Every finding on record at Avalon View Health and Wellness

Based on interviews and record review, the facility failed to ensure the registered nurse working as the charge nurse had a current nursing license. The facility census was 129. On [DATE], the Administrator was notified of the past noncompliance which occurred on [DATE]. On [DATE] facility administration was notified of the incident, an investigation immediately began, and corrective actions were implemented to include; complete audit of all employee files to ensure all staff licenses are current and complete audit of all resident's medical records. All residents were interviewed, and no concerns were noted. The Administrator now reviews all potential new staff hires to ensure all required licenses are current. The noncompliance was corrected on [DATE].The facility did not provide a policy and procedure regarding licenses verification.Review of the facility's undated Registered Nurse Job Description showed:-The Registered Nurse (RN) is responsible for ensuring the delivery of efficient and effective nursing care while achieving positive clinical outcomes and resident/family satisfaction in accordance with accepted standards of practice, state and federal regulations and licensing requirements. Operates within the scope of practice defined by the state Nurse Practice Act. Responsible for resident care and direction of nursing care during assigned shifts; includes staff assignments, mentoring, and educating nursing personnel, working with physicians and other medical professionals. -Principal Responsibilities include admit/transfer/discharge residents, participate in facility surveys, assume nursing administrative responsibilities of the center as requested, ensures physician orders are followed as prescribed.-Direct Care Responsibilities include charting progress notes, reporting of incidents/accidents, identifies/reports changes in condition, accurately identifies skin changes, orders and reports diagnostic tests, counts narcotics at beginning and completion of shift, follows policy and procedures for medication order and delivery, assists in meal services, participates and conducts investigations related to any alleged abuse as appropriate, ensures approaches on care plan are being followed. -Special Nursing Care Responsibilities include demonstrating knowledge and ability to work with feeding tube/colostomy care/catheter care, demonstrating knowledge and ability to implement positioning techniques, emergency procedures, intravenous (IV) care, suctioning of residents, and collection of lab specimens. -General Responsibilities include attending and participating in scheduled trainings/education classes/meetings to maintain current certifications and adheres to established employee policies. -Understands, upholds and promotes resident rights. -Follows established safety policies and procedures. -Qualifications include being a graduate of an approved Registered Nurse program and licensed in the state of practice, required. Review of correspondence provided by the Missouri State Board of Nursing on [DATE], showed RN A was notified by letter and e-mail on [DATE], at 11:01 A.M., that his/her nursing license had been revoked.Review of the facility investigation showed on [DATE], Human Resources Officer (HRO) was conducting an audit of all employee files when he/she discovered that Registered Nurse (RN) A had been working as a nurse at the facility without a valid nursing license. HRO was not available for interview. Review of RN A's employee file on [DATE] showed:-RN A applied for a nursing position on [DATE]. A check of RN A's nursing license was run on [DATE]. This check showed RN A's nursing license expired on [DATE]. -RN A was hired by the facility on [DATE]. His/her employment was terminated on [DATE] after it was discovered his/her nursing license was expired. During an interview on [DATE] at 1: 45 P.M., the Administrator said:-It is his/her expectation that all staff employed at the facility have the appropriate, current license. -It is his/her expectation that all information for potential employees be verified through the appropriate agencies, including required licensures.Intake 3027356

Based on interview and record review the facility failed to allow one resident (Resident #1) to exercise his/her rights when funds were transferred from Resident #1's personal checking account to the Business Office Manager's (BOM) personal [NAME] account ( a mobile banking application used to transfer funds from one account to another) without Resident #1's permission. The facility census was 117. Review of the facility's Resident Rights Policy dated 09/01/21 showed:-The resident had the right to a dignified existence and self-determination;-The resident had the right to exercise his/her rights as a resident of the facility;-The resident had the right to be free from interference and coercion from the facility in exercising his/her rights;-The resident had the right to manage his/her financial affairs;-The resident had the right to know in advance what charges the facility may impose against the resident's personal funds. Review of the facility's Transactions Involving Resident Funds or Property Policy dated 06/01/23 showed:-The facility would establish and maintain a system that assures a complete and separate accounting of each resident's funds and is according to generally accepted accounting principles;-The facility would ensure that resident funds are not comingled with funds of someone other than the resident, such as a staff member managing the resident's personal funds;-The facility would not utilize the resident's credit or debit card or non cash forms of payment on personal devises;-No facility employee shall knowingly exploit resident property. 1. Review of Resident #1's care plan dated 11/26/25 showed:-The resident's rights would be promoted and protected placing emphasis on individual preferences, dignity and self determination;-The resident's autonomy and dignity would be honored in the personal choices that he/she makes;-The resident had the right to manage his/her own financial/personal affairs. Review of the resident's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/02/26 showed:-No cognitive impairment;-Dependent on staff for Activities of Daily Living (ADL)s;-Incontinent of bowel and bladder;-Diagnoses included multiple sclerosis, depression and hemiplegia (paralysis of one side of the body). Review of the resident's Facility admission Agreement showed:-The admission Agreement was signed electronically by the resident on 02/27/25;-The Resident had the right to manage his or her financial affairs and need not deposit personal funds with the facility;-The Facility must have written permission from the Resident or Responsible Party to handle Resident's personal funds. Review of the resident's personal bank account records showed:-On 02/04/26, a withdrawal in the amount of $2,000.00 was made by the BOM's [NAME] account.-On 02/05/26, a withdrawal in the amount of $2,000.00 was made by the BOM's [NAME] account. -On 02/06/26, two withdrawals in the amounts of $1,000.00 and $600.00 were made by the BOM's [NAME] account. -On 03/11/26, a withdrawal in the amount of $1,168.70 was made by the BOM's [NAME] account. Review the BOM's [NAME] account showed:-On 02/04/26 a payment in the amount of $2,000.00 was deposited into the BOM's [NAME] account from the resident's personal bank account;-On 02/05/26 a payment in the amount of $2,000.00 was deposited into the BOM's [NAME] account from the resident's personal bank account;-On 02/06/26 a payment in the amount of $1,000.00 was deposited into the BOM's [NAME] account from the resident's personal bank account;-On 02/09/26 a payment in the amount of $600.00 was deposited into the BOM's [NAME] account from the resident's personal bank account;-On 03/11/26 a payment in the amount of $1.168.70 was deposited into the BOM's [NAME] account from the resident's personal bank account. Review of the resident's facility Transaction Report, dated 04/29/26, showed:-On 02/04/26, a payment was made to the facility for $2,000.00-On 02/05/26, a payment was made to the facility for $2,000.00-On 02/06/26, a payment was made to the facility for $1,600.00.-On 03/11/26, a payment was made to the facility for $1, 168.70. Review of the facility investigation, dated 03/25/26, showed:-On 03/24/26, a statement was brought to facility administration that Floor Technician A was asked by the BOM to impersonate the resident over the phone to the bank to authorize the BOM to access the resident's bank account; -The BOM denied asking Floor Technician A or any other employee to impersonate a resident;-The BOM said the resident gave the BOM verbal permission to use his/her [NAME] account to transfer funds from the resident's bank account to the facility; -A financial review of the resident's facility account was completed and no concerns were noted. During an interview on 03/31/26 at 02:08 P.M., the BOM said:-GThe resident gave him/her verbal permission to withdraw the money from the resident's personal bank account and deposit into the BOM's [NAME] account;-The resident's facility room and board was paid out of the BOM's [NAME] account;-He/She should not have used the [NAME] account to withdraw money out of the resident's account;-The resident did not sign anything that gave the BOM permission to take the funds out of the personal bank account. During an interview on 04/02/26 at 11:48 A.M. the resident said:-He/She did not give the BOM or the facility verbal permission to withdraw funds out of his/her personal banking account;-He/She did not sign any document giving the BOM or the facility permission to withdraw funds from his/her personal banking account;-He/She did not give any person permission to withdraw funds out of his/her personal bank account and pay the facility;-He/She is capable of talking to the bank himself/herself;-He/She should be the one to say how his/her money is spent;-The facility did not give him/her the freedom to exercise his/her rights. During a follow up interview on 04/27/26 at 10:58 A.M., the BOM said:-In January 2026, he/she was working with the resident to make the Patient Liability payment to the facility;-The resident had no money in his/her bank account and denied spending the funds; -The BOM assisted the resident to call Social Security to determine why the resident's Social Security payments have not been deposited into the resident's account;-It was discovered the resident had not completed the required paperwork to update his/her information and the Social Security payments had been frozen; -The BOM assisted the resident in completing the needed forms and returned them to Social Security; -The BOM then assisted the resident in calling the resident's bank;-The resident's checking account had been closed due to non-use and the payments from Social Security had been deposited in the resident's savings account;-The resident had no bank card or checks to use to make payments from this savings account; -The resident suggested using a [NAME] app or Cashapp to transfer the money from the resident's savings account to the facility to pay his/her paitent liability;-The BOM said he/she had a [NAME] account;-The resident initially said he/she didn't want to use the BOM's [NAME] account to transfer the money;-However, after additional discussion, the resident agreed to use the BOM's [NAME] account to transfer the money, as the BOM and resident could not find another method to transfer the money; -The resident was present when the BOM called the resident's bank to transfer money from the resident's bank account to the BOM's [NAME] account to the facility; -The BOM denied asking Floor Technician A or any other employee to impersonate the resident to the bank; -The BOM does not know why the resident would deny giving the BOM verbal permission to use the BOM's [NAME] account; -The BOM does not know why Floor Technician A would say the BOM asked him/her to impersonate the resident; -The BOM said he/she should not have accessed and transfer the resident's funds in order to make payments to the facility. During a follow up interview on 04/29/26 at 4:27 P.M., the BOM said:-Initially, the BOM said he/she didn't know how the resident was making payments to the facility before February 2026;-He/She later said the resident had a bank card attached to his/her checking account and the BOM would process the payments using the credit card processing machine; -The BOM said he/she didn't think about if it was wrong or if he/she felt bad about transferring funds this way, but that he/she was only trying to get the money collected, as the resident frequently changed his/her mind in the past about making payments to the facility. During an additional interview on 04/30/26 at 11:20 A.M., the BOM said:-The BOM denied making calls to the resident's bank with other people, only with the resident; -The BOM said he/she and the resident made multiple calls to the bank, but cannot recall how many or the exact dates; -They always used the resident's phone to make calls to the bank; -The BOM denied asking anyone to impersonate the resident to the bank; -He/She did not know why it would sound like other males on the recorded calls with the bank. During a follow up interview on 04/30/26 at 11:52 A.M., the resident said:-He/She lived at the facility for a little over a year; -He/She was aware that transfers were made from his/her bank account using a [NAME] account belonging to the facility's BOM and the money was used to pay the resident's bill at the facility; -He/She has never given verbal or written permission to the BOM or other facility staff to access his/her bank account and/or transfer funds using the [NAME] account; -He/She did not make calls to the bank with the BOM; -He/She does not know who the people on the recorded calls from the bank; -He/She denied having the idea of using the [NAME] account to transfer money from his/her bank account; -The BOM and the Administrator would take the resident's phone without his/her permission to check the resident's bank account. During an interview on 03/31/26 at 2:39 P.M. Floor Technician A said:-The BOM asked him/her to impersonate the resident and speak for the resident over the phone when the bank was called;-The BOM called the resident's personal bank and Floor Technician A pretended to be the resident;-The BOM told Floor Technician A to authorize the resident's bank to transfer money to the BOM's [NAME] account;-The BOM said the resident owed the facility money and the money would go to room and board;-It was a mistake to impersonate the resident and authorize a transfer of money without the resident's permission. During an additional interview on 04/27/26 at 11:43 A.M., Floor Technician A said: -He/She was asked by the BOM to impersonate the resident over the phone to the bank in January 2026;-He/She was on the Home Bound Unit (HBU) hall, cleaning the floors, when the BOM approached him/her and asked for a favor;-The BOM asked him/her to impersonate the resident to the bank to allow the BOM to access the resident's bank account; -The BOM took Floor Technician A into an empty resident room;-The BOM had the resident's cell phone and used it to call the bank;-The BOM asked Floor Technician A to pretend to be the resident and give the bank permission to talk to the BOM;-Floor Technician A said the Administrator gave the resident's phone to the BOM;-The resident told Floor Technician A this, but Floor Technician A could not recall when he/she was told this; -Floor Technician A initially said he/she only impersonated the resident one time;-He/She later said he/she impersonated the resident two times, as only a cetain amount of money could be transferred from the resident's account at one time; -He/She could not recall how the bank representative asked him/her to verify the resident's identify;-Floor Technician A told the Administrator the same afternoon the BOM asked him/her to impersonate the resident;-The Administrator told Floor Technician A never to bring the event up again; -Floor Technician A agreed to impersonate the resident for the BOM because staff are told that all department heads in the facility are bosses and he/she felt like he/she could not tell the BOM no;-He/She did not feel there was another department head he/she could discuss this with; -Floor Technician A does not know why there would be different males claiming to be the resident in the recorded calls from the bank. During an interview on 3/31/26 at 5:14 P.M., Bank Fraud Investigator A said:-Between 2/4/26 and 3/11/26 two individuals called the resident's personal bank and impersonated the resident;-One individual had been identified through their investigation as the BOM;-The call was traced back to the BOM's phone number;-The second individual had not been identified but sounded like a male and identified himself as the resident;-The bank had a recording of the telephone call where the BOM was heard telling the unidentified male they had the resident's social security number ready to go in case the bank asked for it;-The resident had been a customer of the bank for 10 years and was slow of speech;-The male heard on the telephone calls between 2/4/26 and 3/31/26 was not slow of speech and did not sound like the resident; -The male caller said he was paying the facility the money taken out of the account. During an interview on 03/31/26 at 2:55 P.M. the Administrator said:-On 3/24/26 Floor Technician A told him/her the BOM had asked Floor Technician A to pretend to be the resident so they could open a new account at the resident's personal bank;-Floor Technician A said the purpose of the new account was to pay the facility;-An investigation was started on 3/25/26;-The resident was discharged from the facility on 3/17/26 and she had been unable to reach the resident to verify what happened;-The BOM and Floor Technician A were suspended during the investigation;-The BOM and Floor Technician A are back to work;-The findings of the facility's investigation were inconclusive;-The BOM should not have used his/her personal account to transfer money out of the resident's account without the resident's permission;-The facility should have ensured the resident's funds were not comingled with a staff member;-The resident had the right to exercise his/her rights as a resident of the facility;-The resident had the right to be free from interference and coercion from the facility in exercising his/her rights;-The resident had the right to manage his/her financial affairs;-The money transferred went to pay room and board at the facility;-The facility had not refunded the money to the resident as of 03/31/26. #2963375#2965421

Based on observation, interview, and record review the facility failed to follow facility policy and physician orders to implement contact precautions and infection control measures to prevent the spread of scabies for three of three sampled residents, on the special care unit, (Resident #1, #2, and #3). All residents of the special care unit had to be prophylactically treated with 18mg Ivermectin by mouth, and Permethrin topically and showered. The facility census was 118.Review of the facilities policy titled, Identification and Management of Scabies, showed:-Affected residents should remain on contact precautions until 24 hours after treatment;-A resident sharing a room with someone infected with scabies should be examined carefully for scabies and should be treated if signs and symptoms are present, if symptoms are not present daily assessments should be made until the case has resolved;-Individuals who come into contact with the infected resident or with potentially contaminated bedding or clothing should wear a gown and gloves or other protective clothing as established by the facility's infection and exposure control programs;-Place residents with scabies on contact precautions during the treatment period. 1. Review of Resident #1's skin assessment dated [DATE], showed the resident had a rash on his/her shoulder and upper back, palms of hands and in between fingers.Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/11/25, showed:-The resident required partial assistance with showering/bathing;- The resident diagnosis included dementia with anxiety.Review of the Resident's care plan, revised on 11/11/25, showed:-The resident had severe cognitive impairment and resided on the memory care;-Was dependent on staff for meeting emotional, physical, and psychosocial needs;-The care plan did not address the treatment or diagnosis of scabies.Review of the resident's physician's order sheet (POS) dated November 2025, showed the resident had an order for Ivermectin 18mg by mouth on 11/1/25 and repeat the same dose on 11/14/25.During an interview with the Dermatology clinic's Physician Assistant (PA) on 11/20/25 the PA said:- The resident was being treated for a diagnosis of a scabies rash located on the palms and fingers of the resident's left and right hands, shoulder and upper back;- The PA said the clinic sent documentation to the facility after the resident had been seen for follow up care and recommendations. Review of the patient education sheet, provided by the Dermatologist for November 2025 showed: -Scabies is an infestation of mites that is very contagious;-Household contacts should be treated;- Contaminated clothing should be isolated for 72 hours and washed and dried on high heat;-The resident had an additional diagnosis of Post-Scabietic Dermatitis (a persistent allergic reaction to dead mites that causes intense itching);- The resident was prescribed Zyrtec for itching and Triamcinolone (a topical medication used to help alleviate redness, itching, and discomfort cause by skin conditions) 0.1% topical ointment to apply to rash twice daily for two weeks.Observation of the resident, who resided on the memory care unit, on 11/19/25 at 4:10 P.M., showed:- The resident sitting in the dining room at a table with other residents of the memory care;- CMT A held the resident's hand in the dining room without gloves on and did not prevent contact with staff or other residents.2. Review of Resident #2's MDS, dated [DATE] showed:- The resident was dependent on staff for showering/bathing;- Diagnoses included: Non-Alzheimer's Dementia and generalized muscle weakness.Review of the Resident's Care Plan, revised on 9/6/2025 showed:-The resident resided on the memory care unit due to dementia;- The resident had impaired cognitive function due to dementia;- The care plan did not address diagnosis or treatment of scabies.Review of the resident's skin assessment dated [DATE], showed the resident had a rash to his/her chest and back.Review of the resident's POS dated November 2025, showed the resident had an order for Ivermectin 18mg by mouth on 11/5/25 and to repeat the dose on 11/19/25.During an interview on 11/20/25 the Dermatology clinic's PA said:- The resident was being treated for a diagnosis of Scabies rash located on chest and upper back;- The PA said the clinic sendt documentation to the facility after the resident was seen for follow up care and recommendations;- The resident was being treated for a diagnosis of Scabies located back and the chest;- The resident's treatment plan included Ivermectin 18mg by mouth with food and repeat dose in two weeks;- Wash linens and clothing, follow scabies treatments and isolation measures per Centers for Disease Control (CDC) recommendations;- The facility was provided written education by the dermatologist and that others in the household should be treated. Observation of the memory care unit on 11/28/25 at 10:30 A.M. showed no signs posted indicating the need for contact precautions or any personal protective equipment (PPE) in or near the resident's room.3. Review of Resident #3's Quarterly MDS, dated [DATE], showed:- The resident required moderate assistance from staff for bathing/showering assistance;-The resident required supervision or touching assistance with dressing;- The resident had a diagnosis of mild cognitive impairment of unknown etiology and muscle weakness. Review of the Resident's care plan, dated 10/13/25,showed: -The resident had impaired cognitive function due to dementia;- The resident had limited physical mobility;-The resident had potential for impaired skin integrity;- The care plan did not address diagnosis or treatment of scabies.Review of resident's skin assessment dated [DATE], showed the resident had a rash to his/her abdomen, both arms, and back.Review of resident's POS dated November 2025, showed the resident had an order for Ivermectin 18mg by mouth on 11/5/25 and to repeat the dose on 11/19/25.During an interview on 11/20/25 the Dermatology clinic's PA said:- The resident was being treated for a diagnosis of Scabies rash located on abdomen;- The PA said the clinic sends documentation to the facility after residents have been seen for follow up care and recommendations;-The Resident had a diagnosis of scabies, with an outbreak of scabies at the residents nursing home, resident had tried and failed permethrin cream (a topical medication used to treat scabies) and triamcinolone (a topical medication used to help alleviate redness, itching, and discomfort cause by skin conditions.)-Treatment plan to include Ivermectin 18mg by mouth with food and repeat dose in 14 days.Observation on 11/19/25 at 10:00 A.M. showed no sign posted indicating the need for contact precautions or any personal protective equipment (PPE) in or near the resident's room.Observation showed on 11/1925 at 4:00 P.M. ten residents were in a circle in the dining room playing with a ball. Three staff members were with the residents kicking the ball to the resident's and hitting the ball with their hands in a group activity. No contact precautions were implemented. During an interview on 11/18/25 at 10:24 A.M. Nursing Assistant (NA) A said a couple of the residents had rashes and are receiving ointment to treat the rashes. He/she does not know what the rashes were caused by and did not know if was contagious.During an interview on 11/18/25 at 12:08 P.M. CNA A said a few residents had rashes and he/she thought the residents were being treated but was not sure what caused the rashes and did not know if the residents with rashes were contagious or not. During an interview on 11/18/25 at 3:18 P.M., LPN A said he/she was not aware of an outbreak of scabies on the memory care unit. The residents that had an order for Ivermectin was for a rash but the order did not specify what kind of rash.During an interview on 11/18/25 at 3:48 P.M. the Infection Control Nurse said:- Residents with rashes went to the dermatologist and were prescribed ivermectin, none of the residents received scrape testing;- The progress notes put in by the Director of Nursing (DON) on the residents that were seen by the Dermatologist stated that the residents were not contagious, so no precautions were put in place to prevent the spread of scabies;- The facility's Scabies policy states that residents with scabies should be placed on contact precautions during the course of treatment and we did not believe the residents had scabies because there was no skin scape test done by dermatology.During an interview on 11/18/25 at 3:57 P.M. The DON said there were no confirmed cases of scabies in the memory care unit;- A skin check was performed on all of the residents in the memory care unit and any resident who had a rash went to the dermatologist;-She went with two of the residents to the dermatologist appointment and the dermatologist did not do a skin scrape, the Dr. wanted to try Ivermectin and if it did not work, have the residents return in 4-6 weeks.During an interview on 11/19/25 at 9:24 A.M. LPN B said he/she had not been notified of a scabies outbreak or concerns about scabies in the memory care unit.During a follow up interview on 11/19/25 at 12:23 P.M. The DON said:- A staff member had reported he/she had a rash and went to the emergency room where he/she was prescribed Permethrin (a topical treatment used to treat headlice and scabies) for scabies;- This staff member did not have skin scrape performed and was unable to provide paperwork confirming that he/she had scabies;- A staff member had tested positive for scabies, so then all 30 residents in the memory care unit were treated prophylactically for scabies at the end of September;- The dermatologist treated three of the residents that had rashes with Ivermectin since they had already been treated with Permethrin and still had rashes;- Which resulted in all of the residents who resided on the memory care unit being treated with ivermectin prophylactically;-The use of PPE was not implemented at any time after the report of a staff member having scabies;- Since there was not a skin scraping performed, there was no definitive diagnosis of scabies.During an interview on 11/19/25 at 12:30 P.M. the Administrator said:-When the staff member reported that he/she had scabies, all residents in the memory care unit were treated with Permethrin;- The staff member was unable to provide any proof of a diagnosis of scabies, so all residents in the memory care unit were treated with permethrin as a precaution, no contact precautions were put into place.During an interview on 11/19/25 at 2:46 P.M. the Medical Assistant (MA) A at the Dermatologist office said:-The residents that were seen at the dermatology office were being treated for scabies and needed to be isolated and have contact precautions put into place;-These residents needed to be on contact precautions for a week after their first dose of Ivermectin; -Resident #1 would need to be on contact precautions from 10/30/25 through 11/7/25, Resident #2 would need to be on contact precautions from 11/4/25 through 11/12/25, Resident #3 would need to be on contact precautions from 11/4/25 through 11/12/25. During an interview on 11/19/25 at 2:26 P.M. the facilities [NAME] Director said:- If staff member or a resident had a diagnosis of scabies all the residents would be treated prophylactically;-Residents #1, #2, and #3 still had rashes after permethrin treatment so they were referred to dermatology;- The Dermatologist reported to [NAME] Director they could not rule out Scabies when Residents #1, #2, and #3 were taken to see dermatology, so all residents in the memory care unit were treated with Ivermectin and contact precautions followed. During an interview on 11/19/25 at 3:50 P.M. The Assistant Director of Nursing (ADON) said if a resident had scabies they should be isolated in their room and on contact precautions.During an interview and observation on 11/19/25 at 3:55 P.M. Certified Medication Technician (CMT) A who was seen holding the hand of a resident with a rash said he/she was unaware of any residents being diagnosed with scabies and if she had known the resident was diagnosed with scabies he/she would have had gloves and a gown on and followed contact precautions.During an interview on 11/19/25 at 3:58 P.M. Registered Nurse (RN) A said If a resident was diagnosed with scabies the resident would be placed on contact precautions. During an interview on 11/19/25 at 4:05 P.M. CMT B said:- He/She was unaware of any residents being diagnosed with scabies;- If a resident had scabies, he/she would wear a gown, gloves, hair net, and mask, when caring for that resident. During an interview on 11/19/25 at 4:10 P.M. CMT C said:- He/She had not heard of any residents having scabies;- If a resident had scabies, he/she would wear a gown, gloves, and a mask since some residents like to touch his/her face. During a follow up interview on 11/20/25 at 11:45 A.M. the Dermatologist's PA said:-Resident #1,2,3 had active scabies infections at the time of their dermatology appointments; - He/She would expect the facility to put contact precautions into place for residents diagnosed with scabies to prevent the spread to others;- Facilities typically have a protocol that is followed regarding scabies that includes contact precautions and isolation;- He/She would expect the facility to follow their infection control guidelines regarding preventing the spread of scabies.Intakes 2644199, 2646388, 2647372, 2660176,2664057, 2660358

