Every finding on record at Arbor View Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to perform a proper transfer from the chair to the bed for one resident (Resident #1), of four sampled residents. The facility census was 83.The facility did not provide a safe transfer policy and procedure.Observation of a video, dated 09/27/2025, from a camera in Resident #1's room, showed:At 8:08 P.M, Certified Nurse Aid (CNA) entered the resident's room and removed the foot pedals attached to the Geri-chair Resident #1 reclined in. Resident #1 begins to scream, kick out at the CNA;CNA A leaves and comes back with Certified Medication Technician (CMT) B;The resident begins to scream;As the resident continues to scream and thrash his/her extremities, CNA A lifts the resident by the back of the resident's pants while CMT B holds the resident's arms together, lifting the resident from the Geri-chair to directly over the bed. CNA A and CMT B release the resident quickly into the bed.Review of Resident #1's admission assessment showed:The resident was admitted on [DATE];Diagnoses included Traumatic Brain Injury (TBI) - (an injury to the brain causing multiple issues with cognition and the ability to process information), cognitive communication deficit (an inability to communicate and understand what is being communicated), muscle weakness, Chronic Kidney Disease (CKD), (a progressive disease in which the kidney loses the ability to filter waste), Aphasia (an inability to speak), depression, Schizophrenia (a mental disease that may lead to hallucination and delusions, and Post Traumatic Stress Disorder (PTSD) - (a mental health condition that develops after experiencing a traumatic event).Review of the resident quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 09/23/25, showed:The resident has difficulty understanding and being understood;The resident is total assist with all ADLs;The resident is cognitively intact;Review of the resident's Care Plan, last updated 08/25/25, showed:The resident is totally dependent upon staff for all ADLs;Allow the resident time to verbalize feelings, perceptions and fears with each interaction;When conflict arises, remove to a calm safe environment and allow to vent and share;Do not push the resident, step out and contact the Guardian/sister;There was no information on requirements for transfers. During an interview on 10/20/25 at 12:00 P.M., the Administrator (ADM) said Resident #1 notified his/her guardian and told him/her there had been an incident on 09/27/2025 The Guardian then called the ADM and requested to meet at the facility and watch the video. The ADM and guardian viewed the video and agreed no abuse occurred, but determined that the resident had been upset and unable to calm. The ADM said they did not do a proper transfer and did not follow the care plan.During an interview on 10/20/25 at 2:00 P.M., Licensed Practical Nurse (LPN) C said CNAs are trained to walk away if a resident is upset and unable to redirect. LPN C did not know why CNA A did not walk away.During an interview on 10/20/25 at 2:45 PM, the Director of Nurses (DON), said CNAs should use the appropriate technique for transferring the residents. She would expect a staff member to use a gait belt on a one person assist and the transfer was performed in an unsafe manner. During an interview on 10/20/25 at 3:10 P.M., CMT B said CNA A came to the hallway and asked for assistance putting Resident #1 to bed. Upon entering the room, the resident was obviously upset, and they are trained to walk away. CMT B was not sure why CNA A did not walk out and come back later, but continued with transferring the resident from the chair to the bed. CMT B said he/she was not going to assist, but then felt he/she had to step in to prevent injury to the resident because CNA A did not have a gait belt. They are trained to always use a gait belt for transferring. During an interview on 10/20/25 at 7:10 P.M., CNA A said they were told if the resident was upset and would not calm down to put the resident in the bed. CNA A said the resident had been in the chair for more than 2 hours and that is why he/she had to go to bed. The CNA A said she never uses a gait belt when she transfers Resident #1 and he/she normally does not fight her during transferring.Complaints MO2647279, 2646309

Based on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchens, which prepared food for all residents. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 86. Review of the facility policy titled, Qualified Dietary Staff, dated 10/01/23, showed: -The dietary/ food services department is staffed by dietary/ food and nutrition services personnel to meet the needs of the residents and the skilled Dietitian will help oversee the dietary/ food and nutrition services in the facility; -The Dietitian or nutrition professional may be full time or part time consultant or an employee, depending on the current requirements of the facility; -The qualifications of the Dietitian will include a bachelor's degree from a regionally accredited college with successful completion of a nationally accredited program in nutrition or dietetics, completion of at least 900 hours of dietetics practice supervised by a registered dietitian or nutritional professional, or certification as a dietitian or nutritional professional by the state services are being performed; -If a dietitian is not employed full time, then a director of food service management will be designated and will be a certified dietary manager, certified food service manager, be nationally certified in food service management and safety, or have an associate's degree or higher in food service management and meet any state requirements and receive frequently scheduled consultations from a qualified dietitian or nutritional professional. Review of the Dietary Manager (DM) showed he/ she received a certificate of training for completing the food handler essentials course, dated 12/13/24, from StateFoodSafety. Review of the facility's current employee list, undated, showed a hire date of 09/30/24 for the Dietary Manager (DM). During an interview on 03/30/25 at 11:30 A.M., the DM said he/she started the role of DM in November of 2024. The previous facility company had worked it out that they would pay for him/her to become certified but then have not done anything yet and do not know if they will now that the facility had a new company in charge. If the facility would help him/her get certified, then he/she would have no problem taking the classes as he/she was more than willing and wanting to become certified. During an interview on 03/31/25 at 5:00 P.M., the Registered Dietician (RD) said she signed a contract to start yesterday 03/30/25 as the RD. She had worked here in the past and does not think they have had a RD for months. She talked to the DM and said he/she is not certified yet but hopeful that the facility would be helping that problem soon. During an interview on 04/02/25 at 3:05 P.M., the Administrator would expect the DM to be certified and qualified. The facility had not had an RD since august 2024.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This deficiency had the potential to affect all residents. The facility census was 86. The facility did not provide a RN coverage policy. Review of the facility's Facility Assessment Tool, dated 4/10/24, showed: - The facility required five licensed nurses providing direct care for day shift, which included at least one RN for the day shift. Review of the Nursing Schedules and the Daily Nursing Staffing Sheets for 01/01/25 - 03/31/25, showed: - No RN coverage for eight consecutive hours on 01/06/25, 01/23/25, 01/24/25, 01/27/25, 01/30/25, 01/31/25, 02/03/25, 02/06/25, and 02/07/25; - No RN coverage for eight consecutive worked for nine days out of 90 days. During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect the facility to have an RN working eight consecutive hours daily seven days a week.

Based on interview and observation, the facility failed to ensure bedtime snacks had been offered to all residents at bedtime. This had the potential to affect all residents in the facility. The facility census was 86. Review of the facility policy titled, Nutrition and Hydration Assistance, dated 04/01/22, showed: - Additional sources of nourishment should/may include provision of snacks; - Staff will make provision for appropriate snacks as requested or ordered by the physician. Review of the facility policy titled, Provide Diet to Meets Needs of Each Resident, dated 04/01/22, showed: - The facility would provide the services of a Registered Dietitian Nutritionalist or designee to participate in the interdisciplinary care planning team and assure that the nutritional needs of individuals living in the facility are met. Review of the meal times, as provided by the facility, showed breakfast was served at 7:30 A.M., lunch was served at 11:30 A.M., and dinner was served at 4:30 P.M. with a 16 hour gap between each dinner and breakfast. During group interview on 03/31/25 at 1:20 P.M., Residents #1, #17, #33, and #35 said snacks were kept at the nurse's station at night. If you were not able to physically go up and ask for a snack, then you did not get one. Staff did not round on the residents to see if they wanted a snack. Observation on 03/31/25 from 10:15 P.M. through 11:30 P.M., showed: - A snack cart kept by the nurse's station; - The only residents that received snacks were the residents who physically came to the nurse's station to ask for one; - Staff did not round to pass or offer the residents a snack. During an interview on 04/02/25 at 11:30 A.M., the Dietary Manager said snacks were left each night behind the nurse's station for anyone who wanted them, and did not think each resident was supposed to be offered one. He/She did not think staff rounded on each resident to offer them a snack. During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect each resident to be offered a snack at night.

Based on interview and record review, the facility failed to provide the nurse aides (NAs) an annual individual performance review or evaluation and failed to provide regular in-service education based on these reviews for two certified nursing assistants (CNAs) (CNA A and CNA B). The facility census was 86. Review of the Facility Assessment Tool, dated 04/10/24, showed: - A facility must develop, implement, and maintain an effective training program for all new and existing staff; - In-service training must address areas of weakness as determined in NA's performance reviews; - In-service training may address the special needs of residents as determined by the facility staff. 1. Review of CNA A's employee file showed: - A hire date of 09/15/08; - No documentation of an annual performance review or evaluation; - No documentation of annual in-service training based on the annual performance review or evaluation for the time frame from 09/15/23 through 09/15/24. 2. Review of CNA B's employee file showed: - A hire date of 06/10/21; - No documentation of an annual performance review or evaluation; - No documentation of annual in-service training based on the annual performance review or evaluation for the time frame from 06/10/23 through 06/10/24. During an interview on 04/02/25 at 3:05 P.M., the Administrator and Director of Nursing (DON) said they would expect CNAs receiving in-services to have at least 12 hours of training annually and for annual performance reviews to be done yearly. The DON and Assistant Director of Nursing (ADON) would be responsible for the annual performance reviews. There had been a lot of staff changes recently and the performance reviews were not done.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide (NA) in-service education per year. This affected two Certified Nurse Assistants (CNAs) (CNA A and CNA B) out of two sampled CNAs. The facility's census was 86. The facility did not provide a policy regarding annual NA education. 1. Review of CNA A's employee file showed: - A hire date of 09/15/08; - A total of 2 hours 50 minutes of annual in-service training completed for the time frame of September 2023 through September 2024; - The facility failed to provide at least 12 hours of in-service education for September 2023 through September 2024. 2. Review of CNA B's employee file showed: - A hire date of 06/10/21; - A total of 5 hours 45 minutes of annual in-service training for June 2023 through June 2024; - The facility failed to provide at least 12 hours of in-service education for June 2023 through June 2024. During an interview on 04/02/25 at 3:05 P.M., the Administrator and Director of Nursing (DON) said they would expect CNAs to receive at least 12 hours of training annually.

Based on observation and interview, the facility failed to provide a safe and functional environment for the residents by allowing items to be stored on top of the overbed light fixtures for residents in three rooms. Storing items on the overbed light creates a hazard of the items falling on the resident below, and does not utilize the light fixtures as intended. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 86. The facility did not provide a policy regarding storing items on the overbed light fixtures. 1. Observation on 03/03/25 at 2:39 P.M., of Room B 5-1 showed a large picture in a wooden frame on the light above the resident's bed. 2. Observation on 03/31/25 at 11:09 P.M., of Room C 8-2 showed three medium sized stuffed animals, two medium glass figurines, and two small plastic animals on the light fixture above the bed on the left side of the room. 3. Observation on 04/01/25 at 1:00 P.M., of Room C 10-2 showed two large stuffed animals and three medium sized stuffed animals on the light fixture above the bed on the right side. 4. Observation on 04/01/25 at 4:30 P.M., of Room A 6-1 showed one medium stuffed animal and one boxed figurine resting on the light fixture above the bed. During an interview on 04/02/25 at 1:15 P.M., the Maintenance Director said he/she could purchase shelves for the residents' personal belongings. The light fixtures above the bed should be free of clutter for safety reasons. During an interview on 04/02/25 at 1:45 P.M., the Administrator said she would expect light fixtures to be free from items due to a possible fire hazard. 49150

Based on observations, interviews, and record review, the facility failed to maintain essential equipment in a safe and operable working condition. This deficient practice had the potential to affect all residents. The facility census was 86. The facility did not provide a policy for equipment maintenance. Review of the following invoices showed: - On 12/16/24, an invoice for a laundry washer was serviced but no details of actions taken; - On 12/30/24, an invoice for a laundry washer was serviced with a valve and hose replaced. Observation on 04/02/25 at 9:40 A.M. of the laundry room, showed: - Three commercial laundry washing machines; - Two of the machines were covered in dust and debris and not in use; - The third machine was running a load of laundry. On top of the third machine was a plastic cup marked with a black line which indicated the fill line for bleach to pour into each load of laundry. During an interview on 04/02/25 at 9:40 A.M., Laundry Aide (LA) K said he/she had been a laundry employee for over a year and in that time, only one of the three washing machines had worked. The one washer that did work had broken down several times and each time the residents had to go two days or more without clothes getting washed. The working washer broke down every couple of months, and was probably due any time. LA K said they did at least 50 loads of laundry a day, which took it's toll on the one machine. At this moment, the one working machine did not get any hot water for some reason, and the detergent dispensing equipment was not working as well. LA K said for the time being, they were manually adding detergent and bleach to each load. When the only washer did break down, arrangements were made to take the laundry to a laundry mat. Arranging to get all the laundry to and from the laundry mat was complicated and delayed the process time significantly. LA K said the facility administration/company owners had said there was a quote to get a washer a while back, but he/she did not think it would happen. During an interview on 04/02/25 at 10:10 A.M., the Maintenance Director (MD) said there was a quote for a commercial laundry washing machine, but did not know where the company was in the process of actually getting one. He/She was aware of the hot water problem, and hoped the latest filter replacement would help get the hot water to the laundry During an interview on 04/02/25 at 2:00 P.M., the Administrator said the backup plan for when the laundry machine went out would be to go to the laundromat. She would expect the laundry equipment to be in proper working conditions and function appropriately.

