE], and was signed by 14 staff. The bullet points on the policy showed: - Good skeletal alignment; - Body weight evenly distributed across the buttocks; - Provide external supports to achieve proper position; - Position away from spastic patterns; - Encourage symmetrical postures; - Do not force uncomfortable positions; - Neither image showed the person sitting on pillows or with pillows behind the back. - The sheet had a handwritten asterisk, which read, Do not allow resident to sit on a pillow. Contact therapy or restorative aide for proper cushion. Review of the facility's undated Distracted Driving Policy showed in order to increase employee safety and eliminate unnecessary risks behind the wheel, the facility has enacted a distracted driving policy, effective [DATE]. We are committed to ending the epidemic of distracted driving and have created the following rules, which apply to any employee operating a comply vehicle or using a company-issued cell phone while operation a personal vehicle: - Employees may not use a hand-held cell phone while operating a vehicle, whether the vehicle is in motion or stopped at a traffic light. This includes, but is not limited to, answering or making phone calls, engaging in phone conversations, and reading or responding to emails, instant messages and text messages. - If employees need to use their phones, they must pull over safely to the side of the road or another safe location. - Employees may not use earphones, earplugs, eat drink or listen to music while operating a vehicle. - Additionally, employees are required to: turn cell phones off or put them on silent or vibrate before starting the car; consider modifying voicemail greetings to indicate you are unavailable to answer calls or return messages while driving; inform clients, associates and business partners of this policy as an explanation of why calls may not be returned immediately. - Failure to abide by the above conditions may involve disciplinary actions up to and including termination. - The policy did not include direction for staff when passengers become the distractions. - TA signed the form on [DATE], and initialed as reviewed on [DATE] and [DATE]. Review of the QRT Series Q'Straint Wheelchair Passenger Safety Solutions user instructions, revised [DATE], showed: - Secure Wheelchair: Place wheelchair facing forward in securement area, apply wheel brakes or turn power off Attach tie-downs onto floor anchorage and ensure they are locked in Attach the four tie-down hooks to solid frame members or weldments near seat level. Ensure tie-downs are fixed at approximately 45 degrees and are within angles shown. Ensure all tie-downs are locked and properly tensioned. If necessary, rock wheelchair back and forth or manually tension retractor knobs to take up additional webbing slack - Warning: Wheelchair accessories and equipment should be properly secured or removed from wheelchair. Whenever possible, items attached to wheelchair in front of the passenger should be removed and secured separately during transport. Review of the facility's New Employee and Annual Driving Policy Check List showed: - Please read the Driving Policy, sign and return to your supervisor. - Review and sign the QRT SERIES User Instruction pamphlet. - Return demonstration of how to correctly secure a resident in wheelchair and in passenger seat. - Signed Distracted Driving Policy. - Copy of Current License. - Copy of current CPR (cardiopulmonary resuscitation) Certification. - TA signed to say he/she had training on all of the information and he/she understood the proper procedure on how to transport residents on [DATE], and initialed as reviewed on [DATE] and [DATE]. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: - Brief Interview for Mental Status (BIMS) of 13, which indicated no cognitive impairment; - No behaviors; - Limited staff assistance with bed mobility, transfers, walking in his/her room and the corridor, moving on and off the nursing unit, dressing, personal hygiene and toilet use; supervision with eating; - Not steady with moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface-to-surface transfers; - Range of motion impairments on both sides, upper and lower extremities; used a walker and wheelchair for mobility; - Use of orthotics/prosthetics; - Diagnoses included [CONDITION(S)] ([CONDITION(S)]), dependence on [CONDITION(S)], acquired absence of left lower extremity below the knee, and artificial left lower leg. Review of the resident's care plan, developed on [DATE] and revised [DATE], showed: - Requires staff assistance for most activity of daily living (ADLs); - At risk for falls related to below the knee amputation (BKA); - Requires renal [CONDITION(S)] for [CONDITION(S)]; coordinate transportation to the [CONDITION(S)] center as scheduled. Review of the facility's investigation summary form, dated [DATE], showed: - Date of event: [DATE] at 5:53 A.M.; - Where event occurred: Facility van; reported by TA. - Briefly describe event: Resident slid from wheelchair during transport; - Physician Notified: yes, on [DATE]; - Resident see by physician: yes on [DATE] in emergency department (ED) at local hospital; - The conclusion indicated the investigation did not support neglect/misconduct; - TA called administrator at [DATE] at 5:53 A.M. and reported the resident refused to remove two pillows from underneath his/her bottom and behind his/her back while in the wheelchair. TA loaded him/her in wheelchair in facility van to transport to [CONDITION(S)]. On the way, the resident started complaining of hurting and was leaning to the right. When TA looked up from rearview mirror, a car had pulled out in front of the van and he/she hit the brakes. Resident