Based on interview and record review, the facility failed to ensure staff invoked (activated by verifying incapacity of the resident to make decisions) Durable [NAME] of Attorney (DPOA) prior to allowing the designated agent to make medical decisions for the resident. The facility also failed to ensure two residents had designated individuals to make medical decisions when the resident was declared incapacitated by two physicians. This affected seven of eleven sampled residents (Residents #33, #48, #53, #63, #73, and #95). The facility census was 111.Review of the facility's Residents' Rights Regarding Treatment and Advanced Directives Policy, dated 2021, showed:-It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advanced directive. -Advanced directive is defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or a recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. -On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive. -The facility will periodically assess the resident for decision making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. -The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions. 1. Review of Resident #33's electronic medical record on 9/17/2025 showed:-He/she has the diagnoses of history of traumatic brain injury, bipolar disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), impulse disorder (a behavioral condition that makes it difficult to control one's actions or reactions), psychosis not due to a substance or known physiological condition (a mental disorder characterized by a disconnection from reality), dementia with agitation (a group of thinking and social, and major depressive disorder (a mental health condition characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Review of the quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 7/11/2025, showed he/she scored 10 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates moderately impaired cognition. -Review of the comprehensive care plan showed interventions related to residing on the memory care unit due to a risk for elopement and exit seeking, aggression toward staff and other residents, delusions and impaired cognitive functioning. -A Certificate of Capacity stating Resident #33 is incapacitated due to the diagnosis of dementia and the Durable Power of Attorney (DPOA)/Health Care Directive should be invoked at this time. This was signed by Physician A on 7/7/2021 and Physician B on 8/22/2021. -There is no guardianship, DPOA, or Health Care Directive in place for Resident #33. -Resident #33 signed his/her vaccination consent forms on 9/13/2022, 11/15/2022, 5/12/2023, 10/20/2024, and 4/16/2025. 2. Review of Resident #48's electronic medical record on 9/17/2025 showed:-He/she has the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), mood disorder (a mental health condition characterized by persistent and pervasive change in a person's emotional state), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), generalized anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), dysphagia (difficulty swallowing), major depressive disorder. -Review of the Annual MDS, dated [DATE] showed he/she has a BIMS score of 3. This score indicates severely impaired cognition. -Review of the comprehensive care plan showed interventions related to cognition/memory loss, depression/anxiety, residing on the memory care unit due to elopement risk and wandering, communication, and hospice care. -A Certificate of Capacity stating Resident #48 is incapacitated due to the diagnoses of cognitive impairment/dementia. It was signed by Physician C on 5/28/2021 and Physician B on 6/6/21. -There is no guardianship, DPOA, or Health Care Directive in place. -The resident gave verbal consent for vaccines on 9/2/2022.-The resident's son gave verbal consent to decline vaccinations for the resident on 12/5/2022, 10/7/2024, and 9/4/2025. 3. Review of Resident #53's electronic medical record on 9/17/2025 showed:-He/she has the diagnoses of COPD, type 2 diabetes mellitus with circulatory complications (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), chronic kidney disease (a progressive irreversible conditions where the kidneys are damaged and lose their ability to filter waste and fluids from the blood), and major depressive disorder. -Review of the resident's quarterly MDS dated [DATE] showed he/she scored 9 on the BIMS. This score indicates moderately impaired cognition. -Review of the comprehensive care plan showed residing on the memory care unit, risk for behaviors related to vascular dementia, cognition/memory loss, communication, and mood problem. -The resident has a Living Will on file, stating the resident's daughter is his/her Personal Representative. -There are no letters/certificates of capacity on file for the resident. -The resident's daughter gave verbal consent for the resident to receive vaccines on 4/2/2025. 4. Review of Resident #63's electronic medical record on 9/17/25 showed:-The resident has the diagnoses of chronic kidney disease, dysphagia, vascular dementia, anxiety disorder, and major depressive disorder.-Review of the resident's quarterly MDS, dated [DATE], showed the resident scored 12 on the BIMS. This score indicates moderately impaired cognition. -Review of the comprehensive care plan showed interventions related to residing on the memory care unit, impaired cognition/dementia, and depression/anxiety.-The resident has a DPOA on file, stating it is invoked when the resident is certified incapacitated by one physician. The document names the resident's son as his/her Power of Attorney. -There are no letters/certificates of capacity on file for the resident. -The resident's son gave verbal consent for the resident to receive vaccines on 4/3/2025. 5. Review of Resident #73's electronic medical record on 9/17/2025 showed:-He/she has the diagnoses of chronic kidney disease, bipolar disorder, mild neurocognitive disorder (a condition characterized by a subtle decline in cognitive abilities, such as memory, attention, language, and problem-solving, that is significant enough to be noticed by the individual or others but does not interfere significantly with daily functioning), and dementia.-Review of the resident's significant change MDS, dated [DATE], he/she scored 11 on the BIMS. This score indicates moderately impaired cognition. -Review of the comprehensive care plan showed interventions related to residing on the memory care unit.-The resident has a DPOA on file, naming his/her brother as the Power of Attorney. The DPOA document does not specify when the DPOA is invoked, thus requiring two physician statements of incapacity per Missouri state statute. -There are no letters/certificates of capacity on file for the resident. -The resident's brother verbally declined for the resident to receive vaccines on 4/1/2025. 6. Review of Resident #95's electronic medical record on 9/17/25 showed:-He/she has the diagnosis of dementia with agitation. -Review of the resident's quarterly MDS dated [DATE], showed the resident scored 5 on the BIMS. This score indicates severely impaired cognition. -Review of the comprehensive care plan showed interventions related to residing on the memory care unit, and impaired cognitive functioning/dementia.-The resident has a DPOA for Health Care document on file, naming his/her mother as Power of Attorney. The document states that the DPOA is effective when two physicians decide and certify the resident is incapacitated and unable to make and communicate a health care decision.-There are no letters/certificates of capacity on file for the resident. -The resident's mother signed the vaccination declination forms for the resident on 4/30/2025. During an interview on 9/19/25 at 11:25 A.M., the Social Services Designee (SSD) said:-He/she was unaware that there are residents in the facility whose family members were making medical decisions for the resident, without the resident's Durable Power of Attorney being invoked.-He/she was unaware that there are two residents that have letters of incapacity on file but have no guardian or DPOA in place. -He/she knows that a resident's DPOA has to be invoked before the person named in the DPOA can make a decision for the resident. During an interview on 9/19/25 at 11:25 A.M., the Administrator said:-He/she was unaware there are residents in the facility whose family members were making medical decisions for the resident, without the resident's DPOA being invoked.-He/she was aware that there are two residents in the facility who have been declared incapacitated by two physicians but have no guardians or DPOA in place. -Residents #33 and #48 were transferred from another skilled facility and had letters of incapacity in place prior to admission to this facility. -The facility has started the process with an attorney for Resident #48 to obtain a guardian. -He/she knows someone other than the resident cannot make medical decisions for the resident if the DPOA has not been invoked.

Based on interview and record review the facility failed to ensure the environment for one (Resident #1) of five sampled residents remained free of accident hazards and additionally failed to follow their own transportation policy when the resident was injured during transportation in facility vehicle as a result of not being properly restrained and supervised by the facility designated driver. The facility census was 111.Review of the facility's Transportation Driving Safety Policy, dated reviewed on 08/10/24, showed:- It is the drivers responsibility to operate the vehicle in a safe manner and to drive defensively to prevent injuries and property damage;- Drivers of company vans, buses, or vehicles carrying patients should have at least three years of driving experience and will be required to complete initial and annual training per manufacturers guidelines to include how to properly restrain a wheelchair and use of safety mechanisms for residents in wheelchairs per manufacturers guidelines and van safety;- The driver shall ensure each passenger is properly restrained to include wheelchair(s) properly fastened and shoulder strap in place and/or passenger seat belts are properly latched;- All drivers and passengers operating or riding in a company vehicle must wear seat belts.On 09/19/2025, the Administrator was notified of the past noncompliance which occurred on 08/25/25. On 08/25/25, facility administration conducted an investigation immediately began and implemented corrective actions to include:- Resident #1 was assessed, primary physician notified, and family notified;- Employee #1 and Director of Maintenance were suspended pending the investigation;- Administrator/designee re-educated the Director of Maintenance;- All staff who are responsible for transportation were re-educated using facility competency that follows manufacturer's guidelines for transport safety restraints and have completed return demonstrations on use prior to future transports;- Facility has a standard competency to ensure proper demonstration is performed by all staff responsible for resident transport prior to transporting residents (which had been provided and reviewed); - The senior maintenance director inspected the facility van including safety restraints to ensure all components are in good working order prior to resident transport and the inspections will be audited by the Administrator for compliance; - Facility will validate driving record for staff who are responsible for transporting residents and the validations will be monitored by the Administrator ; - Future employees that will be transporting residents in the facility van will be educated on manufacturer guidelines and perform competency demonstrations prior to transporting residents. Monthly audits will be performed by maintenance to ensure all components are in proper working condition. -The non-compliance was corrected on 09/02/25.1.Review of Resident#1s Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/23/25, showed:- Cognitive skills intact;- Dependent on staff for all cares;- Diagnoses included: Central cord syndrome at unspecified level of cervical spinal cord, contractures, and neurogenic bladder. Review of Resident #1's care plan, revised 8/28/25, showed:- The resident was hit by a bus last year causing major injuries. Trauma informed care assessment will be administered upon quarterly, annually, and as needed - Trauma informed care assessment was re-administered on 8/26/25;- The resident is non-weight bearing;- The resident is dependent on staff for bathing, toileting, and transfers;- The resident has limited physical mobility related to central cord syndrome (a type of incomplete spinal cord injury that affects the upper motor neurons in the center of the spinal cord. This damage leads to weakness, sensory loss, and other neurological problems primarily in the arms and hands). Review of nursing progress notes showed:- On 8/25/25 at 6:17 P.M. Licensed Practical Nurse (LPN) A documented the resident was in facility van being transported from appointment. When the driver stopped at red light, the resident slid out of wheelchair to floor and landed on his/her left side. The resident hit the left side of his/her face/forehead on the back of the driver's seat. No redness/swell to face/forehead. The resident denies pain;- On 8/25/25 at 6:18 P.M. the Director of Nursing (DON) documented the physician was notified and new orders obtained to monitor the resident for decreased range of motion (ROM) in extremities, obtained vital signs (VS) every shift, and to monitor for worsening pain from baseline for 72 hours. The resident currently doesn't have any new onset of pain. ROM is at baseline;- On 8/28/25 late entry-with effective date 8/26/25 at 10:15 A.M. Interdisciplinary Team (IDT) Progress note: IDT team met and discussed residents fall. Resident is alert and oriented and able to make his/her needs known. Resident was in wheelchair at the time of fall and slid out of wheelchair. Resident has bilateral lower extremity contractures at knee level at baseline. The resident denies any worsening or new onset of pain. Nonslip mat applied to wheelchair to help aid in traction and prevent resident from slipping out of wheelchair. All parties notified.During an interview on 9/3/25 at 10:40 A.M., the Resident said:- He/She didn't have a seat belt on the wheelchair while in the facility van;- He/She had used transportation van before and this had never happened. This was the first time with this driver from the facility;- The driver locked his/her wheelchair in place but did not put the seatbelt across him/her;- The driver was on the highway and went to get into the outer lane, the driver sped up and car in front hit the brakes, the driver then hit the brakes, and it threw him/her forward and smacked into the cushion on the back of the driver seat;- He/She rode on the floor of the van all the way back to the facility;- He/She was not hurt but the idea of no safety precautions taken worried him/her; - The facility notified his/her family and representatives;- The facility told him/her they would make sure they used a seat belt for all wheelchairs when in the van from now on.During an interview on 9/3/25 at 12:00 P.M., the DON said: - Nothing was missing or not working in the transportation van;- The facility Maintenance Director trains staff on procedure for securing residents in the van;- The transportation driver is new at transportation but was a certified nursing assistant (CNA) and had worked at the facility for awhile. During an interview on 9/3/25 at 12:16 P.M., the Transportation driver said:- He/She had just recently started transportation; - He/She was pulling up to the last stop light before arriving at the facility, came to a stop and the resident slid out of his/her chair falling forward into the back of the driver seat; - The Resident was locked into the van with the wheelchair hooks in place. The lap belt was not on, He/she had simply forgot to put it on; - He/She stopped the vehicle to check the resident, believed the resident was okay, and continued driving to the facility; - After arriving at the facility, he/she got out and knocked on the front door and staff came out to help and got the resident up off the floor of the van;- Seat belts and straps are to always be applied;- He/She had a review of safety best use with the Maintenance Director after the incident and went over the transportation checklist; - The Administrator had him/her demonstrate the loading and securing resident procedure on 9/2/25. During an interview on 9/3/25 at 1:20 P.M., the Administrator said: - The transportation driver should always apply proper restraints and residents should be safely secured in their wheelchairs during transport; - The Regional Maintenance signed off on the facility Transportation driver's training, with him/her, after the incident;- He/She had stopped all transportation until he/she verified through return demonstration the transportation driver could use safety belts and transport residents safety, this was completed on 9/2/25. During an interview on 9/3/25 at 1:25 P.M. the Maintenance Director said: - He/She did instruct the Transportation driver on how to apply the seat belt strap, all four ratchet straps for the wheelchairs, and the shoulder strap which connects with the seat belt if needed, after the incident; - He/She showed the Transportation driver how to lock all the wheels on the wheelchairs after the incident; - He/She showed and demonstrated all the procedures to the transportation driver and had them show and demonstrate the procedures back to him/her after the incident. During an interview on 09/16/2025 at 2:25 P.M. the Resident said: - He/She did feel that something was missed by not having the seatbelt applied and felt it was negligent;- He/She felt some pain around his/her eye after the incident but there wasn't any bruising or cuts;- He/She felt the driver did okay after he/she had fallen by looking back to see if he/she was okay and since they were close to the facility, went back to the building;- The facility had used seatbelts before, just didn't this time. During an follow-up interview on 09/18/2025 at 1:47 P.M., the Administrator said:- The process for new staff drivers going forward would be that everybody's driving record would be checked and the staff member would complete the training with the check off list;- There is a daily check off list with the van now;- No staff member would transport residents in the facility van without completing the competency and performing a return demonstration so that he/she feels confident enough in their ability;- He/she, the Regional Maintenance person, or the corporate vice president are the ones that will ensure the competencies are completed and the process is audited properly;- A resident should be safely secured in the wheelchair during transport;- She had been offsite before the Transportation Driver's first transport and the driver was supposed to only set up appointments, not drive the van at that time;- The transportation driver has since been properly instructed how to use and apply seat belts to residents, how to apply and lock the four-point ratchet straps, and how to lock wheelchair wheels and has done an excellent job;- She had Regional Maintenance come in the day after the incident to do competencies with the driver; - She had completed driver check offs with return demonstration on 09/02/25 with the Transportation Driver; - The Administrator or designee are responsible to audit the maintenance check off sheets and staff record reviews;- We hadn't used facility transport for a while prior to this and had used other medical transport.During a follow-up interview on 09/18/2025 at 1:55 P.M., the Transportation Driver said:- Before she drove further, after the resident slid forward, she turned to ask and ensure the resident was okay, checked the resident's positioning, then proceeded to the facility since it was in such close proximity;- Prior to the incident, she had been with the Business Office Manager (BOM) at the front desk and the BOM offered to show her the buckles in front and back to stabilize wheelchair and lock into place, and that was it;- Since the incident, she had gone over the checklist with maintenance and had the competency completed and teach back performed;- Maintenance and the Administrator have both trained her and she signed off on the competency sheets;- She hadn't been aware of the seatbelt, the BOM hadn't shown her that;- The resident didn't say anything when he/she fell but did respond to questions saying he/she was okay and that when he/she had slid forward hitting the front right part of his/her head on the back of the driver's chair. There was no obvious injury that she could see;- When he/she got back to the facility, the DON went out to the van and assessed the resident before anyone moved him/her, then two male staff members from therapy came out, positioned the resident, scooped him/her up and placed into a wheelchair outside the van. The resident was then taken inside for further assessment.During a follow-up interview on 09/18/25 at 2:04 P.M., the DON said:- The seatbelts should be used to secure residents for transport;- If a resident were to fall during transport and if further away from the facility or injured, she would expect the driver to stop and call 911 for assistance;During a follow-up interview on 09/18/2025 at 2:09 P.M., the Maintenance Director said:- Going forward, before any new driver would start, he would properly train them to strap, load residents using the ramp, lock wheels, straps, and locks, then ensure seat belt is applied;- Every resident should be secured in a seat belt properly;- The transportation driver is the only driver we have and has now been trained properly.Intake 2604452

Based on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from physical abuse when Resident #2 hit Resident #1 in the back. Resident #1 was noted to have redness to his/her back. The facility census was 108. On 4/2/25 the Administrator was notified of the past noncompliance which began on 3/24/25. Upon discovery, the facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 3/24/25. Review of the facility's Abuse, Neglect and Exploitation policy, dated 8/22/2022, showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish; -Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment; -Identification of Abuse, Neglect and Exploitation: Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. 2. Physical marks such as bruises, patterned appearances such as a hand print, belt or [NAME] mark on a resident's body. 3. Physical injury of a resident, of unknown source. 6. Physical abuse of a resident observed. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 3/6/25, showed: -The resident has the diagnoses of dementia with agitation (a group of thinking and social symptoms that interferes with daily functioning), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), , low back pain, mood disorder (a mental health condition characterized by persistent and pervasive change in a person's emotional state) and dysphagia (difficulty swallowing); -He/She has adequate hearing, clear speech, understands other and is able to make self understood; -He/She scored 3 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates severely impaired cognitive abilities; -He/She has displayed no behaviors. Review of Resident #1's comprehensive care plan, dated 3/24/25, showed: The resident has a behavior issue related to wandering and rummaging in peer's rooms. He/She had a resident-to-resident altercation on 3/24/25. He/She requires staff supervision during meals. Staff to intervene as necessary to protect the rights and safety of others. Approach and speak to the resident in a calm manner. Divert the resident's attention. Remove the resident and take him/her to an alternate location as needed. Assess the resident for pain, hunger, thirst, care needs. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -The resident has the diagnoses of aphasia (a language disorder that affects a person's ability to communicate), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) , seizures (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness), mild cognitive impairment (the in-between stage between typical thinking skills and dementia), dementia; -The resident has adequate hearing, clear speech, usually understands others and usually makes self understood; -He/She scored zero on the BIMS, indicating severely impaired cognitive abilities; -He/She displays verbal behaviors. Review of Resident #2's comprehensive care plan, dated 3/31/25, showed: -The resident has potential to be physically aggressive (hitting, breaking things) related to anger. He/She had a resident-to-resident altercation on 3/24/25. Staff will administer medications to the resident as ordered. Analyze times of day, placed, circumstances, triggers and what de-escalates behavior. Staff will provide physical and verbal cues to alleviate anxiety. Staff will assess and anticipate the resident's needs. When the resident becomes agitated, staff will intervene before agitation escalates, guide them away from the source of distress, engage calmly in conversation. Review of the facility investigation, dated 3/24/25, showed: -On 3/24/25 at 7:50 A.M., Certified Medication Technician (CMT) A notified the charge nurse, Licensed Practical Nurse (LPN) A of a physical altercation between Resident #1 and Resident #1. CMT A stated that Resident #2 was seated at a table in the dining area and Resident #1 walked by. Resident #2 yelled at Resident #1 to go away and then reached out and hit Resident #1 on the back. CMT A intervened, separated the residents and notified the charge nurse. Both residents were assessed, and Resident #1 was noted to have redness to his/her back; -During interviews conducted shortly after the altercation, neither resident could recall the incident. Both residents responded that they feel safe in the facility. - Summary of actions taken include, residents assessed and monitored, physician and responsible parties were notified, environmental changes were implemented to reduce future incidents including: Increase staff support at meal times, staff to observe resident participation in table clearing after meal service, laminated Spanish reminder placement for Resident #1 before cleaning. - Trauma Informed Care interventions were completed for both residents. - Evaluation completed by mental health professional services, medications reviewed and care plans updated accordingly. During an interview on 4/2/25 at 145 P.M. CMT A said: -CMT A was in the dining room, helping residents get ready for breakfast and passing medication. Resident #2 was sitting at the dinning table, waiting for breakfast. Resident #1 walked by Resident #2's table. Resident #2 yelled at Resident #1 to go away and then reached out and hit Resident #1 on the back; -CMT A immediately separated the two residents and notified the charge nurse. During an interview on 4/2/25 at 2:40 P.M., LPN A said: -At approximately 7:50 A.M., CMT A told LPN A that there was an altercation between Residents #1 and #2. Resident #2 yelled at and hit Resident #1 in the back when he/she walked by Resident #2's table. CMT A separated the residents and notified the charge nurse; -LPN A assessed both residents. Resident #2 had no injuries. There was redness noted to Resident #1's back. LPN A notified the Director of Nursing (DON), physician, and responsible parties. During an interview on 4/2/25 at 2:12 P.M., the Administrator said: -Resident #1 has a history of working as a housekeeper and server. He/She frequently walks around the memory care unit, attempting to tidy up rooms, clear tables and other housekeeping tasks. He/She often needs redirection at mealtime to avoid cleaning tables before other residents are done; -Resident #2 has a history of being a registered nurse and a Director of Nursing at a long-term care facility. He/She frequently reverts to his/her previous occupation, attempting to oversee and direct staff and other residents. He/She enjoys assisting with small tasks and prefers everything to be well organized; -Staff education involving de-escalation, abuse and neglect, and intervention strategies was started and completed on 3/24/25; -Meal schedules on the memory care unit were re-evaluated to provide increased staffing support during meal times; -Staff are supporting and assisting Resident #1 in clearing tables after meals; -Laminated placemats have been placed on the tables, with a note in Spanish, to cue Resident #1 in asking for staff assistance before clearing tables. MO251626

