Valley Care And Rehab Llc

Based on observation, interview and document review, food items were not served in a sanitary and clean manner to residents observed during meals served from the steamer table in the kitchen. This deficient practice had the potential to affect all 10 residents who were served bread during their meal.
Findings include:
During an observation on 4/21/25 at 12:14 p.m. ,dietary manager (DM)-A removed the saran wrap over the cold items, and covers over other items in the steam table after washing hands and applying gloves. DM-A placed the resident meal choice slips of paper which were approximately three by three inches onto the metal counter area in the front of the steam table with gloved hands. DM-A began to set up a plate of taco salad which she used utensils to place the lettuce, tomatoes, cheese and taco meat and chips onto the plate. DM-A picked up a piece of bread with her right hand, held it in her left hand while buttering the bread, and placed it onto the plate. DM-A proceeded to dish up other plates of food with either the chicken Kiev meal, or the taco salad. Not all plates included the buttered bread slice. DM-A continued to touch the meal choice slips, with one or both hands, moving them around, turning them over and continued to pick up bread slices and butter them without changing her gloves after touching the meal choice slips. DM-A indicated meal choice slips were filled out by the residents, nursing assistants or activity staff during the lunch the day before. At 12:18 p.m. DM-A took two slices of bread with her left gloved hand over to the toaster, used both gloved hands and put the bread in the toaster. DM-A removed the gloves and applied new gloves. DM-A went back to the steam table, touched multiple meal choice slips, and began to dish up more meals. DM-A moved the slips around again, removed gloves, applied new gloves, went to the toaster and removed the toast from the toaster with gloved hands, applied peanut butter to the toast, and went back to the steam table to finish dishing up that meal. DM-A removed gloves and applied new gloves and began to touch and move around the meal slips and dished up other meals. DM-A indicated not all residents received the bread and picked up a meal choice slip to show surveyor. On the meal slip the word bread was circled. DM-A indicated those residents would be served bread. DM-A proceeded to pick up bread slices and butter them with her gloved hands, after touching the meal choice slips.
During an interview on 4/22/25 at 10:56 a.m., DM-A stated their usual process for serving foods, was not to touch the foods with hands and were expected to use utensils. DM-A stated if they walked away from the steam table they changed their gloves. DM-A confirmed she had touched the meal choice slips with gloved hands and touched the bread without changing gloves between. DM-A indicated she had felt flustered yesterday during the observation. DM-A indicated her usual process was to have all bread buttered and to use tongs to put onto plates. DM-A stated she would usually have all the meal choice slips laid out so she could read them and confirmed yesterday during the observation it had not been done that way. DM-A stated it was important not to touch foods with gloved hands after touching the slips to prevent cross contamination and stated the slips were considered dirty.
Review of facility policy titled Food Procurement, Store/Prepare/Serve-Sanitary revised 3/5/24, identified the facility would ensure they followed sanitation and food handling practices, and ensured food safety was maintained during buffet style or steam table food serving opportunities. The policy identified gloved hands were considered a food contact surface that could become contaminated or soiled. The policy identified failure to change gloves and wash hands between tasks, including handling ready to eat foods, could contribute to cross-contamination. Cross contamination could occur between harmful substances or disease-causing microorganism transferred to food by hands, including gloved hands. Food would be handled with new clean gloves, clean equipment and utensils.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to immediately report no later than two hours, an allegation of abuse to the State Agency (SA) for 1 of 1 residents (R1) reviewed for abuse.
Findings include:
Nursing Assistant (NA)-A's Employee Acknowledgment dated and signed on 6/23/21, identified she had received, read, and understood and comply with the Valley Care and Rehab's Social Media policy. Any questions regarding this policy would be addressed by human resources. A violation of Social Media policy would result in disciplinary action and/or termination.
NA-A's personnel file identified previous write-ups completed on the following dates:
-On 7/19/21, director of nursing (DON) was made aware NA-A had utilized snapchat (social media) during work without regard as to who was in the background. NA-A admitted she had used her phone on the shift during the night. She verbalized understanding of phone expectations and when/where it was appropriate to use.
-On 9/14/23, the writer had been made aware NA-A had posted pictures on social media of herself with diarrhea on covered pants in the hopper room (dirty utility room) with a caption what a shitty Friday and a thumbs up. She was informed even though the picture did not have personal information, the resident family could probably identify or suspect, with the style and color of the pants. She was informed this displayed unprofessional, and many companies would consider posting a picture such this to any online platform would be grounds for termination. She did not agree it was unprofessional and only wanted to know who had shown it to the writer. She was informed by writer it was expected she stop posting things of that nature from this facility.
According to the State Operations Manual Appendix PP dated 8/8/24, identified the definition of mental abuse includes abuse that was facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. If a photograph or recording of a resident, or the manner that it is used, demeans or humiliates a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. include, but is not limited to, photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, using the bathroom, providing perineal care such as after an incontinence episode, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part such as breasts or buttocks without the resident's face, labeling resident's pictures and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position.
R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition without behaviors. He required supervision with sit to stand, chair to bed transfers, and ambulation up to 10 feet, partial/moderate assistance with upper body dressing, personal hygiene, substantial/maximal assistance with lower body dressing, roll left/right in bed, dependent upon staff for toileting hygiene, and used a walker and wheelchair for mobility. He had an indwelling urinary catheter and colostomy (a surgical procedure that creates an opening in the abdomen for waste to exit the body). R1's diagnoses included neurogenic (lack of bladder control due to brain, spinal cord, or nerve problems), arthritis, and depression.
R1's care plan dated 12/12/24, identified he had an assisted daily living (ADL) self-care performance deficit related to supra pubic (empties the bladder through an incision in the abdomen instead of a tube in the urethra) urinary catheter and colostomy, and was dependent upon staff to manage these external devices and provide assistance with toilet hygiene.
Review of nursing assistant schedule from 1/13/25 through 1/26/25, identified NA-A was scheduled to work on 1/17/25, Friday 4:00 p.m. to 9:30 p.m.
Facility investigation report dated 1/18/25, identified DON received a telephone call from Barnesville Police department and a phone text message from a citizen in Barnesville regarding actions by one of the staff members of the facility. The picture showed a resident's right hand with liquid stool on it, a catheter bag on the floor with tubing attached to a stat lock (a cassette that held the urinary catheter tubing in place) and the resident's colostomy bag which had leaked. The caption to the photo was my 13 th reason name at the top of photo identified a name of social media account and below it was NA-A's name. The PO identified the staff member as NA-A. DON spoke with NA-A and she stated she had not made any snaps today and once she was informed of the photo evidence she confessed and told DON she had posted something to her private story, had taken it down, but not soon enough, when she realized it was inappropriate. She had a rough night prior to her shift and had influenced her decision making. NA-A had received verbal warnings in July 2021 and 2023 regarding cell phone use and social media. Education regarding facility policy on social media and electronic devices were reviewed with her and verbalized understanding. It was determined that despite the education, she lacked understanding of the seriousness of this incident as was at risk for repeat offenses, employment was terminated on 1/21/25. The photographs contained no identifying information to breach Health Insurance Portability and Accountability Ace of 1996 (HIPAA) (prohibiting the disclosure of protected health information). The photograph was not explicit in nature. The resident did not have any verbal/nonverbal distress to the incident. All resident needs were met and it was not identified that NA-A acted in a willful manner. There was no physical confinement, punishment, or intimidation identified. DON and interdisciplinary team (IDT) determined the incident was poor judgment it would not be reported. Strict enforcement of facility cell phone policy will be implemented to protect residents, moving forward.