slid forward in wheelchair. After incident, and after being assisted by local police and paramedics to place the resident in wheelchair, resident refused [CONDITION(S)] because he/she did not want to sit for hours then did go to [CONDITION(S)]; then was sent to the emergency department; - [DATE] at 1:30 P.M., hospital called and stated the resident was being admitted with a fractured vertebrae. During an interview on [DATE] at 9:42 A.M., Certified Nurse Aide (CNA) A said he/she was working the morning of the incident where the resident was injured. He/she got the resident up that morning and he/she appeared fidgety and complained his/her bottom was hurting. The resident wanted a pillow underneath him/her and one behind his/her back. He/she attempted to take the pillows but the resident threw a fit. He/she always has a pillow or a pad underneath him/her but not usually behind. He/she did not seem off balance when TA took him/her out of the building. Review of the verbal statement provided to the administrator by TA on [DATE], showed: - TA came in this morning and staff said the resident's blood pressure was low; - Resident not positioned correctly, had pillows under him/her; TA and CNA A went to remove pillow and resident refused with complaints of pain; - Buckled wheelchair and resident (into the van); - Almost to [CONDITION(S)], the resident was moaning and leaning toward the right; TA asked him/her to sit up and he/she said no; - TA was watching him/her in the rearview mirror and when he/she looked up, a car pulled out in front of the van and he/she hit the brakes but did not slam on the brakes or leave black marks. - TA immediately pulled over and checked on the resident; he/she found the resident to be leaning forward against seats in front of him, sitting on the edge of the wheelchair; his/her right food bent and under the seat; resident was complaining of that the seatbelt was cutting him/her; - TA was unable to reposition him/her and he/she drove the last block to [CONDITION(S)] to get help; - [CONDITION(S)] nurse and tech came outside to assist and were unable to reposition the resident; - TA called ambulance; paramedics and local police department arrived and a female officer along with TA got the seatbelt off and were able to get resident out of the van. Observation and Interview on [DATE] at 2:30 P.M., TA said and did the following: - He/she has transported the resident many times without any issues to [CONDITION(S)]; - At 4:30 A.M., the day of the incident, the resident had an attitude when he/she went to get him/her; - He/she felt the resident was not sitting correctly in the wheelchair so he/she went to get CNA A; they readjusted him/her; - The resident was sitting on a large pillow with a similarly sized pillow behind his/ her back; when TA told the resident he/she should not have the pillows, he/she said you don't have the problems I do; so he/she left the pillows and proceeded to the facility van. - Observation of the pillows showed two large, approximately 4 inches () to 5 pillows with stripped cases covering them. The pillows appeared to be firm without much give; - TA pushed the resident's wheelchair up the ramp into the back of the facility's van and locked him/her in place; the resident remained seated on the pillows and he/she moaned the whole time TA moved the wheelchair and clocked the chair into place. - They were about two blocks from the facility and the resident had leaned over to the right; he/she told the resident to sit up; he/she was turned around looking back at the resident has he/she moved back and forth in the chair; - When he/she turned around, a car had pulled out in front of the van and he/she slammed on the brakes; TA demonstrated this in a stomping manner to show the force in which he/she applied the brakes; - When he/she turned around, the resident had slid forward and was leaning over the seatbelt; his/her bottom barely on the wheelchair seat; his/her right shin on the ledge that surrounded the wheelchair well and his/her knee pressed up against the passenger seat in front of the wheelchair well; his/her left stump rested on the wheelchair leg rest. - TA pulled the van over and climbed in the back, straddled him/her and tried to get the resident repositioned in his/her chair but could not reposition him/her so he/she drove on to [CONDITION(S)]; - TA left the seatbelt on him/her because he/she wanted them to see that the seatbelt was on the resident; - [CONDITION(S)] staff came out and could not help get the resident out so he/she called 911; - A female police officer climbed into the van, straddled the resident and said, The seatbelt is really hooked and he/she is going to go down when we release. - TA demonstrated that he/she had to climb into the van. He/she indicated the straps, which locked the wheelchair in place in the van, had wrapped around the spokes of the back wheels of the chair. TA indicated he/she struggled to get the straps out of the spokes to free the chair. - TA clicked the seatbelt and went underneath the police officer to release the straps on the chair. They raised him/her up enough to pull the wheelchair out and used a blanket to transfer him/her back into the wheelchair. - TA said the resident was moving and jerking during the entire ride from the facility to the [CONDITION(S)] center and he/she felt this loosed the seatbelt enough to allow the resident to slide out of the chair when he/she slammed on the brakes. - He/she thinks the pillows caused the resident to slide out of the wheelchair. During an interview on [DATE], at 12:30 P.M., the resident said TA hit the brakes really hard which threw him/her forward. He/she did not think he/she was strapped in well. During