Every finding on record at Seneca Nursing

Based on interview and record review, the facility failed to report all allegations of abuse immediately to facility management and to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe when staff did not report multiple allegations of abuse involving four residents (Resident #1, #2, #3, and #4). The facility census was 53.Review of the facility policy Abuse, Prevention and Prohibition Policy, dated 2021, showed the following:-Each resident has the right to be free from abuse, corporal, punishment, and involuntary seclusion;-Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals;-Resident abuse must be reported immediately to the Administrator;-The facility Administrator, employee, or agent who is made aware of any allegation of abuse or neglect shall report or cause a report to be made to the mandated state agency per reporting criteria;-The allegation will be reported no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury.1. Review of Resident #1 face sheet (brief information sheet about the resident) showed the following: -admission date of 02/06/26;-Diagnoses included intellectual disabilities (neurodevelopmental condition characterized by significant limitations in both intellectual functioning (learning, reasoning, problem-solving and adaptive behavior (everyday social/practical life skills)), deaf and non-speaking, hemiplegia (weakness of one side) affecting the nondominant left side.Review of the resident's nursing progress notes dated 04/14/26, at 9:35 A.M., showed Resident #1 found in back sitting area taking off his/her clothes. He/she had shirt off with other residents present and was removing his/her skirt when staff intervened to redress him/her. Nursing and management notified. (Staff did not document reporting an allegation of abuse to DHSS.)Review of DHSS records showed the facility did not self-report the allegation abuse on 04/14/26.Review of the resident's nursing progress notes dated 04/20/26, at 12:24 A.M., showed Resident #1 had to be redirected daily for inappropriate touching of his/her body and not respecting boundaries. (Staff did not document reporting an allegation of abuse to management or DHSS.)Review of DHSS records showed the facility did not self-report the allegation abuse on 04/20/26.Review of the resident's nursing progress notes dated 04/21/26, at 1:00 P.M., showed Resident #1 found in back sitting area laying against male resident. Staff redirected Resident #1 took him/her to the front nursing area. He/she was not redirectable and continued to return to back and try to lay on couch with males present. Nursing notified. (Staff did not document reporting an allegation of abuse to management or DHSS.)Review of DHSS records showed the facility did not self-report the allegation abuse on 04/21/26.Review of the resident's nursing progress notes on 04/22/26, at 9:33 A.M., showed staff heard a resident yelling in a room NO, NO. Staff went to the room and Resident #1 was in another resident's room going through the resident's stuff and then trying to get into the resident's bed. Resident #1 was taken to nurses' station and staff notified. (Staff did not document reporting an allegation of abuse to management or DHSS.)Review of DHSS records showed the facility did not self-report the allegation abuse on 04/22/26.2. Review of Resident #2 face sheet showed the following: -admission date of 01/29/26;-Diagnoses included chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning ) with anxiety, and mild cognitive impairment.Review of the resident's nursing progress notes dated 03/14/26, at 6:06 P.M., showed the following:-Staff redirected Resident #2 after he/she was observed fondling Resident #1's breasts. Support staff removed Resident #1 from the area; -Staff did not document family, physician, DON, or Administrator notification;-Staff did not document DHSS notification. Review of DHSS records showed the facility did not self-report the allegations of abuse on 03/14/26.3. Review of Resident #3's face sheet showed the following: -admission date of 04/09/26;-Diagnoses included: Acute osteomyelitis (localized inflammation of the bone due to an infection) left ankle and foot, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breath). Review of the resident's electronic chart census showed the following:-On 04/09/26, admitted to same room as Resident #1;-On 04/14/26, moved room to a different semi-private room.During an interview on 04/30/26, at 11:30 A.M., Resident #3 said the following:-When he/she admitted to the facility, he/she was roommates with Resident #1;-On his/her second night in the facility, he/she woke up to Resident #1 naked laying on top of him/her and touching his/her upper chest area and pulling at his/her central line (long, flexible tube inserted into a large vein in the neck, chest, or groin and threaded near the heart to deliver medications, fluids, or nutrition over an extended period). He/She told the resident to move away; -This upset him/her as he/she was startled from sleep;-He/she reported to the staff on duty and requested to be moved to a different room;-He/She witnessed Resident #1 and Resident #2 kissing in the dining room and staff redirected the residents.Review of the resident's progress notes showed no documentation regarding the allegation of inappropriate and unwanted touching or to the room change request.Review of DHSS records showed the facility did not self-report the allegations of abuse on 04/13/26.4. Review of Resident #4's face sheet showed the following:-admission date of 03/14/23;-Diagnoses included hemiplegia (complete paralysis) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, presence of cardiac pacemaker, and dysarthria (motor speech disorder caused by nervous system damage that weakens or impairs control of muscles used for breathing, speaking, and swallowing) following cerebral infarction.During an interview on 04/30/26, at 12:40 P.M., Resident #4 said the following:-Approximately two weeks ago, Resident #1 tried to bite him/her around where he/she has a pacemaker. Resident #1 also tried to touch his/her left chest;-Resident #1 made him/her mad and uncomfortable, and he/she is not happy;-He/she told the Resident #1 to move away and told an aide about the incident.Review of the resident's progress notes showed staff did not document related to the resident being bitten or touched inappropriately.Review of DHSS records showed the facility did not self-report an allegation of abuse related to a resident being bitten or touched inappropriately.5. During an interview on 04/30/26, at 1:50 P.M., Nurse Aide (NA) C said the following: -He/She considers abuse to be a resident hitting, yelling, or unwanted touching of another resident;-If he/she observed abuse, he/she would immediately redirect residents, ensure safety, and then contact the charge nurse.During an interview on 04/30/26, at 2:00 P.M., Certified Medication Tech (CMT) B said the following:- Abuse can include verbal tone, physical abuse or sexual abuse, including innuendos or grabbing someone's buttocks or private areas;-He/She would notify the DON and Administrator immediately if he/she witnessed abuse or if he/she was told of an abuse allegation.-He/she observed other residents push Resident #1 away;-All behaviors should be charted. During an interview on 04/30/26, at 2:15 P.M., Registered Nurse (RN) D said the following:-Abuse included residents slapping other residents or other physical or sexual touching;-The incident of Resident #1 sitting on Resident #5's lap was reported;-He/She was unaware of any other incidents;-Abuse allegations should be reported to DHSS within two hours.During an interview on 04/30/26, at 2:30 P.M., Licensed Practical Nurse (LPN) A said the following:-He/She received abuse training. Abuse includes unwanted touching from other residents-Staff should report abuse immediately and the facility should notify DHSS within two hours.During an interview on 05/01/26, at 10:30 A.M., Certified Nurse Aide (CAN) E said the following:- Abuse includes residents touching others without consent; -Staff should report abuse allegations to the charge nurse, DON, and Administrator and State should be notified within 2 hours.During an interview on 05/01/26, at 10:45 A.M., Laundry F said the following:-He/She has not received abuse training;-He/she would notify DHSS if he/she was aware of abuse. He/she would also report to the Administrator.During an interview on 05/01/26, at 11:40 A.M., CMT G said the following:-Abuse included residents touching others inappropriately;-If he/she observed inappropriate touching, he/she would separate the residents and notify the nurse, administrator and DON.During an interview on 05/01/26, at 11:55 A.M., DON said the following:-Resident to resident abuse includes unwanted touching and sexual abuse;-Four residents have approached her and reported that Resident #2 was kissing Resident #1 and touching Resident #1's breast;-He/she discussed this with the Administrator and the Administrator felt the residents were exaggerating and not telling the truth;-Staff should document all behaviors during their shift and behaviors should be reported.During an interview on 05/01/26, at 12:30 P.M., Administrator said the following:-No residents have voiced concerns of being inappropriately touched other than the self-report related to Resident #1 and Resident #5;-She expected staff to intervene and report any abuse allegations; -Abuse allegations should be reported to DHSS within two hours.

Based on record review and interview, the facility failed to have services in place to ensure the accurate document of administration of controlled pain medications for three resident's (Resident #2, Resident #3, and Resident #4). The facility census was 45.Review of the facility's policy titled Medication Storage in the Facility, dated 06/01/18, showed the following:-Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations;-The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met;-Current controlled substance accountability records are kept in the Medication Administration Record (MAR), or designated book.1. Review of Resident #2's face sheet (admission data) showed the following:-admission date of 11/16/21;-Diagnoses included low back pain, muscle weakness, and cognitive communication deficit.Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated comprehensive assessment tool completed by facility staff), dated 12/29/25, showed the following:-Cognitive skills intact;-Received scheduled and as needed (PRN) pain medications.Review of the resident's care plan, revised on 02/16/26, showed the following:-The resident complained of chronic back and leg pain related to diabetic neuropathy (nerve damage caused by long-term high blood sugar), cervical disc degeneration, gout (a form of arthritis that causes pain and swelling in joints), and restless legs syndrome;-The resident required pain management.Review of the resident's current Physician Order Sheet (POS) showed the following:-An order, dated of 12/15/25, for hydrocodone-acetaminophen (APAP) (prescription medication containing an opioid and a non-opioid used to treat moderate to severe pain) oral tablet 7.5-325 milligrams (mg), staff to give one tablet by mouth every four hours as needed (PRN) for pain related to restless legs syndrome and low back pain;-An order, dated of 12/15/25, for hydrocodone-acetaminophen oral tablet 7.5-325 mg, for staff to give one tablet by mouth three times a day for pain related to restless legs syndrome and low back pain.Review of the resident's Controlled Substance Record (the form used to account for each dose of a controlled substance), dated 12/29/25, showed on 01/08/26, staff documented administration of one tablet of hydrocodone/apap at 5:24 A.M.Review of the resident's January 2026 MAR showed on 01/08/26, staff did not document administration of the resident's hydrocodone/apap. Review of the resident's January 2026 MAR showed on 01/09/26, staff documented administration of the resident's hydrocodone/apap. Review of the resident's Controlled Substance Record, dated 12/29/25, showed on 01/09/26, staff did not document administration of the resident's hydrocodone/apap at 6:00 A.M. Review of the resident's Controlled Substance Record, dated 12/29/25, showed on 01/12/26 at 11:59 P.M., staff documented administration of the hydrocodone/apap.Review of the resident's January 2026 MAR showed on 01/12/26, staff did not document administration of the resident's hydrocodone/apap at 11:59 P.M.Review of the resident's Controlled Substance Record, dated 12/29/25, showed on 01/13/26 at 9:00 A.M., staff documented administration of the resident's hydrocodone/apap PRN, with a note of the resident out of the building.Review of the resident's January 2026 MAR showed on 01/13/26, staff did not document administration of the resident's PRN hydrocodone/apap.Review of the resident's Controlled Substance Record, dated 12/29/25, showed on 01/20/26, at 8:50 A.M., staff documented administration of the resident's hydrocodone/apap with a note of the resident out of the building.Review of the resident's January 2026 MAR showed on 01/20/26, staff did not document administration of the resident's hydrocodone/apap PRN.Review of the resident's January 2026 MAR showed on 1/30/26, staff documented administration of the hydrocodone/apap at 6:00 A.M. Review of the resident's Controlled Substance Record, dated 01/10/26, showed on 01/30/26, staff did not document administration of the resident's hydrocodone/apap at 6:00 A.M.Review of the resident's Controlled Substance Record, dated 01/10/26, showed on 02/04/26, at 10:20 P.M., showed staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/04/26, staff did not document administration of the resident's hydrocodone/apap at 10:20 P.M. Review of the resident's Controlled Substance Record dated 01/10/26 showed on 02/12/26, no time, showed staff administration of the resident's hydrocodone/apap with a note of the resident out of the building. Review of the resident's February 2026 MAR showed on 02/13/26, at 6:00 A.M., staff documented administration of the resident's hydrocodone/apap.Review of the resident's Controlled Substance Record, dated 01/10/26, showed on 02/13/26, at 6:00 A.M., staff did not document administration of the resident's hydrocodone/apap.Review of the resident's Controlled Substance Record, dated 2/16/26, showed on 02/27/26, at 9:59 P.M., staff documented administration of the resident's hydrocodone/apap. Review of the resident's February 2026 MAR showed on 02/27/26, staff did not document administration of the resident's hydrocodone/apap at 9:59 P.M.Review of the resident's Controlled Substance Record, dated 02/24/26, showed on 02/28/26, at time not readable, staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/28/26, staff did not document administration of the resident's hydrocodone/apap. 2. Review of Resident #3's face sheet showed the following:-admission date of 06/04/25;-Diagnoses included major depressive disorder, difficulty in walking, and muscle weakness.Review of the resident's care plan, dated 06/25/25, showed the following:-The resident had pain;-Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of the resident's quarterly MDS assessment, dated 02/25/26, showed the following:-Moderately impaired cognitive skills;-The resident received PRN pain medications. Review of the resident's POS, dated 01/01/26, showed an order, start date of 12/12/25, for oxycodone (opioid medication used to manage pain), 5 mg, for staff to give one capsule by mouth every four hours as needed for moderate to severe pain.Review of the resident's Controlled Substance Record, dated 12/06/25, showed on 01/19/26, at 7:45 P.M., showed staff administered the resident's oxycodone.Review of the resident's January 2026 MAR showed on 01/19/26, staff did not document administration of the resident's oxycodone at 7:45 P.M.Review of the resident's Controlled Substance Record, dated 12/06/25, showed on 02/03/26, at 5:00 P.M., staff documented administration of the resident's oxycodone.Review of the resident's February 2026 MAR on 02/03/26, showed staff did not document administration of the resident's oxycodone at 5:00 P.M.Review of the resident's Controlled Substance Record dated 12/15/25, showed on 02/05/26, at 11:00 P.M., staff documented administration of the resident's oxycodone.Review of the resident's February 2026 MAR showed on 02/05/26, showed staff did not document administration of the resident's oxycodone at 11:00 P.M.Review of the resident's Controlled Substance Record, dated 12/15/25, showed on 02/11/26, at 9:35 P.M., staff documented administration of the resident's oxycodone. Review of the resident's February 2026 MAR showed on 2/11/26. staff did not document administration of the resident's oxycodone at 9:35 P.M.Review of the resident's Controlled Substance Record dated 12/15/25, showed on 02/15/26 at 8:00 P.M., staff documented administration of the resident's oxycodone.Review of the resident's February 2026 MAR showed on 2/15/26, staff did not document administration of the resident's oxycodone at 8:00 P.M.Review of the resident's Controlled Substance Record dated 12/15/25 showed on 02/16/26, at 11:45 P.M., staff documented administration of the resident's oxycodone.Review of the resident's February 2026 MAR showed on 02/16/26, staff did not document administration of the resident's oxycodone at 11:45 P.M.Review of the resident's Controlled Substance Record dated 12/15/25 showed on 02/17/26, at 7:45 P.M., staff documented administration of the resident's oxycodone.Review of the resident's February 2026 MAR showed on 02/17/26, staff did not document administration of the resident's oxycodone at 7:45 P.M.Review of the resident's Controlled Substance Record dated 12/15/25, showed on 02/18/26, at 8:40 P.M., staff documented administration of the resident's oxycodone.Review of the resident's February 2026 MAR showed on 02/18/26, staff did not document administration of the resident's oxycodone at 8:40 P.M.Review of the resident's Controlled Substance Record dated 12/15/25 showed on 02/23/26, at 7:20 P.M., staff documented administration of the resident's oxycodone.Review of the resident's February 2026 MAR showed on 02/23/26, staff did not document administration of the resident's oxycodone at 7:20 P.M.Review of the resident's Controlled Substance Record dated 12/15/25, showed on 02/24/26, at 7:20 P.M., staff documented administration of the resident's oxycodone.Review of the resident's February 2026 MAR showed on 02/24/26, staff did not document administration of the resident's oxycodone at 7:20 P.M.Review of the resident's Controlled Substance Record dated 12/15/25, showed on 02/26/26, at 8:30 P.M., staff documented administration of the resident's oxycodone. Review of the resident's February 2026 MAR showed on 02/26/26, staff did not document administration of the resident's oxycodone at 8:30 P.M.Review of the resident's Controlled Substance Record, dated 12/15/25, showed on 03/02/26, at 7:10 P.M. staff documented administration of the resident's oxycodone.Review of the resident's March 2026 MAR showed on 03/02/26, staff did not document administration of the resident's oxycodone at 7:10 P.M.Review of the resident's Controlled Substance Record, dated 12/15/25, showed on 03/03/26, at approximately 7:00 P.M. (minutes unreadable), staff documented administration of the resident's oxycodone.Review of the resident's March 2026 MAR showed on 03/03/26, staff did not document administration of the resident's oxycodone.Review of the resident's Controlled Substance Record, dated 12/15/25, showed on 03/04/26, at 2:00 A.M., staff documented administration of the resident's oxycodone.Review of the resident's March 2026 MAR showed on 03/04/26, staff did not document administration of the resident's oxycodone at 2:00 A.M. 3. Review of Resident #4's face sheet showed the following:-admission date on 01/08/25;-Diagnoses included cognitive communication deficit, muscle weakness, and chronic kidney disease. Review of the resident's significant change in status MDS assessment, dated 03/02/26, showed the following:-Severely impaired cognitive skills;-Received as needed pain medications.Review of the resident's care plan, revised 03/08/26, showed the following:-The resident required routine pain management for complaints of lower back pain;-Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of the resident's current POS showed an order, dated 12/18/25, for hydrocodone acetaminophen 5-325 mg, for staff to give one tablet by mouth every four hours as needed for pain control. Review of the resident's Controlled Substance Record, dated 09/09/25, showed on 02/02/26, at 11:30 P.M., staff documented administration of the resident's hydrocodone/apap. Review of the resident's February MAR showed on 02/02/26, showed staff did not document administration of the resident's hydrocodone/apap.Review of the resident's Controlled Substance Record, dated 09/09/25, showed on 02/05/26 at 11:40 P.M., staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/05/26, staff did not document administration of the resident's hydrocodone/apap for 11:40 P.M.Review of the resident's Controlled Substance Record, dated 09/09/25, showed on 02/06/26, at 11:30 P.M., staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/06/26 staff did not document administration of the resident's hydrocodone/apap for 11:30 P.M. Review of the resident's Controlled Substance Record, dated 09/09/25, showed on 02/07/26, at 3:30 P.M., staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/07/26, staff did not document administration of the resident's hydrocodone/apap for 3:30 P.M.Review of the resident's Controlled Substance Record, dated 09/09/25, showed on 02/09/26, at 8:18 P.M., staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/09/26, staff did not document administration of the resident's hydrocodone/apap for 8:18 P.M.Review of the resident's Controlled Substance Record, dated 09/09/25, showed on 2/14/26, at 8:25 P.M., staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/14/26, staff did not document administration of the resident's hydrocodone/apap for 8:25 P.M.Review of the resident's Controlled Substance Record, dated 09/09/25, showed on 2/15/26, at 8:10 P.M., staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/15/26, staff did not document administration of the resident's hydrocodone/apap for 8:10 P.M.Review of the resident's Controlled Substance Record, dated 09/09/25, showed on 02/16/26, at 8:20 P.M., staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/16/26, staff did not document administration of the resident's hydrocodone/apap for 8:20 P.M.Review of the resident's Controlled Substance Record, dated 09/09/25, showed on 02/17/26, at 8:00 P.M., staff documented administration of the resident's hydrocodone/apap.Review of the resident's February 2026 MAR showed on 02/17/26, staff did not document administration of the resident's hydrocodone/apap for 8:00 P.M.Review of the resident's Controlled Substance Record, dated 9/09/25, showed on 02/18/26, at 6:55 P.M., staff documented administration of the resident's hydrocodone/apap. Review of the resident's February 2026 MAR showed on 02/18/26, staff did not document administration of the resident's hydrocodone/apap for 6:55 P.M. Review of the resident's current POS showed an order, dated 02/25/26, for hydrocodone/apap 5-325 mg, for staff to give one tablet by mouth every four hours as needed for pain control. Review of the resident's Controlled Substance Record, dated 02/18/26 showed on 03/02/26, at 7:30 P.M., staff documented administration of the resident's hydrocodone/apap. Review of the resident's March 2026 MAR showed on 03/02/26, staff did not document administration of the resident's hydrocodone/apap at 7:30 P.M. 4. During an interview on 030/4/26, at 11:44 A.M., Certified Medication Technician (CMT) D said staff should sign administration of pain medications on the MAR and on the controlled drug form.During an interview on 03/05/26, at approximately 11:30 A.M., CMT E said the following:-Staff administer pain medications to residents as scheduled or upon resident request;-Staff should check the order, document on the MAR and in the narcotic book;-The resident's MAR and controlled drug form should match with documentation.During an interview on 03/05/26, at 1:19 P.M., Registered Nurse (RN) A said the following:-The nurses or CMT's pass narcotics;-Staff administer pain medications if a resident requests. Nurses assess the resident for pain;-Staff should document pain medications administered on the MAR and controlled drug form;-The residents' MAR and controlled drug forms should match with staff signatures/initials.During an interview on 03/05/26, at 1:55 P.M., RN F said staff should document administered pain medications on the MAR and narcotic sheets. During interviews on 03/06/26, at 4:01 P.M., and on 03/07/26, at 10:06 A.M., the administrator said the following:-She expected staff to document on the MAR as a medication given and document the pain medication on the narcotic sheet;-If staff did not sign out on the MAR, it is easy to forget. She felt it was a documentation issue. #2734672 and #2792822