Based on observation, interview, and record review, the facility failed to maintain or implement a policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by food delivery services, family, and/or other visitors, to ensure the food's safe and sanitary handling, storage, and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 86. Review of the facility form titled, Resident Responsibilities and Rules, Appendix 4, undated, showed: - Food may be brought into our facility; - It must be kept in airtight containers; - Because of diet restrictions, nursing staff should be made aware of any food brought into the facility; - Should food need to be monitored, it will be kept in a designated room; - The policy did not address how facility staff will assist the resident in accessing and consuming the food brought in by visitors in a way that either separates or easily distinguishes from the facility food. Observation on 03/31/25 at 10:45 P.M., a refrigerator located next to ice machine behind the nurse's station had dated resident snacks provided by the facility and several unmarked and undated food items in multiple types of bags and containers in it not provided by the facility. During an interview on 03/31/25 at 10:30 P.M., [NAME] G said snacks were kept behind the nurse's station and residents had access to it. All items in the refrigerator should be labeled with a date and name. During an interview on 04/02/25 at 2:30 P.M., the Dietary Manager (DM) said he/she did not know if the facility had any policies about outside food brought in for the residents. He/She had not had any food brought into the kitchen that was a resident's property. During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect to have a policy regarding the use and storage of foods brought to residents by family members or other visitors to ensure safe and sanitary storage, handling, and consumption.

Based on observation, interview, and record review, the facility failed to create an environment that was respectful of the rights of each resident to make choices about aspects of their lives that were significant by providing a bathing schedule based on staff preference and not resident preference for one resident (Resident #1) and by failing to honor one resident's (Resident #24) preference to be shaved daily out of 18 sampled residents . The facility's census was 86. Review of the facility's policy titled, Resident Rights, Dignity and Visitation Rights, dated 04/01/22, showed: - It will be the policy of this facility that employees shall treat residents with kindness, respect, and dignity. The facility promotes the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems, and cognition limits) in the exercise of these rights. The facility will ensure the resident can exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability; - Residents are entitled to exercise their rights and privileges to the fullest extent possible; - The facility will make the effort to assist each resident in exercising his/her rights to assure the resident is always treated with respect, kindness, and dignity; providing care that is comfortable and consistent with his/her normal life habits; observing resident's choices whenever able; - The facility will promote care for residents in a manner and in an environment that maintains or enhances dignity and respect in recognition of his/her individuality, preferences, activities, pursuits, goals, and desires; - The facility will provide for residents and reception of services with reasonable accommodation of resident needs and preferences except when to do so would endanger the health of safety of the resident or other residents; - The right to participate in the development and implementation of his/her person-centered plan of care, including but not limited to: the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process; the right to request meetings and the right to request revisions to the person-centered plan of care; the right to participate in establishing the expected goals and outcomes of care; the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care; the right to be informed, in advance, of changes to the plan of care; the right to receive the services and/or items included in the plan of care; the right to see the care plan, including the right to sign after significant changes to the plan of care; - The facility will encourage and assist residents to dress in their own clothes appropriate to the individual choices of the resident; 1. Review of Resident #1's medical record showed: - admitted [DATE]; - Diagnoses of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in actives), pain in the left lower leg, non-pressure chronic ulcer of the left lower leg with the fat layer exposed (a sore that takes more than two weeks to heal), hypothyroidism (underactive thyroid disease), generalized anxiety disorder (mental health condition characterized by persistent and excessive worry and anxiety about a wide range of everyday events), and cellulitis (a common bacterial infection of the skin and underlying tissues). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated , 02/12/25, showed: - Cognitively intact; - Activities and preferences not completed; - Dependent on staff for assistance with personal hygiene and required substantial/maximal assistance with bathing and showering. Review of the resident's Skin Monitoring: Comprehensive Certified Nurse Assistant (CNA) Shower Review Sheets, dated February and March 2025, showed: - Resident refused shower/bath on 02/07/25, 02/11/25, 02/18/25, 03/04/25, 03/07/25, 03/11/25, 03/14/25, 03/19/25, 03/25/25, and 03/28/25; - Resident received a shower/bath on 02/25/25 and 03/21/25; - No documentation staff offered a shower/bath after the resident refused at a specific time/date. During an interview on 04/02/25 at 12:55 P.M., Resident #1 said staff asked him/her to shower at times when he/she was in pain or during activities. Activities were one of the few times he/she had to socialize with other residents. The staff would only ask the resident one time to shower/bathe and would document refused if the resident didn't want to right then. The staff didn't come back later at a more convenient time for the resident. 2. Review of Resident #24's medical record showed: - admitted [DATE]; - Diagnoses of unspecified injury at unspecified level of cervical spinal cord (injury to the neck); quadriplegia (paralysis); spinal muscular atrophy unspecified (deteriorating muscles); and contracture of the right shoulder, the right elbow and the right wrist (shortening and hardening of the muscles, tendons or other tissue). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Activities and preferences not completed; - Dependent on staff for assistance with personal hygiene, bathing, and showering. Observation on 03/30/25 at 11:32 A.M., 03/31/25 at 1:16 P.M., and 04/02/25 at 12:55 P.M., of the resident showed: - Whiskers/stubble on resident's chin. During an interview on 03/31/25 at 1:30 P.M. Resident #24's two roommates said they had to shave the resident because the staff won't shave him/her. During an interview on 04/02/25 at 1:21 P.M., Resident #24 said the staff would not shave him/her. Only times he/she was shaved was when his/her roommates did it. He/She preferred to keep a clean shaven chin daily and did not like it when he/she was not able to do so. During an interview on 04/02/25 at 1:30 P.M., the Administrator said she would expect residents to be able to have the right to make their own decisions regarding if they want to be shaved and when they were showered. 49150

Based on interview and record review, the facility failed to provide a final accounting of a resident's fund balance within 30 days to the individual or probate jurisdiction administering the resident's estate for one expired resident (Resident #87) out of one expired resident. The facility census was 86. The facility did not provide a policy regarding resident funds balance. Review of Resident #87's medical record showed: - The resident expired on [DATE]. Record of the facility maintained Trust Trial Balance, dated [DATE], showed: - Resident #87 with an account balance of $2,694. During an interview on [DATE] at 9:03 A.M., the Social Services Designee (SSD) said normally if someone passed away, their money would go towards any funeral home bills. If the resident had a financial power of attorney (POA), then they would get them a check for the balance and if not, they would send the money to the state. The facility tried to do this process within a week of a death. During an interview on [DATE] at 9:24 A.M., the Administrator said she would expect remaining resident funds to be sent to the appropriate party within 30 days. 49152

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. The facility failed to ensure that foods were kept covered while waiting to be served and had policies and procedures in place for food brought in from outside the facility. These practices had the potential to affect all residents who are served food from the kitchen. The facility census was 86. Review of the facility policy titled,Food Delivery and Storage, dated 10/01/23, showed: - It will be the policy of this facility that foods shall be received and stored in a manner that complies with safe food handling practices; - Dietary/Food Services, or other designated staff, will maintain clean food storage areas at all times; - Dry foods that are stored in bins will be removed from original packaging, labeled and dated. Such foods will be rotated using a first in - first out system; - All foods stored in the refrigerator or freezer will be covered, labeled, and dated. 1. Observation on 03/30/25 at 10:30 A.M., of the kitchen showed: - Pancakes, hashbrowns, and an open metal container of a brown substance in the freezer with no label or date on the contents; - Opened wrapped margarine, wrapped cut up onion, four metal pans not dated with two of them open and unlabeled, and two trays of red jello uncovered and not dated in the refrigerator; - Three unlabeled and undated tubs with cereal sat on cart outside the freezer; - Inside of the oven with brown/black debris and buildup with pieces of aluminum foil on the floor of the oven; - Stove top with all six burners with black/ brown debris and buildup; - One #10 can of beans and two #10 cans of sauerkraut commercial cans unlabeled; - A bag of sugar in a plastic tub with no date or label. 2. Observation on 03/30/25 from 11:30 A.M. - 12:28 P.M., showed: - Drink cart containing lunch drinks for the residents uncovered in the dining room; - Three different unknown residents self-poured coffee from the coffee container in the dining room with one of those residents coughing before pouring his/her drink; - One unknown resident in a wheelchair pushed him/herself to a cart with an orange drink picture on it in the dining room, poured his/her old drink out through the kitchen window with some of the liquid spilling on the trays, picked up the picture with the right hand, poured orange drink into the old container, and put the orange picture back on the cart. 3. Observation on 03/31/25 at 10:45 P.M., showed: - An ice machine behind the nurse's station in a room; - The outside of the ice machine was covered with brown and white substance; - An unknown resident walked into the room, grabbed the ice scoop with his/her bare hand, opened the ice machine door, scooped ice into cup in his/her left hand, and placed the scoop back in the container on the refrigerator located next to the ice machine. 4. Observation on 04/01/25 at 5:02 P.M., showed: - A kitchen cart in the dining room with four out of four trays of uncovered beverages. 5. Observation on 04/02/25 at 10:36 A.M., of the kitchen showed: - Pancakes, hashbrowns, and an open metal container of a brown substance in the freezer with no label or date on contents; - Opened wrapped margarine, wrapped cut up onion, four metal pans not dated with two of them open and unlabeled, and two trays of red jello uncovered and not dated in the refrigerator; - Three unlabeled and undated tubs with cereal sat on a cart outside the freezer; - Inside of the oven with brown/black debris and buildup with pieces of aluminum foil on the floor of oven; -Stove top with all six burners with black/ brown debris and buildup; - One #10 can of beans and two #10 cans of sauerkraut commercial cans unlabeled; - A bag of sugar in a plastic tub with no date or label; - One tub labeled powdered milk with an undated bag of salt inside; - One bag of white cream baking chips opened and undated. During an interview on 04/02/25 at 10:50 A.M., the Dietary Manager (DM) said he/she would expect everything in the refrigerator, freezer, and dry storage to be labeled and dated appropriately. He/ She would expect the kitchen equipment to be working correctly and cleaned after use. The stove top and oven could use a better cleaning and drinks should be covered when leaving the kitchen. The coffee was self-serve but did not know of anything for infection control for it but would look into it. During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect food products to be labeled and stored appropriately, food and drinks to be covered when exiting the kitchen to go to the resident room for resident use, and for kitchen equipment to be clean and working correctly.

Based on observation, interview, and record review, the facility failed to monitor and keep one resident's (Resident #54) equipment in good, working order. The facility also failed to provide a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 86. The facility did not provide a policy regarding a safe, clean, comfortable, and homelike environment. The facility did not provide a policy regarding maintenance of residents' equipment. 1. Observation on 03/30/25 at 10:56 A.M., of Room C9 showed: - A window unit below the window with drywall placed around the top and both sides that did not completely in case the window unit. There were open areas to the top and right side of the unit with light from the outside that showed around the top of the unit. There was insulation pushed in an open area directly above the window unit to cover a gap from the window unit to the drywall nailed in place around the window unit. The top opening was approximately 32 inches (in) by 1 in and the right-side opening was approximately 20 in by 0.5 in. 2. Observation of the dining room on 03/30/25 at 11:30 A.M., showed: - The wall beneath the kitchen windows with red, green, and brown splatters on it; - Approximately two feet of baseboard trim missing underneath the dining room kitchen window; - Approximately 6 inches of baseboard trip missing next to the left exit door; - Three ceiling tiles with dark brown/black substance close to the left exit door. 3. Observation on 03/30/25 at 12:30 P.M., of Room B10 showed: - Four holes in the wall above the bed next to the door; - Paint chipping off the wall over the bed next to the window; - Black scuff marks along the wall and bathroom door; - The window unit missing vents inhibiting the resident's ability to control the direction of the air flow; - The closet door broken and unable to stay closed; - The bathroom door latch/handle broken and unable to stay closed. During an interview on 03/30/25 at 12:30 P.M. the resident in Room B10 said he/she was unhappy with his/her room. The bathroom door handle had been broken for a long time and would not close or latch. He/She purchased some velcro tape to put on the door, so it would stay closed. However, since the door did not latch, there was no way to ensure his/her privacy. He/She had to do the same thing to the closet door because it was broken and would not stay closed. The room needed to be repainted due to all the black scuff marks and the paint chipped off the walls. The air conditioner also needed to be fixed or replaced. It bothered him/her that the vents were missing, because without the vents, the direction of the air flow couldn't be controlled. 4. Observation on 03/30/25 at 2:07 P.M., of Resident # 54's wheelchair showed: - Both arms of the wheelchair with cracked and ripped vinyl; - The right wheelchair arm with pieces of peeling duct tape around the end of the ripped area. During an interview on 03/30/25 at 2:07 P.M., Resident # 54 pointed to the arms of his/her wheelchair and said the cracked and ripped vinyl bothered him/her and wanted it replaced or fixed. 5. Observation on 03/30/25 at 2:31 P.M., of Room B8 showed: - A brown area on the ceiling in front of the window next to the privacy current railing approximately 12 inches wide; - The window unit with missing vents; - The drywall of the window ledge chipped and crumbling into pieces; - The bathroom door handle/latch broken. During an interview on 03/30/25 at 2:31 P.M., the resident in Room B8 said he/she was upset the bathroom door handle was broken and he/she had no way to ensure privacy when using the bathroom. It was embarrassing when someone would accidentally open the door. He/She was not happy with the way the area around the window unit was. The window seal had been messed up for a long time and the air unit had been missing the vents for a long time. 6. Observation on 03/30/25 at 2:36 P.M., of Room B6 showed: - The right edge of the curtain hung loose from the window; - The closet door was missing; - The air unit was missing vents. 7. Observation on 03/30/25 at 3:24 P.M. of Room D8 showed: - Paint peeled off the wall around the air conditioning unit; - The ceiling vent in the bathroom covered in dust. 8. Observation on 03/31/25 at 8:14 A.M., of Room B3 showed: - The closet door was missing; - The window seal and area around the air unit with chipped drywall, marks, and exposed unpainted areas with gray caulking. During an interview on 04/02/25 at 10:30 A.M., the Maintenance Director said that he/she was unaware of the window unit in Room C9 had any openings to the drywall around the window unit. During an interview on 04/02/25 at 10:40 A.M., the Administrator said that she would expect window units to be properly placed and not be able to see daylight from inside a resident's room with gaps around the unit in the drywall. During an interview on 04/02/25 at 1:45 P.M., the Administrator said she would expect the facility to have a homelike environment and things to be repaired as needed. There was a maintenance log book that anyone could write things that need to be repaired. Normally the repair time should be within a few days even if it's something that had parts that need to be ordered for the repairs. 49150 49152

