Every finding on record at Strafford Rehabilitation & Health Care Center

Based on interview and record review, facility staff failed to ensure timely notification of each resident's responsible party of changes when the facility failed to notify one resident's (Resident #2) responsible party of the addition of Benztropine (medication used to treat Parkinson's disease (progressive disorder affecting movement, balance, and coordination), nervous, mental, and emotional conditions). The facility had a census of 55.Review of a facility policy titled, Significant Condition Change and Notification, dated December 2024, showed nursing staff are to notify a resident/responsible party and medical practitioner of significant alterations to treatment. Review of Mayoclinic.org drug and supplements section for Benztropine, revised 08/01/26, showed the following information:-The medication had unknown effects in geriatric patients;-The medication requires physician evaluation for determining proper dosage and implementation. 1. Review of Resident #2's face sheet showed the following:-admission of 10/01/21;-An enacted Durable Power of Attorney (DPOA- a legally appointed representative to make financial or medical decisions for incapacitated individuals);-Diagnoses included Alzheimer's Disease (impaired memory and thinking skills), dementia ((a group of symptoms causing loss in thinking, memory, mood, and behavior interfering with daily life) with behavioral disturbance, chronic kidney disease, heart disease, unspecified swelling, high blood pressure, and major depressive disorder (persistent low mood, deep sadness, and loss of interest in activities). Review of the resident's annual Minimum Data Set (a standardized, federally mandated clinical assessment tool), dated 05/07/26, showed the following:-Severe cognitive impairment;-No mood impairment. Review of the resident's care plan, last revised on 05/12/26, showed the following:-The resident's DPOA is in charge of the resident's care;-Staff are to contact the DPOA before making changes to the residents ordered medications. Review of the resident's Physician's Order Sheet (POS), current as of 07/20/26, showed the following orders:-An order, dated 06/23/26, for Benztropine Mesylate 0.5 milligrams (mg), administer 1/2 tablet (0.25 mg) twice daily for vascular dementia with behavioral disturbance;-Behavior/side effect monitoring twice daily. Review of the resident's nurse's notes, dated June 2026, showed the facility did not document DPOA notification regarding the new order for Benztropine. Review of the resident's medication administration record (MAR), dated June 2026, showed the resident received Benztropine as ordered. Review of psychiatric visits documented on 07/01/26 and 07/22/26, showed the assessment plan comments listed the resident's diagnoses of vascular dementia with behavioral disturbance with, resident is having some intense possible akathisia (a movement disorder causing intense, uncomfortable feelings of inner restlessness and powerful urges to move) will try low dose Benztropine 0.25 mg twice daily. Review of the resident's nurse's notes, from July 2026 to current, showed the facility did not document DPOA notification regarding the order for Benztropine. Review of the resident's MAR, from July 2026 to current, showed the resident received Benztropine as ordered. During interview on 08/06/26, at 11:20 A.M., Resident #2 said the following:-The facility should call his/her DPOA for anything regarding his/her care;-He/She does not know what medications or treatments he/she receives. During an interview on 08/07/26, at 10:20 A.M., Nurse Practitioner (NP) A said the following:-He/She visits the facility three times per week and as needed to evaluate residents;-He/She typically contacts the responsible party regarding medication changes;-He/She is unaware of the medication contact procedures utilized by the facility or psychiatric provider. During an interview on 08/07/26, at 2:19 P.M., Certified Medication Technician (CMT) E said the following:-The charge nurse enters new orders in the MAR;-The nurse is responsible for contacting the resident's responsible party for new orders or changes in orders;-The nurse should document the notification of a resident's responsible party in the nurse's notes. During an interview on 08/26/26, at 3:06 P.M., Licensed Practical Nurse (LPN) G said the following:-The Director of Nursing (DON) confirms orders from the physician prior to relaying to a charge nurse for input in the medical record;-The nurse should notify the responsible party of any medication changes and document in the nurse's notes. During an interview on 08/07/26, at 4:04 P.M., LPN C said the following:-The nurse should notify the responsible party regarding new medication orders or changes and document in the nurse's notes;-He/She has forgotten to notify a responsible party and/or document contact in the nurse's notes. During an interview on 08/07/26, at 4:18 P.M., LPN H said the following:-He/She does not recall when Resident #2 was prescribed Benztropine;-LPN C is a charge nurse and is responsible for notifying a resident's responsible party and documenting the contact in the nurse's notes;-LPN C would have been responsible for contacting Resident #2's responsible party. During an interview on 08/07/26, at 4:51 P.M., the DON said the following:-LPN C documented Resident #2's Benztropine order and should have contacted the responsible party;-Nursing staff are responsible for contacting the responsible party and documenting the contact in the nurse's notes. During an interview on 08/07/26, at 5:14 P.M., the Administrator said the nurse should contact the resident's responsible party regarding medication additions or changes and document in the nurse's notes. Complaint 3123908

Based on observation, interview, and record review, facility staff failed to ensure each resident receives treatment as ordered when one resident (Resident #2) did not receive Tubi grips (elastic support bandage used to apply continuous compression and support to extremities) daily as ordered by the Physician. The facility also failed to ensure documentation of daily implementation of the orders within the Treatment Administration Record (TAR) to effectively track completion of treatment orders. The facility had a census of 55.Review of facility records showed the facility did not provide a policy regarding implementation of treatment orders. 1.Review of Resident #2's face sheet showed the following:-admission of 10/01/21;-Diagnoses included Alzheimer's Disease (impaired memory and thinking skills), dementia ((a group of symptoms causing loss in thinking, memory, mood, and behavior interfering with daily life) with behavioral disturbance, chronic kidney disease, heart disease, unspecified swelling, high blood pressure, and major depressive disorder (persistent low mood, deep sadness, and loss of interest in activities). Review of the resident's annual Minimum Data Set (a standardized, federally mandated clinical assessment tool), dated 05/07/26, showed the resident had severe cognitive impairment. Review of the resident's care plan, dated 05/12/26, showed the resident has kidney disease, with interventions including administration of medications as ordered and monitoring for signs and symptoms including swelling. Review of the resident's Physician's Order Sheet (POS), current as of 07/20/26, showed the following orders:-An order, dated 03/25/25, to apply Tubi grips (elastic support bandage used to apply continuous compression and support to extremities) to lower legs in the morning and remove at night for swelling. No order for documentation indicated;-An order, dated 02/05/26, for Tubi grips to lower legs in the morning and remove at night for kidney disease. No order for documentation indicated. Review of the resident's monthly Medication Administration Record (MAR) and Treatment Administration Record (TAR) from May 2026 to August 2026 showed the facility did not document implementation of Tubi Grips. Observation and interview on 08/06/26, at 11:20 A.M., showed the following:-Resident #2 did not have Tubi grips or compression sleeves applied to his/her lower legs;-He/She said the facility should call his/her DPOA for anything regarding his/her care;-He/She did not know what medications or treatments he/she received. Observation on 08/06/26, at 12:08 P.M., showed Resident #2 sitting in the dining room during an activity. The resident did not have Tubi grips or compression sleeves applied to his/her lower legs. Observation on 08/07/26, at 10:40 A.M., showed Resident #2 sat in a chair near the nurse's station office. The resident did not have Tubi grips or compression sleeves applied to his/her lower legs. During an interview on 08/07/26, at 12:33 P.M., the Medical Director said the following:-The facility should document implementation of orders for Tubi grips;-The facility should contact him if there are issues fulfilling an order;-The facility did not notify him regarding issues with implementing Resident #2's Tubi grip orders. During an interview on 08/07/26, 2:06 A.M., Certified Nurse's Aide (CNA) D said the following:-CNA staff place Tubi grips on residents in the morning and the charge nurse removes them at night according to the order;-He/She asked nursing staff multiple times regarding Tubi grips for Resident #2;-Nursing staff told him/her the facility does not have Tubi grips for the resident. During an interview on 08/07/26, at 2:19 P.M., Certified Medication Technician (CMT) E said the following:-CMT's and nurses should document implementation of treatment orders including Tubi grips in the TAR;-The CMT or nurse should document any orders unable to complete in the nurse's notes and contact the physician;-The facility did not have Tubi grips for Resident #2. He/She spoke to nursing concerning the issue, but does not know if the issue was addressed. During an interview on 08/26/26, at 3:06 P.M., Licensed Practical Nurse (LPN) G said the following:-The Director of Nursing (DON) confirms orders from the physician prior to relaying to a charge nurse for input in the medical record;-The nurse should document treatment orders in the TAR as ordered;-Tubi grips should show in the TAR and have a nurse sign off daily to show completion;-He/She did not know of any residents going without Tubi grips;-The nurse should contact the physician and pharmacy immediately if items required to fulfill treatment orders are not available and notify the DON;-The nurse should document all contacts made in the nurse's notes. During an interview on 08/07/26, at 4:04 P.M., LPN C said the following:-The facility does not have Tubi grips for Resident #2 and he/she reported the issue to the DON;-He/She does not know how long the resident has gone without Tubi grips, but has not noticed any concerns;-He/She recently placed an order for the Tubi grips (date unknown), and the Tubi grips should arrive sometime next week;-He/She entered the order for Resident #2's Tubi grips but needs to change the order so it shows in the TAR to allow documentation of completion of the order;-Treatment orders should show in the TAR to allow nursing staff to document implementation of the treatment. During an interview on 08/07/26, at 4:18 P.M., LPN H said the following:-The Medical Director held Resident #2's Tubi grips a few weeks ago due to issues with the facility being unable to obtain the Tubi grips;-He/She does not know if staff documented the hold;-The DON and corporate office are responsible for ensuring treatment items and medications are available and onsite in a timely manner for use. During an interview on 08/07/26, at 4:51 P.M., the DON said the following:-Resident #2's Tubi grip were not available from pharmacy, however just recently became available. The issues obtaining the Tubi grips should have been documented;-Treatment orders such as Tubi grips should show in the TAR and nursing should document completion of orders;-LPN C created the order and did not input properly. During an interview on 08/07/26, at 5:14 P.M., the Administrator said the following:-Treatment orders should show in the TAR, and the nurses are responsible for documenting;-The nurse should contact the physician immediately if medications or treatments are not available and document in the nurse's notes;-She was unaware that Resident #2 was not receiving his/her Tubi grips. Complaint 3123908

Based on interview and record review, facility staff failed to ensure all residents were free from unnecessary drugs when the facility failed to clarify Depakote (Valproic acid-medication used to prevent seizures and stabilize mood) orders with the prescribing physicians and pharmacy for one resident (Resident #1) with two Depakote orders from two different providers (Psychiatrist and Medical Director) prior to administration possibly resulting in excessive Depakote administration which may have contributed to falls. The facility had a census of 55.Review of a facility policy titled, Significant Condition Change and Notification, dated December 2024, showed the following information:-Nursing staff are to notify the medical practitioner of change in level of consciousness such as agitation, lethargy, and sudden lack of responsiveness or manic behavior;-Nursing staff are to document in the medical record each contact attempt, time of attempt, individual contacted by staff, and what information provided staff provided to the medical practitioner. Review of Mayoclinic.org drug and supplements section for Depakote (Valproic acid-medication used to prevent seizures and stabilize mood), revised 08/01/26, showed the following information:-Functions as an anticonvulsant to prevent seizures, treat manic phase of bipolar disorder (manic-depressive illness), and prevent migraine headaches;-Elderly patients are more likely to experience side effects including tremors (involuntary, rhythmic, and oscillatory muscle movement causing shaking or trembling in one or more parts of the body) and drowsiness;-Doses exceeding 250 mg per day typically require division into smaller doses taken two or more times per day;-The medication may cause agitation, irritability, abnormal behaviors, increased suicidal thoughts and depression (persistent low mood, deep sadness, and loss of interest in activities), dizziness and lightheadedness. Review of Drugs.com Depakote dosage, revised 05/31/26, showed the following:-Therapeutic Depakote concentrations for most patients with seizures range between 50-100 micrograms per milliliter (mcg/ml);-Evaluate benefit of improved therapeutic effect with higher doses against the possibility of incidence of adverse reactions. 1. Review of Resident #1's face sheet (basic information sheet) showed the following:-admission date of 06/25/26;-discharge date of 07/09/26 to the hospital;-Diagnoses included dementia (a group of symptoms causing loss in thinking, memory, mood, and behavior interfering with daily life) with agitation, major depressive disorder (persistent low mood, deep sadness, and loss of interest in activities), cognitive and emotional deficits following a ischemic stroke (blood flow restriction to the brain or when a blood vessel in the brain bursts), traumatic subdural hemorrhage with loss of consciousness (a medical emergency where blood gathers between the skull and brain), generalized anxiety (feelings of persistent worry), and long term use of narcotic pain medications. Review of the resident's care plan showed the following:-Resident has falls, confusion, and unawareness of safety needs. Interventions for falls include wearing appropriate footwear when out of bed, ensuring personal items within reach, bed in low position, and fall mat when in bed;-Resident has a behavior problem. Interventions included monitoring of behaviors including location, time of day, persons involved, and behavior situation anticipation of resident needs, staff intervention as needed to ensure safety of others, approach/speak in a calm manner, remove from situation and move to alternate location;-No documentation regarding dementia diagnosis or prescribed medications. Review of the residents Physician's Order Sheet (POS), dated June 2026, showed the following orders:-An order, dated 06/26/26, for Depakote extended 24-hour release tablet 500 milligrams (mg), administer one tablet twice daily, for dementia with agitation, discontinue date of 06/26/26;-An order, dated 06/26/26, for Depakote extended 24-hour release tablet 250 mg, administer three tablets at night (750 mg), discontinue date of 06/26/26;-An order, dated 06/26/26, for Depakote extended 24-hour release tablet 500 mg, administer two tablets twice daily (1000 mg);-An order, dated 06/26/26, for Depakote extended 24-hour release tablet 250 mg, administer one tablet at night;-Monitor and document adverse side effects including falls and signs of sedation every shift;-Therapeutic lab testing for Depakote once every 90 days. Review of the resident's provider progress notes dated 06/26/27, showed the following:-At 7:00 A.M., the Nurse Practitioner (NP) A assessed the resident. He/she documented the resident as emotional with impulsive behavior. The resident was ambulating without assistive device and is slightly unsteady. Physical therapy and occupational therapy to consult for fall assessment and functional status post craniotomy (a surgical operation to remove part of the skull). Wheelchair was made available to resident for ambulating. Stat (immediate) psych evaluation ordered. Alerted staff to possible change in behavior;-At 3:39 P.M., medication order clarification was requested from the provider. The resident was discharged to the facility with Depakote and the order needs clarification for dosing. admission labs need to be completed. Review of the resident's nurse's notes, dated 06/27/26, showed the following:-The resident fell from his/her wheelchair twice. The first fall was witnessed by staff, and the resident was assisted to the floor, no injury. The second fall was witnessed, which resulting in a skin tear on his/her right arm;-The resident voiced complaints of dizziness and headache;-Staff notified NP B, next of kin, nurse manager, and implemented neurological checks (an evaluation used to monitor brain function and track changes in alertness following possible head injury). Review of the resident's provider progress notes, dated 06/27/26, showed the following:-At 3:45 P.M., NP B assessed the resident via telehealth (electronic visit) following two witnessed falls from his/her wheelchair within fifteen minutes of each other;-The resident receives Depakote for seizure management;-The resident reported dizziness after the first fall and prior to the second fall. The second fall resulted in a head strike and skin tear on the right elbow;-The resident currently receives Depakote 500 mg twice daily and one 250 mg tablet at night. Depakote level ordered. Review of the resident's nurse's notes, dated 06/28/26, showed the following:-Resident had multiple falls over the weekend;- Staff contacted NP B regarding the resident's medication regimen concerning the amount of Depakote and Haldol (antipsychotic medication) administration;-The NP ordered laboratory testing of Depakote levels on 06/26/26. Staff contacted the lab to have a stat order. The lab is sending a technician to the facility today (06/28/26). Review of the resident's provider progress notes dated 06/28/26, showed the following:-At 6:33 A.M., NP B received a secure message from the facility concerning the possibility of incorrect dosing of Depakote and Haldol;- Staff reported notable change in resident functional status and said the resident ambulated independently prior;-The previous evening, (06/27/26), the resident lowered him/herself to the floor. This morning, (06/28/26) he/she was found sliding off the edge of the bed. No witnessed falls documented;-Review of the active medication list revealed two concurrent Depakote ER orders: Depakote ER 500 mg two tablets by mouth twice daily (initiated 06/26/2026) and Depakote ER 250 mg one tablet by mouth at bedtime (initiated 06/27/2026), consistent with a possible duplicate order;-If both orders were administered concurrently, the patient may have been receiving up to 1,250 mg of valproate daily, exceeding the typical recommended range for behavioral disturbances in elderly patients;-An addendum order to hold the Depakote ER 250 mg QHS (at bedtime) has been placed pending provider review. Awaiting Depakote level results to guide further management. Review of the resident's laboratory results, dated 06/28/26, showed the following:-Depakote level showed at 108 micrograms per milliliter (mcg/ml);-Reference range showed, Normal, as 50 to 100 mcg/ml;-Resident's level was outside of normal range. Review of the resident's nurse's notes, dated 06/29/26, showed the following:-Staff found the resident sitting in the bathroom floor. Resident denied pain or injury;-Staff implemented neurological checks and contacted the next of kin, Director of Nursing (DON), and Medical Director. Review of resident's provider progress notes, dated 06/29/26, showed the following:-Follow-up visit as the resident was admitted 4 days ago;-Witnessed falls without injury while transferring and ambulating on two occasions per nursing;-Lab results received, Depakote level is 108 mcg/ml;-Medications: Depakote ER Oral Tablet extended release 24-hour 250 mg, give 1 tablet at bedtime for behavioral disturbances and Depakote ER oral tablet extended release 24-hour 500 mg, give two tablets by mouth two times a day for behavioral disturbances. Review of the resident's admission Minimum Data Set (a standardized, federally mandated clinical assessment tool), dated 07/01/26, showed the following:-Severe cognitive impairment;-Partial to moderate staff assistance required for mobility;-Diagnoses included non-Alzheimer's Dementia and traumatic brain injury (TBI);-No physical or verbal behavioral symptoms;-Resident is prescribed an antipsychotic (prescription medications primarily used to manage psychosis, schizophrenia, bipolar disorder, and other severe mental health conditions) and an antidepressant;-Unknown if history of falls prior to admission;-Over two falls indicated since admission with at least one sustaining injury. Review of the resident's physician's order sheet (POS), dated July 2026, showed the following orders:-An order, discontinued on 07/04/26, for Depakote extended 24-hour release tablet 500 mg, administer two tablets twice daily (1000 mg);-An order, discontinued on 07/04/26, for Depakote extended 24-hour release tablet 250 mg, administer one tablet at night;-An order, dated 07/04/26, for Depakote extended 24-hour release tablet 500 mg, administer two tablets (1000 mg) twice daily (2000 mg total), prescribed by the Medical Director;-An order, dated 07/04/26, for Depakote extended 24-hour release tablet 250 mg, administer three tablets (750 mg) at night, prescribed by the Psychiatrist;-Monitor and document adverse side effects including falls and signs of sedation every shift;-Therapeutic lab testing for Depakote once every 90 days. Review of the resident's nurse's notes showed the following:-On 07/01/26, at 5:21 P.M., a nurse documented an unwitnessed non-injury fall. Staff implemented neurological checks and notified the Administrator, Director of Nursing, Medical Director, and next of kin;-On 07/09/26, at 7:47 A.M., a nurse documented the resident experienced a change in condition. The physician and family were notified. The condition the resident experienced (fall without injury) is not a known reason to send him/her to the emergency room (ER). The resident's family requested to send the resident to the hospital;-On 07/09/26, at 8:15 A.M., a nurse documented a Certified Nurse's Aide (CNA) observed the resident lying on the floor on his/her right side on his/her fall mat. The resident could not say how or why he/she ended up on the floor. A nurse assessed the resident with no injuries noted and vitals in normal range. Staff assisted the resident to bed and continued neurological checks. Staff notified the resident's family who requested to send the resident to the hospital;-On 07/10/26, at 12:00 P.M., the Social Services Director (SSD) documented follow-up contact with the hospital regarding the resident's status. Hospital staff said due to the resident's continued fall issues and diagnoses, the resident would be more appropriate for a Traumatic Brain Injury (TBI) facility. Hospital staff indicated the family did not want the resident to return to the facility and would no longer need a bed hold. Review of the resident's Medication Administration Record (MAR) for July 2026, showed staff administered Depakote as ordered. During an interview on 08/07/26, at 10:20 A.M., NP A said the following:-He/She visits the facility three times per week and as needed to evaluate residents;-Resident #1 admitted with history of falls and impulsive behavior;-Interventions put in place following the falls around admission included implementation of a wheelchair, low bed positioning, fall mat at bedside;-The Medical Director put a hold on the Depakote on admission due to multiple orders with different times per day and having no baseline labs;-The Physician determines proper dosage for medications based on lab results;-He/She and the Medical Director were unaware of the second Depakote order on 07/04/26 from the Psychiatric Physician;-The pharmacy did not indicate a possible concern regarding the Depakote orders;-The Medical Director ordered Depakote for mood stabilization;-Side effects of Depakote can include numbness emotionally, drowsiness, and slowed movement;-Depakote could have contributed to the resident's falls;-He/She did not notice a difference in the resident's behavior or demeanor since admission;-He/She does not know if the facility communicates orders between providers. During an interview on 08/07/26, at 12:33 P.M., the Medical Director (MD) said the following:-If two physicians order the same medication, the facility should hold administration of the medication until the prescribing physicians clarify the orders to ensure appropriate medication administration;-If the Psychiatrist prescribes the same medication, he typically will defer to their order. The facility should clarify the orders;-If staff administered both medications, without obtaining clarification, the resident may receive inappropriate or excessive dosing;-If a resident received two different conflicting orders of Depakote, it could lead to side effects including sedation and decreased alertness;-He does not know if Resident #1's prescribed amount of Depakote was excessive to him/her, possibly causing negative side effects, as each person can have widely varied appropriate dosages. During an interview on 08/07/26, at 1:12 P.M., the pharmacist said the following:-The pharmacist completes medication review on admission and monthly;-He completed medication review for Resident #1 on 06/26/26 with no noted recommendations;-Depakote dosage varies depending on the individual and requires lab levels to determine proper therapeutic dosage;-The medication usage is primarily for seizure disorders and sometimes off-label as a mood stabilizer;-Resident #1's had a high dosage of Depakote, but not an order that would necessarily raise a concern or prevent the pharmacy from fulfilling the order;-Depakote can cause drowsiness as a possible side effect. The facility should monitor for lethargy and increased falls;-The facility should contact the pharmacy for possible conflicting or unusual provider orders prior to administration of a medication;-The facility did not contact the pharmacy. During an interview on 08/07/26, at 2:19 P.M., Certified Medication Technician (CMT) E said the following:-The charge nurse enters orders in the MAR;-The CMT's and nurses monitor residents for medication side effects;-The CMT and nurse should implement orders according to the physician's instructions and document;-He/She immediately reports to the nurse any concerns of high medication dosages or conflicting orders prior to administration;-If two physicians prescribe the same medication, the nurse should contact both physicians to get order clarification prior to administration and document the contact in the nurse's notes;-The nurse should contact the pharmacy for possible conflicting orders or concerns of the same orders from two different providers prior to administration and document the contact in the nurse's notes;-Administration of conflicting orders without clarification could cause lethargic behavior or other side effects;-He/She did not notice any changes in Resident #1's behavior while residing at the facility. During an interview on 08/26/26, at 3:06 P.M., Licensed Practical Nurse (LPN) G said the following:-The DON confirms orders from the physician prior to relaying to a charge nurse for input in the medical record;-The nurse should hold medications from two providers with similar orders and receive clarification prior to administration. The contact should be documented in the nurse's notes;-Administration of similar medication orders without clarification from the physicians could cause sedation or other complications;-He/She reported concerns regarding Resident #1's Depakote orders to the Medical Director due to the resident's confusion upon admission and a need for lab levels;-He/She believes the physician adjusted Resident #1's Depakote order after initial admission;-He/She did not notice changes in the resident's behavior or condition while residing in the facility. During an interview on 08/07/26, at 4:04 P.M., LPN C said the following:-If two physicians prescribe similar medications, the nurse should withhold administration until clarification from each physician can be obtained to prevent possible sedation or medication complications. The nurse should document the communication and clarification in the nurse's notes;-The nurse should contact the pharmacy for medication issues or concerns and document the contact in the nurse's notes;-He/She is unaware of any concerns with Resident #1's Depakote orders. During an interview on 08/07/26, at 4:18 P.M., LPN H said the following:-He/She was unaware of any issues with Resident #1's medications;-If different physicians prescribe the same medication, the nurse should contact both providers immediately for clarification on the orders prior to administration. This communication and clarification should be documented in the nurse's notes;-Administering both medications prior to clarification could cause sedation which can lead to falls and a change in condition;-The nurse should contact the pharmacy regarding order concerns and should document in the nurse's notes. During an interview on 08/07/26, at 4:51 P.M., the DON said the following:-Resident #1 did not have behavioral changes during his/her time at the facility;-Resident #1 falls were due to lack of safety awareness;-The MD and psychiatrist communicate with each other and review the medical record;-The MD and/or his NP visit the facility four times a week;-The psychiatrist visits the facility weekly;-The physicians are responsible for verifying all medications the residents receive;-Nursing staff are responsible for verifying that the physicians are aware of possible conflicting orders;-The nurse should document communications with the physician and pharmacy in the nurse's notes. During an interview on 08/07/26, at 5:14 P.M., the Administrator said the following:-Nurses should review medication orders when received and clarify concerns with the physician immediately prior to administration;-The nurse should hold administration of two similar medications from different providers until clarification from both providers occurs to prevent risk to the resident;-The nurse should also contact the pharmacy and document the communication in the nurse's notes. Complaint 3074544

Based on observation, record review, and interview, the facility staff failed to ensure all meals met the nutritional needs of residents when staff failed to follow approved menus, including appropriate serving sizes, for all residents including two residents (Resident #3 and #4) who stated portion sizes were not sufficient. The facility census was 62. Review of the facility's policy titled, Standardized Recipes, undated showed the following:-Standardized recipes will be used for all menu items;-The registered dietician will approve recipe changes or new recipes utilized for a menu item.Review of the facility's policy titled, Diet Spreadsheet, Portion Serving Communication Tool, undated , showed the following:-Diet spreadsheets or similar meals and portion serving communication tools are available to the serving staff for reference and serving guidance;-Diet spreadsheets are based on the planned menu and reflect serving portions for regular and therapeutic diet orders offered in the community;-Diet spreadsheets are dated for each day of the menu cycle and are reviewed and approved by the registered dietician;-Specific portion serving information for regular and therapeutic diets may be communicated to the serving staff, in place of diet spreadsheets, during meal service, by utilizing innovative communication tools such as meal cards. 1. Review of the facility menu, dated 03/24/26, showed three chicken tenders, macaroni and cheese, mixed vegetables, and chilled peaches to be prepared and served.Observation on 03/24/26, beginning at approximately 11:30 A.M., showed Dietary [NAME] K added two chicken strips to each resident's plate.2. Review of the facility menu, dated 03/24/26, showed for the following pureed diet serving sizes:-Chicken tenders - 2/3 cup;-Macaroni and cheese - 1/2 cup;-Mixed vegetable 2/5 cup of mixed vegetables;-Chilled peaches to be prepared and served.Observation on 03/24/26, at approximately 11:30 A.M., showed Dietary [NAME] K placed 1/2 cups of pureed chicken tenders, 1/2 cups of macaroni and cheese and 1/4 cup of mixed vegetables on all three residents receiving pureed meals.3. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following information:-admission date of 02/10/25;-Diagnoses included hemiplegia (paralysis of one side of the body), type II diabetes (body develops insulin resistance and fails to use insulin properly, and major depressive disorder (persistent feelings of sadness). Review of the resident's care plan, revised 02/25/26, showed the following:-Resident's dietary preferences will be honored;-Favorite food was brats with sauerkraut. Review of the resident's quarterly, Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/04/26, showed the resident was cognitively intact.During an interview on 03/23/26, at 9:25 A.M., the resident said he/she got small portions almost every meal. Last night the only food he/she got was a chicken pot pie. He/she doesn't really like the food.4. Review of Resident #4's face sheet showed the following information:-admission date of 03/22/23;-Diagnoses included pre-diabetes (body develops insulin resistance and fails to use insulin properly), depression (persistent feelings of sadness), and diverticulitis (inflammation of the colon that causes abdominal pain).Review of the resident's care plan, revised 02/25/26, showed the following:-Resident's dietary preferences will be honored;-Favorite food was spaghetti. Review of the resident's quarterly MDS), dated [DATE], showed the resident was cognitively intact.During an interview on 03/24/26, at 12:25 P.M., the resident said the following: -They do not get enough food;-One night they got a hotdog and one teaspoon of sauerkraut;-The food they received today was more than they normally receive.5. During an interview on 03/24/26, at 1:30 P.M., Dietary [NAME] J said the following:-The Dietary Manager (DM) prints out the menus and they're placed on the board in the kitchen;-The menus tell him/her the quantity of food to serve, and they're supposed to serve that amount unless told otherwise;-He/she relied on the DM to tell him/her the quantity of food that needed to be prepared to ensure all residents receive enough food;-He/she saw the menu said three chicken strips and didn't know why Dietary [NAME] K only served two;-He/she has heard some residents complaining about not getting enough food when Dietary [NAME] L worked;-He/she was at the facility one evening when Dietary [NAME] L made sauerkraut and he/she only gave the residents 1 ounce and the guidance called for 4 ounces. During an interview on 03/24/26, at 1:39 P.M., Dietary [NAME] K said the following:-They receive the menus from their home company, and the DM posts them daily;-Each menu has the quantity of food to be served;-He/she saw that the menu said three chicken strips, but the DM told him/her to serve two;-He/she knew the quantity of food to prepare for each food item by calculating how many residents and how many servings each;-He/she has heard of residents complaining about not getting enough food. It started about month ago or sooner, he/she reported this to the DM.During an interview on 03/25/26, at 10:44 A.M., Dietary [NAME] L said the following:-He/she usually worked evenings and weekends;-He/she didn't really know how much food to cook, he/she just eyeballs the food to know how much to cook;-They were supposed to serve what the menu says, however, if there was not enough food, the DM tells staff to serve smaller serving sizes;-The sheet in the kitchen had scoop sizes and the menu had the scoops to use;-Not having enough food happens three to four times per week. When he/she did pudding, it's supposed to be a gray scoop which is 4 ounces, but he/she used a smaller scoop almost daily;-The other day there was a casserole, and it said to use two #8 scoop (1 cup), and they only gave 1/2 cup;-He/she didn't know if there were different sizes for residents on puree foods;-He/she assumed the DM knew there wasn't enough food since the DM told them to use smaller scoops. During an interview on 03/23/26, at 1:39 P.M., Certified Nurse's Aide CNA (B) said the following:-The residents consistently receive small portions. The unit gets half the amount they do in the rest of the facility;-One day for lunch there was a 1/2 pork chop. He/she struggled to get seconds if a resident wanted seconds;-It's been that way for the last year. He/she has tried to bring that up to the DM and he/she said the residents in the unit eat less. During an interview on 03/23/26, at 1:55 P.M., CNA C said the following:-He/she believed some residents do not get enough food, especially some receiving puree foods;-He/she said the food seems less at certain times, one day he/she was feeding someone on mechanical foods, and he/she had eaten 8 spoonsful, and it was all gone;-They can usually get more food. During an interview on 03/23/26, at 2:13 P.M., Licensed Practical Nurse (LPN) D said the following:-The residents don't receive enough food. When they make a sheet cake the residents in the unit might get a half slice;-The ones on puree foods don't get enough food, sometimes they have to order more;-There are times they only get soup and a piece of bread for dinner;-They can get seconds if they haven't cleaned the steam table and if they have food. During an interview on 03/24/26, at 9:35 A.M., Certified Medication Technician (CMT) G said the following:-Food portions are not big enough. For dinner they may only get a sandwich and chips;-They seem to receive less food in the evenings and weekends.During interviews on 03/23/26, at 11:33 A.M.; on 03/24/26, at 1:45 P.M.; and on 03/25/26, at 9:00 A.M., the DM said the following:-He/she made the menus, and the dietician signs off on the menus;-Staff know the portions as there is the chart in the kitchen that shows the spoon sizes and the menu with the quantities are there below;-Dietary [NAME] L consistently served less food than what the menu required. He/she has received complaints from staff and residents. He/she had educated the cook on multiple occasions, and the cook would do better for a while and then went back to the same bad habits;-He/she had been in when Dietary [NAME] L had been serving food out and he/she has seen only small amounts of food such as one time when the cook served out a chicken sandwich, fries and mixed vegetables. There were only a few fries and not 1/2 cup of mixed vegetables;-He/she expected staff to serve the amount of food on the menu.During an interview on 03/25/26, at 8:43 A.M., the Registered Dietician (RD) said the following:-The menus are generated, and the DM can make adjustments. There is a substitution log where the DM puts any changes, and he/she signs off on them;-The staff should be serving what the menu says. If it says three chicken strips, the staff should serve three chicken strips;-The staff know how much food to ensure all residents have sufficient amounts by using the production sheet that tell show much food to fix;-He/she was in the facility last week and he/she was told by various residents they were not receiving enough food. This has been passed on to the Director of Nursing (DON) as the DM was not in the facility when he/she was there on 03/20/26.During an interview on 03/24/26, at 2:00 P.M., the Director of Nursing (DON) said the following:-He/she had heard residents are not getting enough food to eat;-He/she knew there were serving sizes on the menus, and the staff should be following those;-If the menu said three chicken strips, they should serve three not two;-The residents should always be able to get seconds as well. During an interview on 03/25/26, at 3:26 P.M., the Administrator said the following:-He/she didn't know how the staff determined how much food was needed to ensure all residents receive the amount required;-He/she expected the staff to serve the amount of food the menu required;-If the menu said three chicken strips, they should be serving three not two.Complaint #2790852

