**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when another resident hit the resident in the face, resulting in the resident's face being scratched (Residents #4 and #5). The sample was five. The census was 113. Review of the facility's Abuse, Neglect and Exploitation Policy, dated 4/28/25, showed the following: -Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Definition: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/3/25, showed the following: -Moderate cognitive impairment; -Verbal behaviors; -No impairment to extremities; -Partial to Moderate assistance with activities of daily living (ADLs, self care); -Diagnoses of stroke, high blood pressure, diabetes and depression. Review of the resident's care plan, dated 6/9/25, showed the following: -Focus: The resident has a behavior problem of physical aggression, and verbal aggression in regards to cognitive communication deficit and depression; -Intervention: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and potential causes. Review of the resident's nurse's notes, dated 6/25/25 at 5:02 P.M., showed, the nurse heard yelling coming from 400 west hallway. The nurse went down the hall to see why resident was yelling. Another resident stated he/she was hit by Resident #4 in the face. Certified Nurse Aides (CNAs) had already separated residents from each other and confirm this resident was aggressive and hit the other resident in the face, causing an injury. Another nurse removed Resident #4 from the west hallway and down to his/her room to provide a quiet space. The resident was placed in line of sight monitoring. skin assessment was attempted and resident refused. The resident's family was notified. The nurse practitioner (NP) and nurse manager was notified and 911 called. The resident was interviewed by police and resident sent to hospital for further evaluation. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -Cognitive status not documented; -No behaviors; -No impairment of extremities; -Wheelchair mobility; -Partial to Moderate assistance with ADLs; -Diagnoses of stroke, high blood pressure and seizure disorder. Review of the resident's nurse's note dated 6/25/25 at 4:43 P.M., showed the nurse heard yelling coming from 400 west hallway. The nurse went down the hall to see why the resident was yelling. The resident said he/she was hit by another resident in the face. CNAs had already separated the residents from each other. The nurse assessed the resident and he/she has two scratches to his/her face. One above his/her top lip and one on the side of his/her left eye. The nurse cleaned blood off the resident with wound cleaner, no bandages were needed. The resident's glasses were bent during altercation, which were able to be bent back into shape. The resident did complain of pain and as needed pain medication was given. The resident's power of attorney was notified. The NP and nurse manager were notified. During an interview on 6/26/25 at 9:15 A.M. the resident said he/she did not want to be hit in the face by Resident #4. The resident said he/she has had a problem with Resident #4 but had not been hit before. The resident said he/she felt safe at the facility. Observation at that time, showed the resident had no visual bruising to his/her face. During an interview on 6/26/25 at 9:27 A.M., Certified Medicine Technician (CMT) B said Resident #4 came rolling in his/her wheelchair down the west wing hall. Resident #5 was sitting outside his/her room. When Resident #4 wheeled almost past Resident #5, Resident #4 swung a with an open fist and hit Resident #5 in the face. CMT B yelled for Resident #4 to stop. Resident #4 looked at Resident #5 and hit him/her fast three or four more times in the face. CMT B said he/she grabbed Resident #4's hands, and he/she shook loose. Resident #4 reached again and tried to grab for Resident #5's face. CMT B turned Resident #4's wheelchair around to get him/her away. CMT B said he/she had heard the two residents did not get along but he/she had never seen anything. CMT B said Resident #4 could be aggressive with care and when getting medications. CMT B said he/she was recently inserviced on the facility abuse and neglect policy. During an interview on 6/26/25 at 9:23 A.M., Licensed Practical Nurse (LPN) A said the two residents had sat together and talked and socialized and also argued. LPN A said Resident #4 had never gotten physical until now. Resident #4 was sent to the hospital for evaluation. LPN A said he/she was recently inserviced on the facility abuse and neglect policy. During an interview on 6/26/25 at 12:13 P.M., the Administrator and Director of Nursing said they would expect the facility's abuse and neglect policy to be followed as written. The Administrator said Resident #4 had a history of being verbally aggressive with residents and staff. The staff would just try to redirect the resident. This was the first time Resident #4 had gotten physical with anyone. The resident was given an immediate discharge and not be allowed back due to safety issues. MO00256468

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to follow its policy to have an Administrator who planned, directed and monitored compliance with State and Federal government regulatory agencies by not having an active Administrator on-site on a full time basis. The facility census was 123. Review of the facility's (undated) job description for the Administrator, showed: -Job Title: Administrator; -Reports To: Chief Operating Officer; -Status: Exempt; -Positions Summary: -Provides leadership, oversight and administration to all long-term care operations. Responsible for ensuring maximum operating efficiency, overall cost-effectiveness, and strict compliance with all applicable State and Federal rules and regulations; -Develops, monitors and improves facility quality standards; -Essential Duties and Responsibilities: -Develops and ensures the implementation of the facility's short and long-term goals and objectives; -Establishes, supports and continually assesses the facility structure for maximum realization of objectives; -Assures that facility maintains standards at the highest possible level and is responsible for results of survey by the Department of Health; -Develops, implements and assesses facility policies and procedures to ensure compliance with applicable State and Federal rules, regulations, and accreditation standards; -Oversees and directs the department heads in direct line of responsibility. Conducts regular department head meetings to promote a constant flow of information, open discussions, knowledge sharing and to keep department heads well-informed; -Oversees, evaluates and ensures the ongoing delivery of care and services. Provides routine analysis of the quality of care based on observation, customer service surveys and feedback; -Plans, directs and monitors compliance with State and Federal government regulatory agencies; -Ensures the implementation and continued maintenance of facility standards in compliance with the organization's values, goals and objectives; -Participates actively in census development and public relations process to provide input and management; -Maintains contacts with peers and professional colleagues among other local health care facilities, vendors, service providers, and other potential referral sources; -Serves as a mentor, leader, and role model, representing the corporation in a manner that conveys professionalism, confidentiality, courtesy, honesty and fairness; -Promotes excellent community relations; -Performs all tasks and duties in an efficient and safe manner; -Performs other related duties as assigned or as necessary; -Remains flexible and adaptable in work schedules and work assignments as defined by departmental and facility needs; -Represents the corporation in a manner that conveys professionalism, confidentiality, courtesy, fairness, personal integrity, and respect for the fundamental rights, dignity, personal comfort and privacy of others; -In the event that the corporation has an opening for an Administrator in any of its Missouri facilities, the current Administrator will be responsible for assigning a licensed Administrator to assume duties at [NAME] Bluffs. The Administrator will serve as the interim Administrator for the vacant facility until a permanent hire is made, or until the current administrator notifies the corporation that he/she is no longer able to accommodate the interim assignment; -Signed by: Administrator M and Dated 1/20/2025; -The job description did not include if the position was a full time position and/or a remote position. Review of an email sent to the facility's Residents and Family members on 1/21/25 at 5:40 P.M. showed; Dear facility Residents and Family Members, I hope this message finds you well. At this facility, we value transparency and want to share some important updates regarding our leadership and medical services. As of today, Former Administrator L is no longer the Administrator of the facility. We are pleased to announce that Administrator M will be stepping in as Interim Administrator while we conduct a search for a permanent replacement. Many of you may remember, Administrator M's name, from her time as Interim Administrator last summer. In addition to her experience here, Administrator M , serves as the Executive Director of [NAME] Bluffs and [NAME] Bluffs [NAME] in [NAME] City. She is deeply committed to ensuring the care and well-being of your loved ones remains our top priority. If you have any questions or concerns Administrator M can be reached directly and her personal cell phone and/or her work email address. 1. During interviews on 3/28/25 at 6:53 A.M., 8:55 A.M., 10:30 A.M., and 3:00 P.M., the Director of Nursing (DON) said she was aware the facility had had multiple citations one right after the other, including three Immediate Jeopardies (IJ). It seemed like there had been a different surveyor in the facility every week with multiple complaints. The facility couldn't get one thing fixed before there was something else. She had never seen anything like it. The facility had an interim Administrator. Administrator M would not be at the facility today because she had a survey team in her other building in [NAME] City, MO. Administrator M was an interim Administrator at the facility and split her time between the facility in St. Louis, MO and two other facilities in [NAME] City, MO. Administrator M usually worked two to three days in St. Louis and the remaining time at the other two facilities. It would benefit the facility to have a full time Administrator. Administrator M was available by phone or text but it was not the same as having that support in the facility. The corporation does not have a local Regional Nurse Manager to assist with the day to day operations of the facility. She was only one person and could only handle so much. It had been overwhelming the past couple of months since former Administrator L left. 2. During an interview on 3/28/25, at 6:57 A.M., the Assistant Director of Nursing (ADON) said Administrator M was physically in the facility two to three times a week. Administrator M was over two additional facilities in [NAME] City, MO. 3. During interviews on 3/28/25 at 8:11 A.M., and 3/28/25 at 11:00 A.M., the Human Resource (HR) representative said Administrator M was an interim Administrator. Administrator M was onsite at the facility two to three days per week. She splits her time between the facility in St. Louis and two additional facilities in [NAME] City. 4. During an interview on 3/28/25, at 8:40 A.M., Administrator M said she was in the facility five days per week. She worked a 40 hour week. She would not be in the facility today because she was in [NAME] City. There is no way to track the time she actually spent working in the facility. 5. During an interview on 3/28/25, at 8:55 A.M., Staffing Coordinator (SC) A said he/she had worked at the facility for a little over a month. Administrator M was not physically in the facility five days a week. Administrator M was there maybe two to three days a week. She splits her time between St. Louis and [NAME] City. 6. During an interview on 3/28/25, at 9:13 A.M., Social Worker (SW) C said Administrator M did not typically work a five day week at the facility. Administrator M was there at the most three days a week. Administrator M was also the Administrator of two additional facilities in [NAME] City. Administrator M was there last week for five days, but that was the first time he/she could recall the Administrator M was in the facility for five consecutive days. 7. During an interview on 3/28/25, at 9:15 A.M., Registered Nurse (RN) D said Administrator M was there Monday through Friday last week. Other than that, Administrator M was usually there two to three days a week. She splits her time between one home in St. Louis and two homes in [NAME] City. 8. During an interview on 3/28/25, at 9:22 A.M., Admissions Coordinator (AC) E said Administrator M was onsite in the facility approximately three days a week. She had two additional facilities in [NAME] City she was responsible to oversee. Administrator M was the interim Administrator. AC E believed the facility had hired a new full time Administrator, but he/she didn't know when that person was supposed to start. 9. During an interview on 3/28/25, at 9:28 A.M., Medical Records (MR) F said the Administrator M was in the facility on a flexible schedule. Administrator M was usually in the building two to three days per week, but had worked up to five days in the past. Administrator M was also the Administrator at two facilities in [NAME] City. Administrator M was an interim Administrator and was only working until a full time Administrator could be hired for the facility. 10. During an interview on 3/28/25, at 9:30 A.M., Licensed Practical Nurse (LPN) G said Administrator M was physically in the facility about three days per week. Administrator M was not in the facility today because there was an ongoing survey at her other facility. 11. During an interview on 3/28/25, at 9:32 A.M., Business Manager (BOM) F said Administrator M averaged maybe two or three days physically in the facility. Administrator M was also the Administrator of two facilities in [NAME] City. Administrator M was available by phone if BOM F needed anything. 12. During an interview on 3/28/25, at 9:37 A.M., the Director of Rehabilitation (DOR) I said Administrator M was did not work five days a week in the facility. She worked remotely. Administrator M averaged about three days a week in the facility. Administrator M was also the Administrator of two additional facilities in [NAME] City. 13. During an interview on 3/28/25, Activity Director (AD) J said Administrator M was not physically in the facility five days a week. Administrator M was the interim Administrator. Administrator M split her time between the facility and two other facilities in [NAME] City. 14. During an interview on 3/28/25, at 10:15 A.M. Housekeeping and Laundry Supervisor (HLS) K said Administrator M did not work a 40 hour week in the facility. Administrator M worked two to three days a week because she was also the Administrator at two facilities in [NAME] City. When Administrator M was in the facility things seemed to be much calmer. 15. During an interview on 3/28/25, at 2:00 P.M. the Ombudsman for the facility said the facility had not had a full time Administrator since Administrator L left in January. Administrator M was splitting her time between St. Louis and [NAME] City, MO. The Ombudsman had heard complaints and concerns voiced by residents and residents' family members about the lack of a full time Administrator in the facility. He/She has been in contact with the Administrator M by email. He/She felt there should be a full time Administrator on site at least five days a week.

Based on observation, interview and record review, the facility failed to follow their Abuse Prevention and Prohibition Program policy by failing to thoroughly investigate Resident #4's allegation that Certified Nurse Assistant (CNA) BB provided rough care while cleaning him/her up causing a hematoma (a localized collection of blood outside of blood vessels that forms due to injury or trauma) on his/her left inner calf. The resident resided on the fourth floor. The CNA's normal assignment was on the third floor. Review of the facility investigation showed three residents who resided on the fourth floor were interviewed, including Resident #4. No residents from the third floor were interviewed and no staff from either floor were interviewed including staff that worked when the alleged incident occurred. In addition, the facility failed to notify the resident's physician regarding Resident #4's allegation. The sample size was 14. The census was 135. Review of the facility Abuse policy dated 11/22/23, showed: -Definitions: -Abuse is defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Mistreatment is defined as inappropriate treatment or exploitation of a resident. -Policy: This organization recognizes and respects that each resident has the right to be free from abuse and neglect as defined in the federal regulations. -The facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of allegations of abuse, neglect, and mistreatment. The facility will encourage reporting of reasonable suspicions of a crime and will develop and implement policies and procedures that promote a culture of safety and open communication in the work environment. -Prevention: -The organization will maintain protocols and procedures to identify, correct and intervene in situations in which abuse and neglect is more likely to occur. This may include an analysis of: -The supervision of staff to identify inappropriate behaviors, such as derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in the briefs. -Identification: -Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking; -Example of injuries that could indicate abuse include, but are not limited to: Injuries that are non-accidental or unexplained. -Mental and verbal abuse: Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. -Injuries of Unknown Source: Injuries of unknown source that meet the criteria for reporting may include but are not limited to: -Unobserved/Unexplained swelling that is not linked to a medical condition. -Note: Any injury that is explained and appears to be a result of abuse must be reported. -Reporting: -The facility will inform the resident's physician when the resident has alleged or been involved in an incident of abuse or mistreatment. -Protection: -In the event of an allegation or observation of abuse, the facility will immediately assess the resident, notify the physician, and protect the resident and other residents from further harm or incident. -Investigation: -Designated staff will immediately review and investigate all allegations or observations of abuse. -The results of the investigations are to be communicated to the administrator or his or her designated representative and to other official in accordance with State law, including the State Survey Agency, within 5 working days of the incident. Review of Resident #4's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/24/25, showed: -Adequate hearing/vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Moderately impaired cognition; -No behaviors identified; -Toileting Hygiene: Partial/moderate assistance. Helper does less than half the effort; -Roll Left and Right: Supervision or touching assistance; -Always incontinent of bowel and bladder; -Diagnoses of atrial fibrillations (irregular heart rate and rhythm), coronary heart disease (a condition where the coronary arteries that supply blood to the heart become narrowed or blocked), and congestive heart disease (the heart can't pump efficiently), high blood pressure, anxiety and Alzheimer's Disease. Review of the resident's care plan, located in the electronic medical records (EMR), showed: -2/20/25: Focus: Bladder incontinence. Goal: Will remain free from sin breakdown due to incontinence and brief use. Interventions/Tasks: Clean peri-area (genitalia/buttocks) with each incontinence episode; -3/7/25: Focus: Anticoagulant Therapy (blood thinner): Goal: Will be free from discomfort or adverse reactions to anticoagulant use. Interventions/Tasks: Daily skin inspection, report abnormalities to the nurse. Monitor for side effects every shift; -3/9/25: Focus: Impaired cognition or impaired though processes related to impaired decision making. Goal: Will be able to communicate basic needs on a daily basis. Interventions/Tasks: Communicate with the resident/family/caregivers regarding capabilities and needs. Use resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Resident understands consistent, simple, directive sentences. Stop and return if agitated; -3/9/25: Focus: Requires assistance with self-care and mobility. Goal: Will maintain current care/mobility status. Interventions/Tasks: Lower body dressing - substantial/maximal assistance. Personal hygiene and showering/bathing - substantial/maximal assistance. Review of the resident's medication administration record (MAR), located in the EMR and dated 3/1/25 through 3/31/25, showed the resident received an Oxycodone (narcotic pain medication) 10 milligram at 1:20 A.M. on 3/6/25. Review of the resident's progress notes, located in the EMR, showed: -3/6/25 at 9:23 A.M. and documented by NM Z: Left inner calf there is a discolored area midway up the calf oval shaped and slightly raised; -3/7/25 at 9:17 A.M. and documented by NM Z: Area to left inner calf remains unchanged. Resident states it does not hurt; -3/7/25 at 6:53 P.M.: Family member to desk. Very upset regarding hematoma to left inner calf. Reports that resident is very upset and scared when he/she sees the CNA BB walk by. Spoke with Nurse Manager x2 with decision made to send the CNA home pending investigation. Family member updated and ok with plan; -3/7/25 at 7:15 P.M. and documented by NM Z: Resident's family member called this NM today with questions about resident's hematoma and with concerns he/she had heard different stories. This NM informed family member that an investigation was done, and the resident even stated he/she did not believe anyone caused this area to his/her calf. Resident even stated, look there isn't even anywhere he/she could have hit it on. NM said to resident remember when we talked yesterday about this area and mentioned resident leaning forward with his/her right arm on his/her left leg as he/she was picking skin off his/her left foot? Resident said he/she remembered. NM also looked at resident's medication and he/she is on two different kinds of blood thinners which can cause someone to bruise very easily and if you had any kind of pressure on your inner left leg it's highly possible that's what caused this hematoma. Resident voiced that this could possibly be what happened. When this NM explained this to family member, family member said thank you, he/she felt better now. We also discussed that family knows the resident doesn't always get all the facts correct when telling things to the family; -3/8/25 at 9:25 A.M.- Resident was complaining of pain on his/her left lower extremity. Nurse observed an area that was red and purple in color and slightly swollen. Nurse Practitioner was called and order to get a doppler (used to measure blood flow through the blood vessels) of the left lower extremity; -3/8/25 at 11:20 A.M.- Resident is alert and oriented to person, place, time and situation; -3/10/25 at 12:00 A.M. and documented by the resident's physician- Chief Complaint/Nature of Presenting Problem: 3/8 Reason for call. Has a raised bruise on his/her left leg. Concerns for blood clot. Requesting order for doppler. Family member was present last night voicing concerns about the area. New orders for venous doppler to rule out blood clot. Extremities: pulses are present, no edema (swelling). Left thigh (calf) has subcutaneous (the lower most layer of the integumentary system (skin)) hematoma about 3 inches by 3 inches. No redness to suggest infection. Plan: Patient (hematoma) is likely traumatic in nature. Currently there is no evidence of inflammation of cellulitis (a bacterial infection of the skin). Discussed with nursing to put ice packs three times a day to decrease the edema. Continue monitoring for possible developing infection. Resident is at increased risk for bleeding and bruising due to anticoagulation therapy. Doppler results pending. During an interview on 3/12/25 at 11:33 A.M., the Administrator provided the facilities completed investigation regarding Resident #4, and CNA BB. She said Resident #4 resides on the fourth floor. CNA BB normally works the third floor but worked the fourth floor that night. The investigation was completed on 3/6/25. The facility could not substantiate Resident #4's allegation CNA BB was rough while providing care and potentially causing the hematoma. CNA BB was allowed to return to work on 3/7/25, on the third floor. Review of the investigation showed three resident interviews: Resident #4, his/her roommate Resident #2, and Resident #11 who resides across the hall from Resident #4. The investigation did not include staff interviews that worked with CNA BB that night, residents residing on the third floor where CNA BB frequently worked, or staff from the third floor that worked with CNA BB. Review of the facility investigation dated 3/6/25, and completed by Nurse Manager (NM) Z, showed: -3/6/25 (no time documented): The 4th floor charge nurse came to this NM saying Resident #4 has a large hematoma to his/her left leg and said night CNA BB caused it. As we were walking to his/her room the nurse said the resident said the CNA would not change him/her. Whenever he/she put the light on, the CNA would stand in the doorway and tell him/her to never put the light on again. The resident then proceeded to say the CNA caused the hematoma. As we entered the room the resident was lying on his/her back with legs bent and feet on the bed. The resident said this morning after he/she got a pain pill he/she put the call light on to be changed and the CNA said he/she would have to wait a minute because he/she was busy, but then the CNA never came back. The resident said he/she put his/her call light on again and this time he/she had a bowel movement, and the CNA was very mad he/she had to clean him/her up. NM Z asked the resident what did the CNA do that made the resident know the CNA was mad. NM Z asked was the CNA rough when cleaning him/her up and rolling him/her back and forth did the CNA hit your inner calf on something? The resident said he/she can't even blame the CNA for that because there is nothing here that he/she could have hit it on. And no, the CNA was not rough while cleaning him/her up. NM Z told the resident he/she would continue to investigate what happened. The resident said ok and asked for pain medication. Upon assessing the area to the left inner calf noted some light green discoloration at the top of the bruise; -NM Z went to resident's roommate (Resident #2) and asked if he/she heard anything when CNA BB was taking care of Resident #4. The Resident #2 said no, he/she did not hear the CNA yell and when the CNA came in the room he/she did not seem upset. NM Z asked the Resident #2 if he/she heard Resident #4 yell ouch or stop and Resident #2 said he/she never heard anything. Resident #2 said CNA BB did not take care of him/her, but when the CNA came in, he/she did ask the roommate if he/she was wet or needed to be changed; -NM Z then went across the hall and asked Resident #11 how his/her night went and he/she said ok. NM Z asked the resident how CNA BB treated him/her. The resident said CNA BB asked him/her why he/she did not use the urinal and was not happy that he/she was wet, but he/she changed him/her. CNA BB was fine when he/she changed him/her; -NM Z went to the Director of Nursing (DON) and informed her what was being said. They called CNA BB together. The CNA denied yelling at Resident #4 about the call light. He/She then said when he/she went into the resident's room, the resident had his/her leg up and was picking at something. He/She did not see anything on the resident's left leg but noticed a scab on the right leg. They went over reporting things to the nurse and told CNA BB about a form that will be on the floor so staff can fill them out and give to the nurse when staff notice anything different with residents; -After talking with Resident #4 and CNA BB, the resident's medications were reviewed, and the resident takes two blood thinners (Eliquis and Plavix) and when the resident had his/her leg up and picking at it his/her arm would have pressed against his/her inner calf and with that dose of blood thinners a hematoma could very likely happen. Review of the facility investigation dated 3/6/25, and completed by the DON, showed: -3/6/25 (no time documented): Received call from resident's family regarding the resident. Family said he/she had received a text from the resident that CNA BB was rough with him/her the prior night. Alerted 4th floor NM Z who was already aware and investigating. The NM said Resident #4 said the CNA BB was irritated that the resident had a bowel movement, but the CNA was not rough. The NM questioned the roommate who said he/she did not hear anything going on between the resident and the CNA. The NM questioned the resident across the hall who did not have any issues to report. The NM and I called the CNA who denied being rough or yelling at the resident. He/She said when he/she went into the resident's room, the resident had his/her leg in the air and appeared to pick at something. Called family member and discussed the text and told him/her the NM was investigating and had spoken to the resident's roommate and residents in nearby rooms. Discussed the results of the NM interviews and interview with the CNA. Family member said he/she was not sure about his/her mother's complaint because he/she knows how the resident is. The resident lived with him/her for 5 years, and he/she did not want someone's job to be affected. He/She did not want to dismiss the resident's text but also knew firsthand about the resident's behavior. Family member was satisfied with the interviews and the information we had assembled. Observation on 3/12/25 at 11:53 A.M., showed Resident #4 lay in bed with a large purple/yellow hematoma on his/her inner left calf. He/She said a CNA (CNA BB) threw him/her around in his/her bed a few days ago. He/She was not sure if that is what caused the hematoma but he/she did grab him/her by the leg and he/she was not gentle. The CNA was not cursing at him/her, he/she was just loud and rough while providing care. The CNA took care of him/her on the evening shift and the night shift. He/She did not have any problem with the CNA until the night shift. He/She had turned on his/her call light a couple of times and the CNA would turn it off and said he/she would be back. The third time he/she turned on his/her call light, he/she had a bowel movement. When the CNA came in, he/she was upset because of him/her having the bowel movement and that is when he/she was rough with him/her. He/She told the nurse on the day shift and two nurses came back to talk to him/her. The CNA had not taken care of him/her since, although he/she did see the CNA walk by his/her room again. He/She told the nurse he/she did not want that CNA to take care of him/her. He/She is afraid of that CNA. During an interview on 3/12/25 at 11:53 A.M., Resident #4's roommate, Resident #2 said he/she did not see anything because the privacy curtain was closed. He/She did not hear CNA BB cursing at Resident #4, but the CNA's voice did seem aggravated and raised. He/She had not had any problems with the CNA. During an interview on 3/12/25 at 12:10 P.M., Resident #3 said he/she had not had any problems with staff. During an interview on 3/12/25 at 12:25 P.M., agency Licensed Practical Nurse (LPN) H said he/she had worked at the facility on-off for over a month. He/She had not witnessed any staff being abusive or rough with residents and had not had any residents complain about staff. During an interview on 3/12/25 at 12:30 P.M., agency CNA I said he/she had not witnessed any staff being abusive or rough with residents. He/She had not had any residents complain to him/her about staff being abusive or rough. During an interview on 3/12/25 at 12:40 P.M., a family member of Resident #5 said he/she had never had any problems with staff taking care of the resident. The resident had never had any unexplained injuries or bruises. Review of doppler study results dated 3/13/25, showed: Impression: No evidence of an acute (sudden) deep vein thrombosis (clot) left lower extremity. Suspected hematoma of the left ankle measuring 2.0 centimeters (cm) by 0.5 cm by 0.8 cm. During an interview on 3/13/25 at 7:00 A.M., Resident #11 said CNA BB does not give him/her the assistance he/she needs, doesn't honor his/her wishes. The CNA acts as if he/she is annoyed that he/she has to help him/her with incontinence care. The CNA will answer his/her call light, turn it off and say he/she will be right back but never return. The CNA has not been rough or abusive to him/her though. During an interview on 3/13/25 at 7:30 A.M., Resident #10 said CNA BB is rough with him/her. About a week ago, the CNA came in to his/her room to provide incontinent care and acted annoyed he/she had to help him/her. The CNA then pulled his/her sheet off and ripped his/her clothes off in a fast-sweeping motion. The CNA tossed him/her around like a rag doll. He/She does not want that CNA to take care of him/her anymore. That was the only incident he/she had. He/She said he/she had told NM Z about the incident. During an interview on 3/13/25 at 8:30 A.M., NM Z denied the resident told him/her about the incident involving CNA BB. He/She conducted the investigation. He/She interviewed Resident #4, Resident #2 and Resident #11. He/She was going to interview more residents, but it was lunchtime and he/she never went back to get more interviews. He/She should have gone back and interviewed more residents. CNA BB typically works the third floor, not the fourth floor where Resident #4 resides. He/She did not think to interview residents on the third floor. He/She did not think to interview staff that worked with CNA BB the night Resident #4 said the incident happened and he/she did not think to go to the fourth floor and interview staff that frequently work with the CNA. He/She is going to start his/her investigation again. Review of NM Z's resumed investigation dated 3/13/25, and sent to the Department of Health and Senior Services via e-mail on 3/14/25 at 2:51 P.M., showed: -12 residents residing on the third floor were interviewed and no problems were found; -CNA JJ said Resident #14 told him/her he/she does not want CNA BB taking care of him/her any longer because the CNA won't put him/her on the bed pan and tells him/her to just go in his/her brief; -CMT KK said Resident #13 told him/her CNA BB tells him/her to stop putting on his/her call light. Sometimes the CNA can be rough. NM Z discussed with CMT KK the importance of reporting this to the charge nurse right away. He/She tried to interview Resident #13 who told him/her to go away; -Both CNA JJ and CMT KK were in-serviced to the importance of reporting any allegations immediately to the nurse or NM. During an interview on 3/13/25 at 1:34 P.M., the Administrator said the facility should have interviewed more residents including residents from the third floor. They should have interviewed staff that worked when alleged the incident occurred and staff from the third floor that frequently work with CNA BB. She has added new guidelines to include in the facility investigations going forward. Due to Resident #4, Resident #10, and Resident #13 having similar stories of the CNA being rough during care she is she is terminating the CNA's employment. Review of the Administrator's new guidelines, showed: -Send staff member home pending investigation as soon as report/complaint is received; -Get statement from resident/family with complaint. Dates, times, staff/residents involved; -Interview any witnesses and get written and signed statement During an interview on 3/14/25 at 11:21 A.M., the Medical Director, and also the resident's physician said he expects staff to follow their abuse/neglect policy including investigating and reporting. He expects staff to conduct a thorough investigation. He was at the facility and assessed the hematoma. No one told him about the allegation. He should have been told. During an interview on 3/19/25 at 8:23 A.M., NM Z said this was the first time he/she had done an abuse investigation. On 3/13/25, after speaking to the surveyor he/she expanded his/her initial investigation by questioning more residents and also began to question staff. He/She attempted to talk to Resident #13, but he/she is rather confused and he/she was unable to get any information from the resident. He/She also spoke to Resident #14 who said he/she did not have any problems with CNA BB being abusive or rough.