Based on observation, interview, and record review, the facility failed to ensure the food served to the residents was palatable, attractive, and at a safe and appetizing temperature when staff did not temperature check cooked foods and recipes were not followed for five (#27, #49, #90, #91, and #96) of 21 sampled residents. In addition, 15 of 20 residents from the resident council group interview said the food was cold and recipes were not followed. The facility census was 104. 1. Review of the facility policy, on Palatability and Nutritive Value, dated 6/27/23, showed: - Hot foods will be held at temperature 135 degrees or above and cold foods will be held at 41 degrees or below prior to serving to maintain food safety; - Best efforts will be made to present hot food hot and cold foods cold at point of service by using thermal lids and bases, heated or chilled plates and thermal pellets as necessary; - Food service staff will monitor palatability of food at point of service by periodic test tray evaluation and review of resident council concerns. Review of the facility policy on Recording of Food Temperatures, dated 9/1/21 showed: - It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled; - Hot foods will be held at 135 degrees Fahrenheit or greater; - Hot foods will be stirred during holding to redistribute heat throughout the food product; - If the food temperature falls into an unsafe range, immediately follow procedures for reheating previously cooked food; - No food will be served that does not meet the food code standard temperatures. Review of the facility policy on Food Safety and Sanitation, undated, showed: -There was no guidance on how to prepare, distribute, and serve food in accordance with professional standards for food safety. Review of the facility policy on Assistance with Meals, revised September 2013, showed: -For all residents, hot foods shall be held at a temperature of 136 degrees or above until served. Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement. Review of the 9/17/24 lunch menu showed, beef taco with chopped lettuce and tomato, Spanish rice, and chocolate brownie. Review of the beef taco recipe card, dated 9/17/24, showed: -Brown beef in skillet until the internal temperature reaches 160 F; -Drain off fat. Add onions and cook until softened; -Combine cornstarch and seasonings in a bowl. Add to ground beef and onions. Mix well; -Add 3 quarts of water to meat mixture. Mix. Simmer for 45 minutes, stirring frequently; -Place soft taco shells in counter pans. Warm in oven; -To serve, fill each taco shell with No. 16 dipper of meat mixture; -Cover meat mixture with lettuce, then tomato, and top with shredded cheese. Observation of the Beef Taco preparation on 9/17/24 showed: Cook A completed all the below tasks: -9:30 A.M., Removed the defrosted beef from the refrigerator, removed packaging, and placed the beef into a large pot. -9:37 A.M., Added water to the pot with the beef and placed it on a heated stove; -9:38 A.M., Broke up the beef with a spoon while stirring the water mixture; -9:42 A.M., Added two containers of unmeasured hot water to the beef/water mixture; -9:52 A.M., Stirred the beef/water mixture on the stove; -10:03 A.M., Removed the beef mixture from the stove and poured the liquid into containers sitting on the counter. No temperature checks were taken; No strainer was used. -10:05 A.M., The pot was placed back on the stove and the beef, with remaining liquid, was stirred; -10:22 A.M., One spice was added to the beef mixture on the stove and was stirred; -10:28 -10:32 A.M., Six more seasoning ingredients were added and stirred one at a time into the mixture, the pot was covered with tin foil and placed into a heated oven. No temperature checks or taste testing was done on the mixture. -10:53 A.M., The taco meat was removed from the oven, an initial temperature check was done which read<160 F -11:30 A.M., The taco meat container was observed on the serving line covered in foil. The temperature log showed>160 F when placed on the line. Review of the Spanish Rice recipe card, dated 9/17/24, showed: -Cook rice according to directions; -Saute onion, peppers, and celery, cook about 10 minutes; -Add remaining ingredients (diced tomatoes, Chile sauce, tomato paste, seasonings, 1 quart water) to Sauteed vegetables; -Combine with cooked rice; -Place in oven for 1 hour in 12x20 2 pans. Observation of the Spanish Rice preparation on 9/17/24 showed: Cook A completed the below tasks: -10:07 A.M., Water was poured into a pot and placed on the stove under heat; -10:12 A.M., Diced celery was added to the hot water on the stove; -10:15 A.M., Diced onions were added to the hot water on the stove; -10:35 A.M., A block of butter without measurement was added to the boiling water containing celery and onions. (The recipe did not have butter as an ingredient but did have vegetable oil for the saute process which was not followed); -10:40 A.M., Uncooked rice was added to the boiling water with butter and vegetables; -10:46 A.M., Diced tomatoes, chile sauce, tomato paste and seasonings were added to boiling rice mixture; -10:49 A.M., [NAME] A said he/she will know the rice is cooked when it starts to swell up; -10:56 A.M., Temperature check of the Spanish rice showed 175 F. The mixture was placed into a heated oven to harden up. It was in a soupy state; -11:13 A.M., The Spanish rice was starting to harden up and lose the watery consistency, temperature check was 180 F, placed on the steam line, and no taste test of the product was completed. Observation of meal service 9/17/24 showed: -12:05 P.M., The meal service started, no food items were taste tested and no temperature checks were done from the steam line prior to serving residents. -12:06 P.M., Tacos are filled with a No. 16 dipper with meat into soft taco shells which were directly taken from plastic storage bag (room temperature), topped with lettuce, and tomatoes. The recipe card called for cheese, but none was added; -The taco meat appeared watery with a pale grayish white color; -The Spanish Rice showed the correct consistency, however, no taste test or temperature check was done prior to serving; -Residents were provided rough paper towels for napkins wrapped around the silverware tightly and were wet due to sitting in semi-wet trays on the serving line before being passed to the residents. Observations of the Test Tray from lunch on 9/17/24 received directly after the last resident was served at 1:31 P.M., showed: -Taco meat temperature was 105.8 F. The meat was bland, no taste of spices, and watery. -The taco shell was room temperature, the shell broke apart immediately upon picking it up. The taco, lettuce and tomatoes could only be eaten with a spoon. 2. Review of Resident #27's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/12/24 showed: -Resident is cognitively intact; -Diagnoses of heart failure, hypertension (high blood pressure), diabetes (disease of the pancreas), hyperlipidemia (high cholesterol), anxiety disorder, depression, asthma (inflammation of lung airways); During an interview on 9/16/24 at 10:16 A.M., the resident said the food is inedible most of the time. He/She has been served moldy hamburger buns, unidentifiable menu items, and bad quality meals with no consistency. The substitutes for hamburgers and hot dogs are equally bad. He/She takes meals in their room and the presentation of the meals is poor. Review of Resident #49's Quarterly MDS, dated [DATE] showed: -Resident is cognitively intact. -Diagnoses of stroke (brain damage), heart failure, hypertension (high blood pressure); diabetes (disease of the pancreas), hyperlipidemia (high cholesterol), hemiplegia (paralysis of one side of the body), depression, and PTSD (fear from a traumatic event or situation). During an interview on 9/16/24 at 6:30 P.M., the resident said the food is always cold and he/she is not able to chew the food very well. He/She prefers to eat in his/her own room. Review of Resident #90's Quarterly MDS, dated [DATE] showed: -Resident is moderately cognitively impaired; -Diagnoses of stroke (brain damage), hypertension (high blood pressure), hyperlipidemia (high cholesterol), hemiplegia (paralysis of one side of the body); Review of resident #90's undated care plan showed: -Resident has difficulty performing ADLs (activities of daily living) and required substantial assistance with eating. -Resident had dehydration related to poor intake of fluids. Review of resident's orders, dated 7/10/24, showed: -Regular diet, mechanical soft texture, nectar thick liquids consistency. During an interview on 09/16/24 03:58 PM, the resident said: -The food does not taste good and is so salty that he/she cannot eat it; He/She eats in his/her room; -The resident's family member said the resident eats in his/her room and is on a mechanical soft diet. The resident's family member said the food is served clumped together, which made it difficult for the resident to get a bite size. Review of Resident #91's Admission MDS, dated [DATE] showed: -Resident is cognitively intact; -Diagnoses of anemia (lack of healthy red blood cells), deep venous thrombosis (blood clots), heart failure; hypertension (high blood pressure), renal insufficiency (poor kidney function), obstructive uropathy (urinary tract issues), hip fracture, malnutrition, and asthma (inflammation of lung airways); During an interview on 9/16/24 10:36 A.M., the resident said the food is often cold and difficult to chew. Review of Resident #96's Quarterly MDS, dated [DATE] showed: -Resident is cognitively intact; -Diagnoses of Debility Cardio-respiratory, heart failure, hypertension (high blood pressure), diabetes (disease of the pancreas), hyperlipidemia (high cholesterol), anxiety disorder, depression, asthma (inflammation of lung airways); During an interview on 9/16/24 at 11:47 A.M., the resident said the food preparation quality is done poorly, tastes bad as a result, and often times it is served very late. He/She has been living here for five months and the food has always been this way. Instead of a napkin to use with his/her meal they are given soggy paper towels. Sometimes he/she does not get the items that are listed on the menu. During a group interview of the Resident Council on 9/18/24 at 10:00 A.M., The residents said: -Food service was their number one complaint at the facility; -Meals are not served on time and are cold or sometimes burnt; -Meal tickets are not followed consistently; -Food service is getting worse; -They must bring their own spoon if they want to stir cream and sugar into their coffee before it gets cold because utensils take so long to get passed out; -Some meals are just a clump of food that is unrecognizable. During an interview on 9/17/24 at 2:00 P.M., the Dietary Manager said: -She would expect temperature checks to be done as the recipe requires; -She would expect the recipe followed per the recipe card when preparing meals. During an interview on 9/23/24 at 9:55 A.M., the Registered Dietician said: -She would expect food temperatures checked on the steam line right before beginning meal service; -She would expect temperature checks to be done per the recipe card if it's called for; -Taco shells should be heated up per the recipe card for the beef taco menu; -She would not expect hot foods to be held at 135 F when serving hall trays to residents, it's fine as long as it's above 120 F; -The difference between the serving line of 135 F and the 120 F serving hall requirement is because you're always going to lose heat between serving and getting the trays to the residents, it must be over 120 F. 51166 During an interview on 9/23/14 at 3:30 P.M., the Administrator said: -She would expect residents served coffee to have cream and sugar readily available and utensils for stirring their coffee; -Would expect residents to have access to clean napkins for each meal; -She expects that recipes can be done in any order and that the staff are fully competent to add ingredients in any order they choose; -She expects temperature checks to be done when required; -She would expect food temperatures checked on the serving line prior to serving the first meals to residents.

Based on observation and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior throughout the facility. Additionally, the facility failed to ensure furnishings were in good repair. The facility census was 104. Review of the facility provided policy Routine Cleaning and Disinfection dated 9/1/21 showed: -It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment; -Cleaning refers to the removal of visible soil from objects and surfaces; -Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine areas should be cleaned on a regular basis; when soiling or spills occur; when a resident is discharged ; -Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. Review of the facility provided, undated, policy Safe and Homelike Environment included, in accordance with resident rights the facility will provide a safe, clean, comfortable and homelike environment. Observation on 09/18/24 at 8:03 A.M. showed the special care unit with a strong odor of urine. Observation on 09/18/24 at 12:33 P.M. showed on the Special Care Unit: -Resident room [ROOM NUMBER]A, the baseboards peeled away from the wall, had a strong odor of urine, and the entry door had multiple scuff marks; -Resident wheelchairs with torn arm rests, exposing foam underneath; -Resident wheelchairs with dirt and debris, caked on the metal frames, seats and cushions. During an interview on 9/19/24 at 11:33 A.M., Physical Therapy Assistant A said: -He/She tells the Central Supply Manager when a new wheelchair or part is needed; -The facility was aware there were wheelchairs in disrepair. During an interview on 9/19/24 at 11:33 A.M. the Director of Physical Therapy (PT) said: -He/She had placed an order for 20 new wheelchairs from central supply recently; -PT is in charge of ensuring all wheelchairs are in good repair and working order. During an interview on 9/19/24 at 11:33 A.M. the Central Supply Manager said: -He/She had not ordered any wheelchairs since January 2024; -Therapy will let him/her know if wheelchairs or parts are needed; -If a wheelchair is torn and foam is showing a new one needs ordered; -He/She has not had any recent orders for new wheelchairs. During an interview on 9/19/24 at 11:33 A.M. the Corporate Nurse said: -The facility was aware wheelchairs needed to be replaced; -No one in the facility ensured a system was in place for replacing wheelchairs; -There was a system breakdown in this area. Observations beginning on 09/16/24 at 12:58 P.M. on [NAME] Hall showed: -Multiple room doors with scratches and nicks in the kick plate. Observation on 9/23/24 at 11:26 A.M. showed: - Room A20 privacy curtain had multiple stains and small tears. The second curtain was missing multiple hooks; -Room A22 privacy curtain had a hole in the mesh at the top of the curtain; -Room A23 privacy curtain had stains and small tears over the curtain; -Room A18 privacy curtain had holes in the mesh at the top of the curtain. Observation on 9/16/24 at 9:36 A.M., showed dirty dishes sitting in the common area between the [NAME] and Maple halls. No residents present. Observation on 9/16/24 at 10:13 A.M., showed room A-1 on Maple hall had caked on dirt and food with sticky spots on the floor. Chew spit was also observed on floor of resident's room. Observation on 9/16/24 at 6:55 P.M., showed dead bugs in base of holder of hand sanitizer dispensers on Maple hall. Observation on 9/17/24 at 6:59 A.M., showed a strong odor of urine in hallway by the nurses station on Maple hall. During an interview on 09/23/24 at 7:33 A.M., Housekeeper A said: -He/She completed daily cleaning of the resident bathrooms and mops the floor; -One person cannot complete everything that needed to be completed; -There is a floor technician in the evening to buff floors; -There was no check off list for completed tasks. During an interview on 09/23/24 at 8:17 A.M., the Housekeeping Supervisor said: -The Administrator expects the facility to be clean and odor free; -Cleaning is completed daily by a list; -He/She expects the facility to be clean, odor free and floors and ceilings to be free of dirt and debris. During an interview on 9/23/24 at 9:11 A.M., the Maintenance Director said: -He had been employed in the facility four months; -Morning meetings are where he finds out repairs that are needed, or staff can fill out a work order; -He completed weekly walk through inspections with Administration; -He expects things to be in good repair; -The baseboards are paint stained. Housekeeping is responsible for cleaning baseboards; -Repairs are prioritized by need; -Housekeeping is responsible for all floors, dusting and baseboard cleaning; -He used a log book to know what needs fixed. If it was not on the log then it would not be fixed; -Log books were at each nurses station and any staff can write in them. During an interview on 9/23/24 at 3:33 P.M., the Administrator said: -Housekeeping was to complete daily cleaning to include dusting and high dusting; -She expected the facility to attempt to be odor free as much as possible; -Vents, floors and ceilings should be cleaned by housekeeping and maintenance as a collaborative effort; -Anyone can put a work order in if something is broken; -Each Department Head completes weekly rounds and would make a note of any issues that need addressed by a different department; -She would expect work orders to be completed if the department head found a concern for maintenance; -They have made progress in the cleanliness of the building but had more to go. MO#241807 46706 47195

Based on observation, interview and record review, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for five (Resident #12,#15, #69, #77 and #154 ) out of 23 sampled residents when the facility failed to store medications in a locked storage area for Resident #12 and Resident #154 and failed to ensure medications were inaccessible to unauthorized staff and residents when the medication cart was left unlocked and unattended. Additionally, the facility failed to ensure staff were able to read the pharmacy label for Resident #69, failed to destroy expired medications for Resident #69 and Resident #77, and failed to destroy expired house stock medications. The facility census was 104. Review of the facility's Medication Storage Policy, revised, 9/1/21, showed in part: - It is the policy of this facility to ensure all medications will be stored according to the manufacturers recommendation and securely; - All drugs and biologicals will be stored in locked medication rooms or carts; - Only authorized personnel will have access to medications; - Medication that is outdated, discontinued or with missing or illegible labels will be destroyed. 1. Observation on 09/18/24, at 11:58 P.M., of the medication cart showed: -The second, third and fourth drawers of the medication cart had multiple loose pills, dirt and debris in the bottom of the drawer; - The fourth drawer had a white liquid spilled in the bottom of the drawer; - A bottle of house stock Milk of Magnesia (used to treat constipation) with an expiration date of April 2024; - A bottle of Flonase Nose Spray (used to treat allergies) for Resident #15 with an expiration date of July 2024; - A bottle of Haldol (used to treat certain types of mental disorders) for Resident #77 with an expiration date of July 2024; - A bottle of Valproic Acid (used treat seizures and bipolar disorder) for Resident #69 with the label covered with sticky liquid and illegible. During an interview on 9/18/14, at 12:08 P.M., Certified Medication Technician (CMT) B said: -Expired medications should be removed from the medication cart daily; -The CMTs are responsible for making sure the expired medications are taken out of the medication cart; -He/she was not sure who was responsible for making sure the there were no loose pills in the bottom of the medication cart and that the medication cart was clean; -There should not be loose pills, dirt and debris in the bottom of the medication cart; -Any labels that are damaged or unreadable should be replaced; -The nurses get replacement labels for medications if needed; -The nurse takes care of destroying expired medications. During an interview on 09/18/24, at 12:16 P.M., Licensed Practical Nurse (LPN) B said: -Expired medications should be removed from the medication cart at least every week; -The CMTs are responsible for removing the expired medications from the medication cart; -The nurses should ensure the expired medications are removed from the medication cart by the CMTs and that the cart is clean and good order; -He/she does not have time to ensure this gets done; -There should not be loose pills, dirt and debris in the bottom of the drawers of the medication cart; -The nurses take care of destroying the medications. During an interview on 9/23/24 at 3:33 P.M., the Director of Nursing (DON) said: -He/she expects the CMTs to monitor the medication carts for expired medications, labels that are not readable, and general cleanliness of the medication cart; -He/she expects the nurses to check the medication carts as well as the CMTs to ensure there are no expired medications, the medication labels are readable and the medication carts are clean; -The DON should monitor at least every month. During an interview on 9/23/24 at 3:33 P.M., the Administrator concurred with the DON. 47195 2. Review of Resident #12's, quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/6/24, showed: -He/She was cognitively impaired. -He/She had clear speech and was able to make self understood and understand others; -He/She had no impairment to upper or lower extremities; Diagnosis included breathing abnormality, asthma (a lung disease that affects the airways, making it difficult to breathe), cognitive communication deficit (difficulty with communication that's caused by disruption in cognitive processes such as attention, memory, or problem solving, emphysema (a lung condition that causes shortness of breath), chronic obstructive pulmonary disease (a lung disease that makes it difficult to breath). Review of the resident's care plan, revised 9/1/24, dated: -He/She had emphysema, chronic obstructive pulmonary disorder due to smoking; -Give aerosol or bronchodialator as ordered. Monitor/document any side effects and effectiveness; -Head of bed elevated to or out of bed upright in a chair; -Monitor for difficulty breathing (dyspnea) or exertion. Remind resident not to push beyond endurance; -Monitor for signs and symptoms of impending asthma attack: coughing spells, decreased energy, rapid breathing, complaint of chest tightness or hurting, wheezing, shortness of breath, tightness of neck or chest muscles, malaise or fatigue; -Monitor for anxiety. Offer support, encourage resident to vent frustrations, fears. Reassurance. Give as needed medications for anxiety as ordered. -Monitor/document/report as needed any signs and symptoms of respiratory infection. -Occupational therapy consult for energy conservation recommendations. Review of the physician's orders, dated 9/17/24, showed: -Order started 5/16/23, Preventil HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate), 2 puffs inhale orally every 4 hours as needed for shortness of breath related to chronic obstructive pulmonary disease, unspecified , emphysema, unspecified, shortness of breath or wheezing; -No orders to self administer medications. Review of the electronic medical record showed: -No self-administration of medications assessment completed. Observation on 9/16/24 at 10:06 A.M., showed an albuterol sulfate inhaler on the bedside table beside the resident's bed. The inhaler showed 50 on the side of inhaler dispenser. Observation on 9/19/24 at 5:24 P.M., showed two inhalers laying on the bedside table in the resident's room. The ventolin inhaler at bedside with 000 showing in dispenser and albuterol sulfate inhaler with no visible number on the inhaler unit. Observation on 9/23/24 at 9:54 A.M., showed an albuterol inhaler labeled and dated as filled on 9/19/24. Number displaying on inhaler showed 180/16. During an interview on 9/23/24 at 9:43 A.M., Certified Medication Technician (CMT) A said: -He/She was not sure if resident was allowed to keep his/her inhaler at bedside; -The inhaler is administered by the nurse; -The other nurse kept the inhaler in his/her medication cart. During an interview on 9/23/24 11:19 A.M., Registered Nurse A said: -He/She had only one resident on the Maple hall that self administered medications; -Resident #12 was not able to self administer his/her medications; -Resident #12 should not have his/her inhaler at bedside; -Residents must have physician's orders and self-administration of medications assessment completed prior to being able to self-administer medications. During an interview on 9/23/24 at 3:33 P.M., the DON said residents who have medications at bedside should have a physician's order and self-administration of medication assessment. During an interview on 9/23/24 at 3:33 P.M., the Administrator said: -Residents who self-administer medications should have physician's orders; -Residents who self-administer medications should have a self-administration of medication assessment completed. 3. Observation on 9/16/24 at 9:08 A.M., showed the medication cart on the [NAME] hall was unlocked and unattended. The treatment cart on the Maple hall was unlocked and unattended. Observation on 9/16/24 at 9:33 A.M., showed the treatment cart on the Maple hallway was unlocked and unattended. Observation on 9/16/24 at 7:39 P.M., showed the medication cart on the [NAME] hall was unlocked and unattended in hallway outside of rooms B18 and B19. Staff was not in line of sight of the cart. Drawers to the cart were facing the middle of the hall. Observation on 9/16/24 at 7:46 P.M., showed the treatment cart was unlocked on the Maple hall. Observation on 9/17/24 at 5:06 A.M., showed the medication cart on the Maple hall was left unlocked and unattended. Licensed Practical Nurse (LPN) A was observed coming out of room A-25 at the end of the hall while the medication cart was up at the nurses station. Observation on 9/23/24 at 8:57 A.M., showed the treatment cart was unlocked on the Maple Hall. Observation on 09/23/24 08:57 AM, showed the treatment cart unlocked on the Maple hall. During an interview on 9/23/24 at 9:43 A.M., CMT A said: -Medication carts should be locked all the time; -He/She has observed residents come by the medication cart and grab at things on the medication cart; -The medication treatment cart should be locked, but staff sometimes forget. During an interview on 9/23/24 11:19 A.M., RN A said: -Medication carts should be locked at all times. -Medication and treatment carts should not be left unattended and unlocked. During an interview on 9/23/24 at 3:33 P.M., the DON said medication carts should be locked when not attended. During an interview on 9/23/24 at 3:33 P.M., the Administrator said medication carts should be locked when staff are not present. 44395 4. Review of Resident #154 Admission MDS dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 7; indicated moderate cognitive loss -Able to make self understood and understands others -Ability to make daily decisions safely is not addressed -Supervision of staff to maximum assistance of staff for ADLs. -Diagnoses of Chronic Obstructive Pulmonary Disease (COPD: A group of lung diseases that block airflow and make it difficult to breathe), Chronic Kidney Disease (a condition that occurs when the kidneys are damaged and cannot filter blood properly), Post Traumatic Stress Disorder (PTSD: a mental health condition that can develop after a person experiences or witnesses a traumatic event), Tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe (trachea) to allow air to flow into the lungs), and Barrett's Esophagus (a condition that occurs when the lining of the lower esophagus changes due to stomach acid damage). Review of the resident's undated care plan showed: -The resident had a self care deficit; -No care plan for self administration of medication or storage of medication at bedside. Review of the physician orders for September 2024 showed: -Gabapentin Oral Solution (an anticonvulsant and nerve pain medication that can have a sedative effect) give 6 milliliters by mouth three times a day for pain. Ordered 9/12/24; -Nystatin powder, apply to groin topically three times a day for yeast. Ordered 9/12/24 -No order for resident to keep medications at bedside. Review of the resident's medical record showed: -No assessment for self administration of medication. Observation on 09/16/24 at 1:05 P.M. showed: -Nystatin powder sitting in the resident's window sill. -Gabapentin liquid 250 milligram(mg)/5 ml sitting in the resident's windowsill. -The resident was not in the room During an interview on 9/23/24 11:19 A.M., RN A said: -He/She had only one resident that self administered medications; -Resident #154 should not have his/her medications at bedside; -Residents must have physician's orders and self-administration of medications assessment completed prior to being able to self-administer their own medications. During an interview with the DON and the Administrator on 9/23/24 at 3:33 P. M., -The DON said, medications cannot be left at bedside without an order. He/She was not aware a resident had Gabapentin, a sedative medication, at bedside. -The Administrator said, she would not expect medication to be left at bedside without a physicians order and proper assessments.

