Every finding on record at Maryville Rehabilitation & Health Care Center

Based on interview and record review the facility staff failed to follow the facility staffing policy of two staff members during the daytime hours for the Memory Care Unity (MCU) when Licensed Practical Nurse (LPN) A left the MCU, leaving Certified Nurse's Aide (CNA) A as the only staff member on the MCU when Resident #1 put his/her hand over Resident #2's mouth and hit Resident #3's arms with his/her hand. This deficient practice affected three of three sampled residents. The facility census was 44. On 07/30/26, the Administrator was notified of the past noncompliance which began on 07/22/26. Upon discovery, the facility administration immediately conducted an investigation, and corrective actions were implemented to include staff training regarding dementia care, staffing on the memory care unit, and abuse and neglect. The noncompliance was corrected on 07/23/26. Review of the facilities Investigation Report, dated 07/22/26, showed:-Resident's #1, #2, and #3 were sitting in the dining room on the memory care unit with CNA A;-Resident #1 and Resident #2 were verbally arguing and Resident #1 covered Resident #2's mouth with his/her hand;-CNA A separated the resident's;-Resident #1 then threw his/her walker at CNA A and a pair of pants that were on Resident #1's walker fell onto the floor;-Resident #3 reached down to pick up Resident #1's pants;-Resident #1 became irritated with Resident #3 picking up his/her pants and swung at Resident #3 and Resident #3 swung back at Resident #1, both resident's then began swatting at each other;-The resident's were immediately separated by CNA A;-LPN A was notified as he/she was walking up the hallway;-Resident #1 was placed on one on one observation;-All resident's were assessed for injuries and no resident had any injuries;-A urine sample was obtained from Resident #1 that showed he/she had a urinary tract infection;-The family of all resident's involved were notified;-A police report was filed with the local police department;-Education was provided for all nursing staff regarding abuse and neglect, dementia and behaviors, and ensuring two staff were on the memory care unit at all times from 6:00 A.M to 10:00 P.M. and to call for help when needed;-Corrective action was given to LPN A to not leave the MCU with only one staff member. Review of the facility staffing guidelines, not dated, showed:-Two staff need to be on the MCU from 6:00 A.M. until 10:00 P.M. at all times;-If a staff member is assigned to the MCU and needs to leave, that staff member needs to ensure that another staff member replaces them until they return. 1.Review of Resident #1's Quarterly Minimum Data Set (MDS) a federally required assessment tool completed by facility staff, dated 06/30/26, showed:-The resident was not cognitively intact;-The resident had not exhibited physical or verbal behavioral symptoms;-Diagnoses of dementia (a decline in mental ability severe enough to interfere with daily life), major depressive disorder, and history of urinary tract infections. Review of the resident's progress note, dated 07/23/26, showed: New medication order received for Bactrim DS (an antibiotic) twice a day for seven days due to a urinary tract infection. 2.Review of Resident #2's Quarterly MDS, dated [DATE], showed: -The resident had severe cognitive impairment;-The resident had not exhibited physical or verbal behavioral symptoms;-Diagnoses of dementia, Alzheimer's Disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), and depression. During an Interview on 07/30/26 at 12:12 P.M. Resident #2's representative said:-The facility notified him/her of the altercation with Resident #1;-He/She did not have any concerns regarding Resident #2's safety at the facility. 3.Review of Resident #3's Quarterly MDS, dated [DATE], showed: -The resident was not cognitively intact;-The resident had not exhibited physical or verbal behavioral symptoms;-Diagnoses of dementia, anxiety, and major depressive disorder. During an Interview on 07/30/26 at 11:53 A.M. Resident #3's representative said:-The facility notified him/her of the altercation with Resident #1;-Resident #3 did not appear fearful after the altercation with Resident #1 and he/she did not have any concerns for Resident #3's safety at the facility. During an Interview on 07/30/26 at 1:13 P.M. Certified Medication Technician (CMT) A said: He/She had received training after the altercation with Resident's #1, #2, and #3 regarding abuse and neglect, dementia, and always having at least two staff members on the memory care unit at all times. During an Interview on 07/30/26 at 1:32 P.M. LPN A said:-Resident #1 had been a little agitated so he/she was sitting with the resident's in the dining room to keep an eye on them;-He/She had to take some paperwork to another staff member that was not on the MCU asked CNA A to watch the residents in the dining room while he/she was gone;-He/She was not gone very long, he/she had dropped of some paperwork then went right back to the MCU;-He/She had left the MCU with just one staff member since he/she was not going to be gone very long;-He/She had training regarding abuse and neglect, dementia, and always having two staff members on the MCU at all times since the altercation between Resident's #1, #2, and #3 occurred. During an Interview on 07/30/26 at 1:43 P.M. CNA A said:-LPN A had said that he/she needed to go do something off of the MCU and asked CNA A to sit with the residents in the dining room while LPN A was gone; -Right after LPN A had left the MCU, Resident #1 put his/her hand over Resident #2's mouth since Resident #2 was yelling at resident #1;-CNA A separated Resident #1 and Resident #2, Resident #1 then hit CNA A with his/her walker causing a pair of pants that were hanging on the resident's walker to fall onto the floor;-Resident #3 reached down to pick up the pants that had fallen off of Resident #1's walker;-Resident #1 then swung at Resident #3 with a closed fist and Resident #3 swung back at resident #1 with a closed fist, both hitting each other in the arms. During an Interview on 07/30/26 at 2:53 P.M. the Administrator said:-She expected LPN A to call, text, or use a walkie talkie to get another staff member to be on the MCU before he/she left; -Facility staff were provided training regarding abuse and neglect, dementia care, and ensuring two staff members were on the MCU at all times between the hours of 6:00 A.M. through 10:00 P.M. Intake 3108318

Based on observation and interview the facility failed to provide a dignified existence for one resident, who resided on the Special Care Unit, (Resident #1), when Certified Nurse Aide (CNA) A took a picture of Resident #1, without resident or family/guardian consent and shared it with a coworker. The facility census was 48Review of the facility provided Resident Rights Policy dated 12/2024 showed:-Each resident residing in this community has the right and will be afforded the right to a dignified existence;-It is the responsibility of all who work in this community including employees, to protect the rights of each resident;-Resident Rights include privacy and confidentiality.Review of Resident #1's Significant Change Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) showed:-He/She had significant cognitive loss; -He/She was dependent on staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself); -Diagnosis of dementia and hearing loss. Review of Resident #1's Comprehensive Care Plan date 03/25/2026 showed:-He/She was unable to voice previous routines and preferences, please refer to the Durable Power of Attorney (DPOA) for routines and preferences, date initiated 03/25/2025; -He/She had impaired cognitive function and thought process due to dementia and resides on the SCU;-The resident's dignity and autonomy will be maintained at the highest level.Review of the facility provided investigation dated 06/03/2026 showed:-On 06/03/2026 at approximately 2:45 P.M. Certified Nurse Aide A, took a photo, with a mustache filter, of Resident #1 fully dressed walking into the kitchen of the SCU in the facility, and a caption of are you working tonight to Certified Medication Technician A;-When CMT A reported for work at 6:00 P.M on 06/03/2026 he/she reported the picture to Licensed Practical Nurse (LPN) B ; -CNA A was suspended; -Other residents were questioned, felt safe and were unaware of any pictures being taken; -The Administrator started Abuse and Neglect education with all staff. During an interview on 06/09/2026 at 11:20 A.M. Family Representative A for Resident #1 said:-He/She was unsure how Resident #1 would have felt about taking a picture; -Resident #1 probably would have been okay with the picture if it was between the two of them but not being shared with others; -Resident #1 took pictures with Family Representative A previously, but he/she was unsure how the resident would feel about those being shared as he/she never shared them with anyone.During an interview on 06/09/2026 at 2:32 P.M. LPN B said: -He/She was notified by CMT A had received a picture of Resident #1 from CNA A; -Resident #1 would not understand that a picture was even taken; -He/She cared for Resident #1 previously and the resident may have thought the picture was funny, but he/she did not know for sure; -Taking pictures of residents was not okay and he/she reported to the Administrator immediately; -He/She had education on abuse and neglect after the picture was taken. During an interview on 06/09/2026 at 3:39 P.M. CMT A said:-On 06/03/2026 at approximately 2:45 P.M. he/she received a picture of Resident #1 from CNA A; -The picture showed Resident #1, with a mustache, fully clothed, walking with his/her walker, and a caption that asked are you working tonight; -He/She reported to LPN A when he/she arrived for his/her shift;-He/She had education on abuse and neglect after the incident.During an interview on 06/09/2026 at 4:07 P.M. CNA A said:-He/She did take a picture of Resident #1 with a mustache filter and sent it to his/her friend who worked at the facility; -He/She did not ask the resident permission to take the picture as the resident would not understand what he/she was doing;-He/She did not save the picture, put the picture on line or anywhere but to CMT B; -He/She did not remember if he/she had any education on taking photos, dignity or privacy, but had education not to take photos and post them online; -He/She thought if he/she didn't post the picture on line it was not a big deal and would not cause any harm; -He/She did not mean to cause any harm to the resident.During an interview on 06/12/2026 at 2:27 P.M. the Administrator said:-He/She would expect staff not to take any pictures of residents; -CNA A was suspended and had been terminated;-Education on Abuse and Neglect was provided to staff; -Residents were questioned about pictures and safety and no concerns were brought up; -Resident Rights training is done at time of hire and annually. Intake 3033227

Based on interview and record review, the facility failed to protect one resident (Resident #1) right to be free from misappropriation of property, when an employee did not follow policy for accurate narcotic (highly addictive prescription medication) count, did not visualize liquid narcotic medication during count procedures and the resident was missing 40 milligrams (mg) of morphine sulfate (liquid narcotic medication that is highly addictive) medication on 06/29/26 and no documented use. The facility census was 45.Review of the facility Controlled Substance Policy dated 12/2024 showed:-Controlled substances are subject to special record keeping requirements;-The authorized person receiving and checking in a drug is to prepare a controlled substance proof of use record form;-Thereafter a physical inventory of that medication will be made at the change of each nursing shift;-All controlled substances are to be counted every shift; -The on-coming nurse or Certified Medication Technician (CMT) will be responsible for looking at the medication to verify the amount of the medication present at the time of count; -Any discrepancy in the inventory of a controlled substance is to be reported to the Director of Nursing immediately. Review of the facility Abuse Prevention and Prohibition Policy dated 11/2025 showed:-Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent; -The person made aware of allegations of abuse or neglect OR the Administrator will report the allegations of abuse and neglect to law enforcement.Review of Resident #1's Significant Change Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 04/22/26 showed:-Significant cognitive impairment; -Diagnoses included: Alzheimer's Disease, cognitive communication deficit, dementia, anxiety, and heart failure; -He/She received Hospice services.Review of the resident's Comprehensive Care Plan dated 04/25/26 showed the resident had a terminal prognosis (illness that will lead to death typically within six months), and received Hospice care. Review of the facility Investigation Report dated 06/29/26 showed:-During shift change on 06/29/26 at 6:00 A.M. Licensed Practical Nurse (LPN) A found that the resident's bottle of liquid Morphine sulfate had a total of 28ml of a 30ml bottle and no documentation of administration; -Conclusion was unable to determine missing narcotic medication; -Interviews with staff showed CMT A reported he/she and LPN C counted narcotics on 06/27/26 and 06/28/26 and did not remove the bottle from the box or look at the bottle of medication. Review of the resident's physician orders for July 2026 showed:-Morphine sulfate (a potent opioid pain medication) oral solution 20milligrams (mg)/milliliter (ml); give 0.25 ml by mouth every hour as needed for minimal pain/air hunger of 1-3. Give 0.5ml every hour as needed for moderate pain/hair hunger. Give 0.75ml every hour as needed for severe pain/air hunger and 1 ml by mouth every hour as needed for excruciating pain/air hunger of, ordered 05/12/26. Review of the resident's July Medication Administration Record (MAR) showed the facility staff did not document administration of Morphine Sulfate.Review of the resident's Controlled drug receipt/record/disposition form showed:-No signature of the nurse the received the medication; -No quantity received recorded; -Date dispensed 04/29/26; -Name and Strength: Morphine Sulfate 100mg/5ml; -Quantity Dispensed: 30mls; -On 06/29/26 0ml administered, 28ml remained. During an interview on 07/07/26 at 4:05 P.M., the local Police Officer A said he/she had not been notified of missing narcotics. The facility staff did not make a police report of missing narcotics.During an interview on 07/07/26 at 4:16 P.M., the Medical Director said she had not been notified the resident had missing narcotics. She would expect to be notified when narcotics are missing. During an interview on 07/07/26 at 5:03 P.M., the Administrator said:-She was awaiting lab results of staff involved in missing narcotics; -The police had not been notified, but she would call them; -Education on correct narcotic count procedures was done with staff. During an interview on 07/08/26 at 8:58 A.M., LPN A said:-On 06/29/26 was the first shift he/she had worked at the facility; -He/She counted narcotics with CMT A on 06/29/26 around 6:00 A.M.; -He/She saw that the bottle of morphine for the resident had been opened and there were not 30 ml of fluid in the bottle; -He/She notified LPN B immediately; -LPN B took the bottle of morphine and the count sheet.During an interview on 07/20/26 at 9:05 A.M., LPN B said; -He/She was notified of missing narcotics on 06/29/26 during count because he/she went to the Special Care Unit to check on staff; -LPN A showed him/her a discrepancy where the resident's morphine had 28ml in the bottle instead of 30ml and 2 ml were unaccounted for; -He/She took the morphine bottle and the count sheet and locked them in the medication room to await the Director of Nursing's (DON) arrival;-The DON was notified of the discrepancy between 7:30 A.M. and 8:00 A.M. when she arrived. During an interview on 07/20/26 at 2:10 P.M., LPN C said:-He/She counted narcotics over the weekend of 06/27/26 and 06/28/26 with CMT A; -He/She was not working 06/29/26 when the discrepancy was found;-He/She saw the resident's bottle of Morphine Sulfate, but did not look closely enough to see there was medication missing; -He/She should have checked the bottle more closely for discrepancy; -The DON should be notified immediately of any missing narcotics.During an interview on 07/20/26 at 2:30 P.M., the Director of Nursing said:-She was notified of the discrepancy in narcotic count for the resident when she arrived to work on 06/29/26; -LPN B placed the medication and count sheet in the medication room prior to her arrival; -The nurse who was working on the special care unit was the one who recognized the discrepancy; -She counted the medication with LPN B to determine there were only 28 ml in the bottle; -There was medication residue in the syringe used to administer the medication; -She researched the discrepancy by asking staff if they had administered the medication; -She was unable to find a staff member who had administered the medication so Department of Health was notified; -She would expect staff to notify her of missing narcotics; -Staff probably should have texted or called her immediately when the discrepancy was found. Intake 3063583

Based on observation, interview and record review the facility failed to have sufficient staff to prevent one resident (Resident #2) who resided on the Special Care Unit, from exiting the facility unattended, sustaining a fall in the courtyard, obtaining a 6 inch abrasion to his/her arm and caused extreme pain, while unaccompanied by staff. The facility census was 48.Review of the facility provided Skilled Fall Policy dated 05/2025 showed:-The fall program promotes safety, prevention and education of both staff and residents; -Each resident will be provided services and care that ensures that the resident's environment remains as free from accident hazards as is possible and each resident receives adequate supervision and assistive devices to prevent accidents.Review of the facility provided Elopement Policy dated 09/2025 showed:-It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible; -When a door alarm sounds staff shall immediately respond to and determine the cause of the alarm; Review of the Facility assessment dated [DATE] showed:-A census of 42 residents;-34 Residents needed 1-2 staff for assistance; -8 residents were dependent on staff ; -No staffing ratios noted. The facility did not provide a policy on staffing.Review of Resident #2's Significant Change Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 04/09/2026 showed:-Significant cognitive loss; -Moderate to maximum assistance of staff with Activities of Daily Living (ADLs: tasks completed in a day to care for oneself)-Walks with supervision or one assistance of staff.Review of Resident #2's Fall Risk Assessment completed on 05/16/2026 showed:-score of 35 indicated high risk for falls. Review of Resident #2's Comprehensive Care Plan dated 06/06/2025 showed: -He/She was at risk for falls and had a history of falls, confusion, balance problems and he/she was unaware of safety needs date initiated 06/12/2025; -Maintenance was to check courtyard for safety concerns, date initiated 08/25/2025-Do not leave the resident in the courtyard without staff presence, date initiated 06/08/2026; -The resident had a behavior problem at times, wanted to leave the facility, went into other residents rooms, and resided on the dementia unit, date initiated 06/18/2025; -The resident had exit seeking behaviors at times, redirect as needed, date initiated 06/18/2025 -Staff were to anticipate and meet the resident's needs, date initiated 06/18/2025.Review of the resident's Nurse Progress Notes showed:-On 06/07/2026 at 7:45 P.M. Certified Nurse Aide (CNA) B reported Resident #2 was found outside on his/her backside; the resident complained of extreme pain in his/her upper left femur (long bone of the upper leg) and elbow; a 6 inch abrasion was noted to his/her left outer forearm; unable to perform Range of Motion (ROM the normal movement of a joint) because of pain and position, family notified and said to send the resident to the emergency room if needed, the ambulance was notified and the resident was sent to the emergency room. Observations on the Special Care Unit on 06/09/2026 at 2:10 PM showed:-No staff visible in hallway; -Doors to multiple resident rooms were closed;-No sounds of staff, such as voices, equipment etc, in resident rooms,-Resident #3 was walking in nurses station area; walked down the hall to the dining area, and attempted to push open the locked courtyard exit door; -At 2:30 P.M. CNA B came out of one resident room; -At 2:45 P.M. the Certified Medication Technician entered the SCU through the front doors. During an interview on 06/09/2026 at 2:00 P.M. Licensed Practical Nurse (LPN) A said:-All fall events should be charted in Progress Notes and Risk Management completed;-The courtyard door on the SCU is unlocked all the time and there is an alarm; -The alarm is loud so it can be heard throughout the unit; -Resident #2 was only outside for 10 minutes; -There was a CNA on the SCU at the time of Resident #2's fall and the CMT was passing medication on the front hall. During an interview on 06/09/2026 at 3:39 P.M. Certified Medication Technician (CMT) A said:-He/She worked a 12 hour shift on 06/09/2026; -He/She was usually assigned to the SCU; -He/She got report at 6:00 P.M. when he/she arrived on the SCU then immediately went to the front hall to pass medications; -Assigned CNA staff were on the SCU alone while the CMT was passing medications for an hour and a half to two hours; -He/She did not inform Certified Nurse Aide A, that he/she was going off the hall; -The door to the courtyard is supposed to be locked unless staff are taking residents outside; -Most staff know that CMTs go up front to pass medications and they are alone on the SCU at that time.During an interview on 06/09/2026 at 2:40 P.M. CNA B said:- The exit door to the courtyard was supposed to be locked at all times; -A CMT was scheduled on the SCU on 06/07/2026 with him/her; -The CMT assigned to the SCU left the unit to pass medications up front;-It was normal for the CMT to leave the assigned SCU and pass medications up front;-On the evening of 06/07/2026 he/she was assisting a resident into bed; he/she heard the door alarm sound; completed covering the resident and went to investigate the alarm; he/she saw that Resident #2 was sitting in the courtyard and yelled for assistance; no one responded; he/she left the SCU and went in search of assistance; -He/She knew he/she should not leave Resident #2 outside on the ground but needed to find help and he/she was alone on the unit; -Only one staff was on the unit when the second staff was passing medications, taking residents out to smoke or on break; -He/She was not sure how long Resident #2 was outside or what time the resident was seen last; -The nurse responded to his/her request for help and the resident was sent to the hospital;-Resident #2 was moaning and crying in pain;-When only one staff was on the unit they make the residents wait for assistance, so the one staff on the unit is not in a room and can monitor residents.Intake 3037653

Based on record review and interview, the facility failed to provide an appropriate discharge for one resident, (Resident #1), of six sampled residents, when the facility refused to allow the resident to return to the facility after hospitalization, based on the resident's behaviors prior to hospitalization. The facility census was 46. Review of the facility provided, undated Notice of Transfer/Discharge form showed:-You may only be transferred or discharged from this nursing facility for one of the following reasons: the safety of individuals in this facility is endangered; -This facility plans to transfer/discharge you to the following location.The facility did not provide a policy on Discharge. Review of Resident #1's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 03/27/26 showed:-Brief Interview for Mental Status (BIMS) of three (3), indicated significant cognitive loss; -No behaviors; -Diagnoses included: Stroke, high blood pressure, vision loss, amnesia (the partial or total loss of memory) and brain damage. Review of the resident's Comprehensive Care Plan dated 03/30/26 showed:-He/She had a behavior problem; -He/She wrapped the call light around his/her neck; denied attempting to or plan of harming him/herself. -He/She shoulder bumped another resident;-Destructive behaviors, such as: kicked another residents TV, tore wooden trim off of the wall/window, stood on the air conditioning unit;-He/She had hallucinations at times; -He/She was placed on 15 minute checks on 05/18/26.Review of Nurse Progress Notes dated 05/13/26 showed:-At 11:43 A.M. the resident had no behaviors while at the hospital and returned to the facility with orders for hydroxizine (a medication used for anxiety) intramuscularly (IM) every six hours as needed for agitation and behaviors;-At 8:31 P.M. the resident continually asked staff to kill him/her and described it in disturbing detail how to do so;-He/She took the handle off a broom and then asked staff to hit him/her with the handle;-He/She became increasingly agitated when redirected;-He/She pulled a light fixture out of the wall; -He/She pulled screens out of the windows and attempted to punch out windows;-He/She was placed on 1:1 observation with staff;-At 11:42 P.M. the resident was sent to the emergency room for increased behaviors; -Emergency Medical Services and law enforcement were on site to assist with resident transfer.Review of Nurse Progress Notes dated 05/20/26 showed:-On 05/20/26 at 9:45 A.M the resident continued to have behaviors and remained on 1:1 observation with staff; -The resident was admitted to the hospital for increased violent behaviors. Review of the Resident's Electronic Medical Record showed A Notice of Transfer/Discharge Form:-No resident name, no facility name, no Administrator, no Business Office Manager, no phone number, no Resident Representative, no address, no date of transfer, and no location of transfer; -The health of individuals in this facility would otherwise be endangered was marked. During an interview on 05/27/26 at 12:45 P.M. the Administrator said:-The resident had a lot of behaviors; -The resident threatened staff and other residents; -The resident had been sent to the hospital multiple times;-An emergency discharge was initiated when the resident went to the hospital on [DATE] because he/she was a danger to other residents;-Transfer and discharge paperwork was completed by the Director of Nursing; -There was not a transfer and discharge policy; -He/She would expect the discharge paperwork to be complete when the resident was discharged . Intake 3021011