Based on observation, interview, and record review, the facility failed to protect each resident's right to self-determination through support of resident choice when the facility failed to honor the reasonable shower preferences for four residents (Resident #3, #4, #5, and #6). The facility census was 62.Review showed the facility did not provide a policy on showers.1. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following information:-admission date of 02/10/25;-Diagnoses included hemiplegia (paralysis of one side of the body), heart disease, type II diabetes (body develops insulin resistance and fails to use insulin properly), Chronic obstructive pulmonary disease (constriction of the airways and difficulty breathing), and major depressive disorder (persistent feelings of sadness). Review of the resident's shower sheets, titled bathing for February 2026 showed the following:-On 02/05/26, six days after the last shower, the resident received a shower;-On 02/09/26, the resident received a shower;-On 02/12/26, the resident received a shower;-On 02/19/26, the resident received a shower (seven days after the last documented shower);-On 02/24/26, the resident received a shower (five days after the last documented shower). Review of the resident's care plan, last revised 02/25/26, showed the following:-Potential for skin integrity related to decreased mobility;-Resident had bladder incontinence;-Resident had an adult daily living self care deficit;-Resident required two staff assist for bathing,Review of the resident's progress notes, dated February 2026, showed staff did not document any additional showers or shower refusals by the resident.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/04/26, showed the following:-Cognitively intact;-Very important to the resident to choose between a tub bath, shower or bed bath;-Set up for personal care assistance;-Partial assistance with upper body dressing;-Substantial assistance for showers;-Dependent upon staff for toileting hygiene and lower body dressing;-Frequently incontinent of the bowel and bladder. Review of the resident's shower sheets, titled bathing for March 2026, showed the following:-On 03/10/26, the resident received a shower (fourteen days after the last documented shower);-On 03/15/26, the resident received a shower (five days after the last shower);-On 3/24/26, the records showed the resident had not received a shower in the last nine days. Review of the resident's progress notes, dated March 2026, showed staff did not document any additional showers or shower refusals by the resident.During an interview on 03/23/26, at 9:25 A.M., Resident #3 said his/her last shower was on 03/15/26. The last few times he/she was supposed to have a shower, they were short staffed and he/she doesn't get a shower. The resident believes he/she smells and feels others probably doesn't want to be around him/her. He/she would like two showers per week. During an interview on 03/24/26, at 9:51 A.M., Certified Nursing Assistant (CNA) H said the following:-Resident #3 never refuses showers. He/she asked for one yesterday but he/she didn't get to it. He/she gave Resident #3 a shower today. Resident #3 told him/her it had been over a week since the last shower.During an interview on 03/24/26, at 2:00 P.M., the Director of Nursing (DON) said the following:-He/she has not received any complaints from Resident #3 regarding showers.During an interview on 03/25/26, at 3:26 P.M., the administrator said the following:-Resident #3 caught him/her a couple of weeks ago and said he/she didn't get a shower as he/she was scheduled to earlier in the day. 2. Review of Resident #4's face sheet showed the following information:-admission date of 03/22/23;-Diagnoses included lumbar region spondylosis with myelopathy (a severe age-related degenerative condition where wear and tear in the lower spine compresses the spinal cord), depression (persistent feelings of sadness, osteoarthritis of the knee (breakdown of cartilage in the knee that causes joint pain), osteoporosis (a decrease in bone mass), muscle wasting and shrinking, and difficulty walking.Review of the resident's shower sheets, titled bathing for February 2026, showed the following:-On 02/02/26, the resident was offered a shower, but did not receive a shower due to the resident requesting to take a shower on 02/03/26;-On 02/03/26, the resident did not receive a shower;-On 02/09/26, the resident received a shower (11 days after the last documented shower);-On 02/20/26, the resident received a shower (11 days after the last documented shower).Review of the resident's care plan, last revised 02/25/26, showed the following:-Had an activities of daily living self-care performance deficit of fatigue;-Resident required the assistance of one staff for bathing.Review of the resident's progress notes, dated February 2026, showed staff did not document any additional showers or shower refusals by the resident. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Very important to the resident to choose between a tub bath, shower or bed bath;-Used a wheelchair and/or scooter;-Partial to moderate assistance with tub/shower transfer and showering/bathing self;-Supervision or touch assistance with personal hygiene;-Setup or clean up assistance with toileting hygiene. Review of the resident's shower sheets, titled bathing for March 2026, showed the following:-On 03/10/26, the resident received a shower (18 days after the last documented shower);-On 03/15/26, the resident received a shower (five days after the last documented shower);-On 3/24/26, the records show the resident has not received a shower in the last nine days. Review of the resident's progress notes, dated March 2026, showed staff did not document any additional showers or shower refusals by the resident. During an interview on 03/23/26, at 10:30 A.M. and 03/25/26, at 12:45 P.M., Resident #4 said the following:-His/Her last shower was one week and one day ago (03/15/26), but sometimes he/she does not get a shower for two weeks or longer;-The timeframe between his/her showers varies because the facility always has someone different giving the showers;-Recently, one staff member said they did not want to get wet, so he/she had to do his/her own shower without assistance;-The inconsistencies in receiving showers has been happening for a while;-When he/she does not receive a shower in several days, it makes him/her feel dirty and embarrassed;-He/She has itching of his/her skin when he/she does not receive showers consistently;-He/She knows that his/her hair looks greasy right now;-The facility lost their beautician in September of 2025 and there has not been a beautician at the facility since.-His/her hair is oily. 3. Review of Resident #5's face sheet showed the following information:-admission date of 01/16/25;-Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness or inability to move one side of the body) following a stroke affecting the left side, muscle wasting and shrinking, need for assistance with personal care, depression (feelings of sadness, chronic obstructive pulmonary disease (progressive and incurable lung disease that makes breathing difficult), unsteadiness on feet, cervicalgia (pain in the neck region), and low back pain. Review of the resident's care plan, last revised 01/08/26, showed the following:-Had hemiplegia/hemiparesis related to a stroke;-Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility;-Dependent on staff for activities, cognitive stimulation, and social interaction;-Will maintain involvement in cognitive stimulation and social activities as desired;-Does not mind or care who takes care of him/her as long as they respect him/her and take care of him/her;-Prefers to have his/her spouse involved in discussions of care:-Had potential/actual impairment to skin integrity related to hemiplegia;-Monitor pressure areas for changes in color, sensation, and temperature and report any changes to the nurse;-Had an activities of daily living self-care performance deficit;-Will maintain current level of function;-Often refuses to get up for showers, offer a bed bath or a partial bed bath when he/she refuses;-Totally dependent on staff for repositioning and turning in bed;-Totally dependent on staff for dressing;-Required total assistance with personal hygiene:-Required mechanical aid (sling) for transfers;-Required total assistance with transfers.Review of the resident's shower sheets, titled bathing for February 2026, showed the following:-On 02/02/26, the resident received a shower;-On 02/05/26, the resident received a shower;-On 02/24/26, the resident refused a shower;-On 02/25/26, the resident refused a shower.Review of the resident's progress notes, dated February 2026, showed staff did not document any additional showers or shower refusals by the resident. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Used a wheelchair;-Occasional urinary incontinence;-Always incontinent of bowel;-Risk of pressure ulcer/injury;-Partial to moderate assistance with upper body dressing;-Supervision or touch assistance with personal hygiene;-Setup or clean up assistance with eating and oral hygiene;-Dependent for toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear, tub/shower transfer, chair/bed to chair transfer, and rolling left and right. Review of the resident's shower sheets, titled bathing for March 2026, showed the following:-On 03/02/26, the resident received a shower (25 days after the last documented shower);-On 03/09/26, the resident received a shower (seven days after the last documented shower);-On 03/23/26, the resident received a shower (14 days after the last documented shower).Review of the resident's progress notes, dated March 2026, showed staff did not document any additional showers or shower refusals by the resident. During an interview on 03/23/26, at 10:00 A.M., Resident #5 said the following:-He/She just received a shower;-He/She is supposed to get a shower two times per week;-He/She is lucky if heshe gets one shower every two weeks;-Prior to today, his/her last shower was on a Tuesday and quite a few Tuesdays ago;-Staff kept promising him/her a shower on 03/10/26, but it did not happen;-He/She does not refuse his/her shower;-He/She would like to have at least two showers per week;-It makes him/her feel neglected when he/she does not get a shower like he/she is supposed to;-He/She would like to be shaved with every shower, but he/she forgot to ask the aides to shave him/her when he/she got his/her shower this morning. During an interview on 03/24/26, at 2:00 P.M., the DON said Resident #5 always complains about not getting his/her showers, even after he/she just had one. 4. Review of Resident #6's face sheet (brief information sheet about the resident) showed the following information:-admission date of 10/03/23;-Diagnoses included osteoarthritis (breakdown of cartilage in the joints that causes joint pain), muscle wasting and shrinking, dementia (progressive memory loss), spinal stenosis (narrowing of the spinal canal that compresses nerves), adult failure to thrive (a decline in physical and cognitive function), and need for assistance with personal care. Review of the resident's care plan, last revised 01/29/26, showed the following:-Had an activities of daily living (ADL) self-care performance deficit requiring staff assistance with ADL and cares;-Resident required assistance from one staff for bathing, dressing, personal hygiene and oral care, and using the toilet;-Had bladder incontinence and needed assistance with toileting needs;-Will be free from skin changes related to incontinence and brief use;-Required monitoring of pressure areas for changes in color, sensation, and temperature;-Required staff to check for incontinence, and wash, rinse, and dry his/her perineum (area located between the thighs and buttocks), and change clothing as needed after incontinence episodes.Review of the resident's shower sheets, titled bathing for February 2026 showed the following: -On 02/12/26, the resident received a shower;-On 02/19/26, the resident received a shower (seven days after the last documented shower);-On 02/24/26, the resident received a shower (five days after the last documented shower). Review of the resident's progress notes, dated February 2026, showed staff did not document any additional showers or shower refusals by the resident.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Moderate cognitive impairment;-Very important to the resident to choose between a tub bath, shower or bed bath;-Used a wheelchair and walker;-Partial to moderate assistance for sit to stand;-Supervision or touch assistance with toilet transfer and tub/shower transfer;-Substantial/maximal assistance with upper body dressing;-Dependent with toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and putting on/taking off footwear;-Occasional urinary incontinence;-Continent of bowel. Review of the resident's shower sheets, titled bathing for March 2026, showed the following:-On 03/15/26, the resident received a shower (26 days after the last documented shower);-On 3/24/26, the records showed the resident had not received a shower in the last eight days.Review of the resident's progress notes, dated March 2026, showed staff did not document any additional showers or shower refusals by the resident. During an interview on 03/23/26, at 11:00 A.M., Resident #6 said the following:- He/She only gets one shower per week on Tuesdays, if there is enough staff available;-His/Her last shower was about a week ago;-He/She would like to have two showers per week;-When he/she came to the facility approximately three years ago, he/she received a shower two times per week;-He/She feels better after he/she has a shower;- The resident was concerned about stinking and hoped he/she did not stink;-When he/she does not get a shower, he/she uses more deodorant than normal so other people will not smell him/her.5. During an interview on 03/23/26, at 1:39 P.M., Certified Nursing Assistant (CNA) C said the following:-Residents are supposed to be offered showers two times per week;-There is a problem with residents receiving showers;-The staff working on the hall providing direct care are responsible for giving showers. The resident's showers are split between the day and evening shift staff;-He/she has received complaints from various residents, some say it's been two weeks since they received a shower;-Staff documented showers on shower sheets until two weeks ago when the staff began documenting them in the medical records; -If a resident has non-applicable (N/A) marked on their sheet, it means they did not receive a shower as it wasn't their day.During an interview on 03/24/26, at 9:51 A.M., CNA H said the following:-Nurse's aides are expected to give resident showers;-There are usually three aides working outside of the unit to cover 100, 300, 400 and 500 halls;-If they have enough staff, they offer showers two times per week;-If the residents don't get showers on the day shift, the evening shift is supposed to do them;-The schedule goes by room number, they have a list in the three ring binder;-There have been complaints from residents not getting showers, he/she doesn't believe any residents are getting them consistently;-They used to complete shower sheets but now everything is documented in the medical records;-If there is no documentation, there was no shower.During an interview on 03/24/26, at 9:35 A.M., Certified Medication Technician, (CMT) G said the following:-No certain staff are appointed to do showers. The aides are supposed to split the residents up, but he/she is not certain exactly how that's supposed to work;-He/she has heard residents are complaining of not receiving showers;-The staff are supposed to document showers in the medical record;-The residents should be offered showers two times per week.During an interview on 03/24/26, at 10:12 A.M., CMT I said the following:-He/she doesn't know how the shower schedule works. He/she believes there is a book and the aides split the showers between days and evenings;-He/she has not heard complaints recently;-He/she knows the showers are documented in a book, he/she doesn't know if they're documented in the electronic medical record;-He/she doesn't know which residents have or have not received showers.During an interview on 03/25/26, at 9:44 A.M., CMT M said the following:-They have a list of residents to shower daily. It's set up by room numbers;-Each of the aides have the responsibility of completing showers for their halls;-When they have enough aides, the showers are completed, and that's not always the case;-Some residents have complained about not getting showers. They should be offered two showers per week;-He/she doesn't know where the showers are documented.During an interview on 03/23/26 at 2:13 P.M., and on 03/25/26, at 9:58 A.M., Licensed Practical Nurse (LPN) D said the following:-Residents receive showers two days per week, he/she has not heard of any issues with residents not offered showers.During an interview on 03/23/26, at 2:59 P.M., Registered Nurse (RN) Q said the following:-The aides are responsible for providing the residents with a shower two times per week;-The shower schedule is put on a daily assignment sheet;-Sometimes daytime showers get pushed to the evening;-He/She did not know of any residents going two weeks without getting a shower;-Some residents have asked him/her what day they are going to get a shower.During an interview on 03/24/26, at 2:00 P.M., the DON said the following:-He/she knows showers have been a problem in the past;-He/she came up with a new formula. Each room is given a shower day two days per week;-First two rooms of each hall get them on Monday and Thursday, the next two rooms on Tuesday and Friday, and the next two rooms on Wednesday and Saturday and it starts over;-He/she should be looking over the shower sheets to ensure they are completed, but he/she has not done that. LPN D looks over the electronic shower charting too;-If the not applicable is marked on the electronic record, that would mean it wasn't their shower day and they did not receive a shower.During an interview on 03/25/26, at 3:26 P.M., the Administrator said the following:-Residents should be offered two showers per week;-These are documented in the electronic records; however, some may still be completing the shower sheets;-If the electronic medical record shows not applicable, the resident did not get a shower.Complaints #2790852, 2794316, 2806439, 2960762

Based on interviews and record review, the facility failed to protect all residents' right to be treated with dignity and respect when one staff member (Registered Nurse (RN) F) insisted one resident (Resident #2) to be placed in a wheelchair and moved against his/her wishes. Seven residents were sampled in the facility with a census of 62. Review of the facility policy titled Resident Rights Policy, dated December 2024, showed the following:-Each resident residing in this community has the right and will be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination or reprisal;-It is the responsibility of all who work in this community, including employees of the community and any others who provide services to the residents of the community, to advocate and protect the rights of each resident;-All staff members are trained on the Resident Rights policy at the time of employment, prior to providing care to residents, and at least annually to ensure full understanding related to ensuring each resident's rights;-Each resident will have the opportunity to exercise his/her rights as a citizen or resident of the United States and staff members will assist with exercise of those rights as needed. 1. Review of Resident #2's face sheet (admission date) showed the following:-admission date of 10/06/25;-Diagnoses included Alzheimer's disease (dementia), anxiety (worried thoughts, and increased heart rate), depression (persistent sadness, hopelessness), low back pain, cognitive communication deficit, and unspecified dementia, severity with agitation (cognitive decline). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), showed the following information:-Memory problems;-No behaviors;-Impairment on one side.Review of the resident's current care plan showed the following:-The resident had a behavior problem of lowering him/herself to the floor and scooting around;-When the resident gets restless, assist him/her to the floor to scoot around;-Resident is care planned that he/she doesn't think it's wrong to scoot around on the floor.Review of the resident's progress note dated 03/14/26, at 3:15 P.M., showed Licensed Practical Nurse (LPN) D documented the following;-This nurse went into the stockroom to get medical supplies for RN F. When this nurse came out of the stock room, yelling was heard;-Certified Nurse Aide (CNA) B and CNA E reported that RN F yelled at them to help get the resident up from the floor, even though the resident was care planned to be on floor;-RN F was told the resident did not want to get up, and RN F replied, I don't care what the resident wants;-Staff placed resident into the wheelchair and the resident took a backhanded swing at RN F.During interviews on 03/23/26, at 2:13 P.M., and on 03/25/26, at 9:58 A.M., LPN D said the following:-He/she did not witness the incident between RN F and the resident;-The LPN D heard CNA B yelling;-LPN D asked CNA B and CNA E what happened, and they had the exact same story. Both aides said RN F told the resident when the resident didn't want to get into the chair, that RN F didn't care what the resident wanted. RN F then preceded to put his/her hand under the resident's arm to lift him/her to the chair and for safety reasons CNA B assisted with the transfer;-The aides said the resident swung his/her arms at RN F;-RN F should have asked the resident if he/she wanted to get into the wheelchair;-It's the resident's right to scoot around on the floor. They should not be forced to do things. -The resident is care planned to scoot on the floor.Review of CNA B's written statement, dated 03/14/26, showed the following:-The resident was on the floor as per his/her care plan;-Resident took him/herself into the office and CNA B was trying to guide the resident out of the office;-A separate issues occurred, and CNA B ran over to handle that;-RN F was in the doorway of the office. RN F yelled at CNA B to help move the resident out of the floor;-CNA B came back to the resident and asked the resident if he/she wanted to get up. The resident did not want to get up;-RN F said he/she didn't care what the resident wanted;-Staff picked up the resident up and put him/her in the wheelchair. Immediately the resident backhanded the nurse;-If the resident was respected and not forced, he/she wouldn't have made contact.During an interview on 03/23/26, at 1:39 P.M., CNA B said the following:-The resident sometimes stood and would become wobbly. He/she did not always like to sit in the chair so he/she would want to scoot. The resident would scoot around the unit. The resident was care planned to scoot;-On 03/14/26, RN F came to the unit, and the resident had scooted into the nurses' station behind RN F. RN F said you need to get the resident to come out. The resident was slowly scooting out. LPN D had gone to the stock room for supplies;-He/she asked the resident to come out and then was distracted by the need of another resident, so he/she left;-CNA B got back to the nurses' station and asked the resident if he/she wanted to get up. The resident said no and did not want to get up;-RN F said he/she did not care what the resident wanted; he/she wanted the resident to get into the chair;-RN F had his/her arm under the resident's arm so CNA B felt like he/she needed to help RN F, so the resident was transferred safely;-After the resident was put into the chair the resident took his/her hand and hit RN F in the belly;-The resident has the right to scoot around on the floor and should not be made to get into the wheelchair if he/she doesn't want too.Review of CNA E's written statement, dated 03/14/26, showed the following: -CNA E noticed the resident sitting on the floor in the nurses' station and CNA B was trying to convince the resident to scoot his/her way out the door;-CNA E grabbed the resident's wheelchair from the dining room to bring it closer in case the resident wanted to get off the floor;-RN F was trying to keep the resident lined up with his/her wheelchair and yelled at CNA B to help RN F get the resident in his/her chair;-CNA B was trying to get our other residents settled;-CNA E held the wheelchair ready for whatever the resident wanted to do;-CNA B got on the other side of the resident and said I don't think the resident wants back in his/her chair;-RN F said I don't care what the resident wants;-Staff put the resident back in his/her wheelchair and the resident smacked the nurse.During an interview on 03/23/26, at 3:18 P.M., CNA E said the following:-The resident was sitting in the nurses' station. The resident was care planned to sit and scoot around on the floor;-CNA B tried to get the resident to come out of the nurses' station;-LPN D went to the storage room to get something for RN F;-He/she went and got the resident's wheelchair out of the dining room in case the resident wanted to get into it;-The resident was making his/her way out of the nurses' station slowly;-RN F came out of the office to line the resident up with the wheelchair. RN F then yelled at CNA B to help him/her get the resident into the wheelchair;-CNA B asked the resident if he/she wanted to get into the wheelchair and the resident said no. RN F told the resident he/she didn't care what the resident wanted and told CNA B to help;-RN F get the resident into the wheelchair;-The resident was angry and smacked RN F on the arm or hip. -Staff should not make a resident get into a wheelchair, it's unsafe. Staff should allow a resident to scoot on the floor, especially if it's care planned.During an interview on 03/24/26, at 8:32 A.M., Registered Nurse (RN) F said the following:-He/she went back to the unit to get supplies. He/she didn't work in the unit and didn't know the resident;-The resident was scooting around in the floor, and he/she was told it's the resident's normal behavior. The resident was scooting into the office, and it's small and he/she almost stepped on the resident's hands;-One of the CNA's tried to get the resident to come out, and so did he/she;-One of the CNA's got the resident's wheelchair;-The resident kept scooting out of the office. He/she thought the aide that tried to get the resident to come out, was going to help him/her put the resident into the wheelchair;-The aide was doing something with another resident. He/she asked the aide to help, and he/she screamed as the aide wasn't listening;-He/she was afraid he/she would step on the resident or someone else would step on the resident;-The aide came over and they both lifted the resident into the wheelchair;-The aide said he/she didn't know if the resident would stay;-The resident started trying to hit him/her several times;-He/she did not remember asking the resident if he/she wanted to get into the wheelchair.;-He/she didn't remember anyone asking the resident if the resident wanted to get into the wheelchair;-He/she should have asked the resident;-The resident did resist when he/she and the aide were transferring the resident to the wheelchair;-It was against the resident's right to force them up. The resident has the right to stay in the floor.During an interview on 03/23/26, at 1:39 P.M., CNA C said the following:-The resident was on the floor because he/she walked, and it was unsafe for him/her to walk. The resident will scoot around;-If the resident wanted to scoot in the floor, and he/she was care planned to do this, it's the resident's right;-Staff should not make a resident to transfer to a wheelchair if they don't want too.During an interview on 03/24/26, at 9:35 A.M., Certified Medication Technician (CMT) G said the following:-The resident scooted on the floor, and he/she was care planned to do this;-It would be against the resident's rights to force them into a wheelchair if they don't want to sit in the wheelchair. During an interview on 03/24/26, at 9:51 A.M., CNA H said it would never be appropriate to make a resident transfer to a wheelchair; it's against their rights.During an interview on 03/24/26, at 10:12 A.M., CMT I said the following:-It would not be appropriate to make a resident get into a wheelchair; it's against their rights;-If a resident was care planned to scoot on the floor, they should be allowed to do this until they're ready to get into the chair.During an interview on 03/24/26, at 2:00 P.M., the Director of Nursing (DON) said the following:-The resident liked to scoot on the floor;-It would not be appropriate to force a resident to get into a wheelchair if they were not ready;-RN F did not work in the unit and did not know the residents;-He/she didn't know why RN F thought the resident should be up off from the floor, if the resident wanted to be on the floor, it's their right, especially if they're care planned for the behavior.-It's against the resident's rights to put them in a wheelchair if they don't want to. During an interview on 03/25/26, at 3:26 P.M., the Administrator said the following:-It would not be appropriate to make a resident get into a wheelchair. They should be allowed to do what they're doing as long as they're safe;-The resident was care planned to scoot and that's something he/she does, and it was his/her right.Complaint #2795050