Based on observation, interview, and record review, the facility failed to provide an ongoing activities program to support the needs of three of 21 sampled residents (Resident #153, #93, and #52). The facility census was 104. Review of the facility provided policy, Activities, dated 9/1/21 showed: -It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical,mental and psychological well being of each resident. -Activities refer to any endeavor, other than routine ADLs(Activities of Daily Living: tasks completed in a day to care for oneself, such as using the toilet, bathing, nail care, brushing hair and teeth.)in which the resident participates that is intended to enhance his/her sense of well being and to promote or enhance physical, cognitive and emotional health. -Activities will be designed with the intent to: -Enhance the resident's sense of well-being, belonging and usefulness; -Promote or enhance physical activity; -Promote or enhance cognition; -Promote or enhance emotional health; -Promote self esteem, dignity, pleasure, comfort, education, creativity, success and independence; -Reflect the resident's interests and age; -Reflect cultural and religious interests; -Reflect choices of the residents. -Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. 1. Review of Resident #153's Initial Activity Assessment completed on 11/8/21, showed he/she liked: -visits with family/friends; -poker; -gardening/outdoor activity; -movies/tv; -music/talk radio; -pet visits; -smoking. Review of the resident's face sheet showed an initial admitted [DATE] and a readmitted [DATE]. Review of the resident's Admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 7/12/24 showed: - Brief Interview of Mental Status of 99; indicated severe cognitive deficit; -Daily preference not completed; -Activity preference not completed; -He/she was dependent on staff for all activities of daily living (ADLs: tasks completed in a day to care for oneself); -Use of foley catheter (a sterile tube inserted into the bladder to drain urine); -Nutrition via tube (Gastrostomy: a tube surgically implanted in his/her stomach to provide liquid nutrition); -Nothing by mouth; -He/she had a tracheostomy (a surgical opening into the neck and windpipe, fitted with a plastic tube, to allow air to fill the lungs); -He/She did not speak; -Diagnoses of Respiratory Failure (a serious condition that happens when the lungs cannot get enough oxygen into the blood), Encepholopathy (brain disease that alters brain function or structure), Need for assistance with personal care, Chronic Obstructive Pulmonary Disease (COPD:common lung disease causing restricted airflow and breathing problems). Review of Resident #153 Comprehensive Care Plan dated 7/19/24 showed: -The resident has little or no activity involvement; -He/she prefers television drama and sports; -The resident will express satisfaction with type of activities and level of activity involvement when asked through the review date. -No care plan for activity preferences. Review of the resident's record of activities for July 2024 showed: -5th: the resident met with his/her brother, marked as a 1:1 visit; -8th: music therapy and staff combed his/her hair; -10th: staff provided nail care; -12th: church on television; -15th: music therapy; -17th: staff provided nail care; -20th: church music played; -22nd: rock music played; -24th: staff provided nail care; -26th: church on television; -28th: music played ; -30th: staff provided nail care. Review of the resident's record of activities for August 2024 showed: -5th: staff talked to him/her a bit; -8th: staff talked to him/her while the foot doctor worked on his/her feet; -10th: television was playing a show; -12th: staff went to talk to him/her; -14th: some peers visited him/her; -16th: music was on, and staff said good morning; -18th: television was playing the weather; -21st: staff saw him/her and checked his/her nails; -24th: staff turned television to music; -28th: staff put on rock and roll music; -30th: television playing. Review of the resident's record of activities for September 2024 showed: -1st: staff turned on music and gave him/her a hand massage; -3rd: staff combed his/her hair and talked about leaves falling; -5th:sleeping; -7th:sleeping; -8th to the 13th he/she was hospitalized . Observations showed: -On 9/17/24 at 5:15 A.M., the resident was in bed; his/her television on without sound; -On 09/17/24 at 9:08 A.M., he/she was in bed; his/her television on without sound; -On 09/18/24 at 10:26 A.M., he/she was in his/her room, in bed, television on menu of available channels and without sound; -On 09/18/24 at 2:24 P.M., he/she was in his/her room, in bed, television on menu of available channels and without sound. Live music program was in the dining room. 2. Review of Resident #93 Quarterly MDS dated [DATE] showed: -BIMS of 99; indicated significant cognitive impairment; -He/She was dependent on staff for all ADLs; -Use of foley catheter; -Nutrition via tube (Gastrostomy: a tube surgically implanted in his/her stomach to provide liquid nutrition); -Nothing by mouth; -He/she had a tracheostomy (a surgical opening into the neck and windpipe, fitted with a plastic tube, to allow air to fill the lungs); -Diagnoses of Nontraumatic Intracerebral Hemorrhage in the Brain Stem (a condition where blood pools in the brain stem after a stroke), Hemiplegia (muscle weakness or loss of movement on one side of the body), Tracheostomy , Gastrostomy, Cerebral Infarction (also known as a stroke: where blood flow to part of the brain is stopped, causing damage to the brain). Review of the resident's Comprehensive Care Plan dated 7/22/24 showed: -No care plan for activities. Review of Resident #93's One to One Activity Record for July 2024 showed: -3rd: staff talked about his/her new room; -4th: staff went to read to him/her, the resident was asleep, popped in later and said hello; -8th: he/she was asleep; -11th: staff talked with him/her, he/she used his/her eyes to communicate; -15th: staff read the chronicle to him/her; -18th: he/she was asleep; -20th: he/she was asleep; -22nd: he/she was asleep; -25th: he/she was watching TV and enjoyed it; -29th: he/she was asleep. Review of Resident #93's One to One Activity Record for August 2024 showed -2nd: staff talked to him/her about getting new books; -5th: staff asked him/her if he/she wanted a book read, he/she shook his/her head no; -6th: he/she was asleep; -8th: 8th: staff talked to him/her while the foot doctor worked on his/her feet; -12th: he/she did not want to be read to; -14th: he/she was asleep; -16th: staff combed his/her hair, listened to music; -18th: staff talked to him/her; -21st: listened to music; -24th: staff read a book to him/her; -26th: he/she did not seem to want to wake up; -28th: staff played music for him/her; -30th: staff brushed his/her hair and told a story about staff members child. Review of Resident #93's One to One Activity Record for September 2024 showed: -1st: staff talked about children and start of school; -3rd: staff massaged hands and cut fingernails; -5th: staff brushed his/her hair and sang; -7th: listened to music; -9th: staff read a book; -11th: listened to music; -13th: he/she was sleeping; -15th: staff read a book; -17th staff massaged hands and fingernails. Observation on 09/16/24 at 1:05 P.M. showed: -The resident was in bed, faced toward TV with soap opera on. Hand written sign below the TV showed the resident likes: crime shows, documentaries, and a local football team. Observation on 9/17/24 at 6:32 A.M. showed: -The resident was in bed, turned away from the TV. The TV was on without sound. Observation on 9/18/24 at 9:52 AM showed: -The resident was in bed, turned toward the TV. The TV was on without sound. Observation on 9/18/24 at 4:25 P.M. showed: -The resident was in bed, turned toward the TV. The TV was on without sound. 3. Review of Resident #52's admission MDS dated [DATE], showed: -His/Her cognitive status was undetermined; -He/She had no speech; -He/She rarely or never understand others; -He/She had adequate vision; -He/She did not wear corrective lenses; -He/She had limited range of motion in upper and lower extremities on both sides; -He/She was dependent on a wheelchair for mobility; -He/She was dependent for all cares and mobility; -Diagnoses included anxiety disorder, aphasia (a language disorder that affected a person's ability to understand and express language, as well as read and write), depression, and respiratory failure. Review of resident's face sheet, showed: -He/She admitted to facility on 7/23/24. Review of the resident's care plan, dated 7/31/24, showed: -Encourage social interactions and participation in activities with others that have similar interests; -Provide emotional and spiritual support for resident and/or family/guardian decisions as needed; -He/She had no activity preferences care planned. Review of activities evaluation, dated 9/19/24, showed: -He/She found strength in faith and religion and was of catholic affiliation; -He/She enjoyed arts and crafts, going to the beauty/barber shop, community outings, education programs, exercise/sports, family/friend visits, parties/social events, pet visits, reading/writing, and religious activities; -He/She loved rabbits; -He/She enjoyed stuffed animal dolls but preferred them to be called dolls; -He/She enjoyed bowling, gardening movies, television, music, talk radio; -He/She enjoyed doing activities in his/her room and preferred one on one activities; -He/She preferred to do activities in the afternoon or evening times; -He/She could hear and loved being talked to. Review of facility record of activities showed in July: -On 7/23, he/she talked with his/her family when they visited; -On 7/25, resident had a room visit and staff read a book; -On 7/28, he/she received nails and hand massage. Review of facility record of activities showed in August: -On 8/5, staff went to talk to resident and got no response; -On 8/16, resident listened to country music; -On 8/18, resident was read a book; -On 8/21, resident had his/her nails checked and staff talked with him/her; -On 8/24, staff read a book to resident; -On 8/26, staff talked to resident about his/her dolls; -On 8/28, resident listened to country music; -On 8/30, staff read resident a book. Review of facility record of activities showed in September: -On 9/1, resident listened to music and staff did his/her nails; -On 9/3, resident was read a book and received a hand massage; -On 9/5, music was played for resident; -On 9/7, music was played for resident; -On 9/9, resident was read a book; -On 9/11, resident was sleeping and had music on; -On 9/13, resident was sleeping and had music on and was read a book; -On 9/15, resident had music on; -On 9/17, resident was read a book. Observation on 9/16/24 at 7:30 P.M. showed the resident awake and alert during a visit from family members. Resident was able to give family a thumbs up to acknowledge understanding and excitement. Family engaged with resident by turning on his/her radio, showing pictures on his/her phone, and talking about various family events. Resident had eye contact with family during their visit and seemed in tune to his/her surroundings. Observation on 9/17/24 at 9:46 A.M-12:01 P.M., resident did not have any activity engagement. Activity staff went into room and told roommate about morning activity, but did not engage with resident. Observation on 9/18/24 from 8:01 A.M.-11:58 A.M. showed no activity engagement with resident. RN A went into resident's room to provide tube feeding at 9:48 A.M. RN A replaced wash cloth, provided oral care, and gave medications. Resident rubbed head with arm. Observation on 9/18/24 at 10:20 A.M. showed an activity calendar hanging on wall was from August- the calendar had not been updated to September. The resident was observed rubbing her head making motion like he/she wanted his/her head rubbed. During an interview on 9/18/24 at 3:14 P.M., the MDS Coordinator said he/she wrote most of care plans but activities staff were supposed to complete their section. During an interview on 9/23/24 at 10:43 A.M., the Activities Director said: -Activity staff went into resident's rooms every other day; -Staff will brush his/her hair or do residents nails; -Resident #52's mother said resident #52 liked dolls so he/she sometimes put dolls and stuff on resident's bed; -He/She has read children's book to residents; -He/She has not turned on television for resident but he/she knew resident #52 liked cartoons; -His/Her part time staff typically do the one on ones with residents; -He/She had church services scheduled every Sunday; -Activities should be care planned; -He/She documented activities on activity sheets. During an interview on 9/23/24 at 3:33 P.M., the Administrator said: -Activities calendars should be updated monthly; -He/She expected one on one activities to be care planned; -He/She expected one on one activities to be individualized. MO#241359 47195

Based on observation, interview and record review, the facility failed to employ a qualified activity professional to oversee the activity program for the facility. The designated employee was employed as the full time activity director for one year, however, had not completed an approved activity professional training program. The facility census was 104. Review of the facility's Activity Director Qualifications, dated 2023, showed: -Activity Director, at a minimum, shall meet the following qualifications: -Licensed or registered by the state in which practicing; -One or more of the following: -Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; -Has 2 years of experience in a social or recreational program within the last 5 year, one of which was full-time in a therapeutic activities program; -Is a qualified occupational therapist or occupational therapy assistant; or -Has completed a training course approved by the state; -Qualifications shall be verified prior to hire as Activity Director, and verified annually as part of the employee's performance appraisal process. Documentation of the employee's qualifications shall be maintained in the employee's personnel file; -It is the responsibility of the employee to fulfill requirements for maintaining licensure or registration and providing the facility with documentation of renewals, revocations, surrenders, or suspensions of such licensure or registration. Review of facility Activities Director job description, signed 6/3/24, showed: - Accreditation as a certified activity director; completion of a state approved activity director training course; -Bachelor's degree in recreation therapy or related area. Should be licensed or registered either nationally or by the state in which practicing; -One year experience as an Activity Director in long term care; -Two years of experience conducting social/recreational programs within the past five years, one of which was full time in a resident activities program in a health care setting; -Attends and participates in scheduled training, educational classes, and meetings to maintain current certification as applicable. Attends and participates in in-service training as mandated by regulatory agencies and company policy. Review of facility provided invoice, dated 8/12/24, showed: -Missouri Health Care Association billed Activity Director on 8/12/24 for purchase of online activity director workshop and long term care for activity and social services textbook. During an interview on 9/23/24 at 11:10 A.M., the Activity Director said: -He/She had not been trained on working in activities; -He/She worked twenty-five years in housekeeping; -He/She went to a sister facility to train for one day with activity staff member; -He/She had not been enrolled in any training course for activity certification; -He/She had been in position for one year. During an interview on 9/23/24 at 3:33 P.M., the Administrator said: -Activity Director needed certifications; -Facility had determined to invest in the Activity Director and purchased a course for him/her to participate in during September 2024; -Activity Director was anticipated to complete coursework in October 2024.

Based on observation, interview, and record review, the facility failed to ensure the environment for three of 21 sampled residents (Resident #3, #67, and #89) was free from accident hazards when observations of the memory care unit showed residents had access to the unlocked clean utility room that contained three open electrical boxes, two tanks of oxygen, and cleaning supplies, and the unlocked biohazard room that contained sharps, as well as hazardous chemicals, and the unlocked area behind the nurses desk that contained a jug of drug destroyer and a bottle of multipurpose cleaner. The facility census was 104. Review of the facility's Accidents and Supervision Policy, dated, 9/1/2021, showed in part: -The resident's environment will remain free of accident hazards as is possible; -Each resident will receive adequate supervision to prevent accidents; -This includes - Identifying hazards and risks; - Evaluating and analyzing hazards and risks; - Implementing interventions to reduce hazards and risks; - Monitoring for effectiveness and modifying interventions when necessary. -All staff are to be involved in observation and identifying potential hazards in the resident's environment; -The facility should make reasonable efforts to identify the hazards and risk factors for each resident; -Various sources provide information about hazards and risks in the resident environment; - These sources may include: - Environmental rounds; - Individual observations. 1. Observation of the memory care unit on 9/16/24, at 9:23 A.M., showed: - The clean utility room was unlocked; - Three electrical boxes were open on the wall inside the unlocked clean utility room; - A tank of oxygen sitting in a trolley; - The gauge on the oxygen tank said the tank had 100% of oxygen in it; - An empty tank of oxygen was sitting in the clean utility room in a trolley; - Five cans of shaving cream were sitting on the sink in an unlocked clean utility room; - A cup of clear liquid was sitting on the counter by the sink in the unlocked clean utility room; - There was an orange stick sitting on the counter by the sink in the unlocked clean utility room; - Trash was overflowing with used gloves and cigarette packages in the unlocked clean utility room; - There was a black substance on the wall behind the trash can in the unlocked clean utility room. Observation on 9/16/24, at 9:43 A.M. showed: -The door to the clean utility was still unlocked: -The Social Services Director (SSD) walked into the clean utility and came out with a pillow case; -The SSD did not lock the door of the clean utility when he/she left the clean utility room; -The area behind the nurses desk was unlocked; -The area behind the nurses desk contained a bottle of multi-purpose cleaner, a bottle of perfume setting on the nurses desk and bottle of drug destroyer on the floor next to the shred box behind the nurses desk. During an interview on 9/16/24, at 9:48 A.M., the SSD said: -He/she did not know if the clean utility room should be locked or not; -Residents should not have access to areas with unlocked electrical boxes or unsafe areas. 2. Review of Resident #3's care plan dated 8/6/24, showed: -The resident has an Activities of Daily Living (ADLs) self care performance deficit; -The resident has impaired cognitive function related to dementia; -The resident resists cares. Review of the Resident's PPS 5-Day Minimum Data Set (MDS, a federally mandated assessment tool completed by facility staff), dated, 8/12/24, showed: -Severe cognitive impairment; -Physical and verbal behaviors directed towards others; -Takes antipsychotics and antidepressants daily; -Supervision with mobility using a wheelchair; -Diagnoses included, dementia, anxiety, asthma, and stroke. Observation on 9/16/24, at 9:50 A.M. showed:-The resident propelling himself/herself in a wheelchair along the wall next to the unlocked clean utility room: -The resident grabbed the door knob of the clean utility room door on his/her way by; (he/she was not able to turn the door knob); -No staff were present on the hall; -The clean utility door remained unlocked. Observation on 9/16/24, at 9:58 A.M. showed:-The door to the biohazard room unlocked; -The biohazard room contained a bucket with black water and a mop setting in it; -A tall cardboard box with multiple sharps containers full with sharps; -A container of caulking compound open and sitting in the room; -Certified Nurses Aide (CNA) D pushed two dirty linen barrels in to the biohazard room; -CNA D closed the door and did not lock it. Observation on 9/16/24 at 10:00 A.M. showed -The biohazard door unlocked; -The resident propelling himself/herself in a wheelchair by the unlocked biohazard door; -There were no staff near the unlocked biohazard room or the unlocked clean utility room. Observation 9/16/24 at 10:05 A.M. showed: -10:05 A.M., CNA E and Licensed Practical Nurse (LPN) B walked into the unlocked clean utility room; -10:35 A.M., CNA E and LPN B came out of the clean utility room and did not lock the door; -10:42 A.M., CNA E and LPN B walked by the unlocked biohazard door; -10:45 A.M., Neither CNA E or LPN B checked to see if the biohazard door was locked; -10:55 A.M., CNA D took a trash barrel into the unlocked biohazard room; -11:05 A.M., CNA D came out of the biohazard room and did not lock the door. Observation 9/18/24 at 8:03 A.M. showed: - The clean utility room unlocked; - The clean utility room still contained the linen cart; - Three electrical boxes were open on the wall inside the unlocked clean utility room; - Five cans of shaving cream were sitting on the sink in unlocked utility room; - A cup of clear liquid was sitting on the counter by the sink; - There was an orange stick still sitting on the counter by the sink; - Trash was overflowing with used gloves and cigarette packages; - There was a still a black substance on the wall behind the trash can; -The resident propelling himself/herself in a wheelchair up and down the hall along the walls next to the unlocked clean utility room and the unlocked biohazard room; -There were no staff near the unlocked biohazard room or the unlocked clean utility room. 3. Review of Resident #89's care plan dated 2/22/24, showed: -The resident has an ADL self care performance deficit; -The resident has impaired cognitive function related to dementia; -The resident resists cares. Review of the resident's Significant Change MDS, dated , 8/9/24, showed: -Severe cognitive impairment; -Impairment on one side of upper and lower extremity; -Uses a wheelchair for mobility with supervision; -Diagnoses included, dementia, anxiety, and osteoporosis (a condition that causes bones to become weak and brittle). Observation 9/16/24 at 10:10 A.M. showed: -The resident came out of his/her room and pushed on the wall by the unlocked biohazard room door; -The resident pushed on the unlocked biohazard door as he/she went up the hall; -The door to the nurses station remained unlocked as the resident pushed along the wall next to the nurses station; -No staff were present near the resident or the unlocked rooms or nurses station. Observation 9/18/24 at 8:03 A.M. showed: - The clean utility room unlocked; - The clean utility room contained the linen cart; - Three electrical boxes were open on the wall inside the unlocked clean utility room; - Five cans of shaving cream were sitting on the sink in unlocked utility room; - A cup of clear liquid was sitting on the counter by the sink; - There was an orange stick sitting on the counter by the sink; - Trash was overflowing with used gloves and cigarette packages; - There was a still black substance on the wall behind the trash can; -The resident propelling himself/herself in a wheelchair up and down the hall along the walls next to the unlocked clean utility room and the unlocked biohazard room; -There were no staff near the unlocked biohazard room or the unlocked clean utility room. 4. Review of Resident #67's Annual MDS, dated , 8/9/24, showed: -Moderate cognitive impairment; -Impairment on one side upper extremity; -Diagnoses included, dementia, anxiety, stroke and psychotic disorder( a disorder when people lose contact with reality). Review of the resident's undated care plan showed: -The resident is dependent on staff for meeting emotional, intellectual, physical and social needs; -The resident has an ADL self-care performance deficit related to confusion from stoke; -The resident has impaired cognitive function and impaired thought process related to dementia. Observation on 9/17/24 at 10:15 A.M. showed: - The clean utility room remained unlocked; - The clean utility room still contained the linen cart; - Three electrical boxes were still open on the wall inside the unlocked clean utility room; - Five cans of shaving cream were still sitting on the sink in unlocked utility room; - A cup of clear liquid was still sitting on the counter by the sink; - There was an orange stick still sitting on the counter by the sink; - Trash was still overflowing with used gloves, cigarette packages; - There was a still black substance on the wall behind the trash can. Observation on 9/17/24 at 10:19 A.M. showed: -The resident walking up and down both sides of the by the unlocked clean utility room, and the unlocked biohazard room. Observation 9/18/24 at 08:03 A.M. showed: - The clean utility room unlocked; - The clean utility room contained the linen cart; - Three electrical boxes were open on the wall inside the unlocked clean utility room; - Five cans of shaving cream were sitting on the sink in unlocked utility room; - A cup of clear liquid was sitting on the counter by the sink; - There was an orange stick sitting on the counter by the sink; - Trash was overflowing with used gloves and cigarette packages; - There was a still black substance on the wall behind the trash can; -The resident walking up and down both sides of the by the unlocked clean utility room, and the unlocked biohazard room. -There were no staff near the unlocked biohazard room or the unlocked clean utility room. During an interview on 9/16/2024, at 10:12 A.M., CNA E said: -This was his/her first day; -He/she usually worked at a sister facility; -He/she would expect the doors to the clean utility room, biohazard room, and nurses desk to be locked; -The doors to the clean utility room and the biohazard room have been unlocked since he/she came in; -Residents should not have access to sharps, dangerous chemicals, or any accident hazards. During an interview on 9/23/2024, at 9:18 A.M., CNA D said: -He/she was not sure if the doors to the clean utility room, biohazard room, and nurses desk should be locked; -The doors to the clean utility room and the biohazard room have always been unlocked; -Residents should not have access to sharps, dangerous chemicals, or any accident hazards. During an interview on 9/23/2024, at 9:38 A.M., LPN B said: -The lock broke on the nurse's station last night; -The door to the nurse's station should be locked; -He/she did not know if a work order had been filled out for the broken door; -The doors to the clean utility and the biohazard room should be locked; -Resident's should not have access to areas with sharps, open electrical boxes, or hazardous chemicals. During an interview on 9/23/24 at 9:11 A.M., the Maintenance Director said: -He/she tries to do a walk through every week and write on a list the things that need repaired; -He/she would not expect the electrical boxes on the memory care unit to be accessible to the residents; -He/she expects the door to the room containing the electrical boxes to be locked; -He/she expects the door to the biohazard room to be locked; -The nurses have keys to both of those rooms and they should be kept locked; -The area behind the nurse's desk should be locked. During an interview on 9/23/24 at 3:33 P.M., the Administrator said: -The door to the nurse's station should be locked; -The doors to the clean utility and the biohazard room should be locked; -Resident's should not have access to areas with sharps, open electrical boxes, or hazardous chemicals; -He/she expects the nurses to ensure those rooms are not accessible to the residents.

Based on observation, interview and record review, the facility failed to ensure residents had water at bedside that was easily accessible for four of 23 residents sampled (#90 #49, #87, and #12). The facility census was 104. Review of the facility's undated policy for hydration showed, in part: -The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. - Nursing staff shall assess hydration status upon admission and throughout the resident's stay in accordance with assessment protocols; the dietary manager or designee shall obtain the resident's beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay; the dietician will assess hydration as part of the comprehensive nutritional assessment within 72 hours of admission, annually, and upon significant change in condition. -The assessment shall clarify the resident's current hydration status and individual risk factors for dehydration or fluid imbalance; the dietician shall use the data gathered from the nutritional assessment to the resident's fluid needs and whether intake is adequate to meet those needs. -Interventions will be individualized to address the specific needs of the resident such as offering the resident a variety of fluids during and in between meals; provide assistance with drinking; ensure beverages are available and within reach; evaluate resident's medications that may place the resident at risk for dehydration; offer alternative fluids such as broths, popsicles, gelatin, and ice cream. 1. Review of Resident #90's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/19/2024 showed: -Resident has minor cognitive impairment. -Resident is dependent on a staff for eating. -Resident needs partial/moderate assistance with oral hygiene. -Diagnoses include stroke; high blood pressure; and paralysis of one side of the body. Review of the resident's undated care plan showed: -Resident has dehydration or potential fluid deficit related to poor intake. -Resident has a swallowing problem. Resident at risk for impaired nutrition and dehydration due to dependence on tube feeding for all nutrition and hydration needs. All staff is to be informed of resident's special dietary and safety needs. Review of the resident's active physician order sheet (POS), dated 9/18/24 showed: -Regular diet, mechanical soft texture, nectar thick liquids consistency. Start date 7/10/24. Review of progress notes dated 9/19/2024 2:22 PM showed: -Resident was on antibiotics (ABT) for UTI (urinary tract infection) and has requested to not get out of bed thus far on this shift. Review of progress notes dated 9/20/2024, unknown time, showed: -Resident had ABT/UTI. Dependent on staff for cares; fluids encouraged. Review of progress notes dated 9/22/2024, unknown time, showed: -Continue ABT/UTI monitoring; fluids encouraged. Observation and interview on 09/16/24 04:02 P.M. showed, the resident did not have water at bedside. The resident's daughter said when he/she asked for water, the staff brought flavored water, but the resident would prefer unflavored water. Observation on 9/19/24 08:19 A.M., showed there was no water at bedside. Observation on 09/19/24 11:54 A.M., showed there was no water at bedside. Observation on 09/23/24 09:02 A.M., showed no thickened water. During an interviews on 09/23/24 09:55 A.M., RN A said water is passed once in the morning and once in the afternoon before dinner. During an interview on 09/23/24 10:16 A.M., CNA A said day shift passes water once during breakfast pass and once during lunch pass. Observation on 09/23/24 11:15 A.M. showed no water being passed on Maple Hall between 9:00 A.M. and 11:15 A.M. Observation and interview on 09/23/24 11:30 A.M. showed, RN A said the resident has a UTI. Observation showed the resident did not have water at bedside. 47195 2. Review of Resident #12's, Quarterly MDS, dated [DATE], showed: -He/She was cognitively impaired; -He/She required supervised or touching assistance with eating; -Diagnosis included lack of coordination, difficulty walking, muscle weakness, unsteadiness on feet, depression, and bipolar disorder (mental illness that causes extreme mood swings). Review of the resident's care plan, revised 1/25/24, showed: -He/She was at risk for dehydration and/or potential fluid deficit due to diuretic use (Lasix) and history of poor intake; -Monitor and document intake and output as per facility policy; -Monitor vital signs as ordered per protocol and record. Notify medical doctor of significant abnormalities; -Monitor/document/report as needed any signs and symptoms of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness, or sitting/standing, increase pulse, headache, fatigue,/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes -Notify Physician if: Persistent symptoms of diarrhea, nausea/vomiting unresolved past 48 hours; persistent output exceeding intake past 48 hours; abnormal lab. Date Initiated: 12/08/2023 -Obtain and monitor lab/diagnostic work as ordered. Report results to medical doctor and follow up as indicated. -Offer and encourage adequate fluid as long as not contraindicated i.e.: signs of fluid overload. Review of the physician's orders, dated 9/17/24, showed: -Ordered 5/31/24, Regular diet, regular texture, regular/thin consistency. During an interview on 9/16/24 at 10:27 A.M., the resident said: -The facility did not pass water very often; -He/She had no water in his/her room right now. Observation on 9/18/24 at 8:00 A.M., showed the resident had no water in his/her room. Observation on 9/18/24 at 8:16 A.M., showed the resident wheeled him/herself up the hallway next to the cooler and waited for staff to come by to have his/her water cup filled. No staff were observed in the area. The resident sat next to the cooler waiting for eight minutes. CNA A obtained ice for the resident when the resident said something to him/her. 3. Review of Resident #49's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had impairment on one side of upper and lower extremities; -He/She required set up or clean up assistance with eating; -Diagnoses included stroke (condition causing damage to the brain from an interruption of its blood supply), hemiplegia (condition causing weakness on one side of the body), heart failure, high blood pressure, diabetes (too much sugar in the blood), depression, post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, lack of coordination, pain in left shoulder, need for assistance with personal care, and osteoarthritis of the right shoulder (a chronic joint disease that causes the cartilage in one or more joints to break down over time). Review of the resident's care plan, revised 7/30/24, showed: -He/She had an ADL self-care performance deficit due to a stroke; -He/She was able to feed him/herself but staff needed to set up his/her meals; -Monitor and document any signs or symptoms of increased thirst and appetite; -Ensure commonly used items (ice water) are within reach of resident prior to leaving room; -He/She was on a diuretic medication due to edema. Review of the physician's orders, dated 9/17/24, showed: -Ordered 4/29/22, Regular diet, regular texture, regular/thin consistency. During an interview on 9/16/24 at 6:22 P.M., the resident said: -Water was passed only one time per day; -He/She had never had his/her water cup changed out or washed. Observation on 9/18/24 at 7:57 A.M., showed the water cup was half empty. During an interview on 9/18/24 at 7:57 A.M., the resident said: -He/She last received water and ice sometime yesterday afternoon. Observation on 9/19/24 at 6:22 P.M., showed the resident had only 1/4 cup of water left in cup, no ice. During an interview on 9/19/24 at 2:08 P.M., the resident said: -He/She had not received ice or water pass yet today. During an interview on 9/19/24 at 5:31 P.M., the resident said: -Water was passed for the first time all day at 4:15 P.M. Observation on 9/23/24 at 10:10 A.M., showed the resident was asleep. He/She had no water or ice in his/her cup. 4. Review of Resident #87's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had impairment on one side of upper extremity, and impairment on both sides of lower extremities; -Diagnosis included traumatic spinal cord dysfunction, central cord syndrome as an after effect of disease, condition, or injury at the fifth cervical vertebra level of the cervical spinal cord (type of incomplete spinal cord injury characterized by weakness, loss of sensation below injury site, loss of bladder control, pain such as tingling and burning), paraplegia (paralysis of legs and lower body caused by spinal injury), spinal stenosis in cervical region (a chronic condition that occurs when spinal canal narrows, putting pressure on spinal cord and nerve roots), muscle weakness, and difficulty walking. Review of the resident's care plan, revised 1/31/24, showed: -He/She had diabetes mellitus; -Observe for signs and symptom hyperglycemia including increased thirst; -Ensure commonly used items (ice water) were within reach prior to leaving room; -He/She had renal insufficiency due to kidney disease; -He/She had potential for impairment of skin integrity; -Resident will have no signs and symptoms of complications due to fluid deficit through the review date. -The resident will have no signs and symptoms of complications related to fluid overload through the review date. Review of the physician's orders, dated 9/17/24, showed: -Ordered 1/25/24, Regular diet, regular texture, regular/thin consistence. Double portions every meal. During an interview on 9/16/24 at 11:07 A.M., the resident said: -It had taken the facility over a week to change out water; -The facility did not pass ice or water everyday. Observation on 9/16/24 at 11:15 A.M., showed no ice water had been passed. Observation on 9/17/24 at 5:30 A.M., showed no ice water had been passed. During an interview on 9/23/24 at 3:33 P.M., the Director of Nursing said ice and water should be passed two times per shift. During an interview on 9/23/24 at 3:33 P.M., the Administrator said: -Ice water should be passed twice per each shift; -Staff work 12 hour shifts.

