Every finding on record at Sylvia G Thompson Residence Center, Inc

Based on interview and record review, facility staff failed to ensure five nurse aides ((NA) NA A, NA B, NA C, NA D, and NA E) out of six sampled NA's, completed the nurse aid training program within four months of their facility hire date. The facility census was 116.1. Review of the facility provided policies did not contain a policy to direct staff on timeframe for the completion of nurse aide training program.2. Review of NA A's personnel file showed a hire date of 11/01/25. The file did not contain documentation NA A completed the nurse aide training program.During an interview on 04/29/26 at 2:42 P.M., NA A said he/she has worked as an NA since 2025. He/She said he/she is supposed to be done with the CNA class now but waiting on an email to be able to take the test. He/She said that he/she works the floor by himself/herself and performs resident cares.3. Review of NA B's personnel file showed a hire date of 10/31/25. The file did not contain documentation NA B completed the nurse aide training program.4. Review of NA C's personnel file showed a hire date of 10/31/25. The file did not contain documentation NA C completed the nurse aide training program.During an interview on 04/29/26 at 2:39 P.M., NA C said he/she has worked as an NA since April 2025. He/She said he/she finished the CNA class a couple weeks ago but is still waiting to take the test. He/She said he/she has been working the floor by himself/herself and performing resident cares.5. Review of NA D's personnel file showed a hire date of 10/31/25. The file did not contain documentation NA D completed the nurse aide training program.During an interview on 04/29/26 at 10:35 A.M., NA D said he/she has worked the floor for two years as an NA and performed cares for residents. He/She said he/she is currently in class for Certified Nurse's Aide (CNA). He/She said the class started in November and he/she still has one or two classes left because some have been canceled. He/She said class is normally every Thursday.6. Review of NA E's personnel file showed a hire date of 10/31/25. The file did not contain documentation NA D completed the nurse aide training program.7. During an interview on 04/29/26 at 3:03 P.M., Human Resources said back in October 2025 they terminated some NA's because they were not certified and then they hired them back.During an interview on 04/30/26 at 8:40 A.M., the Director of Nursing (DON) said he/she knew there were several NA's working but did not realize there were NA's passed their four months. He/She said he/she doesn't have anything to do with Human resources and was not aware that some NA's were terminated and rehired because they were not certified.During an interview on 04/29/26 at 3:20 P.M., the administrator said he/she knew there were a few NA's over the four month time frame. He/She said the class is over and they are ready to take their test. He/She said yes, they did terminate some NA's in October 2025 and then rehired them because they were over the time frame and not certified. Complaint #2997819

Based on observation and interview facility staff failed to ensure two of three ice machines, used to supply ice to residents, drained through an air gap to prevent cross-contamination. Facility staff failed to ensure one ice machine was free of materials to prevent ice contamination. The facility census was 112.1. Observation on 10/08/25, during the Life Safety Code tour showed:-the ice machine located in the clean utility room contained two small white plastic tubes which drained from the rear of the ice machine into a larger white plastic floor drain and did not contain an air gap. Observation showed the white plastic above the ice storage bin contained a black speckled substance;-the nurse station 2 dining room ice machine contained a black drain hose which ran into a white plastic drain and did not contain an air gap.During an interview on 10/09/25 at 11:35 A.M., the Safety Coordinator said the facility's contracted vendor was responsible for cleaning the ice machines, but he/she did not know how often. The safety coordinator said maintenance staff were responsible for maintaining facility plumbing but he/she did not know about the air gap requirement.During an interview on 10/09/25 at 12:50 P.M., the administrator said maintenance staff were responsible for the ice machines. The administrator said he/she was familiar with ice machine air gap requirements, but he/she did not know the two machines did not have air gaps. The administrator said he/she was not aware of the black material in the ice machine.

Based on interview and record review, the facility staff failed to follow their Facility Assessment to ensure the facility staffed enough staff to meet the needs of the residents. Staff failed to provide a sufficient number of direct care staff members to ensure call lights were answered in timely manner. The facility census was 112. 1. Review of the facility assessment tool, dated 08/28/25, showed: -Average census of 117 residents;-Goal staffing is one to eight ratio for Certified Nursing Assistants (CNAs), the day-to-day average is one to ten for CNAs;-Days: Five Registered Nurses (RNs), two Licensed Practical Nurses (LPNs), and 17 CNAs;-Evenings: One RN, one LPN, and 14 CNAs;-Nights: Two LPNs and eight CNAs;-Weekend days: One RN, one LPN, and other direct care hours remain the same.2. Review of the facility census sheet, dated 08/30/25, showed the facility census at 117.Review of the employee schedule, dated 08/30/25, showed: -Eight CNAs on evening shift;-Seven CNAs on night shift.3. Review of the facility census sheet, dated 08/31/25, showed the facility census at 117.Review of the employee schedule, dated 08/3/25, showed: -Nine CNAs on day shift;-Nine CNAs on evening shift;-Six CNAs on night shift.4. Review of the facility census sheet, dated 09/06/25, showed the facility census at 117.Review of the employee schedule, dated 09/06/25, showed: -One RN on day shift;-Eight CNAs on evening shift.5. Review of the facility census sheet, dated 09/07/25, showed the facility census at 117Review of the employee schedule, dated 09/07/25, showed one LPN and nine CNAs on evening shift scheduled.6. Review of the facility census sheet, dated 09/13/25, showed the facility census at 118.Review of the employee schedule, dated 09/13/25, showed: -11 CNAs on day shift;-Seven CNAs on evening shift;-Six CNAs on night shift.7. Review of the facility census sheet, dated 09/20/25, showed the facility census at 117.Review of the employee schedule, dated 09/20/25, showed: -Nine CNAs on evening shift;-One LPN on night shift.8. Review of the facility census sheet, dated 09/21/25, showed the facility census at 117Review of the employee schedule, dated 09/21/25, showed: -Seven CNAs on evening shift;-One LPN and seven CNAs on night shift.9. Review of the facility census sheet, dated 09/27/25, showed the facility census at 117.Review of the employee schedule, dated 09/27/25, showed: -11 CNAs on day shift;-Nine CNAs on evening shift;-One LPN and seven CNA's on night shift.10. Review of the facility census sheet, dated 09/28/25, showed the facility census at 117.Review of the employee schedule, dated 09/28/25, showed: -One LPN and five on evening shift;-Six CNAs on night shift.During an interview on 10/9/25 at 4:05 P.M., the Director of Nursing (DON) said they staff one charge nurse, one CMT and four to five CMT's on each unit on day shift. He/She said they have three units. He/She said for the weekends they staff two nurse, three CMT's and the same number of aides. He/She said they have plenty of staff scheduled, but their issue is having no shows and call ins. He/She said they have incentives in place to try and encourage staff to show up to shifts and they have administrative staff come work the shifts when needed.During an interview on 10/9/25 at 4:07 P.M., the administrator said they use their facility assessment as a goal for how many staff they should have on the floor. He/She said they do not always staff according to the facility assessment. He/She said they have plenty of staff on payroll and scheduled but that they do not always show up to work their shifts. He/She said when that happens the DON, himself/herself, or other administrative staff with work the floor.11. Review of the facility's policy titled, Answering the Call Light, dated September 2022, showed the purpose is to ensure timely responses to the resident's requests and needs, and staff are directed to answer the resident call system immediately. The policy did not contain direction for who may answer the call light.12. Review of the daily nursing staff assignment sheet, dated 10/02/25, showed:-Day shift: 29 CNA/CMT;-Evening shift: 13 CNA/CMT.Review of the facility's wireless call light report, dated 10/02/25 showed: -At 5:27 A.M., room [ROOM NUMBER] with call light response time of 30 minutes;-At 5:45 A.M., room [ROOM NUMBER] with call light response time of 51 minutes;-At 6:23 A.M., room [ROOM NUMBER]'s bathroom with call light response time of 43 minutes;-At 6:41 A.M., room [ROOM NUMBER] with call light response time of 44 minutes;-At 7:04 A.M., room [ROOM NUMBER] with call light response time of 37 minutes;-At 7:14 P.M., room [ROOM NUMBER] with call light response time of 31 minutes.13. Review of the daily nursing staff assignment sheet, dated 10/03/25, showed:-Day shift: 19 CNA/CMT;-Evening shift: 11 CNA/CMT.Review of the facility's wireless call light report, dated 10/03/25 showed: -At 11:41 A.M., room [ROOM NUMBER]'s bathroom with call light response time of 36 minutes;-At 5:30 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 21 minutes;-At 7:34 P.M., room [ROOM NUMBER]'s bathroom with call light response time of 32 minutes;-At 7:38 P.M., room [ROOM NUMBER] with call light response time of 44 minutes;-At 7:54 P.M., room [ROOM NUMBER] with call light response time of 33 minutes. 14. Review of the daily nursing staff assignment sheet, dated 10/04/25, showed:-Day shift: 14 CNA/CMT;-Evening shift: 11 CNA/CMT.Review of the facility's wireless call light report, dated 10/04/25 showed: -At 6:44 A.M., room [ROOM NUMBER] with call light response time of 2 hours and 59 minutes;-At 6:55 A.M., room [ROOM NUMBER] with call light response time of 1 hour and 13 minutes;-At 7:29 A.M., room [ROOM NUMBER] with call light response time of 36 minutes;-At 7:36 A.M., room [ROOM NUMBER]'s bathroom with call light response time of 2 hours and 8 minutes;-At 8:57 A.M., room [ROOM NUMBER] with call light response time of 40 minutes;-At 12:33 P.M., room [ROOM NUMBER] with call light response time of 31 minutes;-At 4:20 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 9 minutes;-At 5:47 P.M., room [ROOM NUMBER] with call light response time of 56 minutes;-At 6:07 P.M., room [ROOM NUMBER] with call light response time of 34 minutes;-At 7:45 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 4 minutes;-At 7:50 P.M., room [ROOM NUMBER] with call light response time of 55 minutes.15. Review of the daily nursing staff assignment sheet, dated 10/05/25, showed:-Day shift: 15 CNA/CMT;-Evening shift: 12 CNA/CMT.Review of the facility's wireless call light report, dated 10/05/25 showed: -At 1:13 P.M., room [ROOM NUMBER] with call light response time of 31 minutes;-At 7:11 P.M., room [ROOM NUMBER] with call light response time of 40 minutes;-At 8:06 P.M., room [ROOM NUMBER] with call light response time of 30 minutes.16. Review of the daily nursing staff assignment sheet, dated 10/06/25, showed:-Day shift: 26 CNA/CMT;-Evening shift: 11 CNA/CMT.Review of the facility's wireless call light report, dated 10/06/25 showed: -At 1:43 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 42 minutes;-At 1:48 P.M., room [ROOM NUMBER]'s bathroom with call light response time of 1 hour and 49 minutes;-At 2:23 P.M., room [ROOM NUMBER] with call light response time of 1 hour and 12 minutes;-At 2:28 P.M., room [ROOM NUMBER]'s bathroom with call light response time of 1 hour and 7 minutes;-At 2:39 P.M., room [ROOM NUMBER] with call light response time of 59 minutes;-At 3:00 P.M., room [ROOM NUMBER] with call light response 37 minutes;-At 3:58 P.M., room [ROOM NUMBER] with call light response time of 53 minutes;-At 4:13 P.M., room [ROOM NUMBER] with call light response time of 55 minutes;-At 4:25 P.M., room [ROOM NUMBER] with call light response time of 44 minutes;-At 4:27 P.M., room [ROOM NUMBER] with call light response time of 45 minutes;-At 4:31 P.M., Nurse's Station two women's bathroom with call light response time of 40 minutes;-At 6:02 P.M., room [ROOM NUMBER] with call light response time of 37 minutes;-At 7:57 P.M., room [ROOM NUMBER] with call light response time of 33 minutes.17. During an interview on 10/06/25 at 11:32 A.M., Resident #111 said he/she needs help from staff to transfer and to use the bathroom, but staff sometimes takes up to 30 minutes to respond to his/her call light which sometimes causes him/her to have bladder accidents and require him/her to change his/her brief. During an interview on 10/06/25 at 11:40 A.M., Resident #28 said he/she needs help from staff with toileting, and sometimes staff takes over 30 minutes to answer his/her call light which has caused him/her to have bladder accidents which he/she does not like because he/she does not ask for much.During an interview on 10/06/25 at 12:02 P.M., Resident #44 said he/she often waits over 30 minutes to an hour for staff to respond to his/her call light and ends up having bladder accidents because of the long wait for help. During an interview on 10/06/25 at 1:27 P.M., Resident #26 said he/she doesn't think there is enough staff to assist because it can take over 30 minutes for staff to answer his/her call light during the evenings. The resident said he/she now eats dinner in his/her room to avoid having to wait a very long time for staff to assist him/her back to his/her room from the dining room after meals.During an interview on 10/07/25 at 9:27 A.M., Resident #38 said staffing is an issue. He/She said he/she often waits longer than 20 to 30 minutes for staff to answer his/her call light often causing him/her to wet himself/herself. The resident said he/she sometimes wonder if the call lights are working because of how long it takes for someone to respond. During an interview on 10/08/25 at 1:38 P.M., Resident #81 said there isn't enough staff, and staff often tells him/her there is only one person on the hall, so it takes them longer to respond to his/her call light. The resident said he/she waited over an hour more than once the past few days for staff to answer his/her call light, which caused him/her to have a bowel movement on himself/herself and staff had to take him/her to the shower room to get cleaned up and showered. He/She said it's not a good feeling to have to go on yourself because they don't have the help to help you when you need it.During an interview on 10/09/25 8:20 A.M., Resident #37 said he/she sometimes wait for up to an hour for staff to answer his/her room or bathroom call light and it makes him/her feel like he/she is nothing and that staff doesn't care. The resident said when he/she gets tired of waiting, he/she thinks about walking back to his/her bed by himself/herself but is scared he/she may fall and hurt himself/herself, so he/she just sits there and wait till staff decides to show up.During an interview on 10/09/25 at 1:06 P.M., Nurse Aid (NA) I said staff are expected to answer call lights within two to five minutes and 30 minutes or longer is a long unacceptable time for a call light to go unanswered. He/She said staff should not leave a resident in the bathroom unattended other than to gather supplies or get assistance. He/She said if a resident's room or bathroom call light goes unanswered for longer than 30 minutes, the resident may get tired of waiting and attempt to transfer or have an accident. During an interview on 10/09/25 at 1:10 P.M., RN C said staff are expected to respond to a resident's call light within five minutes. RN C said 30 minutes or longer for a call light to go unanswered is unacceptable, but it seems to happen mostly on the evening shift because there aren't as many staff working due to regular staff call-ins. RN C said the nursing staff checks the computer at the nurses' stations to see which call light is on and staff are expected to respond to the light that has been on the longest (at the top of the list) first. During an interview on 10/9/25 at 4:05 P.M., the Director of Nursing (DON) said anything over 20 minutes is considered a concern for call light times. He/She said they look over the call light response report and investigate the call light times to figure out why there is long call light times. He/She said he/she was not aware of call light times over an hour long, but they would have to investigate it to determine the cause.During an interview on 10/9/25 at 4:07 P.M., the Administrator said he/she considers anything longer than 20 min is too long. He/She said he/she takes the report for the call light times and investigate why call lights were taking so long and they address those issues based off those findings. He/She said he/she saw the call light report showed multiple call lights going off longer than 30 minutes and some over 2 hours. He/She would have to investigate before he/she could determine the reasoning for that and if it was truly that long. He/She said staff must be at the nurse station to hear the call lights go off and see what room number pops up on the screen. He/She said they do not carry pagers or have lights that go off in the hallways. He/She said it lights up green on the screen at the nurse's station and turns red after 20 minutes. Complaint # 2631904