Based on observation, interview, and record review, the facility failed to ensure residents right to receive services in the facility with reasonable accommodation of resident needs when staff failed to follow up on and order a customized wheelchair for one resident (Resident #5), which would increase his/her ability to get out of bed and stay out of bed longer. The facility census was 62.Review of a facility policy titled Durable Medical Equipment Manual, dated 04/08/25, showed the following information:-The health plan is financially responsible for custom and power wheelchairs that have been prior authorized by the health plan prior to the enrollment effective date in the fee for service (FFS) program, but placement occurs after the effective date of FFS program enrollment;-Durable medical equipment (DME) is not covered for those participants in a nursing home. DME is included in the nursing home per diem rate and not paid for separately with the exception of custom and power wheelchairs;-Missouri HealthNet Division (MHD) requires all providers of custom and wheelchairs provide equipment that meets the participant's needs for mobility and positioning in a cost-effective manner for participants in a nursing home;-When submitting a prior authorization (PA) request for a custom or power wheelchair, there must be comprehensible written documentation submitted with the PA request. Letters of medical necessity LMNs) and supporting documentation must be signed by the prescribing physician as well as the nursing home's director of nursing or the nursing homes employed or contracted licensed physical or occupational therapist;-In addition, LMSs generated by the supplier must be written on the supplier's letterhead and signed by both the supplier and the prescribing physician as well as the nursing homes director of nursing or the nursing homes employed or contracted licensed physical or occupational therapist;-Custom or power wheelchairs for participants residing in a nursing home must be supplied by a DME provider that employes a Rehabilitation Engineering Assistive Technology Society of North America (RESNA)-certified Assistive Technology Professional (ATP) who specializes in wheelchairs. The ATP must meet the supplier and quality standards established for DME suppliers and must be present during the patient evaluation;-The provider record should document how the ATP was involved and directed the wheelchair selection process;-For a custom or power wheelchair to be covered for a participant residing in a nursing home, a treating physician must be the first point of contact with the participant and conduct a face-to-face examination of the participant before writing an order for the custom or power wheelchair. The physician's required face to face examination must be completed prior to any evaluation or contact by any person associated with the DME provider, including an ATP. Physicians shall document the face-to-face examination in a detailed narrative note in the participant's chart in the format they use for other entries. Forms or sample documentation created by a supplier or facility that the physician completes are not substitute for the comprehensive medical record/chart note indicated above. The physician face to face examination must provide the following information, symptoms that limit ambulation, diagnoses that are responsible for symptoms, progression of ambulation difficulty over time, other diagnoses that may relate to ambulatory problems, cardiopulmonary examination, and weight and height;-The physical examination that is related to mobility needs shall include existing ambulatory assistance, ability to stand up from a seated position without assistance, description of the ability to perform activities of daily living, distance the participant can walk without stopping, pace of ambulation, musculoskeletal examination to include arm and leg strength and range of motion, neurological examination to include documentation of functional ambulation and balance and coordination, and weight and height;-After the face-to-face examination with the physician, the physician may choose to refer the participant to a licensed physical therapist or occupational therapist for completion of the physical portion of the exam. If utilized, the therapy examination must be authorized by the therapist and reviewed by the physician after completion, agreed upon or amended. The therapy evaluation would complete the physical portion of the face-to-face examination and would contain all the required items listed under the physical portion of the face-to-face examination. This would be a therapy evaluation only, not a wheelchair evaluation;-A prior evaluation completed by a licensed physical or occupational therapist within the past 90 days may also be utilized for the physical portion of the examination. All areas noted above for the physical examination must be addressed. If utilized, the physical or occupational therapist examination must be reviewed by the physician after completion, agreed on or amended and signed before issuing the physician order;-The face-to-face examination must be completed by the physician or nurse practitioner prior to any evaluation performed by the DME provider, including the ATP. The DME provider must receive the written report of this examination within 90 days after completion of the face-to-face physician examination. A date stamp or equivalent must be used to document the date that the provider receives the report of the face-to-face physician examination. The written report of the physician examination must be submitted with the PA request;-Evaluations written or scribed by the DME provider and signed by the therapist is not acceptable as an occupational/physical therapist evaluation. All documentation from the DME provider shall be separate from the therapy evaluation. All documentation submitted by the ATP should be on DME letterhead signed and dated by the ATP;-All documentation explaining medical necessity for items requested on the PA request must be reviewed and approved by the physician/practitioner as indicated by signing and dating the document;-When requesting a custom or power wheelchair for a nursing home participant, a physician order must be received by the DME provider within 90 days after the completion of the face-to-face physician examination and prior to any DME provider evaluation. The physician's order must contain the participant's name, description of the item that is ordered, date of the face-to-face examination, pertinent diagnoses/conditions that relate to the need for the custom or power wheelchair, length of need, physician's signature, and date of physician's signature;-A date stamp or equivalent must be used to document receipt date of the physician or nurse practitioner order. This order must be included with the PA request. If it is not included, the PA request will be returned as incomplete;-MDS will reimburse for medically necessary custom wheelchairs for participants residing in a nursing facility. A custom wheelchair is defined as a chair that is tailor made for one participant and cannot be used by anyone else. PA required. All PA requests must indicate why a less costly wheelchair is unable to meet the participant's needs.Review showed the facility did not provide a policy related to physician's orders.1. Review of Resident #5's face sheet (brief information sheet about the resident) showed the following information:-admission date of 01/16/25;-Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness or inability to move one side of the body) following a stroke affecting the left side, muscle wasting and shrinking, need for assistance with personal care, depression (feelings of sadness, chronic obstructive pulmonary disease (progressive and incurable lung disease that makes breathing difficult), unsteadiness on feet, cervicalgia (pain in the neck region), and low back pain.Review of the resident's progress notes, dated 06/24/25, showed the resident currently sitting up in wheelchair, denies having any pain or discomfort at this time.Review of the resident's progress notes, dated 10/24/25, showed a social services note stating the spouse called and wanted the facility to get a new wheelchair for the resident. The social worker informed the spouse that he/she would have to pay out of pocket for the wheelchair. The spouse stated that he/she could not afford to pay for a wheelchair out of pocket. The social worker spoke with the resident, and he/she stated he/she would like to try one of the facility's wheelchairs and see what happens. The social worker spoke with the Physical Therapy Director, and he/she said he/she would get one out and have the resident try it out on Monday.Review of the resident's care plan, revised 01/08/26, showed the following:-Had hemiplegia/hemiparesis related to a stroke;-Will maintain optimal status and quality of life within limitations imposed;-Pain management and alternative comfort measures as needed;-Had pain and will not have an interruption in normal activities due to pain;-On pain medication therapy;-Will be free of any discomfort or adverse side effects of pain medication;-Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility;-Dependent on staff for activities, cognitive stimulation, and social interaction;-Will maintain involvement in cognitive stimulation and social activities as desired;-Prefers to have his/her spouse involved in discussions of care:-Monitor pressure areas for changes in color, sensation, and temperature and report any changes to the nurse;-Had activities of daily living self-care performance deficit;-Will maintain current level of function;-Often refuses to get up for showers, offer a bed bath or a partial bed bath when he/she refuses;-Totally dependent on staff for repositioning and turning in bed;-Totally dependent on staff for dressing;-Required total assistance with personal hygiene:-Required mechanical aid (sling) for transfers;-Required total assistance with transfers.Review of the resident's active Physician Order Sheet (POS), dated 03/25/26, showed an order, dated 01/22/26, for a custom wheelchair for proper positioning of right hemiplegia and hemiparesis following a stroke affecting left non-dominant side.Review of the resident's care plan showed on 01/23/26, staff added custom wheelchair for proper positioning related to hemiplegia to the care plan.Review of the resident's nursing progress note, dated 02/11/26, showed the resident had back pain, mostly from laying on his/her back all the time. The resident said that at times he/she will get in his/her wheelchair and that can help relieve some pain.Review of the resident's quarterly, Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/16/26, showed the following:-Cognitively intact;-Used a wheelchair;-Occasional urinary incontinence;-Always incontinent of bowel;-Risk of pressure ulcer/injury;-Partial to moderate assistance with upper body dressing;-Supervision or touch assistance with personal hygiene;-Setup or clean up assistance with eating and oral hygiene;-Dependent for toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear, tub/shower transfer, chair/bed to chair transfer, and rolling left and right.During an interview on 03/23/26, at 10:00 A.M., the resident said the following:-He/She has a wheelchair that he/she uses, but there is not enough room in his/her room to keep it in the room when he/she is not using it;-He/She used his/her wheelchair this morning to go to the shower;-He/She is not sure where the staff stores his/her wheelchair;-He/She has not had a need for any medical equipment to be ordered for him/her. He/She has a wheelchair;-Staff have asked him/her several times before if he/she wanted to go eat in the dining room and he/she thinks he refused so many times that they just quit asking him/her;-He/She prefers to stay in his/her bed than get up in his/her wheelchair because his/her wheelchair is uncomfortable;-He/She can only stay in his/her wheelchair for about 20 minutes, then he/she has to get back in bed because of the pain.During an interview on 03/23/26, at 2:59 P.M., Registered Nurse (RN) Q said the following:-The resident had not complained to him/her about his/her wheelchair hurting his/her back;-The resident does not get up out of bed often;-He/She thinks the resident has a wheelchair in his/her room;-He/She has not heard about the resident needing or wanting a new wheelchair;-The resident requires a Hoyer lift and the assistance of two staff to get into his/her wheelchair;-Staff offer to get the resident up for meals, but he/she refused to get up.During an interview on 03/24/26, at 11:00 A.M., Licensed Practical Nurse (LPN) D said he/she does not know anything about the resident wanting a new wheelchair. During an interview on 03/23/26, at 12:35 P.M. and 03/24/26, at 11:57 A.M., the physical therapy director said the following:-He/She usually helps residents get a wheelchair and they had been working on getting th resident a new wheelchair;-He/She completed a couple of evaluations on the resident. One evaluation was completed in July of 2025;-He/She attended the care plan meeting with the resident's family members around July of 2025;-The resident said his/her wheelchair was uncomfortable;-The resident would not and still does not get out of bed much. There was a period of time when he/she did not get out of bed for about eight months;-The facility gave the resident a roommate who would not get out of bed either and the resident followed the roommate's habits until the roommate passed away;-After the roommate passed away, the physical therapy director went and talked to the resident about not getting out of bed;-In June of 2025, the resident told him/her that he/she liked the wheelchair he/she had, but the resident was telling his/her family that he did not like his/her wheelchair;-The physical therapy director found the resident a different wheelchair to try, but the resident refused it;-The wheelchair that was offered was bigger than the wheelchair the resident has now;-When Resident #5 was in the 500 hall for approximately 2 1/2 years, staff stored his/her wheelchair in the spa room on 400 hall;-The resident had never told him/her that he/she does not like the wheelchair that he/she currently has;-He/She recalls putting the resident's wheelchair form in one of the previous physician's folders for approval and an order, but he/she does not recall the exact date or timeframe;-For three weeks, he/she kept moving the wheelchair form to the front of the previous doctor's folder;-The last time he/she went to see if the wheelchair form was signed, all the papers were gone from the physician's folder, so he/she assumed the form went to the next person in the facility;-Two months later, the physician's nurse practitioner came to him/her and asked for the resident's wheelchair form;-He/She told the nurse practitioner the physician already had the form in his/her folder to sign;-The nurse practitioner reported that he/she had not seen the form for Resident #5;-The Physical Therapy Director completed another wheelchair form for Resident #5 and put it back in the same previous physician's folder;-During that time, none of the three physicians that were coming to the facility were coming in at all and their folders were growing and growing with paperwork;-Another physician started coming to the facility, but he/she did not do anything with the resident's wheelchair form again because he/she thought the form was sent to the wheelchair company the second time;-He/She suddenly saw an order pop up for January or February of 2026 for a custom wheelchair again;-The January or February 2026 order was not brought to his/her attention until three weeks ago by the administrator;-In a recent morning meeting, he/she told the administrator they could streamline the wheelchair order for the resident if the family would pick a wheelchair provider;-At this point, the wheelchair evaluation for the resident is too old, but if someone will get with the family to pick a medical device company, he/she will assist with getting the wheelchair evaluation company here to help get the resident a custom wheelchair;-He/She recalls telling the resident's family in June of 2025 that they would need to pick a wheelchair company, but he/she never heard back from anyone;-Since January of 2026, the resident has been up more in his/her wheelchair since he/she got the new roommate that gets out of bed and uses his/her wheelchair;-If the social worker will come to him/her and tell him/her which wheelchair company the family wishes to use, he/she will complete the wheelchair evaluation again even though the resident is not enrolled in therapy.-He/She does not have any paperwork in his/her therapy file for the resident's custom wheelchair process;-The custom wheelchair request occurred June of 2025 during Resident #5's care plan meeting;-He/She got a facility wheelchair from the shed to let the resident try before they tried to order him/her a new custom chair, but the resident refused to try it;-He/She asked the resident if he/she would get up in a wheelchair if he/she had one that was more comfortable;-He/She recalls that he/she got a stack of signed paperwork back from the physician's folder that he/she placed other paperwork in, but Resident #5's signed paperwork was never returned to him/her;-He/She plans to talk with the Social Services Director after he/she returns to work after his/her training is finished to let him/her know that he/she will need to tell the family that the custom wheelchair will depend on payment and the family's willingness to pay for it.During interviews on 03/24/26, at 2:00 P.M., and on 03/25/26, at 10:55 A.M., the facility's medical director said the following:-In January of 2026, he/she did sign an order for the resident to receive a custom wheelchair;-He/She would expect the wheelchair to be at the facility by now.-He/She recalls calling the wheelchair company and followed up on the wheelchair for the resident;-He/She could not find any documentation in the resident's electronic medical record that showed what day and time he/she called, who he/she called, or what the outcome was;-He/She knows that the order did get to the wheelchair company, but he/she does not recall which wheelchair company;-He/She does not think the resident's insurance will pay for the specialty wheelchair.During a phone interview on 03/25/26, at 9:16 A.M., the business office manager said the following:-The process of ordering a new wheelchair goes through the therapy department;-He/She does not have any paperwork regarding the custom wheelchair that was ordered for Resident #5 on 01/22/26;-The therapy department uses a mobility equipment supplier to measure and size a wheelchair for a resident;-Even if the resident is not on therapy services, the therapy department completes the evaluation for a wheelchair and sends it through the equipment supplier company.During a phone interview on 03/26/26, at 3:45 P.M., the Social Services Director said the following:-He/She has not heard anything about the resident's custom wheelchair order;-He/She knows that he/she was not much help and would have to defer questions about Resident #5's custom wheelchair order to the Administrator or Business Office Manager.During an interview on 03/25/26, at 10:35 A.M., the Director of Nursing (DON) said the following:-The resident only gets out of bed to get a shower;-The resident refuses to get out of bed all the time and staff should be documenting that;-He/She does not know why the resident requested a custom wheelchair;-He/She has not complained to him/her about his/her wheelchair hurting him/her;-Therapy said they cannot get the resident to get up out of bed, so there is no need for the resident to get a new wheelchair;-A mobility equipment supplier was supposed to be involved with the new wheelchair process for the resident;-The DON received a call from the equipment supplier regarding the resident's wheelchair order about a month ago or longer and he/she tried to get the physical therapy department to look into it;-The resident does not qualify to get the wheelchair paid for;-If the resident will get out of bed and prove he/she will get up out of bed, it may be easier for him/her to get a new wheelchair;-The resident's wheelchair issue is new for him/her;-He/She would expect the 01/22/26 physician's order for the custom wheelchair to be resolved by now or at least something documented about the progress on it;-He/She does not have any paperwork regarding the custom wheelchair that was ordered for the resident on 01/22/26.During an interview on 03/25/26, at 3:45 P.M., the Administrator said the following:-There was a face-to-face meeting about the resident's custom wheelchair request, but he/she is not sure who the face-to-face meeting was with;-There is an active order, dated 01/22/26, in the resident's chart for a custom wheelchair;-He/She is not sure if anyone is working on getting the custom wheelchair for the resident as it was ordered;-He/She will check with the physical therapy director and the DON to follow up on where things are at with ordering the resident's custom wheelchair;-After the therapy department did their part and talked to the medical equipment company, he/she is not sure what happened with the process to obtain the resident's wheelchair;-He/She does not have any paperwork regarding the custom wheelchair that was ordered for the resident on 01/22/26.2. During an interview on 03/23/26, at 12:35 P.M. and 03/24/26, at 11:57 A.M., the physical therapy director said the following:-To get a new wheelchair, staff have to identify the need for a new wheelchair and then do a wheelchair evaluation assessment;-After the assessment is completed, someone at the facility should contact the company that the resident would potentially get a new wheelchair from, complete a form and send it back to the company. After that, the form is put into the physician's folder for approval and an order;-An occupational therapy wheelchair therapist at the facility works with the medical supply company;-Before the facility had the current medical director, they had three other physicians in the facility;-He/She thinks the social worker was supposed to work with the family to pick a medical device company, but he is not sure. That is something that he/she is not involved in.-He/She does not usually get the signed forms back. Someone else at the facility takes care of the wheelchair process after the form is signed, but he/she does not know whose responsibility that is;-The facility was bought out by another company a little over a year ago and he/she is not familiar with the new company's policy on ordering a wheelchair for a resident that is not on therapy services.3. During an interview on 03/24/26, at 11:00 A.M., Licensed Practical Nurse (LPN) D if any resident wanted a new wheelchair, he/she would refer them to the therapy department.4. During a phone interview on 03/26/26, at 3:45 P.M., the Social Services Director said the following:-He/She has only worked at the facility for three weeks, so he/she does not know anything about the process for ordering a custom wheelchair for a resident;-He/She is not aware of a medical equipment ordering policy;-He/She only knows that the maintenance department would order beds and similar equipment;-If he/she needed to have anything ordered for a resident, he/she would get it cleared through the Administrator first.5. During an interview on 03/25/26, at 10:35 A.M., the Director of Nursing (DON) said the following:-He/She does not know what the facility process is for assisting resident with getting a customized wheelchair;-The DON thinks the therapy department heads that up and communicates with the family;-He/She thinks the social worker would potentially be involved with ordering a custom wheelchair for a resident, but he/she is not sure;-Even if a resident is not enrolled in therapy, the physical therapy department would still evaluate them for a wheelchair; -The therapy department would start the process for a new wheelchair;-The family would pick the durable medical equipment company they want to use.6. During an interview on 03/25/26, at 3:45 P.M., the Administrator said the following:-The DON should be following and reviewing physician orders to make sure they are taken care of;-The social worker has no role in assisting a resident with obtaining a new wheelchair;-The maintenance director, DON, and/or the administrator orders equipment. Complaint 2806439 and 2794316

Based on observation, interview, and record review the facility failed to provide one resident (Resident #8) or the resident's representative with notice regarding a room change, including the reason for the room change, before the facility moved the resident to another room. The facility's census was 62.1. Review of Resident #8's face sheet (brief information sheet about the resident) showed the following information:-admission date of 05/16/25;-Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque builds up in the heart's arteries and restricts blood flow), high blood pressure, dementia (a progressive decline in memory and thinking), anxiety (excessive uncontrollable fear), and age-related cognitive decline.Review of Resident #8's care plan, dated 5/19/25, showed the resident preferred to have his/her family involved in care discussions.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 3/20/26, showed the following:-Severe cognitive impairment;-Used a wheelchair.Review on 03/25/26, at 4:45 P.M., of the facility census report for Resident #8 showed the following:-Staff moved the resident to a different room on 05/16/25;-Staff moved the resident to a different room on 06/12/25; -Staff moved the resident to a different room on 12/10/25;-Staff did not document a room change for 03/25/26;-Room change documentation for 03/25/26 was requested from the facility but not provided.Review on 03/25/26, at 4:45 P.M. of the resident's nurses' notes showed the following:-Facility staff did not document any information regarding a room change for the resident. -Facility staff did not document discussing the room change with the resident or the resident's representative.Observation and interview on 3/25/26, at 5:00 P.M., showed the following:-Resident #8's room on the special care unit was empty; -Resident's #8's name showed on the name tag outside of a new room.During an interview on 3/25/26, at 5:00 P.M., Certified Nursing Assistant (CNA) P said the following:-Resident #8 was moved to a different room around 2:00 P.M. today;-The resident was moved because the facility is getting a new resident that will be private pay;-Resident #8 is not moved from his/her room a lot;-Resident #8 gets along well with other residents;-He/She has not seen any visitors for the resident today or any other day that he/she has cared for Resident #8;-Resident #8 may or may not understand that he/she has been moved to a new room with a resident. It is hard to say if he/she fully understands.-The facility has two rooms in the special care unit that are used for private pay residents.During an interview on 3/25/26, at 5:10 P.M., Resident #8 said the following:-Staff did not ask him/her if he/she wanted to be moved to a different room, but he/she is fine with the move;-He/She does not know when he/she was moved to a different room;-He/She has a new apartment and a new roommate.During an interview on 3/25/25, at 5:33 P.M., Licensed Practical Nurse (LPN) D said the following:-He/She is the charge nurse on the special care unit, but he/she was not the one that moved Resident #8 to a different room. He/She was recently informed by staff that the resident was moved;-He/She thought the facility was supposed to notify the family before the room change was made, but that did not happen with Resident #8;-The housekeeping staff moved the resident to the new room this afternoon and the Maintenance Director came by the nurse's station and handed him/her a written note that said Resident #8 was moved from one room to another;-The resident was moved to a different room because the facility was supposed to get a new admission, but no one seems to know about the new admission;-He/She just spoke with the corporate nurse on the phone and was informed that notifying the family of the room change was just a courtesy call;-LPN D did not tell Resident #8 or his/her family about the move, so there is no documentation in the resident's progress notes regarding the room change;-He/She will call the family soon to notify him/her that the resident was moved this afternoon, and he/she will document it in the resident's progress notes.During an interview on 3/25/26, at 5:10 P.M., the Director of Nursing (DON) said the following:-There was a resident moved earlier today, so staff could make the room a private room for a new resident;-LPN D should have notified the resident and/or their family and documented it.-Residents are moved if there is a reason to move them;-If the resident is their own person, staff would let the resident know and the social worker would document the resident was notified of the room change in their medical record notes.During an interview on 3/25/26, at 5:43 P.M., the Corporate Nurse and the Administrator said the following:-Resident #8 was moved to a different room today due to a new admission needing a private room;-Resident #8 is his/her own person and his/her family member is his/her emergency contact;-Resident #8 was not notified of the room change before he/she was moved;-No documentation or paperwork is available showing that Resident #8 and/or his/her family was notified of the room change prior to the room change being completed.-The facility does let the family or responsible party know when a room change is made;-The staff member that moves the resident should document the move and notification to the resident or family.Complaint 2964439

Based on observation, interview, and record review, the facility failed to protect each resident's right to a safe, clean, comfortable, and homelike environment when staff failed to properly and frequently clean the floor in a resident room for two residents (Resident #5 and Resident #9) resulting the floor being sticky The facility census was 62.1. Review of Resident #5's face sheet (brief information sheet about the resident) showed the following information:-admission date of 01/16/25;-Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (partial weakness or inability to move one side of the body) following a stroke affecting the left side, and unsteadiness on feet. Review of the Resident #5's care plan, last revised 01/08/26, showed the following:-Had hemiplegia/hemiparesis related to a stroke;-Dependent on staff for activities, cognitive stimulation, and social interaction.Review of Resident #5's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/16/26, showed the following:-Cognitively intact;-Used a wheelchair.During interviews on 03/23/26, at 10:00 A.M., and on 03/23/26, at 1:00 P.M., Resident #5 said his/her family member recently brought a wet Swiffer sweeper in to mop his/her floor twice due to it being sticky.2. Review of Resident #9's face sheet (brief information sheet about the resident) showed the following information:-admission date of 03/26/24;-Diagnoses included chronic right heart failure and high blood pressure.Review of Resident #9's care plan, last revised 03/11/26, showed the following:-The resident had a communication problem;-The resident will be able to make basic needs known on a daily basis;Review of Resident #9's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/19/26, showed the resident was cognitively intact.During an interview on 03/24/26, at 10:14 A.M., Resident #9 said the following:-Staff does not mop his/her room every day.-The floor stays sticky in his/her room because he/she has urine incontinence;-The aides do mop the floor, but he thinks they do not change the water in the mop bucket, so that is why his/her floor stays sticky.3. Observation on 03/23/26, at 10:00 A.M., showed Resident #5 and Resident #9's floor in their room was sticky. Observation on 03/23/26, at 1:00 P.M., showed Resident #5 and Resident #9's floor in their room was sticky.Observation on 03/24/26, at 10:14 A.M., showed Resident #5 and Resident #9's floor was sticky.4. During an interview on 03/24/26, at 10:08 A.M., Housekeeper R said the following:-Earlier, he/she was in Resident #5 and Resident #9's room mopping and he/she noticed the floor was sticky before and after he/she mopped;-He/She plans to tell his/her supervisor that the floor in the residents' room is sticky;-He/She does not know if the residents' floor was mopped yesterday because he/she worked in laundry and did not mop any floors.-He/She mops the floor in every room every day;-He/She changes his/her mop water frequently. During an interview on 03/24/26, at 11:06 A.M., Housekeeper S said the following:-Resident #5 and Resident #9's floor is just that sticky all the time because Resident #9 is incontinent and urinates everywhere;-He/She sees urine on the floor all the time.-The urine comes out of Resident #9's depend;-He/She assumes the nurse aides mop the floor when Resident #9 is incontinent and they clean him/her up, but he/she is not sure.-He/she changes his/her mop water with every hall.During an interview on 03/25/26, at 10:06 A.M., Housekeeper T said the following:-He/She is aware of the sticky floor in Resident #5's and Resident #9's room and he/she thinks it is caused by Resident #9 having urinary incontinence;-The housekeepers use their disinfectant mop to mop their room the same as they mop all other resident rooms;-Resident #5's and Resident #9's floor in their room is sticky almost every day, but he/she has not mentioned it to his/her supervisor.-All resident rooms are mopped every day;-The new housekeeping supervisor just started on 03/20/26, and he/she is still learning. During an interview on 03/24/26, at 11:25 A.M., Certified Medication Technician (CMT) G said the following:-Staff cleans the urine off of Resident #5's and Resident #9's floor with towels or a mop, or they let the housekeepers know they need to mop.-Resident #5's and Resident #9's floor in their room is sticky;-If he/she uses a mop to clean the urine off the residents' floor, he/she changes the mop bucket water.-Resident #9 is incontinent of urine;-He/She is aware of the sticky floor in their room and he/she thinks it is caused by Resident #9 having urinary incontinence;-The housekeepers use their disinfectant mop to mop their room the same as they mop all other resident rooms;-The floor in their room is sticky almost every day, but he/she has not mentioned it to his/her supervisor. During an interview on 03/25/26, at 10:14 A.M., RN Q said he/she is aware of the floor being sticky in Resident #5's and Resident #9's room, but the residents have not complained to him/her about it. During an interview on 03/25/26, at 10:35 A.M., the Director of Nursing (DON) said the following:-Resident #5's room is usually a mess because of Resident #9;-He/She has not noticed the floor in Resident #5's and Resident #9's room being sticky;-Resident #5 may spill his/her urine on the floor;-Staff tried to use special cleaning wipes in their room and they mop;-The DON has never seen Resident #5's family mopping his/her room.-Housekeeping staff is here every day;-The head housekeeper walked out about two weeks ago and took all the housekeepers with her;-The facility just hired new housekeeping staff, and it has been hard to get things done;-Nursing is picking up the laundry task to help the new housekeepers out;-The new housekeeping supervisor started two days ago;-He/She sees the housekeepers mopping all the time. During an interview on 03/25/26, at 3:45 P.M., the Administrator said the following:-Resident #5 bangs his/her urinal on the wall in his/her room;-He/She did not know Resident #5's family brought in a Swiffer mop to mop the floor in his/her room;-He/She did not know Resident #5's and Resident #9's floor was sticky, but he/she is not in that room a lot;-If a resident is incontinent of urine on the floor of their room and housekeeping is not here, the nurse aides are expected to clean it up, but he/she is not sure what they would use. Complaint 2960762

