Every finding on record at Aspire Senior Living Moberly

Based on observation, interview, and record review, the facility failed to administer medications per physician's order, manufacturer guidelines, and per professional standard of practice for four additional residents (Residents #80 #32, #59, and #54), and failed to provide proper care for a urinary catheter (tube inserted into the bladder to drain urine) for one resident (Resident #7). The facility census was 71. Review of the facility policy, Medication Administration, dated 10/01/25, showed the following:-Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection;-Administer medication as ordered in accordance with manufacturer specifications (provide appropriate amount of food and fluid). 1. Review of Resident #80's physician's orders, dated May 2026, showed the following:-His/Her diagnoses included hypokalemia (low potassium);-Potassium chloride (nutritional supplement) 10%, 20 milliequivalents (meq) per 15 milliliters (ml); administer 7.5 ml orally two times a day for treatment of hypokalemia (low potassium levels);-Dilute every 15 ml in 3-ounces of liquid. Review of the potassium chloride suspension bottle showed it directed staff to dilute the medication prior to administration. Observation on 05/19/26 at 9:37 A.M. showed Certified Medication Technician (CMT) J removed 7.5 ml of potassium chloride and administered it to the resident without diluting the medication in liquid as ordered. During an interview on 05/21/26 at 11:20 A.M., CMT J said he/she thought the potassium chloride was already diluted so he/she did not know he/she was to dilute it prior to administration. 2. Review of the facility policy, Administration of Metered-Dose Inhalers, dated 10/01/25, showed if using a corticosteroid (an anti-inflammatory steroid medication), allow the resident to rinse and gargle with water if desired, to remove medication from the mouth and back of throat. Review of Resident #32's significant change Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 03/04/26, showed the following: -His/Her cognition was severely impaired;-His/Her diagnoses included chronic lung disease. Review of the resident's physician's orders, dated May 2026, showed an order for a Combivent inhaler (steroid inhaler used with treatment of chronic lung diseases), one puff inhaled four times a day. Rinse mouth and spit after each use. Observation on 05/19/26 at 4:22 P.M. showed CMT J assisted the resident to administer the Combivent inhaler. The resident inhaled the medication as ordered. CMT J provided the resident with a cup of water, and the resident took a drink. CMT J did not instruct the resident to rinse his/her mouth with the water and spit. During an interview on 05/21/26 at 11:20 A.M., CMT J said residents were to rinse their mouth by swishing water and spitting after using an inhaler. Staff needed to instruct the resident to swish and spit. He/She did not realize he/she did not instruct the resident to swish and spit after the resident used the inhaler. During an interview on 05/21/26 at 4:30 P.M., the Director of Nursing said staff should administer medications as ordered and per professional standards of care. Staff should instruct residents to rinse their mouths after using an inhaler if they were directed to do so. 3. Review of Resident #59's physician order sheet (POS), dated May 2026, showed the following:-The resident had an order for Novolog (fast-acting insulin) FlexPen four times a day; -The fast-acting insulin was ordered to be administered according to the resident's blood sugar level; -0-150 blood sugar, administer no insulin; -151-200 blood sugar, administer 2 units of insulin; -201-250 blood sugar, administer 4 units of insulin; -251-300 blood sugar, administer 6 units of insulin; -301-350 blood sugar, administer 8 units of insulin; -351-400 blood sugar, administer 10 units of insulin; -Call the resident's physician if blood sugar is over 400. Review of NovoLog.com, specific instructions for the Novolog FlexPen showed the following: -Inject the needle into the skin and hold the push button in all the way;-Continue holding the push button and keep the needle under the skin for six seconds. Observation on 5/20/26 at 7:08 A.M. showed the following:-Licensed Practical Nurse (LPN) K primed the insulin pen with 2 units of insulin;-LPN K prepped the skin on the resident's right lower abdomen, injected the needle under the skin and administered the ordered 2 units of insulin;-LPN K immediately removed the needle from the resident's skin;-LPN K did not hold the insulin pen under the skin for at least six seconds per the manufacturer's recommendation. 4. Record review of Resident #54's POS, dated May 2026, showed the following:-Insulin Lispro Junior KwikPen, inject as per sliding scale;-If blood sugar is 151-200, administer one unit of insulin;-If blood sugar is 201-250, administer three units of insulin;-If blood sugar is 251-300, administer five units of insulin;-If blood sugar is 301-400, administer seven units of insulin;-Administer insulin under the skin four times a day. Record review of Instructions for use of Humalog Junior KwikPen (insulin lispro), dated 3/31/20, showed the following:-Choose your injection site and insert the needle into the skin;-Continue to hold the dose knob in and slowly count to five before removing the needle. Observation on 5/20/26 at 7:20 A.M. showed the following:-LPN K primed the resident's insulin pen with 2 units of insulin;-LPN K prepped the resident's skin on his/her left upper arm with alcohol;-LPN K injected the needle in the resident's arm and pushed the dose knob to administer the 1 unit of ordered insulin;-LPN K immediately removed the needle from the resident's skin after he/she administered the insulin;-LPN K did not hold the needle under the resident's skin for a slow count of five before removing the needle per the manufacturer's recommendation. During an interview on 5/21/26 at 4:56 P.M., LPN K said the following:-LPN K did not know he/she should hold the needle under the skin for at least six seconds after he/she administered insulin from a pen;-He/She administered the ordered amount of insulin and then immediately removed the needle. That was how he/she was taught to do it. During an interview on 5/21/26 at 4:30 P.M., the Director of Nursing said she expected the staff to administer medication per physician orders and follow the manufacturer's guidelines for administering insulin pens. 5. Review of the facility policy, Indwelling Catheter Use and Removal, dated 10/01/25, showed the following:-Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination;-If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to;-Additional care practices include securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder. Review of Resident #7's Care Plan, dated 08/27/25, showed the following:-The resident had impaired cognitive function/dementia or impaired thought processes;-The resident had an ADL self-care performance deficit related to fracture (broken bone) of left ankle;-Dependent on staff and Hoyer lift (mechanical lift) for transfers;-The resident had an indwelling catheter related to urinary retention (inability to completely or partially empty the bladder). Review of the resident's Quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-Indwelling catheter;-Diagnoses of neurogenic bladder (the bladder does not empty properly due to a neurological condition) and dementia. Observation on 05/18/26 at 1:04 P.M. showed the following:-CNA G and the Restorative Aide (RA) prepared to transfer the resident from his/her wheelchair to the bed with the mechanical lift;-During the transfer, CNA G hung the resident's catheter drainage bag from the hooks on the mechanical lift, resulting in the drainage bag being higher than the resident's bladder. Dark yellow urine in the tubing flowed back towards the resident's bladder;-CNA G and the RA transferred the resident from the chair to his/her bed. During an interview on 05/21/26 at 11:35 A.M., CNA G said the catheter bag and tubing should always be kept below the bladder. During an interview on 05/21/26 at 4:20 P.M. the DON said staff should always keep the urinary catheter bag and tubing below the level of the bladder.

Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet residents' needs for seven residents (Resident #6, #71, #7, #11, #24, #15 and #5), in a review of 23 sampled residents, and for one additional resident (Resident #43). Staff failed to provide restorative therapy when the restorative aide (RA) was pulled to work as a certified nurse assistant (CNA) and was unable to complete duties for the restorative therapy nursing program. The facility failed to ensure sufficient staff were available to provide routine showers to ensure good personal hygiene and failed to ensure there was sufficient staff to provide assistance with residents' activities of daily living and care needs. The facility census was 71. Review of the Facility Assessment, last revised on 09/23/25, showed the following:-Staffing decisions are determined at the facility level (corporate input may be included) to ensure there are enough staff with appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care.;-The facility will consider staffing needs for each shift, such as day, evening and night, and will adjust as necessary based on any changes to its resident population;-The facility will develop and maintain a plan to maximize recruitment and retention of direct care staff;-The facility will have contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources as needed for resident care; -Assessment process includes evaluating the overall staffing requirements to ensure we have an adequate number of qualified personnel available to meet each resident's specific needs as outlined in their assessments and care plans. This approach ensures that our staffing aligns closely with resident care requirements;-Services provided included activities of daily living (bathing, showers, oral/denture care, dressing, eating, support with needs related to hearing/vision/sensory impairment, restorative nursing, contracture prevention/care; bowel/bladder toileting programs, incontinence prevention and care, and building of relationships with the resident to get to know him/her, then engage resident/representatives in conversation to find out what resident's preferences and routines are, what makes a good day for the resident, and what upsets him/her;-The facility systematically evaluates the staffing requirements to ensure sufficient qualified personnel are available to meet each resident's individual needs;-Direct Care staff for the secured unit (SCU) included a CNA for eight to 16 hours for both days and evenings. (There was no documentation in the facility assessment of night staff utilized on the SCU.) Review of the facility policy, Nursing Services and Sufficient Staff, dated 10/1/25, showed the following:-It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care;-The facility will supply services in sufficient numbers on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans;-The facility is required to provide licensed nursing staff 24 hours a day along with other nursing personnel, including but not limited to nurse aides;-Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. 1. Review of Resident #71's physician order sheet (POS), dated 5/21/26, showed the following:-On 4/28/26, staff received an order for the resident to begin restorative therapy;-Active range of motion, passive range of motion, transfers and bilateral upper and lower strengthening. Review of the resident's restorative therapy log from 5/1/26 to 5/21/26 showed the following:-Staff provided the resident with restorative therapy on 5/1/26 and 5/13/26;-The Restorative Aide was pulled to the floor to work as a CNA on 5/4/26, 5/5/26, 5/12/26, 5/14/26, 5/18/26, 5/19/26, and 5/20/26. During an interview on 5/18/26 at 10:10 A.M. Resident #71 said the following:-He/She was supposed to get restorative therapy, but it didn't always happen;-The resident thought he/she was scheduled for more therapy than he/she received. 2. Review of Resident #6's Physician's Orders, dated April 2026, showed an order for restorative therapy as follows: PROM contracture prevention program seated or supine strength. Review of the resident's Restorative Therapy Log, dated April 2026, showed the following:-The resident received restorative therapy 04/01/26, 04/02/26, 04/08/26, 04/13/26, 04/15/26, 04/16/26, 04/17/26, 04/20/26, 04/22/26, 04/24/26 and 04/30/26;-The RA documented he/she was pulled to work on the floor as a CNA on 04/10/26, 04/21/26, 04/23/26, 04/27/26 and 04/28/26. Review of the resident's Physician's Orders, dated May 2026, showed an order for restorative therapy as follows: PROM contracture prevention program seated or supine strength. Review of the resident's Restorative Therapy Log, dated 05/01/26 through 05/17/26, showed the following:-The resident received restorative therapy 05/01/26 and 05/13/26;-The resident refused restorative therapy on 05/06/26;-The RA was pulled to the floor on 05/04/26, 05/05/26, 05/12/26 and 05/15/26. Observation on 05/19/26 at 8:20 A.M. showed the following:-The resident sat in a reclining wheelchair in the dining room;-Both of his/her hands were contracted;-He/She had foot drop (inability to lift the front part of the foot) in both of his/her feet;-The RA worked as a CNA passing trays and assisting residents with dining. During an interview on 05/19/26 at 8:20 A.M., the resident said the following:-He/She could not hold drinks or utensils with his/her hands;-He/She was supposed to receive restorative therapy when the RA had time and wasn't working as a CNA;-He/She tried to exercise his/her own hands when the RA was working as a CNA, but he/she was unable to do exercises independently with his/her legs;-The range of motion exercises helped with his/her flexibility. 3. Review of Resident #43's Physician's Orders, dated April 2026, showed an order for the resident to participate in restorative nursing program for 24 weeks/180 days per therapy/primary care physician (PCP) recommendations. Review of the resident's Restorative Therapy Log, dated April 2026, showed the following:-The resident received restorative therapy 04/01/26, 04/02/26, 04/08/26, 04/13/26, 04/15/26, 04/17/26, 04/20/26, 04/22/26, and 04/24/26;-The RA documented he/she was pulled to the floor to work as a CNA on 04/10/26, 04/21/26, 04/23/26, and 04/27/26. Review of the resident's Physician's Orders, dated April 2026, showed a new order for restorative therapy as follows: lower extremity stretched all directions emphasis on knee extension to reduce contraction (start date 04/28/26). Review of the resident's Restorative Therapy Log dated April 2026 showed the following:-The RA documented he/she was pulled to the floor to work as a CNA on 04/28/26;-The resident received restorative therapy on 04/30/26. Review of the resident's Physician's Orders, dated May 2026, showed an order for restorative therapy as follows: lower extremity stretched all directions emphasis on knee extension to reduce contraction. Review of the resident's Restorative Therapy Log, dated 05/01/26-05/21/26, showed the following:-The RA documented he/she was pulled to the floor to work as a CNA on 05/04/26, 05/05/26, 05/12/26, 05/14/26, 05/18/26 and 05/19/26;-The resident received restorative therapy on 05/01/26, 05/20/26 and 05/21/26. 4. Review of Resident #7's shower sheets, dated April 2026, showed the following:-On 04/02/26, staff gave the resident a shower and shaved the resident;-On 4/11/26, staff gave the resident a shower (nine days since his/her last documented shower). No documentation staff shaved the resident;-No documentation staff gave the resident a shower or shaved the resident from 04/12/26 through 04/30/26. Review of the resident's shower sheets, dated May 2026, showed the following:-On 05/06/26, staff gave the resident a shower and shaved the resident (25 days since his/her last documented shower)-On 05/07/26, staff gave the resident a shower and shaved the resident;-On 05/13/26, staff gave the resident a shower (six days since his/her last documented shower). No documentation staff shaved the resident;-No documentation staff gave the resident a shower or shaved the resident from 05/14/26 through 05/18/26. Observation on 05/18/26 at 11:12 A.M. showed the following:-The resident lay in bed;-His/Her face was covered with stubble, and his/her hair was greasy. Observation on 05/19/26 at 12:40 P.M. showed the following:-The resident sat in his/her wheelchair in the hallway;-His/Her face was covered with stubble that appeared longer than the day before, and his/her hair was greasy and disheveled. During an interview on 05/19/26 at 12:40 P.M., the resident said he/she had not had a shower in a week. He/She would like a shower. Observation on 05/20/26 at 5:01 A.M. showed the following:-The resident sat in his/her wheelchair in the dining room; -The resident's face was covered with stubble that appeared longer than the day before, and his/her hair was greasy. Observation on 05/21/26 at 9:05 A.M. showed the following:-The resident sat in his/her wheelchair in the hallway;-His/her face was covered with stubble that appeared longer than the day before, and his/her hair was greasy. 5. Review of Resident #11's shower sheets for the month of April 2026, showed the following: -On 04/01/26, staff gave the resident a shower and shaved the resident;-On 04/09/26, staff gave the resident a shower (eight days since his/her last documented shower);-On 04/15/26, staff gave the resident a shower and shaved the resident (six days since his/her last documented shower);-On 04/20/26, staff gave the resident a shower (five days since his/her last documented shower);-On 04/23/26, staff gave the resident a shower. Review of the resident's care plan, dated 05/08/26, showed the following:-The resident preferred a shower for bathing;-The resident required extensive assistance with showering and personal hygiene. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/13/26, showed the following:-The resident did not reject any care;-The resident required substantial/maximum assistance from staff for bathing and personal hygiene (shaving). Review of the resident's shower sheets for May 2026 showed the following:-Staff did not document any showers for the resident from 05/01/26 through 05/17/26;-On 05/18/26, staff gave the resident a shower and shaved the resident (22 days since his/her last documented shower). During an interview on 5/18/26 at 10:18 A.M., the resident said the following:-Staff woke him/her at 4:00 A.M. to take a shower that day. It had been three weeks since his/her last shower;-He/She would really like to have two showers a week but there was only one person who usually gave showers at the facility;-He/She would like to be clean shaven and that didn't happen very often. 6. Review of Resident #24's care plan, dated 09/21/25, showed the resident required limited assistance from one staff for showering. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident required partial to moderate assistance from staff for bathing;-The resident had impairment of both upper extremities. Review of the resident's shower sheets for the month of April 2026 showed the following: -On 04/01/26, staff gave the resident a shower; -On 04/07/26, staff gave the resident a shower (six days since his/her last documented shower); -On 04/15/26, staff gave the resident a shower (eight days since his/her last documented shower);-On 04/23/26, staff gave the resident a shower (eight days since his/her last documented shower). Review of the resident's shower sheets, dated 05/12/26, showed the following: -Staff did not document any showers for the resident from 05/01/26 through 05/11/26;-On 05/12/26, staff gave the resident a shower (19 days since his/her last documented shower). Observation on 05/18/26 at 9:26 A.M. showed the resident had hairs, approximately 0.25 to 0.5 inches long, on his/her chin. During an interview on 05/18/26 at 9:26 A.M., the resident said the following:-He/She got one shower a week if he/she was lucky; -He/She tried to keep himself/herself clean with wet wipes when he/she went to the bathroom. If he/she could keep his/her peri area clean, he/she felt that helped;-He/She did not like the chin hair and wished staff would pull them out. The staff never offered to shave his/her chin. 7. Review of Resident #15's significant change in status MDS, dated [DATE], showed he/she was dependent on staff for bathing. Review of the resident's shower sheets from 04/01/26 to 04/30/26 showed the following:-No documentation staff gave the resident a shower from 04/01/26 through 04/16/26;-On 04/17/26, 04/21/26, 04/24/26, and 04/28/26 staff gave the resident a shower;-There was no documentation the resident refused showers. Observation on 05/20/26 at 9:11 A.M. showed the following:-Certified Nurse Assistant (CNA) G and CNA H assisted the resident to the bed and removed his/her pants;-The resident was incontinent of foul smelling urine and his/her perineal area was reddened;-CNA G cleaned urine from the resident's perineal area with a wipe. The resident continued to urinate, CNA G cleansed more urine from the perineal area with a wipe, but did not allow the resident to finish urinating before placing a clean incontinence brief under the resident and securing it in place. During an interview on 05/20/26 at 9:20 A.M., CNA G said he/she should have ensured the resident was finished urinating before he/she applied a new incontinence brief on the resident. He/She did not have enough time to do it properly because they did not have enough staff and he/she was rushed to care for the other residents. 8. Review of Resident #5's quarterly MDS, dated [DATE], showed he/she required substantial/maximum assistance with shower/bathing. Review of the resident's care plan, last updated on 04/07/26, showed the following:-He/She showered twice a week, shampoo weekly, trim toenails and fingernails weekly and as needed;-Assist the resident with shaving as needed. Review of the resident's shower sheets, dated 05/01/26 through 05/20/26, showed the following:-On 5/1/26, staff gave the resident a shower;-On 5/15/26, staff gave the resident a shower (14 days since his/her last documented shower);-No documentation the resident refused any offered showers. Observation on 05/20/26 at 6:00 A.M. showed the resident had a foul body odor and untrimmed fingernails. 9. During interviews on 05/20/26 at 6:00 A.M. and 05/21/26 at 11:58 A.M., the Restorative Aide said the following:-He/She was often pulled from restorative duties to assist with resident care which made it difficult to complete restorative therapy three times a week;-He/She was pulled from his/her restorative duties to work on the floor often;-He/She could not complete restorative therapy sessions with residents when he/she was working on the floor. During an interview on 5/21/26 at 2:00 P.M., the Director of Rehabilitation said he added orders in a range of three to six times a week for each resident. He did this because the Restorative Aide was pulled from his/her duties to work on the floor. 10. During an interview on 05/21/26 at 11:35 A.M., CNA G said CNA staff were responsible for shaving residents, but they did not have time because the facility did not have enough staff. During an interview on 5/21/26 at 1:26 P.M., CNA C said the following:-The other shower aide was pulled from being the scheduled shower aide to work on the floor often;-He/She could not complete showers for all residents scheduled on Monday and Tuesday if he/she was the only shower aide. During an interview on 05/19/26 at 1:20 P.M., CNA A said the residents rarely received two showers a week because there were not enough staff to complete them. During an interview on 05/18/26 at 9:50 A.M., CNA E said he/she worked the previous weekend (05/15/26 and 05/17/26) on the special care unit (SCU). He/She was the only staff on the unit. On Sunday (05/17/26), he/she provided care for residents on E hall and F hall and the SCU from 6:00 A.M. until 9:30 A.M. There was usually one staff scheduled on the SCU with residents who required assistance from two staff to transfer. Residents had to wait until a second staff member could assist him/her with the transfer. Staff on the SCU were responsible for giving the residents on the SCU their showers. The special care unit was not equipped with a shower room, so staff had to leave the unit with a resident to give a shower. It was not possible to leave the unit to give the residents a shower when there was only one staff on the unit. During an interview on 05/19/26 at 8:20 A.M., CNA D said there was usually one CNA on the SCU. He/She could not give the residents their showers when there was only one CNA. There wasn't a shower located on the SCU, and staff had to take the residents off the SCU to use the shower. During an interview on 05/19/26 at 2:05 P.M., CNA Z said he/she was the only CNA on the SCU today and was not sure if there was someone to come assist him/her. This was his/her first time working at the facility and he/she really didn't know much about the residents. During an interview on 05/19/26 at 4:25 P.M., CMT J said there were supposed to be two staff members on the SCU at all times, but half the time, there was only one staff member. During an interview on 05/21/26 at 2:45 P.M., Licensed Practical Nurse (LPN) T said typical daily staffing consisted of one charge nurse, one CNA for halls E and F, one CNA for the SCU (C hall), and two CNAs for halls A and B. It was difficult for one charge nurse to oversee all the residents. During an interview on 05/21/26 at 4:30 P.M., the Director of Nursing (DON) said she was not aware the shower aide was pulled to the floor and residents were not receiving their showers. Restorative therapy should be completed as ordered. She was aware the Restorative Aide was to the floor because there was not enough staff.

Based on observation, interview, and record review, the facility failed to ensure seven residents (Residents #7, #11, #24, #13, #60, #5 and #15), who required assistance with activities of daily living (ADLs), in a review of 23 sampled residents, received necessary care and services to maintain grooming and personal hygiene. The facility census was 71. Review of the facility policy, Grooming a Resident's Facial Hair, dated 10/01/25, showed it was the facility's practice to assist residents with grooming facial hair to help maintain proper hygiene as per current standards of practice. (The policy did not provide direction on how often staff were to shave a resident's facial hair.) Review of the facility policy, Resident Showers, dated 10/01/25, showed the following:-It was the facility's practice to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice;-Staff will provide residents with showers as per request or as per facility schedule protocols and based upon resident safety;-Staff may give partial baths between regular shower schedules;-Assist the resident with showering as needed. Encourage the resident to participate as much as possible. Give help and verbal cues as needed. 1. Review of Resident #7's Care Plan, dated 08/27/25, showed the following:-The resident had impaired cognitive function/dementia or impaired thought processes;-The resident had an ADL self-care performance deficit;-Dependent on staff for bathing/showering. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/23/26, showed the following:-Severe cognitive impairment;-No rejection of care;-Dependent on staff for shower/bathing;-Required partial/moderate assistance for personal hygiene. Review of the resident's shower sheets, dated April 2026, showed the following:-On 04/02/26, staff gave the resident a shower and shaved the resident;-On 4/11/26, staff gave the resident a shower (nine days since his/her last documented shower). No documentation staff shaved the resident;-No documentation staff gave the resident a shower or shaved the resident from 04/12/26 through 04/30/26. Review of the resident's shower sheets, dated May 2026, showed the following:-On 05/06/26, staff gave the resident a shower and shaved the resident (25 days since his/her last documented shower)-On 05/07/26, staff gave the resident a shower and shaved the resident;-On 05/13/26, staff gave the resident a shower (six days since his/her last documented shower). No documentation staff shaved the resident;-No documentation staff gave the resident a shower or shaved the resident from 05/14/26 through 05/18/26. Observation on 05/18/26 at 11:12 A.M. showed the following:-The resident lay in bed;-His/Her face was covered with stubble, and his/her hair was greasy. Observation on 05/19/26 at 12:40 P.M. showed the following:-The resident sat in his/her wheelchair in the hallway;-His/Her face was covered with stubble that appeared longer than the day before, and his/her hair was greasy and disheveled. During an interview on 05/19/26 at 12:40 P.M., the resident said he/she had not had a shower in a week. He/She would like a shower. Observation on 05/20/26 at 5:01 A.M. showed the following:-The resident sat in his/her wheelchair in the dining room; -The resident's face was covered with stubble that appeared longer than the day before, and his/her hair was greasy. Observation on 05/21/26 at 9:05 A.M. showed the following:-The resident sat in his/her wheelchair in the hallway;-His/her face was covered with stubble that appeared longer than the day before, and his/her hair was greasy. 2. Review of Resident #11's shower sheets for the month of April 2026, showed the following: -On 04/01/26, staff gave the resident a shower and shaved the resident;-On 04/09/26, staff gave the resident a shower (eight days since his/her last documented shower);-On 04/15/26, staff gave the resident a shower and shaved the resident (six days since his/her last documented shower);-On 04/20/26, staff gave the resident a shower (five days since his/her last documented shower);-On 04/23/26, staff gave the resident a shower. Review of the resident's care plan, dated 05/08/26, showed the following:-Personal Care: staff will accommodate and support the resident's valued activities in care routine as able;-The resident preferred a shower for bathing;-The resident had an activity for daily living (ADL) self-care performance deficit related to impaired mobility;-The resident required extensive assistance with showering and personal hygiene;-The resident required total assistance from two staff to transfer. Review of the resident's comprehensive MDS, dated [DATE], showed the following:-The resident did not reject any care;-The resident required substantial/maximum assistance from staff for bathing and personal hygiene (shaving). Review of the resident's shower sheets for May 2026 showed the following:-Staff did not document any showers for the resident from 05/01/26 through 05/17/26;-On 05/18/26, staff gave the resident a shower and shaved the resident (22 days since his/her last documented shower). During an interview on 5/18/26 at 10:18 A.M., the resident said the following:-Staff woke him/her at 4:00 A.M. to take a shower that day. It had been three weeks since his/her last shower;-He/She would really like to have two showers a week but there was only one person who usually gave showers at the facility;-He/She would like to be clean shaven and that didn't happen very often. 3. Review of Resident #24's care plan, dated 09/21/25, showed the following:-Anticipate and meet the resident's needs;-The resident had an ADL self-care performance deficit;-The resident required limited assistance from one staff for showering. Review of the resident's quarterly MDS, dated [DATE], showed the following:-The resident did not reject care;-The resident required partial to moderate assistance from staff for bathing;-The resident had impairment of both upper extremities. Review of the resident's shower sheets for the month of April 2026 showed the following: -On 04/01/26, staff gave the resident a shower; -On 04/07/26, staff gave the resident a shower (six days since his/her last documented shower); -On 04/15/26, staff gave the resident a shower (eight days since his/her last documented shower);-On 04/23/26, staff gave the resident a shower (eight days since his/her last documented shower). Review of the resident's shower sheets, dated 05/12/26, showed the following: -Staff did not document any showers for the resident from 05/01/26 through 05/11/26;-On 05/12/26, staff gave the resident a shower (19 days since his/her last documented shower). Observation on 05/18/26 at 9:26 A.M. showed the resident had hairs, approximately 0.25 to 0.5 inches long, on his/her chin. During an interview on 05/18/26 at 9:26 A.M., the resident said the following:-He/She got one shower a week if he/she was lucky; -He/She tried to keep himself/herself clean with wet wipes when he/she went to the bathroom. If he/she could keep his/her peri area clean, he/she felt that helped;-He/She did not like the chin hair and wished staff would pull them out. The staff never offered to shave his/her chin. 4. Review of Resident #13's admission MDS, dated [DATE], showed the following:-Cognitively intact;-No rejection of care;-Required substantial/maximal assistance for shower/bath;-Required supervision or touch assistance for personal hygiene. Review of the resident's Care Plan, dated 04/13/26, showed the following:-The resident had an ADL self-care performance deficit;-Bathing preference: shower;-The care plan did not include staff direction regarding the frequency of shaving or assistance required for personal hygiene. Review of the resident's shower sheets, dated April 2026, showed the following:-On 04/02/26, staff gave the resident a shower. No documentation staff shaved the resident;-On 04/09/26, staff gave the resident a shower (seven days since his/her last documented shower). No documentation staff shaved the resident;-On 04/16/26, staff gave the resident a shower (seven days since his/her last documented shower). No documentation staff shaved the resident;-On 04/21/26, staff gave the resident a shower (five days since his/her last documented shower). No documentation staff shaved the resident;-On 04/23/26, staff gave the resident a shower. No documentation staff shaved the resident. Review of the resident's shower sheets, dated May 2026, showed the following:-On 05/04/26, staff gave the resident a shower (11 days since his/her last documented shower). No documentation staff shaved the resident;-On 05/07/26, staff gave the resident shower. No documentation staff shaved the resident;-On 05/11/26, staff gave the resident shower. No documentation staff shaved the resident;-On 05/14/26, staff gave the resident shower. No documentation staff shaved the resident. Observation on 05/18/26 at 11:03 A.M. showed the following:-The resident sat in his/her wheelchair in his/her room;-His/Her chin was covered with hair, approximately 1 inch long. Observation on 05/19/26 at 3:42 P.M. showed the following:-The resident propelled himself/herself in a wheelchair down the hallway;-The resident's chin was covered with hair, approximately 1 inch long;-The resident had body odor. Observation on 05/20/26 at 10:00 A.M. showed the following:-The resident sat in his/her wheelchair in the dining room;-His/Her chin was covered with hair, approximately 1 inch long. Review of the resident's shower sheet, dated 05/21/26, showed staff gave the resident a shower and shaved the resident (seven days since his/her last documented shower). During interviews on 05/18/26 at 11:03 A.M. and 05/19/26 at 3:42 P.M., the resident said the following:-He/She was supposed to receive a shower twice a week;-Staff did not always give him/her two showers a week;-He/She was supposed to receive a shower on 05/18/26 but he/she did not receive a shower;-He/She hoped staff would give him/her a shower on 05/21/26 because he/she was going out with his/her family;-There was not enough staff to provide care for the residents and to give showers;-Staff only shaved him/her on shower days. 5. Review of Resident #60's shower sheets, dated April 2026, showed the following:-On 04/02/26, staff gave the resident a shower. No documentation staff shaved the resident-On 04/08/26 staff provided a shower (six days since his/her last documented shower). No documentation staff shaved the resident -On 04/13/26, staff documented the resident refused a shower three times;-On 04/20/26, staff gave the resident a shower (12 days since his/her last documented shower). No documentation staff shaved the resident-On 04/23/26, staff gave the resident a shower. No documentation staff shaved the resident;-On 04/27/26, staff gave the resident a shower and shaved the resident. Review of the resident's Care Plan, dated 04/27/26, showed the following:-Bathing preference: shower;-The resident has an ADL self-care performance deficit;-No direction regarding frequency of shaving or assistance required for personal hygiene. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Severe cognitive impairment;-No rejection of care;-Required substantial/maximal assistance for shower/bathing;-Required partial/moderate assistance for personal hygiene. Review of the resident's shower sheets, dated May 2026, showed the following:-On 05/04/26, staff gave the resident a shower (seven days since his/her last documented shower). No documentation staff shaved the resident;-On 05/15/26, staff gave the resident a shower and shaved the resident (11 days since his/her last documented shower). Observation on 05/18/26 at 11:12 A.M. showed the following:-The resident sat in his/her wheelchair in his/her room watching TV;-The resident's face was covered with stubble;-The resident had white flaky skin on his/her shirt. Observation on 05/19/26 at 1:12 P.M. showed the following:-The resident sat in his/her wheelchair in his/her room watching TV;-The resident's face was covered with stubble that appeared longer than the day before.-The resident had white flaky skin on his/her shirt. Observation on 05/21/26 at 9:08 A.M. showed the following:-The resident sat in his/her wheelchair in his/her room watching TV;-The resident's face was covered with stubble that appeared longer than the previous three days;-The resident had white flaky skin on his/her shirt. During an interview on 05/21/26 at 9:08 A.M., the resident said he/she would like to be shaved because he/she liked to be clean shaven. 6. Review of Resident #5's quarterly MDS, dated [DATE], showed the following:-His/Her cognition was severely impaired;-He/She was frequently incontinent of bladder;-He/She was always incontinent of bowel;-He/She required partial/moderate assistance with personal hygiene;-He/She required substantial/maximum assistance with shower/bathing and transfer to and from shower/bath. Review of the resident's care plan, last updated on 04/07/26, showed the following:-He/She was incontinent of bowel and bladder and required assistance of one staff with toileting and hygiene;-He/She showered twice a week, shampoo weekly, trim toenails and fingernails weekly and as needed;-Assist the resident with shaving as needed;-He/She was usually noncompliant with bathing and hygiene. Review of the resident's shower sheets, dated 05/01/26 through 05/20/26, showed the following:-On 5/1/26, staff gave the resident a shower;-On 5/15/26, staff gave the resident a shower (14 days since his/her last documented shower);-No documentation the resident refused any offered showers. Observation on 05/20/26 at 6:00 A.M. showed the resident had a foul body odor and untrimmed fingernails. 7. Review of Resident #15's care plan, last revised on 02/09/26, showed he/she was incontinent of bowel and bladder and needed staff to check him/her for incontinence and provide peri care as needed. Review of the resident's significant change in status MDS, dated [DATE], showed the following:-His/Her cognition was severely impaired;-He/She was dependent on staff for bathing and toilet hygiene;-He/She was always incontinent of bowel and bladder. Review of the residents' shower sheets from 04/01/26 to 04/30/26 showed the following:-No documentation staff gave the resident a shower from 04/01/26 through 04/16/26;-On 04/17/26, 04/21/26, 04/24/26, and 04/28/26 staff gave the resident a shower;-There was no documentation the resident refused showers. Observation on 05/20/26 at 9:11 A.M. showed the following:-CNA G and CNA H assisted the resident to the bed and removed his/her pants;-The resident was incontinent of foul smelling urine and his/her perineal area was reddened;-CNA G cleaned urine from the resident's perineal area with a wipe. The resident continued to urinate, CNA G cleansed more urine from the perineal area with a wipe, but did not allow the resident to finish urinating before placing a clean incontinence brief under the resident and securing it in place. During an interview on 05/20/26 at 9:20 A.M., CNA G said he/she should have ensured the resident was finished urinating before he/she applied a new incontinence brief on the resident. He/She did not have enough time to do it properly because they did not have enough staff and he/she was rushed to care for the other residents. 8. During an interview on 05/18/26 at 9:50 A.M., CNA E said usually, there was only one CNA on the special care unit (where the resident lived). He/She could not give the residents their showers. The special care unit was not equipped with a shower room, so staff had to leave the unit with a resident to give a shower. It was not possible to leave the unit to give the residents a shower when there was only one staff on the unit. During an interview on 05/19/26 at 1:20 P.M., CNA A said the residents rarely received two showers a week because there were not enough staff to complete them. During an interview on 5/20/26 at 12:56 P.M. CNA E said the following:-He/She got pulled from being the scheduled shower aide; -Staff filled out and turned in a shower sheet when staff gave a shower or when staff offered a shower and the resident refused. During an interview on 05/21/26 at 9:05 A.M., CNA B said staff only shaved the residents on their shower days. During an interview on 05/21/26 at 11:35 A.M., CNA G said the following:-CNA staff were responsible for shaving residents, but they did not have time because the facility did not have enough staff;-Staff only shaved residents if they got a shower. During an interview on 5/21/26 at 1:26 P.M. CNA C said the following:-CNA E got pulled from being the scheduled shower aide to work on the floor often;-He/She could not give showers to all the residents scheduled on Monday and Tuesday if he/she was the only shower aide;-He/She arrived at the facility at 4:00 A.M. today to start on showers so he/she could get them completed;-He/She went in early almost every day in order to give residents their showers. During an interview on 05/21/26 at 4:30 P.M., the Director of Nursing (DON) said she was unaware the shower aide was being pulled to the floor and residents were not receiving their showers.