Based on observation, record review, and interview, the facility failed to provide trauma informed care to one sampled resident (Resident #49) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a traumatic event). The facility failed to mitigate triggers of loud noises that caused re-traumatization for one resident (Resident #49) who was residing on a hall with several residents who scream and yell out. The failed to identify and mitigate triggers for one resident (Resident #87) when the resident had identified several traumatic events. The facility also failed to identify and communicate interventions to staff for both residents to assist in promoting a sense of safety for both residents (Resident #49 and #87). The facility census was 104. Review of facility policy, Trauma Informed Care, dated 9/1/22, showed: -It is policy of facility to provide care and services which are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. -The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which retraumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be addend to the residents care plan. -The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understanding if interventions must be modified. -In situations where a trauma survivor is reluctant to share their history, the facility will still try and identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. 1. Review of Resident #49 quarterly, minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/22/24, showed: -He/She was cognitively intact; -He/She had clear speech, and was able to make self-understood and understand others; -He/She felt down, depressed or hopeless half or more days; -He/She had impairment on one side of upper and lower extremities; -He/She was dependent on walker and wheelchair; -He/She was taking an antidepressant; -His/Her mood severity score was a 12 (indicating moderate depression); -He/She had trouble falling asleep or staying asleep or sleeping too much nearly every day; -He/She felt tired or had little energy nearly every day; -He/She exhibited a poor appetite or overeating on more than half of the days; -He/She had trouble concentrating on things such as reading the newspaper or watching television on half or more of the days; -Diagnoses included post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, and lack of coordination Review of the resident's care plan, revised 3/15/24, showed: -He/She had a history of a traumatic event; -His/Her spouse was verbally and emotionally abusive to him/her with triggers of loud noises startling him/her; -Known triggers of potential trauma included loud noises; -No interventions identified for known triggers. During an interview on 9/16/24 at 6:40 P.M., the resident said: -His/Her ex-spouse choked him/her one time, went to jail, and was emotionally abusive; -The resident across the hall was throwing a fit of yelling and cussing which triggered him/her; -Loud noises trigger the resident to relive his/her abuse; -The resident across the hall was yelling the other morning so the resident started yelling back at the other resident; -Staff came and yelled at the resident for confronting the other resident. Review of facility electronic medical record showed: -On 5/1/22, resident had a trauma, abuse, neglect screening completed with a score of 4.0 which showed he/she had a history of abuse and/or neglect, increased vulnerability, psychiatric history and present mental health diagnosis, and had depressive illness including low self esteem, isolation, and withdrawn behaviors. His/Her spouse had physically and emotionally abused him/her. -On 1/1/23, the resident had a trauma informed care assessment completed and no trauma was noted; -On 11/8/23, the resident had a trauma informed care assessment completed and no trauma was noted; -On 4/22/24, the resident had a trauma informed care assessment completed and reported that his/her ex husband was verbally and emotionally abusive. -On 7/23/24, the resident had a trauma informed care assessment completed and reported that his/her ex husband was verbally and emotionally abusive; During an interview on 9/18/24 at 3:28 P.M., Certified Nurse Aide (CNA) A said he/she did not know this resident was triggered by hearing yelling. During an interview on 9/23/24 at 9:43 A.M., Certified Medication Technician (CMT) A said he/she was not aware of the resident having any triggers. During an interview on 9/23/24 at 10:05 A.M., Registered Nurse (RN) A said he/she was not aware of the resident having any trauma triggers. During an interview on 9/18/24 3:40 P.M., the Social Services Director said: -He/She was aware this resident was triggered by loud noises; -He/She was not aware the resident was triggered by other residents yelling on the hall, but was aware the resident's roommate would get upset and come out yelling at other residents across the hall; -The resident has a history of closing his/her door a lot, and likes to do arts and crafts as part of his/her coping strategies; -He/She communicates the resident's triggers directly with the charge nurse on the hall who then verbally communicates with the staff providing direct care. 2. Review of Resident #87's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood, and understand others; -He/She had impairment on one side of upper extremity, and impairment on both sides of lower extremities; -He/She was dependent on a wheelchair; -Behaviors included hallucinations and delusions; -He/She had an an antipsychotic on routine basis; -Diagnosis included central cord syndrome as a after affect at the cervical vertebra five level of the cervical spinal cord (type of incomplete spinal cord injury characterized by weakness, loss of sensation below injury site, loss of bladder control, pain such as tingling and burning), dementia (loss of cognitive function such as thinking, remembering, and reasoning), paraplegia (paralysis of legs and lower body caused by spinal injury), cognitive communication deficit, muscle weakness, and difficulty walking. Review of the resident's care plan, revised 8/9/24, directed staff of the following: -Resident had past trauma of being in a tornado, car accident that left him/her with a spinal cord injury, being jumped (assaulted or attacked), and homeless. Resident reported no triggers or distress related to traumas; -He/She had impaired cognitive function/dementia and impaired thought processes; -He/She stated on 1/26/24 that everyone was out to get him/her and he/she was tired of the witches in the place. He/She stated he knew for a fact that a CNA was casting spells with chicken bones and the constant laughter in the hallway and was always smiling about him/her; -He/She stated on 3/13/24 that therapy staff were making fun of him/her, and he/she knew people were making fun of him/her; -He/She stated on 6/5/24 that he/she knew when people were making fun of him/her and then refused his/her morning shower stating shower aide was a witch and that his/her potions and lotions cause him/her to burn and itch; -The care plan did not identify any resident triggers for prior trauma. Observation on 9/17/24 at 10:49 A.M., showed the resident came out of his/her room yelling at Resident #87 sitting in a wheelchair in the hallway. During an interview on 9/17/24 at 10:55 A.M., CNA A said: -The resident had specific behaviors targeting him/her and RN A; -The resident will state that he/she put stuff in the resident's soap to make him/her itch. During an interview on 9/23/24 at 9:43 A.M., CMT A said: -The resident was triggered by certain staff on the hall, specifically CNA A and RN A; -The resident gets agitated at others and call staff witches and a cuss word; -The resident will only accept his/her medication and treatments from CMT A, because he/she did not have a problem with him/her and he/she liked to interact with CMT A. During an interview on 9/23/24 at 10:05 A.M., RN A said: -The resident was very delusional and paranoid; -The resident acts out every Friday afternoon; -He/she was aware the resident was best supported by staff praying with him/her as long as the person praying with him/her was not the person he/she was targeting; -He/she had learned the resident was best supported when the staff member he/she is targeting walks away. He/she had learned the more that staff members interact with the resident, the likelihood the resident will continue to escalate. During an interview on 9/18/24 at 3:40 P.M., the Social Services Director said: -The resident was triggered by any kind of mention of mental health around him/her; -The resident could be a difficult resident to identify his/her triggers, as he/she could be triggered by someone simply approaching him/her and feeling threatened and having severe paranoia; -The resident would start calling people witches and warlocks when he/she was triggered; -The resident seemed to be triggered very easily. 3. Review of facility training logs for last year showed no trauma informed care training was provided to the facility staff. During an interview on 9/18/24 at 3:14 P.M., the MDS Coordinator said the social services director completed the trauma informed care section regarding care plans and the trauma informed care assessments. During an interview on 9/18/24 at 3:28 P.M., CNA A said: -He/She had not received any trauma informed care training; -He/She was not aware of any residents that were triggered from their past abusive relationship; -No one had conveyed any resident trauma triggers to him/her or methods of interventions; -He/She did know that some residents are triggered by yelling. During an interview on 9/23/24 at 9:43 A.M., CMT A said: -He/she received trauma informed care training a long time ago, but no training in the past year; -If he/she observed a resident was being triggered by another resident's yelling he/she would separate the residents and inform the nurse. During an interview on 9/23/24 at 10:05 A.M., RN A said: -He/she had no trauma informed care training by the facility since starting three months ago; -He/she was not aware of trauma triggers for residents. During an interview on 9/18/24 3:40 P.M., the Social Services Director said: -He/She completed trauma assessments upon admission, every quarter, and annually; -He/She notified staff of trauma triggers directly by going to the charge nurse; -The charge nurse then filtered down the information to floor staff; -He/She was not aware of any trauma informed care training to staff at facility since he/she started the position in February; -If a resident was triggered due to a past abusive relationship/marriage by another resident who was yelling and cussing loudly then he/she would offer to look at moving the resident to create a calming environment, work to help resident identify and develop coping skills, and obtain noise canceling headphones; -The facility had purchased noise canceling headphones in the past for residents who were triggered by loud noises but not for Resident #49. During an interview on 9/23/24 at 3:33 P. M, the Administrator said: -He/She completed trauma informed training to staff in facility; -He/She trained on trauma two or three times; -He/She documented training in staff meeting notes.

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet basic care needs for seven residents (Residents #13, #67, #80, #12, #49, #87, and #74) including assistance to reposition and incontinent care for two residents (Resident #13 and #80), failed to provide basic hygiene for one resident (Resident #67), and failed to provide assistance with bathing for three residents (Residents #12, #49 and #87) of 21 sampled residents. Additionally the facility failed to answer call lights timely for nine of 20 Resident Council attendees. The facility census was 104. Review of the facility provided policy Activities of Daily Living (ADLs: tasks completed in a day to care for oneself) dated 9/1/21 showed: -A resident who is unable to carry out ADLs will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Review of the facility provided policy Bathing a Resident dated 9/1/21 showed: -It is the practice of this facility to assist residents with bathing to maintain proper hygiene. Review of the facility provided policy Nursing Services and Sufficient staff dated 9/1/21 showed: -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. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment; -The facility will supply services by sufficient numbers of each of the following personnel types on a 24 hour basis to provide nursing care to all residents in accordance with resident care plans; -Providing care includes, but not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. 1. Review of Resident #13's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated, 6/20/24, showed: -Severe cognitive impairment; -Dependent on staff for Activities of ADLs; -Incontinent of bowel and bladder; -Diagnoses included, dementia, high blood pressure and anxiety. Review of the resident's care plan revised, 3/27/24, showed: -The resident has an ADL self care performance deficit; -The resident is dependent on staff for toileting; -Clean peri-area after each incontinent episode; -The resident has the potential for pressure ulcer development related to incontinence; -The resident requires total assistance of one staff for transfers; -The resident has the right to be treated with dignity. Continuous observation of the resident beginning on 09/16/24 at 09:20 A.M., showed: -09:20 A.M., the resident was setting at the table in the dining room in his/her wheelchair; -10:13 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident; -10:59 A.M., the resident still setting in his/her wheelchair at the table with his/her eyes closed; -11:03 A.M., the resident still setting in his/her wheelchair at the table and LPN B walked by and did not provide incontinent care for the resident; -11:25 A.M., CNA D walked by the resident setting in his/her wheelchair at the table and did not offer to provide incontinent care for the resident; -12:26 P.M., lunch was delivered to the memory care unit and was still setting in his/her wheelchair at the table with his/her eyes closed; -12:42 P.M., lunch was delivered to the resident and he/she was still at the table in his/her wheelchair; -12:46 P.M., no staff have repositioned or toileted the resident; - 01:01 P.M., the resident finished his/her lunch and was still setting in his/her wheelchair at the table and no staff have provided incontinent care for the resident; -01:25 P.M., the resident was setting at the table in his/her wheelchair and no staff have toileted the resident. Continuous observation of the resident beginning on 09/17/24 at 05:39 A.M., showed: -05:39 A.M., the resident was setting at the table in the dining room in his/her wheelchair; -06:15 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident; -07:30 A.M., the resident was still setting in his/her wheelchair at the table; -08:30 A.M., the resident was setting at the table in the dining room in his/her wheelchair; -09:30 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident. 2. Review of Resident #67's Annual MDS dated , 7/17/24, showed: -Moderate cognitive impairment; -Visual impairment; -Substantial assistance from staff for toileting; -Supervision of staff for dressing; -Incontinent of urine; -Diagnoses included, stroke, depression, high blood pressure and cataracts (a clouding of the eye's lens that can lead to vision loss). Review of resident's undated care plan showed: -The resident has an ADL self care performance deficit; -The resident requires supervision for dressing; -The resident requires supervision with personal hygiene; -The resident requires assistance with toileting; -The resident has the right to be treated with dignity. Observation on 09/16/24 at 09:50 A.M., showed: -The resident walking into the dining room; -The resident hair was unkempt and his/her glasses had white specks on the lenses; -The resident's pants and shirt had black stains on them. Observation on 09/16/24 at 12:24 P.M., showed: -The resident was setting in the dining room at a table; - The resident's glasses still had white specks on the lenses; -The resident's hair was still unkempt and his/her clothes still had black stains on them. Observation on 09/17/24 at 08:01 A.M., showed: -The resident was setting in the dining room; -The resident was wearing the same clothes as yesterday; -The resident's pants and shirt still had black stains on them. -The resident's hair was unkempt and his/her glasses still had white specks on the lenses. 3. Review of Resident #80's Quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for ADLs; -Incontinent of bowel and bladder; -Diagnoses included, dementia, high blood pressure and anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues). Review of the resident's care plan revised, 6/13/24, showed: -The resident has an ADL self care performance deficit; -The resident requires total assistance of one to two staff for showers and toileting; -The resident requires total assistance of one to two staff for transfers; -The resident has impaired cognitive function related to dementia; -The resident has the right to be treated with dignity; -The resident has the right to privacy and confidentiality. Continuous observation of the resident beginning on 09/16/24 at 09:20 A.M., showed: -09:20 A.M., the resident was setting at the table in the dining room in his/her wheelchair; -10:13 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident; -10:59 A.M., the resident was still setting in his/her wheelchair at the table with his/her eyes closed; -11:03 A.M., the resident was still setting in his/her wheelchair at the table and LPN B walked by and did not provide incontinent care for the resident; -11:25 A.M., CNA D walked by the resident setting in his/her wheelchair at the table and did not offer to provide incontinent care for the resident; -12:26 P.M., lunch was delivered to the memory care unit and the resident was still setting in his/her wheelchair at the table with his/her eyes closed; -12:42 P.M., lunch was delivered to the resident and he/she was still at the table in his/her wheelchair; -12:46 P.M., no staff have repositioned or toileted the resident; - 01:01 P.M., the resident finished his/her lunch and was still setting in his/her wheelchair at the table and no staff have provided incontinent care for the resident; -01:25 P.M., the resident was setting at the table in his/her wheelchair with his/her eyes closed and no staff have toileted the resident. Continuous observation of the resident beginning on 09/17/24 at 05:39 A.M., showed: -05:39 A.M., the resident was setting at the table in the dining room in his/her wheelchair; -06:15 A.M., the resident was setting at the table in the dining room in his/her wheelchair and no staff have offered to toilet the resident; -07:30 A.M., the resident was still setting in his/her wheelchair at the table and the DON delivered breakfast to him/her and the DON did not offer to reposition or toilet the resident; -08:30 A.M., the resident was setting at the table in the dining room in his/her wheelchair; -09:30 A.M., LPN B said good morning to the resident and did not toilet the resident. During an interview on 9/18/24 at 1:14 P.M., CNA D said: -He/she tries to toilet Residents #13, #67 and # 80 at least every two hours, but he/she did not have enough time today; -It gets busy sometimes and he/she does not have time; -Incontinent residents should be toileted at least every two hours. During an interview on 9/18/24 at 1:28 P.M., LPN B said: -The CNAs usually toilet the residents; -He/she expects the residents to have incontinent care every two hours or as needed; -He/she was not aware the incontinent residents had not been toileted for over two hours; -Incontinent residents should be toileted at least every two hours. During an interview on 9/18/24 at 1:42 P.M., the DON said -He/she expects residents to have incontinent care every two hours or as needed; -He/she was not aware the incontinent residents had not been toileted for over two hours; -He/she expects incontinent residents should be given pericare and changed at least every two hours. 4. Review of Resident #12's Quarterly MDS) dated [DATE], showed: -He/She was cognitively impaired; -He/She had moderate difficulty with hearing, speaker has to increase volume and speak distinctly; -He/She had clear speech and was able to make self understood and understand others; -He/She had no impairment to upper or lower extremities; -He/She was dependent on a walker/wheelchair; -He/She required supervised or touching assistance with bathing, sit to stand and chair to bed transfers; -Diagnosis included lack of coordination, difficulty walking, muscle weakness, unsteadiness on feet, depression, bipolar disorder (mental illness that causes extreme mood swings). Review of the resident's care plan, revised 9/1/24, showed: -He/She had an ADL self-care performance deficit due to stroke and chronic obstructive pulmonary disease (COPD); -Resident required assistance from one staff with showering twice weekly and as necessary; -Check nail length and trim and clean on bath day and as necessary; Observation on 9/16/24 at 10:06 A.M. showed: -The resident's hair was greasy and had not been brushed; -He/She had long nails with black/brown color underneath his/her nail bed. During an interview on 9/16/24 at 10:06 A.M., Resident #12 said: -He/She did not get showers or baths when he/she wanted them; -He/She had went 7-8 days without a shower; -He/She wanted a shower twice a week on Mondays and Fridays; -He/She had scheduled shower days, but he/she never got showers on his/her scheduled shower days; -He/She was lucky because he/she got one shower on Saturday during the past week; -During the night he/she could not find staff; -Call lights are on throughout the night and there was no staff to answer the lights; -Food was not served on time; -Staff do not pass ice water very often, he/she had to go after water themselves. Review of shower schedule, dated 4/30/24, in the shower book for Maple hall showed: -His/Her room number had shower days on Mondays and Thursdays. Review of Resident #12's shower sheets, dated 6/1/24 to 9/17/24 , showed: -He/She received one shower in September on 9/17 out of [NAME] scheduled opportunities, which was nineteen days from his/her last prior shower in August; -He/She received five showers in August on 8/1, 8/7, 8/13, 8/26, and 8/29 of nine schedule opportunities; -He/She received four showers in July on 7/2, 7/9, 7/19, and 7/23 of nine scheduled opportunities; -He/She received three showers in June on 6/17, 6/20, and 6/26 of eight scheduled opportunities. 5. Review of Resident #49's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, and was able to make self-understood and understand others; -He/She felt down, depressed or hopeless half or more days; -He/She had no behavioral symptoms or rejection of care; -He/She had impairment on one side of upper and lower extremities; -He/She was dependent on walker and wheelchair; -He/She required substantial/maximal assistance with bathing; -He/She was frequently incontinent; -Diagnoses included: stroke (condition causing damage to the brain from an interruption of its blood supply), hemiplegia (condition causing weakness on one side of the body), heart failure, high blood pressure, diabetes (too much sugar in the blood), depression, post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, lack of coordination, pain in left shoulder, need for assistance with personal care, osteoarthritis of the right shoulder (a chronic joint disease that causes the cartilage in one or more joints to break down over time). Review of the resident's care plan, revised 7/30/24, showed: -He/She had an ADL self-care performance deficit due to hemiplegia; -He/She required extensive assistance with one person assist for shower twice weekly and as necessary; -He/She required assistance washing under his/her arm, abdominal folds, and lower body; -He/She had a rash under breast and pannus due to moisture; -Preventive skin care as ordered, keep area under breast and pannus clean and dry. During an interview on 9/16/24 at 6:24 P.M., Resident #49 said: -Showers were very infrequent; -The last shower he/she had was less than a week ago and the shower prior to that was about 2 weeks in between showers; -Not having showers regularly made him/her feel dirty and disgusting; -Prior to his/her stroke he/she was taking two or three showers a day; -He/She would like to receive at minimum of two showers a week; -He/She was scheduled to have showers on Tuesdays and Fridays, but he/she rarely received showers as scheduled; -A lot of times there was not any pads or sheets available; -Staff do not keep beds made as there was not enough sheets to put back on the beds; -He/She had to sleep on a bare mattress due to facility not having any clean sheets; -Water is only passed one time a day; -The facility had never changed out his/her water cup since he/she had been there; -Call light response time is slow; -He/She had to wait thirty minutes or more for his/her call light to be answered. Review of shower schedule, dated 4/30/24, in shower book on Maple hall showed: -His/Her room number was assigned shower days on Mondays and Thursdays. Review of shower sheets, dated 6/1/24 to 9/17/24 , showed: -He/She received one shower in September on 9/5 out of five scheduled opportunities; -He/She received two showers in August on 8/6 and 8/21 out of nine scheduled opportunities; -He/She received two showers in July on 7/9 and 7/21 out of nine scheduled opportunities; -He/She received two showers in June on 6/15 and 6/25 out of eight scheduled opportunities; -He/She received only 7 out of 31 shower opportunities from June to September. 6. Review of Resident #87's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood, and understand others; -He/She had impairment on one side of upper extremity, and impairment on both sides of lower extremities; -He/She was dependent on a wheelchair; -He/She was dependent for bathing and tub transfers; -Diagnosis included traumatic spinal cord dysfunction, central cord syndrome as an after effect of disease, condition, or injury at the fifth cervical vertebra level of the cervical spinal cord (type of incomplete spinal cord injury characterized by weakness, loss of sensation below injury site, loss of bladder control, pain such as tingling and burning), paraplegia (paralysis of legs and lower body caused by spinal injury), spinal stenosis in cervical region (a chronic condition that occurs when spinal canal narrows, putting pressure on spinal cord and nerve roots), muscle weakness, and difficulty walking. Review of the resident's care plan, revised 1/31/24, showed: -Resident had an ADL self-care performance deficit; -He/She was dependent on two staff for transfers from chair to bed, and shower; -He/She required set up, supervision, and physical assistance to maintain personal hygiene; -Revision 7/5/24 showed patient refused shower that morning because he/she said shower aide was a witch and that his/her potions and lotions cause him/her to burn and itch. During an interview on 9/16/24 at 10:40 A.M., Resident #87 said: -He/She received a shower one time every two weeks; -He/She felt like garbage when he/she had to go so long without showers; -He/She had a shower on 9/14, prior to that his/her last shower was two weeks prior; -He/She would like to have a shower every day; -His/Her bedding is only changed every two weeks; -Water is not passed to his/her room everyday. Review of shower schedule, dated 4/30/24, in shower book for Maple hall showed: -His/Her room number was assigned shower days on Wednesdays and Saturdays. Review of shower sheets, dated 6/1/24 to 9/17/24 , showed: -He/She had no documented showers in September out of four opportunities, and he/she had one documented refusal on 9/17/24; -He/She received three showers in August on 8/7, 8/17, and 8/31 out of nine scheduled opportunities, with no documented refusals; -He/She received two showers in July on 7/3 and 7/7 out of nine opportunities with 2 refusals on 7/19 and 7/24; -He/She received three showers in June on 6/5, 6/19, and 6/26 out of nine scheduled opportunities, no documented refusals; -He/She received 8 out of 31 opportunities for showers, and 3 refusals out of 31 scheduled opportunities for showers. During an interview on 9/16/24 at 12:11 P.M., Certified Nurse Aide (CNA) A said: -He/She was only aide scheduled to work Maple hall most of the time; -He/She was a shower aide, but he/she was pulled from completing showers to work the floor all the time; -Residents go without showers for much longer than a week at time due to staffing shortages; -He/She had given showers and the white towels will be black; -He/She did not have time to do all patient care needs due to staffing; -He/She had three residents on Maple hall that required feeding assistance and there was insufficient staff to feed the residents in timely manner; -Laundry staff do not stock linens; -He/She had to go to laundry to obtain linens because linens were not restocked on halls. During an interview on 9/16/24 at 7:48 P.M., Certified Medication Technician (CMT) A said: -Insufficient staff working the facility was an issue that affected patient care; -He/She had to work late because he/she had to help the CNAs work the floor and had to stop passing medications; -He/She had to stop medication passes to assist with passing food trays on the floor; -Showers were not getting done; -The hall had only one CNA scheduled, but needed two to meet resident cares due to transfers, incontinence, and Hoyers; -Staffing is an issue which has resulted in patient care not getting done; -Showers were not being completed due to staffing shortages; -The shower aide was constantly pulled to floor to work as a CNA so showers were not getting completed. During an interview on 9/17/24 at 5:18 A.M., Licensed Practical Nurse (LPN) A said: -Biggest issue in the facility was staffing; -He/She had been asked to cover multiple halls due to staffing shortages; -He/She was not comfortable covering multiple halls due to residents with tracheotomies that needed to be checked more frequently; -He/She found that it was hard to hold CNAs accountable when that CNA was the only CNA working the floor; -Patient care needs were not being met with just one aide covering a hall. During an interview on 9/17/24 at 5:48 A.M., CNA B said: -Staffing was an issue in facility; -Residents did not receive adequate pericare, toileting, transfers, feeding assistance, and showers as a result of staffing shortages; -There had been shortage of bed pads and sheets; -Laundry staff was short for time period; -He/She had to go to other halls to track down bed pads and sheets; -Facility has ran out of sheets and bed pads. During an interview on 9/23/24 at 10:05 A.M., Registered Nurse (RN) A said: -There was never enough staff; -Staff do the best they can to meet resident needs but there was never enough staff to go around; -Resident care suffered as a result of short staffing; -One CNA was assigned thirty residents and half of the residents on the hall were incontinent; -The CNA was also expected to pass drinks and meal trays; -The CMT had to stop passing medications and assist at meal times; -Showers are a problem throughout the facility, not just on one hall; -Showers are not done due to not having sufficient staff. During an interview on 9/23/24 at 3:33 P.M., the Director of Nursing said: -The facility was doing the best it could with staffing; -He/She could not control staff call ins. During an interview on 9/23/24 at 3:33 P.M., the Administrator said: -Showers had not been completed twice weekly due to staffing; -His/Her goal was to have two CNAs, a CMT, and a nurse working on each hall; -Time goal had not been met due to staffing in facility. 7. During a group interview of the Resident Council on 9/18/24 at 10:00 A.M., eight of 20 residents (Residents #13, #67, #80, #12, #49, #87, #74, and #12) said: -Call times take a long time and can be an hour or longer; -Delays for call lights to be answered is due to the staff being overworked and short-handed; -At night there is not enough staff to take care of the residents; -On the weekends staffing is very low. 8. Review of Resident #74's Admission assessment, completed by facility staff, dated 9/10/24, showed: -He/She was cognitively intact; -Incontinent of both bowel and bladder; -Diagnoses included brain disease; shortness of breath; urinary tract infection; kidney disease; asthma; heart disease; depression; osteoarthritis; malnutrition. Review of the resident's undated care plan, showed: -Resident's autonomy and dignity will be honored in the personal choices they make; -Resident had an ADL performance deficit; -Resident was at risk for falls. Review of progress notes dated 9/14 showed: -Resident continued ABT (antibiotic therapy) for UTI (urinary tract infection) with no adverse reactions. Fluids encouraged while awake. Review of progress notes dated 9/15 showed: -Resident remained on ABT/UTI without any adverse reaction. Review of Progress notes dated 9/16 showed: -Resident continued ABT/UTI with no adverse reaction. Resident was incontinent with some control. Assist of one with toileting and cares. Fluids encouraged while awake. Review of progress notes, dated 9/17, showed: -Continued Cipro (antibiotic) for UTI; encouraged to increase water intake. Observation and interview on 09/16/24 09:59 A.M. showed: -The resident was observed sitting on bed in a hospital gown. The resident said he/she had been waiting since 8:30 A.M. and expressed frustration that he/she was not dressed yet. -The resident said he/she often doesn't get help to the bathroom in time and sometimes soils themselves while waiting for assistance. During an interview on 09/17/24 at 11:19 A.M., the resident's daughter said: -She is concerned the resident has not had a bath since he/she has been here (admitted : 9/08/24) and said the resident has started scratching at his/her head due to his/her hair and scalp being dirty. Observation and interview on 09/23/24 at 09:13 A.M., showed: -The resident was unshaven and resident said he/she asked several days ago for assistance. He/she said there is not enough staff at the facility to help resident shave. During an interview on 09/18/24 at 03:35 P.M., Nurse B said: -The resident's shaving/shower schedule depends on resident preference vs. resident schedule and there are residents that are scheduled for twice a week. During an interview on 09/19/24 at 07:08 A.M., CNA B said: -He/she checks on the resident to see if he/she needs to use the bathroom and the resident uses a urinal. During an interview on 09/23/24 at 10:16 AM , CNA A said: -There is not enough staff in general, but especially the CNAs. It makes employees and residents on edge because residents do not get changed or put down for a nap in a timely manner. -He/she is working alone on the floor on average, 3-4 times per week and does not always get breaks. During an interview on 09/23/24 at 03:36 PM, the Administrator said: -Most of the time the facility has enough staff to meet the residents needs. The goal is to have two CNAs per hall, but it does not always happen due to staff calls out. MO#241353 MO#241172 MO#241807 46706 47195 50980 51166