an interview on [DATE] at 9:50 A.M., the resident's representative said the resident told him/her, TA did not lock him/her in. He/she fell forward when TA hit the brakes hard and then had to ride like that all the way to [CONDITION(S)]. The resident said he/she told TA the belts were loose but he/she did not stop to fix them. The resident suffered a compression fracture of the T4 vertebrae. He/she felt that if the resident had been buckled in properly, this would not have happened. Review of the written statement completed by the facility's administrator of an interview with the [CONDITION(S)] administrator and a [CONDITION(S)] nurse, dated [DATE], showed: - TA needed help so staff went to try to help move him/her back to the wheelchair; - The wheelchair was facing forward; the resident was on the floor, with his/her right leg bent under him/her and the left leg in front; he/she leaned forward. - The seatbelt was extremely loose. They could not get him/her moved so TA called the ambulance who helped move him/her to the wheelchair. - They asked if he/she wanted to go to the emergency room , then asked if he/she wanted to continue to [CONDITION(S)]. - The resident complained of his/her bottom hurting, gave him/her Tylenol and he/she slept about an hour, was then repositioned and went back to sleep. - The last 45 minutes, the resident complained of pain in his/her back, left hip and right shoulder. He/she told staff he wanted to go to the emergency department after finishing [CONDITION(S)]. During an interview on [DATE] at 11:15 A.M., the [CONDITION(S)] administrator said: - She was working at the [CONDITION(S)] facility on [DATE]. - She was uncertain about the time but while she was working when TA called for help to get the resident off the van floor. - TA told her that as a behavior the resident slid out of his/her wheelchair on to the floor. - She went to the van and found the resident on the floor; - The resident's seat belt was not fastened. - The resident told her that TA did not fasten his/her seatbelt, TA stopped abruptly and he/she fell out of his/her wheelchair. - Staff could not safely lift the resident and they called 911. - Paramedics and the police officer got the resident in his/her wheelchair. - She questioned the resident and he/she said he/she wanted to have [CONDITION(S)]. - The resident requested and was given Tylenol. - Initially the resident slept through [CONDITION(S)]. About half way through [CONDITION(S)] the resident started moaning and was complaining of back pain so he/she was taken to the emergency department by paramedics. Review of the departmental notes, printed at [DATE] at 4:37 P.M. and completed by nursing staff, showed: - [DATE] at 6:49 A.M.: transportation notified this nurse at 5:30 A.M. that he/she slid out of the wheelchair in the van while at [CONDITION(S)]. Transporter informed this writer that staff was unable to help, instructed to call ambulance to help assist him/her back into the wheelchair to attend [CONDITION(S)]. Administrator notified; - No other notes regarding the resident being transported to the hospital after [CONDITION(S)]; - No notes to indicate the resident had been admitted to the hospital or his/her diagnosis. Review of the ambulance district's patient records, dated [DATE], showed: - Assessment time: [DATE] at 5:42 A.M. - Called to [CONDITION(S)] due to patient needing lift assist. - Arrived to find patient on the ground of transport bus outside [CONDITION(S)] building. - Assessed patient prior to moving to wheelchair. - No abnormalities found. - Patient picked up and moved to wheelchair using lift sheet and two emergency medical services (EMS) personnel and two police officers. - Patient refused vital signs and stated he/she did not want to be taken to the hospital because he/she was already at [CONDITION(S)] and needed to start treatment. Review of the ambulance district's Refusal of Care/Transport form, dated [DATE], showed EMS indicated the resident slid and fell , assisted caregiver getting patient into [CONDITION(S)]. Review of the local hospital's emergency department (ED)/outpatient record showed: - admitted [DATE] at 2:49 P.M., discharged [DATE] at 4:00 P.M. - Arrived in ED at 10:10 A.M. for evaluation of pain; patient was being transferred to [CONDITION(S)] when he/she slipped from the wheelchair and landed on the floor; reported pain to back and right shoulder. At this time patient is groaning in pain and reports pain all over. Review of the local hospital's Short-Stay summary, dated [DATE], showed: - On the way to [CONDITION(S)], patient fell from wheelchair in the van that was transporting him/her. - CT-scan (computerized tomography scan that combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than plain X-rays do) of the dorsal and [MEDICATION(S)] (center spine which runs from the base of the neck to the bottom of your rib cage) spine showed acute fracture of the endplate of T4 (well-known features of compression and burst type fractures). - CT-scan of the abdomen and pelvis showed a right non-displaced posterior 10th rib fracture (appear as cracks in the rib or a jagged edge and near the end). During an interview on [DATE] at 3:45 P.M., and [DATE] at 10:29 A.M., Licensed Practical Nurse (LPN)/Social Services Designee (SSD), who was the designee in charge of the facility that day, said staff should not transport residents with pillows as thick as the resident had behind and underneath him/her. TA should have contacted the nurse prior to securing the resident in the van when he/she refused to remove the pillows. TA should have stopped the van when the resident started moving in the wheelchair to help him/her readjust instead of driving distracted. MO 5 MO 2