Based on observation, interview, and record review, the facility failed to ensure a safe environment for all residents. On 8/22/25, the facility received information from a structural engineer the middle common area framing, in its current condition, was not structurally sound. The structural engineer advised that the area below this needed to be unoccupied until all the framing deficiencies were addressed. The facility continued to utilize the middle common area, which included the resident sitting area toward the front entrance, the central nurses station, and the access to six hallways and the dining room and did not prohibit access until repairs were made. The facility census was 70. The facility was notified of the Immediate Jeopardy (IJ) on 09/04/25 at 5:08 P.M. which began on 08/22/25. The IJ was removed on 09/04/25 as confirmed by the surveyor's onsite verification. Review of the facility's policy, Maintenance, dated 01/30/24, showed the following: -Purpose was to protect the assets of the building; provide a safe environment for residents, families, visitors and staff, and meet life safety code requirements;-All staff were responsible to identify areas of concern regarding the maintenance of the building;=Preventative maintenance will occur throughout the year. Review of the facility's policy, Maintenance Work Request, dated 01/30/24, showed the following: -When a resident, staff member, or family member recognizes the need for maintenance services, a maintenance work request form will be completed by a staff member;-Maintenance personnel will review all maintenance work requests daily (Monday - Friday) and prioritize work to be done. 1. Review of a letter from the structural engineer to the facility's regional project manager, dated 08/22/25, showed the following: -Per facility request, an onsite visit to the building was completed to perform a non-destructive structural investigation of the middle common area due to the ceiling showing signs of deflection;-Investigation began in the common area of the building where the ceiling had multiple areas over the circular desk where the drywall appeared to be sagging and had various cracks;-Investigation continued in the attic of the building over the previously mentioned area where multiple frame deficiencies were noted;-Those deficiencies included: -The sheathing was not continuous where there was over-framing installed over trusses, which had caused the top chord of the trusses to have a significant amount of horizontal deflection; -The top of the girder [NAME] at the north side of the common area had rotated inward to the common area and was no longer [NAME] (flush); -There were jack posts that support the over-framing that currently bear directly on sheathing and not on a solid framing member;-In its current condition, this framing was not structurally sound;-The area below this needed to be unoccupied until all the framing deficiencies were addressed;-This more than likely would require removal of the ceiling and reframing of portions of the roof in this area. During interview on 09/04/25 at 3:48 P.M., the structural engineer said the entire core space, including the nurses station, the walkways around the nurses station, and the common area was not structurally sound in its current condition. The area should be unoccupied, including no one traversing through the area, in the short-term until the shoring (the process of temporary supporting a building) was completed. This was communicated to the facility's regional project manager in his/her letter dated 8/22/25. 2. Review of the facility provided document, Site Visit Report, which the facility identified as an internal report from the project manager, dated 08/27/25, showed the following: -Overview: The drywall ceiling in the common area located over the nursing station was dropping;-All nursing personnel were moved to an area located in the entrance hallway;-The contractor site visit was completed on 08/26/25;-Observation and comments: Both contractors commented that employees should continue to avoid working in this area. 3. Observation on 09/02/25 at 4:45 P.M, of the central nursing station area showed the following: -The ceiling area, located between the back of the nurses station and the dining room wall with windows, had a crack approximately six to eight feet in length;-This area was readily accessible to staff and residents;-Staff were present at the nurses station. 4. During interview on 09/02/25 at 4:45 P.M., 09/02/25 at 5:55 P.M., and 09/18/25 at 11:18 A.M., the Administrator said the following: -The cracked ceiling area was brought to maintenance director's attention (could not recall by who) the ceiling seemed to be cracking; -A local contractor was brought in for an evaluation and suggested a structural engineer evaluate the area;-The structural engineer said the area was structurally unsound;-She had not seen the structural engineer's report (dated 8/22/25) until 09/04/25;-She moved the nursing station to the lobby as a pre-emptive measure and was not directed to do so by anyone; -She did notify corporate about temporarily moving staff due to not knowing what the cause of the ceiling issue was;-She had not been told this area should be avoided by residents or staff. 5. Review of the facility provided document from the engineering consultant company, dated 09/03/25, showed the following: -As a follow up to the investigation letter provided to the facility representative (project manager), dated 08/22/25, the existing roof framing that was identified in that letter will need to be exposed and shoring will need to be installed in the short term to temporarily support the compromised members until they are permanently repaired;-Those elements will include any of the roof trusses that have deflected top chords and are now compromised, the girder [NAME] at the north side of the common area that has rotated, any jack posts that do not have direct load path to bearing walls and any other compromised component that were unable to be seen/identified during the original investigation;-This shoring can consist of temporary wood stud walls or beams and posts that are adequately supported at ground level. 6. Observation on 09/04/25 at 9:05 A.M., showed the following: -The central nurses station had caution tape attached to the handrail below the dining room glass window to the right of the nurses station, and wrapped around the front of the nurses station attached to the handrail below the dining room glass window to the left of the nurses station;-Areas around the nurses station were all accessible to residents, staff, family and visitors; this area was a central hub where all resident occupied halls converged; -The sitting area in front of the nurses station was fully accessible to residents, staff, family and visitors. During an interview on 09/04/25 at 9:25 A.M., the Minimum Data Set (MDS) Coordinator said the nurses station and area between the nurses station and the dining room, was roped off on 09/03/25 per the Administrator's direction. No one specifically directed the facility to rope off the area; it was just done as a preemptive measure for resident and staff safety. During an interview on 9/04/25, at 10:57 A.M., Certified Nursing Assistant (CNA) H said the following: -He/She had been told a week or so ago that the ceiling above the nurses station was going to fall in and that staff could not be in the nursing station;-Until yesterday the area was open, yesterday the maintenance man put up caution tape to prevent people from being in the area. 7. Observation on 09/04/25 at 11:00 A.M., showed the following:-There was no caution tape around the nurses station; -Areas around the nurses station were all accessible to residents, staff, family and visitors; this area was a central hub where all resident occupied halls converged; -The sitting area in front of the nurses station was fully accessible to residents, staff, family and visitors. -Three residents sat in the main common area watching television. (This was a part of the area the engineering company had identified to be structurally unsound.) During an interview on 09/04/25, at 11:07 A.M., Certified Medication Technician (CMT) I said the following:-The nursing station had been moved about a week or so ago because the area above the nursing station was not safe;-The caution tape was put up yesterday. Observation on 09/04/25 at 12:05 P.M., showed the caution tape remained on the floor against the dining room wall, with part of the area the engineering company had identified to be structurally unsound, directly accessible to staff and residents. Observation on 09/04/25 at 12:08 P.M., showed the maintenance director put caution tape back up around the nurses station. Areas around the nurses station were all accessible to residents, staff, family and visitors; this area was a central hub where all resident occupied halls converged; Observation on 09/04/25, at 12:55 P.M., showed four residents sat in the main common area watching television. (This was an area the engineering company had identified to be structurally unsound.) During an interview on 09/04/25, at 12:55 P.M., Licensed Practical Nurse (LPN) K said the following: -The area above the nursing station had a crack in if for maybe a month;-Staff had recently been told the area was not safe and the nurses station was moved to the front lobby;-The area got roped off yesterday. During an interview on 09/04/25, at 1:04 P.M., CNA L said the following: -He/She had been recently told the area above the nursing station was not safe;-The nursing station had been moved to the front lobby a couple of weeks ago. During an interview on 09/04/25, at 1:16 P.M., LPN M said the following: -He/She was told by one of the other nurses that the area above the nursing station was not safe and the nursing station was moved to the front lobby;-The ceiling had been checked and after it was checked the nursing station was moved;-The area got roped off the day before he/she believes. Observation on 09/04/25 at 3:41 P.M., showed two residents sat in the main common area watching television. (This was an area the engineering company had identified to be structurally unsound.) During an interview on 09/04/25 at 12:14 P.M., 2:27 P.M. and 2:50 P.M., the Maintenance Director said the following: -Someone (he could not remember who) notified him of the cracked ceiling above the nursing station about a month ago;-It looked like the ceiling was sagging a bit;-He immediately told the Administrator, and she contacted the corporate regional project manager/corporate contact for maintenance; -A local contractor evaluated the issue and told him they would not do any work on the area until a structural engineer was contacted;-A structural engineer evaluated the area, and there was something with the beams bowing and the sheetrock separating that required repair; -To his knowledge, the ceiling was still structurally stable but needed repairs;-On 09/03/25, the Administrator told him to remove all items from the nurses station and to rope off the area with caution tape;-He was instructed by the administrator to rope off the area for safety to keep staff and residents from going through the area. During an interview on 09/09/25 at 9:39 A.M., and 09/18/25 at 10:28 A.M., the facility's regional project manager said the following: -He made a visit to the facility and contracted a structural engineering company and two local contractors to evaluate the issues with the ceiling and formulate a plan for fixing the issues; -He was at the facility when the structural engineer did the inspection, and he asked the engineer if staff should continue to stay out of the affected area. The engineer advised for people to stay out of the nurses station and table area at the front lobby near the entrance; -He was under the impression the Administrator understood that as she had already moved staff out of the nurses station area;-He received email communication from the engineering consultants on 8/22/25, at 5:06 P.M., that included their investigation letter and photo documentation;-The communication from the engineering consultants was acknowledged and then forwarded as an email to the administrator on 08/22/25 at 5:14 P.M.; -He was under the impression the Administrator received a copy of the same letter he received from the engineering consultants (on 8/22/25); -He did not recall making specific contact with the Administrator related to the letter that referenced the structural issue; -After he received the letter, dated 08/22/25, from the engineering consultants he understood that residents were not allowed in that area. It was his assumption that no one was allowed in that area. He did not ask that specific question of the Administrator or follow-up with her as to what was being done related to this area and probably should have; -He assumed when he asked the engineer if people should stay out of the central nursing station area, that would include not only staff but residents too; -He was not sure why the contractor's comments from the 08/27/25 report was not addressed by the facility to keep residents and staff out of the identified areas of concern; -It would have been his expectation the Administrator reviewed his forwarded emails and communication that included the letters from the engineer and contractors and to implement any recommendations addressed in that communication; -He did not follow-up with the Administrator at any time related to those emails or communication and he probably should have as the project manager;-If the area was unsafe for the employees, it should have also been restricted to residents and visitors. During an interview on 09/09/25 at 10:11 A.M. and 09/18/25 at 11:18 A.M., the Administrator said the following: -The ceiling issue was originally reported by the maintenance director, to the corporate project manager by phone, around the beginning of August;-She did not have written documentation of when the corporate project manager was initially contacted about the ceiling issues;-She did not review the reports/letters from the contractors or the engineer until 09/04/25;-The original reports were forwarded to her on 08/22/25; -When the engineer said the area was unsound and employees should continue to avoid the area, this should have been addressed at that time;-The facility site report, dated 08/27/25, showed both contractors indicated that employees should continue to avoid working in the area. This should have been addressed for not only the employees but for the residents at that time and it was not because she did not read the report until 09/04/25. NOTE: At the time of the recertification survey, the violation was determined to be at the immediate jeopardy level L. Based on interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the F level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). 26044822607524

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) eight consecutive hours a day, seven days a week, for 15 of 32 days reviewed. The facility census was 70. Review of the facility policy, Registered Nurse, dated 01/30/24, showed the following: -Purpose: ensure that an RN is available for supervision in the facility;-Procedure: except when waived, the facility must use the services of an RN for at least eight consecutive hours a day, seven days a week. 1. Review of the facility assessment, revised 05/14/25, showed a staffing plan of eight RN hours per a resident day on the day shift. 2. Review of the facility posted staffing sheets, from 08/05/25 through 09/05/25, documenting staff who worked each day, showed the following: -No RN coverage on 08/05/25;-No RN coverage on 08/06/25;-No RN coverage on 08/09/25;-No RN coverage on 08/10/25;-No RN coverage on 08/16/25;-No RN coverage on 08/17/25;-No RN coverage on 08/19/25;-No RN coverage on 08/23/25;-No RN coverage on 08/24/25;-No RN coverage on 08/30/25;-No RN coverage on 08/31/25;-No RN coverage on 09/02/25;-No RN coverage on 09/03/25; -No RN coverage on 09/04/25;-No RN coverage on 09/05/25. During an interview on 09/04/25 at 2:12 P.M., the staffing coordinator said the following: -She had been doing the scheduled since 08/22/25;-There was supposed to be a RN at least eight hours every day;-She was responsible for ensuring there was adequate nursing staff;-She reported the lack of a RN on the schedule for multiple days to the administrator since the prior Director of Nurses (DON) quit and a new one was hired. During an interview on 09/09/25 at 2:25 P.M., the DON said the following:-She was aware there had been an issue with RN coverage;-The staffing coordinator was responsible for ensuring a RN was on the schedule for eight hours each day;-The facility did not have enough RN's to staff as required. During an interview on 09/09/25 at 10:11 A.M., the administrator said the following: -There should be an RN scheduled eight hours every day to meet regulation;-The facility utilized the DON and facility nurses that worked as needed (PRN) to fill shifts; -At present the facility was not meeting the requirement for an RN eight hours of every day;-If the staffing coordinator has concerns related to the schedule, she will report those concerns to the DON or herself;-She was not aware there were so many days of no RN coverage.

Based on interview and record review, the facility failed to ensure medication was administered according to professional standards of practice for one resident (Resident #1), in a review of five sampled residents. Licensed Practical Nurse (LPN) A administered an antipsychotic medication prepared by another nurse, LPN D, was unaware of the contents of the medication cup when he/she administered the medication to the resident and failed to document administration of the medication. LPN D gave a certified nurse aide medication LPN D prepared and when the certified nurse aide was unsuccessful in administration, LPN A administered the medication. The facility census was 64. Review of the facility undated Medication Administration policy showed the following: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so, as ordered by the physician and in accordance with professional standards of practice; -Review Medication Administration Record (MAR) to identify medication to be administered; -Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time; -Remove medication from source; -Administer medication as ordered, provide appropriate amount of food and fluid, crush medication s as ordered; -Observe resident consumption of medication; -Sign MAR after administered; -Report and document any adverse side effects or refusals. Review of dhss.mo.gov Certified Nurse Assistant (CNA) registry website showed the CNA training program prepares individuals for employment in a long-term care facility. The program teaches skills in resident care under the direct supervision of a licensed nurse and does not include medication administration by the CNA. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/13/25, showed the following: -Severe cognitive impairment; -No delusions or hallucinations; -No physical or verbal behaviors towards others; -Other behavioral symptoms not directed toward others occurred (symptoms such as hitting or scratching self, pacing, rummaging, disrobing in public, verbal or vocal symptoms like screaming or disruptive sounds); -Required antianxiety medications during the previous seven days; -No antipsychotic medications required. Review of the resident's Care Plan, dated 2/17/25, showed the following: -Diagnoses of Parkinson's disease (a progressive neurological disease that caused decline in mobility, movement and cognitive ability), adjustment disorder with mixed anxiety and depressed mood, dementia with agitation, anxiety disorder, and mood disorder; -The resident was forgetful and confused with anxiety and agitation at times related to dementia. He/She could be resistive and agitated during care. Behaviors appeared to be worse in the late afternoon-evenings. Staff should not confront or argue with the resident, attempt to interest in diversional activity. Approach in calm manner. If unable to calm the resident and he/she remained resistive to care, assure a safe environment and allow the resident to calm down, reapproach later. If the resident refused medication when upset, reapproach when the resident was calm, have a different nurse/medication technician offer medications. Review of the resident's Nurses Note, dated 2/17/25, showed staff documented at 6:47 P.M. the resident continued to yell out for family and for help. Staff redirected and sat with the resident. Physician notified and one time order for Trazadone (medication in the treatment of major depressive disorder) 25 milligrams (mg) received. Review of the resident's Physician Order Sheets (POS), dated 2/17/25, showed Trazadone 25 mg one time only for anxiety and yelling out. Review of the resident 's Medication Administration Record (MAR), dated 2/17/25, showed at 6:24 P.M., staff documented administration of Trazadone 25 mg, one time only. Review of the resident's record showed no documentation regarding the resident's condition, behaviors or effectiveness of Trazadone 25 mg administered on 2/17/25 at 6:24 P.M. Review of the resident's POS, dated 2/18/25, showed Zyprexa (antipsychotic medication used to treat mental illness) 2.5 mg every 12 hours as needed for anxiety. Review of the resident's Nurses Notes showed staff did not document the resident's condition or behaviors regarding the physician's orders on 2/18/25 for Zyprexa 2.5 mg every 12 hours as needed for anxiety. Review of the resident's MAR showed staff documented on 2/18/25 at 7:11 P.M., Zyprexa 2.5 mg administered as needed for anxiety. Review of the resident's Nurses Note, dated 2/18/25 at 9:24 P.M., showed staff documented Zyprexa 2.5 mg administered at 7:11 P.M. and was ineffective. Review of the resident's MAR showed staff documented on 2/19/25 at 8:18 A.M. Zyprexa 2.5 mg. administered as needed for anxiety. Review of the resident's Nurses Notes showed no staff documentation regarding the resident's condition or behaviors regarding administration of Zyprexa 2.5 mg at 8:18 A.M. Review of the resident's Nurses note, dated 2/18/25 at 9:47 A.M., showed staff documented Zyprexa 2.5 mg administered at 8:18 A.M. and was effective. During an interview on 2/27/25 at 10:20 A.M., Licensed Practical Nurse (LPN) D said the resident was frequently agitated and refused medication. Recent medication changes were made. On 2/19/25 at about 6:00 P.M., the resident was agitated and refused medications. LPN D obtained the resident's as needed Zyprexa medication and mixed the medication in applesauce. The resident refused the medication. LPN D gave Certified Nurse Assistant (CNA) C the cup of Zyprexa and applesauce to administer, and the resident refused. LPN A was at the desk for change of shift report and said he/she would administer the medication. LPN A took the cup of Zyprexa and applesauce. LPN D went down the hall to attend another resident. When LPN D returned, LPN A said he/she administered the resident's Zyprexa and applesauce. LPN D did not document Zyprexa 2.5 mg had been administered on the resident's MAR. LPN A should have documented Zyprexa 2.5 mg administered on the resident's MAR. Review of the resident's MAR, dated 2/19/25, showed no documentation staff administered Zyprexa 2.5 mg at approximately 6:00 P.M. Review of the resident's record showed no staff documentation regarding the resident's condition or behaviors regarding administration of Zyprexa 2.5 mg at approximately 6:00 P.M. and no staff documentation regarding the effectiveness of the medication. During an interview on 2/27/25 at 1:45 P.M., LPN A said on 2/19/25 at about 6:00 P.M., he/she came to work and the resident was agitated. Certified Medication Technician (CMT) G handed LPN A a medication cup of applesauce and asked LPN A to administer the medication in the cup. LPN A did not know what medication was in the medication cup, never saw who prepared the medication, and did not document any as needed medication as administered on 2/19/25 at about 6:00 P.M. LPN A did not know the medication cup contained Zyprexa mixed in applesauce. During an interview on 2/27/25 at 4:00 P.M., the Director of Nursing said the same staff who prepared a medication should administer the medication and document administration of the medication. Staff should document in the resident's nurses' notes behaviors and communication with physicians regarding behaviors and new physician orders. Staff should not pass a prepared medication cup from one nurse to another for administration. Only licensed nurses and CMT staff were allowed to administer medications. CNA staff were not allowed to administer medications. The resident had behaviors. Staff should follow the facility policy regarding medication administration. During an interview on 3/12/25 at 11:20 A.M., the Administrator said staff should assess and document the resident's condition and behaviors before and after any as needed medication was administered. Staff should follow the facility medication administration policy and the nurse that prepared a medication should administer the medication to ensure accuracy. Staff should document in the resident's MAR all medications administered. If a medication was not given, staff should document in the MAR and nurses' notes the reason the medication was not given.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for one resident (Resident #4), in a review of 24 sampled residents, when staff did not ensure the resident had a comfortable wheelchair that fit him/her properly and did not cause him/her discomfort and pain. The resident presented with an increase in depression symptoms and reported that due to not having a comfortable wheelchair, he/she stayed in bed and felt abandoned, thrown away and like nobody cared. The facility also failed to ensure call lights were within reach for three residents (Residents #3, #22 and #29), in a review of 24 sampled residents. The facility census was 64. Review of the facility policy, Accommodation of Needs, revised 03/2021, showed the following: -Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being; -1. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered; -2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis; -4. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. For example: a. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication, and maintain dignity. Review of the facility policy, Resident Call System, dated 01/30/24, showed the following: -Ensure that residents have a means of direct communication between the resident and his/her caregivers when in their rooms and toilet and bathing areas; -The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. 1. Review of Resident #4's undated Continuity of Care Document (CCD) showed the following: -Admission to the facility on [DATE]; -Diagnoses included acquired absence of right leg above knee, osteoarthritis of right and left shoulder, anxiety disorder, depression, and legal blindness; -Goals: He/She will be allowed to safely smoke cigarettes, with supervision. He/She will participate in activities of choice at least two times weekly through next review. He/She will be comfortable and free from signs and symptoms of pain through next review. His/Her care plan will be followed through next review. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/03/24, showed the following: -Cognitively intact; -Able to make self-understood and understood others; -Moderately impaired vision - can identify objects; -Feeling down, depressed or hopeless; -Mild depression; -Activities that were very important to the resident included attending favorite activities and going outside when the weather was good; -Scheduled pain medication with complaints of frequent, moderate pain; -Pressure reducing device for chair; -Current tobacco user. Review of the resident's Telehealth Notes, dated 7/17/24, showed the following: -The resident was seen for follow-up related to psychotropic medication management and mood; -The resident had stopped going out for meals and smoking (no indication as to why); -The resident reported his/her mood was fair; -Feeling down, depressed or hopeless: several days; -Mood: discouraged; -Nonpharmacological recommendations: encourage the resident to continue to engage in meaningful activities. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Able to make self-understood and understood others; -Moderately impaired vision - can identify objects; -Feeling down, depressed or hopeless; -Mild depression; -No behaviors or rejection of cares; -Required substantial/maximum assistance with upper body dressing, personal hygiene, and rolling from left to right; -Dependent on staff for lower body dressing, putting on/taking off footwear, sitting to lying transfer, lying to sitting on the side of the bed, chair/bed-to-chair transfers, tub/shower transfers and all aspects of wheelchair mobility; -Scheduled pain medication with complaints of frequent, moderate pain; -Pressure reducing device for bed and chair; -No indication on MDS of tobacco use status. Review of the resident's Telehealth notes, dated 08/07/24, showed the following: -The resident was seen for follow up on mood and behaviors; -The resident reported his/her mood had been the same and continues to feel down on a daily basis; -Feeling down, depressed or hopeless: several days; -Nonpharmacological recommendations: encourage the resident to continue to engage in meaningful activities. Review of the resident's Telehealth notes, dated 08/12/24, showed the following: -The resident has poor eyesight, so he/she spent much of his/her day listening to books on tape; -Feeling down, depressed or hopeless: more than half of the days; -The resident was referred by the facility for psychotherapy due to possible increase in depressive and anxiety symptoms; -The resident reported he/she had been doing ok; -Mood: within normal limits, depressed/sad; -Interventions: supportive active listening ad rapport building, encouraged the resident to participate in social activities and continue to encourage contact with family, friends and staff; -Recommendations: encourage adherence to daily schedules and provide opportunities during the day for cognitive and mental stimulation. Review of the resident's September 2024 Physician Order Sheets showed the following: -May participate in activities as tolerated; -Pressure reducing device (wheelchair cushion) utilized in wheelchair every shift (original order dated 03/20/24); -High back reclining wheelchair for positioning, support and comfort (original order dated 03/27/24). Observation on 09/16/24 at 4:02 P.M. showed the following: -The resident lay in bed with his/her eyes closed. He/She had head phones on his/her ears connected to a book on tape; -A high back wheelchair sat at the resident's bedside. A positioning cushion was on the left arm rest of the wheelchair. There was no pressure relieving cushion present in the seat of the wheelchair. During interviews on 09/16/24 at 4:02 P.M., 4:25 P.M. and 5:03 P.M., the resident said the following: -He/She did not get up anymore because his/her wheelchair hurt him/her so bad that he/she did not get up; -The wheelchair hurt his/her back, hips and shoulders; -He/She had bad shoulders and the wheelchair squeezed his/her hips; -The pain in his/her hips transferred to his/her buttocks and caused pressure; -The wheelchair had caused discomfort for quite some time; he/she was unsure exactly how long but as long as he/she had the chair (original order for the chair was 3/27/24); -He/She told anyone and everyone that would listen that his/her wheelchair hurt when he/she was in it, but nothing was done about it. He/She still had the chair that hurt. Sometimes he/she went to physician appointments in the wheelchair and that hurt his/her body; -He/She ate meals in his/her room, but would like to go to the dining room if he/she had a wheelchair that was comfortable; -He/She would like to get out of his/her room and listen to conversations. It would be a nice change of scenery. If he/she was stuck in bed, he/she could not make friends; -He/She would like to get up out of bed to smoke, but he/she could not get up to smoke because of how uncomfortable his/her wheelchair made him/her; -He/She would like to smoke at least two times a day. He/She usually only got up to smoke once. One day last week, he/she was hurting so bad because of the wheelchair that he/she only smoked once and went inside to supper. He/She was hurting so bad that he/she could not eat. He/She had to sit in the chair for a couple of hours and it was horrible; -He/She did not know for sure when he/she smoked last, maybe two or three days ago, that was the time he/she sat up and was hurting so bad and did not eat; -If he/she had a more comfortable chair, he/she would smoke more than once a day and get up for meals and possibly more activities; -Since he/she was stuck in bed because the wheelchair caused discomfort and pain, he/she felt abandoned, like he/she had been thrown away and like nobody cared about him/her. Observation on 09/17/24 at 5:30 A.M., showed the resident lay in bed asleep with the same high back wheelchair at his/her bedside. No pressure relieving cushion was present in the seat of the wheelchair or visible in the surrounding area of the room. Review of the resident's Care Plan, revised 09/17/24, showed the following: -He/She had frequent complaints of chronic bilateral shoulder pain, neck and chronic back pain due to osteoarthritis; -He/She would be comfortable and free from signs and symptoms of pain through the next review; -Assist him/her to a position of comfort and reposition as needed; -He/She was at risk for skin breakdown due to limited mobility and had a pressure reducing cushion in his/her wheelchair; -He/She was on medications for depression and anxiety. Monitor him/her for any sign or symptoms of depression, and if any are noted, report to the charge nurse; -He/She would benefit from interactions with others during group activities; -He/She will participate in activities of choice at least two times weekly through next review; -He/She enjoyed audio books, manicures, listening to classical music, and going outdoors to smoke; -He/She was a smoker and would like to continue to smoke during his/her stay at the facility; -He/She smoked cigarettes daily. Staff will provide the resident with his/her cigarettes when it is smoke time. During an interview on 09/17/24, at 6:34 A.M., Certified Nursing Assistant (CNA) G said the following: -The resident was a smoker; -The resident told staff when they got him/her up if he/she wanted to smoke, which was usually only one time a day; -The resident had complained that his/her wheelchair caused him/her discomfort or pain when he/she got up and that was why the resident did not like to get up much; -The resident did not participate in activities and wanted to stay in bed because the wheelchair hurt him/her when he/she got up. During an interview on 09/17/24, at 8:10 A.M., CNA C said the following: -The resident was a smoker but did not smoke very often, usually just at the 2:00 P.M. smoke break; -The resident told staff when he/she wanted to smoke; -He/She had never specifically asked the resident why he/she did not want to get out of bed more; -The resident complained that his/her wheelchair caused discomfort and pain when he/she was up in the chair; -He/She was aware the resident wanted a more comfortable wheelchair. During an interview on 09/17/24, at 8:23 A.M., CNA D said the following: -The resident was a smoker but only liked to be up for the afternoon smoke time; -The resident did not want to get up to smoke because he/she hurt when up in his/her wheelchair; -The resident voiced complaints about his/her wheelchair causing discomfort or pain; -The resident's hips were too tight in the current chair; -The resident did not participate in activities and did not come out of his/her room because his/her wheelchair caused him/her discomfort; -The resident only got up for one meal, dinner, when he/she got up because the wheelchair caused discomfort; -He/She was aware the resident wanted a more comfortable wheelchair; -The resident told him/her that he/she felt alone and that no one cared. He/She reported this to the charge nurse when it occurred, but he/she was unsure who he/she reported it to and when. During interviews on 09/27/24 at 11:43 A.M., and 10/2/24 at 8:32 A.M., the Activities Director said the following: -The resident did not like to get out of bed because he/she did not like to sit in his/her wheelchair because his/her body hurt; -The resident told her (unsure when this occurred) one time that he/she did not attend group activities and did not get out of bed, because he/she was in pain and his/her wheelchair caused discomfort; -The last time the resident was in a group activity (prior to the recertification survey), the resident complained that his/her neck and back were hurting; -She did not report the wheelchair caused discomfort to anyone. During an interview on 09/17/24, at 9:03 A.M., the Director of Nursing (DON) said the following: -The resident only smoked one time a day; -The staff took the resident to smoke when he/she requested; -Sometimes the resident got up and sometimes he/she did not; -The resident did not participate in activities and chose to stay in his/her room and listen to books on tape; -The resident usually just got up for one meal, usually lunch; -She did not specifically ask the resident why he/she did not want to get out of bed more; -She was not aware the resident had not been out of bed since Friday due to complaints about the wheelchair causing him/her discomfort or pain; -She was not aware the resident would like to smoke more, wanted to attend more activities, or felt alone/thrown away or like no one cares about him/her. During an interview on 09/17/24 at 9:14 A.M., and 09/25/24 at 3:45 P.M., the Administrator said the following: -The resident very rarely requested to smoke, mainly only when he/she was out of bed; -The resident did not usually attend group activities, just usually one-on-one activities with the activities director; -To her knowledge, the resident never expressed the desire to attend group activities; -The resident got up sometimes for one meal a day by his/her choice; -She was not aware the resident would like to go out and smoke more or wanted to attend more activities; -She was aware the resident made statements of feeling alone and triggered for depression; the resident received counseling services for his/her depression; -Prior to 09/17/24, she was unsure if anyone specifically asked the resident why he/she was not getting out of bed. The resident usually requested when he/she wanted to get up and typically only got up one time per day. 2. Review of Resident #22's Face Sheet showed the resident's diagnoses included dementia with behaviors, Parkinson's disease (a disorder that affects movement symptoms are slow movement, stiffness, and loss of balance), anxiety, depression, a history of a stroke, and an unspecified mood disorder. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Was usually understood and usually understood others; -Moderately impaired vision with corrective lenses; -Dependent on staff for transfers. Review of the resident's Care Plan, last reviewed on 06/18/2024, showed the following: -At high risk for falls; -The resident was forgetful and confused with very poor vision, weak and unsteady. -Required the assistance of one to two staff with transfer and ADLs; -History of falls; -Ensure the resident's call light is within reach at all times. Observation on 09/16/24, at 4:47 P.M., showed the resident in his/her room in a recliner. The resident's feet are elevated high in the chair. The resident's call light was across the room and clipped high up on the curtain that divided the room. The call light was not in the resident's reach. During an interview on 09/16/24, at 4:47 P.M., the resident said he/she used his/her call light to call for help if he/she could find it. The resident asked, do you know where it is? The resident said he/she could not put the feet down on his/her recliner. Observation on 09/17/24, at 4:08 P.M., showed the resident sat reclined in the recliner chair in his/her room. The resident has his/her eyes open. The resident's call light was across the room and clipped high up on the curtain that divided the room. The call light was not in the resident's reach. 3. Review of Resident #3's Face Sheet showed the resident's diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), vascular dementia (brain damage caused by multiple strokes, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Clear speech, usually made self understood and usually understood others; -Required partial/moderate staff assistance for rolling left and right; -Required substantial/maximum staff assistance for sitting to lying, lying to sitting on side of bed, and wheelchair mobility; -Dependent on staff for chair/bed-to-chair transfers. Review of the resident's Care Plan, reviewed on 7/11/24, showed the following: -He/She was forgetful, confused, and unsteady with poor safety awareness, poor wheelchair positioning and a history of falls; -He/She needed assist of one to two with all activity of daily living (ADL) care; -Make sure his/her call light is within reach at all times. Observation on 09/17/24, at 5:30 A.M., showed the resident lay in bed sleeping. The resident's call light was draped over the end of the foot board out of the resident's reach. Observation on 09/18/24, at 8:30 A.M., showed the resident sat in his/her wheelchair watching television. The resident's call light was across the room on the bed out of the resident's reach. 4. Review of Resident #29's Face Sheet showed the resident's diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning) and anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Adequate hearing, clear speech, sometimes understood others; -Dependent on staff assistance for rolling left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfers, wheelchair mobility. Review of the resident's Care Plan, reviewed on 07/18/24, showed the following: -He/She was weak and unsteady and at risk for falls; -He/She needed assistance with all ADL care; -Make sure his/her call light is within reach at all times. Observation on 09/17/24, at 5:32 A.M., showed the resident lay in bed sleeping. The resident's call light was across the room in the recliner out of the resident's reach. Observation on 09/18/24, at 8:35 A.M., showed the resident sat in the middle of the room in his/her Broda chair. The resident's call light sat in the recliner out of the resident's reach. 5. During an interview on 09/28/24, at 11:34 A.M., the DON said residents' call lights should always be in reach, even for a resident with a diagnosis of dementia. During an interview on 09/27/24, at 12:11 P.M., the Administrator said the residents' call lights should always be in reach, even for a resident with a diagnosis of dementia.