Based on interview and record review, the facility failed to notify the State Survey Agency (Department of Health and Senior Services-DHSS) no later than two hours after one resident (Resident #4) alleged Certified Nurse Aide (CNA) BB was rough while providing personal care, causing a hematoma (a localized collection of blood outside of blood vessels that forms due to injury or trauma) on his/her left inner calf. The sample size was 14. The census was 135. Review of the facility Abuse policy dated 11/22/23, showed: -Definitions: -Abuse is defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish; -Mistreatment is defined as inappropriate treatment or exploitation of a resident; -Policy: This organization recognizes and respects that each resident has the right to be free from abuse and neglect as defined in the federal regulations; -The facility is committed to developing and operationalizing policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of allegations of abuse, neglect, and mistreatment. The facility will encourage reporting of reasonable suspicions of a crime and will develop and implement policies and procedures that promote a culture of safety and open communication in the work environment; -Reporting: -The organization will maintain systems to ensure that all alleged violations involving abuse or mistreatment, including injuries of known source are reported in accordance with federal and state guidance; -For alleged violations of abuse or if there is resulting serious bodily injury, the facility must report the allegation immediately, but no later than 2 hours after the allegation is made; -For alleged violations of neglect or mistreatment that do not result in serious bodily injury, the facility must report the allegation no later than 24 hours -Follow Up Investigation Report: -Within 5 working days of the incident, the facility will provide in its report sufficient information to describe the results of the investigation, and indicate any corrective information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified; -The facility will inform the resident's physician when the resident has alleged or been involved in an incident of abuse or mistreatment; -Investigation: -Designated staff will immediately review and investigate all allegations or observations of abuse; -The results of the investigations are to be communicated to the administrator or his or her designated representative and to other official in accordance with State law, including the State Survey Agency, within 5 working days of the incident. Review of Resident #4's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/24/25, showed: -Adequate hearing/vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Moderately impaired cognition; -No behaviors identified; -Toileting Hygiene: Partial/moderate assistance. Helper does less than half the effort; -Roll Left and Right: Supervision or touching assistance; -Always incontinent of bowel and bladder. Review of the resident's care plan, located in the electronic medical records (EMR), showed: -2/20/25: Focus: Bladder incontinence. Goal: Will remain free from skin breakdown due to incontinence and brief use. Interventions/Tasks: Clean peri-area (genitalia/buttocks) with each incontinence episode; -3/7/25: Focus: Anticoagulant Therapy (blood thinner): Goal: Will be free from discomfort or adverse reactions to anticoagulant use. Interventions/Tasks: Daily skin inspection, report abnormalities to the nurse. Monitor for side effects every shift; -3/9/25: Focus: Impaired cognition or impaired though processes related to impaired decision making. Goal: Will be able to communicate basic needs on a daily basis. Interventions/Tasks: Communicate with the resident/family/caregivers regarding capabilities and needs. Use resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Resident understands consistent, simple, directive sentences. Stop and return if agitated; -3/9/25: Focus: Requires assistance with self-care and mobility. Goal: Will maintain current care/mobility status. Interventions/Tasks: Lower body dressing - substantial/maximal assistance. Personal hygiene and showering/bathing - substantial/maximal assistance. During an interview on 3/12/25 at 11:33 A.M., the Administrator provided the facility's completed investigation regarding Resident #4, and CNA BB. Review of the facility investigation dated 3/6/25, and completed by Nurse Manager (NM) Z, showed: -3/6/25 (no time documented): The 4th floor charge nurse came to this NM saying Resident #4 has a large hematoma to his/her left leg and said night CNA BB caused it. As we were walking to his/her room the nurse said the resident said the CNA would not change him/her. Whenever he/she put the light on, the CNA would stand in the doorway and tell him/her to never put the light on again. The resident then proceeded to say the CNA caused the hematoma. As we entered the room the resident was lying on his/her back with legs bent and feet on the bed. The resident said this morning after he/she got a pain pill he/she put the call light on to be changed and the CNA said he/she would have to wait a minute because he/she was busy, but then the CNA never came back. The resident said he/she put his/her call light on again and this time he/she had a bowel movement, and the CNA was very mad he/she had to clean him/her up. NM Z asked the resident what the CNA did that made the resident know the CNA was mad. NM Z asked was the CNA rough when cleaning him/her up and rolling him/her back and forth did the CNA hit your inner calf on something? The resident said he/she can't even blame the CNA for that because there is nothing here that he/she could have hit it on. And no, the CNA was not rough while cleaning him/her up. NM Z told the resident he/she would continue to investigate what happened. The resident said ok and asked for pain medication. Upon assessing the area to the left inner calf noted some light green discoloration at the top of the bruise. Review of the facility investigation dated 3/6/25, and completed by the DON, showed: -3/6/25 (no time documented): Received call from resident's family regarding the resident. Family said he/she had received a text from the resident that CNA BB was rough with him/her the prior night. Alerted 4th floor NM Z who was already aware and investigating. The NM said Resident #4 said the CNA BB was irritated that the resident had a bowel movement but the CNA was not rough. The NM questioned the roommate who said he/she did not hear anything going on between the resident and the CNA. The NM questioned the resident across the hall who did not have any issues to report. The NM and I called the CNA who denied being rough or yelling at the resident. He/She said when he/she went into the resident's room, the resident had his/her leg in the air and appeared to pick at something. Called family member and discussed the text and told him/her the NM was investigating and had spoken to the resident's roommate and residents in nearby rooms. Discussed the results of the NM interviews and interview with the CNA. Family member said he/she was not sure about his/her mother's complaint because he/she knows how the resident is. The resident lived with him/her for 5 years, and he/she did not want someone's job to be affected. He/She did not want to dismiss the resident's text but also knew firsthand about the resident's behavior. Family member was satisfied with the interviews and the information we had assembled. Review of the resident's progress note dated 3/6/25 at 9:23 A.M., and documented by NM Z showed left inner calf there is a discolored area midway up the calf oval shaped and slightly raised. Observation on 3/12/25 at 11:53 A.M., showed Resident #4 lay in bed with a large purple/yellow hematoma on his/her inner left calf. He/She said a CNA (CNA BB) threw him/her around in his/her bed a few days ago. He/She was not sure if that is what caused the hematoma but he/she did grab him/her by the leg and he/she was not gentle. The CNA was not cursing at him/her, he/she was just loud and rough while providing care. The CNA took care of him/her on the evening shift and the night shift. He/She did not have any problem with the CNA until the night shift. He/She had turned on his/her call light a couple of times and the CNA would turn it off, and said he/she would be back. The third time he/she turned on his/her call light, he/she had a bowel movement. When the CNA came in he/she was upset because of him/her having the bowel movement and that is when he/she was rough with him/her. He/She told the nurse on the day shift and two nurses came back to talk to him/her. The CNA had not taken care of him/her since, although he/she did see the CNA walk by his/her room again. He/She told the nurse he/she did not want that CNA to take care of him/her. He/She is afraid of that CNA. During an interview on 3/13/25 at 1:34 P.M., the Administrator said they did not report the resident's allegation about CNA BB being rough with him/her to the state agency because they did not feel the hematoma was caused by abuse. The facility completed their investigation the same day the resident reported it and at that time they could not substantiate the resident's allegation. She did not know what caused the hematoma. During an interview on 3/14/25 at 11:21 A.M., the Medical Director, and also the resident's physician said he expects staff to follow their abuse/neglect policy including investigating and reporting. He expects staff to conduct a thorough investigation. He was at the facility and assessed the hematoma. No one told him about the allegation. He should have been told.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to keep a resident free from hazards and provide the necessary monitoring and supervision for a resident when outside of the facility. The facility failed to follow their Elopement/Missing Person policy after one resident (Resident #1) left the facility's premises without the staff's knowledge of the resident's whereabouts or expected time of arrival back to the facility. The facility also failed to assess the risk of leaving the facility without notification to staff due to a possible substance abuse disorder when staff found four shot bottles (miniature bottles of 50 milliliters (ml) alcohol) in the resident's bedroom. The sample size was three. The census was 138. Review of the facility's Elopement/Missing Person policy, dated 11/24, showed: -Policy: It is the intent of the facility to provide a safe and home-like environment for all residents and to provide adequate supervision and assistance to prevent accidents. It is the responsibility of all staff members to report immediately to the administrator or Director of Nursing (DON) or Nursing Supervisor, and resident attempting to leave the premise or is suspected of not being on the premises without properly checking out in accordance with established policy and procedures; -Elopement: means that a disoriented or confused resident or a resident who has been determined to be at risk for elopement, leaves the nursing facility premises without notification to the staff or escort; -Missing Resident: is any resident that cannot easily be located or one that fails to return to the nursing facility while out of facility without notifying the facility; -Any staff member observing a resident attempting to leave the premises, without proper facility notification or escort, shall attempt to re-direct the resident and prevent such departure; -If the resident is thought or found to be missing, the staff person will immediately alert the nursing supervisor or charge nurse; -A search will be conducted throughout the nursing unit/neighborhood; -If the immediate search is not successful, the Nursing Supervisor, or designee, will notify the DON and the administrator; -The administrator, DON or designee will coordinate the search efforts. A missing resident alert will be communicated to staff; -Staff will immediately return to their assigned areas and immediately search for the resident. -The Administrator, DON, or Nursing Supervisor, or designee, will assign staff to search area within and outside the facility; -If the resident is not located within 15 minutes, the Nursing Supervisor/designee, will notify the police department with a description of the resident; -The Nursing Supervisor/designee will notify the administrator, and/or on-call facility manager of the event and the status of the search if the person is not on the facility premises; -The Nursing Supervisor/designee will notify the attending physician and the resident's responsible of the event and actions being taken; -Once the police have arrived and received a briefing from the Nursing Supervisor, the police will assume command of the search and facility staff will assist as requested, and within the resources and capabilities of the facility; -Upon return of the resident to the facility, or upon finding the resident, the following steps shall be carried out: -The missing person alert announcement will be cancelled, and staff will be notified that the resident has been found; -All previously contacted persons and organizations shall be notified of the status of the resident. This includes physician, responsible party; -The resident will be evaluated by a licensed nurse and/or physician/practitioner; -The resident's medical record will document the details of the event, including evaluation of the resident, treatment/care provided, and monitoring of the resident; -The resident's plan of care shall be revised to include interventions to prevent further elopement or the potential for elopement. The plan of care will also be revised to include any treatment resulting from the incident; -Following the direction of the administrator or DON, initial notification will be made to required state authorities in accordance with state regulations and guidelines. Review of Resident #1's hospital records, dated 12/19/24, showed: -The resident presented from to the emergency room with complaint of generalized weakness. The resident had a significant fall a couple of weeks ago and broke his/her right shoulder and was admitted to a facility for rehabilitation for several weeks. The resident left the facility early and returned to his/her independent living apartment. The resident said for the past couple of days he/she had generalized weakness and multiple ground level falls without head injury. For the past 24 hours, he/she had not been able to get out of bed and Emergency Medical Services (EMS) was called. EMS found the resident covered in his/her own feces and bed-bound. Review of the resident's elopement risk assessment, dated 12/27/24, showed the resident was a low risk of elopement. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/24, showed: -admitted on [DATE] from hospital; -The resident was able to make him/herself understood and understood others; -Severe cognitive impairment; -The resident had thoughts he/she would be better off dead, or of hurting him/herself in some way two to six days a week; -No behaviors noted; -Wheelchair for locomotion; -Required set-up assistance with eating; -Required moderate assistance for toileting; -Required maximal assistance for showering, upper and lower body dressing, putting on and off footwear, personal hygiene, bed mobility and transfers; -Dependent for walking 10 feet or more and for picking up objects; -Bladder and bowel continence were not rated; -Received a mechanically altered diet; -Diagnoses included atrial fibrillation (a-fib, irregular heart rhythm), hypertension (high blood pressure), orthostatic hypotension (blood pressure drops when standing up from sitting or lying down), osteoarthritis (OA, chronic degeneration of the joint cartilage), anxiety, depression, emphysema (lung condition that causes shortness of breath), fracture of the right shoulder, sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts) and stroke. Review of the resident's progress notes, dated 12/31/24. At 1:52 A.M., showed the resident was rolling down the hall with something black on his/her teeth. The resident said he/she was eating cookies. Therapy found a can of chewing tobacco in the resident's room. It was the second can found in the resident's room since the weekend. The resident's family was called to make aware the facility was a tobacco free facility. Review of the resident's care plan note, dated 1/2/25 at 9:25 A.M., showed: -The resident's family member (FM) C was in attendance with the resident; -The resident saw a neurologist (physician specializing in diagnosing disorders of brain, spinal cord and nervous system) two years ago who stated the resident was suffering from alcoholic dementia; -Discharge plan to long term care at the facility. Review of the resident's care plan, undated, showed: -Problem: Impaired cognitive function or impaired thought processes; Interventions included: Cue, reorient and supervise as needed; Communicate with the resident and family regarding resident's capabilities and needs; -Problem: At risk for falls; Interventions included: Educate the resident and family about safety reminders and what to do if a fall occurs; Anticipate and meet the resident's needs; -Problem: Mood problem related to admission; Interventions included: Monitor, document and report any risk for harm to self, including impaired judgment or safety awareness and risky actions; -Problem: Bladder incontinence; Interventions included provide perineal care (peri-care, washing the front and back of the hips, genitals, anal area and buttocks) with each incontinence episode; -There was no documentation showing risk of elopement was care planned with appropriate interventions; -There was no documentation showing risk of alcoholic dementia with appropriate interventions; -There was no documentation showing the resident was at risk of tobacco and/or alcohol abuse with appropriate interventions. Review of the resident's physiatry (physical medicine and rehabilitation) progress note, dated 1/17/25, showed: -Chief complaint: Mobility and activities of daily living (ADLs) deficits related to failure to thrive, recent right shoulder fracture and unable to ambulate; -The resident was alert and oriented to person and place (A & O X 2); -The resident was able to follow one to two step directions with intermittent cueing; -Discharge planning included: The resident was discharging from skilled therapies on 1/18/25 after achieving short and long term goals; The resident will remain at the facility for long term care going forth. Review of the resident's progress notes, showed: -On 1/22/25 at 12:48 P.M., the resident's FM C was informed he/she need to retrieve the resident's power wheelchair due to concerns about its unsafe use by the resident. FM C said FM B would come and pick it up to take it home; -There was no documentation the family removed the resident's power wheelchair from the facility; -On 2/10/25 at 2:53 A.M., the resident was witnessed sliding out of his/her wheelchair onto the floor. The resident was assessed and showed no signs or symptoms of injury; -On 2/12/25 at 12:07 A.M., the resident was found with three empty shot bottles of alcohol in his/her bed. The resident went out to an appointment today. The resident was able to talk and did not seem to be intoxicated; -On 2/12/25 at 5:52 A.M., the resident was found with a fourth empty shot bottle of alcohol in his/her bed; -On 2/12/25 at 9:00 A.M., the resident left the facility without telling staff. A call was made to FM C, who said he/she was not speaking to the resident and would call FM B to see if FM B knew where the resident was located; -On 2/12/25 at 6:28 P.M., the resident had not returned from leave of absence (LOA), family, Primary Care Physician (PCP) and administration made aware. Review of the resident's unit 24 hour report sheets, showed: -On 2/12/25, Licensed Practical Nurse (LPN) A wrote in the day shift column, the resident was on Incident Follow Up (IFU) related to a fall without injury and the resident left at 9:00 A.M., without telling staff, FM C aware, management aware. There was no documentation found in the evening shift column; -On 2/13/25, the night nurse wrote possible elopement? in the night shift column. There was no other documentation found in the day or evening shift column. Review of the resident's progress notes, showed: -On 2/13/25 at 12:36 A.M., the resident had not returned to the facility. A call was placed to the DON to obtain any information regarding resident's LOA status. The call was not answered and a message was left. On 2/13/25, at 12:46 A.M., a call was made to FM B. The call was not answered and a message was left. A call was made to FM C, who did not answer the call and a message was left. A call was made to all floor managers to obtain any information regarding the resident's whereabouts. All staff conducted an internal and external search of the facility for the resident without results. The Administrator was called twice without answer and a message was left. Staff monitored the phone for any return calls, continued to search outside of the building for any sign of the resident and his/her motorized wheelchair. The resident's power cord to the motorized wheelchair was not in his/her room; -On 2/13/25 at 10:39 A.M., showed the resident had returned to the facility at 9:20 A.M. The resident reported he/she was at his/her apartment located in a different county and was unable to return to the facility last night due to inclement weather. The resident was assessed and found stable and within his/her normal limits; -There was no documentation the family or PCP were updated on the resident's return to the facility; -There was no documentation there were any changes made to the resident's plan of care; -There was no documentation an elopement risk assessment was completed on the resident after the resident's return on 2/13/25. During an interview on 2/14/25 at 9:55 A.M., LPN A said: -He/She would know if a resident was an elopement risk if a resident left the unit or facility without notifying staff; -He/She would report any residents who showed signs of elopement risk to the Nurse manager (NM), who was expected to assess the resident, call the PCP, implement new orders if given, and update the floor information sheet, available to all staff, to show the resident was an elopement risk; -Residents and/or their visitors were expected to sign resident's in and out on the unit's LOA log, available at the nurse's station. Review of the resident's floor information sheet, on 2/14/25 at 9:56 A.M., showed: -Last updated on 2/9/25; -There was no documentation the resident was an elopement risk. Review of the resident's unit LOA sign out/in log, on 2/14/25, at 10:03 A.M., showed there was no documentation the resident signed in or out. Review of the resident's electronic medical record, showed no documentation found under assessments showing a new elopement assessment was completed after 2/13/25. Observation of the resident on 2/14/25 at 10:04 A.M., showed: -He/She sat in a motorized wheelchair, eating breakfast which was placed on his/her bedside table in front of him/her; -The resident looked unkept with dried unidentified substances on his/her face, unwashed hair, and dry, visibly flaking skin on his/her arms. The resident had an unwashed odor; -The resident wore dirty, stained sweatpants and a dirty short sleeved shirt which had both dried food and fresh scrambled egg attached to his/her chest; -The resident was barefoot and his/her feet were dark purple with dry, flaky skin; -The resident struggled to feed him/herself, using an adaptive fork with a wide handle, spilling scrambled egg down his/her shirt as he/she tried to bring the food to his/her mouth; -There were papers and medical documents spread all over the floor in front of the resident's bed and on top of the resident's unmade bed. During an interview on 2/14/25 at 10:05 A.M., the resident said: -He/She left the facility a few days ago because he/she had a doctor's appointment; -He/She arranged transportation by calling his/her insurance, because he/she was allowed a certain amount of rides a year; -He/She could not get the transportation service to pick him/her up from the doctor's appointment to return him/her to the facility as he/she was refused service due to the snowy weather; -He/She used his/her cell phone to call his/her FM B, who came to pick him/her up and took the resident to his/her senior living apartment, which was approximately twenty-five miles away from the facility; -He/She called the transportation service and scheduled a pick up for the next morning for return to the facility; -He/She returned to the facility the next morning, he/she was unsure of the time. During an interview on 2/14/25 at 10:11 A.M., LPN A said: -Nurses were responsible for documenting in a progress note when a resident leaves the facility as an LOA including when the resident left, with who, how transported, contact numbers and expected time of return; -Nurses were also expected to write in the 24 hour report sheet when a resident was LOA and expected time of return so the next shift would be aware of residents' whereabouts; -Nurses were expected to write a progress note and update the 24 hour sheet showing when a resident returned for continuity of care and to account for all residents; -Nurses were expected to round on each resident when they came on shift, after receiving report from off-going nurse, to ensure all residents were accounted for per the census and their needs were met; -He/She did not believe any residents, regardless of their cognitive awareness, were appropriate to sign themselves out of the facility or go out on their own because if they were capable of going out into society safely, they would not need care in the facility; -He/She would try to call any contact numbers to find the resident's new expected time of return if the resident did not return an hour or so after his/her expected time of return as written when the resident left the facility; -Nurses were expected to notify the NM or DON if a resident did not return when expected so they could act quickly to find/locate the resident; -The facility was responsible for notifying police and the appropriate State department if a resident was not found within two hours of the facility's awareness the resident's location was unknown; -The facility management team was responsible for starting an investigation, interviewing staff and other residents, to gather information such as when was the last time the resident was seen, if anyone knew where the resident was, what the resident was last seen wearing, in order to help the police in their search for the resident; -He/She was the nurse assigned to the resident on 2/12/25 during the day shift, from 7:00 A.M. until 3:00 P.M.; -He/She received a call from the receptionist at approximately 9:00 A.M., asking if the resident had a doctor's appointment that day because the receptionist just saw the resident leave the facility, get into a medical transport vehicle and drive off; -LPN A told the receptionist the resident did not have a doctor's appointment and he/she did not know the resident left the unit or the building; -The receptionist told LPN A that he/she did not know where the resident was going when he/she exited the building; -LPN A informed the NM that the resident had left the building alone, without informing staff where he/she was going, how to contact the resident, or when the resident was expected to return; -The NM instructed the LPN to call any family members to see if they had any information on the resident's location; -LPN A called FM C, who answered the phone, claiming he/she did not know where the resident was because he/she was not on speaking terms with the resident; -FM C said he/she would call FM B to see if FM B had any information on the resident's location and he/she would call LPN A back; -FM C never called LPN A back to update the nurse with any information; -LPN A did not make any other calls, nor did he/she update the NM with the results of the call from FM C; -LPN A reported to the on-coming nurse the resident was LOA without informing staff and left the building at approximately 3:15 P.M.; -The resident had not returned to the facility before the end of LPN A's shift; -The NM did not give LPN A any further instruction, did not ask LPN A to update him on any phone calls the nurse may have made and did not interview LPN A regarding what had happened before LPN A was notified by the receptionist of the resident leaving the facility, what he/she was wearing, etc. -The resident was not safe out in the community by him/herself because he/she was a fall risk, was alert and oriented to self, place, time and situation (A & O x 4) sometimes, but had periods of confusion, overestimated his/her abilities and was not able to make safe decisions; -LPN A did not know the resident had a cell phone until this morning when the nurse saw the phone in the resident's possession; -He/She expected the management team at the facility to notify the police and appropriate State offices when they could not locate the resident so a search would begin for the resident's safety; -LPN A was not updated by the NM or any other management team member regarding where the resident was or when he/she returned to the facility; -He/She was told in report by the off-going nurse today that the resident returned to the facility on 2/13/24 at approximately 9:00 A.M.,; -LPN A was very afraid for the resident's safety when the nurse left to go home on 2/12/25; -The weather on 2/12/25 and 2/13/25 was below freezing and the resident was at risk of hypothermia (dangerous drop in body temperature) if he/she was outside for too long or was not properly dressed for the cold temperatures. During an interview on 2/14/25 at 11:04 A.M., Certified Nurse Assistant (CNA) D said: -He/She was assigned to care for the resident during the day shift on 2/12/25; -On 2/12/25 at around 8:30 A.M., the resident told the CNA he/she had a doctor's appointment that day; -CNA D asked LPN A if the resident had a doctor's appointment scheduled on 2/12/25 and LPN A said no; -CNA D returned to the resident's room and told the resident he/she did not have a doctor's appointment that day. The resident yelled back you don't know!; -CNA D last saw the resident in his/her room around 10:00 A.M.; -He/She put the resident's lunch tray in his/her room at 12:30 P.M.; -The resident was not in his/her room when the CNA put in the lunch tray in his/her room; -CNA D did not inform the nurse the resident was not in his/her room as expected to eat lunch nor did the CNA go and look for the resident; -CNA D picked up the resident's lunch tray around 1:00 P.M., and noted the resident was still not in his/her room and did not eat any of the lunch; -CNA D told LPN A the resident did not eat any of his/her lunch but did not report he/she had not seen the resident since approximately 10:00 A.M.; -He/She can not remember if LPN A said the resident was missing; -CNA D did not think the resident was missing or that he/she was an elopement risk as the resident never showed signs of trying to leave the facility; -CNA D left the facility at the end of his/her shift at 3:00 P.M.; -CNA D did not give report to the on-coming CNA; -On 2/13/25, CNA D was assigned to the resident's care when he/she came on shift at 7:00 A.M.; -CNA D was told by someone, he/she could not remember who, the resident had not returned to the facility yet; -At 7:30 A.M., CNA D went to the resident's room and saw his/her bed had not been slept in the night before because it was still made up; -The resident arrived back to the unit sometime later, before breakfast; -The resident told CNA D he/she had gone to visit a friend and the friend would not drive the resident back to the facility due to the snow on 2/12/25; -The resident told CNA D he/she stayed overnight at his/her apartment; -CNA D did not know how the resident got to the apartment or the location of the apartment; -CNA D told the NM the conversation he/she had with the resident; -He/She expected the NM to start an investigation on where the resident was overnight as soon as the resident returned to the facility and CNA D gave his/her report; -CNA D was not interviewed by any of the management team regarding the resident leaving on 2/12/25; -CNA D did not receive any direction on any new plan of care for the resident and was not told if the resident was now an elopement risk; -He/She did not receive any in-services on the facility's elopement/missing person policy after the incident; -He/She could not remember the last in-service he/she received on the facility elopement/missing person policy. During an interview on 2/14/25 at 11:25 A.M., LPN A said: -He/She was never interviewed by the management team about the resident's incident on 2/12/25; -He/She was not told if the resident was now an elopement risk or if there a change in the plan of care; -He/She expected the management team to assess the resident's elopement risk, update the resident's care plan with the risk of elopement with appropriate interventions, and update the unit information sheet showing the resident was an elopement risk; -He/She did not receive any in-services on the facility's elopement/missing person policy after the resident's incident. During an interview on 2/26/25 at 12:00 P.M., LPN B said: -He/She worked the 2/12/25 11:00 P.M.-7:00 A.M. shift. When he/she arrived, the off-going nurse told him/her the resident had been gone since 9:00 A.M. They did not know where the resident was; -LPN B told the Nursing Supervisor (NS), who didn't seem to know what to do. The NS called the Administrator and DON several times, but got no response. LPN B told the NS he/she needed to call the police and State, but the NS said he/she wanted to wait to hear from management before he/she did anything; -This morning, the NM told LPN B the resident is an alcoholic. He/She frequently went out to buy alcohol without telling anyone; -LPN B never laid eyes on the resident. Staff searched the building. Staff told LPN B the resident was itty bitty frail and used a motorized wheelchair. During an interview on 2/14/25 at 12:05 P.M., the NM said: -A resident was considered an elopement when they leave the facility without notifying their nurse where they were going, who they were with, what transportation was utilized, contact numbers, and expected time of return to the facility; -A resident was considered missing when they do not return at the expected time from LOA and the facility was not able to make contact with the resident or the responsible party to find out their location and when they planned to make their return to the facility; -He expected staff to follow the facility's elopement/missing person policy as soon as a resident was determined an elopement or a missing person; -Staff were expected to notify the police and the appropriate State departments when a resident was determined an elopement or missing, so a search could begin as quickly as possible; -Residents who were in care of the facility were not safe out in the community by themselves and were at increased risk of injury, harm, or death. If residents were able to make safe decisions out in the community, they would not need to be in the care of the facility; -Residents could not sign themselves out LOA because they were not able to function in society safely, otherwise they would not require oversight of the facility; -Nursing staff assessed residents for elopement risk when admitted , quarterly and as needed after an attempted or actual elopement; -Both he and the charge nurse were responsible for updating the care plan to address elopement risk with appropriate interventions after a resident was deemed an elopement risk; -He was the NM over the unit in which the resident resided; -On 2/12/25, at approximately 9:00 A.M., he saw there was a medical transport vehicle outside with its wheelchair ramp lowered; -The receptionist told him the medical transport was waiting for the resident; -He called LPN A to inform him/her the resident's ride was waiting for the resident to come down; -The resident told LPN A he/she was leaving to go and see family; LPN A sent the resident down to front of the building after making sure the resident was dressed appropriately for the weather; He could not remember how he knew this information; -He did not see the resident exit the building; -Shortly after the resident left the building, for some reason, he became concerned about the resident and where he/she went as the NM remembered there was no doctor appointment set up for the resident and it didn't make sense for the resident to go and see family as they were not on good terms; -He instructed LPN A to call the resident's FM B to find out if FM B knew the location of the resident; -He did not follow up with LPN A to see if he/she made contact with FM B; -He did not follow up with LPN A to see if he/she had any knowledge of the resident's location before LPN A left the facility at the end of day shift, approximately 3:00 P.M.; -He left the building at the end of his shift between 3:00 P.M. and 4:00 P.M. without knowing where the resident was or expected time of the resident's return; -He did not alert the Administrator or the DON the resident left the building without staff's knowledge of his/her destination, transportation method, contact numbers or expected time of return; -He did not give the on-coming nurse any instruction regarding the missing resident; -He assumed the resident was with FM B; -He arrived back to the facility the next morning, on 2/13/25 at approximately 7:30 A.M., and was told by the night nurse the resident had not returned to the facility; -He then was alarmed and called the resident's FM C, who did not answer; -He called FM B, who answered the phone who told the NM the resident was with a friend but didn't know who the friend was or where the resident was located; -The NM called the resident's cell phone number and the resident answered, saying he/she was not able to return to the facility the night before due to the snowy weather but was getting picked up by medical transport at 8:00 A.M. to return to the facility. He/She was at his/her apartment safe but alone; -The NM was not aware the resident had an apartment; -The resident arrived back to the facility on 2/13/25 at approximately 9:00 A.M.; -The NM assessed the resident head to toe for any injury or change of condition and found the resident was stable and performing within his/her normal limits; -The resident said he/she left the facility, on 2/12/25, to check on his/her apartment; -The NM notified the DON of the resident's safe return; -The DON had texted him on 2/13/25 at 4:27 A.M., that the resident had not returned to the facility. The NM did not read the text until he arrived at the facility the next morning; -He did not make any change to the resident's care plan; -He did not know if the PCP was made of aware of the resident's incident and if there were any changes to the plan of care; -He did not provide any education on the facility's elopement/missing person policy to the nursing staff; -He was responsible for following the facility's elopement and missing person policy as soon as he confirmed the facility did not know where the resident was on 2/12/25 at approximately 10:30 A.M., and should have notified the police and appropriate state agencies; -He should have started an investigation immediately, interviewing staff, as every moment was key when trying to find a resident; -The longer residents were out in the community alone, their risk for injury, harm to self or by others, or possible death increased. During an interview on 2/14/25 at 2:50 P.M., the DON said: -Elopement was when a resident exited the building without anyone knowing they left, where they were going, or who was with them, contact information or expected time of return; -She expected staff to follow the facility elopement/missing person policy as soon as they found out the resident left without leaving any information; -She expected staff to notify the administrative team immediately if a resident was LOA without a known location; -She expected nursing staff to call the police if the resident was not located within two hours of first knowing the resident had left the building; -She expected nursing staff to notify the PCP of the missing resident after the police were notified; -She was not sure of the timeline of when to call State, maybe two hours after known missing, within those two hours, the facility was making calls, to try to locate the resident; -She expected nursing staff to document the elopement, showing what happened, when resident left, who called family, list of contacts, everythi

