Every finding on record at Apple Ridge Care Center

Based on interview and record review, the facility failed to prevent resident abuse for one sampled resident (Resident #9) out of eight sampled residents. On 08/23/26 Resident #10 punched Resident #9 causing a 2-centimeter (cm) laceration to his/her left cheek that required five sutures. The facility census was 43 residents.Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, showed:-Residents had the right to be free from abuse, including physical abuse;-Objectives of the Prevention Program were:--To protect residents from abuse by anyone, including facility staff, other residents, as well as visitors. Review of the facility's Identifying Types of Abuse policy, dated September 2022, showed:-Abuse of any kind against a resident was strictly prohibited;-Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish;-Abuse towards a resident occurred as:--Resident to resident abuse;-Physical abuse included but was not limited to hitting, slapping, biting, punching or kicking. 1. Review of Resident #10's PASSR, dated 05/29/26, showed the resident had moderate depression, suspicion and paranoia, and homicidal ideation. Review of Resident #10's admission Minimum Data Set (MDS- a health status screening and assessment tool used for all residents of long-term care nursing facilities) dated 07/16/26, showed:-The resident was moderately cognitively impaired;-The diagnoses included unspecified mood disorder, depression, dementia and a traumatic brain injury (TBI);-The resident was admitted to the facility on [DATE]. Review of Resident #10's Care Plan, dated 07/13/26, showed:-The resident was at risk for impaired coping and adverse behaviors with a history of TBI;-Monitor and document all behaviors each shift;-The resident had impaired cognitive function, dementia and impaired thought processes;-Cue the resident and redirect and supervise as needed. Review of Resident #9's comprehensive MDS, dated [DATE], showed:-The resident was severely cognitively impaired;-The resident was diagnosed with dementia and depression. Review of Resident #9's Care Plan, dated 06/24/26, showed:-The resident was at risk for unwanted behaviors/mood changes related to history ofaggressive behaviors;-The resident had aggressive, combative, and threatening behaviors when staff tried to draw blood for lab tests on 05/05/26 and refused;-Strategies included encouragement in participation in self-calming behaviors such as breathing exercises, meditation or guided imagery;-The goal was to keep the resident and peers safe;-Monitor behaviors every shift. Review of the Facility Investigation Report, dated 08/27/26, showed:-On 08/23/26 physical contact occurred between the two residents;-There was no evidence of intent to harm or cause injury; Review of Resident #9's hospital discharge paperwork, dated 08/22/26, showed:-The resident was treated for a two-centimeter laceration on his/her left cheek;-There was marked bruising and swollen tissue of the left side to the face;-The wound was irrigated and cleansed with saline;-The skin was closed with five sutures;-Resident was discharged back to facility. During an interview on 08/24/26 at 2:00 P.M., Resident #10 said:-Resident #9 came after him/her and he/she thought the resident was going to hit him/her, so he/she reacted and grabbed the resident's foot while he/she tried to kick him/her, then he/she hit the resident in the face;-He/She did not know why he/she reacted that way. During an interview on 08/24/26 at 2:11 P.M., Resident #9 said:-He/She woke up from sleep and Resident #10 was going through his/her closet;-He/She got up from bed, and Resident #10 hit him/her about three times in the face;-He/She was taken to the emergency room;-He/She had stitches under his/her eye;-He/She was not hurt anywhere else. During an interview on 08/24/26 at 3:39 P.M., Certified Nurse Aide (CAN) B said:-He/She had returned from break and looked down the hall toward the resident's room. The Director of Nursing (DON) was near the resident room saying it was an emergency;-He/She ran down the hall and took Resident #10 out of the room to the dining room and kept him/her on a one to one while the DON investigated. During an interview on 08/24/26 at 4:09 P.M., CNA D said:-He/She was called to the resident's room for an emergency;-He/She went into the room and saw Resident #9 standing at the sink covered in blood;-Resident #10 was panicking and saying he/she was sorry;-He/She took Resident #10 to the dining room. During an interview on 08/24/26 at 4:09 P.M., CNA D said:-Resident #9 was not upset or mad or scared and was ok, that it was over and wanted to move on;-Resident #9 went to hospital via EMS;-He/She picked up Resident #9 from the hospital, and during the ride back he/she was very quiet, and he/she just wanted to go to bed. During an interview on 08/24/26 at 1:38 P.M. the DON said:-He/She and Licensed Practical Nure (LPN) C responded to the resident room and saw Resident #9 standing at the sink with a trail of blood from his/her bed to the sink. Resident #9 had a gash on his/her cheek;-CNA B responded and took Resident #10 out of the room to the dining room;-Resident #9 said he/she was lying bed and saw Resident #10 going through his/her closet;-Resident #9 told Resident #10 to get out of his/her closet when Resident #10 came over and punched him/her in the face;-Resident #9 denied hitting Resident #10 back;-Resident #10 denied remembering hitting Resident #9 but said Resident #9 attacked him/her and he/she had to defend him/herself; During an interview on 08/24/26 at 4:43 P.M., the Administrator said:-The incident was an isolated incident that was not predictable;-The resident had not exhibited these behaviors in the past. 3173729

Based on interview and record review, the facility failed to ensure staff received appropriate training and were competent in handling aggressive behaviors of one newly admitted resident (Resident #3) out of 14 sampled residents and were unable to effectively provide appropriate behavioral intervention strategies to keep the resident safe. The facility census was 43 residents. Review of the facility's Behavioral Assessment, Intervention and Monitoring policy, dated February 2025, showed:-Behavioral symptoms were identified by using facility-approved behavioral screening tools and the comprehensive assessment (Minimum Data Set (MDS- a health status screening and assessment tool used for all residents of long-term care nursing facilities);-Residents had minimal complications associated with the management of altered or impaired behavior;-As part of the initial assessment, the nursing staff and attending physician identified individuals with a history of impaired cognition, altered behavior, substance abuse disorder or mental disorder;-All residents received a Level I Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition (a federally mandated evaluation known as Preadmission Screening and Resident Review -PASRR);-If the Level I PASRR indicated the individual may meet criteria for a mental disorder, intellectual disability, or related condition he or she was referred to the state PASRR representative for the Level II screening process;-The Level II screening report was used when conducting the resident assessment and developing the care plan;-A resident may warrant a behavioral assessment if the resident had new or worsening change in status or condition, or if a new psychotropic medication was ordered as an emergency intervention;-The Care Plan (a person-centered plan developed by the Interdisplinary team (IDT) that outlined the specific medical, functional, and supportive services a resident needed) minimally included:--A description of behavior symptoms, that included: frequency, intensity, duration, outcomes, location, environment and precipitating factors or situations;--Targeted and individualized interventions for behavioral and/or psychosocial symptoms;--Rationale for the interventions and approaches;--How the staff monitored the effectiveness of the interventions. 1.Review of Resident #3's Level One Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition (a federally mandated evaluation known as Preadmission Screening and Resident Review -PASRR), dated 07/29/26, completed by the discharging hospital provided by the facility as part of the admission packet showed:-The resident showed signs/symptoms of poor sleep, passive suicidal ideation (SI) statements, aggression toward hospital staff, verbalizing physical threats toward staff and hallucinations.-The resident was diagnosed with:--Schizophrenia (a chronic mental health condition with symptoms such as hallucinations or delusions, with mood disorder symptoms, like depression or mania);--Anxiety Disorder;--Personality Disorder;--Delusional disorder;--Mood disorder. Review of the resident's PASRR Level II Evaluation provided by Central Office Medical review Unit (COMRU-a section of the Missouri Department of Health and Senior Services (DHSS) that determined if an individual qualified for the level of care provided by a nursing facility) , dated 05/20/26, showed:-The resident had a history of agitation, aggression and assaultive behavior, including spitting, toward staff in March of 2026 which required sedation;-The resident had a history of substance abuse;-The resident required administration of Ativan (a medication that slowed down the central nervous system to treat anxiety) to calm him/her down;-The resident had serious difficulty adapting to typical changes in situations. Review of the resident's Baseline Care Plan (a short-term care guide that a nursing home must create within 48 hours of a new resident arriving at the facility) dated 08/14/26, showed:-The resident was admitted on [DATE];-The resident had cognitive impairment and delusions/confusion;-The resident was taking psychotropic (a medication that affected how a person thought, felt, or acted prescribed by doctors to treat mental health conditions like depression, anxiety, and bipolar) medication;-Mental health needs included follow up with the Psychiatric Nurse Practitioner (PNP);-The Administrator completed the Baseline Care Plan. Review of admission Hospital Discharge Paperwork, dated 08/14/26, showed:-The principle problem for hospitalization was psychosis (a mental state that causes a loss of contact with external reality) and behavioral dysregulation (struggle to manage intensity, duration or expression of their feelings) and vascular neurocognitive disorder (a decline in thinking skills caused by conditions that block or reduce the blood flow to the brain) and psychiatric illness; -The resident had a Level II PASRR;-The resident was ready to discharge to a long-term care facility;-The resident's disposition was in fair condition and ready to discharge to nursing home;-Recommended diet showed: suicide precaution/Prisoner Tray. Review of the resident's Electronic Health Record (EHR) Progress Notes dated 08/14/26 through 08/15/26 showed:-On 08/14/26 at 3:35 P.M. the resident arrived at the facility for admission;--The resident was able to make his/herself understood but was a poor historian about what his/her capabilities were believing he/she could walk independently but attempted to get up by him/herself and slid to the ground in front of her wheelchair.-On 08/14/26 at 11:30 P.M. the resident was sitting at table in dining room and stated he/she got dizzy and then was hit with a stop sign and then I pulled a knife out and was going to stab them;--He/She had no injuries or pain noted. -On 08/15/26 at 5:36 A.M. The resident was noted to:--Be wandering around the facility speaking loudly to residents and staff;--The Resident screamed, I'm goanna get my brother to come down here and smack a bitch;--Resident went to the front door in wheelchair and banged on the glass with his/her fists and attempted to open the door; --Resident redirected (NOTE: note does not state how the resident was redirected);--Resident stated he/she was starving and was given double portions as well as offered snacks between meals;--Contacted facility physician and received new order for 1milligram (mg-a unit of measure) of Ativan and 250 mg Depakote (a medication used to stabilize mood) twice a day; --Resident took the Ativan and refused rest of medication; --Resident was offered and provided a shower by Certified Nursing Assistant (CNA) and resident was calm; --Resident ate supper and was given double portions; --Resident upset and stated staff had not fed him/her and were starving him/her;--Resident went back and banged on the front door and screamed at staff and residents;--Resident told staff he/she hated this place and wanted to leave, cussing and lashing out at them physically;--Facility physician was notified and new order received for additional dose of Ativan 1 mg and to contact the PNP.-On 08/15/26 at 5:38 A.M. call placed to PNP, resident behaviors reviewed and new order received for Haldol (an antipsychotic medication used to treat schizophrenia, acute psychosis, severe agitation) 2 mg every 6 hours as needed (PRN); --Attempted to notify family of behaviors and new medications. -On 08/15/26 at 10:15 A.M. the resident continued acute monitoring following admission. Review of the resident's Care Plan, dated 08/15/26, showed:-The resident was at risk for elopement;-Behavior management included the following behaviors:--Hyper talkative, delusional, manipulative, spitting at staff, hitting staff, kicking staff, reported not eating in five years, requested repetitive smoke breaks, stated he/she was abused, hitting and kicking the front door, moving furniture and ripping things off the walls.-Interventions include engaging the resident in conversation, ensure safety of resident and others, provide snacks such as cereal and fluids, redirect disruptive behaviors, redirect resident to calm location away from peers, utilize diversion techniques as needed. Review of the resident's Electronic Health Record (EHR) Progress Notes dated 08/16/26 through 08/19/26 showed:-On 08/16/26 9:59 A.M. the resident continued acute monitoring.-On 08/16/26 at 10:41 P.M. the resident had numerous behaviors on this shift: arguing with staff, told staff they were racists, threw items in dining room, kicked doors, called staff and other residents names, threatened to kill staff, refused to go to room to calm down, received PRN Haldol and pain pill, tore parts off wheelchair threatening to kill and stab staff and peers, cut sofa with broken pieces of the wheelchair;--Staff got items away from resident, resident hit staff pulled on staffs shirts, scratched staffs neck and chest, refused to let go of staffs shirt, requested to be given shower;--Resident was provided a shower by staff, while staff showered the resident he/she repeatedly put his/her hand on staff's crotch area;-Call was placed to PNP and received order to give Haldol 5mg intramuscular one time only;-Haldol was given to resident. -On 08/17/26 7:16 A.M., the resident called 911 and stated staff was mean to him/her and beating him/her and he/she was the doctor, sheriff arrived at facility-On 08/17/26 at 7:58 A.M. the resident called the police again, the sheriff officers x2 arrived at facility. -On 08/18/26 at 6:08 A.M.; the resident continued acute monitoring for admission to facility.--Resident rested in bed until 5:40 A.M. when resident got up yelled and cussed at staff;--Resident demanded coffee, cereal, and to smoke;--Resident educated that breakfast was at 7:00 A.M. and smoke break was at 6:30 A.M. --Resident offered a snack;--Resident threatened staff;--Resident redirected multiple times; (NOTE: note does not say how the resident was redirected);--Resident then went to his/her room; --Resident redirected and educated on expectations and respect. -On 08/18/26 at 1:12 P.M. the resident continued to roll around building cursed at staff, other residents and visitor;--Resident redirected multiple times without improvement (NOTE: note did not indicate what the redirection was);--Resident was not adjusting to facility very well, will continue to monitor; --Resident tore fire extinguisher off the wall, threw it on the floor and it broke open releasing the retardant powder;----Resident repeatedly stated he/she wanted to leave;--At 8:16 P.M. the Director of Nursing (DON) received a call about the resident's behaviors;--At 9:45 P.M. the resident was transported to the local rural hospital by Emergency Medical Services (EMS);-At 10:35 P.M. the local rural hospital contacted the facility and notified the resident was ready to be transported back to the facility;--Facility's Transportation Driver (TD) drove the facility van to the hospital to pick up the resident and return to the facility;--Resident remained aggressive, combative toward staff, attempted to go after a peer with no harm or contact;--Resident repeatedly stated he/she wanted to leave;--Resident was taken to his/her room then came out with only a shirt and brief on;--Staff asked him/her to go back and put pants on, he/she refused;--Resident then moved to the front door and stood at the door refusing to move to let staff in or out;--Resident tried to get to other fire extinguishers;--Staff removed all extinguishers from the walls and placed them at nurses station;--Resident presented with an Against Medical Advice (AMA) form and the resident signed it;-On 08/19/26 at 12:52 A.M. staff contacted the DON again;--DON arrived at facility and contacted physician; --Resident then transported to a Psychiatric Unit 70 miles away, via facility van with TD and DON;--Message left on the resident's daughter's phone with the two numbers listed, notified that resident was being transferred to a psychiatric hospital. During an interview on 08/20/26 at 6:39 P.M., Certified Nurses Aide (CAN) B said:-He/She was working the night the resident went out to the hospital;-He/She gave the resident a shower when the resident returned from the local hospital;-The resident knocked the fire extinguisher off the wall and was verbally aggressive with staff;-He/She was not dealing directly with the resident during his/her behaviors; -The resident had behaviors every day since he/she arrived;-The resident did grab his/her arm and with his/her fingernails but there was a towel between the arm and the fingernails; -He/She did not receive any training since the incident but had not worked with the resident since that night; -There was no training for the resident's specific behaviors or triggers, just behaviors in general, a while ago, not recently. During an interview on 08/20/26 at 6:53 P.M., Certified Medication Technician (CMT) A said:-The resident was way out of control and hit and called staff names;-The resident knocked fire extinguisher off the wall and accused staff of things they didn't do;-Licensed Practical Nurse (LPN) A was the one who called EMS on 08/18/26; -That was the first night he/she worked since the resident was admitted ;-Staff did say the resident was having all kinds of behaviors;-The staff did the best they could with what training they had;-Training was not offered for the residents' specific behaviors or triggers; -They did not train him/her specifically. During an interview on 08/20/26 at 7:02 P.M., CNA E said:-He/she worked the night the resident went out to the ER;-The resident was in the dining room and the hall, and knocked off the fire extinguisher;-He/She let EMS in the building to transport the resident to the local hospital;-As he/she left for the evening the resident stood up, hit staff, grabbed items and threw them at the staff;-He/She had not received any recent training on behaviors or triggers;-He/She had not had a resident that out of control before. During an interview on 08/20/26 at 7:13 P.M., CNA B said:-The resident set off the fire extinguisher;-He/She kept the other residents safe; -He/She was scratched, hit and spit on by the resident; -He/She did not know what to do other than keep the resident and the other residents safe;-The resident had behaviors the whole time he/she had been at the facility. During an interview on 08/21/26 at 12:18 P.M., LPN D said:-He/She was working on Monday;-The resident screamed and yelled most of the day;-The resident liked cereal and it was offered to him/her as an intervention, but it only worked momentarily;-The resident was calm when he/she went out to smoke breaks then came in and got upset all over again;-There were two staff people out there on smoke breaks in case the resident had behaviors;The resident liked to eat cereal and snacks, which were offered as an intervention;-The staff did what they could with what they had, the resident was extremely difficult;-Staff did share about the resident's behaviors during shift change report about what worked and did not work for redirection, not much worked.-Staff were expected to redirect as best as they could.-No one was aware of the resident's behaviors prior to his/her arrival. During an interview on 08/21/26 at 5:44 P.M., LPN A said:-When he/she arrived at work he/she did not know there was a new resident;-The information he/she received about the resident came from the shift change report;-The report had nothing specific about triggers or interventions; -He/She had to look at the computer to get the resident's diagnoses;-No additional training was offered;-The resident had behaviors all weekend;-The resident liked one on one conversations;-Staff ignored the residents' behaviors as much as they could;-The resident had behaviors all weekend;-Staff tried to redirect the resident but it didn't always work;-The resident cussed, threatened staff and physically tore things off the wall;-On Sunday the resident tried to get through front door;-The resident would not redirect;-The PNP was contacted and he/she ordered Haldol; -After that the resident returned to his/her room and slept for a couple of hours;-On Tuesday when he/she returned to work, the resident had the same behaviors, staff were told to redirect him/her, but the resident kept threatening staff and broke open a fire extinguisher;-He/She was not sure what to do;-EMS was called and they took the resident to the local hospital;-When the resident returned from the hospital the behaviors did not stop;-Staff removed everything from within the resident's reach so he/she could not throw it;-The resident wanted to leave but we could not let him/her go in that state; -He/She told the resident it was not safe for him/her to leave;-The resident was adamant he/she was leaving;-He/She had the resident sign the Against Medical Advise (AMA) form;-The resident knew exactly what he/she was doing by signing the form, he/she understood it and just wanted to leave. During an interview on 08/20/26 the DON said:-The resident left AMA on Wednesday, 08/19/26;-The resident may be at the Psychiatric Hospital; -The resident tore the fire extinguisher off the wall, threw it on the floor and it broke leaving powder all over the floors and walls;-The resident had a history of psychiatric issues that included schizophrenia and bipolar disorder (a long-term mental health condition that caused extreme shifts in mood, energy, and activity levels);-The resident had only been at the facility a few days before leaving AMA;-The resident wanted to go;-The staff called him/her at home on Tuesday at 8:16 P.M. and notified him/her of the resident behaviors;-The resident was spitting and hitting staff as well as the police and fire fighters;-The resident went with EMS to the local hospital;- At 10:35 P.M. the local hospital called the facility to notify them that the resident was ready to go back to the facility and requested our staff to come to get him/her;-The local hospital released the resident and said nothing was wrong;-The TD took the facility van to get the resident;-When the resident returned the aides provided him/her a shower;-The resident refused to get dressed, remained in a shirt and a adult brief as well as scratch and hit and spit at the aides;-He/she left the facility;-The resident went to the dining room and shoved tables and chairs and banged on the front door;-Residents who were up were all moved back to their rooms;-Staff called him/her again, and the physician was contacted; -He/She talked to the resident who made threats and spoke in vulgar language stating he/she wanted to leave the facility;-He/She asked the resident where they wanted to go and the resident wanted to go to the church across the street that he/she owned, but there is no church across the street;-He/She was unaware if the local hospital did a toxicology report;-The facility physician had not seen him/her yet since admission;-The resident continued to say he/she wanted to leave and was asked if he/she wanted to go to a different hospital, to which he/she agreed;-The resident was loaded into the van in his/her wheelchair and strapped in correctly;-The TD and the DON went on the van with the resident and drove to a psychiatric hospital 70 miles away;-The resident continued to be violent on the van, throwing things and kicking the sides of the van;-The resident continued to talk non-sense and threatened us with death and violence, hitting the windows of the van, kicking the floor;-When they arrived at the emergency room (ER) of the psychiatric hospital and parked the van;-The TD brought the resident into the facility and left him/her at the ER window. -Staff were to redirect but that didn't work, nothing worked.-He/She was unaware of the behaviors prior to admitting the resident. During an interview on 08/20/26 at 10:27 A.M., the TD said: -He/She went to pick up the resident when the local hospital called and said the resident was ready to come back;-On the way back, the resident was rambling about random stuff;-He/She tried to keep a conversation with the resident, but the resident could not stay focused; -CNA A and CNA B provided the resident a shower when they returned to the facility;-CNA B was attacked by the resident in the shower;-The resident cursed and threatened staff; -After the shower the resident went down the hall ripping pictures and signs off the walls;-The resident then moved to the dining room and started doing the same thing, and flipping over chairs and tables;-The resident continued striking out and contacting staff; -The resident said multiple times since he/she arrived that he/she did not want to be there; -The nurse told the resident he/she could leave AMA if he/she signed the form and the resident signed the form;-He/She told the resident to get in the van, and he/she would take the resident wherever he/she wanted to go; -The resident wanted his/her items, and they were given to him/her before leaving;-He/She and the DON transported the resident to a psychiatric hospital;-The resident continued to beat the inside of the van and continued to cuss and fight and took items out of his/her bag and threw them at the TD and the DON;-When they arrived at the psychiatric hospital a man in a uniform escorted them to the ER;-The DON stayed in the van;-He/She made it to the ER and pushed the resident in his/her wheelchair up the ramp to the ER window;-He/She heard footsteps coming but did not see anyone so he/she returned to the van;-He/She had not dealt with a resident with those kinds of behaviors;-He/She had training in the past but not specifically for this resident. During a follow-up interview on 08/21/26 at 12:40 P.M., the Administrator said:-He/She completed the admission paper work for the resident;-The resident's PASRR came with the admission paperwork from the hospital; -The resident admission was based mostly on the hospital discharge paperwork that showed the resident was pleasant to be around; -The resident had schizophrenic signs and symptoms;-The resident was calm and pleasant when he/she was admitted from the hospital;-The resident's family was present when the resident arrived;-He/She was doing some Registered Nurse (RN) coverage Saturday and Sunday;-The resident spent a lot of time in his/her office where they talked, mostly delusional stories; -The resident would yell out, and he/she redirected the resident with snacks, talked to him/her, walked with the resident back to his/her room, removed any stimuli that looked like it was affecting him/her; -The resident stayed in his/her room for a few minutes then came back out;-There were no obvious triggers for the resident's behavior; -They were possibly more internal than external triggers;-The resident liked one on one interactions, that was a strategy to keep him/her calm;-After the resident exhibited exit seeking behaviors on Monday, referrals were sent to locked facilities and nearby facilities that had locked units;-The psychiatric hospital was the only one that replied with a suggestion for a 96-hour hold;-The resident needed a psychiatric evaluation, but the local hospital did not have psychiatric care, which is why the resident was ultimately taken to the psychiatric hospital;-Strategies to handle the resident behaviors were developed as things were figured out and then staff were trained as they arrived for their shift. -He/She thought staff did a good job with redirection, they notified the physician, as well; During an interview on 08/24/26 at 8:57 A.M., the PNP said:-The staff had called related to the residents' behaviors;-The resident was exit seeking and unable to be redirected;-He/She gave orders of the phone for Ativan;-He/She had not yet been to the facility, and was planning on going this week;-All the information he/she had about the resident was provided by the nurse; -He/She expected the facility to have read the PASRR before accepting the resident;-He/She was unaware of what else the staff could have done for the behaviors, other than to call 911 to take to nearest psychiatric facility. 3169543