Based on observation, interview and record review the facility failed to provide follow up care in a timely manner after one resident, Resident #2, sustained a fall, had reported signs of pain, did not receive treatment for four days and subsequently had a fractured hip. The facility census was 43.Review of the facility policy titled, Skilled Fall, Policy dated 05/2025 showed each resident of this community who experiences a fall will be treated and assessed to adequately treat any current injuries. Review of the facility policy titled, Significant Condition Change and Notification, dated 12/2024, showed:-To ensure the resident's medical practitioner was notified of resident changes such as: an accident or incident with or without injury that has the potential for needed medical intervention;-Mobility changes;-Abnormal, unusual or new complaints of pain;-Need to significantly alter treatment. Review of the facility policy titled, Pain Management, dated 02/2025 showed:-It is the policy of this facility to respect and support the residents right to optimal pain assessment and management; -Acute pain is usually sudden in onset, and is often caused by injury, trauma or medical treatments; -Strategies for pain management include but are not limited to: Addressing/treating underlying causes of pain to the extent possible; -Expressions of pain may be verbal or non-verbal and are subjective to the resident (i.e. groaning, crying, whimpering, screaming). Review of Resident #2's admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 01/02/26, showed:-Brief Interview of Mental Status (BIMS) of 99 indicated significant cognitive deficit; -Able to understand and make self understood; -Dependent on staff for toileting and bathing; -No falls or history of falls; -Diagnoses included: Stroke with right side weakness, need for assistance with personal care, Chronic Obstructive Pulmonary Disease (COPD a disease where the lungs do not take in and use oxygen appropriately), and Transient Ischemic Attack (TIA :a temporary blockage of blood flow in the brain causing stroke like symptoms and does not cause permanent damage). Review of the resident's Fall Risk Assessment, dated 01/03/26, showed he/she was a low risk for falls. Review of the resident's Comprehensive Care Plan, dated 01/10/26, showed: -He/She was at risk for falls, and had walking and balance problems;-He/She was not to be left alone in the wheelchair (w/c) in his/her room;-He/She was not to be left alone in the bathroom;-He/She should have call light within reach when in his/her room;-The resident's fall on 02/10/26 was not addressed on the care plan;-The resident's pain was not addressed on the care plan. Review of the resident's nurse progress note, dated 1/21/26 at 12:51 P.M., showed:-Therapy reported the resident remained on services for a stroke;-Some days the resident required minimum assistance of staff for transfers, he/she had adequate strength and cognition varied. Review of the resident's nurse progress note, dated 02/10/26 at 7:15 P.M., Licensed Practical Nurse (LPN) A documented:-The nurse was called to the resident's room where the resident was found on the floor near his/her bed;-The resident said he/she was trying to get into bed;-Staff used a mechanical lift to get the resident into bed. Review of the resident's progress notes, for February 2026, showed the facility staff did not document an assessment after the resident's fall on 2/10/26. Review of the resident's nurse progress note, dated 2/11/26 at 10:59 P.M., showed the resident's gait (walking), grasp (hand holding) and upper and lower extremity movement was not assessed. Review of the resident's nurse progress note, dated 2/12/26 at 4:23 P.M, the Administrator documented:-The resident's family reported the resident complained of pain in his/her right leg/hip area especially with therapy;-Order received for mobile x-ray to be completed of right hip;-Mobile x-ray was unable to obtain the x-ray on 2/12/26 and would obtain the x-ray on 2/13/26. Review of the resident's nurse progress note, dated 2/12/26 9:00 P.M., showed the resident's gait, upper and lower extremity movement was not assessed. Review of the resident's nurse progress note, dated 2/13/26 at 10:17 A.M., LPN B documented he/she did not assess the resident's lower extremity movement. Review of the resident's nurse progress note, dated 2/13/26 at 3:39 P.M., the Director of Nursing (DON) documented:-The resident's family was concerned with the resident's complaints of pain;-The family was educated on awaiting x-ray;-The family asked if the resident could be given Tylenol for pain. Review of the resident's February Physician Orders Sheet (POS) showed an order, dated 02/13/26 at 4:12 P.M., for acetaminophen tablet 325milligram (mg), give two tablets by mouth every 4 hours as needed for general discomfort and no other pain medication ordered. Review of the resident's radiology report, dated 2/13/26, showed the impression of an acute right hip fracture. Review of the resident's nurse progress note, dated 2/14/26 at 4:45 A.M., showed:-The resident's x-ray report was called to the facility nurse;-The resident's family was notified and permission was granted to send him/her to an area hospital for evaluation;-The resident went to the hospital by ambulance. Review of the resident's Medication Administration Record (MAR), dated February 2026, showed-No acetaminophen was administered in the month of February; -Pain assessments were completed on February 11th, 12th and 13th and recorded as 0 on a 0-10 scale on all shifts. During an interview on 03/06/26 at 2: 30 P.M., Physical Therapist (PT) A said: -The resident had not had any complaints of pain until after the fall on 2/10/26; -He/She attempted to provide therapy on 02/11/26 and the resident would grimace and his/her face would turn red; -He/She knew something was wrong and notified LPN B the resident was having pain;-Nothing was done to address the resident's pain; the resident was not sent to the hospital for a few days. During an interview on 03/06/26 at 2:56 P.M., the Administrator said:-The resident's family reported he/she had pain on the 12th and 13th; -She did not know why the resident was not sent to the hospital the night the x-ray was ordered, since the mobile x-ray company could not get to the facility; -She would base the need to be sent to the hospital if the resident was in distress or having acute pain; -She tried to avoid sending the resident to the hospital due to the acute illness the resident may come in contact with at the hospital, and increased confusion for confused residents;-She spoke with the resident's family on 02/12/26 and offered to get a mobile x-ray. During an interview on 03/06/26 at 3:05 P.M., LPN B said:-He/She did not recall if staff reported to him/her the resident was in pain; -The resident's family reported he/she was in pain one day but was unsure what day it was; -He/She did not feel like the resident's pain was urgent or that it was an emergency to send him/her to the hospital; -If a mobile x-ray was going to take an excessive amount of time to obtain, he/she would send the resident to the hospital. During an interview on 03/11/26 at 1:50 P.M., Certified Nurse Aide (CNA) A said:-He/She was present when the resident fell on [DATE]; -The resident was grunting and groaning with movement;-The resident's leg looked swollen;-A licensed nurse checked the resident so, CNA A did not report any swelling to anyone else. During an interview on 03/11/26 at 2:10 P.M. LPN C said :-The resident did not complain of pain that he/she was aware of; -The resident was non-verbal and would mostly nod yes or no when asked; -After a fall an assessment should be completed for 72 hours;-At the time of the resident's fall the resident did not see any swelling of the resident's thighs. During an interview on 03/11/26 at 3:15 P.M., the DON said:-The resident should have been sent to the hospital when mobile x-ray was not available when ordered; -During her investigation multiple CNA's staff reported the resident had complaints of pain after the fall and before being sent to the hospital; -She spoke with the resident's family about his/her pain and asked the charge nurse to administer pain medication;-She is unsure why the medication was not given;-It was unacceptable that a resident laid in pain for several days prior to treatment; -She expected staff to provide immediate intervention and assess a resident for 72 hours after a fall to include range of motion for upper and lower extremities;-She expected pain assessments to be completed for 72 hours after a fall. Intake 2743923Intake 2748212Intake 2785301

Based on interviews and record review, the facility failed to protect one resident (Resident #1) from misappropriation, when $600 of the resident's money went missing from the Social Services Designee's (SSD) office. The facility did not reimburse the resident for the missing money until 03/10/26. The facility census 43.Review of the facility's Abuse Prevention, and Prohibition Policy, dated November 2025, showed:-This facility prohibits mistreatment, neglect, or abuse or residents; -The facility prohibits misappropriation of resident property;-Misappropriation of Resident Property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent;-Social Services or designee will assist the resident/family to identify and mark personal possessions upon admission;- An inventory will be completed and maintained in the resident's clinical record;-Social Services or designee will educate the resident/family of the need to report any items of significance being brought in or removed so that this can be noted on the inventory in the clinical record;-Social Services or designee will educate the resident on how to report suspected occurrences, explaining the need to report, how to report, the investigation process, and the facility's response to the allegation; -Social Services Designee, overseen by the Administrator, will investigate all reports or complaints of missing resident property following the policy and procedure;-The Administrator will make the appropriate notifications and initiate an investigation of the allegation of misappropriation of resident property;-Should a specific employee be suspected of or have allegations made of misappropriation, the facility will follow the investigation protocol set forth in this policy;-The facility will educate the resident/family on how to deal with valuable items: i.e. taking items home, proper storage;-The facility will educate staff on the policy and procedure for prevention of misappropriation of resident property and of investigation, reporting, and staff responsibility. 1. Review of Resident #1's undated face sheet showed:-The resident's diagnoses included: Atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), vertigo (a sensation of spinning or swaying, often caused by inner ear issues, that leads to severe dizziness and balance loss). Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 02/24/26, showed he/she scored an 8 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents) indicating moderate cognitive decline. No behaviors were exhibited during the assessment period. Review of the resident's comprehensive care plan, dated 03/04/26, showed interventions related to locking up personal belongings to keep them safe. Review of the resident's progress notes showed the SSD documented on 2/19/26 at 4:53 P.M.:-The resident informed the SSD there was some cash in his/her purse; -The SSD and charge nurse counted $2137.00, along with a check book and three bank cards;- The resident kept $20;- The SSD put $2117, the check book and bank cards in the box in the SSD desk;-The SSD then called and notified the resident's family of the money and requested it to be picked up. Review of the facility investigation, dated 02/20/26, showed:-On 02/19/26, the resident was admitted to the facility at approximately 3:00 P.M.-At approximately 5:00 P.M., the resident informed the SSD that he/she had a cash in his/her purse;-He/She allowed the SSD to go through the purse and secure the cash;-The SSD counted the cash with the charge nurse on duty;-It was noted that the resident had $2137.00 in cash, along with a check book and three bank cards;-The resident elected to keep $20 in cash on his/her person;-The SSD took the remainder of the cash, $2117.00, the check book, and bank cards, and placed them in the safe box in the desk in the SSD office;-The SSD placed a call to the resident's family, requesting they come and pick up these items;-The SSD then left the facility for the day, locking the door to the SSD office; -On 02/20/26 at approximately 1:30 P.M., the SSD went to retrieve the cash, check book and bank cards to give them to the resident's family;-It was noted the cash was not in the same position as it had been placed in the safe box the evening prior;-The cash was counted and it was discovered $600.00 was missing, leaving $1517.00;-The check book and bank cards were still in the safe box;-It was noted that the safe box and desk drawer in the SSD office do not lock;-The Director of Nursing (DON) and Administrator were notified of the missing money;-The DON notified local law enforcement and family of the missing money; -The Administrator initiated an investigation;-All staff working between 02/19/26 at 5:00 P.M. to 02/20/26 at 2:00 P.M. were interviewed;-No staff had any knowledge regarding the missing money;-The set of keys the charge nurses carry does not have a key to the SSD office;-There was a box kept in the medication room with emergency keys to all rooms in the facility;-This key box was found to be unlocked and the zip lock around the lock box was missing;-The SSD key was present in the lock box;-The SSD was suspended pending the results of the investigation;-He/She returned to work on 02/25/26;-All staff were educated on how to handle resident money and property, and how to report missing resident money or property;-The safe box was removed from the SSD office;-A new lock box was ordered for the Administrator's office;-All resident money will now be given to the Business Office Manager (BOM) or the Administrator;-The facility will reimburse the resident for the missing money. Review of the police report dated 02/20/26 showed:-Law enforcement was contacted on 02/20/26 at 2:45 P.M. and arrived to the facility at 2:53 P.M.:-Officers met with the Administrator and SSD and were given the details of how the money was acquired, stored and noted to be missing;-SSD reported there had been $617.00 in miscellaneous bills and $1500.00 in $100 bills;-SSD stated that he/she documented the money in a progress note in the resident's electronic medical record; -SSD also stated that he/she did not inform other staff members of the money and only staff who had access to progress notes are the nurses;money and denied accessing the SSD office. During an interview on 03/11/26 at 11:22 A.M., the BOM said:-A grievance was filed on behalf of the resident on 02/20/26, indicating he/she had $600.00 go missing while being held in the SSD office; -The Administrator instructed the BOM to submit a request for the refund for the resident from the corporate office on 03/10/26;-He/She was waiting for a response from the corporate office to release the funds to the resident's family. During an interview on 03/11/26 at 3:25 P.M., the SSD said:-The resident had $2137 in cash in his/her possession;-The SSD counted the money with the charge nurse;- The resident kept $20 and $2117 in cash, the checkbook and bank cards were put in the box in the drawer in the SSD's desk; -He/She contacted the resident's family on the afternoon of 02/19/26 to pick up the cash, check book and bank cards from the SSD office;-He/She has not had money or property go missing from the SSD office before this event; -He/She was in the office on 02/20/26, from 8:00 A.M. to 1:30 P.M. with the exception of attending a meeting 9:00 A.M. to 9:30 A.M.;-When he/she went to retrieve the money from the box in the drawer at approximately 1:30 P.M. he/she saw it had been moved and some was missing;-SSD confirmed he/she locked the office when leaving for the day on 02/19/26 and the office was locked when he/she returned to work on 02/20/26;-The Administrator and DON had a key to the Social Services Office, and a key is kept in the emergency box in the medication room;-The nurses and certified medication technicians have a key to the medication room. During an interview on 03/11/26 at 2:45 P.M., the Administrator said:-The request for the funds to reimburse the resident of the missing money was delayed due to waiting for approval from the corporate office to submit a request;-The SSD was suspended on 02/20/26 after law enforcement arrived at the facility and interviewed him/her;-The SSD was allowed to return to work on 02/25/26 after the facility investigation was complete and the investigation showed it was undetermined who had taken the money from the SSD office; -The facility has received no additional reports of missing money or property from residents and/or their families.-A new lock box has been ordered for the Administrator's office;-All resident money and valuables will now be kept in the BOM office or Administrator office while awaiting pick up by the resident's family. Intake 2784530