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Based on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity when one resident continued to have a certain staff assigned to them despite their request for a different staff member (Resident #84). In addition, staff used their personal cell phones in resident care areas and while providing care to the residents. The sample was 23. The census was 115. Review of the facility's Resident Rights policy, dated 11/22/24, showed: -Policy: The facility recognizes and respects that each resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. Exercising right means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The facility will ensure that facility operations and systems are implemented in a manner that facilitates the resident/resident representative can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. The facility will implement and maintain systems to ensure all facility staff understand and foster the rights of every nursing home resident. Review of the facility's Employee Handbook, dated 7/1/24, showed: -Telephone Calls and Messages: -The Facility is dedicated to the care of the elderly and disabled. The care of these residents cannot be adequately accomplished when the employees are interrupted by outside personal phone calls or text messages. Unless you are authorized to use a cell phone as part of your job duties, cell phones are to be used only during the employee's rest or meal breaks and must be turned off in resident care or work areas. Please note, cell phones which are only muted, or silenced, are not turned off. 1. Review of Resident #84's annual Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 9/30/24, showed: -Cognitively intact; -Diagnoses included coronary artery disease, heart failure, high blood pressure, cirrhosis (chronic liver damage), diabetes, and depression. Review of the resident's progress notes, showed no documentation of the resident reporting unprofessional behavior from staff. During an interview on 11/21/24 at 10:42 A.M., the resident said there was a Certified Nurse Aide (CNA) who had yelled at him/her. The CNA entered the room and started to complain about how the resident should not be in bed and be in the wheelchair. It was as if he/she yelled at the resident, but at the same time complained about what staff did or was not supposed to do. The resident reported to staff and asked that the CNA not be assign him/her anymore, but yesterday, the CNA was assigned to him/her. During an interview on 11/25/24 at 11:43 A.M., the resident said the CNA worked again. He/She knew they are not supposed to be in here. The resident said that to the CNA. The resident said the CNA is meaner than hell. The resident got his/her daughter on the phone. The resident's daughter said there was a nurse aide who came into the room that was rough and nasty to the resident. The aide took the resident's water bottles that were purchased by family, without permission and told the resident to buy more. This happened approximately one month ago, and it was reported to the nurse manager, either the Director of Nursing (DON) or Licensed Practical Nurse (LPN) M. She was told it was not acceptable and they would look into it. The aide was not his/her favorite person. During an interview on 11/25/24 at 1:31 P.M., the Director of Nursing (DON) said she remembered an incident about the water, but it ended up being another issue and the water was not taken. The resident did not believe the aide was nice. The aide spoke in a loud voice, and the resident did not like it. She remembered something about the aide not being assigned to the resident. If a resident requested not to have a certain staff assigned to them, they would talk to the nurse manager and staffing. Staffing would be able to put them on a different floor. During an interview on 11/25/24 at 1:48 P.M., Licensed Practical Nurse (LPN) M said the resident reported staff did not bring him/her water and staff allegedly said, you don't need water. LPN M also remembered it was reported that the aide stood at the door and screamed at the resident. LPN M added they did not know a name at that time and the description changed from tall and thin to average. LPN M was told the name of the aide and said there are more than one aide with the same name, but the one he/she was familiar with speaks quietly. LPN M said if they found out who it was, they would tell them not to go in the room. They would not be assigned to the resident. During an interview on 11/25/24 at 2:20 P.M., the DON confirmed the identity of the aide and checked the schedule. The resident had the correct name of the aide and that aide worked on the unit during the night shift. The DON started the investigation and interviewed residents. The aide has been suspended. During an interview on 11/25/24 at 3:08 P.M., Hospice Registered Nurse (RN) N said the resident had strong complaints in the past two months, but not specific. They had an interaction that was upsetting to the resident. You could still tell he/she was upset. RN N said he/she reported to RN B and he/she talked to the DON. 2. During a group interview on 11/21/23 at 1:27 P.M., seven residents, whom the facility identified as alert and oriented, attended the group meeting. All residents said the staff used their cell phones while providing care to the residents. One of the residents said he/she was told by a staff person to keep quiet because the staff was listening to music on their phone while assisting the resident with care. Another resident said he/she was told that he/she being too loud and that the staff could not hear his/her cell phone. The residents were unable to identify the staff by their names. Observation on 11/22/24 at 10:14 A.M., showed a staff person walked down Hall 300 looking down at his/her cell phone, then entered a resident's room. The staff person left the room after approximately one minute. At 10:18 A.M., the staff person returned with linens in his/her left hand and a cell phone in the right hand. He/She walked slowly while looking down at his/her phone. During an interview on 11/26/24 at 11:17 A.M., LPN H said personal phones or cell phones should not be used in the resident care areas. During an interview on 11/26/24 at 11:35 A.M., CNA C said staff were not supposed to use their cell phones while providing care to the resident. If important or emergency calls were expected, staff will let the residents know and step out of the resident areas to answer the call. 3. During an interview on 11/26/24 at 12:06 P.M., the Administrator said residents should be treated with dignity and respect. If a resident was uncomfortable with certain staff, the staff member will not take care of the resident. He expected staff to interview the resident and investigate the concerns. It should be documented. He expected staff to ensure the aide was not assigned to the resident. The aide is expected to be taken off the schedule until further notice. In addition, the Administrator expected staff to refrain from using their cell phones while providing resident care. The staff can have their cell phones but should not be actively using them in the resident care areas. MO00243731 MO00241905

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents or the resident's responsible party (RP) were invited to participate in all aspects of person-centered care planning for one resident who was not notified after his/her insurance was changed by the facility (Resident #67). The sample was 23. The census was 115. Review of the facility's Resident Rights policy, dated 11/22/24, showed: -The facility recognizes and respects that each resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Exercising rights mean that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules, as long as those rules do not violate a regulatory requirement. The facility will ensure that facility operations and systems are implemented in a manner that the resident/resident representative can exercise his or his rights without interference, coercion, discrimination, or reprisal from the facility. The facility will implement and maintain systems to ensure all facility staff understand and foster the rights of every nursing home resident; -Resident Rights include: The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meeting and the right to request revisions to the person-centered plan of care; -The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care; -The right to be informed, in advance, of changes to the plan of care; -The right to see the care plan, including the right to sign after significant changes to the plan of care; -The right to request, refuses, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Review of Resident #67's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/5/24, showed: -Cognitively intact; -Diagnosis included diabetes. Review of the resident's medical record, showed: -admitted on [DATE]; -Diagnosis of type 2 diabetes with foot ulcer. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has little, or no activity involvement related to resident wishes not to participate; -Intervention: Resident is able to tell you his/her preferences about attendance/activities. During an interview on 11/25/24 at 9:03 A.M., the resident's family member said the facility, without permission or discussion with the resident or family, changed him/her from a Medicare Advantage plan to classic plan. Review of the resident's progress notes, dated 11/10/24 at 2:46 P.M., showed the resident's Trulicity (medication used for type 2 diabetes) out of stock. Pharmacy said medication is not covered by insurance. I spoke to resident and said if he/she would like to try Ozempic (medication used for type 2 diabetes) or another medication covered. Resident became upset, no, I would like to know who the hell changed insurance. Said he/she would call family and have family follow up with Endo (Endocrinology, specializes in diagnosing and treating conditions related to hormones) and insurance. Review of the resident's Physician's Orders Sheet (POS), dated November 2024, showed: -An order, dated 6/21/24, for Dulaglutide (Trulicity) subcutaneous (applied under the skin) solution pen-injector 3 milligram (mg)/0.5 milliliters (ml). Inject 4.5 mg subcutaneously one time a day, every Friday for hyperglycemia (blood sugar level too high). During an interview on 11/25/24 at 4:45 P.M., the Business Office Manager (BOM) said the resident's payor source is Medicaid. There was a mess up on the facility part. The BOM was informed there were two insurances. Some residents with dual plans and those two insurances were no longer able to see their medical provider, so he/she switched those residents to traditional Medicare with Part D so they would be able to see the house doctor. He/She assumed someone spoke to the residents and/or responsible party. The BOM later found out he/she had the incorrect information regarding Resident #67's insurance and medical provider after he/she switched the resident to classic Medicare. He/She explained to Resident #67's family that it was an error. The resident's family called the facility because he/she was concerned about the resident's medications, briefs, and extra money used to buy the resident snacks. The previous insurance provided money for the resident's family to purchase those items even though it is usually community-based supplies, and the facility has those items. They reached out to the resident's insurance and ensured there was a contract between the insurance and new ownership. The BOM said 14 residents were accidentally switched during that time. The BOM has since contacted the residents and responsible party, but Resident #67's family was the only one that wanted him/her to switch back. During an interview on 11/25/24 at 4:50 P.M., Licensed Practical Nurse (LPN) Manager L said there was never an issue with the resident's medication, Trulicity. The pharmacy delivered the medication, but it went missing. The facility paid for the replacement. There must have been a miscommunication because the medication is covered. During an interview on 11/26/24 at 9:30 A.M., the resident said no one notified him/her or his/her family about the insurance switch. He/She would have wanted someone to tell him/her. He/She confirmed there had been no change in his/her care or medications. Someone must have talked to corporate because LPN Manager L found a way to get him/her the Trulicity. During an interview on 11/12/24 at 12:06 P.M., the Administrator said he expected residents and their responsible party/power of attorney (POA) to have been notified regarding possible changes to providers and insurance. Typically, the social worker would have been responsible for notifying them. The residents have the right to be informed in advance of changes to the plan of care. MO00245661

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify third party (TPL) within 30 days when a resident expired. This affected two residents who expired (Residents #171 and #172). The census was 115. Review of the facility's undated Resident Personal Funds - Accounting and Management policy, showed: -Hold, safeguard, manage, and account for: Means that the facility must act as fiduciary of the resident's funds and report at least quarterly on the status of these funds in a clear and understandable manner. Managing the resident's financial affairs includes money that an individual gives to the facility for the sake of providing a resident with a non-covered service. In these instances, the facility will provide a receipt to the gift giver and retain a copy; -Procedures/Requirements: The resident may manage his or his own personal funds; -The resident may designate a representative to manage his or her personal funds; -The resident may have the facility hold, safeguard, and manage his or her personal funds; -Should the resident elect to have the facility manage his or her personal funds, it must be authorized in writing by the resident or the resident's representative, and a copy of such authorization will be documented in the resident's medical record; -Should the facility manage the resident's funds, the facility will act as a fiduciary of the resident funds and hold, safeguard, manage and account for the personal funds of the resident. No service charge will be levied against the resident for the management of personal funds; -Should the facility manage the resident's funds, there will be a designation of duties of multiple staff members to ensure that the process is not managed solely by one individual; -Should the facility be appointed the resident's representative payee, and directly receive monthly benefits to which the resident is entitled, such funds will be managed in accordance with established policies related to financial management; -The resident will be informed in advance of any changes imposed to his or her personal funds; -A copy of all financial transactions will be filed in the resident's permanent records; -The resident may withdraw his or her request for the facility to manage his or her personal funds at any time by submitting a written notice to the Administrator; -Inquiries concerning the facility's management of resident funds should be referred to the Administrator or to the business office. Review of the facility's Resident Fund Account and Change in Management/Ownership, dated [DATE], showed: -Policy: The facility will provide new management or ownership with a full accounting of resident funds on deposit with facility; -Procedure/Requirements: Should a change of management or ownership occur, the following transactions concerning our resident trust fund and/or our resident petty cash fund with be implemented; -Duties to new owner and/or Administrator: Upon the change of Administrator, sale of the facility or other transfer of ownership, the current Administrator/ designee will provide the new Administrator/Owner with a written accounting of all resident funds deposited with the facility; -The report will be prepared by a Certified Public Accountant (CPA) in accordance with generally accepted accounting principals; -A new Administrator/Owner will sign for receipt for such funds; -Duties to residents: The current Administrator/Designee will provide to each resident, or representative (sponsor), a written accounting of the resident's personal funds held by the facility; -Such accounting will be presented to the resident, or representative (sponsor), prior to the change in management or transfer of ownership; -Rights of residents: An the event that a resident disagrees with the accounting of his or her funds, the current Administrator/Designee will attempt to resolve the issue before new management/ownership assumes responsibility for such funds. Should the disagreement not be resolved, the resident retains all rights and remedies provided under state law; -It is the responsibility of the resident, or representative (sponsor), the report all discrepancies as soon as possible after they are discovered. 1. Review of #171's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admitted on [DATE]; -Death in facility: [DATE]. Review of the facility's trust account statement, dated [DATE], showed: -Expired on [DATE]; -Current balance of $5,693.01. 2. Review of Resident #172's medical record, showed: -admitted on [DATE]; -Expired on [DATE]. Review of the facility's resident trust account statement, dated [DATE], showed: -Expired on [DATE]; -Current balance of $1,077.66. 3. During an interview on [DATE] at 9:50 A.M., the Business Office Manager (BOM) said he/she had been the BOM since [DATE]. He/She had to get the TPL letters ready for Resident #171, but he/she was getting ready to send it to the state. Resident #172 was his/her own responsible party, private pay, and did not have an estate. The BOM was looking into how to send it off since the resident was private pay. 4. During an interview on [DATE] at 12:06 P.M., the Administrator said he expected staff to ensure a final accounting for all residents who had expired or discharged from the facility within 30 days. He expected a letter to be sent to the appropriate parties timely. It was not appropriate for a resident who expired on [DATE] to still hold a trust account with over $1000 in it.