Based on interview and record review, the facility failed to complete timely and thorough investigations of all allegations of abuse when staff failed to document investigation into allegations of abuse involving four residents (Resident #1, #2, #3, and #4). The facility also failed to document steps taken to protect all residents during the investigation. The facility census was 53.Review of the facility policy Abuse, Prevention and Prohibition Policy. dated 2021, showed the following:-Each resident has the right to be free from abuse, corporal, punishment, and involuntary seclusion;-Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals;-The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action;-While a facility investigation is under way, steps will be taken to prevent further abuse.1. Review of Resident #1 face sheet (brief information sheet about the resident) showed the following: -admitted [DATE];-Diagnoses included: Intellectual disabilities (neurodevelopmental condition characterized by significant limitations in both intellectual functioning (learning, reasoning, problem-solving and adaptive behavior (everyday social/practical life skills)), deaf and non-speaking, and hemiplegia (weakness of one side) affecting left nondominant side.Review of the resident's nursing progress notes showed the following:-On 04/14/26, at 9:35 A.M., Resident #1 found in back sitting area taking off his/her clothes. He/she had shirt off with other residents present and was removing his/her skirt when staff intervened to redress him/her. Nursing and management notified;-On 04/20/24, at 12:24 A.M., Resident #1 had to be redirected daily for inappropriate touching of her body and not respecting boundaries;-On 04/21/26, at 1:00 P.M., Resident #1 found in back sitting area laying against male resident. Staff redirected Resident #1 took him/her to the front nursing area. He/she was not redirectable and continued to return to back and try to lay on couch with males present. Nursing notified;-On 04/22/26, at 9:33 A.M., staff heard a resident yelling in a room NO, NO. Staff went to the room and Resident #1 was in another resident's room going through the resident's stuff and then trying to get into the resident's bed. Resident #1 was taken to nurses' station and staff notified;-On 04/28/26, at 1:47 P.M., Resident #1 was in back common area with peers, and it was reported to staff that Resident #1 sat on male peer's lap, no intimate contact was made.Review of facility documents showed staff did not document a timely investigation and thorough investigation, or steps taken to protect others during an investigation for the incidents documented on 04/14/26, 04/20/24, 04/21/26, and 04/22/26.2. Review of Resident #2 face sheet showed the following: -admitted [DATE];-Diagnoses included chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning ) with anxiety, and mild cognitive impairment.Review of the resident's nursing progress note dated 03/14/26, at 6:06 P.M., showed the following:-Staff redirected Resident #2 after he/she was observed fondling Resident #1's breasts. Support staff removed Resident #1 from the area. Review of facility documents showed staff did not document of a timely investigation or steps taken to protect others during an investigation regarding the 03/14/26 behaviors.3. Review of Resident #3's face sheet showed the following: -admitted [DATE];-Diagnoses included acute osteomyelitis (localized inflammation of the bone due to an infection) left ankle and foot, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breath). Review of the resident's electronic chart census showed the following:-On 04/09/26, admitted to same room as Resident #1;-On 04/14/26, moved room to a different semi-private room.During an interview on 04/30/26, at 11:30 A.M., Resident #3 said the following:-When he/she admitted to the facility, he/she was roommates with Resident #1;-On his/her second night in the facility, he/she woke up to Resident #1 naked laying on top of him/her and touching his/her upper chest area and pulling at his/her central line (long, flexible tube inserted into a large vein in the neck, chest, or groin and threaded near the heart to deliver medications, fluids, or nutrition over an extended period). He/She told the resident to move away; -This upset him/her as he/she was startled from sleep;-He/she reported to the staff on duty and requested to be moved to a different room;-He/She witnessed Resident #1 and Resident #2 kissing in the dining room and staff redirected the residents.Review of facility documents showed no documentation of a timely investigation or steps taken to protect others during an investigation.4. Review of Resident #4's face sheet showed the following:-admitted [DATE];-Diagnoses include: hemiplegia (complete paralysis) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, presence of cardiac pacemaker, and dysarthria (motor speech disorder caused by nervous system damage that weakens or impairs control of muscles used for breathing, speaking, and swallowing) following cerebral infarction.During an interview on 04/30/26, at 12:40 P.M., Resident #4 said the following:-Approximately two weeks ago, Resident #1 tried to bite him/her around where he/she has a pacemaker. Resident #1 also tried to touch his/her left chest;-Resident #1 made him/her mad and uncomfortable, and he/she is not happy;-He/she told the Resident #1 to move away and told an aide about the incident.Review of facility documents showed no documentation of a timely investigation or steps taken to protect others during an investigation.5. During an interview on 04/30/26, at 1:50 P.M., NA C said the following: -He/She considers abuse to be a resident hitting, yelling, or unwanted touching of another resident;-If he/she observed abuse, he/she would immediately redirect residents, ensure safety, and then contact the charge nurse; -He/she was not familiar with the investigation process. During an interview on 04/30/26, at 2:00 P.M., Certified Medication Tech (CMT) B said the following:-Abuse can include verbal tone, physical abuse or sexual abuse, including innuendos or grabbing someone's buttocks or private areas;-All behaviors should be investigated.During an interview on 04/30/26, at 2:15 P.M., Registered Nurse (RN) D said the following:- Abuse includes residents slapping other residents or other physical or sexual touching;-Staff should investigate the cause of abuse allegations.During an interview on 04/30/26, at 2:30 P.M., Licensed Practical Nurse (LPN) A said the following:-Abuse included unwanted touching from other residents-Each occurrence of behaviors should be documented by staff.During an interview on 05/01/26, at 10:30 A.M., Certified Nurse Aide (CNA) E said the following:-Abuse included residents touching others without consent; -He/She was not familiar with the investigation process. During an interview on 05/01/26, at 10:45 A.M., Laundry F said the following:-He/She has not received abuse training;-He/she was not familiar with the investigation process. During an interview on 05/01/26, at 11:40 A.M., CMT G said the following:- Abuse included residents touching others inappropriately;-He/she was not familiar with the investigation process. During an interview on 05/01/26, at 11:55 A.M., DON said the following:-Resident to resident abuse includes unwanted touching and sexual abuse;-Four residents have approached her and reported that Resident #2 was kissing Resident #1 and touching Resident #1's breast;-He/she discussed this with the Administrator and the Administrator felt the residents were exaggerating and not telling the truth;-An investigation was initiated, and after the two residents confirmed the allegations, they stopped interviewing residents;-Staff should document all behaviors during their shift and behaviors should be reported;-Any allegations of abuse should be investigated. During an interview on 05/01/26, at 12:30 P.M., Administrator said the following:-No residents have voiced concerns of being inappropriately touched other than the self-report related to Resident #1 and Resident #5;-Any allegations of abuse should be investigated.