During an interview on 1/24/25 at 1:00 p.m. complainant (C) stated NA-A had taken a picture of a resident who sat at edge of bed after the colostomy bag had exploded. The picture showed stool on the resident hand and leg and caption on the picture was 13 Reasons why. C stated she must have had a crappy day and most likely the reason she posted it. C stated this was an invasion of privacy and a HIPAA violation.
During review of a photo attachment on 1/26/25 submitted with complaint identified a person sat with right lower arm positioned on a mattress and right hand hung over the edge with dark golden mushy yellow substance (appeared to be stool) located on the thumb, pointer and middle fingers. The person's right leg was bare from the center of the upper thigh down to the upper calf. Located on the middle top part of the right thigh was a stat lock that held the urinary catheter tubing in place with tubing attached to the catheter bag that was located on the floor folded over. The person had a colostomy bag that hung down from their right upper thigh area that contained the same stool substance located on the fingers. Top of colostomy bag was covered with material. The end of the colostomy bag clamp appeared to have let loose, and stool was located on the bed sheet off to the right side of the person and had ran down the side of the mattress. There was a moderate amount of stool on the floor underneath the person's right leg. Written towards the bottom of the picture was my 13th reason and at the top of the picture identified 2 hours ago by NA-A's name.
During an interview on 1/27/25 at 11:07 a.m. licensed practical nurse (LPN)-A stated taking photos of residents and posting them on social media would be considered very serious HIPPA violation, and an invasion of their privacy. She had told staff in report cell phone must be placed in the staff locker room and were not allowed out on the floor while they worked. The facility had posted a yellow sign a long time ago on the door by the kitchen area that indicated: No Cell Phones Allowed Beyond this Point.
During an interview on 1/27/25 at 11:17 a.m. NA-B stated staff were not allowed to have their cell phones on them while on duty and caring for residents. Residents needed to be protected and it would not be ok to take pictures and post them on social media, would be considered a HIPPA violation and most likely embarrass the resident for sure.
During an interview on 1/27/25 at 12:12 p.m. NA-A stated she had been terminated, was wrongful just from an incident with her cell phone. She had used her cell phone while she cared for a resident in his room. R1's colostomy bag had exploded, she had taken a picture of the feces, his hand, colostomy, the bed, floor, and part of his bare leg. She did not think family could have identified him in the picture there was not a picture of his face. She posted the picture of R1 on 1/17/25, while she was at work on a private social media site snapchat with only a handful of people on it. She removed it an hour later because she was ashamed, embarrassed, was unprofessional, and she had let her emotions get the best of her. She knew what she was doing, did it anyway, and regrets it. R1 was not asked if the picture could be taken nor was he aware it was taken, he had dementia. She said if R1 knew it had been taken and posted on social media it would have affected him negatively, he would feel embarrassed and was an invasion of his privacy. NA-A stated this would not be a HIPPA violation because there were not any specific identifiers therefore, unable to identify him. On her private social media site there were at least 15 people and at least two of them worked with her at this facility. She stated only one resident currently had a colostomy and never though about those that worked with her, they could have identified him. Staff were allowed to have had their cell phones and used them while they worked at the facility with residents. She was unable to recall any write ups in the past regarding issues with her use of cell phone at work and social media posts.
During an interview on 1/27/25 at 3:11 p.m. family member (FM) stated R1 was a very private person, made sure his colostomy and urinary catheter bags were always covered. R1 was consciousness and did not want them exposed. If a picture was taken of anyone for that matter and posted on social media even without a face would be demeaning and humiliating. R1 did not know this happened but if he did, it would have bothered him and was an invasion of his privacy.
During an interview on 1/27/25 at 3:37 p.m. DON stated 2021 NA-A had taken a picture with her cell phone along with another staff member at work and there was a resident behind her. She stated 2023 NA-A had taken a picture with her cell phone in a utility room by herself, held up resident's pants soiled with stool, and posted it to social media. Education was provided and included facility policy and expectations. DON stated on 1/18/27 she was made aware by a police officer (PO) on 1/17/25, NA-A had taken a picture of R1 and posted it onto social media for anyone on her account to see, unsure of how many but was too many. R1 was not aware of what happened, had a poor memory and was not interviewable. The facility had a cell phone policy in place since she became DON (2015) and staff were expected to leave their cell phones in the staff locker room while on the floor working with residents. DON stated NA-A made a poor choice in the moment, had taken a photo of a resident and posted it to social media which affects privacy and dignity. The incident was not filed with SA, the resident was not identifiable in the photo. She stated NA-A was immature, knew what she did was wrong, used poor decision making that led her to take the picture. The incident was not a willful act and was not done to hurt or embarrass R1. A reasonable person would been upset about this and asked why are you taking a picture of my colostomy. The picture was not taken to complete cares or replace the appliance and was not necessary. Any normal person would have been embarrassed, humiliated and felt it was demeaning.
During an interview on 1/27/25 at 4:07 p.m. administrator stated on 1/18/25, he was made aware of the incident when NA-A had taken a picture of a resident and posted it on social media. The incident was not reported to the SA, did not meet the reportable guidelines of the algorithm. The person in the photo was unidentifiable. This employee had worked at other faculties and not sure where the photo was taken, location, or which employer. He was aware of two other incidents where NA-A used her cell phone at work and posted pictures to social media. He stated staff were expected to leave their cell phones in the locker room while at work and a sign was posted by the back door for years, no cell phones beyond these doors. Immediate action was taken to ensure that there was no other staff with personal devices on the floor, provider and family notified, educated staff, and terminated staff involved. The resident was not made aware of this incident per family request.
Facility Combined Federal and State [NAME] of Rights last revised 2/1/17, identified each resident must be treated with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his/her quality of life. The resident has the right to be free from abuse, neglect and misappropriation of resident property, and exploitation of this subject. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
Facility policy Free from Abuse and Neglect dated 11/1/22, identified the facility will ensure that each resident has the right to be free form abuse, neglect, and corporal punishment of any type by anyone. 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, and mental abuse including abuse facilitated or enabled using technology. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental and verbal abuse was defined as verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.
Facility policy titled Reporting of Reasonable Suspicion of a Crime/Reporting of Alleged Violations dated 2/14/24, identified:
-What should be reported: all alleged violation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property.
-Who is required to report: the facility.
-To whom: Facility administrator, Office of Health Facility Complaints (OHFC), Clay County Social Services, Law Enforcement, Attending Physician, and Resident's Representative.
-When: All alleged violations. Immediately, but not later than 2 hours. If alleged violation involves abuse or results in serious bodily injury.