Based on interview and record review, the facility failed to notify hospice services after a resident fell and was transferred to the emergency room. The facility also failed to notify the resident's responsible party prior to transferring the resident to the emergency room (Resident #222). The sample size was 23. The census was 115. Review of the facility's undated Hospice Services Policy and Procedure, showed: -Definitions: Hospice Care means a comprehensive set of services identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care; -Terminally Ill means the individual has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course; -Policy: The facility contracts for hospice services for residents who wish to participate in such programs; -Specific Procedures/Requirements; -The facility has entered into a contractual arrangement for hospice services to ensure that residents who wish to participate in a hospice program may do so; -The hospice agency retains overall professional management responsibility for directing the implementation of the plan of care related to the terminal illness and related conditions, which includes: -Designation of a hospice registered nurse to coordinate the implementation of the plan of care; -Provision of substantially all core services that must be routinely provided directly by the hospice employees, and cannot be delegated to the facility; -Communication between the hospice and facility when any changes are indicated or made to the plan of care. Review of Resident #222's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/15/24, showed: -Severe cognitive impairment; -Rejection of care occurred one to three out of seven days; -Dependent on staff for self-care and mobility; -Diagnoses included end stage renal disease and fractures; -Hospice services not indicated. Review of the resident's October 2024 physician's orders, showed: -An order dated 10/1/24 for hospice evaluation for severe malnutrition; -An order dated 10/3/24 to admit to hospice services. Review of the resident's Hospice Election Statement, showed the resident and hospice company signed the agreement on 10/2/24. Review of the resident's undated care plan, last revised 10/7/24, showed no information regarding hospice services. Review of the resident's progress notes, showed: -On 10/12/24 at 4:32 A.M., during rounds resident observed laying with legs in bed and head resting on floor mat next to bed. Resident appeared to have emesis (vomit), brown coffee grounds and was yelling out. 911 called related to being unable to move resident. Resident sent to the hospital for further evaluation and treatment. The resident's emergency contact notified of transfer. Message left for physician notifying him of the same; -On 10/12/24 at 8:30 A.M., resident received from hospital via medical transport. Resident had no changes when he/she arrived. Power of Attorney (POA) into visit and hospice nurse arrived. The hospice nurse visited with resident and stated he/she is actively dying. Nurse was upset with staff regarding resident going to hospital via 911 related to coffee ground emesis and fall with injury. During an interview on 11/26/24 at 11:05 A.M., Licensed Practical Nurse (LPN) I said he/she was the nurse on duty. When he/she assessed the resident, he/she was moaning and had coffee ground emesis all over and also had a back fracture. Whenever they touched the resident, he/she would moan in pain. LPN I did not contact the Hospice Nurse prior to sending the resident out. LPN I said he/she contacted the family and told them the resident would be sent out. He/She was not sure of the policy regarding contacting hospice before sending a resident out. During an interview on 11/26/24 at 11:00 A.M., the resident's responsible party said the facility called him/her after the resident was sent to the hospital. If the facility had called prior to sending the resident to the hospital, he/she would have informed the facility to not send the resident out. During an interview on 11/26/24 at 10:01 A.M., the Hospice Manager said when a resident had a change in condition at the facility, the facility staff were educated to contact hospice before calling 911 or sending a resident to the hospital. The facility staff notified hospice after they had already sent the resident to the hospital. The Hospice Nurse expected facility staff to contact hospice prior to sending the resident out. During an interview on 11/25/24 at 11:22 A.M., the Director of Nursing (DON) said the night the resident had a fall, two nurses said they called the family and the family agreed to send the resident out to the hospital. However, when she spoke with the family, the family said they did not agree to send the resident to the hospital. The resident received hospice services and the facility staff should have called the hospice nurse prior to sending the resident to the hospital. MO00243731

Based on interview and record review, the facility failed to ensure one resident (Resident #507) was free from verbal abuse and treated with respect and dignity, when a Certified Nurse Aide (CNA) used profanity at the resident and to not identity him/herself after being asked. In addition, the CNA continued to worked at the facility and was assigned to the resident. The sample was 30. The census was 114. Review of the facility's Resident's Rights policy, dated 11/22/24, showed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the resident. The resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. Review of Resident #507's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/16/25, showed: -Diagnoses included coronary artery disease (heart disease), high blood pressure, hyperlipidemia, anxiety, depression, and asthma; -Cognitively intact; -No physical or verbal behaviors. Review of the resident's care plan, in use during survey, showed: -Focus: The resident has a behavior problem related to repetitive vocal complaints regarding other patients care and embellishing the specifics of what actually happened; -Goal: Resident will have fewer episodes; -Interventions: Anticipate and meet the resident's needs; -Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by; -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternate location as needed; -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes; -Offer alternate placement and/or room change. Review of the resident's progress notes, February 2025, showed no documentation of the resident's interaction with staff or behaviors. During an interview on 4/16/25 at 9:15 A.M., the resident said he/she was on the phone with Ombudsman CC when an aide entered the room to assist the roommate. The resident told staff the roommate was hard to understand. The CNA told the resident to shut the fuck up. He/She said Ombudsman CC was on the phone, and the CNA said Fuck him/her too. During an interview on 4/16/25 at 10:00 A.M., Administrator MM said he/she was aware of the incident. The resident often interferes with other residents' care. He/She received an email from Ombudsman CC. The incident occurred on 2/18/25. Administrator MM read the email that he/she received and his/her response to the email. Ombudsman CC overheard CNA BB tell the resident to Mind your fucking business. Administrator MM spoke to CNA BB. He/She reported that he/she did not use profanity. He/She told the resident to Mind your own business. Administrator MM told CNA BB to leave the room whenever he/she feels frustrated. Administrator MM confirmed that CNA BB continued to work shifts at the facility. Review of the email correspondence from Ombudsman CC to Administrator MM, dated 2/18/25 at 4:50 P.M., showed We received a call from the resident regarding some of his/her concerns. While on the phone with the resident, a staff member was overheard telling the resident to Mind his/her own f***ing business when he/she asked the staff member's name. He/She refused to give the resident his/her name. He/She was caring for the resident at 4:45 P.M. on 2/18/25. The resident said this individual was also working last night. Can someone please follow up with the resident regarding these concerns. Review of the email correspondence from Administrator MM to Ombudsman CC, dated 2/18/25 at 6:04 P.M., showed I spoke to him/her (CNA BB), and he/she denies cussing, but did admit to telling him/her to mind his/her business and refusing to give his/her name. I also told him/her this was heard by someone on the phone, but he/she still denied it. We discussed the expectation moving forward is for him/her to leave the room when the resident starts to be disrespectful to him/her, and not to respond to the resident regarding the care for other residents as it is not his/her concern. He/She does not need to make any comment in regard to the resident being in anyone else's business. He/She can get someone else to provide the resident's care if he/she needs to. The resident can be very disrespectful and after a long day, it is best for them to walk away rather than engage. During an interview on 4/16/25 at 2:30 P.M., the resident said CNA BB was standing on the roommate's side of the room. He/She told CNA BB the roommate had trouble speaking. CNA BB told the resident to Mind his/her fucking business. He/She told the CNA that Ombudsman CC wanted to speak to him/her, and the CNA said, Fuck him/her too. The resident said he/he feared for his/her roommate's life and his/her own life, but especially for the roommate, because CNA BB was working with him/her. CNA BB tried to give the resident a shower in the past, and he/she refused. He/She told the CNA, No, not from you. He/She had witnessed disrespectful behavior to other residents from CNA BB. Sometimes the resident feels he/she has to speak for his/her roommate because he/she cannot communicate well. Review of the resident's shower sheet, dated 3/15/25, showed: -Refused; -Documented by CNA BB. During an interview on 4/16/25 at 3:06 P.M., Ombudsman CC said he/she remembered the incident. He/She was in the middle of a phone conversation with the resident. He/She heard the resident ask the aide a question. Ombudsman CC did not make out what the aide said, but could tell he/she had answered the question with an attitude towards the resident. The resident asked the aide what his/her name was, and the aide told the resident to Mind his/her fucking business. The resident made a point to tell the aide he/she was on the phone. He/She tried to further the conversation, but the aide left the room. Ombudsman CC clearly heard the aide say Mind your fucking business. He/She asked the resident if the aide knew he/she was on the phone. Ombudsman CC added he/she did not hear the CNA say Fuck him/her too. The resident's voice started to become louder, continuing to engage in a conversation, but the aide could not be heard as well. It was if the aide was leaving the room or left the room because his/her voice was fading. He/she did not hear what was said by the aide. At first he/she was concerned the aide responded that way and emailed Administrator MM. Administrator MM immediately went upstairs and started the investigation. The CNA was agency staff and Administrator MM was handling it. Ombudsman CC was unaware of the outcome. He/She did not know if the aide was suspended or terminated. The resident told her the aide was still working at the facility. The resident did not seem concerned, but he/she wanted an apology. The resident said the Administrator told the agency aide to apologize to the resident. The resident was never fearful, and Ombudsman CC felt confident the resident was able to confront staff. The resident said he/she saw the aide in the hall, but he/she never went to apologize to the resident. The resident was more concerned with the apology. Ombudsman CC said the CNA continuing to work with the resident would be an issue. The resident mentioned he/she saw the aide, but not that he/she was assigned to him/her. During an interview on 4/21/25 at 12:00 P.M., CNA BB said he/she remembered the incident. He/She confirmed he/she worked for agency and was offered a job at the facility, but never finished on-boarding. The roommate was at an activity, so when Resident #507 turned on the call light, he/she was surprised because the resident does not turn their call light on often. When CNA BB entered the room, he/she was not aware the roommate returned from the activity because he/she did not bring the roommate back. Resident #507 started telling CNA BB that agency staff do not know how to take care of his/her roommate. They did not understand the roommate. The resident continued to talk about the roommate and how to take care of him/her. CNA BB told the resident that he/she could take care of the roommate, and he/she was not talking to him/her about the roommate. CNA BB said he/she understood privacy laws and was not discussing anything about the roommate. CNA BB was aware the resident was on the phone with someone, an advocate or Ombudsman. CNA BB got on the phone with the advocate and said the same thing. CNA BB said he/she got on the phone and said he/she was not discussing the roommate with the resident. CNA BB did not know what was said on the phone because he/she gave the phone back and left the room. The resident told the Administrator. CNA BB was not sent home, and did not give a written statement. CNA BB never told the resident to Mind his/her business or Mind his/her fucking business. He/She was never asked what his/her name was from the resident. He/She had worked with the resident since the incident. He/She will do rounds and ask if he/she needed anything, and that is it. Review of CNA BB's employee punch report, showed he/she worked at the facility on 2/18, 2/19, 2/20, 2/21, 2/26, 2/28, 3/1, 3/2, 3/3, 3/4, 3/5, 3/6, 3/12, 3/14, 3/15, 3/16, 3/18, 3/19, 3/20, 4/2, and 4/6/25. During an interview on 4/21/25 at 2:50 P.M., the Social Service Coordinator said she started working at the facility one month ago. If there was an incident that resulted in a resident alleging unprofessional or disrespectful behavior from staff, she would contact their immediate supervisor, the Social Worker, and conduct a safe survey. A safe survey is when they ask residents if they had any issues and if they felt safe. She would talk to the Director of Nursing (DON) and ask that they do not put that staff on the resident's assignment anymore. She was not aware of the incident that occurred with the resident and staff. During an interview on 4/21/25 at 3:00 P.M., the Social Worker said she had worked for the facility for ten years. The resident did report there was an incident that occurred when he/she was cussed at. The Social Worker heard about it during report by the Nurse Manager and the DON. It was reported and addressed by upper management. The resident wanted to talk about it. He/She said the staff cursed at him/her. The Social Worker did not remember if the resident said anything about the aide working with him/her again. It would not be appropriate for the aide to return after a resident reported they were cursed by them. It would not be appropriate for the aide to be assigned to that resident. They would have that person leave the building and determine if it happened. Even if they still worked in the facility, they would try not to assign the aide to the resident. Residents are also interviewed to see if they had problems with that aide. During an interview on 4/17/25 at 2:00 P.M., Administrator MM said there were interventions taken. CNA BB was told when providing care to the roommate, he/she did not have to explain anything when the resident is cussing or yelling. The aide should leave, step away, and get another aide to cover. Administrator MM spoke to the resident. Per the resident, he/she was asking questions about the roommate, and CNA BB said he/she would not answer questions about the roommate's care. Per CNA BB, he/she denied saying, Mind your fucking business. He/She said Mind your business. However, in addition to the resident's statement there is an interview with the ombudsman where he/she said he/she clearly heard CNA BB use the f word. Administrator MM was asked if there were conversations regarding assignment changes to ensure the aide would not work with the resident. Administrator MM did not recall conversations or documentation to show assignments were changed or interventions to ensure the CNA did not work with the resident. It ended with the email that was sent to the ombudsman. Administrator MM was unaware if he/she spoke to the unit manager. He/She did not have a reason for not sending the CNA home. He/She would expect all residents to be treated with dignity and respect. It was not appropriate for a staff member to tell a resident to mind his/her business when a resident asked for their name. MO00252008 MO00252419 MO00252173 MO00251714 MO00248649

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address the specific needs of the residents (Residents #87 and #99). The sample was 23. The census was 115. Review of the facility's Resident Centered Care Plan Policy, dated 7/17/23, showed: -Policy: A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. To the extent practicable, the resident/resident representative will be provided with opportunities to participate in the care planning process. -A comprehensive care plan for each resident will be developed within seven (7) days of completion of the resident's comprehensive Minimum Data Set (MDS) assessment; -The comprehensive care plan will be developed by a Care Planning/interdisciplinary Team (IDT) which includes at a minimum: -The resident's attending physician; -A registered nurse responsible for caring for the resident; -A nursing assistant responsible for the resident's care; -A member of food and nutrition services staff; -And may include as the resident's condition dictates: -A social services worker or designee; -An activities worker or designee; -Rehabilitative therapists as applicable; including but not limited to physical therapy, speech therapy, occupational therapy, and rehabilitative services for mental disorders or intellectual-disability; -Consultants (as appropriate, e.g., hospice representative, mental health professional, special services professional, pharmacist); -Others as appropriate or necessary to meet the needs or request of the resident.; -All reasonable efforts will be made to incorporate the resident's personal and cultural preferences and life choices in developing goals of care; -The resident/resident representative is encouraged to participate in the development of and revisions to the resident's care plan; -An explanation will be included in the resident's medical record if the participation of the resident/resident representative is determined not practicable for the development of the resident's care plan; -All reasonable efforts will be made for the resident/resident representative will be informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition; -The resident/resident representative will be encouraged to exercise his or her right to: -Participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care; -Participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. iii) See the care plan; -To sign after significant changes to the plan of care; -The resident/resident representative will be informed, in advance, of changes to the plan of care; -The resident will receive the services and/or items included in the plan of care; -Every effort will be made to schedule care plan discussions at the best time of the day for the resident/resident representative; -The mechanics of how the IDT meets (e.g., face-to-face, teleconference, written communication, etc.) for care planning is at the discretion of the resident/resident representative and care planning team. 8) Each resident's comprehensive care plan will describe the following: -Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Any services that would otherwise be required but are not provided due to the resided s exercise of right to refuse treatment; Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of Preadmission Screening and Resident Review (PASARR) recommendations. Or, if the IDT disagrees with the findings of PASARR, rationale will be documented in the resident's medical record; -In consultation with the resident/resident representative, the comprehensive care plan will include: -Resident's goals and desired outcomes ii) Resident's preference and potential for future discharge iii) The resident's discharge plan and any referrals to the local contact agency 10) The comprehensive care plan will: -Incorporate identified problem areas; -Incorporate risk factors associated with identified problems; -Build on the residents' strengths; -Be culturally competent and trauma informed as applicable; -Reflect treatment goals, timetables, and objectives in measurable outcomes; -Identify the professional services that are responsible for each element of care; -Aid in preventing or reducing declines in the resident's functional status and/or functional levels; -Promote resident safety; -Enhance the optimal functioning of the resident by focusing on a rehabilitative program; -Reflect currently recognized standards of practice for problem areas and conditions; -Areas of concern that are triggered during the resident assessment are evaluated using specific assessment tools (including Care Area Assessments) before interventions are added to the care plan; -The Care Planning/interdisciplinary Team is responsible for the review and updating of care plans: -When requested by the resident / resident representative; -When there has been a significant change in the resident's condition; -When the desired outcome is not met; -When the resident has been readmitted to the facility from a hospital stay; -At least quarterly and after each OBRA (Omnibus Budget Reconciliation Act) MDS assessment. 1. Review of Resident #87's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/25/24, showed: -Cognitively impaired; -No impairment to both upper and lower extremities; -Independent in mobility; -Walk up to 150 feet independently; -Wandering occurred one to three out of seven days; -Diagnoses included low blood pressure, high cholesterol, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), malnutrition and depression. Review of the resident's Elopement Evaluation, dated 10/22/24, showed: -Resident is ambulatory or self-mobile in wheelchair; -Cognitively impaired with poor decision-making and/or pertinent; -Wandering history: resident has history of wandering, opening doors to the outside and/or elopement, making statements that they are leaving or seeking to find someone/something, displaying behavior, body language, etc. indicating an elopement may be forthcoming; -Resident at risk of elopement; -Rationale: Always makes statement about leaving. Review of the resident's care plan, revised 10/23/24, showed: -Focus: The resident has impaired cognitive function or impaired thought processes related to Alzheimer's dementia; -Goal: Will be able to communicate basic needs on a daily basis through the review date; -Interventions: Administer medications as ordered, monitor/document for side effects and effectiveness. Identify self at each interaction, face the resident when speaking and make eye contact, reduce any distractions. Provide the resident with necessary cues, stop and return if agitated; -The care plan did not reflect the resident's risk of elopement. Observation on 11/20/24 at 11:37 A.M., showed the resident ambulated independently in the common area of Hall 100r memory care unit. The resident was pleasantly confused, had a coat on and pointed outside through the window and said his/her car was outside waiting for him/her. During an interview on 11/25/24 at 1:34 P.M., Certified Medication Technician (CMT) O said the resident had multiple attempts of exiting, standing by the doors and/or attempts of pushing the doors. The resident did not need a wanderguard (electronic monitoring device) because all the doors in Hall 100 were equipped with an alarm system, and the main entrance to the unit required codes to access. 2. Review of Resident #99's admission MDS, dated [DATE], showed: -Cognitively impaired; -Wandering occurred one to three out of seven days; -Walked 10-50 feet with partial assistance; -Used a manual wheelchair; -Diagnoses included diabetes, dementia and traumatic brain injury. Review of the resident's care plan, revised 10/9/24, showed: -Focus: The resident is at risk for falls related to dementia, diabetes and high blood pressure medication; -Goal: The resident will be free of falls through the review date; -Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Bed in lowest position at all times. Review of the resident's progress notes, dated 11/8/24 at 2:33 P.M., the CMT called this nurse to look at resident for any injuries as resident told CMT he/she fell last evening. Upon entering room, noted resident lying on his/her bed and spouse in chair next to the resident. The nurse obtained vital signs and looked at his/her back and knee; -No further documentation regarding the resident's fall. Review of the resident's care plan, showed no information regarding the fall on 11/8/24. 3. During an interview on 11/26/24 at 11:17 A.M., Licensed Practical Nurse (LPN) H said the nurses have access to the residents' care plan. The care plan should be reflective of the residents' needs and care. 4. During an interview on 11/26/24 at 12:07 P.M., the Administrator and Director of Nursing (DON) said care plans should be specific to residents. Falls and elopement risk should be included in the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services and/or treatment to increase or prevent reduction of range of motion. The facility failed to develop a measurable, goal oriented restorative nursing program, and/or exercise program, to ensure resident's requiring physical assistance were assisted by staff to maintain or improve their physical abilities, per facility policy. The facility provided a list of 16 current residents who had been discharged from skilled therapy services (Physical therapy (PT), Occupational Therapy (OT) or Speech Therapy (ST)) within the past 90 days. Of those 16, three were identified who would benefit from services to prevent reduction of range of motion (Residents #527, #525, and #526). The census was 114. Review of the facility's undated Restorative Nursing Services Policy and Procedure, showed: -Definitions: Restorative Nursing Program: refers to nursing interventions that promote the resident's ability to living as independently and safely as possible. This program focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning; -Policy: Residents will receive restorative nursing care as needed to help promote optimal safety and independence; -Specific Procedures/Requirements: -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies); -Restorative nursing care will be provided by qualified and competent staff and in accordance with federal/state regulation and/or guidance. Restorative nursing interventions may be incorporated with the provision of ADL (activities of daily living) care or while carrying out other defined tasks; -Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care; -The resident or representative will be included in determining goals and the plan of care; -Restorative goals may include, but are not limited to supporting and assisting the resident in: adjusting or adapting to changing abilities. Developing, maintaining or strengthening his/her physiological and psychological resources. Maintaining his/her dignity, independence and self-esteem. Participating in the development and implementation of his/her plan of care; -The restorative nursing services restorative interventions will be implemented and documented in the medical record; -The MDS (Minimum Data Set, a federally mandated assessment instrument completed by facility staff) will only be coded as receiving restorative nursing for those interventions meeting the criteria defined in the RAI (resident assessment instrument) manual. 1. Review of Resident #527's quarterly MDS dated , 2/28/25, showed: -Upper/lower extremity impairment; -Dependent on staff for: toileting hygiene, shower/bathe, upper/lower body dressing, personal hygiene, and roll left/right; -Walk 10 feet ('): Not attempted due to medical condition or safety concerns; -Diagnoses of heart failure, high blood pressure, diabetes mellitus (low/high blood glucose level), hemiplegia (paralysis of one side of the body)/hemiparesis (weakness on one side of the body), seizure disorder and depression; -Received skilled speech therapy (ST), occupational therapy (OT) and physical therapy (PT) in the last 7 days; -Restorative Nursing Programs (range of motion (exercising the muscles that surround the joints), bed mobility, transfers, walking, dressing and/or grooming, eating and/or swallowing, and communications) for at least 15 minutes a day in the last 7 days: 0. Review of the resident's care plan, located in the electronic healthcare record (EHR), showed: -8/21/24: Focus: Chronic pain. Goal: Will verbalize adequate relief of pain or ability to cope with pain. Interventions/Tasks: Administer pain medications per physician orders; -8/22/24: Focus: At risk for falls with falls on 8/22/24, 8/25/24, 10/15/24, 10/26/24, 12/19/24, 12/20/24, 1/7/25 and 4/4/25. Goal: Will be free from falls and will not sustain serious injury from falls. Interventions/Tasks: Anticipate and meet the resident's needs. Be sure the call light is within the resident's reach and encourage the resident to use it for assistance as needed. Determine and address causative factors of the fall; -11/4/24: Focus: Impaired cognitive function or impaired thought processes related to stroke. Goal: Will be able to communicate basic needs on a daily basis. Interventions/Tasks: Ask yes/no questions in order to determine the resident's needs. Communicate with the resident/family/caregivers regarding resident's capabilities and needs; -The care plan did not show the resident was on a structured, goal oriented walking program to maintain or improve his/her walking ability. Review of the resident's physician's order sheet (POS) showed: -2/25/25: PT/OT/SP to evaluate and treat; -3/25/25: Extend ST five times a week for 30 days; -3/25/25: Extend OT five times for four weeks; -No order for a restorative nursing program or an exercise program. Review of a Training Sign-in Sheet dated 4/2/25, and signed by the Physical Therapy Assistant (PTA), showed: -Training Description: Ambulation and Transfers with wheeled walker and assist time one staff; -Bring wheelchair along for ambulation. Do not leave resident unattended on the toilet; -The training was signed by one Certified Nursing Assistant (CNA), three Certified Medication Technicians (CMTs), and one Licensed Practical Nurse (LPN); -The training did not show how often or how far the resident should walk. Review of the resident's PT discharge notes, showed: -Start of Care: February 25, 2025; -Date of discharge: [DATE]; -Precautions: Fall risk; -Ambulation: Supervision or touching assistance to walk 10' and 50' with two turns; -Summary of Skilled Interventions: Therapeutic exercises to improve strength and endurance. Therapeutic activities to improve safety and independence with functional mobility. Gait (walking) training to improve safety and endurance with ambulation; -Barriers that impacted progress: Cognitive impairment; -Reason for discharge: Resident has met goals. Review of the resident's OT discharge notes, showed: -Start of Care: February 25, 2025; -Date of discharge: [DATE]; -Precautions: Fall risk; -Discharge Level: Sit - Stand: Supervision or touching assistance; -Discharge Level: Chair/Bed-to-Chair: Partial/moderate assistance; -Discharge Recommendations: Resident at maximum potential with self cares and mobility at this time. Have staff allow resident to do what he/she safely can do for himself/herself. Observation and interview on 4/17/25 at 10:07 A.M., showed the resident was in the dining room. Observation of the resident's room showed his/her wheeled walker was in his/her room with a sign taped to the walker. The sign was undated and showed the resident's name, room number, the device was a wheeled walker, level of assistance (contact guard (standing next to the resident)), walk in room and corridor. The sign did not show how many times a day the resident should walk or how far the resident should be walked. CNA T, who was assigned to the resident said he/she walked the resident a few feet in the resident's room to/from the resident's bathroom from his/her wheelchair or bed, about 10' with a gait belt (a belt applied the waist to provide stability during walking). He/She had never walked the resident in the corridor or to the dining room. He/She looked at the sign and confirmed it did not give instructions on how many times the resident should be walked or how far. CNA T had not been inserviced on any current walking program for the resident. The resident was already in the dining room this morning when he/she came to work. He/She did not walk the resident to the dining room. Review of the Training Sign-in Sheet dated 4/2/25, and completed by the PTA, showed CNA T did not attend the inservice. 2. Review of Resident #525's annual MDS dated [DATE], showed: -No impairment of the upper/lower extremities; -Dependent on staff for toilet hygiene, shower/bathe; -Partial/moderate assistance required for eating, upper/lower body dressing, personal hygiene, roll left/right, sit to lying, lying to sitting on side of the bed, sit to stand, and chair/bed-to-chair transfer; -Walk 10': Not attempted due to medical condition or safety concerns; -Diagnoses of high blood pressure, renal (kidney) insufficiency, diabetes mellitus, dementia and anxiety; -No skilled therapy in the last 7 days; -Restorative Nursing Programs: No. Review of the resident's care plan, located in the EHR, showed: -12/24/24: Focus: Communication problem. Goal: Will be able to make basic needs known. Interventions/Tasks: Monitor/document/report any changes in ability to communicate; -4/3/25: Focus: Impaired visual function. Goal: Will show no decline in visual function. Interventions/Tasks: Ensure proper visual aides are available. Remind resident to wear glasses; -4/3/25: Focus: Pain related to collapsed vertebra. Goal: Will not have an interruption in normal activities due to pain. Interventions/Tasks: Administer pain medication as ordered. Anticipate the resident's need for pain relief and respond immediately; -4/3/25: Focus: Resident had a fall on 8/1/24 with minor injury. Resident is a moderate risk for falls related to gait/balance problems. Goal: Will resume activities without further incident. Will be free from falls. Will not sustain serious injury. Interventions/Tasks: Continue the interventions on the at-risk plan. Be sure the resident's call light is within reach and encourage resident to use it. Ensure resident is wearing appropriate footwear with good traction when ambulating; -The care plan did not show the resident was on a structured, goal oriented walking program to maintain or improve his/her walking ability. Review of the resident's POS, located in the EHR, showed no order for skilled therapy and no order for a restorative nursing program or an exercise program. Review of the resident's PT discharge notes, showed: -Start of Care: 12/10/24; -Date of discharge: [DATE]; -Discharge Level: Walk 10' with supervision or touching assistance; -Discharge Level: Walk 50' with supervision or touching assistance. 3. Review of Resident #526's quarterly MDS dated [DATE], showed: -Impairment of one upper extremity; -Dependent on staff for shower/bathe, personal hygiene, roll left/right, sit to stand and toilet transfer; -Partial/moderate assistance required for upper/lower body dressing; -Walk 10': Not attempted due to medical condition or safety concerns; -Diagnoses of anemia (the blood has a reduced ability to carry oxygen), coronary artery disease (heart disease caused by the build-up of plaque), high blood pressure, diabetes mellitus, hemiplegia/hemiparesis, seizures and depression; -No skilled therapy in the last 7 days; -Restorative Nursing Programs: No. Review of the resident's care plan, located in the EHR, showed: -10/2/24: Focus: Acute/chronic pain. Goal: Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Interventions/Tasks: Administer pain medication as ordered. Anticipate resident's need for pain relief and respond immediately; -12/8/24: Focus: Hemiplegia/hemiparesis related to stroke. Goal: Will remain free from complications or discomfort. Interventions/Tasks: Give medications as ordered. Pain management as needed; -12/20/24: Focus: At risk for falls related to hemiplegia/hemiparesis. goal: Will not sustain serious injury. Interventions/Tasks: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it. Help with transfers; -12/20/24: Focus: Had an actual fall 12/20/24 and 12/30/24. Goal: Will have no further falls; -The care plan did not show the resident was on a structured, goal oriented walking program to maintain or improve his/her walking ability. Review of the resident's POS, located in the EHR, showed: -3/25/25: PT presents at baseline functional level of stand-by assistance/minimal assistance for bed mobility and transfers. Physical therapy is not indicated at this time; -3/26/25: OT evaluation completed this date with no further treatment required as the resident is at baseline; -No order for a restorative nursing program or an exercise program. 4. During an interview on 4/26/25 at 7:07 A.M., LPN O said he/she worked at the facility part time. He/She was not sure if the facility had a list of residents who needed range of motion or walking. If there was a list, he/she had never seen it. Review of the Training Sign-in Sheet dated 4/2/25 and completed by the PTA, showed LPN O did not attend the inservice. During an interview on 4/26/25 at 7:12 A.M., CMT Q said he/she had worked at the facility for a couple of years. He/She worked on the second and third floor. He/She was not aware of any list of residents staff should be providing restorative services or routine exercises to. The facility used to have a restorative nursing program, but that was several months ago. There was no current restorative nursing program he/she was aware of. Review of the Training Sign-in Sheet dated 4/2/25 and completed by the PTA, showed CMT Q did not attend the inservice. During an interview on 4/16/25 at 7:15 A.M., CNA R said he/she was not aware of any residents who were on a restorative program. Review of the Training Sign-in Sheet dated 4/2/25 and completed by the PTA, showed CNA R did not attend the inservice. During an interview on 4/16/25 at 7:46 A.M., CNA N said this was his/her third week working at the facility. He/She did not know of any list of residents who required walking or range of motion exercises. Review of the Training Sign-in Sheet dated 4/2/25 and completed by the PTA, showed CNA N did not attend the inservice. During an interview on 4/16/25 at 7:51 A.M., MDS Coordinator M said he/she had been at the facility since 8/2024. The facility had not had a restorative nursing program since he/she had been there. He/She knew the managers had discussed it before in the daily meetings. The facility staff did try to walk some residents to the dining room, but there was no program and no documentation to show it was being done. Review of the Training Sign-in Sheet dated 4/2/25, and completed by the PTA, showed MDS Coordinator M did not attend the inservice. During an interview on 4/17/25 at 10:15 A.M., CMT X said there were no residents with orders to be walked or receive range of motion to his/her knowledge. Review of the Training Sign-in Sheet dated 4/2/25, and completed by the PTA, showed CMT X attended the inservice. During an interview on 4/17/25 at 10:15 A.M., LPN Y said there were no residents with orders to be walked or for range of motion he/she was aware of. Review of the Training Sign-in Sheet dated 4/2/25, and completed by the PTA, showed LPN Y did not attend the inservice. During an interview on 4/16/25 at 7:55 A.M., the Rehab Director said the last time the facility had a restorative nursing program with a restorative assistant to complete resident exercises was about two years ago. During an interview on 4/17/25 at 9:49 A.M., PT W said he/she had worked at the facility for 3 years, and OT V said he/she had worked at the facility for 5 years. PT W said a restorative program was a maintenance program to ensure residents did not lose their independence gained during skilled therapy. A restorative program was important to have. The facility had not had a restorative program for over a year. There had been discussions with management about starting a restorative program, but he/she did not know when it would happen. Both PT W and OT V looked at the list of 16 residents (completed by the Rehab Director) that had received skilled therapy and still resided at the facility. Both said if the facility had a restorative program, they would have referred Resident #525 for ambulation to/from the toilet, #526 for upper/lower body exercises and strengthening, and #527 for ambulation. Both the PT and OT said staff had been inserviced regarding ambulating Resident #527. They would look for the inservice sheet. All three residents were confused and unable to be interviewed. During an interview on 4/17/25 at 4:00 P.M., the Director of Nurses (DON) said she had been at the facility for about one year and there had not been a restorative program since she had been there. Administrator MM said they had not been able to dedicate a CNA to train as a restorative aide because all of their CNAs were needed on the floor to provide care. She thought that skilled therapy was inservicing the CNAs on who needed range of motion and ambulation assistance. They just don't currently have a program in place. Both Administrator MM and the DON acknowledged restorative nursing was important to ensure residents maintained their physical abilities. MO00252419