Based on observation, interview, and record review, the facility failed to label, date and cover food items, failed to properly wear hair restraints, failed to utilize proper handwashing and glove use while handling ready to eat food items, failed to maintain the walk-in cooler fan shrouds to be free of a buildup of debris, and failed to ensure the ice machine had an appropriate air gap. The facility census was 64. Review of the facility policy, Labeling and Dating Foods (Date Marking), dated 2020, showed the following: -All foods stored will be properly labeled according to the following guidelines; -Date marking for refrigerated storage food items: Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date; -Prepared food or opened food items should be discarded when: The food item does not have a specific manufacturer expiration date and has been refrigerated for 7 days. The food item is leftover for more than 72 hours. The food item is older than the expiration date. 1. Observation on 9/15/24 at 2:42 P.M. showed the following items in the refrigerator: -A container of macaroni salad was not dated; -A container of pepper gravy, dated 9/15/24, had a lid that was open and unsealed; -A container of jelly, dated 9/6/24, had a lid that was open and unsealed; -A container of green beans, dated 9/14/24, and had a lid that was open and unsealed; Observation on 09/16/24 at 9:16 A.M. showed the following items stored inside the walk-in cooler: -A large container of grape jelly, dated September 6, had a lid that was not sealed; -A Ziplock bag with four blocks of sliced cheese, dated 9/16/24, was open to air and not sealed. Observation on 9/16/24 at 9:22 A.M. showed the following food items were stored on the metal preparation counter behind the steam table: -A round plastic container of potato chips was not dated; -A large plastic container of cheese puffs was not dated. 2. Review of the facility policy, Hair Restraints, dated 2020 showed the following: -Dining services staff shall wear hair restraints when in food production areas, dishwashing areas or when serving food; -Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. Observation on 9/16/24 at 9:29 A.M. showed Dietary Staff I placed dirty dishes in a rack and pushed the rack into the dish machine. He/She had facial hair and did not wear a beard restraint. Observation on 9/16/24 at 11:40 A.M. Dietary Staff J wore a hair restraint, but his/her hair restraint did not cover all of his/her hair and approximately 3-inches of hair remained outside of the hair restraint. His/Her facial hair was not covered by a beard guard. He/She prepared turkey and cheese sandwiches at the preparation counter. He/She finished the sandwiches and began cooking a frozen hamburger in a skillet. 3. Review of the facility policy, Proper Hand Washing and Glove Use, dated 2020, showed the following: -All employees will use proper hand washing procedures and glove usage in accordance with State and Federal sanitation guidelines; -All employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident; -Gloves are to be used whenever direct food contact is required; -Hands are washed before donning gloves and after removing gloves; -Gloves are changed any time hand washing would be required. This includes when leaving the kitchen for a break, or to go to another location in the building; after handling potentially hazardous raw food; or if the gloves become contaminated by touching the face, hair, uniform or other non-food contact surface, such as door handles and equipment; -Staff should be reminded that gloves become contaminated just as hands do, and should be changed often. When in doubt, remove gloves and wash hands again; -When gloves must be changed, they are removed, hand washing procedure is followed, and anew pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, removed, re-wash and re-glove. Observation on 9/16/245 at 12:06 P.M. showed Dietary Aide J did not wash his/her hands and donned a pair of gloves. He/She touched the walk-in cooler door, did not remove his/her gloves, then touched two slices of bread, touched a slice of cheese and slices of turkey and prepared a sandwich for a resident. He/She did not wash hands or change gloves during this process. He/She wiped his/her mouth with his/her arm and gloved hand, did not change his/her gloves, and placed the sandwich on a resident's plate with his/her gloved hand. Observation on 9/17/24 at 8:57 A.M. Dietary Aide I placed and arranged dirty silverware on a plastic rack. He/She held and used the sprayer to rinse the dirty silverware. He/She used the handle on the dishmachine to open the dishmachine door. Without washing his/her hands after handling the dirty silverware, he/she reached inside the dishmachine and grabbed a clean steam table pan with his/her dirty hands. 4. Observation on 9/16/24 at 9:16 A.M. showed the walk-in cooler fan shrouds had a heavy buildup of fuzzy debris and rust. 5. Observation on 9/16/24 at 10:43 A.M., of the facility's ice machine, showed an approximate 4-foot long section of 1-inch diameter pipe extended from the ice machine drain and entered into a 3-inch flanged drain pipe. The 1-inch pipe was approximately 2-inches below the flood rim level of the flanged drain pipe and did not contain an air gap. During an interview on 9/16/24 at 10:45 A.M., the Maintenance Director said he did not know an air gap was required at the ice machine drain. 6. During an interview on 9/17/24 at 9:32 A.M., the Dietary Manager said the following: -Staff should label, date and cover all food items; -Some container lids did not fit very well or correctly and probably need to be thrown away; -She was unsure who was responsible for cleaning the walk-in cooler fan shrouds; -Staff should wear hair restraints in the kitchen at all times. Staff with facial hair should wear beard guards. All hair should be contained inside the hair restraint. The person washing dishes should also wear a hair restraint; -Staff should wash their hands when they enter the kitchen and then should wear gloves at their work station. If staff left their station or changed tasks, they should remove their gloves and wash their hands. -Staff should handle ready-to-eat food with clean gloves, clean hands or utensils; -Staff should not touch their hair or face with gloved hands. If so, they should remove gloves and wash hands.

Based on interview and record review, the facility failed to identify that one employee had a previous criminal offense as identified on a Criminal Background Check (CBC) through the Family Care Safety Registry (FCSR), that would have prohibited his/her employment, and allowed Housekeeper H continued resident contact through his/her employment at the facility. The facility census was 64. Review of the undated facility document, titled Department of Health and Senior Services, Can't Hire and Can Hire, showed the Can't Hire column included burglary, first degree, class B felony (S569.160). Review of the facility policy and procedure, Criminal Background Checks, revised 08/21/24, showed the following: -Purpose: Ensure compliance with state and federally required criminal background checks needed to provide a safe environment for residents, staff, and visitors; -All prospective employees must undergo criminal background checks before being hired; -All background checks will be conducted annually; -The background checks cover various offenses, including felonies, misdemeanors and certain offenses that may disqualify an individual from employment; -Disqualifying offenses: individuals with certain criminal convictions are disqualified from working in long-term care (LTC) facilities; -Disqualifying offenses generally include theft and financial exploitation crimes; -Missouri has specific statutes that govern criminal background checks for LTC facilities, such as Missouri Revised Statutes Chapter 660 (Section 660.317), which outlines the requirements and procedures for background checks in the context of elder care; -These policies ensure that the facility maintains a safe environment for vulnerable residents by employing individuals who meet the state's standards for criminal history. 1. Review of Housekeeper H's employee file showed the following: -He/She was hired on 03/27/23; -A FCSR background check was completed on 03/16/23 and showed the employee had a history of a conviction for first degree burglary, class B felony; -A FCSR background check was completed again on 06/26/24 and showed the employee had a history of a conviction for first degree burglary, class B felony -The employee did not have a good cause waiver (GCW, a determination that an applicant's employment restrictions can be waived if they don't pose a risk to the health or safety of clients, patients, or residents. A GCW can apply to individuals who have been disqualified from working for regulated health care employers such as long-term care facilities). During an interview on 09/16/24 at 1:45 P.M. and 3:50 P.M., the Business Office Manager (BOM) said the following: -She was responsible for completing and reviewing the background checks on potential new employees for the facility, and this included the FCSR; -If there was a potential issue that would prohibit the facility from hiring a person, she would bring that to the attention of the administrator, Director of Nurses (DON), and the department head of the area the person had applied for; -If a prospective employee had a criminal background, she used a laminated check list from the Department of Health and Senior Services (Can Hire, Can't Hire list) to help her identify which criminal offenses would prohibit the facility from hiring someone; -She remembered seeing the employee's criminal background check but was not sure how she missed the criminal offense that prohibited his/her hiring; -The facility had two sets of eyes on checking the criminal backgrounds of prospective employees, so she was not sure how the employee's criminal history was missed; -The employee did not have a good cause waiver in place. During an interview on 09/16/24 at 2:30 P.M., the Director of Housekeeping said the following: -She reviewed applications from prospective employees when it indicated an interest in a housekeeping or laundry position; -It was up to the BOM to tell her if a potential employee had a criminal background check that was concerning or that would prohibit the hiring of that person; -If there was a concern on the criminal background check, she spoke to the administrator about those, and it was a joint decision if the facility hired the individual; -If the criminal offense was something that prohibited the facility from hiring the individual, then the administrator made that call; -She remembered looking at the employee's past criminal history when he/she was hired but did not remember what was on it; -She was familiar with what a good cause waiver was but was not aware of any facility employee who had one. During an interview on 09/16/24 at 2:50 P.M., the Administrator said the following: -The BOM was responsible for completing a background check on all prospective employees for the facility; -If there was a concern on the background check of a prospective employee, the BOM would bring that to her attention, and she would review it as well; -The facility had a list from the Department of Health and Senior Services that was used for hiring that showed a column with can't hire and can hire based on a positive criminal background check; -She was not aware the employee had a criminal offense that prohibited him/her from working at the facility; -She was not sure how the employee's criminal background that was positive for a class B felony, first degree burglary was missed on his/her hiring and on his/her yearly background check; -The facility always had at least two people who reviewed the background checks for any concerns, usually it was the BOM and her, sometimes the DON as well, so she was not sure how this slipped through.

Based on observation, interview, and record review, the facility failed to provide adequate staffing to monitor residents, provide oversight, and to provide activities to the ten residents who resided on the memory care unit. The facility census was 64. Review of the Facility Assessment, updated 02/12/24, showed the following: -The facility was licensed for 120 total beds; 14 of these beds were located on the locked unit (dementia care); -The facility had an average daily census of 71 ranging from 65-72 residents at a time; -There was an average of 12 residents located on the locked dementia care unit; -Approach to Staffing: -Five certified nurse assistants (CNAs) on day shift 6:00 A.M.-2:00 P.M.; -Five CNAs on evening shift 2:00 P.M.-10:00 P.M.; -Three CNAs on night shift 10:00 P.M.-6:00 A.M. -Staffing plan for the memory care unit was 16 hours per resident day for days and for nights; -Assignments were determined on a continuing and daily level based upon the acuity/needs of the current residents in the facility. Review of the Resident Bed List Report, dated 09/15/24, showed the census on the locked dementia unit was ten residents. Review of the Daily Staffing Sheet, dated 09/15/24, showed the following: -Five CNAs on the day shift; -Five CNAs on the evening shift; -Three CNAs on the night shift. (One of the CNAs worked on the memory care unit on the day, evening and night shifts.) Observation on 09/15/24, at 5:05 P.M.-5:30 P.M., showed the following: -CNA K was the only staff on the memory care unit; -Resident #21 wandered up and down the hall and in and out of rooms; -Resident #28 and Resident #50 were in the dining room with their supper trays in front of them on the table; -Resident #50's wheelchair wheels were locked and the arm rests were against the table; -Resident #17 sat in his/her room on the side of the bed eating his/her supper; -Resident #22 was in his/her room in bed with his/her eyes open; -Resident #12 sat in his/her room in a recliner eating his/her supper; -The three other residents on the locked unit were in the main dining room for the supper meal; -Between 5:05 P.M. and 5:30 P.M., CNA K went from the dining room, down to the end of the hall to Resident #12's room, cued Resident #21 where ever he/she was at the time, and assisted Resident #17 with his/her meal tray, then went back to check on the residents eating in the dining area; -CNA K left the residents unattended in the dining area when he/she had to leave the dining area to assist other residents and left Resident #21 wandering in and out of rooms without supervision. During an interview on 0915.24, at 5:10 P.M., CNA K said all the residents on the memory care unit, except for one resident, needed assistance with toileting. He/She had to leave all the residents unattended when he/she had to assist with toileting nine residents. Observations in the memory care unit on 09/16/24, between 10:40 A.M.-11:10 A.M., showed the following: -Certified Medication Technician (CMT) N was the only staff on the memory care unit and assisted residents in their rooms; -Resident #50 sat in his/her wheelchair with the arm rests against the dining room table with the wheels locked; -Resident #22 sat reclined in a high-back wheelchair in the dining room. The resident's head was down and his/her eyes were closed; -Resident #21 wandered in and out of residents' rooms, down the hallway and in and out of the dining room; -CMT N assisted residents in their rooms and went into the dining room one time at 10:54 A.M. During an interview on 09/16/24, at 10:51 A.M., CMT N said he/she watched the unit while CNA O gave Resident #12 a shower off of the unit. During an interview on 09/16/24, at 11:37 A.M., CNA O said the following: -He/She was the only staff on the memory care unit and could not watch the residents all the time; -There were incontinent residents he/she had to toilet and other residents he/she had to check on often because they wandered or needed assistance; -There used to be two staff on the memory care unit unit, but the facility census was down so they decreased the staffing to one staff on the unit. It was overwhelming to keep up with all the residents and make sure they had what they needed; -There were no activities for the residents on the memory care unit because they decreased the staffing on the unit; -When there were two CNAs, one CNA would entertain the residents in the dining area with an activity while the other CNA would toilet, groom, and shower the other residents; -The activity staff did not have time to do activities for the residents on the dementia unit. During an interview on 09/16/24 at 4:40 P.M., CNA/CMT R (the staffing coordinator), said since the census was below 70 for the building, they were only allowed to have one staff on the memory care unit. The census for the memory care unit was usually 10 to 12 residents and didn't change much. The facility staffing was based on the census for the entire building. During an interview on 09/18/24 at 10:09 A.M., CNA W said the following: -He/She worked on the memory care unit full time until three weeks ago; -CNA O used to monitor the dining room and keep residents busy with painting or doing activities while he/she took residents to the bathroom, provided showers, and whatever needed to be done; -He/She was now part time because the facility had to cut staffing because the census was below 70; -Now there was no one to do any activities on the unit. The staff were very busy toileting the residents and trying to get showers completed; -All of the residents on the unit, except for one resident, were at risk for falling so staff were up and down the hall, to the dining room and constantly trying to monitor Resident #21. During an interview on 09/18/24, at 09:00 A.M., the Director of Nursing said the staffing on the dementia unit was decreased to one CNA a few weeks ago because of the budget. During an interview on 10/03/24, at 3:30 P.M., the Administrator said the following: -The staffing decreased a few weeks ago when the census fell ; -The staffing on the memory care unit decreased at that time when the census on the memory care unit fell to eight residents. (The census on the memory care unit during the recertification survey was 10); -She and department heads made the decision to decrease staffing; -Since some of the residents came to the main dining room for meals and activities, it made sense to decrease the staffing on the memory care unit; -She felt one staff could handle the ten residents on the unit. 42592