Based on interview, and record review, the facility failed to prevent an injury for one Resident (Resident #1) of the four sampled residents, when the facility staff did not follow the resident's care plan and did not properly transfer the resident, causing a fracture to the right lower leg. The facility census was 48.Review of the undated facility policy titled Transfers Training Policy showed:- Transfers are assessed to determine each resident needs;- Transfer assist needs are located on the resident's care plan;- Always check the resident's transfer requirements before transferring the resident;- All mechanical lifts require two people. If the plan of care is not followed, progressive disciplinary action will proceed up to and including termination.Review of the facility's Safe Lifting and Movement Policy, dated 12/24, showed:-Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents;-Manual lifting of residents shall be eliminated when feasible;-Nursing staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices;-Nursing staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. On 10/8/25 the Administrator was notified of the past noncompliance which occurred at the facility on 10/5/25. On 10/6/25, the facility administrator was notified of the incident, an investigation immediately began, and corrective actions were implemented to include:- The Nursing Aide (NA) A who caused the injury was suspended with progressive action to terminate;- The Director of Nursing (DON) or designee (which includes the Assistant Director of Nursing or the Administrator) will complete 100% staff training on the Kardex (a concise, portable document used in nursing to summarize key patient information and care plans) and how to utilize the care plan, education was initiated on 10/6/25 for all direct care nursing staff; - The DON will ensure education continues until all nursing staff have been educated, staff not available will not be allowed to return to work until the education has been provided; - Documentation showed on 10-6-25 a Quality Assurance and Performance Improvement (QAPI)(refers to Quality Assurance and Performance Improvement (QAPI) activities that are impromptu, as-needed, and specific to a particular problem or initiative, rather than part of regular, scheduled meetings or programs) meeting was held regarding the care plan and safe lifting education;- The DON or designee will conduct five random interviews with staff asking how to access interventions on the care plan for the next eight weeks;- The DON or designee will complete five lift transfer skill check offs per week for eight weeks with all nursing staff; - The actions to address the non-compliance were completed on 10/6/25.1.Review of the Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/17/25, showed:- Cognitive skills severely impaired;- Dependent on staff for transfers, toilet use, showers, dressing, and personal hygiene;- Diagnoses included: dementia, heart failure, advanced age and general debility.Review of the Care Plan record, revised 10/7/25, showed:- The resident had recently obtained a right tibial/fibula fracture from a fall while being transferred by staff;- The resident was at risk for falling related to unsteady balance and impaired safety awareness requiring staff assist of two to use a mechanical lift for transfers.Review of the nursing progress notes showed:- On 10/5/25 at 8:45 P.M. Licensed Practical Nurse (LPN) A documented he/she was called to the resident's room to assess the resident on the floor. Staff was attempting to transfer the resident with a gait belt and had to lower resident to the floor to prevent a fall. No bruising or signs and symptoms of injury noted. Resident was assisted into bed without incident. The ADON (Assistant Director of Nursing) was notified;- On 10/6/25 at 10:16 A.M. the DON documented she was called to the residents' room after resident was given a shower. Certified Medication Technician (CMT) A reported to DON the resident was complaining of right ankle pain. Right ankle was swollen, no redness or warmth noted, and the foot appeared to be turned in. Resident complained of pain at the ankle with movement or when touched. Resident assisted out of bed with a mechanical lift and placed in wheelchair. Ice was applied to the ankle. The physician was notified and mobile x-ray of the right ankle was ordered;- On 10/6/25 at 11:17 A.M. the ADON documented the resident's guardian was notified about the incident of lowering the resident to the floor and gave an update on the current condition of resident complaining of right foot pain;- On 10/6/25 at 5:16 P.M. the initial x-ray result findings showed there was mild swelling over the malleoli (outer aspect of ankle). There was a mildly impacted transverse fracture at the distal diaphyseal aspect of the tibia (broken right lower leg). Impression showed fractures of the distal tibia and fibula as described. Although a Computed Tomography (CT) scan (a medical imaging procedure that uses X-rays to create detailed, cross-sectional images of the body's internal structures) was advised for full assessment;- On 10/6/25 at 6:26 P.M. the ADON documented imaging returned with tibial/fibula fracture. Guardian notified of results and stated as long as resident is not in any uncontrollable pain he/she would like to wait until tomorrow to try and get resident further treatment instead of disrupting the resident that night. The Guardian was notified if anything changed and pain becomes noticeably worse during the night the facility would immediately send to Emergency Department if unable to control pain at the facility;- On 10/7/25 at 6:19 A.M. LPN A documented resident fall risk evaluation showing resident had no falls in the past three months, was not mobile and had no recent hospitalizations in last 30 days, and was a fall risk of nine (indicates a high risk of falling);- On 10/7/25 at 10:13 A.M. the ADON documented she received a call from the physician's office with new order to send resident to Emergency Department for further evaluation and treatment of right ankle fracture. 911 called and Emergency Medical Services (EMS) enroute for transport;- On 10/7/25 at 4:02 P.M. Registered Nurse (RN) B documented resident sent out via ambulance per physician's request. Report received from hospital nurse stating the resident had been evaluated, a splint had been applied to the resident's right ankle, and to follow up with orthopedic physician in one week;- On 10/7/25 at 5:46 P.M. RN B documented resident returned to facility via ambulance following outside appointment related to fall during transfer. Resident to follow up with orthopedics in one week;- On 10/8/25 at 10:57 A.M. RN B documented resident reported increased pain to right ankle, known fracture. Splint intact, resident not able to state pain level on numerical scale but resident noted to have facial grimacing stating it really, really hurts. Provider notified of pain. Resident sitting up in wheelchair with bilateral feet elevated;Review of the resident's physician order sheet (POS), dated October 2025, showed a start date of 10/6/25 for 72-hour charting to monitor for changes in condition, pain or changes is Activities of Daily Living (ADL's) related to lowering to floor on 10/5/25 every shift for three days. Review of the hospital Emergency Department discharge notes, dated 10/7/25, showed:- The resident presented to emergency room (ER) for evaluation of right ankle fracture. - An X-ray of Tibia Fibula 1-2 views Right showed mildly displaced complete transverse distal tibial and fibular metaphyseal fractures. A posterior short leg splint was applied to right ankle. Consisted of elastic bandage, fiberglass and cotton padding. - ED course of treatment said discussed with Orthopedic surgeon on call, who reviewed images, recommended posterior short leg splint, discharge home, follow up in clinic this week, this fracture is not operative. Diagnosis of closed fracture of right ankle; - ER timeline showed resident arrived at 11:41 A.M. had splint application, Xray tibial fibula 1-2 views right, Xray hip 2-3 views right, CT head, CT cervical, CT ankle right, CT pelvis all without contrast, five different lab panels drawn and read, given morphine sulfate for pain, and discharged at 4:23 P.M. back to the facility.Review of the facility's investigation report on 10/6/25, showed: - The Resident had bruising and swelling to right ankle on 10/6/25 at 10:00 A.M. related to improper gait belt transfer and lowered to floor on 10/5/25 at 8:15 P.M. with no noted injury. - Resident was non ambulatory and required mechanical lift for transfers;- The Physician was notified and an order was obtained for x-ray on 10/6/25 with diagnosis of distal tibial and fibula fracture. The resident's family was notified;- Suspended the staff member involved in the transfer and interviewed charge nurse and other staff; - Conclusion showed NA A had not transferred the resident as care plan had stated which resulted in resident being lowered to the floor. Resident had no complaints of ankle pain or signs or symptoms of abnormalities until the next morning around 10:00 A.M. The Nurse received an order for a x-ray, results of x-ray showed fracture of distal tibia and fibula. Physician notified of results and guardian requesting to wait until the next morning to have an orthopedic evaluation completed unless condition worsens; - Follow up documentation showed on 10/7/25 the physician placed an order for the resident to be transferred to the emergency department for an orthopedic evaluation. The resident returned to facility with a boot/splint and orders for a one week follow up for non-surgical fracture;- The majority of staff, including NA B and LPN B, signed acknowledgements stating they all received training on safe transfers, where to find resident transfer status, and reviewed corresponding facility policies for safe transfers;- The termination of staff member NA A was completed.Documentation of the ADON's interview with NA A, on 10/6/25 at 10:12 A.M., showed NA A said:- He/She didn't see the sling in the resident's wheel chair and wasn't aware the resident required a mechanical lift;- He/She used a gait belt to transfer the resident but couldn't lift the resident and lowered the resident to the floor;- He/She asked NA C who was in the same room to go get the charge nurse for help;- He/She knew about the care plan for finding resident transfer information, but didn't have time to look.Documentation of the ADON's interview with NA C, on 10/6/25 at 12:25 P.M., showed NA C said:- He/She and NA A got the resident up at 4:00 P.M. for supper with the mechanical lift. The sling was left under the resident in the wheelchair;- Both of them were in the resident's room after supper and he/she specifically told NA A to use the mechanical lift for transfer and NA A said no;- He/She assisted the resident's roommate while NA A put a gait belt on the resident, did not see the transfer, but saw the resident sitting on the floor and NA A asked him/her to go get the charge nurse;- He/She assisted the charge nurse and NA A with lifting the resident off the floor and back into bed. Resident didn't have any complaints of pain at that time.Documentation of the Administrator's interview with NA A, on 10/6/25 at unspecified time, showed NA A said:- The resident was at the nurse's station yelling out help and complained about upper right knee and thigh hurting and he/she took the resident to lay down;- NA C was also in the room assisting the roommate. NA A didn't see the mechanical sling in the wheelchair, and wasn't sure how to transfer the resident;- He/She used the gait belt and lowered the resident to the floor;- He/She wasn't sure if he/she had ever assisted the resident before with transfers;- He/She transferred the resident alone and had to lower the resident to the floor.Documentation of the Administrator's interview with LPN B, on 10/6/25 at 12:22 P.M., showed LPN B said:- NA C reported that he/she needed assistance and that the resident was on the floor;- He/She entered the room and resident was sitting on the floor, next to the bed, facing the south wall;- He/She with NA A and NA C assisted the resident to the bed and the resident reported no pain and no bruising was seen.Documentation of the Administrator's interview with NA C, on 10/6/25 at unspecified time, showed NA C said:- He/She and NA A both got the resident up for supper and used a mechanical lift;- He/She knew how to use the mechanical lift and how to review the care plan and learned that during orientation;- He/She told NA A to use the mechanical lift and NA A said no used a gait belt on the resident.During an interview on 10/8/25 at 9:42 A.M., NA B said: - He/She knows how to transfer residents by looking at the electronic medical record;- Nursing staff shouldn't transfer a resident who is a mechanical lift with a gait belt only;- Two nursing staff members are required for mechanical lift transfers;- He/She had transfer training, and read the transfer policy;- If a resident fell during a transfer he/she would get the charge nurse immediately;- If he/she saw someone transfer a resident incorrectly he/she would assist them with doing it the right way and if they wouldn't do it the right way would get the charge nurse.During an interview on 10/8/25 at 9:50 A.M., RN A said:- Information on resident transfers and care is in the resident's electronic record;- Nursing staff should never transfer a resident who requires a mechanical lift with a gait belt;- There should be two nursing staff present for a mechanical transfer;- If a resident fell during a transfer he/she would assess the resident for injuries or pain;- If he/she saw nursing staff performing a transfer incorrectly he/she would correct them, show them the right way to do the transfer, and explain why they need to do it the right way. During an interview on 10/8/25 at 10:00 A.M., CMT B said:- The nursing staff know how to transfer the resident because that is listed in the electronic record, and in the care plan;- The nursing staff should never transfer a resident who is a mechanical lift with a gait belt only;- Two nursing staff are required for a mechanical lift;- The last time she had training on transfers was on 10/6/25 going over electronic records, care plans, and transfers;During an interview on 10/8/25 at 10:45 A.M., CMT A said:- He/She was working the day after the resident had been lowered to the floor and reported the injury to the resident's right foot;- Nursing staff had gotten the resident up for the day and he/she asked them to take the resident to the shower room and he/she gave the resident a shower;- The resident does have dementia and normally hollers out, but this day was different and while getting the resident dressed, the resident hollered out loudly when he/she lifted the resident's right foot. The right foot wasn't straight and was curved inward, was bruised on the outside of the ankle. He/She immediately went and notified the DON. - The resident wasn't able to remember anything that had happened;- The nursing staff should always have two staff members present when doing a mechanical lift;- No nursing staff should use a gait belt for a resident who requires a mechanical lift transfer;During an interview on 10/8/25 at 12:30 P.M., RN B said:- Staff had been given care plan training and safe transfer training earlier this week after the incident;- It was not okay to transfer a resident with a gait belt if they are supposed to be a Hoyer lift transfer;- If he/she saw an aide doing an improper transfer he/she would enter the room, stop them and educate them on the right way, and help get the resident up the rest of the way;- If a resident fell or was lowered to the floor he/she would go into the room, assess the resident and get vitals, call the DON/ADON and if the resident required further assistance call the hospital/EMS for further evaluation. Would also call During an interview on 10/8/25 at 12:40 P.M., LPN B said:- We have training in monthly meetings about looking up resident information in the care plan about transfers;- Staff are taught and trained on proper transfers and can look up the information on the resident electronic record;- If he/she saw an aide doing an improper transfer he/she would stop them immediately and teach them the right way;- If a resident fell or was lowered to the floor I would call for help, assess the resident, and get EMS if necessary. During an interview on 10/8/25 at 1:15 P.M., the ADON said:- He/She was training everyone either in person or by calling some on the phone, going over the information;- He/She started the training on Monday 10/6/25, immediately after the pain/injury was discovered;- The training consisted of asking the nursing staff where to locate the transfer status of a resident, then showing the screenshot of the electronic record and showing where to find the information.- The training was safe transfers and the transfer policy with information on mechanical lift transfers and gait belt transfers;- The nursing staff know what each resident requires by looking at the care plan;- The nursing staff should not do a gait belt transfer if a mechanical transfer is required.Intake 2636283

Based on observation, interview, record review, the facility failed to ensure a safe environment for one (Resident #1) of five sampled residents, and failed to follow their hot liquids policy, when a staff member brought in a personal coffee pot at the nursing station area and the nursing staff provided a hot coffee to the resident without checking the temperature before serving and leaving the resident unsupervised. The resident spilled the coffee and sustained burns to his/her chest and abdomen. The facility census was 44. On 9/2/25, the Administrator was notified of the past noncompliance incident which occurred on 08/25/25. On 09/2/25, the facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented to include:- All facility staff educated on the hot beverage policy;- Dietary staff to send air pots (a system that brews coffee directly into a portable, vacuum-insulated beverage dispenser which keeps the coffee hot for extended periods of time) of coffee at meals and at afternoon snack time for residents who want coffee; - All staff, including non-dietary staff, were educated on the hot beverage policy. - Dietary staff to ensure all hot liquid leaving kitchen is within safe temperature range;- Monitoring of temperature of hot liquids audits by Administrator or designee at least five times per week for six weeks;- Personal coffee pot brought by unknown staff member at an unknown time was removed. - The actions to address the non-compliance was completed on 09/2/25.Review of the facility's Hot Beverage Policy, undated, showed:-Coffee and hot water must be chilled to 130 degrees before being served to the resident's;-Dietary is responsible to ensure coffee and hot water are not leaving the kitchen until the temp is 130 degrees, this includes hot beverages for activities;-If using an insulated mug, the lid MUST be firmly and safely on;-If coffee pots are in team members offices or breakrooms, the office must be locked when unattended; -Coffee may not be re-heated/warmed up in the microwave.1.Review of the Resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/18/25, showed:- Moderate cognitive impairment;- Required moderate assistance from the staff for oral hygiene, showers, and personal hygiene;- Diagnoses included: dementia, seizure disorder, and anxiety.Review of Resident #1's care plan, revised 8/26/25, showed:- The resident sustained a burn from hot liquids;- The resident had impaired vision related to macular degeneration and glaucoma;- The resident had memory/recall problems related to impaired cognitive status with diagnosis of dementia;- The resident required cuing assistance with all activities of daily living (ADL's). Review of progress notes showed:-8/23/25 at 3:20 P.M. Licensed Practical Nurse (LPN) A documented the resident requested a cup of coffee and a snack. A Cup of coffee and fig bar given to resident. Resident spilled coffee down the front of chest. Cold compresses applied over reddened areas on chest, and abdomen. Hydrating lotion with aloe applied;-8/23/25 at 3:25 P.M. LPN A documented red areas smaller. Resident resting on bed. No reports of pain or discomfort at this time;-8/23/25 at 5:52 P.M. LPN A progress note - Skin Condition. Skin pink, compared to her white skin. Cold compress applied. Aloe applied. Resident requesting coffee. Coffee placed in clear mug with lid. Temperature checked. moderately warm. No reports of pain or discomfort;-8/23/25 at 6:36 P.M. LPN A documented resident resting on bed. No reports of pain or discomfort. Notice blisters starting on chest injury. More lotion applied;-8/23/25 at 6:47 P.M. LPN A notified the Director of Nursing (DON);-8/23/25 at 6:54 P.M. LPN A notified durable power of attorney (DPOA) ;-8/26/25 at 10:46 A.M. DON documented the resident seen on rounds by Wound Care Plus for rash and burns to chest/abdomen. Resident stated he/she just felt okay today and wasn't feeling the best but had no complaints of pain or discomfort. Resident also seen for burn to chest and abdomen. Resident noted to have a wound to middle of chest between breast 8 x 4.7 cm noted, dry skin present, previous blister to center of wound had popped and dry skin noted, area is red. No drainage noted and no s/s of infection noted. Resident also noted to have burn area to center of abdomen, 17 x 10 cm red and dry, no open wounds noted, no blisters noted. New order to cleanse wound with soap and water, pat dry, apply Bacitracin (Antibiotic Ointment) to wound bed, skin prep surrounding skin, cover with Vaseline gauze and then cover with Opti foam/tape, change every day and PRN. Wound care to round again next week. New order from provider for orders for Zinc 50 mg tablet 1 time per day for 14 days and a protein supplement 30 ml one time per day for 14 days.Review of the resident's physician order sheet (POS), dated September 2025, showed:- Start date: 8/25/25 - Bacitracin order to reddened areas to center of chest three times a day for burn and report any worsening of skin or signs and symptoms of infection;- Start date: 8/25/25 - Apply skin prep to intact blisters noted to center of the chest three times a day until resolved;- Start date: 8/26/25 - Wound care - cleanse burned areas with soap and water, pat dry and apply bacitracin to wounds, skin prep surrounding skin, cover with Vaseline gauze and cover with foam and tape, change dressing every day and as needed (PRN) until healed;- Start date: 9/2/25 - Wound care - cleanse area to chest and abdomen with soap and water, pat dry, apply moisturizing cream to red areas and prep closed/scabbed areas every day and PRN until healed. Record review of the facility's investigation report on 9/2/25., showed: The coffee pot was full of coffee on the counter, and it was placed on the warmer by LPN A. After an hour LPN A poured a cup of coffee without checking the temperature of the hot coffee per the hot liquid policy and served it to Resident #1. LPNA A didn't think the coffee was too hot. LPN A had the resident sitting at a dining room table when the resident spilled the coffee down the front of chest area.LPN A was not available for interview regarding the resident's hot coffee burn.During an interview on 9/2/25 at 10:30 A.M., Housekeeping Assistant (HA) A said he/she had read the hot liquid policy, and if a resident injured themselves/poured coffee on themselves he/she would try to find a nurse to help and stay behind to clean up.During an interview on 9/2/25 at 10:45 A.M., LPN B said:-He/She had been recently reeducated regarding the hot liquid policy and had been told the coffee maker that was there, shouldn't have been;-Policy states that liquids can not be warmed in the microwave.During an interview on 9/2/25 at 11:16 A.M., the Resident said he/she did remember spilling coffee but no details as he/she has memory problems.During an interview on 9/2/25 at 1:24 P.M., the Administrator said:- The hot liquid policy had been in effect prior to the incident, and she didn't know staff had moved the coffee pot from the break room to the unit;- After the incident, the facility staff were re-educated on the policy;- Dietary and nursing was covered separately and signed off on the copy of the policy individually;- Coffee for residents should come from the dietary staff to ensure temperature is safe before serving.Observation of the resident on 9/2/25 at 1:46 P.M., showed the resident had large, scabbed area, approximately quarter sized with pink edges bordering and a few tiny, scabbed spots directly on chest and abdomen. During an interview on 9/2/25 at 1:50 P.M., the DON said:-The hot liquid policy had been in place before the burn occurred;-The policy had been reviewed with everyone, and everyone would get the training on hire and before working the next shift if they hadn't already signed as having it; - She had a few more staff to educate but was getting it done. -The microwave was removed at the same time as the coffee pot;-Kitchen/dietary staff check the temperature of the coffee before sending it out to the unit. Coffee for resident's should be obtained from the kitchen staff only and nursing staff have been educated regarding this.During an interview on 9/2/25 at 2:05 P.M., [NAME] A said:-Dietary can't serve any hot water or coffee unless its less than 130 degrees, they check it with a thermometer, and just recently started doing this;-After 8:00 P.M., there is no kitchen staff at the facility, so we make a coffee urn and leave on the snack cart before we leave and throughout the day;-All of the staff in the kitchen have had the hot liquids training;-There shouldn't be any microwaves except one in the breakroom and no one can heat up coffee if kitchen staff aren't in the facility. Coffee for resident's comes from the kitchen only.Intake 2599594

4. Review of Resident #1's MRR, dated 4/2/25 showed: - The pharmacist recommended Bupropion XL 300 mg every day, Clonazepam 0.5 mg three times daily and Risperidone 0.25 mg twice daily for review; the physician responded the dose had recently been changed, no changes. Review of the resident's Significant Change in Status MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses included cerebral palsy (CP), seizure disorder and anxiety; - The resident received antipsychotics on a regular basis; - 4/17/25 - GDR documented as contraindicated. Review of the resident's POS, dated June, 2025 showed; - Start date - 3/6/25 - Risperidone 0,25 mg., one tab by mouth every morning and at bedtime related to mood disorder due to known physiological condition, unspecified. Review of the resident's MAR, dated June, 2025 showed: - Risperidone 0,25 mg., one tab by mouth every morning and at bedtime related to mood disorder due to known physiological condition, unspecified. Review of the resident's undated care plan showed it did not address the use of antipsychotic medication. Review of the resident's medical record on 6/19/25 at 7:31 A.M., showed it did not contain any consents for psychotropic medications. During an interview on 6/19/25 at 8:00 A.M., the Director of Nursing said unless Social Services had the resident or responsible party sign the consent for psychotropic medications during their care plan meeting, then the facility does did not have any consents. Based on interview and record review, the facility failed to ensure three, out of twelve sampled residents, (Resident #6, #37, and #1) and the resident's representative that were reviewed for unnecessary medications, were informed of the risks and benefits of a physician ordered antipsychotic medication. This failure prevented the resident and/or the resident representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 46. Review of facility policy, psychotropic medication use, dated February 2025, showed: -Resident will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. -Prior to starting psychotropic medications, informed consent will be obtained from resident/representative per state guidelines. 1. Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/22/25, showed: -Severely impaired cognition; -He/She took an antipsychotic and antidepressant on a routine basis; -A gradual dose reduction (GDR) was attempted 10/18/2023 and was documented as clinically contraindicated. -Diagnoses included: dementia and depression. Review of care plan, dated 6/6/25, showed: -Resident took antipsychotic medications for dementia; -Administer medications as prescribed by physician; -Monitor for side effects or adverse reactions of medication. Review of physician's orders, dated 6/18/25, showed: -Started 2/10/25, Duloxetine DR 60 milligram (MG) capsule, give 1 tablet by mouth at bedtime related to major depressive disorder, recurrent, unspecified. -Started 2/10/25, Quetiapine tab 25 MG, give 0.5 tablet orally one time a day related to dementia in other disease classified elsewhere, severe, with psychotic disturbance; -Started 2/10/25, Quetiapine tab 25 MG, give 1 tablet orally at bedtime related to dementia in other disease classified elsewhere, severe, with psychotic disturbance. Review of Medication Regimen Reviews from 6/1/24-5/31/25, showed: -On 8/7/24, the consultant pharmacist notified the physician that duloxetine 60mg one time daily and quetiapine 25mg at bedtime were due for review. The physician responded that an attempted GDR of any listed medication would result in destabilization, impairment of function or increased distressed behaviors. Review of resident's medical record, on 6/18/25, showed no psychotropic medication consents. During an interview on 6/18/25 at 2:58 P.M., the Director of Nursing (DON) said she did not have education or consent forms on the psychotropic medications for the resident. During an interview on 6/19/25 at 8:40 A.M., the Social Services Director said she did not have any psychotropic drug consents for the resident. 2. Review of Resident #37's quarterly MDS, dated [DATE], showed: -Severely impaired cognition; -He/She took antipsychotic and anti-anxiety medication on a routine basis; -A GDR was documented as clinically contraindicated by a physician on 1/17/25; -Diagnoses included: dementia, anxiety, depression, and restlessness and agitation. Review of care plan, dated 6/3/25, showed: -Resident received antianxiety medication, Buspar, related to generalized anxiety disorder. -Administer medication as ordered per medical provider; -Resident took an antipsychotic medication for dementia, unspecified severity, with psychotic disturbance. Target Behaviors: Restlessness, agitation and aggression; -Administer medication, Seroquel, as ordered per medical provider; -Attempt a gradual dose reduction per regulatory guidelines; -Monitor for dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypotension, dark urine, yellow skin, drooling, agitation, restlessness, involuntary movement of mouth or tongue; -Monitor resident's behavior and response to medication; -Pharmacy consultant review monthly and as needed; -Psychiatrist to consult as indicated/ordered; -Document resident's behavior. Review of physician's orders, dated 6/16/25, showed: -Started 2/13/25, Buspirone tablet 10 mg, give 1 tablet by mouth three times a day related to parkinsonism unspecified; -Started 4/12/25, Quetiapine fumarate oral tablet 100 mg, give 1 tablet by mouth two times a day related to unspecified dementia, unspecified severity, with psychotic disturbance; -Started 4/12/25, Quetiapine fumarate oral tablet 25 mg, give 1 tablet by mouth at bedtime related to unspecified dementia, give in with 100 mg at bedtime for total of 125 mg once daily. Review of Medication Regimen Reviews, dated 6/1/24 to 5/31/25, showed: -On 10/1/24, the consultant pharmacist wrote resident was due for review of buspirone ER 150 mg once daily, buspirone 10mg three times a day, quetiapine 100mg PM / 200mg at bedtime. The physician responded that an attempted GDR of any listed medication would likely result in destabilization, impairment of function or increased distressed behaviors. Currently on the lowest effective dose for each medication. -On 1/2/25, the consultant pharmacist wrote the resident received quetiapine 50mg twice a day /25 mg in afternoon, and 200mg at bedtime. The resident's last reduction was successful. The physician reviewed the recommendation and wrote an attempted GDR of listed medication would likely result in destabilization, impairment of function or increased distressed behavior. Currently on lowest effective dose. The physician also wrote failed reduction on last visit. -On 4/2/25, the consultant pharmacist wrote resident was receiving quetiapine 50mg in the morning, 25mg at 1:00 P.M., 50mg in the afternoon, 100mg at bedtime. The manufacturer per FDA approval and mechanism of action, quetiapine can be administered twice daily with same effectiveness while reducing pill burden, nursing time, and/or medication cost. The physician signed on 4/9/25 to consolidate resident's quetiapine to 100mg in the morning and 125 mg at bedtime. Review of resident's medical record, on 6/18/25, showed no psychotropic medication consents. During an interview on 6/18/25 at 2:58 P.M., the Director of Nursing (DON) said she did not have education or consent forms on the psychotropic medications for the resident. During an interview on 6/19/25 at 8:40 A.M., the Social Services Director said she did not have any psychotropic drug consents for the resident. 3. During an interview on 6/18/25 at 4:00 P.M., the DON said: -She discovered that the MDS Coordinator was supposed to be completing the psychotropic medication consent forms but had not obtained the consents; -Psychotropic medication education and consents were in place at facility but she did not have psychotropic medication form consents and education on sampled residents. During an interview on 6/18/25 at 4:58 P.M., the Administrator said: -She expected residents and/or their representatives to be informed of the risks and benefits of psychotropic medications; -She expected consents for use of psychotropic medications to be obtained from resident and or their representative prior to their use. During an interview on 6/19/25 at 8:40 A.M., the Social Services Director said she did not do psychotropic drug consent forms or education. During an interview on 6/19/25 at 10:04 A.M., the Assistant DON said: -She expected residents and/or their representatives to be educated regarding the risks and benefits of psychotropic medication use. -She expected psychotropic medication approval for use consents to be obtained from the resident and or the representatives prior to the use of the psychotropic medication. During an interview on 6/19/25 at 10:04 A.M. the DON said: -She expected residents and/or their representatives to be educated regarding the risks and benefits of psychotropic medication use. -She expected psychotropic medication approval for use consents to be obtained from the resident and or the representatives prior to the use of the psychotropic medication.