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with wounds requiring treatments (Resident #10). In addition, the facility failed to ensure staff used good infection control practices for one resident when staff failed to perform hand hygiene and prepared medications with his/her bare hand (Resident #70) and when one resident's catheter bag (a urine drainage bag that attaches to a catheter, (a tube inserted into the bladder to drain urine) was observed on the floor. (Resident #13). The sample was 23. The census was 115. Review of the facility's Enhanced Barrier Precautions (EBP), undated, showed: -Policy: The facility will ensure staff are trained in EBP and will maintain sufficient supplies to support implementation of EBP. EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff's hand and clothing; -EBP are indicated for residents with any of the following: -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; -Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin teras covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to pressure ulcers (Injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or friction); -For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: -Transfers; -Wound care: any skin opening requiring a dressing; -PPE for enhanced barrier precautions is only necessary when performing high-contact activities; -The resident's care plan will address the need for enhanced barrier precautions and will be communicated to caregivers. Review of the facility's Medication Administration Policy, dated 7/1/24 showed: -Medication will be administered by persons licensed or permitted by this state to prepare, administer, and document the administration of medications; -Staff will follow established facility infection control procedures (handwashing, aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection), gloves, isolation precautions, etc.) for the administration of medications, as applicable. Review of the facility's undated Urinary Catheter Care policy, showed: -Policy: The purpose of this procedure is to prevent catheter-associated urinary tract infections; -Infection Control: Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/23/24, showed: -Cognitively intact; -Diagnoses included heart failure, dementia, and Parkinson's disease (the central nervous system and causes movement problems) ; -Resident had one Stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often included undermining and tunneling); -Resident was dependent (helper does all the effort. Resident does none of the effort to complete the activity) on staff for rolling left to right; -Resident was dependent on staff for chair/bed to chair transfers; Review of the care plan, in use at the time of survey, showed: -Focus: resident had impaired skin integrity related to coccyx (tailbone) pimple that evolved into pressure injury (a localized area of skin damage caused by prolonged or severe pressure, friction, shear, or a combination of these factors); -Goal: resident site of impaired skin integrity will be free of signs and symptoms of infection during the review period; -Interventions: apply treatment per medical doctor orders; -The care plan did not show resident required EBP. Observation on 11/22/24 at 10:35 A.M., showed the resident lay in bed. Licensed Practical Nurse (LPN) H and Certified Nurse Aide (CNA) D entered the resident's room and performed hand hygiene and put gloves on. CNA D unfastened the resident's brief and assisted the resident to roll over towards the window. LPN H removed the dressing from the coccyx area and provided wound care. CNA D assisted the resident to roll onto his/her back and fastened the brief. Then, staff attached the mechanical lift cloth to the mechanical lift and transferred the resident from the bed into his/her chair. LPN D did not wear a gown while providing wound care and neither staff member wore a gown while transferring the resident. There was no EBP sign outside the resident's door. During an interview on 11/25/24 at 1:05 P.M., LPN G said residents who had wounds should be on EBP and staff should wear a gown and gloves while providing wound care and direct resident care. Staff would know which residents required EBP by the sign outside their door. During an interview on 11/25/24 at 1:10 P.M., CNA D said he/she knew which residents required EBP from charting, if the resident had a wound or if he/she saw a dressing on the resident, or if the resident was a new admission. He/She would wear a gown, gloves, and a mask anytime he/she encountered the resident. During an interview on 11/25/24 at 3:00 P.M., the Infection Control Preventionist (ICP) said EBP were used for residents who had a chronic wound that was hard to heal, or if the drainage is not contained within the dressing or if the resident had MDRO. Staff knew which residents required EBP because there would be a sign posted outside their door. The ICP was responsible for putting the signs outside the resident's door. Staff should wear gown and gloves when providing high contact care. The resident was not on EBP. Residents who have a Stage four pressure ulcer should be on EBP. During an interview on 11/26/24 at 12:07 P.M., the Director of Nursing (DON) said she expected staff to wear gown and gloves while providing wound care and performing high contact care and she expected staff to follow the facilities polices and procedure. The facility would place EBP signs out for all residents who had treatments regardless of the stage of the wound. 2. Review of Resident #70's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included heart disease, high cholesterol, aphasia (difficulty speaking), stroke, hemiplegia/hemiparesis (weakness of one side of the body), anxiety disorder and asthma. Review of the resident's Medication Administration Record (MAR), dated 11/2024, showed: -Aspirin EC (enteric coated) (used to prevent heart attack or stroke) tablet delayed release 81 milligrams (mg), give 1 tablet by mouth one time a day for deep vein thrombosis (DVT, blood clot in a deep vein, usually in the legs); -Bupropion HCl ER (anti-depressant) oral tablet extended release 12-hour 200 mg, give 1 tablet by mouth one time a day for depression; -Cephalexin (antibiotics) oral tablet 250 mg by mouth one time a day for preventive for urinary tract infection (UTI); -Cholecalciferol (Vitamin D) oral tablet, give 50,000 unit by mouth one time a day every Monday for Vitamin D deficiency for 10 weeks; -Fluticasone Propionate Suspension 50 micrograms/actuation (mcg/act) (nose spray for allergies) 1 spray in each nostril one time a day for allergies; -Isosorbide Mononitrate ER (used to treat chest pain and high blood pressure) tablet extended release 24 hours 60 mg, give 1 tablet for hypertension; -Lamotrigine (anti-depressant) tablet 25 mg, give 1 tablet by mouth one time a day for depression; -Lidoderm External Patch 5% (Lidocaine, pain reliever), apply 1 patch one time a day for osteoarthritic discomfort, morning on to right knee, remove at 8:00 P.M.; -Melatonin (used to help sleep) tablet 3 mg, give 1 tablet by mouth at bedtime for insomnia; -Omega-3 Fatty Acids (healthy fat supplement) capsule 1000 mg, give 1 capsule by mouth one time a day for supplement; -Pantoprazole Sodium tablet delayed release 40 mg, give 1 tablet by mouth one time a day for GERD (gastroesophageal reflux disease, when acid from your stomach backs up into the esophagus); -Sertraline HCl (anti-depressant) tablet 50 mg, give 1 tablet by mouth one time a day for depression; -Umeclidinium-Vilanterol Inhalation Aerosol Powder Breath Activated 62.5-25 mcg/act, 1 puff inhale orally one time a day for chronic obstructive pulmonary disease (COPD, lung disease that makes it difficult to breathe); -Divalproex Sodium (can treat seizures) capsule delayed release sprinkle 125 mg, give 4 capsules by mouth two times a day for epilepsy (seizures); -Gabapentin (can treat seizures and pain) capsule 300 mg, give 1 capsule by mouth two times a day for pain; -Levetiracetam (anti-seizures) tablet 250 mg, give 1 tablet by mouth two times a day for anticonvulsant; -Acetaminophen (pain reliever, fever reducer) tablet 500 mg, give 2 tablets by mouth three times a day for pain; -Baclofen (muscle relaxant) tablet 10 mg, give 1 tablet by mouth four times a day for muscle spasms; -ProAir HFA Inhalation Aerosol Solution 108 (90 Base) mcg/act (Albuterol Sulfate inhaler) 2 puff inhale orally every 6 hours as needed for shortness of breath (SOB) or wheezing related to COPD; -Sumatriptan Succinate (treats migraine headache) oral Tablet 50 mg, give 1 tablet by mouth every 2 hours as needed for migraine; -Tramadol HCl (can treat moderate to severe pain) oral tablet 50 mg, give 100 mg by mouth every 12 hours as needed for pain. Observation on 11/21/24 at 9:47 A.M., showed Registered Nurse (RN) J prepared medications for the resident. The RN pulled and popped the medications from the bubble cards and poured bottled stock medications into his/her right hand and placed them onto his/her bare left hand. RN J repeated this process with all seventeen pills. RN J did not perform hand hygiene prior to handling the medications. During an interview on 11/26/24 at 11:17 A.M., LPN H said hand hygiene should be done prior to handling medications and in between residents' medication administration. The medications should be popped directly to the cup prior to administering to residents. During an interview on 11/26/24 at 12:07 P.M., the DON said she expected staff to perform hand hygiene and not handle medications with bare hands prior to administering them to residents. 3. Review of Resident #13's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Required partial assistance for toileting hygiene; -Indwelling catheter (a thin, hollow tube that's inserted into the bladder through the urethra to drain urine); -Diagnoses included heart disease, end stage renal failure and neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve problems). Review of the resident's November 2024 physician's orders, showed an order, dated 11/15/24, Resident has a urinary catheter. Catheter care to be provided every shift and as needed. Review of the resident's care plan, initiated 11/16/24, in use during the time of the investigation, showed: -Focus: The resident has a catheter; -Goal: The resident will be/remain free from catheter-related trauma. The resident will show no signs of urinary infection; -Interventions: Change catheter per physician's order. Evaluate as needed for possible removal of catheter and bladder retraining or toileting plan. Observation and interview on 11/20/24 at approximately 11:33 A.M., showed the resident lay on his/her back in bed. The resident's catheter bag lay directly on the floor, to the right of the resident's bed. The resident said he/she did not know if the catheter bag was supposed to be directly on the floor. Observation on 11/21/24 at 9:51 A.M., showed the resident lay in bed with his/her eyes closed. The catheter bag lay directly on the floor, to the right of the resident's bed. During an interview on 11/26/24 at 11:35 A.M., CNA C said catheter bags should be kept off the floor to prevent contamination. If he/she noticed a catheter bag on the floor, he/she would notify the nurse immediately. During an interview on 11/26/24 at 11:17 A.M., LPN H said catheter bags should not lay directly on the floor due to contamination and infection control. During an interview on 11/26/24 at 12:07 P.M., the Administrator and DON said catheter bags should be kept off the floor to prevent contamination and for infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff adequately supervised residents during medication administration and/or assessed residents to self-administer medications and/or keep medications at their bedside (Residents #54, #61, #17, #81, #29, #88 and #92). The sample was 23. The census was 115. Review of the facility's undated Medication Administration Policy, showed: -Policy: the facility is committed to establishing and maintaining processes that promote safe medication administration; -Medications will be administered by the person licensed or permitted by the state to prepare, administer, and document the administration of medications; -The Director of Nursing (DON) services will supervise and direct all nursing personnel who administer medications and/or have related functions; -Medications will be administered in accordance with the orders, including any required time frames; -Residents may self-administer their own medications only if the attending practitioner, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of the facility's undated Self-Administration of Medications and Treatments Policy, showed: -Policy: residents have the right to self-administer medications / treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; -As part of the overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities and choice to determine whether self-administering medications and/or treatments is clinically appropriate for the resident; -If the team determines that a resident cannot safely self-administer medications/treatments, the nursing staff will administer the resident's medications; -The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications/treatments; -Self-administered medications and/or treatment supplies will be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. -Staff shall identify and give to the licensed nurse any medications/treatment supplies found at the bedside that are not authorized for self-administration, for return to the family or responsible party. 1. Review of Resident #54's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/26/24, showed: -Cognitively intact; -Diagnoses included anemia, hypertension (high blood pressure), renal failure, diabetes, hyperlipidemia (high level of lipids in the blood), hyperkalemia (high potassium), other fracture, hemiplegia (partial or complete paralysis on one side of the body), anxiety and depression; -Currently taking hypnotic, antidepressant and antiplatelet medications. Review of the resident's care plan, in use during survey, showed: -Focus: Resident is at risk for falls related to fracture of left femur with weight bearing restrictions, history of stroke, history of falls, end stage renal disease (ESRD) with dialysis; -Interventions: Monitor for side effects of narcotic pain medications which may increase risk for falls; -Focus: Resident has anemia related to ESRD; -Interventions: Give medications as ordered. Monitor for side effects, effectiveness; -Focus: Resident has arthritis of the bilateral knees; -Intervention: Give analgesics (pain reliever) as ordered by the physician. Monitor and document for side effects; -Focus: Resident has an alteration in Musculoskeletal status related to fracture of the lumbar transverse process (a type of spinal fracture), left tibia (shin bone) non-displaced fracture; -Interventions: Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness; -Focus: Resident is on antiplatelet therapy; -Interventions: Administer antiplatelet (prevent blood clots) medications as ordered by physician. Monitor for side effects and effectiveness every shift; -Focus: Resident is on pain medication therapy related to headaches and recent fracture; -Interventions: Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness every shift; -Focus: Resident uses antidepressant medication related to depression; -Intervention: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift; -Focus: Resident has potential for pressure injury development related to immobility due to recent fracture, weight bearing limitations, knee brace; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; -No documentation of self-administration of medications, assessed to self-administer medications, or allowed to keep medications at bedside. Review of the resident's Physician's Orders Sheet (POS), dated November 2024, showed: -An order, dated 10/5/24, Lexapro (treat depression and anxiety) oral tablet 20 milligram (mg). Give one tablet by mouth one time a day for depression; -An order, dated 10/5/24, Minoxidil (treat high blood pressure) oral tablet. Give 2.5 mg by mouth two times a day for hypertension; -An order, dated 10/5/24, Plavix (prevents stroke and heart attacks) oral tablet 75 mg. Give 75 mg by mouth one time a day for stroke; -An order, dated 10/5/24, Protonix (treat acid reflux) oral tablet delayed release 40 mg. Give one tablet by mouth one time a day for gastroesophageal reflux disease (GERD, acid reflux); -An order, dated 10/5/24, Rocaltrol (treat low calcium and psoriasis) oral capsule 0.5 microgram (mcg). Give two capsules by mouth one time a day every Monday, Wednesday, and Friday; -An order, dated 10/5/24, Cozaar oral tablet (treat high blood pressure) 100 milligram (mg). Give one tablet by mouth one time a day for hypertension; -An order, dated 10/21/24, Doxazosin Mesylate tablet (treat urinary problems and high blood pressure) 8 mg. Give one tablet by mouth two times a day for hypertension; -An order, dated 10/21/24, Hydralazine (treat high blood pressure) HCI oral tablet 100 mg. Give one tablet by mouth three times a day for hypertension; -An order, dated 10/21/24, Labetalol (treat high blood pressure) HCL oral tablet 200 mg. Give two tablets by mouth, three times a day for hypertension; -An order, dated 10/21/24, Nifedipine (treat high blood pressure and chest pain) extended release (ER) oral tablet extended release 24-hour 90 mg. Give one tablet by mouth two times a day for hypertension; -An order, dated 10/21/24, Tums (antacid) oral tablet chewable 500 mg. Give 2.5 tablet by mouth one time a day; -No physician's order to self-administer medications or leave medications at bedside. Review of the resident's Medication Administration Record (MAR), dated 11/21/24, showed: -An order, dated 10/5/24, Lexapro oral tablet 20 mg. Give one tablet by mouth one time a day for depression was administered as ordered; -An order, dated 10/5/24, Minoxidil oral tablet. Give 2.5 mg by mouth two times a day for hypertension was administered as ordered; -An order, dated 10/5/24, Plavix oral tablet 75 mg. Give 75 mg by mouth one time a day for stroke was administered as ordered; -An order, dated 10/5/24, Protonix oral tablet delayed release 40 mg. Give one tablet by mouth one time a day for gastroesophageal reflux disease was administered as ordered; -An order, dated 10/5/24, Cozaar Oral tablet 100 mg. Give one tablet by mouth one time a day for hypertension was administered as ordered; -An order, dated 10/21/24, Doxazosin Mesylate tablet 8 mg. Give one tablet by mouth two times a day for hypertension was administered as ordered; -An order, dated 10/21/24, Hydralazine HCI oral tablet 100 mg. Give one tablet by mouth three times a day for hypertension was administered as ordered; -An order, dated 10/21/24, Labetalol HCL oral tablet 200 mg. Give two tablets by mouth, three times a day for hypertension was administered as ordered; -An order, dated 10/21/24, Nifedipine ER oral tablet extended release 24-hour 90 mg. Give one tablet by mouth two times a day for hypertension was administered as ordered; -An order, dated 10/21/24, Tums oral tablet chewable 500 mg. Give 2.5 tablet by mouth one time a day was administered as ordered. Observation on 11/21/24 at 10:13 A.M., showed the resident in the wheelchair in his/her room. The resident's head was down, and eyes were closed. There was a small medication cup on the night table that contained approximately ten pills inside. Observation on 11/21/24 at 11:57 A.M., showed the resident in wheelchair in his/her room. The resident was awake but did not speak. The resident looked up and put his/her head back down. There was a small medication cup on the night table that contained two pink pills and one blue. One of the pink pills appeared to be broken in half. At 1:22 P.M., the medication cup with two pink pills and one blue pill was on the night table. During an interview on 11/25/24 at 12:21 P.M., Registered Nurse (RN) B said the resident is able to administer his/her own medications. RN B gives the resident the medication and he/she takes it. RN B leaves them in the room sometimes but will check on him/her later to ensure he/she took them. RN B said they watch the residents take the medications, so it is an indication they are able to self-administer. During an interview on 11/26/24 at 12:06 P.M., the Director of Nursing (DON) said the resident would not be appropriate to self-administer medications and should not have medications left at bedside. 2. Review of Resident #61's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included chronic obstructive pulmonary disease (COPD, chronic lung disease). Review of the care plan, in use at the time of survey, showed: -Focus: resident has shortness of breath (SOB) related to COPD; -Interventions: did not show use of inhaler; -No documentation of self-administration of medications, assessed to self-administer medications, or allowed to keep medications at bedside. Review of the order summary report, dated 11/21/24, showed: -An order for Trelegy Ellipta Inhalation Aerosol powder 100-62.5-25 micrograms (mcg)/asthma control test (ACT, inhaler used to treat asthma and COPD) inhale one puff once daily for SOB; -An order for: Ventolin hydrofluoroalkane (HFA, type of propellant used in some inhalers)/inhalation aerosol solution 108 mcg/act (rescue inhaler that works quickly to relieve breathing problems), inhale two puffs every six hours as needed for SOB/wheezing related to COPD; -No physician's order to self-administer medications or leave medications at bedside. Observation on 11/21/24 at 10:08 A.M., showed RN B went into the resident's room with the Trelegy inhaler in his/her hand. The resident said he/she had his/her Trelegy inhaler in his/her room and got the inhaler. The nurse told the resident he/she was going to take the inhaler and put it on the cart. The resident said he/she also had a rescue inhaler in his/her room and he/she was not going to give it up. I want my inhalers in my hand, I am not going to be gasping for air while waiting for someone to come. They are short staffed or busy. I want my inhalers in my hand. The resident said he/she has had the inhalers in his/her room for 6 months and he/she used the rescue inhaler a couple times a day depending on how active he/she was. RN B said he/she would talk with the nurse manager about it and removed both Trelegy inhalers from the room. Observation on 11/22/24 at 9:00 A.M., showed the resident was in his/her room and there was a rescue inhaler was on the overbed table next to the bed. The resident said he/she used the inhaler during the night and again said he/she was not going to give up the inhaler. 3. Review of Resident #17's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included dementia and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: resident used psychotropic medications related to major depressive disorder; -Interventions: administer psychotropic medication as ordered by physician. Monitor for side effects and effectiveness every shift; -No documentation of self-administration of medications, assessed to self-administer medications, or allowed to keep medications at bedside. Review of the order summary report, dated 11/22/24, showed: -An order for Aripiprazole (medication used to treat certain mental/mood disorders such as bipolar disorder and schizophrenia) 10 mg, give one tablet daily for major depression; -No physician's order to self-administer medications or leave medications at bedside. Review of the MAR, dated 11/20/24, showed: -An order for Aripiprazole 10 milligrams, give one tablet daily for major depression, showed the medication was administered. Observation on 11/20/24 at approximately 12:15 P.M., showed the resident lying in bed with the overbed table next to the bed. On the over bed table was half of a white pill in a clear medication cup and a cup with approximately one inch of water in it. The resident said he/she did not know what the pill was and maybe it did not come out of the cup. Observation and interview on 11/20/24 at 12:20 P.M. RN E said he/she did not know what the half pill was. RN E took the pill to the medication cart and checked the pill with the pills on the medication cards. RN E identified the medication as Aripiprazole 10 mg. RN E said when he/she punched the pill out this morning, it must have broken in half and when he/she administered the medication this morning, half of pill must have been left in the cup. The nurse went into the resident's room and administered the half of pill. RN E said the resident cannot self-administer his/her own medications. 4. Review of Resident #81's medical record, showed: -Severe cognitive impairment; -Diagnosis included Covid. Review of the resident's care plan, in use at the time of survey, showed: -No documentation of self-administration of medications, assessed to self-administer medications, or allowed to keep medications at bedside. Review of the order summary report, dated 11/25/24, showed: -An order for: guaifenesin 100 mg/5 milliliters (ml), give 10 ml every six hours for cough; -No physician's order to self-administer medications or leave medications at bedside. Review of the MAR, dated 11/1/24 through 11/26/24, showed: -An order for: guaifenesin 100 mg/5 mL, give 10 mL every six hours for cough. One dose of guaifenesin was administered on 11/18/24 at 5:30 P.M. Observation on 11/25/24 at 12:58 P.M., showed a bottle of diabetic guaifenesin on the nightstand, in the resident's room. During an interview on 11/25/24 at 1:15 P.M., the resident said he/she was taking the cough syrup a couple times a day. The staff brings a little cup into the room and poured the medication in and he/she would take it. During an interview on 11/25/24 at 1:25 P.M., Licensed Practical Nurse (LPN) G said the resident cannot have guaifenesin at his/her bedside and he/she would remove it from the room. The resident's family probably brought the medication in and left it at the beside. 5. Review of Resident #29's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure and heart failure. Review of the resident's care plan, in use at the time of survey, showed: -Focus: resident is on diuretic therapy (water pill) related to fluid overload; -Interventions: administer diuretic medication as ordered by the physician. Monitor for side effects and effectiveness every shift; -No documentation of self-administration of medications, assessed to self-administer medications, or allowed to keep medications at bedside. Review of the order summary report, dated 11/25/24, showed: -An order for: Lasix (diuretic) 20 mg, give one tablet twice daily for congestive heart failure (CHF); -No physician's order to self-administer medications or leave medications at bedside. Review of the MAR, dated 11/20/24, showed: -An order for Lasix 20 mg, give one tablet twice daily for CHF, showed the medication was administered. Observation and interview on 11/20/24 at approximately 1:00 P.M., showed a white pill on the nightstand next to the resident's bed. The resident said the pill was Lasix and it was given to him/her to take before going to a function this afternoon so he/she would not be interrupted. 6. Review of Resident #88's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis included COPD. Review of the care plan, in use at the time of survey, showed: -Focus: resident has SOB related to COPD; -Interventions: Administer puffers (inhalers) and nebulizers (a small machine that turns liquid medicine into a mist that can be inhaled through a mouthpiece or mask) as ordered; -No documentation of self-administration of medications, assessed to self-administer medications, or allowed to keep medications at bedside. Review of the order summary report, dated 11/25/24, showed: -An order for: Budesonide Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg/ACT (inhaler used to treat asthma and COPD), inhale two puffs twice daily for COPD, rinse mouth with water and spit back into cup after use; -No physician's order to self-administer medications or leave medications at bedside. Observation and interview on 11/20/24 at approximately 1:00 P.M., showed a Breyna (budesonide and formoterol fumarate) box with an inhaler in it. The resident said he/she used the inhaler. Review of the MAR, dated 11/21/24 through 11/25/24, showed: -An order for: Budesonide Formoterol Fumarate Inhalation Aerosol 80-4.5 mcg/act, inhale two puffs twice daily for COPD, rinse mouth with water and spit back into cup after use; showed the medication was administered twice daily. Observation on 11/21/24 at 11:40 A.M., 11/22/24 at 4:25 A.M., and 11/25/24 at 12:10 P.M., showed the Breyna box with the inhaler in it, remained on the overbed table. 7. Review of Resident #92's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnosis included COPD. Review of the care plan in use at the time of survey, showed: -Focus: resident has altered respiratory status/difficulty breathing related to COPD; -Interventions: Administer medication/puffers as ordered. Monitor for effectiveness and side effects; - No documentation of self-administration of medications, assessed to self-administer medications, or allowed to keep medications at bedside. Review of the order summary report, dated 11/25/24, showed: -An order for: Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act, inhale two puffs every four hours as needed for treat or prevent bronchospasm related to COPD; -No physician's order to self-administer medications or leave medications at bedside. Review of the MAR, dated 11/20/24, showed: -An order for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act, inhale two puffs every four hours as needed for treat or prevent bronchospasm related to COPD, showed the medication was not administered. Observation and interview on 11/20/24 at 2:20 P.M., showed an albuterol inhaler on the overbed table next to the resident's bed. The resident said he/she used the inhaler when he/she needed it. 8. During an interview on 11/25/24 at 1:00 P.M., Certified Medication Technician (CMT) F said when he/she administered medication, he/she would check the medication with the physician order, prepare the medication and administer the medication to the resident. He/She would stay with the resident to be sure the resident took the medication. No residents on the third floor were able to self-administer their medications. 9. During an interview on 11/25/24 at 1:25 P.M., LPN G said no residents on the floor could self-administer their medications and staff should not leave medications with the residents. 10. During an interview on 11/25/24 at 12:23 P.M., LPN K said residents who want to self-administer their own medications would need to be alert and oriented times four (person, place, time and situation), and they would need a physician order. The nurse did not know where the documentation would be for residents who wanted to self-administer their own medications. Resident #61 could self-administer his/her own rescue inhaler. 11. During an interview on 11/25/24 at 12:35 P.M., RN B said when he/she administered medications he/she would stay with the resident to ensure they took their medications. If a resident wanted to self-administer their medications, RN B would need to talk to the nurse manager about it. The nurse would assess the resident to be sure they were alert and oriented times four and they were capable of doing their own medications/inhalers safely. Resident #61 can self-administer his/her inhalers and Resident #88 should be able to. 12. During an interview on 11/25/24 at 3:00 P.M., the DON said she expected staff to stay with the resident while they take their medications. No residents in the facility can self-administer their own medications and there should be no medications left at the bedside. Rescue inhalers should be kept on the medication cart. 13. During an interview on 11/26/24 at 12:07 P.M., the Administrator said there was no residents who self-administer their medications. He expected staff to stay with the residents until their medications were consumed and he expected staff to follow the facility's policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate Resident #524's injury of unknown origin. An x-ray confirmed a right femur/hip fracture on 3/15/25 and the resident was sent to a hospital for evaluation and treatment. In addition, the facility failed to interview all staff with knowledge of Resident #504's fall from bed, which caused a laceration above the resident's right eye, and failed to interview residents and staff after one Certified Nursing Assistant (CNA) allegedly cursed at Resident #507, and failed to investigate Resident #502's left upper and back arm bruises. This deficient practice affected four out of 30 sampled residents. The census was 114. Review of the facility's Abuse policy and procedure dated 11/22/23, showed: Definitions: -Injuries of unknown source - An injury should be classified as an injury of unknown source when ALL of the following criteria are met: The source of the injury was not observed by any person. The resident could not explain the source of the injury. The injury is suspicious because of: The extent of the injury, or the location of the injury, or the number of injuries observed at one particular point in time; -Neglect is defined as the failure of the facility, its employees or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress; -Mistreatment is defined as inappropriate treatment or exploitation of a resident; -Identification: -Injuries of Unknown Source: Injuries of unknown source that meet the criteria for reporting may include, but are not limited to: Unobserved/Unexplained fractures, sprains, or dislocations. Unobserved/Unexplained patterned bruises that suggest hand marks or finger marks, or bruising pattern caused by an object. Unobserved/Unexplained bilateral bruising to arms, bilateral bruising of the inner thighs, wrap around bruises that encircle the legs, arms or torso, and multicolored bruises which would indicate that several injuries were acquired over time; -Neglect: Alleged violations of neglect include cases where the facility demonstrates indifference or disregard for resident care, comfort, or safety, resulting in physical harm, pain, mental anguish, or emotional distress. Review of the facility Accidents and Incidents - Investigating and Reporting policy and procedure, undated, showed: -Definitions: Accident; refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident; -Avoidable Accident; means that an accident occurred because the facility failed to: -Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; -Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; -Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of accident; -Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice; -Policy: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator; -Specific Procedures/Requirements: -The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly report the accident to the Administrator/designee and will initiate and document investigation of the accident or incident; The following data, as applicable, shall be included on the Report of incident/Accident form: -The date/time the accident or incident took place; -The nature of the injury/illness (e.g.; bruise, fall, nausea, etc.); -The circumstances surrounding the accident/incident; -Where the accident or incident took place; -The name(s) of witnesses and their accounts of the accident/incident; -The condition of the injured person; -Any corrective action taken; -Follow-up information; -The signature and title of the person completing the report. 1. Review of the Resident #524's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/23/25, showed: -Severely cognitively impaired; -Adequate hearing and vision; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Behaviors (physical and verbal) frequency: One to three days; -Rejection of care frequency: One to three days; --Diagnoses of weakness, cognitive communication deficit, unspecified dementia, age related osteoporosis (a condition where bones become weakened and brittle, increasing the risk of fractures, particularly in the hip, spine, and wrist), muscle weakness and heart failure. Review of the resident's speech therapy notes, dated 3/14/25 at 10:06 A.M., showed the resident verbalized pain in the right hip area. The medication technician was notified. Review of the resident's progress notes, showed: -On 3/14/25 at 1:56 P.M., the nurse practioner (NP) saw the resident seated in his/her wheelchair down in the dining room and in no acute distress. Therapy asked the NP to see the resident. Resident was noted to be screaming out and would not let anyone move his/her right lower extremity (RLE). It was significantly swollen and tender to palpation (touch) during the exam; -At 7:15 P.M., CNA D informed Licensed Practical Nurse (LPN) GG the resident was having increased right leg pain. Upon assessment, the resident was noted to have right hip pain radiating to his/her right knee. When staff assisted the resident to bed, the resident was noted to have right foot external rotation (the hip joint can have a limited range of internal rotation, leading to the foot turning out as a compensation) and was unable to tolerate bending his/her right knee. When attempted, the resident grabbed his/her right hip and yelled, Ouch! No discoloration noted to his/her right hip or knee. Bi-lateral lower extremity (BLE) edema noted. Staff stated the resident had increased swelling to his/her BLE. When assessing his/her right hip, the resident once again responded to any movement with Ouch! It was previously noted that morning on the nurse's station by the unit manager that a Stop and Watch (staff communication form) was presented by the physical therapist. The resident had no noted recent fall or trauma noted to the right leg or knee and denied hitting his/her knee or leg when asked. There was an order noted in the resident's electronic medical record by the nurse practioner to obtain an X-ray of the right hip related to complaints of pain. LPN GG called the unit manager to inform him/her of the resident's complaint of pain. The unit manager said he/she was aware and informed the nurse an X-ray order was to be placed per previous conversations in the day prior to his/her leaving for the day. The order was noted and the LPN placed the order with the X-ray company at that time; -At 9:40 P.M., the X-ray company at the facility to obtain x-rays of the right hip. Staff called the resident's family member to inform them of the resident's complaints of pain. The Director of Nursing called the facility to check on everyone due to the weather and the nurse informed her of the X-ray obtained due to the resident's pain in right hip; -On 3/15/25 at 2:35 A.M., the X-ray company informed the nurse of critical X-ray results. Findings: Acute intertrochanteric fracture (a broken hip that occurs between the greater and lesser trochanters of the femur- the thighbone) noted. At 2:42 A.M., the nurse called the physician's office and left a message. At 2:59 A.M., the nurse called the physician's office and informed the NP of the X-ray results. The NP gave an order to send the resident to the emergency room (ER) for evaluation and treatment. At 3:30 A.M., staff placed a call to 911 for a non-emergent transfer to the hospital. At 4:00 A.M., emergency medical services (EMS) at facility to transport the resident to the hospital. At 11:03 A.M., the resident was admitted to the hospital with a closed fracture of the right femur; -At 4:46 P.M., the unit manager noted therapy brought the nurse a form he/she filled out for a change in condition from yesterday's therapy saying the resident's leg was warm, red and swollen. The nurse was actually walking out of his/her office for an appointment and passed this information on to the Director of Nursing (DON). Review of the undated incident report prepared by LPN/Nurse manager FF showed: -Date 3/14/25 at 12:00 A.M.; -Incident location: Resident's room; -Predisposing physiological factors: Other (describe); -Other info: Arthritis and osteoporosis; -Statements: No statements found; -Agencies/People notified: -Administrator on 3/15/25 at 4:44 P.M.,; -Director of Nursing on 3/15/25 at 4:13 A.M.; -LPN/Nurse Manager (FF) on 3/15/25 at 2:41 A.M.; -Physician on 3/14/25 at 4:39 P.M. Observation and interview on 4/15/25 at 5:30 A.M., showed the resident lay in bed yelling out Help me, Help me! The resident pointed to his/her right side and said it hurt. He/She did not remember how he/she hurt his/her hip. During interviews on 4/16/25 at 12:45 P.M. and on 4/17/25 at 9:15 A.M., CNA D said the resident was yelling out that morning (3/14/25), and he/she went into the room to check on the resident and get him/her up for the day. The resident was wet. Usually the CNA would get the resident up and take him/her to the bathroom. The resident could stand on his/her own and would transfer to his/her wheelchair with assistance. When the CNA went to help the resident out of bed, he/she yelled out in pain. He/She could not stand on his/her own and the CNA put him/her back into the bed and changed him/her. The resident's leg looked swollen, so he/she went to the certified medication technician (CMT) E and told him/her the resident was complaining of pain and needed some pain medication. The CNA got another staff member to assist him/her with getting the resident out of bed because the resident could not stand on his/her own or assist with the transfer. The CNA got the resident dressed and took him/her to the dining room. The resident got therapy in the morning so he/she asked the physical therapist (PT) to assess the resident to make sure he/she was able to do therapy. The PT assessed the resident and decided he/she could not do therapy and left. The PT did not say anything else to the CNA about the resident. The NP came down later and assessed the resident but did not say anything to him/her about what to do with the resident. The CNA thought a nurse came down but could not remember the nurse's name. He/She did not know the resident's hip was broken because the resident always yelled out throughout the day and he/she thought this was just his/her usual behavior. After dinner, the CNA decided to put the resident to bed first, before the other residents. He/She got another aide to help him/her since the resident could not help with transferring that morning. When they went to transfer the resident into bed, he/she yelled out again in pain and needed more pain medication. The nurse immediately came and assessed him/her and ordered an x-ray. During interviews on 4/17/25 at 9:35 A.M., the DON said she was notified that night about the resident's hip being injured but did not tell the staff to begin an investigation. She did not know why she did not direct the staff to investigate the incident. The nurse manager did investigate the injury of unknown origin by talking to the staff who worked but did not document any of these interviews. They filled out an incident report. The staff interviews should have been included in the investigation. During an interview on 4/17/25 at 1:10 P.M., Administrator MM said he/she could not find an investigation for the resident with statements. All he/she could find was the incident report. The staff are supposed to investigate and report all injures of unknown origin. He/She thought the incident occurred because staff were not using a gait belt properly, and they in-serviced all of the staff on gait belts after the incident. 2. Review of Resident #504's quarterly MDS dated [DATE], showed: -admission date of 5/13/24; -Speech Clarity: No speech - absence of spoken words; -Makes Self Understood: Rarely/never understood; -Ability To Understand Others: Sometimes understands - responds adequately to simple, direct communication only; -Severely impaired cognition; -Functional Limitation in Range of Motion: No impairments; -Mobility Devices: Wheelchair; -Diagnoses of anemia (the blood has a reduced ability to carry oxygen), aphasia (inability to speak ), and hemiplegia (paralysis of one side of the body) or hemiparesis (weakness of one side of the body); -Any Falls Since admission or Prior Assessment: Yes; -Number of Falls Since admission or Prior Assessment: Two or more with no injuries; -Bed rail, bed alarm, floor mat alarm: Not used. Review of the resident's care plan, located in the electronic healthcare record (EHR), showed: -Date Initiated: 8/7/24: Focus: At risk for falls related to muscle weakness and impaired cognition, unaware of safety needs. The resident has had an actual fall: 7/7/24, 7/12/24, 8/13/24, 9/13/24, 9/14/24, 9/15/24, 11/3/24, 1/21/25, 1/25/25, 2/7/25, 3/10/25, 3/22/25, 3/25/25, 3/31/25, and 4/3/25. Goal: Will be free from falls. Interventions/Tasks: anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; -Date initiated: 10/28/24: Focus Impaired cognitive function or impaired thought processes. Goal: Will maintain current level of cognitive function. Interventions/Tasks: Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion; -The care plan did not address keeping the resident's bed in the lowest position or the use of floor mats when in bed and unattended. Review of the resident's progress notes, located in the EHR, showed: -4/3/25 at 5:18 P.M., and documented by LPN S: This nurse made aware that resident fell on floor from bed while CNA Z was in room cleaning him/her up for dinner. Laceration to right eyebrow noted. Resident unable to state what happened. Pain noted to right forehead. Resident was transferred back to bed. Family and physician notified. Order to send resident to hospital for evaluation; -4/3/25 at 5:19 P.M., and documented by LPN S: This nurse went to call 911 for the first fall and resident managed to roll onto the floor mat before emergency medical services (EMS) arrived. Resident was assessed, no further injuries noted. Resident was then transferred to hospital for evaluation. Review of the hospital records, dated 4/3/25 at 7:16 P.M., showed: -Resident presents to the emergency department (ED) after falling out of bed just prior to arrival in ED. The resident has a history of stroke affecting the right side of his/her body. He/She does not currently speak. It sounds as though the staff at the nursing facility were trying to move him/her with a hoyer lift (a mechanical device used to transfer residents unable to bear weight) and some how he/she fell out of bed during the process. He/She has a small wound to his/her right forehead region that is not currently bleeding; -Physical Exam: Small contusion noted to right forehead region with small wound (2 centimeters). On 4/4/25 at 7:16 A.M., facility Administrator MM reported the following to the Department of Health and Senior Services (DHSS): -At approximately 5:00 P.M. on 4/3/25, the resident was sent to the hospital via EMS after a fall from bed resulting in a skin laceration above the right eye. At approximately 9:30 P.M. on 4/3/25, the Administrator was notified by the DON that the nurse at the hospital wanted to speak to someone from the facility. Nurse (hospital) was concerned that per the report from EMS, CNA reported the resident was in bed and he/she went into the resident's bathroom that is located inside the resident's room. Administrator and DON to start investigation immediately; -During an interview on 4/4/25 at 8:15 A.M., Administrator MM said the resident had a diagnosis of stroke, he/she cannot talk and has no safety awareness. The resident wiggles a lot. They sent the resident to the hospital, and he/she has a laceration above the eye/right forehead. The hospital thinks the resident fell twice and fell out of the hoyer lift. The CNA put the resident in bed and went to the bathroom, unknown if the floor mat was down yet. Resident has fallen out of bed before. The Administrator did not know if there was a misunderstanding about the two falls. The nurse on duty was the MDS nurse. Investigation is underway. Review of the facility investigation dated 4/8/25, showed: -On 4/3/25 at 5:19 P.M., the resident's CNA (CNA Z) went to assist the resident with changing his/her soiled brief. He/She assessed the resident and went to the bathroom to gather supplies. As the CNA returned from the bathroom, the resident was noted on the floor and had rolled out of bed sustaining a head laceration. Upon interview with CNA Z, he/she confirmed the bed was in the low position. The resident was assessed by the nurse (LPN S) and assisted the staff placing the resident back to bed. As the LPN went to call 911, when he/she returned to the room the resident had rolled out of the bed again onto the floor mat. The resident was sent out to the hospital and was admitted for placement as the resident's spouse did not want the resident to return. A thorough investigation was conducted and there was no reason to support that any abuse or neglect occurred; -Review of CNA AA's written statement dated 4/4/25, showed: He/She does not know anything about the resident's fall. He/She was taking care of another resident while this occurred. CNA Z did notify him/her about the fall; -Review of CNA Z's telephone statement dated 4/8/25, and written by the Assistant Director of Nurses (ADON), showed: The resident was combative during care and he/she was not sure why until the resident had a bowel movement. The bed was at the low position when he/she went to the resident's bathroom to get what he/she needed to get him/her clean. When in the bathroom, he/she heard a loud noise. The CMT who was on the floor with him/her asked if the resident had fallen, CNA Z responded yes the resident fell; -The investigation did not include a statement from LPN S or the CMT that CNA Z referred to in his/her statement; -Follow up actions include: The clinical staff will be re-educated on the facility's fall protocol, including staff's responsibilities when a fall occurs. During a telephone interview on 4/16/25 at 9:38 A.M., LPN S said CNA Z notified him/her the resident had fallen out of bed on 4/3/25 at 5:18 P.M. He/She went straight to the resident's room and found the resident lying on the bare floor with a laceration above his/her right eye. The CNA said he/she was in the resident's bathroom when the resident fell out of bed. The CNA did not say anything about the resident being combative. There was a hoyer lift at the foot of the bed and the resident was dressed and ready to be gotten up. The bed height was hip high. The bed was not in the lowest position, and there was no mat next to the bed. The resident is a high fall risk having fallen several times in the past. The resident should not have been left unattended without the bed in the lowest position and a floor mat on each side of his/her bed. The resident is too confused to communicate. He/She completed a risk assessment form that should be in the resident's EHR. He/She also wrote a statement and put it in one of the offices. During an interview on 4/16/25 at 12:13 P.M., Administrator MM said the resident is a high risk to fall with a history of falls. All staff are aware the resident is a fall risk. When the resident is in bed and unattended, he/she expected the bed to be in the lowest position with a mat next to the bed. He/She did not interview LPN S as part of his/her investigation. Had he/she known the bed was not in the lowest position and there was no mat on the floor, he/she would have definitely spoken to the CNA about the resident's fall prevention interventions. He/She did not know who the CMT was that CNA Z referred to in his/her written statement, so the CMT was not interviewed. He/She would look for the written statement LPN said he/she left in one of the offices and the risk assessment the LPN said he/she completed. Administrator MM expected staff to follow the facility policies. During an interview on 4/21/25 at 3:15 P.M., Administrator MM said he/she could not find the written statement LPN S said he/she left in the office. He/She would look for the risk assessment the LPN said he/she completed. 3. Review of Resident #507's quarterly MDS dated [DATE], showed: -Diagnoses included coronary artery disease (heart disease), high blood pressure, anxiety, depression, and asthma; -Cognitively intact; -No physical or verbal behaviors. Review of the resident's care plan, in use during survey, showed: -Focus: The resident has a behavior problem related to repetitive vocal complaints regarding other patients care and embellishing the specifics of what actually happened; -Goal: Resident will have fewer episodes; -Interventions: Anticipate and meet the resident's needs; -Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by; -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed; -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes; -Offer alternate placement and/or room change. Review of the resident's progress notes, February 2025, showed no documentation of the resident's interaction with staff or behaviors. During an interview on 4/16/25 at 9:15 A.M., the resident said he/she was on the phone with Ombudsman CC when the aide entered the room to assist the roommate. The resident told staff that the roommate was hard to understand. The CNA told the resident to Shut the fuck up. The resident said Ombudsman CC was on the phone, and the CNA said Fuck him/her too. During an interview on 4/16/25 at 10:00 A.M., Administrator MM said he/she was aware of the incident. He/She received an email from Ombudsman CC. The incident occurred on 2/18/25. CNA BB was an agency staff, but the Administrator believed he/she was hired as PRN (as needed) staff. Administrator MM read the email that he/she received and his/her response to the email. Ombudsman CC overheard CNA BB tell the resident to Mind your fucking business. Administrator MM spoke to CNA BB. He/She reported that he/she did not use profanity. He/She told the resident to Mind your own business. Administrator MM told CNA BB to leave the room whenever he/she feels frustrated. The only documentation regarding the incident was the emails between the Administrator and Ombudsman CC. There was no investigation. Review of the email correspondence from Ombudsman CC to Administrator MM, dated 2/18/25 at 4:50 P.M., showed We received a call from the resident regarding some of his/her concerns. The resident complained that he/she is not receiving his/her medications on time, issues with food quality, and concerns related to staffing. While I was on the phone with the resident, a staff member (I believe agency) was overheard telling the resident to Mind his/her own f***ing business when he/she asked his/her name. The staff member refused to give the resident his/her name. He/She was caring for the resident at 4:45 P.M. on 2/18. Resident said this individual was also working last night. Can someone please follow up with the resident regarding these concerns? Review of the email correspondence from Administrator MM to Ombudsman CC, dated 2/18/25 at 6:04 P.M., showed I spoke to him/her (the staff member) and he/she denies cussing, but did admit to telling the resident to mind his/her business and refusing to give his/her name. I also told the staff member it was heard by someone on the phone, but he/she still denied it. We discussed the expectation moving forward is for him/her to leave the room when the resident starts to be disrespectful and not to respond to him/her regarding the care for other residents as it is not his/her concern. The staff member does not need to make any comment in regard to him/her being in anyone else's business. He/She can get someone else to provide the resident's care if he/she needs to. The resident can be very disrespectful and after a long day, it is best for them to walk away rather than engage. During an interview on 4/16/25 at 2:30 P.M., the resident said CNA BB was standing on the roommate's side of the room. He/She told CNA BB that the roommate had trouble speaking. CNA BB told the resident to Mind his/her fucking business. He/She told the CNA that Ombudsman CC wanted to speak to him/her and the CNA said, Fuck him/her too. He/She had witnessed disrespectful behavior to other residents from CNA BB. Sometimes the resident feels he/she has to speak for his/her roommate because he/she cannot communicate well. During an interview on 4/16/25 at 3:06 P.M., Ombudsman CC said he/she remembered the incident. He/She was in the middle of a phone conversation with the resident. He/She heard the resident ask the aide a question. Ombudsman CC did not make out what the aide said, but could tell he/she had answered the question with an attitude towards the resident. The resident asked the aide what his/her name was, and the aide told the resident to Mind his/her fucking business. The resident made a point to tell the aide he/she was on the phone. He/She tried to further the conversation, but the aide left the room. Ombudsman CC clearly heard the aide say Mind your fucking business. He/She asked the resident if the aide knew he/she was on the phone. Ombudsman CC added he/she did not hear the CNA say Fuck him/her too. The resident's voice started to become louder, continuing to engage in a conversation, but the aide could not be heard as well. It was as if the aide was leaving the room or left the room because his/her voice was fading. He/She did not hear what was said by the aide. At first he/she was concerned that the aide responded that way and emailed Administrator MM. Administrator MM immediately went upstairs and started the investigation. During an interview on 4/21/25 at 12:00 P.M., CNA BB said he/she remembered the incident. When CNA BB entered the room, Resident #507 started telling CNA BB that agency staff do not know how to take care of his/her roommate. They did not understand the roommate. The resident continued to talk about the roommate and how to take care of him/her. CNA BB told the resident that he/she could take care of the roommate and he/she was not talking to him/her about the roommate. CNA BB never told the resident to Mind his/her business or Mind his/her fucking business. He/She was never asked what his/her name was from the resident. CNA BB was aware the resident was on the phone with someone, an advocate or Ombudsman. CNA BB said he/she got on the phone and he/she was not discussing the roommate with the resident. CNA BB did not know what was said on the phone because he/she gave the phone back and left the room. The resident told the Administrator. CNA BB was not sent home and did not give a written statement. During an interview on 4/21/25 at 2:50 P.M., Social Service Coordinator said he/she started working at the facility one month ago. If there was an incident that resulted in a resident alleging unprofessional or disrespectful behavior from staff, he/she would contact their immediate supervisor, the Social Worker, and conduct a safe survey. A safe survey is when they ask resident if they had any issues and if they felt safe. He/she was not aware of the incident that occurred with the resident and staff. During an interview on 4/21/25 at 3:00 P.M., Social Worker had worked for the facility for ten years. There was an incident that occurred when the resident reported he/she was cussed at. The Social Worker heard about it during report by the nurse manager and the DON. It was reported and addressed by upper management. They would have that person leave the building and determine if it happened. Residents are also interviewed to see if they had problems with that aide. During an interview on 4/17/25 at 2:00 P.M., Administrator MM said There was no investigation that included interviews from other staff or residents. He/She spoke to the resident who said he/she was asking questions about the roommate. The resident was told by the CNA that he/she would not answer questions about the roommate's care. CNA BB denied saying, Mind your fucking business. He/She said Mind your business. The follow-up ended with the email that was sent to the Ombudsman. Administrator MM was unaware if he/she spoke to the unit manager. 4. Review of Resident #502's quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Walker and wheelchair; -Tub/Shower transfer - dependent; -Upper body dressing - dependent; -Diagnoses included, diabetes and hypertension. Review of the resident's care plan in use at the time of the investigation showed: -Focus: -Resident has a history of deep vein thrombosis (DVT, a blood clot in a deep vein); -Goal: -Resident will remain free of complications related to anticoagulant therapy through review date; -Interventions/Tasks: -Monitor/document/report as needed any signs/symptoms of DVT complications: -bruising, date initiated 12/21/24; -Focus: -Resident is on anticoagulant therapy related to heart failure, history of deep vein thrombosis; -Goal: -Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date; -Interventions/Tasks: -Monitor/document/report PRN adverse reactions of anticoagulant therapy: -bruising. Review of the resident's physician order sheet (POS) in use at the time of the investigation, showed: -Eliquis (prevents the blood from clotting) oral tablet 2.5 milligram (mg), Give one tablet by mouth, two times a day for DVT prophylaxis; -Status: On hold; -Start date: 6/24/24; -Revised: 11/24/24; -On hold: 4/14/25, on hold due to wound therapy and increased bleeding. Review of the resident's progress notes, in use at the time of the invest