Based on observation, interview, and record review, the facility failed to protect residents from sexual and physical abuse when one resident (Resident #1) exhibited repeated behaviors against others, including touching breasts and chest, biting chest and attempted to lay on another resident unclothed. The attempts at unwanted contact impacted three residents (Resident #2, #3, and #4). The facility census was 53.Review of the facility policy Abuse, Prevention and Prohibition Policy, dated 2021, showed the following:-Each resident had the right to be free from abuse, corporal, punishment, and involuntary seclusion;-Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals;-Resident behaviors will be monitored for changes, which trigger abusive behaviors;-The facility will reassess care plan interventions on a regular basis;-The facility will identify residents whose personal histories render them at risk for abusing other residents through the prescreening process;-When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's physical and mental status, care plan, monitor behaviors and notify the physician for a determination regarding treatment and/or discharge options.1. Review of Resident #1 face sheet (brief information sheet about the resident) showed the following: -admission date of 02/06/26;-Diagnoses included intellectual disabilities (neurodevelopmental condition characterized by significant limitations in both intellectual functioning (learning, reasoning, problem-solving and adaptive behavior (everyday social/practical life skills)), deaf and non-speaking, and hemiplegia (weakness of one side) affecting left nondominant side.Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 02/24/26, showed the following:-Severe cognitive impairment;-No documentation of any behaviors. Review of the resident's care plan, last updated 04/28/26, showed the following:-Resident had a behavior problem and noted to touch his/her breast area, will pull at clothing often, and has lifted up his/her shirt;-Staff should redirect resident to front day room to watch television and if trying to lay down on couch will be redirect to his/her bedroom;-Staff will remind resident not to pull up his/her shift and remind resident to wear sports bra or undershirt;-Staff will monitor and record occurrence of target behavior symptoms and document per facility protocol;-Staff will monitor behavior episodes and attempt to determine underlying causes. Staff will document behavior and potential causes.Review of the resident's nursing progress notes showed the following:-On 03/15/26, at 8:10 P.M., Resident #1 wandered in and out of a resident's room that was not his/hers. The resident asked that we remove resident. Resident #1 was easily redirected out of other resident's room;-On 04/14/26, at 9:35 A.M., Resident #1 found in back sitting area taking off his/her clothes. He/she had shirt off with other residents present and was removing his/her skirt when staff intervened to redress him/her. Nursing and management notified;-On 04/20/24, at 12:24 A.M., Resident #1 had to be redirected daily for inappropriate touching of her body and not respecting boundaries;-On 04/21/26, at 1:00 P.M., Resident #1 found in back sitting area laying against male resident. Staff redirected Resident #1 took him/her to the front nursing area. He/she was not redirectable and continued to return to back and try to lay on couch with males present. Nursing notified;-On 04/21/26, at 3:16 P.M., Resident #1 continued to be redirected for behaviors and not respecting other boundaries. This happened several times throughout the day. Resident #1 ignored staff due to cognitive delay, and he/she was unable to verbalize any event; -On 04/22/26, at 9:33 A.M., staff heard a resident yelling in a room NO, NO. Staff went to the room and Resident #1 was in another resident's room going through the resident's stuff and then trying to get into the resident's bed. Resident #1 was taken to nurses' station and staff notified;-On 04/28/26, at 1:47 P.M., Resident #1 was in back common area with peers, and it was reported to staff that Resident #1 sat on male peer's lap, no intimate contact was made.Review of the resident's care plan, last updated 04/28/26, showed the following:-On 04/28/26, resident attention seeking and will do different things to get attention from others and continued to have little awareness of others personal space;-On 04/29/26, resident will have one on one with staff during waking hours.2. Review of Resident #2 face sheet showed the following: -admission date of 01/29/26;-Diagnoses included chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning ) with anxiety, and mild cognitive impairment.Review of the resident's admission MDS, dated [DATE], showed moderate cognitive impairment.Review of the resident's nursing progress note dated 03/14/26, at 6:06 P.M., showed the following:-Staff redirected Resident #2 after he/she was observed fondling Resident #1's breasts. Support staff removed Resident #1 from the area; -Staff did not document family, physician, Director of Nursing (DON), or Administrator notification.Review of facility documentation, dated 03/15/26, showed the following:-The Business Office Manager (BOM) was reviewing skilled notes, and read a note dated 03/14/26, stating Resident #2 said he/she touched Resident #1;-BOM contacted the Administrator and asked Licensed Practical Nurse (LPN) I about the incident;-LPN I said he/she did not actually witness the resident touching the other resident but felt it was going to happen;-The BOM explained to LPN I that only witness occurrences can be documented. Review of facility documentation, dated 03/15/26, showed the following:-The BOM notified the Administrator of a progress note regarding Resident #2 touching Resident #1's breast;-The Administrator reported to the facility and spoke to LPN I about the documentation;-LPN I said Resident #2 did not actually touch Resident #1's breast, but he/she was concerned that it was going to happen.3. Review of Resident #3's face sheet showed the following: -admission date of 04/09/26;-Diagnoses included acute osteomyelitis (localized inflammation of the bone due to an infection) left ankle and foot, peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breath). Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact.Review of the resident's electronic chart census showed the following:-On 04/09/26, admitted to same room as Resident #1;-On 04/14/26, moved room to a different semi-private room.During an interview on 04/30/26, at 11:30 A.M., Resident #3 said the following:-When he/she admitted to the facility, he/she was roommates with Resident #1;-On his/her second night in the facility, he/she woke up to Resident #1 naked laying on top of him/her and touching his/her upper chest area and pulling at his/her central line (long, flexible tube inserted into a large vein in the neck, chest, or groin and threaded near the heart to deliver medications, fluids, or nutrition over an extended period). He/She told the resident to move away; -This upset him/her as he/she was startled from sleep;-He/she reported to the staff on duty and requested to be moved to a different room;-He/She witnessed Resident #1 and Resident #2 kissing in the dining room and staff redirected the residents. Review of the resident's progress notes showed staff did not document regarding the allegations of inappropriate and unwanted touching or to the room change request.4. Review of Resident #4's face sheet showed the following:-admission date of 03/14/23;-Diagnoses included hemiplegia (complete paralysis) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, presence of cardiac pacemaker, and dysarthria (motor speech disorder caused by nervous system damage that weakens or impairs control of muscles used for breathing, speaking, and swallowing) following cerebral infarction.Review of the resident's annual MDS, dated [DATE], showed the resident was cognitively intact.During an interview on 04/30/26, at 12:40 P.M., Resident #4 said the following:-Approximately two weeks ago, Resident #1 tried to bite him/her around where he/she has a pacemaker. Resident #1 also tried to touch his/her left chest;-Resident #1 made him/her mad and uncomfortable, and he/she was not happy;-He/she told the Resident #1 to move away and told an aide about the incident.Review of the resident's progress notes showed staff did not document related to the resident being bitten or touched inappropriately. 5. Review of Resident #5 face sheet (brief information sheet about the resident) showed the following: -admission date of 04/15/26;-Diagnoses included paroxysmal atrial fibrillation (irregular, rapid heart rhythm that starts and stops suddenly on its own, episodes are intermittent), bipolar disorder (chronic mental health condition characterized by extreme mood swings, including emotional highs (mania) and lows (depression)), anxiety, and low back pain. Review of the resident's nursing progress notes dated 04/28/26, at 11:45 A.M., showed the following:-Resident #5 was in back common area with peers when a female resident sat in his/her lap, no intimate interaction occurred;-Staff questioned Resident #5 and he/she indicated no abuse had occurred. During an interview on 04/30/26, at 11:00 A.M., Resident #5 said the following:-Resident #1 did not sit on his/her lap;-Resident #1 has a problem of lifting his/her shirt around residents;-Staff should redirect the resident. 6. During an interview on 04/30/26, at 1:50 P.M., Nurse Aide (NA) C said the following: -He/She considered abuse to be a resident hitting, yelling, or unwanted touching of another resident;-If he/she observed abuse, he/she would immediately redirect residents, ensure safety, and then contact the charge nurse; -All behaviors should be reported to the nurse. During an interview on 04/30/26, at 2:00 P.M., Certified Medication Tech (CMT) B said the following:-Abuse can include verbal tone, physical abuse, or sexual abuse, including innuendos or grabbing someone's buttocks or private areas;-He/She would notify the DON and Administrator immediately if he/she witnessed abuse or if he/she was told of an abuse allegation;-He/She had seen Resident #1 try to touch people, hugging and patting their upper chest;-Resident #1 tried to take his/her clothes off in front of other residents;-Resident #1 has had these behaviors since admitting to the facility;-He/she heard other residents have touched Resident #1, but he/she has not witnessed it. He/she reported the information to a charge nurse;-He/she observed other residents push Resident #1 away;-All behaviors should be charted. During an interview on 04/30/26, at 2:15 P.M., Registered Nurse (RN) D said the following:-Abuse included residents slapping other residents or other physical or sexual touching;-The incident of Resident #1 sitting on Resident #5's lap was reported;-He/She was unaware of any other incidents;-All behaviors should be documented and reported, and the care plan should be updated. During an interview on 04/30/26, at 2:30 P.M., LPN A said the following:-Abuse included unwanted touching from other residents;-Resident #1 likes to cling to everybody. He/she has seen Resident #1 seated near other residents, laying his/her head on their laps;-He/she redirected Resident #1 to not sit in the back common area with other residents, as there are fewer staff in that area;-Each occurrence of behaviors should be documented by staff.During an interview on 05/01/26, at 10:30 A.M., Certified Nurse Aide (CNA) E said abuse included residents touching others without consent.During an interview on 05/01/26, at 10:45 A.M., Laundry F said the following:-He/she saw Resident #1 in the dining room with Resident #2, touching each other inappropriately on the bare chest and kissing;-The aides usually separate the residents;-He/she believed the aides reported the incident to the nurse. During an interview on 05/01/26, at 11:40 A.M., CMT G said the following:-Abuse included residents touching others inappropriately;-If he/she observed inappropriate touching, he/she would separate the residents and notify the nurse, Administrator and DON;-He/she has seen Resident #1 lift his/her shirt in front of other residents. He/she felt this information should be reported and documented. During an interview on 05/01/26, at 11:55 A.M., the DON said the following:-Resident to resident abuse included unwanted touching and sexual abuse;-Four residents have approached her and reported that Resident #2 was kissing Resident #1 and touching Resident #1's breast;-He/she discussed this with the Administrator and the Administrator felt the residents were exaggerating and not telling the truth;-An investigation was initiated, and after the two residents confirmed the allegations;-Staff should document all behaviors during their shift and behaviors should be reported. During an interview on 05/01/26, at 12:30 P.M., Administrator said the following:-No residents have voiced concerns of being inappropriately touched other than the self-report related to Resident #1 and Resident #5;-She expected staff to intervene and report any abuse allegations. Complaint 2997477

Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for three residents (Resident #6, #7, and #8). The facility census was 53.Review showed the facility did not provide a policy related to showers. 1. Review of Resident #6 's face sheet showed the following: -admission date of 09/15/25;-Diagnoses included infection and inflammatory reaction due to internal left knee prosthesis (replaces damaged bone and cartilage in the left knee with metal and plastic components, aiming to relieve pain and restore function), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and uninhibited neuropathic bladder (type of bladder dysfunction caused by brain or upper spinal cord damage that removes the brain's ability to stop the voiding reflex).Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument, completed by facility staff), dated 04/10/26, showed the following:-Cognitively intact;-Use of wheelchair;-Indwelling catheter (flexible tube inserted into the body-usually the bladder-that remains in place for continuous, long-term urine drainage);-Supervision or touching assistance for oral hygiene, toileting hygiene, showering, personal hygiene, dressing, transfers.Review of the resident's March 2026 shower sheets showed the resident received a shower on 03/03/26, 03/20/26, and 03/30/26.Review of the resident's March 2026 nursing progress notes showed no information related to showers provided or refused.Review of the resident's care plan, dated 04/01/26, showed the following:-Intervention cancelled which showed the resident to be totally dependent on staff to provide a bath per schedule and as necessary;-No current information related to showering or bathing.Review of the resident's April 2024 shower sheets showed the resident received a shower on 04/09/26 and 04/21/26.Review of the resident's April 2026 nursing progress notes showed no information related to showers provided or refused.During an interview on 05/01/26, at 9:50 A.M., the resident said the following:-He/She would prefer to take a shower at least twice per week;-He/she felt dirty due to having a catheter and being incontinent of bowel;-He/she was unsure when he/she received his/her last shower; -Earlier in the day, an aide came into his/her room and sprayed a room deodorizer and said the room smelled;-His/her roommate has gone up to two weeks at a time without a shower. 2. Review of Resident #7's face sheet showed the following: -admission date of 10/04/22;-Diagnoses included dementia without behavioral disturbance and hypothyroidism (underactive thyroid gland producing insufficient hormones, disrupting the body's energy usage). Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Supervision or touching assistance for oral hygiene, toileting hygiene, showering, dressing, personal hygiene.Review of the resident's March 2026 shower sheets showed the resident received a shower on 03/03/26, 03/10/26, and 03/20/26.Review of the resident's March 2026 nursing progress notes showed no information related to showers provided or refused.Review of the resident's care plan, dated 04/01/26, showed the following:-Resident requests assistance with ADL's related to cognitive loss, impaired vision, and self-care deficits;-Resident required staff set up and clean up assistance with personal hygiene;-Resident required staff set up and clean up assistance with showering or bathing;-Staff should assist resident with a sponge bath when a full bath or shower could not be tolerated.Review of the resident's April 2026 shower sheets showed the resident received a shower on 04/12/26 and 04/13/26.Review of the resident's April 2026 nursing progress notes showed no information related to showers provided or refused.During an observation and interview on 05/01/26, at 10:05 A.M., the resident said the following:-He/She would prefer to have a shower twice per week;-He/She could not recall when he/she received his/her last shower; -The resident's hair appeared oily and he/she had a mild body odor.3. Review of Resident #8's face sheet showed the following: -admission date of 10/29/24;-Diagnoses included dysarthria (motor speech disorder caused by neurological damage that weakens or paralyzes the muscles used for breathing, vocalizing, and articulation (mouth, lips, tongue)) following cerebral infarction (stroke - a condition where blood flow to the brain is interrupted, causing brain tissue to die), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), and anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Use of walker and wheelchair;-Substantial to maximal assistance for showering, toileting hygiene.Review of the resident's care plan, last updated 02/19/26, showed the following:-Resident has an activities of daily living (ADL) self-care performance deficit related to diagnosis;-Staff should provide the resident with a sponge bath when a full bath or shower could not be tolerated;-Staff should check nail length and trim and clean on bath day and as necessary;-Resident requires set up and clean up assistance for showering or bathing.Review of the resident's March 2026 shower sheets showed the resident received a shower on 03/01/26, 03/08/26, 03/15/26, and 03/20/26.Review of the resident's March 2026 nursing progress notes showed no information related to showers provided or refused.Review of the resident's April 2026 shower sheets showed the resident received a shower on 04/13/26 and 04/17/26.Review of the resident's April 2026 nursing progress notes showed no information related to showers provided or refused.During an interview on 05/01/26, at 11:30 A.M., the resident's responsible party said the following: -He/She had been shaving the resident him/herself because he/she found the resident unshaved during his/her visits;-The resident's toenails are long and have not been trimmed;-The resident's teeth are not brushed and he/she has found the resident in soiled clothing; -He/she expected the staff to provide the resident a shower at least twice per week and ensure the resident has clean clothing daily. 4. During an interview on 05/01/26, at 10:40 A.M., Certified Nurse Aide (CAN) E said the following: -He/She occasionally helped with showers if he/she has time during his/her shift;-The shower schedule was in the shower room; -He/she was unaware if residents were receiving their preferred shower schedule.During an interview on 05/01/26, at 11:40 A.M., Certified Medication Tech (CMT) G said he/she occasionally helped with resident personal cares. The facility had a shower aide.During an interview on 05/01/26, at 11:55 A.M., the Director of Nursing (DON) said the following: -The shower aide had a schedule which provided all residents with a shower twice per week;-The aide came in early to start showers;-Some residents refuse showers or baths. The aides should at least provide the resident with a bowl of warm water and wash cloth to clean themselves if they do not want a full shower;-Residents should not smell and should be kept clean;-The DON was unaware that Resident #6, #7, and #8 had not received two showers per week. During an interview on 05/01/26, at 12:30 P.M., Administrator said the following:-The expectation was that residents were kept clean and odor free;-On admission, residents should be asked their preference of time and how many showers they prefer per week;-The shower aide was not the only staff that provided showers. Night shift and therapy also assisted with showers;-Resident preferences, which are typically twice per week, should be noted on the shower schedule and honored;-Staff should be documenting resident shower refusals;-She was unaware that Residents #6, #7, and #8 did not receive showers twice per week in March 2026 and April 2026. Complaint #2995835