Based on interview and record review, the facility failed to maintain a surety bond that was equal or greater than one and one-half times the average monthly balance for the residents' trust fund (RTF) account for the last 12 consecutive months from June 2024 to May 2025. The facility census was 46. The facility did not have a policy regarding surety bonds. Record review on 6/19/25 of the RTF account for the last 12 consecutive months from June 2024 to May 2025 showed: -The facility's current approved bond amount equaled $50,000; -The average monthly balance for the RTF account equaled $36,248.59 (which was determined using the total of each ending balance for the last 12 month bank statements plus the petty cash ending balances and divided by 12 months); -An average monthly balance of $36,000 required a bond of at least $54,000; -Surety Bond #PB11511001715 dated July 22, 2022, was changed from $60,000 to $50,000 on July 1, 2022; -Department of Health & Senior Services approved the surety bond adjustment #PB11511001715 to $50,000 on July 22, 2022. During an interview on 6/17/25 at 3:53 P.M., the Administrator said: -She had the facility's prior bond but did not know if the surety bond had been changed when the facility's corporation changed to a new ownership company in 2025; -She expected the surety bond held by the facility to be sufficient by equaling 1.5 times the average monthly account total held in resident trust accounts.

Based on interview and record review, the facility staff failed to implement their Abuse and Neglect policy when they failed to obtain criminal background checks results prior to staff working with residents and check the Certified Nurse 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 ten sampled staff (Certified Nurse Aide (CNA) A, CNA B, Assistant Director of Nursing (ADON), Certified Medication Technician (CMT) A, Housekeeping Aide (HA) A, Licensed Practical Nurse (LPN) A, CNA C, and HA B.). The facility census was 46. Review of facility policy, Abuse, Prevention, and Prohibition Policy, dated 12/2024, showed: -The facility will not knowingly employ individuals who have been found guilty of abusing, neglecting, or mistreating residents, or misappropriating their properties. -All employee will have criminal background checks, state and federal required checks, and license/certification confirmation. -The facility will make reasonable efforts to uncover information about any past criminal prosecutions. 1. Review of CNA A's employee file showed: -Employee was hired on 1/14/25; -The Family Care Registry (FCSR) was searched on 6/9/25 with result of pending registration status and that letter provided was not a background result (this meant the individual's registration information had been received and the background screening process was still underway and had not determined the final clearance status of employee's background); -No criminal background check had been completed. 2. Review of CNA B's employee file showed: -Employee was hired on 2/17/25; -The FCSR was searched on 6/13/25 with result of pending registration status and the letter provided showed that it was not a background result; -No criminal background check had been completed. 3. Review of the ADON's employee file showed: -Employee was hired on 2/20/25; -The FCSR was searched on 2/21/25 with result of pending registration status and the letter provided showed that it was not a background result; -No criminal background check had been completed; -Certified Nurse Aide Registry was not checked. 4. Review of the CMT A's employee file showed: -Employee was hired on 6/3/25; -The FCSR was searched on 6/4/25 with result of pending registration status and the letter provided showed it was not a background result; -No criminal background check had been completed. 5. Review of the HA A's employee file showed: -Employee was hired on 4/15/25; -The FCSR was searched on 4/14/25 with result of pending registration status and the letter provided showed it was not a background result; -No criminal background check had been completed. 6. Review of LPN A's employee file showed: -Employee was hired on 5/27/25; -The FCSR was searched on 6/6/25 with result of pending registration status and the letter provided showed it was not a background result; --No criminal background check had been completed. -Certified Nurse Aide Registry was not checked. 7. Review of CNA C's employee file showed: -Employee was hired on 1/30/25; -The FCSR was searched on 1/30/25 with result of pending registration status and the letter provided showed it was not a background result; -No criminal background check had been completed. 8. Review of HA B's employee file showed: -Employee was hired on 3/16/25; -The FCSR was searched on 6/16/25 with result of pending registration status and the letter provided showed it was not a background result; -No criminal background check had been completed. During an interview on 6/17/25 at 4:40 P.M., the Receptionist said: -She checked the family care registries on new employees at time of hire only; -She did not check the criminal background checks when the family care registry letter showed the staff's registration was pending and not a criminal record check; -She did not know she was supposed to check for federal indicators by searching all employees on the CNA registry; -She did not check the CNA registry for nurses; -She just recently became aware from corporate staff that she was to check the CNA registry for all employees and had been checking all employees since she learned of this expectation. During an interview on 6/18/25 at 4:58 P.M., the Administrator said: -She expected all staff to have a background check completed prior to working with residents; -She expected the family care safety registry to be checked on all employees; -When staff were not registered on the family care safety registry the facility ran criminal background checks on those staff.

4. Review of Resident #20's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses included cancer and multiple sclerosis. Review of the resident's POS, dated June, 2025 showed: - Start date: 6/15/25 - Clean oxygen concentrator filter with water and allow to air dry weekly every night shift every Sunday; - Start date: 6/15/25 - Oxygen at 2 liters per nasal cannula (2L/NC) to keep oxygen saturation greater than 95% every shift; - Start date: 6/15/25 - Change oxygen tubing every Sunday night on the night shift. Review of the resident's Medication Administration Record (MAR), dated June 2025 showed: - Clean oxygen concentrator filter with water and allow to air dry weekly every night shift every Sunday; - Oxygen at 2 liters per nasal cannula (2L/NC) to keep oxygen saturation greater than 95% every shift; - Change oxygen tubing every Sunday night on the night shift. Review of the resident's undated care plan, showed it did not address the use of oxygen. Observation on 6/16/25 at 11:05 A.M., showed: - Did not have a sterile humidified water bottle attached to the concentrator; - The oxygen tubing was not dated. During an interview on 6/19/25 at 8:55 A.M., RN A said: - Night shift was responsible for changing the oxygen tubing on Sundays; - The oxygen tubing should be dated when it is changed; - Should have a humidified water bottle. During an interview on 6/19/25 at 9:21 A.M., CNA G said: - The oxygen tubing should be changed weekly on Sunday nights and it should be dated; - Most of the concentrators have humidified water bottles. During an interview on 6/19/25 at 9:35 A.M., the DON said: - The oxygen tubing should be changed weekly on Sunday nights and dated when it is changed; - The oxygen concentrators should have a humidified water bottle with sterile water in it. Based on observation, interview and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice, by not following physician orders regarding oxygen maintenance of tubing and humidifiers on four of the 12 sample residents, #5, #8, #15 and #20. The facility census was 46. Review of the facility's policy Oxygen Administration dated 03/2025 showed: -To verify that there is a physician's order for oxygen administration; -Humidifier bottle is expected to be part of the equipment and supplies; -Be sure there is enough water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through; -Replenish water in humidifying jar as needed; 1. Review of Resident #5's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/16/25 showed: -Cognition Intact; -Chronic lung disease. Observation on 6/17/25 at 8:05 A.M., showed: -Tubing was out of date on the concentrator in the resident's room. The tubing was dated 6/8/25 but should have been dated 6/15/25, if physician orders were followed. Observation on 6/18/25 at 12:36 P.M., showed: -Oxygen tubing was out of date on concentrator in room and the tubing was still dated 6/8/25. Review of Orders dated 6/6/25, showed: -Oxygen tubing - change weekly every night shift every Sunday; -Oxygen - Clean O2 concentrator filter with water and allow to air dry weekly every night shift every Sunday; -Oxygen 2 L per NC continuously PRN to keep sats above 92%. 2. Review of Resident #8's Quarterly MDS dated [DATE] showed: -Cognitively intact; -Diagnosis: Atrial Fibrillation. Observation on 6/16/25 at 10:00 A.M., showed: -Right sided weakness and facial drooping; -Oxygen at 3 L per NC; -One nasal cannula prong was out of the left nare, the right prong was in the left nare; -Oxygen tubing dated 6/8/25 but should have been dated 6/15/25; -Oxygen Concentrator without a humidifier. Observation on 6/18/25 at 10:00 A.M., showed: -Oxygen at 2 L per NC, both prongs in nares properly; -Oxygen tubing dated 6/8/25 but should have been updated on 6/15/25; -Oxygen concentrator without a humidifier. Review of Orders dated 6/6/25, showed: -Oxygen tubing - change weekly every night shift every Sunday; -Oxygen - Clean O2 concentrator filter with water and allow to air dry weekly every night shift every Sunday; -Oxygen 2 L per NC continuously PRN to keep sats above 92%. 3. Review of Resident 15's Quarterly MDS dated [DATE] showed: -Cognition Moderately Intact; -Diagnoses: Heart failure, Diabetes, Dementia. Observations on 6/16/25 at 3:35 P.M., showed: -Oxygen tubing dated 6/9/25 and should be dated 6/16/25. Observation on 6/17/25 at 12:34 P.M., showed: -Oxygen tubing dated 6/9/25 and should be dated 6/16/25. Observation on 6/18/25 at 12:35 P.M., showed: -Oxygen tubing dated 6/9/25 and should be dated 6/16/25. Review of Orders dated 4/20/25, showed: -Oxygen tubing - change weekly every night shift every Sunday; -Oxygen - Clean O2 concentrator filter with water and allow to air dry weekly every night shift every Sunday; -Oxygen 2 L per NC continuously PRN to keep sats above 90%.

Based on interview and record review, the facility failed to implement a facility-wide system to monitor the use of antibiotics administered to residents with various infections conditions. The sample size was three Resident #8, #12 and #23. The census was 46. Review of the facility's policy titled Infection Prevention and Control Program dated 2019 showed: -The mission of the program is 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; -An antibiotic stewardship program includes antibiotic use protocols and a system to monitor antibiotic use; -Antibiotics stewardship and review including reviewing data to monitor the appropriate use of antibiotics in the resident population; -Responsible to collect, analyze, provide infection data and trends to nursing staff and healthcare practitioners; -Surveillance including ongoing, systematic, analysis, interpretation, and dissemination of data to identify infections and infections risks, to try to reduce morbidity and mortality to improve resident health status; -Review the use of antibiotics including comparing prescribed antibiotics with available susceptibility reports; -Track antibiotic use monthly and complete an antibiogram yearly or as directed. 1. Review of resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/05/25 showed: -Cognition very poor; -neurogenic bladder with indwelling foley. Observation on 6/16/25 at 12:30 P.M., showed the reisdent with a leg bag from an indwelling foley catheter with cloudy urine. Review of Orders dated 5/30/25 showed Sulfamethoxazole-trimethoprim 400-80 mg tab one daily started on 5/30/25. 2. Review of resident #12's MDS dated [DATE], showed: -Cognition Low; -History of urinary infections with Multiple Sclerosis; -Strait Cath every six hours; -Dementia Observation on 6/16/25 at 1:00 P.M., of Resident #12 showed: -Smiling resident sitting in dining area in wheelchair; -Swelling in bilateral lower legs Review of Orders for Resident #12, dated 5/30/25, showed Amoxicillin capsule 500 mg, Give 1 capsule by mouth three times a day for bacterial infection for 10 days. 3. Review of Resident #23s MDS, dated [DATE], showed: -Cognitive function is poor; -Diagnoses: Heart arrhythmias, thyroid disorder, dementia, anxiety. Review of Orders for Resident #23 dated 12/23/24 showed: -Cephalexin Capsule 50 mg, one capsule by mouth one time a day every Monday, Wednesday, and Friday. Review of Infection Control Book on 06/16/25 showed: -If a resident developed an infection in house or had an infection present on admission -Resident's name -Room number -Onset Date of infection -Diagnosis of infection -Infection site Review of the Infection Control Antibiotic Stewardship Book on 06/17/25 at 03:40 P.M., showed: -It did not specify the type and duration of the isolation; -The infectious agent or organism involved was not included in the antibiotic stewardship book; -The antibiotic ordered for the infectious agent was not included in the book; -There was not an antibiotic use protocol nor a system to monitor antibiotic use. During an interview on 06/16/25 at 2:00 P.M., the Infection Control Nurse said he/she had an antibiotic stewardship book but it did not list any antibiotics or the microorganisms for each resident with an infection. During an interview on 06/18/25 at 4:00 P.M., the Administrator said he/she expected staff track and to know what antibiotics are associated with each infection along with the organism.

Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected one of the 12 sampled residents, (Resident #3). The facility census was 46. The facility did not provide a policy for perineal care. 1. Review of Resident #1's urinalysis (UA, test to analyze urine contents), dated 2/20/25 showed the presence of bacteria indicative of a possible urinary tract infection (UTI). Review of the resident's urine culture and sensitivity ( UA with C & S, identifies the amount and type of bacteria present and the medications appropriate to treat the infection), dated 2/20/25, showed the presence of organisms indicative of a possible UTI. Review of the resident's Physician Order Sheet (POS) dated 2/21/25 showed: - Ceftriaxone (broad spectrum antibiotic used to treat UTIs) Sodium injection solution, reconstituted one gram intramuscularly in the evening for infection until 2/27/25. Reconstitute with 3.5 ml. of Lidocaine 1% (used to help injection site pain). Review of the resident's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/18/25 showed: - Cognitive skills intact; - Lower extremity impaired on both sides; - Required substantial to maximum assistance from staff for toilet use; - Required partial to moderate assistance from staff for transfers; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Continent of bowel; - Diagnoses included psychotic disorder, depression, and osteoarthritis (OA). Review of the resident's UA dated 5/17/25 showed the presence of bacteria indicative of a possible UTI. Review of the resident's UA with C & S, dated 5/19/25, showed the presence of organisms indicative of a possible UTI. Review of the resident's POS, dated 5/21/25 showed: - Cephalexin 500 mg., one capsule by mouth three times daily for UTI for seven days. Review of the resident's undated care plan, showed: - The resident had an ADL self care performance deficit related to OA, impaired balance and limitations in lower extremities. The resident was totally dependent on staff for toilet use. The resident required assistance to transfer and provide peri care to use the toilet; - The resident had bladder incontinence related to activity intolerance. The resident used disposable briefs. Change frequently and as needed. Observation on 6/18/25 at 12:14 P.M., showed: - Certified Nurse Aide (CNA) E and CNA F used the mechanical lift and transferred the resident from his/her wheelchair to the bed and lowered the resident onto the bed; - The resident did not have a urinary catheter and had been incontinent of urine and feces; - CNA F wiped down one side of the groin, folded the wipe and wiped down the same groin; - CNA F used a new wipe and wiped down the other side of the groin, folded the wipe and wiped down the same groin; - CNA F did not separate all the skin folds and used a new wipe and wiped down the middle, folded the wiped and wiped down the middle again; - CNA E and CNA F turned the resident on his/her side; - CNA F wiped three times back to front with a smear of fecal material on each new wipe; - CNA F did clean the entire buttocks where urine or feces had touched. During an interview on 6/19/25 at 8:55 A.M., Registered Nurse (RN) A said; - Staff should wipe from front to back; - Staff should not fold the wipe when cleaning fecal material, the staff should throw it away and get a new wipe; - Staff should make sure they separate and clean all areas of the skin where urine or feces had touched. During an interview on 6/19/25 at 9:12 A.M., CNA E said: - Should have wiped from front to back; - Should not have folded the wipe when cleaning fecal material, should have used a new wipe; - Should have separated and cleaned all areas of the skin where urine or feces had touched. During an interview on 6/19/25 at 9:57 A.M., the Director of Nursing (DON) said: - Staff should wipe from front to back, not back to front; - Staff should not fold the wipe when cleaning fecal material; - Staff should separate and clean all areas of the skin where urine or feces had touched. During an interview on 6/19/25 at 9:57 A.M., CNA F said: - He/She should have wiped from front to back; - He/She should not have folded the wipe when cleaning fecal material; - He/she should have separated and cleaned all areas of the skin where urine or feces had touched.

Based on interview and record review the facility failed to protect two residents who resided on the Memory Care Unit (Resident #1 and #5) from physical abuse by Resident #2, when Resident #2 pulled Resident #1's hair and hit Resident #5 with a water pitcher full of water, causing redness and mental distress for Resident #5. The facility census was 49. Review of the facility policy Abuse, Prevention, Prohibition Policy dated 3/2025 showed: -Each resident has right to be free from abuse; -Residents must not be subjected to abuse by anyone, including other residents; -The facility prohibits mistreatment or abuse of residents; - Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. On 5/7/25, the Administrator was notified of the past noncompliance situation which occurred on 4/27/25. On 4/27/25, facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented when the staff immediately seperated Residents #1 and #2 after the first event and seperated Resident #2 and #5 after the second incident. Staff placed Resident #2 on 15 minute check monitoring until he/she was sent to a behavioral health hospital for evaluation and treatment on 5/1/25. The Administrator provided abuse training for the staff after the events. The facility moved Resident #5 on a different hall from Resident #2. Resident #2's Primary Care Physician ordered Lorazepam (a medication to treat anxiety) 0.5 milligram (mg) table by mouth every 6 hours as needed. The noncompliance was corrected on 5/1/25. 1. Review of Resident #5's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 2/25/25 showed: -Extensive cognitive loss; -No behaviors; -Diagnoses of Dementia with psychotic disturbance ( when individuals with dementia experience symptoms such as seeing or hearing things that are not there and believing things that are not real), anxiety, depression, Parkinson's Disease and cognitive communication deficit (communication difficulty from cognitive loss). Review of the resident's Comprehensive Care Plan dated 3/4/25 showed: -He/She received antipsychotic medication for dementia, with psychotic disturbance: Behaviors of restlessness, agitation and aggression. Monitor the resident's behaviors; -He/She had physical behaviors directed towards others during episodes of personal care and toward his/her spouse; he/she will not cause harm to self or others; redirect from other residents when he/she becomes aggressive, intervene as needed; -The resident and his/her spouse have had physical altercations; the residents will be redirected without harm; monitor for signs of agitation or frustration towards/between spouse. If either showed symptoms they should be seperated. Review of Resident #5's medical record showed: -4/29/25 at 6:28 P.M. the resident's spouse hit him/her in the head with a full water pitcher. Staff stopped the spouse and removed the resident immediately. The resident reached his/her hand out and said help. I don't know why he/she did that but he/she is very mad at me. The right side of the resident's face was red with a small abrasion. Review of the facility investigation dated 4/29/25 showed: - 4/29/25 Licensed Practical Nurse (LPN) A heard whimpering coming from Resident #5's room; - LPN A observed Resident #5 in a reclining chair and his/her right upper extremity was raised in a protective position; - Resident #2 leaned over Resident #5 and hit him/her with a full water pitcher in the head, making contact twice before LPN A could intervene; - The residents were seperated; - Resident #5 received abrasions to both hands, neck and right cheek; - 4/29/25 Resident #2 was sent to a local Emergency Department (ED), and returned to the facility later the same day; - 4/29/25 AN order for Lorazepam 0.5 mg by mouth every 6 hours as needed for anxiety was obtained; - 4/29/25 Resident #5 was moved from the Memory Care Unit (MCU) to separate him/her from Resident #2; - 4/29/25 Abuse education was provided to the staff; - 5/1/25 Resident #2 was sent to a behavioral Health hospital for evaluation and treatment. During an interview on 5/7/25 at 2:25 P.M. Certifed Nurses Aide (CNA) B said: -Resident #2 had been agitated more over the past two weeks, screaming at staff and at Resident #5; -On 4/29/25 he/she had gone in to Resident #5's room to clean the resident up after an incontinent episode; -He/She explained what he/she was doing; -Resident #2 sat in a recliner in Resident #5's room; -He/She left the room with Resident #5 sitting on the resident's bed and Resident #2 sitting in the recliner chair; -He/She took the dirty linen and trash out, upon returning approximately 2 minutes later, he/she heard whimpering, and found Resident #2 and #5 in Resident #5's room with Licensed Practical Nurse (LPN) A; -LPN A was attempting to get Resident #2 to leave the room, Resident #5's clothing was wet, the floor was wet, and Resident #5 had his/her hand to the side of his/her head; -LPN A took Resident #2 to his/her room and CNA B took Resident #5 outside for fresh air; -Resident #2 was on 15 minute checks until he/she went to the hospital. During an interview on 5/7/25 at 4:03 P.M. LPN A said : -On 4/27/25 he/she entered the Memory Care Unit, CNA B said he/she was taking out linen and trash, and left the unit; -He/She heard a whimpering and scuffling sound, she entered Resident #5's room and found Resident #5 crouched down beside his/her bed with his/her hands up in a defensive position; -Resident #2 was standing over Resident #5 swinging a full water pitcher at Resident #5's head; -Resident #2 made contact with the side of Resident #5's head twice before he/she could stop Resident #2; -Resident #2 stopped when he/she heard LPN A say his/her name; -CNA B returned to Resident #5's room; -Resident #2 went with LPN A willingly, but was grabbing and trying to throw peri wash as he/she left Resident #5's room, Resident #2 was taken to his/her room, and LPN A went to get help to clean up the water; -Less than 2 minutes later, LPN A returned to Resident #5's room, Resident #2 was again in Resident #5's room; -LPN B removed Resident #2 from Resident #5's room, telling him/her, he/she could not be in there, Resident #2 said he/she remembered what happened and it meant he/she still got it; -Resident #5 reported he/she wanted to cry; -The incident was abuse; -Resident #5 had been happy and pleasant since Resident #2 was gone. Observation on 5/7/25 at 12:45 P.M. showed Resident #5: -Left hand had multiple small scratched, pinpoint open areas to back of his/her hand. 2. Review of Resident #1's Annual MDS dated [DATE] showed: -Extensive cognitive loss; -No behaviors; -Diagnoses of dementia, anxiety, and high blood pressure. Review of the residents Comprehensive Care Plan dated 3/24/25 showed: The resident had behavior problem of being friendly toward male residents; such as touching their face, playing with their hair, hugging them and being close to their faces. Initiated 4/27/25. Review of the Resident's medical record showed: -On 4/27/25 at 9:14 A.M. the resident was walking out of the A.M. meal, cupped his/her hands around a Resident #5's face. Resident #2 yanked Resident #1's hair and pulled him/her down. Resident #2 said to keep his/her hands off Resident #5. Resident #1 said he/she was sorry. The residents were seperated and Resident #1 was taken to his/her room, where an assessment showed no redness, injury or tenderness. Doctor, family and Administrator notified. During an interview on 5/7/25 at 2:00 P.M. CNA A said: -Resident #1 was walking out of the dining room on 4/27/25; -Residents #2 and #5 were at their table; -Resident #1 stopped at Resident #5 and began twirling his/her hair; -Resident #2 grabbed Resident #1's hair, pulling Resident #1 until he/she bent over; -The Charge Nurse seperated the residents and Resident #2 was placed on 15 minute checks; -Resident #2 had been more agitated, more easily upset between mid April and when he/she left for the hospital. 3. Review of Resident #2's Quarterly MDS dated [DATE] showed: -Moderate cognitive loss; -Verbal behaviors directed at others such as cursing and yelling out 1-3 days of the week; -No physical behaviors; -Diagnoses of vascular dementia (a type of dementia caused by loss of blood flow to part of the brain, leading to memory, thinking and behavior problems), depression, and anxiety. Review of the residents Comprehensive Care Plan dated 4/26/25 showed: -He/She would become overwhelmed and anxious about his/her spouse's condition and attempted to help at times. He/She had requested not to share a room. He/She will be comfortable about his/her spouse and not cause harm to either from attempting to help. Initiated 3/4/25; -The resident had a behavior problem, physical behaviors directed toward others; behaviors will be redirected and he/she will not harm others; redirect from others he/she had previous altercations with; Intervene as necessary to protect the rights and safety of others; Divert his/her attention and remove from the situation. Initiated 4/27/25. Review of Resident #2 Progress Notes showed: -4/8/25 a Certified Medication Technician (CMT) reported the resident punched him/her in the arm and had increased behavior of yelling at staff; -4/11/25 the resident's primary care physician (PCP) ordered lab work to be obtained; -4/12/25 the resident's PCP declined a gradual dose reduction (GDR) of psychotropic medications (medicine that effect a persons mind, emotions and behavior) due to the resident's increased behaviors; -4/16/25 the resident became angry and threw his/her spouse's walker. He/She was seen by the psychiatric doctor for increased agitation and behaviors: The physician recommended daily music and crosswords to slow the resident's mental decline, discontinue the medication Buspar (an antianxiety medication) and start Ativan (an antianxiety medication); -4/27/25 the resident pulled Resident #1's hair. The resident's physician and family were notified of the incident. The resident was very confused, wandered in and out of rooms, and thought others were following him/her in the hallway. He/She was upset he/she and the spouse were not in the same room; -4/29/25 Resident #2's family was notified the resident hit Resident #5 with a water pitcher. The Psychiatric physician ordered Ativan to be given every six hours as needed for anxiety. The resident was sent to an area emergency room for evaluation and returned to the facility. The resident was pacing, wanted to go home, and was taking clothes in and out of the closet. As needed antianxiety medication given. Referrals were sent from the facility for psychiatric inpatient stay, with no open beds available; -5/1/25 The resident was transferred for inpatient psychiatric stay. During an interview on 5/7/25 at 4:47 P.M. the Administrator said: -Resident #2 meant to hit Resident #5; -This incident was abuse; -The resident's are a married couple and deserve to have private visits; -There was no indication that Resident #2 was going to hit Resident #5; -He/She was unsure how the incidents with Resident #1, Resident #2 and Resident #5 could have been prevented. -All staff education on Abuse and Neglect was completed on 4/28/25. MO253456 MO253487