Based on interview and record review, the facility failed to report an allegation of sexual assault to the state agency for one resident (Resident #3) out of 14 sampled residents. The facility census was 43 residents.Review of the facility's Abuse Investigating and Reporting policy, dated July 2017, showed:-All reports of abuse and neglect were promptly reported to local, state and federal agencies by facility management;-All alleged violations that involved abuse or neglect were reported by the facility Administrator or his/her designee to the following agencies:--The State licensing/certification agency responsible for surveying/licensing the facility;-An alleged violation of abuse or neglect was reported immediately but not later than two hours if the alleged violation involved abuse or resulted in a serious bodily injury. 1.Review of Resident #3's Baseline Care Plan (a short-term care guide that a nursing home must create within 48 hours of a new resident arriving at the facility) dated 08/14/26, showed:-The resident was admitted on [DATE];-The resident had cognitive impairment and delusions/confusion;-The resident was taking psychotropic (a medication that affected how a person thought, felt, or acted prescribed by doctors to treat mental health conditions like depression, anxiety, and bipolar) medication;-Mental health needs were to follow up with the Psychiatric Nurse Practitioner;-The Administrator completed the Baseline Care Plan. Review of the central registry unit report for the Adult Abuse Hotline for long term care dated 08/13/26 showed an allegation of sexual assault toward Resident #3 by a facility employee had occurred on 8/19/26 on or before 03:00 A.M. During an interview on 08/20/26 at 2:01 P.M. the Director of Nursing (DON) said:-The allegation should have been reported, it was a serious allegation;-Allegations should be reported within two hours to the hotline and to start the investigation process;-The Administrator was responsible for reporting; During an interview on 08/20/26 at 2:20 P.M., the Administrator said:-On 08/19/26 at 8:00 A.M. he/she received a call from the unnamed Nurse Practitioner at the psychiatric hospital;-He/She would have called the allegation into the hotline but since the hospital already called he/she didn't think it was necessary;-The facility policy said the facility must report abuse and neglect, even if it was reported by the hospital. 3169543

Based on interview and record review, the facility failed to provide a safe and appropriate discharge for one sampled resident (Resident #3) out of three sampled residents when on 8/19/26 the facility dropped the resident off at the psychiatric hospital without proper notification. The facility census was 43 residents.Review of the facility's Transfer Discharge Policy, dated March 2025, showed:-Discharge referred to the movement of the resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility was not expected.-The following information was documented in the medical record and communicated to the receiving health care institution or provider:--Basis for the transfer;--Disposition of medication;--A summary of the resident's overall medical, physical and mental condition. 1.Review of Resident #3's Level One Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition (a federally mandated evaluation known as Preadmission Screening and Resident Review -PASRR), dated 07/29/26, provided by the facility as part of the admission packet, showed:-The resident showed signs/symptoms of poor sleep, passive suicidal ideation (SI) statements, aggression toward hospital staff, verbalizing physical threats toward staff and hallucinations;-The resident was diagnosed with:--Schizophrenia (a chronic mental health condition with symptoms such as hallucinations or delusions, with mood disorder symptoms, like depression or mania);--Anxiety Disorder;--Personality Disorder;--Delusional disorder;--Mood disorder. Review of the resident's progress notes, dated 08/14/26 through 08/19/26, showed:-On 08/18/26 The resident was transported to the local hospital for evaluation and treatment and was returned to the facility and continued with the following behaviors: demanding coffee, cereal, and to smoke, cussing and threatening staff and other resident's and their family members, aggressive and combative towards staff, tried to get fire extinguishers off the wall and demanded to leave;-On 08/18/26 the charge nurse had the resident sign an Against Medical Advice (AMA) form and the Director of Nursing (DON) was contacted.-On 08/19/26 at 1:30 A.M. the resident was transported via facility van with the Transportation Driver (TD) and the DON to the psychiatric hospital 70 miles away.--Physician and family were notified via voicemail; no one had answered the phone. Review of the resident's medical record showed no discharge planning before the resident had a mental health crisis on 8/19/26 or when facility staff person had him/her sign paperwork for leaving AMA and the DON with the TD drove the resident in the facility van to hospital. During an interview on 08/20/26 at 8:48 A.M., the DON said:-The resident left AMA on Wednesday, 08/19/26;-The resident was having violent behaviors including tore the fire extinguisher off the wall, threw it on the floor and it broke leaving powder all over the floors and walls;-The resident had a history of psychiatric issues that included schizophrenia and bipolar disorder; -The resident was only at the facility a few days before leaving AMA;-The resident wanted to go;-The staff called him/her at home on Tuesday at 8:16 P.M. and notified him/her of the resident behavior;-The resident was spitting and hitting staff as well as the police and fire fighters;-The resident went with EMS to the local hospital;-At 10:35 P.M. the local hospital called the facility to notify them that the resident was ready to go back to the facility and required facility staff to come get him/her;-The local hospital released him/her and said nothing was wrong;-The TD took the facility van to get the resident;-He/She then left the facility;-Staff called him/her again, stating the resident was still having behaviors.-Staff had contacted the physician and Psychiatric Nurse Practitioner (PNP) who gave orders, but the medications did not help; -He/She returned to the facility and talked to the resident who made threats and spoke in vulgar language stating he/she wanted to leave the facility;-He/She asked the resident where they wanted to go and the resident wanted to go to the church across the street that he/she owned, but there was no church across the street;-The facility physician had not seen him/her yet;-The resident continued to say he/she wanted to leave and was asked if he/she wanted to go to a different hospital, to which he/she agreed;-The resident was loaded into the van in his/her wheelchair and strapped in correctly;-The TD and him/her went in the van with the resident and drove to the psychiatric hospital 70 miles away;-The resident continued to be violent on the van, throwing things and kicking the sides of the van;-The resident continued to talk non-sense and threatened us with death and violence, hitting the windows of the van, kicking the floor;-They arrived at the emergency room (ER) of the psychiatric hospital and parked the van;-The TD brought the resident into the facility and left her at the ER window;-Discharge forms were not provided to the resident. During an interview on 08/20/26 at 10:27 A.M., the TD said:-The resident was having behaviors since he/she was admitted to the facility from the hospital;-The resident slammed a fire extinguisher on the floor, and it broke open, he/she was threatening staff, hitting staff, kicking the door, tipping over dining room chairs and tables, ripping things off the wall and physically hitting staff;-The resident was transported by ambulance to the local hospital;-The hospital called and said the resident was ready to come back to the facility;-He/She got the resident's wheelchair, put it in the van and drove to the local hospital to get the resident;-On the way back, the resident was rambling about random stuff;-He/She brought the resident to the nurse's station where they brought the resident to the shower room to help him/her shower;-The resident attacked the aides who were showering him/her;-The resident was cursing and threatening staff, ripping pictures off the walls and continued aggressive behaviors toward staff, threw a potted plant across the dining room, threw chairs, tossed over tables, tried to get out the front door, banged on the front door;-The DON was contacted and he/she came to the facility;-The resident said multiple times since admission that he/she did not want to be there;-Staff asked the resident if he/she wanted to leave and the resident continued to say yes and cussed at staff;-The resident said he/she wanted to go to the church across the street that he/she owned but there was no church across the street;-Licensed Practical Nure (LPN) A had the resident sign the AMA paperwork; -The resident wanted his/her items before agreeing to get in the van;-He/She got the resident's items and clothing in a bag and put it in the van with the resident;-The DON tried to find a hospital that had a psychiatric unit so as not to leave the resident on the streets;-The closest psychiatric hospital was 70 miles away;-He/She and the DON drove the resident to the psychiatric hospital;-The resident continued to beat the inside of the van on the way;-Once they arrived at the hospital a security guard showed him/her and the resident toward the ER; -The DON stayed in the van;-He/She made it to the ER; the security guard was no longer there;-He/She pushed the resident and his/her wheelchair up the ramp to the ER window;-He/She heard footsteps coming but did not see anyone;-He/She left the resident and went back to the van;-He/She did not see any ER staff prior to leaving the resident;-There was no paperwork to leave at the ER. During an interview on 08/21/26 at 12:40 P.M., the Administrator said: -He/She sent out referrals to locked facilities on Monday following the resident's exit seeking behaviors;-The local hospital did not do psychiatric evaluations which is why the resident went to the psychiatric hospital ER;-The resident was his/her own person, and he/she was able to make his/her own decisions;-Just him/her leaving the building AMA was not a safe option;-The resident was thinking clearly enough to sign AMA;-If they called 911, they would take them to nearest hospital, we could not say to take the resident to a hospital 70 miles away;-The TD was at the facility so taking the resident in the van was the quickest and safest way to get the resident to the psychiatric hospital, which is where he/she said he/she wanted to go;-He/She was unsure why the DON did not go into the hospital with the TD;-He/She was unaware if anyone passed paperwork to ER staff;-It was his/her expectation to bring the resident's face sheet and list of medications all for discharges and transfers;-He/She felt the resident's best option was to be transported to the psychiatric hospital; During a follow up interview on 08/21/26 at 5:11 PM, the DON said:-He/She did not go into the psychiatric hospital ER as it only took one person to push a wheelchair;-No information about the resident was provided to the hospital, he/she left AMA and was no longer the facility's resident;-He/She was not a doctor and could not say if the resident's mental state left him/her incapacitated and not able to fully understand the AMA form;-LPN A had the resident sign the AMA paperwork;-He/She and the TD drove the resident to the psychiatric hospital ER;-Taking the resident to the psychiatric hospital ER was the best way to protect the resident as well as the staff and other residents;-It was the safest option. During an interview on 08/21/26 at 5:44 P.M., LPN A said:-The resident wanted to leave but the facility would not let him/her go due to not being safe;-The resident was adamant he/she was going to leave;-He/She had the resident sign the AMA form;-The resident knew exactly what he/she was doing by signing the form, he/she understood it and wanted to leave;-He/She sent a consent form and face sheet with the DON when they left for the psychiatric hospital as well as faxed it. During an interview on 08/24/26 at 8:57 A.M., the PNP said: -The facility staff had contacted him/her regarding the resident's behaviors;-Staff reported the resident was exit seeking, was unable to be redirected, and being aggressive with staff;-Without seeing the resident, he/she would not be able to say if he/she had capacity to understand and sign AMA.-It was probably not a good decision to let him/her sign AMA;-He/She felt taking the resident to the psychiatric hospital was a good decision to get evaluation and treatment, but not signing the AMA;-The resident was probably not in the right mental state to do that;-He/She expected staff to read the PASSR before accepting any resident;-He/She did not believe it was not the safest transport and the faciltiy should have contacted EMS to transport. During an interview on 09/08/26 10:13 A.M. the Ombudsman said:-The resident has a right to discharge planning;-If the resident was in a mental or acute behavioral crisis it will leave one to question if the resident has the mental capacity to sign;-The resident has the right to receive appropriate clinical, medical and or psychological intervention with the closest emergency services;-If the resident exhibited behaviors that appeared as acute or behavioral crisis immediate emergency services should have been provided. 3169543