Based on interview and record review, the facility failed to ensure all residents' records were complete and accurate when staff failed to document one resident (Resident #1) sliding out of a chair. The facility census was 45.Review of the facility's policy titled, Significant Condition Change and Notification, undated, showed the following:-All significant changes will be recorded on the communication board in the computer and in the resident record. Charting will include an assessment of the resident's current status as it relates to the change in condition. Charting will be done each shift for 72 hours for resident with change of condition. Change of condition is reviewed by Director of Nursing (DON) or designee for the continued need for additional documentation. Review of the facility's policy titled Charting and Documentation, dated February 2021, showed the following:-Chart all pertinent changes in the resident's condition, reaction to treatments, medication as well as routine observations;-Be concise, accurate, and complete and use objective terms. Document only the facts. Use on approved abbreviations and symbols.1.Review of Resident #1's face sheet (admission data) showed the following:-admission date of 11/15/25;-Diagnoses included Type 2 diabetes mellitus (when your body cannot use insulin properly), heart failure, essential hypertension (HTN-high blood pressure), Hypokalemia (abnormally low levels of potassium in the bloodstream), Hyperlipidemia (high levels of lipids (fats) in the blood) and chronic kidney disease stage 3 (moderate kidney damage). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 02/13/26, showed the following:-Cognitive skills intact;-The resident required substantial/maximal assistance with toileting, showering and personal hygiene;-No falls.Review of the resident's care plan, revised 02/22/26, showed the following:-The resident had potential for falls due to weakness and medication side effects;-Ensure the resident's call light is within reach and encourage the resident to use if for assistance as needed. Review of the resident's progress note dated 02/24/26, at 7:48 P.M., showed Licensed Practical Nurse (LPN) C documented fall follow-up. The resident had no latent injuries noted from his/her earlier fall. Staff should continue to monitor. Review of the resident's medical record showed staff did not document a fall.During an interview on 03/16/26, at 2:13 P.M., LPN C said he/she documented the resident's fall follow up due to staff informing him/her of the fall in the shift report. Staff should document in the resident's progress notes of a fall. During an interview on 03/16/26, at 2:47 P.M., Registered Nurse (RN) A said the following:-Staff should document in the nurses' notes of a resident's fall;-He/she worked at the facility on 02/24/26 and the resident did not have a fall. The resident was in his/her recliner and slid out. RN A and another aide entered the resident's room and saw the resident slide slow to the ground out of his/her recliner onto the floor. The resident did not hit his/her head and did not have an injury;-He/she should have documented the resident's sliding out of his/her recliner. During an interview on 03/18/26, at 9:19 A.M., the DON said the following:-She considered it a fall if a resident slid out of a chair;-She expected staff to document in the progress notes if a resident falls or slides out of a chair and to notify the resident's responsible party.During an interview on 03/16/26, at 3:15 P.M., the Administrator said she expected nurses to document in the progress notes if a resident slides out of a chair. She considered it a fall if a resident slid out of a chair. #2734672 and #2798251

Based on interview and record review, the facility failed to promptly notify the ordering physician of labs out of normal ranges when staff failed to notify one resident's (Resident #1) physician of critical lab results. The facility census was 45.Review of the facility's policy titled Significant Condition Change and Notification, undated, showed the following:-To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as those listed below:-A significant change in the resident's physical, mental, or psychosocial status including abnormal lab values;-When the above situation exists, the licensed nurse will contact the resident's representative and their medical practitioner;-Calls will be made to the resident's representative until they are reached. A message may be left on an answering machine that does not give specifics but leaves a request for the facility to be called;-The medical practitioner will be contacted immediately for any emergencies regardless of the time of day. Non-emergency notifications may be made the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. If the medical practitioner cannot immediately be reached in any emergency, the medical director will be called. If the medical practitioner cannot be reached, the Director of Nursing (DON) or the charge nurse can make arrangements for transportation to the emergency department;-Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner. In a non-emergency situation, the primary medical practitioner will be called unless he/she has left an alternate name to call. If after two attempts, there is no response to the calls, the medical director will be contacted;-All significant changes will be recorded on the communication board in the computer and in the resident record. Charting will include an assessment of the resident's current status as it relates to the change in condition. Charting will be done each shift for 72 hours for resident with change of condition. Change of condition is reviewed by DON or designee for the continued need for additional documentation. Review of the facility's policy titled Charting and Documentation, dated February 2021, showed the following:-Chart all pertinent changes in the resident's condition, reaction to treatments, medication as well as routine observations;-Be concise, accurate, and complete and use objective terms. Document only the facts. Use on approved abbreviations and symbols;-For lab work document date and time specimens were obtained (when drawing blood, document site) and date and time physician notified of lab results. 1.Review of Resident #1's face sheet (admission data) showed the following:-admission date of 11/15/25;-Diagnoses included Type 2 diabetes mellitus (when the body cannot use insulin properly), heart failure, essential hypertension (HTN-high blood pressure), hypokalemia (abnormally low levels of potassium in the bloodstream), hyperlipidemia (high levels of lipids (fats) in the blood) and chronic kidney disease stage 3 (moderate kidney damage). Review of the resident's physician order sheet showed an order, dated 11/15/25, for admission labs; complete blood count (CBC), complete metabolic panel (CMP), TSH (thyroid-stimulating hormone), BNP (B-Type Natriuretic Peptide-a test to measure amount of hormone produced by the body when the heart is enlarged) and valproic acid level. Review of the resident's laboratory report, dated 11/21/25, showed the following:-Lab specimen collected on 11/19/25 at 6:23 A.M.;-Resident had a hemoglobin (protein found in the red blood cells responsible for oxygen throughout the body) count of 5.1 (reference range for hemoglobin is 11.2 to 15.7 grams per deciliter (g/dl);-Resident had a hematocrit (measures red blood cells in the total amount of blood) count of 18.7 low (reference range for hematocrit of 34.1 to 44.9%);-The hemoglobin and hematocrit results were in the critical range column of the lab report;-A signature (unable to read) was on the final page (page 3) of the laboratory results with no date. Review of the resident's medical record showed staff did not document notification of the resident' s family member or physician of the resident's critical lab results. Review of the physician's note, dated 12/10/25, showed the line which listed labs did not have documentation regarding lab review. Review of the resident's progress notes dated 12/23/25, at 4:07 P.M. showed the dietician documented no labs located from the electronic medical record. Review of the physician's note, dated 01/14/26, showed the line which listed labs did not have documentation regarding lab review. Review of the physician's note, dated 02/11/26, showed the line which listed labs did not have documentation regarding lab review. Review of the resident's progress note dated 02/19/26, at 2:11 P.M., showed the dietician documented the resident's recent weight and noted no new labs located. Review of the resident's nurse's note dated 03/01/26, at 1:09 P.M., showed a nurse documented the resident acted outside of his/her baseline. Blood pressure of 84/62 millimeters of mercury (mm/Hg) (low). The resident's family was at the facility and requested the resident to go to the hospital for further evaluation. Staff contacted emergency services to transport the resident to the hospital. Review of the resident's hospital emergency department physical exam, dated 3/01/26, showed the CBC with differential laboratory results showed abnormal results of hemoglobin at 3.1 and hematocrit at 13.4. Review of the resident's care plan, revised 03/03/26, showed the following:-The resident had a diagnosis of chronic kidney disease;-Monitor lab reports of electrolytes and report to physician.During interviews on 03/16/26, at 11:22 A.M. and 12:55 P.M. Registered Nurse (RN) A said the following:-Staff obtain admission labs for CBC, CMP, TSH, and lipid for new admissions to determine baseline results to see where a resident is at to ensure they are on proper medications;-The physician orders laboratory work;-The nurse enters the lab orders into the computer, and it goes directly to the lab;-The lab company comes to the facility twice a week;-The nurse checks the lab portal for results and prints them out;-Staff should report to the physician of an urgent lab result;-Staff sends lab results through the facility message system if an urgent manner. Staff fax the physician if the lab results are not urgent;-The physician sends a message back to the facility after review of the lab results and signs the lab;-Staff can take a picture of the lab results, download it into the computer and send it to the physician; -Staff should notify the physician of lab results;-The lab should notify the facility of a critical result;-He/she did not recall a conversation with the physician of the resident's critical lab results of the hemoglobin and hemotocrit;-He/she assumed if the physician saw the resident's lab results. The physician would have wanted to recheck the resident's lab or send the resident out for an evaluation;-He/she did not see any information on the computer of a message to the physician of the resident's lab results;-Staff should had called the physician and documented the resident's critical lab results of the hemoglobin and hematocrit.During an interview on 03/16/26, at 3:44 P.M., the Medical Director said the following:-She orders new admission labs of CBC, CMP, lipids, thyroid, and a Hemoglobin A1C if a resident is a diabetic;-Staff send her lab results through the message system or fax to her office. She comes to the facility on visits and signs any lab results in her box;-Staff can attach the lab results when they send it to her on the message system;-Agency nurses do not always have access to lab results, so they fax the results to her office;-On 3/16/26, the Medical Director reviewed the resident's 11/21/25 lab. The resident's lab results were critical, and staff should have called her. She was not aware of the resident's low hemoglobin and hematocrit results;-The lab should call the facility with critical results and staff should notify her;-She would have ordered anemia labs or sent the resident out for a blood transfusion;-She said the signature on the resident's third page of the lab results was not her signature;-She reviews every page of laboratory results and signs every single page;-She did not see in the computer staff notifying her of the resident's critical lab results;-She expected staff to document reviewing the lab results and notifying her.During an interview on 03/18/26, at 9:19 A.M., the DON said the following:-She expected nurses to review laboratory results;-She expected the nurses to notify the physician through the message system or make a phone call of critical lab results;-She expected nurses to document notification of the physician of critical lab results;-The facility had too many agency nurses and communications were not passed along.During an interview on 03/16/26, at 3:15 P.M. the Administrator said the facility had standing orders for labs. The nurses enter orders into the computer. The lab company comes to facility to draw lab orders. Nurses are responsible for monitoring lab results. The lab company should notify the facility of critical lab results. The nurse should notify the physician through the message system in the computer. Nurses should document notification of the physician of critical lab results. #2792822 and #2798251

Based on observation, interview, and record review, the facility failed to maintain complete medical records for all residents when staff failed to document full details and notifications related to one resident (Resident #1) who died at the facility. The facility census was 50. Review of the facility's policy titled Charting and Documentation, dated February 2021, showed the following: -Chart all pertinent changes in the resident's condition, reaction to treatments, medications as well as routine observations; -Be concise, accurate and complete and use objective terms. Document only the facts. Use only approved abbreviations and symbols; -For death of a resident document code status of resident and whether CPR (cardiopulmonary resuscitation - an emergency lifesaving procedure performed when the heart stops beating) was performed; pertinent information before death (example, symptoms, vital signs, treatments, etc); date and time of death; name of physician notified and when notified; time resident representative notified and by whom; name of funeral home, time notified and by whom; when and to who the resident is released;disposition of medications and personal belongings; and time of coroner notification. 1. Review of Resident #1's face sheet (a general information sheet) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), respiratory failure, unspecified with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), and chronic kidney disease (disease that causes progressive damage and loss of function to the kidneys). Review of resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated [DATE], showed the following: -Cognitive skills intact; -Required set up assistance with eating and oral hygiene; -Required supervision with toileting; -Required partial/moderate assistance with shower/bathing and upper and lower body dressing. Review of the resident's [DATE] Physician Order Sheet (POS) showed a physician order, dated [DATE] , for do not resuscitate (DNR - did not wish to receive CPR). Review of the resident's baseline care plan, dated [DATE], showed the following: -Resident was alert and cognitively intact; -Required assistance of two staff for bed mobility, transfer, and toileting. Review of the resident's progress note dated [DATE], at 6:49 A.M., showed the Social Service Director (SSD) documented the resident's spouse and family member at the facility to say their goodbyes. The family took all the resident's items. The resident's spouse thanked the staff for all their care and assistance with his/her spouse. SSD expressed to the family if they need anything to let him/her know. Review of the resident's nursing notes showed staff did not document regarding the resident's death or physician and responsible party notifications. During an interview on [DATE], at 1:03 P.M., Registered Nurse (RN) C said the following: -The aides reported to him/her on [DATE], at 3:00 A.M., the resident had no pulse or heartbeat; -He/she messaged the physician and called the resident's family; -He/she did not realize he/she did not document a progress note on the resident's death; -He/she should have documented the resident's death. During an interview on [DATE], at 11:47 A.M., RN A said if a resident died unexpectedly, staff should document the physician notification and if the family was at the bedside During an interview on [DATE], at 1:41 P.M., the Director of Nursing (DON) said she expects staff to document in the progress note if a resident has a change in condition or when a resident passes away. Staff should document in the progress note the physician, responsible parties, DON, Administrator, and coroner notifications and how they found the resident. During interviews on [DATE], at 12:02 P.M. and 3:39 P.M., the Administrator said she did not see a summary of a progress note for when the resident died . She expected staff to document if a resident passed away which should include how staff found the resident, what happened and notifications to the physician and responsible parties. MO00249192 51940