Facility Social Media Policy dated 11/1/24, identified Valley Care and Rehab respects the desire of employees to use social media including but not limited to all social networking communications, electronic communications, and electronic information for personal expression. However, employees' use of social media can pose risks to the residents' confidential, proprietary and sensitive information, can harm the facility: reputation in the community, expose facility to discrimination and harassment claims, jeopardize facility compliance with business rules and laws including but not limited to the Health Insurance Portability and Accountability Act (HIPPA) and related laws and regulations protecting residents' protected health information (PHI). Electronic devices were defined as any device used for electronic communication or electronic information included: computers, laptops, tablets, digital cameras, video recorders, fax machines, copiers, scanners, telephone system, smart phones, cell phones, and pagers. Employees are absolutely prohibited from using social media in any way that would violate HIPPA or otherwise disclose or compromise residents' public health information (PHI). This includes but is not limited to the following: Do not use social media to post, upload, send or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law. You must use Valley Care and Rehab's authorization form to obtain such prior written permission. This prohibition includes photos and videos where the resident is not easily identifiable (e.g., a photo of the resident's hand, a close up photo of any part of a resident's body, or a photo of the back of a resident in the far background of the photo). It also includes photos or video where the resident is easily identifiable, whether in the photo or video itself or through a caption. Personal use of social media is never permitted on working time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to protect the resident's right to be free from mental abuse for 1 of 1 resident (R1) reviewed for abuse when staff, while providing cares, took a photo of R1 who was covered in feces and posted the photo to social media.
Findings include:
Nursing Assistant (NA)-A's Employee Acknowledgment dated and signed on 6/23/21, identified she had received, read, and understood and comply with the Valley Care and Rehab's Social Media policy. Any questions regarding this policy would be addressed by human resources. A violation of Social Media policy would result in disciplinary action and/or termination.
Nursing assistant (NA)-A's personnel file identified the following:
-On 7/19/21, director of nursing (DON) was made aware NA-A had utilized snapchat (social media) during work without regard as to who was in the background. NA-A admitted she had used her phone on the shift during the night. She verbalized understanding of phone expectations and when/where it was appropriate to use.
-On 9/14/23, NA-A had posted pictures on social media of herself with diarrhea on covered pants in the hopper room (dirty utility room) with a caption what a shitty Friday and a thumbs up. She was informed even though the picture did not have personal information, the resident family could probably identify or suspect, with the style and color of the pants. She was informed this displayed unprofessional, and many companies would consider posting a picture such this to any online platform would be grounds for termination. She did not agree it was unprofessional and only wanted to know who had shown it to the facility. She was informed by the facility it was expected she stop posting things of that nature from this facility.
According to the State Operations Manual Appendix PP dated 8/8/24, identified the definition of mental abuse includes abuse that was facilitated or enabled through the use of technology, such as smartphones and other personal electronic devices. This would include keeping and/or distributing demeaning or humiliating photographs and recordings through social media or multimedia messaging. If a photograph or recording of a resident, or the manner that it is used, demeans, or humiliates a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status, include, but is not limited to, photographs and recordings of residents that contain nudity, sexual and intimate relations, bathing, showering, using the bathroom, providing perineal care such as after an incontinence episode, agitating a resident to solicit a response, derogatory statements directed to the resident, showing a body part such as breasts or buttocks without the resident's face, labeling resident's pictures and/or providing comments in a demeaning manner, directing a resident to use inappropriate language, and showing the resident in a compromised position.
R1's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition without behaviors. He required supervision with sit to stand, chair to bed transfers, and ambulation up to 10 feet, partial/moderate assistance with upper body dressing, personal hygiene, substantial/maximal assistance with lower body dressing, roll left/right in bed, dependent upon staff for toileting hygiene, and used a walker and wheelchair for mobility. He had an indwelling urinary catheter and colostomy (a surgical procedure that creates an opening in the abdomen for feces waste to exit the body). R1's diagnoses included neurogenic (lack of bladder control due to brain, spinal cord, or nerve problems), arthritis, and depression.
R1's care plan dated 12/12/24, identified he had an assisted daily living (ADL) self-care performance deficit related to supra pubic (empties the bladder through an incision in the abdomen instead of a tube in the urethra) urinary catheter and colostomy, and was dependent upon staff to manage these external devices and provide assistance with toilet hygiene.
Review of nursing assistant schedule from 1/13/25 through 1/26/25, identified NA-A was scheduled to work on 1/17/25, Friday 4:00 p.m. to 9:30 p.m.
Facility investigation report dated 1/18/25, identified DON received a telephone call from a police department and a phone text message from a citizen in town regarding actions by one of the staff members of the facility. The picture showed a resident's right hand with liquid stool on it, a catheter bag on the floor with tubing attached to a stat lock (a cassette that held the urinary catheter tubing in place) and the resident's colostomy bag which had leaked. The caption to the photo was my 13th reason name at the top of photo identified a name of social media account and below it was NA-A's name. The post identified the staff member as NA-A. DON spoke with NA-A and she stated she had not made any snaps today and once she was informed of the photo evidence she confessed and told DON she had posted something to her private story, had taken it down, but not soon enough, when she realized it was inappropriate. She had a rough night prior to her shift and had influenced her decision making. NA-A had received verbal warnings in July 2021 and 2023 regarding cell phone use and social media. Education regarding facility policy on social media and electronic devices were reviewed with her and verbalized understanding. It was determined that despite the education, she lacked understanding of the seriousness of this incident as was at risk for repeat offenses, employment was terminated on 1/21/25. The photographs contained no identifying information to breach Health Insurance Portability and Accountability Ace of 1996 (HIPAA) (prohibiting the disclosure of protected health information). The photograph was not explicit in nature. The resident did not have any verbal/nonverbal distress to the incident. All resident needs were met, and it was not identified that NA-A acted in a willful manner. There was no physical confinement, punishment, or intimidation identified. DON and interdisciplinary team (IDT) determined the incident was poor judgment it would not be reported. Strict enforcement of facility cell phone policy will be implemented to protect residents, moving forward.
During an interview on 1/24/25 at 1:00 p.m. complainant (C) stated NA-A had taken a picture of a resident who sat at edge of bed after the colostomy bag had exploded. The picture showed stool on the resident hand and leg and caption on the picture was 13 Reasons why. C stated she must have had a crappy day and most likely the reason she posted it. C stated this was an invasion of privacy and a HIPAA violation.
During review on 1/26/25 of a photo taken by NA-A and posted to social media, the photo identified a person sitting on the edge of a bed, with the right lower arm positioned on a mattress and the right hand hung over the edge with dark golden mushy yellow substance (appeared to be stool) located on the thumb, pointer and middle fingers. The person's right leg was bare from the center of the upper thigh down to the upper calf. Located on the middle top part of the right thigh was a stat lock that held the urinary catheter tubing in place with tubing attached to the catheter bag that was located on the floor folded over. The person had a colostomy bag that hung down from their abdomen area to the right upper thigh area that contained the same stool substance located on the fingers. Top of colostomy bag was covered with material. The end of the colostomy bag clamp appeared to have let loose, and stool was located on the bed sheet off to the right side of the person and had run down the side of the mattress. There was a moderate amount of stool on the floor underneath the person's right leg. Written towards the bottom of the picture was my 13th reason and at the top of the picture identified 2 hours ago by NA-A's name.