Based on interview and record review, the facility failed to maintain documentation of a system that assured complete accounting of resident personal funds, and the facility failed to ensure access to resident personal funds was transferred to the facility's new management company upon a change in ownership. The facility also failed to ensure that monies held in the resident trust fund account was reconciled each month. The facility also failed to ensure quarterly statements were distributed to residents and/or their responsible party. This deficient practice affected all residents whose funds were handled by the facility. The census was 115. Review of the facility's undated Resident Personal Funds - Accounting and Management policy, showed: -Hold, safeguard, manage, and account for: Means that the facility must act as fiduciary of the resident's funds and report at least quarterly on the status of these funds in a clear and understandable manner. Managing the resident's financial affairs includes money that an individual gives to the facility for the sake of providing a resident with a non-covered service. In these instances, the facility will provide a receipt to the gift giver and retain a copy; -Procedures/Requirements: The resident may manage his or his own personal funds; -The resident may designate a representative to manage his or her personal funds; -The resident may have the facility hold, safeguard, and manage his or her personal funds; -Should the resident elect to have the facility manage his or her personal funds, it must be authorized in writing by the resident or the resident's representative, and a copy of such authorization will be documented in the resident's medical record; -Should the facility manage the resident's funds, the facility will act as a fiduciary of the resident funds and hold, safeguard, manage and account for the personal funds of the resident. No service charge will be levied against the resident for the management of personal funds; -Should the facility manage the resident's funds, there will be a designation of duties of multiple staff members to ensure that the process is not managed solely by one individual; -Should the facility be appointed the resident's representative payee, and directly receive monthly benefits to which the resident is entitled, such funds will be managed in accordance with established policies related to financial management; -The resident will be informed in advance of any changes imposed to his or her personal funds; -A copy of all financial transactions will be filed in the resident's permanent records; -The resident may withdraw his or her request for the facility to manage his or her personal funds at any time by submitting a written notice to the Administrator; -Inquiries concerning the facility's management of resident funds should be referred to the Administrator or to the business office. Review of the facility's Resident Fund Account and Change in Management/Ownership, dated 11/22/23, showed: -Policy: The facility will provide new management or ownership with a full accounting of resident funds on deposit with the facility; -Procedure/Requirements: Should a change of management or ownership occur, the following transactions concerning our resident trust fund and/or our resident petty cash fund with be implemented; -Duties to new owner and/or Administrator: Upon the change of Administrator, sale of the facility or other transfer of ownership, the current Administrator/designee will provide the new Administrator/Owner with a written accounting of all resident funds deposited with the facility; -The report will be prepared by a Certified Public Accountant (CPA) in accordance with generally accepted accounting principals; -A new Administrator/Owner will sign for receipt for such funds; -Duties to residents: The current Administrator/Designee will provide to each resident, or representative (sponsor), a written accounting of the resident's personal funds held by the facility; -Such accounting will be presented to the resident, or representative (sponsor), prior to the change in management or transfer of ownership; -Rights of residents: In the event that a resident disagrees with the accounting of his or her funds, the current Administrator/Designee will attempt to resolve the issue before new management/ownership assumes responsibility for such funds. Should the disagreement not be resolved, the resident retains all rights and remedies provided under state law; -It is the responsibility of the resident, or representative (sponsor), to report all discrepancies as soon as possible after they are discovered. Review of the facility's resident trust account, showed: -November 2023 to July 2024, showed no documentation of ending balances, bank statements, and/or receipts; -August 2024 showed an ending balance of $118,068.63 and was not reconciled; -September 2024 showed an ending balance of $55,189.34 and was not reconciled; -October 2024 showed an ending balance of $50,722.70 and was not reconciled. Review of previous trust account records, received on 11/24/24 at 8:59 A.M., showed a large stack of paper which contained copies of resident receipts from November 2023 through June 2024. There were no reconciliations, bank statements, quarterly statements from November 2024 through June 2024. During an interview on 11/25/24 at 9:50 A.M., the Business Office Manager (BOM) said he/she started on 9/4/24. The facility had new ownership and the initial deposit in the new account was on 8/27/24. He/She did not have access to the resident trust accounts and statements that were maintained by the previous owners until it was requested by the surveyor. He/She was responsible for reconciliating the resident trust, but had not done it. Moving forward, he/she would reconcile the trust monthly, but he/she was still trying to get it together. He/She was not sure who reconciled the resident trust prior to him/her. He/She was responsible for sending the quarterly statements, but had not sent them since he/she started as BOM. The first statements would come out in January. The residents knew they could come to the business office if they needed to know their balance. During an interview on 11/26/24 at 12:06 P.M., the Administrator said he expected the resident trust to be reconciled every month. He expected the bank statements to be a part of the reconciliation and for the residents to have detailed accounting or quarterly statements. He expected the facility to have all previous reconciliation and bank statements from the previous ownership.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was served at a safe and appetizing temperature for two of two observed meal services. This deficient practice affected all residents who ate meals at the facility, including members of the Resident Council who voiced complaints in the monthly resident council meetings and Residents #1 and #92. The census was 134. Review of the facility's Monitoring Food Temperatures for Meal Service policy, dated 2020, showed: -Guideline: Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures; -Procedure: Proper procedures are followed to ensure that food temperatures are accurately and safely obtained according to safe handling practices. These procedures include the following steps; -If the serving/holding temperature of a hot food item is not at 135 degrees Fahrenheit (F) or higher when checked prior to meal service, the item will be reheated to at least 165 degrees (F) for a minimum of 15 seconds; -If the serving/holding temperature of a cold food item or beverage is not at 41 degrees (F) or below when checked prior to meal service, the item will be chilled on ice or in the freezer until it reaches 41 degrees (F) or less before service. 1. Review of the facility's October Resident Council Meeting minutes, dated 10/21/24, showed: -15 residents in attendance; -Dining Services: Residents agreed the food is still being served at room temperature to cold most of the time. Review of the facility's November Resident Council Meeting minutes, dated 11/18/24, showed: -20 residents in attendance; -Dining Services: Residents agreed that the food is still being served room temperature to cold most of the time, especially breakfast. Review of the facility's December Resident Council Meeting minutes, dated 12/16/24, showed: -18 residents in attendance; -Dining Services: A new kitchen manager has been hired. She is addressing food temperatures and all the processes/factors that go into receiving a hot meal. 2. Review of the facility's lunch menu, dated 1/14/25, showed turkey crunch with buttered noodles, vegetables, pea soup, and orange slices. Observation of the meal service on 1/14/25 at 12:42 P.M., showed meal trays arrived in a nonheated and noninsulated carrier on the third floor. At 12:45 P.M., trays were passed out to the rooms. At 12:50 P.M., a resident tray was removed from the carrier. The meal was served on a plate that was heated while in the kitchen with a plastic dome covering the plate. The meal consisted of turkey on a bed of noodles, broccoli, orange slices and pea soup. Food temperatures were taken with a digital thermometer. The noodles and turkey showed a temperature of 102.6 degrees Fahrenheit (F), the broccoli was 110.0 degrees F, and the orange slices were 57.0 degrees F. 3. Review of the facility's lunch menu, dated 1/15/25, showed ham with brown sugar glaze, stuffing, cauliflower and bean soup. Observation on 1/15/25 at 12:55 P.M., showed staff brought the food trays to the third floor in a metal cart that was nonheated and noninsulated. Staff on the floor immediately went to the cart and removed one tray at a time and delivered it to residents who sat in the dining room. Then, staff pushed the cart down the hall and delivered trays to the residents who were eating in their room. At 1:10 P.M. the last tray was removed from the cart. At that time, the following food temperatures were obtained from a test tray off the cart. The meal was served on a plate that was heated while in the kitchen with a plastic dome covering the plate. The baked ham with brown sugar glaze was 109.8 degrees F; the stuffing was 117.5 degrees F; the cauliflower was 111.6 degrees F; and the bean soup was 114.6 degrees F. 4. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/5/24, showed the resident was cognitively intact. During an interview on 1/14/25 at 9:45 A.M., the resident said food was always served cold. He/She expressed concerns regarding this, and nothing had been done. The food had been served cold since August. Review of Resident #92's quarterly MDS, dated [DATE], showed, the resident was cognitively intact. During an interview on 1/14/24 at 10:27 A.M., the resident said the food was always served cold. 5. During an interview on 1/15/25 at 1:15 P.M., Certified Nursing Assistant (CNA) C said residents constantly complained of cold food. The food arrived to the floors late for staff to pass the trays. There were microwaves available on each floor if residents requested to have their food warmed up. During an interview on 1/15/25 at 3:13 P.M., the Dietary Manager said she started at the facility on 11/11/24 and residents complained of cold food. When food was served to residents, hot foods should be served at a holding temperature of 135 degrees F. Cold foods should be under 40 degrees F. After the food was prepared, it was placed in a metal carrier with a lid and placed on a tray to take to the units. The carrier used was not heated. The goal was to have steam tables and take them to each individual floor and serve the food when the resident was ready to eat. She was aware of the cold food and had been trying to address the issue. During an interview on 1/15/25 at 4:32 P.M., the Administrator said he expected hot foods to be served at 120 degrees F and cold foods under 40 degrees F. The cup of orange slices would be considered a cold food. They were in the process of ordering steam tables. MO00246428 MO00247995 MO00247996