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, for five residents (Residents #11, #12, #38, #46, and #59) out of 18 sampled residents and one resident (Resident #44) outside the sample. The facility's census was 86. Review of the facility policy titled, Transfer and Discharge, dated 04/01/22, showed: - It is the policy of this facility to provide appropriate transfer and discharge services, documentation that will be included in the medical record, and who is responsible for making the documentation. The facility will allow for sufficient preparation and orientation by informing the resident where he/she is going to take steps to minimize anxiety; - The Notice of Transfer or Discharge should be made by the facility at least 30 days before the resident is transferred or discharged except under the following circumstances and the Notice must be made as soon as practicable before transfer or discharge when: the safety of individuals in the facility would be endangered; the health of individuals in the facility would be endangered; the resident's health improves sufficiently to allow a more immediate transfer or discharge; an immediate transfer or discharge is required by the resident's urgent medical needs; or a resident has not resided in the facility for 30 days; - When a change in condition or required transfer to the hospital or other higher level of care is determined, the facility should obtain appropriate transfer orders from the physician; - Documentation of the change of condition or required transfer should be reflected in the medical record; - Appropriate documentation and forms will be sent to the receiving facility/accompany the resident during transport and attempt to have them signed by the resident/resident representative should be made. The forms can include such items as the Bed Hold policy, Transfer Discharge Notification, listing of current medications/treatments, face sheet, and other forms that may be appropriate if activated; - Notification of the resident's representative should be denoted in the medical record as is appropriate per the resident's capacity and choice, if applicable; - In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative, and will also send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman; - If the resident transfers to another facility or the community from the hospital, the facility may assist, with the request of the resident's representative, with provision of care assistance set up; - Details regarding the transfer from the facility should be documented in the clinical record. 1. Review of Resident #11's medical record showed: - admitted on [DATE] ; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers. 2. Review of Resident #12's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers. 3. Review of Resident #38's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfer. 4. Review of Resident #44's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers. 5. Review of Resident #46's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfer. 6. Review of Resident #59's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of the transfers. During an interview on 04/02/25 at 8:30 A.M., the Administrator said the facility had not been notifying the resident's representatives in writing of the resident's transfers to the hospital. During an interview on 04/02/25 at 1:45 P.M., the Administrator said she would expect the transfer forms to be completed per the regulation.

Based on interview and record review, the facility failed to provide written notification of their bed hold policy to the residents and/or their resident representatives at the time of transfer for four residents (Residents #11, #12, #38, and #46) out of 18 sampled residents and one resident (Resident #44) outside the sample. The facility census was 86. Review of the facility policy titled, Bed Hold, dated 04/01/22, showed: - It will be the policy of this facility to provide residents with bed hold policies upon admission to the facility and at the time of transfer (i.e. when transferring to hospital or going on therapeutic leave) in accordance with federal and state regulations; - The initial bed hold policy should be provided to the resident/responsible party as soon after admission as possible when completing the admission packet to the facility. Should specify duration of the bed hold policy under the State Plan, if any, during which the resident is permitted to return and resume residence in the nursing facility. Non-Medicaid residents may be requested to pay for all bed hold days; - The initial bed hold policy in the admission packet should be considered an example of how the bed hold policy works in the event it is required by the resident's conditions; - The bed hold policy applies to all residents residing in the facility; - The second bed hold policy should be provided at the time of the transfer and if applicable, given with in advance to the transfer; - In emergency transfer situations, notice at the time of transfer refers to the provision of the resident's copy of the bed hold policy will be provided along with the other transfer paperwork to the hospital; - Bed hold for days of absence in excess of the state's bed hold limit are considered non-covered services and the resident could use his/her own funds to pay for the bed hold if they desire; - Residents that are non-Medicaid in payer source may be requested to pay for all days of bed hold; - Residents are eligible for re-admission following hospitalization or therapeutic leave. per the facility's admission agreement. Private pay, Medicare or other residents not meeting the requirement of Medicaid bed hold: the facility will only reserve a bed for an absent resident if requested in writing by the resident or responsible party and applicable charges paid. In the event that a bed is not reserved, and the resident desires to re-occupy a room in the facility, the resident may be admitted to the next available bed. 1. Review of Resident #11's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 2. Review of Resident #12's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 3. Review of Resident #38's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer. 4. Review of Resident #44's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 5. Review of Resident #46's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer. During an interview on 04/02/25 at 1:45 P.M., the Administrator said she would expect bed hold forms to be completed per the regulation.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for two residents (Residents #21 and #36) out of five sampled residents. The facility's census was 86. Review of the facility policy titled, Pharmacist Recommendations, dated 04/01/22, showed: - It will be the policy of this facility to provide pharmacist services to meet the needs of the residents through monthly regimen review (MRR) and properly addressing recommendations per federal and state guidelines; - The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. This review must include a review of the resident's medical chart. An electronic medication regimen review will be performed within 72 hours of admission for newly admitted residents, or as soon as reasonably possible; - The pharmacist must report any irregularities to the attending physician or Licensed Independent Practitioner (LIP) and the facility's Medical Director and Director of Nursing (DON), and these reports must be acted upon as soon as reasonably able, but prior to the following month's MRR; Irregularities include, but are not limited to, any drug that meets the criteria set forth for unnecessary drugs. Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician/LIP and the facility's Medical Director and DON and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. The attending physician/LIP must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician/LIP should document his/her rationale in the resident's medical record; - Each resident's drug regimen must be free from unnecessary drugs; - The facility, physician/LIP and/or pharmacist shall ensure that residents who have not used psychotropic (medications that affect the brain chemistry, mood, perception, and behavior) drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; Residents do not receive psychotropic drugs pursuant to an as needed (PRN) order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she should document their rationale in the resident's medical record and indicate the duration for the PRN order. 1. Review of Resident #21's medical record showed: - admission date of 07/06/22; - Diagnoses of anxiety (intense, excessive, and persistent worry and fear about everyday situations), major depressive disorder (a mental illness that causes a persistent low mood and loss of interest in activities), psychotic disorder with hallucinations due to known physiological condition (condition where a person experiences hallucinations and other psychotic symptoms like delusions or disorganized thinking), and schizophrenia (a disorder that affects a person's ability to think feel and behave clearly); - An order for Depakote (an anti-seizure medication also used as a mood stabilizer) delayed release 125 milligram (mg) by mouth two times a day related to schizophrenia, dated 02/26/24; - An order for Depakote delayed release 250 mg by mouth two times a day related to schizophrenia, dated 02/26/24; - The physician did not attempt GDRs for the Depakote 125 mg and the 250 mg doses; - The physician did not document any contraindications of medication adjustments for the Depakote 125 mg or 250 mg doses. 2. Review of Resident #36's medical record showed: - admission date of 06/29/23; - Diagnoses of Alzheimer's Disease (progressive mental deterioration), dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), anxiety disorder, major depressive disorder, auditory hallucinations, and visual hallucinations; - An order for olanzapine (an antipsychotic (medication used to treat psychosis) 2.5 mg twice a day for delusions, dated 01/01/24; - The physician did not attempt GDRs for the olanzapine 2.5 mg dose - The physician did not document any contraindications of medication adjustments for the olanzapine 2.5 mg. During an interview on 04/02/25 at 9:33 A.M., the Assistant Director of Nursing (ADON) said they did not do GDRs. During an interview on 04/02/25 at 1:30 P.M., the Administrator said she would expect GDRs to be completed per the regulation.

Based on observation, interview, and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Resident #78) with a diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of three sampled residents. The facility's census was 86. Review of the facility's policy titled, Mental and Psychosocial Adjustment Services, dated 04/01/22, showed: - It is the policy of the facility to ensure (based on the comprehensive assessment of a resident) that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or PTSD, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being; - Residents who experience mental or psychosocial adjustment difficulty, or who have a history of trauma and/or PTSD require specialized care and services to meet their individual needs. The facility will ensure that an interdisciplinary team, which includes the resident, the resident's family and/or representative, whenever possible, develops and implements approaches to care that are both clinically appropriate and person-centered. Expressions or indications of distress, lack of improvement, or decline in resident's functioning should be documented in the resident's record and steps taken to determine the underlying cause of the negative outcome. 1. Review of Resident #78's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, hemiplegia (paralysis of one side of the body) and hemiparesis following a cerebral infarction (stroke), bipolar disorder (a mental disorder that causes unusual shifts in mood), and mood disorder (any mental disorder with a disturbance of mood); - Trauma Informed Care Assessment, dated 02/18/25, did not address the resident's PTSD triggers. Review of the resident's Physician Order Sheet (POS), dated April 2025, showed: - An order for mirtazapine (an antidepressant medication) 7.5 milligrams (mg) daily for mood disorder, dated 08/04/24; - An order for sertraline (an antidepressant medication) 50 mg daily for mood disorder, dated 08/04/24. Review of the resident's Preadmission Screening and Resident Review (PASRR - a federal program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities), dated 08/23/24, showed: - Resident with major depressive disorder (long-term loss of pleasure or interest in life), bipolar disorder, panic disorder, PTSD, and mood disorder; - No behaviors documented. Review of the resident's Care Plan, dated 08/14/24, showed: - Did not identify PTSD as a problem; - Did not address personalized triggers or interventions associated to the resident or triggers. During an interview on 04/02/25 at 2:15 P.M., the Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff) Coordinator said a diagnosis of PTSD should be addressed on the care plan with triggers listed. During an interview on 04/02/25 at 3:15 P.M., the Administrator and DON said that they would expect PTSD and triggers to be addressed on the care plan.

Based on observation and interview, the facility failed to promote resident independence and dignity while dining when staff served the noon meal on disposable dishware. The facility census was 86. Review of the facility policy titled, Resident Rights, Dignity and Visitation Rights, dated 04/01/22, showed: - It will be the policy of this facility that employees shall treat residents with kindness, respect, and dignity. The facility promotes the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. The facility will ensure that the resident can exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability; - The facility will make effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity; providing care that is comfortable and consistent with his/her normal life habits, observing resident's choices whenever able; - The facility will promote care for residents in a manner and in an environment that maintains or enhances dignity and respect in recognition of his/her individuality, preferences, activities, pursuits, goals, and desires. Review of the facility policy titled, Dishes and Infection Control Practices, dated 10/01/23, showed: - Routine use of disposables for residents in isolation/infection precautions is not recommended unless directed by the Infection Preventionist (IP). Residents requiring isolation precautions may utilize disposable products at the discretion of the facility IP and administration; - If adequate resources for cleaning utensils and dishes are not available, then disposable products may be used. Observation on 03/30/25 at 11:45 A.M., showed: - All residents served lunch from the kitchen on disposable plates, cups, and bowls. During an interview on 03/30/25 at 11:33 A.M., Day [NAME] I said the kitchen was shorter staffed on the weekends and served food on paper plates. There was not enough time to cook, clean, and serve with just two staff. During an interview on 03/30/25 at 11:42 A.M., Resident #24 said meals were often served on paper plates. During an interview on 03/30/25 at 3:03 P.M., Resident # 71 said staff served food on styrofoam plates and cups a lot instead of using real dinnerware. During an interview on 03/30/25 at 3:07 P.M., Resident #21 said they always used disposable utensils and plates instead of real dinnerware. During an interview on 03/31/25 at 10:15 P.M., Day [NAME] G said he/she thought the paper products were used more for convenience than not being able to do dishes. Multiple residents had complained about the food being served on paper plates. During an interview on 04/02/25 at 11:35 A.M., the Dietary Manager (DM) said he/she did not like when staff served food on paper plates. Staff were not supposed to serve food on paper plates but sometimes did one meal a day on the weekends. There were enough dishes where staff did not have to use paper products. During an interview on 04/02/25 at 3:05 P.M., the Administrator said she would expect meals to be served in a way that promotes and maintains dignity and respect for the residents.