Based on observation, interview and record review, the facility failed to ensure a resident was able to exercise their rights related to private and unrestricted communication when the facility imposed restrictions on telephone usage, including limiting the duration of calls, restricting individuals the resident could communicate with, and monitoring the resident's phone conversations without documented clinical justification, a physician's order, or appropriate care plan intervention for one sampled resident (Resident #1) out of four sampled residents. The facility census was 43 residents.Review of the facility's Resident Rights policy date February 2021 showed the resident had the right to:-Communication with and access to people and services, both inside and outside of the facility.-Exercise his/her rights as a resident of the facility and as a resident or citizen of the United States.-Be supported by the facility in exercising his/her rights.-Exercise his/her rights without interference, coercion, discrimination or reprisal from the facility.-Privacy and confidentiality.-Voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal.-Communicate with outside agencies (local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations) regarding any matter.-Communicate in person, by mail, email and telephone with privacy. Review of the facility's Telephones, Resident Use of policy revised February 2021 showed:-Residents shall have access to telephones.-Designated telephones are available to residents to make and receive private telephone calls.-Telephones will be in areas that offer privacy and accommodate the hearing impaired, and wheelchair bound residents. 1. Review of Resident #1's Face Sheet showed the following diagnoses:-Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems).-Paranoid Schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations).-Manic episode (a period when your mood, behavior and energy level become much higher or more intense than usual).-Bipolar disorder (a chronic mental health condition characterized by extreme mood swings, alternating between high-energy manic or hypomanic episodes and deep depressive episodes).-Mood disorder (mental health conditions involving persistent, severe disturbances in emotional state, such as depression or mania, that disrupt daily functioning). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) showed the resident was cognitively intact. Review of the resident's medical record dated February 2026 showed:-A message to staff that said the advocate (a representative of a federal non-profit agency) was not allowed to call the resident and the resident was not allowed to call them per the guardian.-An email from the Public Administrator (PA) to the facility dated 02/05/26 at 3:15 P.M., that said the facility staff had reported to the PA that the resident had been making calls to several different lawyers. The resident was not able to hire or be calling different lawyers because of his/her guardianship. The resident had been advised about only being able to contact his/her lawyer or writing the Judge several times in the past. The resident had abused this rule and would have the following consequence. His/her calls restricted to one call per day, that was to be supervised by staff and not to be to a random lawyer. The resident could receive calls from his lawyer that had been appointed through the court. The PA was ok with the resident calling him/her once per month unless the lawyer told staff that he/she was comfortable with the resident calling more often and it would be whatever was approved by his lawyer.-An email from the PA dated 02/11/26 at 10:44 A.M., said he/she told the resident to write down the names and numbers of family he/she wanted to add to his/her call list. He/She did not have the list when the PA went onto the unit and wanted the PA to approve whomever he/she wanted. He/she informed the resident to write down names and numbers so it could be given to the PA to review before the PA can add or increase the resident's calls.-An email from the facility to the PA dated 02/11/26 at 2:49 P.M., contained a list of contacts created by the resident.-An email from the PA to the facility dated 02/11/26 at 3:15 P.M. said the list provided was approved.-An email from the PA to the facility dated 02/11/26 at 3:28 P.M. said that the PA talked to the resident's mother and he/she mentioned he/she was supposed to get mail from the advocate. The email said please do not give the resident any mail from the resident's mother. Hold it or return it to sender.-An email from the facility to the PA dated 02/17/26 at 2:52 P.M. said the state came in and suggested that the facility get the phone restrictions in writing from the lawyer or judge. The email said was it possible for the PA to get those phone restrictions in writing and email them to the facility?-An email from the PA to the facility dated 02/19/26 at 9:05 A.M. said it was not possible to have either the lawyer or the judge do that. The resident's lawyer was told of the restrictions and that the lawyer would need to call the facility to allow more calls. I can only assume he/she did not do that based on how he/she reacted when I told him/her about the restrictions. The restrictions would need to be kept in place going forward to mainly not allow the resident to call the advocate. The restriction was to keep the resident safe from the advocate as they had been negative to several other residents at other facilities. I will say as long as there are no issues next week, we could lift things to three calls, but I want to make sure it is up to the staff availability, so the resident was not dictating when he/she made calls to the staff.-An email from the PA to the facility dated 02/23/26 at 12:43 P.M. asked if there were any other phone issues. If not, the resident could have three calls per day but still needed to be supervised because of the advocate issue. If calls were returned to three per day, let the resident know it was being supervised just because he/she was not allowed to call the advocate.-There was no physician's order, assessment, or clinical documentation supporting justification of restricting telephone access. Review of the residents' care plan revised in February 2026 showed:-Focus: Resident was at risk for behavioral disturbance related to schizophrenia disorder, bipolar disorder, paranoid schizophrenia with history of delusions and paranoia. Resident paced up and down the hall on the unit and crouched along the wall in the hallway often. Conspires with peers to fabricate stories and delusions, calls state frequently, manipulates peers/staff, refuses cares and refuses medications.-Staff interventions included:--Resident could receive calls from his/her lawyer that had been appointed through the court. --The PA was ok with the resident calling them once a month unless the attorney told staff that he/she was comfortable with the resident calling more often and it would be whatever was approved by his/her lawyer.--Resident was not allowed to talk to the advocate from an outside agency.--Per the PA, the resident was not able to hire and should not be calling different lawyers because of his/her guardianship. The resident had been advised about only being able to contact his/her lawyer or writing the Judge several times in the past.-Per the PA, the resident's calls were restricted to two calls per day that were to be supervised by staff and not placed to a random lawyer. Review of the residents progress notes dated February 2026 showed:-On 02/05/26 at 4:32 P.M., a social services note said the Social Services Director (SSD) and charge nurse went and explained to the resident that his/her guardian had changed his/her phone privileges to one call per day and that all calls must now be supervised. This change was made after it was reported that the resident had been contacting a couple of lawyers. The social worker and charge nurse reviewed the guardian's decision with the resident and explained that supervision was in place to ensure the appropriate use of phone privileges.-On 02/05/26 at 7:53 P.M., a behavioral nursing note said The Certified Nursing Assistant (CNA) overheard a conversation between the resident's roommate and another resident. The other resident subsequently took his/her phone down to their room. When the nurse inquired about the phone's whereabouts, the other resident stated he/she had loaned it to the resident. The nurse informed the resident that loaning his/her phone to the resident was not permissible. The resident then retrieved his/her phone. -On 02/13/26 at 11:58 A.M., a plan of care note said the resident exhibited behaviors of agitation and manipulation. The residents redirection was unsuccessful. The resident was upset with the guardian's restrictions. Care plan was updated. Continue POC.-On 02/13/26 at 2:15 P.M., a social services note said the SSD received a call from a person on 2/13/26 requesting to speak with the resident and SSD informed him/her that he/she was not allowed to call here per the guardian. He/She stated the facility was not doing the right thing, and SSD informed him/her that if he/she had any questions or concerns, he/she needed to reach out to the guardian.-On 02/19/26 at 2:14 P.M., a communication with family note said yesterday around dinner time, the resident's uncle called, seeking to speak with him/her. I apologized and clarified that the resident had already utilized his/her two permitted phone calls for the day. The uncle questioned how that policy applied to incoming calls. Staff explained the understanding was that the limit pertained to both incoming and outgoing calls. He/She then used profanity and disconnected the call. During an interview on 05/05/26 at 2:10 P.M., the resident said:-He/She was notified by the guardian and a staff nurse who no longer works at the facility, that his/her phone privileges had been restricted.-He/She was told that the restrictions were because he/she was calling lawyers.-The court appointed lawyer didn't return any of his/her calls.-He/She was allowed three calls per day for a maximum of 15 minutes.-He/She did not feel calls were private because the staff monitored all calls by listening outside of the office.-If the person he/she called didn't answer, it counted as a call made.-If someone called the facility for him/her, it counted as two calls.-The restrictions make him/her feel watched and it really made him/her upset. -It was depressing not to be able to reach out and call family whenever he/she wanted to. -It would really help him/her to stay on track if he/she could call whomever, whenever. 2. Observation on 05/05/26 at 1:41 P.M. showed Resident #4:-Was lying in bed doing a crossword puzzle. -He/She did not have a landline or cell phone in the room. During an interview on 05/05/26 at 1:41 P.M. the resident said:-He/She had used the facility's phone in the past to make calls.-If he/she needed to make a call, he/she would just ask whoever was sitting at the desk.-No one had ever put any restrictions on the number of phone calls he/she could make in a day or the time which he/she could stay on the phone.-He/She could make a phone call whenever he/she wanted to.-He/She felt like his/her calls were private and staff were not monitoring. 3. Observation on 05/05/26 at 1:46 P.M. showed Resident #3:-Was sitting in bed watching television. -He/She had a cell phone on his/her bedside table. During an interview on 05/05/26 at 1:46 P.M. the resident said:-He/She had to use the facility's phone because his/her cell phone hadn't been working properly lately.-He/She did not have any limit on the number of calls placed per day.-He/She could make calls whenever he/she wanted.-He/She felt like calls were private.-If it was crowded with other people, that would be the only time he/she could not use the phone. 4. During an interview on 05/05/26 at 2:24 P.M., Certified Medication Technician (CMT) A said:-The telephone usage policy depended on the resident. The residents could take the cordless phone with them to use unless they had restrictions.-There was a binder labeled communications that outlined the residents and their restrictions that included phone privileges. Information about restrictions could also be found in the residents care plan.-A Social Services employee informed him/her of the restrictions but they no longer worked at the facility.-The reason Resident #1 was placed on communication restrictions was they were making phone calls to and getting calls from lawyers and some unknown lady was calling him/her.-Resident #1 had not had any behaviors that he/she was aware of.-Resident #1 had restrictions of three calls per day with a 15-minute limit.-Staff were to monitor the residents' phone calls. During an interview on 05/05/26 at 2:43 P.M., CNA A said:-Residents could take the cordless phone with them to use unless they had restrictions.-Resident #1 was on phone restrictions for contacting a lady but not sure who or why.-Resident #1 had not displayed any behaviors toward staff or other residents.-Resident #1's calls were supposed to be monitored while in the nurse's station office. During an interview on 05/05/26 at 2:55 P.M., Licensed Practical Nurse (LPN) A said:-He/She was responsible for the residents on the locked unit while on duty.-There was a designated area in front of the nurse's station for residents to make phone calls.--NOTE: Observation of this area was less than three feet from the nurse's station, it was not partitioned off and consisted of two chairs, a table and a phone.-There was no limit to how many calls a resident could place per day unless they had restrictions.-He/She could probably find information on phone restrictions on the resident's face sheet.-He/She was not aware of anyone who currently had phone restrictions. During an interview on 05/05/26 at 3:05 P.M., the PA said:-He/She advised the facility that the resident's phone calls needed to be limited by person and time and also needed to be monitored.-Restrictions were made because the resident was calling the state, talking to non-family members and speaking with an advocate who was giving improper legal advice.-The resident wanted to get a job and live in a less restrictive environment.-There had been no physician involvement saying that this restriction was clinically necessary.-The advocate called numerous facilities and hot lined them.-There was no attempt at any less restrictive measures prior to the ones currently in place.-He/She believed the facility should continue with the current restrictions. During an interview on 05/05/26 at 4:15 P.M., the Administrator said:-There were no limits on the number of phone calls a resident could place unless the guardian directed it.-Staff had been trained on residents' communication rights through in-services and Relias (an online, accredited education platform designed for senior care and skilled nursing facilities to ensure compliance, train staff, and improve patient outcomes) training.-There was a care plan meeting in February the guardian suggested limiting the resident's access, time, and the people he/she could call and who could call him/her.-He/She advocated for the resident by talking with the guardian and having care plan meetings.-There were no less restrictive measures attempted prior to the current phone restrictions.-Residents were educated on their communication rights during the monthly resident council meetings.-The advocate had not promoted any harm that he/she knew of. -The resident had not had any behaviors.-He/She was not sure why the resident's calls had been restricted, the guardian said it was due to issues in the past at another facility.-Communicating with the advocate would cause psychological stress and false hope of emancipation.-The resident had the right to communicate with people outside of the facility.-The resident had the right to communicate with outside agencies.-The resident had the right to communicate on the telephone in private. 2807761

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #2) had appropriate and timely identification and treatment of a Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system) and to report a change in the resident's condition to the physician out of four sampled residents. The facility census was 43 residents.Review of the facility's Change in a Resident's Condition or Status policy revised November 2018 showed:-The facility promptly notified the resident, his/her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.-The nurse would notify the resident's attending physician or physician on call when there had been a significant change in the resident's physical/emotional/mental condition.-A significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.-Except in medical emergencies, notifications would be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.-When identifying situations that warrant immediate notification the nursing staff would consider factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results:--Whether the result should be conveyed to a physician regardless of other circumstances.--Whether the resident's clinical status was unclear or whether he/she had signs and symptoms of acute illness or condition change and was not stable or improving.-If the resident had signs and symptoms of acute illness or condition change and he/she was not stable or improving, or there were no previous results for comparison, then the nurse would notify the physician promptly to discuss the situation, including a description of relevant clinical findings as well as the test results.-A physician could be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent.-Facility staff should document information about when, how and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report. Review of the facility's undated Lab and Diagnostic Test Results-Clinical Protocol policy showed:-The physician would identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.-The staff would process test requisitions and arrange for tests.-The laboratory, diagnostic radiology provider, or other testing source would report test results to the facility.-When test results were reported to the facility, a nurse would first review the results. If staff who first received or reviewed lab results could not follow the remainder of this procedure for reporting and documenting the results, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 1. Review of Resident #2s Face Sheet showed the following diagnoses:-Autistic disorder (a lifelong neurodevelopmental condition related to brain development that affects how people see others and socialize with them).-Bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs).-Severe intellectual disabilities. Review of the resident's health status and medication change notes dated 02/22/26 to 04/03/26 showed the resident was on monitoring for starting Risperdal (antipsychotic medication that treated mental health conditions like schizophrenia, bipolar disorder and some symptoms of autism) and Lithium (primarily used to stabilize mood, treating acute mania and reducing the frequency and severity of manic episodes in bipolar disorder) with no signs or symptoms of adverse effects. Review of the resident's health status note dated 03/08/26 showed:-The physician was contacted about the resident experiencing pain during urination and noted cloudiness. -A new order was received to obtain a urinalysis (UA- a diagnostic test that analyzes a urine sample to detect various health issues, including infections (UTIs), kidney disease, liver disease, and diabetes). Review of the resident's laboratory report dated and reported to the facility on [DATE] showed:-The UA specimen was never received in the lab due to not being collected. -The facility was advised to collect a sample on the next routine lab day. Review of the resident's health status note date 03/14/26 showed:-The resident complained of not feeling well and he/she had been feeling dizzy since 03/13/26 along with intermittent nausea without vomiting, sweats, chills and congestion. -The resident's skin color was noted to be pale with dark circles under the eyes. -Skin was clammy and warm. -Appetite was poor at this time. -Fluids and rest were encouraged and as needed Tylenol was given at this time. -Staff noted they would continue to monitor signs and symptoms and if they worsened, staff would re-evaluate and contact the physician. Review of the resident's health status note dated 03/15/26 showed:-The resident complained of not feeling well and reported generalized body aches and fatigue. -Skin was pale and clammy with dark circle under the eyes. -Nausea without vomiting and decrease in appetite. -The resident complained of dizziness when ambulating. -There was bronchial congestion noted upon inspiration and expiration. -Staff continued to encourage fluids and rest. Review of the residents' health status note dated 03/22/26 showed:-Staff noted no adverse reactions. -The resident refused breakfast, coffee, and snacks. -The resident reported poor sleep the previous night. -The resident continued to feel unwell. Review of the resident's health status note dated 03/23/26 showed:-The resident continued to complain of not feeling well, having nausea, and feeling lightheaded and dizzy. -The resident had a 17-pound weight loss and general malaise feeling. -A call was placed to the primary care physician.-New orders were received for a chest x-ray (a common, painless imaging test that uses electromagnetic radiation to create pictures of the inside of the body, particularly bones and dense tissues) and Zofran (a prescription medication used to prevent nausea and vomiting). Review of the resident's health status note dated 03/25/26 showed:-The resident continued to report feeling unwell, appeared pale, had clammy skin, and was shaky. -The resident reported not sleeping well and experiencing dizziness. -The resident was encouraged to stay hydrated. Review of the resident's health status note dated 03/26/26 at 2:46 P.M. showed:-The physician made rounds and new orders were placed for Ciprofloxacin (a broad-spectrum fluoroquinolone antibiotic used to treat various serious bacterial infections, including urinary tract infections (UTIs), pneumonia, and certain types of infectious diarrhea) 500 milligram (mg) twice daily and Trazadone (prescription antidepressant medication, often used off-label to treat insomnia and anxiety due to its sedative properties) 25 mg at bedtime.--NOTE: There was no culture and sensitivity received from the lab, so the physician would not have known which organism was in the urine and therefore which antibiotic it would be sensitive to. Cipro was a broad-spectrum antibiotic. Review of the resident's medical record showed:-The resident was sent to the emergency room (ER) on 03/26/26 and arrived at 5:15 P.M.-The resident's chief complaint was having nausea and diarrhea for the last two weeks and began having shortness of breath today. -The resident was diagnosed with a UTI. Review of the resident's health status note on 03/26/26 at 10:30 P.M. showed:-The resident returned to facility from the ER with a diagnosis of a UTI and started the Ciprofloxacin medication that evening. --NOTE: The hospital had not yet completed the urine culture, so it was not yet known which antibiotic would be effective. Review of the resident's laboratory results dated and reported to the facility on [DATE] showed:-The results of the UA culture.-Advised that the organism found was susceptible to penicillin (a group of antibiotic medicines derived from Penicillium fungi, used to treat various bacterial infections) as well as other alternate first-generation antibiotics but not Ciprofloxacin. Review of the resident's health status note date 03/30/26 showed:-The facility received a call from the ER where the resident was seen a few days before and notified of the results of the UA culture and noted that the current antibiotic therapy was not effective. -The physician was contacted and issued a new order for Keflex (cephalexin) a widely used oral, first-generation cephalosporin antibiotic that treated bacterial infections) 500 mg twice daily. During an interview on 05/05/26 at 2:23 P.M. the resident said:-He/She had difficulty and pain during urination a couple of months ago and reported it to the staff. -Staff obtained a urine sample about five different times but did not give him/her any medication for it.-There was a delay getting medication.-The hospital did a UA and discovered he/she had a UTI.-When he/she got back to facility, the staff started antibiotic medication, but it was the wrong one because they had to change it a few days later.-Urination was very uncomfortable and painful for several weeks before it got better. I didn't feel well either. During an interview on 05/05/26 at 2:53 P.M., Licensed Practical Nurse (LPN) A said:-Laboratory specimens were collected on Monday and Wednesday.-The procedure for collection was after receiving a physician's order, to get a clean catch sample from a specimen collector, transfer it to a sterile urine cup, fill out the resident's info on the cup's label and place it into the refrigerator on the locked unit. The information for the resident and the specimen was put in the lab's log at the nurse's station then the lab would pick it up on the facility's designated days.-If a UA was not picked up by the lab after it was collected, it was kept in the fridge. He/She was not aware of any alternate procedure.-The nurses were responsible for ensuring the collection of UA specimens.-The UA result from the 03/08/26 collection said the specimen was never received by the lab.-The laboratory the facility was using was having staffing issues and could not pick up specimens on several occasions over several weeks that the staff and facility were aware of.-The physician was not notified until 03/23/26.-The physician and administration should have been notified at least within 24 hours after the specimen had not been collected and received by the laboratory. During an interview on 05/05/26 at 4:15 P.M., the Director of Nursing (DON) and Administrator said:-The UA collection process consisted of placing the physician's order in the resident's medical record, entering the laboratory order into the online system, and collecting and storing the specimen.-The charge nurse was responsible for this, then the DON and the Administrator.-The physician ordered specimen on 03/08/26 had not been picked up on 03/11/26 and the laboratory communicated this to the facility.-The facility had been having problems with the laboratory picking up specimens timely due to staffing issues on their end before the resident's UA order was received and after.-If the specimen had not gotten picked up by the laboratory, the physician should have been notified, then the resident should have been sent out to urgent care to have the specimen collected and tested.-The physician was not notified that the resident's UA had not been collected by the lab after being ordered.-The nurse should have notified him/her and the Administrator that the resident's specimen was not picked up by the laboratory.-The physician was not notified of the resident's reported change in condition 03/14/26 through 03/22/26 but should have been.-The physician should be notified of a change in condition depending on the severity of the issue, typically within 24 hours.-The charge nurse was responsible for notifying the physician regarding the health status of the resident.

Based on interview and record review, the facility failed to ensure adequate staffing coverage to provide supervision and oversight for two sampled residents (Resident #2 and Resident #3) who reside on the secure behavioral locked unit. On 12/26/25 Certified Medication Technician (CMT) A left the secured behavioral health unit unsupervised resulting in a physical and verbal altercation between Resident #2 and Resident #3 out of 7 sampled residents. The facility census was 43 residents.The facility was not able to provide a staffing policy at the time of exit. 1. Review of Resident #2's admission Face Sheet showed the resident admitted with the following diagnoses: -Paranoid Schizophrenia (is Schizophrenia with paranoid features, is a severe mental illness characterized by intense delusions (false beliefs, often persecutory) and hallucinations (especially auditory, like hearing voices), coupled with significant paranoia, distrust, anxiety, and social withdrawal).- Schizoaffective disorder (is a serious, chronic mental illness blending symptoms of schizophrenia (psychosis like hallucinations/delusions) with a mood disorder (mania or depression), causing significant impairment in thinking, perception, mood, and behavior, requiring combined treatment with medication, therapy, and support for effective management). Review of Resident #2's Brief Interview for Mental Status (BIMS) Evaluation dated 12/11/25 showed he/she was moderately cognitively impairment. Review of Resident #3's admission Record showed he/she was admitted with the following diagnoses: -Bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Major depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) Review of Resident #3's BIMS Evaluation dated 12/11/25 showed he/she was cognitively intact. Review of the resident Facility Physical Aggression Initiated report dated 12/26/25 at 7:00 P.M. showed:-Resident #2 was involved in altercation with Resident #3 in the hallway of the behavioral health locked unit. -On 12/26/25 at approximately 7:00 P.M. Resident #3 was upset over not receiving his/her medications. Resident #2 explained that his/her medication was not going to be given yet due to the facility internet being out. Resident #3 approached Resident #2 with a raised voice and was cursing. Resident #2 yelled back at the resident telling him/her to get out of his/her face. Resident #2 then struck at Resident #3 in his/her upper arm. -Resident #2 said he/she told the resident that CMT A told him/her that the facility internet was down and medications were not done yet. Resident #3 got in his/her face and started yelling. Resident #2 told Resident #3 to get out of his/her face and then Resident #2 hit Resident #3. -The facility internet had gone down, and the Director of Nursing (DON) was in the facility printing Medication Administration (MAR) and Treatment Administration Records (TAR) for all residents in order to administer medications. Review of the facility investigation summary dated 12/26/25 showed:-Resident #2 said he/she told Resident #3 that CMT A had told him/her about the facility internet being down and medication administration was not being done yet. Resident #3 got in Resident #2's face and started yelling. Resident #2 told Resident #3 to get out of his/her face and Resident #2 hit Resident #3. Resident #2 did not remember where he/she hit Resident #3. -Resident #3 said he/she did not do anything, and Resident #2 hit him/her in upper arm.-Resident #2 tried telling Resident #3 why the medications were late, and Resident #3 started swinging. -Resident #5 said Resident #2 hit Resident #3 in the arm and Resident #3 was cussing at him/her because Resident #2 told Resident #3 the medications was going to be late that night.-Upon completion of the investigation, it was determined Resident #2 had attempted to redirect Resident #3 out of his/her personal space. Resident #2 yelled get out of my face and struck Resident #3 in the right upper arm. During an interview on 12/29/25 at 11:09 A.M. Resident #2 said:-He/she resided on the behavioral locked unit. -It was a holiday, and staffing was short that evening.-CMT A was on the behavioral unit when facility internet went down. -CMT A was not able to provide medications and left the unit to get printed copies of all resident's MAR's. -No facility staff were on the locked behavioral unit at time of the incident. Review of CMT A's undated witness statements showed: -He/she was starting to prepare for the medication pass and heard banging on the locked behavioral unit door. -He/she went to see what was going on and Resident #5 said Resident #2 and Resident #3 were fighting and throwing punches. -After talking to with each resident separately, Resident #2 admitted he/she punched Resident #3 because he/she was screaming and yelling at him/her. -Resident #3 stated he/she yelled but did not hit anyone. -Resident #5 said both Resident #2 and Resident #3 hit each other. During interview on 12/29/25 at 1:15 P.M. CMT A said:-He/she was assigned to the medication pass for both units. -He/she came into the facility to assist evening medication pass. -He/she was off the unit when the incident happened between Resident #2 and Resident #.-he/she was trying to print the MARs to administer all the resident medications. -He/she was not aware of who assigned as the CNA for the behavioral unit. -There was no staff on the unit at the time of the resident-to-resident incident. -Resident #5 had notified nursing staff by banging on the locked door of behavioral unit, requesting staff to come assist due to Resident #2 and Resident #3 fighting. -After talking to the two residents involved, Resident #2 had hit Resident #3 in his/her arm after an verbal argument between the two residents related to medications not being given yet due to internet was down. -He/she should have waited for the MARs/TARs to have been brought to him/her or found someone to sit on the behavior unit while he/she retrieved the paperwork. During an interview on 12/29/25 at 7:36 P.M. Licensed Practical nurse (LPN) B said. -LPN B and the DON heard CMT A yell for assistance, so they went onto the locked behavioral unit. -Resident #3 was hit in right arm by Resident #2. There was no redness or swelling noted. -Resident #3 said he/she was only yelling and cursing at Resident #2.-He/she could not verify where staff were at time of the incident.-LPN B said the CNA assigned to the behavioral unit had called in sick.-He/she was not sure who was initially assigned to locked behavioral unit.-At 6:30 P.M. the facility internet went down and had another resident situation at the same time. -Normally the daytime nurse will work over until 7:30 P.M. to assist with behavioral health coverage. -That day the nurse left the facility around 6:15 P.M. that evening. -He/she would expect the locked unit have staff coverage all times. -Resident #3 has a history of outbursts when any schedule daily activity routine is delayed. -Resident #3 wanted his/her nighttime medication exactly at 7:00 P.M., and then goes smoke at 7:30 P.M., and if any his/her medication are delayed or he/she cannot go outside smoke at 7:30 P.M., he/she will become agitated and start yelling and cursing at staff. -Due to the facility internet being down this cause the misunderstanding between the residents. During an interview on 12/29/25 at 11:20 A.M. LPN A said:-The behavior unit should never be left unsupervised. -He/she would expect to have at least one staff member on unit all times. During an interview on 12/29/25 at 1:12 P.M. Certified Nurse Aide (CNA) A said the behavioral locked unit should always have at least one facility staff on the locked unit at all times. During an interview on 12/30/25 at 1:30 P.M. Administrator said:-On 12/26/25 CMT A was scheduled for medication administration for both units. -LPN B was initially assigned to the locked unit after CMT A had completed medication pass on the locked unit.-CMT A was not on the locked unit when the resident-to-resident altercation happened. -He/she would have expected the unit to be supervised by facility staff all times.-CMT A had left the behavioral unit unattended prior to the incident to get the resident's paper MARs. During interview on 12/29/25 at 2:20 P.M. the Staffing Coordinator said:-He/she would expect nursing staff and care staff to ensure have one staff member coverage on behavioral unit all times. -The behavioral locked unit should never be left unattended by facility staff members. During an interview on 12/29/25 at 2:26 P.M. the DON said:-The facility locked behavioral unit should not be left unattended by facility staff. -Resident #3 tends to get upset easily when medications or other cares are delayed. -Resident #3 was very demanding in wanting his/her medications on time, which can cause him/her to become upset. During an interview on 12/29/25 at 3:08 A.M. CNA C said: -He/she had been instructed to never leave the behavioral unit unsupervised. -At least one staff is on the unit all times. -The behavioral unit is normal staffed with at least a licensed nurse or CMT and one CNA. During an interview on 12/29/25 at 3:30 P.M. CNA B said the behavioral locked unit always requires staff to remain on the unit.