During an interview on 1/27/25 at 12:12 p.m. NA-A stated she had been terminated, was wrongful just from an incident with her cell phone. She had used her cell phone while she cared for a resident in his room. R1's colostomy bag had exploded, she had taken a picture of the feces, his hand, colostomy, the bed, floor, and part of his bare leg. She did not think family could have identified him in the picture there was not a picture of his face. She posted the picture of R1 on 1/17/25, while she was at work on a private social media site snapchat with only a handful of people on it. She removed it an hour later because she was ashamed, embarrassed, was unprofessional, and she let her emotions get the best of her. She knew what she was doing, did it anyway, and regrets it. R1 was not asked if the picture could be taken nor was, he aware it was taken, he had dementia. She said if R1 knew it had been taken and posted on social media it would have affected him negatively, he would have felt embarrassed and was an invasion of his privacy. NA-A stated this would not be a HIPPA violation because there were not any specific identifiers therefore, unable to identify him. On her private social media site there were at least 15 people and at least two of them worked with her at this facility. She stated only one resident currently had a colostomy and never thought about those that worked with her, and they could have identified him. Staff were allowed to have had their cell phones and used them while they worked at the facility with residents. She was unable recall any write ups in the past regarding issues with her use of cell phone at work and social media posts.
During an interview on 1/27/25 at 3:11 p.m. family member (FM) stated R1 was a very private person, made sure his colostomy and urinary catheter bags were always covered. R1 was consciousness and did not want them exposed. If a picture was taken of anyone for that matter and posted on social media even without a face would be demeaning and humiliating. R1 did not know this happened but if he did, it would have bothered him and was an invasion of his privacy.
During an interview on 1/27/25 at 3:37 p.m. DON stated 2021 NA-A had taken a picture with her cell phone along with another staff member at work and there was a resident behind her. She stated 2023 NA-A had taken a picture with her cell phone in a utility room by herself, held up resident's pants soiled with stool, and posted it to social media. Education was provided and included facility policy and expectations. DON stated on 1/18/27 she was made aware by a police officer (PO) on 1/17/25, NA-A had taken a picture of R1 and posted it onto social media for anyone on her account to see, unsure of how many but was too many. R1 was not aware of what happened, had a poor memory and was not interviewable. The facility had a cell phone policy in place since she became DON (2015), and staff were expected to leave their cell phones in the staff locker room while on the floor working with residents. DON stated NA-A made a poor choice in the moment, had taken a photo of a resident, and posted it to social media which affects privacy and dignity. The incident was not filed with SA, the resident was not identifiable in the photo. She stated NA-A was immature, knew what she did was wrong, used poor decision making that led her to take the picture. The incident was not a willful act and was not done to hurt or embarrass R1. A reasonable person would been upset about this and asked why are you taking a picture of my colostomy. The picture was not taken to complete cares or replace the appliance and was not necessary. Any normal person would have been embarrassed, humiliated, and felt it was demeaning.
During an interview on 1/27/25 at 4:07 p.m. administrator stated on 1/18/25, he was made aware of the incident when NA-A had taken a picture of a resident and posted it on social media. The incident was not reported to the SA, did not meet the reportable guidelines of the algorithm. The person in the photo was unidentifiable. This employee had worked at other faculties and not sure where the photo was taken, location, or which employer. He was aware of two other incidents where NA-A used her cell phone at work and posted pictures to social media. He stated staff were expected to leave their cell phones in the locker room while at work and a sign was posted by the back door for years, no cell phones beyond these doors. Immediate action was taken to ensure that there was no other staff with personal devices on the floor, provider and family notified, educated staff, and terminated staff involved. The resident was not made aware of this incident per family request.
Facility policy Free from Abuse and Neglect dated 11/1/22, identified the facility will ensure that each resident has the right to be free form abuse, neglect, and corporal punishment of any type by anyone. 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, and mental abuse including abuse facilitated or enabled using technology. Willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental and verbal abuse was defined as verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.
Facility Social Media Policy dated 11/1/24, identified Valley Care and Rehab respects the desire of employees to use social media including but not limited to all social networking communications, electronic communications, and electronic information for personal expression. However, employees' use of social media can pose risks to the residents' confidential, proprietary and sensitive information, can harm the facility: reputation in the community, expose facility to discrimination and harassment claims, jeopardize facility compliance with business rules and laws including but not limited to the Health Insurance Portability and Accountability Act (HIPPA) and related laws and regulations protecting residents' protected health information (PHI). Electronic devices were defined as any device used for electronic communication or electronic information included: computers, laptops, tablets, digital cameras, video recorders, fax machines, copiers, scanners, telephone system, smart phones, cell phones, and pagers. Employees are absolutely prohibited from using social media in any way that would violate HIPPA or otherwise disclose or compromise residents' public health information (PHI). This includes but is not limited to the following: Do not use social media to post, upload, send or otherwise share or disclose a photo or video of any resident without prior written permission of the resident or the resident's authorized agent as required by applicable law. You must use Valley Care and Rehab's authorization form to obtain such prior written permission. This prohibition includes photos and videos where the resident is not easily identifiable (e.g., a photo of the resident's hand, a close-up photo of any part of a resident's body, or a photo of the back of a resident in the far background of the photo). It also includes photos or video where the resident is easily identifiable, whether in the photo or video itself or through a caption. Personal use of social media is never permitted on working time.
Facility resident Consent to Photograph dated 1/1/25, located in the resident admission packet, identified I hereby authorize consent to the making of photographs of me while I am a resident at Valley Care Rehab. I understand that the photographs maybe made by my attending physician or an employee of the facility. I understand that such photographs maybe used for treatment purposes, including the assessment and evaluation of my wound(s). I understand that these images will be stored in a secure manner and will protect privacy and that they will be kept for the time required by law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 8 of 8 residents (R2, R3, R5, R6, R8, R13, R24, R28) reviewed for dining services.
Findings include:
R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact and was independent with eating.
R3's quarterly Minimum Data Set (MDS) dated [DATE], indicated R3 was cognitively intact and was independent with eating.
R5's admission Minimum Data Set (MDS) dated [DATE], indicated R5 was cognitively intact and was independent with eating.
R6's significant change Minimum Data Set (MDS) dated [DATE], indicated R6 was cognitively intact and was independent with eating.
R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated R8 was cognitively intact and required supervision with eating.
R13's annual Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact and was independent with eating.
R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated 24 was cognitively intact and was independent with eating.
R28's significant change Minimum Data Set (MDS) dated [DATE], indicated R28 was cognitively intact and was independent with eating.
During an observation on 3/4/24 at 12:00 p.m., dietary manager (DM) was observed pushing the food cart from the kitchen down the hall, unzipped clear cover on cart, delivered food tray to R6, sanitized hands, returned to food cart, delivered tray to R5 and exited room. DM sanitized hands, delivered tray to R24. DM, pushed cart down hall, delivered tray to R28 and returned cart to the kitchen.