Based on observation, interview, and record review, the facility failed to provide an on-going program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. This practice affected five residents (Residents #13, #21, #22, #24, and #31) out of 18 sampled residents and could potentially affect all residents. The facility census was 86. Review of the facility policy titled, Activities, dated 04/01/22, showed: - It will be the policy of this facility to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an on-going program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community; - The facility shall provide an on-going person-centered activities program that incorporates the resident's interests, hobbies, and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well being and independence; - The facility shall create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy and meaning); - The facility shall provide meaningful activities that reflect a person's interests and lifestyle, are enjoyable to the person, help the person to feel useful, and provide a sense of belonging; - The program will be based on the resident's comprehensive assessment and person- centered care plan, and meet the resident's interests and preferences, and support his/her physical, mental, and psychosocial well-being; - Activities can occur at any time, are not limited to formal activities being provided by recreation staff, and can include activities provided by other facility staff, volunteers, visitors, residents, and family members; - Programs should reflect a resident-centered perspective including programming that takes into consideration physical function, behavioral changes, cognitive function and historical recreation preferences: activity preferences; one-to-one programs, independent activities/in-room activities, etc., group programming, community based, person-centered, gender, cultural, religious/spiritual, individual preferences, and continuation of life roles (former occupation, personal preferences, hobbies, etc.); - The facility will develop a monthly schedule of activities which will be accessible to residents or the facility will provide for in room/self-directed activities as determined by the activity assessment; - The facility will honor the resident preference to be independently capable of pursuing their own activities without intervention from the facility. This information will be noted in the assessment and identified in the person-centered care plan; -The facility will support the resident's preferences to remain involved in the community including interactions such as: assisting the resident to maintain his/her ability to independently shop, attend the community theater, local concerts, library. and participate in community groups. Review of the March 2025 Activities Calendar showed: - Two activities per day; - The morning showed coffee with either music, communion, coloring, or currents events; - The afternoon showed games such as bingo, charades, bowling, Deal or No Deal, and Family Feud or an activity of an ice cream social, [NAME] Krispie treats, and resident council meeting; - On Mondays and Wednesdays, there was time listed as 1:1. 1. Review of Resident #13's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 09/14/24, showed: - Very important to participate in activities he/she likes. During an interview on 03/30/25 at 2:39 P.M., Resident #13 said the facility removed the Activities Room. The facility used to have an Activities Room, but it was taken away and the staff expect everything to be held in the dining room. They had a coffee hour in the morning, but they were no longer provide the different creamers. He/She had to purchase his/her own creamer and donated it to the other residents who liked to use it. They didn't normally do anything during the coffee hour like the music or current event listed. It was just coffee in the dining area if residents wanted it. He/She said it wasn't an activity. The calendar listed games in the afternoon, but that was it and nothing else was available for them to do and nothing that interestd him/her. The activities person did not do 1:1 activities with him/her and did nothing for the residents. 2. Review of Resident #21's annual MDS, dated [DATE], showed: - The preferences for routine and activities section not completed. During an interview on 03/30/25 at 3:07 P.M., Resident #21 said the facility did not do activities and if they did, he/she did not know what they were. He/She wished they would do activities so it would give him/her something to do, because watching TV got old. He/She did not know who the activities person was and had never had anyone do any 1:1 activities with him/her. 3. Review of Resident #22's annual MDS, dated [DATE], showed: - Very important to participate in activities he/she likes. During an interview on 03/30/25 at 12:04 P.M., Resident #22 said activities were non-existent. The facility provided a calendar, but half the time, they didn't do anything that was listed on it. The residents used to have an Activities Room but it was taken away. The residents were told any activities would have to be in the dining room and then that was when the staff quit doing them. 4. Review of Resident #24's significant change MDS, dated [DATE], showed: - The preferences for routine and activities section not completed. During an interview on 03/30/25 at 1:16 P.M., Resident #24 said the facility did not have activities he/she could do. He/She spent most days watching TV in his/her room because there was nothing else to do. During an interview on 03/31/25 at 1:16 P.M., Resident #24 said the Activity Director had never done any sort of 1:1 time that he/she could recall. 5. Review of Resident #31's admission MDS, dated [DATE], showed: - Very important to participate in activities he/she likes. During an interview on 03/30/25 11:31 A.M., Resident # 31 said they provided no activities that interested him/her. Half the time what they had listed on the calendar, they didn't even do. The closest thing to an activity he/she had to do was taking a smoke break. During an interview on 03/30/25 at 1:28 P.M. the Activities Director said for residents that needed accommodations, he/she used things like music, movies, or audio books, and tried to do 1:1 time with them to hang out and talk with them for their activities. During an interview on 04/02/25 at 1:54 P.M., the Administrator said she would expect activities to be provided that met the physical, mental, and psychosocial well-being of the residents.

Based on observation, interview, and record review, the facility failed to provide consistent resident care for activities of daily living (ADLs) when the residents went an extended amount of time without showers for three residents (Resident #1, #2, and #3) out of 6 sampled residents. The facility's census was 92. The facility did not provide a policy regarding showers. 1. Review of Resident #1's medical record showed: - An admitted [DATE]; - Diagnoses of chronic obstructive pulmonary disease (COPD) with acute exacerbation (disease that makes breathing difficult), type 2 diabetes mellitus with hyperglycemia (trouble controlling blood sugar), need for assistance with personal care, conversion disorder with seizures or convulsions (a condition where psychological distress manifests as physical symptoms, including seizures), and Parkinson's disease without dyskinesia (Parkinson's without involuntary movements). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 01/01/25, showed: - Cognitive status intact; - Partial or moderate assistance for dressing; - Partial or moderate assistance for toileting; - Supervision or touching assistance for personal hygiene; - Partial or moderate assistance for bathing. Review of the resident's care plan, dated 02/04/25, showed: - The resident with an ADL self-care performance deficit due to decreased mobility, poor endurance, and chronic health conditions. Observation on 02/06/25 at 10:25 A.M. showed the resident lay in bed with disheveled, unkempt hair, sticking out and falling out of a pony tail. During an interview on 02/06/25 at 10:25 A.M., Resident #1 said he/she will go weeks without a shower. He/she said staff will tell him/her they didn't have the time or enough staff to complete his/her shower. Resident #1 said staff will mark the shower sheets as refused when he/she did not refuse the shower. Staff will promise him/her they will complete the shower the next day, but will still not have time, which causes him/her to go weeks without getting to shower. Review of the facility shower schedule showed Resident #1's shower days to be Wednesday and Saturday. Review of the resident's shower sheets for December 2024 through January 2025, showed: - In December 2024, 2 showers documented out of 8 opportunities, a total of 6 opportunities for showers missed; - In January 2025, 3 showers documented out of 9 opportunities, a total of 6 opportunities for showers missed. 2. Review of Resident #2's medical record showed: - admitted [DATE]; - Diagnoses of type 2 diabetes mellitus with diabetic neuropathy (trouble controlling blood sugar), unspecified, chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (trouble breathing), COPD, unspecified, chronic kidney disease, stage 3b (kidneys not working properly), and acquired absence of left leg above knee (lower leg removed). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status intact; - Dependent on staff for dressing; - Dependent on staff for toileting; - Dependent on staff for personal hygiene; - Dependent on staff for bathing. Observation on 02/06/25 at 10:15 A.M. showed the resident with disheveled, unkempt and greasy hair. During an interview on 02/06/25 at 10:15 A.M., Resident # 2 said he/she will go weeks without a shower and would like to be showered more often. He/she said staff will not clean him/her which has caused him/her to be very smelly around the private area and has caused issues with yeast and sores on his/her body. Resident #2 said it is embarrassing and he/she is self conscious about his/her body odor and unkempt appearance. Review of the facility shower schedule showed Resident #2's shower days to be Monday and Thursday. Review of the resident's shower sheets for December 2024 through January 2025, showed; - In December 2024, 1 shower documented out of 7 opportunities, a total of 6 opportunities for showers missed; - In January 2025, 1 shower documented out of 7 opportunities, a total of 6 opportunities for showers missed. 3. Review of Resident #3's medical record showed: - admitted [DATE]; - Diagnoses of cerebral palsy (congenital disorder of movement, muscle tone, and posture), pseudobulbar affect (inappropriate laughing or crying due to a nervous system disorder), dysphagia, oropharyngeal phase (difficulty swallowing food or liquid), schizophrenia (a disorder that affects a person ability to think, feel, and behave clearly), unspecified, and moderate intellectual disabilities (developmental delay that affects a person's ability to understand and use language, communicate and learn). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status moderately impaired; - Dependent on staff for dressing; - Dependent on staff for toileting; - Dependent on staff for personal hygiene; - Dependent on staff for bathing. Review of the resident's care plan, dated 02/04/25, showed: - The resident to have an ADL self-care performance deficit related to cerebral Palsy. Observation on 02/06/25 at 10:15 A.M. of Resident #3 showed: - Disheveled hair; - Hair on upper lip; - Food on front of shirt and in lap; - Faint smell of urine. Review of the facility shower schedule showed Resident #3's shower days to be Wednesday and Saturday. Review of the resident's shower sheets for December 2024 through January 2025, showed; - In December 2024, 4 showers documented out of 8 opportunities, a total of 4 opportunities for showers missed; - In January 2025, 5 showers documented out of 9 opportunities, a total of 4 opportunities for showers missed. During an interview on 02/06/25 at 1:51 P.M., the Assistant Director of Nursing (ADON) said the aides that work the halls should be completing the resident showers following the shower schedule. They should fill out a shower sheet every time. Staff should write refused on them if the resident does not want to have a shower. The ADON said if the resident can shower themselves, the staff should still be completing a shower sheet. The ADON said they have had issues with some staff not completing them. He/she said they have been trying to weed out the bad seeds and feels like staff have been doing better about completing them in the last couple of weeks. During an interview on 02/06/24 at 4:09 P.M., Certified Nurse Aide (CNA) A and CNA B said there is a binder at the front desk that tells who staff are supposed to shower for the day. CNA A and B both said they complete a shower sheet each time if the resident refuses a shower or if the resident completes the shower by himself/herself. They both said if a resident showers independently, they stand by in case they need something. Both aides said they will sign the shower sheet, the resident will sign the shower sheet and the DON will take the shower sheet to upload in the chart. Both aides denied they have ever marked refused if they do not actually refuse to take a shower and always complete their shower sheets. During an interview on 02/06/25 at 4:15 P.M., the Interim Director of Nursing (DON) said there's a basket at the nurse's station and the aides put the completed shower sheets in and she will file them to be scanned in the chart. He/she said sometimes the CNAs in the evening will say they are too busy to get them completed. He/she said some aides are good about completing shower sheets and others are not. He/she said the evening shift struggles to get showers completed. He/she said there is an alert in the electronic records system that will pop up to say when a resident hasn't had a shower in seven days. He/she says when those alerts pop up, he/she will complete a shower sheet and take it to the nurse to tell them the resident must have a shower that day. He/she said there are residents that will refuse showers. He/she said they will verify when the residents refuse the showers. Complaint #MO00249132