Based on interview and record review, the facility failed to prevent verbal and physical abuse for two sampled residents (Resident #2 and Resident #3) out of 7 sampled residents. On 12/26/25 Resident #2 and Resident #3 yelled and hit each other when staff left the behavioral unit unsupervised. The facility census was 43 residents.Review of the facility Abuse and Neglect Policy revised on 9/2021 showed:-The residents have the right to be free of abuse, neglect or mistreatment.-As a facility will be actively protect our resident from abuse. -To the extent possible, nurse aid assignments will be consistent so that the resident is most comfortable with the employee and the employee most knowledgeable about the needs of the resident. -Residents are most likely to strike out when they are in a situation where they feel like may not have control over. 1.Review of Resident #2's admission Face Sheet showed the resident admitted with the following diagnoses:-Paranoid Schizophrenia (is Schizophrenia with paranoid features, is a severe mental illness characterized by intense delusions (false beliefs, often persecutory) and hallucinations (especially auditory, like hearing voices), coupled with significant paranoia, distrust, anxiety, and social withdrawal).- Schizoaffective disorder (is a serious, chronic mental illness blending symptoms of schizophrenia (psychosis like hallucinations/delusions) with a mood disorder (mania or depression), causing significant impairment in thinking, perception, mood, and behavior, requiring combined treatment with medication, therapy, and support for effective management). Review of Resident #2's Brief Interview for Mental Status (BIMS) Evaluation dated 12/11/25 showed he/she was moderately cognitively impairment. Review of Resident #3's admission Record showed he/she was admitted with the following diagnoses: -Bipolar disorder (A disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Major depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living) Review of Resident #3's BIMS Evaluation dated 12/11/25 showed he/she was cognitively intact. Review of the resident's Facility Physical Aggression Initiated report dated 12/26/25 at 7:00 P.M. showed:-Resident #2 was involved in altercation with Resident #3 in the hallway of the behavioral health locked unit. -On 12/26/25 at approximately 7:00 P.M. Resident #3 was upset over not receiving his/her medications. Resident #2 explained to the resident that his/her medication was not going to be given yet due to the facility internet being out. Resident #3 approached Resident #2 with a raised voice and cursing. Resident #2 yelled back asking Resident #3 to get out of his/her face. Resident #2 then struck at Resident #3 in his/her upper arm. -Resident #2 said he/she told Resident #3 what Certified Medication Technician (CMT) A said to him/her about the facility internet being down and medications not being done yet. Resident #3 got in his/her face and started yelling. Resident #2 told Resident #3 to get out of his/her face and then Resident #2 hit Resident #3. -The facility internet had gone down, and the Director of Nursing (DON) was in the facility printing Medication Administration (MAR) and Treatment Administration Records (TAR) for all residents so medications could be administrated. Review of the facility investigation summary dated 12/26/25 showed:-Resident #2 said he/she told Resident #3 that CMT A had told him/her about the facility internet being down and medication administration was not being done yet. Resident #3 got in Resident #2's face and started yelling. Resident #2 told Resident #3 to get out of his/her face and Resident #2 hit Resident #3. He/she did not remember where he/she had hit Resident #3. -Resident #3 said he/she did not do anything, and Resident #2 hit him/her in upper arm.-Resident #4 said Resident #3 went to the door. Resident #2 tried telling Resident #3 the medications was late, and Resident #3 started swinging. -Resident #5 said Resident #2 hit Resident #3 in his/her arm and Resident #3 was cussing at him/her because Resident #2 told Resident #3 the medication was going to be late that night.-Upon completion of the investigation, it was determined Resident #2 had attempted to redirect Resident #3 out of his/her personal space. Resident #2 yelled get out of my face and struck Resident #3 in the right upper arm. Review of the Resident #5's BIMS Evaluation dated 12/23/25 showed he/she was moderately cognitively impaired. During an interview on 12/29/25 at 12:58 P.M. Resident #5 said: -There was just an argument and misunderstanding between Resident #2 and Resident #3.-No staff member was on the unit at the time of disagreement between Resident #2 and Resident #3. Review of Resident #4's BIMS Evaluation dated 12/15/25 showed he/she was cognitively intact. During an interview on 12/29/25 at 12:59 P.M. Resident #4 said:-He/she had witnessed the altercation in the hallway between Resident #2 and Resident #3.-Resident #2 and Resident#3 were yelling at each other, as Resident #2 punched/hit Resident #3 in his/her arm. -There were no facility staff on the locked unit at the time.-He/she had to pound on the locked double door to get a staff members attention on the other side of the locked door. CMT A responded to the pounding. -He/she informed CMT A there was a fight on the locked unit while he/she was off the unit. During an interview on 12/29/25 at 11:09 A.M. Resident #2 said:-He/she lives on the behavioral locked unit. -It was a holiday, and the staffing was short that evening.-CMT A was on the behavioral unit when the facility internet went down. -CMT A was not able to provide medications and left the unit to get printed copies of all resident's MAR. -No facility staff were on the locked behavioral unit at time of the incident.-He/she tried to explain to Resident #3 that the internet was down and CMT A was not able to give the evening medications at that time. -Resident #3 him/her to shut the fuck up and then came toward him/her.-He/she exchanged words with Resident #3 and when he/she turned around to walk away Resident #3 punched him/her in the right upper arm. During an interview on 12/29/25 at 11:13 A.M. Resident #3 said: -Resident #2 punched him/her in his/her right arm during the evening shift on 12/26/25 in the locked unit hallway.-He/she was trying to get his/her medication from CMT A, and he/she had exchanged words with Resident #2. -He/she reported to staff that his/her arm was hurting after he/she got hit. Review of CMT A's undated witness statement showed: -He/she was starting to prepare for the medication pass and heard banging on the locked behavioral unit door. -He/she went to see what was going on and Resident #5 said Resident #2 and Resident #3 were fighting and throwing punches. -After talking to each resident separately, Resident #2 admitted he/she punched Resident #3 because he/she was screaming and yelling at him/her. -Resident #3 stated he/she yelled but did not hit anyone. -Resident #5 who was a witness said both Resident #2 and Resident #3 hit each other. During interview on 12/29/25 at 1:15 P.M. CMT A said:-He/she was assigned to pass medications for both units. -He/she came into the facility to assist with the evening medication pass. -He/she was off the unit when the incident happened between Resident #2 and Resident #3 because he/she was trying to print the resident MAR's so he/she could administer the resident medications. -He/she was not aware of who was assigned as the CNA for the behavioral unit. -There was no staff on the unit at the time of the resident-to-resident incident. -Resident #5 had notified nursing staff by banging on the locked door of behavioral unit, requesting staff to come assist due to Resident #2 and Resident #3 fighting. -After talking to the two residents involved, Resident #2 had hit Resident #3 in his/her arm after a verbal argument related to medications not being given yet due to the facility internet was down. During an interview on 12/29/25 at 7:36 P.M. Licensed Practical nurse (LPN) B said. -He/she heard CMT A yell for assistance on the locked behavioral unit. -Resident #3 was hit on his/her right arm by Resident #2. There was no redness or swelling noted. -Resident #3 said he/she was only yelling and cursing at Resident #2. During an interview on 12/30/25 at 1:30 P.M., Administrator said CMT A was not on the locked unit when the resident to resident altercation happened. -He/she would expect the unit to supervised by facility staff all times to prevent altercation and provide protective oversight.

Based on observation, interview and record review, the facility failed to ensure residents on the locked unit had the opportunity to make and receive phone calls without being overheard. Residents on the locked unit, who did not have their own phone, had to use the telephone in the nurses' office and could not have a private conversation without having to request staff to leave the office, which was not always practicable or possible. The practice affected three sampled residents (Residents #1, #3, and #4) who did not have their own phone, out of eight total sampled residents, five of which were on the locked unit. The census on the locked unit was 16 residents. The total facility census was 44 residents.Review of the facility's Resident Use of Telephones policy, dated February, 2021 showed:-Residents shall have easy access to telephones.-Telephones are available to residents to make and receive private telephone calls. -The telephones at the nursing stations should be reserved for staff use unless no other alternate is available. Residents should use telephones at the nursing stations for as brief a period as possible.-Telephones will be in areas that offer privacy and accommodate the hearing impaired and wheelchair-bound residents.-Resident phones are located inside the nurses' station on one unit and across from the nurses' station on the other unit.1. Review of Resident #1's admission Record showed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems).Review of the resident's behavioral care plan showed no restrictions on his/her phone use or justification for monitoring his/her phone calls.During an interview on 12/18/25 at 1:49 P.M. the resident said:-Residents were only allowed to make phone calls from the nurses' office. Staff stay right next to residents when they talk and don't provide privacy. -He/She was doing legal stuff and needed more privacy and sometimes needed to be on the phone when staff were busy. -Residents were only allowed to talk on the phone when staff were available. In the morning there was an approximately two-hour period residents were allowed to make phone calls between around 9:30 A.M. and 11:30 A.M. In the afternoon residents were allowed to call from approximately 1:00 P.M. or 1:30 P.M. until approximately 3:00 P.M. or 3:30 P.M, but the time periods varied according to what staff was doing. There was one staff person who would cut him/her off when he/she needed to leave the office.Observation on 12/18/25 at 2:30 P.M. showed: -Licensed Practical Nurse (LPN) A yelled from the nursing station for Resident #1 to come to the nurses' office for a phone call.-The resident stood and talked on the phone while LPN A remained seated in front of the computer during the entire conversation. -The phone cord was approximately two to three foot in length when unstretched. There was a second chair in the nurses' office, but not within reach of the phone.-Every word the resident said could be heard in the hallway when standing outside the nurses' office door.During an interview on 12/18/25 at 2:39 P.M. Resident #1 said: -LPN A had asked him/her if he/she wanted privacy before he/she took the call. That was the first time any staff had ever asked if he/she wanted privacy during a phone call.-He/She told LPN A he/she could stay during the call because he/she was OK with it being overheard, but often he/she wanted privacy and had never before been offered privacy from staff during a phone call.During an interview on 12/19/25 at 9:19 A.M. the Administrator said: -Resident #1's legal representative did not want the resident to have electronic devices in his/her room. He/she did not know if that included use of a cordless phone.-The facility had not yet clarified with the resident's guardian what no electronic devices in the resident's room included or if the resident would be allowed to make private calls.During an interview on 12/19/25 at 1:43 P.M. Resident #1's legal representative said: -Resident #1 had behavioral problems in the past involving the use of electronic devices.-He/She hadn't discussed with the facility specifics about how the resident could talk privately on the phone.-The resident should be allowed to make private phone calls and there should be a way he/she could do that. 2. Review of Resident #3's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with a primary diagnosis of attention-deficit hyperactivity disorder (ADHD, a developmental disorder typically characterized by a persistent pattern of inattention and/or hyperactivity - a physical state in which a person is abnormally and easily excitable or exuberant, as well as forgetfulness, loss of control or impulsiveness, and distractibility)During an interview on 12/18/25 at 1:58 P.M. the resident said:-He/She didn't have a personal phone.-He/She called his/her family on or around Christmas. -Residents had to use the phone in the nurses' office, but didn't know what hours residents were allowed to use the phone.-There was no private phone for residents to use on the hall or any portable phone they could use for a private conversation. He/she would prefer to talk privately. 3. Review of Resident #4's admission record showed the resident was admitted to the facility on [DATE] and was most recently readmitted to the facility on [DATE] with a primary diagnosis of autistic disorder (a lifelong neurodevelopmental condition affecting social communication, interaction, and behavior characterized by repetitive patterns, restricted interests, and sensory differences appearing in early childhood with varied severity).During an interview on 12/18/25 at 2:14 P.M. the resident said:-He/She didn't have his/her own phone.-He/She made calls every three days in the nurses' office during times when the nurse wasn't busy. The calls were limited to 15 minutes.-Staff were always there during his/her calls. He/she would like to talk privately but wasn't given privacy because staff were always in the office when he/she or other residents talked.-He/She would prefer a phone that residents could take somewhere else for privacy.4. Review of Resident #5's admission Record showed he/she was admitted to the facility 7/6/12 and most recently readmitted on [DATE] with a primary diagnosis of schizophrenia (a psychotic disorder characterized by loss of contact with the environment, by noticeable deterioration in the level of functioning in everyday life).During an interview on 12/18/25 at 2:19 P.M. the resident said:-He/She had his/her own phone.-Residents who don't have their own phone can use the one in the nurses' office. He/she thought staff had to be with them because there was always staff in the office when residents were talking on the phone.-There used to be a portable phone that residents could use. They hadn't had one for about a year.-Residents should have privacy when they were talking on the phone.5. During an interview on 12/18/25 at 2:47 P.M. Certified Medication Technician (CMT) A said:-If the resident doesn't have a phone they use the phone in the nurses' office.-Staff always stay in the nurses' office when residents are talking unless the resident specifically asks them to leave. -If the resident asks for privacy staff have to secure all private information and stand outside the office door. The door is left ajar so staff can see the resident.During an interview on 12/18/25 at 2:51 P.M. Licensed Practical Nurse (LPN) A said:-The only facility phone the residents had to use was located in the nurses' office. There was no other phone available for resident use on the hall.-If a resident says they want privacy while talking, staff have to secure private information and stand outside the office door. He/she tried to ignore what residents say, but staff can still hear the resident unless the office door is shut. Staff keep the door ajar to keep an eye on the resident when they are in the nurses' office.-Residents can talk on the nurses' office phone only if staff aren't busy. Sometimes staff are busy and can't let them use the phone. Staff were usually busy from 8:30 A.M. to 10:00 A.M.-Other staff have told him/her at night the phone cut-off time for residents was 9:00 P.M. He/she had never seen that in writing, however, and left the facility before then.-Until about a year ago there was a portable phone that residents could take to a more private area. The facility got a new phone system at that time. There were times it was inconvenient to let residents talk on the nurses' phone.-If there was a portable phone it would be way more convenient and residents could take it with them. They could talk any time then. During an interview on 12/18/25 at 4:05 P.M. the Director of Nursing (DON) said:-Residents should be able to use the phone any time they want. There were no time length limits on the use of the phone and there should be no times when residents were denied access to the phone.-There was one LPN in particular they had to educate about that, but as far as he/she knew residents were using the phone whenever they needed to do so. He/she hadn't heard otherwise.During an interview on 12/18/25 at 4:15 P.M. the Administrator said:-There shouldn't be any restrictions on the use of the phone. Residents should be able to use the phone any time they want. -Residents just have to let staff know if they want to talk privately and staff will secure private information in the office and stand outside the nurses' office while the resident talks.-There used to be a cordless phone for residents' use that was kept in the nurses' office. Residents could take that with them to talk privately.-About a year ago the facility went to a new phone system and since that time there has been no cordless phone for the residents to use.-He/She inquired about a cordless phone a year ago and was told no by the corporate office, but wasn't sure why residents no longer had access to a cordless phone.2693671

Based on interview and record review, the facility failed to provide personal privacy and confidentiality of residents personal and medical records by disposing of the records in a public dumpster. This failure affected 136 residents. The facility census was 49.The Administrator was notified on 7/18/25 of the past noncompliance which began on 5/29/25. The facility obtained a contract for proper disposal of Protected Health Information (PHI). The deficiency was corrected on 5/30/25. 1.Review of the facility's Breach of Unsecured PHI policy revised 2013, showed:-In accordance with Health Insurance Portability and Accountability Act (HIPAA) the facility would maintain policies and procedures, referenced herein, that addressed the reporting and documentation of a breach of unsecured PHI.-The facility would use and disclose unsecured PHI and electronic PHI according to facility policies and procedures.-Breach means the acquisition, access, use or disclosure of unsecured PHI in a manner that is not permitted by HIPAA which compromises the security or the privacy of the PHI. Review of the facility's Protected Health Information (PHI) policy revised 4/2014, showed:-Protected health information shall not be used or disclosed except as permitted by current federal and state laws.-It was the responsibility of all personnel who had access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure. Review of the facility's Incident report dated 5/29/25, showed:-On 5/29/25 at approximately 10:20 P.M., the Administrator was made aware of an allegation of HIPAA noncompliance.-The allegation consisted of medical records improperly located in a dumpster off site at a laundry building.-Upon arrival to the dumpster closed boxes were found with resident's names and years labeled on the outside of the boxes. Review of the facility's Medical Record Destruction log dated 5/29/25, showed:-136 resident's medical records were retrieved from the dumpster for destruction.-The dates of the medical records ranged from 2008-2018.-All medical records were retrieved from the dumpster and destructed via means of incineration. Review of photos received on 5/30/25 showed:-A dumpster was packed full of boxes that contained resident's medical records.-Some resident's names and years were noted on the outside of some of the boxes. Review of the maintenance director's incident statement dated 5/30/25, showed:-He/She placed the medical records in the dumpster on 5/29/25. During an interview on 7/17/25 at 10:00 A.M., the Administrator said:-The facility threw residents medical records in a trash dumpster by misunderstanding.-The Maintenance Director was the one who threw the medical records in the public trash dumpster.-The facility removed the records from the trash dumpster and took the records to a private residence and incinerated them.-The medical records were burned in a fire.-The facility currently has a contract with shred it.-He/she would have expected the resident's confidential medical information be protected.-He/She would not have expected residents' medical records to be thrown in a public dumpster. During an interview on 7/17/25 at 11:00 A.M., Licensed Practical Nurse (LPN) A, said:-He/she was aware of HIPAA regulations.-When health protected information needs to be disposed, staff placed the documents in the shred it boxes located throughout the building.-He/She would not expect protected information to be discarded in a trach can or a dumpster.-He/She received recent education from the facility about HIPAA and how to discard protected information. During an interview on 7/17/25 11:03 A.M., Housekeeper A said:-He/She was aware of HIPAA regulations and guidelines.-He/She would give anything that he/she found with residents protected information on it to the charge nurse to be disposed of properly.-He/She would not place anything with resident information on it in a trashcan or dumpster.-He/She had recent education from the facility about HIPAA and protecting residents' privacy. During an interview on 7/17/25 11:15 A.M., Maintenance Director said:-He/She threw some protected resident information in a public trash dumpster on 5/29/25.-He/She made the mistake not knowing about HIPAA regulations and violations at that time.-He/She was educated about HIPAA and now knows what to do with residents protected health information.-He/She has been instructed to give anything that he/she comes across with resident information to the charge nurse and never place anything in the trash or dumpster that has protected resident information on it. Complaint #1542769