Based on observation, interview, and record review, the facility failed to ensure four residents (Resident #1, #2, #3, and #4) out of five sampled residents were free from abuse when three staff members took photos of four residents (Resident #1, #2, #3, and #4) and one staff member took a video (Resident #2) and posted it to social media. Two of the pictures taken had a demeaning comment written on the pictures about the residents (Resident #1 and Resident #2). Three of the four residents had a diagnosis of dementia and all four residents were unaware that they had been recorded or had their pictures taken and posted to a social media platform. The facility census was 44. On 3/11/25, the Administrator was notified of the past noncompliance which began on 02/10/2025. The facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected 02/28/2025. Review of the facility policy, Abuse Prevention, and Prohibition, revised January 2024, showed: -Each resident has right to be free from abuse; -Residents must not be subjected to abuse by anyone, including, but not limited to , facility staff; -The facility prohibits mistreatment, neglect, or abuse of residents; -Facility staff shall be trained on the abuse prohibition program during orientation, annually, and ongoing during educational sessions, and per state regulations; -Resident abuse must be reported immediately to the administrator; -While an investigation is underway, steps will be taken to prevent further abuse; -If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress except to meet with the administrator as part of the investigation; -The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process; -Employee allegations: -When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution, or disciplinary action against the employee. The administrator and/or Director of Nursing will relay this suspension. At that time, the alleged staff member will be advised of the allegation and encouraged to assist in completing a statement relevant to the facts. The employee shall be instructed that the suspension is without pay and will be in effect while the investigation is ongoing. The investigation and due process rights of the alleged perpetrator/s will be observed. If the allegation is found unsubstantiated, the employee will be reinstated with retroactive pay for any days missed that the employee was originally scheduled to work. If the allegation is substantiated, the employee will be terminated. -Reporting/Response: -The facility employee who becomes aware of abuse or neglect shall immediately report the matter to the facility administrator or his/her designated representative in the administrators absence. - Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Technology includes any type of video or voice recording of residents, taking pictures of residents, or social media posts, unless by an authorized individual. - Mental Abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation. Mental abuse includes but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. Review of facility policy from employee handbook, use of cell phones and other portable communication devices, undated, showed; Unless approved for community business, the possession or use of cellular phones, pagers, or other portable communication device is strictly prohibited while on duty except during scheduled rest and meal periods. Use of these devices will be restricted to break room or outside of community. while on duty these devices will be stored in locker, purse, backpack, or vehicle. If purse/backpack stored in work area must be turned to off position. To ensure privacy of our residents, their families, and fell ow team members, the taking of photographs or audio recordings on community property is strictly prohibited without the explicit permission of administrator or executive director. Review of facility policy, Resident's Rights, dated 12/2024, showed: -Each resident residing in the community had a right and will be afforded the right to a dignified existence. -It was responsibility of all who work in the community, including employees, to advocate and protect the rights of each resident; -Resident rights include: privacy and confidentiality The facility did not have a policy on Health Insurance Portability and Accountability Act (HIPPA), a law enacted in 1996 that established national standards to protect individuals' medical records and other personal health information, ensuring patient privacy and security. 1. Review of Resident #1's Annual minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/22/25, showed: -Cognition severely impaired; -No behaviors noted; -Clear speech; -Made self-understood and understood others with clear comprehension; -Partial assistance with bathing and dressing; -Independent with toileting, personal hygiene, and mobility; -Diagnoses included: dementia (a group of brain disorders that causes progressive decline in cognitive function, memory, and behavior), chronic pain, and constipation. Review of the residents care plan, dated 1/28/25, showed: -Risk of constipation due to medical history, impaired mobility, and use of certain medications; -He/She had negative moods at times and made negative statements towards others; -Staff should redirect and not draw attention to negative statements made by resident; -He/She was deemed incompetent to make their own decisions and Durable Power of Attorney (DPOA) was invoked; -All decisions should be made through the DPOA (Durable Power of Attorney); -He/She had memory/recall problem due to dementia diagnosis; -Engage the resident in conversation that is meaningful to resident. Review of facility progress notes showed: -On 2/28/25, The Administrator and Social Service designee placed a phone call to DPOA regarding a picture taken of the resident. No answer. Message left to return call. DPOA returned call and spoke to Administrator and Director of Nursing (DON); -On 2/28/25, a Trauma assessment was completed, the resident voiced no traumas or fears and voiced feelings of safety in the facility. Review of facility provided image, dated 3/5/25, showed: - A Snapchat Image of Resident #1 looking at camera making a peace sign with right hand. The Resident is fully dressed with a blanket over her lap sitting in a recliner in his/her room; -Text on the image showed 'Is there a baby in ur belly it's kinda big today' -Text in upper left hand of image showed Nurse Aide (NA) A and Sunday. During an interview on 3/11/25 at 3:15 P.M., the Administrator said he/she spoke to resident's family member via phone on 2/28/25 at 2:19 P.M. to notify them of the pictures that had been taken of the resident. During an interview on 3/11/25 at 4:22 P.M., Resident said: -He/She was not aware that staff had taken his/her picture; -He/She would not have wanted his/her picture to be taken and posted on social media without his/her knowledge; -He/She did not know anything about Snapchat; -He/She would have feelings about his/her picture taken about her depending on what was written under the picture; -If someone made a comment about her picture it would have made him/her mad about it. 2. Review of Resident #2's Quarterly MDS, dated [DATE], showed: -Cognition moderately impaired; -Clear speech; -Made self-understood sometimes and understood others sometimes; -Displayed physical behaviors one to three days; -Dependent for toileting, personal hygiene, bathing, dressing, and mobility; -Diagnoses included: dementia, anxiety (feelings of unease, worry, fear, and nervousness), psychotic disorder (a mental health condition characterized by loss of touch with reality), and left hand contracture (shortening or hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints), and pain. Review of care plan, dated 6/18/24, showed: -He/She experienced pain related to generalized complaints of pain and contracture of left hand; -He/She had history of aggressive behaviors with cares due to diagnosis of dementia and conflict with residents; -When he/she became agitated of combative with cares when safe to do so allow resident to calm down and attempt cares later. Have a different care giver attempt cares if needed. -He/She was unable to understand most activities due to cognition; -He/She had memory and recall problem due to dementia; -He/She had difficulty making self-understood due to difficulty finding words; -Ask simple questions requiring a yes or no answer or one to two word answers; -Avoid talking to him/her; -Observe for nonverbal signs of distress such as grimacing; -He/She required substantial to dependent assist with all areas of activities of daily living functions; -He/She had decreased cognition related to Alzheimer's disease; -When he/she is trying to remember something, do not rush resident. Minimize distractions; -Allow him/her adequate time to respond. Review of facility progress notes showed: -On 2/28/25, Administrator and social services designee placed call to the resident's guardian. The Guardian returned call at 3:10 P.M. and spoke with administrator and social services designee. The Guardian was informed of the picture and video taken and that it had been shared with others via social media. The Guardian was not concerned by this. The facility staff offered to show picture or video and guardian was unsure if he/she wanted to see either. -On 2/28/25, a Trauma assessment was attempted but resident unable to participate due to poor cognition. -On 3/6/25, the Resident's family member came to facility that morning and requested to see the picture and video taken of their loved one. The DON and social service designee met with family member in DON office and showed video and picture of resident. The Family member was not bothered by either and saw nothing wrong with the picture voicing that he/she thought the staff was just trying to have fun or maybe the Resident was giving the staff a hard time but found no harm in either picture or video. Review of a photograph provided by the facility on 3/5/25, showed: -A Snapchat photo with NA B and date of February 10 displayed in the upper left hand of picture; -The image shows Resident #2 looking directly at the camera wearing only a hospital gown with a bed in the background; -The text across the picture showed 'The look of hatred'. Review of an undated video recording provided by the facility on 3/5/25, showed: -The video was posted on Snapchat on February 10, 2025 was 13 seconds long. -The audio on the video showed NA B said 'Resident #2 hates me guys', then asking Resident 2 'do you hate me', resident 2 then responded 'no', NA B then asked resident #2 if he/she was sure and resident responded yes; -At 0:00 seconds the video was of NA B with the camera on his/her self wearing a blue surgical mask below the chin. -At 0:07 seconds the video pans to Resident #2 sitting in his/her wheelchair wearing only a hospital gown. During an interview on 3/11/25 at 3:15 P.M., Administrator said he/she spoke to the resident's family member via phone with social service designee present on 2/28/25 at 2:20 P.M. to notify them of the pictures that had been taken of the resident without proper consent. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed: -Cognitive status not assessed; -No behaviors noted; -Clear speech; -Made self-understood and had clear comprehension of others; -Independent with personal hygiene, upper body dressing, eating, and oral care; -Set up assistance with lower body dressing; -Moderate assistance with mobility from sit to stand, lying to sitting on side of bed, rolling left and right, chair to bed or chair transfers, and toilet transfers; -Diagnoses included: Depression (a mental health condition characterized by persistent feelings of sadness, loss of interest, and changes in daily functioning), insomnia (a sleep disorder that made it hard to fall or stay asleep), glaucoma (eye disease that can lead to vision loss), and pain. Review of care plan, dated 2/25/25, showed: -Diagnosis of depression and history of showing signs and symptoms; -He/She took an antidepressant medication for diagnosis of depression -Had impaired vision related to glaucoma; -Required supervision/touch assistance transfers, dressing, and bed mobility; -Chose to spend most of his/her time alone in their room. Review of facility progress notes showed: -On 2/28/25, the Administrator and social service designee went to resident room to notify him/her of staff taking his/her picture. The resident asked why a picture was taken of him/her, explained that he/she did not know reasoning. The picture was shown to resident and explained that steps were being taken with a facility investigation, reporting to state agency, and employee suspension. The resident said he/she did not worry about it as it sounded like it had been handled. The resident said he/she felt his/her family member should be notified of the picture so they knew everything that was going on. The family member was notified via phone of the picture being taken and that the resident was aware. -On 2/28/25, a trauma assessment was attempted but resident refused to answer any questions and stated he/she did not understand why they were wanting to ask him/her about trauma and to leave his/her room if that was all they needed right now. Review of facility provided photograph, dated 3/5/25, showed: -A Snapchat image of resident sitting on the side of his/her bed with walker in front of them; -Resident #3 was fully clothed wearing a striped blouse, and black pants and shoes; -Resident #3 was sitting on an unmade bed with the curtains to his/her room open; -The upper image showed date 2/5/25 and NA D's first name. During an interview on 3/11/25 at 3:15 P.M., Administrator said: -He/She spoke to the resident in person due to him/her being their own person at that time. The resident indicated he/she wanted their DPOA to be contacted; -He/She contacted the resident's DPOA via phone on 2/28/25 with an undocumented time, to notify them of pictures that had been taken of the resident. During an interview on 3/11/25 at 3:23 P.M., the residents DPOA said: -The facility notified him/her regarding the resident's picture being posted to social media in a group chat; -The resident would not have consented to have her picture taken as he/she looked now; -Prior to Resident #3's illness he/she always made sure he/she looked perfect and always wore red lipstick; -Resident #3 would not be proud of the way he/she looked currently and would be embarrassed. During an interview on 3/11/25 at 4:26 P.M., the resident said he/she didn't care to talk about his/her photo being taken. 4. Review of Resident #4's Quarterly MDS, dated [DATE], showed: -Cognitive status not assessed; -He/She used clear speech; -He/She sometimes understood others and was sometimes able to make others understand them; -No behaviors noted; -Dependent on a walker; -Substantial assistance with toileting; -Moderate assistance with dressing and personal hygiene; -Independent with most mobility; -Diagnoses included: dementia, macular degeneration (disease that damages the central part of retina responsible for sharp, central vision, leading to vision loss for tasks like reading and recognizing faces), sensorineural hearing loss (permanent hearing loss due to damage to inner ear making it difficult to hear and understand sounds), and pain. Review of the residents care plan, dated 12/31/24, showed: -He/She was unable to voice their routines and preferences, refer to my DPOA for known routines and preferences; -He/She wore dentures and glasses. Please ensure they were clean, proper fitting, and worn while awake; -He/She had history of physical behaviors during personal cares; -He/She may not be able to communicate fears/needs due to neuro cognitive impairment; -Avoid power struggles with him/her; -Avoid over-stimulation (examples noise, crowding, other physically aggressive residents); -He/She had impaired vision due to macular degeneration. Used to wear glasses but as diagnosis progressed no longer wanted to wear them; -He/She had been deemed incompetent to make own decisions, his/her DPOA was invoked and all decisions would be made through them; -He/She had difficulty hearing due to sensorineural hearing loss. Review of facility progress notes showed: -On 2/28/25, the Administrator and Social Service designee placed call to DPOA to inform him/her of pictures taken of resident by staff. The Administrator explained to DPOA the type of pictures that were taken and shared by staff with other staff members. The DPOA did not understand why facility was calling to notify him/her of such thing and question what facility needed from him/her. Explained to him/her the reason for calling and actions being put in place. The DPOA asked if the pictures were shared publicly and he/she was fine with the situation knowing that the pictures were not publicly shared. -On 2/28/25, a trauma assessment was attempted but resident unable to participate due to cognition. Review of two facility provided images of resident, dated 3/5/25, showed: -Snapchat Image 1: - The resident was observed wearing a purple house coat fully dressed reaching towards the camera and was wearing pink heart shaped sunglasses. Resident was sitting in the medication cart storage area in the middle of the memory care unit with the medication cart behind him/her. -Text in the upper left showed NA B and the date of February 14th; -Snapchat Image 2: - The resident was wearing purple housecoat, pink shaped sunglasses, and looking directly at camera making the peace sign. Resident was positioned in front of the medication cart in the medication storage area on the memory care unit. -Text in the upper left showed NA B and the date of February 14th. During an interview on 3/11/25 at 3:15 P.M., the Administrator said he/she contacted resident's DPOA with social service designee on 2/28/25 at 2:22 P.M. Observation on 3/11/25 at 4:29 P.M. showed resident was sleeping in his/her recliner on the memory care unit at the facility. 5. Review of facility investigation showed: -On 2/28/25, CNA A sent Director of Nursing (DON) screen-shots of pictures taken of residents on snap chat that were sent in a group chat between five total CNA's or Nurse Aides. -Facility suspended all five CNA's on 2/28/25 including CNA A, NA A, NA B, NA C, NA D; -Facility provided all staff in-service on 2/28/25 regarding recording policy from employee handbook and abuse and neglect policy; -An on-going in-service was completed with direct care staff to include prior to working their next scheduled shift on recording policy from employee handbook and abuse and neglect; -On 2/28/25 all direct care staff were educated prior to working their next scheduled shift; -On 2/28/25 the facility conducted and quality assurance performance improvement plan meeting with the medical director; -Interviews were conducted with ten sampled residents related to abuse, neglect, and exploitation and no concerns were voiced by residents interviewed. -On 3/3/25, the Administrator implemented audits of asking two staff members per day, five days a week, for eight weeks on the facility cellular phone policy, social media policy, recording and reporting of all recording; -On 3/3/25, the Social Service Designee implemented audits of asking two residents a day, five days a week, for eight weeks on if they had any concerns related to being recorded; Review of employee files showed: -CNA A: -He/She signed abuse, prevention and prohibition policy on 12/6/24; -He/She signed HIPPA form on 12/6/24; -He/She signed the employee handbook acknowledgement form on 12/6/24; -He/She was suspended on 2/28/25; -He/She received a written warning on 3/3/25; -NA A: -He/She signed abuse, prevention and prohibition policy on 11/27/24; -He/She signed HIPPA form on 11/27/24; -He/She signed the employee handbook acknowledgement form on 11/27/24; -He/She was suspended on 2/28/25 for taking photos of resident without their consent; -He/She was terminated on 3/3/25 -NA B: -He/She signed abuse, prevention and prohibition policy on 12/20/24; -He/She signed HIPPA form on 11/21/24; -He/She signed the employee handbook acknowledgement form on 11/21/24; -He/She was suspended on 2/28/25 for taking pictures and videos of resident in resident care areas without their consent; -He/She was terminated on 3/3/25 -NA C: -He/She signed abuse, prevention and prohibition policy on 12/16/24; -He/She signed HIPPA form on 12/16/24; -He/She signed the employee handbook acknowledgement form on 12/16/24; -He/She was suspended on 2/28/25 for failure to follow department policies and procedures in group chat with resident pictures; -He/She received a written warning 3/3/25 -NA D: -He/She signed abuse, prevention and prohibition policy on 11/12/24 and 12/19/24; -He/She signed HIPPA form on 11/12/24 and 12/19/24; -He/She signed the employee handbook acknowledgement form on 11/12/24; -He/She was suspended on 2/28/25 for taking pictures of resident in their room without their consent; -He/She was terminated on 3/3/25. During an interview on 3/11/25 at 11:20 A.M., Administrator said: -An employee reported to him/her that five nurse aides who worked at facility were involved in a Snapchat group and some of the employees had been posting resident pictures to the group; -He/She suspended five employees who were members of this group when he/she learned of an allegation of employees posting resident photos to Snapchat; -He/She completed an investigation and reported to the state agency; -As a result of his/her investigation he/she terminated employment with three of the five employees investigated; -He/She completed education with staff via an in-service and sent a message out through the employee text communication system regarding social media and cell phone use; -He/She had social services attempt to do trauma assessments with all residents but due to cognition status of the four residents involved they were unsuccessful in completing the assessments; -He/She notified all of the residents families immediately about the photos of residents that had been posted to social media. During an interview on 3/11/25 at 3:38 P.M., CNA A said: -He/She did not remember when the Snapchat group was created; -A Snapchat group titled work chat was initially created so employees could communicate to cover each other's shifts; -He/She received the first resident picture sometime in February, but was not sure of exact date; -Everyone in the Snapchat group was employed at the facility; -The group included him/her, NA A, NA B, NA C, and NA D; -The staff members who sent pictures of residents in the group was NA A, NA B, and NA D; -The staff member who sent a video in the Snapchat group was NA B; -Those staff members were terminated following the facility investigation; -He/She notified group members it was against HIPPA and confidentiality and residents rights to send pictures in the group; -He/She notified the Administrator of the Snapchat group; -He/She sent images from the group to the administrator; -The afternoon of when she reported it to the administrator the charge nurses and Certified medication technician spoke to staff on duty and told everyone working they were not to have phones out around residents and no photos or videos were to be taken; -That afternoon all the members of the Snapchat group left the group; -He/She received training on abuse and neglect, HIPPA, and no use of phones, camera's, or videos when he/she was hired by the facility; -After reporting he/she received a message from administration in the all staff texting application that reminded staff that no videos or phones were allowed and that the facility was residents home; -He/She was suspended on Friday the 28th along with NA A, NA B, NA C, and NA D; -He/She was suspended for two hours while the investigation occurred; -Only one of the four residents photographed was cognitively aware; -He/She did not believe any of the residents photographed would have consented to have their picture taken; -Administrator had provided a training on abuse and Neglect policy and HIPPA. During an interview on 3/11/25 at 3:53 P.M., NA C said: -He/She became member of Snapchat group after began employment and the group members included him/her, NA A, NA B, NA D, and CNA A; -Pictures began being shared within the group in February; -The photos shared were not explicit but of fully clothed residents; -Some of the residents were actually posing for pictures; -There was four pictures that were shared in the group including pictures of Resident #1, #2, #3, and #4; -He/She knew it was a violation of HIPPA; -He/She did not report it and he/she knew that he/she should have reported it; -He/She removed themselves from the Snapchat group two weeks after pictures were taken; -He/She never replied to picture in the group and did not send any pictures in the group chat; -He/She only used the Snapchat group to see if any work shifts could be covered; -He/She was suspended by the facility when they became aware of the pictures and Snapchat group; -The facility investigation resulted in three of the group members, NA A, NA B, and NA D being terminated; -Facility implemented training on HIPPA and social media following the report; -A text message was sent by facility administration in our employee chat application sharing the regulation reminder and that no pictures of residents were to be taken as it was a HIPPA violation; -He/She had to sign and review the abuse and neglect policy and social media policy; -The Administrator provided staff education and a quiz on abuse and neglect; -He/She received training on cell phone, social media, abuse and neglect and HIPPA when she completed his/her orientation at the facility. During an interview on 3/11/25 at 4:10 P.M., NA E said: -He/She received abuse and neglect training on Friday; -He/She was educated not to use social media regarding the facility or any residents; -He/She was educated that phone use was prohibited inside the facility with residents; -He/She would report abuse to charge nurse, DON, and follow the chain of command; -He/She had not observed any abuse in facility. During an interview on 3/11/25 at 4:13 P.M., NA F said: -He/She had received abuse and neglect training in the facility; -He/She would report abuse to the DON; -He/She received cell phone policy during orientation; -The policy advised no phones were used in resident rooms or nurses station and they were not to take pictures of any residents; -He/She had received HIPPA training and was not to talk to anyone outside of the facility about residents; -He/She had seen a violation of HIPPA and cell phone policy; -He/She observed NA B with his/her phone out at the end of February; -He/She reported it to his/her coworkers when he/she observed NA B with their phone out; -Facility administration went over HIPPA and phone use at staff in service and reminded us that phones had to stay in break room of facility; -He/She had not observed any abuse of residents in the facility. During an interview on 3/11/25 at 4:31 P.M., Licensed Practical Nurse A said: -He/She had not witnessed any staff taking pictures or videos of residents; -He/She had addressed nurse aides regarding putting their phones awhile while working with them; -Facility had a policy that included no cell phones out while working; -Facility recently had in-service on cell phone use policy, HIPPA, and abuse and neglect; -He/She had not witnessed any abuse in facility; -If He/She did observe abuse or had reported abuse to him/her he/she would ensure protection of resident and notify the DON or administrator; -He/She would also walk abuser out of facility. During an interview on 3/11/25 at 4:35 P.M., NA G said: -He/She heard five NA's were posting photos of residents to Snapchat, but was not a part of Snapchat group; -He/She was educated upon hire that all cell phones had to be kept in the back room of facility; -He/She had not witnessed any staff members with their phones out or taking pictures or videos of residents. During an interview on 3/11/25 at 4:39 P.M., DON said: -He/She expected staff not to be using cell phones while working, have them on their person while working, and expected phones to be left in the breakroom; -He/She expected that no pictures or videos were taken of residents of the facility; -He/She did feel residents pictures and video taken was abuse; -The residents who had their photos taken were unable to provide consent due to cognitive status; -He/She expected staff not to post to social media platforms; -The cell phone and social media policy was covered during orientation for all employees; -He/She expected staff to report any violation of abuse and neglect policy immediately; -The Administrator served as the abuse and neglect coordinator. During an interview on 3/11/25 at 4:44 P.M., Administrator said: -He/She expected cell phones not to be out or seen while working; -He/She expected staff to not post on social media platforms; -He/She expected residents to be free from abuse. MO250299