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the potential spread of COVID-19 (an acute respiratory illness in humans caused by the coronavirus, SARS-CoV-2) and other infections, when staff failed to follow acceptable infection control practices for COVID-19. The facility failed to separate six residents (Resident #1, #2, #3, #4, #5, and #6) who tested positive for COVID-19 from six residents (Resident #7, #8, #9, #10, #11 and #12) who had tested negative for COVID-19, which placed the residents at an increased risk of contracting COVID-19 due to prolonged exposure. The facility census was 85. The Administrator, Director of Nursing, and Assistant Director of Nursing/Infection Preventionist were notified on 10/13/23 at 04:00 P.M. of an Immediate Jeopardy (IJ) which began on 10/01/23. The IJ was removed on 10/13/23, as confirmed by surveyor onsite verification. Review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/8/23, showed: - The recommendations in the guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency; - The Infection Prevention and Control (IPC) recommendations described below (e.g., patient placement, recommended PPE) also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing; - Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom; - If cohorting, only patients with the same respiratory pathogen should be housed in the same room; - Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection. Review of the facility's policy Covid-19 Infection Control Practices, undated, showed: - Transmission based precautions (TBP) should be used with all positive residents and symptomatic residents until tested negative 48 hours after first negative test; - TBP should be used on asymptomatic residents when resident residing on unit with ongoing Covid positive residents; - They should be removed from TBP after day seven following the exposure (day of exposure is day 0); - If resident is suspected or confirmed to be Covid positive, put in a single room with a private restroom. Keep door closed if possible; - Limit transport and movement of the resident outside of the room unless medically necessary; - Communicate information about the resident to appropriate personnel before transferring them to other departments in the facility; - HCP who enter the room of a resident with suspected or confirmed Covid infection should adhere to TBP and use a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filter or higher, gown, gloves, and eye protection; - Duration of TBP for Residents with Covid Infection: Residents with mild to moderate illness who are not moderately to severely immunocompromised: at least ten days have passed since symptoms first appeared and at least 24 hours have passed since last fever without the use of fever-reducing medications and symptoms have improved; - Duration of TBP for Residents with Covid Infection: Residents who are asymptomatic throughout their infection and are not moderately to severely immunocompromised: at least ten days have passed since their first positive viral test. 1. Review of the facility's Testing Tracker showed staff documented Resident #1 tested positive for COVID-19 on 10/08/23. Review of the report showed the resident's roommate Resident #7 tested negative for COVID-19 on 10/08/23, 10/10/23, and 10/12/23. Review of Resident #1's Nurse's Notes, dated 10/08/23, showed the resident with symptoms of being hoarse and having a cough. Observation on 10/13/23 at 01:32 P.M. showed Resident #1 and Resident #7 residing in the same room. 2. Review of the facility's Testing Tracker showed staff documented Resident #2 tested positive for COVID-19 on 10/08/23. Review of the report showed the resident's roommate Resident #8 tested negative for COVID-19 on 10/08/23, 10/10/23, and 10/12/23. Review of Resident #2's Nurse's Notes, dated 10/08/23, showed the resident was asymptomatic. Observation on 10/13/23 at 10:06 A.M. showed Resident #2 and Resident #8 residing in the same room. 3. Review of the facility's Testing Tracker showed staff documented Resident #3 tested positive for COVID-19 on 10/08/23. Review of the report showed the resident's roommate Resident #9 tested negative for COVID-19 on 10/08/23, 10/10/23, and 10/12/23. Review of Resident #3's Nurse's Notes, dated 10/03/23, showed the resident was asymptomatic. Observation on 10/13/23 at 10:06 A.M. showed Resident #3 and Resident #9 residing in the same room. 4. Review of the facility's Testing Tracker showed staff documented Resident #4 tested positive for COVID-19 on 10/12/23. Review of the report showed the resident's roommate Resident #10 tested negative for COVID-19 on 10/12/23. Review of Resident #4's Nurse's Notes, dated 10/12/23, showed no documentation of symptoms. Observation on 10/13/23 at 03:00 P.M. showed Resident #4 shared a room with Resident #10. During an interview on 10/13/23 at 3:00 P.M., Resident #10 said Resident #4 has COVID and he/she does stay in the room and sleeps in there. 5. Review of the facility's Testing Tracker showed staff documented Resident #5 tested positive for COVID-19 on 10/10/23. Review of the report showed the resident's roommate Resident #11 tested negative for COVID-19 on 10/10/23 and positive on 10/12/23. Review of Resident #5's Nurse's Notes, dated 10/10/23, showed the resident was asymptomatic. Observation on 10/13/23 at 03:03 P.M. showed Resident #5 and Resident #11 residing in the same room. 6. Review of the facility's Testing Tracker showed staff documented Resident #6 tested positive for COVID-19 on 10/01/23. Review of the report showed the resident's roommate Resident #12 tested negative for COVID-19 on 10/03/23, 10/05/23, 10/08/23, 10/10/23, and 10/12/23. Review of Resident #6's Nurse's Notes, dated 10/01/23, showed the resident with symptoms of sinus congestion. The resident was not moved from the room with Resident #12 until 10/05/23. During an interview on 10/13/23 at 03:20 P.M., Licensed Practical Nurse (LPN) A said they try to isolate COVID positive residents and use appropriate PPE to care for those residents, and try to move positives together. When asked if she knew why there was still negatives with positives, he/she said I cannot answer that. During an interview on 10/13/23 at 02:00 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said they track when residents test positive and when they are recovered, and residents are considered recovered after having two negative tests 48 hours apart if they were asymptomatic. The ADON/IP said residents who were positive were moved to E hall. When asked about specific residents who have not been separated, she said they did not move them due to not having a room available. She said some were moved in the beginning, then on 10/08/23 when there were several more positives, E hall was full so they didn't move them. The DON said residents won't stay in their rooms anyway so there isn't much point in moving them. The DON and ADON/IP said it is hard to move residents around due to having [NAME] and [NAME] bathrooms. During an interview on 10/13/23 at 4:00 P.M., the Administrator said he was unaware that positive and negative residents were in the same room, and they should have been separated. The plan is to separate all positive residents from negative residents immediately and, if any further COVID-positive residents are identified, they will be immediately moved to a room with a COVID-positive roommate or a private room. Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00225796

Based on record review and interviews the facility failed to verify physician's orders and provide wound care for post operative bilateral [PR[NAME]EDURE] (removal of breasts) incisions for one resident (Resident #1) which resulted in wound dehiscence (surgical wound sutures/staples opened) and infection. The facility census was 102. Review of facility's policy Negative Pressure Wound Therapy (also known as a vacuum dressing or V.[NAME]C. ® dressing vacuum assisted closure, is a therapeutic technique using a suction dressing to remove excess exudation and promote healing in acute or chronic wounds), dated 2014, showed: - The purpose of this procedure is to provide guidelines for establishing and maintaining negative pressure wound therapy (NPWT); - Verify that there is an order for [REDACTED].>- Change dressings per physician's orders and manufacturer guidelines; - Document the wound status at the time of application of NPWT; - Report changes in the wound from baseline or previous dressing change. Review of facility's policy Wound Evaluations, dated (MONTH) (YEAR), showed: - The purpose of this procedure is to provide guidelines for the evaluation of current or new wounds; - Evaluation of wounds will be performed on admission, weekly and on discovery; - Wound characteristic assessed and documented include: *Location *Size, measurement of the length, width and depth(if any) of the wound in centimeters; *Type of wound, ie. Arterial, Vascular, Surgical, Trauma; *Drainage, color, amount and type of drainage (ie. purulent, green, clear, serous, serosanguinous, small, medium, large, copious, thick or thin); *Odor, presence or absence of wound or drainage odor; *Infection, presence or absence of signs of local wound infection ([DIAGNOSES REDACTED], induration, purulent drainage-evaluate drainage for signs and symptoms of infection after cleaning as not to confuse with debridement process, dressing meltdown or occlusion); *Healing; *Surrounding Skin (color appearance and integrity of-ie.denuded, dry, rolled, macerated, intact, red, pink); *Pain; - Evaluation results are communicated the the members of the care team through documentation, care plan meetings and care planning; - Wounds are observed during dressing changes. The nurse will note in the progress notes if the wound has worsened or deteriorated and the doctor will be notified; - The care plan will be created/updated accordingly. A review of Prevena Incision Management System's (NPWT device) manufacturer information showed: - It is a negative pressure wound therapy device intended for use on surgical incisions that continue to drain following sutured or stapled closures; - Holds incision edges together; - Protects incision site from external infectious sources; - Removes fluids and infectious materials from the surgical site; - Indicated for up to seven days of use; - No dressing changes needed; - Removal should be performed under direct medical supervision. Review of Resident #1's hospital discharge orders, dated 11/8/19, included the following wound care instructions: - Empty [NAME] Pratt (JP) drains (Bulb drain that provides a constant low suction to pull air or excess fluid from your surgical site for faster healing and prevention of complications) daily or as needed; - Change the Prevena wound VAC's canister daily or as needed; - No order to change Prevena wound VAC's dressing on surgical incisions. Review of Resident #1's Physician Order Sheet (POS) showed: - admission date of [DATE]; - [DIAGNOSES REDACTED]. - An order dated 11/8/19, to call the Surgeon's office for follow up appointment; - An order dated 11/8/19, to change the NWPT device's canister change daily as needed if soiled/full, with a line marked through, undated and not initialed; - An order dated 11/8/19, to change the incision bilateral breast NPWT device dressing every three days and as needed, with a line marked through, undated and not initialed; - An order dated 11/8/19, to empty the JP drains every shift/as needed and to monitor the drainage output for #1 JP drain right side, #2 JP drain right side, #3 JP drain left side and #4 JP drain left side; - Orders were verified by Licensed Practical Nurse (LPN) D per telephone with the physician on 11/8/19 at 10:30 P.M.; - An order dated 11/11/19 at 4:30 P.M., to remove the NPWT device; - An order dated 11/11/19 for Xeraform (an occlusive dressing which means the dressing prevents air from reaching the wound. An occlusive dressing will retain moisture, heat, and promotes a moist healing environment) dry dressing daily and as needed to chest surgical site. Review of nursing progress notes showed: - On 11/9/19 at 12:32 P.M. JP drain #4 had come out. Registered Nurse (RN) A notified the facility doctor. No documentation of the description of wound or drainage; - On 11/10/19 at 21:48 P.M., RN A wrote staff changed the original (Prevena) NPWT device to another NPWT device the facility had available; - On 11/11/19 at 15:19 P.M., RN B wrote Physician Assistant evaluated the area being treated by the NPWT device that was put on intact skin and said applying a NPWT divide to good tissue could cause the wound to open or worsen, or pull stitches; - On 11/11/19 at 20:34 P.M. to 21:49 P.M., RN B noted the surgeon notified and is upset and concerned about NPWT device the facility put on Resident #1's closed chest incision. NPWT device removed and skin under foam is red and macerated. Received a new order for Xeroform dry dressing daily. RN B reported the surgeon's concerns reported to the Director of Nurses and Assistant Director of Nurses; - On 11/12/19 at 19:32, no description of wound or drainage documented; - On 11/15/19 at 1:17 P.M., noted Social Worker (SW) had received a call from Mercy Clinic inquiring about resident's failure to show up for a follow up appointment with surgeon. The SW found no one had followed up on the order to schedule a follow up appointment; - On 11/16/19 at 8:17 [NAME]M., the resident had emesis x4 and temperature of 100.2. JP drain to right side leaking around insertion site. Clear dressing reapplied and JP drain compressed, drainage of 325 ml was pulled in next two hours then subsided. No description of wound or drainage documented. RN B notified the doctor and family; - On 11/17/19 at 7:27 P.M., RN B noted the JP drain was uncovered and reapplied to maintain suction to drain. Resident temperature 100.4 with nausea. The right JP drain drained 225 milliliter (ml) pink milky drainage. Left medial JP drained 25 ml this shift bright red, left lateral JP dark black to red drainage. No description of wound documented; - On 11/19/19 at 9:37 [NAME]M., RN C noted dressing change to right chest small quarter size black drainage noted. Old brown red drainage noted to old dressing. No bleeding to wound bed. No description of wound documented; - On 11/19/19 at 10:02 [NAME]M., RN B noted that at 8:30 [NAME]M. resident's gown and bedding saturated, foul smell in room. JP drain under resident. Bright red drainage on gown. After removal of dressing noted 2.5 to 3 (note did not indicate inches or centimeters) opening in surgical wound to chest, ABD pad dressing x2 applied and COBAN applied to dressing (pressure dressing). Surgeon called, vital signs requested, bleeding under control and to transport resident to Mercy St. [NAME] Hospital. Also resident new onset short of breath and oxygen saturations of 90%. Oxygen at 2 liters started, lung sounds coarse, Resident complained of increased pain at surgical site. Resident sent to the hospital. Family informed; - No documentation a follow up appointment had been scheduled. Review of Medication Administration Record [REDACTED] - No evidence the order to arrange a follow up appointment with the surgeon had been completed; - The Wound V.[NAME]C. was changed on 11/10/19; - JP wound drains were not emptied and monitored every shift on 11/11/19, 11/12/19, 11/14/19, 11/15/19, 11/16/19, 11/17/19 and 11/18/19.; - Daily Xeraform dry dressing change not done 11/14/19, 11/16/19 and 11/17/19. Review of hospital records dated 11/19/19 to 11/25/19 showed: - Resident #1 was seen in emergency room with complaint of nausea, increased pain, and bleeding drainage from right [PR[NAME]EDURE] site. Right side incision wound appears red, warm to touch, swollen with yellow odorous drainage. Wound is dehisced (wound has opened). - Original (Prevena) NPWT device was replaced with a regular NPWT device, causing her skin to break down; - She has been feeling overall ill with malaise and, chills; - Was admitted with [DIAGNOSES REDACTED]. - Resident #1 had surgery on 11/20/19 for debridement of right [PR[NAME]EDURE] incision and application of (Prevena) NPWT device; - Required hospitalization for intravenous antibiotic therapy for five days. Review of the surgeon's history and physical, dated 11/19/19, showed: - Resident #1 presented to the ED for right [PR[NAME]EDURE] drainage. He/She recently underwent a right modified radical [PR[NAME]EDURE] and left total [PR[NAME]EDURE] with left axillary sentinel lymph node biopsy without reconstruction on 11/7/2019 for her bilateral [MEDICAL CONDITION]; - The resident's incisions had a NPWT device (Prevena wound VAC) applied to both incisions to aid in wound care, however after he/she was discharged from the hospital to a rehab facility, on postoperative day #2 the nurses at the facility removed the Prevena NPWT device and applied a hospital grade NPWT device; - This caused a significant amount of vacuum suction directly on the chest wall skin and was not the appropriate NPWT device; - Directly spoke with a nurse caring for the patient at this facility who called confused with what she found. Advised her (staff) to remove the facility NPWT device, assess the resident's incisions and follow-up in the clinic the following day; - The Resident did not appear for her postoperative follow-up visit. When called, the facility they said there was a transportation issue and the resident was not able to make it; - Spoke with the nurse who cared for the patient upon his/her arrival to their facility and she (nurse) directly verbally admitted to being unfamiliar with the Prevena NPWT device and removed it herself because she was unsure of how it worked. When asked why she did not call the office to speak with surgeon or staff, the nurse said he/she was sorry and would do that next time; - So now the patient has a right [PR[NAME]EDURE] incision wound infection. The resident has fevers and chills. Right chest wall incision with [DIAGNOSES REDACTED] along the incision linein the lateral aspect has dehisced with a 4 x 4 centimeter (cm) area of necrosis, only one JP drain functioning with pus draining around drain site. During an interview on 11/26/19 at 2:00 P.M., RN A said: - He/she was the admitting nurse for Resident #1 on 11/8/19 and provided care on 11/9/19, 11/10/19, 11/12/19 and 11/15/19; - He/she had not previously ever cared for a post operative [PR[NAME]EDURE] resident; - He/she did not know what to do with Prevena Wound V.[NAME]C. (also called NPWT device); - He/she failed to call the surgeon's office to verify orders for wound care regarding Prevena NPWT device; - Other NPWT devices were always changed every three days so on 11/10/19 she changed it to a NPWT device the facility had available; - The JP drains should have been emptied every shift and documented; - The order for follow up appointment should have been made. During an interview on 11/26/19 at 2:35 P.M., the Director of Nurses (DON) said: - He/she expected nurses that are unfamiliar with care of [PR[NAME]EDURE] resident should call for guidance/verification to the surgeon, the hospital nurse, the DON or Administrator; - He/She was made aware of Resident #1's situation on 11/11/19; - The follow up appointment should have been made; - His/her expectations are for staff to follow physician orders and document wound status changes and drainage descriptions. During a phone interview on 12/3/19 at 5:30 P.M., RN B said: - He/she provided care for Resident #1 on 11/11/19 and 11/16/19 to 11/19/19; - On 11/11/19 she noticed the NPWT device did not look right; - He/she reviewed Resident #1's chart and saw original device was a Prevena Wound V.[NAME]C., not being familiar with that brand RN B looked up the manufacturer and realized it was not the same kind of device as the one the facility had put on the resident; - RN B told the primary care Physician Assistant about it, then called the surgeon. The surgeon was upset that we had not called to verify wound care concerns when the resident was admitted ; - RN B received orders to remove other (facility's) NPWT device immediately and clean wound and apply dry xeroform dressing to chest incisions; - He/she said wound and drains were to be assessed and monitored every shift. - RN B said she failed to schedule a follow up appointment at that time. During a phone interview on 12/17/19 at 1:25 P.M., the Surgeon said: - He/she spoke with nurses at the facility several days after resident's admission and they said they did not know how to use a Prevena Wound V.[NAME]C.; - He/she was informed they had removed the Prevena Wound V.[NAME]C. and applied another Wound V.[NAME]C. that was available at the facility and was concerned about the amount of suction applied to the good tissue. They did not know what the amount of suction was set at. The nurse said she had looked under the occlusive dressing of the Wound V.[NAME]C. and saw red excoriated area. The only thing that should have been changed is the drainage canister; - He/She saw Resident #1 in the hospital on [DATE]. The surgical wound was gaping open with purulent drainage. The hospital notes are specific on the status of the wound. He/She was unable to take the resident to surgery on 11/19/19, so surgery was scheduled for 11/20/19 for wound debridement. The wound cultures showed bacterial infection of wound. Complaint #MO 3