Based on observation, interview, and record review, the facility staff failed to provide wound care per standards of practice when staff failed to obtain physician ordered wound treatment supplies and failed to complete dressing changes as ordered by the physician for one resident (Resident #7's) amputation site and left ankle pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) out of four sampled residents. The facility census was 62.Review showed the facility did not provide a policy regarding physician's orders.Review showed the facility did not provide a wound care treatment and management policy.Review of the facility's policy titled, Skin Identification, Evaluation, and Monitoring Policy, dated 01/25, showed the following information:-Complete a weekly skin check to evaluate for changes in skin integrity;-Document in the medical record the following findings: appearance of wound, including measurements if the wound is due for a treatment change. If not, access the dressing and document this in the assessment;-Update the plan of care with each intervention;-The certified nurse assistant should cleanse the skin with bath/shower and after each incontinence episode;-Document completion of bath in the plan of care (POC);-Pressure injuries are staged using the National Pressure Injury Advisory Panel (NPIAP) guidelines. 1. Review of Resident #7's face sheet (brief look at resident information) showed the following information:-admission date of 03/05/26;-Diagnoses included type 2 diabetes mellitus (a chronic condition where the body resists insulin and fails to use glucose (sugar) properly), cellulitis (bacterial infection that causes, red, hot, swollen, and tender skin) of right lower limb, pressure ulcer of left ankle, surgical removal of right foot, and non-pressure chronic ulcer of right ankle.Review of the resident's progress note, dated 03/05/26, showed an admission note stating wound measurements were not documented as part of the assessment due to staff being unable to remove the outer dressing until the resident's next appointment with the orthopedic physician. The resident has a hard brace on the surgical wound to decrease swelling. Review of the resident's progress note, dated 03/06/26, showed skin issues had not been evaluated related to the right below the knee amputation site. The surgical wound was present on admission, and it was unknown how long the wound had been present. Review of the resident's care plan, initiated on 03/06/26, showed the following information:-Administer treatments as ordered and monitor for effectiveness;-Monitor dressing to right stump and left ankle when providing care to ensure it is intact and adhering. Report loose dressing to nurse;-Consult wound, ostomy, and continuance nurse (WOCN) as appropriate;-Wound management;-Wound will show signs of improvement;-Monitor ulcer for signs of infection;-Provide wound care per treatment order. Review of the resident's after visit summary orders/post care instructions from an outside clinic nurse practitioner, dated 03/10/26, showed the following information:-Below-knee amputation (BKA) on 02/20/26;-Evaluation of below-knee amputation site showed the resident was experiencing pain and was concerned about a potential infection at the site. The resident has been using a soft stump shrinker since his/her discharge from the hospital and has been maintaining hygiene by washing the area;-During the exam, the physician noted the skin at the incision site was inflamed and red. Sutures intact, but the area was dry and causing itchiness;-Diagnosis suspected as surgical site infection following below-knee amputation;-Treatment plan for below-knee amputation site and left ankle included starting an antibiotic to treat the suspected infection, begin local wound care using medical-grade honey (TheraHoney-medical grade wound care product to promote faster healing) applied along the incision line, change the dressing and cleanse the wound daily, and follow-up in 1 1/2 weeks;-The physician emphasized the importance of daily wound care and vigilance for signs of infection. If the infection does not improve, revision surgery may be necessary. Review of the resident's 03/01/26 through 03/31/26 physician order sheet (POS) showed the following:-An order dated 03/10/26 with an ending date of 03/23/26 for wound care: Cleanse amputation site with generic wound cleanser, pat dry with gauze pads, apply TheraHoney along the incision line, place ABD (highly absorbent sterile dressing) over. Change dressing daily and as needed if soiled one time a day for wound care.Review of the resident's progress note, dated 03/10/26, at12:30 P.M., showed the resident had a follow up appointment with the surgeon today. New orders were received to begin Augmentin two times per day for seven days. The resident also had three other follow up appointments listed on the paperwork. Review of the resident's March 2026 treatment administration record (TAR) showed the following:-A wound care order with a start date of 03/11/26 to cleanse the amputation site with generic wound cleanser, pat dry with gauze pads, apply TheraHoney (Medihoney) along the incision line, place ABD pad over. Change the dressing daily and as needed if soiled one time a day;-On 03/11/26, staff documented the wound care was on hold (see progress note). Review of the resident's progress note, dated 03/11/26, showed a note from an Licensed Practical Nurse (LPN) stating the resident keeps telling him/her that he/she would prefer to have his/her dressing changed later. The LPN documented that he/she would ask the night shift nurse if he/she could do the wound treatment. Review of the resident's progress note, dated 03/11/26, showed staff documented the resident continued on Amoxicillin for a wound infection. No additional progress notes were documented on 03/11/26 regarding the wound.Review of the resident's March 2026 TAR showed the following:-On 03/12/26, staff documented the wound care as provided. No progress note provided;-On 03/13/26, staff documented the wound care was on hold (see progress notes).Review of the resident's progress note, dated 03/13/26, showed TheraHoney as not available for the ordered wound care, so triple antibiotic ointment was used instead. Review of the resident's March 2026 TAR showed the following:-On 03/14/26, staff did not provide the wound care. No progress note provided.-On 03/15/26, staff documented the resident refused the wound care. No progress note provided.Review of the resident's progress note, dated 03/15/26, showed the resident informed the registered nurse (RN) that his/her dressing did not need to be changed right now, and he/she will maybe want it changed later in the night. The RN explained the importance of wound care and frequency to the resident.Review of the resident's March 2026 TAR showed on 03/16/26, staff documented the wound care as provided. No progress note found or provided showing TheraHoney as not available.Review of the resident's progress note, dated 03/16/26, showed the resident received oral antibiotics and staff changed the dressing to the left ankle per orders. No outward signs and symptoms of infection noted.Review of the facility provided supply company order submitted at 11:59 A.M., on 03/16/26 showed the following:-Two dressing, honey, TheraHoney 0.5-ounce tubes were ordered for a total of $13.32;-The status showed Backordered;-A pending note with an estimated ship date of 04/20/26.Review of the resident's March 2026 TAR showed on 03/17/26, staff documented the wound care as provided. No progress note found or provided showing TheraHoney as not available.Review of the resident's progress note, dated 03/17/26, showed the resident continued on antibiotic therapy for a wound infection.Review of the resident's March 2026 TAR showed the following:-On 03/18/26, staff documented the wound care provided. No progress note found or provided showing TheraHoney as not available;-On 03/19/26, staff documented the wound care provided. No progress note found or provided showing TheraHoney as not available;-On 03/20/26, staff documented the wound care provided. No progress note found or provided showing TheraHoney as not available;-On 03/21/26, staff documented the wound care provided. Review of the resident's progress note, dated 03/21/26 showed staff documented TheraHoney as not available for the wound care provided, so triple antibiotic ointment used in place of the TheraHoney. Review of the resident's March 2026 TAR showed the following:-On 03/22/26, staff documented the wound care as provided. No progress note found or provided showing TheraHoney as not available;-On 03/23/26, staff documented the wound care as provided. No progress note found or provided showing TheraHoney as not available. Review of the resident's after visit summary orders from an outside clinic nurse practitioner, dated 03/23/26, showed the following information:-Medical history of right below-knee amputation (BKA) on 02/20/26;-The resident visited for a follow-up of his/her right below-knee amputation. He/She has ongoing wound care concerns and phantom pain. He/She also has a wound on his/her left ankle;-During the physical exam, necrotic tissue was found on the right below-knee amputation stump. The left ankle wound showed evidence of healing;-Treatment plan for the right below-knee amputation stump included applying a wet to dry dressing with Vashe (professional grade, non-cytotoxic wound cleanser) twice daily and use Aquaphor (healing ointment) to moisturize the surrounding skin;-Treatment plan for the left ankle wound included applying a wet to dry dressing twice daily. Medihoney may be used if available to assist with debridement and healing. Review of the resident's progress note, dated 03/23/26, showed the resident had a scheduled physician's appointment with the surgeon today. New orders received for wound care to the right below the knee amputation and left ankle. The new orders were entered into the resident's electronic health record. Review of the resident's 03/01/26 through 03/31/26 POS showed the following:-An order dated 03/23/26 with an ending date of 03/24/26 for wound care for left ankle wound. Apply wet to dry dressings with Vashe twice daily. Medihoney may be used if available to assist with debridement and healing two times a day for wound care;-An order dated 03/23/26 with no ending date for wound care for right below-knee amputation stump. Apply dry dressing twice daily. Medihoney may be used if available to assist with debridement and healing every day and night shift for wound care;-An order dated 03/24/26 with no end date for wound care for left ankle wound. Wash with soap and water. Apply dry dressing twice daily. Medihoney may be used if available to assist with debridement and healing every day and night shift for wound care;-An order dated 03/24/26 with no ending date to remove shrinker from right amputation, assess skin, and complete proper hygiene, reapply with proper alignment. Monitor skin integrity and notify physician of any abnormalities every day and night shift related to acquired absence of right foot.Review of the resident's March 2026 progress notes showed staff did not document notification to the physician or the pharmacy about the Medihoney not being available. During an interview on 03/23/26, at 12:15 P.M. and on 03/24/26, at 10:04 A.M., Resident #7 said the following: -He/She is happy with the nursing staff, but he/she is not happy with the amount of time he/she has had to wait for his/her wound care supplies;-He/She went to a follow up visit at the surgeon's office this morning and the physician that removed the dressing and shrinker on his/her right leg surgical site was upset that the facility has not had Medihoney available for his/her dressing changes;-Today, the physician changed the wound care order to change the dressing two times per day;-Certified Medication Technician (CMT) G was the transportation driver that took him/her to the physician's appointment today, and CMT G told the physician's office staff that the facility has not had the Medihoney available for his/her wound care dressings as ordered.-He/She is currently on an oral antibiotic;-Facility staff used a triple antibiotic ointment on his/her surgical wound instead of the Medihoney that was ordered by the surgeon;-Facility staff only changed his/her wound dressing three times since 03/10/26;-Facility staff did not change his/her dressing yesterday evening as the physician ordered on 03/23/26, and no one has changed his/her dressing so far today (03/24/26). During an interview on 03/23/26, at 12:20 P.M. and 2:59 P.M., RN Q said the following:-Resident #7 had an order to use Medihoney for his/her dressing changes, but the pharmacy never sent it, so he/she called the pharmacy and was told the pharmacy was sending it. -He/She did not recall what date he/she called the pharmacy, and he/she did not document the call.-He/She called the pharmacy again today and was informed that the Medihoney was on backorder due to it being contaminated. The pharmacy did not tell him/her this the first time he/she called;-He/She should have documented his/her calls to the pharmacy to ask about the Medihoney, but he/she failed to document the calls;-He/She asked the transport driver, CMT G, that took Resident #7 to his/her physician's appointment this morning to ask the surgeon's office if they could send Medihoney back to the facility with the resident;-The transport driver reported back to him/her that the surgeon's office discontinued the Medihoney order and removed the resident's sutures during the visit;-Prior to Resident #7's appointment, he/she noticed drainage on his/her ace wrap;-Resident #7 was upset about his/her dressing not being changed per physician orders, which was prior to the resident being started on an antibiotic;-Staff at the facility have been using an antibiotic ointment on the resident's surgical wound instead of Medihoney since it was not available;-RN Q does not know if anyone at the facility called the surgeon's office to inform them that they were using an antibiotic ointment on the resident's surgical wound instead of Medihoney per the physician's orders;-The facility never had Medihoney for Resident #7;-The facility staff should have called the physician and asked to have the order changed;-RN Q brought some Medihoney from his/her home and used it on Resident #7 on the days he/she changed the resident's dressing;-He/She knows that bringing Medihoney from home was not what he/she should have done;-He/She put the Medihoney that he/she brought into the facility into a cup after he/she removed the foil that sealed the medication, and he/she used it on Resident #7 two times. He/She did not document this anywhere;-No other staff had access to the Medihoney that he/she brought into the facility to use on Resident #7;-He/She should have called the physician, but he/she did not.During an interview on 03/24/26, at 11:00 A.M., LPN D said he/she was not familiar with Resident #7 or his/her dressing changes. During an interview on 03/24/26, at 11:14 A.M., CMT G said the following:-He/She drove Resident #7 to his/her trauma surgery physician's appointment on 03/23/26;-He/She informed the staff at the physician's office that the facility did not have any Medihoney for the resident's dressing changes because the facility was not able to get it from the pharmacy;-The physician's office staff said they would not send Medihoney to the facility;-He/She knows that staff at the facility called the supply company regarding the Medihoney not coming in but even after the call the Medihoney still did not come in. He/She does not know if anyone documented the call to the supply company;-The facility planned to go to a store and buy the Medihoney if the surgeon's office did not send any back to the facility with the resident after his/her 03/23/26 appointment, but the physician's office changed the order on 03/23/26.During an interview on 03/25/26, at 10:35 A.M., the Director of Nursing (DON) said the following:-Resident #7 sees his/her wound physician every week, so the outside wound care company, did not want to see him/her because the surgeon was still following him/her;-The surgeon's office recently changed Resident #7's dressings to a wet to dry dressing;-He/She did not know what staff was using for Resident #7's dressing changes in place of Medihoney since it was not available; -No staff told him/her that they did not have the Medihoney available for Resident #7's dressing changes; -He/She would expect the nurses to call the physician about the medication/ointment not being available and then tell him/her what happened;-The nurses should have made a progress note showing that they did not have the Medihoney available;-The nursing staff should not documented that they were changing Resident #7's dressings with Medihoney when it was not available;-He/She was just told today by RN Q that he/she brought Medihoney from home and used it on Resident #7;-There was a risk for Resident #7 to get an infection in his/her wounds when RN Q used the Medihoney that he/she brought from home on his/her wounds. During an interview on 03/25/26, at 3:45 P.M., the administrator said the following:-The nursing staff should have put Resident #7's wound care order on hold and contacted the physician to ask for an alternative treatment;-He/She was told by RN Q that the Medihoney he/she used on Resident #7 had a foil seal on the container, so he/she could not say for sure if the resident would be at risk for an infection in his/her wound since the Medihoney was reported to be sealed.During an interview on 03/23/26, at 2:59 P.M. and 03/25/26, at 10:14 A.M., RN Q said the following:-Staff should not document that a dressing was changed with the ordered supplies if the correct supplies were not used or if the dressing change was not done at all;-He/She does not usually bring Medihoney in to use on residents;-The wound care nurse is normally the Assistant Director of Nursing (ADON), but the facility does not have an ADON right now;-The nurses are responsible for dressing changes and an outside wound management company comes to the facility on Fridays;-When a new ADON is hired, they will take over as the wound care nurse;-The pharmacy orders come in during the night and he/she thinks the medication technicians, or the DON checks the medications in. During an interview on 03/24/26, at 11:00 A.M., LPN D said the following:-If the facility did not have a wound care supply for a resident, staff should call the physician and get an order for something different;-He/She would not bring a medication/ointment to the facility from home and use it on a resident;-It is not appropriate for staff to bring a medication/ointment from home and use it on a resident;-Staff should not document that they completed a dressing change if it was not completed or document that they completed the dressing change using a medication that was not available;-If the physician's order was not followed for a dressing change, staff should document the situation in a progress note in the resident's medical record. During an interview on 03/24/26, at 2:00 P.M., the facility's medical director said the following:-He/She would expect staff to follow wound care orders as written and notify him/her if a wound care supply or medication was not available for the dressing change, so he/she can consider an alternative treatment.During an interview on 03/25/26, at 10:35 A.M., the Director of Nursing (DON) said the following:-The facility does not get Medihoney from the pharmacy. It is ordered through the facility supply company or purchased over the counter;-The administrator is working on printing the order sheet for the Medihoney/TheraHoney that was ordered from the supply company;-It is not acceptable for staff to bring in their own Medihoney from home to use on a resident.During an interview on 03/25/26, at 9:00 A.M. and 3:45 P.M., the administrator said the following:-He/she would expect staff to let the DON or him/her know if they did not have the wound care supplies or medications they need;-It is not appropriate for staff to bring their own Medihoney in from home and use on a resident;-An outside company is serving as the facility's wound care nurse since the facility does not have an ADON that would normally be assigned that task. The ADON position has been vacant since mid-February 2026.

Based on observation, record review, and interview, the facility staff failed maintain an effective pest control system when were present in one resident's (Resident #6) room. The facility census was 62.Review showed the facility did not provide a pest control policy. 1. Review of a pest control invoice, dated 12/12/25, showed the following:-General pest control maintenance;-Scion insecticide treatment applied to the interior perimeter of the building for the aid and control of occasional invaders;-Mouse caught in snap trap by the refrigerator in the employee breakroom;-Spoke with staff who had no other pest concerns at this time of service;-Call with any concerns between now and next visit. Review of a pest control invoice, dated 01/16/26, showed the following:-General pest control maintenance for rodents;-Treatment applied to interior perimeter of the building and all accessible areas for the aid and control of occasional invaders, ants, roaches, crickets, and beetles;-Serviced, cleaned, and reset all interior rodent stations and found no activity of pests;-Inspected all temporary traps and found one dead mouse under the vending machine. Was informed of mouse sighting in the breakroom;-Installed mechanical rodent trap by the refrigerator, along with two snap traps;-Spoke with multiple staff members who had no other pest concerns at the time of this service;-Call with any concerns between now and the next visit.Review of a pest control invoice, dated 02/20/26, showed the following:-General pest control maintenance for rodents;-Manager had no other pest control concerns at the time of the service;-Call with any concerns between now and the next visit. Review of a pest control invoice, dated 03/09/26, showed the following:-General pest control service provided;-Chemically treated room [ROOM NUMBER] for potential bed bugs;-Treatment applied to interior perimeter of building and all accessible areas for the aid in control of occasional invaders such as crickets, ants, cockroaches, beetles, and spiders;-Spoke with multiple staff members who had no other pest concerns to report at this time of service;-Please call with any concerns between now and your next visit. 2. Review of Resident #6's face sheet (brief information sheet about the resident) showed the following information:-admission date of 10/03/23;-Diagnoses included osteoarthritis (breakdown of cartilage in the joints that causes joint pain), muscle wasting and shrinking, dementia (progressive memory loss), spinal stenosis (narrowing of the spinal canal that compresses nerves), adult failure to thrive (a decline in physical and cognitive function), and need for assistance with personal care.Review of Resident #6's progress note dated 03/17/26, at 8:00 A.M., showed the following:-A progress note with no documentation of which department or who wrote the note;-Resident #6 reported having a lot of ants in his/her room;-The resident is possibly seeing things due to poor vision or could be hallucinating;-The reporter of the note said he/she did not see any ants in the resident's room;-The facility staff does not know of any ant issue. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/19/26, showed the following:-Moderate cognitive impairment;-Used a wheelchair and walker;-Required partial to moderate assistance (the resident can perform 50 percent of the mobility task, while the caregiver assists with 50 percent from sit to stand;-Required supervision or touch assistance with toilet transfer and tub/shower transfer;-Required setup or clean up assistance with eating and oral hygiene;-Required substantial/maximal assistance with upper body dressing;-Dependent with toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and putting on/taking off footwear. During an interview on 03/23/26, at 11:00 A.M., Resident #6 said the following:-For a few weeks he/she has had multiple ants in his/her room;-Housekeeping staff just mopped his/her floor, and they have seen the ants. Observation of Resident #6's room on 03/23/26, at 11:05 A.M., showed the following:-Live ants crawled on various areas of the floor in the resident's room;-The resident only had one package of sealed crackers in his/her room that sat on the bedside table. No ants were present on the bedside table or around the crackers;-Resident #6's room was located next to the 100 hall exit door. During an interview on 03/25/26, at 9:34 A.M., the maintenance director said the following:-He/She has not been informed by facility staff of live ants in Resident #6's room;-Staff have not documented any concerns regarding live ants in Resident #6's room, but he/she is having problems with staff using the log to communicate maintenance concerns to him/her;-If there are ants in Resident #6's room, staff should have written that on the maintenance log sheet at the nurse's station, but no one has;-When the pest control company comes back to the facility on Friday, 03/27/26, he/she will ask what they can do about the ants in Resident #6's room. He will need to find a material safety data sheet (MSDS) for the pest control company, so they will know what they are allowed to use to help eliminate the ant issue.Observation and interview on 03/25/26, at 9:38 A.M., showed live ants observed on the floor in Resident #6's room;-The maintenance director was in the room and killed the live ants with his/her finger;-Resident #6 said there were a lot of live ants in his/her room yesterday. During an interview on 03/25/26, at 10:06 A.M., Housekeeper T said the following:-He/She has seen ants in just a few rooms recently, especially on the 100 hall and in Resident #6's room a few days ago;-Resident #6 complained to him/her about the ants in his/her room;-He/She has not let the maintenance director know about the ants in Resident #6's room;-The maintenance director has a maintenance logbook at the nurse's desk where he/she can report maintenance issues, but he/she has not written the ant issue in the logbook yet for Resident #6's room. During an interview on 03/25/26, at 10:35 A.M., the Director of Nursing (DON) said the following:-He/She knew about the ants in Resident #6's room, because he/she recently saw them, but he/she does not know the exact dates;-He/She told the maintenance director about the ants in Resident #6's room on a Thursday, approximately a week or two ago;-When he/she informed the maintenance director that the resident had ants in his/her room, the maintenance director said he/she noted his/her complaint and that the pest control company would be at the facility on Friday, but the DON did not know which Friday he/she referred to. During an interview on 03/25/26, at 3:45 A.M., the administrator said the following:-Pest control comes to the facility one time per month;-He/She is not sure when the pest control company was at the facility last;-He/She thinks the pest control company may have sprayed at the facility a month ago;-He/She is not sure about this facility, but other facilities he/she has worked at had a pest control company spray inside and outside the facility, but he/she did not know if the pest control company would spray in resident rooms.-Staff should tell the maintenance director or add it to his/her maintenance log that is located at the nurse's station if they become aware of ants in the facility;-He/She plans to talk to the maintenance director and find out when the pest control company will be coming back to the facility. 3. During an interview on 03/25/26, at 9:34 A.M., the Maintenance Director said the following:-The facility recently had problems with mice in the facility, and the pest control company has been coming to the facility every Friday since at least June of 2025 to help eliminate the mice;-While at the facility, the pest control company goes around and checks the containments for mice and monitors treatment areas for mice;-He/She is not allowed to spray any pest sprays in the facility;-The resident rooms are sprayed on a case-by-case basis;-He/She knew of an ant problem by the 100 hall exit door a few days ago, but he/she did not know of any ants in resident rooms;-He/She used hot water to kill the ants at the 100 hall exit door and he/she has not noticed any ants at that door since then;-When he/she started at the facility, there were no inspection forms for him/her to use, so he/she has been trying to develop forms as things come up;-The facility maintenance person before him/her did not have any maintenance records for the facility;-He/She developed a maintenance request folder in December of 2025 that he/she keeps at the nurse's station for staff to communicate maintenance concerns to him/her. The only request on the log is a concern about a call light not working in room [ROOM NUMBER] and it was entered on the log on 03/23/26;-He/She has not seen any live ants in any rooms recently, so he has not addressed any ant concerns within the facility;-He/She looks in every resident room every week, but he/she does not document the inspection anywhere. He/She did not say what he/she looks for in each resident room;-Staff need to start using the maintenance log that is at the nurse's station instead of just walking up to him/her and telling him/her about issues because he/she cannot remember everything;-He/She thinks the pest control company sprayed for ants at the facility in the past, but he/she could not provide the last date, and he/she did not have any pest control maintenance receipts to provide;-He/She recently called a different pest control company to see if they will give him an estimate to take over pest management at the facility because he/she does not like the current pest control company. He/She is waiting on a response from the pest control company he left the message at a few days ago.During an interview on 03/25/26, at 10:35 A.M., the Director of Nursing (DON) said the following:-The DON has never seen a pest control company spray at the facility;-The maintenance director informed him/her that he/she could not spray for the ants, but the pest control company could. During an interview on 03/25/26, at 3:45 A.M., the Administrator said the following:-Pest control comes to the facility one time per month;-He/She is not sure when the pest control company was at the facility last;-He/She thinks the pest control company may have sprayed at the facility a month ago;-He/She is not sure about this facility, but other facilities he/she has worked at had a pest control company spray inside and outside the facility, but he/she did not know if the pest control company would spray in resident rooms.-Staff should tell the maintenance director or add it to his/her maintenance log that is located at the nurse's station if they become aware of ants in the facility;-He/She plans to talk to the maintenance director and find out when the pest control company will be coming back to the facility.Complaint 2959539

Based on interview and record review, the facility failed to ensure all resident representatives were notified of changes in condition in a timely manner when staff failed to inform one resident's (Resident #2) representative of falls resulting in bruising and skin tears. The facility census was 66.Review of the facility policy entitled Significant Condition Change and Notification, dated 12/24, showed the following:-Purpose is to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes;-Examples of changes include new wounds, bruises or skin tears, head trauma, and mobility changes;-Licensed nurse will contact the resident's representative and medical practitioner;-Calls will be made until the residents' representative is reached;-Each attempt will be charted as to what time the call was made, who was spoken to, and what information was given.1. Review of Resident #2's face sheet (a document that gives a resident's information at a quick glance) showed the following information:-admission date of 09/09/24;-Diagnoses included Parkinsons disease (a progressive neurological disease characterized by abnormal movements, tremor and stiffness), cognitive communication deficits, and history of falling.Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/04/25, showed the following information:-Cognitively intact;-Able to walk with a walker;-Maximum assistance for toileting. Review of the resident's care plan, updated 01/28/26, showed the following:-He/she had limited physical mobility due to weakness;-He/she was a risk for falls due to disease process and muscles weakness;-He/she used a wheelchair;-He/she had unwitnessed falls on 02/11/26, 02/19/26, and 02/21/26.Review of the resident's nursing progress note dated 02/11/26, at 12:52 P.M., showed staff documented an unwitnessed fall. (Staff did not document responsible party notification.)Review of the facility fall risk data collection (a tool used by facility to track falls) dated 02/13/26, at 12:59 A.M., showed staff documented a fall occurring on 02/11/26. (Staff did not document responsible party notification.)Review of the resident's nursing progress note dated 02/14/26, at 2:03 A.M., showed staff documented an unwitnessed fall that resulted in skin tear to the resident's right forearm. (Staff did not document responsible party notification.) Review of the resident's nursing progress note dated 02/19/26, at 1:21 A.M., showed staff documented an unwitnessed fall resulting in a hematoma (bruise) to the right side of the resident's forehead. (Staff did not document responsible party notification.)Review of the facility fall risk data collection dated 02/19/26, 1:25 A.M., showed staff documented a fall occurring on 2/19/26. (Staff did not document responsible party notification.)Review of the resident's nursing progress notes, dated 02/21/26, showed no documentation of a fall occurring.Review of the facility fall risk data collection dated 02/22/26, at 2:19 A.M., showed staff documented a fall occurring on and 2/21/26. (Staff did not document responsible party notification.)Review of the resident's nursing progress note dated 02/22/26, at 12:30 P.M., showed staff documented the residents' son requested he/she be sent to the hospital due to a head injury that occurred on the previous shift. Review of the resident's nursing progress note dated 02/23/26, at 9:26 A.M., showed staff documented the resident had a fall on 02/21/26. (Staff did not document responsible party notification.) During an interview on 02/25/26, at 11:50 A.M., Licensed Practical Nurse (LPN) E said the following: -If a resident had an unwitnessed fall they are started on neurological checks (a rapid, periodic assessments performed by healthcare professionals to monitor brain, spinal cord, and nerve function) and they notify the doctor and the family;-If a fall happens in the middle of the night and it is a non-injury fall, the fall can be reported on day shift. During an interview on 02/25/26, at 12:31 P.M., Registered Nurse (RN) F said the following: -On Sunday (02/22/26) the night shift nurse reported that the resident had fallen, and he/she was started on neurological checks;-The night shift nurse reported that he/she did not notify the family of the fall;-He/she did not notify the residents' family of the fall;-Later that day the resident's family member came to visit and requested he/she be sent to the hospital for evaluation of bruising to the resident's head.During an interview on 02/25/26, at 12:40 P.M., LPN G said the following;-He/she was monitoring the resident due to the resident falls;-The resident had bruising to the right side of the forehead that started as a goose egg and turned into a black eye;-He/she did not notify the family since he/she had not done the initial assessment and was currently just monitoring the resident.During an interview on 02/25/26, at 1:30 P.M., LPN H said the following;-He/she was the nurse on duty when the resident fell on [DATE];-He/she started the resident on neurological checks;-He/she did not notify the residents family and asked the day shift to do so. During an interview on 02/25/26, at 2:55 P.M., the Director of Nursing (DON) said the following:-He/she expected staff to start neurological checks on all unwitnessed falls;-He/she expected the doctor, his/herself, and the resident's family to be notified of all falls by staff;-If a non-injury fall happens on night shift, staff can report fall in the morning;-He/she expected all falls and fall notifications to be documented in the nursing progress notesDuring an interview on 02/25/26, at 4:15 P.M., the Administrator said the following:-He/she expected staff to notify the physician and the family for all resident falls;-He/she expected the fall and all notifications to be documented. Complaint 2784842

Based on interview and record review the facility failed to provide care per standards of practice for all residents when staff failed to follow physician orders to obtain an x-ray and failed to follow-up regarding completion of the orders for x-rays for one resident (Resident #1) after a fall. The facility census was 66. Review of the facility policy titled, Test Results, dated 01/2017, showed the following: -Results of laboratory, radiological, and diagnostic tests shall be reported to the facility;-The medical practitioner shall be notified of the results;-The Director of Nursing Services, or nurse receiving the test results, shall be responsible for notifying the medical practitioner of such test results.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 09/13/22;-Diagnoses included Type 2 diabetes mellitus (a chronic metabolic disorder where the body develops insulin resistance, causing high blood sugar levels because cells fail to respond properly to insulin) with hyperglycemia (high blood sugar levels), chronic right heart failure (occurs when the right ventricle becomes too weak or stiff to effectively pump blood to the lungs, leading to systemic venous congestion, fluid retention, and reduced oxygenation), chronic respiratory failure with hypoxia (lack of oxygen), muscle wasting, pain in right knee and lymphedema (a chronic swelling, usually in the arms or legs, caused by a buildup of protein-rich lymph fluid due to damaged or blocked lymph vessels).Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/23/25, showed the following: -Cognitively intact;-Required moderate assistance for transfers.Review of the resident's care plan, dated 02/25//26, showed the following:-At risk for falls;-Educate the resident/family/caregivers about calling for assistance prior to cares and what to do if a fall occurs;-Encourage the resident to participate in activities that promote exercise, physical activity strengthening ,and improved mobility;-Resident had an unwitnessed fall on 02/16/26. Encourage the resident to utilize call light prior to transfers and to check to make sure his/her wheelchair is locked;-The resident had a witnessed fall 02/11/26. Educate the resident prior to transferring to complete task more quickly.Review of the resident's progress notes dated 02/16/26, at 7:30 P.M., showed Registered Nurse (RN) A said the resident was found on the floor laying on his/her left hip beside the bed. The resident said he/she was attempting to transfer from the bed to wheelchair when he/she slid out of bed. The fall was unwitnessed. A head-to-toe assessment and skin assessment was performed. The resident was complaining of bilateral (both sides) hip pain. The resident's family, physician and management were notified of event. A new order was received for bilateral hip x-rays to be obtained.Review of the resident's fall risk data collection dated 02/16/26, at 5:25 P.M., showed the resident had an unwitnessed fall on 02/16/26.Review of the resident's Physician Order Sheet (POS), dated February 2026, showed an order, dated 02/17/26, for bilateral hip x-rays due to a fall and increase pain in both hips entered by RN A.Review of the resident's progress notes showed the following:-On 02/17/26, at 8:58 A.M., RN A said the resident continued to be on fall follow-up charting for a fall that occurred on 02/16/26. The resident denied any pain or discomfort. The resident complained earlier of bilateral hip pain post fall. The order was received for a left and right hip x-ray to be obtained. Vital signs and neuro-checks were within normal range. Staff will continue to monitor any needs. (Staff did not document regarding the ordered x-ray or the results.);-On 02/18/26, at 6:55 P.M., staff noted no complications from previous fall and no concerns. (Staff did not document regarding the ordered x-ray or the results.);-On 02/19/26, at 12:39 A.M., staff noted the resident continued on all follow up following unwitnessed fall. Resident vital signs and neurological check within normal limits. There were no delayed injuries. The resident was resting in bed with eyes closed and call light within reach. There were no signs of pain or discomfort. (Staff did not document regarding the ordered x-ray or the results.)Review of the resident's record showed staff did not have results for an X-ray of the resident's noted or copied. During an interview on 02/25/26, at 3:21 P.M., the resident said the following:-He/she had a fall about a week ago. He/she was assessed by the nurse and had pain in his/her legs;-He/she had not had an x-ray since then.During an interview on 02/25/26, at 9:54 A.M., Certified Nurse Aide (CNA) B said he/she gets the nurse if a resident has a fall. The resident is assessed by the nurse, and he/she will call the physician if there appears to be injury. The nurse will follow the instructions from the physician.During an interview on 02/25/26, at 11:48 A.M., Licensed Practical Nurse (LPN) D said the following:-He/she assessed a resident after a fall. He/she called the physician immediately if there was any sign of injury. If they are having increased pain the physician may want an x-ray to further assess the resident;-The nurse puts in an order for the x-ray. He/she thought the order automatically went to the x-ray company after he/she put in the order;-If x-ray does not come that day, he/she would call them to follow up and let the physician know there was a delay.During an interview on 02/25/26, at 3:24 P.M., RN A said the following:-He/she assessed the resident after he/she had a fall on 02/16/26, while attempting to transfer to a wheelchair. It was unwitnessed. He/she did neurological checks and everything was normal;-The resident was complaining of pain in both hips. He/she called the physician and got orders to get an x-ray;-He/she put orders into the computer and called the radiology company to come to the x-ray. He/she put in the orders later in the day and they said they would come the next day;-He/she got the packet ready to give them with the resident's information;-They did not come the next day. He/she called again to get the x-ray and they said they would come. He/she told the oncoming nurse that radiology should be coming to do the x-ray. He/she did not work the following day and was not sure what happened after that;-He/she did not write a note in the resident's record regarding attempts to reach radiology;-He/she was not sure why the x-ray was never done but staff should have continued to follow up on it and let the physician know if they were unable to get it. The packet that he/she prepared for the radiology staff was still at the facility.During an interview on 03/02/26, at 1:30 P.M., the radiology company staff said the following: -The facility staff did not notify them that an x-ray needed to be done. They have no record of the facility contacting them on 02/16/26 or on 02/17/26;-They document every call that they get and there should be something documented if it occurred. During an interview on 02/25/26, at 2:55 P.M., the Director of Nursing (DON) said the following:-He/she contacted the radiology company, and they said that they never received an order to do the x-ray for the resident;-The facility staff put an order in the computer but have to call the radiology company for them to come onsite to do the x-ray;-He/she was not sure why the x-ray orders were not followed up on;-The physician orders should have be followed and an x-ray should have been done.During an interview on 02/25/26, at 4:13 P.M., the Administrator said the following:-He/she would expect resident's to be assessed after a fall. If the physician recommended an x-ray, the nurse should put in the order and call the radiology company to come do the x-ray;-If radiology does not come. The nurse should continue to follow up and call them;-He/she would expect x-rays to be done.2784842