Based on observation, interview, and record review, facility staff failed to label and store medications in a safe and effective manner in one of two sampled medication storage rooms and one of two sampled medication carts. Staff failed to ensure medications were properly stored during medication administration to residents. The facility census was 112.1. Review of the facility's policy titled, Storage of Medication, revised 11/2020, showed:-The facility stores all drugs and biologicals in a safe, secure, and orderly manner;-Drug containers that have missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling before storing;-Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed;-Schedule II-V (two to five) controlled medications are stored in separately locked, permanently affixed compartments.Review of the facility's policy titled, Administering Medications, revised 04/2019, showed when opening a multi-dose container, the date opened is recorded on the container, and insulin pens are clearly labeled with the resident's name or other identifying information. 2. Observation on 09/06/25 at 10:04 A.M., showed nursing station two's medication storage room contained: -One Lantus insulin (medication to lower blood sugar) a multi-dose vial opened and undated; -One Humalog insulin vial opened and undated; -One Admelog insulin vial opened and undated; -One Tresiba insulin pen opened and undated; -One Humalog insulin pen opened and undated;-58 Tramadol (a schedule IV-controlled medication used to treat pain) 50 milligram (mg) tablets on the countertop next to the sink. Observation on 10/06/25 at 10:25 A.M., showed the memory care unit medication cart contained one Novolog insulin pen without a resident's name, opened and undated, and one bottle of Tums Smoothies Extra Strength (ES) 750 mg tablets, opened, unlabeled, with an expiration date of 10/2024.During an interview on 10/06/25 at 10:16 A.M., Certified Medication Technician (CMT) W said controlled medications should be stored behind two locks until they are administered to a resident or destroyed and should not be left on the counter to ensure proper storage and safety. CMT W said only nurses and CMTs have access to the medication storage room and he/she did not know who removed the Tramadol tablets from the medication cart and left them improperly stored on the counter. CMT W said the nurses mainly administer insulin medication to residents, but any CMT or nurse who opens an insulin pen or vial should ensure a resident's name is on the insulin and label the medication with the opened date and expiration date. During an interview on 10/06/25 at 10:32 A.M., CMT X said the CMTs are responsible to check the medication carts for expired medications every couple of weeks and remove expired medications from the medication carts, so he/she was not sure why the expired Tums were still inside the cart. CMT X said insulin pens should be labeled with the resident's name, and either the CMT or nurse who opens the insulin pen should label the pen with the opened date and expiration date before they place the pen inside the medication cart for storage. During an interview on 10/09/25 at 9:05 A.M., Registered Nurse (RN) C said nurses and CMTs should ensure controlled medications are stored behind two locks and not left on the countertop in the medication storage room. RN C said the nurse or CMT who opens the insulin medication should ensure the insulin pen or vial has a resident's name and label the insulin with the opened and expiration date. RN C said prior to each medication administration to a resident, the nurse or CMT should check the medication's expiration date and remove and discard the medication if it is expired. RN C said the CMTs are responsible to routinely check and remove expired medications from the medication carts, so there should not be any expired medications from a year ago inside the cart. RN C said he/she was not sure if anyone double checks expired meds are removed from the medication carts. During an interview on 10/09/25 at 4:05 P.M. the Director of Nursing (DON) said nurses and CMTs should ensure controlled medications are stored behind two locks until administered or discarded and should not be left on the countertop to limit access to the medications. The DON said when a nurse or CMT opens an insulin medication, he/she is expected to ensure the insulin vial or pen has a resident's name and label the medication with the opened and expiration dates. The DON said there should not be any medications in the carts that have expired over a year because the CMTs are expected to remove expired medications from the carts daily, and one of the senior CMTs who works in the office double checks the medication carts and medication storage rooms once per month for expired medications.During an interview on 10/09/25 at 4:10 P.M., the administrator said the nurses and CMTs should ensure controlled medications are stored behind two locks. The administrator said he/she expects staff to ensure insulin pens and vials have a resident's name from the pharmacy, and when the nurse or CMT opens the insulin pen or vial, he/she should label the medication with the opened and expiration dates. He/She said the clinical nurse manager is responsible to double check that medications are properly labeled and stored inside the medication carts and medication storage rooms monthly.3. Review of the facility's policy titled, Administering Medications, revised 04/2019, showed during administration of medications, the medication cart is kept closed and locked when out of site of the medication nurse or aide, and no medications are kept on top of the cart. 4. Observation on 10/08/25 at 12:19 P.M., showed a medication cart in nursing station two's dining room with two opened insulin pens, three insulin syringe needles pre-filled with medication, in partially opened individual packaging, unattended and residents nearby.Observation on 10/09/25 at 8:42 A.M., showed CMT A walked away from the medication cart in nursing station one's dining room to administer medications to a resident. CMT A left one cup with approximately six to eight unidentified medications, and six bottles of over the counter (stock) medications unattended on top of the medication cart in the dining room, as several residents and staff members walked by the medication cart.Observation on 10/09/25 at 10:24 A.M., showed CMT A entered room [ROOM NUMBER] to administer medications to a resident, and left a bottle of aspirin 81 mg tablets unattended on top of the medication cart in the hallway, as several staff and residents transitioned the hallway pass the cart.During an interview on 10/08/25 at 12:20 P.M., CMT W said the nurse placed the insulin pens and needles on top of the medication cart. CMT W said he/she stepped away from the medication cart to administer medications to a resident in the dining room and should not have left the medications unattended on top of the cart because someone could have taken the medications. During an interview on 10/09/25 at 8:43 A.M., CMT A said staff should not leave medications unattended on top of the medication cart to ensure proper storage and prevent someone from taking them. CMT A said he/she should not have left the medications unattended on the medication cart and was not sure why he/she did.During an interview on 10/09/25 at 9:05 A.M., RN C said staff should not leave any medications unattended on top of the medication cart for safety and proper storage. RN C said he/she accidentally left the insulin pens and needles on top of the cart to assist a resident with meal set-up and should have ensured the medications were stored properly inside the cart or the medication storage room. During an interview on 10/09/25 at 4:05 P.M. the DON said he/she expects staff to lock medications inside the medication cart or medication storage room for proper storage, and staff should not leave any medications unattended on top of the medication carts. During an interview on 10/09/25 at 4:10 P.M., the administrator said staff should not leave any medications unattended on top of the medication carts and should ensure medications are properly stored inside the medication cart or medication storage room. Complaint # 2631904

Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than five percent (5%) out of 25 opportunities observed, nine errors occurred, resulting in a 36% error rate, which affected two residents (Resident #48 and #62) out of seven sampled residents. The facility's census was 112.1. Review of the facility's policy titled, Administering Medications, revised April 2019, showed staff: -Medications are administered in a safe and timely manner, and as prescribed;-Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders);-The individual administering the medication checks the label THREE times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication;-Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.Review of the facility's Medication Pass times, provided by the administrator upon entrance, showed medications are administered at scheduled timeframes. 2. Review of Resident #48's Physician's Order Sheet (POS), dated October 2025, showed:-Spironolactone (to treat high blood pressure) 25 milligrams (mg) by mouth daily at 8:00 A.M.;-Memantine HCL (to treat dementia) 10 mg by mouth twice daily at 8:00 A.M., and 8:00 P.M.;-Torsemide (to treat high blood pressure) 20 mg by mouth daily at 8:00 A.M.;-Aspirin (to prevent a heart attack) 81 mg by mouth daily at 8:00 A.M.; -Omeprazole (to treat heartburn) 20 mg by mouth daily at 8:00 A.M.;-Potassium Chloride Extended Release (to treat low potassium levels) 10 milliequivalent (mEq) daily at 8:00 A.M; -Budesonide inhalation suspension (to treat shortness of breath) 0.5 mg/2 milliliter (ml), one vial via nebulizer twice daily at 7:00 A.M., and 5:00 P.M.;-Arformoterol Tartrate (to treat Chronic obstructive pulmonary disease (COPD)) 15 microgram (mcg) /2 ml nebulization, one vial via nebulizer twice daily at 7:00 A.M., and 5:00 P.M.Observation on 10/09/2025 at 10:24 A.M., showed Certified Medication Technician (CMT) A administered Spironolactone, Memantine, Torsemide, Aspirin, Omeprazole, and Potassium medications to the resident one hour and twenty-four minutes after the ordered administration time.Observation on 10/09/2025 at 10:26 A.M., showed CMT A administered Budesonide and Arformoterol breathing treatments to the resident two hours and twenty-six minutes after the ordered administration time.During an interview on 10/09/25 at 10:24 A.M., CMT A said staff were allowed an hour before and after the schedule medication time to administer the resident's morning medications. CMT A said he/she administered the resident's medications late and would be considered a medication error, which could result in the resident being given another dose of the same medications too close and cause issues. He/She said he/she would notify the charge nurse of the late medication administration error. 3. Review of Resident #62's POS, dated October 2025, showed an order for Lidocaine (treatment for pain) 5% patch (two patches) daily at 8:00 A.M., apply to lower back and hip for pain.Observation on 10/06/25 at 11:24 A.M., showed CMT B applied one Lidocaine four percent (4%) patch to the resident's lower back, and one lidocaine 4% patch to the resident's right hip. The CMT administered the medication two hours and twenty-four minutes after the ordered administration time. During an interview on 10/08/25 at 1:43 P.M., CMT B said he/she administered the resident's pain medication late. He/She said he/she did not verify the correct medication dosage and administered the wrong dose of the lidocaine patches to the resident. The CMT said the late medication administration and wrong dose were both considered a medication error, and he/she would notify the charge nurse per facility policy for follow up. 4. During an interview on 10/09/25 at 9:05 A.M., Registered Nurse (RN) C said staff are allotted two hours before and after the scheduled medication administration time to administer the morning medications. He/She said late medications and wrong dose are considered medication errors, and the CMTs are expected to notify the charge nurse of any medication errors, and the nurse to follow up with the physician and per facility policy. During an interview on 10/09/25 at 4:05 P.M. the Director of Nursing (DON) said staff are allotted two hours before and after the scheduled administration time to administer routine morning medications, so any medications administered outside the allotted time are late. He/She said if staff administer the wrong dose or administer medications late, it is considered a medication error, and the nurse should be notified to follow up per policy. During an interview on 10/09/25 at 4:10 P.M., the administrator said if staff administer the wrong dose or late medications, it is considered a medication error. He/She said the CMTs are expected to notify the nurse of late medications or other medication error and the nurse to follow up with the physician.

Based on interview and record review, facility staff failed to ensure Nurse Aide's ((NA) NA H, NA J, NA P, NA Q, and NA S) of 24 completed the nurse aide training program within four months of his/her employment in the facility. The census was 112.1.Review of the facility's Nurse Aide Qualifications and Training Requirements policy, revised 08/2022, showed nursing assistants failing to successfully complete the required training program within the first four (4) months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services.2. Review of NA H's CNA report, showed a hire date of 03/24/25. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program.3 Review of NA J's CNA report, showed a hire date of 04/28/25. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program.During an interview on 10/17/25 at 10:40 A.M., NA J said he/she started back with the facility in April. He/She has taken the classes online through the facility but has yet to take the test. He/She said he/she has not taken the test because he/she is trying to study more before taking it. He/She said he/she has yet to schedule the test.4 Review of NA P's CNA report, showed a hire date of 02/14/25. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program.5 Review of NA Q's CNA report, showed a hire date of 03/12/25. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program.6. Review of NA S's CNA report, showed a hire date of 05/21/24. Review showed the NA's file did not contain documentation the NA completed a nurse aide training program.7. During an interview on 10/9/25 at 9:48 A.M., the Administrator said he/she is responsible for ensuring that new hired have completed the CNA training within the 4 months. He/She said he/she has a few aides that are outstanding on time frames. He/She said that his/her staff have gone through the classes and have just not passed the test. He/She said the instructor they use offers online and in person classes, but no one is passing the test. He/She said he/she was not aware that the aides had to complete the training and be certified by the 4 months, he/she said he/she thought they just had to have the education done in that time frame.During an interview on 10/9/25 at 4:05 P.M., the Director of Nursing (DON) said the Administrator is in charge of the nurse aide training and scheduling. He/She does not handle hiring or education and it not sure what the required time frames are for ensure aides have completed education and are certified.

Based on observation, interview, and record review, facility staff failed to assess residents for the use of bed rails on a quarterly basis for six residents (Resident #2, #3, #10, #11, #29, and #112) of 28 sampled residents. The facility census was 112. 1. Review of the facility's policy titled, Bed Safety and Bed Rails, dated August 2022, showed the use of bed rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, and resident assessment.2. Review of Resident #2's Quarterly minimum data (MDS), a federally mandated assessment tool, dated 09/26/25, showed staff assessed the resident as follows:-Severe cognitive impairment;-Required substantial/maximal assistance with toileting, showering, personal hygiene; -Bed rails not used as a restraint in bed.Review of the resident's medical record showed the record did not contain a quarterly side rail assessment.Observation on 10/07/25 at 1:20 P.M., showed the resident in bed with bilateral side rails in the upright position.Observation on 10/08/25 at 8:11 AM., showed the resident in bed with bilateral side rails in the upright position. During an interview on 10/08/25 at 3:03 P.M., the MDS Coordinator said the last side rail assessment he/she completed for the resident was on 06/13/25, and he/she did not complete a quarterly side rail assessment for the resident in September.3. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely impaired cognition and bed rails not used as a restraint.Review of the resident's medical record showed the medical record did not contain a quarterly bed rail assessment in July 2025.Observation on 10/06/25 at 1:32 P.M., showed the resident in bed with one quarter length bed rail in the upright position.Observation on 10/07/25 at 8:59 A.M., showed the resident in bed with one quarter length bed rail in the upright position.4. Review of Resident #10's Quarterly MDS, dated [DATE], showed staff assessed as cognitively intact and bed rails not used as a restraint.Review of the resident's medical record showed the medical record did not contain quarterly bed rail assessments for May 2025 and August 2025. Observation on 10/07/25 at 9:07 A.M., showed the resident in bed with one quarter length bed rail in the upright position. Observation on 10/08/25 at 9:30 A.M., showed the resident in bed with one quarter length bed rail in the upright position.5. Review of Resident #11's Significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Dependent on staff for toileting, showers, and ability to roll in bed;-Bed rails not used as a restraint in bed.Review of the resident's medical record showed the record did not contain a quarterly side rail assessment.Observation on 10/07/2025 at 10:29 A.M. showed the resident in bed with bilateral quarter rails in the upright position. Observation on 10/08/25 at 2:05 P.M., showed the resident in bed with bilateral quarter rails in the upright position.Observation on 10/09/25 at 11:00 A.M., showed the resident in bed with bilateral quarter rails in the upright position.During an interview on 10/08/25 at 3:03 P.M., the MDS Coordinator said the last side rail assessment he/she completed for the resident was on 05/05/25, and he/she did not complete a quarterly side rail assessment for the resident in August.6. Review of Resident #29's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment;-Required setup from staff to roll left and right in bed, and partial/moderate assistance with transfers from chair/bed-to-chair;-Bed rails not used as restraint in bed.Review of the resident's care plan, dated 08/06/25, showed the resident uses quarter bed rails on his/her bed to aid in repositioning and bed mobility, and to evaluate risks and benefits of using devices.Review of the resident's medical record showed the record did not contain a quarterly side rail assessment.Observation on 10/06/25 at 2:02 P.M., showed the resident in bed with bilateral side rails in the upright position.Observation on 10/07/25 at 10:05 AM., showed the resident in bed with his/her legs hung loose off the left side of the bed, and bilateral side rails in the upright position. During an interview on 10/08/25 at 3:03 P.M., the MDS Coordinator said the last side rail assessment he/she completed for the resident was on 02/17/25, and he/she did not complete a quarterly side rail assessment for the resident in May or August. 7. Review of Resident #112's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required partial/moderate assistance to roll left and right in bed, and dependent with transfers from chair/bed-to-chair;-Bed rails used daily as restraint in bed.Review of the resident's care plan, dated 07/22/25, showed the resident used bed rails as a restraint, and to evaluate risks and benefits of using devices.Review of the resident's medical record showed the record did not contain a quarterly side rail assessment.Observation on 10/07/25 at 9:56 A.M., showed the resident in bed with bilateral side rails in the upright position.Observation on 10/08/25 at 8:02 A.M., showed the resident in bed with bilateral side rails in the upright position.During an interview on 10/08/25 at 3:03 P.M., the MDS Coordinator said the last side rail assessment he/she completed for the resident was on 04/18/25, and he/she did not complete a quarterly side rail assessment for the resident in July. 8. During an interview on 10/08/25 at 3:03 P.M., the MDS Coordinator said he/she is responsible to complete the quarterly side rail assessments for all the residents with their MDS assessments. The MDS Coordinator said he/she did not complete some of the quarterly side rail assessments due to being busy, and said he/she was not sure if anyone double checks the quarterly side rail assessments are completed. During an interview on 10/09/25 at 1:39 P.M., Registered Nurse (RN) C said the MDS Coordinator is responsible to complete the residents' side rail assessments quarterly along when he/she completes the MDS assessments.During an interview on 10/09/25 at 4:11 P.M., the Director of Nursing (DON) said he/she expects for side rail assessments to be completed quarterly. During an interview on 10/09/25 at 4:15 P.M., the Administrator said he/she expects for side rail assessments to be completed quarterly and said he/she was not aware the side rail assessments were not being completed quarterly.