Based on interview and record review, the facility staff failed to protect one resident (Resident #1) of five sampled residents from sexual abuse by failing to provide sufficient monitoring of (Resident #2) a registered sex offender. The facility census was 98. Record review of the facility's policy titled Abuse Prevention Program showed the following: - The facility prohibits mistreatment, neglect or abuse of its residents by establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment; - The facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions; - For residents who are identified offenders, the facility shall incorporate the Identified Offender Report (criminal background for sexual misconduct) and recommendations into the offender's plan of care including security measures; - The facility shall immediately notify law enforcement of sexual abuse of a resident. 1. Record review of Resident #1's medical record showed: - An admission date of [DATE]; - [DIAGNOSES REDACTED]. - A family member as Power of Attorney and responsible party. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 10/29/18, showed: - The resident cognitively impaired; - The resident requires extensive assistance with personal hygiene, dressing and toileting; - The resident does not ambulate and requires supervision with locomotion. 2. Record review of Resident #2's admission sheet showed: - An admission date of [DATE]; - [DIAGNOSES REDACTED]. Record review of the facility's background check dated 10/2/18 showed: The resident registered on the Federal Sex Offender Register. Record review of Resident #2's base line care plan dated, 11/27/18, showed: - A history of sexually inappropriate criminal behavior; - The resident fit the identified offender criteria; - The resident appeared stable and considered appropriate for the facility; - No documented monitoring or preventive interventions. Record review of the facility's investigation of an incident dated 11/29/18 showed: - The resident (Resident #1) had been placed in bed after dinner around 6:00 P.M. by staff; - Certified Nurse Aide (CNA) K was working the hall and heard a personal alarm sound around 8:00 P.M.; - CNA K followed the alarm to Resident #1's room and upon entering found Resident #2's wheelchair by the door; - Resident #2 was standing over Resident #1 with his/her hand on the resident's peri area; - CNA K called for the charge nurse to assist with relocating Resident #2 from the room; - Resident #2 kept insisting on staying in the room and attempted to return while exiting; - Resident #2 was placed on one on one monitoring and the local authorities were notified. During an interview on 12/5/18 at 11:00 A.M., the Administrator (ADM) said Resident #2 had a previous stay at the facility and there had been no incidents or concerns during that time. The ADM said during the admission process, the resident was believed to be stable and she did not feel Resident #2 required any additional monitoring or preventive interventions as compared to a typical resident. The facility always completes a criminal background check on all admission applicants. They were aware of Resident #2 having a criminal background and a history of sexual offense. The facility felt there was no need for any additional monitoring. The ADM said she and the Director of Nursing (DON) did not tell any of the licensed nursing staff or direct care staff of the resident's criminal background. She said there were two other registered offenders in the facility. During an interview on 12/5/18 at 12:40 P.M., CNA A said he/she did not know Resident #2 had a criminal history. CNA A said there had been no extra monitoring measures or interventions in place. During an interview on 12/5/18 at 1:00 P.M., CNA B said the facility had never informed any of the staff regarding Resident #2's background. The facility had never had any monitoring measures or interventions in place. During an interview on 12/5/18 at 1:15 P.M., CNA C said the floor staff was not informed of Resident #2 having a criminal background of inappropriate sexual behaviors. He/she felt there should have been monitoring and interventions in place. During an interview on 12/5/18 at 1:30 P.M., Licensed Practical Nurse (LPN) D said the facility never informed him/her of Resident #2 having a criminal background of inappropriate sexual behaviors. The floor staff was not informed or asked to use extra monitoring to secure the other residents. During an interview on 12/5/18 at 1:45 P.M., LPN E said the facility never informed him/her of resident #2 having a criminal background of inappropriate sexual behaviors. The floor staff was not informed or asked to use extra monitoring to secure the other residents. There were no interventions in place. During an interview on 12/5/18 at 1:50 P.M., LPN F said the facility never informed him/her of Resident #2 having a criminal background of inappropriate sexual behaviors. The floor staff was not informed or asked to use extra monitoring to secure the other residents. During an interview on 12/5/18 at 2:00 P.M., Certified Medications Technician (CMT) G said the facility never informed the staff of the criminal background of the resident. He/she was never requested to do any additional monitoring to secure the other residents. During an interview on 12/5/18 at 2:10 P.M., CMT H said he/she had been employed there for [AGE] years and had never been advised of any background checks on the residents. He/she was never requested to do any additional monitoring to secure the other residents. During an interview on 12/5/18 at 2:45 P.M., CMT I said the facility never informed the staff of the criminal background of the resident. He/she was never requested to do any additional monitoring to secure the other residents. During an interview on 12/6/18 at 10:00 A.M., LPN J said the facility never informed the staff of the criminal background of the resident. LPN J said no one ever requested any additional monitoring of Resident #2. LPN J was working the night of the incident. CNA K called LPN J into Resident #1's room. LPN J found Resident #2 with his/her hand in Resident #1's brief, on Resident #1's peri area. During an interview on 12/6/18 at 1:00 P.M., CNA K said he/she had entered the room of Resident #1 when a personal alarm had sounded. At that time, Resident #2 was standing over Resident #1 with his/her hand inside the resident's brief and touching the peri area. CNA K had not been aware of Resident #2's criminal background. Complaint #MO 9 NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time of exit. During the onsite visit, the facility administration found alternative placement for the resident, and new policies were written and put into place. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation

Based on observation, interview and record review, the facility failed to consistently and/or thoroughly investigate, implement corrective interventions, document in the resident's records, monitor behaviors and update care plans for resident falls, incidents, accidents and resident to resident altercations and failed to ensure an accurate system to monitor incidents and accidents. The facility's locked unit had a census of 23 residents. Six residents from the unit were selected as a sample and problems were found with all six (Residents #1, #2, #3, #4, #5 and #6). The census was 94. 1. Review of Resident #1's face sheet, showed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's fall risk assessment (a tool used by staff to determine if a resident was at risk for falls), dated 11/26/13, showed the facility identified the resident as a high risk for falls. Review of the resident's initial occupational therapy evaluation, dated 11/27/13, showed the following: -Required maximum to total assistance with Activities of Daily Living (ADLs); -Able to feed self with supervision; -Wheelchair skills; maintained proper body alignment and support, propelled self, no positioning device in chair; -Short/long term memory problems; -Short term goals; resident will be minimal to stand by assist with feeding; moderate to minimum assist with grooming and hygiene with set up; will be able to propel wheelchair and reposition self with minimum assistance by staff; will be able to complete upper extremities and trunk strengthening and flexibility training to improve mobility in the wheelchair and decrease the burden of care with functional mobility and assisted self care; -Therapy 5 x per week for 4 weeks. Review of the resident's occupational therapy daily/weekly summary, dated 11/27/13 through 12/10/13, showed the resident was seen seven times. Review of the resident's electronic progress notes, completed by nursing staff, showed the following: -11/29/13 at 4:33 P.M., resident was leaning forward in wheelchair, lost his/her balance and fell forward striking his/her head on the floor. Large hematoma with knot to left side of forehead with a 1/3 inch laceration to left side of forehead as well. Resident was uncooperative with assessment. Called paramedics to transport to hospital for evaluation and possible sutures. Resident's responsible party and primary care physician notified of transport to hospital. Review of the resident's hospital records, dated 11/29/13, showed he/she was sent to the hospital after a fall with a laceration to the left side of his/her forehead and left eye brow. The resident received three sutures to the forehead and was sent back to the nursing facility. Review of the facility's incident/accident log, for November 2013, showed the resident was not listed as having a fall on 11/29/13. Review of the resident's physician's orders [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. -an order for [REDACTED]. Further review of the resident's electronic progress notes, showed the following: -12/1/13 at 3:36 P.M., clear bandage to forehead to cover stitches per family's request; -12/2/13 at 10:40 A.M., Interdisciplinary Team (IDT) meeting, resident to be evaluated by occupational therapy (OT) for positioning in wheelchair to prevent leaning forward; -(No documentation when the resident returned from the hospital, if the primary physician was notified of the resident's return to the facility. No documentation of new orders received and no nursing assessment that included neuro checks were noted for the first 72 hours after the resident returned from the hospital.) -12/3/13 at 8:00 A.M., the resident was sitting in a wheelchair in the dining room area. Resident fell face first out of the chair onto the floor. The resident did not lose consciousness. The resident received a laceration to the right side of the nose and right mid forehead. Range of motion (ROM) within normal limits. Respirations were 20. The resident refused all other vital signs. The resident kept his/her eyes closed when staff tried to assess pupils. The resident's nose appears fractured. Emergency services called. Message left for responsible party to call the facility. The resident's primary care physician was notified. Emergency services arrived and transported the resident to the hospital; -12/3/13 at 5:09 P.M., the resident returned from the hospital. Resident yelling and kicking up legs in the air, uncooperative with assistance and slapping at the nurse. Pupils equal, round, reactive to light (PERRL), grips equal, responded to questions when spoken to. Up in wheelchair in dining room for dinner. Neck brace on for C-5 fracture. Review of the resident's hospital records, dated 12/3/13, showed the resident presented to the emergency room after a fall out of the wheelchair at the nursing home. He/She had a laceration to the forehead and the bridge of the nose also has healing ecchymosis (bruising) and a laceration to the left side of the face from a previous fall. Review of the resident's computed tomography (CT, a specialized x-ray) scan of the sinus and facial bones, dated 12/3/13, showed a subtle fracture at the tip of the nasal bone. The CT results for the resident's cervical spine showed a fracture was present in the anterior inferior corner of C-5 (neck). The hospital treated the resident with a soft collar and discharged the resident back to the nursing facility. Review of the resident's post fall investigation report, dated 12/3/13, showed the following: -History of falls; yes, area designated to list the falls left blank; -High risk for falls; yes; -Any pattern with falls; leaning forward to get stuff off the floor; -Location of fall; resident's room; -Witnessed fall; yes; -level of injury; minor injury; -Description of injury; possible nose fracture and C 5 fracture. -Description of accident; resident sitting in wheelchair in dining room, alarm sounded and staff witnessed fall as she was turning around; -Findings; resident is known to lean forward in the wheelchair to attempt to grab a small pieces of paper or whatever off the floor. PSA on. Staff could not get to resident fast enough. Will have therapy screen for possible alarmed seatbelt; -One written statement, dated 12/3/13 at 7:15 A.M., showed an untitled staff person wrote, that as he/she walked through the double door into the dining room, he/she saw the resident with his/her eyes shut. The employee turned his/her head to look at another employee and when he/she turned back around the resident was falling face first to the floor. Review of the facility's incident/accident log, dated December 2013, showed the resident flipped his/her wheelchair over and fell face first to the floor on 12/3/13. Action taken; Velcro seat belt to wheelchair. Review of the resident's occupational therapy daily/weekly summary, dated 12/4/13, showed staff tested the resident with a seat belt for safety, the resident was non compliant with verbal commands, very upset and confused. Staff removed seat belt. Further review of the resident's electronic progress notes, showed the following: -12/5/13 at 3:23 P.M., IDT meeting: resident has bolsters in the bed to define parameters, drop seat (wheelchair seat lowered to keep resident's feet on the floor), wedge cushion (a cushion where the back is lower than the front to help prevent leaning forward) and a chair alarm. No signs or symptoms of distress; -(No further documentation of neuro checks or a nursing assessment for the first 72 hours after the fall.) Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/5/13, showed the following: -[DIAGNOSES REDACTED]. -Short/Long term memory loss; -Cognitively impaired; -Behavior symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms life screaming, disruptive sounds). Occurred on a daily basis; -Limited assistance of staff for dressing and personal hygiene; -Extensive assistance of staff for bed transfers, eating and locomotion on the unit; -Total assistance of staff for bathing; -Unable to transfer from seated to standing position and from bed to wheelchair without the assistance from staff; -No functional limitation in range of motion for upper or lower extremities; -Incontinent of bowel and bladder; -One fall with injury and one fall with a major injury; -No restraints used. Review of the resident's care plan, dated 12/5/13, showed the following: -Dementia, yells out at times, can be disruptive to others; -Able to transfer with extensive assistance of staff; -Fall Precautions: At risk for falls; -Independent with wheelchair mobility; -Incontinent of bowl and bladder; -Personal safety alarm (PSA) on at all times, transfer with assist of two, OT evaluation for appropriate safety devices; (i e: drop seat in wheelchair, safety belt); -Assess for possible cause of behaviors; monitor and treat signs and symptoms of pain/discomfort and document response; -Monitor and report any mental status changes; -Transfer to special care unit; -The care plan did not address the resident's nasal or C-5 fracture or sutures. Review of the resident's electronic progress notes, completed by nursing staff, showed the following: -12/11/13 at 9:57 A.M., the facility received a call from resident's physician about the resident's fall. Resident will return to the facility. Requesting the resident go to the special needs unit (SNU) to be monitored more closely. Also continue neuro check per facility policy. Requesting nursing continue to prevent further falls. Will place resident on SNU and utilize a helmet. Will attempt to find anti tippers for the front of the wheelchair and have therapy look at resident for possible use of a lap belt for positioning. -(No documentation the resident fell on [DATE], and was sent to the hospital for treatment.) -12/11/13 at 2:42 P.M., resident returned from the hospital at 12:15 P.M., by ambulance. Resident put to bed with assist of three staff. Resident screaming throughout transfer. Right eye slightly open, 2 centimeter (cm) abrasion to right cheek. Per hospital report the cheek has Durabond (an adhesive wound closure) on it and it should not get wet for 24 hours. Resident refused blood pressure and temperature. Family is aware resident returned to facility; -No further documentation in progress notes as of 11:00 A.M., on 12/12/13. Review of the resident's post fall investigation report, dated 12/11/13, showed the following: -History of falls; yes; -High risk for falls; yes; -Any pattern with falls; greater than two falls in the past two days; -Contributing factors; resident leaning in wheelchair; -Location of fall; dining room; -Witnessed fall; yes; -level of injury; minor injury; -Description of injury; laceration to right cheek. Nose crooked and red; -Description of accident; resident leaned forward and fell out of chair and landed on his/her face. Will assess for possible use of a seat belt (self release). Review of the resident's hospital records, dated 12/11/13, showed he/she presented to the emergency room after a fall out of his/her wheelchair. There was bruising to the right side of the face and under the right eye. The resident fell last week at the nursing home sustaining a C-5 fracture. A CT scan done on 12/11/13, showed a presumed small left acute subdural hematoma and no significant change in the fracture involving the right C-5 vertebral body. The resident was returned to the nursing home as he/she was not a surgical candidate. Review of the resident's occupational therapy discharge notes, dated 12/11/13, showed the resident required maximum to total assistance with transfers. The resident was placed on a drop seat with a wedge cushion with non slip material under him/her. The resident has fallen out of his/her wheelchair. Staff attempted to use a seat belt however the resident was unable to understand how to release the seat belt, making it a restraint. The resident has been unable to follow instructions consistently enough to benefit from occupational therapy. The resident was discharged from occupational therapy. During an interview on 12/12/12 at 8:15 A.M., during the initial tour of the facility, Certified Nurse Aide (CNA) A said the following, about the resident: -Confused at all time; -Transferred with the assistance of two staff, but should be a Hoyer (mechanical) lift; -A couple of recent falls which caused the bruising to his/her face; -Needs a seat belt to stay in chair. The resident always leans forward and is going to probably fall again. Observations on 12/12/13, showed the following: -7:53 A.M.: the resident sat in a standardized wheelchair on a wedge cushion with a personal safety alarm attached. There were no foot pedals on the wheelchair and the resident's feet dangled off the floor. The resident wore a cervical collar and had severe bruising to his/her entire face including his/her eyes, nose, cheeks, chin and forehead. The resident made eye contact and said hello, but did not carry on a conversation. The resident did not wear a seat belt or a helmet; -7:56 A.M.: the resident sat in his/her wheelchair pushed up to the dining room table. The resident's feet continued to dangle off the floor; he/she leaned forward and screamed out; -8:45 A.M., two staff members assisted the resident to bed using a gait belt. No bolsters were on the bed; -10:30 A.M., the resident continued to lay in bed with no bolsters and no PSA. -12:45 P.M., the resident sat in a wheelchair in the dining room with his/her feet dangling off the floor. The resident wore a helmet and a PSA. 1:14 P.M., the resident sat in a wheelchair behind the nurse's station with his/her feet dangling off the floor. Review of the resident's medical record, showed no daily documentation of the resident's behaviors. During an interview on 12/12/13, at 2:00 P.M., the Director of Nursing (DON) said she did not have an incident report for the resident's fall on 11/29/13. Since she did not have an incident report the fall was not listed on the incident/accident log. Staff should have documented in the resident's nurse's notes when the resident returned to the facility on [DATE] and completed a full assessment that included notifying the primary care physician about the resident's return and any new orders. She did not have an explanation why it was not done. Neuro checks should be done for 72 hours after a unwitnessed fall and a fall with a head injury. She has no documentation neuro checks were done for 72 hours after the fall. She did not have an explanation about why there was no documentation in the nurses notes after the resident's fall on 12/11/13. Resident's that receive psychotropic medications should have their behavior monitored on a daily basis. She does not know where that is documented in the resident's record. During an additional interview on 1/13/14 at 3:00 P.M., the DON said nothing was documented to show any interventions in place to prevent further falls after the 11/29/13 fall. At some point, an alarm was put on because staff said they heard the alarm sound when Resident #1 fell on [DATE]. During the IDT meeting on 12/5/13, they implemented the drop seat and put a wedge cushion in his/her wheelchair. She did not know what was actually in place for the 12/11/13 fall. The documentation only showed that the alarm sounded. After this fall they moved the resident to the SNU and gave him/her a helmet. During an interview on 1/14/14 at 3:30 P.M., the resident's primary care physician said the facility never notified him of the resident's first fall on 11/29/13. He was not informed the resident went to the hospital for treatment. The facility did not notify him the resident refused neuro checks. The first time the facility notified him of the resident falling was on 12/3/13, when the resident sustained [REDACTED]. He requested the facility assess the resident for the use of a seat belt. He was informed by the facility, since the resident could not release the seat belt on command, it would be considered a restraint and they were not going to utilize the seat belt. The facility should have put interventions in place after the first fall to prevent the resident from falling. The resident sustained [REDACTED]. The facility never notified him the resident refused neuro checks after the falls. He would expect the facility to let him know if the resident refused care. 2. Review of Resident #2's face sheet, showed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's fall risk assessment, dated 7/13/13, showed the facility identified him/her as a high risk for falls. Review of resident's quarterly MDS, dated [DATE], showed the following: -Short and long term memory problems; -Severely cognitively impaired; -Wandering behaviors that occurred 4-6 days a week, but less than daily; -Extensive assistance of one person required for bed mobility and transfers; -Limited assistance of one person required for ambulation, dressing, toilet use and personal hygiene; -Not steady, but able to stabilize without staff assistance with moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface to surface transfer (transfer between bed and chair or wheelchair); -Frequently incontinent of bowel and bladder; -A fall with no injury since prior assessment; -Received antipsychotic and antidepressant medications daily; -Mobility devices: wheelchair; -No restraints used. Review of the resident's care plan, updated 10/22/13, showed the following: -Bipolar affective disorder, dementia, resides on special care unit. Wanders and has history of aggressive behaviors at times; -Resident will not harm self or others secondary to socially inappropriate/disruptive behaviors; wandering; -Remove resident from other resident's rooms and unsafe situations; -Resident will not sustain serious injury due to memory/recall deficit. -Assess whether the behavior endangers the resident and or other residents, intervene if necessary, avoid over-stimulation, for possible cause of behaviors; monitor and treat signs and symptoms of pain/discomfort and document response; -Resided in special care unit. Review of the resident's electronic progress notes, showed the following: -11/29/13 at 3:18 P.M., the resident got into an altercation with another resident. He/She scratched the other resident's left cheek and right wrist. Responsible party notified and primary care physician notified of altercation. No injuries suffered to self. No complaints of pain or discomfort, no distress noted at this time. No new orders at this time. -(No further documentation about the incident including 72 hour follow up charting.) Review of the resident's POS, dated December 2013, showed the following: -an order for [REDACTED]. -an order for [REDACTED]. Further review of the resident's electronic progress notes, showed the following: -12/8/13 at 5:00 P.M., the resident was being combative and refusing medications. Resident attempted to climb into another resident's bed, both residents tried to swing at each other. Resident caused a small scratch to the other resident's left cheek. -No further documentation of the incident including if staff notified the resident's primary care physician, responsible party or put interventions in place to prevent the resident from scratching another resident. No 72 hour follow up charting; -12/11/13 at 2:55 A.M., on 12/10/13 at 10:30 P.M., heard yelling coming from Resident #3's room. The door was closed. Staff found Resident #2 lying on the floor with laceration to his/her face and abrasions to his/her back and shoulders. Resident #2 was assisted to a wheelchair and brought back to his/her own room. The resident had swollen lips, swelling to the cheeks and forehead. The resident refused to allow staff to do vital signs. The resident was sent to the hospital per emergency services and admitted to the hospital for head trauma. Review of the resident's hospital records, dated 12/10/13, showed the resident was admitted to the hospital after he/she apparently wandered into another patient's room at the nursing home, where he/she was assaulted and suffered abrasions, bruising and swelling to the face. The resident had wandered into the same resident's room earlier in the day and had been thrown to the floor, the resident then went into the same resident's room again where he/she was assaulted with a blunt instrument. A CT of the head, showed a small subdural hematoma and possible skull fracture. The resident was admitted to the intensive care unit (ICU) for observation. Review of the facility's incident/accident log, for December 2013, did not show the resident to resident altercation on 12/8/13 Review of the resident's care plan, last updated on 10/22/13, showed it did not address the resident's altercations on 11/29/13, 12/8/13 and 12/10/13, where he/she wandered into another resident's room and scratched them or any additional interventions put into place to prevent any further resident to resident altercations. Review of the resident's medical record, showed no daily documentation of the resident's behaviors. During a telephone interview on 12/17/13 at 2:30 P.M., the administrator said she was unaware of a previous altercation between Resident #2 and Resident #3 on the same day that Resident #2 was sent to the hospital. During an telephone interview on 12/19/13 at 9:45 A.M., the DON said she was unaware of any previous altercations between Resident #2 and Resident #3 on 12/10/13. Staff should have reported those incidents to her and notified the resident's primary care physicians of the incidents. 3. Review of Resident #3's face sheet, showed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the resident's admission MDS, dated [DATE], showed the following: -No assessment for long and short term memory; -No assessment for cognitive skills for daily decision making; -No physical behavioral symptoms; -Behavior symptoms put the resident at significant risk for physical illness or injury and significantly interfere with the resident's participation in activities and social interactions; -Behaviors put others at a significant risk for physical injury, intrude on the privacy or activity of others and significantly disrupt care of living environment; -Wandered on a daily basis; -Supervision of one staff for bed mobility, transfers, walking, locomotion, dressing and toileting; -Fall history unable to determine; -Received antipsychotic medications seven days per week; -Received antianxiety medications three days per week; -No restraints used. Review of the resident's care plan, dated 10/15/13, showed the following: -At risk for wandering; -Monitor whereabouts and redirect as needed; -At risk for adverse reactions related to receiving daily antipsychotic and antianxiety mediations; -Monitor for adverse reactions from medications; -Monitor every two hours, keep call bell in reach in room and be aware of his/her location at all times; -Resided in special care unit; -(It did not address resident to resident behavior issues at all.) Review of the resident's electronic progress notes, showed the following: -On 11/24/13 at 8:16 A.M., the resident entered another resident's room and pushed the resident down to the floor. The resident also threw a mug of water at staff hitting them in the back of the head. The resident was redirected to his/her room. -(No documentation the resident's primary care physician, psychiatrist or responsible party were notified of the incident. No follow up documentation in the progress notes for 72 hours after the incident.) Review of the resident's care plan, showed the care plan, dated 10/15/13, did not include updates after the resident to resident altercation on 11/24/13. Review of the resident's POS, dated December 2013, showed the following: -an order for [REDACTED]. -an order for [REDACTED]. Review of the resident's electronic progress notes, showed the following: -12/11/13 on 12/10/13 at 8:30 P.M., the resident was involved in an altercation with another resident who came into the resident's room. The altercation resulted in injury to both residents. Staff heard yelling behind the resident's closed door, when staff entered the room they found another resident lying on the floor bleeding from the face, back and shoulders. The other resident was removed from the room. The resident was sitting in a chair in the room with a wet floor sign in his/her grip. He/She had multiple scratches to his/her face and a bruise on the right hand. Staff notified the resident's psychiatrist, primary care physician and responsible party. No new orders were received. Neither resident could recall what happened. -(No further documentation in the resident's progress notes as of 12/12/13 at 9:47 A.M.) Review of the facility's incident/accident log, for December 2013, showed none of these incident's were on the report. Review of the resident's care plan on 12/12/13, showed it did not include updates after the resident to resident altercation on 12/10/13. Review of the resident's medical record, showed no daily documentation of the resident's behaviors. Observation of the resident on 12/12/13 at 8:39 A.M., showed he/she sat in a chair in his/her room. He/She had scratches on his/her face and his/her right hand had a visible bruise between the thumb and the forefinger. The resident was alert to his/her name only. During an interview on 12/12/13 at 7:59 A.M., the administrator said she was aware of the resident to resident altercation. A confused resident went into another confused resident's room and was hit. One resident was sent to the hospital for injuries sustained during the resident to resident altercation. The facility did not report the incident to the Department of Health and Senior Services (DHSS) because it was two confused residents that got into an altercation. There was no intent to abuse. The facility did not have a policy regarding resident to resident altercations. The DON was in the process of doing an investigation about the incident and she would refer all further questions about the resident to resident altercation to the DON when she came in. During an interview on 12/12/13 at 10:10 A.M., the DON said she had not completed the investigation regarding the resident to resident altercation yet. She had not gotten any statements from staff. She did not know the medical condition of the resident sent to the hospital. The other resident involved in the resident to resident altercation remained in the facility. The resident was not on 15 minute watch and no interventions had been put in place to prevent him/her from injuring another resident. The resident's physician had been notified and no new orders were received. The facility felt the other resident was the aggressor in the incident and that resident had been sent to the hospital. The DON was unaware if either resident had a history of [REDACTED]. The residents on the SNU have dementia and/or Alzheimer's disease. When residents have altercations with one another, staff separate the residents and deescalate the situation. Residents are not put on 1:1 monitoring or moved to a different unit. Licensed nurses should document in the resident's medical record and notify the physician and responsible party and keep an eye on the residents. There is no formal incident report or documentation in the resident's medical record as to what the staff did or interventions put in place to prevent further incidents. The staff receive the Alzheimer's training and know to keep an eye on the residents. Seventy two hour charting is not necessary for each incident. Staff are supposed to notify her in writing of the incidents so she can log them on the accident/incident log book. Staff should be documenting resident's behaviors on a daily basis. She did not know where that documentation could be found in the resident's medical records. During a telephone interview on 12/16/13 at 8:30 A.M., Licensed Practical Nurse (LPN) B said he/she was working the 6:00 P.M. to 6:00 A.M. shift on 12/10/11, when the resident to resident altercation occurred. He/She was called back to the SNU by a CNA who said two residents had gotten into an altercation. When he/she arrived to the unit he/she found Resident #2 lying on the floor in Resident #3's room. Resident #2 had blood on his/her face, back and shoulders. Resident #3 was sitting in a recliner with a wet floor sign in his/her hand. The nurse assessed Resident #2 and took him/her to his/her own room. The nurse then assessed Resident #3 for injury. Resident #3 had scratches to his/her face and a bruise on his/her right hand. The nurse called both resident's primary care physicians, psychiatrist and responsible parties. Resident #2 was sent to the hospital for evaluation. The nurse had been told in report that earlier in the day Resident #2 had gone into Resident #3's room and they had gotten into an altercation. He/She did not know the extent of the altercation. He/She had worked at the facility for two years. When residents get into altercations the staff separate the residents and deescalate the situation. The nurses should call both the primary care physician and the responsible party and document in the resident's records. Resident #2 had a history of [REDACTED]. During an telephone interview on 12/17/13 at 2:30 P.M., the administrator said she was unaware of a previous altercation between Resident #2 and Resident #3 on the same day, 12/10/13, that resident #2 was sent to the hospital. She would see what she could find out. During an telephone interview on 12/19/13 at 9:45 A.M., the DON said she was unaware of any previous altercations between Resident #2 and Resident #3 on 12/10/13. Staff should have reported those incidents to her and notified the resident's primary care physicians of the incidents. She would get statements and fax them to the office. Review of witness statements faxed to the office on 12/20/13 at 3:58 P.M., showed the following: -A written statement, dated 12/10/13, (the statement did not clarify if it was written on 12/10/13 or written about events that occurred on 12/10/13), by Registered Nurse C. The nurse wrote at approximately 4:20 P.M., he/she heard noises coming from Resident #3's room. Resident #2 had wheeled himself/herself into Resident #3's room. Resident #3 was sitting on the side of his/her bed yelling, "Get out of here", at Resident #2. Resident #2 sitting on the floor partially under the over bed table, yelling to Resident #3, "You hurt me". Resident #2 said Resident #3 had pushed him/her to the floor. A small hematoma (bruise) over right eye brow (the statement did not show which resident had the hematoma). -A written statement from CNA D, dated 12/10/13 (the statement did not clarify if it was written on 12/10/13 or written about events that occurred on 12/10/13), showed around 11:00 A.M., he/she heard an alarm going off in Resident #3's room. He/she ran up the hall and opened the door and saw Resident #3 standin