Based on observation, interview, and record review, the facility failed to design a meaningful activity program to meet the needs and interests of six residents (Residents #3, #4, #21, #22, #30 and #50), in a review of 24 sampled residents. The facility failed to provide activities to the residents at a frequency consistent with their plan of care and activity assessment, and failed to provide a structured activities program to three residents (Residents #21, #22 and #50) on the memory care unit focused on the individualized needs of the residents to keep them engaged in meaningful activities. The facility census was 64. Review of the facility's policy, Activity Program, dated 01/30/24, showed the following: -Activities refer to any endeavor, other than routine ADLs, in which a resident participates that is intended to enhance his/her sense of well-being and to promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, comfort, education, creativity, success, and independence. -Provide a wide range of activities to enhance the lives of residents; -Provide opportunities for residents and staff to interact on a social basis; -Activities will be scheduled on a regular basis to enrich the lives of residents. Activities will include, but are not limited to: a. Social events; b. Indoor and outdoor activities; c. Activities outside of the facility; d. Religious programs; e. Creative activities; f. Intellectual and educational activities; g. Exercise activities; h. Individualized activities; i. In-room activities; j. Community activities; -Individualized and group activities are provided that; a. Reflect the schedules, choices, and rights of the residents; b. Are offered at hours convenient to and preferred by the residents, including holidays and weekends; c. Reflect the cultural and religious interests of the residents; d. Appeal to both men and women as well as all age groups of residents residing in the facility; -Residents are encouraged but not forced to participate in scheduled activities. Review of the facility's policy, Types of Activity Programs, dated 01/30/24, showed the following: -Activity programs will be provided to support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community; -This facility's Activity Program incorporates the resident's interests, hobbies, and cultural preferences to 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; -Diversional activities, for both male and female residents, are provided to place emphasis on accomplishment rather than sociability and fun, although residents may have fun and find the activity enjoyable; -Diversional activities include, but are not limited to: i. Braiding rugs; ii. Sewing, quilting, etc.; iii. Painting; iv. Refinishing furniture; v. Repairing or making toys, etc.; -Group activities, the involvement of a number of people in physical and mental interaction, are vital to the effectiveness of the activity program; -Group activities maximize resources, involve many people, and promote social interaction; -These activities are encouraged to assist residents in overcoming feelings of loneliness, isolation, and self-pity, which often accompany long-term care and illness; -Group activities are divided into four categories: i. Spectator; ii. Performing; iii. Independent/Individual; iv. Interdependent; -Residents are encouraged to participate in all group activities, but especially those where they are best able to participate physically, mentally, and emotionally; -Individual activities are provided because residents have a need for personal identity. Some residents are unable to or do not wish to participate in group activities; -For those residents whose physical disabilities prohibit movement to a group activity, or those who do not wish to participate in group activities, the individual activity program provides; -Activities which make maximum use of each resident's physical and mental abilities; -Activities which are interesting to and involve the resident and which present a challenge that can be met by the resident; -For residents who have severe emotional problems or who are not alert enough to become part of a group, the individual program of activities includes: a. Activities which are basically uncomplicated, but which can become more elaborate to accommodate increased ability, such as making yarn animals or playing games; b. Short periods of concentration to avoid frustration; c. Enough time for the activity department to develop a close relationship with the resident involved so that activity personnel will be able to regain the resident's attention should his or her mind wander; -Intellectual activities are encouraged and are designed to stimulate the resident's mind. These activities include, but are not limited to participation in discussion groups, clubs, and committees; voting; book reviews/clubs; sketching; drama; music appreciation; current events, etc.; materials such as talking books, records and films are available from the local library as well as other resources; -Social activities are scheduled to help minimize self-consciousness, increase self-confidence, and stimulate interest and friendships by providing fun and enjoyment for those who take part; -Social activities may include, but are not limited to square, folk, and round dancing; group singing; horseshoes; adapted bowling; charades; cards; checkers, bingo, board games; birthday/holiday parties, etc; -Recreational activities with an emphasis on social aspects include outings to places of interest (e.g., historic places, museums, ball games, fairs, parks, etc.); participation in community groups and religious organizations. This type of activity will encourage residents to be more active in the community setting; -Spiritual and Religious Activities: a. Various types of spiritual and religious activities are available and scheduled through local churches and ministers; b. Residents are encouraged to attend religious activities of their choice. These activities may include, but are not limited to worship services, singing, bible teaching, and bible reading; -Residents are always given freedom of choice in attending spiritual and religious activities and are never forced to attend; -Resident requests for private consultation with clergymen are always honored; -Alternative activity programs may be scheduled simultaneously with religious services for those residents who wish to attend non-religious programs; -Activities for Residents with Dementia: a. All residents have a need for engagement in meaningful activities. For residents with dementia, the lack of engaging activities can cause boredom, loneliness and frustration resulting in distress and agitation; b. Activities must be individualized and customized based on the resident's previous lifestyle (occupation, family, hobbies), preferences and comforts. 1. Review of Resident #3's Face Sheet showed the resident's diagnoses included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), vascular dementia (brain damage caused by multiple strokes), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with daily activities). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/28/24, showed the following: -Severely impaired cognition; -Activities very important to the resident included listening to music he/she liked and attending favorite activities; -Activities somewhat important to the resident included doing things with groups of people and going outside for fresh air when weather was good; -Activities that are not very important include: being around animals such as pets and participating in religious services or practices; -Activities that are not important at all include: reading books, newspapers or magazines and keeping up with the news. Review of the Resident Interview Section F Preferences, dated 06/21/24, showed the following interview for activity preferences: -Very important to listen to music, keep up with the news, do things with groups of people, and do favorite activities; -Not very important to be around animals/pets, go outside when good weather, participate in religious practices; -Not important at all: have books/newspapers/magazines to read; -Comments: The resident was encouraged to join group activities. He/She will occasionally get a manicure or social hour; -The resident was the primary respondent for activity preferences; -When the resident did not join activities and groups, he/she had one-on-one visits. Review of the resident's Activity Assessment, completed on 06/25/24, showed the following: -Resident awake all or most of the morning; -Most common use of resident's time: visiting with family, watching TV, and napping; -Average time in activities: little - less than 1/3 of time; -Preferred activity settings: own room, day/activity room and inside facility and off unit; -Special talents/hobbies: loves soda and sour tea; -Resident's preferred program style: one-on-one; -Program frequency: three times a week; -General activity preferences: music, watching TV and talking/conversing; -Focus of programming: one-on-one activities, group games, independent activities, relaxation activities and social interaction activities; -Activity Care Plan is place. Review of the resident's One-to-One Activities Log for the week of 7/7/24 through 7/13/24 showed the following: -07/09/24: length of visit: 15 minutes. Activity: discussion/conversation. Participant response: offered him/her a peach tea, explained to him/her the flavor, he/she tasted it and said, yuck, sour tea; -07/10/24: length of visit: 10 minutes. Activity: grooming. Participant response: resident was cold, got him/her a blanket, he/she was happy. We watched TV. (No documentation the resident attended a group activity, and no documentation staff offered or provided at least three activities for the resident as directed in his/her activity assessment during the week of 7/7/24 through 7/13/24.) Review of the resident's Care Plan, reviewed on 7/11/24, showed the following: -The resident would benefit from interactions with others during group activities; -Goal: he/she will participate in activities of choice at least two times weekly; -Interventions: explain activities that will be offered daily. Invite him/her to all activities and assist him/her to activities of choice. The resident enjoys watching TV, listening to music and attending special events. Provide him/her with one-on-one visits as needed for added support and socialization. Review of the resident's One-to-One Activities Log for the week of 7/14/24 through 7/20/24 showed the following: -07/14/24: length of visit: 7 minutes. Activity: grooming. Participate response: invited and helped him/her come to prayer group, he/she drank coffee and was ready to leave; -07/19/24: length of visit: 30 minutes. Activity: music. Participant response: resident loved the music and smiled the whole time. (No documentation the resident attended at least three activities, including one-on-one activities, during the week of 7/14/24 through 7/20/24.) Review of the resident's One-on-One Activities Log for the week of 7/21/24 through 7/27/24 showed the resident participated in one activity on 7/22/24. The staff asked the resident if he/she wanted ice cream and the resident asked for sour tea instead. (No documentation the resident attended a group activity, and no documentation staff offered or provided at least three activities for the resident as directed in his/her activity assessment during the week of 7/21/24 through 7/27/24.) Review of the resident's One-to-One Activities Log for the week of 7/28/24 through 8/3/24 showed the following: -08/01/24: length of visit: 15 minutes. Activity: discussion/conversation. Participant response: read the calendar to the resident; -08/03/24: length of visit: 10 minutes. Activity: discussion/conversation. Participant response: encouraged resident to join group for watermelon, he/she got watermelon. (No documentation staff offered or provided at least three activities for the resident as directed in his/her activity assessment during the week of 7/28/24 through 8/3/24.) Review of the resident's One-to-One Activities Log for the week of 8/11/24 through 8/17/24 showed the following: -08/11/24: length of visit: 10 minutes. Activity: sensory stimulation (no specific type identified). Participant response: the resident got cake from the birthday party; -08/14/24: length of visit: 15 minutes. Activity: discussion/conversation. Participant response: Got the resident and soda and talked about it being the best drink. (No documentation staff offered or provided at least three activities for the resident as directed in his/her activity assessment during the week of 8/11/24 through 8/17/24.) Review of the resident's One-to-One Activities Log for the week of 8/18/24 through 8/24/24 showed the following: -08/19/24: length of visit: 15 minutes. Activity: grooming. Participant response: resident joined manicures but refused polish and listened to music; -08/22/24: length of visit: 10 minutes. Activity: grooming. Participant response: resident wanted his/her shoes on so got shoes on his/her feet and pushed the resident in dining room to talk with friends. (No documentation staff offered or provided at least three activities for the resident as directed in his/her activity assessment during the week of 8/18/24 through 8/24/24.) Review of the resident's One-on-One Activities Log for August 2024 showed no documentation the resident participated in any activities during the week of 8/25/24 through 8/31/24. Observation on 09/15/24 at 3:52 P.M., showed the resident sat in his/her room in front of the TV. Observation on 09/16/24 at 11:05 A.M., showed staff provided residents with manicures as the scheduled activity in the dining room. The resident was not in the dining room for the activity. Observation on 09/16/24 at 2:30 P.M., showed staff provided yoga as the scheduled activity in the dining room. The resident was not in the dining room for the activity. Observation on 09/18/24 at 8:30 A.M., showed the resident sat in his/her room in front of the TV. During an interview on 10/02/24, at 8:32 A.M., the Activity Director said the following: -Activities for the resident included some group activities like manicures and bingo, but the main activity for the resident was one-on-one visits; -The resident liked to talk about college days and his/her shoes and liked to watch TV; -She saw the resident every day she was at the facility and read the activity schedule to the resident. 2. Review of Resident #4's undated Continuity of Care Document (CCD) showed the following: -Diagnoses included anxiety disorder, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and legal blindness; -He/She would participate in activities of choice at least two times weekly through next review. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Minimal hearing difficulty with clear speech; -Able to make self-understood and understood others; -Moderately impaired vision - can identify objects; -Feeling down, depressed or hopeless; -Mild depression; -Activities that were very important to the resident included having books to read (listen to), keeping up with the news, attending favorite activities and going outside when the weather is good; -Activities that were somewhat important to the resident included snacks and music. Review of the resident's One-to-One Activities Log for the week of 7/07/24 through 7/13/24 showed the resident only participated in an activity on 7/10/24. The activity was cooking club. Staff told the resident they would bring him/her the cowboy hat made during the activity. The resident loved the cowboy hat and asked how it was made. He/She had to guess what the ingredients were. (No documentation staff offered or provided at least two activities for the resident as directed in his/her care plan during the week of 7/07/24 through 7/13/24.) Review of the resident's Activity Assessment, dated 07/26/24, showed the following: -Resident awake all or most of the morning; -Most common use of resident's time: listening to audio books; -Average time in activities: little - less than 1/3 of time; -Preferred activity settings: own room and day/activity room; -Special talents/hobbies: listening to audio books; -Resident's preferred program style: 1:1 and large groups; -Program frequency: the resident loves audio books, being outside and entertainers; -Program time preference: afternoon; -Participation barriers: sight; -General activity preferences: music and talking/conversing; -Focus of programming: 1:1 activities, creative/expressive activities, intellectually stimulating activities, outdoor activities, relaxation activities and social interaction activities; -Sensory Stimulation: 1:1 and group; -Reality orientation: 1:1 and group; -Validation: 1:1 and group; -Describe other programming, if necessary: the resident is blind, he/she needs assistance always; -Activity Care Plan is place. Review of the resident's One-to-One Activities Log for the week of 7/28/24 through 8/3/24 showed the following: -7/29/24, staff painted the resident's nails in his/her room; -08/01/24: length of visit: 15 minutes. Activity: discussion/conversation. Participant response: read the calendar for the month; -08/02/24: length of visit: 10 minutes. Activity: sensory stimulation (no type indicated). Participant response: encouraged the resident to stay awake. (No documentation the staff provided at least two meaningful activities for the resident during the week of 7/28/24 through 8/3/24. Staff read the calendar to the resident and encouraged the resident to stay awake during a visit. The resident only participated in one activity where staff painted his/her nails.) Review of the resident's One-on-One Activities Log for the week of 8/04/24 through 8/10/24 showed on 8/08/24, staff painted the resident's nails. (No documentation staff offered or provided at least two activities for the resident during the week of 8/04/24 through 8/10/24.) Review of the resident's One-on-One Activities Log for the week of 8/18/24 through 8/24/24 showed the resident was up to smoke. Activity staff talked to the resident about lunch and helped him/her to the dining room. (No documentation staff provided at least two meaningful activities for the resident during the week of 8/18/24 through 8/24/24.) Review of the resident's One-on-One Activities Log for the week of 8/25/24 through 8/31/24 showed the following: -08/26/24: length of visit: 15 minutes. Activity: discussion/conversation. Participant response: encouraged resident to stay up for nails; he/she fell asleep; -08/28/24: length of visit: 10 minutes. Activity code: blank. Participant response: resident wanted to go to group coffee chat and snack, but he/she went to smoke. (No documentation the staff provided at least two meaningful activities for the resident during the week of 8/25/24 through 8/31/24.) Observation on 09/15/24, at 6:55 P.M., showed the resident lay in bed with a stocking cap pulled down over eyes. The resident wore head phones that were connected to a book on tape. Observation on 09/16/24, at 9:55 A.M., showed the resident lay in bed with a stocking cap pulled down over eyes. The resident wore head phones that were connected to a book on tape. Observation on 09/16/24 at 11:05 A.M., showed staff provided residents with manicures as the scheduled activity in the dining room. The resident was not in the dining room for the activity. Observation on 09/16/24 at 2:30 P.M., showed staff provided yoga as the scheduled activity in the dining room. The resident was not in the dining room for the activity. During an interview on 09/16/24, on 4:25 P.M., the resident said the following: -He/She had poor eyesight and did not want to have the staff help him/her during activities because it took away from other people to help him/her; -He/She enjoyed being around activities to just hear the conversations and could possibly make a new friend; -He/She mostly stayed in his/her room and listened to books on tape since he/she cannot see well; -He/She had not been getting up out of bed for smoking, meals or activities because his/her wheelchair caused him/her discomfort and pain. Review of the resident's Care Plan, revised 09/17/24, showed the following: -He/She was on medications for depression and anxiety. -He/She would benefit from interactions with others during group activities; -He/She will participate in activities of choice at least two times weekly through next review; -He/She enjoys audio books, manicures, listening to classical music, and going outdoors to smoke. Observation on 09/17/24 at 10:05 A.M., showed staff provided Bingo in the dining room as the scheduled activity. The resident was not in the dining room for the activity. During interviews on 09/27/24 at 11:43 A.M. and 10/02/24, at 8:32 A.M., the Activity Director said the following: -The resident participated in activities and went out to smoke if he/she was out of bed; -The resident did not like to get out of bed; he/she did not like to sit in his/her wheelchair because his/her body hurt; -The resident liked to talk, go outside to smoke, listen to books on tape, and manicures in his/her room; -Activities he/she provided for the resident included mainly manicures in his/her room and one-on-one visits; -She saw the resident every day she was at the facility and read the activity schedule to the resident; -She invited the resident to all groups during her morning talk, and the resident sometimes said he/she would attend and sometimes he/she refused; -When the resident refused activities, the resident would not typically give her a reason for the refusal; -She was unaware the resident wanted to attend more group activities. 3. Review of Resident #30's Face Sheet showed the resident's diagnoses included unspecified dementia (a type of dementia that does not have a specific diagnosis), depression, generalized anxiety disorder and unspecified mood affective disorder (mood disorder symptoms that are significant but do not meet the criteria for a specific mood disorder. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Activities that were very important to the resident included listening to music and attending favorite activities; -Activities that were somewhat important to the resident included being around animals such as pets, doing group activities and going outside when the weather was good; -Activities that were not very important to the resident included keeping up with the news; -Activities that were not important at all were religious services and/or practices. Review of the resident's One-to-One Activities Log for July 2024 showed no documentation staff offered or provided at least three activities for the resident on 7/1/24 through 7/13/24. Review of the resident's Activity Assessment, completed on 07/23/24, showed the following: -Awake all or most of the time in the afternoon; -Average time involved in activities: little - less than 1/3 of time; -Preferred activity settings: own room; -Preferred program style: one-on-one and large groups; -Program frequency: three one-on-one visits per week; -General activity preferences: music, walking/wheeling outdoors; -Focus of programming: one-on-one activities, relaxation activities, and social interaction activities; -Activity care plan in place. Review of the resident's One-to-One Activities Log for the week of 7/21/24 through 7/27/24 showed the following: -07/22/24: length of visit: 15 minutes. Activity: music. Participant response: played old country in the front area. -07/25/24: length of visit: 14 minutes. Activity: discussion/conversation. Participant response: tried to get resident to stay awake but he/she was tired. (No documentation staff offered or provided at least three activities for the resident as identified on his/her activity assessment during the week of 7/21/24 through 7/27/24.) Review of the resident's Care Plan, updated 08/01/24, showed the following: -He/She would benefit from interactions with others during group activities; -Goal: He/She will participate in activities of choice at least two times weekly through next review; -Approaches: Explain the activities that will be offered daily and invite him/her to all activities and assist with activities of his/her choice. The resident enjoys getting his/her nails done, holding and rocking his/her dolls, watching TV at times and socializing with spouse and visitors. Provide him/her with one-on-one visits as needed for increased socialization. Review of the resident's One-to-One Activities Log for the week of 7/28/24 through 8/03/24 showed staff read the monthly calendar to the resident on 8/02/24. (No documentation staff offered or provided at least three meaningful activities for the resident during the week of 7/28/24 through 8/03/24.) Review of the resident's One-to-One Activities Log for the week of 8/11/24 through 8/17/24 showed the following: -08/13/24: length of visit: 10 minutes. Activity: reading material. Participant response: read him/her the menu and talked about the meal; -08/15/24: length of activity: 15 minutes. Activity: music. Participant response: music in dining room - old rock. (No documentation staff offered or provided at least three meaningful activities for the resident during the week of 8/11/24 through 8/17/24.) Review of the resident's One-to-One Activities Log for the week of 8/25/24 through 8/31/24 showed the following: -08/25/24: length of activity: 15 minutes. Activity: music. Participant response: Christian music in the front room; -08/26/25: length of activity: 15 minutes. Activity: grooming. Participant response: brushed hair and talked to him/her about lunch time. (No documentation staff offered or provided at least three activities for the resident during the week of 8/25/24 through 8/31/24.) Review of the resident's One-to-One Activities Log for 9/08/24 through 9/14/24 showed staff played soft jazz for the resident after lunch on 9/08/24. (No documentation staff offered or provided at least three meaningful activities for the resident during the week of 9/08/24 through 9/14/24.) Observation on 09/15/24, at 4:24 P.M., showed the resident lay awake in his/her bed facing the wall. Observation on 09/16/24, at 9:37 A.M., showed the resident lay awake in his/her bed facing the wall. Observation on 09/16/24, at 11:05 A.M., showed activity staff in the dining room painting residents' nails. The resident was not participant of that activity. He/She sat up in his/her wheelchair at the dining room table ready for lunch. Observation on 09/16/24, at 2:30 P.M., showed staff provided yoga as a group activity in the dining room. The resident lay in bed with his/her eyes closed during the activity. During an interview on 10/02/24, at 8:32 A.M., the Activity Director said the following: -Activities for the resident included some group activities like music one time a month but mainly one-on-one visits; -The resident's family was very involved and many days the resident was too tired to talk to staff during one-on-one visit; -The resident liked to talk and she read to the resident; -She saw the resident every day she was at the facility and read the activity schedule to the resident. 4. Review of Resident #21's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Sometimes understands simple direct communication only; -Diagnoses included Alzheimer's disease, dementia, depression, and anxiety. -No wandering, behaviors or rejection of care; -Activity preferences very important to the resident: listen to music he/she likes, around animals/pets, go outside, and religious activities; -It is somewhat important to keep up with news and do things with groups, Review of the resident's quarterly MDS, dated [DATE], showed the following: -Added a diagnosis of unspecified psychosis; -No devices used (wheel chair and /c walker); -Requires supervision/touching assistance from staff for eating, roll left and right, on side of bed, sit to stand, walk 10 feet, walk 50 feet with two turns, walk 150 feet with two turns, walk 150 feet. Review of the resident's One-to-One Activities Log for 07/01/24-07/15/24, showed the following: -07/01/24: length of visit: 15 minutes. Activity: sensory. Participant response: Exercised up and down the hall. -07/02/24: length of visit: 6 minutes. Activity: music. Participant response: resident was tired but listed to Amazing Grace; -07/09/24: length of visit: 10 minutes. Activity: reading material. Participant response: read the menu to the resident and held his/her hand. The resident was sad. -07/12/24: length of visit: 10 minutes. Activity: games. Participant response: played old classic music to see if the resident recognized the music and he/she loved it. -07/13/24: length of visit: 15 minutes. Activity: discussion/conversation. Participant response: listened to Gun Smoke; -No activities documented from 7/14/24-7/19/24. Review of the resident's Activity Assessment, dated 07/16/24, showed the following: -The resident was awake most of the morning, afternoon and evening; -The most common use of the resident's time was visiting with family or staff; -Less than 1/3 to 1/2 of his/her time when awake was spent on activities; -Talents/hobbies: enjoys music; -Prefers activities in his/her own room, day/activity room, and inside nursing home/off unit; -Program style is one-on-one activities, small and large groups; -Program frequency: three or more times a week; -Prefers activities in the morning and afternoon, -Communication and short-term memory is a problem; -Leisure interest are crafts/arts, exercise, music, religious activities and walking outdoors; -Activity preferences are music or talking/conversing; -Focus programming on one-on-one visits, group games, independent activities, intellectually stimulating activities, outdoor activities, relaxation activities, and social interactions; -The resident required special programming for cognitive and/or sensory deficit programming like sensory stimulation, reality orientation, validation, with one-on-one visits, and group; -Activities staff to assist the resident with bingo and other games. Review of the resident's One-to-One Activities Log for 07/16/24-07/31/24, showed the following: -07/20/24: length of visit: blank for minutes. Activity: sensory scent. Participant response: put lotion on the resident's hand he/she loved the smell. -07/25/24: length of visit: 10 minutes. Activity: discussion/conversation. Participant response: combed h

Based on interview and record review, the facility failed to ensure the right to privacy with communication when the facility opened two additional residents' (Resident #51 and #52) personal mail without permission. The facility census was 64. Review of the facility's policy, Mail and Electronic Communication, revised May 2017, showed the following: -Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email and other electronic forms of communication confidentially; -Mail will be delivered to the resident unopened; -Staff members of this facility will not open mail for the resident unless the resident requests them to do so (such request will be documented in the resident's plan of care). 1. During group interview on 09/16/24, at 1:05 P.M., two residents in attendance said they had received mail opened in the past few months and did not want to have their mail opened. Resident #51 said his/her mail was a financial statement and Resident #52 said his/her mail was personal mail. Neither resident said they had any restrictions on mail and neither resident gave the facility permission to open their mail. During an interview on 09/18/24, at 7:12 P.M., the Social Services Director (SSD) said the following: -Activity staff typically delivered the mail, but she would deliver if needed; -Sometimes the business office manager (BOM) would also help to deliver mail; -Mail should be delivered unopened unless the resident asked for it to be opened; -Resident #51 and #52 did not have any restrictions and should receive their mail unopened. During an interview on 09/18/24, at 7:25 P.M., the BOM said the following: -She helped deliver mail to the residents if the activity staff was not able to do it; -Mail was delivered unopened unless the resident asked for it to be opened. During an interview on 09/27/24, at 11:43 A.M., the Activity Director said the following: -She was responsible for delivering mail every day that she worked; -If she was not working, the activity aide delivered the mail; -Mail should be delivered unopened; -She did not recall delivering any mail opened. During an interview on 09/18/24, at 7:06 P.M., the administrator said the following: -Mail should be delivered unopened unless there was a specific reason for it to be opened; -Residents #51 and #52 should receive their mail unopened and had no restrictions.

Based on observation, interview, and record review, the facility failed to ensure staff provided two residents (Resident #42 and #36), who required assistance to complete their own activities of daily living (ADL), in a review of 24 sampled residents, the necessary care and services to maintain good oral hygiene. The facility census was 64. Review of the facility policy, Dental/Oral Care of the Resident, dated 01/30/24, showed the following: -Purpose: to clean and freshen the resident's mouth, prevent infections of the mouth, maintain the teeth and gums in a healthy condition, stimulate the gums and remove food particles from between the teeth; -Assist the resident with brushing their teeth based on individual needs; -Teeth should be brushed every morning and evening; -Flossing of the teeth should be done at least once a day to promote healthy gums; -Inspect the gums for any paleness, discoloration, bleeding sores or irritation; -Inspect the teeth for decay or looseness; -Report and document any issues with the resident's mouth, gums and/or teeth to the charge nurse and attending physician. 1. Review of Resident #42's Face Sheet showed the resident's diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke affecting the non-dominant left side, need for assistance with personal care, and partial loss of teeth. Review of the resident's Dental Note, dated 04/03/24, showed the following: -The resident had heavy plaque (sticky, white film) and calculus (hardened, solidified plaque with a yellowish color); -The resident had red marginal gingivitis (a gum disease that is a result of bacterial buildup on the teeth causing irritation to the surrounding gum tissue and can cause the gums to become inflamed, discolored, and painful); -The resident may need additional extractions; -The resident needed oral hygiene improvement before treatment or extractions can be done; -The resident needed follow ups every three months. Review of the resident's Dental Note, dated 05/15/24, showed the following: -The resident had marginal inflammation (swelling) and bleeding following scaling (removal) of light to moderate plaque and minimal calculus buildup; -The resident had poor oral hygiene; -The resident needed someone to brush his/her teeth twice daily, with focus on the gumline. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/06/24, showed the following: -Cognitively intact; -No behaviors or rejection of care; -Impaired range of motion (ROM) in upper and lower extremities on one side; -Required partial assistance for oral hygiene. -No dental concerns. Review of the resident's Dental Note, dated 07/24/24, showed the following: -The resident had marginal inflammation and bleeding following scaling of moderate plaque and light debris; -Polish was not applied due to inflammation, bleeding, condition of enamel (the protective, outer coating of your teeth), and exposed root surface; -The resident had poor oral hygiene; -The resident needed someone to brush his/her teeth twice daily, with focus along the gumline. Review of the resident's Dental Note, dated 08/14/24, showed the following: -The resident had poor oral hygiene; -The resident had heavy plaque and calculus; -It was recommended the resident have three teeth extracted. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors or rejections of care; -Impaired range of motion in upper and lower extremities on one side; -Required partial assistance for oral hygiene; -No dental concerns. Review of the resident's Care Plan, revised 09/12/24, showed the following: -The resident was mostly dependent on one to two staff for ADLs; -The resident had left sided hemiplegia; -Staff were to assist the resident with ADLs to keep the resident well-groomed; -The resident had a history of 13 dental extractions; -The resident had his/her own teeth; -No documentation of oral hygiene needs. During an interview on 09/16/24 at 12:42 P.M., the resident said the following: -He/She had some teeth the dentist said needed pulled (extracted); -The staff do not offer to brush his/her teeth; -He/She would like to have his/her teeth brushed at least once a day. Observation on 09/16/24 at 12:42 P.M. showed the resident had white plaque build up along the gum lines of his/her lower teeth. During an interview on 09/17/24 at 4:33 P.M., the resident said the following: -Staff did not brush or offer to brush his/her teeth today; -He/She was unsure of the last time staff brushed his/her teeth; -He/She was unsure where his/her tooth brush was. Observation on 09/17/24 at 4:33 P.M. showed the following: -The resident's tooth brush was located in the resident's top dresser drawer; -The toothbrush was in a bag with a tube of toothpaste; -There was no water or toothpaste residue in the bag or on the toothbrush; -The toothbrush was dry. Review of the resident's Dental Note, dated 09/18/24, showed the following: -The resident had marginal inflammation and bleeding following scaling and brushing; -The resident had moderate plaque and debris and very light calculus; -The resident had poor oral hygiene; -The resident needed someone to brush or help brush his/her teeth twice a day with focus along the gum line; -The resident did not have polish applied due to inflammation, bleeding, condition of enamel, and exposed root surface. During an interview on 09/18/24 at 9:51 A.M., the resident said staff did not brush or offer to brush his/her teeth today or last night. Observation on 09/18/24 at 9:51 A.M. and 1:44 P.M. showed the following: -The resident's toothbrush was in the same place in the resident's top dresser drawer; -The toothbrush was in a bag with a tube of toothpaste; -There was no water or toothpaste residue in the bag or on the toothbrush; -The toothbrush was dry. 2. Review of Resident #36's face sheet showed the resident's diagnoses included dementia and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No behaviors or rejection of care; -Required substantial assistance from staff for oral hygiene; -No dental concerns. Review of the resident's care plan, revised 07/11/24, showed the following: -The resident required assistance from one to two staff for all ADLs; -The staff should assist the resident with all ADLs and keep him/her clean, dry and well-groomed; -The resident has his/her own teeth. Review of the resident's Dental Note, dated 08/14/24, showed the following: -The resident's oral hygiene was poor; -The resident had heavy plaque and moderate calculus; -The resident should have his/her teeth brushed twice daily and flossed once daily. During an interview on 09/17/24 at 6:46 A.M., Certified Nurse Aide (CNA) G said the following: -He/She did not offer to brush the resident's teeth after he/she got the resident up and washed his/her face because the resident was going to breakfast; -He/She always offered to brush the resident's teeth during showers; -The resident was on his/her shower list for today, so he/she would offer to brush the resident's teeth then. During an interview on 09/18/24 at 1:45 P.M., CNA C said the following: -He/She did not brush the resident's teeth when he/she got the resident up on 9/17/24 as it was time for breakfast; -The resident was on the shower schedule for 9/17/24 and the shower aide would offer to brush the resident's teeth then. Review of the resident's Dental Note, dated 09/18/24, showed the following: -The resident had poor oral hygiene; -The resident had marginal inflammation and bleeding following scaling and brushing of moderate plaque, and light to moderate calculus; -The resident did not have polish applied due to inflammation, bleeding, conditions of some enamel, and exposed root surface; -The resident required someone to brush, or help brush, his/her teeth twice daily, with focus along the gumline. Observation on 09/18/24 at 8:28 A.M. showed the resident had white plaque buildup along the bottom of his/her lower teeth, near the gumline. During an interview on 09/18/24 at 8:28 A.M., the resident said the following: -Staff did not brush his/her teeth today; -Staff only brush his/her teeth on shower days; -Shower days were two times per week. 3. During an interview on 09/27/24 at 11:34 A.M., the Director of Nursing (DON) said the following: -Staff should brush residents' teeth in the morning and the evening; -Staff should always try and encourage residents to brush their teeth; -Resident #42 had refused oral hygiene in the past, but she was not aware of any recent refusals; -Any staff who get the residents up in the morning or get them ready for bed at night should offer and provide oral hygiene; -He/She expected staff to offer and provide oral hygiene twice per day if the resident would allow it; During an interview on 09/25/24 at 3:45 P.M., the Administrator said the following: -Staff should brush the residents' teeth at least twice a day; -The CNAs were responsible for ensuring oral hygiene was offered and provided.