Based on record review and interview, the facility failed to provide respiratory care per standards of practice when staff failed to clarify hospital discharge orders for pulse oximetry (a test used to measure the oxygen level of the blood), failed to have the resident's oxygen order on the Treatment Administration Record (TAR), and failed to document oxygen usage and pulse oximetry readings for one resident (Residents #1). The facility census was 50. Review of facility policy titled Oxygen Administration, dated February 2021, showed the following: -Verify there is a physician's order for oxygen administration; -After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: the date and time that the procedure was performed; the rate of oxygen flow, route; the frequency and duration of the treatment; the reason for as needed (PRN) administration; if the resident refused the procedure, the reason(s) why and the intervention taken; and the signature and title of the person recording the data. 1. Review of Resident #1's face sheet (a general information sheet) showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), respiratory failure, unspecified with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), and chronic kidney disease (disease that causes progressive damage and loss of function to the kidneys). Review of resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/12/24, showed the resident's cognitive skills were intact and resident received oxygen therapy. Review of the resident's hospital discharge orders, dated 12/07/24, showed the following: -Oxygen home delivery concentrator with portability at two liters per minute via nasal cannula. Oxygen at a setting of two on a conserving device. Anticipated length of six months or greater; -Non monitored home continuous pulse oximeter for spot checks. Anticipated length of need of one month. Resident's baseline pulse oximeter measurement was 95% on two liters/minute by nasal cannula; -If pulse oximeter reading goes below 90% call the hospital or if in distress call 911 immediately. Review of the resident's December 2024 Physician Order Sheet (POS) showed a physician order, dated 12/07/24 , for oxygen at two liters via nasal cannula (nc) PRN for shortness of breath. (Staff did not document an order regarding pulse oximeter monitoring or direction for when to notify the physician.) Review of the resident's December 2024 Treatment Administration Record (TAR) showed staff did not document the physician order for oxygen at two liters via nasal cannula PRN or monitoring for pulse oximeter readings. Review of the resident's baseline care plan, dated 12/09/24, showed the following: -Resident was alert and cognitively intact; -Special treatment/procedures include oxygen with no rate of administration listed. (Staff did not address the pulse oximeter monitoring on the care plan.) During an interview on 02/11/25, at 12:55 P.M., Certified Nurse Aide (CNA) E said the resident was at the facility for rehabilitation and was on oxygen. During an interview on 02/11/25, at 1:07 P.M., CNA F said the following: -The resident was on oxygen; -The resident would take off his/her oxygen during the day on his/her own per his/her choice; -He/she did not remember how often staff checked the resident's vital signs. During an interview on 02/11/25, at 1:35 P.M., Certified Medication Technician (CMT) G said the resident was on oxygen as needed. The aides check residents' vital signs based on the orders in the computer. During interviews on 02/13/25, at 2:29 P.M., and on 02/14/25, at 8:25 A.M., Licensed Practical Nurse (LPN) B said the following: -The resident had a pulse oximeter at his/her bedside and checked his/her pulse oximetry himself/herself; -He/she assumed spot checks meant for staff to check a resident's oxygen saturations each shift; -He/she did not remember if he/she called the physician to clarify the hospital discharge order; -He/she checked the resident's oxygen saturation at times and did not know if he/she documented it; -Nurses review hospital discharge orders and enter them in the computer; -Pulse oximetry checks should be on a residents' TAR and staff should document; -A PRN oxygen order should be on the TAR. During interviews on 02/11/25, at 11:47 A.M. and 2:11 P.M., Registered Nurse (RN) A said the following: -The resident had a diagnosis of COPD; -The resident said he/she used oxygen, but at times he/she refused to wear the oxygen; -The hospital discharge order showed an order for a home device pulse oximeter. The facility did not have a continuous pulse oximeter; -Staff should had clarified the hospital discharge order with the physician; -He/she assumed spot checks meant to check the resident's oxygen saturations every shift and should had been documented on the TAR; -Nurses review the discharge orders and enter them in the computer; -Nurses clarify physician orders with the physician if it did not seem right. During interviews on 02/11/25, at 1:03 P.M., and on 02/13/25, at 6:20 P.M., RN C said the following: -The resident said his/her oxygen was continuous, but he/she did not always wear it; -The resident had his/her own pulse oximetry machine and would use it from time to time; -The resident had an order for oxygen; -He/she did not know of the hospital order for spot checks of the resident's oxygen saturations; -Staff should have clarified the hospital discharge order with the physician; -A normal order would read oxygen PRN to keep oxygen saturations above 90%; -When he/she or the resident took oxygen saturations they were always above 90% and staff should have documented the oxygen saturations. During an interview on 02/13/25, at 2:48 P.M., RN D said the hospital discharge order for the continues pulse oximetry was an unusual order and the facility did not do continuous pulse oximetry checks. Staff should had called the physician to clarify the order. During an interview on 02/13/25, at 6:44 P.M., the Director of Nursing (DON) said the following: -Staff should had clarified what spot checks meant with the physician; -The hospital discharge order is an order to be followed; -She did not know the resident had his/her own pulse oximetry at his/her bedside; -Nurses enter the hospital discharge orders in the computer and print them off and send to the pharmacy; -Oxygen orders should include amount of liters and if the oxygen is continuous or PRN; -She would expect staff to perform spot checks at least three times a day to make sure a resident's oxygen SATS are at 95% and if they are below 95% to notify the physician; -PRN oxygen order should be on the TAR. During an interview on 02/11/25, at 3:40 P.M., the Administrator said the following: -Nurses review physician orders and enter them in the computer; -She expected nurses to clarify orders with the physician if they had any; -On admission the charge nurse inputs new orders; -Part of the admission process is clarifying new orders with the physician; -She assumed spot checks meant if a resident had issues with oxygen not at normal ranges, staff would check a resident's oxygen saturations if a resident is confused or tired; -Oxygen orders and parameters should be specific. MO00249192 51940

Based on observation, interview, and record review, the facility failed to ensure six nurse aides (NA) ( NA B, NA G, NA J, NA K, NA L,and NA C) completed a certified nurse aide (CNA) training program and obtained certification within four months of employment at the facility as a nurse aide. The facility census was 53. Review showed the facility did not provide a nurse aide certification or training policy. 1. Review of a facility list of current nurse aides showed NA B had an initial hire date of 03/28/23 and a rehire date of 12/07/24. Review of the facility's October 2024, November 2024, and December 2024, showed NA B scheduled to work. During interviews on 01/09/25, at 2:26 P.M., and on 01/13/24, at 11:00 A.M., NA B said the following: -He/she had worked at the facility for a month; -He/she had previously worked at the facility for a few years, but left and came back; -He/she provided all care to residents by herself unless the task requires two people; -He/she was not in a CNA class now, but planned to be in the next class; -The next class for nurse aides starts in February. Observation on 01/13/25, at 10:09 A.M., showed NA B provided direct care to residents. Review of the state agency CNA registry website, on 01/14/25, showed NA B was not listed as a CNA. 2. Review of a facility list of current nurse aides showed NA G had a hire date of 08/07/24 (over four months prior). Review of the facility's October 2024, November 2024, and December 2024, showed NA G scheduled to work. Review of the state agency CNA registry website, on 01/14/25, showed NA G was not listed as a CNA. 3. Review of a facility list of current nurse aides showed NA J with a hire date of 02/25/24 (over 11 month prior). Review of the facility's October 2024, November 2024, and December 2024, showed NA J scheduled to work. Review of the state agency CNA registry website, on 01/14/25, showed NA J was not listed as a CNA. 4. Review of a facility list of current nurse aides showed NA K with a hire date of 8/15/24 (four months prior). Review of the facility's October 2024, November 2024, and December 2024, showed NA K scheduled to work. Review of the state agency CNA registry website, on 01/14/25, showed NA K was not listed as a CNA. 5. Review of a facility list of current nurse aides showed NA L with a hire date of 05/15/24 (eights months prior). Review of the facility's October 2024, November 2024, and December 2024, showed NA L scheduled to work. Review of the state agency CNA registry website, on 01/14/25, showed NA L was not listed as a CNA. 6. Review of a facility list of current nurse aides showed NA C with an initial hire date of 07/13/23 and a rehire date of 04/09/24. Review of the facility's October 2024, November 2024, and December 2024, showed NA C scheduled to work. Observation and interview on 01/08/25, at 4:00 P.M., showed NA C provided direct care to residents and said he/she had been working since April and planned to take certification test in January. Review of the state agency CNA registry website, on 01/14/25, showed NA C was not listed as a CNA. 7. During an interview on 01/13/25, at 12:41 P.M., the CNA Instructor said the following: -There are no nurse aide training classes currently at the facility; -He/she completed the last NA class on 09/28/24; -There were no upcoming classes for nurse aide training scheduled; -There are two nurse aides from the September class that have not tested ; -Nurse aides should become certified within 120 days or be reclassified in another position; -Nurse aides should be working with another CNA or licensed nurse staff. 8. During an interview on 01/13/25, at 3:30 P.M., the Administrator said the following: -There are currently two nurse aides working in the facility that are ready to test; -A nurse aide training class just finished within the last two weeks; -There should not be any nurse aides working in the facility for over four months; -Nurse aides should not work on the floor if certification is not obtained in four months; -He/she will relocate staff to another position in the facility if no certification is obtained within four months. 36974

Based on observation, interview, and record review, the facility failed to ensure all controlled medications were stored per standards of practice when controlled substances were not stored in a locked compartment. The facility's census was 53. Review of the facility policy Controlled Substance Policy, revised October 2022, showed the following: -Controlled substances were subject to special handling, storage, disposal and record-keeping requirements; -Controlled substances in Schedules II, III, and IV were subject to special handling, storage, disposal, and record-keeping requirements. Such drugs were to be accessible only to authorized nursing and pharmacy personnel. The Director of Nursing (DON) was responsible for the control of such drugs; -Drugs listed in Schedules II, III, and IV were to be stored under double-lock conditions; -The key to the separately locked storage area is not the same key that is used to gain access to other drugs; -The medication nurse or certified medication tech (CMT) on duty at the time will maintain possession of the key; -The key must remain the possession of the licensed nurse or CMT that completed the count at all times during their shift. Should it be necessary to give the keys to another licensed nurse or CMT, a count will be done to verify the inventory. A count will be done again when the keys were returned to the original licensed nurse or CMT. 1. Observation on 01/08/25, at 9:20 A.M., of the facility's medication room showed the following; -The medication room refrigerator was unlocked with the lock laying on the cabinet next to refrigerator upon entering the medication room. -The refrigerator contained three 30 milliliter (ml) vials of Ativan Intensol (antianxiety medication/controlled substance) 2 milligram (mg)/ml; -The refrigerator contained four 30 ml vials of morphine sulfate (opioid pain medication/controlled substance) 20 mg/ml. Observation on 01/13/25, at 10:05 A.M., with Registered Nurse (RN) O showed the narcotic refrigerator unlocked with the lock sitting beside refrigerator on the counter and unattended. During an interview on 01/08/25, at 9:25 A.M., Certified Medication Technician (CMT) P said the following: -He/she would advise the DON if the narcotic refrigerator was unlocked; -He/she had seen the refrigerator unlocked, but it does not happen that often; -He/she will lock the refrigerator if it is found to be unlocked. During interviewed on 01/08/25, at 9:30 A.M. and 10:45 A.M., RN O said the following: -Nurses should make sure the narcotics refrigerator is locked; -Refrigerator should only be unlocked when obtaining medication; -There have been times he/she has come in to find refrigerator unlocked; -Narcotics should be kept behind two locks; -He/she counted narcotics this morning with the off going nurse but forgot to lock the refrigerator. 17193

Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when staff failed to perform proper hand hygiene when performing personal cares for two residents (Resident #46 and #38), when staff failed to have an Enhanced Barrier Precautions (EBP-infection control measures used to reduce transmission of resistant organisms) policy, and when staff failed to follow EBP when providing care to one resident (Resident #5) with a wound. The facility census was 53. Review of the facility policy Hand Hygiene, dated 2019, showed the following: -Purpose to cleanse hands to prevent the spread of potentially deadly infections; -Purpose to provide a clean and healthy environment for residents, staff and visitors; -Purpose to reduce the risk to the healthcare provider of colonization (when a microorganism survives on a host without causing disease. This can happen on the skin, in the respiratory tract, or in the gastrointestinal tract) or infections acquired from a resident; -Hand hygiene is the primary means of preventing the transmission of infection. 1. Review of Resident #46's face sheet (admission information) showed the following: -admitted [DATE]; -Diagnoses included dementia (progressive impairment in memory, thinking, and behavior), polyarthritis (joint pain), and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/20/24, showed the following: -Severely impaired cognition; -Toileting and personal hygiene required substantial/maximal assistance. Review of the resident's current care plan showed the resident was incontinent of bladder at times. Observation on 01/13/25, at 10:09 A.M., showed the resident lying in bed as Certified Medication Technician (CMT) P and Nurse Aide (NA) B washed their hands and put on gloves. CMT P and NA B removed the resident's incontinence brief. CMT P took several wet wipes and performed perineal care, then they turned the resident to his/her side, and took thick white barrier cream and applied it between and on the resident's buttocks which were red. The resident's brief was wet with urine. CMT P removed gloves, did not wash or sanitize hands, then put on a new pair of gloves. The CMT then put the incontinence brief, the resident's slacks, and then shoes on the resident. The CMT and NA sat the resident up on the edge of the bed and then transferred the resident to the wheelchair. CMT P then removed his/her gloves and washed his/her hands at the sink. NA B removed his/her gloves and washed his/her hands. During an interview on 01/13/25, at 10:59 A.M., CMT P said they were to wash hands when they go into the resident's room and when they leave the room. They were to wash hands after removing gloves and before putting on gloves. 2. Review of Resident #38's face sheet showed the following: -admitted [DATE]; -Diagnoses included hemiplegia (condition that causes paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect arms, legs, and facial muscles) following a stroke on the right side. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Upper/lower extremity impairment; -Toilet hygiene-dependent. Review of the resident's care plan, revised 4/30/24, showed the resident was incontinent of bowel and bladder. Observation on 01/13/25, at 10:29 A.M., showed Certified Nurse Aide (CNA) A and NA B washed their hands at the sink and put on gloves. NA B pulled the privacy curtain. The resident was in bed. His/her incontinence brief was fully saturated and wet with urine. NA B used the cleansing wipes and wiped down the inner right leg with white barrier cream, then turned the wipe and wiped down the left inner leg that had the white barrier cream on the resident. Both inner legs were deep red in color. NA B cleansed the front perineal area which was covered with the white barrier cream. They turned the resident to his/her side. NA B used several cleansing wipes front to back between the buttocks. There was bowel movement smears inside the buttocks. NA B applied a little barrier cream inside buttocks and along the edge of both buttocks, then applied the cream on the front perineal area and inner right and left leg. CNA A removed gloves and applied a new pair of gloves and then removed the soiled brief. NA B removed gloves, did not sanitize or wash hands, then put on new gloves. The CNA and NA put pants on the resident after applying the incontinence brief. CNA A removed his/her gloves, and put on new pair of gloves without sanitizing or washing hands. NA B assisted CNA A to sit the resident up on the edge of the bed, put a gait belt on the resident, and transfer the resident to the wheelchair while wearing the same pair of gloves. They then removed gloves and washed their hands at the sink. During an interview on 01/13/25, at 10:44 A.M., CNA A said they were to wash hands before and after entering room. If staff take their gloves off, the should wash hands. It doing perineal care, staff will remove gloves and wash hands. He/She changed gloves at times because his/her hands sweat. During and interview on 01/13/25, at 11:09 A.M., NA B said they were to wash hands when they enter and leave a resident's room. He/she should have washed hands after removing gloves after peri care. 49585 4. Review showed the facility did not provide a policy regarding enhanced barrier precautions (EBP). Review of the Centers for Disease Control and Prevention's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 04/02/24, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities; -EBP may be indicated (when contact precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status, infection, or colonization with an MDRO; -Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE and hand hygiene supplies at the point of care; -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE; -Make PPE, including gowns and gloves, available immediately outside of the resident room. Review of the Resident #5's face sheet showed the following: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - a chronic lung disease that blocks airflow and makes it difficult to breathe), diabetes mellitus (a group of diseases that affect how the body uses blood sugar (glucose)), and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Dependent on one staff for transfers, mobility, dressing, and showering; -Had a diabetic ulcer. Review of the resident's care plan, revised on 01/02/25, showed the following: -Dependent on one staff with transfer, dressing, mobility, and hygiene; -Had an abrasion on the left foot at the toe amputation site on 12/29/2024. During an observation on 01/09/25, at 1:40 P.M., the Infection Control Specialist (ICS) entered the resident's room to view a wound on the left foot. The room had no EBP signage. The ICS washed his/her hands and applied gloves, but did not don a gown to provide direct care to resident's wound. During an observation on 01/13/25, at 10:10 A.M., Registered Nurse (RN) O entered the resident's room to observe the wound on the left foot. The room ad no EBP signage. RN entered the resident room's and donned gloves, but did not don a gown to assess wound on resident's foot. During an interview on 01/13/25 at 10:25 A.M., the ICS said EBP are used to protect residents due to an increased risk of infection. EBP should be used for residents with multidrug resistant organisms (MDRO - type of bacteria that is resistant to multiple antibiotics), foley catheters (a thin flexible tube that drains urine from the bladder), tube feeding (a small tube inserted in body to provide nutrition for residents unable to eat or drink by mouth) and intravenous lines. Wounds would be included in EBP if there was significant drainage or an infection present. During an interview on 01/13/25, at 11:00 A.M., Nurse Aide (NA) B said if a resident was on EBP there should be a sign posted on the door. The resident is on EBP because of a wound and has gowns in the room, but no sign. EBP is used to protect residents from bacteria and staff should wear gowns and gloves. During an interview on 01/13/25, at 2:00 P.M., NA D said EBP is when staff wear a gown to protect residents. Staff use EBP for residents with wounds. EBP residents should have a sign in front of room with PPE stored in the room. The resident was on EBP and had a PPE cart in the room, but he/she did not know why. During an interview on 01/13/25, at 2:25 P.M., Certified Medication Technician (CMT) P said staff use EBP for residents with open wounds. EBP signage is posted outside of the door and there is a cart with PPE, such as gowns in gloves to be used. 36974 45190