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to manually clean and sanitize kitchen equipment, failed to maintain a clean and sanitary kitchen, failed to wash hands, failed to date and label foods, and failed to wear hair and beard coverings. This had the potential to affect all residents in the facility. The facility census was 104. 1. Review of the facility's policy on three compartment sinks, undated, showed: - Dishes and cookware will be cleaned and sanitized after each meal; - Check sanitation sink frequently using a test strip to ensure the level of sanitizing solution is appropriate; - Sink One Wash: Prepare the clean sink by measuring the appropriate amount of water into the sink and marking the sink with a water line. Determine the appropriate amount of detergent to be used. Water should be 110 F. Change water frequently to ensure effective cleaning of dishes; - Sink Two Rinse: Prepare the clean sink with hot water; - Sink Three Sanitize: Measure the appropriate amount of sanitizing chemical into the water. It should be 75 to 100 F. Test the sanitizing solution using test strips. Sanitize according to chart time (not provided). Review of the facility's policy on sanitizer buckets, undated, showed: - Sanitation solution will be used on items too large to immerse in sink and areas of production; - Sanitation buckets are changed as often as necessary, but not to exceed longer than 4 hours. Observation on 9/16/24 9:00 A.M. showed, the three sink manual washing temperature log was missing for the month of August. Observation on 9/16/24 at 9:24 A.M. showed, no sanitizing buckets were visible in the kitchen. Observation on 9/17/24 at 9:12 A.M. showed: -No temperature checks were documented on the log book for the three compartment sink for September 16th; -Dietary [NAME] B was observed filling the three compartment sinks and pre-washing cookware without taking any temperatures or testing the sanitizing solution concentration. Observation on 09/17/24 at 9:23 A.M. showed: -Cook A washed the cookware in sink one, moved them to sink two, rinsed off the cookware in hot water in sink two, and transferred to sink three. - 45 seconds later [NAME] A removed the items from the sanitizer sink and placed them on the sink counter to dry. No temperature or sanitizing solution checks were done. Continuous observation on 9/17/24 from 9:30 A.M. through 1:15 P.M. showed: - Sanitizing buckets were not changed out after over four hours of use; - No temperature or sanitizing concentration checks were done over the last four hours. The water was not changed out in any of the sinks. During an interview on 9/18/24 at 2:15 P.M., the Dietary Manager said: - She would expect temperature checks for the three-sink manual wash station are taken morning, lunch, and dinner and for each use; - She would expect the sanitizing buckets to be visible in the kitchen during meal service times. During an interview on 9/23/24 at 9:55 A.M., the Registered Dietician said: - She would expect temperatures to be checked prior to washing dishes manually; - She would expect sanitizing buckets to be stationed throughout the kitchen for all meals. 2. Review of the facility's policy on sanitation inspections, dated 9/1/21, showed: - All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. - Daily food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures, and dishwasher temperatures daily. - Weekly, the dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations. - Inspections will be conducted but not limited to the following areas: Dry storage, freezer, refrigerator, dish room, pot wash, main production area, food preparation area, general dietary observations. Observation on 09/16/24 08:59 AM, in the kitchen showed: - Excessive dust and dirt on the ventilation ducts; - Floors were sticky throughout the kitchen, storage areas and cleaning stations; - Accumulation of dust/dirt on the wall next to the refrigerator; - Accumulation of dust, dirt, screws, and lint on top of the freezer; - Vent duct overhead had an accumulation of lint; - Two ovens had old burned food debris inside; - Behind the stove there was a dirty oven shelf grate lying on the floor; - Behind the stove there was a large quantity of food and grease build up; - Vents behind the stove were covered in exhaust dust; - Food splatter on the slicer; - The microwave had old food splattered inside; - Paint was missing and debris and dirt build up near the 3 three compartment sink; - Surface area, where plates were staged at the steam line for serving, were noted to have visible old food debris; - Walls were dirty throughout the kitchen area, with dried food on the walls and ceiling surfaces; - The top of the tea machine had sticky dried liquid and debris; - The juice machine had dust on the exhaust fans; - Liquid had dripped onto the floor below the tea station; - Cut off plastic ties were lying on the kitchen floor. Observation on 09/16/24 09:15 A.M., of the dry storage room showed: - Loose ceiling material was hanging, a potential contamination risk; - Dust build up on the walls. Observation on 09/16/24 09:22 A.M., of the cleaning closet showed: - Cluttered floor with dust pans and tools, a possible harbinger for rodents and insects; - Sink was rusted; - Shelves had visible debris on top of them and an accumulation of dust; - Lint and dust were on the vents and walls. Observation on 9/16/24 10:25 A.M., in the dining room showed: - Orange substance build up over the internal metal lip right above the ice dispensing chute inside the ice machine; - Trash can without a lid, stored in the dining room containing food debris and trash; - Floor going into the kitchen had visible dirt and grime build up. Observation on 09/17/24 at 12:22 P.M. showed: -Cook C emptied cut up tomatoes directly into a container on the steam line from a large cutting board. The bottom surface of the cutting board made contact with the inside of the food serving container as the food transfer was made causing potential cross contamination. During an interview on 9/18/24 at 2:15 P.M., the Dietary Manager said: - The floors are sticky because they needed to be waxed; - Dust and dirt on the ventilation ducts should be cleaned; - The top of the freezer surface area should be free of dust, dirt, screws and lint; - The kitchen in its current state is clean and up to their standards; - He/She would not expect ovens to have old food debris; - He/She would not expect the cleaning closet to be cluttered and strewn with cleaning tools on the floor; - He/She would expect the ice machine to be free of dirt buildup inside the machine; - He/She would expect lids on all trash cans. During an interview on 9/23/24 at 9:55 A.M., Registered Dietician said: - She would expect deep cleaning around equipment and kitchen surfaces to be done weekly and that there is a cleaning schedule posted; - She would expect ventilation openings to be free of dirt and dust build up. 3. Review of the facility's policy on handwashing guidelines for dietary employees, 9/1/2021, showed: - The facility shall provide a handwashing sink(s), with supply of hand cleaning solutions, in a location that is convenient for use by employees in food preparation, food dispensing, ware washing areas and in or immediately adjacent to toilet rooms. - Frequency of Handwashing: (a) After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, (b) after hands have touched bare human body parts other than clean hands (such as face, nose, hair), (c) while preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, (d) before donning (applying) gloves for working with food, (e) after engaging in any activity that may contaminate the hands. - Handwashing procedure: turn on water to a comfortable warm temperature, rinse thoroughly under clean, running warm water. Observation on 9/16/24 at 9:00 A.M., showed, the cold-water faucet did not work and only hot water came out at the sink. Observation on 9/17/24 at 9:28 A.M., showed [NAME] A did not wash his/her hands after working in the sink area before applying gloves and working with meat. Observation on 9/17/24 at 9:30 A.M. showed: - [NAME] A moved beef from the defrosting stage in the refrigerator to the prep area and opened all beef packages, disposed of trash, put utensils into wash sink, and removed gloves; - [NAME] A added water to the pan with meat, and had not washed his/her hands since working with raw meat and removing gloves. Observation on 09/17/24 at 10:08 A.M. showed, [NAME] A did not wash hands before applying gloves after working at stove area, and then went to the prep area and chopped up green peppers. Observation on 09/17/24 at 12:27 P.M. showed: - [NAME] C chopped and prepared a hot dog by wrapping it in tin foil while wearing gloves; - [NAME] C wiped his/her gloved hands off on their apron so he/she could use a pen to write on the product wrapping; - [NAME] C then started preparing a 2nd hot dog with the same gloves, pulled out a bun and filled it with a hot dog with the gloved hands then changed the gloves. Observation on 09/17/24 12:45 P.M. showed, [NAME] C stopped cutting tomatoes and went to the back office with gloves on and picked up and delivered a box of tea to a staff member at the kitchen door. [NAME] C then removed both gloves, put on new gloves, did not wash hands, and went back to the food prep area to prepare a hamburger. [NAME] C used a gloved hand to catch burger grease/water as he/she walked the item across the kitchen then started working on dicing tomatoes with the same gloved hands. During an interview on 9/23/24 at 9:55 A.M., the Registered Dietician said, he/she would expect hot and cold water at the handwashing station. 4. No policy on the requirement for hair and beard coverings was provided. Observation on 09/17/24 at 12:04 P.M. showed: - Dishwashing Aide A not wearing a beard covering over moustache; - Maintenance staff entered the kitchen without a hairnet covering. Observation on 09/17/24 at 1:12 P.M. showed: - [NAME] A wore a beard covering below the chin while working with food in the kitchen. 5. Review of facility's policy on food storage, undated, showed: - All food stock and products are stored in approved sanitary storage containers, of food quality plastic bags, covered, labeled as to contents, and dated. Review of facility policy, food storage (dry, refrigerated, and frozen), undated, showed: - Goods that have been opened with no date, left on the floor, or not properly sealed will be discarded; - Dry goods: food stored in bins are removed from original packaging. Bins are labeled and dated. All open products are sealed, labeled, and dated; - Refrigerated foods: open products are sealed, labeled, and dated; - Frozen foods that are taken out of original packaging, product is labeled and dated. Observation on 09/16/24 at 0910 A.M. showed: - Loose frozen hash browns in a plastic bag in the freezer with no date or label; - Loose pie shell in a plastic bag in the freezer with no date or label; - One shelf of bread not labeled with a date; - No date or label on raw onion bin; - No date on an oatmeal pie box opened. During an interview on 9/18/24 at 2:15 P.M., the Dietary Manager said: - Unlabeled bags in the freezer should be labeled and have a date written on them with a magic marker but the marker wears off. They are looking for other solutions; - Vegetables such as red onions kept in a bin should have a sticker with a date on it which is their normal process.

Based on observation, record review, and interview, the facility failed to maintain all areas of the facility in a safe, functional, sanitary and comfortable environment for visitors, staff and residents. The facility census was 104. Review of the facility provided policy Routine Cleaning and Disinfection dated 9/1/21 showed: -It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment. -Cleaning refers to the removal of visible soil from objects and surfaces. -Horizontal surfaces with infrequent hand contact (window sills and hard surface flooring) in routine areas should be cleaned on a regular basis; when soiling or spills occur; when a resident is discharged . -Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. Review of the facility provided, undated, policy Safe and Homelike Environment included, in accordance with resident rights the facility will provide a safe, clean, comfortable and homelike environment. Observations beginning on 09/16/24 at 12:58 P.M. on [NAME] Hall showed: -Large cobwebs with dead bugs at the corner of the exit door; -Wall paper trim was bubbled and coming off the walls; -The exit door was rusted in multiple places with visible daylight at the bottom on the latch side; -Multiple gouges and nicks in the wallpaper on the upper 2/3 of the hallway, with spackle over them; -Cobwebs on the air vent; -Multiple light fixtures with dead bugs and debris; -Multiple ceiling tiles surrounding air vent, with brown water stains, outside room B9; -Multiple mechanical hand sanitizer drip trays with dirt, debris and dead bugs. Observation of the Director of Nursing Office showed: -Light fixtures with dead bugs and debris; -Cobwebs in the corners with dead bugs and debris; -Gouges and scrapes in the sheet rock. Observation on 09/18/24 at 12:33 P.M. showed on the Special Care Unit: -Entry door push bar was loose from the door panel on both sides of the door; -Entry door was scuffed with black scuff marks; -Tiled floor had multiple scratches and black scuff marks; -Baseboards in the dining area had thick black debris along the floor line; -The dining room window blinds were broken and jagged, with zip ties holding them to the window sill; -The air conditioning units, in the dining room, were loose from the wall; -The ceiling vent was covered with dirt, dust and black debris; -The wallpaper was peeled and bubbled away from the wall; -The ceiling vent outside room E25 was coated with dirt and dust; -The ceiling above the nurses station had 2 lights burned out, both had dirt and debris; -The nurses station desk was chipped in eight places; - The outlet cover was broken and the floor in that area was dirty with dirt and debris; - The shower room curtain had dirt, debris and black mold like substance on both sides; -The baseboards were warped and curved away from the wall, had dirt and debris at edges, and were missing at the nurses station; -No window screen in Room E1. During an interview on 09/23/24 at 7:33 A.M., Housekeeper A said: -He/She completed daily cleaning of the resident bathrooms, and mops the floor; -One person cannot complete everything that needed to be completed; -There is a floor technician in the evening to buff floors; -There was no check off list for completed tasks. During an interview on 09/23/24 at 8:17 A.M., the Housekeeping Supervisor said: -The Administrator expects the facility to be clean and odor free; -Cleaning is completed daily by a list; -He/She expects the facility to be clean, odor free and floors and ceilings to be free of dirt and debris. During an interview on 9/23/24 at 9:11 A.M., the Maintenance Director said: -He had been employed in the facility four months; -Morning meetings are where he finds out repairs that are needed, or staff can fill out a work order; -He knew of the broken window a few days ago; -He completed weekly walk through inspections with Administration; -He tried to paint over some of the water damage after walk through with investors; -He tried to find leaks and fix them as he can; -He expects things to be in good repair; -The baseboards are paint stained. Housekeeping is responsible for cleaning baseboards; -Repairs are prioritized by need; -Housekeeping is responsible for all floors, dusting and baseboard cleaning; -Maintenance is responsible for light fixture cleaning, and repair; -Vents are maintenance responsibility; he has not seen anything that looks like mold; filters are changed once a month; -He used a log book to know what needs fixed. If it was not on the log then it would not be fixed; -Log books were at each nurses station and any staff can write in them. During an interview on 9/23/24 at 3:33 P.M., the Administrator said: -Housekeeping was to complete daily cleaning to include dusting and high dusting; -She expected the facility to attempt to be odor free as much as possible; -Vents, floors and ceilings should be cleaned by housekeeping and maintenance as a collaborative effort; -Anyone can put a work order in if something is broken; -Each Department Head completes weekly rounds and would make a note of any issues that need addressed by a different department; -She would expect work orders to be completed if the department head found a concern for maintenance; -They have made progress in the cleanliness of the building but had more to go.

Based on observation, interview and record review, the facility failed to adequately staff the kitchen with enough dietary staff to ensure meals were served to residents in a timely manner. This has the potential to affect all residents of the facility. The facility census was 104. 1. Review of facility's meal serving policy, dated 12/2/22, showed: -Check on the resident's at regular intervals; -Offer additional fluids and water with the meal when there are no fluid restrictions; Facility did not provide a policy regarding dietary staffing. Review of the facility's planned meal time schedule dated 9/15-9/28/24, showed: -Breakfast 7:30 A.M. -Lunch 11:30 A.M. -Dinner 5:00 P.M. Observations on 9/16/24 showed the following: -11:47 A.M., 19 residents assembled in the dining room for the lunch meal; The dining room had only a few chairs, no place settings, no condiments, no silverware, or centerpieces to indicate a home like environment for the meal time dining experience; -12:10 P.M., Residents received packets of cream and sugar from staff eight minutes after being served coffee, no utensils were provided to the residents to stir the coffee; -12:17 P.M., Some residents received metal silverware, some received plastic utensils; -12:27 P.M., Meals service started in the dining room; -12:30 P.M., The Administrator from a sister facility assisted with passing drinks in the dining room; -12:41 P.M., Meal service was completed in the dining room; -12:50 P.M., The food cart arrived at [NAME] hall; Corporate staff helped to serve the residents noon meal hall trays; -12:58 P.M., Food cart arrived at Maple hall; Corporate RN staff assisted with meal tray pass; -1:00 P.M., Environmental Services staff helped pass out trays; -1:04 P.M., The last tray was served for lunch time service. Observations on 9/17/24 showed the following: -8:18 A.M., During breakfast service nothing was provided for residents to use to stir beverages; -12:04 P.M., 14 residents were sitting in the dining room, no drinks were available and no staff members were in the dining room; -12:08 P.M., The Activities Director started passing drinks in the dining room. The residents at the first table received one drink cup Kool-Aide which was half full. The residents at the second table received two cups of drinks iced tea and juice; -12:13 P.M., Residents who requested coffee did not get any; -12:19 P.M., The Activities Director started passing coffee and creamers, but did not provide any spoons for the residents to stir in the condiments; -12:31 P.M., The hall meal trays were sent to the dementia unit; -12:46 P.M., The first meal tray was served in the dining room; -12:51 P.M., Most residents' drink cups were empty in the dining room, the majority of the residents had not been served lunch and drink refills had not been offered; -12:59 P.M., No drink refills were offered n the dining room; -1:12 P.M., Hall trays delivered to [NAME] Hall. The staff were passing out meal trays, but were unfamiliar where each resident was located; -1:18 P.M., The last meal tray was passed out on [NAME] Hall; -1:30 P.M., Hall meal trays were delivered to Maple Hall. Observations on 9/18/24 showed at: -12:10 P.M., Residents were sitting in the dining room with no drinks or meals; -12:19 P.M., Hall meal trays were starting to go out, no change in the dining room; -12:43 P.M., The drinks were being served to the dining room; -12:45 P.M., Meals were being served in the dining room for lunch service. Observation of posted meal service times showed: -Meal times were not posted anywhere in the facility; -Three lunch services observed, on average the first meal served to the dining room was 69 minutes late. During an interview on 9/23/24 at 3:30 P.M., the Administrator said: -Dining room meals times are 7:00 A.M. - 9:00 A.M. Breakfast, 11:30 A.M. - 1:30 P.M. Lunch, and 5:00 P.M. - 6:30 P.M. Dinner; -She would expect residents to have condiments and utensils readily available for each resident for their coffee.