Based on interview and record review, the facility failed to ensure an approved indication for use of psychotropic medications for one resident (Resident #21), in a review of five residents sampled for unnecessary medications. Resident #21 had an order for risperidone (an antipsychotic medication) which is contraindicated for use in residents with dementia related psychosis. The resident's dosage of risperidone (an antipsychotic medication) was increased after the resident presented with one day of behaviors on 01/19/24 after the medication was decreased on 01/16/24. The resident's medical record did not contain documentation the facility assessed the root cause of the resident's behaviors or attempted non-pharmacological interventions to address the behaviors prior to increasing and adding medications to the resident's medication regimen. The facility census was 64. Review of Drugs.com on 9/18/24, showed the following: -Risperidone is an antipsychotic medicine that works by changing the effects of chemicals in the brain; -Risperidone is used to treat schizophrenia (a mental health disorder that affects a person's ability to think, feel, and behave clearly) in adults and children who are at least [AGE] years old; -Warnings included that risperidone is not approved for use in older adults with dementia-related psychosis; -In randomized placebo-controlled trials in elderly patients with dementia-related psychosis, cerebrovascular adverse events (strokes) occurred more frequently in patients treated with atypical antipsychotics than those receiving placebo; -Buspar is an anti-anxiety medicine that affects chemicals in the brain that may be unbalanced in people with anxiety; -Taking this medicine with other drugs that make you sleepy or slow your breathing can worsen these effects; -Medications that can interact with Buspar included Trazodone (an antidepressant medication) and other medications for anxiety, depression, or seizures. -Trazodone is an antidepressant used to treat major depressive disorder. Review of the facility policy Antipsychotic Medication Use, revised December 2016, showed the following: -Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; -The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; -The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions. -Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: a. Complete PASARR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate; or b. Re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduced, tapered, or discontinued; c. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication; -Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizoaffective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia; g. Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high- dose steroids); h. Tourette's Disorder; i. Huntington Disease; J. Hiccups (not induced by other medications); or k. Nausea and vomiting associated with cancer or chemotherapy. -Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (I) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) behavioral interventions have been attempted and included in the plan of care, except in an emergency (see below). -For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: a. Not due to a medical condition or problem (e.g., headache or joint pain, fluid or electrolyte imbalance, pneumonia, hypoxia, unrecognized hearing or visual impairment, medication side effect, or polypharmacy) that can be expected to improve or resolve as the underlying condition is treated or the offending medication(s) are discontinued; and b. Persistent or likely to reoccur without continued treatment; and c. Not sufficiently relieved by non-pharmacological interventions; and d. Not due to environmental stressors (e.g., alteration in the resident's customary location or daily routine, unfamiliar care provider, hunger or thirst, excessive noise for that individual, inadequate or inappropriate staff response, physical barriers) that can be addressed to improve the psychotic symptoms or maintain safety; and e. Not due to psychological stressors (e.g., loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses) that can be expected to improve or resolve as the situation is addressed. -Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self-care; c. Restlessness; d. Impaired memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; h. Sadness or crying alone that is not related to depression or other psychiatric disorders; i. Fidgeting; J. Nervousness; or k. Uncooperativeness; -All antipsychotic medications will be used within the dosage guidelines listed in F757, or clinical justification will be documented for dosages that exceed the listed guidelines for more than 48 hours. -The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. -Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA. -The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. 1. Review of Resident #21's annual Minimum Data Set (MDS), a federally required assessment completed by staff, dated 10/18/23, showed the following: -Resident admitted to the facility on [DATE]; -Severe cognitive impairment; -Sometimes understands simple direct communication only; -Diagnosis of Alzheimer's disease, dementia, depression, and anxiety. -No wandering, behaviors, or rejection of care; -One non-injury fall since admission; -Receives antipsychotic and antidepressant medication. Review of the resident's Physician's Order Sheet, dated October 2023, showed the resident was admitted to the facility on risperidone 0.25 milligrams (mg) two times daily. Review of the resident's Physician Response to Pharmacist Recommendation, dated 01/16/24, showed the resident's dose of risperidone was decreased to once a day. Review of the resident's Physician's Order Sheet, dated October 2023, showed the resident was admitted to the facility on risperidone 0.25 milligrams (mg) two times daily. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnosis added of unspecified psychosis; -No wandering, behaviors, or rejection of care; -Receives antipsychotic and antidepressant medication; -Antipsychotic medication used routinely. Review of the resident's nursing Progress Note, dated 01/19/24 at 3:22 A.M., showed the resident had an episode of physical aggression towards staff this evening. While trying to perform cares for the resident, he/she became very agitated, combative and was trying to hit staff. Another staff member was able to redirect the resident and assisted the resident to bed. No further behaviors noted. (Review of the resident's Care Plan showed it did not include any interventions for behaviors prior to 7/22/24.) Review of the resident's nursing Progress Note, dated 01/19/24 at 1:35 P.M., showed staff observed the resident hand in hand with another resident standing up in dining/common area on assigned unit. An investigation was completed. Interviews and statements were reviewed, and it was concluded that the resident may have been swatted/struck by a peer in his/her face after he/she grabbed onto the peer's shirt and would not let go. Review of the resident's medical record showed no documentation of non-pharmacological interventions or a root analysis for the cause of the resident's behaviors on 1/19/24. Review of the resident's nursing Progress Note, dated 01/26/24, showed the resident was agitated with staff's assistance. Review of the resident's medical record showed no documentation of non-pharmacological interventions or a root analysis for the cause of the behaviors on 1/26/24. Review of the resident's medical record showed no other documentation of resident behaviors or rejection of care from 01/26/24 -02/07/24. Review of the resident's nursing Progress Note, dated 02/07/24, showed the Nurse Practitioner saw the resident and gave new orders to increase risperidone 0.25 mg to twice daily due to GDR. Review of the resident's Physician's Order Sheet, dated 02/07/24, showed risperidone 0.25 mg two times daily for unspecified psychosis. Review of the resident's quarterly MDS, dated [DATE], showed a new diagnosis of pseudobulbar affect (PBA) (a condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying) was added, and a new antianxiety medication was in use. Review of the resident's Physician Orders Sheet, dated 05/08/24, showed the following: -A new order for Remeron (an antidepressant medication) 15 mg tablet. Take one-half tablet by mouth every night at bedtime for major depressive disorder; -A new order for Buspar (an antianxiety medication) 5 mg three times a day for anxiety disorder. Review of the resident's medical record showed no documentation of increased anxiety or depression. Review of the resident's Physician Orders Sheet, dated 07/10/24, showed a new order for Trazodone (an antidepressant medication) 50 mg at bedtime for insomnia. Review of the resident's medical record showed no documentation of the resident having trouble sleeping. Review of the resident's Pharmacist Recommendations, dated 7/12/24, showed the following: -The resident has an order for risperidone 0.25 mg two times daily since February 2024; -Remeron 7.5 mg at bedtime, trazodone 50 mg at bed time, Buspar 5 mg three times a day, and depakote sprinkles (a seizure medication used off label for mood stabilization) 125 mg three times a day; -Please consider a gradual dose reduction for the resident's medications; -The review included hand written no change on the form. The form did not indicate who documented no change and did not have a physician's signature or signature of a staff member. Review of the resident's Care Plan, last updated 07/22/24, showed the following: -The resident was on medications for anxiety, PBA, psychosis and to help with his/her appetite; -The resident was at risk for side effects of my medications; -Administer medications as ordered for psychosis, pseudobulbar affect, anxiety, insomnia, depression and to help with his/her appetite; -The resident is confused related to Alzheimer's disease and dementia; -He/She does not always understand what is going on around him/her; -The resident wanders about the unit and goes into other residents' rooms at times; -Provide the resident with safe wandering by supervising his/her activity and whereabouts, but not restricting his/her movements unless they are unsafe or unwanted by his/her peers; -Monitor the resident's behaviors and become familiar with his/her individual habits. (The care plan did not provide specific interventions for behaviors.) Review of the resident's Care Plan, updated 07/25/24, showed the resident was combative with a peer related to peer sitting in the recliner the resident preferred to sit in. Review of the resident's medical record showed no documentation of non-pharmacological interventions implemented or a root analysis for the cause of the behaviors/combativeness on 07/25/24. Review of the resident's Physician's Order Sheet, dated 08/01/24, showed a new order for depakote sprinkles 250 mg three times daily for unspecified psychosis. Review of the resident's Psychiatric Note, dated 8/15/24, showed the following: -Diagnosis include dementia without behavioral disturbance, anxiety, depression, insomnia, and PSA; -Remeron 15 mg tablet, take on-half tablet by mouth every night at bedtime; -Buspar 5 mg tablet, take one tablet by mouth twice a day; -Risperidone 0.25 mg tablet, take one tablet by mouth twice a day; -Trazodone 50 mg tablet, take on-half tablet by mouth every night at bedtime; -Depakote sprinkles 125 mg delayed release capsule, take two capsule by mouth three times a day. -Unable to assess for any hallucinations or delusions; -Staff reported the resident can be combative with staff during cares on the last visit. (The psychiatric nurse practitioner did not include a diagnosis of psychosis or symptoms of psychosis in the progress note.) Review of the resident's medical record showed no documentation the facility provided the resident's responsible party with education or obtained consent for the use of antipsychotic medication, no documentation for monitoring for side effects, and no documentation of any other behaviors (other than wandering) than what behaviors are listed above. During an interview on 09/16/24, at 1:16 P.M., the resident's responsible party said the facility staff forgets to call him/her with order changes or issues. He/She was not made aware of medication changes for behaviors. The facility had not contacted him/her about the resident having behaviors. During an interview on 09/18/24, at 9:00 A.M. and 11:20 A.M., the Director of Nursing said the resident was on risperidone for unspecified psychosis, not his/her dementia. She expected staff to follow the Psychotropic Drug use policy.

Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan specific to the resident, for two residents (Resident #42 and #36), in a review of 24 sampled residents. The facility census was 64. Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised March 2022, showed the following: -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; -The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframes; b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Includes the resident's stated goals upon admission and desired outcomes; d. Builds on the resident's strengths; e. Reflects currently recognized standards of practice for problem areas and conditions; -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; -Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. 1. Review of Resident #42's Face Sheet showed the resident's diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke affecting the non-dominant left side, need for assistance with personal care, and partial loss of teeth. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/06/24, showed the following: -Cognitively intact; -Required partial assistance for oral hygiene. Review of the resident's Dental Note, dated 07/24/24, showed the following: -The resident had marginal inflammation and bleeding following scaling of moderate plaque and light debris; -The resident had poor oral hygiene; -The resident needed someone to brush his/her teeth twice daily, with focus along the gumline. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Required partial assistance for oral hygiene. Review of the resident's Care Plan, revised 09/12/24, showed the following: -The resident had left sided hemiplegia; -The resident was mostly dependent on one to two staff for ADLs; -Staff will assist the resident with ADLs to keep the resident clean, dry and well-groomed; -The resident had a history of 13 dental extractions; -The resident had his/her own teeth. (The resident's care plan did not identify the resident needed assistance with oral hygiene including recommendations from the resident's dentist to ensure proper dental care.) During an interviews on 09/16/24 at 12:42 P.M. and on 09/17/24 at 4:33 P.M., the resident said staff do not offer to brush his/her teeth. He/She was unsure of the last time staff brushed his/her teeth. Review of the resident's Dental Note, dated 09/18/24, showed the following: -The resident had moderate plaque and debris; -The resident had poor oral hygiene; -The resident needed someone to brush or help brush his/her teeth twice a day with focus along the gum line. 2. Review of Resident #36's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Required substantial assistance from staff for oral hygiene. Review of the resident's Care Plan, revised 07/11/24, showed the following: -The resident required assistance from one to two staff for all ADLs; -The staff should assist the resident with all ADLs and keep him/her clean, dry and well-groomed; -The resident had his/her own teeth. (The resident's care plan did not identify the resident needed assistance with oral hygiene including recommendations from the resident's dentist to ensure proper dental care.) Review of the resident's Dental Note, dated 08/14/24, showed the following: -The resident's oral hygiene was poor; -The resident had heavy plaque and moderate calculus; -The resident should have his/her teeth brushed twice daily and flossed once daily. Review of the resident's Dental Note, dated 09/18/24, showed the following: -The resident had poor oral hygiene; -The resident had marginal inflammation and bleeding following scaling and brushing of moderate plaque, and light to moderate calculus; -The resident required someone to brush, or help brush, his/her teeth twice daily, with focus along the gumline. During an interview on 09/18/24 at 8:28 A.M., the resident said staff only brush his/her teeth on his/her shower days twice a week. 3. During interviews on 09/18/24 at 7:03 P.M. and 10/02/24 at 4:34 P.M., the MDS Coordinator said the following: -She was responsible for developing the care plans; -She obtained the information needed for the care plans through brief resident interviews, physician orders, outside records (like dental notes), and the MDS; -Other staff contributed information, but they presented it to her and she added it to the care plan; -Staff was responsible for understanding that ADLs on the care plan included oral hygiene, face washing, hair brushing, shaving, and getting dressed; -She listed the general type of assistance the residents needed with ADLs. She did not break the type of assistance the residents needed for each specific ADL; -If a resident needed more or less assistance with a specific ADL than what was identified in the general statement in the care plan, she would list the specific ADL and type of assistance needed; -The general type of assistance needed for ADLs was listed on all the residents' care plans. Staff should follow the care plan and facility policy for providing all ADL care; -Resident #42 was dependent on one to two staff for all ADLs per his/her care plan, so staff should assist the resident with oral hygiene care, morning and night, per the facility policy; -Resident #36 was dependent on one to two staff for all ADLs per his/her care plan, so staff should assist the resident with oral hygiene care, morning and night, per the facility policy. During an interview on 09/27/24 at 11:34 A.M., the Director of Nursing (DON) said the following: -The MDS Coordinator was responsible for developing the care plans; -The MDS Coordinator conducted resident interviews, reviewed physician notes and orders and nursing progress notes to determine what needed to be on the care plan; -ADLs should be included on the care plan and it should list the overall ADL assistance a resident required. At this time, the care plan did not break it down into specific needs for each ADL. During an interview on 09/25/24 at 3:45 P.M., the Administrator said she expected the residents' ADL needs to be listed on the residents' care plans, at minimum an overall ADL assistance. If the type of assistance differed from their overall need, the care plan should be specific and individualized.

Based on observation, interview, and record review, the facility facility failed to provide documentation of a medical diagnosis that warranted the use of a restraint prior to initiation, assessment and monitoring for the use of physical restraints, including a wheelchair locked when placed up to the dining room table, a pommel cushion (a cushion with an upward-projecting protuberance at its front part that prevents a wheelchair dependent resident from sliding down and possibly falling out of a wheelchair), to prevent rising from a wheelchair, and a recliner positioned with he legs elevated (Resident #50 and #22), in a review of 24 sampled residents, who were in chairs to prevent them from rising. The residents could not easily and intentionally rise from their wheelchairs or a recliner. The facility did not document other interventions attempted or the consent of the resident or his/her representative. The facility census was 64. Review of the facility policy Use of Restraints, dated 01/30/24, showed the following: -Ensure that physical and/or chemical restraints are used only when needed to treat the resident's medical symptoms and then, only use the least restrictive alternative for the least amount of time. -It is this facility's policy to support each resident with attaining and maintaining his/her highest practicable well-being and ensure his/her dignity and quality of life in our building. This facility will not impose physical restraints for purposes of discipline or convenience. On rare occasions, it may be medically necessary to consider the use of a physical restraint and/or psychotropic medications; -Prior to the initiation of a physical restraint or psychotropic medication(s), clinicians will thoroughly assess the resident's mental/cognitive, behavior and physical status. This assessment will address other interventions that may be symptoms or the cause of the situation (e.g., identification of an infection process or delirium, presence of pain); -Documentation of assessment/evaluation and symptoms exhibited will be recorded in the resident's medical record; -Clinicians will consult with the attending physician, relaying assessment and observations; -Alternative and less restrictive measures to the use of a physical or chemical restraint, must be initiated and recorded, including effectiveness of any/all alternatives employed; -Clinicians and the attending physician must determine that a physical restraint is a measure of last resort to protect the safety of the resident or others. If there is no alternative to the use of a restraint, a physician's order is necessary for the initiation of any restraint or psychotropic medication; -That order will include the physician's diagnosis and include the medical symptoms prompting the need for such restraint; -It will also include the expected duration of the restraint; -Unless there is an actual emergency, a physical restraint or psychotropic medication will not be initiated until the need for such a restraint is discussed thoroughly with the resident and/or resident representative and written consent is obtained; -The resident/representative must be informed of potential risks and benefits of all options under consideration including using a restraint, not using a restraint and alternatives to restraint use; -The resident, or resident representative (if applicable), has the right to refuse the use of a restraint and may withdraw consent to use of the restraint at any time. If so, the refusal must be documented in the resident's record. The facility is expected to assess the resident and determine how resident's needs will be met if the resident refuses/declines treatment. -Documentation in the resident's medical record regarding the use of a restraint must include: -a. The length of time the restraint is anticipated to be used to treat the medical symptom, the identification of who may apply the restraint, where and how the restraint is to be applied and used, the time and frequency the restraint should be released, and who may determine when the medical symptom has resolved in order to discontinue use of the restraint; -b. The type of specific direct monitoring and supervision provided during the use of the restraint, including documentation of the monitoring; -c. The identification of how the resident may request staff assistance and how needs will be met during use of the restraint, such as for repositioning, hydration, meals, using the bathroom and hygiene; -d. The resident's record includes ongoing re-evaluation for the need for a restraint and is effective in treating the medical symptom; -e. The development and implementation of interventions to prevent and address any risks related to the use of restraint; -The resident's comprehensive care plan will reflect the resident's goals and the interventions/services needed for the safe use of a restraint as long as it is medically necessary; -Convenience is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care and is not in the resident's best interest. Freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control; - Indication for use is defined as the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence based review articles that are published in medical and/or pharmacy journals; -Medical symptom is defined as an indication or characteristic of a physical or psychological condition; -Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: -Is attached or adjacent to the resident's body; -Cannot be removed easily by the resident; -Restricts the resident's freedom of movement or normal access to his/her body; -Removes easily means that the manual method, physical or mechanical device, equipment, or material, can be removed intentionally by the resident in the same manner as it was applied by the staff. 1. Review of Resident #50's significant change in status Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 11/21/2023, showed the following: -Severe cognitive impairment; -Diagnosis of dementia and unspecified mood disorder; -Sometimes understands, responds to only adequately to simple, direct communication only; -Disorganized thinking present and fluctuates: resident thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject); -No behaviors or rejection of care; -It was very important for the resident to have family involved in care; -Requires supervision/touching assistance from staff members for eating; -Requires partial/moderate assistance from staff for oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed; -Requires substantial/maximal assistance from staff for sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, wheel 50 feet and wheel 150 feet; -Always incontinent of bowel and bladder; -No falls. Review of the resident's Care Plan, dated 05/06/24, showed staff observed the resident sitting on the floor on his/her buttocks. Staff added an intervention to assist the resident to a seated position if he/she is observed to be restless and attempting to transfer himself/herself without assistance. Review of the resident's Care Plan, dated 05/25/24, showed staff observed the resident on his/her floor in his/her room. Staff added an intervention to ensure the resident is sitting back and upright in his/her wheelchair to prevent him/her from sliding out of his/her wheelchair. Review of the resident's quarterly MDS, dated [DATE], showed the resident received antianxiety medication and had one no injury fall. Review of the resident's quarterly MDS, dated [DATE], showed the resident had one no injury fall. Review of the resident's Care Plan last reviewed 08/29/24 showed the following: -The resident is confused; -High risk for falls; -He/She was unsteady and needs assist of one to two staff members with his/her activities of daily living (ADLs), toileting and transfers; -Resident can be combative during cares; -Requires assist of one to two staff members with transfers (usually two) and he/she is propelled in his/her wheelchair by staff; -The resident attempts to ambulate without assistance at times., assist him/her to a seated position as allows if he/she is observed attempting to ambulate or stand up without assistance; -He/she is incontinent of bowel and bladder. The resident's medical record did not include a restraint assessment, consent for use of a restraint, interventions for safe use of restraints or any other direction to ensure release of restraints, or restraint monitoring. Observation on 09/15/24, at 3:27 P.M., showed the resident in the dining room in his/her wheelchair on the locked dementia unit. The resident's wheelchair was positioned where the seat of the wheelchair was towards the table with the armrest against the table, the wheelchair was locked. The table was bare, there were no items on the table in front of the resident. There was no staff in the dining room. Observation on 09/15/24, at 5:05 P.M., showed the resident at the dining room table in his/her wheelchair in the locked dementia unit. The resident's food tray was located in front of him/her. The resident mumbled nonsensically and tried to push himself/herself back from the dining room table but his/her wheelchair would not move. The wheelchair was locked. The resident attempted to move his/her chair several times and said, Oh darn it. There was no staff present to monitor the resident in the dining room. Observation on 09/15/24, at 5:27 P.M., showed the resident at the same table dining room table. The resident's wheelchair continued to be locked with the chair up against the table. There were no staff in the dining room on the locked dementia unit. Observation on 09/15/24, at 5:36 P.M., showed the resident sat the dining room table. Certified Nurse Assistant (CNA) K was the only staff on the unit. CNA K stood over the resident and attempted to assist the resident to eat. The resident did not eat, and after a few minutes, the staff member left the dining room. The resident's wheelchair was locked while the resident sat with the arm rest of his/her wheelchair against the table. Observation on 09/15/24, at 6:22 P.M., showed the resident at the same table in the dining room on the locked dementia unit with his/her wheelchair locked and the arm rest against the table. The resident did not have any food or activities in front of him/her. Continuous observation from 09/16/24 at 10:40 A.M. until 11:20 A.M., showed the resident at the same dining room table on the locked dementia unit with the wheelchair brakes locked and the arm rest against the table. There were no items on the table. The resident had his/her head on the table with his/her eyes closed or was mumbling nonsensical sounds and rocking back and forth or in a circular motion during the observation. During an interview on 09/16/24, at 11:10 A.M., CNA O said the following: -The facility did not use restraints; -The resident's wheelchair was locked against the table to prevent him/her from standing up and walking; -The resident will get up and walk and when he/she goes to sit down, doesn't make sure a chair was there and will fall. Staff have to lock the resident's wheelchair up against the table until he/ she had time to walk with the resident. Observation on 9/16/24, at 4:45 P.M., showed the resident at the same table in dining room on the locked dementia unit with his/her wheelchair locked and the arm rest against the table. The resident repeatedly said, I'm tired, can I lay down? and would lay his/her head on the table. There were no staff monitoring the dining room. One staff member would walk into the dining room and then immediately leave. Observation on 9/17/24, at 8:45 A.M., showed the resident at the same table in dining room on the locked dementia unit with his/her wheelchair locked and the arm rest against the table. The table was bare. The resident sat by himself/herself in the dining room. No staff monitored the resident. Observation on 9/17/24, at 4:00 P.M. showed the resident at the same table in dining room on the locked dementia unit with his/her wheelchair locked and the arm rest against the table. The table in front of the resident was bare. The resident would push against the table to move his/her wheelchair and the wheelchair would not move. No staff monitored the resident. During an interview on 9/17/24, at 4:05 P.M., CNA K said staff kept the resident's wheelchair locked at the table because if they sat the resident away from the table, on the couch or in the recliner, the resident would try to get up and walk. The resident could walk but when he/she decided to sit the resident would just sit down without a chair behind him/her and fall. Sitting him/her at the table with his/her wheelchair locked prevented the resident from falling. There were no residents on the unit with restraints. 2. Review of Resident #22's Face Sheet showed diagnosis include dementia with behaviors, Parkinson's disease (a disorder that affects movement - symptoms are slow movement, stiffness, and loss of balance), anxiety, depression, a history of a stroke, and an unspecified mood disorder. Review of the resident's Care Plan, dated 12/12/23, showed staff observed the resident on the floor in his/her room. Resident assessed to find a small bruise to right elbow and raised area/abrasion to forehead. Staff added the intervention to ensure the resident was positioned properly in the middle of his/her bed. His/Her bedside dresser was moved from the side of the resident's bed/recliner and a cushion placed in his/her recliner chair to stabilize the resident. Review of the resident's Care Plan, dated 01/21/24, showed staff observed the resident on the floor related to tipping his/her recliner chair forward. Staff added an intervention to ensure the resident was properly positioned in his/her recliner chair. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis include dementia with behaviors, Parkinson's disease, anxiety, depression, and an unspecified mood disorder; -Usually understood, usually understands; -Moderately impaired vision with corrective lenses; -Requires substantial/maximal assistance from staff for eating, and to roll left and right; -Dependent on staff for toileting hygiene, shower/bathe, dressing, putting on/taking off footwear, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, and to wheel wheelchair; -Always incontinent of bowel and bladder; -One injury fall since last assessment; -Takes psychotropic medications including antianxiety and antidepressant medications; -Restraints and a chair that prevented rising was not used. Review of the resident's Care Plan, last reviewed on 06/18/2024, showed the following: -At high risk for falls; -The resident was forgetful and confused with very poor vision, weak and unsteady. -Requires the assistance of one to two staff with transfer and ADL's; -He/she was incontinent of bowel and bladder; -History of falls and takes medications that increase the risk of falls; -Ensure the resident's call light is within reach at all times; -The resident has a history of putting himself/herself on the floor, taking off his/her clothes and crawling on the floor; -Ensure the resident has proper positioning in his/her wheelchair, bed and recliner chair; -Monitor the resident frequently; -Ensure the resident's bed was in the lowest position and fall matt is in place while in bed; -Assist the resident to a seated position when he/she was observed standing or attempting to transfer himself/herself; -Encourage resident to keep his/her wheelchair brakes on while he/she was not moving; -Educate the resident on the risks associated with crawling on the floor; -The resident's recliner chair sat on a wider board base to help prevent tipping the recliner chair over. -Apply a pommel (a cushion applied in the seat of a wheelchair with a raised area that sits between the residents legs that can prevent the resident from rising or sliding) cushion in my high back reclining wheelchair and a footboard to the resident's foot rest. The resident's medical record did not include a restraint assessment, consent for use of a restraint, interventions for safe use of restraints or any other direction to ensure release of restraints, or restraint monitoring. Observation on 09/16/24, at 11:08 A.M., showed the resident in the dining room on the locked dementia unit in his/her high-back wheelchair with a pommel cushion. The resident was reclined with his/her feet elevated. The resident had a neck pillow around his/her neck and had his/her head down with eyes closed. During an interview on 09/16/24, at 11:10 A.M., CNA O said the resident had a pommel seat and was reclined because he/she had behaviors and tried to get up by himself/herself. Observation on 09/16/24, at 4:47 P.M., showed the resident in his/her room in a recliner. The resident's feet were elevated high in the chair. The base of the chair was connected to a large wooden base on the floor. The resident's call light was across the room and clipped high up on the curtain that divided the room. There are no staff or visitors in the resident's room During an interview on 09/16/24, at 4:47 P.M., the resident said he/she used his/her call light to call for help if he/she can find it. The resident said he/she could not put the feet down on his/her recliner. (The recliner foot rest was elevated.) He/She would rather be in bed than stuck in this chair. During an interview on 09/17/24, at 4:05 P.M., CNA K said the resident yelled out and got restless at times. The resident will wiggle around in the recliner but could not get out of the recliner without staff assistance. There were no restraints used on the unit. Observation on 09/17/24, at 4:08 P.M., showed the resident in his/her room in a recliner. The resident's feet were elevated high in the chair. During an interview on 09/18/24, at 09:00 A.M., the Director of Nursing said the following: -The facility did not use any restraints at this time; -She did not know staff were locking Resident #50's chair up next to the table; -Resident #22 has some of the devices to protect his/her skin and interventions to prevent falls; -If a restraint was going to be used staff were expected to assess the restraint and follow the policy for proper use and monitoring of restraints to ensure resident's needs are met and restraints are used appropriately.

Based on interview and record review, the facility failed to ensure all required components of an arbitration agreement were part of the facility policy. This failure affected all of the residents in the facility, as all residents had a signed arbitration agreement. The facility census was 64. Review of the undated facility Admission Agreement Packet showed the following: -Alternative Dispute Resolution Addendum: This Alternative Dispute Resolution Addendum is attached to and made a part of the Admission Agreement between the facility and the resident. All claims, disputes, and controversies arising out of or in any manner relating, directly or indirectly, to the resident's care or stay at the facility (in each case, a dispute) shall be subject to certain alternative dispute resolution procedures that must be exhausted prior to pursuing any other remedy that may be available. Those required alternative dispute resolution procedures are: (a) mandatory non-binding mediations; and (b) mandatory nonbinding appealable arbitration; -Each party agrees that compliance with the requirements of this addendum shall be a condition precedent to its right to assert any claims with respect to a dispute in any other forum; -Mandatory Non-Binding Mediation: If there is a dispute, the party claiming the existence of a dispute must make written demand for mediation prior to instituting a lawsuit, action or arbitration proceeding. Mediation of any dispute must be attempted in good faith; -The mediation shall be conducted in the county where the facility is located, unless another location is mutually agreed upon by the parties. The cost and expensed of mediation, with the exception of the costs and expenses relating to the investigation, representation and case presentation on behalf of the resident, shall be borne by the facility; -The mediator shall be chosen by joint agreement of the resident and the facility. In the event an agreement cannot be reached with respect to a mediator, either party may request that Judicial Arbitration and Mediation Services (JAMS), Inc. or its successor appoint a mediator. Selection of the mediator by JAMS shall be binding on the resident and the facility; -Mandatory Non-Binding Appealable Arbitration: Should mandatory non-binding mediation of the dispute be unsuccessful, it is agreed that the dispute shall be submitted to non-binding appealable arbitration in accordance with the Health Care Clams Settlement Procedures, as promulgated, amended and administered by the American Arbitration Association; -All arbitration hearings conducted hereunder shall take place in the county where the facility is located. The hearing before the arbitrator(s) of the matter to be arbitrated shall be at the time and place within said county as is selected by the arbitrator(s); -The decision of the arbitrator(s) will respect to a dispute shall be non-binding and appealable to a court having jurisdiction; -This contract contains an arbitration provision. This may be enforced by the parties. Review of the facility provided Admission Agreement showed the Arbitration Agreement did not include: -The resident or his/her representative was not required to enter into the agreement as a condition of admission to the facility or as a requirement to continue to receive care; -Did not include language which made clear the resident or representative could communicate with federal, state, or local officials; -The resident or his/her representative had the right to rescind the agreement within 30 calendar days of signing the agreement. During an interview on 09/18/24, at 5:40 P.M., the Social Services Director said the following: -She was responsible for obtaining initials and signatures on the arbitration agreement; -She asked the resident/resident representative if they understood what they were signing before they signed or initialed the agreement; -It was the resident/resident representative's option to sign the agreement or not sign the agreement; -The signed arbitration agreement was not a condition of admission to the facility; -She was not aware of what specific language was required on the arbitration agreement, as the agreement was produced by corporate; -She was not aware that the resident/resident representative had 30 days to rescind the arbitration agreement. During an interview on 09/18/24, at 5:35 P.M., the administrator said the following: -Social Services was responsible for obtaining the arbitration agreement; -Every resident in the facility had a signed arbitration agreement; -She was unaware of what specific components needed to be listed on the arbitration agreement prior to 09/18/24.

Based on observation and interview, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution. The facility census was 69. 1. Observation on 03/13/23 between 9:32 A.M. and 12:27 P.M., of the preparation and service of the noon meal, showed the following: -At 9:32 A.M., Dietary Cook P prepared the noon meal in the kitchen. He/She did not have the front of his/her hair covered with a hair net. Dietary Aide A washed dishes and did not have the front of his/her hair covered with a hairnet; -At 10:25 A.M., Dietary Aide B rolled silverware into napkins for the residents' meal and did not wear a beard restraint to cover his/her beard; -At 11:05 A.M., Dietary Aide A stacked three wet skillets and put them away on a shelf; -At 11:34 A.M., Dietary Cook P wore gloves during the meal service. He/She picked up pieces of chicken with his/her gloved hands, rather than using a serving utensil, then touched plates, serving utensils, and meal cards. He/She did not change gloves or wash his/her hands. He/She continued to do this with every plate throughout the noon meal service; -At 11:40 A.M., Dietary Aide A washed the pan used to cook the ground chicken, and placed the pan on a shelf wet and dirty. The pan still had chicken pieces stuck to the bottom. Observation, on 3/13/23 at 12:35 P.M., in the dining room, showed the following: -Resident #15 sat in his/her wheelchair eating lunch; -A short white hair was visible in the resident's chicken. During an interview on 3/13/23 at 12:35 P.M., Resident #15 said the following: -Look, there's a hair in it (referring to the hair in his/her chicken); -Hair in the food happened quite often. During interview on 03/13/23 at 1:55 P.M., the dietary manager said he expected staff not to handle the residents' food and serving utensils and meal cards with the same gloves. He expected staff to change their gloves between touching resident food and touching anything else. He expected staff to have all their hair and beards covered at all times while in the kitchen. He expected the dishes to be clean and dry before staff put them away. During interview on 03/13/23 at 2:16 P.M., the administrator said she expected the staff not to handle resident food and utensils with the same gloved hands. She would expect staff to wear hair and beard nets at all times while in the kitchen and all hair to be covered. She expected the dishes to be clean and dry before staff put them away.