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility failed to ensure all residents received a two-step tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) skin test upon admission to the facility for five sampled residents (Residents #15, #32, #36, #37, and #342) and failed to ensure the staff were following Enhanced Barrier Precautions (EBP-a strategy to reduce the spread of Multidrug-Resistant Organisms in Nursing Homes) protocol when providing wound care for two sampled residents with wounds (Residents #23 and #36) and failed to ensure staff knew which residents to use EBP on when providing cares for three sampled residents (Residents #23, #36 and #37) out of 13 sampled residents. The facility census was 40 residents with a licensed capacity for 60 residents at the time of the survey. 1. Observation on [DATE] between 10:04 A.M. and 11:07 A.M. during the initial facility Life Safety Code (LSC) kitchen inspection with the Dietary Manager (DM) showed there was a three-sink area, an ice machine, a low-heat chemical dish-washing machine, and a hand-washing sink. Observation on [DATE] between 12:10 P.M. and 3:09 P.M. during the facility LSC walk-through inspection with the Administrator showed the following: -The building was equipped with a full fire sprinkler system and had its incoming water supplied by the local water company. -There was a piped fire sprinkler riser room (A dedicated space for fire protection equipment) which served the whole facility's system. -There were at least 26 resident rooms with private or shared bathrooms and sinks. -There were two Shower Rooms and two tankless water heaters. -There was a Janitor's Closet with a mop hopper and a Breakroom and a Medication Room with sinks. -There were two gender specific public restrooms and a Beauty Shop with a sink. Review of the facility's maintenance folder entitled Legionella Water Management Plan, last reviewed [DATE] and provided by the Administrator, showed the following: -The first 31 pages of the binder had a watermark (the process of superimposing a logo or piece of text atop a document or image file) that read Draft Version behind the text in a diagonal manner. -The water flow diagram on page 12 did not indicate areas of risk with the potential risk level for each. -On page 15, with the heading Control Measures: Cold Water Systems, the Upper and Lower Control Limits were marked as N/A (not applicable, not available, not assessed, or no answer) and that the water management plan expired on [DATE]. -On page 16, with the heading Control Measures: Hot Water Systems it stated to check the water heaters monthly though there was no documentation for it, and that the water management plan expired on [DATE]. -The page with the heading Water Management Plan Program Team Meeting Minutes did not list the facility name where indicated and was left entirely blank. -There was a printed copy of an email from a state surveyor dated [DATE] with a link to the CDC's Legionella website page and a list of what assessments and toolkits were required to be completed and added to their program. -There was a copy of the 36-page (pg.) CDC toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens, though the assessment included was left blank. -There was an undated 2-pg. Quarterly/Semi Annual/Annual Maintenance Schedule of Duties which had a column of a year's twelve months broken down on the left hand side with an explanation of what actions should be done next to each month, but the right hand column of places for the dates completed was left blank. -The undated 1-pg. [Facility Name] Weekly Maintenance Schedule of Duties had 44 blanks to be filled in that were not. -The 15-pg. CDC environmental Assessment Form had numerous blanks to fill in and questions to be answered, but none were. -There were no facility-specific testing protocols and acceptable ranges for control measures with a method of monitoring them at this facility, with interventions or action plans for when control limits were not met. -There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. During an interview on [DATE] at 11:11 A.M. the Administrator said the following: -Their Director of Maintenance (DOM) would be responsible for implementing the Legionella program when they hired one. -They were currently interviewing applicants for that position. -He/She had been made aware of some of the basic requirements of the program through Quality Improvement Program for Missouri (QIPMO). 32720 2. Review of the facility's Screening Residents for Tuberculosis policy dated [DATE] showed: -No guidance for the facility to complete a two-step TB skin test for all residents with the first step to be administered prior to or upon admission to the facility. Review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's admission two step TB skin test. -An Annual Statement for Tuberculin Reactors signs and symptoms screening form dated [DATE]. Review of Resident #37's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's admission two step TB skin test. -An Annual Statement for Tuberculin Reactors signs and symptoms screening form dated [DATE]. Review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's admission two step TB skin test. -An Annual Statement for Tuberculin Reactors signs and symptoms screening form dated [DATE]. Review of Resident #15's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's admission two step TB skin test. -An Annual Statement for Tuberculin Reactors signs and symptoms screening form dated [DATE]. Review of Resident #342's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -The first step TB skin test was administered on [DATE]. -No date documented when the test was read. The results were negative with zero millimeters of induration. During an interview on [DATE] at 12:21 P.M., the Assistant Director of Nursing (ADON) said: -The nurse admitting the resident was responsible to ensure the first step TB skin test was administered. -The test should be read in ,d+[DATE] hours. -About two weeks later the second step should be administered by the nurse on duty. During an interview on [DATE] at 12:24 P.M., the Director of Nursing (DON) said: -Residents should have a two step TB test upon admission. -The first step test was done by the admitting nurse then the nurse in charge would do the second step a couple weeks later. -The test should have a date it was read. 39469 3. Review of the facility's policy, Enhanced Barrier Precautions, dated 2024 showed: -It was the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. -EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. -All staff receive training on enhanced barrier precautions upon hire and at least annually and were expected to comply with all designated precautions. -The facility would have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff were aware of which residents required the use of EBP prior to providing high-contact care activities. -Enhanced barrier precaution would have been initiated for residents with any of the following: -Wounds (chronic wounds such as pressure ulcers, unhealed surgical wounds), and indwelling medical devices (feeding tubes). -Make gowns and gloves immediately available near or outside of the resident's room. -Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) for enhanced barrier precautions was only necessary when performing high-contact care activities. -The Infection Preventionist would have incorporated periodic monitoring and assessment of adherence to determine the need for additional training and education. -Place a yellow sticker or magnet on the name plate of the resident's door to identify the need of EBP. Review of #36's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of open wound, left lower leg. Review of the Admission Assessment Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated [DATE] showed: -He/She was cognitively intact. -He/She had a surgical wound. Review of the resident's Care Plan dated [DATE] showed: -He/She had a wound on left shin related to a motor vehicle accident (MVA). -Did not show EBP were to be utilized when providing cares, including wound care, for the resident. Review of Nurses' Notes from [DATE] to [DATE] showed no documentation of EBP. Review of the [DATE] Physician's Order Sheet (POS) showed the following orders: -Extended (Enhanced) Barrier Precautions for wound, dated [DATE]. During an observation and interview on [DATE] at 9:12 A.M. the resident said: -He/She had a wound on his/her left shin from a MVA. -He/She had a wound 8 centimeters (cm) long by 3 cm wide that was oozing off-white colored pus. -The nurse changes the dressing daily. -The nurse wore gloves and a mask but did not think he/she wore a gown while changing the dressing. -There was nothing outside the resident's door which showed he/she was on EBP. -There was no isolation cart in the resident's room. Observation on [DATE] at 3:34 P.M. showed: -There was no sign on the resident's door which indicated EBP was to have been used in the room. -There was no isolation cart in the room. Observation of wound care on [DATE] at 10:35 A.M. with Licensed Practical Nurse (LPN) A showed: -He/She provided wound care for the resident without wearing a gown. -There was no sign on the resident's door which indicated EBP was to have been used in the room. -There was no isolation cart in the room. During an interview on [DATE] at 10:43 A.M. LPN A said: -He/She did not know when to use EBP. -The resident came with the wound. -They did not have a Wound Care Nurse each nurse does their own wound cares. -The DON had provided EBP education for the staff. -EBP meant keeping wounds dry. -All you needed to wear was gloves if the wound was not airborne. -He/She did not know if the resident should have had EBP. -If the resident should have had EBP then there should have had a sign on the door a yellow dot. -There was no sign on the resident's door. -The Infection Preventionist would have been responsible for ensuring there was a sign on the resident's door which would have shown staff EBP were needed. During an interview on [DATE] at 10:53 A.M. Certified Nursing Assistant (CNA) D said: -If a resident had an open wound staff should have wore full PPE while providing cares for the resident. -There was no sign on the resident's door which indicated EBP was to have been used in the room. -There was an isolation cart under the sink in the resident's room. -The DON provided an inservice every month but could not remember if they had education on EBP. -He/She was not sure what EBP was for or how to know which residents were on EBP. -He/She was a germaphobe and always wore a gown, mask and gloves while giving providing cares for the resident such as changing them or providing a shower. -The Wound Care Nurse would have been in charge of ensuring the staff knew which residents were on EBP. -There should have been a sign on the door denoting the resident was on EBP. -The resident did not have a sign on his/her door for EBP. Review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Edema (fluid retention within the bodies tissue). -Diabetes. Review of the resident's Care Plan dated [DATE] showed: -Did not show anything about EBP. -He/She had the potential for skin breakdown related to diabetes diagnosis. -He/She had a wound on his/her right heel. Review of the resident's Quarterly MDS, dated [DATE] showed: -He/She was moderately cognitively impaired. -He/She had Diabetes. -He/She had a stage 3 pressure ulcer (a full-thickness skin loss that extends into deeper tissue and fat). -He/She had an application of ointment/medication to his/her feet. -He/She had dressings to his/her feet. Review of [DATE] POS showed the following orders: -Extended (Enhanced) Barrier Precaution for wound, dated [DATE]. Observation on [DATE] at 3:34 P.M. showed: -There was no sign on the resident's door which indicated EBP was to have been used in the room. -There was no isolation cart in the room. -Resident #23 and Resident #36 were roommates. Observation on [DATE] at 10:35 A.M. showed: -There was no sign on the resident's door which indicated EBP was to have been used in the room. -There was no isolation cart in the room. Observation of wound care and interview on [DATE] at 2:59 P.M. LPN A showed: -He/She provided wound care for the resident daily. -The resident had a Stage 3 pressure ulcer on his/her right heel which measured 3 cm by 2 cm. -He/She had not been using EBP on the resident and maybe should have. During an interview on [DATE] at 3:20 P.M. the resident said: -The nurse does wound care every day. -He/She was not able to say if the staff wore full PPE while doing cares with him/her. During an interview on [DATE] at 3:30 LPN B/Charge Nurse (CN) said: -He/She had never heard of EBP. -He/She had heard of isolation but did not know what the difference was. -They (the staff) have completed education on the computer system. -For regular isolation staff should wear gown, gloves, and a mask. -If a resident was on isolation there should have been a little sign in the shape of a gown by the resident's name on the outside of the resident's room. -Isolation residents would have had an isolation cart by their door. -This resident did not have either. -The Assistant Director of Nursing (ADON) was the facilities Infection Preventionist and was currently on vacation. Review of Resident # 37's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis: -Gastronomy status (a surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube). Review of the resident's Admission MDS dated [DATE] showed: -He/Shewas moderately cognitively impaired. -He/She had a feeding tube. Review of the resident's Care Plan dated [DATE] showed: -He/She had an enteral feeding tube. -Staff was to change the dressing around the stoma (insertion site) per physician's order. Review of the [DATE] POS showed the following order: -EBP due to feeding tube, dated [DATE]. Observation of tube feeding and interview on [DATE] at 10:49 A.M. with LPN B/CN showed: -There was no sign on the resident's door which indicated EBP was to have been used in the room -He/She said he/she had not known about EBP before the surveyor asked about it yesterday and had not worn EBP when working with the resident's feeding tube before today. -He/She said there should have been a sign on the resident's door indicating EBP was to have been used as the resident had a feeding tube. During an interview on [DATE] at 11:15 A.M. the resident said: -He/She declined to be interviewed as he/she was too ill. 4. During an interview on [DATE] at 1:20 P.M. CNA A said: -If a resident had a wound or any type of tubing you should wear a mask, gloves, and a gown (EBP). -There should have been a sign on the door indicating EBP should be worn. -He/She was not sure what the sign would have looked like. -There should have been an isolation cart outside the resident's room. -The (DON) or CN was responsible for ensuring staff knew which residents had EBP and ensuring staff also knew. -The facility had two meetings last month about EBP provided by the DON. -Staff did not know before today that they should have started wearing PPE for a resident on EBP. During an interview on [DATE] at 12:00 P.M. the DON said: -If a resident had a wound or any tubing such as a feeding tube or a foley (tube inserted into the bladder to drain urine) they should have been placed on EBP. -If a resident was on EBP there should have been a yellow gown on their name plate on the door. -There should have been an isolation cart outside their door. -Staff had received education by his/her self and the Administrator on EBP this last month. -He/She would have expected staff to wear a gown, gloves, and a mask when entering a resident's room that was on EBP.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the interests as well as the physical, mental, and psychosocial well-being for three sampled residents (Residents #19, #23, and #36) out of 13 sampled residents. This deficient practice had the potential to affect all residents. The facility census was 40 residents. Review of the facility's Activities Policy, undated, showed: -The activities department worked with the nursing department to coordinate resident care and needs with scheduled activities. -Activity staff were aware of the resident's safety concerns and transfer needs. -The Activities Director was responsible for filling out the activities section of the Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning). -The activities director assisted with the activity care plan and attending care plan meetings. -Activities were meaningful and individualized to meet the needs of all residents. 1. Review of Resident #19's Annual MDS assessment, dated 10/18/23, showed it was somewhat important to the resident to be able to go outside and get fresh air. Review of the resident's care plan, dated 3/8/24, showed: -The resident was invited to activities. -The resident was informed of planned activities. -The resident enjoyed playing cards. -The resident enjoyed working with models. Review of the resident's Quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's Activity Participation Log for June 2024 showed the resident participated in coffee club on 6/11/24, 6/12/24 and 6/13/24. Review of the resident's Activity Participation Log for July 2024 showed: -The resident participated in coffee club on July 1, 2, 3, 4, 5, 11, 12, 14, 19, and 25. -The resident participated in bingo on July 5, 12, and 19. Review of the resident's Activity Participation Log for August 2024 showed: -The resident participated in coffee club on August 2, 9, 13, 14, 15, 16, 18, 23, and 30. -The resident participated in bingo on August 2, 9, 16, 23, and 30. Review of the resident's Activity Participation Log for September 2024 showed the resident participated in coffee club on 9/3/24. During an interview on 9/9/24 at 9:30 A.M. the resident said: -There were things to do during the week but not on the weekend. -The Activity Director told the resident that he/she did not know what to plan for the residents on the unit as they were not crafty. 2. Review of Resident #23's quarterly MDS, dated [DATE], showed the resident was moderately cognitively impaired. Review of the resident's Activity Participation Log for July 2024 showed: -The resident participated in coffee club on July 1, 4, 5, 6, 9, 12, 18, 19, 20 and 27. -The resident participated in bingo on July 5, 12, 19 and 27. Review of the resident's Activity Participation Log for August 2024 showed: -The resident participated in coffee club on August 1, 2, 5, 8, 10, 16, 23, 24, 25, and 27. -The resident participated in bingo on August 16 and 17. There were no activity participation logs for September 2024. Review of the resident's care plan, dated 7/1/24 showed the Activities Director was to provide a monthly calendar of scheduled activities. During an interview on 9/9/24 at 9:54 A.M. the resident said: -He/She had nothing to do, especially on the weekends. -He/She would go to activities but there isn't always someone to do them with the residents. -He/She used to go to the dining area and do activities with the other residents at the facility but since some of the residents from his/her unit had behavior issues they were no longer allowed to do activities with the others. 3. Review of Resident #36's admission MDS assessment, dated 6/27/24, showed: -This showed the resident was cognitively intact. -It was very important to the resident to listen to music that he/she liked. -It was very important to do his/her favorite activities. -It was very important to go outside to get fresh air. Review of the residents care plan, dated 7/1/24, showed: -The resident enjoyed social activities. -The Activity Director was to provide a monthly calendar of scheduled activities. The resident's activity participation logs for July, August and September 2024 were requested and not provided. During an interview on 9/9/24 at 9:15 A.M., the resident said: -There was not much to do at the facility. -There was nothing on the calendar in the hall. -He/She wanted something to do on Saturday and Sundays. -The residents on his/her unit used to do activities with the other residents but were no longer allowed to because some residents had bad behaviors and now no one can go up there. -Since that happened there has not been much to do back on the unit. Review of the August 2024 Activities calendar, displayed on the wall in the resident's room on 9/9/24 at 10:41 A.M., showed: -No activities were scheduled on the weekends. -There was no calendar for September noted on the unit. 4. Observations conducted multiple times from 9/9/24 to 9/11/24 between 9:00 A.M. to 3:30 P.M. showed no activities being conducted with the residents on the unit. During an interview on 9/9/24 at 1:16 P.M., Certified Nursing Assistant (CNA) D said: -The Activity Director provided activities for the residents on the unit. -There were no activities on Saturday. -If the Activities Director was not at the facility, then the CNAs were supposed to provide an activity for the residents on the unit, but they do not have time. -The Activities Director was out of the building due to illness so no activities were conducted since he/she has been out. During an interview on 9/10/24 at 2:00 P.M. CNA A said he/she had only seen activities on the unit 2-3 times a week. During an interview on 9/11/24 at 8:13 A.M., Certified Medication Technician (CMT) A said: -There were not many activities to do on the unit. -The residents complained there was nothing to do on the weekends. -The nurse sometimes came in on Sundays and popped popcorn and put on a movie. -The Activities Director was out sick the last few days. -When the Activities Director was out of the facility then nursing staff tried to do something with the residents but not always. -The Activities Director put out a monthly calendar. During an interview on 9/11/24 at 8:44 A.M., CNA A said: -There were no activities for the residents on the unit during the week. -He/She did not receive any notification he/she was supposed to do any activity with the residents. -There was an activity calendar posted on the hall for August, but it was blank. During an interview on 9/11/24 at 8:53 A.M., Licensed Practical Nurse (LPN) A said: -Activities should be done daily. -The activities director was out sick for the last few days. -He/She was unaware if someone else was supposed to be doing activities with the residents. -The residents on the unit used to do activities with the rest of the residents but due to behavior issues they were only to be doing activities on their unit. A phone interview was attempted on 9/11/24 at 10:20 A.M. with the Activities Director. There was no answer. During an interview on 0/11/24 at 12:00 P.M., the Director of Nursing (DON) said: -Activities were scheduled and completed on the unit. -The residents on the unit were offered activities two to three times a day. -The activities calendar should be current and posted on the hall. -The Activities Director was sent home on Monday due to illness. -If residents attended activities, it should be documented on the participation log. -He/She was not aware of activities not being conducted on the unit on the weekends. -He/She was unaware of who did the activities when the Activities Director was not at the facility. -The Administrator was able to do them if needed.