Based on observation, interview, and record review, facility staff failed to provide a safe mechanical lift transfer for two residents (Resident #21 and #90) when staff failed to open the legs of the mechanical lift during transfers and failed to position the resident's wheelchair to prevent bumping the mechanical lift during the transfer. The facility census was 112. 1. Review of the facility's policy titled, Safe Lifting and Movement of Residents, dated July 2017, showed the following:-In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents;-Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices;-Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques;-Safe lifting and movement of residents is part of an overall facility employee health and safety program which provides training on safety, ergonomics and proper use of equipment. 2. Review of Resident #21's Quarterly minimum data set (MDS), a federally mandated assessment tool, dated 10/08/25, showed staff assessed the resident as:-Severely impaired cognition;-Diagnosis of heart failure, neuropathy (damage or dysfunction of the peripheral nerves), and hemiplegia (the loss of the ability to move one side of the body);-Dependent on staff for transfers;Observation on 10/08/25 at 9:05 A.M., showed Certified Nurse Aid (CNA) T and Nurse Aid (NA) U attached the resident's sling to the mechanical lift. CNA T raised the resident from his/her wheelchair without the mechanical lift legs open and rolled the mechanical lift without the legs open towards the resident's bed.During an interview on 10/09/25 at 12:05 P.M., CNA T said he/she should have had the legs of the mechanical lift spread open while transferring the resident. The CNA said he/she just forgot to spread the legs open when transferring the resident. 3. Review of Resident #90's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-Diagnosis of heart failure, diabetes, anxiety disorder, depression, and spinal stenosis of the lumbar region;-Dependent on staff for transfers.Observation on 10/07/25 at 11:55 A.M., showed CNA T and NA J attached the resident's sling to the mechanical lift. CNA T raised the resident from his/her bed and rolled the mechanical lift with the legs open away from the bed. NA J asked CNA T to close the legs of the mechanical lift so he/she can get the residents wheelchair positioned. CNA T then closed the legs of the mechanical lift. NA J attempted to maneuver the resident's wheelchair around the mechanical lift, bumped and shook the mechanical lift with the resident suspended in the air, and was unable to get the wheelchair around the mechanical lift. NA J then asked CNA T to open the legs of the mechanical lift. Observation showed CNA T opened the mechanical lift legs, NA J attempted to maneuver the resident's wheelchair around the mechanical lift, bumped and shook the mechanical lift with the resident suspended in the air, and was unable to get the wheelchair around the mechanical lift. NA J asked CNA T to close the legs of the mechanical lift, NA J then maneuvered the resident's wheelchair around the mechanical lift, placed the wheelchair sideways over the closed legs of the mechanical lift, and lowered the resident into his/her wheelchair. During an interview on 10/08/25 at 9:30 A.M., the resident said he/she has a general fear of being transferred with a mechanical lift due to previous experiences and said the transfer from yesterday made him/her nervous. During an interview on 10/09/25 at 12:05 P.M., CNA T said he/she should have not spread the legs of the mechanical lift open and should have had them closed to get the residents wheelchair positioned sideways over the mechanical lift legs. The CNA said because he/she had the legs opened, NA J was not able to get the residents wheelchair positioned and said he/she realizes the residents transfer was not smooth. The CNA said he/she just started working at the facility a few weeks ago and was not trained or shown by facility staff how to transfer the resident due to his/her larger wheelchair. The CNA said after he/she helped with transferring the resident, NA J explained that the legs of the mechanical lift must be closed in order to get the residents larger wheelchair positioned sideways across the closed legs and to lower the resident into the wheelchair.During an interview on 10/09/25 at 1:40 P.M., NA J said staff must keep the mechanical lift legs closed to get the residents wheelchair in position due to the larger size of the chair. The NA said he/she would open the mechanical lift legs for regular sized wheelchairs but will keep them closed for the resident's larger wheelchair and for some of the residents using a Broda chair (specialized wheelchair or seating system designed for long-term sitting comfort and therapeutic positioning) within the facility. NA J said he/she was trained by facility staff to keep the mechanical lift legs closed and to position the resident's wheelchair sideways across the closed legs when transferring the resident. NA J said he/she realizes he/she bumped the mechanical lift during the resident's transfer, but said if they would have had the legs closed from the start, the transfer would have been smoother. During an interview on 10/09/25 at 2:13 P.M., Registered Nurse (RN) C said he/she would expect for staff to have the mechanical lift legs spread open when transferring a resident, regardless of the resident's type of chair. The RN said the resident is heavy as well, so it is even more important to have the mechanical lift legs spread open while transferring the resident to help with balance. The RN said staff should not bump the mechanical lift with the wheelchair while the resident is suspended in the air. During an interview on 10/09/25 at 4:11 P.M., the Director of Nursing (DON) said he/she would expect for staff to have the mechanical lift legs spread open when transferring all residents and for staff to not bump the mechanical lift while the resident is being transferred. During an interview on 10/09/25 at 4:13 P.M., the Administrator said he/she would expect for staff to have the mechanical lift legs spread open when transferring all residents and for staff to not bump the mechanical lift while the resident is being transferred. The Administrator said he/she believes that the therapy department had trained staff on how to transfer the resident due to the larger wheelchair and said he/she does not think therapy trained staff to keep the mechanical lift legs closed.

Based on interview and record review, the facility staff failed to meet professional standards of care when they failed to document they administered treatments for three residents (Resident #46, #110, and #112) of 28 sampled resident treatments. The facility census was 112.1. Review of the facility's policy titled, Wound Care, revised October 2010, showed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The following information is be recorded in the resident's medical record:-The type of wound care given;-The date and time the wound care was given;-If the resident refused the treatment and the reason(s) why;-Staff are directed to notify the supervisor is the resident refuses the wound care. 2. Review of Resident #46's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/08/25, showed staff assessed the resident as:-Severe cognitive impairment;-Rejection of care not exhibited;-At risk of Ulcers/injuries;-Surgical wound.Review of the resident's Physician Order Sheet (POS), dated 09/10/25, showed an order for apply wet to dry sterile dressing with Dakins, secure with dry dressing twice per day at 9:00 A.M. and, 9:00 P.M., to left buttock. Review of the resident's Treatment Administration Record (TAR), dated 09/25, showed the record did not contain documentation staff provided wound treatment as ordered on 09/10/25, 09/12/25, 09/14/25, 09/16/25, 09/21/25, 09/23/25, 09/24/25, 09/26/25- 09/29/25. Review of the resident POS, dated 10/25, showed an order for apply wet to dry sterile dressing with Dakins, secure with dry dressing twice per day at 9:00 A.M. and, 9:00 P.M., to left buttock. Review of the resident's TAR, dated 10/25, showed the record did not contain documentation staff provided wound treatment as ordered on 10/03/25, 10/04/25, 10/05/25, and 10/08/25.3. Review of Resident #110's Quarterly MDS, dated [DATE], showed staff assessed the resident as:-Severe cognitive impairment;-Rejection of care not exhibited;-One stage 2 (a partial-thickness skin loss involving the epidermis and possibly the dermis) pressure ulcer and one stage 4 (the most server type of pressure sore, characterized by full-thickness tissue loss and exposure of underlying structures such as bone, muscle, or tendons) pressure ulcer.Review of the resident POS, dated 09/25, showed a wound treatment order to coccyx: Cleanse with wound cleanser, pat dry. Sprinkle Pixie (powder medication used in wound healing) dust to wound, cover with Calcium Alginate (a water-insoluble, gelatinous, cream-colored substance that can be created through the addition of aqueous calcium chloride to aqueous sodium alginate) and border foam dressing daily. Review of the resident's TAR, dated 09/25, showed the record did not contain documentation staff provided wound treatment as ordered on 09/05/25- 09/07/25 and 09/17/25-09/30/25.Review of the resident POS, dated 10/25, showed an order for wound treatment to coccyx: Cleanse with wound cleanser, pat dry. Sprinkle Pixie dust to wound, cover with Calcium Alginate and border foam dressing daily. Review of the resident's TAR, dated 10/25, showed the record did not contain documentation staff provided wound treatment as ordered on 10/03/25, 10/05/25, and 10/06/25.During an interview on 10/09/25 at 3:30 P.M., Registered Nurse (RN) V said he/she does most of the treatments in evening. RN V said when treatments are done, staff are expected to sign off on the TAR. The RN said if he/she does not do the treatment then they don't sign off on it. The RN said if the treatment does not get done, they can pass it on to next shift. RN V said he/she does not know why the treatments for those residents would not have been done.4. Review of Resident #112's annual MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment. Review of the resident's POS, dated 10/25, showed physician orders directed staff to change oxygen tubing, nasal cannula, and humidifier one time per week on Friday's 3:00-11:00 P.M. shift and cleanse the resident buttocks with normal saline, pat dry, apply calmoseptine (topical medication used to treat skin irritations) with A and D ointment (barrier) three times a day at 7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M., and 11:00 P.M., to 7:00 A.M., until resolved, start 10/02/25. Review of the resident's TAR, dated 09/25, showed the record did not contain documentation staff changed the resident's oxygen tubing, nasal cannula, and humidifier on 09/12/25.Review of the resident's TAR, dated 10/25, showed the record did not contain documentation staff changed the resident's oxygen tubing, nasal cannula, and humidifier on 10/03/25.Review of the resident's TAR, dated 10/25, showed the record did not contain documentation staff provided the treatment to the resident's buttock on the evening shift for 10/03/25, 10/04/25, 10/05/25, on the night shift on 10/06/25, and on the day shift for 10/08/25. During an interview on 10/09/25 at 1:39 P.M., RN C said staff are expected to sign the residents' TAR after each treatment is administered to show it was completed. During an interview on 10/09/25 at 4:30 P.M., the Director of Nursing (DON) said the expectation is that staff document treatments on the TAR as they are done. The DON said he/she was not aware of there were holes in the TARs showing missed treatments. During an interview on 10/09/25 at 4:34 P.M., the administrator said staff are to document treatments on the TAR. The administrator was not aware of the undocumented treatments on the residents TARs but does not think the treatments are not being done. The administrator said she believes the staff just forgot to sign off on it.

Based on observation, interview and record review, facility staff failed to provide appropriate care and services per facility policy to maintain the highest practicable physical and psychosocial well-being for one resident (Resident #1) when staff failed to safely administer a warm pack for pain, which resulted in a burn injury to the resident's left arm and shoulder area. The facility census was 115.1. Review of the facility's Policy and Procedure for Using a Warm and Cool Pack, dated 08/2024, showed if a resident requests a warm or cool pack, one will be provided that will return to room temperature without intervention. This would consist of rice packs, gel packs, or warm/cool cloths that will return to room temperature on their own. Warm packs are not to be microwaved unless manufacturer recommends. Hot water may be utilized only out of facility faucets to ensure temperature is not too hot. Staff should check periodically to see if resident has relief from the issue that requires the use of the pack. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 05/29/25, showed staff assessed the resident as cognitively intact, occasional pain, and did not receive non-medication interventions for pain.Review of the resident's care plan, revised 06/09/25, showed the care plan did not contain interventions to direct staff on how to apply a warm pack to the resident, or how to monitor the resident when a warm pack is applied.Review of the resident's progress notes, dated 08/21/25, showed staff documented the resident was observed laying on a warm moist pack during a skin assessment, redness to his/her upper arm and upper back. Family and physician were notified that resident had what appeared to be a burn, received new orders for treatment.Review of the resident's Physician's Order Sheet, dated 08/21/25, showed a physician order to apply Silvadene one percent (1%) cream (a topical antimicrobial medication used to prevent and treat infection in second and third-degree burns), one application twice per day for burn on left shoulder until healed.Observation on 08/26/25 at 11:47 A.M., showed the resident back of upper arm with a red area, pale- yellow center the size of a quarter and an oblong-shaped reddened area to his/her left shoulder blade.During an interview on 08/26/25 at 11:47 A.M., the resident said he/she asked staff for a hot pack to relive pain and stiffness to his/her left shoulder. The resident said this was not the first time staff had applied a hot pack to his/her shoulder, but this was the first time staff did it the way they did. He/She said the hot pack staff applied to him/her in the past was different and not as hot.During an interview on 08/26/25 at 12:55 P.M., Registered Nurse (RN) A said he/she was the charge nurse assigned to the resident when the incident occurred, but was never notified by the aides or the Certified Medication Technician (CMT) the resident had requested a hot pack, or that one of the aides had placed a hot pack on the resident's shoulder. The RN said he/she was notified of the burn injury during shift report the next day when he/she returned to work. The RN said Certified nursing Assistant (CNA) G also reported to him/her the resident had requested a hot pack the night before, he/she consulted with CMT E, and after CMT E gave him/her directions, he/she heated a wet towel in a plastic bag with water, which initially felt too hot, so he/she poured off some of the water, added cold water to the bag, wrapped the bag in a towel and placed the hot pack on the resident's shoulder.During an interview on 08/26/25 at 3:05 P.M, CMT E said the resident had requested a hot pack and he/she was busy with something else, so he/she asked CNA G to apply the hot pack. The CMT said he/she gave CNA G directions on how to prepare the hot pack but did not direct CNA G on how long to leave the hot pack on the resident. The CMT said he/she should have checked on the resident since he/she had directed CNA G to apply the hot pack to the resident's shoulder, but he/she forgot. The CMT said he/she could not recall if he/she had told the charge nurse that the resident had requested a hot pack for pain so the nurse could follow up with the resident.During an interview on 08/26/25 at 3:19 P.M., the Assistant Director of Nursing (ADON) said CNAs can administer warm packs to a cognitive resident, but after consulting with the nurse so the nurse can further assess the resident's need/request for the warm pack, and the CMT or nurse to follow up with the resident. The ADON said staff should monitor a resident within 15 minutes if they apply a warm/cold pack to a resident's skin. During an interview on 08/26/25 at 3:57 P.M., Nursing Assistant (NA) F said he/she was training with CNA G when the incident occurred. The NA said CNA G placed a washcloth with warm water in a plastic bag and heated the bag in the microwave for about 15 seconds. The NA said he/she mentioned to CNA G that the bag was probably too hot, and CNA G wrapped the bag into a towel and placed it on the resident's shoulder. The NA said he/she found out the next day the resident had sustained burns to his/her shoulder, and he/she has not received any in-services regarding how to use a warm pack since the incident. During an interview on 08/26/25 at 5:32 P.M., Licensed Practical nurse (LPN) C said he/she reported to work at 10:30 P.M., and the evening shift staff did not report to him/her that staff had placed a warm pack on the resident's shoulder. The LPN said when he/she went to assess the resident shortly after midnight, he/she found the resident laying on a plastic bag with a wet washcloth under his/her left arm between his/her upper back/side. The LPN said he/she removed the towel and plastic bag, assessed the resident's skin with redness and blisters, measured the areas, applied an initial treatment, administered pain meds to the resident, notified the resident's family and Primary Care Physician (PCP). The LPN said the CNAs can apply warm packs if they have been educated and directed by the nurse to do so, and the nurse is responsible to monitor the resident's skin. The LPN said he/she would prefer to apply a warm pack to the resident him/herself, particularly since the resident has decreased sensation due to his/her diagnosis and would need to be monitored more closely.During an interview on 08/27/25 at 1:07 P.M., the resident's physician said he/she would expect facility staff to be educated on the proper application of warm packs if they should use it on a resident in the future. Complaint #2596159