Based on interview and record review, the facility failed to review the Certified Nurse Aide (CNA) Registry for a Federal Indicator (which would disquality an individual from working in the facility) for eight employees in a review of ten newly hired employees. The facility also failed to develop a policy and procedure to address reviewing the CNA Registry for a Federal indicator for all potential new hires. The facility census was 69. Review of the undated facility policy titled CNA Registry Check for Skilled Nursing Facilities, showed the following: Purpose: -The purpose of this policy is to ensure resident safety by requiring all skilled nursing facilities to conduct a CNA Registry Check before hiring CNAs. This policy aims to ensure that all CNAs employed by the facility are properly trained, qualified, and have no history of abuse or neglect in the provision of care for residents; Policy Statement: -All skilled nursing facilities shall conduct a CNA Registry Check on all applicants for CNA positions. The registry check must be conducted prior to extending an offer of employment to the applicant. The facility shall not employ any CNA who has a record of abuse, neglect, or misappropriation of resident property or funds; Procedures: -The facility shall conduct a CNA Registry through the state's Department of Health website or other approved means; -The facility shall review the results of the CNA Registry Check before extending an offer of employment to the applicant; -If the CNA Registry Check indicates that the applicant has a history of abuse, neglect, or misappropriation of resident property or funds, the facility shall not hire the applicant; Responsibility: -It is the responsibility of the facility administrator or designated personnel to ensure compliance with this policy; Review showed the facility's policy did not address reviewing the CNA registry for all potential hires prior to hire. 1. Review of Housekeeping Staff H's employee file showed the following: -Date of hire 12/28/22; -Documentation showed staff conducted a CNA registry check on 3/15/23 during the survey process. 2. Review of Licensed Practical Nurse (LPN) I's employee filed showed the following: -Date of hire 3/10/23; -Documentation showed staff conducted a CNA registry check on 3/15/23 during the survey process. 3. Review of Hall Monitor/Nurse Aide (NA) J's employee file showed the following: -Date of hire 7/19/22; -Documentation showed staff conducted a CNA registry check on 3/15/23 during the survey process. 4. Review of Hospitality Aide K's employee file showed the following: -Date of hire 5/24/22; -Documentation showed staff conducted a CNA registry check on 3/15/23 during the survey process. 5. Review of LPN L's employee file showed the following: -Date of hire 8/18/22; -Documentation showed staff conducted a CNA registry check on 3/15/23 during the survey process. 6. Review of Maintenance Staff M's employee file showed the following: -Date of hire 1/16/23; -Documentation showed staff conducted a CNA registry check on 3/15/23 during the survey process. 7. Review of Dietary Aide A's employee file showed the following: -Date of hire 2/9/23; -Documentation showed staff conducted a CNA registry check on 3/15/23 during the survey process. 8. Review of Housekeeping Staff N's employee file showed the following: -Date of hire 1/2/23; -Documentation showed staff conducted a CNA registry check on 3/15/23 during the survey process. During an interview on 3/15/23 at 11:30 A.M., the Business Office Manager said the following: -The date of hire is the first day of resident contact; -The CNA registry checks were done on 3/15/23 for Housekeeping Staff H, LPN I, Hall Monitor/NA J, Hospitality Aide K, LPN L, Maintenance Staff M, Dietary Aide A and Housekeeping Staff N; -She was not aware until 3/15/23 that she had to do CNA registry checks on new employees that are not CNAs. During an interview on 3/16/23 at 5:35 P.M., the Administrator said the following: -The Business Office Manager is responsible for completing the CNA registry checks on all new hires; -She would expect the CNA registry checks to be completed by the first day of resident contact.

Based on observation, interview, and record review, the facility failed to ensure staff spoke to one resident (Resident #4), in a review of 18 sampled residents, and one additional resident (Resident #45), in a dignified manner. The facility census was 69. Review of the facility policy Dignity, revised February 2021, showed the following: -Each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; -Residents are treated with dignity and respect at all times; -Staff speak respectfully to residents at all times, including addressing the resident by his/her name of choice and not labeling or referring to the resident by his/her room number, diagnosis or care needs; -Demeaning practices and standards of care that compromise dignity are prohibited. 1. Review of Resident #45's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/22/22, showed the following: -Cognitively intact; -Required assistance from one staff for transfers. Review of the resident's care plan revised 12/27/22 showed the following: -The resident has a diagnosis of depression; -He/She is at increased risk for signs/symptoms of depression or mood decline; -The resident is weak and unsteady and needs assistance from one to two staff with some of his/her activities of daily living (ADLs) and all transfers; -The resident is non-ambulatory at this time because his/her legs are weak. During interview on 3/13/23 at 10:39 A.M., 3/14/23 at 12:00 P.M. and 3/15/23 at 1:00 P.M., the resident said the following: -He/She had an incident with Nurse Aide (NA) J approximately a month ago; -His/Her call light was on and NA J came into his/her room; -His/Her legs are weak and he/she needed assistance with transferring himself/herself; -NA J just stood there and said, you mean I wasted my time coming in here for this? -He/She didn't like the way NA J talked to him/her; -NA J was hateful and rude; -He/She went to bed crying that night; -He/She is not afraid of NA J but he/she won't ask for help if NA J is the only aide working; -NA J complains about having to be in his/her room to help him/her; -He/She doesn't like the way NA J acts. 2. Review of Resident #4's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No rejection of care; -Totally dependent on two or more staff for transfers; -Only able to stabilize with human assistance for surface to surface transfers, not steady; -Upper extremity impairment in range of motion on both sides; -Lower extremity impairment in range of motion on one side; -Always incontinent of bladder and bowel. Review of the resident's care plan revised 2/3/23 showed the following: -He/She has a history of depression and anxiety; -Encourage the resident to express his/her feelings and be supportive; -He/She is weak and unsteady with limited range of motion (ROM) in his/her bilateral upper extremities (BUE)/shoulders, a right above the knee amputation (AKA) and poor vision; -He/She needs assist of one to two with his/her ADLs and transfers. During interview on 3/15/23 at 12:50 P.M., the resident said the following: -NA J, who works on the night shift, bullies him/her; -NA J stands over him/her, it's a dominance thing; -NA J is rough spoken. -A couple of months ago he/she told an unknown staff member about NA J, and now NA J doesn't provide care for him/her anymore; -NA J came into his/her room after he/she reported NA J to staff, and NA J told him/her, I heard you don't like me. He/She told NA J, I don't want you in my room. During interview on 3/15/23 at 5:20 A.M. and 3/16/23 at 5:10 P.M., the Director of Nursing (DON) said the following: -She expected staff to treat and speak to residents with dignity and respect; -She had not received any complaints about NA J since December 2022; -NA J is a bigger person with a low gruff voice which could be intimidating to some; -It might be NA J's approach towards the residents; -She was unaware Resident #45 had complaints regarding NA J; -Resident #4 might have complained about NA J in the past; -For residents that have complained about NA J, he/she sends another staff member of the opposite sex in the room with him/her to provide care. During an interview on 3/16/23 at 5:53 P.M., the Administrator said she expected staff to treat and speak to residents with dignity and respect. 46506

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, was free from abuse when Certified Nurse Assistant (CNA) A cursed and was rough with the resident during care. The resident was upset and teary eyed following the incident, and said he/she had never been talked to like this in his/her life. The facility census was 69. On 10/26/22, the administrator was notified of the past noncompliance which occurred on 10/13/22. On 10/13/22, the facility identified CNA A cursed and was rough with Resident #1 during care. Upon discovery, staff suspended the employee pending investigation, conducted an investigation, and notified the appropriate parties. Facility staff reviewed their abuse and neglect policies, and inserviced staff on abuse and neglect on 10/13/22 and 10/14/22. The alleged perpetrator was terminated from employment. Review of the facility's Abuse and Neglect policy, updated September 2019, showed the following: -Ensure each resident has the right to be free from all types of abuse, neglect, or exploitation or misappropriation of property; -Investigate all alleged violations and prevent further potential abuse neglect or exploitation or misappropriation of property while the investigation is in progress; -The facility will not tolerate the abuse or mistreatment of residents by facility staff, by other residents, by family members or other visitors, by consultants or volunteers, or by any other individual; -Abuse includes deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being; -Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability; -Mental abuse includes but is not limited to: humiliation, harassment. Review of Resident #1's Care Plan, dated 6/14/22, showed the following: -The resident had frontal lobe dementia and was forgetful and confused at times; -History of depression; -Required one to two staff members with activities of daily living (ADLs); -The resident was incontinent of bowel. Check and change the resident every two hours and as needed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 9/13/22, showed the following: -Cognition was moderately impaired; -Made self-understand and usually understood others; -Required extensive assistance from two or more staff for bed mobility and toileting; -Always incontinent of bowel; -Had a urinary catheter. Review of the facility's self-report showed on 10/13/22 at 4:15 P.M., Resident #1 reported to Licensed Practical Nurse (LPN) C that Certified Nurse Aide (CNA) A was rough with him/her, used foul language and was racist toward fat/(specified race) people. The staff was suspended pending investigation, statements obtained by those involved and witnesses, emergency in-servicing, skin assessed, and physician and family notified. Review of the facility's investigation, dated 10/14/22, showed the following: -Incident: Resident #1 reported to LPN C that CNA A was rough with him/her, used foul language, and was racists towards fat/(specified race) people. Investigation started immediately. CNA A denied the accusation and was suspended immediately pending investigation. Emergency in-services of all staff on abuse and neglect policy was initiated. The resident's physician and family were notified. CNA A will be terminated. -Nurse Assistant (NA) B's written statement, dated 10/13/22, showed CNA A asked him/her to come help with Resident #1. CNA A began to complain about the resident, and called the resident a fat mother fucker, and told the resident that he/she didn't need to know his/her name. CNA A told the resident he/she was talking too much. When CNA A was walking out of the room, he/she said, the mother fuckers know better than to put me on this hall, they always do this shit. -LPN C's written statement dated 10/13/22, showed NA B informed him/her at 4:15 P.M. of the rough treatment of the resident. He/She spoke to the resident who was visibly upset and teary eyed, and the resident reported that CNA A had handled him/her roughly. CNA A used foul inappropriate language. CNA A told the resident not to talk to him/her, and he/she wondered if CNA A was racist against (specified race) people and fat people. -Resident #1's statement dated 10/13/22, showed CNA A was rough in handling him/her and used inappropriate foul language. CNA A seemed very angry, unhappy, and kept complaining about providing care. During an interview on 11/1/22, at 4:03 P.M., NA B said the following: -While he/she and NA B were turning the resident, CNA A was being rough and rolled the resident back and forth. CNA A did not explain what he/she was doing to the resident, and was jerking the resident when he/she turned him/her; -CNA A moved the resident's catheter roughly, and the resident yelled out; -CNA A was speaking in a raised voice the whole time while working with the resident; -CNA A was huffing and puffing while they were turning the resident, and saying things like, this shit and they know not to put me on this hall; -The resident asked CNA A what his/her name was, and CNA A told the resident he/she didn't need to know his/her name; -CNA A was at standing by the head of the resident's bed, and loudly said, this fat mother fucker. The resident clearly heard CNA A; -The resident teared up and looked like he/she was going to cry; -CNA A said in front of the resident, those mother fuckers knew better than to put me over here; -CNA A left the room, and the resident asked NA B to get the charge nurse; -The resident said he/she had never been talked to like this in his/her life; he/she was teary eyed, and looked like he/she was going to cry; -The resident said he/she didn't want to see CNA A again. During an interview on 11/1/22, at 1:33 P.M., LPN C said the following: -He/She was at the nurse's desk and heard raised voices coming from the resident's room down the hall; -He/She started down the hall, and met CNA A coming out of the resident's room; -As he/she got to the resident's room, NA B was coming out of the resident's room and asked to speak to him/her; -NA B reported that CNA A was jerking the resident around during care, and was unnecessarily rough with the resident; -NA B also said when the resident asked CNA A his/her name, CNA A told the resident he/she didn't need to know his/her name; -CNA A called the resident a fat mother fucker. The resident was very upset; -He/She went to the resident. The resident was very upset and teary eyed (which was not normal for the resident); -The resident said several times that CNA A was rough with him/her and was really hostile; -The resident said CNA A used vulgar and inappropriate language. The resident would not say what the vulgar and inappropriate language was, he/she said he/she doesn't like to say those words; -The resident said it was physically uncomfortable but CNA A did not physically hurt him/her, but it scared him/her; -The resident said he/she had never been treated like that before. During an interview on 10/26/22, at 9:50 A.M., the resident's family member said the following: -He/She spoke to the resident that day (10/13/22), and the resident said a staff member cursed at and about him/her. The resident was really upset; -The resident would not say what the staff member said, but the resident said the staff member was rough with him/her and cursed at him/her. The resident was crying and wanted to come home; -The resident said the staff member was just rougher than he/she thought the staff member should be and was shouting; -Cursing always bothered the resident. During an interview on 10/26/22 at 10:10 A.M., the resident said he/she remembered staff asking him/her about a situation; he/she cannot remember things for long periods of time. He/She does not remember much about it, but if people say curse words it really bothers him/her. During an interview on 10/26/22, at 12:02 P.M., the assistant director of nursing (ADON) said the following: -Resident #1 does not like cursing; the resident was very upset and tearful; -CNA A was pulled from the floor immediately; -When he/she asked CNA A about what happened, CNA A replied, Jesus; -CNA A then asked the ADON if the resident said he/she called him/her a fat mother fucker? -CNA A was suspended pending investigation; -The investigations showed CNA A used inappropriate language near and about the resident; -CNA A was terminated. During an interview on 10/26/22, at 12:30 P.M., the administrator said the following: -CNA A was suspended pending the investigation; -Treatment of this kind to a resident was not tolerated, and CNA A was terminated; -Staff were immediately in-serviced on the abuse and neglect policy for all staff working and staff as they came to work on 10/13/22, and continued until all staff reviewed the policy and procedures. MO208379

Based on interview and record review, the facility failed to ensure one resident (Resident #4) did not receive antipsychotic medications without thorough documentation to identify the indication for use. The resident received [MEDICATION NAME] (an antipsychotic medication) to treat a [DIAGNOSES REDACTED]. The resident also received [MEDICATION NAME] (an antipsychotic medication) as needed for agitation, however, the facility failed to provide a specific [DIAGNOSES REDACTED]. of the resident and of indications, specific circumstances for use, and the desired frequency of administration. Resident #4 received two antipsychotic medications which were not approved for use in psychotic conditions related to dementia and were labeled to potentially increase the risk of death in older adults with dementia-related conditions. While receiving antipsychotic medications, the resident was admitted to the hospital with [REDACTED]. The facility also failed to ensure one sampled resident's (Resident #16) and one additional resident's (Resident #28) physician orders for as needed (PRN) [MEDICAL CONDITION] drugs were limited to 14 days as required except if an attending or prescribing physician believed that it was appropriate for the PRN order to be extended beyond 14 days, then the physician should document their rationale in the resident's medical record and indicate the duration for the PRN order, in a review of 16 sampled residents. The facility census was 57. 1. Review of the facility policy Pharmacy Consultant Expectations dated (YEAR) showed the following: -The overall goal of the pharmaceutical services system within a facility was to ensure the safe and effective use of medications; -The intent was that the facility maintained the resident's highest practicable level of physical, mental and psychosocial well being and prevented or minimized adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist, attending physician, medical director, and the director of nursing; -The facility implemented gradual dose reductions and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing [MEDICAL CONDITION] medication; -PRN orders for [MEDICAL CONDITION] medications were only used when the medication was necessary and PRN use was limited. 2. Review of the facility policy Antipsychotic Medication Use, dated(NAME)(YEAR), showed the following: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms and risks; -The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions; -Nursing staff will document in detail an individual's target symptoms; -The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; -Staff will observe, document, and report to the physician information regarding the effectiveness of any interventions, including antipsychotic medications; -Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medications; -Antipsychotic medications shall only be used for the following conditions/diagnoses as documented in the record: Schizo-affective disorder, mood disorders, depression with psychotic features, [MEDICAL CONDITION], brief [MEDICAL CONDITIONS], delusional disorder, schizophreniform disorder, atypical [MEDICAL CONDITION], dementing illnesses with associated behavioral symptoms, and medical illnesses or [MEDICAL CONDITION] with manic or psychotic symptoms; -For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: -Not due to a medical condition that can be expected to improve or resolve as the underlying condition is treated; and -Persistent of likely to reoccur without continued treatment; and -Not sufficiently relieved by non-pharmacological interventions; and -Not due to environmental stressors that can be addressed; -Not due to psychological stressors that can be expected to improve or resolve as the situation is addressed. -Antipsychotic medications will not be used if the only symptoms are one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, [MEDICAL CONDITION], unsociability, inattention, fidgeting, nervousness, uncooperativeness, verbal expressions or behavior that are not due to conditions listed under indications and do not represent a danger to the resident or others. 3. Review of drugs.com showed the following for [MEDICATION NAME]: -[MEDICATION NAME] is an antipsychotic medicine; -[MEDICATION NAME] is indicated for use in the treatment of [REDACTED]. -[MEDICATION NAME] is not approved for use in psychotic conditions related to dementia. This medicine may increase the risk of death in older adults with dementia-related conditions. Review of drugs.com showed the following for [MEDICATION NAME]: -[MEDICATION NAME] is an antipsychotic medicine; -[MEDICATION NAME] is used to treat [MEDICAL CONDITION] and is also used to treat symptoms of [MEDICAL CONDITION] disorder; -[MEDICATION NAME] is not approved for use in psychotic conditions related to dementia. It may increase the risk of death in older adults with dementia-related conditions. 4. Review of Resident #4's physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety; -[MEDICATION NAME] (an antipsychotic medication) 0.25 milligrams (mg) every morning for delusional disorder (original order dated 7/18/17); -[MEDICATION NAME] 1 mg at bedtime (original order dated 9/15/17); -[MEDICATION NAME] (an antianxiety medication) 15 mg twice daily (original order dated 9/11/17); -[MEDICATION NAME] (an antianxiety medication) 1 mg every six hours as needed (PRN) for anxiety and aggressiveness (original order dated 7/7/17). Review of the resident's physician progress notes [REDACTED]. -Family wants the resident off of [MEDICATION NAME]. Discontinue [MEDICATION NAME] and change to [MEDICATION NAME] for self-protection and agitation. Decrease [MEDICATION NAME]; -The resident is confused and easily agitated; -[DIAGNOSES REDACTED]. Review of the resident's physician orders, dated (MONTH) (YEAR), showed new orders were received on 10/12/17 for the following: -Discontinue [MEDICATION NAME]; -Decrease [MEDICATION NAME] at bedtime to 0.75 mg; -Add [MEDICATION NAME] 2 mg every six hours PRN for agitation. Review of the resident's [MEDICAL CONDITION] monitoring record showed the resident had paranoia on the 3:00 P.M. to 11:00 P.M. shift on 10/13/17. (This was the only day staff documented the resident had paranoia in (MONTH) (YEAR). There was no documentation to show the resident had delusions.) Review of the resident's Medication Administration Record (MAR), dated (MONTH) (YEAR), showed on 10/13/17 at 4:35 P.M., staff administered PRN [MEDICATION NAME] for increased anxiety and agitation. Review of the resident's nurses notes, dated 10/13/17, showed no evidence the resident received PRN [MEDICATION NAME] as documented in the MAR, and no documentation of non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION NAME] on this day. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/14/17, showed the following: -Usually understood others; -Usually able to make himself/herself understood; -Severe cognitive impairment; -Inattention present, but fluctuates; -No behaviors, no delusions, and no hallucinations; -Diagnoses included dementia and anxiety; -No [DIAGNOSES REDACTED]. -Received antipsychotic and antianxiety medications on all days in the seven-day look back period; -Antipsychotic medications received on a routine basis. Review of the resident's MAR, dated (MONTH) (YEAR), showed on 10/14/18 at 9:30 A.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident's nurses notes, dated 10/14/17 at 11:54 P.M., showed the resident had periods of restlessness earlier this shift; he/she was difficult to redirect. Will continue to monitor. (Review showed no evidence the resident received PRN [MEDICATION NAME] as documented in the MAR, and no documentation of non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION NAME] on this day.) Review of the resident's care plan, dated 10/17/17, showed the following: -[DIAGNOSES REDACTED]. -[MEDICAL CONDITION] medication use: Give [MEDICATION NAME] (an antipsychotic medication) scheduled and [MEDICATION NAME] (an antipsychotic medication) as needed for increased anxiety. The resident is at risk for side effects from his/her medications. -The resident will be free from adverse affects or worsening symptoms related to the use of [MEDICAL CONDITION] medications; -Assess the resident for any changes in his/her behaviors or moods; -Notify the physician of status changes; -The pharmacist and physician are to review record and assess the effectiveness of medication, and routinely assess for possible decreased dose or discontinuation of medication. -The resident is forgetful and confused and does not always understand what is going on around him/her or where he/she is at. He/she has made threats and gestures to hit at staff and can be resistive to care. The resident has a [DIAGNOSES REDACTED].>-Provide the resident with frequent reorientation; -Allow resident time to comprehend what is said; -Do not confront or argue with the resident. Attempt to interest the resident in a diversional activity with decreased stimuli; -If the resident becomes aggressive during care, stop and explain what you are doing and why, allow the resident time to calm down. -If unable to calm the resident and he/she remains resistive, assure him/her he/she is in a safe environment and leave the room to let him/her calm down and reapproach later. If he/she still resists, have someone else try to assist him/her; -Encourage socialization and activities. Offer toileting and activities; -Notify charge nurse of the resident's unresolved behaviors and the resident's family member who may come to help decrease the resident's agitation; -Administer [MEDICATION NAME] (an antipsychotic medication) scheduled and [MEDICATION NAME] as ordered; -Notify the physician of changes in mood or behaviors that are unresolved. Review of the resident's MAR, dated (MONTH) (YEAR), showed on 10/22/17 at 2:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident's nurses notes, dated 10/22/17 at 4:43 P.M., showed the resident was displaying increased agitation and was difficult to redirect. Staff gave the resident PRN [MEDICATION NAME] per physician orders with no further negative behaviors. (Review showed no documentation of non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION NAME].) Review of the resident's MAR, dated (MONTH) (YEAR), showed on 10/30/17 at 3:30 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident's nurses notes dated 10/30/17 showed no evidence the resident received PRN [MEDICATION NAME] as documented on the MAR, and no documentation of non-pharmacological interventions attempted prior to administration of the PRN [MEDICATION NAME] on this day. Review of the resident's physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety; -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. Review of the resident's MAR, dated (MONTH) (YEAR), showed on 11/6/17 at 6:00 P.M., staff administered PRN [MEDICATION NAME] for agitation. Review of the resident's nurses notes, dated 11/6/17, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident's MAR, dated (MONTH) (YEAR), showed on 11/20/18 at 11:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident's PRN Anti-anxiety, Anti-Psychotic, and Hypnotic Documentation, dated 11/20/17, showed the following: -Non-pharmacological interventions attempted: Calm resident, offer bathroom, and offer food; -PRN [MEDICATION NAME] given at 11:00 P.M. for agitation. Review of the resident's nurses notes, dated 11/20/17, showed no documentation for the resident on this day. Review of the resident's MAR, dated (MONTH) (YEAR), showed the following: -On 11/21/18 at 11:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given; -On 11/22/18 at 5:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident's nurses notes for 11/21/18 and 11/22/18, showed no documentation for the resident on these days. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident's [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed on 11/22/17, the resident had on delusions the 3:00 P.M. to 11:00 P.M. shift. (There was no documentation to show the resident presented with delusions on other days during (MONTH) (YEAR).) Review of the resident's physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician's orders did not indicate the duration of this PRN order.) Review of the resident's MAR, dated (MONTH) (YEAR), showed the following: -On 12/11/17 at 4:30 A.M., staff administered PRN [MEDICATION NAME] for agitation; -On 12/14/17 at 8:00 A.M., staff administered PRN [MEDICATION NAME] for anxiety and agitation. Review of the resident's nurses notes, dated 12/11/17 and 12/14/17, showed no documentation for the resident on these days. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident's physician's progress notes, dated 12/14/17, showed the following: -The physician saw the resident; -The resident has increased confusion; -The resident's medical record and medications were reviewed; -Diagnoses of confusion and multi infarct dementia; -Continue current therapy. (Review showed no evidence the resident's physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME].) Review of the resident's MAR, dated (MONTH) (YEAR), showed on 12/29/17 at 5:00 P.M., staff administered PRN [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident's nurses notes, dated 12/29/17, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident's [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident's physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety; -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician's orders did not indicate the duration of this PRN order.) Review of the resident's MAR, dated (MONTH) (YEAR), showed on 1/8/18 at 7:00 A.M., staff administered PRN [MEDICATION NAME] for combative behavior, uncooperative, and unable to redirect. Review of the resident's nurses notes, dated 1/8/18, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident's physician's progress notes, dated 1/11/18, showed the following: -The physician saw the resident and reviewed his/her medical record and medications; -Staff reported no new changes; -Diagnoses of confusion and multi infarct dementia; -Continue current treatment. (Review showed no evidence the resident's physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME].) Review of the resident's MAR, dated (MONTH) (YEAR), showed on 1/13/18 at 1:05 P.M., staff administered PRN [MEDICATION NAME] for agitation. Review of the resident's nurses notes, dated 1/13/18, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the pharmacist consultation report, dated (MONTH) (YEAR), showed the following: -Recommendation to discontinue the PRN [MEDICATION NAME]. The physician declined the recommendation and wrote, the resident has post head trauma with episodic outbreaks requiring medication. The physician signed and dated the consultation report on 2/13/18; -The resident received [MEDICATION NAME] 0.25 mg A.M. and 0.75 mg P.M. since 10/12/17, when it was reduced. This reduction seems successful. Please consider gradual dose reduction to 0.25 mg A.M. and 0.5 mg P.M. while monitoring for emergence of target and/or withdrawal symptoms. The physician declined the recommendation because a reduction was clinically contraindicated. Continued use of the medication was in accordance with current standards of practice and an reduction attempt is likely to impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition of psychiatric disorder as documented below (space below was left blank). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Usually understood others; -Usually able to make himself/herself understood; -Severe cognitive impairment; -Inattention present, but fluctuates; -Disorganized thinking continuously present, does not fluctuate; -No behaviors, no delusions, and no hallucinations; -Diagnoses included dementia and anxiety; -No [DIAGNOSES REDACTED]. -Received antipsychotic and antianxiety medications on all days in the seven-day look back period; -Antipsychotic medications received on a routine basis. Review of the resident's [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident's physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician's orders did not indicate the duration of this PRN order.) Review of the resident's physician's progress note, dated 2/8/18, showed the following: -The physician saw the resident and reviewed his/her medical record and medications; -The resident was confused; -Diagnoses of confusion and multi infarct dementia; -Continue current therapy. (Review showed no evidence the resident's physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME].) Review of the resident's MAR, dated (MONTH) (YEAR), showed on 2/23/18 at 4:00 P.M., the resident received PRN [MEDICATION NAME] for agitation. Review of the resident's nurses notes, dated 2/23/18, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident's [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident's physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder and anxiety; -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. (The physician's orders did not indicate the duration of this PRN order.) Review of the resident's PRN Antianxiety, Antipsychotic, and Hypnotic Documentation, dated 3/4/18 at 6:15 A.M., the resident was hitting other residents and staff. He/she was restless, loud, hollering, rude, making verbal threats, scaring and upsetting other residents, taunting and aggravating other residents, and kicking chairs. Staff attempted to calm the resident; reorient the resident; offer water, bathroom, and food; reposition the resident; offer pain medication; and waited a few minutes and tried again. PRN [MEDICATION NAME] was given at 7:00 A.M. Review of the resident's MAR, dated (MONTH) (YEAR), showed on 3/4/18 at 7:00 A.M., staff administered PRN [MEDICATION NAME]. Review of the resident's physician's progress notes, dated 3/8/18, showed the following: -The physician saw the resident and reviewed his/her medical record and medications; -The resident was very confused; -Diagnoses of confusion and multi infarct dementia; -Continue with current therapy. (Review showed no evidence the resident's physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME].) Review of the resident's MAR, dated (MONTH) (YEAR), showed on 3/30/18 at 7:15 A.M., staff administered PRN [MEDICATION NAME] for agitation. Review of the resident's nurses notes, dated 3/30/18, showed no documentation for the resident on this day. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the pharmacist consultation report, dated for (MONTH) (YEAR), showed the following: -The resident has a PRN order for an antipsychotic, which has been in place for greater than 14 days without a stop date. [MEDICATION NAME] 2 mg every six hours as needed for agitation. -Recommendation- Please review and discontinue PRN [MEDICATION NAME]. If this PRN antipsychotic cannot be discontinued at this time, current regulations require that the prescriber directly examine the resident to determine if the antipsychotic is still needed and document the specific condition being treated prior to issuing a new PRN order. -Rationale for recommendation: CMS requires that PRN orders for antipsychotic medications be limited to 14 days. A new order should not be written without the prescriber directly examining the resident and assessing the resident's condition and progress to determine if the PRN antipsychotic is still needed. Report of the resident's condition from facility staff to the prescriber does not meet the criteria for an evaluation. -The physician marked he/she declined the recommendation above and did not wish to implement any changes due to the reasons below. The physician wrote to continue the PRN for severe change in mood with self-harm environment (illegible). Review of the resident's [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident's physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder and anxiety; -[MEDICATION NAME] 0.25 mg every morning for delusional disorder; -[MEDICATION NAME] 0.25 mg, take three tablets (75 mg) at bedtime; -[MEDICATION NAME] 15 mg twice daily; -[MEDICATION NAME] 2 mg every six hours PRN for agitation. Handwritten note, dated 4/2/18, showed to continue PRN for severe change in mood with self-harm. (The physician's orders did not indicate the duration of this PRN order.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Usually understood others; -Usually able to make himself/herself understood; -Severe cognitive impairment; -Inattention present, but fluctuates; -Disorganized thinking continuously present, does not fluctuate; -No behaviors, no delusions, and no hallucinations; -Diagnoses included dementia and anxiety; -No [DIAGNOSES REDACTED]. -Received antipsychotic and antianxiety medications on all days in the seven-day look back period; -Antipsychotic medications received on a routine basis. Review of the resident's nurses notes showed the following: -On 4/17/18 at 7:20 A.M., the resident sat in his/her chair, leaning forward to the point of almost falling out of his/her chair. The resident was jerking all over upper and lower extremities and torso. Did not answer to verbal stimuli, moaned at intervals. -On 4/17/18 at 7:54 A.M., the resident was transported to the hospital. -On 4/19/18 at 1:04 P.M., the resident returned to the facility. Review of the resident's hospital discharge summary, dated 4/19/18, showed the resident was admitted from a nursing home secondary to changes in behavior. The resident has advanced dementia with behavioral issues. The resident's [MEDICATION NAME] was stopped secondary to tardive dyskinesia (a condition affecting the nervous system, often caused by long-term use of psychiatric medications). Review of the patient transfer form from the hospital, dated 4/19/18, showed to discontinue [MEDICATION NAME] secondary to tardive dyskinesia Review of the resident's physician's orders, dated 4/19/18, showed the following: -Discontinue [MEDICATION NAME] and [MEDICATION NAME]; -Handwritten note added on 4/19/18 to restart [MEDICATION NAME] 0.25 mg, three tablets at bedtime. Review of the resident's physician progress notes [REDACTED]. There was no further documentation in the note. (Review showed no evidence the resident's physician evaluated the indication for use, specific circumstances for use, benefits for continued use and the desired frequency of administration of the PRN [MEDICATION NAME]. The medical record did not include documentation to support adding [MEDICATION NAME] 0.25, three tablets at bedtime.) Review of the resident's [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed no evidence the resident had delusions during the month. Review of the resident's physician orders, dated (MONTH) (YEAR), showed an order for [REDACTED]. Further review showed no physician order for [REDACTED]. Review of the resident's History and Physical, dated 5/10/18, showed the following: -Medical diagnoses included Alzheimer's dementia and recurrent UTIs; -Resident is confused; -Resident's behavior is appropriate. (Review showed no documented evidence to address the resident's medication regimen.) Review of the resident's MAR, dated (MONTH) (YEAR), showed the following: -[MEDICATION NAME] 2 mg every six hours PRN for extreme behaviors. (Review of the resident's physician's orders showed no evidence the resident had an order for [REDACTED]. -On 5/22/18 at 9:40 A.M., staff administered PRN [MEDICATION NAME]. The resident was yelling, hitting, and fighting with staff and family; -On 5/25/18 at 1:00 P.M., staff administered PRN [MEDICATION NAME]. The resident was hitting and trying to stand; -On 5/25/18 at 9:00 P.M., staff administered PRN [MEDICATION NAME]. The resident was yelling and hitting; very agitated; -On 5/27/18 at 8:30 P.M., staff administered PRN [MEDICATION NAME]. The resident had increase agitation, and was yelling and hitting; -On 5/28/18 (time illegible), staff administered PRN [MEDICATION NAME]. The resident was agitated and hitting. The medication helped the resident stay busy; -On 5/28/18 at 2:00 P.M., staff administered PRN [MEDICATION NAME]. The resident was agitated and had aggression. (Review showed no evidence staff documented the effectiveness of the medication, except for on 5/28/18.) Review of the resident's nurses notes for (MONTH) (YEAR) showed no evidence the resident had delusions, aggression, agitation, or any physical or verbal behaviors directed towards others during the month. There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME] during (MONTH) (YEAR). Review of the resident's physician orders, dated (MONTH) (YEAR), showed the following: -Diagnoses included dementia, delusional disorder, and anxiety; -[MEDICATION NAME] 0.25 mg, take three tablets (0.75 mg) at bedtime; -[MEDICATION NAME] 2 mg every six hours as needed for agitation. (The physician's orders did not indicate the duration of this PRN order.) Review of the resident's MAR, dated (MONTH) (YEAR), showed the following: -[MEDICATION NAME] 2 mg every six hours PRN for extreme behaviors; -On 6/4/18 at 6:30 A.M., staff administered [MEDICATION NAME] for agitation; -On 6/5/18 at 3:25 A.M., staff administered [MEDICATION NAME] for agitation and yelling; -On 6/5/18 at 11:30 P.M., staff administered [MEDICATION NAME], however, staff did not document the reason the medication was given. Review of the resident's nurses notes for (MONTH) (YEAR) showed no documentation for the resident on 6/4/18 and 6/5/18(when staff administered PRN [MEDICATION NAME]). There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident's MAR, dated (MONTH) (YEAR), showed on 6/8/18 at 2:00 A.M., showed staff administered [MEDICATION NAME] for yelling. Review of the resident's [MEDICAL CONDITION] monitoring record, dated (MONTH) (YEAR), showed on 6/8/18 on the 7:00 A.M. to 3:00 P.M. shift, showed the resident presented with delusions. Review of the resident's nurses notes for (MONTH) (YEAR) showed no documentation for the resident on 6/8/18 (when staff administered PRN [MEDICATION NAME]). There was no evidence non-pharmacological interventions were attempted prior to the administration of the PRN [MEDICATION NAME]. Review of the resident's MAR, dated (MONTH) (YEAR), showed on 6/10/18 at 10:45 A.M., staff administered [MEDICATION NAME] for agitation and yelling. Review of the resident's nurses notes for (MONTH) (YEAR) showed no documentation for the resident on 6/10/18 (when staff administered PRN [MEDICATION NAME]). There was no evidence non-pharmacological inter