Based on observation, interview and record view, the facility failed to provide trauma informed care (understanding a resident's life experiences to provide effective care) for one sampled resident (Resident #30) with a diagnosis of Post Traumatic Stress Disorder (PTSD-a mental health condition caused by an extremely stressful or terrifying event), out of 13 sampled residents. The facility census was 40 residents. Review of the facility's Trauma Informed Care Policy, dated March 2019, showed: -The purpose of the policy was to guide staff in appropriate and compassionate care specific to individuals who had experienced trauma. -All staff were provided in-service training about trauma, its impact on health, and PTSD. -Nursing staff were trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization. -All staff were guided in evidence-based organizational and interpersonal strategies that supported trauma informed care. -Trauma informed care was person centered. -Caregivers were taught strategies to help eliminate, mitigate, or sensitively address a resident's triggers. -The facility used trauma-informed principles in strategic planning. -Include trauma informed care as part of Quality Assurance Improvement Plan (QAPI). -Implement universal screenings for residents with trauma. 1. Review of Resident #30's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 7/10/24, showed: -The resident was moderately cognitively impaired. -The resident was diagnosed with anxiety disorder (a condition that causes excessive worry and feelings of fear, dread, and uneasiness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and PTSD. Review of the resident's care plan (an individualized plan that summarizes a person's health conditions and current treatments for their care), dated 6/11/24, showed: -The resident had mental distress evidenced by the inability to concentrate related to PTSD. -Approaches included: --Keep an open and accepting attitude with the resident al all times. --Notify the physician if resident was having PTSD events, which may need an psych referral. --Administer medications per order. --Offer counseling if resident was agreeable. Observation on 9/9/24 at 11:58 A.M. showed the resident walking from his/her room to the dining area. The resident ate at a table with no other residents. Resident sat quietly and ate his/her lunch and returned to his/her room. Observation on 9/10/24 at 10:42 A.M. showed the resident in his/her room in bed with his/her eyes closed. During an interview on 9/11/24 at 8:13 A.M., Certified Nursing Assistant (CNA) A said: -He/She worked on the unit on a regular basis and knew the residents pretty well. -He/She was familiar with the resident. -He/She was not a hundred percent sure of what his/her needs or diagnoses were. -He/She could find the information on the care plan. -The resident did need some guidance for personal care and lots of redirection. -The resident seemed to feel sorry for him/herself and was sad. -The resident repeated said he/she though he/she was going to die at the facility. -The resident had PTSD. -Some of the resident's behaviors included pacing, and watching other resident's televisions from the hallway. -The resident was not verbally or physically aggressive. -The resident did not have outbursts. -The resident just seemed to be confused a lot of the time. -The resident was a smoker and sometimes the resident said he/she was claustrophobic while smoking outside with the other residents. -He/She was not sure what to do for the residents claustrophobia she he/she told the resident to go out to the picnic table where he can be alone. -Sometimes it made the resident feel better. -The resident didn't focus on one thing at a time and was restless sometimes. -He/She just talked to him/her or tried to redirect him/her to something else. Observation on 9/11/24 at 8:46 A.M. showed the resident in bed watching television. During an interview on 9/11/24 at 8:24 A.M., Licensed Practical Nurse (LPN) A said: -He/She usually worked on the unit. -He/She was familiar with the resident. -He/She looked up the resident's on the electronic health record (EHR) and saw his/her diagnoses included major depressive disorder, anxiety, and PTSD. -He/She was unaware of any triggers the resident had. -He/She had not seen any behaviors related to PTSD. -He/She was unsure why the resident had that diagnosis. -If the resident had specific triggers and approaches, he/she found it in the residents progress notes or care plan. -He/She believed the PTSD was possibly alcohol related. -He/She had not received any recent training or in-service related to PTSD. During an interview on 9/11/24 at 8:28 A.M., LPN B said: -He/She did not work on the unit with the resident. -If a resident was diagnosed with PTSD he/she expected to see it addressed on the resident's care plan and should include triggers and strategies to help the resident. -The diagnosis should also be on resident's orders. -He/She had not received any recent training regarding PTSD. -He/She was unaware of any negative behaviors from the residents on that unit. During an interview on 9/11/24 at 9:21 A.M., the MDS coordinator said: -He/She had been in this position since February of this year. -He/She expected the resident's MDS was accurate and reflected current conditions at the time it was completed. -He/She was unaware of the resident's history or what the main cause of the PTSD was for the resident. -He/She was unaware if the care plan addressed the resident's PTSD diagnosis. -He/She expected to see triggers on the care plan as well as any history related to PTSD. During a follow up interview on 9/11/24 at 9:56 A.M., the MDS coordinator said: -The resident's PTSD was caused from being in the war. -He/She did not specify which war or how it was related specifically to the resident. During an interview on 9/11/24 at 11:49 A.M., the Director of Nursing (DON) said: -If a resident had a diagnosis of PTSD, he/she expected to see the history of the diagnosis on the care plan. -He/She expected to see triggers and approaches for the resident on their care plan. -He/She was unaware of how often trauma informed care training was offered or provided to the staff. -He/She suggested to talk to the administrator or the Regional Nurse Consultant. During an interview on 9/11/24 at 2:50 P.M., the administrator said: -He/She was unable to locate the last training sign-in sheets for trauma informed care. During an interview on 9/11/24 at 2:50 P.M., the Regional Nurse Consultant said: -He/She was developing trauma informed care in-services that he/she has started to implement. -He/She was unaware of when the last training was.

Based on interview and record review, the facility failed to ensure accurate documentation of narcotic pain medication on the Medication Administration Record (MAR) and the narcotic count log for four sampled residents (Resident # 8, Resident # 23, Resident #19, and Resident #36) out of 13 sampled residents and failed to complete and/or sign shift change narcotic counts each shift. The facility census was 40 residents. Review of the facility policy titled Pharmacy and Medication Administration, not dated, showed: -Narcotics must be counted at the beginning and end of each shift and signed on the narcotic log by the oncoming and off going nurse or medication technician. -Monitoring the log weekly can help identify any missed counts or lax in counting by staff. -Medication Administration Records (MARs should be completed with each med pass and audited regularly for missing initials or holes in the MAR. -Documentation should be provided on the MAR for PRN (medications given on an as needed basis) meds, pain meds, and behavior meds. -The facility must ensure that it is free from medication error rates of five percent (5%) or greater and residents are free of any significant medication errors. Review of the facility policy titled Pain, not dated, showed: -The MAR should document the frequency of pain, medication use, and its effectiveness. 1. Review of Resident #8's face sheet, with an admitted [DATE], showed he/she had: -Pain in other specified joint. -Unspecified abdominal pain. -Pain in right shoulder. -Chronic pain syndrome. Review of the resident's Physician Order Sheet (POS), dated 7/2024, showed: -Oxycodone (a narcotic pain reliever) 20 milligram (mg) 1 tablet every 6 hours while awake dated 6/24/24 and discontinued on 7/3/24. -Oxycodone 20 mg 1 tablet by mouth every 6 hours PRN for pain dated 7/3/24. Review of the resident's MAR, dated 7/2024, showed: -Oxycodone 20 mg 1 tablet every 6 hours while awake dated 6/24/24 and discontinued on 7/3/24. -A physician order for Oxycodone 20 mg 1 tablet by mouth every six (6) hours PRN for chronic pain dated 7/3/24. -Oxycodone 20 mg was documented as administered 102 times between 7/1/24 - 7/31/24. -NOTE: Only 51 Oxycodone 20 mg tablets were documented as being available for administration for the resident between 7/1/24-7/31/24. The facility was not able to provide documentation for the additional 51 tablets staff documented as administered between 7/6/24-7/23/24. Review of the resident's Oxycodone (opioid) 20 mg tablet narcotic log for 7/2024, showed: -51 Oxycodone 20 mg tablets were signed out between the dates of 7/1/24-7/31/24. -No documentation of Oxycodone 20 mg tablets between 7/6/24 - 7/23/24. (Note- the resident's MAR showed documentation Oxycodone 20 mg was administered during this timeframe). -The resident's narcotic count went from 6 available tablets on 7/5/24 to 52 available tablets on 7/24/24 with no documentation regarding the 46 tablet discrepancy. -On 7/3/24 at 6:00 A.M., two Oxycodone 20 mg tablets were signed out at the same time, by different staff members. -On 7/28/24 at 7:30 P.M., two Oxycodone 20 mg tablets were signed out at the same time, by the same staff member. -Note: The physician order is for one Oxycodone 20 mg tablet. Review of the resident's POS, dated 8/2024, showed an order for Oxycodone 20 mg 1 tablet by mouth every 6 hours PRN for chronic pain dated 7/3/24. Review of the resident's MAR, dated 8/2024, showed: -A physician order for Oxycodone 20 mg 1 tablet by mouth every 6 hours PRN for chronic pain dated 7/3/24. -56 Oxycodone 20 mg tablets were documented as administered to the resident between 8/1/24-8/19/24. -Documentation of the resident's MAR for 8/20/24-8/31/24 was requested and not provided at the time of exit. Review of the resident's Oxycodone 20 mg tablet narcotic log for 8/2024, showed: -70 Oxycodone 20 mg tablets were signed out between the dates of 8/1/24-8/19/24. -Note: 56 Oxycodone 20 mg were documented as administered by the staff on the resident's MAR. 14 tablets were unaccounted for. -44 Oxycodone 20 mg tablets were signed out between the dates of 8/20/24-8/31/24. The resident's MAR for those dates were requested and not provided at the time of exit. 39469 2. Review of Resident #23's POS showed Hydrocodone (a narcotic pain reliever) 5/325 mg one or two tablets every six hours as needed for pain dated 7/13/24. Review of the resident's Hydrocodone narcotic log showed between 8/1/24 - 8/31/24: -One tablet Hydrocodone 5/325 mg was removed from the narcotic count 10 times. -Two tablets Hydrocodone 5/325 mg was removed from the narcotic count three times (for a total of six tablets). Review of the resident's 8/2024 MAR showed: -Hydrocodone 5/325 mg one tablet every six hours as needed was documented as administered four times. -Hydrocodone 5/325 mg two tablets every six hours as needed showed no documentation of administration. -NOTE: A total of 12 tablets of Hydrocodone 5/325 mg are unaccounted for. 3. Review of Resident #19's July 2024 POS showed a physician order for Norco 10/325 mg one tablet orally two times a day for pain, dated 1/17/24. Review of the resident's Narcotic log for July 2024 showed 47 Norco tablets were signed out for administration. Review of the resident's July 2024 Medication Administration Record showed: -Norco 10/325 mg one tablet orally two times a day for pain, dated 1/17/24. -53 Norco tablets were signed out as administered. No documentation where the additional six tablets were obtained. 4. Review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of an open wound to his/her left lower leg(after motor vehicle accident). Review of the resident's June 2024 POS showed a physician order for Oxycodone 5 mg every six hours as needed for pain dated 6/17/24. Review of the resident's Narcotic log for June 2024 showed 17 Oxycodone tablets were signed out for administration. Review of the resident's June 2024 MAR showed: -Oxycodone 5 mg every six hours as needed for pain dated 6/17/24. -14 Oxycodone tablets were documented as administered. NOTE: Three tablets were unaccounted for. Review of the resident's Narcotic log for July 2024 showed 41 Oxycodone tablets were signed out for administration. Review of the resident's July 2024 MAR showed: -Oxycodone 5 mg every six hours as needed for pain dated 6/17/24. -30 Oxycodone tablets were documented as administered. NOTE: 11 tablets were unaccounted for. Review of the resident's August 2024 POS showed a physical order for Oxycodone hydrochloride oral tablet 5 mg one tablet by mouth every six hours as needed for pain, dated 8/14/24. Review of the resident's Narcotic log for August 2024 showed 16 Oxycodone tablets were signed out for administration. Review of the resident's August 2024 Medication Administration Record showed: -Oxycodone 5 mg every six hours as needed for pain dated 8/14/24. -14 Oxycodone tablets were documented as administered. NOTE: Two tablets were unaccounted for. 5. During an interview on 9/11/24 at 10:30 A.M. Licensed Practical Nurse (LPN) B said staff removing the narcotics from the narcotic logs were responsible to ensure the narcotic was also on the MAR documented as administered. During an interview on 9/11/24 at 12:00 P.M. the DON said: -Medications that were signed off on the Narcotic Count Sheet should have match the amount that was signed off on the MAR. -He/She was ultimately responsible for ensuring the narcotic count was correct and that the count matched what was signed off on the MAR. During an interview on 9/11/24 at 12:56 P.M., LPN A said: -Staff should document PRN pain medication on the front and back of the MAR when administered. -Staff should document PRN pain medication on the narcotic log when administered. -The MAR and the narcotic log should match. -Two PRN Oxycodone should not have been administered at the same time for resident #8. -The narcotic logs and MAR's had medication errors. During an interview on 9/11/24 at 1:00 P.M., the Regional Nurse Consultant said: -Narcotic sign out logs and MAR's should match. -There had been no previous audits of the narcotic logs and MAR's prior to him/her coming to the facility. -Narcotics logs and MAR's should have been audited to ensure accuracy. -Narcotic logs and MAR's should have been audited at least once per month. -The narcotic logs and MAR's had medication errors. 6. Review of the Controlled Drug Count Sheet on the Men's unit from June 1, 2024 through September 10, 2024 showed: -Staff were directed to count all controlled drugs accessible to the medication nurse at each shift change. -NOTE: the facility shift change was two times daily. -Each shift were to sign the count sheet by the incoming nurse and the outgoing nurse. In addition, staff were to check yes or no if the count was okay (meaning no discrepancies). -Between 6/1/24 - 6/30/24 showed no documentation by either the incoming nurse and/or the outgoing nurse 28 out of 120 opportunities. No documentation the count was ok 15 out of 60 shifts. -Between 7/1/24 - 7/31/24 showed no documentation by either the incoming nurse and/or the outgoing nurse 86 out of 124 opportunities, including no documentation by either shift between 7/5/24 night shift through 7/23/24 night shift. No documentation the count was ok 43 out of 62 shifts. -Between 8/1/24 - 8/31/24 showed no documentation by either the incoming nurse and/or the outgoing nurse 47 out of 124 opportunities. No documentation the count was ok 24 out of 62 shifts. During an observation of medication pass and interview at 9/9/24. at 8:43 A.M. with LPN B said: -Observation of the narcotic count did not show the nurse counted the liquid Morphine that was stored in the refrigerator. -He/She said that don't usually count it because it was a full bottle still unopened. During an interview on 9/11/24 at 8:20 A.M. Certified Medication Technician (CMT) A said: -Staff was expected to count the narcotics with the off going nurse and both the nurses would sign at the same time that they counted. -Counting the narcotics should have been done at the beginning and end of each shift or whenever the keys to the medication cart were passed on to the next shift. -There have been times when there were not two signatures on the narcotic count. -If someone did not sign and count the narcotics he/she would have notified the DON. During an interview on 9/11/24 at 9:02 A.M. LPN A/Charge Nurse (CN) said: -As soon as you receive report you and the off going nurse should have counted the narcotics at the same time and signed at the same time. -There should not have been any blanks on the narcotic count. -If there were blanks the DON should have been notified. -There have been many blanks on the narcotic sheet, maybe people forgot to sign it. -He/She had not notified the DON about the blanks on the narcotic sheets. -The DON or Assistant Director of Nursing (ADON) were ultimately responsible for ensuring the narcotic count was correct. During an interview on 9/11/24 at 10:30 A.M. LPN B said: -The narcotics should have been counted with the oncoming and off going nurses together at the same time. -The count should have been correct. -If the count was not correct he/she would not have taken the keys from the previous shift. -If the count was not correct he/she would have notified the DON or ADON. -There was some blanks on the Narcotic Count Sheet and that should never have happened. -He/She had not notified the DON as it had not happened on his/her shift. -The number of narcotic cards and the liquid medication in the medication refrigerator were counted first. -Then you count how much medication was on each card. -The amount should be correct. -They had received education recently from the DON on ensuring the narcotic count was correct. During an interview on 9/11/24 at 12:00 P.M. the DON said: -Nursing staff was expected to count the narcotics at the beginning and at the end of their shift with a second nurse. -If there were any blank spots the staff should have notified him/her or the ADON. -All of the medications including the Narcotics in the medication refrigerator should have been counted even if it was full as someone could have taken the whole bottle and just left the box. -He/She was ultimately responsible for ensuring the narcotic count was correct.

Based on interview and record review, the facility failed to ensure a resident's vaccination status and/or provide education regarding the pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus) vaccines upon admission to the facility for five sampled residents (Residents #15, #32, #36, #37, and #342) out of 12 sampled residents. The facility census was 40 residents. Review of the facility's Pneumococcal Vaccine policy dated March 2022 showed: -All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. -Prior to or upon admission, residents are assessed for eligibility to receive pneumococcal vaccine series. -Before receiving the vaccine, residents or their representatives are offered education regarding the benefits, risks, and potential side effects of the vaccine. 1. Review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's pneumonia vaccination status. -No documentation the resident was offered a pneumonia vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. 2. Review of Resident #37's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's pneumonia vaccination status. -No documentation the resident was offered a pneumonia vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. 3. Review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's pneumonia vaccination status. -No documentation the resident was offered a pneumonia vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. 4. Review of Resident #15's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's pneumonia vaccination status. -No documentation the resident was offered a pneumonia vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. 5. Review of Resident #342's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's pneumonia vaccination status. -No documentation the resident was offered a pneumonia vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. 6. During an interview on 9/10/24 at 12:21 P.M., the Assistant Director of Nursing (ADON) said: -He/She was not sure who was responsible to ensure resident pneumonia education was provided upon admission to the facility. -Vaccination status should be documented in the resident's medical record. During an interview on 9/11/24 at 12:24 P.M., the Director of Nursing (DON) said: -Pneumonia education and/or vaccination records should be obtained and entered in the resident's medical record upon admission. -He/She was not sure if the residents were given education regarding pneumonia vaccines upon admission to the facility.

Based on interview and record review, the facility failed to ensure provision and documentation of education regarding the benefits, risks and potential side effects associated with the COVID-19 (a new disease caused by a novel (new) coronavirus) vaccine for residents upon admission to the facility for five sampled residents (Residents #15, #32, #36, #37, and #342) out of 12 sampled residents and for five out of five sampled staff (Employees A, B, C, D, and E). The facility census was 40 residents. Review of the Coronavirus Disease (COVID-19) Vaccination of Resident's policy dated May 2023 showed: -Each resident is offered the COVID-19 vaccine unless the vaccine is medically contraindicated or the resident is fully vaccinated. -The resident (or resident's representative) has the opportunity to accept or reject a COVID-19 vaccine. -COVID-19 vaccine education, documentation, and reporting are overseen by the Infection Preventionist. -Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. The information is provided in a format or language that is understood by the resident and/or representative. Review of the Employee Infection and Vaccination Status policy dated August 2013 showed: -Employees will be offered vaccinations per state or local agency policies/regulations. -Employees will be provided with educational materials to make informed decisions for non-mandated vaccinations. If declined, a declination form will be completed and placed in the employee's health record. 1. Review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's COVID vaccination status. -No documentation the resident was offered a COVID vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. Review of Resident #37's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's COVID vaccination status. -No documentation the resident was offered a COVID vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. Review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's COVID vaccination status. -No documentation the resident was offered a COVID vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. Review of Resident #15's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's COVID vaccination status. -No documentation the resident was offered a COVID vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. Review of Resident #342's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's medical records showed: -No documentation of the resident's COVID vaccination status. -No documentation the resident was offered a COVID vaccination upon admission to the facility. -No documentation the resident was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon admission to the facility. Review of Employee A's employment record showed: -His/Her date of hire was 8/22/24. -No documentation of the employee's COVID vaccination status. -No documentation the employee was offered a COVID vaccination upon hire. -No documentation the employee was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon hire. Review of Employee B's employment record showed: -His/Her date of hire was 5/18/24. -No documentation of the employee's COVID vaccination status. -No documentation the employee was offered a COVID vaccination upon hire. -No documentation the employee was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon hire. Review of Employee C's employment record showed: His/Her date of hire was 12/14/23. -No documentation of the employee's COVID vaccination status. -No documentation the employee was offered a COVID vaccination upon hire. -No documentation the employee was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon hire. Review of Employee D's employment record showed: -His/Her date of hire was 3/8/24. -No documentation of the employee's COVID vaccination status. -No documentation the employee was offered a COVID vaccination upon hire. -No documentation the employee was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon hire. Review of Employee E's employment record showed: -His/Her date of hire was 4/30/24. -No documentation of the employee's COVID vaccination status. -No documentation the employee was offered a COVID vaccination upon hire. -No documentation the employee was provided education regarding the risks and benefits and potential side effects associated with the vaccine upon hire. During an interview on 9/10/24 at 12:21 P.M., the Assistant Director of Nursing (ADON) said: -He/She did not provide the education for COVID vaccines for the staff or residents. -He/She thought the Director of Nursing (DON) did that. During an interview on 9/10/24 at 1:37 P.M., the Regional Nurse said: -He/She would not have COVID vaccination information for staff or residents. -He/She did not think the facility needed to get vaccination status or provide education to staff or residents regarding the COVID vaccination since the Public Health Emergency was over. During an interview on 9/11/24 at 12:24 P.M., the Director of Nursing (DON) said: -Staff should have vaccination records so they can be entered in their employee medical file. -Residents should have vaccination records so they can be entered in their medical record. -He/She was not sure if residents were given education regarding COVID vaccines, but he/she was sure if the staff were provided with the education. -He/She did not think it was still required.