Based on interview and record review, the facility failed to protect one resident (Resident #1), who resided on the Special Care Unit (SCU), from abuse when Certified Medication Technician (CMT) A hit Resident #1 in the face with an open hand. The facility staff then allowed the Alleged Perpetrator (AP) to stay in direct contact with Resident #1 and without supervision for over 2.5 hours. The facility census was 54. On 12/11/24, the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which began on 12/11/24. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The IJ was corrected on 12/11/24. Review of the undated facility Abuse Prevention and Prohibition Policy showed: -The facility prohibits mistreatment, neglect or abuse of residents; -Resident abuse must be reported immediately to the Administrator; -While a facility investigation is underway, steps will be taken to prevent further abuse; -If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress, except to meet with the administrator as part of the investigation; -The facility will immediately remove any alleged perpetrator from any further contact with any resident; -When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents, through suspension, pending the outcome of the investigation, prosecution or disciplinary action against the employee; -The facility employee or agent, who becomes aware of abuse or neglect shall immediately report the matter to the facility Administrator or his/her designated representative. Review of Resident #1's Annual Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 11/27/24, showed: -Brief Interview of Mental Status (BIMS) of 99 indicating significant cognitive loss; -Physical Behaviors such as hitting and kicking 1-3 of the 7 day assessment period; -Moderate assistance of staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself) such as toileting, dressing, and personal hygiene; -Diagnoses of Dementia with Psychosis (a decline in mental abilities that affects daily life and a condition where a person with dementia experiences seeing or hearing things that are not real or false beliefs), muscle weakness, unsteadiness, cognitive communication deficit (communication difficulty caused by a cognitive impairment), restlessness, agitation (feeling of irritability, mental distress or severe restlessness), and generalized anxiety disorder (excessive and uncontrollable worry about everyday events or activities). Review of the resident's comprehensive care plan, dated 11/27/24, showed: -The resident had the potential for agitation, anxiety, and behaviors; -Explain all procedures to the resident; -Approach the resident in a calm manner; -Provide the resident a calm environment and care. Review of the facility investigation, dated 12/11/24, showed: -On 12/11/24 at 12:45 A.M., Resident #1 was found by CMT A on the floor of his/her room. Licensed Practical Nurse (LPN) A was notified and assessed the resident for injuries. Nurse Aide (NA) B and Certified Nurse Aide (CNA) C went to assist CMT A in getting Resident #1 to bed; -At 12:55 A.M., CMT A was at the resident's head, CNA C was at the resident's feet. Resident #1 was swinging his/her arms and kicking at CNA C. NA B was standing to the side observing. CMT A grabbed the resident's arm, and smacked the resident in the face, across the cheek and eye of the right side, with his/her open palm. The resident was placed in bed and NA B and CNA C left the SCU and returned to the other hall of residents; -At 2:45 A.M., the incident was reported to Charge Nurse LPN A; -At 2:49 A.M., LPN A notified the on call nurse MDS Coordinator of the incident that had occurred between 12:50 A.M. and 12:55 A.M.; -At 3:15 A.M., the Director of Nursing (DON) was notified of the incident; -At 3:30 A.M., the MDS Coordinator arrived at the facility and proceeded to the SCU where he/she found CMT A sitting in Resident #1's room. Resident #1 was in bed asleep. CMT A was then interviewed and escorted from the building; -CMT A admitted to 'bopping' the resident on the head as a knee jerk reaction. Review of the CMT A's undated written statement showed: -On 12/11/24 at approximately 12:45 A.M., Resident #1 was on the floor of his/her room. -CNA B and NA C were in the room to assist CMT A in getting the resident up. -CNA B was standing towards the resident's knees and NA C was off to the side observing. -The resident attempted to kick CNA B in the back. -CMT A pulled his/her hand away, tapped the top of the resident's head and told the resident to stop it. -He/She did not know why she tapped the resident and it was a knee jerk reaction During an interview on 12/16/24 at 2:50 P.M., NA B said: -He/She and CNA C had gone to assist CMT A with getting Resident #1 up off the floor on the night of 12/11/24 about 12:55 A.M. CMT A was standing above Resident#1's head. Resident #1 was lying on the floor. CNA C was standing toward the resident's legs/feet facing the side of the resident, applying the gait belt. Resident #1 was kicking and hitting at CNA C. CMT A used his/her open hand and smacked Resident #1 across the face/eye. Resident #1 went completely still. Resident #1 then growled and gritted his/her teeth at CMT A. CMT A asked did anyone see that; I hope not. CMT A and CNA C assisted Resident #1 to get into bed. CNA C and NA B left the SCU and returned to the other hall of the facility; -He/She had been at this job about 2 weeks and was very unsure what to do in the situation; -He/She and CNA C provided care and did rounds for the other residents prior to him/her going to the Charge Nurse about the incident; -He/She watched a video about abuse when he/she started at the facility, however the video did not tell him/her who to report suspected abuse to; -Resident #1 had never made a growling sound or barred his/her teeth to NA B; -He/She knew it was not right for CMT A to smack the resident. During an interview on 12/16/24 at 3:15 P.M., CNA C said: -He/She went to assist CMT A get Resident #1 off the floor on the night of 12/11/24; -NA B was standing to the side and was not physically assisting the resident; -He/She heard CMT A say you didn't see that. I hope not; -He/She did not see CMT A smack or harm Resident #1 in any way; -Every time CMT A would speak, Resident #1 would growl and chomp his/her teeth at CMT A; -He/She had never had another staff member potentially abuse someone and he/she did not know what to do; -He/She knew abuse should be reported. However, he/she was not sure who to report to. During an interview on 12/16/24 at 3:37 P.M., MDS Coordinator said: -He/She was the management nurse on call the night of 12/11/24; -LPN A notified him/her of the incident with Resident #1 and CMT A; -He/She did not tell the Charge Nurse to remove CMT A from resident care; -CMT A should have been removed from contact with residents immediately; -He/She made a mistake by not removing CMT A from resident contact. During an interview on 12/16/24 at 3:40 P.M., the DON said: -She would expect an alleged perpetrator to be removed from resident contact immediately; -CMT A might have worked for the facility a week, she was not sure; -CMT A was an agency staff member; -Agency staff do not receive education from the facility except expected care of residents. During an interview on 12/16/24 at 4:03 P.M., the Administrator said: -She was not made aware of the incident until later in the morning on the 11th; -She was not made aware the CMT was allowed to stay in resident contact until she arrived for work on the morning of the 11th; -She would expect the alleged perpetrator to be removed from resident contact. MO246431