Based on observation, interview and record review the facility failed to ensure one resident (Resident #52) in a review of 16 sampled residents received care and services in accordance with the resident's goals for care and professional standards of practice to meet the resident's physical, mental and psychosocial needs. Facility staff failed to administer Resident #52's medication as physician ordered, failed to obtain weekly and daily weights as physician ordered and failed to notify the physician of the resident's change in condition resulting in the resident's re-hospitalization and increased pain. The facility census was 57. 1. Review of the facility policy Notification of Changes dated (YEAR) showed the following: -It was the policy of the facility that changes in a resident's condition or treatment were immediately reported to the attending physician or delegate. Nurses and other care staff were educated to identify changes in a resident's status and define changes that require notification of the resident's physician to ensure best outcomes of care for the resident; -The objective was to ensure the facility staff made appropriate notification to the physician when there was a change in the resident's condition that might require physician intervention. The intent was to provide appropriate and timely information about changes relevant to a resident's condition to the parties who would make decisions about care, treatment and preferences to address the changes; -Requirements for notification of resident's physician included a significant change in the resident's physical, mental, or psychosocial status such as deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications and/or a need to alter treatment significantly; -Notification was provided to the physician to facilitate continuity of care and obtain input from the physician about changes, additions to or discontinuation of treatments -The nurse would immediately notify the resident's physician regarding the significant change in condition or a need to alter treatment significantly; -The nurse would notify the resident's physician for non-immediate changes of condition on the shift the change occurred unless otherwise directed by the physician and document the notification and record any new orders in the medical record. 2. Review of the facility policy Weight Monitoring dated (MONTH) 2006 showed the following: -Weight and height would be obtained on each resident by the nursing department on admission; -Monthly weights would be completed by the nursing department by the seventh of each month; -Weekly weights would be obtained on residents who show a significant weight change. 3. Review of Resident #52's face sheet showed the following: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Review of the resident's Physician Order Sheet (POS) dated 4/26/18 showed the following: -[MEDICATION NAME] (diuretic medication used to remove excess fluid from the body) 20 milligrams (mg) one by mouth as needed for [MEDICAL CONDITION] (swelling of the tissues); -Weekly weights on Thursdays; -Supplemental oxygen at 2 liters per nasal cannula (through the nose), maintain oxygen saturation (oxygen levels in the blood) above 90 percent (normal 92 to 100 percent). Review of the resident's Baseline Care Plan dated 4/26/18 showed the following: -Disease management concerns included respiratory and pain; -Observation detail list included oxygen therapy; -Monitor medications, condition and report changes to Director of Nursing (DON) and physician as applicable; -Monitor lab values and report to physician; -Intervention of weigh weekly not marked. Review of the resident's Admission Clinical assessment dated [DATE] showed the following: -Admission weight 231 pounds; -1+ [MEDICAL CONDITION] (the degree of observable swelling of body tissues due to fluid accumulation that may be demonstrated by applying pressure to the swollen area such as by depressing the skin with a finger. Ranges from 1+ up 4+) to both feet; -Regular and unlabored breathing and right and left upper lung fields clear. Right and left lower lung fields diminished. Review of the resident's Admission Minimum Data Set (MDS) a federally mandated assessment instrument, completed by facility staff, dated 5/3/18 showed the following: -Moderately impaired cognition; -Required extensive assistance of two staff members with bed mobility, dressing and toileting; -Required total assistance of two staff members with transfers; -Received scheduled and as needed pain medication in the last five days; -Frequent presence of pain in the last five days that effected the resident's sleep and day to day activities rated at 8 on a 0-10 pain scale; -Shortness of breath or trouble breathing when lying flat; -Weight 231 pounds; -Received no diuretic medication in the previous seven days. Review of the resident's POS dated (MONTH) (YEAR) showed weekly weights on Thursday related to [MEDICAL CONDITION] (a heart condition of the inability or failure of the heart to adequately meet the needs of organs and tissues for oxygen and nutrients causing fluid to leak from capillary blood vessels into the tissues. This leads to symptoms that may include shortness of breath, weakness, and swelling of tissues and fluid in the lungs). Review of the resident's nurses' notes showed the following: -On 5/3/18 lung sounds diminished in lower lobes bilaterally; -On 5/5/18 lung sounds diminished; -On 5/8/18 lung sounds diminished throughout. Review of the resident's MAR indicated [REDACTED]. Review of the resident's Treatment Administration Record (TAR) dated (MONTH) (YEAR) showed the following: -On 5/10/18 weight 228.6; -Staff documented no other weights for the month of May. Review of the resident's nurses' notes showed the following: -On 5/13/18 choked on bedtime medication, complained of extreme shortness of breath, oxygen saturation 42 percent on 4 liters of supplemental oxygen. Oxygen changed from nasal cannula to mask with oxygen saturation increased to 73 percent. The physician was notified and resident was transferred to the emergency room by ambulance; -On 5/14/18 resident admitted to the hospital with [REDACTED]. Review of the resident's POS dated 6/4/18 showed the following: -Readmit to facility; -[DIAGNOSES REDACTED]. -Weekly weights; -[MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]. Review of the resident's TAR showed on 6/7/18 a weight of 202.6 pounds. Review of the resident's MAR indicated [REDACTED]. Review of the nurses' note dated 6/10/18 showed the resident was on [MEDICATION NAME] for 2+ [MEDICAL CONDITION] of bilateral (both) lower extremities (The MAR indicated [REDACTED]. Lungs clear with respirations unlabored. Becomes short of air easily. Review of the resident's Admission MDS dated [DATE] showed the following: -Severely impaired cognition; -Required total assistance of two staff members with bed mobility, dressing, toileting and transfers; -Received as needed pain medication in the last five days; -Frequent presence of pain in the last five days that effected the resident's sleep and day to day activities rated at eight on a 0-10 pain scale; -Shortness of breath or trouble breathing when lying flat; -Weight 207 pounds; -Received no diuretic medication in the previous seven days. Review of the nurses' note dated 6/14/18 showed the resident's lungs were clear, respirations labored at times with exertion. Review of the resident's care plan dated 6/15/18 showed the following: -The resident was at risk for pneumonia (lung infection), upper respiratory infection and respiratory distress related to [DIAGNOSES REDACTED]. Staff should administer medications as ordered, monitor supplemental oxygen use at 2 liters per nasal cannula, monitor for peripheral (arms and legs) [MEDICAL CONDITION] and notify physician of increased [MEDICAL CONDITION], monitor weights as ordered and document, monitor for lung congestion, shortness of breath and notify the physician of changes; -The resident had [MEDICAL CONDITION] and was at risk for complications. Staff should monitor for pain and administer pain medications as ordered; -The resident had intermittent complaints of pain. Staff should monitor for signs and symptoms of discomfort, notify the medication nurse of pain and administer pain medications as ordered. Staff should notify the physician if interventions were unsuccessful of if current complaint was a significant change in past experience of pain; -The resident was at risk for cardiac complications. Staff should monitor for increased [MEDICAL CONDITION] and administer [MEDICATION NAME] as ordered, if unresolved notify physician. Staff should monitor weights and vital signs as ordered and notify physician of changes in cognition. Review of the resident's TAR for (MONTH) (YEAR) showed the following: -Staff documented no assessment of the resident's weight on 6/11/18 (Physician ordered weekly weights beginning 6/4/18); -On 6/18/18 weight of 209.6 pounds, a seven pound weight gain in 11 days; Review of the resident's nurses' notes dated 6/18/18 showed no documentation staff notified the resident's physician of the seven pound weight gain in 11 days. Review of the resident's nurses' notes showed on 6/25/18 staff documented the resident was sliding out of his/her wheelchair and unable to go to his/her physician's appointment. Lung sounds diminished, respirations labored with any exertion, abdomen firm. Review of the resident's Electronic Medical Record (EMR) showed on 6/25/18 staff documented the resident's blood pressure was 141/92 millimeters of mercury (mmHg)(normal 120/80). No documentation staff notified the physician of resident's condition. Review of the resident's nurses' notes showed on 6/26/18 staff documented the resident's lung sounds with expiratory wheezes and diminished breath sounds in posterior bases. Will continue with current plan of care. Review of the resident's EMR showed on 6/25/18 staff documented the resident's blood pressure was 89/77 with no documentation staff notified the physician of the resident's condition. Review of the resident's nurses' notes showed on 6/27/18 staff documented the resident's lungs with faint wheezes in bilateral upper lung fields with no documentation staff notified the resident's physician. Review of the resident's computed tomography scan (CT scan) (x-ray measurements taken from different angles to produce cross-sectional images of specific areas of the body) scan of the abdomen and pelvis (related to a groin wound) dated 6/29/18 showed a small right effusion and trace left effusion with bibasilar (both lung bases) subsequent atelectasis (collapsing of part of the lung). Review of the resident's MAR indicated [REDACTED]. Review of the resident's electronic medical record vital signs tab dated 7/1/18 showed the resident's weight as 219.2 pounds, a 10 pound weight gain from the previous weight on 6/18/18 and a 16 pound weight gain from his/her readmission weight on 6/4/18. Review of the resident's MAR indicated [REDACTED]. Review of the resident's nurses' notes showed staff documented on 7/1/18 the resident's lungs were clear, abdomen slightly distended, no [MEDICAL CONDITION] noted. The resident preferred not to get out of bed. Periods of confusion noted. Review of the resident's EMR vital signs tab showed staff documented the following: -On 7/1/18 the resident's blood pressure was 138/52 mmHg and respirations 22 breaths per minute (normal 12-20 breaths per minute); -On 7/2/18 the resident's blood pressure was 167/77 mmHg. Review of the resident's nurses' notes showed staff documented the following: -On 7/3/18 the resident had light wheezes in the upper bilateral lung fields; -On 7/4/18 the resident refused repositioning during the night. Review of the resident's EMR vital signs tab dated 7/4/18 showed staff documented the resident's blood pressure was 173/89 mmHg. Review of the resident's nurses' notes showed staff documented the following: -On 7/5/18 the resident refused turning side to side, preferred to lay on back at all times; -On 7/6/18 the resident complained of pain at times to feet and back, had a poor appetite, was total assistance with activities of daily living, lungs were clear. Review of a Registered Dietician note dated 7/6/18 showed the resident's weight was up 16 pounds over the last 30 days. Review of the resident's MAR indicated [REDACTED]. Review of the resident's nurses' notes dated 7/10/18 showed the resident's skin was moist and [MEDICAL CONDITION] from left thigh to foot, from abdomen around to back with bottom part of back hard to touch, and had a weight gain of nine pounds in two days with lung sounds diminished on the right and crackles to the left posterior lung fields. The resident complained of back and abdominal pain. The physician was notified and orders received to send the resident to the emergency room for evaluation. Resident transferred by ambulance. Review of the resident's hospital transfer form dated 7/10/18 showed the reason for transfer was [MEDICAL CONDITION] and crackles. He/she had low back pain, was on supplemental oxygen at 4 liter/minute by nasal cannula. Review of the resident's Hospital emergency room record dated 7/10/18 showed the following: -Presented with complaint of leg swelling; -History of [MEDICAL CONDITION]; -On 6/29/18 the resident had a CT of his abdomen and pelvis to evaluate a cutaneous groin abscess. This found [MEDICAL CONDITION] (liver disease) with small volume of ascites (fluid accumulation in the abdominal cavity) in abdomen and pelvis; -Presented with increased abdominal ascites going on for the past five days, increased weight gain from 219 pounds to 228 pounds, crackles in left lung base. Chronically on oxygen at 3 liters by nasal cannula; -Chest x ray showed trace pleural effusions (pleural space or sac around the lung contained fluid) and chronically enlarged cardiac silhouette (enlarged heart); -Medications administered in the emergency department included [MEDICATION NAME] 40 mg intravenous (IV) and [MEDICATION NAME] (narcotic pain medication) 4 mg; -Clinical impression was anasarca (wide spread swelling of the skin due to effusion or spreading of fluid into the extracellular space), [MEDICAL CONDITION] (high potassium blood level), [MEDICAL CONDITION] and acute on chronic [MEDICAL CONDITION]. Review of the resident's Hospital Inpatient Discharge Summary dated 7/16/18 showed the following: -Discharge [DIAGNOSES REDACTED]. The heart has to work harder to pump the blood), acute kidney injury superimposed on [MEDICAL CONDITION] and [MEDICAL CONDITION] stage five; -Hospital course: admitted for increasing weight gain following discharge to nursing facility. Was found to have acute on chronic diastolic [MEDICAL CONDITION] due to inadequate diuresis (the process of removal of excess fluid from the tissues with medication). The resident was [MEDICATION NAME] with improvement in ascara. Nephrology (kidney specialist) was consulted and resident was placed on [MEDICATION NAME] (diuretic medication used to remove excess fluid from the tissues) 50 mg by mouth daily. Educated extensively regarding monitoring daily weights and titrate diuretics based on fluid status. discharged to skilled nursing facility with new prescription of [MEDICATION NAME]; -Special instructions: Resident started on [MEDICATION NAME] 50 mg daily for diastolic [MEDICAL CONDITION] in the setting of [MEDICAL CONDITION] stage 3. Weight/fluid status as well as electrolytes and renal function (blood tests) should be monitored and [MEDICATION NAME] dose titrated as appropriate. Recommend repeat Basic Metabolic Panel (BMP) (laboratory blood test) in 2-3 days; -Discharge medications included [MEDICATION NAME] 50 mg daily. Review of the resident's Post-Acute Care Transport Report from the hospital to the facility dated 7/16/18 showed the following: -Weight 213 pounds 10 ounces; -Medication orders included [MEDICATION NAME] 50 mg daily with instructions resident was started on [MEDICATION NAME] 50 mg daily for diastolic [MEDICAL CONDITION] in the setting of [MEDICAL CONDITION] stage three. Weight/fluid status as well as electrolytes and renal function should be monitored and [MEDICATION NAME] dose titrated as appropriate. Recommend repeat BMP in two to three days. Review of the resident's POS showed the following: -On 7/16/18 readmit to facility with previous orders. Add [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -On 7/17/18 daily weights for two weeks. Review of the resident's MAR indicated [REDACTED] -No administration of [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -No administration of [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician) one time daily (MONTH) 17 through (MONTH) 28. Review of the resident's nurses' note dated 7/16/18 showed readmit from the hospital, physician notified of readmission and new orders. Lungs clear. Review of the resident's TAR dated /18 and 7/18/18 showed no documentation staff obtained daily weights. Review of the resident's MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. Review of the resident's nurses' note dated 7/18/18 showed lungs with expiratory wheezing in lower bases. Review of the resident's nurses' note dated 7/19/18 showed [MEDICAL CONDITION] to lower extremities 2+. Review of the resident's TAR on 7/19/18 showed staff obtained no ordered daily weight. Review of the resident's MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on the 7/16/18 hospital discharge. Review of the resident's TAR on 7/20/18 showed no documentation staff obtained the resident's daily weight. Review of the resident's MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on the 7/16/18 hospital discharge. Review of the resident's nurses' note dated 7/21/18 showed staff documented the resident's lungs were clear, respirations labored with exertion. Review of the resident's TAR on 7/21/18 and 7/22/18 showed no documentation staff obtained the resident's daily weight. Review of the resident's MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. Review of the resident's TAR showed the following: -On 7/23/18 weight 228.8 pounds. A 15 pound weight gain since 7/16/18; -On 7/24/18 no daily weight obtained. Review of the resident's MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on the 7/16/18 hospital discharge. Review of the resident's EMR showed staff documented the following: -On 7/23/18 blood pressure 134/83 mmHg; -On 7/24/18 blood pressure 181/87 mmHg. Review of the resident's nurses' notes showed staff documented the following: -On 7/25/18 lungs diminished in bases; -On 7/26/18 lungs diminished, respirations labored with exertion, abdomen distended. Review of the resident's EMR dated 7/26/18 showed staff documented the the resident's blood pressure was 135/97 mmHg. Review of the resident's TAR on 7/25/18 and 7/26/18 showed no documentation staff obtained the resident's daily weights. Review of the resident's MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. Review of the resident's TAR showed on 7/27/18 a weight of 232.6 pounds, a 19 pound weight gain since 7/16/18. Review of the resident's MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -Staff administered [MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician); -No documentation staff administered [MEDICATION NAME] 50 mg daily as ordered on [DATE] hospital discharge. Review of the resident's POS dated 7/27/18 showed a new order for [MEDICATION NAME] 10 mg as needed (PRN) for a weight gain of 3 pounds or increased [MEDICAL CONDITION] in addition to the current [MEDICATION NAME] dose. (facility was still giving 10 mg. of [MEDICATION NAME] rather than the ordered 50 mg.; this day the resident received a total of 20 mg. [MEDICATION NAME]). Review of the resident's MAR indicated [REDACTED].M. staff administered an additional [MEDICATION NAME] 10 mg as needed for a weight gain of 3 pounds or increased [MEDICAL CONDITION]. (Total of [MEDICATION NAME] 20mg administered on 7/27/18, 30mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician). Review of the resident's EMR dated 7/28/18 showed staff documented the resident's blood pressure was 149/98mmHg. Review of the resident's nurses' note dated 7/28/18 showed staff documented the following: -Total dependence on staff with activities of daily living; -Staff turned and repositioned resident. He/she refused to sit up in wheelchair; -Daily weights. Review of the resident's TAR showed on 7/28/18 a weight of 231.0 pounds; an 18 pound weight gain since 7/16/18. Review of the resident's MAR indicated [REDACTED] -No documentation staff administered [MEDICATION NAME] 20 mg daily as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION]; -[MEDICATION NAME] 10 mg daily (40 mg less than the prescribed dose of [MEDICATION NAME] by the hospital discharge physician) administered; -No administration of [MEDICATION NAME] 50 mg daily as ordered on the 7/16/18 hospital discharge. Review of the resident's nurses' note dated 7/29/18 showed on 7/28/18 the resident was transferred to the hospital via ambulance at 9:00 P.M. Staff noted thick yellow-white urine with thick sediment in urinary catheter. Noted increased abdominal girth, puffy [MEDICAL CONDITION] to bilateral upper extremities, fluid pockets to back of head and neck, [MEDICAL CONDITION] present to face and [MEDICAL CONDITION] to temple. Review of the resident's hospital transfer form dated 7/28/18 showed reason for transfer was fluid overload, B/P 188/78, pain level 10/10 with pain medication administered at 8:30 P.M. Review of the resident's Hospital emergency room record dated 7/28/18 showed the following: -Chief compliant of leg swelling, leg, abdomen and facial fluid retention, shortness of breath; -History of [MEDICAL CONDITION] chronically on supplemental oxygen at 3 liters per nasal cannula. Presented to the emergency department with shortness of breath onset yesterday and worsening today as well as extremity [MEDICAL CONDITION] and 8-9 pound weight gain over the last few days (219 pounds on 7/1/18 and 232 pounds today). Recent urinary catheter placed. Past medical history included hosptalized on [DATE] for anasarca; -Respiratory status was shortness of breath with decreased breath sounds in the right lower field; -[MEDICAL CONDITION] with 3+ pitting from feet to groin bilaterally. Swelling of arms and legs; -Abdominal distension and ascites; -Lab results of B-type Natriuretic Peptide (Pro BNP) ( substances that are produced in the heart and released when the heart is stretched and working hard to pump blood. Tests for BNP and NT-proBNP measure the levels in the blood in order to detect and evaluate heart failure with levels above 1200 picogram/ml in a person with kidney disease indicating [MEDICAL CONDITION]). Results of 6,551 pg/ml; -Clinical impression of urinary tract infection associated with indwelling urinary catheter, acute [MEDICAL CONDITION] superimposed on [MEDICAL CONDITION], chronic [MEDICAL CONDITION]. Review of the resident's Hospital History and Physical dated 7/29/18 showed the resident was last seen at the hospital on [DATE] under admission and underwent treatment with diuresis for decompensated heart failure, was transitioned to by mouth diuretics and discharged to skilled nursing facility. Review of the resident's Hospital Inpatient Discharge Summary dated 8/9/18 showed the following: -[DIAGNOSES REDACTED]. -Resident was discharged from the hospital on [DATE] after treatment of [REDACTED]. -Known diastolic [MEDICAL CONDITION], inadvertently following the last discharge the resident only received 10 mg of [MEDICATION NAME] daily instead of 50 mg of [MEDICATION NAME] daily that was prescribed at the time of discharge and this was likely cause for acute heart failure exacerbation; -On 8/9/18 resident was seen by palliative care and based on 24 hour [MEDICATION NAME] utilization start [MEDICATION NAME] (a long acting narcotic pain medication absorbed through the skin through placement of a patch) 12 microgram (mcg) patch with [MEDICATION NAME] ([MEDICATION NAME] with [MEDICATION NAME] narcotic pain medication) one tablet every four hours as needed for breakthrough pain. Discharge prescriptions provided for facility; -Acute on [MEDICAL CONDITION] stage 3 or 4 likely secondary [MEDICAL CONDITION] as well as acute on chronic diastolic [MEDICAL CONDITION]; -Firm [MEDICAL CONDITION] over bilateral lower abdomen, hips, upper thighs, legs and feet at discharge. Review of the nurses' note showed on 8/9/18 the resident was admitted to facility. Review of the resident's POS dated 8/9/18 showed the following: -[MEDICATION NAME] 50 mg daily; -Daily weights; -[MEDICATION NAME] 12 mcg/hour patch, change every third day, placed on 8/9/18, change 8/12/18; -[MEDICATION NAME] 5/325 mg one or two tablets every four hours as needed for pain. Observations of the resident on 8/9/18 at 10:30 A.M. showed the following: -[MEDICAL CONDITION] noted to bilateral feet and legs, arms and hands appear fluid filled and puffy; -Attempted to answer questions and talk with family with repetitive answers and difficulty understanding questions and topic of conversation. During interview on 8/9/18 at 3:00 P.M. the resident's family said the following: -Staff did not administer the resident's [MEDICATION NAME] dose correctly. Staff gave [MEDICATION NAME] 10mg daily instead of 50mg daily and the resident filled up with fluid. His/her hands, arms, feet and legs were full of fluid and had areas of fluid weeping out the skin. He/she was transferred to the hospital in respiratory distress; -Staff delayed his/her treatment for [REDACTED]. -The family informed the staff three times the resident needed to go to the hospital before the ambulance was called. Review of the resident's MAR indicated [REDACTED].M. staff administered [MEDICATION NAME] 5/325 mg one tablet. Review of the nurses' note showed on 8/10/18 staff documented the resident was on comfort measures. Review of the resident's MAR indicated [REDACTED] -On the 6:00 A.M. to 2:00 P.M. shift the resident's pain level was zero on a scale of 1-10. At 9:00 A.M. administered [MEDICATION NAME] 5/325 mg one tablet; -On the 2:00 P.M. to 10:00 P.M. shift the resident's pain level was zero on a scale of 1-10. At 7:30 P.M. administered [MEDICATION NAME] 5/325 mg one tablet; -On the 10:00 P.M. to 6:00 A.M. shift the resident's pain level was zero on a scale of 1-10. Review of the nurses' notes dated 8/11/18 showed the resident's lungs were diminished throughout, abdomen round and firm. Physician notified and ordered comfort medications sublingual only. Discussed with family resident's current status including multiple organs failing and wish to be comfortable. Several new comfort medication orders received, resident concerned about pain. Review of the resident's MAR indicated [REDACTED] -On the 6:00 A.M. to 2:00 P.M. shift the resident's pain level was four on a scale of 1-10. At 9:00 A.M. administered [MEDICATION NAME] 5/325 mg one tablet and documented the resident said he/she felt bad all over; -On the 2:00 P.M. to 10:00 P.M. shift the resident's pain level was five on a scale of 1-10. At 2:30 P.M. administered [MEDICATION NAME] 5/325 mg one tablet and documented the resident hurt; -On the 10:00 P.M. to 6:00 A.M. shift the resident's pain level was eight on a scale of 1-10. No documentation of pain medication administered. Review of the nurses' note dated 8/12/18 showed the resident was concerned about pain. His/her abdomen was distended and tight with absent bowel sounds. Lungs were diminished with bilateral peri