Based on interview and record review, the facility failed to provide written notification of a hospital transfer/discharge for one sampled resident (Resident #23) out of 13 sampled residents, as well as the Ombudsman (a person who advocates for residents of nursing homes) when the resident was transferred to the hospital. The facility census was 40 residents. A policy regarding transfer/discharge was requested from the facility and not provided. 1. Review of Resident #23's nurse progress notes, dated 7/7/24, showed: -The resident was reported to be on the floor. -Resident complained of pain to his/her right hip. -Hospice, Assistant Director of Nursing (ADON), and Administrator were notified. -Facility physician notified and sent orders to send the resident to the emergency room . Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 8/20/24 showed the resident had moderate cognitive impairment. Review of the resident's paper chart and electronic health record showed no notification of a transfer/discharge was provided to the resident as well as no notification provided to the Ombudsman. During an interview on 9/11/24 at 10:00 A.M. the resident said: -He/She was sent to the hospital due to a fall. -He/She was unaware if he/she received notification in writing regarding being transferred to the hospital. During an interview on 9/11/24 at 10:30 A.M., Licensed Practical Nurse (LPN) B said: -He/She was not employed at the facility when the resident had the fall. -When residents were transported out of the facility the physician and family were notified in writing. -The Ombudsman must also be notified. During an interview on 9/11/24 at 11:54 A.M., the Director of Nursing (DON) said: -Transfer/discharge notifications were given to residents when they were sent to the hospital. -A transfer/discharge notification should have been issued to the resident. -The Ombudsman should have been notified of transfer to hospital. -Family and residents should be notified in writing with reason for transfer to the hospital.

Based on interview and record review, the facility failed to provide written notification of the facility's Bed Hold policy (a policy that specified how residents can secure their bed in the facility if they have to go to the hospital) for one sampled resident (Resident #23) out of 13 sampled residents when the resident was transferred to the hospital. The facility census was 40 residents. A policy regarding bed hold was requested from the facility and not provided. 1. Review of Resident #23's nurse progress notes, dated 7/7/24, showed: -The resident was reported to be on the floor. -Resident complained of pain to his/her right hip. -Facility physician notified and sent orders to send the resident to the emergency room . Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 8/20/24 showed the resident had moderate cognitive impairment. Review of the resident's paper chart and electronic health record showed no bed hold policy was issued to the resident. During an interview on 9/11/24 at 10:00 A.M. the resident said: -He/She was sent to the hospital due to a fall. -He/She was unaware if he/she received notification in writing regarding holding his/her bed. During an interview on 9/11/24 at 10:30 A.M., Licensed Practical Nurse (LPN) B said: -He/She was not employed at the facility when the resident had the fall. -Bed hold policies must be provided in writing. During an interview on 9/11/24 at 11:54 A.M., the Director of Nursing (DON) said: -Bed hold policies were given when residents were sent to the hospital. -A bed hold policy should have been issued to the resident.

Based on interview, and record review, the facility failed to complete an annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for one sampled resident (Resident #32) out of 13 sampled residents. The facility census was 40 residents. Review of the facility's undated policy titled MDS Completion and Submission Timeframes showed: -The assessment coordinator or designee was responsible for ensuring resident assessments were submitted in accordance with current federal and state guidelines. -The timeframes for completion and submission of assessments were based on the current requirements published in the Resident Assessment Instrument Manual (RAI). Review of the RAI manual, Version 1.18.11, dated October 2023 showed after the admission assessment, the next comprehensive assessment would be scheduled within 366 days. 1. Review of Resident #32's assessments showed the following: -Admission MDS was completed on 1/27/23. -No annual MDS was completed (an annual MDS was due 1/28/24). During an interview on 9/11/24 at 9:21 A.M., the MDS Coordinator said: -He/She was the MDS Coordinator since the end of February 2024 (was not at the facility when the annual should have been completed). -The previous program they used for MDS completion had a calendar that showed when each MDS was due. -The previous program did not send notices of past due assessments. -He/She did not have a notification in the old program that the resident's MDS was late. -The previous program was available until 8/1/24. -They switched to a new program on 8/19/24. -The new program gave a list of residents and when their MDS was due. -The new system showed the resident's next MDS was due in June 2024. During an interview on 9/11/24 at 11:49 A.M., the Director of Nursing (DON) said the MDS should be done timely and completed following the RAI manual.

Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) no less frequently than once every three months for one sampled resident (Resident #32) out of 13 sampled residents. The facility census was 40 residents. Review of the facility's undated policy titled MDS Completion and Submission Timeframes showed: -The assessment coordinator or designee was responsible for ensuring resident assessments were submitted in accordance with current federal and state guidelines. -The timeframes for completion and submission of assessments were based on the current requirements published in the Resident Assessment Instrument Manual (RAI). Review of the RAI manual, Version 1.18.11, dated October 2023 showed after the admission assessment, quarterly assessments should be scheduled within 92 days after the previous assessment and the next comprehensive assessment would be scheduled within 366 days after any comprehensive assessment including admission, significant change or annual assessment. 1. Review of Resident #32's assessments showed the following: -Admission MDS was completed on 1/27/23. -First quarterly MDS was completed on 4/24/23. -Second quarterly MDS was completed on 7/22/23. -Third quarterly MDS due 10/22/23 was not completed timely. -Third quarterly MDS was completed on 11/2/23 (one month late). -Annual MDS due 1/28/24 was not completed. -Another quarterly MDS was completed on 4/19/24. -No assessments completed since 4/19/24. Review of the facility's assessment transmission report dated 5/3/24 showed: -5/3/24 was the date of the last transmission. -The resident's assessment was late. -No other transmissions for the resident were received. During an interview on 9/11/24 at 9:21 A.M., the MDS Coordinator said: -He/She was the MDS Coordinator since the end of February 2024. -The previous program they used for MDS completion had a calendar that showed when each MDS was due. -The previous program did not send notices of past due assessments. -He/She did not have a notification in the old program that the resident's MDS was late. -The previous program was available until 8/1/24. -They switched to a new program on 8/19/24. -The new program gave a list of residents and when their MDS was due. -The new system showed the resident's MDS was due in June 2024. During an interview on 9/11/24 at 11:49 A.M., the Director of Nursing said the MDS should be done timely and completed following the RAI manual.

Based on interview and record review, the facility failed to provide supervision for one sampled resident (Resident #1) identified as a fall risk when on 10/12/22 during an outside activity on the facility patio on the Northside of the building, he/she was left outside without staff supervision when he/she released the break on his/her wheelchair, rolled off the patio, hit the curb and fell out of his/her wheelchair landing on the grass and rolled about 25 feet down the hill. The resident sustained abrasions (is a type of open wound that's caused by the skin rubbing against a rough surface. It may be called a scrape or a graze) to his/her left arm, right side of his/her face, right arm, both shins and a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to his/her right hand pinky finger area. He/she also complained of pain to his/her left ribs, right knee was swollen and a dime size knot to his/her right elbow. X-rays revealed he/she had a fracture to his/her metacarpal (any of the five bones of the hand) bone of his/her right hand. Additionally four sampled residents (Resident #6, #7, #8 and #9) identified as elopement and or fall risks were also left outside without supervision and or in the line of sight of facility staff out of nine sampled residents. The facility census was 43 residents. Record review of the facility's Safety and Supervision of Residents Policy showed: -The facility strived to make the environment as free from accident hazards as possible. -Resident safety and supervision and assistance to prevent accidents were facility-wide priorities. -Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes and a facility-wide commitment to safety at all level of the organization. -Employees were be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. -The care team were to target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. -Resident supervision was a core component of the systems approach to safety. 1. Record review of Resident #1's Face Sheet showed he/she readmitted [DATE] with the following diagnosis: -Displaced fracture of his/her right femur. (the thigh bone). -Schizoaffective disorder. (A condition where symptoms of both psychotic and mood disorders are present together during one episode). -Generalized anxiety disorder. (A persistent feeling of anxiety or dread, which can interfere with daily life). -Dementia. (Impaired ability to remember, think, or make decisions that interferes with doing everyday activities) -History of falling. -Severe intellectual disabilities (involves problems with general mental abilities that affect functioning in two areas: Intellectual functioning (such as learning, problem solving, judgement) and adaptive functioning (activities of daily life such as communication and independent living). Record review of the resident's Fall Risk Evaluation dated 8/5/22 showed: -He/she was at risk for falls. -Intervention included: --Two facility staff were to transfer him/her by Hoyer lift (a mechanical lift) . --His/her bed was set in the lowest position to prevent falls. Record review of the resident's Annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/5/22 showed his/her Brief Interview for Mental Status (BIMS) Score of 5, (The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the resident is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment.). Record review of the resident's undated Care Plan showed: -The resident had cognitive loss, impaired judgment and a diagnosis of impaired disability. -He/she was to be reoriented as needed daily with cares and/or activities. -He/she was given verbal cues/reminders if resident cannot remember. -He/she was at risk for side effects and falls from antipsychotic drug use. -He/she had fell out of his/her wheelchair while outside at activity dated on 10/12/22. -He/she was not to be left unattended outdoors for safety. Record review of the resident's Incident Report dated 10/12/22 showed: -He/she was sitting outside in his/her wheelchair on the patio when he/she unlocked his/her wheelchair and rolled to a grass hill causing him/her to roll down hill and fall out of his/her wheelchair. -He/she sustained abrasions to right arm, right side of face, bilateral (both) shins, hematoma (bruise) to right hand little finger, right knee swollen, right elbow with dime sized knot. -Post incident action was the resident was not to be left alone outside. 2. Record review of Resident #6's Face Sheet showed he/she admitted [DATE] with the following diagnosis: -Alzheimer's disease. (The most common cause of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life) -Chronic obstructive pulmonary disease. (Refers to a group of diseases that cause airflow blockage and breathing-related problems) -Major depressive disorder. (Causes a persistent feeling of sadness and loss of interest and can interfere with your daily) Record review of the resident's Fall Risk Evaluation dated 7/28/22 showed: -He/she was at risk for falls. -No interventions were documented. Record review of the resident's Quarterly MDS dated [DATE] showed he/she had a BIMS score of 7. Record review of the resident's undated Care Plan showed: -On 5/3/22 he/she was elopement/wandering risk related to dementia and intermittent confusion. -He/she had an increased risk for falls related to psychotropic medication use. -He/she would not experience any injuries related to falls. -He/she was monitored for changes in resident's condition that may warrant increased supervision/assistance and notify the physician. 3. Record review of Resident #7's Face Sheet showed he/she readmitted [DATE] with the following diagnosis: -Dementia. -Bipolar disorder. (Extreme mood swings that include emotional highs and lows) -Brief psychotic disorder. (The presence of one or more psychotic symptoms with a sudden onset and full remission within one month) -Syncope (another word for fainting or passing out) and collapse. Record review of the resident's Fall Risk Evaluation dated 9/9/22 showed: -He/she was at risk for falls. -No intervention: were documented. Record review of the resident's Annual MDS dated [DATE] showed his/her BIMS score 00, as unable to assess. Record review of the resident's undated Care Plan showed: -He/she had a history of claiming harm to self, elopement risk upon admission. -Elopement assessment quarterly and as needed. -Behavior monitoring every shift. -Give verbal cues/reminders if resident was unable to remember. -He/she had an increased risk for falls related to daily medication use. -He/she ambulated without devices, short distances with staff assist. -Wheelchair primary mode of locomotion. -History of rolling out of bed to floor. -Will not experience any injuries related to falls through next review period. -He/she was monitored for changes in resident's condition that may warrant increased supervision/assistance and notify the physician. -He/she required staff assistance with activities of daily living (ADL) cares, staff to push in wheelchair to meals in dining room. -He/she would receive ADL assistance as needed through next review period. 4. Record review of Resident #8's Face Sheet showed he/she readmitted [DATE] with the following diagnosis: -History of falling. -Leg fracture. -Pain in his/her right hip. -Lack of coordination. Record review of the resident's Quarterly MDS dated [DATE] showed his/her BIMS score 15. Record review of the resident's undated Care Plan showed: -He/she had an increased risk for falls related to daily psychotropic mediation use. -He/she would have no fall related injuries through next review period. -Remind to keep area free of clutter and assist if needed. 5. Record review of Resident #9's Face Sheet showed he/she had readmitted [DATE] with the following diagnosis: -Wedge compression fracture of lumbar vertebra. (the front of the vertebral body collapses but the back does not, meaning that the bone assumes a wedge shape) -Muscle weakness. Record review of the resident's Fall Risk assessment dated [DATE] showed: -He/she was at risk for falls. -Interventions include the use of a wheelchair for mobility, pedal broda chair. Record review of the resident's Significant Change MDS dated [DATE] showed his/her BIMS score 8. Record review of the resident's undated Care Plan showed: -He/she was at increased risk for elopement related to delusion with diagnosis of schizophrenia. -He/she would remain on facility ground and have schizophrenia managed through next review period. -Redirected per staff. -He/she was at risk for injury related to seizure disorder. -Protect resident from injury during witnessed seizures. -History of falls, medication increased risk of falls. -Wheelchair primary mode of locomotion with ability to propel self at times and propelled by staff at times. -Involved in activities as he/she tolerated. 6. During an interview on 11/2/22 at 10:40 A.M. the Administrator said: -There was an incident in which a resident had rolled down the hill beside the facility. -The resident was outside with the Activities Director, unlocked his/her wheelchair, rolled to the curb, the wheelchair tipped and the resident rolled on a grassy hill. During an interview on 11/2/22 at 1:58 P.M. the Activities Director said: -The activity was just outside the front doors on the patio, which was to the right. -He/she had about 5 or 6 residents (Resident's #1, #6, #7, #8 and #9) outside for an activity. -He/she left the patio area to push another resident inside the facility and to ask staff for help bringing the other residents back inside. -He/she entered the first door, walked through a 10 foot corridor and entered the facility through the second door. -When he/she came out the exterior door, he/she saw the resident had rolled towards the curb. -Resident #1 was sitting next to the rail on the farthest end of the patio from the door. -Another resident reported Resident #1 unlocked his/her wheelchair brakes. -Resident #1 went to the edge of the patio, the chair veered to the right, traveled across the parking lot, hit the curb, the resident was ejected from the wheelchair and rolled approximately half way down the embankment. -It was not common for him/her to come outside with the residents alone. -The staff that were outside with him/her had went inside to assist with cares for another resident, leaving him/her alone with the residents. -He/she was not supposed to leave the residents alone. -He/she was unsure if he/she had a walkie talkie that day. During an interview on 11/2/22 at 2:13 P.M. the Medical Records Nurse said: -He/she assessed the resident at the place in which he/she came to rest in the grass outside. -Five staff assisted the resident into the wheelchair, then into the van to return to the facility. -The resident could propel him/herself and unlock his/her wheelchair brakes. -He/she expected staff to be with the resident at all times. -Staff should never leave residents alone outside, even if bringing someone else inside. During an interview on 11/2/22 at 2:27 P.M. the Administrator said: -The Activities Director usually sat outside with the residents by him/herself. -The staff have walkie talkies to call for assistance. -The Activities Director said he/she used the walkie talkie to call for assistance. -Leaving residents alone for any reason was not an acceptable practice. -Although it was not a policy it was an expectation of staff to not leave residents unattended outside. During an interview on 11/2/22 at 3:37 P.M. the Director of Nursing (DON) said: -The walkie talkie was used on the day of the incident. -The Activities Director usually went outside alone with the residents. -He/she said the residents should not be left alone. During an interview on 11/3/22 at 12:44 P.M. the Regional Director said: -Residents were not to be left outside alone at any time. -Expectation was the Activities Director should use the walkie talkie to call for assistance instead of entering the building and leaving the residents alone outside on the patio. MO00208672