During an observation on 3/4/24 at 12:06 p.m., DM was observed placing food from steam table onto individual uncovered food trays and placed onto food cart that was covered with a clear plastic cover in the kitchen. DM pushed food cart down hall to deliver tray to R4. At 12:13 p.m., DM was asked to temp the food before delivering to R4.
Temperatures were noted to be as follows:
fish 100 degrees Fahrenheit (F)
rice 122 (F)
vegetables 99.2 (F)
DM took tray to kitchen and threw food away. DM confirmed she was unable to retain heat to food during transport without individual tray covers or plate warmers that were not available at the facility.
During an observation on 3/4/24 at 12:18 p.m., DM placed three food trays onto food cart, and at 12:24 p.m., placed another food tray onto the food cart. DM pushed food cart down hallway and knocked on R8's door. DM was asked to temp food prior to delivering to R8.
Temperatures were noted to be as follows:
fish 60 degrees (F)
DM left pudding with R8 stating, fish was cold and would bring back fresh fish. DM delivered food tray to room [ROOM NUMBER] with alternative food choice of chicken nuggets. At 12:27 p.m., DM was asked to temp food tray to be delivered to R2.
Temperatures were noted to be as follows:
chicken 100 degrees (F)
rice 110 (F)
vegetables 101 (F)
R2 asked why she wasn't getting her food, DM stated, it was cold and was going to get her fresh warm food. R2 replied, my food is always cold.
During an interview on 3/4/24 at 2:05 p.m., R6 stated the food was not very good and lunch was warm but not hot.
During an interview on 3/4/24 at 2:12 p.m., R5 reported the food was normally cold when served in the room.
During an interview on 3/4/24 at 2:20 p.m., R24 stated he had informed staff numerous times about the poor food quality and hot foods not being hot when delivered to his room and R24 indicated nothing had changed. R24 stated lunch today was barely warm enough to eat.
During an interview on 3/5/24 at 2:22 p.m., DM stated the expectation of staff were to know their job procedures, policies and health codes of the kitchen. Staff were provided specific education on food temps and cooks had serve safe certification for proper food temp storage and preventing cross contamination. DM verified food temps needed to be at safe parameters to prevent food borne illnesses and infections.
During a interview on 3/6/24 at 2:32 p.m., director of nursing (DON) verified the food cart should have been covered with no interruptions in delivery to maintain proper temps. DON stated she did not know how to keep food delivery trays to rooms warm without hot plates or covers. DON confirmed food temps should remain at the recommended levels according to food service guidelines and if hot food was cold and not at appropriate temperatures residents could develop gastrointestinal illness.
Review of the facility policy titled Food Procurement, Store/Prepare/Serve- Sanitary policy revised 3/5/24, indicated all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit.
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A copy of the policy prior to date of 3/5/24, was requested however had not been received.

Based on observation, interview, and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 2 of 2 hallways observed for linen transportation.
Findings include:
Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items.
During an observation on 3/4/24 at 3:56 p.m., housekeeping aid (HA)-A exited R16's room with laundry, lifted linen bin cover off of dirty linen bin in hallway next to transmission based precaution room and placed laundry in dirty linen bin. HA-A removed laundry from uncovered cart, delivered laundry to R26's room and exited room. HA-A entered R20's room and was observed to take a blanket off of R20's bed and placed blanket on R20 who was laying in the recliner. HA-A removed laundry from uncovered cart, placed laundry in R20's room, took empty hangers out of R20's room and hung on cart. HA-A removed laundry from cart, knocked on R18's door, opened closet door, hung laundry in closet, opened drawer, placed laundry in drawer, exited R18's room with empty hangers and hung hangers on cart. HA-A removed laundry from uncovered cart, knocked on R9's door, entered R9's room, opened drawer, placed laundry in drawer, opened closet, hung laundry in closet and exited R9's room. HA-A removed laundry from cart, placed laundry on R21's bed, opened closet, hung laundry in closet, opened drawer, placed laundry in drawer, exited R21's room with empty hanger and hung on cart. HA-A removed laundry from cart, entered R7's room, opened drawer, placed laundry in drawer, opened closet, placed laundry in closet, left R7's room with empty hangers and hung on cart. HA-A covered empty laundry cart and returned it to the laundry room. HA-A removed another laundry cart from the laundry room and pushed the covered cart down the north hall. HA-A uncovered the cart, removed laundry from cart, entered R35's room, opened closet door, hung laundry in closet, opened drawer, placed laundry in drawer and exited R35's room. HA-A removed laundry from the uncovered cart, entered R19's room, opened closet door, hung laundry in closet, opened drawer, placed laundry in drawer and exited R19's room. HA-A removed laundry from cart, placed in R17's closet, exited R17's room with empty hanger and hung hanger in cart. HA-A removed laundry from cart, entered R28's room, opened closet door, hung laundry in closet, exited R28's room with empty hanger and hung hanger on uncovered cart. HA-A removed laundry from cart, placed laundry in R81's closet, emptied R81's room with empty hangers and hung on cart. HA-A removed laundry from cart, knocked on R22's door, placed laundry in R22's closet and exited R22's room. Three visitors were observed to walk past the uncovered cart. In addition, R22 and two visitors walked past uncovered cart. HA-A removed laundry from cart, entered R23's room, opened closet door, hung laundry, opened drawer, placed laundry in drawer, exited R23's room with empty hangers and hung hangers on cart. HA-A removed laundry from cart, entered R27's room, opened closet door and hung laundry, opened drawer, placed laundry in drawer, exited R27's room with empty hangers and hung on cart. HA-A removed laundry from cart, knocked on R13's door, opened door, opened closet and hung laundry, opened drawer and placed laundry in drawer. HA-A exited R13's room with empty hangers and hung hangers on cart. HA-A removed laundry (blankets/quilts) from cart and placed laundry in R13's closet. HA-A closed door to R13's room, covered cart and pulled the cart down hall. HA-A returned the cart to the laundry room, opened door and pushed cart into clean area of laundry room.
HA-A did not sanitize her hands during the entire observation. The laundry carts remained uncovered during the entire observation while in the resident hallways.
During an interview on 3/4/24 at 4:25 p.m., HA-A stated the facility policy for laundry was to keep the cart covered when transporting down hallways. HA-A confirmed she did not cover the linen cart while in the hallway distributing laundry. HA-A stated she sanitized her hands before she started distributing laundry and when she was completely done distributing laundry. HA-A verified she knocked on resident doors, touched closet handles, drawer handles, assisted with resident cares, removed hangers from resident rooms and put into laundry cart. HA-A confirmed that resident and family members walked past the uncovered cart and could potentially contaminate the laundry when the cart was left uncovered. Environmental service director (EVS) walked down hallway and joined the conversation. EVS confirmed the facility could improve on their process for preventing cross contamination and that hand hygiene should have been completed in between resident rooms.