Based on observations, record review and interviews the facility failed to store, prepare, distribute, and serve food under sanitary conditions. Specifically, the facility: failed to label food items in dry storage, the chef cooler, the freezer, the produce walk in, snack food and drink walk in refrigerator, and deli/sandwich preparation refrigerator; failed to clean the kitchen floors, preparation table shelves and drawers, stove, ovens, air fryer, red colored hotbox, the tilt skillet, and the steamer/convection oven; and failed to ensure cutting boards did not have cut marks (scarring) from the knives. The facility census was 106. The findings included: During the initial tour of the kitchen on 7/25/23 at 10:59 a.m. the following items were not labeled in the dry storage room: -one (1) - 11 pound vanilla crème icing tub did not have a label and was covered in plastic wrap, -one (1) two (2) pound bag of powdered sugar did not have a label and was wrapped in plastic wrap, - plastic utensils were in open boxes, not covered, -one (1) number 10 can (holds approximately six (6) pounds six (6) ounces of product was in the bottom of the can rack with no label. The following items were not labeled in the chef's cooler that was used when items were pulled to thaw, pull prior to use and leftovers: -a four (4) quart container of liquid, -BBQ sauce unable to read the label was not covered, -deluxe smoked sliced breast two (2) in a box, -turkey bacon in a box partially covered, -another unopened box of turkey bacon, -one (1) white package roll of unidentified (meat?) in a silver half pan with red colored liquid on the bottom of the pan, -one (1) box of five (5) ounces (oz) chicken breasts not covered and another box covered, -two (2) boxes of chicken thighs, -one (1) pan of cooked meat, -cooked baby carrots in a pan, -cut green bell peppers, and -a 20 quart container with chopped lettuce, onion, celery, bell peppers on the leftover rack. The following items were not labeled in the freezer: Hamburger patties in an open box. The following items were not labeled in the produce walk in refrigerator: a silver bowl with brown colored item with red liquid on the plastic wrap. The following items were not labeled in the snack food and drink walk in refrigerator: one (1) - 46 oz container of prune juice, and shredded white cheese wrapped in plastic. The following items were not labeled in the deli/sandwich preparation refrigerator: one (1) jar of yellow banana peppers, a seven (7) oz package of roast beef, Deli Fresh oven roasted turkey, a package of black forest ham, and bottle of Dijon mustard. During the initial tour on 7/25/23 at 10:59 a.m., Dietary Staff LL was writing labels and placing them on different items already identified as not having labels and removing items from the dry storage area that were not covered or labeled. During a second tour of the kitchen on 7/26/23 at 9:45 a.m. the following items were in the dry storage room: -plastic utensils were in open boxes, not covered, - one (1) number ten (10) can (holds approximately six (6) pounds six (6) ounces of product was in the bottom of the can rack with no label. The following items were not labeled in the chef's cooler that was used when items were pulled to thaw, pull prior to use and leftovers: -deluxe smoked sliced breast two (2) in a box, -turkey bacon in a box partially covered, another unopened box of turkey bacon, -one (1) box bulk hamburger, -one (1) box of chicken thighs with 7/25/23 handwritten-pulled 7/21/23 (was not labeled day before), -white package roll of unidentified (meat?) in a silver half pan dated 7/23 (was not labeled the day before). The following items were not labeled in the freezer: Hamburger patties in an open box. The following items were labeled 7/24/23 and use by 7/29/23 in the deli/sandwich preparation refrigerator: seven (7) oz package of roast beef, Deli Fresh oven roasted turkey, a package of black forest ham. They were not labeled on 7/25/23. During an interview on 7/27/23 at 10:54 a.m. the Dining Services Director stated all items should have been covered properly and labeled with a sticker that identified what the item was, the date when it was opened, prepared, or pulled, and the use or expiration by date. The Dining Services Director said the can in dry storage was beets, and he/she knew what it was because when the cans were placed in the can rack the label fell off, so it was placed in between the other cans of beets. He/She said they should have placed the can in the office so it would not be used. The Dining Service Director said labeling was important, so everyone knew what the items were, how old it was, and what/when it was going to be prepared. During the initial tour of the kitchen on 7/25/23 at 10:59 a.m. the following items were not clean: the kitchen and dry storage room floors had grease under the fryer, flat top, oven, grill and stove; and the floor under the preparation tables had black colored debris shelves and drawers, stove, ovens, air fryer, red colored hotbox, the tilt skillet and the steamer/convection oven. The sides of the fryer had yellow colored grease debris on the sides. The preparation tables shelves and drawers had food debris/crumbs on the outside and inside. The hood above the fryer was dusty and greasy, the inside of both ovens had crusty, black colored debris/burnt food on the bottom shelves. The red hotbox had black color debris on the outside by and on the handles, the inside racks had food debris and not yellowish color, not clean. The steamer/convection oven had food debris inside and was not clean on the inside and outside. The stove was not clean, there were drips (lines) of dried food/liquid on the front, back and sides. The tilt skillet had food debris on the outside, unable to see the inside due to boxes of bread were on top of it. During a second tour of the kitchen on 7/26/23 at 9:45 a.m. the following items were not clean the kitchen and dry storage room floors had grease under the fryer, flat top, oven, grill and stove, the floor under the preparation tables had black colored debris shelves and drawers, stove, ovens, air fryer, red colored hotbox, the tilt skillet and the steamer/convection oven. The sides of the fryer had yellow colored grease debris on the sides. The preparation tables shelves and drawers had food debris/crumbs on the outside and inside. The hood above the fryer was dusty and greasy, the inside of both ovens had crusty, black colored debris/burnt food on the bottom shelves. The red hotbox had black color debris on the outside by and on the handles, the inside racks had food debris and not yellowish color, not clean. The steamer/convection oven had food debris inside and was not clean on the inside and outside. The stove was not clean, there were drips (lines) of dried food/liquid on the front, back and sides. The tilt skillet had food debris on the outside, unable to see the inside due to boxes of bread were on top of it. During an interview and observation on 7/27/23 at 10:54 a.m. with the Dining Services Director, he/she agreed the floor had grease under the fryer, flat top, oven, grill and stove, the floor under the preparation tables had black colored debris shelves and drawers, stove, ovens, air fryer, red colored hotbox, the tilt skillet and the steamer/convection oven. The sides of the fryer had yellow colored grease debris on the sides. The preparation tables shelves and drawers had food debris/crumbs on the outside and inside. The hood above the fryer was dusty and greasy, the inside of both ovens had crusty, black colored debris/burnt food on the bottom shelves. The red hotbox had black color debris on the outside by and on the handles, the inside racks had food debris and not yellowish color, not clean. The steamer/convection oven had food debris inside and was not clean on the inside and outside. The stove was not clean, there were drips (lines) of dried food/liquid on the front, back and sides. The tilt skillet had food debris on the outside, unable to see the inside due to boxes of bread were on top of it. the Dining Services Director stated there was a cleaning schedule the staff were supposed to follow. He/She stated she did not know where the cleaning schedules were when requested. The exhaust was cleaned 3/16/23 and was scheduled to be cleaned sometime in September of 23, it was cleaned by an outside company every six months. Follow-up he/she stated they could not find the cleaning schedules for the previous three months. The Dining Services Director stated it was important to have a clean kitchen to not spread infection, lessened the possibility of critters and bugs. During the initial tour of the kitchen on 7/25/23 at 10:59 a.m. the following cutting boards had cut marks (scarring) from the knives. There were three (3) white cutting board, one (1) blue cutting board, two (2) red cutting boards, one (1) green cutting board and three (3) yellow cutting boards. During a second tour of the kitchen on 7/26/23 at 9:45 a.m. the following cutting boards had cut marks (scarring) from the knives. There were three (3) white cutting board, one (1) blue cutting board, two (2) red cutting boards, one (1) green cutting board and three (3) yellow cutting boards. During an interview and observation on 7/27/23 at 10:54 a.m. with the Dining Services Director, he/she agreed the following cutting boards had cut marks (scarring) from the knives. There were three (3) white cutting board, one (1) blue cutting board, two (2) red cutting boards, one (1) green cutting board and three (3) yellow cutting boards. The Dining Services Director said cutting boards were purchased as needed and stated a new set was ordered in either February or March. A request for a copy of the invoice was made and was not provided. The Dining Services Director said it was important to not have scarring due to cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident had a choice of code status documented in the medical record (Resident #78). In addition, the facility failed to ensure four out of 23 sampled residents' code status' were reviewed annually (Residents #56, #103, #42 and #84). The census was 110. Review of the facility Life Sustaining Treatment policy, revised [DATE], showed: -Practice: Upon admission the resident will be made aware of his/her right to make informed decisions through the information contained in the resident handbook and other materials furnished by Social Services and/or the business office; -Should a resident have an advance directive, it will be filed in the front of the resident's medical record; -In Missouri, a CPR (cardiopulmonary resuscitation, life saving measures)/treatment directive order form will be completed according to the advance directive and signed by the physician and the resident or his/her legal representative or surrogate family member; -The physician's signature on the monthly order will constitute a renewal of the CPR/treatment directive. The order will remain in effect unless the decision is rescinded. If this occurs, the physician will immediately be notified and a new CPR/treatment directive order will be obtained reflecting the new decision; -Social services staff is responsible for reviewing and documenting this review of the CPR/treatment directive on an annual basis in the medical record and on the back of the CPR/treatment directive form. A new CPR/treatment directive only needs to be initiated if their directives change; -The CPR/treatment directive will be maintained in the medical record directly behind the out of hospital DNR (do not resuscitate, no life saving measures) form, if applicable. Otherwise, the CPR/treatment directive form will be maintained directly behind the face sheet. 1. Review of Resident #78's electronic medical record, dated [DATE] showed: -admitted [DATE]; -A physician order sheet with the order for follow CPR/treatment directive; -Inside the resident's hard chart, located on the floor where the resident resides, showed an advance directive form and out of hospital DNR form. Both forms were blank and were not signed by the resident or his/her responsible party. During an interview on [DATE] at 12:33 P.M., Licensed Practical Nurse (LPN) C said to identify a resident's code status, he/she would follow the facility's policy. LPN C was asked what the facility's policy was and he/she could not answer. LPN C confirmed that the resident's code status forms were not signed, but did not know who would be responsible for ensuring the forms were signed at the time of admission. LPN B said the code status forms are kept in the front of the chart and should have been signed. 2. Review of Resident #56's medical record, showed: -An out of hospital DNR from signed on [DATE], by the resident's responsible party; -Inside the resident's paper chart, located on the floor where the resident resides, a copy of the facility's long term care directive physician order sheet. The form indicated the resident did not want CPR and a hand written note reviewed with the resident's responsible party via telephone electing the resident remained a NO CODE, dated on [DATE]; -No further codes status annual review documented. 3. Review of Resident #103's medical record, showed: -A current electronic physician order sheet with the order for follow CPR/treatment directive; -Inside the resident's paper chart, located on the floor where the resident resides, a copy of the facility's long term care directive physician order sheet. The form indicated the resident did want CPR, dated [DATE]. On the back of the form, documented reviewed with family member, no changes, dated [DATE]; -No further codes status annual review documented. 4. Review of Resident #42's medical record, showed the following: -A current electronic physician order sheet with the order for follow CPR/treatment directive; -Inside the resident's paper chart, located on the floor where the resident resides, a copy of the facility's long term care directive physician order sheet. The form indicated the resident did not want CPR, dated [DATE]; -No annual code status verification documented. 5. Review of Resident #84's electronic medical record, dated [DATE], showed: -A current electronic physician order sheet with the order for follow CPR/treatment directive; -Inside the resident's paper chart, located on the floor where the resident resides, a copy of the facility's long term care directive physician order sheet. The form indicated the resident did not want CPR, dated [DATE]; -No annual code status verification documented. 6. During an interview on [DATE] at 1:42 P.M. the Administrator and the Director of Nursing (DON) said the admitting facility nurse is responsible to verify code status with the resident and the responsible party and it should be signed at the time of admission to the facility. The resident's code status choices are reviewed annually and the floor nurses can review the code status with the resident or the responsible party. All of the residents should have a signed code status that is current. The DON would expect all staff to know the facility's policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff regarding discharge status for two out of three closed records reviewed (Residents #110 and #109). The census was 110. 1. Review of Resident #110's discharge MDS, dated [DATE], showed: -Type of discharge (planned or unplanned): Unplanned; -Discharge status: To community; -discharge date : [DATE]. Review of the resident's progress notes, dated 11/6/19, showed the resident transferred to the hospital on this date and time. Family refused to wait on discharge papers from this nurse and stated the resident still had his/her personal items in the room. 2. Review of Resident #109's discharge MDS, dated [DATE] showed: -discharge date : [DATE]; -Discharge status: Acute hospital. Review of the resident's progress notes, showed: -On 10/9/19 at 11:24 A.M., the social worker received a call from another facility and the resident's guardian was going to pick the resident up and transfer the resident to a sister facility. The social worker met with the resident for the exit interview. The resident confirmed he/she was to be picked up by his/her responsible party and will be transferred to the sister facility; -On 10/9/19 at 12:32 P.M., a nursing discharge summary noted the resident was discharged with verbal and written instructions given to the resident's responsible party. The writer called the receiving sister facility and provided the verbal report to the receiving nurse. All of the resident's medications sent with the responsible party and the resident. 3. During an interview on 1/10/20 at 11:34 A.M., the MDS coordinator said the MDS should be coded accurately to reflect the resident's condition at the time the assessment was completed. The MDS should correctly identify where a resident is discharged to. He/she added that he/she is the only MDS coordinator at the facility. 4. During an interview on 1/10/20 at 1:42 P.M., the Director of Nursing said she expected the MDS to be accurate and reflect the appropriate discharge destination for the resident.