Based on interview and record review, the facility failed to keep all residents free from misappropriation of resident property when the staff could not account for 30 doses of medication for one resident (Resident #14) that had been signed by staff as being received from the pharmacy. The facility census was 53. Review of the facility policy Abuse, Prevention, and Prohibition, revised 10/2022, showed the following: -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings without the resident's consent; -The facility prohibits misappropriation of resident property; -The owner, licensee, administrator, employee or agent of the facility must prohibit the misappropriation of resident property; -The facility employee who becomes aware of alleged misappropriation of resident property, shall immediately report the matter to the administrator; -The facility administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. 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. 1. Review of Resident #14's face sheet (admission information) showed the following: -admitted [DATE]; -Diagnoses included anxiety disorder. Review of the resident's current physician's orders, on 01/13/25, showed an active order for alprazolam (used to treat anxiety) 0.5 milligram (mg). Staff to administer 0.5 mg by mouth at bedtime for anxiety. Review of the facility's investigation, dated 12/30/24, showed the following: -The resident's alprazolam 0.5 mg had not been delivered to facility. Staff ordered the medication before 12/19/24. The staff had been pulling this medication daily from the emergency kit) to provide to the resident; -The Director of Nursing (DON) called the local pharmacy who informed the DON the medication was delivered on 12/19/24. Licensed Practical Nurse (LPN) N signed the count sheet. The pharmacy sent a copy to the DON which showed LPN N signed for the medication; -The DON spoke with Certified Medication Technician (CMT) P who said he/she put away the medications that were delivered on 12/19/24, but he/she did not receive any medications for the resident. CMT P said the pharmacy should send a narcotic count sheet with all narcotic medications each time they deliver, however there had been occasions the pharmacy did not do this. CMT P said he/she just created a narcotic sheet and put the medication away when the pharmacy did not send a narcotic sheet with the medication; -The DON and CMT P searched both medication carts, the narcotic box, and the medication room and there was no record of the medication in the facility. The narcotic sheet was not located and the medication was never logged into the narcotic book; -The DON interviewed several nurses who worked on 12/19/24, and no staff were aware of any medication delivered during the day and had not seen any medications left sitting out at the nurse's desk or in the medication room; -The DON notified the Administrator who made a self-report to Department of Health and Senior Services for missing medication; -The DON spoke to LPN N who confirmed he/she signed medications in on 12/19/24. LPN N said he/she did not count the medications individually and did not see any narcotic medications with the white narcotic sheet around the medication. LPN N was unaware there was any narcotic medications delivered on 12/19/24 because that was how he/she identified narcotic medications upon delivery. LPN N said he/she put all delivered medications in the medication room for CMT P to put them away. The DON re-educated LPN N to properly count the medications and check them into the facility. The DON then suspended LPN N for failure to follow policy and procedure; -The DON notified and received approval from the resident's physician to order another card of medication with the facility to pay for the resident's medication and notified the resident's guardian. -The Administrator did made a self-report to the local police department for the missing medication. Review of the pharmacy's delivery log, dated 12/19/24, showed a quantity of 30 alprazolam 0.5 mg delivered to the facility and signed for by LPN N. Review of the written police voluntary statement dated 01/03/25, at 3:15 P.M., showed the following: -On 12/30/24, the DON was made aware of a card of medication missing which was the resident's alprazolam 0.5 mg; -The pharmacy sheet, dated 12/19/24, had this medication listed as delivered to the facility; -The nurse failed to properly check medication in the medication and the nurse signed to accept medications; -There is no record of the alprazolam 0.5 mg 30 tablets medication in the building. During an interview on 01/07/25, at 11:45 A.M., the resident said he/she goes up to the nurses' station to get his/her medications. For a while, the nurses had to get the alprazolam 0.5 mg medication from the e-kit since the medication card did not arrive from the pharmacy. During interviews on 01/09/25, at 10:30 A.M. and 12:16 P.M., CMT P said the following: -The pharmacy makes a delivery between 4:30 P.M. and 5:15 P.M. depending on how they are running. The narcotic medications are delivered with regular medications. They usually have a narcotic sheet wrapped around the narcotic medication card. -About 3 weeks ago, he/she was doing medications with the dinner pass. He/she was working with LPN N. He/She finished the medication pass with dinner and went into medication room and saw medications on the back counter to put away. He/She separated medications by resident name. -He/she was off work a few days and when he/she returned the resident let him/her know he/she wasn't getting his/her alprazolam at night. Some nights they were pulling it from the emergency medical kit. -If the alprazolam was ordered within the week before, it should have been delivered on 12/19/24 and should have been there in the facility. -LPN N always left the medications on the counter in the medication room. During an interview on 01/09/25, at 10:49 A.M., LPN N said the following: -When the pharmacy delivered medications, there was a sheet with all the medications listed. He/She looks at each one to see if all medications were there. He/She signs the sheet and keeps the copy and will sign the other copy and places it into a binder. -Narcotic meds come in the same tub or basket. There is a white sheet wrapped around the medication card usually. -He/She did not remember the particular day on 12/19/24. The pharmacy delivery always come in right after dinner, and they are trying to get residents laid down. -Around 12/19/24, the pharmacy delivered medications in a tub and he/she did not count them. He/she usually takes narcotic medications and puts them in the narcotic drawer and locks them up. He/she didn't remember if he/she laid it on the counter in the medication room, but he/she does not usually set narcotics on counter. He/she usually always counts the medications. -If he/she was the only nurse, and things got busy, he/she would have put it on the counter in the locked medication room. During an interview on 01/09/25, at 11:15 A.M., the DON said the following: -The resident had asked if his/her medication had come in from the pharmacy on 12/30/24, which was 11 days since the resident's medication card of alprazolam went missing and the nurses were taking the alprazolam 0.5 mg medication from the emergency medication kit. -The local pharmacy was to deliver the alprazolam 0.5 mg medication card of 30 tablets on 12/19/24; -The DON looked for the medication and was not able to find it. She found the alprazolam 0.5 mg was pulled each night from emergency medication kit. -LPN N's signature was on the pharmacy delivery paper. -The nurse was to checkmark each medication and he/she did not do this. -The DON called the local pharmacy to confirm the alprazolam 0.5 mg card of 30 was sent out on 12/19/24. During interview on 01/07/25, at 12:34 P.M., the Administrator said they did an investigation and interviewed nurses and CMTs. They were not sure what happened to the resident's alprazolam. MO00247293

Based on interview and record review, the facility failed to implement an abuse/neglect policy that ensured all reported allegations of possible abuse were reported to the State Survey Agency (Department of Health and Senior Services-DHSS) within two hours when staff failed to report a documented allegation of verbal abuse involving two residents (Resident #7 & #35). The facility census was 53. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, undated showed the following: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. -The facility administrator is designated as the facility abuse coordinator. -Resident abuse must be reported to the administrator immediately. Review of the facility policy titled, Reporting Policy, undated,showed the following: -The facility will ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property are reported immediately to the supervisor. The supervisor will then report to the Administrator or Director of Nursing (DON); -The results of all investigations will be reported to the Administrator or DON and to the other officials in accordance with state and local laws, as well as federal regulations; -Initial report to state certifying agency will be made immediately, but not later than two hours if allegation involves abuse or serious bodily injury, or not later than 24 hours if the allegation does not involve abuse or does not result in serious bodily injury. 1. Review of Resident #7's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), generalized anxiety disorder, intermittent explosive disorder (a mental health condition that causes sudden and impulsive episodes of anger, aggression, or violence that are disproportionate to the situation), past history of alcohol use, drug induced myopathy (a disease that affects the muscled that control voluntary movement in the body), and drug induced subacute dyskinesia (a disease affecting the nervous system often caused by long-term use of psychiatric drugs). Review of Resident #7's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 11/03/24, showed the following: -Cognitively intact; -Resident experienced delusions and hallucinations; -Resident had physical and verbal behavior symptoms towards others, which significantly interfere with the resident's participation activities or social interactions and significantly interrupts care or living environment. Review of the Resident #7's care plan, last revised on 01/06/25, showed the following: -Resident has behavior problems which included pulling fire alarm and laughing about it, inappropriate behaviors towards male caregivers, yelling and cursing at staff and others. -Resident will try to intimidate and bully caregivers. -Resident will urinate on the floors and on the beds in his/her room. -Resident will refuse medications and be socially inappropriate. Review of Resident #35's quarterly MDS showed the following: -admitted [DATE]; -Moderate cognitive impairment; -Diagnoses included stroke, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), depression, schizophrenia (a disorder that affects a person's ability to think, feel, and behave correctly), and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -Used a wheelchair; -Independent with most ADL's. Review of the Resident #7's nursing note dated 12/09/24, at 9:40 P.M., showed Registered Nurse (RN) U noted during the smoke break Resident #7 attempted to take a cigarette back inside when Resident #35 saw this and reminded him/her that residents are not allowed to take cigarettes inside. Resident #7 replied stating, I will cut your throat. This threat was head by other residents outside smoking. The resident denied saying this. He/she was advised making threats are very serious and not tolerated. Resident #7 verbalized understanding and again denied saying anything like that. (Staff did not document notifying management or DHSS of the allegation of verbal abuse.) Review of facility records showed staff did not provide documentation of reporting the allegation of possible abuse to DHSS. Review of DHSS records show DHSS did not have record of the facility reporting allegation of Resident #7 threatening to cut Resident #35's throat. During an interview on 01/14/25, at 7:59 A.M., Registered Nurse (RN) U said the following: -On 12/09/24, when residents were coming in from the 9:00 P.M., smoke break, Resident #35 reported to him/her Resident #7 was attempting to bring a cigarette into the facility. Resident #35 told Resident #7, he/she was not supposed to bring a cigarette back inside the facility; -Resident #7 then told Resident #35, I will cute your throat; -Another resident reported he/she also heard the threat; -He/she ensured the residents were separated and talked with Resident #7 who denied making the comment; -He/she immediately notified the Administrator and DON via text message and made a nursing note; -He/she considered it to be abusive behavior which needed to be reported to management; -He/she was unsure if the allegation should have been reported to the state; however, abuse allegations are to be reported to the state agency within two hours. -Resident #7 later admitted to making the threat and apologized. During an interview on 01/13/25, at 12:00 P.M., Certified Nurse Assistant (CNA) A said the following: -If a resident threatened to cut another resident's throat, he/she would separate the residents and report immediately to the Director of Nursing (DON) or charge nurse or both; -He/she would consider a resident threatening to cut another resident's throat to be abuse and should be reported to the state within two hours. During an interview on 01/13/25, at 12:08 P.M., Certified Medication Technician (CMT) P said he/she would consider a resident threatening to cut another resident's throat to be abuse, and he/she would report this to the Administrator immediately. The state should be notified within two hours. During an interview on 01/13/25, at 12:17 P.M., RN O said the following: -He/she was not aware of any residents threatening or being abusive to other residents; -He/she would consider a resident threatening to cut another resident's throat to be abusive; -He/she would separate residents and report to Administrator immediately and the state should be notified within two hours. During an interview on 01/13/25, at 12:30 P.M., the Infection Prevention Specialist (IPS) said the following: -She was not aware of any resident-to-resident abuse allegations, including a resident threatening to cut another resident's throat; -She would consider this to be abuse, and would separate residents, report to the DON and Administrator immediately; -The state should be notified within two hours and an investigation should be completed. During an interview on 01/13/25, at 1:24 P.M., Social Services Director (SSD) said the following: -She was not aware of any resident-to-resident abuse allegations and no grievances had been filed, including a resident threatening to cut another resident's throat; -She would consider this to be abuse and would report immediately to the DON and Administrator; -The state agency should be notified within two hours and an investigation should be completed. During an interview on 01/13/25, at 1:35 P.M., Business Office Manager (BOM) said the following: -She has no knowledge of any resident-to-resident abuse allegations, including a resident threatening to cut another resident's throat; -She would consider this to be abusive and would report immediately to management; -She would depend on management to report to the state agency within two hours if applicable. During an interview on 01/13/25, at 1:45 P.M., the Administrator said the following: -She had not received any reports of a resident being abusive to other residents; -She would consider a resident threatening to cut another resident's throat to be abusive and should be reported to her and then to the state within two hours; -She was not aware of the progress note from 12/09/24, alleging the resident told another resident he/she would cut the resident's throat; -This allegation was not reported to her.