Based on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to maintain a clean and sanitary kitchen, failed to take food temperatures on the steam table before food service and when cooking items, failed to reheat foods to safe temperatures before serving, stored glasses with openings facing up, stored eggs on the floor, did not properly sanitize food preparation surfaces in kitchen, did not have a thermometer in refrigeration unit, did not ensure proper parts per million (PPM) sanitation levels were reached while using a 3 compartment sink, did not wash hands after contamination, did not have paper towels available at hand washing sink, and when dietary staff did not wear hairnets prior to entering kitchen. The facility census was 59. 1. Review of facility policy, Receiving and storage of food, dated [DATE], showed: -Keep storage areas clean and dry. Review of facility policy, storage of dry food and supplies, dated [DATE], showed: -Storeroom must be neat and orderly. Shelving is kept clean and free of rust and chipped paint; -Metal and plastic containers with tight fitting covers, labeled top or side, bust be used for storing opened products; -Food is to be stored a minimum of six inches above the floor. Review of facility policy, using the food safety and sanitation checklist, dated [DATE], showed: -Monitor and correct deficient safety and sanitation practices in dietary department. Review of facility policy, cleaning schedules, dated [DATE], showed: -It is responsibility of dining services manager to enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks; -Daily, weekly, and monthly cleaning schedules prepared by the dining services manager with all cleaning tasks listed will be posted in dietary department. Review of facility policy, developing cleaning schedules, dated [DATE], showed: -To develop detailed cleaning schedules to ensure sanitation is at acceptable standards. -The employee responsible for performing the task is responsible for initialing the cleaning schedule on the day the task was completed; -Daily cleaning schedule showed: counter tops, steam table, 3 compartment sink, stove top, dishwashing area, refrigerator,, garbage cans and lids, hand sink/soap/paper towels, tray carts, floors - sweep and mop, microwave; -Monthly cleaning schedule: oven - clean thoroughly, ceiling, ceiling lights and covers, baseboards; -Weekly cleaning schedule showed: stove, steamer, utility carts - polish/clean, storage room. Review of facility policy, guidelines for cleaning gas stove, dated [DATE], showed: -Remove pot rests from above burners on the cooking surfaces; -Wash, rinse, and dry; -Remove sections of the cooking surface by lifting upward and outward, place sections on newspaper and brush with oven cleaner. -Wipe off dissolved grease with paper towels; -If any grease remains, brush again, and wipe off; -Clean area around and under burners with warm detergent solution and rinse; -Place units in pot sink with hot detergent solution, wash, rinse, and dry or run through dishwasher; -Empty grease pan and wash with hot detergent solution, rinse, dry, and replace. Review of facility policy, guidelines for cleaning gas oven, dated [DATE], showed: -Oven will be cleaned weekly -Wipe off loosened grease with paper towels -Wash and rinse the racks and let air dry Review of facility policy, stoves, ovens and microwaves, dated [DATE], showed: -Each cook is responsible for the use and care of the stove on his or her shift. Review of facility policy, guidelines for cleaning microwave, dated [DATE], showed: -Wash out spills and splatters as they occur, using a detergent solution; -Sanitize with appropriate strength of solution. Review of facility policy, cleaning floors, undated, showed: -Kitchen floor maintenance will be done after each meal. Spills need to be mopped up immediately; -Sweep the floor, pushing all debris forwarding, using dustpan to remove debris. Review of facility sanitation checklists completed by facilitation dietician showed: -[DATE]: carts needed deep cleaned, many holes in cleaning tasks, garbage can lid dirty, deep cleaning needed of dish machine, all food was not properly covered, labeled, and dated; -[DATE]: floors were not clean, shelving and carts needed cleaned; corrected dietary manager on getting all hair in hair net, deep cleaning needed of dish machine, garbage can lid was dirty, holes in cleaning list tasks. Observation of the kitchen on [DATE] at 9:28 A.M. showed: -Tables had not been cleaned from breakfast, carts of dishes were stacked at doorway to dish room; -Trash can lid next to food preparation table had chunks of food stuck and liquid substances coated to lid; -Stove top had burnt on food residue caked to burners and stove top including a black egg noodle; -Grease trap on stop top griddle had food residue in it; -Back and sides of stove top were black from grease and cooking residue; -Handles of stove were sticky, caked in grease and grime, and food crumbs sitting on edges of handle; -Outside of stove had streaks of spilled food items running down front of stove; -Steam table was observed with kernels of corn sitting in the steam table water and a cream colored sticky substance was stuck to inside of one of the steam table vats; -Plate warmer has food residue and crumbs all around top of unit; -Microwave was not clean and had spilt food inside and stuck to walls of unit; -Dish drying rack next to three compartment sink had dust caked to the metal shelves of unit; -A bowl of ,d+[DATE] eaten oatmeal was sitting on cart with clean adaptive silverware in dish room; -Dry storage room showed 3 tiered metal cart had brown sticky substance spilled on bottom tier, second tier had spilled cereal crumbs and the container of rice Krispies did not have the lid secured to top, the top tier of the cart had cheerios and corn flakes spilled and crumbs of powder residue laying on top of cart; -Walk in cooler had a box of pasteurized eggs sitting directly on floor and ,d+[DATE] individualized butter containers were scattered about walk in cooler floor; -Floors of kitchen had food particles and crumbs all over; -Empty boxes laying on the ground by back door; -No paper towels were available at hand washing sink as the paper towel dispenser was empty; -Paint was peeling and chipping off of ceiling; -Ceiling vent at entry of kitchen is covered with dust. Observation of cleaning logs on [DATE] at 10:01 A.M. showed: -Daily cleaning logs had no entries on Thursday, Friday, Saturday, or Sunday; -Weekly cleaning schedule log had no dates entered as to when schedule was started and what dates were week 1, 2, 3 or 4; Week 1 had no entry for cleaning of stove, mixer, refrigerators, freezers, food storage bins, utility carts, tray carts, vent hood screens, delime of dish machine, walls, fans, kitchen vents, ice machine, dish storage units, janitor closet, back door areas, doors, and dietary manager office, and no entries at all on the log for week 2, week, 3, week 4. -Monthly cleaning schedule log had no entries. Continuous observation in the kitchen on [DATE] from 11:11 A.M. - 1:12 P.M. showed: -11:30 A.M., Dietary Aide observed adding clean dishes to plate warmer. Plate warmer had crumbs and dirt piled on top of unit. Observation on [DATE] at 11:30 A.M. showed paint chipping off ceiling by the air ventilation units and air ventilation units are caked in layers of dust. During an interview on [DATE] at 8:49 A.M., [NAME] A said: -Clean cups should be stored with the opening down; -Kitchen had a cleaning list to follow; -He/She did not clean items in kitchen that was not used like the griddle; -He/She should sweep, mop, and wipe off everything in kitchen; -When he/she wiped off surfaces in kitchen he/she should use bucket with sanitizer water in it; -When he/she swept he/she needed to sweep under tables and counters; -He/She checked to make sure nothing was expired in fridge; -Night shift emptied water from steam table; -Steam table was not cleaned on [DATE] when their was food found in steam table on morning of ,d+[DATE]. During an interview on [DATE] at 9:07 A.M., the Dietary manager said: -He/She expected the floors to be swept, mopped, and stove top burners to be cleaned right after a meal; -He/She expected the dish room to be clean and sanitary; -Surfaces in the kitchen should be cleaned as they go about meal preparation; -Grease trap should be cleaned every time it is used and checked weekly; -Maintenance was responsible for cleaning vents in the kitchen; -Staff know what serving spoons to use during meal service by looking at menu book that shows what spoon or spoodle to be used; -Steam table should be cleaned every night; -There should not be leftover food such as corn or spilled substance on steam table, the unit should be wiped out and refilled every evening; -The trash can lid should be cleaned regularly and should not have food caked to top of it. During an interview on [DATE] at 10:04 A.M., Dietary Aide A said: -He/She did not clean surfaces in the dish room; During an interview on [DATE] at 10:32 A.M., [NAME] B said: -Cleaning list is hanging on bulletin board to back of kitchen; -He/She tried to clean up food surfaces he/she used during meal preparation; -He/She did not always following cleaning list. During an interview on [DATE] at 2:34 P.M., Administrator said: -He/She expected kitchen to be sanitary; -Food should not be stuck to top of stove top; -There should not be grease or grime on stove and refrigerator; -Trash can should not have food stuck to the lid; -Floor should be swept and mopped at end of every shift; -He/She would not expect corn or sticky substance coated to inside of steam table; -He/She expected maintenance to clean air vents in kitchen; -He/She would not expect paint to be peeling off kitchen ceiling; -He/She expected food preparation services to be cleaned using sanitizing spray; -It was not appropriate to use soapy wash cloth to sanitizer kitchen preparation services. 2. Review of facility policy, food temperatures, dated [DATE], showed: -The dietary manager or designee is responsible for seeing that all food is the proper serving temperature before trays are assembled; -Keep the temperature of hot foods no less than 140 degrees during tray assembly; -Hot foods should be at least 120 degrees Fahrenheit when served to the resident; -Keep temperatures of potentially hazardous cold foods no greater than 40 degrees F. Prepare cold items a day in advance when possible. Place items in freezer 45 minutes before serving and use ice baths when needed; -Take and record the temperatures of all items at all meals; -Once weekly a test tray should be sent with the hall trays. Food temperatures should be taken and recorded after all trays have been delivered; -Heat food to the proper temperature by direct heat (using a stove, oven, steamer) and then transfer food to the preheated steam table no more than thirty minutes before meal service; -To ensure adequate temperatures, proper-holding techniques should be used; -Food is not placed on steam table more than 30 minutes before meal service; -Food is not held in warm ovens more than 30 minutes before meal service. It is recommended that food not be held on steam table for longer than two hours; -Only remove up to five plates at a time from the heated plate warmer; -Foods should be reheated to a minimum temperature of 165 degrees for fifteen seconds. Review of facility policy, using the food safety and sanitation checklist, dated [DATE], showed: -Monitor and correct deficient safety and sanitation practices in dietary department. -Food safety and Sanitation checklist; -Does hot food leave the kitchen above 140 degrees. Observation on [DATE] at 9:28 A.M. showed: -A snack cart had container of room temperature water with five containers of yogurt and two mozzarella sticks sitting in it, tea on snack cart had no ice in it. Continuous observation in the kitchen on [DATE] from 11:11 A.M. to 1:12 P.M., showed: -11:16 A.M., [NAME] B added chicken fritters to steam table, no temperature taken; -11:17 A.M., [NAME] B used white wash cloth that had not been in sanitizer to wipe off counter of steam table. -11:18 A.M., [NAME] B prepared minced and moist meat. He/She added minced and most to steam table and did not temperature check the meat; -11:20 A.M., [NAME] B removed macaroni from microwave, added to steam table, was not temperature checked; -11:46 A.M., Administrator in dish room rinsing dishes and running dish washer; -11:46 A.M., Baked beans dated ,d+[DATE], use by ,d+[DATE] added to microwave for two minutes; -11:53 A.M., Baked beans still sitting in microwave, have not been touched; -11:59 A.M., Baked beans removed from microwave and added to steam table, 13 minutes after being placed in microwave. Beans were not temperature checked; -12:06 P.M., Dietary Manager added pureed carrots to a container from robot coupe, then temperature checked pureed carrots at 148.6 degrees (below serving temperature), did not document temperature, carrots added to steam table not at appropriate temperature; -12:42 P.M., Dietary Manager brought food temperature log over to clip board; -12:46 P.M., [NAME] B completed food temperatures on some foods on steam table but not all of them were temperature checked, items were not at appropriate holding temperature: -Chicken 159.6 degrees; -Cut up chicken patties - 129.9 degrees; -Carrots 170.6; -Minced carrots 127.9 degrees; -pureed chicken 157.8 degrees; -Mashed potatoes were not temperature checked -Minced and moist chicken 158.7 degrees; -1:06 P.M., Dietary Manager brought cooked hamburger patty to cook B, temperature checked it at 147.7 degrees (not to safe temperature) During an interview on [DATE] at 8:49 A.M., [NAME] A said: -Food should be cooked mostly to 165 degrees, and fish was lower at 145 degrees; -He/She temperature checked foods right when it came out of the oven; -He/She documented food temperatures on a paper in the kitchen; -He/She temperature checked food after it sat in the steam table; -He/She had many people complained that food was cold; -Food is cold because staff let it food sit and do not serve the trays right away; -Food temperatures that are taken on steam table are documented on same paper cooking temperatures are documented where there is a holding temperature row; -He/She had no specific time for doing temperature checks on food on the steam table, he/she usually temperature checked food at some point between serving food and being done with food service; -He/She reheated vegetables in the oven; -He/She reheated hot dogs and items that were already cooked in the microwave. During an interview on [DATE] at 9:07 A.M., the Dietary manager said: -Food should be temperature checked when it came out of oven; -Mechanical diets should be temperature checked to ensure food is hot and fresh; -Foods are not temperature checked on steam table; -Food is temperature checked before room trays are served; -When food was not at temperature then he/she expected staff to bring it up to proper temperature by putting food back in stove or oven; -Food should be held on steam table at a minimum of 135 degrees; -Meats are to be held between 145 degrees and 175 degrees; -Most of the time the staff crank the steam table; -He/She had told staff that the steam table was not to be used to cook foods; -Food temperature checks should be documented; -He/She had issues getting staff to document temperatures of foods; -Cold food items should not be sent out on snack cart at night time; -Cold food items should be kept on ice at all times, if cold food items return to kitchen no longer in ice bath the food should be thrown out if not stored at appropriate temperature. During an interview on [DATE] at 10:56 A.M., Dietician said: -He/She expected staff to temperature check food as soon as it came out of oven, before it was placed on steam table, and before serving food; -He/She expected staff to check food temperatures after meal service to ensure temperature was maintained throughout the meal service; -When temperature checked food was not to temperature, he/she expected staff to cover food and put back into the oven, steamer, or stove top to be brought back to proper holding temperature; -He/She expected food cooked in microwave to be temperature checked; -He/She would not expect staff to serve food without hitting correct temperature points; -He/She expected most leftover foods to be reheated in oven or steamer to 165 degrees; -He/She would not expect staff to reheat fish patties in the microwave. During an interview on [DATE] at 2:34 P.M., Administrator said: -He/She was unsure what policy was but before being placed on steam table, during meal time, after food is cooked; -Cooking temperature and serving temperature should be recorded. 3. Review of facility policy, general dish room sanitation, dated [DATE], showed: -All items must be stored inverted, covered, or stacked with top of dish/tray inverted. Observation on [DATE] at 9:28 A.M. showed: -Drinking cups were stored upright in storage containers. During an interview on [DATE] at 9:07 A.M., the Dietary manager said: -Clean cups should be stored with their openings flipped down. 4. Review of facility policy, storage of food and supplies, dated [DATE], showed: -Food is to be stored a minimum of six inches above the floor. Observation on [DATE] at 9:42 A.M. showed a box of pasteurized eggs was sitting directly on the floor of walk in cooler. During an interview on [DATE] at 9:07 A.M., the Dietary manager said: -Eggs should not be stored on floor of cooler, they should be stored six inches off the ground. During an interview on [DATE] at 10:32 A.M., [NAME] B said: -Eggs should not be stored on floor, nothing should be stored on the floor. During an interview on [DATE] at 2:34 P.M., Administrator said: -Eggs should not be stored on floor; -Food should be stored on a shelf. 5. Facility had no policy regarding sanitation bucket use. Review of facility policy, using food safety and sanitation checklist, dated [DATE], showed: -Are cleaning clothes stored in sanitizing solution; -Are food contact surfaces cleaned and sanitized after each use. Observation on [DATE] at 9:49 A.M. showed no sanitizer buckets were prepared or set up in kitchen. Observation on [DATE] at 9:58 A.M. showed there was two sanitizer buckets sitting on shelf under the three compartment sink that were empty and had not been used. During an interview on [DATE] at 10:03 A.M., [NAME] A said: -He/She did not prep sanitizer-buckets; -He/She thought aides are supposed to do that; -He/She does not use sanitizer buckets as he/she cooks to clean to food preparation surfaces in kitchen. Continuous observation in the kitchen on [DATE] from 11:11 A.M. - 1:12 P.M. showed: -11:36 A.M., No sanitizer buckets filled anywhere in kitchen; -11:46 A.M., Dietary Manager observed adding sanitizer to green bucket; -11:54 A.M., [NAME] B uses wash cloth from soapy water to wipe off food preparation service; -12:04 P.M., [NAME] B used wash cloth dipped in soapy water to wipe off gravy off surface of preparation table. During an interview on [DATE] at 9:49 A.M., Dietary Aide C said: -He/She had not set up sanitizer buckets yet because he/she just used them to wipe off tables in dining room; During an interview on [DATE] at 8:49 A.M., [NAME] A said: -Sanitizer buckets should be prepared by the dietary aide, he/she prepared the bucket before or after the meal. During an interview on [DATE] at 9:07 A.M., the Dietary manager said: -Staff should use a wash cloth dipped in sanitizer to clean food preparation services; -Sanitizer buckets should be set up prior to staff clearing the tables in dining room and silver soak needs to be set up to clean off table; -Detergent went in green buckets, and then sanitizer in red buckets; -Sanitizer buckets should be tested ; -Wash clothes being used should be stored in sanitizer solution. During an interview on [DATE] at 10:04 A.M., Dietary Aide A said: -He/She set up sanitizer buckets for washing dining room tables only; -The sanitizer buckets should be used to wash down the three tiered carts; -Wash clothes should be stored in the sanitizer solution when not in use. During an interview on [DATE] at 10:32 A.M., [NAME] B said: -He/She washed kitchen preparation surfaces with soapy dish water first and then went back over surfaces with sanitizer water; -He/She stores his/her wash rag in the soapy dish water. During an interview on [DATE] at 10:56 A.M., Dietician said: -He/She expected food preparation surfaces to be cleaned off first with sanitizer solution. During an interview on [DATE] at 2:34 P.M., Administrator said: -He/She expected food preparation services to be cleaned using sanitizing spray; -Sanitizer buckets should be prepped prior to meal service; -It was not appropriate to use soapy wash cloth to sanitizer kitchen preparation services. 6. Review of facility policy, refrigerator and freezer temperatures, dated [DATE], showed: -There should be a thermometer in all refrigerator and freezers. Thermometers should be located in the front of the unit. Observation on [DATE] at 9:56 A.M. showed no thermometer located in refrigerator unit, outside of the unit had a digital temperature reading of 34 degrees. During an interview on [DATE] at 9:58 A.M., [NAME] A said the refrigerator had no thermometer inside unit, they just used the digital thermometer on the outside of the refrigerator to track temperatures. During an interview on [DATE] at 2:34 P.M., Administrator said: -Thermometers should be located in all refrigerators and freezers. 7. Review of facility policy, sanitizing the three-compartment sink, dated [DATE], showed: -Ensure that the sanitizing water is at the appropriate level, is being monitored, documented, and used correctly, according to the instruction below. -Fill third compartment of 3-compartment sink with water to the line as indicated on the sink. -Add pre-measured sanitizing solution per manufacturer's setting. Solution must be at room temperature. -Test paper must be clean and dry. Remove 1 ,d+[DATE] inches of test paper from container. -Dip test paper into solution and hold for 10 seconds. -Compare color on strip to chart on container (desired reading is 200ppm). -Document test strip completion on log provided. -Dishes should be submerged in sanitizing solution for 1 to 2 minutes and allowed to air dry. -Sanitizing solution should be tested and logged three times daily prior to the use of the 3 compartment sink. Observation on [DATE] at 9:42 A.M., showed [NAME] A had soap in first compartment of sink, no water or sanitizer in other containers of three compartment sink. Three compartment sink log hanging above sink showed it had no entries for [DATE]. During an interview on [DATE] at 9:42 A.M., [NAME] A said the first compartment of sink had dish soap and water only. Continuous observation in the kitchen on [DATE] from 11:11 A.M.-1:17 P.M. showed: -11:14 A.M. Three compartment sink was filled, steam coming off from hot water; -11:17 A.M., [NAME] B used white wash cloth that had not been in sanitizer to wipe off counter of steam table; -11:21 A.M., [NAME] B took robot coupe container to sink and washed container in first compartment of three compartment sink with soapy water; -11:24 A.M., [NAME] B ran a test strip at request of surveyor in third compartment of sink, test strip did not change colors showing 0 parts per million (PPM) of sanitizing solution. [NAME] B said he/she added sanitizer to third compartment of sink but he/she had not completed a test strip yet today. Observation showed dishes had already been washed and were sitting in clean dish return. Dietary manager advised [NAME] B to run another test strip. [NAME] B put another sanitizer strip in third compartment of sink and strip did not change color showing 0 PPM. Dietary Manager advised [NAME] B to drain third compartment of sink and re-add sanitizer solution. Water begins to drain from third compartment of sink. -11:27 A.M., [NAME] B obtains robot coupe container that had not been ran through sanitizer, and only washed in soapy water, and used a paper towel to dry the robot coupe. -11:29 A.M., Dietary manager ran test strip in third compartment of sink showing 200 PPM. During an interview on [DATE] at 8:49 A.M., [NAME] A said: -The three compartment sink should be tested every morning before he/she did dishes for breakfast and before lunch; -Sanitizer was not coming out at the sink so when he/she tested the three compartment sink it was at 0 parts per million (PPM), showing he/she had no sanitizer in sink; -He/She had done dishes this morning in three compartment sink without having sanitizer in the sink; -The robot coupe was always washed in the sink. During an interview on [DATE] at 9:07 A.M., the Dietary manager said: -There had been issues with the sanitizer machine working at the three compartment sink; -Staff have had to call him/her to come and look at hose due to hose being finicky because of gravity and sanitizer not dispensing from unit on wall; -The three compartment sink should be set up with sanitizer set up in third compartment and tested prior to starting washing of dishes; -The three compartment sink should be tested and logged three times a day; -Robot coupe should be washed with normal dishes in three compartment sink; -Robot coupe should be sat in sanitizer. During an interview on [DATE] at 10:32 A.M., [NAME] B said: -Robot coupe is washed in soapy dish water after each item is prepared; -He/She did not wash robot coupe in dish washer, but he/she washed it, rinsed it, and stuck robot coupe into sanitizer water. During an interview on [DATE] at 10:56 A.M., Dietician said: -He/She expected staff to test sanitizer solution prior to starting to wash dishes to ensure accurate sanitation occurred. During an interview on [DATE] at 2:34 P.M., Administrator said: -He/She expected staff to test sanitizer solution in three compartment sink before they washed dishes. 8. Facility did not provide a dating and labeling of foods policy. Observation of the kitchen on [DATE] at 9:28 A.M. showed: -A snack cart had a bowl of crackers with a room temperature sandwich in a plastic bag that was dated [DATE] and a pitcher tea on snack cart had no ice in it and no label or date on pitcher. Observation on [DATE] at 9:28 A.M. showed: -Opened and undated vitamin d milk container; -Opened and undated chocolate milk; -Opened and undated apple juice; -Two containers of opened and undated quart sized half and half. During an interview on [DATE] at 8:49 A.M., [NAME] A said: -Food should be labeled and dated before it went into the refrigerator; -He/She did not know if opened milk should be dated when opened. During an interview on [DATE] at 9:07 A.M., the Dietary manager said: -Milk should be dated when opening; -Food should be dated as soon as it is opened or put in container. During an interview on [DATE] at 10:32 A.M., [NAME] B said: -Food should be dated and labeled when opened; -Food should be dated when placed in fridge; -All food items need to be labeled. During an interview on [DATE] at 2:34 P.M., Administrator said: -He/She expected food to be dated when it was delivered and when it was opened. 9. Review of facility policy, general dish room sanitation, dated [DATE], showed: -If a door separates the dish room from a heavily used common hallway or dining area, it should be closed during dish washing; -An associate working on the soiled end of the dish machine must wash their hands before working on the clean end of the dish machine. Review of facility policy, hand washing, dated [DATE], showed: -Wipe hands dry with clean paper towel. -Observation on [DATE] at 9:54 A.M. showed Dietary Aide C took clean dishes off dishwasher clean side without washing hands after loading dirty dishes into sanitizer. He/She went back and forth between dirty and clean sides of dishwasher without washing his/her hands. During an interview on [DATE] at 9:49 A.M., Dietary Aide C said: -They were out of paper towels for hand washing sink. Continuous observation in the kitchen on [DATE] from 11:11 A.M. - 1:12 P.M. showed: -11:31 A.M. [NAME] B had not washed hands since observation start time of 11:11 A.M. and has gone from touching microwave, getting items out of fridge, dish water, and steam table; 11:36 A.M., [NAME] B applied gloves to cut up meat patties; -11:45 A.M., [NAME] B had not washed hands, gone from washing robot coupe back to food preparation; -11:55 A.M., Dietary Aide A re-entered kitchen from dining room, did not wash hands; -12:09 P.M., [NAME] B moved glasses from top of head down to face, did not wash hands; -12:12 P.M., [NAME] B used bare hands and opened serving window, he/she did not wash hands; 12:35 P.M., Dietary Manager exited and then re-entered kitchen, did not wash hands, obtained clean cups off dish washer clean side and stacked them on clean cup stack in main dining room; -12:38 P.M., Dietary manager re-entered kitchen, did not wash hands, got item out of the refrigerator, and obtained container of broth. During an interview on [DATE] at 11:03 A.M., Dietary Aide A said: -He/She was trained on washing hands before pulling clean items and how to load items into the dishwasher. During an interview on [DATE] at 10:56 A.M., Dietician said: -He/She identified hand hygiene as a concern during his/her on-site visits; -He/She had not done any formal in-services or training with facility staff; -Facility had an influx of staff; -He/She had done some informal training with staff as he/she observed issues while not washing hands when changing from tasks. During an interview on [DATE] at 8:49 A.M., [NAME] A said: -Hand washing should be completed before he/she touched food, before and after touching food, when he/she left kitchen and re-entered kitchen, and if he/she left work station and went to new area of kitchen. During an interview on [DATE] at 9:07 A.M., the Dietary manager said: -He/She expected staff to wash their hands every time they touched food, removed gloves, after doing dishes and going from dirty side to clean side, whenever staff touched their face, nose, glasses, heads, and anything personally on them, after handling food, when going to a different food preparation station, and after remove their gloves; -There should be paper towels available for staff at the hand washing sink; -There was no paper towels in the dispenser on [DATE]. During an interview on [DATE] at 10:04 A.M., Dietary Aide A said: -He/She should wash hands after handling food, before he/she touched drinks, after touching residents, before going to clean side of dish washer to put away clean dishes, when going in and out of kitchen, after he/she used restroom, and when he/she returned to his/her work space. During an interview on [DATE] at 10:32 A.M., [NAME] B said: -He/She should wash hands when he/she went from one activity to another; -He/She did not wash hands while cooking food; -He/She would stick his/her hands in wash water and sanitizer; -He/She did not wash hands when he/she went to serve foo

Based on observation, interview, and record review the facility failed to respect resident rights of six residents out of the 15 sampled residents, when the facility failed to provide grooming for three residents ( #312, #36, #44) and failed to respect the privacy of three residents (#25, #40, #43). The facility census was 59. Facility did not provide a dignity policy. Review of facility policy, shaving the resident, undated, showed: To remove facial hair and improve the resident's appearance and morale. Review of facility policy, resident rights, undated, showed: -Residents will be provided the highest level of care and service; -Each resident shall be treated with consideration, respect a full recognition of his/her dignity, and individuality. -Right to dignified existence 1. Review of Resident #312's Admission face sheet showed: Resident was admitted on [DATE] -Bipolar disorder (mental health disorder that alternates between depression and mania); -Macular degeneration (progressive loss of vision); -Hypertension; -Irritable bowel syndrome with diarrhea; and -Urinary incontinence. Cognition intact, can make all needs known. During an interview on 6/9/24 at 2:53 P.M., the resident said: -That recently he/she had to wait longer than 30 minutes for assistance in the bathroom; -Resident said he/she had incontinent episode and asked for assistance from a staff member and was told somebody would get him/her help since resident was on a different hall than the staff member was assigned; -Resident stated he/she transferred self to the toilet and waited 30 minutes for someone to bring him/her an incontinent brief; -Resident stated he/she felt embarrassed about requiring help and that their care was unimportant to the staff; -Resident stated when help was provided, the staff member did not speak to him/her during cares. During an interview on 6/11/24 at 8:15 A.M.; Nursing Assistant (NA B) said: If a resident asked him/her for aid from another hall and he/she was short of staff he/she would help if possible, contact staff for help, explain any delays to the resident, and do everything he/she could do to help. During an interview on 6/11/24 at 8:25 A.M.; ADON said: If a resident asked her for aid from another hall and she was short of staff she would make sure her hall was safe and help the resident, otherwise she would page someone for help on the staff. During an interview on 6/12/24 at 2:34 P.M.; the Administrator said: She would not expect a staff member to say to a resident that they are not on their assigned hall and could not help them. During an interview on 6/12/24 at 2:34 P.M.; the DON said: She would not expect a resident to wait for 30 minutes for transfer help to the bathroom and hygiene aid. 47195 2. Review of Resident #36's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/24/24, showed: -He/She was severely cognitively impaired; -He/She had no physical, verbal, or other behavioral symptoms; -He/She did not exhibit wandering behavior; -He/She was dependent for personal hygiene; -He/She required partial to moderate assistance with bathing; -He/She had no documented preference for customary routines or activities; -Diagnoses included dementia (condition characterized by impairment of at least two brain functions such as memory loss and judgement), bipolar disorder (condition characterized with episodes of mood swings ranging from depressive lows to manic highs), insomnia (problems falling and staying asleep), Alzheimer's disease with late onset (type of dementia that affects memory, thinking, and behavior), psychotic disorder (a condition characterized by a disconnection from reality). Review of care plan, dated 5/28/24, showed: -Resident is limited in ability to dress/undress due to needing assist with activities of daily living (ADL's). Needs limited to partial assist with ADL's. Resident is expected to have decline in all ADL's as dementia progresses; -Do not rush resident. Allow extra time to complete the ADL's; -Allow resident to do as much of ADL's as possible; -Assist with personal cares when resident has been incontinent of bowel and bladder. Observation on 6/10/24 at 8:43 A.M. showed resident was observed facial hair on chin, quarter of inch in length. Review of shower logs from 4/16/24 to 6/11/24 showed: -Resident was provided shaving 4 out of 11 shower opportunities. -4/16/24 shaving was not offered; -4/23/24 shaving provided; -4/26/24 his/her chin was shaved; -4/30/24 his/her chin was shaved; -5/3/24 shaving was not offered; -5/10/24 shaving was not offered; -5/14/24 shaving was not offered; -5/17/24 shaving was not needed; -5/21/24 shaving was not offered; -5/24/24 shaving was not offered; -5/29/24 shaving provided. 3. Review of Resident #44's MDS, dated [DATE], showed: -He/She was severely cognitively impaired; -He/She was dependent on a walker; -He/She was independent with eating, oral hygiene, toileting, dressing, and mobility; -He/She required partial moderate assistance with bathing; -He/She had highly impaired vision; -No preferences for customary routines and activities documented; -He/She was independent with personal hygiene; -He/She had clear speech, was able to make self understood and understand others; -He/She required partial to moderate assistance with bathing; -Diagnoses included dementia, anxiety, osteoarthritis (a degenerative disease that worsens over time), osteoporosis (condition in which the bones become weak and brittle), macular degeneration (eye disease that causes vision loss), hearing loss, urinary tract infection Review of care plan, dated 6/4/24, showed: -He/She was at risk for deterioration in self care due to disease processes including osteoarthritis and dementia; -Do not rush resident. Allow extra time to complete ADL's. Encourage independence or set up and cueing to complete ADL's; -Resident had impaired vision related to macular degeneration. Observation on 6/09/24 at 10:15 A.M. showed resident had quarter inch facial hair on chin. During an interview on 6/9/24 at 10:15 A.M., resident said: -The facial hair bothered him/her; -He/She used to try to pull it themselves but now cannot see; -He/She would like his/her chin shaved by staff. Observation on 6/12/24 at 8:03 A.M. showed resident still had facial hair growth of quarter inch and had not been shaved. Review of shower log from 3/11/24 to 6/11/24 showed: -Shaving was offered 8 of 18 opportunities; -3/1/24 shaving provided; -3/5/24 shaving not offered; -3/23/24 shaving not offered; -3/26/24, shaving not offered; -3/29/24, shaving of chin was offered; -4/2/24, shaving not offered; -4/5/24, shaving not offered; -4/9/24, shaving offered but refused; -4/12/24, shaving offered; -4/16/24, no shaving offered; -4/26/24, chin was shaved; -4/30/24, chin was shaved; -5/3/24, no shaving offered; -5/10/24 no shaving offered; -5/14/24, no shaving offered; -5/17/24, no shaving offered; -5/21/24, chin was shaved; -5/29/24, chin was shaved. During an interview on 6/12/24, at 2:34 P.M., Assistant Director of Nursing said: -He/She expected residents to be shaved and maintained regularly; -Residents who were not alert and orientated he/she would expect resident to also be shaved and maintained. During an interview on 6/12/24 at 2:34 P.M., Director of Nursing said: -He/She expected all residents to be shaved and maintained. 31102 4. Review of Resident #25's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Independent with eating and transfers; - Diagnoses included diabetes mellitus and dementia; - Had seven insulin injections in the last seven days. Review of the resident's physician order sheet (POS) showed: - Start date: 12/3/19 - Accucheck (a glucose monitoring machine that tests the blood sugar level of residents which may determine a dose of insulin). Observation on 6/11/24 at 6:55 A.M., showed: - The Director of Nursing (DON) obtained the resident's blood sugar in the hallway. During an interview on 6/12/24 at 2:34 P.M., the Assistant Director of Nursing (ADON) said blood sugars should not be obtained in the hallways. 5. Review of Resident # 40's Significant change in status MDS, dated [DATE], showed: - Cognitive skills intact; - Required partial to moderate assistance with toilet use; - Always incontinent of bowel and bladder; - Diagnoses included cirrhosis ( a condition in which the liver is scarred and permanently damaged) and anxiety. Review of the resident's care plan, revised 4/23/24 showed: - The resident experiences bowel and bladder incontinence. Declines to use the bedpan, bathroom or commode. Requests brief changes as needed; - Encourage to use bedpan instead of being incontinent in brief; - Provide incontinence care after each incontinent episode. Encourage the resident to do as much hygiene care as possible. Observation on 6/10/24 at 8:38 A.M., showed: - A sign on the bathroom door in a clear plastic sleeve describing how peri care was to be completed for the resident and included the resident's name; - The sign was in plain view of any staff, visitor or family member who entered the resident's room. 6. Review of Resident #43's Quarterly MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Lower extremity impaired on one side; - Required substantial to maximal assistance with toilet use, dressing and transfers; - Had a Suprapubic catheter (a catheter which enters the bladder through the lower abdomen; - Diagnoses included pressure induced deep tissue damage of the left heel, obstructive uropathy ( a urinary tract disorder that occurs when urine flow is blocked causing urine to back up and potentially injure the kidneys) and urinary tract infection (UTI, presence of bacteria indicative of a possible UTI), Review of the resident's care plan, revised 5/1/24 showed: - The resident had a deep tissue pressure injury to the left heel; - Heel protectors when in bed and chair. Use offloading shoe with any weight bearing on left foot; - The resident had an indwelling supra pubic urinary catheter related to obstructive uropathy. Monitor placement of the catheter tubing. Avoid obstructions in the tubing. Observation on 6/9/24 at 10:52 A.M., showed: - A sign on bright yellow paper above the resident's recliner said, Heel protectors on at all times; - A sign on blue paper above that said, 2/14/24 until further notice please only use overnight bag - no more leg bag! Thanks! (leg bag- a small drainage bag attached tot he catheter and secured to either thigh to collect urine); - A sign on green paper above the resident's bed said, Top of head board must be level with green tape on wall when resident is in bed. During an interview on 6/12/24 at 8:46 A.M., Registered Nurse (RN) A said;- Should not have signs visible that discuss the resident's care. During an interview on 6/12/24 at 10:32 A.M., Certified Nurse Aide (CNA) B said: - The signs should be in a closet and not out in the open. During an interview on 6/12/24 at 2:34 P. M., the DON and the ADON said the signs in the resident's rooms should not be visible to other residents or family members; - The Administrator said Resident #40 has a sign but it is at his/her request and the resident will not allow it be placed anywhere else. 50980