During an interview on 3/5/24 at 2:13 p.m., the director of nursing/infection preventionist (DON) stated the expectation was staff would complete hand hygiene in between resident rooms and the cart would be covered during laundry/ linen delivery to prevent the spread of infections.
Review of a facility policy titled Handling Clean Linen Policy dated 5/24/22, indicated laundry should be packaged, transported and stored in a manner that ensured cleanliness and protected the laundry from dust and soil. Clothing would be taken out of cart and covered again while unattended in the hallways.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to report to the State Agency (SA) immediately for an injury of unknown origin for 1 of 1 residents (R1) who fell, resulting in a fractured right leg.
Findings include:
R1's annual Minimum Data Set (MDS) dated [DATE], indicated no cognitive impairments. R1's diagnoses included heart failure, diabetes, major depression, unspecified dementia and anemia.
R1's care plan dated 1/25/24, indicated R1 was a fall risk and goal indicated to be free from falls. Interventions included call light within reach, floor mats alongside R1's bed, and bed positioned to the lowest setting before staff were to leave.
R1's fall management program dated 2/3/24, indicated at 1:00 a.m., R1 was found sitting on the floor by bed. R1 reported he had not hit his head however reported pain all over body; R1 refused hospital evaluation. R1's fall management program dated 2/3/24, indicated at 6:30 a.m., R1 was found lying on the floor near bed. R1 was unable to state what happened. Pain was located on right lower leg and R1 agreed after approximately 1 hour to be evaluated at the hospital. Hospital diagnosis was right lower leg fracture (oblique proximal tibial). Facility failed to report injury of unknown origin to the SA. R1 was unable to inform facility how fall occurred and outcome was fractured right leg.
During interview on 2/9/24 at 2:32 p.m., registered nurse (RN) stated she was present after R1's fall at 6:30 a.m. on 2/3/24. RN stated R1 could not tell what caused the fall, and later agreed to go the hospital after pain medications were given. RN stated a call to the assistant director of nursing (ADON) was completed and RN reminded ADON to call in the incident to the SA as he didn't know how the fall occurred.
During interview on 2/9/24 at 3:48 p.m. ADON stated R1's last fall at 6:30 am on 2/3/24 a preliminary investigation was started and was determined to not report to SA as there was no abuse that occurred. ADON further explained the preliminary investigation consisted of only the report from RN at the time of the fall. ADON stated the preliminary investigation took longer than the 2 hour which was required by the facilities policy. ADON agreed this incident should had been reported to the SA and continue the investigation.
Review of facility's internal investigation lacked evidence a report was submitted to SA.
The facility's policy titled Reporting of Reasonable Suspicion of a Crime Reporting of Alleged Violations, revised date 11/1/2022, indicated serious bodily injury-immediately but not later than 2 hours after forming the suspicion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 1 residents (R7) who utilized an indwelling catheter.
Findings include:
R7's quarterly Minimum Data Set (MDS) dated [DATE], identified R7 had intact cognition and diagnoses which included cancer and renal insufficiency (poor functioning kidneys). Identified R7 required extensive assistance with activities of daily living which included personal hygiene and toileting. Indicated R7 had an indwelling catheter.
R7's significant change in status Care Area Assessment (CAA) dated, 4/10/23, identified R7 required extensive assistance with toileting. Indicated R7 had an indwelling catheter related to urinary retention (unable to completely empty the bladder).
R7's care plan revised on 1/26/23, identified R7 had an indwelling catheter due to urinary retention. Care plan instructed staff to position catheter bag and tubing below the level of the bladder and away from entrance of the door. Care plan indicated R7 required extensive staff assistance for toilet use.
During an observation on 7/24/23 at 1:12 p.m., R7 was seated in his wheelchair in the hallway and a visitor walked by. R7's indwelling catheter leg bag which contained dark yellow urine was hanging out the bottom of his left pant leg and was visible to anyone who walked by.
During an interview on 7/24/23 at 1:17 p.m. ,R7 stated it would be nice if his leg bag was higher on his leg or covered so that it was not visible to everyone who walked by.
During an observation on 7/25/23 at 8:55 a.m., R7 was seated in his wheelchair in the dining room. R7's indwelling catheter leg bag which contained dark yellow urine was hanging out the bottom of his left pant leg. The leg bag was visible to visitors and other residents who were in the dining room.
During an observation on 7/25/23 at 12:21 p.m., R7 was seated in his wheelchair in the dining room with several residents and two visitors present. R7's indwelling catheter leg bag which contained dark yellow urine was hanging out the bottom of his left pant leg. The leg bag was visible to other residents and visitors who were in the dining room.
During an interview on 7/25/23 at 12:23 p.m., nursing assistant (NA)-A verified R7's indwelling catheter leg bag was visible to other residents and visitors. NA-A indicated it was not dignified for R7's leg bag to be visible and the expectation was R7's leg bag would have been covered with a catheter bag cover.
During an interview on 7/25/23 at 12:27 p.m., licensed practical nurse (LPN)-A verified R7's indwelling catheter leg bag was visible to other residents and visitors. LPN-A stated it was not dignified for R7's leg bag to be visible and the expectation was R7's leg bag would have been covered.
During an interview on 7/26/23 at 8:50 a.m. , director of nursing (DON) confirmed R7 required extensive staff assistance with his indwelling catheter leg bag. DON stated her expectation would have been R7's indwelling catheter leg bag would not have been visible to other residents or visitors.
Review of a facility policy titled Resident Rights-Respect & Dignity revised 11/2/22, identified all residents were to be treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of his/her quality of life. The policy indicated staff were to assist in maintaining dignity of a resident requiring a catheter by covering catheter bags.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure resident advance directives were accurately documented in the electronic health record (EHR) and displayed correctly on the doorframe to reflect the residents current wishes (green dot indicated- cardiopulmonary resuscitation (CPR); red dot indicated- do not resuscitate (DNR), which affected 2 of 16 residents (R10 and R29) reviewed for advance directives. This deficient practice resulted in an immediate jeopardy (IJ) for (R10) who would not have received CPR, contrary to her wishes, in the absence of a pulse or respirations.
The IJ began on [DATE], when R10's current physician's order for life sustaining treatment (POLST) signed on [DATE], identified R10 was to receive CPR, however R10's EHR's main screen (banner), physician orders and the magnetic red dot identified R10's wishes were DNR. The administrator and director of nursing (DON) were notified of the IJ on [DATE] at 1:06 p.m.
The IJ was removed on [DATE] at 6:51 p.m., when the facility had implemented corrective action, however non-compliance remained at the lower scope and severity level of D, isolated with no actual harm but potential to cause more than minimal harm.
Findings include:
R10
During an interview on [DATE] at 11:17 a.m., R10 confirmed in the event her heart stopped or she was not breathing, she would want staff to perform CPR and she stated, that's what I want them to do.
R10's admission Minimum Data Set (MDS) dated [DATE], identified R10 had diagnoses which included: heart failure and malnutrition.
R10's current POLST signed by her on [DATE], identified R10's wishes were to receive CPR in the event she had no pulse or respirations. The POLST was scanned into her EHR and signed by her primary physician on [DATE].