Based on interview and record review, the facility failed to ensure all allegations of possible abuse were reported to the Department of Health and Senior Services (DHSS) within the required two hours timeframe when the facility did not report one resident's (Resident #1) statement of abuse. The facility census was 68.Review of the facility's policy titled Abuse, Prevention and Prohibition Policy, dated November 2025, 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, 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. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The person made aware of allegations of abuse or neglect, or the administrator will report the allegation of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than two hours, or per state regulations, after the allegation is made. 1. Review of Resident #1''s face sheet (admission data) showed the following:-admission date of 12/27/25;-Diagnoses included major depressive disorder, other chronic pain, and congestive heart failure (CHF - a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/30/25, showed the resident's cognitive skills intact.Review of the facility grievance form dated 12/31/25, no time, showed the Social Service Director (SSD) documented the resident stated that Certified Nurse Aide (CNA) A comes in and is hateful and verbally abusive towards him/her. The resident said the CNA gets mad when he/she asked for stuff and asked to get up and the CNA refused. Review of DHSS records showed the facility did not report the allegation of possible abuse on 12/31/25. Review of the resident's care plan, revised 01/05/26, showed the following:-The resident had a mood problem;-The resident needs time to talk;-The resident had a behavior problem;-The resident refused to get out of bed and refused therapy. During an interview on 01/05/26, at 9:29 A.M., CNA A said the following:-Staff should report to the charge nurse and Administrator immediately any allegation of abuse; -The facility should call the state within two hours with an allegation of abuse; -Last week the Director of Nursing (DON) called him/her into the office and said staff said he/she threw down the resident's meal tray, the resident's food was cold, stated to the resident you get what you get and did not assist the resident up in his/her bed;-The DON said this was borderline abuse due to an allegation of stating to the resident to butt out of his/her roommate's care.During an interview on 01/05/26, at 10:46 A.M., CNA B said the following:-Staff should report to the charge nurse immediately any allegation of abuse;-Staff should report an allegation of abuse to the state within two hours. During an interview on 01/05/26, at 10:54 A.M., the DON said the following:-On 12/31/25, the SSD said the resident was mad about the eggs and later said the resident said CNA A and another aide was rough with his/her roommate; -She spoke with the resident who said the aide was rude;-She did not tell CNA A it was borderline abuse of the statement of butt out of roommate's business;-The resident did not state abuse to her;-Staff should report an allegation of abuse to the administrator immediately;-Staff should report an allegation of abuse to the state within two hours;-Observation showed the DON reviewed the grievance report, dated 12/31/25, and said it stated verbal abuse. During interviews on 01/05/26, at 11:24 A.M. and 1:00 P.M., the SSD said the following: -For abuse allegations, SSD called the state first then told the Administrator;-If a resident was in immediate danger, he made sure the resident was safe and then notified the administrator;-On 12/31/25, he spoke with the resident in his/her room. CNA A came into the resident's room and said the resident said he/she thought CNA A was getting him/her up. CNA A said he/she tried to get him/her up and he/she refused. The resident stated to SSD every time CNA A came in, he/she was mean to him/her;-SSD informed the Administrator on 12/31/25 the resident said CNA A was rude, disrespectful, and mean;-SSD said the resident said mean, meaning CNA refused to warm up his/her food and pull him/her up in bed;-The Administrator informed him to speak to the DON. He informed the DON that he witnessed CNA A be disrespectful to the resident and refuse to pull up the resident in bed. CNA A was mean in the way he/she spoke to the resident and dismissed the resident;-The DON informed him to bring her a grievance form;-He did not remember what he put on the grievance form;-On 1/05/26, at 1:00 P.M., the SSD reviewed the grievance form dated 12/31/25 and said he handed the form to the DON and the resident did state verbal abuse. He did not receive the grievance form back.During an interview on 01/05/26, at 1:00 P.M., the SSD said he emailed the grievance form to the Administrator and on 12/31/25 he informed the Administrator that the resident said verbal abuse. He did not hear anything else until today. The DON said she did not have the grievance form when he requested it from her.During an interview on 01/05/26, at 2:50 P.M., the ADON said the following:-Staff should notify the Administrator immediately of any allegation of abuse;-She did not know of the allegation of abuse. During an interview on 01/05/26, at 12:47 P.M., the DON said staff should report an allegation of abuse to the supervisor immediately and to the state within two hours. She did not think she understood the word abuse was on the grievance form. The SSD said the resident was upset with the eggs. She was not sure if she saw verbally abusive on the form.During an interview on 01/05/26, at 11:50 A.M., and the Administrator said the following:-Staff should report to the charge nurse or her immediately of an allegation of abuse; -The facility should report to the state within two hours of an allegation of abuse;-The SSD took the grievance form to the DON on 12/31/25;-She did not think the SSD informed her of what he wrote on the grievance form;-The Administrator did not know of the allegation of abuse on the grievance form dated 12/31/25 until today;-She considered the statement of verbal abuse an allegation of abuse. During an interview on 01/05/26, at 1:49 P.M., the Administrator said she had to leave on 12/31/25 and was in the facility for a little while on 01/01/26 and 01/02/26. She did not check her email. She expected staff to inform her of the allegation of abuse and notify DHSS timely. Complaint 2705749

Based on interview and record review, the facility failed to ensure that all allegations of possible abuse were thoroughly investigated in a timely manner and that steps were taken to protect all residents during the investigation when staff failed to document an investigation and steps to protect all resident during the investigation after an allegation of abuse involving one resident (Resident #1). The facility census was 68. Review of the facility's policy titled Abuse, Prevention and Prohibition Policy, dated November 2025, 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 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. If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress, except to meet with the administrator as part of the investigation. The person identified in the allegation of abuse will have no contact with residents or other employees during the investigation process;-When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution, or disciplinary action against the employee. The administrator and/or the Director of Nursing (DON) will relay this suspension. At that time, the alleged staff member will be advised of the allegation and encouraged to assist in completing a statement relevant to the facts. The employee shall be instructed that the suspension is without pay and will be in effect while the investigation is ongoing. 1. Review of Resident #1''s face sheet (admission data) showed the following:-admission date of 12/27/25;-Diagnoses included major depressive disorder, other chronic pain, and congestive heart failure (CHF - a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply). Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/30/25, showed the resident's cognitive skills intact.Review of the facility grievance form dated 12/31/25, no time, showed the Social Service Director (SSD) documented the resident stated that Certified Nurse Aide (CNA) A comes in and is hateful and verbally abusive towards him/her. The resident said the CNA gets mad when he/she asked for stuff and asked to get up and the CNA refused. Review of the resident's care plan, revised 01/05/26, showed the following:-The resident had a mood problem;-The resident needed time to talk;-The resident had a behavior problem;-The resident refused to get out of bed and refused therapy.Review showed the facility did not provide a previously completed written investigation or documentation of steps taken to protect all residents during the investigation. During an interview on 01/05/26. at 9:29 A.M., CNA A said the following:-Last week the DON called him/her into the office and said staff said he/she threw down the resident's meal tray, the resident's food was cold, stated to the resident you get what you get and did not assist the resident up in his/her bed;-The DON said this was borderline abuse due to an allegation of stating to the resident to butt out of his/her roommate's care;-CNA A worked with another CNA the rest of the day with the resident. CNA A worked with other residents on his/her own. During an interview on 01/05/26, at 10:54 A.M., the DON said the following:-Observation showed she reviewed the grievance report dated 12/31/25 and said it stated verbal abuse;-She was responsible for investigating an allegation of abuse;-Staff should have suspended CNA A pending the abuse investigation. During an interview on 01/5/26, at 11:24 A.M., the SSD the following: -When an allegation of abuse is received, if a resident is in immediate danger, he makes sure the resident is safe and then notified the Administrator;-On 12/31/25, he informed the Administrator the resident said CNA A was rude, disrespectful, and mean. SSD said the resident said mean, meaning CNA refused to warm up his/her food and pull him/her up in bed;-The Administrator informed him to speak to the DON. He informed the DON that he witnessed CNA A disrespectful to the resident and refused to pull up the resident in bed. CNA A was mean in the way he/she spoke to the resident and dismissed the resident. -The DON informed him to bring her a grievance form. He did not remember what he put on the grievance form;-On 01/05/26, at 1:00 P.M., the SSD reviewed the grievance form, dated 12/31/25, and said he handed the form to the DON. The resident did state verbal abuse.During an interview on 01/05/26, at 2:50 P.M., the Assistant Director of Nursing (ADON) said staff should notify the Administrator immediately of an allegation of abuse. Staff should speak with the residents, staff, and obtain statements during an abuse investigation. She did not know of the allegation of abuse.During an interview on 01/05/26, at 11:50 A.M., the Administrator said the following:-The SSD took the grievance form to the DON on 12/31/25;-She did not think the SSD informed her of what he wrote on the grievance form;-The Administrator did not know of the allegation of abuse on the grievance form dated 12/31/25 until today;-She considered the statement of verbal abuse an allegation of abuse;-Staff should protect the residents immediately of an allegation of abuse and suspend the named employee pending the investigation;-The DON is responsible for investigating an allegation of abuse with the help of the ADON. During an interview on 01/05/26, at 12:47 P.M., the DON said she did not think she understood the word abuse was on the grievance form. She was not sure if she saw verbally abusive on the form. Staff should had suspended CNA A immediately until the allegation of abuse was investigated by staff.During an interview on 01/05/26, at 1:49 P.M., the Administrator said she left the faciity on [DATE] and was in the facility for a little while on 01/01/26 and 01/02/26. She did not check her email. She expected staff to inform her of the allegation of abuse, call DHSS timely, and suspend CNA A pending the abuse investigation. Complaint 2705749

Based on observation, interview, and record review, the facility failed to provide restorative services to prevent loss of strength and range of motion when staff failed to have a process in place to ensure ordered and care planned restorative services we were provided and documented for four residents (Resident #1, #2, #3, and #4). The facility had a census of 63. Review of the facility policy, Restorative Nursing Policy and Procedure, undated, showed the following:-It is the policy of the facility to provide restorative nursing which promotes the resident's ability to adapt and adjust to living as independently and safely as possible;-Restorative nursing focuses on achieving and/or maintaining optimal physical, mental, and psychological function of the resident;-The restorative nurse, restorative nursing assistants, along with interdisciplinary team (IDT), will determine what programs will be initialed for the residents;-Restorative nursing services are provided by Restorative Nursing Assistants (RNA), Certified Nursing Assistants (CNA), and other individuals trained in restorative techniques, under the supervision of a licensed nurse;-Screening residents using restorative assessment in electronic medical record software program (EMR) to identify appropriate candidates for programs. These include but are not limited to any resident recently discharged from physical, occupation, or speech therapy; any new admission, quarterly, annual and with any significant change; any resident demonstrating decline in ADL's, ROM or other change in condition; and residents who have the potential for an increased level of functioning, or who require programs to maintain current level of functioning;-Specific types of the restorative nursing program include range of motion, passive and active; splint or brace therapy; and training and skill practice in transfers, bed mobility, ambulation, dressing or grooming, eating;-Each restorative service is recorded with minutes provided per shift by the CNA or RNA;-Implement programs for a designated period or time;-Re-evaluate quarterly at a minimum and revise and continue program if indicated;-Every resident who receives restorative nursing has a care plan with individualized, measurable goals and interventions.1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admission date of 09/13/22;-Diagnoses included chronic right heart failure (long-term condition where the right side of the heart cannot pump deoxygenated blood (blood with a reduced oxygen concentration as compared to blood departing the lungs) efficiently to the lungs, leading to a buildup of fluid in the body), chronic respiratory failure with hypoxia (long-term condition where the lungs cannot supply enough oxygen to the blood, causing dangerously low oxygen levels in the body), muscle wasting and atrophy (loss of muscle tissue that results in a decrease in muscle mass, strength, and function) multiple sites, generalized muscle weakness, and dependence on wheelchair.Review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 09/19/25, showed the following:-Cognitively intact;-Use of a wheelchair;-Dependent on staff for toileting hygiene, showering, dressing, personal hygiene;-Independent with eating and oral hygiene.Review of the resident's care plan, last updated 07/14/25, showed the following: -Resident was at risk for falls due to gait and balance problems, dependent on wheelchair and staff for cares;-Staff should encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility;-Resident had activity of daily living (ADL - dressing, grooming, etc.) self-care performance deficit, activity intolerance, fatigue, dependent on wheelchair, and multiple comorbidities requiring the need for assistance with ADLs and personal cares;-Staff should have physical therapy and occupational therapy evaluation and treatment as per physician orders;-Staff should provide restorative program - NuStep for lower extremity and upper extremity strengthening.Review of the resident's Physician's Order Sheet (POS), current as of 11/25/25, showed an order, dated 10/16/25, for may participate in restorative program: NuStep (brand of exercise equipment designed for low-impact, full-body workouts) for lower extremity and upper extremity strengthening exercises. Review of resident's nursing notes showed staff did not document related to restorative therapy.Review of the handwritten restorative nursing notes, dated 11/07/25, showed the resident on omni-cycle for 30 minutes.Review showed of the resident's record showed no restorative nursing notes provided for 11/10/25 to 11/25/25.During an interview on 11/25/25, at 11:45 A.M., the resident said RNA E was the restorative aide. He/she saw the aide once in a while. The resident said he/she would like to exercise more often. When he/she does exercise they go to therapy room and use a machine there.2. Review of Resident #2's face sheet showed the following: -admission date of 03/28/25;-Diagnoses included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), muscle wasting and atrophy, generalized weakness, and need for assistance with personal care.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Partial to moderate assistance with toileting;-Dependent on staff for showering;-Supervision or touching assistance for dressing;-Independent for eating, oral hygiene, and personal hygiene.Review of the care plan, last updated 09/16/25, showed the following:-Resident had an ADL self-care performance deficit;-Restorative program - ambulation with FWW required SBA times 120 feet. NuStep for strengthening. Standing balance batting ball with weight two-pound bar.Review of the resident's POS, current as of 11/25/25, showed an order, dated 10/31/25, for may participate in restorative program: ambulation with four-wheel walker (FWW) with stand by assistance (SBA) times 120 feet. NuStep for lower extremity and upper extremity strengthening. Standing balance batting ball with two-pound bar.Review of resident's nursing notes showed staff did not document related to restorative therapy.Review of the handwritten restorative nursing notes showed the following:-On 11/20/25, resident refused restorative today. He/she did not go to sleep until 4:00 A.M. this morning and was tired;-On 11/25/25, resident refused restorative today. He/she said he/she loved riding the bike but was not feeling well today.Review of the resident's restorative nursing notes showed, dated 11/10/25 to 11/25/25, showed no time or date documented as completed.During an interview on 11/25/25, at 11:35 A.M., the resident said he/she used to have restorative, but not anymore. He/she said the last time was about a month ago.3. Review of Resident #3's face sheet showed the following: -admission date of 04/24/25;-Diagnoses included emphysema (chronic lung condition that damages the air sacs in the lungs, making it difficult to breathe), chronic kidney disease stage 3 (CKD - mild to moderate kidney damage and cannot filter blood the way they should), muscle wasting and atrophy, generalized muscle weakness, abnormalities of gait and mobility, and need for assistance with personal cares. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Use of walker;-Use of wheelchair;-Setup or clean-up assistance with eating, oral hygiene, and personal hygiene;-Supervision or touching assistance for toileting hygiene;-Partial to moderate assistance with dressing;-Dependent for showering.Review of the resident's care plan, last updated 10/22/25, showed the following:-Resident had osteoporosis (condition in which bones have lost minerals-especially calcium-making them weaker, more brittle, and susceptible to fractures);-Staff should encourage weight bearing exercise as tolerated to help maintain bone mass;-Resident was at risk for falls;-Staff should encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility;-Resident had an ADL self-care performance deficit;-Staff should encourage restorative program - ambulation with FFW requires CGA assistance times 120 feet. NuStep for upper extremity and lower extremity strengthening.Review of the resident's POS, current as of 11/25/25, showed an order, dated 10/31/25, for may participate in restorative program: Ambulation with FWW with contact guard assistance (CGA) times 120 feet. NuStep for lower extremity and upper extremity strengthening.Review of resident's nursing notes showed staff did not document related to restorative therapy.Review of the handwritten restorative nursing notes showed the following:-On 11/07/25, resident was still sick and refused restorative today;-On 11/20/25, resident was not out of bed today.Review of the resident's restorative nursing notes showed the following:-On 11/10/25, at 1:50 P.M., 20 minutes spent with restorative transfer;-On 11/18/25, at 1:28 P.M., 20 minutes spent with restorative transfer;-On 11/20/25, at 1:22 P.M., resident not available for restorative;-On 11/25/25, at 1:57 P.M., 20 minutes spent with restorative transfer.4. Review of Resident #4's face sheet showed the following: -admission date of 09/08/25;-Diagnosis included COPD, lymphedema (swelling in an arm or leg caused by a blockage in the lymphatic system, which prevents lymph fluid from draining properly), repeated falls, muscle wasting and atrophy, generalized muscle weakness, and need for assistance with personal cares. Review of the resident's care plan, last updated 09/16/25, showed the following:-Resident had an ADL self-care performance deficit;-Staff should encourage restorative program - NuStep for upper extremity and lower extremity strengthening. Review of the resident's admission MDS, dated [DATE], showed the following:-Cognitively intact;-Use of wheelchair;-Setup or clean-up assistance with eating;-Substantial to maximal assistance with oral hygiene, showering, dressing, personal hygiene, toileting hygiene.Review of the resident's POS, current as of 11/25/25, showed an order, dated 10/16/25, for may participate in restorative program: Ambulation with FWW with minimal to moderate assistance times 20 feet. NuStep for lower extremity and upper extremity strengthening. Review of resident's nursing notes showed staff did not document related to restorative therapy.Review of the handwritten restorative nursing notes showed the following:-On 11/06/25, resident on bike from 12:30 P.M. to 12:55 P.M.;-On 11/25/25, resident refused restorative today. Said his/her legs hurt and he/she would probably be leaving tomorrow or the next day. Review of the restorative nursing notes showed the following:-On 11/20/25, at 1:31 P.M., 30 minutes spent on restorative program splint or brace;-On 11/25/25, at 1:56 P.M., 20 resident refused restorative program.5. During an interview on 11/25/25, at 10:30 A.M., RNA E said there were currently five residents on restorative services. He/she should be charting resident therapy in the electronic medical record but had not been shown how to, so he/she was keeping handwritten notes on the desk in therapy room. Residents should receive services at least three times per week. He/she was pulled to work on the floor more than working with the restorative program. Therapy writes the order for restorative and gives to the Director of Nursing (DON). The DON gives the order to the RNA. There was a handwritten paper that showed worked with residents on 11/17/25 and 11/25/25.During an interview on 11/25/25, at 10:45 A.M., the Director of Rehab said he/she gave restorative therapy recommendations to the Interim DON. Residents that come off therapy services are recommended to have restorative to keep range of motion. They will put recommendation such as 3-pound weights or how far to ambulate. It would be best for resident to have the therapy at least 3 times per week, but they would prefer 5 times per week. During an interview on 11/25/25, at 1:48 P.M., CNA C said he/she would help get residents up for therapy and ensure they have any adaptive items needed. RNA E was the restorative aide, and he/she gets weekly weights and walks with residents. Sometimes he/she was assigned to work the floor. During an interview on 11/25/25, at 1:55 P.M., Certified Medication Tech (CMT) F said RNA E was on the floor a lot as a CNA. The CMT had also seen RNA E so some range of motion with residents.During an interview on 11/25/25, at 1:50 P.M., CNA D said the restorative aide was RNA E and he/she does have to work the floor often.During an interview on 11/25/25, at 2:05 P.M., RN B said the restorative aide was RNA E. He/she had seen the aide doing resident weights and exercise on Mondays and Tuesdays. He/she did not know what other days the aide completed restorative therapy. During an interview on 11/25/25, at 2:10 P.M., Licensed Practical Nurse (LPN) A said RNA E was the restorative aide. He/she had seen RNA E work on the floor as a CNA. He/she did not know how often the aide was scheduled for restorative services with residents.During an interview on 11/25/25, at 3:00 P.M., the Interim DON said the restorative aide was RNA E. The aide received recommendations and orders after a resident was evaluated by therapy staff. Therapy would work with restorative and the resident to make a plan. Restorative services are based on the individual plan. There should be an order that includes what services are being recommended and how often should be completed. Residents should have restorative therapy about twice per week.During an interview on 11/25/25, at 3:00 P.M., Administrator said the restorative aide was RNA E. There were currently five residents on services. The RNA should follow the resident's individual therapy plan. There was a time management concern with restorative. The restorative aide was provided two hours each shift to complete restorative services and another day or two per week to complete task.2665564

Based on interview and record review, the facility failed to ensure all allegations of abuse and neglect were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required two-hour time frame when staff failed to report an allegation of employee to resident abuse of one resident (Resident #1) in a timely manner. The facility census was 62.Based on interview and record review, the facility failed to ensure all allegations of abuse and neglect were reported immediately to facility management and to the State Survey Agency (Department of Health and Senior Services - DHSS) within the required two-hour time frame when staff failed to report an allegation of employee to resident abuse of one resident (Resident #1) in a timely manner. The facility census was 62.The Administrator was notified on the morning of 9/15/25, at approximately 10:15 A.M., of the Past Non-Compliance which occurred on 9/11/25, between 10:00 P.M. and 12:00 A.M. The accused certified nurse aide was suspended on 9/15/24. Staff assessed the resident for injuries, and none were found. On 9/15/25, in-service of all staff was started. Staff began the full investigation on 9/15/25 and completed interviews on 9/15/25. The facility implemented training of all employees, including asking two staff members a day, five days a week on the abuse policy and reporting policy. The noncompliance was corrected on 9/16/25. Review of the facility's policy titled, Abuse, Prevention and Prohibition Policy, dated 3/2025, showed the following: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion;-The facility prohibits mistreatment, neglect, or abuse of residents;-The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or his/her designated representative in the administrator's absence;-An employee or agent or any covered individual will make or cause a report to be made to law enforcement and the facility;-The administrator, or his/her designated representative if administrator is not present, will notify the regional corporate nurse;-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. Such reports may also be made to the local law enforcement agency in the same manner. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The person made aware of allegations of abuse or neglect, or the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement. The allegation will be reported no later than two hours, or per state regulations, after the allegation is made.Review of the facility's policy titled When and Who to Call List, not dated, showed the following: -Call the Director of Nursing (DON) immediately for abuse;-Call the Administrator immediately for abuse.1. Review of Resident #1's face sheet (resident's information at a quick glance) showed the following: -admission date of 09/08/25;-Diagnoses included dementia (a general term for a number of neurological conditions that cause a decline in cognitive abilities).Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 09/15/25, showed the following: -The resident had moderate cognitive impairment;-The resident was dependent on others for assistance in completing the activities of daily living (ADL - dressing, grooming, etc.).Review of the resident's care plan, revised on 9/16/25, showed the resident preference was not to have ethnic/color care givers.Review of the facility's Investigation Summary, dated 9/16/25, showed the following:-The Administrator was notified on 9/15/25, at 10:15 A.M., of an allegation of employee to resident abuse, that had occurred on 9/11/25, between 10:00 P.M. and 12:00 A.M.;-The staff reported the allegations of abuse to DHSS on 9/15/25 at 12:10 P.M.Review of DHSS's intake information dated 09/15/25, at 12:10 P.M., showed the facility self-reported an allegation of abuse by a CNA. Review of a written statement, dated 9/15/25, showed Certified Nurse Aide (CNA) A noted the following:-On 9/12/25, at around 12:30 A.M., the resident told CNA A that a man wearing all blue came in his/her room. He/she stood over there with his/her hands in his/her pants, moving them around and masturbating;-CNA A then went to the nurses' desk and asked CNA B and CNA D, who the man in all blue was and they stated it was CNA C; -CNA B and CNA D told CNA A that the incident had been reported to the nurse on duty.Review of a written statement, dated 9/15/25, showed CNA F noted the following: -The resident told CNA F that CNA C came in his/her room thinking he/she was asleep, but the resident was awake. The resident told CNA B that he/she saw CNA C playing with his/her private area; . -CNA B asked the resident if he/she reported that to anyone and the resident said yes, to that one staff that was tall, skinny with red hair; -CNA B immediately reported this information to the DON. During an interview on 09/19/25, at 1:17 P.M., CNA E said the following: -If he/she witnessed, or if a resident reported, any abuse or neglect to him/her, he/she would immediately report the allegations to the charge nurse;-The state required allegations of abuse and neglect to be reported to the state within two hours.During an interview on 09/19/25, at 1:23 P.M., Restorative Nursing Aide (RNA) G said the following: -All allegations of abuse and neglect were to be reported immediately to the charge nurse;-Reports of abuse/neglect were to be reported to the state within two hours. During an interview on 09/19/25, at 1:29 P.M., Certified Medication Tech (CMT) H said the following: -If a resident reported abuse or neglect to him/her CNA B would report it to the charge nurse;-The state required all allegations of abuse and neglect to be reported within two hours.During an interview on 09/19/25, at 1:35 P.M., Licensed Practical Nurse (LPN) I said the following: -LPN I would report all allegations of abuse and neglect to the Director of Nursing (DON) and the Administrator;-The Administrator should start an investigation and report the allegations to the responsible state agency within two hours.During an interview on 9/19/25, at 1:44 P.M., the Director of Nursing said the following: -The DON was notified on the morning of 9/15/25, by CNA F, that the resident reported that on Friday night an aide, CNA C, came in his/her room and stood by the bathroom door, with his/her hands in his/her pants, making grunting noises. During an interview on 09/19/25, at 1:58 P.M., the Assistant Director of Nursing (ADON) said the following: -All allegations of abuse/neglect should be reported to the Administrator immediately;-The state required all allegations of abuse and neglect to be reported within two hours.During an interview on 09/19/25, at 2:29 P.M., the Administrator said the following: -The Administrator was notified on 09/15/25, around 10:15 A.M, of the allegation of abuse that the resident had made on 09/12/25 against CNA C;-The Administrator started her investigation immediately upon being notified of the allegations;-The Administrator said that all allegations of abuse/neglect should be reported to the state within two hours. Complaint #2617487

Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when staff failed to transcribe new admission orders resulting in one resident (Resident #2) not receiving insulin for six days. The facility census was 62.Review of the facility policy titled Medication Administration-General Guidelines, dated July 2021, showed the following: -Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system;-Medications are administered in accordance with written orders of the prescriber.Review of the facility policy titled Medical Errors & Adverse Events, dated December 2024, showed the following: -When medical errors or adverse resident events are identified, the facility will analyze the cause, implement corrective actions to prevent future events, and conduct monitoring to ensure desired outcomes are achieved and sustained. 1. Review of Resident #2's face sheet (a brief summary of the resident's medical and admission history) showed the following: -admission date of 09/02/25;-Diagnoses included type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar).Review of the resident's care plan, dated 09/15/25, showed the following: -Resident had unstable blood glucose levels;-Administer medications as prescribed;-Evaluate blood glucose level per ordered frequency;-Monitor medication effectiveness for management of blood glucose level.Review of the resident's admission Minimum Data Set (MDS - a federally required assessment tool completed by facility staff), dated 09/19/25, showed the following: -The resident was cognitively intact;-The resident did not have orders for insulin and did not receive insulin injections during the last 7 days or since admission. Review of the resident's hospital Discharge summary, dated [DATE], showed the following medications to be continued on discharge: -Humalog (fast acting insulin) KwikPen 100 units/milliliter (ml), medium dose sliding scale with meals and bedtime. Medium dose correction scale as follows:-If blood glucose level of 150 milligrams/deciliter (mg/dL) to 199 mg/dL, staff to administer 2 units of insulin;-If blood glucose level of 200 mg/dL to 249 mg/dL, staff to administer 4 units of insulin;-If blood glucose level of 250 mg/dL to 299 mg/dL, staff to administer 6 units of insulin;-Date/Time of next dose due on 09/08/25 before next meal;-Insulin glargine (long actin insulin), 75 units, at bedtime. Date/Time of next dose due on 09/08/25 at bedtime.Review of the resident's September 2025 Physician Order Sheet (POS) showed staff did not transcribe the hospital orders for Humalog and insulin glargine to the resident's physician's orders. Review of the resident's medical record showed staff documented the following: -On 09/15/25, at 7:50 A.M., the nurse checked the resident's blood sugar and result was 157 mg/dL. The nurse then began looking up discharge medications from hospital per resident's request, specifically regarding insulin; -On 09/15/25, at 1:31 P.M., the nurse called and spoke with the physician regarding resident's blood sugars and insulin. New orders received at this time to add Humalog, sliding scale and to increase Lantus from 60 units to 65 units at bedtime. Review of the resident's September 2025 Physician Order Sheet (POS) showed the following: -An order, dated 09/15/25, Lantus (insulin glargine) 100 unit/ml, inject 65 units at bedtime for diabetes;-An order, dated 09/15/25, for Humalog injection, injects as per following sliding scale:-If blood glucose level of 150 mg/dL to 199 mg/dL, staff to administer 2 units of insulin;-If blood glucose level of 200 mg/dL to 249 mg/dl, staff to administer 4 units of insulin;-If blood glucose level of 250 mg/dL to 299 mg/dl, staff to administer 6 units of insulin.Review of the resident's September 2025 Medication Administration Record (MAR) showed the following: -Staff did not document administration of the ordered Humalog from admission until 09/15/25 at 5:00 P.M.;-The resident did not receive the ordered Lantus 100 units/ml until 09/14/25 at 8:00 P.M.During an interview on 09/19/25, at 8:47 A.M., the resident said the following: -The facility had contacted the doctor and received orders for blood sugar checks and insulin;-The resident had been getting his/her blood sugars checked before meals and at bedtime;-The resident received insulin when needed per sliding scale and at bedtime. During an interview on 09/19/25, at 1:17 P.M., Certified Nurse Aide (CNA) E said the following: -The resident was upset because the facility had not contacted the doctor regarding her blood sugars;-The resident told CNA E that he/she had been on insulin prior coming to the facility and since the resident arrived at the facility, he/she had not received it. During an interview on 09/19/25, at 1:29 P.M., Certified Medication Tech (CMT) H said the admitting nurse was responsible for transcribing medications order by the discharging physician to the facility MAR. During an interview on 09/19/25, at 1:35 P.M., Licensed Practical Nurse (LPN) I said the following: -admission orders were to be transcribed by the admitting nurse;-The Director of Nursing (DON) was responsible for double checking medication orders the following day;-Upon admission the resident did not have physician orders for blood glucose checks or insulin;-Not receiving insulin when needed could affect the resident's mental status, cause medical complications and affect the residents ability to heal from wounds. During an interview on 09/19/25, at 1:44 P.M., the DON said the following: -The nurse admitting the resident was responsible for transcribing medications from the discharge summary to the facility MAR;-The physician orders were to be reviewed the next day after admission by the Assistant Director of Nursing (ADON);-The resident had orders for blood glucose monitoring and insulin upon discharge from the hospital that did not get transcribed to the facility MAR when admitted ;-If a resident did not receive insulin when needed, it could lead to the resident going back to the hospital. During an interview on 09/19/25, at 1:58 P.M., the ADON said the following: -The charge nurse was responsible for admitting new residents;-The admitting nurse was to transfer medications from the discharge summary to the facility records;-A nurse working the weekend shift brought to the DON's attention that the resident had orders for insulin from the hospital and that those orders had not been carried over to the facility MAR;-Side effects of not receiving insulin when needed could cause the resident to become sicker and affect the body's ability to heal wounds.During an interview on 09/19/25, at 2:29 P.M., the Administrator said the following:-The charge nurse was responsible for admitting new residents;-The admitting nurse was responsible for making sure medications were transferred from the discharge documents to the facility MAR;-The DON and the ADON did not review the resident's discharge summary and facility MAR after admission.Complaint #2617548