Based on observation, interview and record review, facility staff failed to review and revise the plan of care to address individualized physical and functional care needs for three residents (Resident #1, #2, and #3) out of four sampled residents. The facility's census was 115.1. Review of the facility's Comprehensive Care Plans Policy, revised 03/2022, showed a comprehensive, person-centered care plan will include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents' condition change. Review showed the policy did not address timeframes for revising a resident's care plan after an injury or change in functional care needs. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 05/29/25, showed staff assessed the resident as cognitively intact, occasional pain, and did not receive non-medication interventions for pain. Review of the resident's progress notes, dated 08/21/25, showed staff documented the resident was observed laying on a warm moist pack during a skin assessment, redness to his/her upper arm and upper back. Family and physician were notified that resident had what appeared to be a burn, received new orders for treatment. Review of the resident's care plan, dated 06/09/25, showed the care plan did not contain direction for the application of warm packs for pain relief, or interventions to address the burns to the resident's left upper arm and upper back. During an interview on 08/26/25 at 12:55 P.M., Registered Nurse (RN) A said he/she was not sure if the resident's care plan had been updated yet regarding the burn and new treatment, but he/she would expect to see new interventions added to the resident's care plan by now.During an interview on 08/26/25 at 2:33 P.M., the Care Plan Coordinator said he/she had not yet updated the resident's care plan to reflect the burn injury or application of hot/cold treatment, because he/she usually updates the care plans on Fridays. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and frequently incontinent of bowel and bladder. Review of the resident's care plan, dated 07/28/25, showed the care plan did not contain direction or interventions to address the resident's bowel incontinence. During an interview on 08/26/25 at 2:33 P.M., the Care Plan Coordinator said the resident is incontinent of bowel and bladder and should have had interventions on his/her care plan to address bowel/functional incontinence, but he/she did not realize he/she had not documented those interventions. 4. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, continent of bowel and bladder, and diagnoses to include constipation. Review of the resident's care plan, dated 07/09/25, showed the care plan did not contain direction or interventions to address the resident's constipation. Review of the resident's Physician's Order Sheet (POS), dated 08/26/25, showed physician orders as followed: -Docusate Sodium 100 milligrams (mg) capsules by mouth, give two capsules twice daily for constipation;-Milk of Magnesia 1200 mg/15 milliliters (ml) suspension, by mouth, give 30 ml daily as needed for constipation, start date 05/23/25; -Polyethylene Glycol Powder 17 grams (gm) mixed in juice or water by mouth, every other day for constipation, start date 07/31/25. During an interview on 08/26/25 at 11:37 A.M., the resident said he/she has issues with constipation and takes medications to help provide relief. The resident said he/she recently started increasing fruits in his/her diet to help provide added relief from constipation.During an interview on 08/26/25 at 2:33 P.M., the Care Plan Coordinator said he/she uses information from the resident's POS, nurses' notes, and the Interdisciplinary Team meetings to add interventions to the resident's care plan, but would have only included interventions for constipation if the resident had triggered or expressed constipation in the seven-day review period of the MDS assessment dated [DATE] 5. During an interview on 08/26/25 at 2:09 P.M., Licensed Practical Nurse (LPN) D said nurses use care plans to help guide each resident's care, and the Care Plan Coordinator is responsible to update the residents' care plans per schedule and with changes regarding specific care needs for the residents. The LPN said interventions to address pain, treatment for injuries, bowel and bladder incontinence and constipation should be included on the residents' care plans if applicable. During an interview on 08/26/25 at 2:33 P.M., the Care Plan Coordinator said he/she is responsible to update the residents care plans quarterly, after an injury/fall, and with significant changes. He/She said he/she usually updates the care plans within a week, usually on Fridays after an injury or change in condition. He/She said he/she was not sure if anyone double checks that the care plans are updated. During an interview on 08/26/25 at 3:39 P.M., the administrator said the Care Plan Coordinator is responsible to update residents' care plans quarterly, and within seven days after a fall or other injury. The administrator said the residents' medical chart is a part of the residents' care plan. Complaint #2596159 and 2599788

Based on interview and record review, facility staff failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), a complete and accurate direct care staffing information to the Payroll Based Journal (PBJ) data from July 1, 2024 through September 30, 2024. The facility census was 116. 1. Review of the facility policy titled, Reporting Direct Staffing Information (Payroll-Based Journal), Revised August 2022, showed: -Complete and accurate direct care staffing information is reported electronically to CMS through the PBJ system in a uniform format specified by CMS; -Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly; -Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: --Fiscal Quarter 1: Date Range October 1-December 31: submission deadline February 14; --Fiscal Quarter 2: Date Range January 1-March 31: submission deadline May 15; --Fiscal Quarter 3: Date Range April 1-June 30: submission deadline February 14; --Fiscal Quarter 4: Date Range July 1-September 30: submission deadline November 14. 2. Review of the facility's CMS PBJ Staffing Data Report, dated January 2, 2025, did not contain a report for the period of July 1, 2024 through September 30, 2024. During an interview on 01/22/24 at 8:46 A.M., Human Resources (HR) said it is his/her responsibility to ensure the PBJ report is submitted timely. He/She is aware the facility's PBJ reports were not filed timely. He/She said the facility hired a new payroll management company and they have had issues with their payroll information uploading to CMS correctly. He/She said he/she and the board members have been working with the new payroll management company each quarter to try and fix the uploading errors. During an interview on 01/22/25 at 9:00 A.M., the administrator said HR is responsible for submitting the PBJ reports. He/She said he/she did know the facility had not submitted the PBJ reports timely/accurately. He/She said HR has had issues since they switched payroll management companies. He/She said the system had not allowed them to upload to CMS with the correct data and they are working to get the errors corrected. 47193

Based on observation, interview, and record review, facility staff failed to follow infection control practices during medication administration for five (Resident #109, #45, #110, #5, & #120) out of 24 sampled residents. The facility census was 116. 1. Review of the facility's policy titled Administering Medications, revised 04/2019, showed staff are directed to follow facility infection control procedures (hand washing, antiseptic technique, gloves, etc.) for the administration of medications. Review of the facility's policy titled Handwashing and Hand Hygiene, revised 08/2019, showed: -All staff shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other staff, resident, or visitors; -Use an alcohol-based had rub for the following situations; -Before and after coming in contact with a resident; -Before preparing or handling medications; -After contact with objects and/or medical equipment in the vicinity of the resident; -After removing gloves. 2. Observation on 01/21/25 at 7:45 A.M., showed Certified Medication Technician (CMT) D prepared medications for Resident #109. Observation showed CMT D dropped an Aspirin on top of the medication cart and used his/her bare hand to pick the medication up and put it in the cup. Observation showed CMT D administered the Aspirin to the resident. Observation on 01/21/25 at 7:57 A.M., showed CMT D prepared medications for Resident #45. Observation showed CMT D dropped a medication on the floor, picked it up and threw it in the trash, did not wash his/her hands or apply gloves and adminstered the residents eye drops. During an interview on 01/22/25 at 9:30 A.M., CMT D said he/she should wear gloves to administer eye drops to residents. CMT D said he/she did not realize he/she forgot to wear gloves until after administering the eye drops. CMT D said he/she should not touch a resident's medication with his/her bare hands. CMT D said he/she should have washed his/her hands after picking medication up off the floor. 3. Observation on 01/21/25 at 8:13 A.M., showed CMT E prepared medications for Resident #110. Observation showed CMT E dropped a Vitamin D 3 on the medication cart. Observation showed CMT used his/her bare hands to pick the medication up and put it in the medication cup. Observation showed CMT E administered the medication to the resident. During an interview on 01/22/25 at 9:10 A.M., CMT E said staff should wear gloves to touch resident's pills to prevent cross contamination and spreading of germs. 4. Review of the facility's policy titled Instillation of Eye Drops, revised 01/2014, showed staff are directed to put on gloves before administering eye drops. Observation on 01/21/25 at 8:13 A.M., showed CMT E administered Artificial tears (an eye lubricant) to Resident #5. Observation showed CMT E did not wear gloves to administer the medication. During an interview on 01/22/25 at 9:10 A.M., CMT E said he/she should have worn gloves to administer eye drops to a resident. 5. Observation on 01/21/25 at 9:30 A.M., showed CMT D completed a narcotic count of the nurse station two medication cart. Observation showed CMT D did not perform hand hygiene, counted a bottle of Oxycodone (pain medication) 5/325 milligrams (mg) for Resident #120, and touched the pills with his/her bare hands. Observation showed CMT D put the medication back in the bottle for resident use. During an interview on 01/22/25 at 9:30 A.M., CMT D said not washing his/her hands caused cross-contamination and spreading of germs. CMT D said he/she did not think about washing his/her hands at the time. 6. During an interview on 01/22/25 at 1:15 P.M., the Director of Nursing (DON) said staff should not pick something up off the floor and then administer medications to the resident without washing their hands. The DON said this is cross contamination and can cause infections to spread. The DON said staff are expected to wear gloves when giving eye medications as standard precautions and to prevent cross contamination or possible infection risks. The DON said staff should wear gloves to touch a resident's medication and not use their bare hands. The DON said this helps prevent the spread of germs. The DON said the glucometer should be placed on a barrier once sanitized to prevent contamination. The DON said if staff do not use a barrier after sanitizing the glucometer it could spread germs from the surface to the resident. The DON said staff should not put a dirty glucometer in the carrier as this causes contamination. During an interview on 01/22/25 at 1:45 P.M., the Administrator said staff should not pick something up off the floor and then administer medications to the resident without washing his/her hands as this causes cross contamination and can cause infection to spread. The Administrator said staff are expected to wear gloves when giving eye medications as standard precautions and to prevent cross contamination or possible infection risks. The Administrator said staff should wear gloves to touch a resident's medication and not use their bare hands. The Administrator said if staff do not use a barrier after sanitizing the glucometer it could cause a spread of germs from the surface to the resident. The Administrator said staff should not put a dirty glucometer in the carrier as this causes contamination.

Based on observation, interview and record review, the facility staff failed to provide each resident with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs, when staff failed to provide portions as directed in standardized recipes. This affected all residents who received their meals from the facility's kitchen. The facility census was 116. 1. Review of the facility's standardized menu for 01/20/25 (Week 4 - Day 23), showed staff were directed to serve the residents eight ounces of beef goulash and eight ounces of tossed salad. Observation on 01/20/25 at 12:52 P.M., showed [NAME] M served the residents one, #6 (5.33 ounces) scoop of goulash (2.66 ounces less than directed) and a four-ounce spoodle of salad (four ounces less than directed). Observation on 1/20/25 at 1:08 P.M., showed Dietary Aide (DA) O served a #6 scoop of goulash (2.66 ounces less than directed and pre-made salads from the kitchen which were four ounces (four ounces less than directed). During an interview on 01/20/25 at 12:52 P.M., [NAME] M said he/she was the evening cook and the day shift cook placed the serving utensils for the noon meal. [NAME] M said he/she did not check the serving utensils to ensure they matched the menu so he/she did not realize he/she was not serving the correct portions. During an interview on 01/20/25 at 1:22 P.M., [NAME] N said he/she was responsible for pulling correct utensils for the noon meal service. [NAME] N said another staff member handed him/her the salad spoodle but he/she did not check it. [NAME] N said he/she just completed training and did not check the menu for correct serving sizes. [NAME] N said he/she was not sure where to find correct portion sizes. 2. Review of the facility's standardized menu for 01/21/25 (Week 4 - Day 24), showed staff were to serve the residents four ounces of cubed potatoes with breakfast. Observation on 01/21/25 at 8:05 A.M., showed DA O served the station two residents a #12 scoop (2.66 ounces) of cubed potatoes (1.33 ounces less than directed). During an interview on 01/20/25 at 1:10 P.M., DA O said the cooks send the serving utensils to station two along with the meal cart. DA O said salads were prepared in the kitchen and delivered on a tray with the meal cart. During an interview on 01/22/25 at 10:00 A.M., [NAME] P said he/she was responsible for providing breakfast utensils for the station two dietary aide. [NAME] P said he/she pulled the scoop for the breakfast meal but he/she pulled the wrong size. [NAME] P said he/she uses the scoop chart and standardized recipes to determine which utensils to pull. During an interview on 01/20/25 at 1:05 P.M., the Dietary Manager (DM) said he/she had been working evenings and training the night cook so he/she had not been keeping up with the day shift cook's training. The DM said he/she was not aware the day shift cook did not know where to find correct portion sizes.