Review of R10's EHR Order Summary Report dated [DATE], identified R10 had an order for DNR and was signed by her primary physician on [DATE].
Review of R10's EHR banner on [DATE] at 6:03 p.m., identified R10 was a DNR.
R10's care plan revised on [DATE], lacked R10's advance directives and wishes.
Review of R10's Progress Notes from [DATE] to [DATE], lacked any documentation regarding her advanced directive or her wishes.
During an observation on [DATE] at 6:09 p.m., a red magnetic dot was affixed to the inside of the doorway frame in the left upper corner of R10's door indicating R10's wishes were to be DNR.
During an interview on [DATE] at 6:03 p.m., assistant director of nursing (ADON)-B indicated in the event a resident did not have a pulse or respirations, she would refer to the magnetic dot on the resident's doorframe to determine if CPR should be administered or not and would have proceeded accordingly.
During an interview on [DATE] at 6:04 p.m., ADON-A indicated in the event a resident did not have a pulse or respirations, she would refer to the resident's EHR's banner to determine what their wishes were and proceed accordingly. Stated if she did not have access to the EHR, she would look at the magnetic dot located on the resident's doorway. Indicated the social worker reviewed and completed the POLST with each resident during the admission process and was then signed by the resident's primary physician. Once the POLST was signed, a copy would be provided to her and she was responsible for updating the EHR's banner and scanning it into the EHR.
During an interview on [DATE] at 6:09 p.m., registered nurse (RN)-A indicated in the event a resident did not have a pulse or was not breathing, she would look at the magnetic dot located on the resident's doorway frame to determine if she should initiate CPR or not.
During an interview on [DATE] at 6:14 p.m., licensed practical nurse (LPN)-C indicated in the event a resident did not have a pulse or was not breathing, she would look to see if there was a magnetic dot on the door to determine if she should initiate CPR or not.
During an interview on [DATE] at 9:13 a.m., LPN-A indicated in the event a resident did not have a pulse or no respirations, she would look at the dot on the doorway to determine if she should initiate CPR or not.
During an interview on [DATE] at 9:14 a.m., LPN-B indicated in the event a resident coded she would look at the EHR banner to determine if the resident wanted CPR or was DNR.
During an interview on [DATE] at 9:13 a.m., RN-B indicated in the event a resident did not have a pulse or respirations, she would look at the dot on the doorway to determine is she should initiate CPR or not.
During a follow up in interview on [DATE] at 9:54 a.m., ADON-B indicated R10's current POLST dated [DATE], identified R10's wishes were to be CPR. ADON-B verified R10's EHR banner and the magnetic dot on the inside of R10's doorway indicated DNR was inaccurate according to the POLST. ADON-B indicated in the event R10 did not have a pulse or respirations, CPR would not have been initiated per her wishes. The ADON-B verified the POLST was to be completed during the admission process with the social worker and was provided to her after completion and she or ADON-A were responsible to update the EHR.
During an interview on [DATE] at 11:21 a.m., the DON indicated the social worker completed the POLST with each resident upon admission, provided a copy to the ADON's and the EHR would then be updated with the resident's wishes. She confirmed there was a discrepancy and R10's EHR, the red dot on R10's doorway and her current POLST did not match to accurately reflect R10's wishes. DON confirmed in the event R10 did not have a pulse or respirations, CPR would not have been initiated per R10's wishes and could have resulted in an unnecessary death. She indicated she would expect staff to follow the POLST, the resident wishes and to follow the facility policy.
Review of the facility policy titled, Cardio-Pulmonary Resuscitation (CPR) revised [DATE], identified all residents would be informed of their option to formulate an advance directive. If a resident had a valid advanced directive, the facility would ensure the care reflects the resident's wishes as expressed on the directive. Identified, upon admission all residents/representatives would complete a POLST. The medical orders were based on the resident's current medical condition and preferences. The policy indicated the facility would maintain the original copy of the signed POLST, the status would be in the medical record, care plan, care guides, nurse's notes, and indicator (red-DNR and green-CPR) would be affixed to the inside of the door jam.
The IJ was removed on [DATE] at 6:51 p.m., when the facility developed and implemented a systemic removal plan which was verified by interview and document review:
- All residents' records were reviewed to ensure the POLST form, the electronic medical records were updated to ensure resident's wishes for advance directives, red and green dot system was accurately in place and care plan interventions were accurate on [DATE].
- Advanced Directive audit tool reviewed by interdisciplinary team and found to be appropriate in preventing future deficient practices related to documentation of advance directives.
- All current direct care staff (certified nursing assistants & licensed nurses) were educated on the policy for advanced directives, obtaining and documenting the POLST to reflect the resident's wishes, on [DATE], as evidenced by the Education Sign in Sheet and interviews.
- A process was implemented to assure all other nursing staff completed mandatory education prior to the start of their next shift on [DATE], by notification of required mandatory education via phone/text. Education to all future shifts would be provided by the charge nurse, ADON, or DON prior to the start of the shift. Education would be verbal and written. Direct care staff would sign off once education had been completed.
- The Advanced Directive policy was reviewed and revised to reflect changes on [DATE].
R29
R29's significant change Minimum Data Set (MDS) assessment dated [DATE], identified R29 had diagnoses which included: heart failure and hypertension.
R29's POLST form dated [DATE], located in R29's EHR indicated R29 wanted CPR.
Review of R29's EHR current Physician Orders dated [DATE], revealed R29 had an order for CPR.
R29's care plan dated [DATE], indicated R29 requested CPR.
During an observation on [DATE] at 6:25 p.m., R29's door frame lacked a magnet in place to identify what his code status was.
During an interview on [DATE] at 12:42 p.m., ADON-A stated R29's room lacked a magnet to alert staff what his code status was. She indicated she placed a magnet on the door frame of R29's room on the evening of [DATE], after she had learned the magnet was not in place to identify R29 wanted CPR. During a follow up interview on [DATE] at 1:42 p.m., ADON stated his code status was CPR as verified by his order signed on [DATE].
During an interview on [DATE] at 2:41 p.m., R29 confirmed he would want CPR administered in the event he experienced cardiac arrest.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the Long-Term Care (LTC) ombudsman of facility initiated transfers/discharges for 1 of 1 residents (R21) who was transferred to an acute care facility on an emergency basis and discharged to the hospital.
Findings include:
R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated R21 had severe cognitive impairment and had diagnoses which included: Parkinson's, anxiety, dementia. Identified R21 required limited assistance of one staff for bed mobility, dressing, toileting, personal hygiene, and bathing.
Review of R21's Progress Notes from 4/16/23 to 7/25/23, revealed the following:
- On 4/21/23, R21 complained of chest pain, upper back pain and was having difficulty breathing during dinner. R21 indicated she was having anxiety and R21's oxygen saturations were 92% - 93% on three liters of oxygen.
- On 4/22/23, R21 continued to have chest and back pain and was sent to the emergency room for further evaluation. R21 was admitted to the hospital for blood transfusions due to low hemoglobin.
- On 4/26/23, R21 returned to the facility after receiving a blood transfusion, iron transfusion, and receiving antibiotics for a urinary tract infection (UTI).