Based on interview and record review, the facility staff failed to implement nutritional interventions to promote optimal food intake for one (Resident #21) resident identified by the facility as having a significant weight loss; to follow their policy to fully inform the physician, family and to notify the consultant Registered Dietitian (RD) for an assessment related to the significant weight loss, and to assess or identify reasons for the weight loss, or develop and implement interventions to prevent further weight loss. The resident experienced a severe weight loss of 17.8 pounds or 13.9% loss of his/her body weight in 20 days. The facility identified two residents with weight loss. The facility census was 41 residents. Record review of Federal Guidelines showed they defined suggested parameters for evaluating significance of unplanned and undesired weight loss as: - A one month loss of 5% indicates significant weight loss and greater than 5% indicates severe loss; - Three months loss of 7.5% indicates significant weight loss and greater than 7.5% indicates severe loss; - Six months loss of 10% indicates significant weight loss and greater than 10% indicates severe loss. Record review of "The Diet Manual," a comprehensive resource and guide for facilities from Becky Dorner and Associates, dated 2006 showed the following information: - The goal of medical nutrition therapy is to stabilize the weight, identify underlying causes or factors contributing to the significant unplanned weight loss, and intervene as appropriate to resolve the problem. - Identify individuals with significant/severe weight losses: - Significant weight loss (which also included a 1-2% weight loss in one week in addition to the federal guidelines) - Review the food intake records; - Assess the risk of [MEDICAL CONDITION], identify potential causes, and document findings in the medical record; - Review the plan of care; - Interview the individual to identify possible causes and to determine appropriate interventions; - Request/implement nutrition interventions; - For residents that have 1% to 2% weight loss in a week, staff should provide individualized aggressive calorie augmentation. This may include, but is not limited to: high calorie/high protein supplement, whole milk or cream, extra mayonnaise or gravy on foods, pudding/ice cream/milk shakes/sherbet; enhanced foods (high calorie/protein), brightly colored napkins on tray to signify that this resident needs extra attention and cater to individual preferences as much as possible; - Confer with appropriate family, staff and physicians regarding intervention to be taken; - Document findings, assessment of nutritional status, and nutritional intervention in the resident's medical record (including plan of care); - A copy of monthly weights should be forwarded to the RD each month to review and calculate significant change over 5% in one month, 7.5% in three months, and 10% in six months; - A copy of all significant weight losses and gains should be given to the facility's Interdisciplinary Team for appropriate review and documentation; - The RD should review and document all significant weight changes; - The physician and family should be notified of any individual with a significant loss; - All individuals with significant weight variances should be re-weighed prior to reporting this to the Physician. - The facility is responsible for obtaining correct weights on a regular basis. Record review of the facility's undated Weight policy showed it was the policy of the care center to assist all residents to reach or maintain their optimal nutritional level; and the following were to be implemented by monitoring, documenting and treating, as deemed necessary by the multifaceted weight loss clinical team; for resident(s) with significant weight loss (5% in one month, 7.5% in three months, 10% in six months): - The charge nurse to was notify the physician/responsible party of the weight loss. - Obtain an RD consult. - Obtain a Speech Therapy (ST) screening and/or consult if deemed appropriate. - Obtain orders for supplements three times daily (TID) until weight stabilizes, and/or until the physician/RD consult orders differ. - Continue weekly weights for new admissions times four weeks, and until weight stabilizes at least four weeks, decision per team. - Obtain lab work such as complete blood count (CBC), pre-[MEDICATION NAME] and protein (monitor's of nutritional status) as the physician recommends. - Review the resident in the multifaceted weight loss clinical team meetings and documentation in the chart. - Social Service will discuss Advance Directive with physician/resident/responsible party regarding intravenous (IV) and/or tube feedings and review psychosocial needs/status. - A change of condition per Resident Assessment Instrument (RAI) process and updated care plan will be implemented addressing interventions for weight loss. - If the weight loss continues, additional supplements may be given (as ordered) with medication passes for additional calories. 1. Record review of Resident #21's face sheet showed the resident was originally admitted to the facility on [DATE], and had the following [DIAGNOSES REDACTED]. - Late effect intracranial injury (also known as [MEDICAL CONDITION] (TBI), when an external force traumatically injures the brain). - [MEDICAL CONDITION] (a disorder of the nervous system that can cause people to suddenly become unconscious and to have violent, uncontrolled movements of the body). - Insulin dependent diabetes mellitus (IDDM - the inability to metabolize carbohydrate because of absolute insulin deficiency). - [MEDICAL CONDITION] (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). - [MEDICAL CONDITION] (any abnormal condition of the structure or function of brain tissues, especially chronic, destructive, or [MEDICAL CONDITION] conditions). - [MEDICAL CONDITION] (loss of ability to produce or comprehend language due to [MEDICAL CONDITION]). Record review of the resident's Vital Signs and Weight Record, showed he/she weighed: - 133 pounds in January 2013, - 130 pounds in February 2013, - 127 pounds in March 2013, - 127 pounds in April 2013, and - 128 pounds in May 2013. Record review of the resident's nutritional status care plan dated 5/16/13, showed the resident had a history of [REDACTED]. The resident was fed by staff and also received a supplement per the physician's orders [REDACTED]. The following interventions were provided to the staff: - Provide his/her diet as ordered. - Provide his/her supplement as ordered. - Boost Glucose (a medical specifically formulated for the dietary management of blood glucose levels) with meals and at bedtime. - Obtain his/her weight and monitor weekly/monthly. - Flag for RD consult. - Offer alternate food/fluid for refused items. - Monitor his/her lab data as available. - Staff were to feed the resident and to encourage meal intake. - Inform/invite the resident to all food/beverage related activities. Record review of the resident's dental care plan dated 5/16/13, showed the resident had impaired chewing due to some/all of his/her natural teeth being lost, and he/she was served a pureed diet. The resident required staff to perform oral care. The goal was for the resident to be able to eat current food without difficulty through the next review period and for the staff to perform oral care. The following instructions were provided to the staff: - Provide his/her diet as ordered. - Monitor for the resident's ability to chew food appropriately. - Monitor for gum pain. - Allow the resident to eat at his/her own pace. - Do not rush the resident. - Monitor the resident for choking. - Perform oral care, assist with set-up, encourage his/her self-performance, and complete the task if he/she was unable. Record review of the resident health condition care plan dated 5/16/13, showed the resident had a [DIAGNOSES REDACTED]. The goal was for him/her to have his/her diabetes managed as ordered by the physician through the next review period. The following instructions were provided to the staff: - To provide AccuChecks (a blood sugar reading obtained by a small sample of blood from the finger) per the physician's orders [REDACTED]. - Serve his/her diet per the physician's orders [REDACTED]. - Administer insulin per the physician's orders [REDACTED]. - Do weekly/monthly weights. - Report to the resident's physician any weight loss or weight gain of five pounds. - Report skin issues such as redness, abrasions, rash, and/or dry cracked skin as he/she has poor healing related to diabetes. - Monitor for hypo/hyperglycemic condition. Record review of the resident's comprehensive annual Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) dated 5/14/13, showed he/she: - Had short-term and long-term memory problems, - Was severely impaired with daily decision making, - Had [DIAGNOSES REDACTED].g., chronic [MEDICAL CONDITION] and [MEDICAL CONDITION]); and late effects of injuries to the nervous system, - Required minimal staff assistance with transfers and ambulation, - Was dependent upon staff for dressing, eating, hygiene, bathing and toileting, - Received a mechanically altered therapeutic diet, - Had no natural teeth or tooth fragments, and - Had a weight of 128 pounds. Record review of the resident's Vital Signs and Weight Record showed he/she weighed: - 128 pounds in June 2013, - 129 pounds in July 2013, and - 129 pounds in August 2013. Record review of the resident's quarterly MDS dated [DATE], showed he/she: - Had short-term and long-term memory problems, - Was severely impaired with daily decision making, - Had a [DIAGNOSES REDACTED]. - Required minimal staff assistance with transfers, - Was independent with ambulation, - Was dependent upon staff for dressing, eating, hygiene, bathing and toileting, - Received a mechanically altered therapeutic diet, and - Weighed 129 pounds. Record review of the resident's nutritional status care plan updated 8/13/13, showed: - His/her goal had been met, and - Staff would continue with his/her current plan of care. Record review of the resident's Dietary Intake Record for September 2013, showed the resident: - Consumed 100% of 48 out of 90 meals, or 53% of his/her meals. - Consumed 75% of 15 out of 90 meals, or 17% of his/her meals. - Consumed 50% of eight out of 90 meals, or 9% of his/her meals. - Consumed 25% or less of one out of 90 meals, or 1% of his/her meals. - The resident did not refuse any meals. - The resident refused 24 snacks out of 90 snacks or 20% of the snacks. - The resident was in the hospital for 18 meals and snacks or 20% of the time. Record review of the resident's undated Vital Signs and Weight Record showed he/she weighed 127 pounds in September 2013. Record review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The documentation did not reflect how much of the supplement the resident consumed. Record review of the resident's discharge assessment with return anticipated dated 9/6/13, showed he/she weighed 127 pounds. Record review of the resident's fall care plan updated on 9/13/13, showed the staff would encourage the resident to eat his/her bedtime snack daily to prevent low morning blood sugars. Record review of the resident's physician's orders [REDACTED]. - The resident was to receive a consistent carbohydrates pureed large portions diet with a Boost supplement. - A physician's orders [REDACTED]. - A physician's orders [REDACTED]. to include nectar thickened liquids. - A physician's orders [REDACTED]. - A physician's orders [REDACTED]. - A physician's orders [REDACTED]. - A physician's orders [REDACTED].M. for treatment of [REDACTED]. - A physician's orders [REDACTED]. - A handwritten physician's orders [REDACTED]. - A handwritten physician's orders [REDACTED]. - A handwritten physician's orders [REDACTED]. to include nectar thickened liquids. - A hand written physician's orders [REDACTED]. Record review of the resident's MAR indicated [REDACTED]. The documentation by the staff did not reflect how much of the supplement the resident consumed. Record review of the resident's last dietary note from the RD dated 9/19/13, showed: - His/her weight was stable, and - No documentation of any note completed by the RD after 9/19/13. Record review of the resident's discharge assessment with return anticipated dated 9/22/13, showed he/she weighed of 121 pounds (a six pound weight loss and a 4.7% loss of body weight in 16 days). Record review of the resident's nurse's note dated 9/25/13 at 12:00 P.M., showed he/she weighed 127 pounds, remained on a pureed with thin regular liquids, and no other new interventions were noted. Record review of the facility's Weight Meeting note dated 9/25/13, showed the resident: - Weighed 127 pounds. - Had a recent hospitalization with IV fluids. - Would be monitored weekly. - Had a six pound weight discrepancy in three days, with no documentation of a reweigh. Record review of the resident's nurse's note dated 9/26/13, showed: - The staff reviewed the resident's plan of care for weights. - The resident had a weight change of 121 pounds to 127 pounds from discharge to the hospital to readmission to the facility. - The resident received IV fluids at the hospital. - The resident's weights would continue to be monitored weekly. - His/her care plan was appropriate at this time. - No documentation of the physician, RD or the family being notified of his/her weight loss. - No new interventions were noted. Record review of the resident's Monthly Summary dated 9/28/13, showed he/she: - Was dependent upon staff for eating and drinking. - Received a pureed diet. - Received a mechanically altered diet. - Received a dietary supplement between meals. - Had no teeth. - Was dependent upon staff for all oral care. - Was in a Geri-chair (a special reclining chair). Record review of blood work performed on 9/28/13, showed he/she had: - Normal total protein level of 7.2 (a test that measures the total amount of two classes of proteins found in the fluid portion of your blood). - A low [MEDICATION NAME] level (measures the amount of a protein made by the liver in the clear liquid portion of the blood) at 3.1 (normal = 3.5 - 4.8). Record review of the resident's telephone order dated 9/30/13, showed a physician's orders [REDACTED]. Record review of the resident's discharge assessment with return anticipated dated 9/30/13, showed he/she weighed 127 pounds. Record review of the resident's Speech Therapy Initial Treatment Plan for Rehabilitation from 9/30/13 through 10/25/13, showed: - The resident was to receive skilled Speech Therapy three times a week for four weeks as a medical necessity to increase his/her swallowing competence. - The resident was recently hospitalized for [REDACTED]. - The nursing staff reported the resident was unable to swallow thin liquids. - His/her current diet included pureed consistency, large portions and consistent carbohydrates with thick liquids. - He/she would be at significant risk of aspiration, aspiration pneumonia, [MEDICAL CONDITION] and dehydration without skilled Speech Therapy intervention for dysphagia. - The resident refused to follow directions for oral motor exercises. - The resident had a wet voice and weak cough noted following thin liquids. - The resident showed no indication of a wet voice or cough following nectar thickened liquids. - The resident was dependent upon nursing staff for feeding. - A recommendation to change his/her diet to pureed consistency, large portions, and consistent carbohydrates with nectar thickened liquids. Record review of the resident's nurse's note dated 10/3/13 at 4:00 P.M. showed the resident readmitted to the facility with an order for [REDACTED]. Record review of the facility's Weight Meeting note dated the second week of October 2013, showed he/she: - Was readmitted from the hospital on [DATE]. - Had a weight of 128 pounds. - Had a weight of 121.2 pounds on 10/7/13. - Had received several liters of fluid while in the hospital related to [MEDICAL CONDITION]. - Would be monitored by staff. - Had no documentation of new interventions addressing his/her weight loss. - Had no documentation of contact with the physician, RD and family regarding his/her weight loss. - Had no documentation of being reweighed. Record review of the resident's nutritional status care plan updated on 10/3/13, showed staff was to obtain weekly weights related to readmit after his/her hospital stay. Record review of the resident's nurse's note dated 10/4/13 at: - 1:30 P.M., showed the resident was fed by staff. The resident's appetite at breakfast was poor and his/her appetite at lunch was fair. The resident continued with thickened liquids, with no documentation of whether the liquids were to be thickened to a nectar, honey or pudding consistency. - 7:00 P.M. showed the resident was fed by staff, ate 100% of his/her meal, and had a fluid intake of 720 cubic centimeters (cc) of nectar thickened fluids. Record review of the resident's Dietary Intake Record for 10/4/13, showed he/she: - Consumed nothing for breakfast. - Consumed 25% of his/her lunch and drank 180 cc of his/her fluids. - Consumed 75% of his/her dinner and drank 480 cc of his/her fluids. Record review of the resident's nurse's note dated 10/5/13 at: - 10:00 A.M., showed the resident was up in a Geri-chair for breakfast but refused to eat. - 1:00 P.M., showed the resident continued to refuse to eat, and after a few bites clamped his/her mouth shut. - 5:00 P.M., showed he/she was fed by staff and consumed approximately 10% of his/her meal and approximately 50% of the Glucerna supplement. Record review of the resident's Dietary Intake Record for 10/5/13, showed he/she: - Refused his/her breakfast. - Consumed one bite of food and one sip of fluid for lunch. - Consumed 75% of his/her dinner and drank 480 cc of his/her fluids. Record review of the resident's nurse's note dated 10/6/13 at: - 9:00 A.M., showed staff attempted to feed him/her but he/she would not open his/her mouth to eat. - 1:00 P.M., showed "what food is gotten in mouth remains there. Resident not swallowing." - 1:30 P.M., showed he/she was not eating or drinking anything, and staff would continue to encourage PO (my mouth) intake. - 9:00 P.M., showed the resident ate 100% of his/her meal and drank 720 cc of his/her thickened fluids. Record review of the resident's Dietary Intake Record for 10/6/13, showed he/she: - Consumed four bites of food and two sips of fluids for breakfast. - Consumed 25% of his/her lunch and the amount of fluid was illegible. - Consumed 100% of his/her dinner and drank 480 cc of his/her fluids. Record review of the resident's nurse's note dated 10/7/13 at: - 7:00 A.M. and 8:00 A.M., showed the resident consumed 100% of the morning meal with staff assistance. Record review of the resident's Dietary Intake Record for 10/7/13 showed he/she: - Consumed 100% of his/her breakfast and drank 720 cc of his/her fluids. - Consumed 100% of his/her lunch and drank 600 cc of his/her fluids. - Consumed 100% of his/her dinner and drank 480 cc of his/her fluids. Record review of the resident's Speech Therapy weekly summary dated 10/7/13, showed his/her baseline diet was pureed with large portions and thin liquids, and was changed to include nectar thickened liquids. Record review of the resident's nurse's note dated 10/8/13 at 1:15 P.M., showed the resident consumed 75% of the morning meal with staff assistance. Record review of the resident's Dietary Intake Record for 10/8/13, showed he/she: - Consumed 100% of his/her breakfast and drank 600 cc of his/her fluids. - Consumed 100% of his/her lunch and drank 600 cc of his/her fluids. - Consumed 75% of his/her dinner and drank 480 cc of his/her fluids. Record review of the resident's nurse's note dated 10/8/13 at 9:00 P.M., showed the resident ate 100% of his/her meals and drank 1,080 cc of fluids. Record review of the resident's nurse's note dated 10/9/13 at 1:15 P.M., showed the resident's appetite and fluid intake were good. Record review of the resident's Dietary Intake Record for 10/9/13, showed he/she: - Consumed 100% of his/her breakfast and drank 600 cc of his/her fluids. - Consumed 100% of his/her lunch and drank 600 cc of his/her fluids. - Consumed 50% of his/her dinner and drank 480 cc of his/her fluids. Record review of the resident's nurse's note dated 10/10/13 at 10:00 P.M., showed he/she refused supper and refused to drink more than 180 cc of his/her fluids. Record review of the resident's Dietary Intake Record for 10/10/13, showed he/she: - Consumed 75% of his/her breakfast and drank 480 cc of his/her fluids. - Consumed 25% of his/her lunch and the amount of fluid was illegible. - Consumed 25% of his/her dinner and drank 300 cc of his/her fluids. Record review of the resident's nurse's note dated 10/12/13 at 1:00 P.M., showed the resident's parents were present and feeding the resident his/her lunch. The documentation did not indicate how much the resident consumed of his/her lunch. Record review of the resident's nurse's note dated 10/12/13 at: - 2:30 P.M., showed the resident was pocketing food and not eating well according to his/her parent's, and staff would attempt offering ice cream and extra snacks brought in by his/her parents. - 5:30 P.M., showed staff continued to feed the resident and his/her appetite was good at this time. Extra fluids were also given to the resident. Record review of the resident's Dietary Intake Record for 10/12/13, showed he/she: - Consumed 75% of his/her breakfast and drank 480 cc of his/her fluids. - Consumed 25% of his/her lunch and drank 400 cc of his/her fluids. - Consumed 25% of his/her dinner and drank 300 cc of his/her fluids. Record review of the resident's Pre-Restraining Assessment updated on 10/15/13, showed the resident's safety issue had been resolved and the resident was using the Geri-chair without the table for positioning, comfort and correct body alignment. This enabled the resident to socialize and be up for meals. The device did not prevent the resident from performing movement otherwise capable and does not restrict the resident's access to his/her body. Record review of the resident's Device Decision Guide dated 10/15/13, showed: - The device had an enabling effect. - The device was used for positioning, comfort, correct body alignment, socialization and being up for meals. Record review of the resident's nutritional status care plan updated on 10/16/13, showed: - He/she had a weight loss. - The resident refused to eat at times. - The resident spits food out. - Staff was instructed to continue with supplements and weight monitoring. - The care plan did not provide instructions on what the staff was to do when the resident refused to eat his/her meals. Record review of the resident's POS dated 10/16/13 through 11/15/13, showed: - The resident was to receive a consistent carbohydrates pureed large portions diet with Boost and nectar thickened liquids. - A physician's orders [REDACTED]. - A physician's orders [REDACTED].M. (noon) for treatment of [REDACTED]. - A physician's orders [REDACTED]. - A physician's orders [REDACTED]. - A physician's orders [REDACTED]. - A physician's orders [REDACTED]. Record review of the facility's Weight Meeting note dated 10/16/13, showed he/she: - Had a current weight of 112.4 pounds (an 8.8 pound weight loss, or 7.2% loss of body weight in 13 days) - Lost weight and had poor intake. - Refused to eat at times or spits food out. - Continued receiving Boost glucose with meals and at bedtime. - Was offered in between meal snacks. - Would have his/her weight monitored next week for further change. - Had no documentation of new interventions. - Had no documentation staff notified his/her physician, RD and family. - Had no documentation of a reweigh. Record review of the resident's Vital Signs and Weight Record showed: - The resident weighed 110.2 pounds on 10/22/13 (a 16.8 pound weight loss from September 2013 to 10/22/13, a 13% weight loss in 30 and 180 days, and a 2.2 pound weight loss in six days. Record review of the facility's Weight Meeting note dated 10/22/13, showed he/she: - Had a weight of 110.2 pounds. - Had a 2.2 pound weight loss from the previous week. - Had a meal intake from 25% to 75%. - Continued to receive Boost with meals and at bedtime, and staff contacted the resident's physician for further interventions, and were awaiting a return call. - Had no documentation of new interventions. - Had no documentation his/her family or the RD were notified of his/her weight loss. Record review of the resident's nutritional status care plan updated 10/22/13, showed: - He/she had a weight loss of 18 pounds since readmit. - The family and physician were notified. - Orders received to consult with another physician for a percutaneous endoscopic gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) tube placement related to weight loss. Record review of the resident's nurse's note dated 10/22/13 at: - 1:45 P.M., showed the resident's parent was called and notified of a significant weight loss of 17.8 pounds since admission on 10/3/13, and possible interventions of a feeding tube or an evaluation for hospice (end of life care) were discussed. The resident's parent stated hospice was not something he/she wished to talk about at this time, however, he/she would talk with his/her spouse regarding the feeding tube and would let the facility know. The resident was given several liters of fluid in the hospital related to [MEDICAL CONDITION] (an electrolyte disturbance that is defined by an elevated sodium level in the blood; that is generally not caused by an excess of sodium, but rather by a relative deficit of free water in the body. For this reason, [MEDICAL CONDITION] is often synonymous with the less precise term, dehydration) and he/she refused some meals. The physician was called for further interventions - awaiting return call at this time. - 3:00 P.M., showed the resident's parent called and stated he/she would like the resident to be placed on a feeding tube as soon as possible, and staff were awaiting further instruction from the physician at this time. - 6:00 P.M., showed the staff received a telephone order from the physician to refer the resident to another physician for feeding tube placement. The resident's parent was called and informed of the order. The resident ate 100% of his/her meal and drank 960 cc of fluids at meal time. Record review of the resident's Dietary Intake Record for 10/22/13, showed the resident: - Consumed 50% of his/her breakfast and drank 480 cc of his/her fluids. - Consumed 100% of his/her lunch and drank 480 cc of his/her fluids. - Consumed 100% of his/her dinner and drank 480 cc of his/her fluids. Record review of the resident's POS dated 10/16/13 through 11/15/13, showed: - A handwritten physician's telephone order dated 10/22/13, to refer the resident to another physician for a feeding tube placement related to weight loss. - A handwritten physician's telephone order dated 10/23/13 to transport the resident to the hospital emergency room for evaluation and treatment of [REDACTED]. Record review of the resident's nurse's note dated 10/23/13 at: - 11:00 A.M., showed the resident had an appointment on 10/28/13 at 11:30 A.M. for consult for a gastrostomy tube ([DEVICE] - a tube that is placed directly into the stomach for long term administration of food, fluids, and medications) placement. The resident's guardians were notified. Record review of a change in condition report dated 10/23/13, showed the resident's guardians were in to visit due to severe weight loss and the resident pocketing food and not eating, and requested the resident to be sent to the emergency room for evaluation. Record review of the resident's discharge assessment with return anticipated dated 10/23/13, showed he/she weighted 110 pounds. Record review of the resident's nurse's note dated 10/24/13 at 3:00 P.M., showed the facility staff contacted the hospital for an update on the resident's condition. The nurse reported the resident had refused both meals and IV fluids were continued. Electrolytes looked better. The nurse reported that a PEG may not be placed due to all other labs and condition within normal limits. Record review of the resident's Dietary Intake Record for 10/1/13 through lunch on 10/30/13, showed he/she: - Consumed 100% of 14 out of 89 meals or 16%. - Consumed 75% of 12 out of 89 meals or 13%. - Consumed 50% of 11 out of 89 meals or 12%. - Consumed 25% or less of 17 out of 89 meals or 19%. - The resident refused 6 out of 89 meals or 7%. - The resident refused 22 out of 89 snacks or 25%. - The resident was in the hospital for 29 meals and snacks or 33% of the time. Record review of the resident's Monthly Summary with an illegible dat