Based on interview and record review, facility staff failed to provide necessary treatment and services to promote healing of a wound and prevent infection for one resident (Resident #37), who developed an open wound which required surgical intervention. Staff noted the resident's open wound on 8/3/15 and treatment was started on 8/4/15. The resident expressed pain in the area over multiple days and was sent to the hospital on [DATE] due to increased abdominal pain. Upon assessment at the hospital, the genital area was swollen with necrosis (dead body tissue), and the wound had purulent drainage (any product of inflammation that contains pus.) There was no documentation to show facility staff identified these changes to the wound. Staff failed to ensure the resident's skin was kept clean and dry to prevent infection. Additionally, staff failed to update the resident's care plan to reflect the development of the wound and failed to identify interventions to promote healing and prevent infection. The facility census was 71. 1. Review of the facility's Charting and Documentation policy, dated March 2015, showed the following: -[MEDICAL CONDITION]. Documentation should include: --Specific location of the skin care problem; --Number, size, degree, and measurement of pressure ulcers; --Documentation that skin surfaces are looked at regularly for the resident at risk or residents exhibiting any rash irritation, or other skin problem; --Regular observations of skin surfaces that touch each other (i.e., prominences, etc.); --Clear indication of contributing factors to the development of the skin condition (i.e., inactive, incontinent, undernourished, etc); --Documentation of the cause of pressure ulcers developed in-house, as well as substantiation of preventative interventions; --Turning and positioning schedules to prevent undue pressure, pressure ulcers, etc; --Any changes in the resident's condition or response to treatment; --Date of occurrences of a skin problem or pressure ulcer as well as the date the problem was solved; --Progress, deterioration, or the development of new problems; --Use of special creams, lotions, medications, or protective devices; --The cause of any bruise or wound; --Consultation from other disciplines; --Other pertinent observations; -Treatments. Documentation should include: Date and time each treatment was administered, name of person administering the treatment, and specific duties performed. Review of the facility's Wound Care and Treatment Policy, dated July 2015, showed the following: -It is the purpose of this facility to prevent and treat all wounds; -Note: If the resident is soiled, cleaning of the resident will be done before the wound treatment; -The physician will specifically order the treatment to be provided; -Explain the process to the resident; provide pain medication prior to the treatment if needed; -After completing treatment, complete documentation. 2. Review of Resident #37's Nursing Evaluation/Data Collection on Admission, dated 7/14/15 at 3:30 P.M., showed staff documented the resident had no open areas upon admission. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/21/15, showed facility staff assessed the resident as: -Date of entry into the facility: 7/14/15; -Moderate cognitive impairment; -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; -Required extensive assistance of one staff for personal hygiene and bathing; -Used walker or wheelchair for mobility; -Occasionally incontinent of bowel and bladder; -Had pain occasionally; -Weighed 99 pounds; -At risk of developing pressure ulcers; -Had no other ulcers, wounds, or skin problems; -Active [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 7/24/15, showed the following: -Problem: The resident is forgetful, weak, and unsteady. He/she needs extensive assistance with his/her activities of daily living (ADLs) and transfers; -Approach: The resident is weak and unsteady and needs assist with all ADLs and transfers. He/she takes a shower twice a week. He/she is weak and is an assist of two with transfers. He/she is incontinent of urine at times, offer and assist with toileting upon awakening in the morning and at bedtime, before meals and activities, and as needed during the day and night. Provide incontinence care and apply skin barrier as needed. Make sure he/she is repositioned in his/her wheelchair and turned side to side every two hours and as needed. Notify the physician of changes or decline in condition. (Review showed no documentation of the resident's open area, nor any interventions to promote healing and prevent infection.) Review of the resident's Daily Skilled Nurses Notes, dated 7/30/15 (no time), showed staff documented the resident had loose stools. Review of the resident's Daily Skilled Nurses Notes, dated 7/31/15 at 3:20 A.M., showed staff documented the resident was incontinent of bowel and bladder and required moderate assistance with ADLs. Review of the resident's Daily Skilled Nurses Notes, dated 8/1/15 at 10:35 A.M., showed staff documented the following: -Skin warm, dry, and intact; -Incontinent at times; -Requires assistance with ADLs and transfers. Review of the resident's Daily Skilled Nurses Notes, dated 8/2/15 at 10:30 A.M., showed staff documented: -Skin within normal limits; -Loose stools- yellow, foul-smelling; -Poor appetite and fluid intake; -Required assistance with ADLs and transfers; -Incontinent of bowel and bladder. Review of the resident's bath sheet, dated 8/2/15, showed the following: -Any reddened areas? YES; -A picture of the posterior body with the buttocks circled and very red was written to the side of the circle; -Signed by Certified Nurse Aide (CNA) R. Review of a written statement from CNA J, dated 8/7/15, showed: -On Monday 8/3/15, during dinner the resident complained of pain in his/her groin area. -Staff removed the resident from the dining room and took him/her to his/her room and CNA J administered perineal care; -During perineal care, CNA J noted skin discoloration on the resident's genitalia; -Upon further inspection, CNA J saw a large white area with exudate (any fluid forced out of the tissues or capillaries because of inflammation or injury) on the area as well as an open area; -CNA J informed CNA I to get the charge nurse (Licensed Practical Nurse (LPN) K); -CNA J completed perineal care and LPN K measured the wound. There was tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) on the resident's genitalia; -The resident's genitals were also swollen and red. Review of the resident's Daily Skilled Nurses Notes, dated 8/3/15 at 11:45 P.M., showed staff documented they noted an open area to the resident's genitalia at 6:00 P.M. The area measured 3 centimeters (cm) by 2.4 cm with 0.6 cm depth with tunneling and yellowish drainage. Staff noted a firm area around the open area. Staff faxed the resident's physician. During an interview on 8/27/15 at 6:10 P.M., LPN K said: -He/she was the nurse that took the measurements of the resident's wound on 8/3/15; -There was tunneling; -He/she faxed the physician about the open wound; -He/she did not have orders to treat the wound, so he/she just covered the wound with gauze. Review of the resident's Daily Skilled Nurses Notes, dated 8/4/15, showed the following: -Night shift - Open area to right side of the genitalia with yellow drainage noted; -At 9:25 A.M., the resident's physician was notified of open area to the genitalia and gave an order to obtain a consultation with Physician F; -Appetite remains poor. Review of the resident's consultation with Physician F, dated 8/4/15, showed Physician F documented: -Wound consult; -Incontinence brief soaked with urine on arrival; -The resident is incontinent; -Open area on right perineum just lateral to the genitalia; -Ulcer with slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light-colored, soft, moist, and stringy (at times)); -Open wound to right side of the genitalia, could be abscess (pus-filled bump on the skin, as a result of a bacterial infection) that opened versus cyst; -Measures: 2.5 cm by 1.5 cm with depth of 1.5 cm and undermining of 5 millimeters (mm); -Strong odor of urine; -Consider Boost supplement (dietary supplement); -Normal saline moist dressing to wound twice a day; -Genital support; -Keep clean and dry; -Recheck next week; -Bactrim DS (antibiotic) one pill twice a day for 10 days; -Urinalysis with culture. During a telephone interview on 8/27/15 at 8:55 A.M., Physician F said: -He/she saw the resident on 8/4/15; -The resident came to his/her office smelling very strongly of urine. The resident was very incontinent of urine and the urine had soaked through the resident's clothing; -The resident had an ulceration on his/her genitals; -The ulceration was over a bony prominence and was located between his/her leg and genitals; -The area could have been caused by friction, shearing, incontinence, being left wet and dirty, lack of nutrition, or a little open area in the skin; -The open area was definitely an ulceration and not an abscess when he/she examined the area. Review of the resident's Daily Skilled Nurses Notes, dated 8/5/15, showed the following: -Resident required moderate assistance with ADLs; -Continue treatment to genital wound per physician's orders [REDACTED].>-At 9:30 P.M., received new order for [MEDICATION NAME] for wound pain. Review of the resident's Treatment Administration Record (TAR), dated 8/5/15, showed the following: -Order for genitals to be supported- staff circled that they did not complete the treatment on the 2:00 P.M. to 10:00 P.M.; -Documentation on the backside of the TAR showed on 8/5/15 the genital support was not available. Review of the resident's record for 8/5/15 showed no documentation regarding the appearance of the resident's genital wound. Review of the resident's Daily Skilled Nurses Notes, dated 8/6/15 (no time), showed staff documented: -Dressing to genitalia with yellow exudate noted; -At 12:30 P.M., the resident required maximum assistance with ADLs and personal care. He/she complained of genital pain at times and medications given as ordered. Dressing clean, dry, and intact; -At 6:50 P.M., the resident required maximum assistance with ADLs and personal care. The dressing to the wound is clean, dry, and intact. The resident complained of pain at times and pain medications given as ordered. Review of the resident's undated skin assessment, showed staff documented: -Stage: Abscess; -Date of onset: 8/3/15; -Measurements: 2.4 cm by 1.2 cm with depth of 1.6 cm; -Acquired: In-house; -Undermining 1.5 cm; -Pink [MEDICATION NAME] tissue noted, no signs or symptoms of infection; -Comment: Wet to dry dressing three times a day and back to physician in one week. During a telephone interview on 9/2/15 at 3:50 P.M., the Director of Nursing (DON) said she completed the undated skin assessment on 8/6/15. Review of the resident's Daily Skilled Nurses Notes, dated 8/7/15, showed staff documented: -At 10:00 A.M., the resident required moderate assistance with ADLs. -Staff attempted three times to obtain urinalysis without success; notified the resident's physician, who ordered a consultation with a urologist. Attempted to reach the urologist, including paged through local hospital; -At 6:15 P.M., report called to the local emergency room . Review of the resident's nursing home to hospital transfer form, dated 8/7/15 at 6:15 P.M., showed staff documented: -Reason(s) for transfer: Complaints of lower abdominal pain, weight loss, and loose bowels; -Skin/Wound Care: Genitalia has open area with tunneling; -Risk Alerts: Pressure ulcer(s) marked with genitals written in above it. Review of the resident's Daily Skilled Nurses Notes, dated 8/7/15 at 6:15 P.M., showed the resident was transported to the local emergency room for evaluation and treatment. Review of the resident's medical record showed no documentation of the appearance of the resident's wound on 8/7/15. During a telephone interview on 8/27/15 at 7:25 A.M., LPN D said: -He/she was the charge nurse on the evening the resident was sent to the hospital; -He/she did not observe the resident's wound; -He/she did not do the dressing change that day; -He/she was concerned about the resident's complaints of lower abdominal pain. During an interview on 8/27/15 at 6:15 P.M., Nurse Aide (NA) G said: -He/she took care of the resident on 8/7/15 prior to being discharged to the hospital; -The resident's genitalia was swollen and red at that time; -The resident was usually incontinent and was having loose stools prior to discharge. Review of the emergency room physician documentation, dated 8/7/15, showed: -Arrival time: 6:40 P.M.; -Presents with complaints of pain in genitalia; -The resident presents with moderate tenderness of the genitalia. The symptoms are alleviated by nothing. The resident comes from a nursing home where they report he/she has a tunneling wound on the right side of his/her genitalia, has lost ten pounds recently, has loose bowels, weakness, and they are currently unable to place a foley catheter (tube inserted into bladder through urethra) to obtain a urinalysis; -Exam: Genitalia swollen (1+). Ecchymotic (blackened) thickened necrosis noted extending over the genitalia. Tender, open ulceration (Stage IV) (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling) on right side of the genitals with purulent drainage with redness extending onto medial thighs. Swollen lymph nodes of the groin more pronounced on the right than the left; -Disposition: Sent to outlying hospital. [DIAGNOSES REDACTED]. -Reason for transfer: Higher level of care; -Accepting Physician: Physician N. Review of the outlying hospital's history and physical , dated 8/7/15, showed the following: -The resident is known to have had a small genital wound, which according to his/her records was being packed for at least the past four days. The resident states he/she has been having pain in his/her perineal area for the past several days. The resident was seen in the local emergency room this evening. The resident was started on intravenous (IV) antibiotics and a foley catheter was inserted; -Exam: Right side of genitalia is tender to the touch. The resident has an approximate 5 cm in diameter wound in the dependent portion of the right side of genitalia. He/she has hardening and tenderness extending posteriorly. No purulent material is draining from the wound at this time; -Impressions: Genital wound with possible early [DIAGNOSES REDACTED] (a type of necrotizing infection or gangrene usually affecting the perineum). I am concerned that he/she may have some tunneling back towards the area of the anus. The resident has consented to genital and perineal exploration incision and drainage. Review of the resident's Operative Report, dated 8/7/15, showed: -Preoperative and postoperative [DIAGNOSES REDACTED]. -Procedure: Incision and drainage of genital wound; -The wound extended with [MEDICATION NAME] dissection another 2 to 3 cm into the right groin area and then across the lower portion of the genital into the dependent portion of the left side of the genitals. During a telephone interview on 8/27/15 at 11:35 A.M., Physician N said: -The resident improved dramatically and was discharged from the hospital to home on 8/14/15; -The resident's discharge [DIAGNOSES REDACTED]. -Being left incontinent of bladder and bowel could have contributed to the abscess since the resident had an open area in the perineal area to begin with. During a telephone interview on 8/26/15 at 11:30 A.M., LPN Q said the resident's genitalia were enlarged quite a bit from the time the open area was found ( 8/3/15) until the resident was sent to the hospital. During a telephone interview on 8/27/15 at 10:50 A.M., family member S said: -While the resident was at the facility, the family found the resident incontinent of bladder and bowel on several occasions; -He/she had a discussion with the Administrator about ten days prior to the resident's discharge from the facility related to the resident being found incontinent of urine and bowel. The Administrator informed him/her the resident would be placed on hourly checks to see if he/she was incontinent, however he/she still found the resident incontinent of urine and bowel when he/she visited the facility; -The resident told family member S, he/she was afraid to eat because he/she would have an accident and no one would clean him/her up for hours; -One evening at the supper meal, the resident was incontinent of bowel and wanted to be cleaned. Staff told the resident he/she would have to wait until the supper meal was complete. The family member, who was assisting the resident with his/her meal, told staff the resident could not wait to be changed since he/she had an open area. After waiting approximately 15 minutes, the facility staff changed the resident; -The resident was doing a lot better and was discharged to home from the outlying hospital on [DATE]; -Physician N at the outlying hospital informed the family the resident had gangrene in genitals related to the open area on the side of the genitalia. During a telephone interview on 8/27/15 at 2:15 P.M., the Administrator said staff initiated the hourly incontinence checks for the resident (as identified by family member S) on the evening shift on 8/7/15. (The resident was sent to the hospital on the evening shift on 8/7/15.) During a telephone interview on 8/27/15 at 1:00 P.M., family member T said: -When he/she visited the resident at the facility, he/she would find the resident incontinent of urine and bowel on many occasions; -The resident told family members that he/she was afraid to eat because he/she would have an accident and no one would clean him/her up for hours; -One evening at supper, he/she witnessed staff tell the resident he/she would have to wait to be cleaned up until after staff were done assisting other residents in the dining room. He/she informed staff the resident was incontinent of bowel and had an open area and needed to be changed. After arguing with staff for approximately 15 minutes, a staff member finally cleaned the resident. During an interview on 8/27/15 at 7:30 P.M., Staff Member M said the following: -He/she had witnessed the resident left incontinent of bowel and bladder. He/she would try to find help for the resident and sometimes it would take 15 to 20 minutes; -Staff Member M started his/her shift in the afternoon and many times the resident would tell him/her that he/she had been laying in urine or feces for almost an hour; -The resident told Staff Member M that he/she was afraid to eat because he/she would be incontinent and it would take staff an hour to clean him/her up. During a telephone interview on 9/2/15 at 3:50 P.M., the DON said: -She expected staff to call the physician to notify him/her of the resident's open area instead of faxing upon the identification of the area. If the resident's regular physician was not available, staff could have called the medical director or the emergency room to get treatment orders; -She expected staff to check and change or toilet residents every two hours; -The treatment nurses should have noticed the swelling and documented those changes as they occurred in the nurse's notes. (Review of the resident's medical record showed no facility documentation of the appearance of the resident's wound on 8/5/15 or 8/7/15. According to the emergency room 's documentation on 8/7/15, the resident presented with swollen genitalia with necrosis noted, and an open ulcer (Stage IV) on the right side of the genitalia with purulent drainage with redness onto the medial thighs. The resident was sent to the emergency room for complaints of lower abdominal pain, weight loss, and loose bowels. There was no documentation to indicate the resident was experiencing any changes to the wound.) During a telephone interview on 9/2/15 at 4:05 P.M., CNA I said: -He/she did take care of the resident on the evening he/she was transferred out; -The resident's genitalia were swollen; -The resident was usually incontinent of bowel and bladder and needed assistance with turning and repositioning. During a telephone interview on 9/2/15 at 4:10 P.M., Registered Nurse (RN) O said: -He/she provided the treatment to the resident's genitals on the morning of 8/7/15; -He/she did not notice any swelling or redness at that time; -The resident complained of a lot of lower abdominal pain and it got worse on 8/7/15; -The resident was usually incontinent of bowel and bladder and needed assistance with incontinence care and turning and repositioning. During a telephone interview on 9/8/15 at 10:05 A.M., the resident said: -He/she was currently at home and doing well; -While a resident at the facility, he/she was left incontinent of bowel and bladder on many occasions; -He/she did not want to eat at the facility because he/she would be incontinent and no one would clean him/her up for hours. Complaints MO 8 and MO 6

Based on interview and record review, the facility failed to provide prompt and adequate assessment, intervention, and failed to notify the physician with symptoms that presented as a significant change for one resident (Resident #1). Resident #1 had decreased meal consumption; increased falls; decline in activities of daily living, normally ambulated but unable to walk; changes in vital signs, to include low blood pressure and a slower heart rate; increased confusion and memory loss; [MEDICAL CONDITION]; increase in tearfulness; and the resident had an increase in his/her [MEDICATION NAME] level from 1.2 MEQ/L on 6/6/11 to 2.2 MEQ/L on 7/4/11. Resident #1 also reported to facility staff that he/she did not feel well. On 7/15/11, facility staff only notified the resident's physician of the resident's 7/4/11 [MEDICATION NAME] levels; the physician ordered a decrease in the resident's [MEDICATION NAME]. Facility staff inaccurately assessed the resident as having "behaviors", and on 7/18/11, staff notified the physician that the resident had increased confusion and was putting his/herself on the floor. Upon admission to the geriatric psychiatric unit in the hospital on [DATE], a hospital physician assessed that the resident seemed to have [MEDICATION NAME] toxicity with acute [MEDICAL CONDITION]. The resident's [MEDICATION NAME] level on 7/20/11 had increased to 3.48 MEQ/L. The resident was then transferred to the intensive care unit (ICU) at the local hospital, then transferred again to a regional hospital's ICU for treatment of [REDACTED]. 1. Review of Resident #1's annual minimum data set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/26/11 showed the following: - The resident was cognitively intact with no memory problems; - The resident had verbal behavior (one to three days a week), and the resident had no other behaviors during the assessment review period; - The resident had no mood symptoms; -The resident was independent for activities of daily living including transfers, ambulation, dressing, eating, toileting, bathing and hygiene; - The resident used a walker for mobility; -Resident's height noted as 67 inches and weight as 175 pounds with no or unknown weight loss; - Active health Diagnoses: [REDACTED]. - The resident had two or more falls with minor injuries since admission/or since prior assessment. Review of the resident's care plan dated 5/2/11 showed the following: -[MEDICAL CONDITION] medication plan of care showed the resident was on [MEDICATION NAME] (an antipsychotic) and [MEDICATION NAME] (an anti-anxiety/hypnotic) and gave information on the side effects and nursing interventions for these medications; - The care plan did not address [MEDICATION NAME], the side effects of the medication, or signs and symptoms of toxicity; - The care plan identified the resident with verbally aggressive behavior; -The care plan noted the resident as alert and oriented; -The resident had a history of [REDACTED]. Review of the resident's monthly weights showed the resident's weight had been stable with weights noted as follows: -May 2011 174.6 pounds; -June 2011 174.2 pounds; -July 2011 172.6 pounds (noted 7/7/11). Review of the resident's labs 4/5/11, 5/2/11, 5/16/11 and 6/6/11 showed the following: -Normal initial [MEDICATION NAME] levels: 0.5 to 1.0 MEQ/L (millequivalents per liter), maintenance level 0.5 to 1.0 MEQ/L. ; -On 4/5/11 [MEDICATION NAME] level 1.4 MEQ/L; -On 5/2/11 [MEDICATION NAME] level 1.1 MEQ/L; -On 5/16/11 tests indicated renal function completed including blood urea nitrogen (BUN) 25 MG/DL (normal 10-26 MG/DL), creatinine 1.3 MG/DL (normal 0.4-1.5 MG/DL), eGFR (used to screen for and detect early kidney damage and to monitor kidney status) 57 (normal values 90-120 ML/MIN- ); -On 6/6/11 [MEDICATION NAME] level 1.2 MEQ/L; - On 7/4/11 [MEDICATION NAME] level 2.2 MEQ/L. Review of the resident's July 2011 physician's orders [REDACTED]. Review of the resident's [MEDICAL CONDITION] monitoring record for [MEDICATION NAME] and [MEDICATION NAME], dated July 2011 showed the resident exhibited no behaviors from July 1 through July 19, 2011. Review showed no [MEDICAL CONDITION] monitoring record for the resident's [MEDICATION NAME]. Review of the resident's food intake record dated July 2011 showed: - July 1st through July 13th the resident's breakfast meal intake averaged 90-100%; - July 1st through July 13th the resident's lunch meal intake averaged 75%; - July 1st through July 13th the resident's supper meal intake averaged 50%; - July 14th through July 19th the resident's breakfast meal intake averaged 35%; - July 14th through July 19th the resident's lunch meal intake averaged 25%; - July 14th through July 19th the resident's lunch meal intake averaged less than 10%; Review of the resident's nurses notes dated 7/5/11 through 7/15/11 showed the following: - On 7/5/11 the resident stated he/she had fallen in his/her room, unwitnessed, no injury. The resident ambulating with his/her walker after fall without any difficulty; - On 7/12/11 resident said he/she tripped and fell and hit his/her head on the door. No apparent injuries, vital signs included temperature 95.9, pulse 68, respirations 20 and blood pressure 112/68; - On 7/13/11 resident up in wheelchair (resident normally ambulated), vital signs included temperature 95.1, pulse 72, respirations 20 and blood pressure 164/80; - On 7/14/11 at 3:00 A.M. resident's gait unsteady and weak, temperature 95, pulse 59, respirations 17, blood pressure 99/70 (normal pulse 60-80 beats per minute and normal blood pressure range 95-140 systolic and 60-90 diastolic), resident using a wheelchair to ambulate, resident complained of generally not feeling well, continue to monitor; - On 7/14/11 at 8:00 A.M. temperature 96, pulse 56, respirations 20 and blood pressure 107/60, resident using wheelchair for mobility, asking staff to propel chair for him/her, crying at times, when asked what was wrong resident said," I don't know"; -Review showed no documentation staff notified the resident's physician of the resident's high [MEDICATION NAME] level drawn on 7/4/11 prior to 7/15/11. Review of the resident's lab sheet, with report dated 7/4/11 of the resident's high [MEDICATION NAME] level of 2.2 MEQ/L, showed on 7/15/11 staff noted the [MEDICATION NAME] level called to the physician with orders received to decrease the resident's P.M. dose of [MEDICATION NAME] to 150 mg for one week, then recheck [MEDICATION NAME] level. The lab sheet showed no documentation the lab sheet facility staff called or faxed to the physician prior to 7/15/11. Review of the resident's physician's orders [REDACTED].M. dose of [MEDICATION NAME] to 150 mg for one week then recheck the [MEDICATION NAME] level. Review of the resident's nurse's notes dated 7/17/11 through 7/19/11 showed the following: - On 7/17/11 at 9:50 P.M. resident found laying on the floor in hallway, resident said he/she hit his/her head on the floor, vital signs included temperature 94.2, pulse 69, respirations 22 and blood pressure 132/71; - On 7/17/11 at 11:20 P.M. resident found sitting on the floor between the chair and bed, vital signs included temperature 94.9, pulse 78, respirations 18 and blood pressure 120/60; - On 7/19/11 at 4:00 A.M. vital signs included temperature 94.9, pulse 53, respirations 18 and blood pressure 77/41. The nurse's notes showed no documentation staff reported and pulse to the resident's physician or the facility monitored the resident's blood pressure; - On 7/19/11 at 11:30 A.M. resident transferred to the geri psych unit at the hospital. Review showed no documentation in the resident's nurses notes of any behaviors exhibited by the resident. During interview on 8/3/11 at 1:40 P.M. the resident's physician said he was notified on 7/15/11 of the resident's [MEDICATION NAME] level that was drawn on 7/4/11. The physician said he decreased the [MEDICATION NAME] and ordered the lab be redrawn in one week. The physician said he wanted to be called with any high or critical levels and then staff should also fax the report to his office. He said he was monitoring the resident's [MEDICATION NAME] levels closely with monthly lab levels. The physician said there was no reason the facility would have had to notify him immediately about the resident's 7/4/11 level. The staff were monitoring the resident and called him when the resident started having mental status changes, and he felt like the resident needed to go to the ER. He said ER staff should have checked the resident more closely when the resident arrived at the ER check his/her [MEDICATION NAME] level. ER staff determined the resident needed to go to geriatric (geri) psych. The resident's physician said it was the emergency room that determined the resident needed to be admitted to the geri psych unit. The resident's physician said he/she had heard the resident was transferred to a regional hospital's intensive care unit (ICU) for [MEDICATION NAME] toxicity and [MEDICAL CONDITION]. During interview on 8/4/11 at 2:30 P.M. the facility's Social Service Designee (SSD) said the week prior to the resident being hospitalized he/she had been coming to her office crying and saying he/she did not feel well. The SSD said both she and the nursing staff assumed the resident was in a manic episode. The SSD said the resident was too weak to walk and had fallen several times. The SSD said the resident was usually independent with ambulation and had never used a wheelchair prior to this episode. The SSD said the only complaint the resident had was he/she was ill and did not feel well. The SSD said nursing staff informed her on 7/18/11 of an order for [REDACTED]. The geri psych unit called on 7/19/11 and said they had a bed available to admit the resident and the resident was transferred. During interview on 8/4/11 at 2:50 P.M. Licensed Practical Nurse (LPN) A said he/she called the resident's physician on 7/18/11 and informed the physician of the resident's increased confusion, and resident putting self on the floor. LPN A said he/she did not see the resident put his/herself on the floor but thought the resident was having behaviors. LPN A said the SSD told him/her that he/she needed to call the physician and get orders to admit to geri psych. LPN A said he/she got an order to send the resident to geri psych to evaluate behaviors. Review of the resident's care plan, showed no behaviors that the resident put his/herself on the floor or refused to walk. Review of the resident's transfer sheet from the facility dated 7/19/11 showed staff noted the reason for transfer as mental status changes. The resident to be an admit to the geri psych unit at the hospital. Staff noted no vital signs and no information about the resident's recent elevated [MEDICATION NAME] level or medication changes. The transfer sheet was not completed in full and unsigned. Review of the resident's admission assessment from the senior mental health unit dated 7/19/11 at 12:30 P.M. showed the resident's admission weight as 163.2 ( a weight loss of 9.4 pounds in 12 days). The assessment showed the resident was transferred from the facility by staff to the senior mental health unit. The resident was drowsy and at times was falling asleep during assessment. The resident reported his/her legs were weak and he/she could not walk. The resident also said he/she had several recent falls. It was reported the resident had increased confusion, paranoia, crying, erratic sleep patterns, was refusing to eat and refusing to walk. Review of the resident's senior mental health nurse's notes dated 7/20/11 showed the resident had a [MEDICATION NAME] level drawn in the A.M. and it was critically high and another stat [MEDICATION NAME] level drawn and it was even higher in the lethal range, the physician was notified and the resident transferred to the ICU unit. Review of the resident's hospital history and physical dated 7/20/11 showed the following: - The physician was called by the senior mental health unit on suspicion of [MEDICATION NAME] toxicity, resident transferred to the Intensive Care Unit (ICU); - Apparently the resident was sent from the LTC (long term care facility) facility to the senior mental health unit because of altered mental status and restlessness but was found to have an elevated [MEDICATION NAME] level; - The resident seemed to have [MEDICATION NAME] toxicity with acute [MEDICAL CONDITION] with a elevated serum creatinine level of 1.3; - The resident's [MEDICATION NAME] level "today" at 9:22 A.M. was 3.48. Review of the resident's hospital [MEDICATION NAME] levels showed: - On 7/20/11 at 7:15 A.M. [MEDICATION NAME] level 3.34 (critical level) normal 0 .6 - 1.2; BUN (blood,urea, nitrogen),52 normal 7-18, creatinine 3.1 normal 0.6-1.3; - On 7/20/11 at 9:20 A.M. [MEDICATION NAME] level 3.48 (critical level). Review of the resident's hospital transfer sheet dated 7/24/11 showed the resident was transferred to a regional hospital for services including nephrology services due to [MEDICATION NAME] toxicity. During interview on 8/4/11 at 10:35 A.M. the director of the geri psych unit said the facility informed him/her on 7/18/11 the resident had been falling, had [MEDICAL CONDITION], normally ambulated but was not able to walk now, increase in tearfulness, increased confusion, and memory loss. The director said the facility said the resident had been cleared by the resident's physician as being medically stable. The director of the geri psych unit at the hospital said the facility brought the resident to the unit on 7/19/11 and the resident did not look very well. The director said they drew a [MEDICATION NAME] level on 7/20/11 and it was extremely high and the resident was sent directly to the ICU. The director said the resident was in the unit less than 12 hours (and then transferred to a regional hospital). During interviews on 7/27/11 at 9:00 A.M., 8/4/11 at 1:30 P.M. and 8/11/11 at 9:20 A.M. the Director of Nurses (DON) said the following: -The facility's [MEDICAL CONDITION] monitoring sheets came from the pharmacy monthly with the Medication Administration Records (MAR). The DON said all [MEDICAL CONDITION] medication should have monitoring sheets. The DON said she did not know why the resident did not have a [MEDICAL CONDITION] monitoring sheet for his/her [MEDICATION NAME] or why the [MEDICATION NAME] was not addressed on the care plan; -When a resident's lab report comes in staff are to fax the report to the physician's office. Staff are to write 'faxed' on the lab report and sign the report. Staff are expected to document the report was faxed in the nurse's notes. She did not know why the resident's lab report ([MEDICATION NAME] level), dated 7/4/11 was not faxed to the physician until 7/15/11; - The resident's low blood pressure on 7/19/11 should have been reported to the physician. The DON said the resident's blood pressure should have also been retaken. The facility's policy for change of condition required staff to report to the physician a change in vital signs. The DON said the resident walked unassisted until the week before he/she was sent to the hospital. The week before the resident was sent to the hospital the resident requested a wheelchair because he/she was too weak to walk. During interview on 8/11/11 at 2:10 P.M. the resident said he/she had recently returned from the hospital. The resident said he/she had gotten very ill and weak before going to the the hospital. When he/she was ill he/she could not eat and did not know what happened but he/she was too weak to walk before he/she went to the hospital. The resident said he/she was still weak but hoped soon he/she could walk without assistance. Review of the facility's undated change of condition policy showed: - A change of condition included abnormal vital signs, weakness and abnormal blood work; - If a significant change in a resident is found staff should page the resident's physician. 2. Review of Principles and Practice of Psychiatric Nursing Sixth Edition, showed the following:- " [MEDICATION NAME] toxicity is an emergency " . Review of the web site http://www.drugs.com, showed the following information regarding [MEDICATION NAME]:- Adverse reactions may be encountered with a [MEDICATION NAME] level below 1.5 MEQ/L, mild to moderate adverse reactions to adverse reactions may occur at levels from 1.5 MEQ/L to 2.5 MEQ/L, and moderate to severe reactions may be seen at levels of 2.0 MEQ/L and above. - Serum [MEDICATION NAME] levels above 3.0 mEq/L may produce a complex clinical picture, involving multiple organs and organ systems. Complaint MO NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began inservicing of staff to facility policy regarding response to abnormal lab reports, change of condition, recognition of side of effects of drugs, including [MEDICATION NAME] and recognizing illness. The facility began identification of residents having the potential to be affected by the deficient practice. At the time of the survey Resident #1 was no longer on [MEDICATION NAME] and no other residents at the facility maintained orders for [MEDICATION NAME]. The facility had not completed the inservice education or resident assessment. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo) requiring that prompt remedial action be taken to address Class I violations.