Based on observation and interview, the facility failed to ensure each resident's right to privacy was maintained when a staff member posted a photo to social media that showed one resident's face (Resident #1) and private medical information of another resident (Resident #2). The census was 62.Review of the facility's policy named, Social Media, undated, showed the following:-The community recognizes the importance of social media websites as a form of communication in today's society and to a great extent respects the staffs privacy while off-duty. However, when the staff's use violates the facility policies, disrupts operations, interferes with a team members work, is used to harass a team member, creates a hostile work environment or harms the [NAME] and reputation among customers and the community, the facility may need to conduct an investigation and take appropriate corrective action as needed;-Prohibited activity included unauthorized disclosure of resident information on internet sites that violate Health Insurance Portability and Accountability Act (HIPPA), resident rights, and community policies,-Prohibited Activity included information in the context of their work environment regarding clients, residents, or other team members, including names, photos, or related information to any kind that violates privacy standards or release of confidential information;-The staff is required to report alleged violations of the policy to the Administrator/Executive director. Review of the facility's policy titled, HIPPA, what is it., undated, showed the following:-The facility tries to give the resident's the best healthcare. Part of the facility's job of caring for them is to keep their health information private;-Private information includes the resident's name address, age, social security number and any other personal information. Such as, why they are at the nursing home, their medications or treatments, or any other information about the resident's health condition, past or present;-The facility staff have to make sure they done give out private information to those who should not have it or don't have permission from the resident to have it, even if it is spoken to someone, over the phone, or information on the computer that could be seen or a fax;-Facility staff should use the need to know rule. If the facility staff need the information to their job, then they are allowed to see it. The staff should only look at the information they need to know and not share it with anyone. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date 10/03/23;-Diagnoses included cerebrovascular disease (a group of conditions that affect the blood vessels in the brain, leading to reduced blood flow and oxygen supply to the brain), Alzheimer's disease (a progressive, irreversible brain disorder that causes memory loss, confusion, and other cognitive decline), and heart failure.Review of the resident's care plan, dated 05/13/25, showed the following:-The resident had a communication problem;-Monitor for/record confounding problems, decline in cognitive status, mood, decline, in activities of daily living, deterioration in respiratory status, oral motor function,and hearing impairment. 2. Review of Resident #2's face sheet showed the following:-admission date of 02/09/24;-Diagnoses included dementia with anxiety (a group of conditions that cause a decline in cognitive functions, such as memory, thinking, problem-solving, and language, disorientation).Review of the resident's care plan, dated 05/19/25, showed the following:-The resident had impaired cognitive function/dementia or impaired thought processes;-Break tasks into small sub tasks to support short term memory deficits;-Engage the resident in simple, structured activities. and avoid overly demanding tasks. 3. During an interview on 09/11/25, at 3:30 P.M, Certified Nurse Aide (CAN) E said the following:-He/she saw that Licensed Practical Nurse (LPN) G, who used to work at the facility, had posted a picture to their own personal social media (Facebook) account that had Resident #1 sitting in the background. There was also some resident documentation on the table that was visible;-He/she did not report it to anyone;-He/she did not think it was appropriate to post photos or resident information on their own personal social media. He/she believed it is against the facility's policy and violates the resident's privacy; During an interview on 09/12/25, at 10: 28 A.M., CNA J said the following:-He/she saw, a few days ago, that LPN H had posted a photo to his/her social media page that was taken at the facility and posted on 08/31/25;-He/she noticed that Resident #1 was sitting in the background and was visible;-He/she was also able to see a neurological assessment with Resident #2's full name on it with vital signs documented;-He/she did not think it was appropriate to post photos of residents or pictures of their information to social media;-He/she had not told the Administrator, but he/she thought he/she probably should. Observations on 09/12/25, at 10:28 A.M., showed CNA J pulled up LPN H's social media page that showed a photo of a female resident that CNA J confirmed was Resident #1 and a piece of paper titled, Neurological Assessment Flow Sheet with Resident #2's name, room number written on it and dated 8/30/25, there were vital signs visible;-The post was dated 08/31/25. During an interview on 09/12/25, at 11:20 A.M., LPN G said the following:-On 9/12/25, he/she was shown a picture by one of the other staff that LPN H had posted to his/her social media page while he/she worked at the facility;-In the picture he/she could see Resident #1 sitting in the background and then a neurological assessment with Resident #2's full name on it with vital signs listed;-It was not appropriate to take pictures of the residents for his/her own personal use and resident medical records should be kept private;-The staff that showed her had reported it to the Administrator on 09/12/25. During an interview on 09/12/25, at 11:54 A.M., the Social Services Designee said the following:-It was not appropriate for staff to take pictures of residents and post it to their own personal social media page. The residents can sign a release form for photos but it is only for facility/company use;-It is against facility policy to post any resident medical records to social media. The staff are supposed to keep resident records private. During an interview on 09/12/25, at 12:15 P.M., Certified Medication Tech (CMT) I said it was not appropriate for staff to take pictures of the residents and post them to their personal social media account. They also should not be sharing any medical records of any residents. During an interview on 09/12/25, at 12:35 P.M., the Assistant Director of Nursing (ADON) said the following:-It was not appropriate for staff to take photos of resident's and post to their personal social media;-Staff should not be posting any photos with medical information to the internet. The Administrator should be immediately notified. During an interview on 09/12/25, at 12:48 P.M., the Director of Nursing (DON) said he/she was not aware of any staff posting photos of resident on their social media pages or resident information. That would not be appropriate and would need to be reported to the Administrator. The photo release is only for the use of the facility/company; During an interview on 09/12/25, at 2:47 P.M., the Administrator said the following:-He/she was shown a picture by CNA J earlier today that showed a resident. He/she could not identify the resident but did see that there was a neurological assessment that had Resident #2's name on it. According to CNA J it was posted to LPN H's social media page;-He/she was not sure why it was not immediately reported to him/her;-LPN H transferred to another one of the company's facilities. He/she called the facility's Administrator to get LPN H to take down the photo;-It was not appropriate for LPN H to take a picture of any residents or resident information and post it on the internet. 2609807

Based on record review and interview, the facility failed to ensure catheter (a tube that is inserted into the bladder allowing your urine to drain) use and care per standards of practice when staff failed to obtain complete catheter orders for one resident's (Resident #3's ) self-catheterization, including specifications or monitoring. The facility census was 62.Review of the facility's policy, Catheter Care, Urinary, dated 12/24, showed the following:-The purpose of this procedure is to prevent catheter- associated urinary tract infections (CAUTI);-The following information should be recorded in the resident's medical record: the date and time that catheter care was given, any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain; any problems or complaints made by the resident related to the procedure; and if the resident refused the procedure, the reason(s) why, and the intervention taken; Review of the facility's policy, Catheter, Intermittent, dated 12/24, showed the following:-Verify that there is a physician's order for the procedure;-The following information should be recorded in the resident's medical record: the date and time the procedure was performed; the amount of urine drained, the character, clarity, and color of urine, any observation of obstruction; evidence of blood, pus, etc.; any change in the resident's condition; any problems or complaints made by the resident related to the procedure; and if the resident refused the procedure, the reason why and the intervention taken. 1. Review of Resident #3's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date 08/23/25;-Diagnosis included paraplegia (a condition characterized by the loss of voluntary movement and sensation in both lower limbs, typically resulting from an injury to the spinal cord), pressure ulcer of the right buttock, stage 4 (a severe form of pressure injury that involves full-thickness tissue loss, exposing bone, tendon, or muscle), neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should), muscle weakness, and need for assistance with personal care.Review of the resident's nurses' notes showed the following:-On 08/23/25, at 11:49 A.M., resident arrived to the facility from the hospital. The resident was incontinent of both bowel and bladder. The resident self-cathetered him/herself. The resident was doing that prior to admission. He/she periodically had stress incontinence;-On 08/24/25, at 12:40 P.M., the resident was incontinent of bladder, is on a toileting program for bladder incontinence, and did not have a urinary catheter. The resident used a self-catheter to assist with bladder control. Will continue to monitor;-On 08/25/25 at 2:43 P.M., the resident was incontinent of bladder, was on a toileting program for bladder incontinence, and did not have a urinary catheter. The resident self-catheterized to assist with bladder control;-On 08/25/25, at 5:00 P.M., the resident needed straight catheters to be able to self-catheterize and was told that the facility ordered some of the style he/she needed because facility was out. They were able to get two 16 French catheter tubes to give to the resident to use;-On 08/26/25, at 3:10 A.M., the resident was incontinent of bladder, was not on a toileting program for bladder incontinence, and did not have a urinary catheter. Resident uses the following items to assist with bladder control: self cath.Review of the resident's 5-Day Stay Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 08/27/25, showed the following: -The resident was cognitively intact;-Intermittent catheterization;-The resident was dependent for transfers. Review of the resident's care plan, dated 08/27/25, showed the following:-The resident has a catheter;-Monitor/ document for pain/discomfort due to catheter;-Monitor/record/report to the physician for signs symptoms of a urinary tract infection (UTI) including pain burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urine frequency, foul smelling urine, fever, chills, altered mental status, change in behaviors, and change in eating patterns.Review of the resident's nurses' notes showed the following:-On 08/27/25, at 1:52 A.M., the resident was incontinent of bladder, was not on a toileting program for bladder incontinence, and did not have a urinary catheter. The resident was experiencing the following urinary issues: none. The resident used the following items to assist with bladder control: self cath.-On 08/27/25, at 3:55 P.M., the resident went to a doctor's appointment and was admitted to the hospital. Review of the resident's August 2025 Physician Order Sheet (POS) showed staff did not document orders for urinary catheterization or monitoring of urinary catheterization by the staff or resident. Review of the resident's August 2025 Treatment Administration Record (TAR) showed staff did not document monitoring of urinary catheterization. During an interview on 09/11/25, at 12:28 P.M., Licensed Practical Nurse (LPN) C said the following: -The resident self-catheterized him/herself due to being paraplegic;-He/she was not sure if there needed to be an order if a resident was performing the catheterization themselves, but staff should probably be monitoring it. During an interview on 09/11/25, at 3:30 P.M, Certified Nurse Aide (CNA) E said the resident self catheterized due to being paralyzed. He/she was not sure if anyone was monitoring, but he/she would think the nurses would. He/she was not asked to get any output. During interviews on 09/12/25, at 11:20 A.M and 4:26 P.M., LPN G said the resident used straight catheters to self-cath. He/she was not sure if there would need to be an order for that. During interviews on 09/12/25, at 9:11 A.M, 12:35 P.M., and 4:18 P.M., the Assistant Director of Nursing (ADON) said the following:-The resident self catheterized as he/she had done when he/she was at home. The resident should have an order if he/she self-catheterized with the size, how often, and making sure that he/she was compliant and able to complete safely;-He/she was not sure if there was an order in the chart. It should also be added to the resident's care plan. During interviews on 09/12/25, at 12:48 P.M. and 5:07 P.M., the Director of Nursing (DON) said he/she was aware that the resident self-catheterized for urination. There should have been an order in the computer including size, frequency and who is responsible. There should also be an order for staff to monitor. During an interview on 09/12/25, at 2:47 P.M., the Administrator said he/she wound expect that there would be a physician order for any type of catheterization whether staff or the resident is completing it. 2599894

Based on observation, interview, and record review, the facility failed to ensure each resident was free from abuse when two staff (Certified Nurses Aide (CNA) E and Certified Medication Technician (CMT) F) physically forced one resident (Resident #1) to shower against his/her wishes- resulting in the resident yelling out for help, fighting against the aides, receiving bruises on both the right and left hand/wrist, and voicing he/she was upset. The facility census was 72. The Assistant Administrator and the Administrator were notified on 10/29/24, at 4:05 P.M., of an Immediate Jeopardy (IJ) which began on 10/26/24. The IJ was removed on 10/31/24 as confirmed by surveyor onsite verification. Review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, undated, showed the following: -The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation, including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not to treat the residents medical symptoms; -The intent of this requirement was for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience and prohibits the use of physical restraints to unnecessarily inhibit a resident's freedom of movement or activity. Review of the facility's Patient [NAME] of Rights policy, undated, showed the following: -Residents shall be treated with consideration, respect, and full recognition of their dignity and individuality, including privacy in treatment and in care for personal needs; -Residents are entitled to take part in planning care and in being informed of all aspects of care. Residents may refuse any treatment they do not want. -Residents shall be free from physical, sexual or emotional harm. -Chemical or physical restraints should not be imposed for purposes of discipline or staff convenience. Restraints are only to be used as a treatment for medical symptoms. Review of the facility's Restraint, Physical policy, undated, showed the following: -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the resident cannot remove easily, which restricts freedom of movement or normal access to ones body. -Guidelines include, assessing the resident's need for the use of a restraint and obtain a physicians order for the use of a restraint. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following; -Diagnoses included depression, suicidal ideation, and unspecified symptoms and signs involving cognitive functions and awareness. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive resident assessment completed by facility staff), dated 10/08/24, showed the following: -Severe cognitive impairment; -Behavioral symptoms not directed at others exhibited; -Rejection of care observed; -Wandering observed; -Independent with mobility/walking; -Required assistance (helper does all the effort) with showering/bathing. Review of the resident's care plan, reviewed date 10/07/24, showed the following: -The resident suffered from depression; -The resident had signs and symptoms of behavior issues directly related to post traumatic stress disorder (PTSD - a mental health condition that can develop after someone experience or witnesses a traumatic event); -Staff will approach the resident in a kind and considerate way; -If the resident responds inappropriately staff will walk away and approach at a later time; -Staff will give the resident time to process. Review of the resident's Skin Assessment/Shower Sheet, dated 10/25/24, showed the following: -Some redness on wrist area from hitting staff; -Hair not washed; -CNA E and CMT F's initials present indicating shower completed. Review of the resident's progress note dated 10/25/24 at 1:12 P.M., showed the following: -The resident had not had a shower for a while. -Two CNAs assisted the resident to the shower. -The resident was combative, yelling, and cursing at staff. -The resident got a shower. -The resident calmed during the shower and was able to complete shower. -A CNA came to Licensed Practical Nurse (LPN) I and reported how the resident acted. -Staff assessment of the resident showed no injury noted except small bruises where resident had bracelets. Review of the resident's progress note dated 10/25/24, at 2:02 P.M., showed the following: -The Assistant Administrator was notified the resident was having behaviors while two aides attempted to give the resident a shower. -The two aides tried to coax the resident into taking a shower. -Upon entering the shower room the resident was displaying behaviors. -Both aides continued to shower the resident in a safe and controlled manner. -The resident had refused showers for quite awhile. -The resident stated he/she was mad, but couldn't tell why. When asked if he/she felt safe the resident said he/she guessed so. Review of the resident's progress notes, dated 09/2024 to 10/2024, showed staff did not document other behaviors listed in the resident's progress notes or medical chart. Review of the facility's investigation, dated 10/25/24 and revised on 10/30/24, showed the following: -On 10/26/24, at 12:58 P.M., the Assistant Administrator was notified of an an allegation of abuse related to an allegation that a resident was forced into taking a shower. The incident in question occurred on 10/25/24, at 12:30 P.M. -On 10/25/24, this writer (the Assistant Administrator) was informed of concerns regarding the CNAs that gave the resident a shower in the memory care unit of possibly being rough. -LPN I reported to the Assistant Administrator that CNA E and CMT F were possibly rough when giving the resident a shower. -LPN I assessed the resident and found no injuries noted except for small bruises where he/she had bracelets. The resident had some old bruising noted yellow in color on upper forearms. -The Assistant Administrator investigated the report of concerns of CNA E and CMT F being rough with the resident on 10/25/24, at 12:50 P.M. -During an interview, CNA D stated that he/she felt that they were being rough with the resident, because the resident did not want to take a shower. He/she had approached the resident to shower and resident stated no. The resident did not want to go take a shower and they (CNA E and CMT F) made the resident go. They were rough with the resident when getting him/her to the shower room. They were holding the resident's legs up to wheel him/her into the shower. -The Assistant Administrator later informed CNA D there was new information from the active investigation and needed to ask a few questions. CNA D said he/she informed the charge nurse, Registered Nurse (RN) A, that he/she felt the resident was being forced into the wheelchair and RN A seemed unclear of how to handle it so, CNA D went to LPN I. He/she said CNA E and CMT F physically made the resident get out of the recliner and put the resident into a wheelchair while holding his/her legs so the resident could not resist. CNA D stated he/she informed both RN A and LPN I that he/she felt they were restraining the resident and that he/she heard the resident yelling for help. CNA D opened the shower room door and saw CNA E and CMT F restraining the resident. He/she immediately reported the incident to RN A. CNA D stated CNA E's back was toward him/her, the resident was in the shower chair and he/she could see that CNA E had a hold of the resident's hands and the resident asked are you going to let go of me?. CNA D stated he/she believed the resident's hands were in front of his/her lap. CMT F was on the side of the resident showering him/her. CNA D then left the shower room to report to RN A. CNA D stated he/she should have intervened at that time. CNA D stated that at first CMT F and CNA D were trying to get the resident to take a shower by talking to him/her and the resident started to get agitated and would walk away. Staff were in the area in front of the resident's door. CNA D would say something to the resident and then CMT F would say something, then CNA D would say something again and at one point the resident tried to hit CNA D and missed. The resident was yelling profanities and tried to hit CMT F. CNA D stated he/she did walk away, but was still in the day room area because the residents were getting upset. CNA E and CMT F forced the resident out of the chair and into a wheelchair. CNA D stated the resident did not appear unstable and had just sat down in his/her recliner. At that time CNA E and CMT F placed their arms under the resident's arms and transferred him/her into the wheelchair by force. Then CNA E pushed the wheelchair and CMT F had the resident by the legs. The resident was fighting when they were getting the resident out of the chair and was yelling profanities and get away from me you fucking bitch and was trying to put his/her legs down. CMT F used both hands to lift the bottom of the resident's feet. While the CNAs took the resident to the shower room the resident was fighting and yelling to get away from him/her, somebody help, and nobody went to the resident's aide. CNA D stated he/she should have yelled for help. The resident was yelling help and that is when he/she went into the shower room. During an interview on 10/26/24, at 3:03 P.M., CNA D said the following: -On 10/25/24, about 12:45 P.M. to 1:00 P.M., CNA D and CMT F attempted to convince the resident to take a shower. The resident was very anxious and paranoid that people were going to come in his/her room and take his/her things and kept walking in and out of his/her room. -The staff were talking to the resident about a shower and the resident attempted to hit CNA D -The resident continued to walk away from staff and CNA D told CMT F, that he/she did not think the shower was going to happen. -CNA D said he/she would usually leave and reapproach the resident at another time. CMT F told the resident he/she could either walk to the shower or he/she could get into the wheelchair and be pushed to the shower. CMT F had a wheelchair by the resident's door and the resident tried to slam his/her room door trying to get CMT F away. CNA D thought the resident hit CMT F and threw his/her water pitcher at them. -CMT F told the resident to stop hitting and throwing things. The other residents out in the common areas appeared to be visibly upset, so CNA D stepped away to check on the other residents while CMT F remained in the resident's doorway with the wheelchair. CMT F then went into the resident's room and yelled at the resident that we do not hit or throw things. CNA E then entered the room with CMT F and continued to try to get the resident to take a shower. The resident asked CNA E and CMT F to leave his/her room that he/she was not taking a shower and shouted profanities. -The resident sat in the recliner, CNA E and CMT F stood on both sides of the resident and put their hands under the residents arms to get him/her out the recliner. The resident was yelling and trying to get the staff away from him/her and telling the aides to get way from him/her using profanities. CNA E and CMT F forced the resident out the recliner and into the wheelchair. One of the staff pushed the wheelchair and one of the staff held the resident's legs and feet in the air so he/she could not put his/her feet in the ground. The resident was trying to kick the staff and put his/her feet on the ground to stop the staff from pushing him/her in the wheelchair. The staff got the resident to the shower room and shut the door. The resident was yelling a lot and saying please somebody help me. -CNA D went to the common area to calm the other residents down. He/she then went into the shower room and saw CNA E restraining the resident by his/her hands/wrist while in the shower chair. CNA E was standing in front of the resident and holding both hands down in the resident's lap while CMT F gave the resident a shower. The resident said are you going to let me go and CNA E said are you going to stop trying to hit us. CNA D left the shower room and went to RN A and reported what was happening and said CNA E and CMT F forced and restrained the resident in the shower and said this should not be happening to this resident. CNA D said RN A told him/her that he/she was unsure what to do and what the policies were so, CNA D went and reported it to LPN I. LPN I said he/she would handle it. -CNA D said prior to the incident on 10/25/24, there was no bruising on the resident, but noticed bruises around dinner time and reported the bruises to RN B and he/she assessed the resident. -CNA D said he/she considered what occurred as abuse, he/she described it as forcing and restraining the resident. During an interview on 10/26/24, at 1:35 P.M., CMT F said the following: -After lunch, he/she was doing showers in the special care unit. -The resident was alert to self, ambulated independently, and had behaviors. He/she would throw items and stay in his/her room most of the time. He/she was on the list to have a shower. The resident had not had a shower in a couple of weeks. -The resident had had a fall and was still not walking very steady, so he/she got a wheelchair. The resident was not very fond of leaving his/her room and thinks people will take his/her things. CMT F and CNA E were both in the room with the resident. There were no pedals on the wheelchair, so when they put the resident in the wheelchair, he/she was walking backwards holding the resident's feet up while CNA E was pushing the wheelchair. The resident was upset when we took him/her out of his/her room, he/she was yelling and moving his/her arms about. -CMT F and CNA E got the resident into the shower room, removed his/her clothing and transferred the resident into the shower chair. The resident was yelling that he/she wanted to go back to his/her room. He/she got a little scratch from the resident. -The resident was trying to take the shower hose out of the aide's hands. -Once they got the resident into the shower, he/she mostly calmed down. -He/she did not think forcing a resident to take a shower was okay, it would be considered abuse. -He/she did not force the resident to take a shower. -After the shower when he/she was filling out the shower sheet, LPN I approached him/her and asked him/her what had happened with the resident. -CMT F said he/she continued to work in the unit where the resident resided and was not suspended until 10/26/24. During an interview on 10/28/24, at 3:15 P.M., CNA E said the following: -He/she was working with CMT F to try and get the resident to take a shower. The resident did not like to leave his/her room, because he/she is afraid people will steal from him/her. -CNA E said the resident said he/she did not want to take a shower; -He/she walked into the room and said the resident's name and come on you need to get in the shower. The resident stood up from the recliner and CMT F brought in the wheelchair and the resident again said he/she did not want to go to the shower; -For the most part, the resident does walk independently, but had a recent fall and was unsteady enough to put the resident in the wheelchair. The resident did not want to walk to the shower room. -CNA E said at first that the resident sat in the wheelchair by his/herself, then said he/she and CMT F were on each side of the resident and helped the resident into the wheelchair. The resident called CNA E a bitch and said several times damn it no. -CNA E and CMT F got the resident's clothing off and put the resident into the shower chair and the resident slapped at him/her. CNA E said this was the first time he/she had given the resident a shower. -CNA E said at first, he/she was holding the shower wand and CMT F was washing the resident, then they switched and he/she was holding the resident's left hand so the resident could not grab the shower wand. The resident tried to grab the shower wand and CMT F held the resident's right hand so the resident could not grab the shower wand. The resident was yelling out, stop bitch I don't wanna do this. CNA E told the resident that he/she needed a shower. -He/she said the resident did not have any bruises at that time; -The resident had not had a shower in two months; -CNA E said they should have stepped back, it was getting to the point that it was not healthy for the resident. -The resident would not walk to the shower room. It was about 5 to 10 feet away. They put the resident into the wheelchair and lifted his/her legs and feet and pushed the resident to the shower room. He/she could not push the resident until CMT F lifted the resident's legs/feet. -CNA E said he/she would not do this again, that the resident had the right not to take a shower. During an interview on 10/28/24, at 10:30 A.M., LPN I said the following: -If staff reports abuse, that he/she is supposed to assess the situation and if anything is going on he/she is supposed to separate everyone and then report to the Director of Nursing (DON) and Administrator. -On 10/25/24. at approximately 1:00 P.M., CNA D came to the front to talk to him/her, was very tearful and said he/she felt CNA E and CMT F were being rough with the resident in the shower. LPN I said he/she did not ask CNA D what he/she meant by the word rough. LPN I said the word rough to him/her means being firm to a dementia resident. -CNA D said he/she felt uncomfortable with what CNA E and CMT F did to the resident and that they were not gentle; -When LPN I went back to the unit the resident was already out of the shower, dressed, and standing in his/her doorway. The resident said don't you ever do that to me again. -LPN I said the resident had two fresh small purple bruises on his/her left wrist. -He/she asked CNA E and CMT F what happened and they said the resident was aggressive and had a harder time walking so they used a wheelchair. -He/she took CMT F to see the Assistant Administrator and they reported to the Assistant Administrator that CNA D said CNA E and CMT F where rough with the resident during a shower. The Assistant Administrator said that she would take care of it. -If a resident is forced or body movement is restricted that is abuse; -LPN I said he/she should have gotten more details from CNA D and that CNA E and CMT F continued to work on the unit with the resident. During an interview on 10/26/24, at 4:55 P.M., CMT H said the following: -He/she was working in the unit on 10/25/24 and could hear the resident screaming through the door of the shower room, but did not intervene. The resident walked independently out of the shower room, not in a wheelchair and appeared visibly upset. He/she asked the resident if he/she was ok and the resident said no. -Later that night on 10/25/24, CMT H saw fresh bruises on the resident's hands and wrists. The bruising on one of the hands went from the top to the underside part of the wrist. -Residents should not be forced to take a shower that would be abuse. -CNA E and CMT F continued to work on the unit with resident. During an interview on 10/26/24, at 2:30 P.M., RN A said the following: -On 10/25/24, CNA D reported to him/her that he/she was very uncomfortable with CNA E and CMT F forcing the resident to take a shower. -It had been 3 months since the resident had a shower, the resident was very smelly and his/her room was smelly. -The resident could walk independently. -He/she did not see the staff take the resident to the shower. -If he/she saw the staff holding the residents feet up and wheeling the resident to the shower, that would have been forcible and retrain the resident from moving and putting his/her feet to the ground. -If the resident was yelling or scratching staff, he/she would expect the staff to back away. During an interview on 10/29/24, at 10:07 A.M., RN A said the following: -No bruising was noted on the resident during medication pass on Friday; -CNA D reported yelling from the shower area; -He/she did not hear any yelling from the shower room due to the television volume being up high; -He/she went to the shower room to check on the resident and observed the resident with no clothes on and no evidence of any bruising; -No shouting was heard when she entered the shower room; -CMT F was in the shower room with the resident, but the resident would not let him/her dress him/her; -The resident can dress him/herself- if staff will hand him/her clothes. Observation and interview on 10/26/24, at 2:55 P.M., showed the resident sat in the recliner in his/her room with his/her head down and feet propped up. The resident had four reddish-purple bruises on his/her left hand/wrist and on the right hand/wrist had reddish-purple bruise that circled around the top of hand and wrist. The resident said the kids did that to him/her. Observation and interview on 10/28/24, at 11:30 A.M., showed the resident appeared alert and was standing in his/her room. When asked what happened to his/her hands/wrist, the resident said they hurt me in the shower/water. The resident said he/she was screaming for help and that no one came to help him/her. He/she said they frightened him/her and made him/her very upset. He/she does not like the wheelchair. Observation and interview on 10/28/24, at 11:31 A.M., showed the resident walking in room with a steady gait and he/she was able to bend down and pick an item up off the floor without any assistance or difficulty. The resident was alert and able to answer some simple questions during the interview. The resident appeared clean and well groomed. He/she had bracelets on both wrists. The resident had scattered bruising noted to right wrist and forearm and on the left hand and wrist. A silver [NAME] bracelet loosely placed around right wrist and three small, beaded bracelets on string noted to left wrist. The resident reported two girls, unknown names, hurt him/her in the water and wouldn't let him/her leave. During an interview on 10/31/24, at 10:52 A.M., the resident's family member said the following: -The facility staff called and reported to him/her the allegations of abuse and the resident was involved; -He/she was not sure who had allegedly abused the resident, but the resident could get mean; -The facility staff did not give any specifics of the abuse; -The facility did not tell him/her the resident was forced to take a shower; -The facility did not tell him/her the resident had bruises on his/her hands/wrists; -He/she wanted the resident to have a shower, but not to be forced. During an interview on 10/26/24, at 1:00 P.M. and 2:00 P.M., the Assistant Administrator said the following: -She had an allegation of abuse on 10/25/24 that involved the resident. CNA D reported that CMT F and CNA E were being rough with the resident and forced the resident into the shower. -She said CNA D reported to RN A that CMT F and CNA E were being abusive and forcing the resident into the shower. -She said RN A did not report the allegation to anyone, so CNA D reported it to LPN I. -LPN I and CMT F came to his/her office and then he/she went and spoke to CNA E, CNA D and the resident and at that time he/she determined that this was not abuse. -Originally CNA D and CMT F were trying to coax the resident into taking a shower. -The resident was independent with walking, did not like water, did not like to change his/her clothing, and scratches and pinches the staff. The resident has a history of refusing showers and needed two staff because he/she was combative. -CNA E approached to help get the resident to the shower. CNA E and CMT F got the resident up from the recliner into the wheelchair and the resident was yelling at them. When they got the resident to the shower room, CNA E and CMT F said the resident was fine. -CNA D reported to LPN I that CNA E and CMT F were being a little rough with the resident while getting the resident to the shower and in the shower room. -LPN I assessed the resident and spoke with RN A about it. RN A told LPN I that CNA D also reported to him/her that CNA E and CMT F were rough with the resident while getting the resident to the shower and in the shower room. -He/she spoke to the resident about the shower and the resident said he/she did not like the water. During an interview on 10/26/24, at 4:00 P.M., CNA J said the following: -The resident was alert to self, very confused, doesn't like shower, walks independently, does not use a wheelchair, has not been aggressive toward him/her and has not had a shower in three months; -If a resident outside the unit did not want a shower, staff did not force them to, but in the unit because combative residents he/she said he/she was trained that naughty children face the corner and that means you put a resident in the corner of the shower and wash the resident from behind. During an interview on 12/28/24, at 12:50 P.M., CNA G said the following: -The resident is alert, but at times is confused; -The resident walks independently and does not use a wheelchair; -The resident can use the restroom and perform most activities independently; -An aide told him/her the resident will refuse showers and staff need to force him/her to take one; -He/she has not given the resident a shower, but would ask another aide for help or ask again later if a shower was refused. During an interview on 10/26/2,4 at 1:10 P.M., the Social Service Director (SSD) said the following: -She was involved in abuse and neglect investigations; -She was not aware of any recent allegations of abuse; -If a resident is forced to take a shower, that would be abuse; -You cannot force a resident to anything; -Staff cannot hold or restrain a resident in order to complete a shower, that would be abuse; -The resident was not alert and oriented, very confused and at times rejects cares; -She was not aware of the resident ever getting physical with staff and at times refused showers. The resident has a right to refuse a shower. During an interview on 10/29/24, at 11:17 A.M., the DON said the following: -It is not appropriate for staff to take an independent resident to the shower in a wheelchair if they do not want to go; -A resident should not be forced to take a shower; -Staff should not hold a resident's hands down during the shower; -The Assistant Administrator informed him/her a resident was resistive to taking a shower and staff used a wheelchair and elevated an ambulatory resident's legs to get him/her in the shower. During an interview on 10/26/24, at 1:14 P.M., the Administrator said the following: -It was reported to him/her that CNA D approached the Assistant Administrator about how CMT F and CNA E were showering the resident, who was yelling out; -The resident was not alert and oriented and did have behaviors; -She was not told the resident was forced or held down to shower; -She would have told the staff they cannot force or hold down a resident; -If a resident was being forced to shower, it should have been reported as abuse; -CMT F and CNA E should have been suspended pending an investigation. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00244133