Based on interview and record review, the facility failed to implement an abuse/neglect policy that ensured staff completed and documented a timely investigation of all reported allegations of possible abuse when staff failed to complete a documented investigation of a documented allegation of verbal abuse involving two residents resident (Resident #7 and #35). The facility census was 53. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, undated, showed the following: -Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals; -The facility administrator is designated as the facility abuse coordinator and will be responsible for overseeing the Abuse Prevention and Prohibition Program and directing any abuse investigation; -Resident abuse must be reported to the administrator immediately. The administrator will do a thorough investigation of alleged violations of individual rights and document appropriate action; -A thorough investigation may include notifying resident representatives, provider, medical director, state agency, and even law enforcement if applicable, utilizing the resident abuse investigation teams, complete a report of alleged resident abuse within required timeline, resident assessment by a licensed nurse, thorough chart review, interviews with residents and employees, follow up counseling by social services to victims of abuse or neglect, and review by the regional nurse; -Resident to resident altercations: when another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's physical and mental status, care plan, monitor behaviors and notify the provider for a determination regarding treatment and/or discharge options. Residents will be referred for behavior management when indicated. The safety of other residents and employees of the facility is primary concern. 1. Review of Resident #7's face sheet (a brief resident profile) showed the following: -admitted [DATE]; -Diagnoses included schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), generalized anxiety disorder, intermittent explosive disorder (a mental health condition that causes sudden and impulsive episodes of anger, aggression, or violence that are disproportionate to the situation), past history of alcohol use, drug induced myopathy (a disease that affects the muscled that control voluntary movement in the body), and drug induced subacute dyskinesia (a disease affecting the nervous system often caused by long-term use of psychiatric drugs). Review of Resident #7's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 11/03/24, showed the following: -Cognitively intact; -Resident experienced delusions and hallucinations; -Resident had physical and verbal behavior symptoms towards others, which significantly interfere with the resident's participation activities or social interactions and significantly interrupts care or living environment. Review of the Resident #7's care plan, last revised on 01/06/25, showed the following: -Resident has behavior problems which included pulling fire alarm and laughing about it, inappropriate behaviors towards male caregivers, yelling and cursing at staff and others. -Resident will try to intimidate and bully caregivers. -Resident will urinate on the floors and on the beds in his/her room. -Resident will refuse medications and be socially inappropriate. Review of Resident #35's quarterly MDS showed the following: -admitted [DATE]; -Moderate cognitive impairment; -Diagnoses included stroke, hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles), depression, schizophrenia (a disorder that affects a person's ability to think, feel, and behave correctly), and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); -Used a wheelchair; -Independent with most ADL's. Review of the Resident #7's nursing note dated 12/09/24, at 9:40 P.M., showed Registered Nurse (RN) U noted during the smoke break Resident #7 attempted to take a cigarette back inside when Resident #35 saw this and reminded him/her that residents are not allowed to take cigarettes inside. Resident #7 replied stating, I will cut your throat. This threat was head by other residents outside smoking. The resident denied saying this. He/she was advised making threats are very serious and not tolerated. Resident #7 verbalized understanding and again denied saying anything like that. (Staff did not document notifying management or or beginning an investigation.) Review showed the facility did not provide a written investigation into the allegation of possible abuse. Review of Department of Health and Senior Services (DHSS) records showed a written investigation into the allegation of possible abuse was not received. During an interview on 01/14/25, at 7:59 A.M., Registered Nurse (RN) U said the following: -On 12/09/24, when residents were coming in from the 9:00 P.M., smoke break, Resident #35 reported to him/her Resident #7 was attempting to bring a cigarette into the facility. Resident #35 told Resident #7, he/she was not supposed to bring a cigarette back inside the facility; -Resident #7 then told Resident #35, I will cute your throat; -Another resident reported he/she also heard the threat; -He/she ensured the residents were separated and talked with Resident #7 who denied making the comment; -He/she immediately notified the Administrator and DON via text message and made a nursing note; -He/she considered it to be abusive behavior which needed to be reported to management; -Resident #7 later admitted to making the threat and apologized. During an interview on 01/13/25, at 12:00 P.M., Certified Nurse Assistant (CNA) A said the following: -If a resident threatened to cut another resident's throat, he/she would separate the residents and report immediately to the Director of Nursing (DON) or charge nurse or both; -He/she would consider a resident threatening to cut another resident's throat to be abuse. During an interview on 01/13/25, at 12:08 P.M., Certified Medication Technician (CMT) P said he/she would consider a resident threatening to cut another resident's throat to be abuse. During an interview on 01/13/25, at 12:17 P.M., RN O said the following: -He/she is not aware of any residents threatening or being abusive to other residents; -He/she would consider a resident threatening to cut another resident's throat to be abusive. During an interview on 01/13/25, at 12:30 P.M., the Infection Prevention Specialist (IPS) said the following: -She was not aware of any resident-to-resident abuse allegations, including a resident threatening to cut another resident's throat; -She would consider this to be abuse, and would separate residents, report to the DON and Administrator immediately; -An investigation should be completed. During an interview on 01/13/25, at 1:24 P.M., Social Services Director (SSD) said the following: -She was not aware of any resident-to-resident abuse allegations and no grievances have been filed, including a resident threatening to cut another resident's throat; -She would consider this to be abuse and would report immediately to the DON and Administrator; -An investigation should be completed. During an interview on 01/13/25, at 1:35 P.M., Business Office Manager (BOM) said the following: -She had no knowledge of any resident-to-resident abuse allegations, including a resident threatening to cut another resident's throat; -She would consider this to be abusive and would report immediately to management. During an interview on 01/13/25, at 1:45 P.M., the Administrator said the following: -She has not received any reports of a resident being abusive to other residents; -She would consider a resident threatening to cut another resident's throat to be abusive and should be reported to her and then to the state within two hours; -She was not aware of the progress note from 12/09/24, alleging the resident told another resident he/she would cut the resident's throat; -This allegation was not reported to her, and the required investigation was not completed.

Based on observation, interview, and record review, the facility failed to routinely monitor for edema (swelling caused by too much fluid trapped in the body tissues), failed to notify the physician of changes in weight and edema, and failed to apply interventions as ordered for one resident (Resident #2). The facility census was 53. Review of a facility policy titled Significant Condition Change and Notification, undated, showed the following: -Facility to ensure the resident's family and/or representative and medical practitioner are notified of the following resident changes: new wounds, bruises, or skin tears; abrupt onset of edema; onset of swelling; or a need to significantly alter treatment. When any of the listed situations exists, the nurse will contact the resident representative and their medical practitioner; -Medical practitioner contacted immediately for emergencies. Non-emergency practitioner notifications may be made the next morning if situation occurs late evening or night shift; -Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given to the medical practitioner; -All significant changes will be recorded in resident record; -Charting will include an assessment of the resident's current status; -Charting will be done each shift for 72 hours; -Change of condition is reviewed by Director of Nursing (DON). 1. Review of the Resident #2's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included schizophrenia (a mental illness that affects how a person thinks, feels, and behaves), dementia (condition that makes someone unable to remember, think clearly, or make decisions), diabetes mellitus, and chronic venous hypertension (condition in which veins valves in the legs function improperly causing swelling and skin changes) Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 12/19/24, showed the following: -Moderate cognitive impairment; -Dependent on one staff for transfers, mobility, dressing, and showering; -Resident not taking a diuretic (medication to reduce fluid buildup in the body). Review of the resident's care plan, revised on 01/02/25, showed the following: -Dependent on one staff with transfer, dressing, and hygiene; -Monitor, document, and report to physician as needed for edema or weight gain of over two pounds a day; -Notify physician of significant weight loss or gain; -Inspect lower extremities weekly for redness, weeping, edema, tenderness, or puffiness; -Tubi grip (elasticated tubular bandage to assist with edema) stockings to bilateral lower extremities as resident allows. Review of the resident's nursing admission assessment, dated 02/15/24, showed staff noted the resident did not have edema. Review of the resident's admission paperwork, dated February 2024, showed a weight of 230.2 pounds. Review of the resident's Physician Order Sheet (POS) showed an order, dated 08/28/24, for Tubi grips to bilateral lower legs for increased edema as needed. (There was no order for a diuretic.) Review of the resident's weekly skin assessments showed staff did not document related to the resident having edema until 08/29/24. Review of the resident weekly skin assessment, dated 08/29/24, showed resident baseline is high edema to bilateral lower legs. Tubi grips applied to bilateral lower legs to help aid in scant redness and 3 to 4 plus edema noted. Review of the resident's November 2024 weight showed a weight of 235.8 pounds (an increase of 5.6 pounds since admission). Review of the resident's November 2024 progress notes showed staff did not document notification of the physician of the resident's increase in weight. Review of the resident's weekly skin assessment, dated 12/05/24, showed resident had baseline 3 to 4 plus edema in bilateral legs and wore Tubi grips to assist in edema. Review of the resident's weekly skin assessment, dated 12/19/24, showed resident had baseline 3 to 4 plus edema in bilateral legs and wore Tubi grips to assist in edema. Bilateral feet area swollen and red. (Staff did not document physician notification of the new redness noted to the resident's feet.) Review of resident's December 2024 Treatment Administration Record (TAR) showed an order to apply Tubi grips to bilateral lower legs for edema as needed. Staff did not document to indicate Tubi grips used during the month. Review of resident's December 2024 weight showed a weight of 245.6 pounds (a gain of 9.8 pounds in one month). Review of the resident's December 2024 progress notes showed staff did not document notification of the physician of the resident's increase in weight, the redness of the resident's feet, or the resident's Tubi grips not being applied. Review of resident's January 2025 Treatment Administration Record (TAR) showed an order to apply Tubi grips to bilateral lower legs for edema as needed. Staff did not document to indicate Tubi grips used during the month. Review of the resident's December 2024 progress notes showed staff did not document notification of the physician of the resident's Tubi grips not being applied. During an observation and interview on 01/13/25, at 9:39 A.M., the resident was in his/her room sitting in a wheelchair with no foot pedals. The resident's ankles appeared swollen, and the resident's pants appear visibly wet on the back side of right calf. No Tubi grips were in place. Resident said the staff were not doing much for his/her legs. During an observation on 01/13/25, at 2:40 P.M., the resident sat in his/her wheelchair with Tubi grips in place and a dressing to the right leg shin dated 01/13/24. Registered Nurse (RN) O said the resident's left leg was red and a little warm on the shin with scattered dried scabs noted. The left leg appeared to have + 1 pitting edema from the ankle to the knee and +2 to 3 pitting edema on the foot. The right leg had a small, popped blister with another small fluid filled blister noted in the middle of the shin. The right leg had + 2 pitting edema from the ankle to the knee and the foot had + 1 pitting edema. The shin area appeared red, but was not warm. During an interview on 01/13/25, at 10:00 A.M., Occupational Therapist Aide (OTA) W said the resident's legs were hot, and the back of his/her legs were wet through the pants. The right leg was swollen, red in color, scaly, and hot to the touch. Staff encouraged the resident to elevate legs due to swelling. The wound nurse puts Tubi grips on the resident sometimes. He/she was unable to find the Tubi grips in the resident room at that time. During an interview on 01/13/25, at 11:00 A.M., Nurse Aide (NA) B said the resident's legs were swollen and red with flaky skin when he/she observed them two weeks ago. During interviews on 01/13/25, at 10:10 A.M. and 2:40 P.M., Registered Nurse (RN) O said the following: -He/she would contact the physician for a resident with pitting edema to obtain an order for diuretics, compression stockings, or Tubi grips; -The wound nurse was responsible for applying Tubi grips to residents; -He/she saw the resident's legs a couple times last month and they had edema; -He/she contacted the physician due to possible cellulitis and was advised to elevate his/her legs and monitor; -He/she had not observed the resident with weeping edema (swelling that causes fluid to leak through the skin); -Each resident should have a weekly assessment conducted by the nurse; -The resident had an order for Tubi grips, but there is no documentation that they were applied on the TAR. During an interview on 01/13/25, at 10:25 A.M., the Infection Control Specialist said the following: -The resident had non pitting edema; -The resident had weeping edema with red, dry skin to the right leg, and it is possibly cellulitis (bacterial skin infection); -He/she notified the physician due to the resident possibly having cellulitis; -He/she also observed resident had two open areas to the right leg, one on the inner calf measuring 2.2 centimeters (cm) by 1.1. cm by 0.1 cm and one on the shin measuring 1.5 cm by 1.0 cm by 0.1 cm; -He/she cleaned and applied a dressing to the wounds and then applied Tubi grips; -Resident has weeping edema that comes and goes; -Resident is on a diuretic; -He/she was responsible for applying Tubi grips for residents; -The resident can wear Tubi grips continuously, but they were not on today. During an interview on 01/13/25, at 3:30 P.M., the Administrator said staff should encourage interventions such as elevation of extremities for residents with edema. Staff should advise the nurse of any resident with edema. The nurse is responsible for notifying the physician. The nurse should document in the TAR for any treatments such as Tubi grip application. If a treatment is not documented then it was not completed.

Based on observation, interview, and record review, the facility staff failed to ensure an environment as safe and as free from accident hazards as possible when staff failed to complete a safe transfer, as care planned, for one resident (Resident #46) and when staff failed to care plan and transfer one resident (Resident #38) who was non-weight bearing in a safe fashion. The facility census was 53. Review of the facility policy Safe Lifting and Movement of Residents, reviewed 02/2021, showed the following: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding safe lifting and moving of residents; -Manual lifting of residents shall be eliminated when feasible; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices. 1. Review of Resident #46's face sheet (admission information) showed the following: -admitted [DATE]; -Diagnoses that included dementia (progressive impairment in memory, thinking, and behavior), polyarthritis (joint pain), anxiety, and muscle weakness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/20/24, showed the following: -Severely impaired cognition; -Upper extremity impaired on one side; -Transfer from bed to wheelchair required substantial/maximal assistance (helper does more than half the effort). Review of the resident's care plan, dated 08/29/24, showed staff to use a gait belt (used to assist with transfer and prevent falls for weight bearing persons) at all times to transfer the resident. Observation on 01/13/25, at 10:09 A.M., showed Certified Medication Technician (CMT) P and Nurse Aid (NA) B sat the resident up on the edge of the bed to assist the resident to the wheelchair. With one arm, CMT P went underneath the resident's arm on one side and NA B put one arm beneath the resident's arm on the other side. CMT P held on to the back of the resident's pants and lifted the resident up with his/her arms and sat the resident in his/her wheelchair. The resident's feet touched the floor during the transfer. They both washed hands and then NA B wheeled the resident out of the room. (Staff did not use a gait belt to assist with the transfer as care planned.) During an interview on 01/13/25, at 10:59 A.M., CMT P said the resident did bear a little weight like 25%. He/She did not bear weight 75% of the time. Any time they try to use the gait belt, the resident gets upset. He/she should not pull up on the resident's pants to transfer the resident. During interview on 01/13/25, at 1:09 A.M., NA B said he/she did lift beneath the resident and tried not to hold on to back of her pants to transfer, but ended up doing this anyway because the resident did not bear much weight. During an interview on 01/13/25, at 12:39 A.M. Registered Nurse (RN) O said the resident ambulated with a walker when admitted to the facility. He/She fell and broke an arm, had increased pain, and declined. He/She did take part in therapy and was walking with a walker, then became depressed, and dementia had progressed. He/She can stand up and his/her knees won't buckle. He/She can be toileted. 2. Review of Resident #38's face sheet showed the following: -admitted [DATE]; -Diagnoses included hemiplegia (condition that causes paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect arms, legs, and facial muscles) following a stroke on the right side. Review of the resident's care plan, revised 04/30/24, showed transfer with staff assistance. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Upper/lower extremity impairment; -Resident was dependent on staff for transfer from bed to wheelchair Observation on 01/13/25, at 10:29 A.M., showed Certified Nurse Aide (CNA A) and NA B assisted the resident to sit up on the edge of the bed. NA B asked for a gait belt and CNA A got one from behind the door. CNA A put gait belt around resident. Both CNA A and NA B both took one arm and went under the resident's arm on both sides of him/her, and held on to the gait belt in the back of the resident and then lifted the resident to the wheelchair. The resident's knees were both bent and stiff during the transfer. The resident's feet did not touch the floor. During interview on 01/13/25, at 10:43 A.M., NA B said sometimes the resident will help with his/her left legs but today, most of his/her weight was on his/her arms. During interview on 01/13/25, at 10:43 A.M., CNA A said most of the resident's weight was on his/her arms. During an interview on 01/13/25, at 12:39 A.M., RN O said the resident was a two-assist transfer. There was residual (what remains) from his/her stroke on the right side. He/She didn't think the resident bore weight. The resident shouldn't be a gait belt transfer. The resident had not declined or improved. 3. During an interview on 01/13/25, at 12:39 A.M. RN O said a resident's transfer should be in their care plan. There was a sheet that showed if a resident was a two person transfer, gait belt, walker and if there is a change whether they got better or they got worse with how they transferred. If they decline, they speak to therapy to assess them. They do try to do walk to dine. If a transfer is unsafe for residents and staff, they were to use a mechanical hoyer lift. 4. During interview on 01/13/25, at 2:23 P.M., the Administrator said the following: -If staff were to check and a resident was weak, the aide can go get the nurse or get assistance; -If staff were uncertain about how to transfer a resident, they should go ask the nurse; -If there was a change in the residents condition or maybe they had been sick, staff should get therapy involved; -Staff can always get more help if needed and use two staff to transfer the resident; -If a resident was not bearing weight, they should be a mechanical lift; -If the transfer could hurt the resident or staff, they were to use a gait belt.