Based on observation, interview, and record review, facility staff failed to store medications in a safe and effective manner in two of two medication rooms and failed to discard expired medications in one two medication carts. The Facility census was 116. 1. Review of the facility's policy titled Controlled Drug Policy and Procedure, revised 08/2024, showed a separate compartment for controlled drugs is provided in a locked cabinet inside the medication room or locked medication cart. The compartment has a special lock and key, and must be kept locked at all times. 2. Observation on 01/21/25 at 10:00 A.M., showed the Nurse's station one's medication room contained an unlocked refrigerator. Observation showed two opened bottles of liquid Ativan (a controlled drug). Observation showed the unlocked narcotic cabinet contained one opened four opened bottles of liquid morphine. Observation on 01/21/25 at 11:59 A.M., showed (Licensed Practical Nurse) LPN C unlocked the nurses's station one medication room, propped the door open and walked away from the open medication room. Observation showed the unlocked refrigerator in the medication room contained two bottles of liquid Ativan. Observation showed the unlocked narcotic cabinet in the medication room contained four bottles of opened liquid morphine. Observation showed the medication room sat with the door propped open, unlocked, and unattended for 10 minutes until LPN C returned to close the door. During an interview on 01/21/25 at 12:15 P.M., LPN C said he/she should not have left the medication door propped open for resident safety and to prevent medications being taken. LPN C said all medications should be kept under lock unless staff are preparing them. LPN C said narcotics should be kept under a double lock and he/she just forgot to lock the cabinet. LPN C said the refrigerator does not have a lock on it, but it should since it contained Ativan. 3. Observation on 01/21/25 at 9:00 A.M., showed nurse's station two's medication room contained an unlocked refrigerator. Observation showed one opened and undated vial of Tuberculosis (TB) solution (a medication used to test for TB), one opened bottle of probiotic with an expiration date of 10/24, and one opened bottle of liquid Ativan. Observation on 01/22/25 at 8:47 A.M., showed nurse's station two's medication room refrigerator sat unlocked and contained one opened bottle of liquid Ativan. During an interview on 01/21/25 at 9:00 A.M., LPN B said he/she did not know the refrigerator in the medication room had a bottle of Ativan in it. The LPN said Ativan is a narcotic and it should be kept under a double lock, and the refrigerator should have a lock on it to prevent discrepancies. During an interview on 01/21/25 at 9:30 A.M., Certified Medication Technician (CMT) D said all narcotics should be kept under a double lock. CMT D said he/she knew there was not a lock on the refrigerator in the nurse's station two's medication room and that it contained Ativan. CMT D said the facility changed the refrigerator out a few months ago and he/she has not seen a lock on it since. CMT D said he/she did not know if it had been reported and he/she had not reported it. During an interview on 01/21/25 at 10:20 A.M., the Director of Nursing (DON) said he/she narcotics should be stored under a double lock and he/she did not know this had not been happening. During an interview on 01/21/25 at 10:22 A.M., the Administrator said he/she was not aware staff were not storing narcotics under double lock. The Administrator said the refrigerators and cabinets that contain narcotics should be locked inside the medication rooms. 4. Review of the facility's policy titled Administering Medications, revised 04/2019, showed: -The Director of Nursing (DON) supervises and directs all staff on administering medications and related functions; -The expiration date on the medication label is checked prior to opening or administering; -When opening a multi-dose container, the date opened is recorded on the container; 5. Observation on 01/21/25 at 9:10 A.M., showed the nurse's station two medication cart contained: -One opened bottle of Geri-lax (a medication used as a laxative) as a stock medication with an expiration date of 06/24 and an open date of 12/15/24; -One opened bottle of ear wax drops with no resident name and an expiration date of 07/24; -One opened bottle of ear ache drops with no resident name, an expiration date of 08/24 and an open date of 10/14/24; -One opened box of Benadryl 25 mg as a stock medication with an expiration date of 08/24; -One opened bottle of Geri-tussin (a medication used for cough) as a stock medication with an expiration date of 12/24. During an interview on 01/21/25 at 9:00 A.M., LPN B said licensed staff who pass medications are responsible to ensure medications are not expired and administered to residents. LPN B said expired medications should be removed from the supply and destroyed. LPN B said staff should check every medication before they open it to ensure it is not expired. During an interview on 01/21/25 at 9:30 A.M., CMT D said he/she is responsible for the nurses's station two medication cart. CMT D said it is the responsibility of the licensed staff giving medications to check for expiration dates and if a medication is expired it should be removed and destroyed. CMT D said staff should check the expiration date before they open a new medication. CMT D said he/she should do a better job at checking for expired medications but he/she gets busy and doesn't have time. During an interview on 01/21/25 at 12:15 P.M., LPN C said all staff who administer medication are responsible to check for expiration dates. LPN C said staff should remove any expired meds and destroy them, he/she said they should not be administered to a resident. LPN C said the staff person who opens a new medication is responsible to date the medication and check the expiration date. 6. During an interview on 01/22/25 at 1:15 P.M., the DON said staff should date medications when opened, and should check expiration dates. The DON said all staff who administer medications are responsible for checking expirations dates, and discarding expired medications. The DON said expired medications should not be administered to residents. The DON said he/she expects staff to keep medications locked up when not being administered. The DON said the medication room door should not be propped open, and all narcotics including Ativan and Morphine, should be stored under a double lock. The DON said this is done to ensure resident safety and to prevent discrepancies. The DON said he/she did not know there were not locks on the refrigerators in the medication rooms but there should be since they contain Ativan. During an interview on 01/22/25 at 1:45 P.M., the administrator said staff are expected to check expiration dates before administering medications, and should not be administering expired medications. The administrator said all staff who administer medications are responsible for monitoring for expired medications and discarding when appropriate. The administrator said the medication room door should not be propped open, and all narcotics such as Morphine and Ativan should be kept under a double lock. The administrator said he/she did not know there were not locks on the refrigerators in the medication rooms but there should be since they contain Ativan. The Administrator said this is to ensure resident safety and to prevent discrepancies.

Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than five percent (%). Out of 41 opportunities observed, three errors occurred, resulting in a 7.32% error rate, which affected two residents (Resident #45, and #5) out of 10 sampled residents. The facility census was 116. Review of the American Academy of Allergy Asthma and Immunology recommendations titled Tips for Administering Eye Drops, dated 08/2010, showed close the eyelids and apply pressure for one to two minutes over the point where the eyelid meets the nose (nasolacrimal duct) after administering eye drops. 1. Review of the facility's policy titled Administering Medications, revised 04/2019, showed: -Medications are administered according to prescriber orders; -Medication errors are documented, reported, and reviewed by the Quality Assurance Performance Improvement (QAPI) team; -The individual administering the medications: 2. Review of Resident #45 Physician's Order Sheet (POS), dated 01/21/24, showed: -Memantine (a medication for dementia) 10 milligrams (mg) 1 tablet by mouth; -Dorzolaminde HCL/Timolol (a medication used to treat glaucoma and eye conditions that cause high pressure in the eye) 2 percent (%)-0.5% 1 drop each eye. Observation on 01/21/25 at 7:57 A.M., showed Certified Medication Technician (CMT) D prepared medications for Resident #45. Observation showed CMT D crushed the resident's medications per orders, and administered the crushed medications. Observation showed the resident spit a whole pill out on the dining room table and CMT D picked the pill up and threw it away. Observation showed CMT D did not attempt to re-administer the medication. Observation showed CMT D administered Dorzolamide HCL/Timolol 2%/0.5% (a medication used to treat glaucoma) eye drops to the resident and did not hold the lacrimal duct after administration. During an interview on 01/22/25 at 9:30 A.M., CMT D said he/she did not know he/she should have held the lacrimal duct after he/she administered eye drops. CMT D said this could be considered a medication error as the eye drops may not absorb completely. CMT D said he/she should have made a second attempt to administer the medication that Resident #45 spit out. CMT D said it would be a medication error for not attempting to give it again the proper way. 3. Review of Resident #5's POS, dated 01/21/25, showed an order for Artificial tears one drop in each eye. Observation on 01/21/25 at 8:13 A.M., showed CMT E administered Artificial tears to Resident #5 and did not hold the lacrimal duct after administration. During an interview on 01/22/25 at 9:10 A.M., CMT E said he/she should have held the lacrimal duct when administering the eye drops. CMT E said this would be considered a medication error as the eye drops may not absorb completely. 4. During an interview on 01/22/25 at 1:15 P.M., the Director of Nursing (DON) said if a resident spits a medication out that should have been crushed staff are expected to crush the medication and offer it again. She said if staff do not do this it would be considered a medication error. The DON said the proper way to administer eye drops is to hold the lacrimal duct after administration, he/she said if staff don't do this it would be considered a medication error. During an interview on 01/22/25 at 1:45 P.M., the Administrator said if a resident spits a medication out that should have been crushed staff are expected to crush the medication and offer it again. She said if staff do not do this it would be considered a medication error. The Administrator said the proper way to administer eye drops is to hold the lacrimal duct after administration, he/she said if staff don't do this it would be considered a medication error.

Based on observation, interview, and record review, facility staff failed to provide safe mechanical transfers for two residents (Resident #51, and #39). Facility staff failed to safely store hazardous materials in three shower rooms and one storage area and failed to ensure medications were safely stored. The facility census was 116. 1. Review of the facility's Using a Mechanical Lifting Machine policy, dated July 2017, showed staff were directed: -Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility; -Clear an unobstructed path for the lift machine. Review of the mechanical lift operating instructions, dated 2018, showed the legs of the lift must be opened to the widest position when transferring a resident. 2. Review of Resident #51's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1127/24, showed staff assessed the resident as: -Severe Cognitive impairment; -Transfer as total dependence. Observation on 01/20/25 at 10:32 A.M., showed Certified Nurse Aid (CNA) F and Nurse Aid (NA) G transferred the resident from bed to the wheelchair. Observation showed CNA F operated the lift while NA G supported the resident. Staff lifted the resident off the bed, the CNA closed the legs of the lift, backed away from the bed, pivoted towards the wheelchair with the legs of the lift fully closed. The CNA then opened the legs to clear the wheelchair and lowered the resident into the wheelchair. During an interview on 01/20/25 at 10:41 A.M., CNA F said he/she closed the legs of the lift for balance and was trained to close them when turning. 3. Review of Resident #39's quarterly MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact; -Transfer total dependence. Observation on 01/21/25 at 10:45 A.M., showed CNA H and CNA I transferred the resident from bed to a wheelchair with a mechanical lift. CNA H operated the lift and CNA I supported the resident. CNA H lifted the resident off the bed, pulled the lift away from the bed and pivoted towards the wheelchair with the mechanical lift legs closed. During an interview on 01/21/25 at 11:00 A.M., CNA H said he/she does not open the legs of the lift during mechanical transfer because there is not enough room for the lift. He/She said it was safe not to open the lift legs. 4. During an interview on 01/22/25 at 1:18 P.M., the Director of Nursing (DON) said staff should transfer residents with the lift legs open to the widest position for stability. The DON said staff are trained to use the lift this way for resident safety. He/She said they were ultimately responsible with ensuring staff used the lift correctly. During an interview on 01/22/25 at 1:20 P.M., the administrator said the lift legs should be open to the wide position for stability. The administrator said if the legs are not open the lift is not stable and could injure a resident. 5. Review of the facility's policy's showed the facility did not provide a hazardous material storage policy. 6. Observation on 01/20/25 at 11:32 A.M., showed the 200 hall shower room door open with a unlocked cabinet contained a bottle of aftershave, and a bottle of peroxide multi-disinfectant. Observation showed residents and staff passed by the door. Observation on 01/21/25 at 12:50 P.M., showed the memory care unit shower room near room [ROOM NUMBER] unlocked and a cart contained two disposable razors. Observation on 01/21/25 at 12:53 P.M., showed the memory care unit common area lower cabinet not locked. The cabinets contained one spray bottle of disinfectant. Observation on 01/21/25 at 12:55 P.M., showed the memory care unit shower room near room [ROOM NUMBER] unlocked and contained a one gallon container of hand sanitizer gel floor. Observation on 01/21/25 at 3:30 P.M., showed the 100 hall shower room door open and a resident in a wheelchair left the room. Observation showed staff were not present. Observation showed the shower room contained an unlocked cabinet which contained a bottle of heavy duty acidic cleaner, a bottle of disinfectant cleaner, and an open pack of disposable razors. Observation showed multiple staff walked by the shower room. During an interview on 01/21/25 at 12:55 P.M., CNA K said razors should not be left in the shower rooms. CNA K said cleaning chemicals should not be stored in the common area cabinets. CNA K said all aides were responsible for ensuring hazardous items were kept away from residents. CNA K said he/she did not know the razors and cleaning materials were not secured. During an interview on 01/21/25 at 1:00 P.M., NA L said chemicals should not be left unsecured in common area cabinets. NA L said he/she did not know the chemicals were in the cabinet. NA L said the hand sanitizer gel was in the shower the day prior but he/she did not know who put it there. NA L said he/she did not think about the hand sanitizer as a safety issue since it was there already. NA L said he/she left the cart with the razors in the shower room. NA L said he/she had to leave the unit earlier and forgot to secure the cart. During an interview on 01/22/25 at 9:35 A.M., CNA Q said hazardous materials should be in a locked area. The CNA said the shower rooms have cabinets that lock. CNA G said residents could be poisoned or injured in some way with the cabinets being left unlocked. During an interview on 01/22/25 at 9:42 A.M., RN R said residents should not have access to chemicals or other hazardous materials. The RN said these hazards should be locked up to prevent injury to the residents. During an interview on 01/22/25 at 9:47 A.M., RN J said the shower room cabinets should be locked when not in use and no staff present. He/She said a resident could ingest the chemicals and be injured. During an interview on 01/22/25 at 1:18 P.M., the DON said the shower room cabinets should be locked to prevent injury to residents when not in use. During an interview on 01/22/25 at 1:22 P.M., the administrator said leaving cabinets and other hazardous materials unlocked could cause a resident to be injured. 7. Review of the facility's policy titled Administering Medications, revised 04/2019, showed: -The Director of Nursing (DON) supervises and directs all staff on administering medications and related functions; -The expiration date on the medication label is checked prior to opening or administering; -When opening a multi-dose container, the date opened is recorded on the container; -The medication cart is to be kept closed and locked when out of sight of the medication aide or nurse; -No medications are to be kept on top of the cart. 8. Observation on 01/21/25 at 7:44 A.M., showed nursing station two medication cart in the dining room with 11 bottles which contained medication on top of the cart unattended and residents nearby. Observation on 01/21/25 at 7:51 A.M., showed Certified Medication Technician (CMT) D prepared medications for a resident, walked away from nurse's station two medication cart with 11 bottles of medications on top of the cart, unlocked and unattended. Observation on 01/21/25 at 8:50 A.M., showed nurse's station two medication cart in the dining room with 11 bottles which contained medication on top of the cart unattended and residents nearby. Observation on 01/22/25 at 7:30 A.M., showed nurse's station two medication cart in the dining room with nine bottles which contained medication on top of the cart unattended and residents nearby. Observation on 01/22/25 at 8:53 A.M., showed nurse's station two medication cart in the dining room with nine bottles which contained medication on top of the cart unattended and residents nearby. During an interview on 01/22/25 at 9:30 A.M., CMT D said it is acceptable to leave over the counter medications on top of his/her medication cart. CMT D said he/she did not think about a resident potentially getting the medications and taking them. CMT D said he/she should always lock his/her cart when not working in it and he/she forgot. 9. Observation on 01/21/25 at 8:12 A.M., showed the nurse's station one medication cart in the dining room with 14 bottles which contained medication on top of the cart unattended and residents nearby. Observation on 01/21/25 at 9:50 A.M., showed the nurse's station one medication cart in the dining room with two bottles of medication on top of the cart, unattended and Resident #80 grabbed at the cart. Observation on 01/22/25 at 7:35 A.M., showed the nurse's station one medication cart in the dining room with 11 bottles of medication, four insulin pens, and two syringes of insulin on top of the cart, unattnded and residents nearby. During an interview on 01/21/25 at 9:56 A.M., CMT E said he/she is responsible for the medication cart. CMT E said medication carts should not be left unattended and medications should not be left on top of the cart. CMT E said this could result in a resident taking medications and cause potential harm. CMT E said he/she did leave medications on top of his/her cart and should not have. 10. During an interview on 01/22/25 at 1:15 P.M., the DON said staff are expected to keep medications locked up when not being administered. The DON said staff should not keep medications on top of the medication cart and walk away from it. The DON said medication or treatment carts should not be unlocked or unattended. The DON said this is done to ensure resident safety. During an interview on 01/22/25 at 1:45 P.M., the administrator said staff are expected to keep medications locked up when not being administered, and staff should not keep medications on top of their carts. The administrator said medication or treatment carts should not be unlocked or unattended. The administrator said this is to ensure resident safety.