Based on record review and interviews, the facility failed to properly assess and act in a timely manor, failing to notify the physician and the responsible party, Durable Power of Attorney (DPOA) when staff noted a change of condition for one resident (Resident #1) when the resident sustained a dislocated right shoulder. The resident's shoulder was not reduced (put back in place) due to the unknown amount of time the shoulder had been out of socket, possibly up to a week. Staff began to document a possible injury to the resident's right shoulder on 1/6/23; staff did not notify the physician until 1/10/23 when he ordered an X-ray The facility received the results received of the X-rays on 1/10/23. Staff did not send the resident to the emergency room until 1/11/23. The facility census was 52. The facility did not provide a policy regarding notifying a resident's physician with x-ray results. Review of the undated facility policy titled Condition Change, Resident (Observing, Recording and Reporting) (Includes Fall or Injury) showed the following: - Purpose: To observe, record and report any condition change to the attending physician so that proper treatment can be implemented; - Notify resident's responsible party; - Notify physician of condition change, need for treatment orders and/or medication order changes. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/17/22, showed the following: - Date admitted [DATE]; - Severe cognitive impairment; - Total dependence requirement for activities of daily living including bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene; - No impairment was indicated for the resident's upper extremities (shoulder, elbow, risk, hand); - Used a wheelchair; - Diagnoses included Alzheimer's disease, and aphasia (loss of ability to understand or express speech, caused by brain damage). Review of the resident's revised care plan, dated 1/12/23, showed the following: - The resident had a potential for pain due to a right shoulder dislocation that the physician said was not appropriate to relocate. Interventions included pain medications as ordered, always dress with right arm first, do not push or pull on the resident's right arm/shoulder to reposition, and report to charge nurse if any pain is indicated; - The resident was dependent on the staff to assist with activities of daily living due to advanced dementia, balance deficits, weakness and arthritis in his/her hands. Review of the resident's medical records showed the following: - Nurse's note dated 1/6/23 time stamped 6:13 A.M. by Licensed Practical Nurse (LPN) A: o The aide on the hall asked this writer to look at the resident's arm. Upon assessment the right shoulder appeared to be swollen and abnormal. Resident did not grimace or retract with range of motion (ROM) and touching the area. Charge nurse on the other hall assessed the resident as well and noted the swelling and abnormality. Passed onto nurse in shift change; - Nurse's note dated 1/6/23 time stamped 8:15 A.M. by the Director of Nursing (DON): o Certified nurse aide (CNA) requested this write come to the resident's room to assess right shoulder. Noted swelling to right shoulder with no evidence of guarding or grimacing with passive ROM, however it is noted by this writer that resident's right arm does move more freely than his/her norm. This resident tends to clench arms down tight to body when staff attempts to move them. Resident does offer some resistance to passive ROM but less than his/her norm. No bruising noted to shoulder or arm; - Nurse's note dated 1/7/23 time stamped 6:36 P.M. by LPN D: o Fading green bruise area noted to chest between breast. Right shoulder remains slightly swollen. Resident shows no sign of discomfort when right arm is touched or moved - Nurse note dated 1/8/23 time stamped 10:33 A.M. by DON: o CNA requesting this writer to assess the resident at this time. The resident noted to have golf ball sized, purple bruising to lateral right breast and approximately 3 inch () oblong purple bruising to medial left breast as well as a small dime-sized purple bruise to each shoulder blade. Upon inspection, bruising to the resident's breasts appears to be consistent with the resident clenching arms to chest as he/she often does. Small bruising to the resident's shoulder blade area is consistent with upright bars on the resident's high back wheelchair. The resident temporarily placed in different reclining wheelchair more appropriately fit to his/her, pending therapy evaluation for proper fit and setup. Right shoulder reassessed at this time, assessment unchanged from Friday (1/6/23). Swelling still noted, no bruising noted in shoulder or arm; - Nurse's note dated 1/9/23 time stamped 8:39 P.M. by Registered Nurse (RN) A: o The resident usually has stiff arms and staff cannot easily move them. The resident's right arm is limp and can be moved without resistance from the resident. There is more flexibility with his/her legs when doing peri care. It seems to be easier to do care. The resident does not have any face drooping at this time. Will continue to monitor; - Nurse's note dated 1/10/23 time stamped 12:37 A.M. by LPN E: o The resident has a large bruise on right elbow, fluid filled swelling of right elbow and inner aspect of upper right arm. Noted a 4 centimeter (cm) by 2 cm purple bruise on inner aspect of upper right arm. The resident does moan when right arm moved. Right arm elevated for the swelling. Resting quietly at this time. Will continue to monitor, call light in reach; - Nurse's note dated 1/10/23 time stamped 8:10 A.M. by the DON: o Staff requesting this writer to again assess the resident due to continued swelling to right shoulder as well as changes in condition to include grimacing and some guarding with passive ROM and bruising appearing under right upper arm. DPOA notified of change of condition. Physician contacted due to change of condition and request made for order for x-ray, self-report made to Missouri Department of Health and Senior Services, internal investigation initiated; - Nurse's note dated 1/10/23 time stamped 10:24 A.M. by RN A: o The resident usually has stiff arms and staff cannot easily move them. The resident's right arm is limp and can be moved without residence from the resident. He/she has several bruises to his/her arm. One on his/her elbow and under his/her arm. There is also more flexibility with his/her legs when doing peri care. It seems to be easier to do care. The resident does not have any face drooping at this time. The resident seems to be experiencing some discomfort with movement of his/her arm. Could we have an order to do an x-ray to check for possible injury?; - Nurse's note dated 1/10/23 time stamped 7:27 P.M. by RN A: o Results received. Impression: Anterior subcoracoid glenohumeral joint dislocation; - Nurse's note dated 1/11/23 time stamped 12:25 P.M. by DON: o Spoke to DPOA regarding results of x-ray, this writer advised him/her that the facility was currently investigating to see if the facility can pinpoint source and cause of injury as well as working with the primary care physician (PCP) to determine next steps; - Nurse's note dated 1/11/23 time stamped 3:51 P.M. by RN B: o PCP called and gave order for the resident to be sent to the emergency room for treatment of dislocated right shoulder. Transported to emergency room by facility van/staff; - Nurse's note dated 1/11/23 time stamped 9:17 P.M. by RN C: o The resident retuned from the emergency room via facility transport accompanied by facility staff. The resident seen by orthopedic physician at emergency room and decision was made to not manipulate the resident's dislocated right shoulder back into socket as there is no definite date of injury. The resident is also not a candidate for surgical repair of the dislocation. The resident was given a prescription of oxycodone (used to treat pain) 5 milligrams (mg) every six hours as needed for pain control. - X-ray results dated 1/10/23, electronically signed on 1/10/23 at 6:09 P.M. indicated shoulder dislocation; Review of the resident's hospital records dated 1/11/23, showed the following: - Date admitted [DATE] - Date discharged [DATE]; - Presented to the emergency department for an evaluation due to concern for a right shoulder dislocation; - Resident did display some grimacing response to pain with movement of the shoulder either elevation or internal or external rotation; - Given that there was no identified traumatic episode and an uncertain time that the shoulder has been out, perhaps nearly a week, the change of getting the shoulder back in position via closed reduction it it staying back in position is much less; - In a situation where a patient would be more active in terms of relying on the arms for daily activities and pushing up to transfer etc. it would warrant more risk to restore the resident's shoulder function, but in this resident's care, he/she did not use his/her shoulder at all even at baseline prior to this in terms of daily activities. We there for talked about the relative risk in terms of reasonably being able to give the resident pain relief or better function versus the risk of sedation. In normal circumstances, surgical treatment is possible to restore the stability of his/her shoulder as well but that is again much higher risk and in discussion with his/her family judged to be unwarranted risk for open surgical treatment. Therefore given the remaining options of observation with the shoulder as is versus attempt to close reduction, the resident's DPOA agrees that leaving the shoulder as is is his/her chosen option based on the risk of the resident going under anesthesia/sedation. We did discuss also that the longer the shoulder is out going forward, the less likely a closed reduction would be possible and the possible complications of axillary nerve injury which would further inhibit his/her function. During a phone interview on 2/7/23 at 3:52 P.M., CNA A said: - On 1/6/23 when he/she lifted the resident's arm to put on deodorant the resident usually really tensed up but the resident was not as tense. - He/she looked at the resident's arm and it had a divot in it in the shoulder area like it was dislocated or something. - He/she checked other shoulder to compare and it was not the same so he/she went to get the nurse. - The nurse he/she believed he/she notified was LPN A. - LPN B also looked at it. During a phone interview on 2/4/23 at 12:37 P.M., Licensed Pactical Nurse A said: - He/she worked the night shift on 1/5/23 to 1/6/23 and the nurse's note was typed after the fact; - Got off his/her shift at 6:00A.M. It was probably at 5:50 A.M. when CNA A came to him/her and said something did not look right about the resident's shoulder; - He/she went to see the resident and his/her shoulder was clearly swollen, and there was a bump; - The resident did not show any signs of pain with touching; - He/she lifted the resident's arm but did not do full range of motion because he/she knew something was not right; did not know what it was but the shoulder just did not look right, so he/she got another nurse LPN B; - LPN B confirmed there was a bump and abnormality; - The swelling was not around the arm but around the bump which it was right above where the clavicle meets the shoulder; - LPN B touched around the area and lifted the arm a little bit but he/she did not do full range of motion. LPN B said there is an abnormality but it was not broken; - Another nurse also assessed the resident but did not remember who that was; - Did not remember if he/she contacted the physician or the DON at that time; did notify the DON but did not remember when. During a phone interview on 2/3/23 at 12:55 P.M., LPN B said : - He/she had just come to work on the morning on 1/6/23 when LPN A asked him/her to look at the resident's shoulder; - He/she looked at the resident's shoulder and checked it for pain with movement which there was not any. There was some swelling around the right shoulder; - Reported it to the day shift charge nurse and notified the DON of the swelling; - They talkeda bout the resident's shoulder about in morning meeting and it was discussed that they would continue to monitor it. - Facility staff notified the physician but he/she was unsure who or when. During a phone interview on 2/7/23 at 2:01 P.M., LPN C said: - LPN A told him/her in report about the resident having swelling in his/her shoulder; - CNA A also reported it to him/her; - He/she looked at the resident's shoulder and by the resident's deltoid looked to be shorter, but when he/she looked at the other shoulder to compare, he/she knew it was off. Then the DON came down and looked at it; - The shoulder looked like it may have been swollen, but not pitting edema. During a phone interview on 2/2/23 at 11:00 A.M., RN A said: - He/she worked as the charge nurse when the x-ray results were received even though his/her shift would have been done by 6:00 or 6:30 P.M. but he/she would have been charting; - He/she did not remember what time the x-ray results were received; - Did not remember if he/she notified the resident's DPOA when the results were received; - The reason why the resident was not sent to the emergency roiagnom on [DATE] when the x-ray results were received was because the family did not want the resident being sent to the emergency room , the family wanted comfort only, that has been the standing policy for the resident; - He/she would have called the oncall physician or the DON and was not ordered to send out at that time but he/she did not recall who he/she spoke with; it was standard procedure to notify the oncall physician or DON; - He/she acknowledged he/she did not document contacting a physician or the DON. During a phone interview on 2/2/23 at 11:36 P.M., RN B said: - He/she did not remember if he/she she was working or if he/she was the one who faxed the resident's physician; - Was not sure if he/she was there when the x-ray was completed; - He/she only worked that hall once every two weeks and only worked at the facility two days a week; - He/she remembered hearing the nurses talk about the resident being more limber because he/she is usually pretty stiff; - The facility sent the x-ray results to the physician who ordered them to send the resident to the emergency so it could be evaluated by an orthopedic surgeon; - In a situation like this, he/she would fax report to the physician's office with a question of what they would like to do. If they call, the physician would probably ask for the report; - It probably should be reported to the on-call physician when they received the results if after hours; - He/she heard other nurses talk about how loose the resident was, not just the shoulder but his/her entire body. During a phone interview on 2/3/23 at 2:51 P.M. the resident's DPOA said: - The facility notified him/her of the positive x-ray results on the 1/11/23 around 11:00 A.M.; - He/she spoke to the orthopedic surgeon and the emergency room physician and was told due the shoulder being out so long, surgery would not work because it would come back out. He/she asked if they did not reduce the shoulder if there would be any health issues related to this and he/she was told there may be pain due to a nerve on the shoulder and they would give the resident pain medication. The resident's hand did swell which the physician thought it was due to arthritis and the shoulder dislocation; - He/she was not notified on 1/6/23; an x-ray should have been completed on 1/6/23; - He/she was notified on 1/8/23 regarding the bruising on the resident's back and chest area which he/she was told was due to his/her wheelchair and due to clenching his/her arms; - They should have notified him as soon as they knew about the dislocation, they usually call him/her about everything if something happens; - Sunday they noted bruises to his/her breast and back and no one notified him/her, they claimed due to his/her wheelchair, and breast due to clenching; - The resident was on comfort care only but he/she would still expect to be notified of change of condition. During a phone interview on 2/2/23 at 1:15 P.M. PCP Nurse A said he/she: - Facilty staff first notified the physician on 1/10/23 by phone; staff said the resident had tenderness with range of motion, and bruising of his/her right arm. The physician ordered an x-ray at that time; - The x-ray was completed on 1/10/23 and was electronically signed by radiologist on at 6:09 P.M. - Thought the resident was seen by another physician (Medical Director) who was in the facility on the 1/11/23 before they received the results of the x-ray; - Was not sure if they even got x-ray results before the resident being sent out; - Thought the Medical Director had seen him/her that morning; - If the facility had thoughts of injury then the physician would want to be notified right away; - Being more flexible than normal should trigger that something was not right; - The orthopedic surgeon evaluated the resident and discussed the injury with the DPOA. Due to the resident's age, risk factors and anesthesia as well as due to not knowing how long the shoulder had been out, it was decided to not reduce the shoulder. During a phone interview on 2/7/23 at 2:11 P.M., PCP Nurse B said: - The facility did not call the PCP; the facility received the results after 6:00 P.M. on 1/10/23; and the physician expected staff to contact the oncall physician expectation at that time due to it being after hours; - The Medical Director was at the facility doing rounds on 1/11/23 and she saw the resident and reviewed the x-ray results. The Medical Director's nurse then contacted PCP Nurse B who notified the PCP; the PCP then called the facility to see what was going on; - The PCP received the resident's x-ray results from the Medical Director's nurse on 1/11/23 at approximately 1:50 P.M. - The facility last contacted the PCP's office on 1/10/23 when they called for the x-ray order. The facility faxed the results to them on 1/12/23, after they had already received it from the Medical Director's nurse. During a phone interview on 2/3/23 at 1:14 P.M., the Adminsitrator said: - On 1/6/23 during morning meeting, staff brought up that the resident had swelling of his/her shoulder; - She asked if the resident needed an x-ray and the DON said no because she thought it was arthritic; - On Sunday, 1/8/23, an aide came and got the DON again and told her about the bruising in that area and that is when she (the Administrator) was notified. The DON completed an investigation and thought the bruising was due to the a crossbar on his/her wheelchair and due to the resident's arms being clenched. Therapy found the crossbar on the wheelchair was not installed; - On 1/9/23, the resident got a new reclining wheelchair; - Staff reported the resident's first sign of pain during the morning meeting on 1/10/23; - She expected staff to contact the physician on Tuesday, 1/10/23, for the x-ray based on the information she was given at that time; - She did not know anything about LPN C noting an abnormality in the resident's shoulder; - She knew the DON assessed the resident's shoulder and she was going based on her assessment; - The physician should be notified as soon a possible following received positive x-ray results; - The Medical Director was in house on 1/11/23 for Quality Assurance and Performance Improvement meeting. The Medical Director saw the x-ray results and said the resident needed to be sent to the emergency room even though she was not the PCP; - She was not sure how the PCP was notified. During a phone interview on 2/3/23 at 1:30 P.M., the DON said: - She saw the nurse's notes noting an abnormality in the resident's shoulder; - When she came in at 8:00 A.M. on 1/6/23, she thought CNA A asked her to come look at it because they said it looked different so she assessed it. The only thing she could see that was different was swelling in the joint area of the resident's shoulder which she thought it was arthritic; - What they described to her as abnormality was the swelling in that joint area; - After her assessment, she talked to LPN B about it; - When asked if noting the resident was more flexible than his/her norm was identifying a change of condition, she said the resident's rigidity was not always 100 percent of the time so it was not considered a change of condition at that time; - The physician should be notified as soon as possible when an x-ray results are received with positive results. Some physicians are ok with staff talking to an oncall physician or a colleague and some other physicians do not want them talking to anyone else. Resident #1's primary physician did not want anyone else to make medical decisions for the resident; - When asked how staff are supposed to contact the resident's physician during after hours she said they have tried to contact the hospital, but at one time the hospital asked them for the physician's number; - The x-ray results were sent on Tuesday night to the physician and a phone call placed at Wednesday morning to physician; - A nurse for the Medical Director had contacted the resident's physician's nurse about the X-ray result, the physician's nurse told the physician about the results then the physician called the facility to send him/her out. - This was a different scenario because the resident's DPOA wanted comfort measures only; - Knew there was discomfort caused by a dislocated shoulder but there have been conversations about not doing more than they have to per the DPOA; - Did not know if the DPOA was notified of positive x-ray; - Understood the timeframe concerns but if she could go back to 1/6/23, and look at the shoulder again, not knowing what she knew now she did not know that she would have done anything different; - From the assessment she did on 1/6/23, there was nothing that indicated an injury and no signs of pain of moving the resident's arm. 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