Based on observation, interview, and record review, the facility failed to ensure food was served in accordance with standards of practice when staff had bare hand contact with food and food contact surfaces while assisting residents with meals. The facility census was 53. Review of the facility policy Hand Hygiene, dated 2019, showed the following: -The purpose was to cleanse hands to prevent the spread of potentially deadly infections; -The purpose was to provide a clean and healthy environment for residents, staff and visitors; -Hand hygiene was the primary means of preventing the transmission of infection. Review of the 2022 Food Code, by the Food and Drug Administration (FDA), showed the following: -Bare hand contact with ready-to-eat foods can contribute to the transmission of food borne illness; -There should be no bare hand with ready-to-eat food. 2. Observation on 01/08/25, at 12:12 P.M., during the lunch meal service, showed the following: -Nurse Assistant (NA) B was in the dining room talking to a resident and touching the resident's clothing while rubbing the resident's shoulder; -NA B did not perform hand hygiene and went to obtain a straw for another resident, opened the straw, and placed the straw in the resident's cup, touching the straw with his/her bare hands; -NA B did not perform hand hygiene and went to talk to another resident and touched the resident's clothing while rubbing the resident's back; -NA B did not perform hand hygiene and returned to the resident with the straw, picked up the cup and gave the resident a drink, touching the straw with his/her bare hand in the process. Observations on 01/08/25, at 12:21 P.M., during the lunch meal service, showed NA C assisting a resident with eating. NA C was giving the resident a bite of chicken by holding a whole piece of chicken with his/her bare hand and placing it near the resident's mouth for the resident to take a bite. During an interview on 01/09/25, at 1:04 P.M., Dietary Aide M said staff should sanitize their hands in between serving each resident food and drink. During an interview on 01/09/25, at 1:07 P.M., the Dietary Manager said staff should sanitize hands after every third plate and drink is passed to residents. During an interview on 01/08/25, at 1:27 P.M., NA B said the following: -Staff should use hand sanitizer between serving residents drinks and between assisting residents with eating; -Staff should wear gloves when assisting residents with eating and should not touch food with bare hands; -Staff should not touch residents' clothing and then assist a resident with drinking or eating without performing hand hygiene first. During an interview on 01/08/25, at 4:00 P.M., NA C said the following: -Staff should perform hand hygiene in between passing drinks to residents; -Staff should wear gloves when assisting residents with eating and should change gloves and sanitize in between residents; -Staff should not touch food with bare hands while assisting residents with eating. During an interview on 01/13/25, at 10:25 A.M., the Infection Control Specialist (ICS) said the following: -Staff should perform hand hygiene between serving residents at meal times; -Staff should not touch resident food unless using silverware. During an interview on 01/13/25, at 12:00 P.M., CNA A said the following: -Staff should perform hand hygiene in between assisting residents with eating; -Staff should wear gloves when assisting residents with eating; -Staff should perform hand hygiene after touching a resident's clothing and before assisting another resident with eating/drinking or passing trays/drinks. During an interview on 01/13/25, at 2:25 P.M., Certified Medication Technician (CMT) P said the following: -Staff should perform hand hygiene after any resident contact; -Staff should not touch resident food, gloves should be used if needed. During an interview on 01/13/25, at 12:17 P.M., Registered Nurse (RN) O said the following: -Staff should perform hand hygiene after touching a resident and before assisting another resident with eating during mealtimes; -Staff should not touch food with bare hands while assisting residents with eating. During an interview on 01/13/25, at 1:45 P.M., the Administrator said the following: -Staff should perform hand hygiene in the dining room in between assisting residents with eating/drinking; -Staff should perform hand hygiene after touching a resident's person and before assisting another resident with eating/drinking; -Staff should not touch food with bare hands when assisting residents with eating,

Based on interview and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff member (Certified Nursing Assistant (CNA) B) placed his/her hand close to one resident's (Resident #1) mouth while providing cares to the resident to muffle the sound of the resident yelling. Four residents were sampled out of a facility census of 50. Review of the facility's policy titled Resident Rights, undated, showed the following: -Residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility; -A facility must treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance or enhancement of her quality of life, recognizing each resident's individuality. Facility must protect and promote rights of resident; -Residents have a right to be treated with respect and dignity. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included anxiety, dementia, and depression. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/06/24, showed the following: -The resident had severe cognitive impairment; -The resident had no behaviors; -The resident required maximum assistance from staff for toilet hygiene and was dependent on staff for personal hygiene, upper and lower body dressing, and bathing; -The resident used a wheelchair for locomotion and required moderate assistance from staff for locomotion; -The resident required maximum assistance from staff for bed mobility and was dependent on staff for all transfers. Review of the resident's care plan, revised 10/29/24, showed the following: -The resident resisted care including taking showers related to diagnoses of anxiety and psychosis. -The resident would yell out inappropriately at times and become combative with staff. -Staff to ask the resident if he/she was in pain or uncomfortable and let the nurse know if he/she was. -Staff to encourage as much participation/interaction by the resident as possible during care activities. -Staff to give the resident a clear explanation of care activities before and as they occur during each staff/resident contact. -If the resident was unable to be redirected, give him/her a few minutes to calm down and return. Review of the facility's investigation, dated 10/31/24, showed the following: -On 10/26/24, at approximately 12:05 P.M., Nursing Assistant (NA) A reported to the Business Office Manager (BOM) that CNA B put his/her hand over the resident's face; -On 10/26/24, the Administrator spoke with NA A about the NA's written statement. The NA stated he/she and the CNA were in the resident's room and were changing the resident. The resident was screaming. The CNA placed his/her hand over the resident's mouth and the NA told the CNA no. The CNA then leaned down and yelled in the resident's ear to shut up. The NA was unsure of which hand the CNA used. The NA said he/she stood on the left side of the resident's bed and the CNA stood on the right side. The CNA held the resident on his/her side while the NA cleaned the resident. When they rolled the resident to his/her back, the CNA leaned forward and told the resident to shut up. The NA did not believe the resident heard the CNA as the resident yelled louder than normal this date. The NA said the CNA then used his/her right hand and placed it above the resident's mouth for a split second and the NA told the CNA no. The CNA said he/she did not mean to actually touch the resident. The NA and CNA got the resident up with the Hoyer lift (mechanical lift); -On 10/26/24, the Administrator contacted the CNA and asked the CNA to come to the facility to discuss the incident. The CNA arrived at the facility at approximately 5:10 P.M. The Administrator and Social Worker went over the CNA's statement. The CNA said he/she went with the NA to assist the resident. The CNA said the resident said in a semi-loud voice that's enough over and over again. The CNA rolled the resident towards him/her while the NA cleaned the resident and when the resident was clean, rolled the resident back to the resident's back. The CNA noticed the NA's tattoo and started a conversation about the tattoo. The CNA said he told the NA to shut up jokingly about the NA's tattoo. The resident continued to yell louder and the CNA leaned to the resident's right ear and asked the resident to please be quiet as he/she could not hear the NA. This had no effect, so the CNA attempted to block the resident's mouth from his/her line of vision with his/her left hand. The CNA said he/she was not attempting to cover the resident's mouth, but because he/she was not looking, he/she accidentally touched the resident's chin with the loose part of his/her glove. The CNA said he/she touched the resident and he/she was sorry and the NA told the CNA that he/she could not do that. The CNA told the NA he/she did not mean to and that it would not happen again. -On 10/30/24, the Administrator, Director of Nursing (DON) and regional team determined resident abuse did not occur, however the resident was not treated with good customer service and the CNA failed to treat the resident with dignity and respect. During an interview on 10/29/24, at 10:42 A.M., NA A said the following: -He/she and CNA B were providing care for the resident; -The resident was yelling because they were changing him/her and this was normal for the resident; -CNA B told the resident to shut up and the resident continued to yell; -CNA B put his hand on the resident's mouth for a split second; -The NA told the CNA not to do this and the CNA said he/she did not mean to touch the resident; -The CNA did not strike the resident, he/she was just trying to get the resident to stop yelling; -He/she and the CNA finished caring for the resident; -He/she found the Business Office Manager (BOM) and reported the incident to the BOM; -He/she did not believe the CNA treated the resident with dignity and respect. During interviews on 10/29/24, at 11:33 A.M., and on 10/31/24, at 1:24 P.M., CNA B said the following: -He/she and NA A were changing the resident; -The resident yelled and the CNA could not hear the NA; -He/she was trying to block the sound of the resident so he/she could hear the NA; -He/she touched the resident's chin with the glove he/she had on his/her hand; -He/she did not tell the resident to shut up, but did tell the NA to shut up in a joking manner; -He/she did not believe it was appropriate to tell a resident to shut up or place a hand over the resident's mouth; -He/she was not going to cover the resident's mouth and was just trying to block the sound with his/her hand so he/she could hear the NA; -He/she did not intend to put his/her hand in the resident's face, but they way it happened, he/she did not treat the resident with dignity and respect; -Staff should treat residents with dignity and respect. During an interview on 10/29/24, at 1:12 P.M., CNA C said staff should treat residents with dignity and respect. He/she did not believe it was appropriate for staff to put a hand in front of a resident's face to muffle the sound. During an interview on 10/29/24, at 1:17 P.M., CNA E said staff should treat residents with dignity and respect. This is the residents' home. He/she did not believe it was appropriate for staff to place their hand in front of a resident's mouth and if they did this would not be treating the resident with dignity and respect. During an interview on 10/29/24, at 1:14 P.M., Registered Nurse (RN) D said staff should treat residents with dignity and respect. He/she believed it was never appropriate to for staff to put a hand in front of a residents face to muffle the sound. During interviews on 10/29/24, at 12:20 P.M. and 1:23 P.M., the BOM said the following: -On 10/26/24, NA A reported to him/her that the NA was in the resident's room with CNA B. The resident was yelling and the CNA leaned over and told the resident to be quiet and started to place his/her hand over the resident's mouth; -The NA reported he/she told the CNA to not do this; -The CNA admitted to putting his/her hand near the resident's mouth to try to muffle the resident's yelling; -The charge nurse assessed the resident and the resident had no injuries and no changes in the resident's behaviors; -CNA B did not treat the resident with dignity and respect; -Staff should treat residents with dignity and respect. This is the residents' home; -He/she did not believe it was appropriate for staff to place their hand in front of a resident's mouth. During an interview on 10/29/24, at 1:31 P.M., the Director of Nursing (DON) said the following: -When he/she spoke with CNA B, the CNA said he/she assisted NA A with changing the resident; -The CNA said he/she was making small talk with the NA and the resident was screaming and he/she asked the resident to be quiet; -The CNA reported he/she placed his/her hand up to block the noise from the resident and accidentally touched the resident's chin; -The CNA reported he/she did not place his/her hand over the resident's mouth; -The DON said the CNA did not treat the resident with dignity and respect; -The CNA should have backed away from the resident, left the resident's room, and attempted to reapproach the resident later; -If, when the CNA approached the resident later, and the resident continued to scream, the CNA should get another staff to perform the cares; -Staff should treat residents like family and with dignity and respect. MO00244168

Based on interview and record review, the facility failed to protect all resident's from misappropriation of property when a staff member had one resident's (Resident #1's) personal cellular phone, in his/her possession. The facility census was 52. Review of the facility policy titled, Abuse, Prevention, and Prohibition Policy, revised November 2018, showed the following: -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 facility prohibits misappropriation of resident property; -The facility will not knowingly employ individuals who have been found guilty of abusing , neglecting, or mistreating residents or misappropriating their properties. 1. Review of Resident #1's significant change Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 11/03/23, showed the following: -admitted [DATE]; -Moderate cognitive impairment; -Dependent on staff assistance for transfers, dressing, toileting, and bathing. Review of the resident's face sheet showed the following: -Readmitted [DATE]; -Diagnoses included chronic kidney disease, heart failure, diabetes, anxiety, and depression. Review of the facility's Misappropriation of Property Self-Report showed the following: -On 01/03/24, a family member of the resident reported the resident's cell phone was missing from the resident's room. Staff searched for cell phone, but were unable to locate the phone; -On 01/04/24, Nurse Assistant (NA) A came to the Administrator concerned one of the other nurse assistants at the facility, NA B, may have stolen the resident's cell phone and given the phone to NA A's child as a gift. NA A denied stealing the phone. Staff obtained the identification number from the cell phone in NA A's possession; -On 01/11/24, NA B spoke with the Administrator and completed a written statement. NA B denied taking the resident's cell phone and denied any knowledge of the phone. The administrator suspended NA B pending the outcome of the investigation; -On 01/12/24, NA A returned the cell phone to the facility; -On 01/25/24, one of the resident's family members contacted their cell phone provider and confirmed the phone NA A returned to the facility belonged to the resident. The Administrator notified the Department of Health and Senior Services (DHSS) and the local police department of the misappropriation of resident property and terminated NA B. During an interview on 01/30/24, at 12:52 P.M., the Administrator said the following: -On 01/03/24, the family of the resident reported the resident's cell phone missing from the resident's room; -Staff attempted to locate the phone in the facility, but were unsuccessful; -On 01/04/24, NA A came to the Administrator and said he/she suspected that a phone given to his/her child as a present from NA B, could be the missing phone and staff brought the phone to the facility; -Several days later, on 1/25/24, a family member of the resident contacted the cellular phone provider and determined the phone brought into the facility by NA A was the resident's phone. The Administrator terminated NA B, who denied stealing the phone from the resident. The Administrator notified the local police and DHSS of the situation. MO00230853