Based on interview and record review, the facility failed to ensure staff used approved mechanical lift slings, as recommended by the manufacturer when facility staff used Bestcare brand mechanical lift slings when transferring one resident (Resident # 1) with an Invacare brand mechanical lift (a battery powered lift and sling used to transfer a resident from bed to chair, etc.), and failed to follow manufacturer's instructions for care of the mechanical lift slings when staff bleached the slings and washed and dried the slings in a commercial dryer. On two staff documented occasions, 01/04/16 and 02/29/16, the straps from the sling broke while staff transferred the resident resulting in the resident falling and sustaining injuries. Staff also failed to document and investigate a fall, witnessed by family, which occurred between 12/21/15-12/31/15, caused by mechanical lift sling strap failure. The facility identified eight residents who required a mechanical lift for transfers. This deficient practice affected one of 12 sampled residents. The facility census was 72. The administrator was notified, on 04/15/16, of the Immediate Jeopardy (IJ) Past Non-Compliance, which occurred on 01/04/16. On 03/02/16, the facility received 16 new transfer slings for use with the electric transfer lift and on 03/10/16 conducted an all staff in-service related to the proper care and use of these transfer slings. The IJ was removed and corrected on 03/10/16. Review of the Invacare owner/operator manuals for the Invacare Reliant 450 lift showed the following warning: -Invacare slings are made specifically for use with Invacare patient lifts. -For the safety of the patient, do not use slings and patient lifts of different manufacturers. Review of the Bestcare brand sling care and washing instructions provided by the facility showed the following: -Never use bleach to wash or clean a Bestcare sling as the material may be damaged; -Hand or machine wash, in a gentle cycle, with a mild soap solution at a maximum temperature of 180 degrees Fahrenheit; -Rinse thoroughly and air dry; -Always wash slings separately from other items; -Caution warning: Do not use bleach with any sling. The sling will be damaged and unsafe to use. Review of the Bestcare Guideline for Identifying Deteriorated Slings showed the following: -Slings, especially loop straps that have been damaged from being laundered in unsuitable conditions (bleach, high heat wash or dry) may appear to be in good condition, but the actual tensile strength of the material may be compromised and pose a safety risk and should not be used for lifting a resident; -This guide is intended to help staff and caregivers better identify slings that have been exposed to above laundry conditions and subsequent loss of tensile strength; -We encourage any sling identified with these following characteristics to be removed from service immediately as a preventative measure; -Bestcare slings have been designed and tested for laundry wash conditions of 120 degrees Fahrenheit and air dry or dry at low temperatures; -The slings should never be bleached; -Commercial washers and dryers are not recommended. -Completely faded/missing/illegible tags are a good indicator the sling may have been washed with bleach at high temperatures. 1. Review of Resident #1's April 2016 physician order [REDACTED]. -[DIAGNOSES REDACTED].), osteoporosis (a disease where decreased bone strength increases the risk of a broken bone), and degenerative joint disease (arthritis of the joints); -Staff to use a mechanical lift at all times for transfers. Record review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/03/15, showed the following: -Cognitively intact; -Required extensive assistance of two or more staff with transfers; -Weighed 341 pounds. During multiple interview times on 04/13/16, 04/14/16 and 04/15/16, Resident #1 said the following: -He/she required a mechanical lift and sling to get out of bed; -On three separate occasions, during staff assisted transfers, the mechanical lift's sling straps broke; -The first time the sling straps broke, he/she fell 6 to 12 inches, landing hard on the bed below; -The second time the sling strap broke he/she was in midair between his/her bed and his/her roommate's bed. During this fall, he/she hit his/her head on the roommate's bed, which caused a goose egg (swelling or lump, especially one caused by being struck) on his/her, head. He/she also sprained his/her ankle. -His/her family member (Family Member A) brought an Invacare sling from home to show staff the type of sling the resident previously used at home. The facility told Family Member A they could not use that brand of sling because they had a contract with another company. -When the sling straps broke a third time, the resident landed head first into his/her wheelchair with his/her legs on the floor. The resident hurt his/her left arm and knee. -Again, Family Member A brought in an Invacare transfer sling from home to show staff. Facility staff ordered new slings from the Invacare Company as suggested by the family. Review of the resident's nursing flow sheet report (DART chart) showed the following: -On 01/06/16, at 3:40 A.M., (late entry for 01/04/16 at 5:50 A.M.), Registered Nurse (RN) A documented during report with an oncoming nurse, a staff member called RN A to Resident # 1's room. Staff reported while transferring the resident with the mechanical lift, the transfer sling strap broke causing the resident to fall and bump his/her head on the roommate's bed frame. The resident sustained [REDACTED]. The resident had slight cyanosis (blue or purple coloration of the skin) around his/her mouth and was anxious. Staff administered pain medication due to the resident's complaints of pain all over. -On 01/04/16, at 12:23 P.M., a nurse documented a fall follow-up with neurological checks and x-ray results. The resident refused to get up for breakfast. The resident complained of pain to his/her ankle, lower back and left shoulder. The resident's x-rays did not show any fractures. The nurse applied an ice bag to the back of the resident's head and to the resident's ankle. The resident again chose to stay in bed for lunch. The resident received pain medication at 8:00 A.M. and 12:15 P.M.; -On 01/04/16, at 9:42 P.M., a nurse documented the resident refused to get out of bed for supper. The resident complained of pain all over and staff administered pain medication with moderate effectiveness. -On 01/05/16, at 12:00 P.M., a nurse documented the resident complained of pain and soreness from the fall, mostly in his/her legs and ankles. The resident again refused to get out of bed for breakfast or lunch. -On 01/05/16, at 9:14 P.M., a nurse documented the resident remained in bed and staff administered pain medication for complaints of pain all over. Record review of the fall investigation, dated 01/04/16, showed the following information: -Factors related to fall: Sling to mechanical lift broke during transfer; -The nurse signed and dated completing the form on 01/04/16; -Staff handwrote Director of Nursing (DON) to complete with arrows pointing to the care plan changes initiated portion of the form and nursing office review signature line; -Care plan changes initiated: Start replacing old transfer slings; -Nursing office review: The DON signed and dated reviewing the form on 01/20/16 (sixteen days after the 01/04/16 fall occurred). Record review of the resident's Fall Care Plan, dated 01/04/16 at 5:55 A.M., showed the following: -Alert, pupils equal and reactive to light, hand grips equal, moves all extremities, appropriate pain response; -Bump to back of head; -Sling broke; -Fall with bump to head; -First aide provided: Ice pack to back of head; -Device: Mechanical lift; -Problem: Resident fell today at 5:55 A.M. due to sling to the mechanical lift broke; -At risk for fall due to: neuropathy, obesity, degenerative joint disease and osteoporosis; -Resident had no falls in the last 30 days; -Bed/chair bound, degenerative joint disease; -Isolated incident, checked all slings and ordered new slings; -Family notified and physician notified. During an interview on 04/15/16, at 9:40 A.M., Certified Nurse Aide (CNA) F said he/she worked on 01/04/16. When he/she entered the room Resident # 1 was lying on the floor. The resident's head had struck the side of the roommate's bed and the resident complained of a headache. During an interview on 04/15/16, at 12:50 P.M., CNA G said on 01/04/16, he/she was in the parking lot, when a staff member came out and asked for lifting help. The CNA entered the resident's room and saw the resident lying on his/her back, partially turned to his/her side on the floor by the roommate's bed. Staff told the CNA the resident's transfer sling strap broke during the transfer. The resident complained his/her head hurt and the resident said he/she had a sore ankle and back. During an interview on 04/18/16, at 12:30 P.M., Family Member A said after one of the falls, Licensed Practical Nurse (LPN) B showed Family Member A the mechanical lift sling strap, then tore the strap easily in front of the family member. The strap appeared fragile and frayed. During an interview on 04/18/16, at 2:40 P.M., LPN B said he/she was in report with the night shift nurse on the morning of 01/04/16 when Resident # 1's sling broke and the resident fell . When the resident's spouse came to the facility later that day, the nurse showed him/her the torn sling strap. The strap material was weak; the nurse pulled the strap apart with his/her hands in front of the resident's spouse. The resident's spouse voiced concerns about the way staff washed and cared for the slings. The nurse said the facility had now changed the way they cared for the slings; they changed how the slings were dried and what chemicals laundry staff used to wash them. During an interview on 04/15/16, at 10:20 A.M., the DON said after the resident's fall on 01/04/16, the resident's family informed him/her the straps broke on a previous occasion (which made the 01/04/16 fall the second time the resident fell due to the sling straps breaking). The DON did not complete a fall investigation for the previous fall. Record review of the resident's quarterly MDS, dated [DATE], showed the resident sustained [REDACTED]. Record review of the resident's current plan of care, updated on 02/08/16, showed the following information: -The resident required maximum assistance of three staff with transfers; -Use a mechanical lift with a sling for all transfers. Record review of the resident's nursing flow sheet report (DART chart) showed the following: -On 02/29/16, at 8:12 A.M., a nurse documented during a staff assisted transfer of the resident at 6:40 A.M., using a transfer lift with a sling, staff lifted the resident from bed using the lift to approximately four inches from the wheel chair, at that time the strap on the sling broke before the resident made it to the in the wheelchair. The resident complained of pain to his/her right knee and requested a pain pill. -On 03/2/16, at 3:41 P.M., a nurse documented the resident complained of some pain and had a bruise to his/her right lower leg from the fall. Record review of the fall investigation, dated 02/29/16, showed the following information: -Factors related to fall: mechanical lift's sling strap broke. New sling, strap not frayed; -Care plan changes initiated: three aides with all transfers, do not wash in regular cycle, purchase all new mechanical lift slings, environmental services to observe all slings before put back on floor; -No nurse signed the nurse completing form section of the form; -Nursing office review: the DON signed and dated reviewing the form on 02/29/16. Record review of the resident's Fall Care Plan, dated 02/29/16 at 6:40 A.M., showed the following: -Alert, pupils equal and reactive to light, hand grips equal, moves all extremities, appropriate pain response; -Complained of knee pain at 6:40 A.M., staff administered scheduled pain medication at 7:00 A.M.; -Resident used a wheelchair; -Problem: Resident fell today at 6:40 A.M., mechanical lift sling broke four inches above wheelchair; -Resident had no falls in the last 30 days; -Ordered 16 new mechanical lift slings; -Three staff with transfers; -In-serviced laundry; -All slings observed before use after laundry; -Family notified and physician notified. During an interview on 04/14/16, at 9:40 A.M., CNA E said Resident #1 fell two or three times due to the transfer sling straps breaking during staff assisted transfers. During an interview on 04/14/15, at 10:00 A.M., Certified Medication Technician (CMT) H said he/she and two other aides were assisting Resident #1 to transfer on the morning of 02/29/16. The CMT said he/she stood behind the resident's wheelchair, as staff used a lift to transfer the resident off the bed. As staff moved the resident in the sling toward the wheelchair, both straps on one side of the sling broke and the resident rolled to the left as he/she fell . The resident's head hit the wheelchair, and the resident landed face down with his/her head and shoulders on the wheelchair and legs on the floor. At the time of the fall, the facility used mechanical lift slings that appeared more worn with frayed straps. During an interview on 04/14/16, at 3:55 P.M., the Assistant Director of Nursing (ADON) said staff used an Invacare Reliant 450 lift to transfer Resident # 1. She was aware the resident fell two times while being transferred. Both of these falls resulted from straps breaking on the sling. During both falls, staff was transferring the resident using a Bestcare brand mechanical lift sling. The sling used during the first fall was an older one. After the last fall on 02/29/16, the resident's spouse came in and showed staff the Invacare brand transfer sling he/she used at home to assist the resident. At that time, the facility ordered 16 Invacare brand mechanical lift slings. The facility used an Invacare Reliant 450 lift with residents since 2014. During an interview on 04/15/16, at 12:35 P.M., Laundry Aide I said some of the slings were fraying at the edges and faded. The slings were treated the same as other facility linens. He/she used to wash the slings in a commercial washer using bleach and dry them in a commercial dryer. This practice continued until the facility purchased 16 new lift slings in March 2016. At this time, staff are not supposed to bleach or place the new slings in the dryer; we hang dry the new slings. Staff inspects the new slings before laundry staff sends them out for resident use. The facility purchased new slings because the other slings had seen better days. The new slings are Invacare brand, but prior to this the slings were not Invacare brand slings. During an interview on 04/18/16, at 12:30 P.M., Resident #1's Family Member A said the following: -The resident had three falls resulting from broken sling straps; -The first time the resident fell , Family Member A and Family Member B were in the resident's room. During an interview on 04/18/16, at 1:00 P.M., Family Member B said the following: -The resident had three falls. -The first fall occurred sometime between 12/21/15 and 12/31/15. He/she did not record the date of the first fall because he/she thought it was an isolated event. He/she and Family Member A were in the resident's room. Staff began to transfer the resident out of bed using the lift, staff raised the resident approximately seven inches off the bed and the sling strap broke causing the resident to fall back down to the bed. Everyone in the room was startled; the resident denied injuries. At that time, the charge nurse on duty came to the room and assessed the resident. -Family Member B spoke to the ADON about the fall. The ADON told him/her the facility would purchase two new slings for the resident. -The transfer slings were muted in color, as if they had been through multiple washings and bleached. Staff told the family member they were not using bleach, but the family member asked them to investigate. -On 01/04/16, staff called the family member to report the resident had again fallen, this time in mid-transfer. The resident fell hitting his/her head on the roommate's bed. He/she also hit his/her back and ankle on the floor. The physician ordered multiple x-rays. The family member arrived at the facility approximately one hour after the fall. The resident complained his/her ankle hurt. -The family member talked to the administrator and the DON and told them his/her concerns regarding staff bleaching the slings. They said they believed they were using proper manufacturer's recommendations for care of the slings. -On 02/29/16, when the sling broke a third time, the family member went to the facility again and told the DON, ADON and administrator that he/she feared the slings were not being cared for/laundered properly. The following week, the family member again met with the facility and they assured the family member they purchased all new slings and were not drying or bleaching the slings. During an interview on 04/18/16, at approximately 11:00 A.M., an Invacare representative said the Invacare company could not guarantee the safety of any other brand of slings for use with their transfer lifts. The company did not test any other brand of slings; therefore, they cannot guarantee the quality. During an interview on 04/18/16, at 11:20 A.M., the corporate nurse said prior to 02/29/16, the facility ordered their slings through another company. The representative from that company said the Bestcare slings had the same serial number as the Invacare slings, therefore, were the same sling. The representative also told them they could dry the slings in the dryer using low heat (110 degrees Fahrenheit to 130 degrees F). Facility staff did not routinely check the temperature of the dryer. During an interview on 04/18/16 at 4:10 P.M., the DON said the following: -Resident # 1's falls on 01/04/16 and on 02/29/16 were the result of mechanical lift sling strap failures. -The mechanical lift sling that broke on 01/04/16 looked like it had been at the facility for a while. It was not frayed, torn or tattered, but it looked like it had been used and washed many times. -On 02/29/16, the resident's family came in and brought an Invacare sling from home. At that time, the resident's family mentioned the resident fell a total of three times due to the sling strap breaking. The DON did not document the conversation with the family. -The DON interviewed staff regarding a fall prior to 01/04/16, but the staff she interviewed did not know about a previous fall. She did not document the interviews with staff about the previous fall. -After the resident fell on [DATE], the facility decided to start replacing mechanical lift slings. -After the 02/29/16 fall, the facility ordered all new Invacare slings and in-serviced staff.

Based on observation, interview and record review, the facility failed to assess, thoroughly investigate and effectively address inappropriate sexual behavior of one alert and oriented resident (Resident #14) who had a history within the facility of inappropriate and unwanted sexual contact with staff and confused residents of the opposite sex. Since January 2014, alert residents reported that Resident #14 sexually touched the genitalia of two confused residents (Resident #17 and #4) within 49 days of each other. The facility staff also failed to properly assess and evaluate the appropriateness of an ongoing relationship of Resident #14 (that included sexual touching) with another resident (Resident #16) whose quarterly and annual cognition assessments ranged from moderately impaired to severely impaired. Thirteen residents along with four additional residents and two closed records were chosen for review in a facility with a census of 73. 1. Review of a form from the facility's Abuse Prohibition Protocol Manual titled, "Identification Guidelines" dated March 2012, showed in part the following information: -During the Resident Assessment Instrument (RAI) process, resident's needs and behaviors will be assessed. The Care Plan team will develop appropriate interventions. This information will be communicated to direct care staff through verbal instruction, resident care card and resident care plans; -If the suspected abuser is a resident, the facility will intervene appropriately, notify the appropriate state agency and follow the directions of the Division of Aging (Currently recognized as The Department of Health and Senior Services (DHSS)). 2. Record review of Resident #16's care plan dated 01/15/14 and updated 02/14/14, showed in part the following information: -At risk for sexually inappropriate behavior in public and private areas; -On 01/15/14, Durable Power of Attorney (DPOA) granted facility permission for resident to hold hands with a resident of the opposite sex (Resident #14); -Check on rounds routinely and redirect/divert attention as needed; -Explain that inappropriate touching of members of the opposite sex is not allowed and redirect to diversional activity or to common areas; -Inform the physician if behavior worsens without the ability to redirect; -Monitor whereabouts and remind no males are allowed in female rooms/no females in male rooms; -Use a calm approach when resident is being inappropriate. Record review of the resident's Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff from 10/13/10 to 11/14/13 showed the following information pertaining to the resident's cognition: -10/13/10, cognition moderately impaired; -From 01/9/11 to 05/23/13, cognition severely impaired; -From 08/19/13 to 02/12/14, cognition moderately impaired. Record review of an annual Social Services assessment dated [DATE], showed the resident is confused and often speaks word salad (confused or unintelligible mixture of seemingly random words and phrases). Record review of the resident's annual MDS dated [DATE], showed the following information: -Dementia; -Memory loss; -Cognition moderately impaired; -Interview with resident for daily activities preferences not completed because the resident is rarely/never understood; -Does not ambulate; -Wheelchair for mobility. During an interview on 03/11/14, at 10:13 A.M. a Certified Medication Technician (CMT) L said Resident #16 used to tell everybody he/she and Resident #14 were going to be married. Staff kept an eye on them when they were together and reported to the charge nurse when inappropriate touching was observed. Resident #16's cognition comes and goes. Someday's he/she is more confused than others. During an interview on 03/11/14, at 3:17 P.M., the Assistant Director of Nurses (ADON) said the DPOA for Resident #16 gave permission for the resident to hold hands with Resident #14. Marriage was spoken of mostly by Resident #16. Resident #14 just kind of went along with it. Observation and interview on 03/13/14, at 9:03 A.M., showed the resident in a wheelchair in his/her room. When asked if the resident knew Resident #14 the resident indicated he/she did but did not have any idea where the resident was. The resident said Resident #14 never touched him/her inappropriately and they were not romantically involved. The resident said sometimes staff kept them apart and he/she did not know why. During an interview on 03/13/14, at 9:45 A.M., the Social Worker said she began working at the facility in December 2013. At that time she was told Resident #16 could only hold hands with Resident #14. The Social Worker said she spoke with Resident #16's DPOA on 01/15/14, and he/she granted that permission. During an interview on 03/13/14, at 10:14 A.M., Certified Nurses Aide (CNA) M said, off and on, he/she saw Resident #14 with his/her hands down the pants or up the shirt of Resident #16. Staff have been instructed if they witness anything sexually inappropriate, to notify the charge nurse. We are encouraged to separate them without embarrassment in order to maintain their dignity. CNA M said these two residents were an item and were together for a long time. Several years ago, staff found them together in Resident #14's bathroom. It was not known until then that Resident #14 had a lock on the bathroom door. Staff opened the door with a key and found the two undressing each other. Staff removed the lock after that incident. The resident is "with it" approximately 90% of the time but does have his/her moments of confusion. Observation and record review of two confused resident's known to have been touched inappropriately by Resident #14 showed the following information: 3. Record review of Resident #4's quarterly MDS dated [DATE], showed the following information: -[MEDICAL CONDITION]; -Cognition severely impaired; -Does not ambulate; -Wheelchair for mobility. Record review of the resident's care plan updated on 02/27/14, showed in part the following information: -Resident touched inappropriately by a resident of the opposite sex; -Monitor for emotional distress post incident. Observation of the resident on 03/12/14, at 12:06 P.M., showed the resident seated in a wheelchair at the dining room table. Staff sat next to the resident and fed him/her a pureed meal. The resident did not speak during this observation. 4. Record review of Resident #17's quarterly MDS dated [DATE], showed the following information: -[MEDICAL CONDITION]; -Cognition severely impaired; -Does not ambulate; -Wheelchair or walker used for mobility. Record review of the resident's care plan updated on 01/09/14, showed in part the following information: -Reported incident of this resident touched inappropriately by a resident of the opposite sex; -Social Worker, DON, nursing staff monitoring this resident for emotional distress post incident. Observation of the resident on 03/13/14, at 11:15 A.M. showed the resident in a wheelchair in the hallway staring off in the distance. The resident did not communicate with the surveyor when approached. Staff propelled the resident in the wheelchair to and from the dining room. 5. Record review of MDS assessment information of three residents who witnesses Resident #14 inappropriately touching residents of the opposite sex showed the following information: Record review of Resident #18's recent quarterly MDS dated [DATE] showed the following information: -Cognitively intact. Record review of Resident #19's recent quarterly MDS dated [DATE] showed the following information: -Cognitively intact. Record review of Resident #7's recent quarterly MDS dated [DATE], showed the following information: -Cognitively intact. 6. Record review of Resident #14's hospital admission History and Physical dated 06/03/09, showed the resident was admitted to the hospital for decreased level of consciousness with a history of chronic [MEDICAL CONDITION]. The resident was placed on an alcohol withdrawal program. Record review of the hospital History and Physical dated 06/04/09, showed the resident drank as many as 30 cans of beer a day and suffered from acute and chronic alcohol induced dementia. Record review of Resident #14's nurses notes dated 06/14/09, showed "Resident sexually inappropriate asking the staff for sexual favors." Record review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated 06/23/09, showed the following information: -admitted [DATE]; -Dementia; -Socially inappropriate/disruptive behavior symptoms one to three days in the last seven days. Record review of the resident's Care Plan dated 06/23/09, showed in part the following information: -Be aware that the resident may say sexually inappropriate things to staff; -Divert attention to something else when conversation is inappropriate; -Inform the physician if problem behavior worsens without ability to redirect; -Staff interventions when noted to be sexually inappropriate; -Use calm approach when inappropriate behavior is exhibited; -Behaviors resolved and interventions discontinued on 03/01/10. Record review of a psychosocial quarterly progress note dated 06/30/10, showed staff recognized the resident to be involved in a relationship with a peer of the opposite sex in the facility (Resident #16). Record review of Resident #14's 07/30/10 and 02/18/11, care plans showed in part the same unchanged information: -At risk for sexually inappropriate behavior in public and private areas; -Check on rounds routinely and redirect/divert attention as needed; -Explain that inappropriate touching of the opposite sex is not allowed and redirect to diversional activity; -Inform the physician if problem behavior worsens without ability to redirect; -Monitor location and remind no males are allowed in female rooms/no females in male rooms; -Staff interventions when noted to be sexually inappropriate; -Use calm approach when inappropriate behavior is exhibited. Record review of the nurses notes dated 02/22/11, showed staff witnessed the resident ask a lewd and inappropriate verbal question to a peer of the opposite sex. Record review of a social services progress note dated 06/02/11, showed staff discussed with the resident regarding several reports of him/her grabbing the bottoms of staff members of the opposite sex and laughing. Staff documented the resident "shows no remorse" but agreed to stop. Record review of the Monthly Summary report dated 11/08/13, showed staff recognized the resident to be involved in a relationship with a resident of the opposite sex in the facility (Resident #16) and show he/she is often inappropriate with this resident and with other staff of the same gender. Record review of Resident #14's most recent Annual MDS dated [DATE], showed: -Cognition intact; -Alcohol dependence; -Walker or wheelchair for mobility; -No psychological therapy (by any licensed mental health professional); -No behaviors. Record review of a nurses note dated 01/08/14, showed two residents (Resident #18 and #19) reported to the social worker about seeing Resident #14 put his/her hands down the pants of a resident of the opposite sex (Resident #17) and touching his/her genitalia. The Director of Nursing (DON) was notified and investigated. Resident #14 informed that if the behavior continued he/she would be given notice and asked to leave the facility. Record review of the nurses notes from 01/08/14 to 01/19/14, showed staff documented the resident showed no inappropriate sexual behavior towards peers of the opposite sex. Record review of the resident's care plan updated on 01/09/14, showed the following information: -Reported incident of 01/09/14, that resident inappropriately touched a resident of the opposite gender; -New order for [MEDICATION NAME] (hormone medication) daily; -Resident to be seen by a licensed counselor; -Check on rounds routinely and redirect/divert attention as needed; -Inappropriate touching of the opposite sex is not allowed and redirect to diversional activity; -Monitor location and remind no males are allowed in female rooms/no females in male rooms; -Use a calm approach when having inappropriate behavior. Record review of the facility's Resident Abuse Report/Investigative Form, dated 01/09/14 and completed on 01/14/14, showed the following information: -Two residents witnessed Resident #14 touch another peer (Resident #17) inappropriately by the nurses station; -Witness states, "happens all the time"; -Nursing staff did not observe/witness incident; -The DON, Administrator, Assistant Director of Nurses (ADON), and Social Worker, met with the accused resident and informed that the behavior was not appropriate or acceptable; -Resident advised if further behavior occurs, he/she will be issued a 30 day notice; -DON and Social Worker to interview alert and oriented residents regarding any inappropriate behavior by the accused resident towards other residents; -Spoke with nursing staff who care for both residents involved. No inappropriate behavior observed. (Staff from other departments were not interviewed for possibly witnessing suspicious behaviors or events); -Staff to monitor offender and victim for 72 hours and document every shift by the charge nurse; -Findings indicated abuse did not occur. Incident was not witnessed by staff. No other incidents reported by staff regarding the accused inappropriate behavior towards other residents since this incident reported. No recent incidents prior to present incident. Record review of the nurses notes dated 02/27/14, at 11:39 P.M., showed at approximately 6:00 P.M., the resident was witnessed by a peer to be touching a resident (Resident #4) inappropriately in the perineal region (between the legs). Staff notified the DON, family and Nurse Practitioner. No new orders received. Record review of the nurses notes dated 02/28/14, at 5:07 A.M., (11 hours after the incident) staff documented the resident continues on incident follow up for touching a resident (Resident #4) inappropriately. Resident in bed at this time and no behaviors noted this shift. Record review of the nurses notes dated 02/28/14, at 1:09 P.M., showed the administrator and the social worker met with the resident and discussed the reported incident of last evening. Resident stated, "I'm not gonna say I did it." Resident informed this inappropriate behavior is not acceptable at the facility. Resident said he/she would keep his/her hands off of peers of the opposite sex. Medical Director ordered staff to send the resident to the hospital for evaluation. Resident kept on close observation by nursing staff until transport arrived. Record review of the nurses notes dated 02/28/14, at 4:02 P.M., showed staff spoke with the hospital nurse to inform of the resident transporting to the emergency room for evaluation and hospital admission (22 hours following this incident and 49 days following the previous incident of 01/09/14). Record review of the Nursing Home to Hospital Transfer Form dated 02/28/14, showed staff transferred Resident #14 due to inappropriately touching residents of the opposite sex, especially the ones that are incapable of stopping him/her. Record review of the facility's Resident Abuse Report/Investigative Form, dated 02/28/14, showed the following information: -A resident (Resident #18) witnessed Resident #14 touching another resident inappropriately between the legs in the Day Room/TV room; -Witness stated Resident #14 sat next to a peer with hand down their pants and was looking around to see if anyone was watching; -Licensed Practical Nurse (LPN) unit coordinator moved the residents away from one another and monitored Resident #14 for 30 minutes after the incident was reported and saw no further inappropriate behavior; -Resident #14 is aware of being watched; -Based on statement received by the resident (Resident #18) who witnessed the incident, the DON feels at this time the resident is not appropriate to continue his/her stay at the facility. The resident knows when he/she is being watched and is highly likely to continue with inappropriate sexual behavior towards other residents, especially those who cannot report the incidents; -Findings indicate sexual abuse occurred by Resident #14 to cognitively impaired residents. Interviews conducted between 03/10/14 and 03/13/14, showed the following information: -On 03/11/04, at 9:45 A.M. and 11:08 A.M., Housekeeping (HSK) D said Resident #14 was sexually inappropriate towards residents and staff of the opposite sex not long after he/she was admitted to the facility. He/she was aware of what he/she was doing and would stop when staff saw him/her. The resident went after residents of the opposite sex who were confused and not able to consent to what he/she was doing to them. HSK D said he/she did not report every time he/she witnessed the resident violating others because the charge nurse instructed to tell the resident to stop and to redirect him/her. -On 03/11/14, at 9:55 A.M., HSK E said he/she witnessed Resident #14 touching another resident (Resident #17) inappropriately and separated them, then informed the charge nurse. HSK E said the resident also touched him/her inappropriately a few times in the hallway; -On 03/11/14, at 10:06 A.M., a Certified Nurse Assistant (CNA) F said the resident always grabbed and fondled the chest of one resident (Resident #16). Approximately two months or longer, during a shower, CNA F said he/she noticed bruising on top of one breast of (Resident #16) and reported this to the charge nurse. On another occasion, CNA F notified the charge nurse of witnessing the resident trying to put his/her hand down the pants of a confused resident (Resident #17). I separated them and was told to keep an eye on him/her (Resident #14). -On 03/11/14, at 2:34 P.M., a CNA G said Resident #14 had a tendency to put his/her hands down the pants of peers of the opposite sex and was warned numerous times by the DON and Administrator not to do this and why. Nurses and CNAs were asked to keep an eye on him/her. The CNAs did not maintain any formal monitoring documentation. Aside from witnessing the resident with his/her hands down the pants of one resident (Resident #16), CNA G said he/she witnessed the resident fondling the chest of another resident (Resident #17) who was confused. "He/She was sneaky about it." The CNA informed the charge nurse and was instructed to keep them apart and to monitor the resident. On 03/11/14, at 2:50 P.M., CNA J said approximately three to four months ago, he/she witnessed the resident fondling the chest of another resident (Resident #17) who was confused. I reported the incident to the charge nurse and was told to separate them and to monitor with visual checks every 15 to 30 minutes. The resident would single out residents of the opposite sex who were confused. On 03/11/14, at 3:00 P.M., Licensed Practical Nurse (LPN) H said Resident #16 was friendly towards and liked Resident #14. LPN H received in report at shift change on 02/27/14, about the resident inappropriately touching another confused resident (Resident #4) in the TV room. LPN H said this angered him/her because this resident was obviously very confused. The LPN said the nurses and the CNAs monitored the resident throughout the shift. Nurses documented the resident's behavior and the CNAs watched him/her all shift. During an interview on 03/13/14, at 9:37 A.M., one resident (Resident #18) witnessed Resident #14 "fondling" a peer in the dining room with his/her hands down the resident's pants. Resident #18 said the peer was not aware of what Resident #14 was doing to them. Staff were also in the dining room and witnessed it also and moved them away from each other. The resident's roommate (Resident #7), also in the room during the interview, confirmed the reported accounts. "I have noticed this going on for a long long time." Resident #14 used to reside in the room next to ours and took advantage of everyone, especially the confused peers of the opposite sex. "It was said" Resident #14 had a relationship with a peer of the opposite sex (Resident #16) but that resident did not have all his/her faculties either. He/she had his/her hands down that resident's pants all the time. Staff did not take our reports seriously and nothing was done about it. Resident #14 knew what he/she was doing and sought out peers of the opposite sex who could not or would not understand what was going on. During an interview on 03/11/14, at 3:17 P.M., the Assistant Director of Nurses (ADON) said the DON and Administrator informed her of the resident's inappropriate sexual behavior on 03/03/14. The ADON knew the Administrator and the DON spoke with the resident about his/her sexual inappropriateness and to keep his/her hands to him/herself. Was aware to keep an eye on him/her when out on the floor. The ADON said she was responsible for the assessments and care plans and gathered information from multiple sources and records including staff and resident interviews. The Social Worker completes the behavior assessments on the MDS but the ADON said she is responsible for their accuracy. During an interview on 03/13/14, at 9:45 A.M., the Social Worker said she started working at the facility in December of 2013. On 01/09/14, two residents (Resident #18 and #19) reported to her of Resident #14 inappropriately touching a confused resident (Resident #17). The Social Worker took the witnesses to the DON and had them repeat what they told her. The social worker said neither resident was reliable (her opinion) but did not believe they would make this story up. The DON interviewed staff and residents and I told the nurses to keep an eye on the confused resident (Resident #17) for safety reasons. On 02/27/14, the DON investigated and performed interviews. The physician was notified and the resident was sent to the hospital. The Social Worker said the resident belongs in a behavior unit and we will not take him/her back. During an interview on 03/13/14, at 2:30 P.M., the DON said she began working at the facility in October 2013. She was not informed of Resident #14's inappropriate sexual behaviors until the incident of 01/09/14. The DON said she did not interview any department staff other than nursing during the investigation. Staff monitored Resident #14 for 72 hours. Nursing documented where the resident was and what he/she was doing each shift. All staff and residents were inserviced. Spoke with Resident #14 about his/her inappropriate behavior and he/she verbalized understanding. On 02/28/14, sent the resident to the hospital following another report of inappropriate behavior.