Based on observation, interview, and record review, the facility failed to provide assistance to dependent residents with grooming, and showers at least twice a week for nine of 21 sampled residents (Resident #12, #13, #14 #49, #67, #74, #80, #87, and #91). The facility failed to provide shaving assistance and nail care for one resident (Resident #14). The facility failed to provide incontinent care for two residents (Resident #13 and #80). The facility census was 104 Review of facility policy, Activities of Daily Living, dated 9/1/21, showed: -The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable including ability to bathe, dress, groom, and toilet. -The facility shall provide a maintenance and restorative program to assist the resident in maintaining the highest practicable outcome based on the comprehensive assessment. -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of facility policy, resident showers, dated 9/1/21, showed: -It was practice of facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. -Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Review of facility policy, Bathing a Resident, dated 9/1/21, showed: -It was practice of facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues. 1. Review of Resident #12's, quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/6/24, showed: -He/She was cognitively impaired; -He/She had moderate difficulty with hearing, speaker has to increase volume and speak distinctly; -He/She had clear speech and was able to make self understood and understand others; -He/She had no impairment to upper or lower extremities; -He/She was dependent on a walker/wheelchair; -He/She required supervised or touching assistance with bathing, sit to stand and chair to bed transfers; -Diagnosis included lack of coordination, difficulty walking, muscle weakness, unsteadiness on feet, depression, bipolar disorder (mental illness that causes extreme mood swings). Review of care plan, revised 9/1/24, showed: -He/She had an ADL self-care performance deficit due to stroke and chronic obstructive pulmonary disease (COPD); -Resident required assistance from one staff with showering twice weekly and as necessary; -Check nail length and trim and clean on bath day and as necessary; Observation on 9/16/24 at 10:06 A.M. showed: -Resident's hair was greasy and had not been brushed; -He/She had long nails with black/brown color underneath his/her nail bed. During an interview on 9/16/24 at 10:06 A.M., the resident said: -He/She did not get showers or baths when he/she wanted them; -He/She had gone 7-8 days without a shower; -He/She wanted a shower twice a week on Mondays and Fridays; -He/She had scheduled shower days but he/she never got showers on his/her scheduled shower days; -He/She was lucky because he/she got one shower on Saturday during the past week. Review of shower schedule, dated 4/30/24, showed Resident #12's room number had shower days on Monday and Thursdays. Review of shower sheets, dated 6/1/24 to 9/17/24 , showed: -He/She received one shower out of five scheduled opportunities in September on 9/17/24, which was nineteen days from his/her last prior shower in August; -He/She received five showers in August on 8/1, 8/7, 8/13, 8/26, and 8/29 out of nine scheduled opportunities; -He/She received four showers in July on 7/2, 7/9, 7/19, and 7/23 out of nine scheduled opportunities; -He/She received three showers in June on 6/17, 6/20, and 6/26 out of eight scheduled opportunities. 2. Review of Resident #49's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, and was able to make self-understood and understand others; -He/She felt down, depressed or hopeless half or more days; -He/She had no behavioral symptoms or rejection of care; -He/She had impairment on one side of upper and lower extremities; -He/She was dependent on walker and wheelchair; -He/She required substantial/maximal assistance with bathing -He/She was frequently incontinent; -Diagnoses included stroke (condition causing damage to the brain from an interruption of its blood supply), hemiplegia (condition causing weakness on one side of the body), heart failure, high blood pressure, diabetes (too much sugar in the blood), depression, post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, lack of coordination, pain in left shoulder, need for assistance with personal care, osteoarthritis of the right shoulder (a chronic joint disease that causes the cartilage in one or more joints to break down over time). Review of the resident's care plan, revised 7/30/24, showed: -He/She had an ADL self-care performance deficit due to hemiplegia; -He/She required extensive assistance with one person assist for shower twice weekly and as necessary; -He/She required assistance washing under his/her arm, abdominal folds, and lower body; -He/She had a rash under breast and pannus due to moisture; -Preventive skin care as ordered, keep area under breast and pannus clean and dry. During an interview on 9/16/24 at 6:24 P.M., the resident said: -Showers were very infrequent; -The last shower he/she had was less than a week ago and the shower prior to that was about 2 weeks in between showers; -Not having showers regularly made him/her feel dirty and disgusting; -Prior to his/her stroke he/she was taking two or three showers a day; -He/She would like to receive at minimum of two showers a week; -He/She was scheduled to have showers on Tuesdays and Fridays but he/she rarely received showers as scheduled; Review of shower schedule, dated 4/30/24, showed Resident #49's room number had showers scheduled on Mondays and Thursdays. Review of shower sheets, dated 6/1/24 to 9/17/24 , showed: -He/She received one shower in September on 9/5 out of five scheduled opportunities; -He/She received two showers in August on 8/6 and 8/21 out of nine scheduled opportunities; -He/She received two showers in July on 7/9 and 7/21 out of nine scheduled opportunities; -He/She received two showers in June on 6/15 and 6/25 out of eight scheduled opportunities -He/She received a shower 7 out of 31 opportunities from June to September. 3. Review of Resident #87's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, was able to make self-understood, and understand others; -He/She had impairment on one side of upper extremity, and impairment on both sides of lower extremities; -He/She was dependent on a wheelchair; -He/She was dependent for bathing and tub transfers; -Diagnosis included traumatic spinal cord dysfunction, central cord syndrome as an after effect of disease, condition, or injury at the fifth cervical vertebra level of the cervical spinal cord (type of incomplete spinal cord injury characterized by weakness, loss of sensation below injury site, loss of bladder control, pain such as tingling and burning), paraplegia (paralysis of legs and lower body caused by spinal injury), spinal stenosis in cervical region (a chronic condition that occurs when spinal canal narrows, putting pressure on spinal cord and nerve roots), muscle weakness, and difficulty walking. Review of the resident's care plan, revised 1/31/24, showed: -Resident had an ADL self-care performance deficit. -He/She was dependent on two staff for transfers from chair to bed, and shower; -He/She required set up, supervision, and physical assistance to maintain personal hygiene. -Revision 7/5/24 showed patient refused shower that morning because he/she said shower aide was a witch and that his/her potions and lotions cause him/her to burn and itch. During an interview on 9/16/24 at 10:40 A.M., the resident said: -He/She received a shower one time every two weeks; -He/She felt like garbage when he/she had to go so long without showers; -He/She had a shower on 9/14, prior to that his/her last shower was two weeks prior; -He/She would like to have a shower every day; -He/She completed his/her own shaving. Review of the shower schedule, dated 4/30/24, showed Resident #87's room number had assigned shower days on Wednesday and Saturdays. Review of shower sheets, dated 6/1/24 to 9/17/24 , showed: -He/She had no documented showers in September out of four opportunities, and he/she had one documented refusal on 9/17/24; -He/She received three showers in August on 8/7, 8/17, and 8/31 out of nine scheduled opportunities, with no documented refusals; -He/She received two showers in July on 7/3 and 7/7 out of nine opportunities with 2 refusals on 7/19 and 7/24. -He/She received three showers in June on 6/5, 6/19, and 6/26 out of nine scheduled opportunities, no documented refusals; -He/She received 8 out of 31 opportunities for showers, and 3 refusals out of 31 scheduled opportunities for showers. During an interview on 9/16/24 at 12:11 P.M., Certified Nurse Aide (CNA) A said: -He/She was a shower aide, but he/she was pulled from completing showers to work the floor all the time; -Residents go without showers for much longer than a week at a time; -He/She has given showers and the white towels will be black. During an interview on 9/16/24 at 7:48 P.M., Certified Medication Technician (CMT) A said: -Showers were not getting done; -The hall had only one Certified Nurse Aide scheduled; -Staffing is an issue which has resulted in patient care not getting done. -the shower aide was constantly pulled to floor to work as a CNA, so showers were not getting completed. During an interview on 9/23/24 at 10:05 A.M., Registered Nurse (RN) A said: -Showers are a problem throughout the facility, not just on one hall. -Showers are not done due to insufficient staff. During an interview on 9/23/24 at 3:33 P.M., Administrator said: -Residents should be offered showers at a minimum of one time a week but facility goal was to offer twice weekly; -He/She expected same for resident's nail care, hair care, and shaving. -There had been time goal had not been met due to staffing in facility. 4. Review of Resident #13's care plan revised, 3/27/24, showed: -The resident has an ADL self care performance deficit; -The resident is dependent on staff for toileting; -Clean peri-area after each incontinent episode; -The resident has the potential for pressure ulcer development related to incontinence; -The resident requires total assistance of one staff for transfers; -The resident has the right to be treated with dignity. Review of the resident's quarterly MDS dated , 6/20/24, showed: -Severe cognitive impairment; -Dependent on staff for Activities of ADLs; -Incontinent of bowel and bladder; -Diagnoses included, dementia, high blood pressure and anxiety. Continuous observation beginning on 09/16/24 at 09:20 A.M., showed: -09:20 A.M., the resident sat at the table in the dining room in his/her wheelchair; -10:13 A.M., the resident sat at the table in the dining room in his/her wheelchair. Facility staff had not offered to toilet the resident; 10:59 A.M. the resident sat in his/her wheelchair at the table, with his/her eyes closed; -11:03 A.M., the resident sat in his/her wheelchair at the table. LPN B walked by the resident and did not provide incontinent care for the resident; -11:25 A.M., CNA D walked by the resident who sat in his/her wheelchair at the table CNA D did not offer to provide incontinent care for the resident; -12:26 P.M., lunch was delivered to the memory care unit. The resident sat in his/her wheelchair at the table with his/her eyes closed; -12:42 P.M., Lunch was delivered to the resident at the table, while he/she sat in his/her wheelchair; -12:46 P.M., No staff offered to reposition or toilet the resident; - 01:01 P.M., The resident finished his/her lunch and sat in his/her wheelchair at the table. No staff provided incontinent care for the resident; -01:25 P.M., the resident sat at the table in his/her wheelchair. No staff had toileted the resident. Observation on 09/17/24 at 05:22 A.M., showed: -The resident's room had a strong smell of urine; -CNA D changed the resident's brief; -The resident's brief was saturated with a yellow substance and smelled of urine; -CNA D performed perineal care and applied a new brief. Continuous observation beginning on 09/17/24 at 05:39 A.M., showed: -05:39 A.M., the resident sat at the table in the dining room in his/her wheelchair; -06:15 A.M., the resident sat at the table in the dining room in his/her wheelchair. No staff offered to toilet the resident; -07:30 A.M., the resident sat in his/her wheelchair at the table; -08:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair. No staff offered to toilet the resident. 5. Review of Resident #67's annual MDS dated , 7/17/24, showed: -Moderate cognitive impairment; -Visual impairment; -Substantial assistance from staff for toileting; -Supervision of staff for dressing; -Incontinent of urine; -Diagnoses included, stroke, depression, high blood pressure and cataracts (a clouding of the eye's lens that can lead to vision loss). Review of Resident #67's undated care plan showed: -The resident has an ADL self care performance deficit; -The resident requires supervision for dressing; -The resident requires supervision with personal hygiene; -The resident requires assistance with toileting; -The resident has the right to be treated with dignity. Observation on 09/16/24 at 09:50 A.M., showed: -The resident walking into the dining room; -The resident's hair was unkempt and his/her glasses had white specks on the lenses; -The resident's pants and shirt had black stains on them. Observation on 09/16/24 at 12:24 P.M., showed: -The resident sat in the dining room at a table; - The resident's glasses had white specks on the lenses; -The resident's hair was unkempt and his/her clothes had black stains on them. Observation on 09/17/24 at 08:01 A.M., showed: -The resident sat in the dining room; -The resident wore the same clothes as 9/16/24; -The resident's pants and shirt had black stains on them. -The resident's hair was unkempt and his/her glasses had white specks on the lenses. 6. Review of Resident #80's care plan revised, 6/13/24,showed: -The resident has an ADL self care performance deficit; -The resident requires total assistance of one to two staff for showers and toileting; -The resident requires total assistance of one to two staff for transfers; -The resident has impaired cognitive function related to dementia; -The resident has the right to be treated with dignity; -The resident has the right to privacy and confidentiality. Review of the resident's quarterly MDS dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for Activities of Daily Living (ADLs); -Incontinent of bowel and bladder; -Diagnoses included, dementia, high blood pressure and anemia (not having enough healthy red blood cells to carry oxygen to the body's tissues). Continuous observation beginning on 09/16/24 at 09:20 A.M., showed: -09:20 A.M., the resident sat at the table in the dining room in his/her wheel chair; -10:13 A.M., the resident sat at the table in the dining room in his/her wheel chair. No staff offered to toilet the resident; -10:59 A.M. the resident sat in his/her wheel chair at the table with his/her eyes closed; -11:03 A.M., the resident sat in his/her wheel chair at the table. LPN B walked by and did not provide incontinent care for the resident; -11:25 A.M., CNA D walked by the resident setting in his/her wheel chair at the table and did not offer to provide incontinent care for the resident; -12:26 P.M., lunch was delivered to the memory care unit and the resident still sat in his/her wheel chair at the table with his/her eyes closed; -12:42 P.M., lunch was delivered to the resident and he/she sat at the table in his/her wheel chair; -12:46 P.M., no staff had repositioned or toileted the resident; - 01:01 P.M., the resident finished his/her lunch and sat in his/her wheel chair at the table. No staff provided incontinent care for the resident; -01:25 P.M., the resident sat at the table in his/her wheel chair with his/her eyes closed. No staff toileted the resident. Continuous observation beginning on 09/17/24 at 05:39 A.M., showed: -05:39 A.M., the resident sat at the table in the dining room in his/her wheel chair; -06:15 A.M., the resident sat at the table in the dining room in his/her wheel chair. No staff offered to toilet the resident; -07:30 A.M., the resident sat in his/her wheel chair at the table. The DON delivered breakfast to him/her and did not offer to reposition or toilet the resident; -08:30 A.M., the resident sat at the table in the dining room in his/her wheel chair; -09:30 A.M., LPN B said good morning to the resident, but did not offer to toilet the resident. During an interview on 9/18/24 at 1:14 P.M., CNA D said: -He/she tries to toilet incontinent residents at least every two hours; -It gets busy sometimes and he/she does not have time; -Incontinent residents should be toileted at least every two hours. During an interview on 9/18/24 at 1:28 P.M., LPN B said: -The CNAs usually toilet the residents; -He/she expects the residents to have incontinence care every two hours or as needed; -He/she was not aware the incontinent residents had not been toileted for over two hours; -Incontinent residents should be toileted at least every two hours. During an interview on 9/18/24 at 1:42 P.M., the DON said -He/she expects residents to have incontinence care every two hours or as needed; -He/she was not aware the incontinent residents had not been toileted for over two hours; -He/she expects incontinent residents be provided peri care and changed at least every two hours. 7. Review of Resident #14's quarterly Minimum Data Set (MDS), dated , 7/22/24, showed: -Brief interview for mental status (BIMS) score of 13, indicating the resident was not cognitively impaired; -Partial/moderate assistance for oral care, toileting, showering, lying to sitting on side of bed, transfers to/from bed -Supervision for dressing, personal hygiene, sit to stand, toilet transfer; -Utilizes a walker for mobility; - Occasionally incontinent of urine, always continent of bowel; - Diagnoses included Parkinson's Disease (brain disorder affecting body movements), hypertension (high blood pressure), diabetes (chronic disease of the Pancreas). Review of the resident's care plan, dated 3/28/24, showed: - The resident has an ADL self-care performance deficit. Impaired mobility, cognition impaired, memory impaired, impaired eyesight that may worsen; -Resident needs cues and supervision with all self care. Resident sometimes requires more physical assistance when feeling weaker than normal or is having tremors. -Personal Hygiene: The resident requires supervision and periodic assist with set up by (1) staff with personal hygiene and oral care. Resident needs staff to comb hair and to shave. Observation on 9/17/24 at 11:42 A.M., showed, Resident #14 had long hair, their nails were long, his beard growth was uneven and about one half inch long. During an interview on 9/17/24 at 11:42 A.M., Resident #14 stated his last shower was two weeks ago. He prefers a shower every day but getting one every other week right now. The resident said he would like his beard shaved but he/she has no utensils to do it and needs staff to do this for them. He can't remember his last shave but it's been a while. He also would like his nails cut and they hurt sometimes because they are so long,. Staff told him/her they did not have the tools to cut his/her nails. Observation on 9/18/24 at 11:40 A.M., showed Resident #14 still long nails and no hair cut and beard was not shaved. Interview on 9/23/24 at 3:30 P.M., Administrator and Director of Nursing (DON) stated: -Expectations for resident grooming is that they receive a shave, fingernails cut, clean appearance and odor free clothes; -Residents are offered and receive showers twice a week. The goal is to bathe residents twice a week, and provide some nail and hair care as well. There have been times when they have not met that goal, but they try their best on the floor. 8. Review of Resident #74's admission MDS assessment, completed by facility staff, dated 9/10/24, showed: -He/She was cognitively intact; -Always incontinent of both bowel and bladder; -Diagnoses included brain disease; shortness of breath; urinary tract infection; kidney disease; asthma; heart disease; depression; osteoarthritis; malnutrition. Review of the undated care plan, showed: -Resident's autonomy and dignity will be honored in the personal choices they make; -Resident had an ADL (activities of daily living self-care) performance deficit; -Resident was at risk for falls. Review of progress notes dated 9/14 showed: -Resident continued ABT (antibiotic therapy) for UTI (urinary tract infection) with no adverse drug reaction (ADR) noted. Fluids encouraged while awake. Review of progress notes dated 9/15 showed: -Resident remained on ABT/UTI without any adverse reaction. Review of Progress notes dated 9/16 showed: -Resident continued ABT/UTI with no adverse reaction. Resident was incontinent with some control. Assist of one with toileting and cares. Fluids encouraged while awake. Review of progress notes, dated 9/17, showed: -Continued Cipro (antibiotic) for UTI; encouraged to increase water intake. Observation and interview on 09/16/24 09:59 A.M. showed: -Resident sat on the bed in a hospital gown. The resident stated he/she had been waiting since 8:30 A.M. and expressed frustration that he/she was not dressed yet. -Resident stated he/she often doesn't get help to the bathroom in time and sometimes soils himself/herself while waiting for assistance. During an interview on 09/17/24 at 11:19 A.M., the resident's daughter said: -She is concerned the resident has not had a bath since he/she was admitted (admitted : 9/08/24) and said the resident has started scratching at his/her head due to his/her hair and scalp being dirty. Observation and interview on 09/23/24 at 09:13 A.M. showed the resident unshaven and stating he/she asked several days ago for assistance. He/she said there is not enough staff at the facility to help the resident shave. During an interview on 09/18/24 at 03:35 P.M., Nurse B said the resident shaving/shower schedule depends on resident preference vs. resident schedule and there are residents that are scheduled for twice a week. During an interview on 09/19/24 at 07:08 A.M. CNA B said he/she checks on the resident every couple of hours to see if he/she needs to use the bathroom and the resident uses a urinal. 9. Review of Resident #91's annual minimum data set assessment (MDS), completed by facility staff, dated 7/10/24, showed: -Resident is cognitively intact; -Diagnoses include anemia, heart failure, hip fracture, high blood pressure, kidney failure, urinary blockage, arthritis, lung disease, blood clot in lung. -Resident requires substantial assistance to maintain personal hygiene. -Resident is completely dependent on assistance with toileting and bathing. Review of resident's care plan, dated 4/19/24 showed: -Check resident every two hours and assist with toileting as needed. -Clean peri-area with each incontinence episode. During an interview on 09/16/24 at 10:39 A.M., the resident said: -He/she often waits an hour for call light to be answered to be changed. -He/she prefers to get up by 8:00 A.M. but frequently does not get assistance to get up until 11:00 A.M. During an interview on 09/19/24 at 07:08 A.M., staff said: -CNA B asks residents if they want to get up to get dressed for the day. -CNA C said that it is up to the resident to decide what time they want to get up. During an interview at 09/23/24 at 03:36 P.M., the DON (director of nursing) said: -To ensure residents hydration needs are met, staff are to make ensure each resident's cup is full of fluid and is being offered more than two hours. 46706 50980 51166

Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect, when staff failed to cover up a resident (Resident #71) who was walking down the hallway in a white pull-up brief, without pants, and failed to assist a resident into his/her personal clothes when requested by the resident (Resident # 74). The facility also failed to provide a resident with clean bed pads and sheets so he/she could return to bed after an incontinent episode (Resident #49). This affected two of 21 sampled residents. The facility census was 104. The facility did not provide a policy on resident dignity. Review of nursing home Resident's Rights, showed: -Residents had a right to be treated with consideration, respect, dignity, and recognizing each resident's individuality. -Equal access to quality of care; -Quality of life is maintained or improved. 1. Review of Resident #71's significant change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/29/24, showed: -He/She was cognitively intact; -He/She required substantial/maximal assistance with his/her personal hygiene and lower body dressing; -He/She required supervision or touching assistance with transfers from chair to bed, mobility from sitting to lying; -He/She was dependent on a wheelchair; -He/She did not attempt walking 10 feet due to medical condition or safety concerns; -Diagnoses included: Arthritis, schizophrenia (a mental illness that affects a person's thoughts, feelings, and behaviors), anxiety disorder (a condition that causes excessive worry and fear that can affect a person's daily life), bipolar disease (a mental illness that causes extreme mood swings, or shifts in energy, activity levels, and concentration), depression (a mental health condition that can cause a persistent low mood or loss of interest in activities), need for assistance with personal care, generalized muscle weakness, difficulty walking, tendency to fall, and bone infection of left ankle and foot. Review of the resident's care plan, revised 8/2/24, showed: -Receive adequate and appropriate care; -Resident has a right to privacy and confidentiality; -Resident had an activities of daily living self-care performance deficit. -Resident was able to walk independent 10 feet, 50 feet with 2 turns and 150 feet; -Resident required staff assistance to extent needed to accomplish task. -Resident was an elopement risk/wanderer. Observation on 9/18/24 at 9:59 A.M. showed the resident walking up Maple hall wearing no pants and only a white pull up brief. He/She walked pass the nurses station, passed Registered Nurse (RN) A, and continued down the hallway. He/She was met by a therapy staff member who offered to take the resident to the therapy room. The resident was then walked past the [NAME] nurses station, rooms B20, B19, B9, B10, B18, and into therapy with no pants on. Multiple residents, staff, and family members observed witnessing the resident. 2. Review of Resident #49's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech, and was able to make self-understood and understand others; -He/She felt down, depressed or hopeless half or more days; -He/She had no behavioral symptoms or rejection of care; -He/She had impairment on one side of upper and lower extremities; -He/She was dependent on walker and wheelchair; -He/She required substantial/maximal assistance with bathing -He/She was frequently incontinent; -Diagnoses included: Stroke (condition causing damage to the brain from an interruption of its blood supply), hemiplegia (condition causing weakness on one side of the body), heart failure, high blood pressure, diabetes (too much sugar in the blood), depression, post traumatic stress disorder (PTSD) (a mental health condition that can develop after a person experiences a traumatic event), unsteadiness on feet, lack of coordination, pain in left shoulder, need for assistance with personal care, osteoarthritis of the right shoulder (a chronic joint disease that causes the cartilage in one or more joints to break down over time). Review of resident's care plan, revised 7/30/24, showed: -He/She had an ADL self-care performance deficit due to hemiplegia; -He/She required extensive assistance with one person assist for shower twice weekly and as necessary; -He/She required assistance washing under his/her arm, abdominal folds, and lower body; -He/She had a rash under breast and pannus due to moisture; -Preventive skin care as ordered, keep area under breast and pannus clean and dry. During an interview on 9/16/24 at 6:32 P.M., the resident said: -He/She felt staff were degrading at times and treated him/her like he/she was a kid and could not think for him/herself; -He/She had staff tell him/her that he/she needed to go to the bathroom; -Staff wake him/her up at 4:00 A.M. to go to the bathroom; -Staff will wake him/her up to go to the bathroom and then not have clean sheets to put back on his/her bed; -He/She is forced to sit up and not able to go back to sleep; -He/She was a night owl and it is difficult for him/her not to be able to go back to bed after being awakened. During an interview on 9/16/24 at 12:11 P.M., Certified Nurse Aide (CNA) A said: -The laundry staff do not restock linens; -He/She had to go to laundry room to locate bed pads and sheets; -It took him/her away from patient care when he/she had to go down and try and locate clean sheets and bed pads. During an interview on 9/17/24 at 5:18 A.M., Licensed Practical Nurse (LPN) A said: -There had been issues with bed pads and sheets; -The washing machine had broke down; -The facility got disposable pads to put on beds. During an interview on 9/17/24 at 5:48 A.M., CNA B said: -There had been issues with supplies of linens and bed pads; -They had ran out of linens and bed pads in the past few months several times. 3. Review of Resident #74's Admission assessment, completed by facility staff, dated 9/10/24, showed: -He/She was cognitively intact; -Always incontinent of bowel and bladder; -Diagnoses included: Non-traumatic brain dysfunction( brain damage or acquired brain injury ) shortness of breath, urinary tract infection, asthma, heart disease, depression, osteoarthritis, and malnutrition. Review of the resident's undated care plan, showed: -Resident's autonomy and dignity will be honored in the personal choices they make; -Resident had an ADL (activities of daily living self-care) performance deficit; -Resident was at risk for falls. During an observation and interview on 09/16/24 9:59 A.M., the resident stated he/she liked to be dressed by 8:30 A.M. and did not understand why he/she was not dressed yet. The resident was physically upset about not being dressed by the staff. The resident was observed in a hospital gown and had been waiting to get dressed since 8:30 A.M. Observation showed the staff having a discussion outside the resident's room regarding the resident not having any clean pants to put on. During an interview on 9/17/24 at 5:59 A.M., the Administrator said residents deserved to be treated with dignity and respect. 51166