Based on interview and record review, the facility failed to ensure a resident admitted into a Medicaid certified bed, regardless of payment source, had the DA-124c level I screen (used to evaluate for the presence of psychiatric disorders and intellectual disabilities) completed prior to admission into the Medicaid certified bed, for one of five residents investigated for preadmission screening and resident review (PASARR) (Resident #88). The sample was 23. The census was 110. Review of Resident #88's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/19, showed: -Section A0410: Unit certification or licensure designation: Unit is Medicare and/or Medicaid certified; -Section A1500: PASARR: No -Section A1510: Level II PASARR conditions: -A 1510: A serious mental illness: blank; -A 1510: B intellectual disability: blank; -A 1510: C other related condition: blank; -Section 1550: Conditions related to ID/DD status: -A 1550 A: Down syndrome: No; -A 1550 B: Autism: No; -A 1550 C: Epilepsy: No; -A 1550 D: Other organic condition related to ID/DD: No; -A 1550 E: ID/DD with no organic condition: No; -A 1550 Z: None of the above: Yes; -Diagnoses of major depressive disorder, unspecified dementia without behavioral disturbance, pseudobulbar affect (condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), cancer, irregular heartbeat, and psychotic disorder. During an interview on 1/10/20 at 11:26 A.M., the Administrator said that the resident was private pay, and he thought the resident did not need a DA 124c. The resident did not have a DA-124c completed before or since his/her admission into the facility. The resident will receive Medicaid benefits soon.

Based on observation, interview and record review, the facility failed ensure the services provided or arranged by the facility met professional standards of quality, by failing to follow physician orders for a fall mat for one resident (Resident #87) who had a history of falling. The sample was 23. The census was 110. Review of Resident #87's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/5/19, showed: -Moderately impaired cognition; -Extensive assistance of staff required for bed mobility, dressing, grooming and bathing; -Total assist of staff required for transfers; -Used a wheelchair; -Frequently incontinent of urine and occasionally incontinent of bowel; -Diagnoses included heart failure, high blood pressure, diabetes, high cholesterol and depression. Review of the resident's medical record, showed: -On 12/3/19, the resident was found on the floor next to the bed, and was unable to tell staff what happened. Intervention to prevent falls included: adequate lightening, call device within reach, personal items in reach, traffic path in room free of clutter, and ensuring the wheels on the wheelchair were locked; -On 12/29/19, the resident was found on the floor, next to the bed, laying on his/her back. The bed was positioned at hip height. The resident was sent to the hospital for suspected fracture. Intervention to prevent falls included: low bed with fall mats and remind to use the call light. Review of the resident's care plan, in use during the survey, showed: -Problem: At risk for falls and related injury due to weakness, confusion and a history of falls; -Goal: Not obtaining injury from a fall through next review; -Interventions: Keep call light in reach at all times. Monitor environment for safety issues such as spills or clutter. Fall from bed on 12/3/19, please complete rounds and reposition in bed, provide mats by the side of bed. Review of the resident's physician order sheet (POS), showed an order dated 12/4/19, for floor mats while resident is in bed. Have bed at lowest position. Observations of the resident, showed: -On 1/7/20 at 11:41 A.M. and 1:39 P.M., the resident lay in bed, only one fall mat on the floor, the fall mat closest to the door. The other fall mat folded in half and placed over by the window; -On 1/9/20 at 2:22 P.M., the resident lay in bed. One fall mat on the floor, the one closest to the door. The other fall mat folded in half, up against the wall by the window; -On 1/10/20 at 7:32 A.M., the resident lay in bed. One fall mat, located closest to the door on the floor. The other fall mat folded in half, up against the wall by the window. During an interview on 1/10/20 at 1:28 P.M., the Director of Nursing (DON) said if a resident has an order for fall mats, the mats should be in place, as ordered. She had just recently spoke with the staff regarding the resident's fall mats and how to position the fall mats so both fall mats could be in place and the resident could still use the over bed table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain proper placement of an indwelling urinary catheter (a tube inserted into the bladder for purpose of continual urine drainage) and failed to obtain physician orders for the catheter. The facility identified seven residents as having indwelling urinary catheters. Of those seven, five were chosen for the sample. Of those five, problems were found with two residents (Residents #106 and #78). The sample was 23. The census was 110. Review of the facility's catheter care policy, revised April 2019, showed: -Policy: Catheter care is performed each shift and as needed to keep catheter and perineal area clean; -The urinary drainage bag and tubing is not changed unless absolutely necessary and it is of utmost importance to maintain strict aseptic (free from contamination) technique; -Catheter Care Practice: Check catheter drainage and tubing at beginning of the shift, periodically throughout the shift, and at the end of the shift. Check to be sure there are no kinks or obstructions and that the bag is below the level of the bladder; -When the resident is in a wheelchair or Geri-chair (medical reclining chair), the drainage bag should be placed in a privacy/modesty bag. Keep drainage bag below the level of the bladder and make sure the drainage bag does not touch the floor. Review of the facility's catheter insertion policy, revised November 2017, showed: -Policy: A physician order is required to insert an indwelling catheter. Use of an indwelling catheter requires an appropriate diagnosis. An appropriate diagnosis may include the following: urinary retention, atonic bladder, skin issues, pressure sores or irritations that are being contaminated by urine or terminal illness or severe impairment which makes bed and clothing changes uncomfortable or disruptive. Only a licensed nurse will insert a catheter. 1. Review of the Resident #106's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/18/19, showed: -Cognitively intact; -Diagnoses included fractures and other multiple trauma, deep vein thrombosis (DVT, blood clots), urinary tract infection (UTI), arthritis, hip fracture, anxiety, and depression; -Has a urinary catheter; -Total dependence with transfers; -Required extensive assistance with bed mobility, dressing, toileting, and hygiene. Review of the resident's physician order sheet (POS), dated 1/1/20 through 1/31/20, showed: -An order 12/17/19, to change indwelling urinary catheter every four weeks; -An order dated 1/2/20, for indwelling urinary catheter care every eight hours for urinary retention; -No orders for the size of the catheter. Review of the resident's care plan, updated 1/5/20 and in use during the survey, showed the resident had a catheter for urinary retention. Staff are to ensure that he/she has a privacy bag on when he/she is out of the room and to do catheter care and empty bag every shift. Observation of the resident, showed: -On 1/7/20 at 1:20 P.M., the resident sat in a wheelchair. The catheter tube exited the resident's left pant leg to the drainage bag connected under the wheelchair. The catheter tube lay on the floor and approximately 15 inches of the tube contained yellow urine. At 1:35 P.M., the resident propelled him/herself in the wheelchair as the catheter tube dragged on the floor; -On 1/9/20 at 1:48 P.M., the resident sat in the wheelchair. The catheter tube lay on the floor with amber colored urine inside the tube. The resident transported him/herself out of the dining room as the catheter tube dragged on the floor; -On 1/10/20 at 8:36 A.M., staff transported the resident down the hall. There was approximately 18 inches of catheter tubing that dragged on the floor underneath the wheelchair. At 12:32 P.M., the resident sat in the dining room. The catheter tube on the floor underneath the wheelchair. During observation and interview on 1/10/20 at 12:38 P.M., Licensed Practical Nurse (LPN) B said the catheter tube is never to be on the floor. LPN B walked to the resident and fixed the catheter tube. 2. Review of Resident #78's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included non-traumatic brain dysfunction, neurogenic bladder (difficulty or inability to urinate due to neurological conditions), UTI and stroke; -Extensive assistance with bed mobility, transfers, dressing, toileting and hygiene; -Had an indwelling urinary catheter. Review of the resident's POS, dated 1/1/20 through 1/31/20, showed: -An order dated 12/30/19, for urinary catheter care every 8 hours; -No orders for the size of the catheter. Review of the resident's care plan, updated on 1/7/20 and in use during the survey, showed the resident had a suprapubic catheter (catheter inserted through the abdominal wall into the bladder). The nurse cleans the insertion site daily and applies a dry dressing. Staff are to empty the catheter bag every shift. Observation on 1/9/20 at 8:55 A.M. and 1:53 P.M., showed the resident's catheter tube looped underneath the wheelchair with approximately 8 inches of yellow urine in the tube that did not drain. 3. During an interview on 1/10/20 at 1:42 P.M., the Director of Nursing (DON) said she would expect there to be physician order for an indwelling urinary catheter. The orders should indicate its use, the size, and when it is replaced. She would expect staff to ensure the tubing is below the bladder and not looped. It is not appropriate for the catheter tube to be on the floor due to infection control.

Based on observation, interview and record review, the facility failed to ensure residents are free of significant medication errors for one resident (Resident #103) when the facility staff administered a medication then immediately initiated a tube feeding (nutrition administered per a gastric tube, g-tube. A tube placed through the abdomen into the stomach), for a medication that should not be given with food. The census was 110. Review of Resident #103's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/13/19, showed: -The resident is rarely or never understood; -The resident required total assistance of staff for grooming, dressing, bathing, hygiene, transfers and eating; -Diagnoses included stroke with hemiplegia or hemiparesis (paralysis of the arm, leg, and trunk on the same side of the body), diabetes, high cholesterol, dementia, and seizures. Review of the Resident's electronic physician order sheet (ePOS), dated 1/1/20, showed: -Phenytoin (a medication used to treat seizures) 125 milligrams (mg) per milliliter (ml) suspension, give six ml every 12 hours by g-tube; -Nothing by mouth; -G-tube flush, flush G-tube with 120 ml of water every 4 hours; -DiabetaSource AC (supplemental nutrition) give 75 ml per hour by g-tube. Begin tube feeding every day at 10:00 A.M. for 14 hours, discontinue at midnight. Review of the facility's medication administration via enteral tubes reference sheet, dated 11/11/11, showed: -Policy: A physician's order is required for administration of any medication via feeding tube; -Procedure: Turn off pump to stop continuous feedings one to two hours prior to medication administration, if medications is associated with an incompatibility or 30 minutes prior to administration if the medication should be given on an empty stomach; -Put 30 ml of water in syringe and flush tubing using gravity flow; -Pour dissolved/diluted mediation in syringe, allowing medication to flow to gravity; -Flush tubing with 30 ml of water or prescribed amount; -Restart continuous feeding, if appropriate. If medication with incompatibility issues was administered, leave pump off for 1-2 hours after medication administration. Observation on 1/8/20 at 10:10 A.M., showed, Registered Nurse (RN) F administered phenytoin 125 mg per 5 ml solution, 6 ml to the resident. He/she then immediately attached the end of the g-tube to the feeding and started the feeding. RN F said the Dilantin (phenytoin) and food may need to be separated but the doctor said just to give the Dilantin. Review of the Resident's paper POS, located in the hard chart, dated 1/1/20, showed no documentation to give phenytoin with the tube feeding. During an interview on 1/8/20 at 10:40 A.M., RN F said he/she was not aware of any documentation that showed to give phenytoin with the tube feeding. During an interview on 1/8/20 at 12:10 P.M., Pharmacist I said the tube feeding should be stopped for an hour before and after phenytoin is administrated. During an interview on 1/8/20 at 1:15 P.M., the Director of Nursing (DON) said staff should follow standards of care. The DON is not aware of the physician telling staff to administer phenytoin and immediately start the tube feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles, for two of two medication carts reviewed. The census was 110. Review of the facility's pharmacy services, storage and expiration dating of medications, biologicals, syringes and needles policy, updated 10/2016, showed: -Facility should ensure that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines or have been contaminated or deteriorated are stored separate from other medications until destroyed or returned to the pharmacy or supplier; -Once any medication or biological package is opened, the facility should follow manufacturers/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has shortened expiration date once opened; -Facility staff may record the calculated expiration date based on date opened on the medication container; -The facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels. 1. Observation and interview on [DATE] at 8:56 AM., showed the 400 unit nurse medication cart contained three insulin pens. One Lantus (long acting insulin) pen undated. Licensed Practical Nurse (LPN) A said the observed insulin is ordered to be given to the resident at bedtime. It is the charge nurses responsibility to label the insulin pen when it is removed from the refrigerator, with the expiration date. The nurse also should verify the expiration date before the insulin is administered to the resident. If an insulin pen is discovered undated, the insulin should be destroyed and a new pen obtained, dated and then a new pen reordered. 2. During an observation and interview on [DATE] at 1:00 P.M., the 200 hall nurse medication cart showed five insulin pens. Two of these insulin pens noted to be undated. LPN B said the date sticker is filled out when the medication is started. It is the responsibility of the nurse who obtained the insulin to date the insulin with when the insulin should be discarded. 3. During an interview on [DATE] at 1:32 P.M., the Director of Nursing said that it is the charge nurse's responsibility to verify that the insulin used has the correct date on it before use. The staff should follow the facility policy for labeling the insulin. The nurses should label the insulin when it expires. If insulin is discovered unlabeled, the nurse should dispose of the insulin, obtain a new insulin and label the new insulin according to policy.

Based on observation, interview and record review, the facility failed to follow the hand hygiene policy during personal care for one of three residents observed during personal care (Resident #17). The census was 110. Review of the facility's hand hygiene policy, dated 10/18, showed: -Purpose: To establish guidelines for proper hand hygiene practices for infection control; -Responsibility: It is the responsibility of all employees to follow this policy regarding hand hygiene for infection control; -Policy: Hand hygiene will be maintained at all times. Hands will be washed with soap and water when they are visibility soiled or contaminated with blood or other body fluids; -Practice: Recommended times for handwashing with soap and water, when hands are visibly soiled or after contact with blood or body fluids. Review of Resident #17's care plan, revised on 4/16/19, showed: -Problems: Bowel and bladder, the resident is frequently incontinent of urine due to confusion. He/she needs reminder to use the toilet and then needs extensive staff assistance once he/she is in the bathroom. He/she has not had any recent infections. The resident would like to remain clean, dry and odor free with no infections. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/1/19, showed: -Severe cognitive impairment; -Extensive staff assistance needed with toileting, hygiene and dressing; -Frequently incontinent of bowel and bladder; -Diagnoses of dementia, anxiety and depression. During an observation and interview on 1/7/20 at 7:01 A.M., Certified Nurse Aide (CNA) G entered the resident's room, washed his/her hands, applied gloves and explained care to the resident. He/she assisted the resident from his/her bed to the resident's bathroom. CNA G placed four wash cloths in the bathroom sink and turned on the warm water to run over the wash cloths. As the resident sat on the toilet, CNA G removed the resident's shirt and urine wet brief. CNA G used the same gloved hands and obtained a wash cloth from the sink basin, applied cleanser to the cloth and provided personal care to the resident. He/she assisted the resident to sit on the toilet. CNA G used the same gloved hands to put on the resident's clean shirt and pants, obtained a wet a wash cloth from the sink, wrung the wash cloth out with both gloved hands, handed the wash cloth to the resident and the resident used the potentially soiled wash cloth and cleaned his/her face. CNA G disposed of the used wash cloth, removed his/her gloves and applied clean gloves. He/she assisted the resident to stand and applied barrier ointment to the resident's buttocks. CNA G removed his/her gloves and assisted the resident to pull up his/her brief and pants and assisted the resident to ambulate out of the bathroom. CNA G said that he/she did not realize he/she had not changed his/her gloves. Hands should be washed and gloves changed after completing personal hygiene, before touching clean items. His/her hands and gloves should have been clean before touching a clean wash cloth and allowing the resident to wash his/her face. During an interview on 1/10/20 at 1:42 P.M., the Director of Nursing said she expected staff to follow the facility policy regarding infection control and hand hygiene. Hands should be washed and gloves changed after providing personal hygiene and before touching clean care items or resident clothing. Failure to maintain infection control could increase the risk of infection and spreading germs.