Based on observation, interview, and record review, facility staff failed to verify medications to the Medication Administrator Record (MAR) for two (Resident #90 and #50) of three sampled residents. The facility census was 116. 1. Review of the facility's policy titled Administering Medications, revised April 2019, showed: -Medications are administered according to prescriber orders; -Verify the resident's identity before giving medication by checking photo attached to the medical record; -Check the medication three times to verify the right resident, right medication, right dose, right time, and right route of administration before giving the medication; -The individual administering the medication initials the MAR after giving each medication. 2. Observation on 01/21/25 at 12:00 P.M., showed Licensed Practical Nurse (LPN) C drew up Novolin Insulin (a medication used to control blood sugars) for Resident #90 and did not check the MAR to ensure he/she administered the proper dosage. Observation showed LPN C looked at a cheat sheet that hung on the medication room cabinet to know how much insulin to administer. During an interview on 01/21/25 at 12:15 P.M., LPN C said the nursing administration updates the cheat sheet for staff to use to administer insulin instead of using the MAR. LPN C said he/she then goes back later and signs the MAR. LPN C said if the orders change for a resident the administration is responsible to update the cheat sheet for the staff and post it. 3. Observation on 01/22/25 at 11:10 A.M., showed Registered Nurse (RN) R administered Humalog Insulin to Resident # 50 and did not check the MAR to ensure he/she administered the proper dosage. Observation showed RN R looked at a cheat sheet on the blood glucose carrier to know how much insulin to administer. During an interview on 01/22/25 at 11:15 A.M., RN R said staff are given cheat sheets for insulin to make it faster. RN R said he/she is responsible to update the cheat sheet with any new orders but he/she is not sure what happens if he/she is not working. 4. During an interview on 01/22/25 at 1:15 P.M., the Director of Nursing (DON) said staff are expected to compare the MAR to the medication prior to administering it. The DON said staff should not use a cheat sheet to give medications as there is a potential for a new order to be given and a medication error would be made. During an interview on 01/22/25 at 1:45 P.M., the Administrator said he/she knew staff used a cheat sheet to give certain medications but should compare medications to the MAR before administering.

Based on interview and record review, facility staff failed to report to the Department of Health and Senior Services (DHSS) two allegations of resident abuse with three residents (Resident #1, Resident #2, and Resident #4) out of four sampled residents within the required two hour timeframe. The facility census was 120. 1. Review of the facility's Abuse Prohibition Policy, dated August 4, 2023, showed it is the policy of the facility to investigate any incident or allegation of suspected abuse, injury of unknown origin, neglect or misappropriation of resident's property. The facility will not permit residents to be subjected to abuse by anyone, to include staff members, other residents, consultants, volunteers, staff of other agencies that serve the resident, family members, legal guardians, sponsors, friend, or other individuals. Review of the facility's Internal investigations policy, dated December 2021, showed staff are directed to investigate and include documentation of detailed descriptions of the suspected violation, details of the investigative process, copies of the notes and interviews, corrective actions or remedies taken and notifying law enforcement or state/federal authorities. 2. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/18/24, showed staff assessed the resident with severe cognitive impairment. Review of Resident #1's nurses notes, dated 4/19/24, showed staff documented Resident #1 went to Resident #3, who was sitting on the couch, removed Resident #3 blanket off of Resident #3 and Resident #1 struck Resident #3 on the stomach with a closed fist. Review of Resident #1 nurses notes did not contain documentation staff notified DHSS of the altercation. Review of Resident #1's nurses notes, dated 5/2/24, showed staff documented at 6:12 P.M., Resident #1 kicked and hit Resident #2. Staff documented Resident #1 got a little too close to Resident #2 and Resident #1 raised his/her hand up, backhanded and pushed Resident #2. Review of Resident #1 nurses notes did not contain documentation staff notified DHSS of the altercation. Review of the facility's resident to resident investigation log did not contain documenation staff notified DHSS with the two hour timeframe for the altercations on 04/19/24 and 05/02/24. During an interview on 5/29/24 at 12:23 P.M., Certified Nursing Assistant (CNA) C said Resident #1 was easily aggravated with Resident #2, and Resident #4. The CNA said he/she tried to make sure the resident were never close to each other. He/She said the resident had a foul mouth and did not like other residents in his/her personal space and would get physical if space was intruded on. 3. Review of Resident #2's Admission MDS, dated [DATE], showed staff assessed the resident with severe cognitive impairment. Review of Resident #2's nurses notes, dated 5/2/24, showed staff documented at 6:18 P.M., Resident #1 backhanded and pushed Resident #2 away. Review of Resident #2 nurses notes did not contain documentation staff notified DHSS within the required two hour timeframe. During an interview on 5/29/24 at 2:23 P.M., the administrator said no one reported an incident to him/her on 5/2/24 so he/she did not report the incident to state. During an interview on 6/13/24 at 9:09 A.M., Licensed Practical Nurse (LPN) A said he/she believes he/she reported the resident altercation but it has been over a month so he/she was not certain. 4. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of Resident #4's nurses notes, dated 5/19/24 at 2:31 P.M., showed staff documented Resident #1 hand grazed Resident #4's left cheek. Review showed the nurses notes did not contain documentation staff notified DHSS within the required two hour timeframe. Review of the facilities staff written statements, dated 5/19/24, showed staff documented Resident #1 displayed agitated behaviors that morning. Resident #1 was up wondering around the memory care unit when he/she approached Resident #4, who was also wondering the unit. Resident #1 raised his/her arms and grazed the check of resident #4. The nurse did not know if the incident was purposeful, the aide reported the movement to be purposeful and stated resident #1 swung on resident #4 due to agitation. The administrator documented he/she felt Resident #1 did not intentionally hit Resident #4. The facility statement did not contain documentation staff notified DHSS within the required timeframe. 5 During an interview on 5/29/24 at 2:23 P.M., the administrator said staff are recalling incidents to the nurses that aren't all the way true in hopes to remove Resident #1 out of the facility, he/she said the nurses are documenting what the other staff say. He/She does not believe that there is falsifying of records but that it is not always reported correctly. During an interview on 5/30/24 at 3:01 P.M., the administrator said he/she wanted to provide some additional information. He/She said he/she is not sure the staff documenting the incidents didn't actually witness these things that are documented. He/She said he/she believes several incidents were very embellished because staff knew he/she would self-report. He/She said he/she did self report when he/she felt a true incident had occurred. MO00236612

Based on interview and record review, facility staff failed to thoroughly investigate two allegations of resident abuse with three residents (Resident #1, Resident #2, and Resident #4). The facility census was 120. 1. Review of the facility's Abuse Prohibition Policy, dated August 4, 2023, showed it is the policy of the facility to investigate any incident or allegation of suspected abuse, injury of unknown origin, neglect or misappropriation of resident's property. The facility will not permit residents to be subjected to abuse by anyone, to include staff members, other residents, consultants, volunteers, staff of other agencies that serve the resident, family members, legal guardians, sponsors, friend, or other individuals. Review of the facility's internal investigations policy, dated December 2021, showed staff are directed to investigate and include documentation of detailed descriptions of the suspected violation, details of the investigative process, copies of the notes and interviews, corrective actions or remedies taken and notifying law enforcement or state/federal authorities. 2. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/18/24, showed staff assessed the resident with severe cognitive impairment. Review of Resident #1's nurses notes, dated 5/2/24, showed staff documented at 6:12 P.M., resident kicked and hit Resident #2. Staff documented Resident #1 got a little too close to Resident #2 and Resident #1 raised his/her hand up, backhanded and pushed the Resident #2 away. Review of the facility's resident to resident investigation log did not contain documentation staff investigated the altercation between Resident #1 and Resident #2. 4. During an interview on 5/29/24 at 2:23 P.M., the administrator said no one reported an incident to him/her on 5/2/24 so he/she did not investigate the incident or report to the Department of Health and Senior Services (DHSS). During an interview on 6/13/24 at 9:09 A.M., Licensed Practical Nurse (LPN) A said he/she believes he/she reported the resident altercation but it has been over a month so he/she was not certain. 5. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of the residents nurses notes, dated 5/19/24, showed staff documented at 2:31 P.M., that the resident was grazed on left cheek by resident #1. Review of the facilities staff written statements, dated 5/19/24, showed staff documented Resident #1 displayed agitated behaviors in the morning. Resident #1 was up wondering around the memory care unit when approached Resident #4 who was also wondering the unit. Resident #1 raised his/her arms and grazed the check of resident #4. The nurse did not know if the incident was purposeful, the aide reported the movement to be purposeful and stated resident #1 swung on resident #4 due to agitation. The administrator documented he/she Resident #1 did not intentionally hit Resident #4. Review of the facility's investigation log showed the documents did not contain detailed descriptions of the suspected violation to include the details of the investigative process, copies of the notes and interviews, corrective actions or remedies taken, notifying law enforcement or state/federal authorities. During an interview on 5/29/24 at 2:23 P.M., the administrator said staff are recalling incidents to the nurses that aren't all the way true in hopes to remove Resident #1 out of the facility, he/she said the nurses are documenting what the other staff say. He/She does not believe that there is falsifying of records but that it is not always reported correctly and he/she does not see it the way the staff have reported it. He/She said he/she is responsible for investigating when incidents occur. During an interview on 6/13/24 at 9:09 A.M., Licensed Practical Nurse (LPN) A said all incidents are required to be reported to the Administrator to be investigated. MO00236612

Based on interview and record review, facility staff failed to properly assess two residents', (Resident #1 and #2) capacity to consent to sexual activity and failed to ensure residents with severe cognitive impairment remained free from sexual abuse when staff found Resident #2 holding Resident #1's hand to perform a sexual act. The facility census was 117. The administrator was notified on 3/22/24 at 5:09 P.M., of an Immediate Jeopardy (IJ) which began on 3/19/24. The IJ was removed on 3/29/24 as confirmed by the surveyor's onsite verification. Review of the facility's Abuse Prohibition Policy, dated August 4, 2023, showed it is the policy of this facility to investigate any incident or allegation of suspected abuse, injury of unknown origin, neglect or misappropriation of resident's property. Our facility will not permit residents to be subjected to abuse by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friend, or other individuals. Sexual abuse is defined as, but not limited to, sexual harassment, sexual coercion, or sexual assault. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 1/27/24, showed staff assessed the resident as follows: -Severe cognitive impairment; -Disorganized thinking which fluctuates; -Wanders daily; -Ambulates independently; -Behaviors were not identified; -Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia with other behavioral disturbance. Review of Resident #1's medical records did not contain documentation of an assessment of the resident's capacity to consent. Review of the resident's medical record did not contain documentation of the resident's sexual interaction with another resident on 2/18/24. Review the resident's plan of care, reviewed and revised 2/19/24, showed staff assessed the resident alert and oriented to himself/herself, independent for transfers and ambulation. Review showed the resident enjoys spending time with other residents, particularly a certain resident and staff are instructed to ensure resident is aware and consenting of any intimate activity. Review of the resident's mini mental state exam (a brief, structured test of mental status), dated 2/19/2024, showed the resident scored one out of a total of 30 points, indicating severe impairment of cognitive function. 2. Review of Resident #2's MDS, dated [DATE], showed staff assessed the resident as follow: -Severe cognitive impairment; -Wanders one to three days per week; -Required supervision with ambulation; -History of sexual behaviors by resident; -Diagnoses of dementia with unspecified severity with other behavioral disturbances. Review of Resident #2's medical records did not contain documentation of an assessment of the resident's capacity to consent. Review of the resident's medical record did not contain documentation of the resident's sexual interaction with another resident on 2/18/24. Review of the resident's plan of care, reviewed and revised 2/19/24, showed the resident to be alert and oriented to himself/herself, required one-person assist with a gait belt for transfers and supervision for ambulation. The plan of care stated the resident enjoys female companionship and staff are instructed to ensure resident is alert and consenting of any intimate activity. Review of the resident's mini mental state exam (a brief, structured test of mental status), dated 2/19/2024, showed the resident scored one out of a total of 30 points, indicating severe impairment of cognitive function. 3. During an interview on 3/19/24 at 1:44 P.M., Certified Medication Technician (CMT A) said he/she was doing his/her rounds and noticed Resident #2's door was shut. He/She knocked and entered to find Resident #2 standing in front of Resident #1 with his/her pants down. Resident #2 had Resident #1's hand in his/her hand and was moving the hand to perform a sexual act. He/She said neither resident looked to be in distress. He/She said he/she separated the residents immediately and brought Resident #1 to the dining area and offered him/her a snack. He/She said he/she alerted the charge nurse to what had happened. He/She said neither of the residents asked him/her to leave. He/She said this was not the first time Resident #2 has had behaviors like this. He/She said staff are expected to re-direct Resident #2 if he/she was to display behaviors of touching other residents, trying to be inappropriate, or wandering. He/She said residents are allowed to be intimate if neither appear to be in distress or asking for help to stop what is going on, regardless of their marital status. The CMT said he/she reported the incident to Licensed Practical Nurse (LPN) B. During an interview on 3/20/24 at 2:41 P.M., Licensed Practical Nurse (LPN) B said he/she did not see what happened, but it was reported to him by CMT A. Resident #1 and Resident #2 were being sexually intimate. LPN B said he/she waited to report to the one of the Social Service Directors (SSD) and LPN D at the end of his/her shift, because he/she didn't know what to do in this situation. He/She said he/she filled out a concern note and left it with SSD to give to the Director of Nursing (DON). He/She said he/she did not call the family or the physician. He/She said staff are expected to let residents engage in intimate acts, regardless of their marital status, as long as the residents do not appear in distress. He/She said they look for distress by facial expressions, verbal expression, or if the resident is trying to leave. He/She said he/she has seen the SSD fill out a scale, Mini Mental State Exam (MMSE), to assess resident's cognition level but it is not his/her responsibility to do this. He/She has not seen behaviors like this from Resident #1 before, but staff would be expected to redirect the resident. During an interview on 3/21/24 at 3:04 P.M., the SSD said LPN B reported to him/her the morning of 2/18/24, about the incident between Resident #1 and Resident #2. The SSD said he/she did not know what their policy stated regarding this issue, so the message was passed onto the Assistant DON (ADON). He/She said it is their policy if the residents are consenting in the moment, not in distress, or trying to get away, it is okay for them to be intimate. He/She does not know how it is determined if they have capacity to consent. During an interview on 3/19/24 at 11:00 A.M., the Administrator said Certified Medication Technician (CMT) A walked into Resident #2's room to find Resident #1 with his/her hand on Resident #2's sexual organ. He/She was told Resident #1 told the staff to get out and the residents did not look to be in distress and this was how they were consenting to the sexual activity. He/She said both residents were aware of what happened when they were questioned by him/her, a bit later, after he/she was made aware of the incident. He/She said staff did contact the physician but should not have and they did not contact the resident's families because they are both their own responsible parties, this was not considered sexual assault, and both are consenting adults. He/She said the residents were not trying to stop the act and told staff to leave, this is how the residents were determined to consent. The Administrator said he/she was made aware of the incident between the residents the following day. He/She said both residents are their own responsible parties and were able to voice their wants and needs During an interview on 3/21/24 at 2:38 P.M., the MDS coordinator said he/she was notified of the incident, which occurred on 2/18/24, during the morning nurses meeting on 2/19/24. He/She said resident's cognition level is determined through the Brief Interview for Mental Status (BIMS). The BIMS is on a scale of 00 to 15, with a score closer to 15 being cognitively intact and a score closer to 00 being severely cognitively impaired. He/She said Resident #1 has not ever displayed sexual behavior and Resident #2 has flirted with others but never been sexually physical towards others. He/She said Resident #2's flirtation had consisted of complementing others, winking, and occasionally other resident's straightening Resident #2's collar on his/her shirt. He/She said the DON or ADON was who contacted Resident #2's psychiatrist who asked them to complete the MMSE. He/She does not know how it was determined the residents were cognitive to consent. He/She said the state guideline interpretation he/she was given said if the resident is enjoying the act, not in distress, resisting or try to get away, they are both consenting in the moment to the intimate act. During an interview on 3/22/24 at 10:38 A.M., the ADON was made aware of the incident between Resident #1 and Resident #2 on 2/19/24 during the morning nurses meeting. He/She said staff discussed this was not sexual abuse because both residents did not seem in distress, did not try to stop the act, and were consenting to the act at the time. The ADON said to his/her knowledge the residents did not speak to CNA A when he/she entered the room. He/She said the MDS Coordinator is responsible for assessing residents' BIMS scores and both residents would be cognitively impaired going by this score. He/She said the psychiatrist was notified and he/she had them fill out a MMSE. He/She said he/she does not know how or what assessment is used to determine the residents ability to consent to intimate acts. He/She said staff are directed to redirect residents with behaviors unless they appear consenting, it is a gray area. It was interpreted if a resident is not showing any signs with their body language, voicing to stop, or trying to get away staff are to let them engage. Staff later moved Resident #2 close to nurse station to ensure they stayed separate, because their BIMS were low enough for the residents to realize it was not their spouse they were interacting with. During an interview on 3/21/24 at 3:15 P.M., the DON said he/she was notified of the incident on 2/19/24 by the ADON. He/She said they contacted the psychiatrist who recommended completing the MMSE to have on file. He/She said they were going off of the report given by the CMT who witnessed it and said the residents were not in distress, so it was not sexual assault. He/She said staff use the BIMS to determine a resident's cognition and the scores of Resident #1's and Resident #2 show they are not cognitively intact. He/She said Resident #2 has not had sexual behaviors prior, but is flirtatious by complementing other residents. He/She said their policy states if the residents are not in distress or trying to stop the act, regardless of their cognition level, they are consenting in the moment. During an interview on 3/21/24 at 2:25 P.M., CMT E said he/she was not present for the incident, but did hear about it. He/She said Resident #2, to his/her knowledge, had not seen sexual behaviors but would be flirty by asking residents to rub his/her shoulders. He/She had easily redirected Resident #2 when he/she was following residents of the other gender on the memory care unit. He/She said he/she would check with the MDS coordinator to see if a resident was cognitive to consent. He/She said it is the expectation of staff to let residents engage in intimate acts as long as the resident is not in distress, trying to get away, or verbally consents. He/She said residents on the memory care unit do not have the mental capacity to consent to such acts. During an interview on 3/22/24 at 11 :29 A.M., Resident #2's spouse said he/she had not been made aware of any intimate interactions between residents at the facility. He/She said he/she is the resident's responsible party because of his/her diagnosis of dementia. He/She said if the resident was cognitively intact, he/she would have told anyone coming on to him/her to stop and would be angry. During an interview on 3/19/24 at 2:10 P.M., the Administrator said Resident #2 was moved to ease staffs minds and remove him/her from any other situations that could occur, and his/her spouse had wanted the resident moved off of the unit. During an interview on 3/20/24 at 3:39 P.M., Resident #2's physician said the resident does not have the mental capacity to make decisions regarding sexual intimacy, due to the resident's diagnosis of Dementia. He/She said he/she expects staff to monitor the resident and redirect him/her if he/she started to display these types of behaviors. He/She said this is not the first time the resident has displayed behaviors like this. During an interview on 3/22/24 at 1: 36 P.M., the DON said it's a tricky question but based on the scores of the BIMS and MMSE alone he/she would say the residents could not consent. He/She said since he/she knows the residents and their backgrounds, he/she feels they can consent. During an interview on 3/22/24 at 12:20 P.M., the Administrator said regardless of Resident #1 and Resident #2's BIMS and MMSE scores, he/she feels both residents can consent to intimate acts. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite 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). MO00233380

Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #2) remained free from physical abuse, when another resident (Resident #1) pushed the resident down and caused him/her to fracture his/her hip. The facility census was 109. 1. Review of the facility's Abuse and Neglect Clinical Protocol Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised March 2018, showed: -Abuse, Neglect, Misappropriation of Patient Property and Exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor of any other individual in this center. The patient has the right to be free from abuse, neglect, misappropriation of patient property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. -Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Includes: verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Physical abuse: includes hitting, slapping, pinching and kicking. -Mental abuse: Includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated, 2/15/23, showed facility staff assessed the resident as follows: -Moderate cognitive impairment; -Rejects care four to seven days out of seven; -Wanders one to three days out of seven; -Diagnoses of dementia (a group of thinking and social symptoms that interferes with daily function), hypertension (high blood pressure), and anemia (low iron level in the blood). Review of Resident #1's plan of care, dated 2/11/23, showed staff did not document the resident's behaviors in the plan of care. Review Resident #1's nurse's notes, dated 4/8/23 at 4:51 P.M., showed staff documented the resident was exhibiting signs or symptoms of distress or agitation. The resident's door was opened by another resident. The other resident pushed him/her down. Review of Resident #2's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Severely cognitively impaired; -Verbal behaviors one to three days out of seven; -Diagnoses of Dementia, hypertension, and Cerebral Vascular Accident (when blood flow to part of the brain is stopped by blockage or rupture of a blood vessel); -Independent with bed mobility, transfers, and dressing. Review of Resident #2's plan of care, dated 4/11/23, showed staff documented the resident had a diagnoses of dementia. Review showed staff are directed to encourage the resident to sit in a quiet area when upset, request pharmacy review as needed, and psychiatric evaluation as needed for behaviors. Review of Resident #2's nurses notes, dated 04/08/23, showed staff documented they assessed the resident with severe decline in mobility with complaint of pain to his/her left hip. Staff transferred the resident to the hospital. Review of Resident #2's hospital x-ray report, dated 04/08/23, showed the resident had a left hip fracture. Review of the facility's internal investigation report, dated 4/13/23, showed staff documented an allegation of resident to resident altercation between Resident #1 and Resident #2 which occurred on 04/08/23. Review showed staff reported Resident #1 pushed Resident #2 which caused Resident #2 to fall. Staff assessed Resident #2's left leg was externally rotated. Review showed staff documented Resident #2 complained of pain when rotated, and they sent Resident #2 to the hospital for evaluation. Resident #2's diagnosis at the hospital was an acute fracture of the left intertrochanteric femur. During an interview on 4/12/23 at 10:00 A.M., Certified Nurse Assistant (CNA) A said Resident #1 had constant behaviors where he/she would yell, scream, or swat and push at other residents if they tried to go into his/her room. CNA A said he/she witnessed Resident #2 try to go into Resident #1's room, Resident #1 then pushed Resident #2 and caused the resident to fall. He/She said they have reported the behaviors but no one provided direction on what they are supposed to do with the resident other than redirect him/her. During an interview on 04/12/23 at 10:35 A.M., Registered Nurse (RN) C said he/she was over the memory care unit but was not on duty the day of the incident. He/She said they did tell him/her about it in report. RN C said this was not Resident #1's first incident and there was another similar incident where Resident #1 pushed and punched another resident. RN C said he/she had reported for a while that Resident #1 had behaviors such as yelling at other residents if they tried to go into his/her room. During an interview on 04/12/23 at 11:50 A.M., the Administrator said they did not implement any new measures after Resident #1's other incidents, only after the current incident between Resident #1 and Resident #2. The administrator said they added a chain to his/her door to try and keep residents out and adjusted his/her medications. He/She said there is not enough time in the day with all the staffing issues to address every resident and everything. During an interview on 04/12/23 at 11:15 A.M., CNA E said he/she has seen Resident #1 lunge at other residents or run after them to get them out of his/her room. During an interview on 04/12/23 at 1:45 P.M., the DON said he/she was aware of other incidents of behaviors with Resident #1 but just could not remember with who or when they occured. He/She just remembers staff reported them. He/She said no interventions were put into place with previous behaviors except they just seperated them, which he/she said was their intervention, but after this altercation they added the chain to Resident #1's door and did a medication adjustment. MO00216802

Based on observation, interview and record review, the facility staff failed to properly assess and care for a facility acquired pressure ulcer for one sampled resident (Resident #15) out of 24. The facility census was 120. 1. Review of the facility's Wound Protocol, dated 06/05/13, showed the following: - Registered Nurse (RN) Clinical nurse manager will assess residents for risk for pressure areas using the Braden Scale (predicts pressure ulcer risk) upon admission, quarterly, and as needed with status change; - The charge nurses are to do skin assessments weekly; - RN's are to care plan approaches for pressure areas: 1. Resident has open area/stage II wound (partial thickness, skin loss involving epidermis or dermis. Ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater), the charge nurse will notify the RN and wound assessments will be done weekly. An order will be obtained for a treatment. Treatments will be done for seven days then re-evaluated by the RN. Residents at "high risk" for pressure areas will have a gel cushion in their wheelchair and in their recliner chair. This information will be found on the ambulation list in the Certified Nursing Assistant (CNA) books at each nurses station; 2. If the stage II wound has shown no evidence of healing after seven days of treatment, the resident should be placed on a [MEDICATION NAME] vitamin with zinc, vitamin C, and a diabetic supplement two times a day to promote wound healing. (Diabetic supplements have more protein and less sugar); 3. [MEDICATION NAME] (moisture barrier) should be used initially to treat stage II wounds. If a resident is excoriated, use Selant/A&D ointment. Selant and A& D should be used for excoriation and preventative purposes only. If the wound is not showing evidence of healing after seven days, a [MEDICATION NAME] dressing (adherent wound dressing) such as Duoderm should be applied. 14 days after initial assessment (seven days of barrier cream, seven days of Duoderm) if there is no evidence of healing, an order for [REDACTED]. - Skin tear treatments will continue to be done by the Certified Medication Technician (CMT) as always. 2. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 02/18/15, showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance with ambulation, dressing, toileting, personal hygiene, and bathing; -Required limited assistance with bed mobility and transfers; -At risk for developing pressure ulcers; -One stage II pressure ulcer developed in house; -Pressure relieving devices; -Moisture associated skin disorder; -Application of ointments and dressings. Review of the resident's comprehensive care plan, dated 03/06/15, showed the following: -Transfers with one to two assist, requires extensive assist with grooming, and bathing; -Staff are to provide perineal care after every incontinent episode; -The resident has a potential for skin breakdown; -Staff are to place heel protectors and Selant/A&D ointment; -Dietary to provide sugar free supplement two times daily to promote wound healing; -Nursing to complete weekly skin assessment; -Reduce pressure and friction; -Pressure relieving devices for chair; -Reposition every two hours while in bed, heel protectors, keep skin clean and dry; -02/24/15-Has a small open area on his/her right foot, near a callous, possible cause from friction by shoes. The area is healing well at this time, continue the plan of care; -03/27/15- The open area on right foot worsened, wound consult obtained. At this time the resident is not to wear shoes and foot is to be floated. Review of the resident's Physician order [REDACTED]. -Apply moisturizing cream to affected areas at bedtime as preventative to both legs; -Cleanse the right outer foot with normal saline. Apply silver alginate ( absorbent dressing with antimicrobial) and cover with foam dressing daily and day shift and as needed, dated 04/03/15; -Regular diet with sugar free house supplement two times daily; -Pressure relief devices as needed; -Multiple Vitamins with Minerals. Review of the resident's Treatment Administration Records (TARs), dated 01/11/15 to 04/10/15, showed staff were directed to do the following: -Cleanse the right outer foot wound with normal saline, apply Bactricin (antibiotic ointment), and cover with a dry dressing until resolved (ordered 01/11/15); -Order changed to cleanse the right outer foot wound with normal saline, apply [MEDICATION NAME] blue (wound dressing that inhibits microorganism growth) as ordered and cover with a dry dressing until resolved on 03/12/15 due to wound worsened; -Order changed to cleanse the right outer foot wound with normal saline, apply Hydrafera blue as ordered and cover with a dry dressing two times daily and as needed until resolved on 03/15/15; -Order changed to cleanse with normal saline, apply calcium alginate (absorbent dressing) to wound bed, cover with dry dressing daily until healed (03/23/15); -Order changed to cleanse right outer foot wound with normal saline, apply silver alginate, cover with foam dressing daily and as needed. Review of the resident's Braden score assessment, dated 02/24/15, showed staff assessed the resident as a mild risk for skin breakdown. Review of the resident's weekly skin assessment, dated 01/11/15, showed staff documented a new ulcer on the right outer foot as a stage II, discovered on 01/09/15. Review showed staff documented the area red with cracked surrounding tissue, granulation tissue (is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) present, length of 0.6 centimeters (cm) by 0.3 cm width. Staff are to apply barrier cream and a dressing. Staff are to float heels, plantar, lateral, and distal aspect of foot. Review of the resident's weekly skin assessment, dated 01/28/15, showed staff documented a scab over the lateral aspect of the fifth toe on the right foot. Review of the resident's weekly skin assessment , dated 02/13/15, showed staff documented the stage II on the right outer foot as improving. The wound tissue is yellow and the surrounding tissue is reddened, with granulation occurring. Staff documented the length of the wound is 1.0 cm by 0.7 cm in width. Review of the resident's weekly skin assessment , dated 02/20/15, showed staff documented the stage II on the right outer foot as improving. The wound tissue is reddened and the surrounding tissue is reddened, the wound is getting smaller with granulation tissue occurring. Staff document the length of the wound is 0.5 cm by 0.3 cm in width. Review of the resident's weekly skin assessment , dated 02/27/15, showed staff documented the stage II on the right outer foot is the same. The wound tissue is yellow and the surrounding tissue is reddened, the wound is smaller with granulation tissue occurring and appears more clean. Staff document the length of the wound is 0.7 cm by 0.3 cm in width. Review of the resident's weekly skin assessment, dated 03/06/15, showed staff documented the stage II on the right outer foot is improving. The wound tissue is pink with a reddened surrounding tissue. Granulation tissue is occurring and appears more clean. Staff document the length of the wound is 0.6 cm by 0.3 cm in width. Review of the resident's weekly skin assessment, dated 03/13/15, showed staff documented the stage II on the right outer foot is worsening. The wound tissue is dark blue-red with a cracked surrounding tissue and the wound is becoming larger and deeper. Staff document the length of the wound is 1.3 cm by 0.8 cm in width and 0.3 depth. The resident is not to wear shoes at this time. Review of the resident's weekly skin assessment, dated 03/23/15, showed staff document the right out foot wound is a stage III (full thickness of skin lost, exposing the subcutaneous tissues. Presents as a deep crater) and is worsening. The current treatment is Calcium Alginate. Staff documented the wound tissue is yellow, the surrounding tissue is reddened, and sloughing is occurring. The length of the wound is 1.5 by 0.8 width by 0.4 depth. Review of the resident's weekly skin assessment, dated 03/31/15, showed staff document the stage III wound on the right outer foot is the same. Staff documented the wound tissue is reddened, greenish-yellow, the surrounding tissue is reddened, and sloughing is occurring. The length of the wound is 1.6 by 1.4 width by 0.4 depth. Review of the resident's weekly skin assessment, dated 04/06/15, showed staff documented the wound to the right outer foot as a stage IV (full thickness of skin and subcutaneous tissue lost, exposing muscle and/or bone) and improving. The wound nurse derided the wound. Staff documented the wound nurse suggested a special boot and he/she will look into obtaining one. Review of the resident's nurses notes, dated 01/28/15, showed staff documented the resident had a scab to the lateral aspect of the fifth toe. Review of the resident's nurses notes, dated 03/16/15, showed staff documented he/she spoke with with the attending physician in regards to the worsening of the wound on the right outer foot, and the physician ordered a new treatment. Review of the resident's nurses notes, dated 03/23/15, showed staff documented he/she spoke with with the attending physician in regards to the worsening of the wound on the right outer foot with redness around the area, exudate. Staff documented they requested an antibiotic and wound consult. New orders for wound consult received. Review of the resident's nurses notes, dated 03/24/15, showed staff documented the Certified Wound Nurse ordered the resident to start Bactrim (antibiotic) for 10 days. Review of the wound consult progress note, dated 04/03/15, showed the Certified Wound Nurse documented the wound to the right lateral foot is a chronic stage four. The initial measurements are 2 cm length by 1.7 cm width by 0.3 cm depth. The wound nurse documented the periwound (surrounding tissue) presents with signs and symptoms of infection. Treatment plan is a culture and sensitivity, X-ray, and antibiotics. Additionally, the wound nurse documented he/she performed an excisional debridement to the wound. Review of the resident's x-ray results, dated 04/06/15, showed soft tissue swelling seen adjacent to the right fifth metatarsal, distally with no obvious bony destructive process. Review showed the radiologist documented an Magnetic Resonance Image (MRI) of the right foot may benefit to further evaluate for potential Osteomyolitis. Review of the resident's wound culture results, dated 04/09/15, showed the wound contained a moderate amount of proteus mirabilis (a bacteria found in putrid meats, abscesses, and fecal material). Review of the documents sent by the Director of Nursing, on 04/14/15 at 10:27 A.M., the Director of Nursing documented the following: -On 1/11/15 the pressure ulcer was identified as a scab/calloused area on the lateral aspect of the fifth digit of the resident's right foot. At that time a treatment of [REDACTED]. -On 01/28/15 the area was closed and a small cab remained; -The area reopened on 02/13/15 with measurements of 1.0 cm by 0.7 cm; -On 02/20/15 the area was observed as healing; -Wound assessments are done weekly by the Clinical Nurse Manager if a resident has an open area; -Physicians are notified if a wound appears to be worsening and a new treatment is ordered; -The physician was notified on 03/13/15 and the order changed to [MEDICATION NAME] Blue daily then on 03/15/15 changed to two times daily; -The resident has limited mobility due to his/her [MEDICAL CONDITION] diagnosis; -The treatment was not changed until the wound began to deteriorate because there was evidence of healing. Observation on 04/07/15 at 05:00 P.M., showed the resident sitting in his/her wheelchair at the dining room table. Observation showed the resident's right foot resting on the outer aspect of his/her foot. Observation on 04/08/15 at 10:00 A.M., showed the resident reclined back in the recliner. Observation showed the resident did not have heel protectors on and his/her heels were not floated. Observation on 04/09/15 at 07:50 A.M., showed the resident sitting in his/her wheelchair at the dinning room table. Observation showed the resident's right foot resting on the outer aspect of his/her foot. Observation on 04/09/15 at 09:38 A.M., showed the resident's heels were not floated and heel protectors were not in place. The Clinical Nurse Manager A completed the treatment to the resident's right foot. During an interview on 04/09/15 at 09:38 A.M., the Clinical Nurse Manage A said the wound is a stage four with 50-75% slough (necrotic tissue in the process of separating from viable portions of the body) and 25% granulation. The Clinical Nurse Manager said the resident has had the area for about two months. The wound started as a tiny pinpoint area, closed once, then reopened. Observation on 04/09/15 at 12:00 P.M., showed the resident sitting in his/her wheelchair at the dinning room table. Observation showed the resident's right foot resting on the outer aspect of his/her foot. Observation on 04/10/15 at 01:00 P.M., showed the resident reclined back in the recliner. Observation showed the resident did not have heel protectors on and his/her heels were not floated. During an interview on 04/10/15 at 01:05 P.M., the Clinical Nurse Manger B said the wound bed contained 75% adherent slough and 25% beefy red tissue. The Clinical Nurse Manger said the wound dressing contained large amount of yellow-green drainage. Staff are directed to apply heel protectors and she floats his/her heels but is unsure if they are suppose to. During an interview on 04/10/15 at 03:13 P.M., the Certified Wound Nurse said the wound is currently presenting as an unstageable pressure ulcer. There is 75% slough and granulation tissue through the base, 1.8 cm length, by 1.2 cm width by 0.3 cm depth. The resident is currently on antibiotics for the wound infection. During an interview on 04/10/15 at 04:41 P.M., Licensed Practical Nurse (LPN) D said he/she would expect the Certified Nursing Assistant (CNA) to report any new wounds then he/she would go and assess the wound. The RN is the one who notifies the physician. During an interview on 04/10/15 at 06:37 P.M., the Clinical Nurse Manager A said he/she assesses pressure ulcers and places the documentation into the chart. The charge nurses inform him/her of any new wounds. Wounds are assessed with [REDACTED]. The facility policy is used. If a wound is not improving, we try something else per the physician orders [REDACTED]. The LPNs are responsible for the weekly skin assessments. The resident's wound started as a pin point area, it closed then reopened and should be documented that it closed in the wound documentation. The resident's wound has changed several times. When the wound first opened it appeared macerated. The resident was put on a supplement, staff are to float his/her feet, the resident is not to wear shoes.