Based on observation, interviews, and record review, the facility failed to maintain the hot water temperatures, in resident use areas, within a safe zone (105-120 degrees Fahrenheit (F)). Resident room hand sinks, on two out of five resident halls, had hot water temperatures measuring between 124.6 degrees F to 134.2 degrees F. This presented a risk for burns for all residents who were cognitively impaired yet had the ability to mobilize to a hot water outlet. The facility had six cognitively impaired, mobile, diabetic residents, 40 cognitively impaired mobile residents, and 16 cognitively impaired residents who wandered. Twenty-two (22) residents lived on the 200 hall (Special Care Unit (SCU)). The facility also failed to assess risk for falls in a timely manner, failed to initiate and implement new fall interventions to prevent additional falls from occurring for two residents (Resident #1 and #8), identified by the facility as high risk for falls. The facility failed to assess, care plan, and consistently implement interventions to prevent skin tears and bruising for one resident (Resident #9). The facility failed to consistently notify the physician in a timely manner, obtain treatment orders and monitor the skin tears and bruising until healed for one resident (Resident #9) in a sample selection of 13 residents in a facility with a census of 76. 1. According to the 03/22/99 MemrySafe chart, "Exposure Time to Receive a Severe Burn,": -A person could receive a second degree burn, no irreversible damage, after 3 seconds of skin exposure to water that was 140.0 degrees F and in 17 seconds in water that was 131 degrees F. -A person could receive a third degree burn, full thickness injury, after 5 seconds of skin exposure to water that was 140.0 degrees F. and in 30 seconds in water that was 131 degrees F. According to the Consumer Product Safety Commission: -The majority of the hot water accidents involve the elderly. -Burns would occur after 6-second exposure to 140-degree water or after 30-second exposure to 130-degree water. -Even if the hot water temperature is 120.0 degrees F., a 5 minute exposure could result in third degree burns. Record review of the resident roster showed the residents occupied five halls in the facility. The 100, 300, 400 and 500 halls were outside the Special Care Unit (SCU) and the SCU was on the 200 hall. There were six mobile diabetic residents (this disease decreases circulation and skin sensitivity so they are more prone to skin injury) that are cognitively impaired, 40 cognitively impaired mobile residents, and 16 cognitively impaired residents that wander. Twenty-two (22) residents lived on the 200 hall, Special Care Unit (SCU). During observation of the SCU most of the 22 resident were mobile; either ambulatory or self-propelled their wheel chairs. Observations on 01/10/12, beginning at 3:25 P.M., showed occupied resident rooms on 200 and 500 halls had hand sinks with hot water temperatures measuring between 123 degrees F to 134.2 degrees F as measured with two Department of Health and Senior Services (DHSS) Facility Surveyors' thermometers. One thermometer was digital and the second was analog. -At 3:25 P.M., a visitor in Resident Room #301 cautioned the surveyor stating, "Be careful, that water is really hot. I have to add cold." The water temperature measured 120.7 degrees F. Observations on 01/10/12 beginning at 4:00 P.M., using both a digital thermometer and an analog thermometer at each location showed the following: -At 4:00 P.M., the hot water in the hand sink in resident room 501 measured 134.2 degrees F. -At 4:19 P.M., the hot water in the hand sink in resident room 207 measured 128.6 degrees F. -At 4:37 P.M., the hot water in the hand sink in the 500 hall shower room measured 126.5 degrees F. -At 4:38 P.M., the hot water in the 500 hall bathtub measured 125.1 degrees F. -At 4:59 P.M., the hot water in the hand sink in resident room 501 measured 129.5 degrees F. -At 5:00 P.M., the hot water in the hand sink in resident room 203 measured 123 degrees F. -At 5:07 P.M., the hot water in the hand sink in resident room 207 measured 124.6 degrees F. During an interview on 01/10/12 at 4:44 P.M., the Facility Administrator said the following: -Maintenance checked water temperatures weekly and she double checked those temperatures at least monthly. -They used only analog thermometers that were calibrated using ice water. -They had never found one of their thermometers to be off calibration. -They do not keep a log of the calibration because they get thermometers from the kitchen and staff just automatically calibrate them everytime before use. -The Monthly Hot Water Temp log did not show a date or time staff took the water temperature but it would be added to the new sheet. Observations on 01/10/12 beginning at 5:00 P.M., a surveyor using the surveyors' digital thermometer and the facility Administrator using a facility analog thermometer, showed temperatures were taken in the following resident rooms: -At 5:00 P.M., the hot water in the hand sink in resident room 501 measured 129.5 degrees F. with the digital thermometer and 128/129 degrees F. with the analog thermometer; -At 5:02 P.M., the hot water in the hand sink in resident room 203 measured 123 degrees F. with the digital thermometer and 118 degrees F. with the analog thermometer; (When the digital thermometer reached 123 degrees F. the administrator removed the digital thermometer from the water.) -At 5:03 P.M., the hot water in the hand sink in resident room 207 measured 124.6 degrees F. with the digital thermometer and 112 degrees F. with the analog thermometer; (The administrator held the analog thermometer and at times protruded out the side of the water flow so the censor was not showing an accurate reading.) -At 5:07 P.M., the hot water in the hand sink in resident room 301 measured 120.7 degrees F. with the digital thermometer and 117 degrees F. with the analog thermometer; (The administrator held the analog thermometer and at times protruded out the side of the water flow so the censor was not showing an accurate reading.) -At 5:15 P.M., the hot water in the hand sink in resident room 307 measured 117 degrees F. with the digital thermometer and 112 degrees F. with the analog thermometer; (The analog thermometer was still moving but the administrator removed it from the water stream when the digital thermometer stopped at 117 degrees F.) The facility Administrator said she had been trained by the food supply company how to measure temperatures with the analog thermometer. Record review of the facility's Monthly Water Temperature Logs, showed the following: - Staff checked water temperatures weekly on each resident hall, the kitchen and the laundry.. - Temperatures logged on temperature records dated October November and December showed all resident halls had temperature levels maintained between 110 degrees F. and 114 degrees F.. -None of the logs showed specific room numbers or times staff obtained the temperature readings. Observations and interview on 01/11/12 beginning at 8:30 A.M., showed the following: -At 8:40 A.M., the hot water in the hand sink in the resident shower room in the 200 hall special care unit measured 130 degrees F. -Certified Nurse Assistant (CNA) F said he/she had not noticed the water being that hot before. -The Maintenance Supervisor said he was unaware the water in the shower room sink was that hot, but he had turned off the hot water in the hand sink in resident room 207 because it had tested too hot. He said nursing would not be giving baths in the 200 hall shower room until the problem had been fixed. -At 8:45 P.M., Licensed Practical Nurse (LPN) G said he/she had noticed some resident room sinks had hotter water than others. He/she couldn't recall what rooms but said he/she just made sure to turn on cold water with the hot. He/she could not remember how long there had been a problem with the water. During interview on 01/11/12 at 8:55 A.M., the Maintenance Supervisor said he had checked the water in resident rooms last evening until 9:00 P.M. and the temperatures had stabilized for an hour. He turned off the water in resident rooms with water temperatures over 120 degrees F. The shower rooms had been taken out of use until the problem could be resolved. Plumbers had already been called again that morning and the new mixing valves (valves that mix cold water with hot water to avoid extreme temperatures) would be installed as soon as they were delivered on 01/13/12. 2. Record review of Resident #8's admission Minimum Data Set (MDS) assessment, a federally mandated comprehensive assessment instrument completed by facility staff, dated 07/19/11, showed the following information: -Usually makes self understood; -Usually understands others; -Disorganized thinking that fluctuates; -Required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -Staff assessed the resident's balance as not steady and only able to stabilize with human assistance when moving from a seated to a standing position and transfer between bed and wheelchair; -Staff assessed the resident's balance as not steady, but able to stabilize without human assistance when moving on and off the toilet; -Frequently incontinent of bladder; -Occasionally incontinent of bowel; -[DIAGNOSES REDACTED]. -Staff documented no therapy or restorative services were provided for the resident in the previous seven days; Record review of the resident's interim care plan, for admission date of [DATE], showed the following information: -Requires assistance with transfer to wheel chair daily; -Requires assistance to toilet on rounds and as needed; -Requires assistance to reposition on rounds and as needed; -Requires maximum to total assistance to complete activities of daily living (ADLs); -Resident is frequently incontinent; -Resident is at risk for communication deficit because of dementia; -Resident is at risk for difficulty making daily decisions and has a durable power of attorney involved in complex decision-making needs. Record review of the resident's fall risk assessments dated 07/19/11 and 10/15/11 indicated the resident fall risk score as 13. A score of 10 or above indicated high risk for falls. Record review of the nurses' notes dated 09/28/11, at 7:00 P.M., showed staff documented no injuries noted from the previous incident. (Staff did not record what the previous incident was and what had happened.) No complaints of pain or discomfort reported. Record review of the falls investigation follow-up, showed the date of fall 09/28/11. The nurse completed the form on 09/28/11 but did not explain the fall or any interventions to protect the resident from future falls. Under the section titled, "care plan changes initiated", staff documented "Remind to utilize call light for assistance as needed" (even thought the resident had dementia). Record review of the nurses' notes dated 11/04/11, at 4:30 A.M., showed staff observed the resident lying on the floor beside the bed and between a recliner and wheelchair. He/she had no complaints of pain. He/she had full active range of motion of all four extremities. No redness, swelling skin tears or bruising noted. He/she was unaware how he/she fell . Record review of the falls investigation follow-up completed on 11/04/11, showed the date of the resident's fall was 11/04/11. Under the section titled, "care plan changes initiated", staff documented "Cont. CPOC" (continue current plan of care) as above. During an interview on 1/13/12, at 2:20 P.M., MDS Coordinator said, when the care plan said, continue with current plan of care (CPOC) it means no new interventions were put in place or he/she couldn't find any more interventions to try. Record review of the falls investigation follow-up, date of fall 11/17/11, showed the resident fell again. Staff documented "the resident just stood up out of his/her wheelchair and sat down in the floor ". Staff documented no injuries were noted. The nurse completed the form on 11/17/11. Under the section titled, "care plan changes initiated", staff documented CPOC/continue plan of care. Staff did not suggest or implement other interventions to protect the resident from future falls. Record review of the nurses' notes showed staff did not document the incident or assessment of the resident. Record review of the care plan showed staff made no changes in the resident's care plan following the documentated falls other than, "remind the resident to use the call button". Record review of nursing notes dated 12/06/11, at 11:30 A.M., showed staff found the resident sitting on the floor in the middle of the room on his/her buttocks in a sitting position. Staff asked resident what he/she was doing. He/she responded "shining the floor, I don't remember how I fell ". The resident said he/she did not hit his/her head. Resident had range of motion times four and no complaints of pain. The wheelchair was by his/her door pointing towards the hallway. Record review of the falls investigation follow-up showed the nurse completed the form on 12/06/11, the date of the fall. Under the section titled, "care plan changes initiated", staff documented CPOC/continue plan of care. Staff did not suggest or implement other interventions to protect the resident from future falls. Record review of nursing notes dated 12/26/11, at 6:30 A.M., a CNA, who was in the room, heard the resident hitting the floor. No injuries found. Assisted resident back into wheelchair. Found small skin tear to left elbow that measured 0.7 cm. Cleaned with wound cleanser, triple antibiotic ointment applied and band aide applied. Resident stated only bruised his/her pride. Record review of the falls investigation follow-up, that the nurse completed on 12/26/11, the date of the fall. The nurse documented, "The resident was walking his/her wheelchair around the end of the bed to the closet and I think he/she pulled himself/herself by the foot of his/her bed and the wheelchair got stuck and he/she pulled self out of the wheelchair onto the floor". Under the section titled, "care plan changes initiated", staff documented provide treatments per orders. Staff did not suggest or implement other interventions to protect the resident from future falls. Record review showed the resident had five falls in four months. The only intervention noted on the care plan was to remind the resident to use the call light. The MDS dated [DATE] evaluated the resident as having: -Disorganized thinking that fluctuates. -Required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -Resident's balance not steady and only able to stabilize with human assistance when moving from a seated to a standing position and transfer between bed and wheelchair. 3. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 11/19/11, showed the following information: -Short and long term memory problem; -Severely impaired decision-making skills; -Required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene; -Staff assessed the resident's balance as not steady and only able to stabilize with human assistance when moving from a seated to a standing position, moving on and off the toilet, and transfers between bed and wheelchair; -Frequently incontinent of bowel and bladder; -[DIAGNOSES REDACTED].; -Staff did not document any therapy or restorative services provided for the resident in the previous seven days; -Staff documented the resident did not have any falls or fractures in the six months prior to admission; -Staff documented the resident did not have any falls since admission. Record review of the resident's interim (brief one page temporary) care plan, for admission date of [DATE], showed the following information: -Requires assistance with activities of daily living (ADLs); Staff to provide assist with ADLs as needed; -Resident is nonverbal; -Resident is dependent with transfers, dressing, bathing, grooming, and toilet use; -Resident requires assistance from staff for bed mobility and eating; -Resident is incontinent of bowel and bladder; -Therapies as ordered; -The care plan did not address the resident's level of fall risk, any interventions initiated in response to his/her fall risk score assessment to prevent falls, or any changes or additions to the care plan in response to actual falls. Record review of the physician order [REDACTED]. Record review of the Rehabilitation Screen, dated 11/10/11, showed physical therapy (PT) screened the resident due to new admission to determine if an evaluation was indicated for therapy services. PT skilled intervention was indicated for bed mobility, transfer, balance, endurance training, lower extremity range of motion and passive stretching, contracture prevention management, and lower extremity strengthening exercises. Record review of the nurses' notes showed the following information: -On 11/29/11, at 8:00 P.M., the resident slid down in the wheelchair. Three staff assisted the resident to sit back up in the wheelchair. The staff noted a 1 cm skin tear to the right elbow area. The nurse cleansed the area and applied a band aid. -On 12/2/11, at 6:50 P.M., the resident sat in the wheelchair at the nurses' station. After supper, the resident began to slide out of the wheelchair and turned slightly to the right and hit his/her head on the wall by the day area. The resident sustained [REDACTED]. The nurse documented vital signs and neurological checks (assessment of neurologic status and symptoms) started and the staff put the resident to bed. Record review of the falls investigation follow-up, date of fall 12/2/11, showed staff documented the resident was sitting up in the wheelchair after supper. The resident should be first down after meals and he/she would not slide out of wheelchair. The nurse completed the form on 12/2/11. Under the section titled, "care plan changes initiated", staff documented CPOC/continue plan of care as above. During an interview on 1/13/12, at 1:12 P.M., LPN A, who is responsible for MDS assessments, care plans, and medical records said, regarding interventions staff began after the resident's fall on 12/2/11; the staff was getting to know the resident. The resident did not have a lot of tolerance at that time. Staff did not leave the resident up for long periods of time, but after the fall, staff moved the resident to the first of the line to lie down after meals. Record review of the nurses' notes, showed on 12/3/11, at 6:15 P.M., the physician saw the resident and noted new orders. Record review of the physician's progress note, dated 12/3/11, showed the resident had a fall yesterday. The resident is in the wheelchair today with good stability. The resident tends to scoot down sometimes, but leaning forward is not something the resident normally has done. The physician's impression was ataxia (impaired ability to coordinate movement) without injury. The physician's plan was to obtain occupational therapy and physical therapy for strength and safety. Also, the physician planned to continue the iron medication for anemia. Record review of the nurses' notes dated 12/4/11, at 1:10 P.M., showed the resident continued to slide down in the wheelchair or sit on the edge of the wheelchair. Staff repositioned the resident frequently. Record review of the fall risk assessment, dated 12/7/11 (one month after admission to the facility), showed the resident's fall risk score as 12. A score of 10 or above indicated high risk for falls. No previous fall risk assessment was found in the medical record or produced by staff on request. Record review of the nurses' notes dated 12/11/11 (later corrected to 12/10/11), at 10:45 P.M. showed staff found the resident on the floor beside his/her bed, apparent fall from the bed. Apparently, the resident attempted to get out of bed without staff assistance. Staff found the resident leaned against the bed on his/her right hip with right elbow and forearm on the floor. The resident is aphasic and unable to relate what happened and what he/she was attempting to do. The resident denied hitting his/her head. Staff assisted the resident back into bed. Record review of the falls investigation follow-up form, date of fall 12/11/11, showed the following information: -Staff listed resident's attempt to self-transfer may have contributed to the fall; -Staff commented resident apparently attempted to get out of bed without assistance; -The staff documented care plan changes initiated as CPOC/continue plan of care as above. During an interview on 1/13/12, at 1:12 P.M., regarding interventions staff began after the fall on 12/11/11, LPN A said staff made sure the resident stayed up by the day area/nurses' station until staff were ready to provide care for the resident. Record review of the nurses' notes, showed on 12/12/11, at 12:30 P.M., the nurse documented notification of the physician regarding the fall on 12/10/11. Record review of the restorative care program, dated 12/12/11, showed staff to provide posterior pelvic alignment on sliding in wheelchair. Staff to provide restorative services 2-5 times a week for nine weeks for the resident. Record review of the nurses' notes dated 12/24/11, at 6:30 P.M., showed the resident sat in the wheelchair in the area around the day area. The resident leaned forward in the wheelchair. Staff repositioned the resident several times and told the resident to stop. The resident turned the wheelchair over face first, hitting floor face first, hitting right forehead on the concrete/tiled floor, sustaining a 3-4 centimeter (cm) contusion to the right forehead. The nurse documented "get self-release lap belt for wheelchair, have PT re-eval" . Record review of the falls investigation follow-up form, date of fall 12/24/11, showed care plan changes initiated a self-release seat belt when in wheelchair. Record review of the POS, dated 12/24/11, showed the physician ordered a lap (seat) belt, self-release for the resident. During interview on 1/13/12, at 1:12 P.M., regarding interventions after the fall on 12/24/11, LPN A said he/she did not know anything about the order being discontinued. As far as he/she knew, the resident currently used that intervention to prevent falls. The LPN said he/she thought the staff called the physician and obtained an order for [REDACTED]. The facility had tried therapy for the resident, but the resident was not productive and it was discontinued. Record review of the January 2012 POS show staff did not carry over the order for the lap belt to this month's order sheet so there was no continued physician order [REDACTED]. There was no order to discontinue the seatbelt. Record review of the fall risk screen, dated 1/5/12, showed the resident had a fall on 12/24/11. The resident had two falls in the last three months. The physical therapy staff documented the resident had the following risk factors for falls: recently hospitalized , taking four or more medications, confused, agitated, decreased range of motion, history of falls. The therapy staff documented the resident refused therapy and no skilled intervention provided at this date. Observation on 1/9/12, at 6:35 P.M., showed CNA B and CNA C wheeled the resident to the resident's room in the wheelchair. The resident did not have any seatbelt fastened or noted on the wheelchair. The staff changed the resident's shirt to a hospital gown and transferred the resident to the bed. The resident did not have any alarms attached to the wheelchair. The aides provided personal care to the resident. At 6:42 P.M., the aides left the room. The resident did not have any alarms attached to the bed. The resident's wheelchair seat did not have any cushion. During interview on 1/10/12, at 10:03 A.M., the social services director (SSD), said the resident did not have any restraints, positioning devices, alarms, or anything else like that. The resident had no recent falls that she was aware. The resident required two staff assistance with transfers. The resident had weakness to one side. The SSD thought the resident currently received restorative and had been off therapy services about three weeks. The SSD did not know about the resident's bowel and bladder control. The resident came to the facility about two months prior. Observation on 1/11/12, at 8:19 A.M., showed the resident sat in the dining room chair in the dining room. At 8:44 A.M., staff transferred the resident from the dining room chair to the wheelchair. The resident's wheelchair seat did not have any cushion in it. At 9:13 A.M., the staff wheeled the resident to the room. CNA D and CNA E wheeled the resident to the bathroom and transferred the resident to the toilet. After providing personal care, the aides transferred the resident to the wheelchair and wheeled the resident to the day area. The resident did not have any seat belt or alarms. During interview on 1/13/12, at 10:35 A.M., the administrator said the resident had worked with therapy a lot for positioning and range of motion. The administrator said after the fall on 12/2/11, staff began laying the resident down earlier. The administrator said that would not have been added to the care plan. Upon reviewing the nurses' notes, the fall dated 12/11/11 should be dated 12/10/11. The administrator said the staff had obtained a different cushion for the resident and a different back for the wheelchair at some point. The administrator did not know when that occurred. Referring to the restorative note regarding the posterior pelvic alignment plan, the administrator said that just meant staff makes sure the resident's bottom is pulled back in the wheelchair and is against the wheelchair back. During interview on 1/13/12, at 1:12 P.M., LPN A, who is responsible for MDS assessments, care plans, and medical records, said they add falls to the care plans. LPN A said he/she had slips of paper that match the fall investigation forms to add to the resident's comprehensive care plan when it is completed. The fall investigations include the changes in interventions implemented for the resident to prevent falls. The staff obtained a high-backed wheelchair for the resident to help the resident. That intervention is not on the fall investigation form. The LPN said he/she did not know off the top of his/her head when staff obtained the high-backed wheelchair for the resident. 4. Record review of Resident #9's annual MDS, dated [DATE], showed the following information: -Short and long term memory problem; -Severely impaired decision-making skills; -Required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Frequently incontinent of bowel; -Always incontinent of bladder; -The resident had one fall without injury since the previous assessment or admission. Record review of the resident's care plan, dated 7/2/11, showed the following information: -Requires assistance of one with ADLs; -Assess skin weekly and with showers. Report any red/open areas to nurse and physician; -At risk for episodes of yelling and striking out at staff and being resistive to cares; -At risk for falls due to medication, immobility, previous falls, and cognitive impairment; -Assist of one to two staff for transfers; -Staff did not address the risk for or interventions to prevent skin tears or bruises to the resident's skin. Record review of the nurses' notes, showed on 9/19/11, at 12:20 A.M., a CNA noted a 0.4 mm x 0.4 mm skin tear to the resident's right upper back and a 3 mm x 0.4 mm abrasion to the right side of the resident's scalp. The nurse documented the cause is unknown. The nurse did not note anything in the environment that may have caused the injuries. Record review of the skin tear investigation form, dated 9/19/11, showed the following information: -The resident has behaviors that put them at risk for skin tears; -The resident receives medication that increases skin fragility; -The resident has a care plan for prevention of skin tears; -The care plan is being used as outlined; -The nurse did not document if the resident had skin tears in the last 90 days; -The nurse did not document whether there was any unusual occurrence in the nurses' notes; -The nurse did not document a treatment order written on a phone order sheet, or the order transcribed to the POS, or document adding a treatment to the treatment sheet; -Staff reported the skin tear on the 24 hour report (shift to shift communication book); -A CNA documented he/she was doing rounds and found a skin tear on the resident's upper middle back and an abrasion to the right side of the head. The aide notified the nurse of the areas. The nurse documented there was nothing in the environment that may have caused the skin tear and no changes needed to be made to the environment. Staff did not document notification of the physician. Record review of the care plan, reviewed on 9/27/11, showed staff did not make any additions or changes to the care plan. Record review of the nurses' notes, showed on 10/4/11, at 3:15 P.M., a skin tear to the resident's right forearm after a CNA reported blood on the CNA's hand. The nurse noted . The area measured 1 cm x 1 cm with a "V" shape to it. The nurse cleansed the area, approximated the skin and applied steri-strips. The nurse documented bleeding easily controlled. The nurse did not document notification of the physician. Record review of the skin tear investigation form, dated 10/4/11, showed the following information: -The nurse documented the resident had skin tears in the last 90 days; -The resident had behaviors that put them at risk for skin tears; -The resident received medications that increase skin fragility; -The resident has a care plan for prevention of skin tears; -The care plan approaches are being used as outlined; -The nurse documented awaiting physician orders; -The nurse documented the treatment was not written on the POS or the treatment sheet. -Staff documented getting the resident up and noted blood on his/her (CNA's) hand. -The nurse documented nothing in the environment may have caused the skin tear and no changes needed to be made to the environment. The nurse did not document notification of the physician. Record review of the care plan, last reviewed on 9/27/11, did not show staff made any changes or additions to the care plan. Record review of the nurses' notes, showed on 10/18/11, at 10:55 P.M., the nurse observed the resident lying on the right side on the floor beside the bed. The resident had minimal bleeding from two lacerations (torn, jagged wound) on the scalp. The bleeding stopped with direct pressure after two minutes. The resident had bruising and swelling around both lacerations. The resident also had a bruise to the left hand middle finger, right outer lower leg, left posterior lower leg, right side of face near jaw line and right neck. Staff assisted the resident to bed and documented call light and personal body alarm in place. Record review of the falls investigation follow-up, date of fall 10/18/11, showed the nurse checked the resident's neurological checks as per protocol and initiated a raised-side mattress. Record review of the care plan showed, on 10/18/11, staff added the resident had a fall with injury on 10/18/11. On 10/18/11, staff added the intervention of a rai