After further review of R21's medical record, lacked documentation the LTC ombudsman had been notified of R21's transfer/discharge to the hospital.
During an interview on 7/25/23 at 4:24 p.m., social services designee (SSD) confirmed R21 had been hospitalized on [DATE]. SSD indicated she was not an employee during R21's hospitalization and stated she was not aware if the ombudsman had been notified. The SSD stated the facility's process was to fax the ombudsman on a monthly basis of the facility's transfer/discharges which included the resident's name, transfer/discharge location, when the transfer occurred, and the reason for the transfer/discharge. The SSD indicated a copy of the notification to the ombudsman was to be placed into the electronic health record (EHR).
During an interview on 7/26/23 at 10:42 a.m., the director of nursing (DON) confirmed the above findings and indicated there was no documentation the ombudsman had been notified of R21's transfer/discharge to the hospital on 4/22/23. The DON indicated she would expect staff to follow facility policy and notify the ombudsman of transfer/discharges on a monthly basis.
Review of the policy titled, Notice of Transfer or Discharge revised 11/2/22, indicated the facility would copy all transfers/discharges and would be sent to the ombudsman. The facility indicated the transfer/discharges may be sent when practicable, such as a list of residents monthly. The facility would maintain a fax transmittal receipt of the fax being successfully sent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide assistance with providing oral cares for 1 of 2 residents (R22) who was dependent upon staff for activities of daily living (ADLs).
Findings include:
R22's quarterly Minimum Data Set (MDS), dated [DATE], identified R22 had diagnoses which include: cerebral vascular accident (CVA/stroke), dementia, and depression. Indicated R22 required assistance of one staff with transfers, toileting, dressing, bathing, personal hygiene, and oral cares.
R22's care plan revised on 6/14/23, indicated R22 had ADL self-care deficits related to infection, old stroke, carotid artery disease, and peripheral vascular disease (PVD). The care plan indicated R22 required staff assistance with oral cares and personal hygiene. Identified R22 had dentures and staff were to brush, rinse, and place dentures into R22's mouth.
Review of Admission/Annual Nursing assessment dated [DATE], indicated R22 had natural teeth and required assistance with ADLs due to weakness and contractures of left hand.
During an observation on 07/26/23 at 8:13 a.m., R22 laid in bed covered with a blanket. Nursing assistant (NA)-B entered R22's room, asked R22 if she was ready to get up for breakfast and R22 agreed. NA-B gathered her supplies and proceeded to assist R22 with morning cares which included washing her up, providing incontinent cares, dressing, and assisting with personal hygiene. NA-B transferred R22 via mechanical standing lift from her bed to her wheelchair. NA-B wheeled R22 out of her room, down the hallway when licensed practical nurse (LPN)-A indicated R22 needed her medication. NA-B wheeled R22 back to her room and LPN-A entered R22's room and administered R22's medications. LPN-A proceeded to wheel R22 down the hallway and into the dining room for breakfast. R22 began eating her breakfast independently. R22 had natural teeth that were stained and discolored yellow. NA-B and LPN-A were not observed to offer or provide oral cares to R22 while getting her ready for the day.
During an interview on 7/26/23 at 12:09 p.m., NA-B confirmed R22 required staff assistance with oral cares and personal hygiene and never refused cares. NA-B verified she had not offered or provided oral cares to R22 because she had forgotten.
During an interview on 7/26/23 at 12:46 p.m., LPN-A confirmed R22 required staff assistance with oral cares and personal hygiene. LPN-A verified she had not offered oral cares to R22 because she indicated the NA's usually provide oral cares during morning cares. LPN-A further indicated she would expect nursing staff to follow the resident care guides/care plan and to communicate with her if the residents are refusing oral cares.
During an interview on 7/26/23 at 12:53 p.m., director of nursing (DON) confirmed the above findings and indicated R22 required assistance of one staff for ADLs. The DON indicated she would expect staff to follow facility policy and R22's care plan as written.
Review of facility policy titled, Oral Cares revised 11/1/22, indicated the facility would provide oral cares twice daily with morning and evening cares.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 4 of 5 residents (R7, R10, R21 and R24) were offered or received pneumococcal vaccinations in accordance with the Center for Disease Control (CDC) recommendations.
Findings include:
Review of the current CDC recommendations 3/15/2023, revealed The CDC identified Adults [AGE] years of age or older who had not previously received Pneumococcal 13-valent Conjugate Vaccine (PCV13) and who had previously received one or more doses of Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive a dose of Pneumococcal 15-valent Conjugate Vaccine (PCV15) or one dose of Pneumococcal 20-valent Conjugate Vaccine (PCV20). The dose of PCV15 or PCV20 should be administered at least one year after the most recent PPSV23 dose. In addition, the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 was received at age [AGE] and older, based on shared clinical decision-making, one dose of PCV20 at least five years after the last pneumococcal vaccine dose. In addition CDC guidelines dated 2/13/23, identified Adults [AGE] years of age or older who have not received any pneumococcal vaccines should receive one dose of PCV15 or PCV20.
Review of R7's facesheet, identified R7, age [AGE], was admitted to the facility on [DATE]. Review of R7's Minnesota Immunization Information Connection (MIIC) undated, identified R7 had received Pneumo-PPSV13 on 11/30/2015, and the Pneumo- PPSV23 on 10/10/13. R7's medical record lacked documentation R7 had been offered or received the PCV20 vaccine.
Review of 10's face sheet, identified R10, was admitted to the facility on [DATE]. Review of R10's MIIC undated, identified R10 had received Pneumo-PPSV13 on 11/19/2002, and 9/13/2017. In addition, MIIC identified R10 received Pneumo-PPSV23 on 9/29/2014. R10's medical record lacked documentation R10 had been offered or received the PCV20 vaccine.
Review of R24's facesheet, identified R24, age [AGE], was admitted to the facility on [DATE]. Review of R24's MIIC undated, identified R24 had not received any of the Pneumococcal vaccines. R24's medical record lacked documentation R24 had been offered or received the PCV15 or PCV20.
Review of R21's facesheet, identified R21 age [AGE], was admitted to the facility on [DATE]. Review of R21's MIIC undated, identified R21 had received Pneumo-PPSV13 on 12/12/2005, and 10/26/2015. In addition, MIIC identified R21 had received Pneumo-PPSV23 on 12/12/2005, and 2/19/2013. R21's medical record lacked documentation R21 had been offered or received the PCV20.
During an interview on 7/26/23 at 1:50 p.m., director of nursing (DON) confirmed the facility process was to review the MIIC report and to administer pneumococcal vaccinations according to the CDC recommendations. DON confirmed R7, R10, R21, and R24 had not received the pneumococcal vaccinations as recommended by the CDC.
Facility policy titled Influenza and pneumococcal Immunizations revised 11/1/22, identified unless medically contraindicated or previously immunized, all residents would be offered pneumococcal immunizations per CDC/Minnesota Department of Health (MDH) guidelines. The policy indicated the facility would maintain documentation as to why the vaccine was not administered.