Based on interview and record review the facility staff failed to notify one resident's (Resident #1) physician of a change in condition in a timely manner. The confused resident groaned in pain during movement of his/her right arm during direct care around 7:00 P.M. and licensed nurses assessed abnormal movement, swelling, and bruising in the resident's right arm. Licensed nurses recorded they administered Tylenol for pain with no change in the resident's pain. Licensed staff recorded they assessed worsening of the resident's arm during the night, but failed to notify the resident's physician of this assessment until the next morning when the physician directed staff to send the resident to the local hospital. The resident was diagnosed with [REDACTED]. The facility census was 120. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 08/17/11, showed staff assessed the resident as follows: - Confused; - Absence of spoken words; - Rarely understood/understands; - Required extensive to total assistance of staff for his/her Activities of Daily Living; - Full range of motion with no limitations in his/her upper extremities (shoulder, elbow, wrist and hand); - Incontinent of fecal material and bladder; - Dementia; - No indicators of pain or possible pain, including moaning, facial grimacing or guarding of a body part during movement, in the last five days. Review of the resident's nurses notes dated 08/20/11 showed licensed staff recorded the following: - 7:00 P.M., "Upon assessment revealed right arm, red, slight warm to touch, complaint of discomfort with range-of-motion. Temperature 98.8 axillary (armpit). Ice applied and as needed Tylenol utilized. Call placed to Registered Nurse (RN) A and was instructed to monitor. No signs or symptoms distress. Will report to on-coming nurse." Licensed staff did not record they notified the resident's physician of the change in condition. Review of the resident's August 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additional review showed licensed staff recorded on 08/20/11 at 7:15 P.M., Tylenol 325 mg, two tablets administered for elevated temperature. Additional review showed licensed staff did not record if the Tylenol was effective. Review of the resident's nurses notes dated 08/21/11 showed licensed staff recorded the following information: - 1:12 A.M., "Resident right arm has redness and swelling with bruising at AC (antecubital which is at the inside bend of the elbow) space and elbow. Called RN A on-call and instructed to monitor closely. Resident appears to be uncomfortable and has guarding and cries out with range of motion." Licensed staff did not record they notified the resident's physician of the resident's continued pain and change in condition. Review of the resident's MAR, dated 08/21/11 at 2:00 A.M. showed staff recorded they administered Tylenol 325 mg, two tablets for right arm pain. Additional review showed licensed staff recorded at 3:00 A.M., the Tylenol was not effective in alleviating the resident's right arm pain. Review of the resident's nurses notes showed on 08/21/11 at 5:18 A.M. licensed staff recorded, "Resident arm appears to be more swollen. With report again to RN A. As needed Tylenol utilized at 2:00 A.M. Tylenol order reads every six hours." Licensed staff did not record they notified the resident's physician of the worsening of the resident's condition and continued pain. Review of the resident's nurses notes dated 08/21/11 showed licensed staff recorded the following information: - 6:50 A.M., "Upon assessment noted resident right arm at AC space reddened down forearm, swollen and warm to touch. Resident showed great discomfort with any movement. Also noted purple discoloration to left side of AC space right arm. Call placed to daughter reporting. Call placed to physician and received telephone order to send the resident to the local hospital for evaluation and treatment. Resident sent by ambulance at approximately 7:10 A.M. with appropriate paperwork sent. Received report from the local hospital that resident was going to be admitted for right humerus (upper bone of the arm from the elbow to the shoulder joint) fracture and dislocation, and would probably have surgery to repair." During an interview on 08/25/11 at 12:45 P.M., RN A said he/she was the RN on-call the weekend of 08/20/11 through 08/21/11. RN A said Saturday evening (08/20/11) Licensed Practical Nurse (LPN) G, the evening charge nurse, phoned him/her and notified him/her the resident's right arm AC space was red and painful to touch. RN A said he/she instructed LPN G to monitor the resident's right arm and to notify him/her of any changes. RN A said LPN B, the night charge nurse, phoned him/her and notified him/her of the resident's right arm being red and painful to touch. RN A said he/she informed LPN B that he/she was aware of the resident's right arm condition. RN A said he/she instructed LPN B to monitor the resident's right arm, and to notify him/her of any changes. RN A said LPN B notified him/her twice that night with concerns of the resident's right arm. RN A said he/she told LPN B that he/she would assess the resident's right arm when he/she came on duty in the morning. RN A said when he/she came on duty the next morning, he/she assessed the resident's right arm was red and swollen with bruising to the resident's AC space. RN A said the resident would not allow him/her to raise his/her right arm. RN A said when he/she attempted to move the resident's right arm, the resident "yelled out" in pain and displayed a facial grimace. RN A said in conducting a visual assessment of the resident's right arm, there appeared to be something "damaged." RN A said he/she notified the resident's physician and received orders to send the resident to the local hospital for evaluation and treatment. RN A said the hospital called the facility and informed them, the resident had a right fractured humerus and might possibly require surgery. During an interview on 08/25/11 at 6:30 P.M., LPN G said Certified Nurse Assistants (CNA) E and F were taking care of the resident on the evening of 08/20/11. LPN G said around 7:00 P.M., CNA E and F were undressing the resident for bed. LPN G said when the CNAs removed the resident's shirt, they noticed the resident's right arm was swollen and bruised. LPN G said he/she assessed the resident's right arm and found it to be red, swollen and bruised at the AC space. LPN G said when he/she attempted to check the resident's right arm range of motion, the resident showed discomfort by groaning and displaying a facial grimace. LPN G said this was a change in the resident's condition, so he/she called RN A, who was the RN on-call, and notified him/her of the resident's right arm. LPN G said RN A instructed him/her to apply ice to the arm, elevate the right arm on a pillow, administer Tylenol and notify him/her of any further changes. During an interview on 08/25/11 at 7:00 P.M., CNA E said he/she worked the evening of 08/20/11. CNA E said when he/she and CNA F were undressing the resident for bed, he/she noticed the resident's right arm was red and bruised. CNA E said when he/she attempted to raise the resident's right arm, he/she heard "popping" noises in the resident's right arm. CNA E said the resident "moaned out in pain" when he/she tried to raise him/her right arm. CNA E said both he/she and CNA F immediately notified LPN G. During an interview on 08/25/11 at 7:30 P.M., CNA F said he/she worked the evening of 08/20/11. CNA F said when he/she and CNA E were getting the resident ready for bed, he/she noticed the resident's right arm was red and bruised. CNA F said when he/she attempted to raise the resident's right arm, he/she heard "popping" and "crackling" noises in the resident's right arm. CNA F said he/she had never heard it before. CNA F said when he/she tried to raise the resident's right arm, the resident "moaned out in pain." CNA F said both he/she and CNA E immediately notified LPN G. During an interview on 08/26/11 at 3:20 P.M., LPN B said he/she worked the night of 08/20/11, and came on duty at 10:30 P.M. LPN B said during report from the evening nurse, LPN G informed him/her of the resident's right arm being red, swollen and bruised. LPN B said when he/she saw the resident's right arm it looked "terrible" and had the "appearance of being broken." LPN B said when he/she attempted to lift the resident's right arm, he/she "felt bones shifting." LPN B said the resident grimaced, guarded his/her right arm and "moaned out in pain." LPN B said he/she notified RN A who instructed him/her to monitor the resident's right arm. LPN B said he/she did give the resident Tylenol, but it did not change the resident's signs of pain. LPN B said staff checked the resident every two hours throughout the night and every time the staff repositioned the resident, he/she would "moan out in pain." LPN B said the resident continued to grimace and guarded his/her right arm throughout the night. LPN B said he/she felt "bad" because the resident was in obvious pain, but Tylenol was the only pain medication ordered. LPN B said he/she asked LPN C, who was the other night nurse on duty, to assess the resident's right arm. LPN B said LPN C was in agreement with his/her assessment that the resident's right arm was broken. LPN B said he/she again notified the RN on-call and was instructed to continue to monitor the resident's right arm, and that the RN would be in, in the morning and would assess the resident at that time. During an interview on 08/29/11 at 8:00 A.M., LPN C said he/she was the other night nurse working 08/20/11. LPN C said LPN B asked him/her to assess the resident's right arm because LPN B suspected it was broken. LPN C said the resident's arm did appear to be broken. LPN C said when he/she attempted to lift the resident's right arm, he/she "heard and felt bones moving." LPN C said with any movement of the resident's right arm, the resident "moaned out in pain" and had a facial grimace. Review of the resident's hospital radiology report dated 08/21/11 showed hospital staff recorded the following: - "Examination of the right elbow showed a comminuted supracondylar and epicondylar fracture (break in the upper arm bone just above the elbow joint)." Review of the resident's hospital surgical report dated 08/24/11 showed the hospital staff recorded the following surgical procedure was conducted: - "Procedure: ORIF (open reduction internal fixation-a method of surgically repairing a fractured bone) and splinting." During an interview on 09/01/11 at 9:15 A.M., the Director of Nursing said when LPNs assessed a change in the resident's condition, they were instructed to call the RN on-call and follow his/her instructions including whether or not to notify the physician on-call. During an interview on 08/30/11 at 9:20 A.M., Physician D said when the nurses suspected the resident's right arm was fractured, he/she would have expected staff to notify him/her at that time. Physician D said he/she would have ordered an immobilizer (splint used in the treatment of [REDACTED]. MO 502