Based on observation, interview and record review, the facility failed to obtain and verify physician's orders regarding Resident #2's gastrostomy tube feeding administration, assess and care plan for the resident's nutritional needs, consult the dietician for the tube feeding and nutritional needs, take measures to prevent a severe weight loss for the resident and contact the physician regarding the weight loss. The facility identified five residents who received nutrition through a feeding tube. Of those five, three were included in the sample of 14 residents and one resident did not did not receive care and services (Resident #2). The census was 81. 1. Review of Resident #2's admission physicians order sheet (POS) dated 2/25/11, showed the following: -Admission to the facility from the hospital on [DATE]; -[DIAGNOSES REDACTED]. -An order dated 2/25/11, for staff to administer the resident tube feeding via a gastrostomy tube ([DEVICE], a tube surgically inserted through the abdomen to provide fluid, nutrition and medication); -No order for the type of tube feeding or the amount of tube feeding for staff to administer. Review of the physician progress notes [REDACTED]. [DIAGNOSES REDACTED]. The resident underwent [REDACTED]. Review of the resident's discharge summary from the hospital dated 2/25/11, showed an order for [REDACTED]. During an interview on 3/15/11 at 8:30 A.M., the Director of Nurses (DON) said the resident was totally dependent on staff for activities of daily living, bedfast, received all medications and nutrition by a [DEVICE], had an indwelling urinary catheter and was incontinent of bowel. Review of the resident's February 2011, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the resident's POS dated 3/1/11, showed no order for the staff to administer tube feeding and no order for fluid flushes until 3/16/11. Review of the resident's medical record, showed no comprehensive assessment completed by staff to determine the resident's current care needs. Review of the resident's medical record showed, no initial or comprehensive care plan instructing the staff on the resident's current care needs. Review of the residents weekly weight log, showed the following weights: -2/25/11 (Admission) - 145.4 pounds; -3/1/11 - 135.5 pounds; -3/8/11 - 131.3 pounds; -3/15/11 - 131.3 pounds; -A 14.1 pound weight loss or a 9.69% severe weight loss in two weeks. Review of the Centers for Medicare and Medicaid Services (CMS) guidelines for surveyors defines a severe weight loss as greater than 5% weight loss in one month. Review of the Nutritional Assessment for the dietary manager's (DM) note dated 2/25/11, showed the resident was to receive no food or fluids by mouth. The DM made no documentation regarding the resident's required nutritional needs or tube feeding. The registered Dietician's notes (undated, but located on the same form) showed the estimated nutritional needs at 131 pounds, the resident needed 1607-1707 calories and 1487 cc's of fluid. (This was estimated after the weight loss for the resident not at the admission weight of 145.4) Review of the nutritional consultation from the registered dietician, showed she completed recommendations for Resident #2 on 3/16/11. During an interview on 3/16/11 at 9:15 A.M., after the Registered Dietician (RD) came to the facility, she said the facility called her on 3/8/11, about the resident's weight loss. She recommended the facility change the tube feeding from Glucerna to Fibersource HN and to increase the amount of tube feeding from four cans a day to five until she could come to the facility to assess the resident. Her last visit to the facility was on 3/8/11 but she did not assess the residents nutritional needs because the staff did not tell her the resident was a new tube feeder. She changed the tube feeding to Fibersource HN and increased the amount until she could come on 3/16/11 to do a comprehensive assessment. No documentation in the resident's medical record could be found as late as 3/21/11, that facility staff verified the hospital discharge orders with the physician including the tube feeding order dated 2/25/11, or staff made the physician aware of the resident's weight loss. Review of the the resident's March 2011, MAR indicated [REDACTED]. Observation during the survey, showed the resident received the Fibersource HN by [MEDICATION NAME] feedings. During an interview on 3/18/11 at 12:20 P.M., the DON said the resident's physician should have been called to verify all orders on new admissions. The nurses should document all orders on the Physician's Order Sheet. The Registered Dietician should assess all newly admitted tube feeders for nutritional needs within 3 days of admission either by phone or in person. After the Registered Dietician completed her nutritional assessment the staff contacted the physician and received an order from the physician for staff to administer a can of Diabetisource AC six times a day. Review of the resident's March 2011, POS showed an order dated 3/16/11, for staff to administer a can of Diabetisource AC tube feeding six times a day for a total of 1,728 calories a day. During an interview on 3/21/11, the care plan coordinator said she has only been in the position since 3/1/11. She had not done a care plan for the resident. The resident was on her list to complete the care plan this week. During an interview on 3/21/11 at 9:00 A.M., Physician F said she did not order the admission tube feeding of a can of Glucerna 1.2 four times a day. Staff did not inform her of the hospital's discharge orders for tube feeding. The facility did not notify her of the resident's 10 pound weight loss and felt that it could be a result of the decrease in calories. If she had been aware of the hospital's orders for the resident to receive Glucerna 1.2 tube feeding at a rate of 60 cc's continuous that is what she would have ordered. The facility first called her for a tube feeding order on 3/16/11.