Based on observation, interview, and record review, the facility failed to implement interventions for two residents (Resident #1 and Resident #2) who displayed physically aggressive behaviors towards staff and other residents, when Resident #1 pushed another resident down (Resident #3) who sustained a fractured hip, and when Resident #2 pushed Resident #4 down causing a laceration to the residents forehead. The facility census was 87. Review of the facility's Dementia Care policy, dated 10/18/2022, showed: -It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. -Dementia is defined as a general term to describe a group of symptoms related to loss of memory, judgement, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptomology and rates of progression. -The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible. -The care plan goals will be achievable and the facility will provide resources necessary for the resident to be successful in meeting their goals. -The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintained of the expected stable rate of decline associated with dementia and dementia-like illness. -Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well being. -The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed/revised as necessary. -Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood, or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker). -All staff will be trained on dementia and dementia care practices upon hire, annually, and as needed to ensure they have the appropriate competencies and skill sets to ensure residents' safety and help residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. 1. Review of Resident #1's Admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 9/1/22, showed: -The resident had clear speech, usually makes self understood and usually understands others. -Score of 7 on the Brief Interview for Mental Status (BIMS), a structured evaluation aimed at evaluating aspects of cognition in elderly patients. The score of 7 indicates severely impaired cognitive abilities. -Behaviors not directed at others, such as rummaging and wandering, were present daily. -The resident wandered daily. -Required limited to extensive assistance with activities of daily living, including dressing, bathing, and personal hygiene. -Received antipsychotic medication (are a class of psychotropic medication primarily used to manage psychosis) daily. -Diagnoses of encephalopathy (A broad term for any brain disease that alters brain function or structure), Type I Diabetes Mellitus (a chronic condition in which the pancreas produces little or no insulin), psychosis (a mental disorder characterized by a disconnection from reality), wandering, dementia (dementia is not a specific disease but is rather a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with agitation, psychotic disorder with delusions. Review of the resident's base line care plan, dated 8/25/2022, showed: -Admitting diagnoses of altered mental status, dementia, diabetes mellitus. -Hearing impairment to both ears. -The resident had impaired cognition. Staff will administer medications as ordered, ask yes or no questions, and keep the resident's routine consistent. -The resident displays being easily distracted, wandering, restlessness, abusive/refuses cares, combative/severely agitated. Review of the resident's August to October 2022 progress notes showed: 8/25/2022 at 10:00 P.M.: During 9:38 P.M. blood sugar check, the resident was resting in bed and had stripped down. The nurse and a nursing staff member tried to get the resident dressed but he/she got combative and starting swinging and kicking, yelling get the fuck out of here. Will continue to monitor. 8/30/22 at 8:46 A.M.: Social Services Note: admitted from a local hospital with a primary diagnoses of encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition (such as viral infection or toxins in the blood)), unspecified. He/she presents alert and oriented with forgetfulness and confusion. He/she was able to make needs known. Mental function was noted with variability. BIMS score of 7 with difficulty exhibited knowing the month, day of the week, and remembering 3 words. Resident denied any problems with mood or depression. Resident denied any suicidal or homicidal ideation's and had not displayed any delusions or hallucinations. He/she was prescribed denepozil (a medication used to treat dementia), memantine (a medication used to treat dementia), and haloperidol (a medication used to treat certain mood or mental disorders) for mood. A consult for psychological evaluation had been initiated. 9/9/22 4:29 P.M.: New order to increase haloperidol to 2 milligrams (mg) at bedtime by the psychiatrist, for psychosis/agitation. 9/25/22 6:05 A.M.: Resident anxious, hand wringing, paces, had prancing in place foot movements, wanders into other's rooms, tearful, took sink apart in room, took air conditioner cover off, turned furniture over. 9/26/22 at 5:29 P.M.: Resident was seen by the psychiatrist. New order to add haloperidol 1 mg at 8:00 A.M. and 12:00 P.M., then take haloperidol 2 mg dose at bed time. 9/29/22 at 5:20 P.M.: Nurse went to check on patient to collect blood glucose. The patient was found on the floor, wobbly and trying to get up. This nurse notices bleeding coming from left arm with a big hematoma (a collection of blood outside of blood vessels). Hematoma also noted to right side forehead and new skin tear noted to right forearm. Patient was unable to give a description as to what happened due to history of dementia per baseline. Physician notified and order to transfer to emergency room . 9/29/22 9:17 P.M.: Spoke with nurse at local hospital. Hematoma to forehead. CT scan (medical imaging technique used to obtain detailed internal images of the body) and x-ray (painless test that produces images of the structures inside the body), are all negative, will return to the facility, no new orders. 10/8/22 6:16 P.M.: This writer attempted to stick this resident's finger for a glucose reading. The first attempt, the resident became agitated and started swinging at the writer and trying to push the writer away. The second attempt, the resident again became agitated and started swinging and pushing the writer away. Last attempt was made and behavior had not changed. 10/9/22 1:00 P.M.: Resident had an episode where he/she was attempted to come behind the desk. When redirected, he/she became angry/aggressive and said what the fuck are you doing and I'll knock the shit out of you. 10/11/22 8:50 P.M.: Resident was reported by Resident #3 that the resident hit Resident #3 in the face and pushed him/her to the floor because he/she told Resident #1 to get out of the roommate's bed. Resident #1 was found in his/her own bed. He/she had short and long term memory deficits and does not recall what happened. Received order to send out to emergency room for change in mental status. 10/12/22 4:16 A.M.: Resident got up from resting in bed at approximately 3:45 A.M. and took his/her television from the stand in the room and put it on his/her bed. Resident also took mattress from the other bed in the room and put it on the floor in the room. Resident denied pain. Resident was given food and resident ate. This nurse went to another hall and requested for a second certified nurses assistant (CNA) to come and do 1 on 1 observation with the resident. 10/12/22 8:38 A.M.: Social Services Note: This writer attempted to meet with the resident to discuss events from the night before. Resident appeared to lack insight and judgement into the events of the previous night. This writer spoke with the staff on the floor and they said that resident appears to be in no distress surrounding the events of the previous night. 10/17/22 6:50 A.M.: The resident had mattresses off the beds, blinds are broken, food on the floor and under bed. Chair is across the room. Staff put mattress on bed and resident laid down and went to sleep. Review of the resident's comprehensive care plan, dated 10/18/22, showed: -Resident had a behavior problem: removes clothing, wanders, urinates on doors, exit seeking, wanders into peers rooms/sleeps in peers beds, tears up room, combative, yells/curses at staff, tries to go behind nurses desk, physical aggression toward female peer/pushed her down, removes television from stand and puts mattress on the floor, refuses to be toileted/brief change/combative with cares, delusions, breaks blinds/rearranges room/puts food on the floor. -The resident will have fewer behaviors by review date. -10/11/22: Sent to emergency room for evaluations due to aggression/mental status change; returned with no new orders. -Administer medication as ordered. -Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. -Do cares with 2 people assist due to combativeness with cares. Offer food and drink to attempt to redirect. -Explain all procedures to the resident. -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternative location as needed. -Redirect when he/she attempts to enter other's rooms. -Resident required assist to find the bathroom. When resident was taking clothes off and wandering around, ask if the resident needs to use the toilet. Review of the resident's behavior intervention report showed: -The report asks what interventions were attempted when a behavior is noted. -10/1/22 4:04 A.M.: No interventions attempted. -10/2/22 3:51 A.M.: No interventions attempted. -10/2/22 12:04 P.M.: No interventions attempted. -10/2/22 11:17 P.M.: Provided Calm Environment, improved. -10/3/22 10:43 A.M.: Redirect, improved. -10/4/22 11:52 A.M.: Redirect, improved. -10/4/22 4:25 P.M.: No interventions attempted. -10/5/22 2:22 A.M. No interventions attempted. -10/5/22 1:13 P.M.: Redirect, unchanged. -10/6/22 4:46 A.M.: No interventions attempted. -10/6/22 10:22 A.M.: Redirect, improved. -10/6/22 10:29 P.M.: Provided Calm Environment, unchanged. -10/7/22 3:59 A.M.: No interventions attempted. -10/7/22 1:24 P.M.: Redirect, unchanged. -10/8/22 3:27 A.M.: No interventions attempted. -10/8/22 1:45 P.M.: Provided Calm Environment, unchanged. -10/9/22 9:18 A.M.: No interventions attempted. -10/10/22 4:28 A.M.: No interventions attempted. -10/10/22 10:36 A.M.:No interventions attempted. -10/11/22 12:43 P.M.: No interventions attempted. -10/12/22 4:46 A.M.: Redirect, improved. -10/12/22 10:43 A.M.: No interventions attempted. -10/13/22 4:56 A.M.: No interventions attempted. -10/13/22 9:55 A.M.: Redirect, unchanged. -10/14/22 4:41 A.M.: Redirect, unchanged. -10/14/22 11:27 A.M.: Redirect, unchanged. -10/15/22 11:23 A.M.: No interventions attempted. -10/16/22 6:17 A.M.: No interventions attempted. -10/16/22 11:02 A.M.: Redirect, improved. -10/17/22 4:45 A.M.: Removed from Situation, worsened. -10/17/22 7:17 A.M.: No interventions attempted. -10/17/22 9:05 P.M.: No interventions attempted. Observation of the Resident #1 on 10/18/22 at 10:52 A.M., showed: -The resident was awake, standing near the bed in his/her room. No staff are present. The resident has bruising to the right side of the face and forehead, fading to a yellow color. 2. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Understands others and was able to make self understood. -Experiences delusions. -Scored 14 on BIMS. This score indicates intact cognitive abilities. -Required supervision with activities of daily living, including bathing, dressing, toileting and personal hygiene. -Diagnoses of dementia with behaviors, osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes.) Review of the resident's progress notes, dated 10/11/22 at 9:02 P.M., showed: - Certified Medication Technician (CMT) reported that the resident was found on the floor. The resident reported that another resident hit him/her and pushed him/her to the floor. The resident stated that he/she yelled at Resident #1 to get out of Resident #3's roommate's bed. Resident #1 got up from the roommate's bed and hit Resident #3 and pushed him/her to the floor. The resident complained of right hip pain and had an abrasion with a hematoma above the right eye. The resident's right leg had external rotation noted. Resident was sent to the emergency room for evaluation and treatment. Review of the resident hospital record, dated 10/13/22, showed: -X-ray of the right hip showed a fractured femur. -The resident had been evaluated by the orthopedic surgeon and will be having surgery this afternoon to repair the fractured hip. During an interview on 10/18/22 at 1:45 P.M., the resident's family member said: -The resident did well in surgery. -The resident is discharging from this facility to a different facility nearer the family. -The family member said that he/she only knew other resident pushed Resident #3 down, resulting in the broken hip. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Rarely/never understands others, rarely/never makes self understood and had hearing impairment. -Scored 4 on BIMS. The score of 4 indicates severely impaired cognitive skills. -Behaviors were present, including physical, verbal, and behavior not directed at others. This includes rejection of care, striking out at staff. -Required extensive assistance with all activities of daily living, including dressing, bathing, toileting, and personal hygiene. -Received antipsychotic, antianxiety, antidepressant medication 6 out of 7 days of the week. -Diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the resident's baseline care plan, dated 8/12/22, showed: -admitted diagnosis was Vascular Dementia. -Reason for admission was aggressive behaviors and inability to remain in current situation. -Resident was confused/disoriented. He/she was easily distracted, experiences restlessness, wanders, and was abusive/resistive to care. -No interventions listed on the base line care plan for the residents aggressive behaviors. Review of the resident's August through October progress notes showed: -8/12/22 9:55 P.M.: The resident refused a physical assessment by the nurse. He/she attempted to strike the nurse when the nurse attempted to conduct a TB test (a test performed by injecting a small amount of fluid (called tuberculin) into the skin on the lower part of the arm to test for tuberculosis, a potentially serious infectious disease that mainly affects the lungs). The resident liked to sit on the floor and will not get up. The resident did not like to take showers. He/she did have aggressive behaviors, difficult to redirect. He/she had attempted to go in other resident's room and attempting to fidget with items on the nurse cart. -8/13/22 5:12 A.M.: Resident had been in others rooms all night, wanders, very difficult to redirect, takes things from others, been aggressive with others, attempted to kick other residents. During redirection, he/she kicked staff in the left leg and in the abdomen, and punched left side of jaw. -8/15/22 9:05 A.M.: Resident refusing to put clothes on. When CNA attempted to assist the resident, he/she became upset and shouting. -8/15/22 3:17 P.M.: Resident was becoming increasingly agitated after lunch. Resident removed his/her shoe and began to charge another resident. Staff were able to intervene before any contact was made. Staff attempted to redirect resident to his/her room and give a snack. Resident became angry and called the nurse a fucking bitch and charged at the nurse. No contact was made. The nurse had staff stay with the resident while the nurse spoke with the assistant director of nursing (ADON), who contacted the physician. An order for haldol injection 2 mg every 6 hours as needed for psychosis and aggression. This nurse was assisted by staff and the injection was given in the resident's left buttock. Resident continued to act out and walk through he/she halls. 8/18/22 10:29 A.M.: Resident was agitated and refusing care. He/she was on the floor and refused to get up. 8/18/22 1:47 P.M.: Resident had remained on the sofa in the dining room since before the shift started, sleeping off/on. Staff has attempted to get him/her to go to his/her bedroom. Resident became aggressive and verbally stated I will beat the crap out of you. Staff were instructed to leave him/her alone. 8/18/22 9:46 P.M.: Resident fell while trying to swing arms and hands out at staff. fell on left side. Resident had skin tear on right forearm. Continued to be combative on the floor and refused assessment. Staff cleaned skin and got resident up from the floor. Resident continued to refuse vital signs the tells staff to get away. 8/19/22 9:19 A.M.: Resident up and out of his/her room at this time. Clothing was wet with urine. He/she was hostile and would not be redirected. Told staff I will knock you the fuck out and was aggressive and combative. When told clothing needed to be changed, he/she walked away into other resident's room and got into the other resident's bed. Staff members were collected and were able to get the resident into the shower and changed. He/she was trying to hit and kick staff. Resident also refused to take meds and haldol injection was given. 8/20/223 7:35 P.M.: Resident was in another resident's room, laying in a bed, when staff approached to help him/her up, the resident became combative and made a close fist and started chasing staff to try and hit them. Staff walked away and left this resident for ten minutes to give a time to calm down. Staff approached this resident again and tried to help him/her up from the bed. Resident started pulling the staff's hair and hit them in the face. ADON was contacted and haldol injection was given. 8/20/22 8:37 P.M.: Staff attempted change bandage and clean wound, but the resident refused and tried to knock the staff down. Staff waited until the resident was ready for bed and tried again but there was no change. 9/1/22 6:22 P.M.: The resident was seen going into a female resident's room, trying to shut the door behind him. The nurse redirected the resident with a struggle to his/her room. Moments later the resident was seen going into several different resident's rooms, moving furniture in and out of rooms. Nurse tried to redirect the resident but it was ineffective. The resident seemed agitated and anxious. The nurse administered haldol. 9/1/22 9:53 P.M.: Nurse was in a resident's room when the nurse heard screaming. Staff started opening resident doors and found the resident in another resident's room in bed with another resident. He/she was not attacking the other resident nor did he/she appear aggressive. The other resident reported Resident #2 came into the room shut the door and approached the bed. Resident #2 called the other resident a name and started punching at the other resident. Resident #2 could not reach the other resident as the bed side table was in the way. He/she moved the bed side table and hit the other resident in the face. Resident #2 was escorted from the room. When the nurse manager approached Resident #2, he/she was shaking the central bathroom door and picking at the seams in the wall. He/she did not appear to be aggressive. The other resident was assessed and had not signs or symptoms of injury. Resident #2 was placed on constant observation. 9/2/22 1:31 P.M.: The resident was sent out per the Director of Nursing (DON) request to be re-evaluated due to increased agitation and aggression towards staff and residents. 9/2/22 6:03 P.M.: Staff spoke to nurse at the psychiatric unit and faxed requested information. The emergency department was continuing to look for psychiatric placement. 9/2/22 6:37 P.M.: Psychiatrist was informed of resident's increased aggression and outbursts and that the resident was sent to the emergency department with intentions for an evaluation and placement. In the event the resident was readmitted to the facility, the psychiatrist gave orders to increase haldol and the psychiatrist will see the resident when he/she returns. The resident was currently being held in the emergency room , who states psychiatric placement was still being sought. 9/2/22 9:47 P.M.: Nurse called the local emergency room to check the status of the resident. Informed that he/she was still in the emergency and placement was still being sought. 9/4/22 4:37 P.M.: Received call from nurse with the local emergency room . Stated the resident remained in the emergency room the entirety of the stay and was assessed by the psychiatric department several times. Resident was found to be safe to to return to the facility. No medication changes were reported. 9/4/22 6:28 P.M.: Resident returned to the facility. 9/9/22 4:46 P.M.: Seen by psychiatrist. Increased order for haldol for psychosis and aggression. 9/11/22 8:15 P.M.: When staff tried to give this resident medication, the resident grabbed the staff's arm and pulled the staff's hair. Staff was able to break free from the resident's grip, the resident then balled up a fist and stated he/she was going to knock the staff out. Staff gave the medication to the charge nurse. Charge nurse attempted to give the medication to the resident, who became aggressive again. 9/15/22 5:46 A.M.: Resident was covered in feces. Fighting, hitting, kicking at staff, would not let staff help. Given haldol injection. 9/18/22 4:05 P.M.: Staff attempted to give resident care, he/she had feces all over pants. Staff explained the care they were about to give this resident and the resident responded okay. As soon as staff went to assist the resident, he/she became agitated and started swinging at staff with a closed hand. Staff walked away and tried again in 10 minutes but the resident then pushed staff and hit staff with closed hand and pulled hair of staff member. Haldol was given. 9/21/22 1:06 P.M.: Resident observed wandering, going in and out of other resident's rooms, rummaging in other's belongings. 9/26/22 7:46 P.M.: The resident was demonstrating aggression and pushed another resident resulting in an injury to the other resident. 10/14/22 5:45 P.M.: While feeding this resident, resident yelled, grabbed styrofoam container on lap and swinging arm agitated with this staff. Review of the resident's comprehensive care plan, dated 9/28/22, showed: -Resident to resident, Resident #2 was aggressor. 9/26/22 Resident pushed another resident. Attempt to engage resident in activities to keep occupied. Medication as ordered. Psychiatry evaluation pending. Check on resident every 15 minutes for 24 hours. Frequent monitoring for location and behaviors. -Resident has behavior problem related to vascular dementia. Attempts to hit/kick staff and peers. No boundaries with other's personal space. Delusional. Removes clothes and comes out in hallway. Becomes physically and verbally aggressive with cares. Charges at staff and peers, attempts to hit. Removes silver sewer covers and peels wallpaper from walls. Places self on floor. Increased depakote. Order for haldol. Administer medications as ordered. After altercations, placed on close observation. Anticipate and meet resident's needs. Approach in a non-confrontational manner. Explain all procedures to the resident before starting. Face resident when speaking to. Hears better in left ear. Divert attention. Remove from situation as needed. Perform cares with 2 people. Provide a program of activities. During an interview on 10/18/22 at 11:03 A.M., Licensed Practical Nurse (LPN) A said: -Resident #1 was no longer on one to one supervision. Observation was lifted the evening of 10/15/22. There was no other monitoring in place for the resident, but LPN A tries to keep an eye on the resident. -The resident was declining physically and acts like he/she was scared. LPN A had been observing this since the resident's recent fall with head injury. LPN A had noticed increased difficulty walking and talking, and seems more scared and paranoid. -The physician has evaluated the resident and recommended palliative care/hospice. The wife was still trying to decide on a hospice company. -LPN A was not working the day the resident pushed another resident to the floor. Prior to the resident's fall, LPN A had not observed any aggression in the resident toward others. -LPN A had received training on working with residents with dementia and behaviors. This was in March 2022 when he/she was hired. He/she also received training last week, conducted by the DON, about approaching a resident. -LPN A is unsure that the resident can be cared for appropriately in the facility due to his/her behaviors. LPN A had never taken care of a resident with similar behaviors of Resident #1. -Resident #2 was brought back to the unit by the former administrator and DON, who instructed staff to watch due to the resident being exit seeking. They failed to mention to the staff that the resident was very aggressive towards staff and other residents. -Staff could not approach Resident #2 quickly, the resident did not understand what the staff was saying or what they wanted him/her to do; -Resident #2 was severely cognitively impaired, he/she did not understand what you were saying to him/her; -Resident #2 would get very agitated and was physically aggressive towards staff and other residents; - On 9/26/22 Resident #2 went into another residents room and when that resident told him/her to get out, he/she pushed the other resident down causing a laceration to the other residents forehead, the other resident went to the hospital and received sutures; -The staff was afraid of Resident #2, you did not know what he/she was going to do. During an interview on 10/18/22 at 2:00 P.M. Certified Nurse Aide (CNA) A said: -Resident #2 would try to hit staff when you attempted to change him/her or redirect him/her; -He/she was aggressive towards other residents; -He/she had not received any special training on how to deal with residents with aggressive behaviors; -He/she would try to redirect the residents and notify the charge nurse if this did not work. During an interview on 10/18/22 at 2:30 P.M., the Social Services Director (SSD) said: -He/she does not have a role in the pre-admission process for a resident; -He/she does not prescreen the residents for any behaviors; -Residents who do have behaviors with be discussed in the Risk Management Meetings to discuss the behaviors and will put interventions on the care plans; -The Risk Management team will discuss the effectiveness of the interventions; -If a behavior was severe enough, the resident will be put on one on one observations; -He/she was unsure who determines when the resident comes off the one on one observations; -He/she has not provided any special in-servicing for the staff on resident behaviors, one hospice provider had given some education on how to deal with resident behaviors. During an interview on 10/18/22 at 4:23 P.M., the Administrator and DON said: -The staff should be receiving continuing education on dementia, including at orientation, annually, and as needed. If a resident has increased behaviors, additional education should be provided to staff. -Evaluation of staff's understanding of the education can be difficult due to the particular behaviors and how often the behaviors occurred. -The DON has dementia education resources and plans to provide ongoing education to staff. -The DON expects staff to approach residents in a calm manner and distract with activities. -The facility is working on having consistent staff on the locked unit. MO207573 and MO208484

Based on observation, interview, and record review, the facility failed to prevent significant medication errors when they failed to correctly administer dilantin (a medication used to treat and prevent seizures) for one sampled resident (Resident #1). The facility census was 78. Review of the facility's undated Medication Administration policy, showed: -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. -10. Review Medication Administration Record (MAR) to identify medication to be administered. -11. Compare medication source (bubble pack, vial, etc.) and MAR to verify resident name, medication name, form, dose, route, and time. 1. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment performed by staff, 5/11/22 showed: -The resident understands others and is able to make self understood. -He/she scored seven on the Brief Interview for Mental Status (BIMS) a structured evaluation aimed at evaluating aspects of cognition in elderly patients. This score indicates severely impaired cognition. -Diagnoses of convulsions (general term used to describe uncontrollable muscle contractions), dementia without behaviors, myocardial infarction (commonly known as heart attack, is caused by decreased or complete stopping of blood flow to a portion of the heart), cerebral infarction (referred to as a stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of the resident's Physician Orders Sheet (POS), dated May 2022, showed: -5/1/2022-5/25/2022 Dilantin Suspension (Phenytoin) 125 Milligrams (mg)/5 milliliters (mL). Give 1.2 mL by mouth two times per day for seizures. -5/25/2022-5/31/2022 Dilantin Suspension 125 mg/5 mL. Give 60 mg orally two times per day for seizures. - An order on May 25 to draw a dilantin level in 1 week. Review of the resident's Medication Administration Record (MAR), dated May 2022, showed: -5/1/2022- 5/25/2022 Dilantin Suspension 125 mg/5 mL (Phenytoin) Give 1.2 ml by mouth two times a day for seizure. It was initialed as given. -5/25/2022- 5/31/2022 Dilantin Suspension 125 mg/5 mL (Phenytoin) Give 60 mg orally two times a day for seizure. It was initialed as given. Review of the resident's POS, dated June 2022, showed: -6/1/2022-6/3/2022 Dilantin Suspension 125 mg/5 mL. Give 60 mg orally two times a day for seizures. -6/3/2022-6/13/2022 Dilantin Suspension 125 mg/5 mL. Give 120 mg orally two times per day for seizures. -6/13/2022-6/30/2022 Dilantin Suspension 125 mg/5 mL. Give 250 mg by mouth two times per day for seizures. Review of the resident's MAR, dated June 2022, showed: -6/1/2022-6/3/2022 Dilantin Suspension 125 mg/5 mL (Phenytoin) Give 60 mg orally two times per day for seizure. It was initialed as given. -6/3/2022-6/13/2022 Dilantin Suspension 125 mg/5 mL (Phenytoin) Give 120 mg by mouth two times per day for seizure. It was initialed as given. -6/14/2022-6/30/2022 Dilantin Suspension Give 250 mg by mouth two times a day for seizure. It was initialed as given. Review of the resident's physician's orders, dated 7/15/2022, showed: -Dilantin Suspension (Phenytoin) Give 250 mg by mouth two times a day for seizure, start date of 6/14/2022. Review of the resident's MAR, dated July 2022, showed: -7/1/2022-7/17/2022 Dilantin Suspension (Phenytoin) Give 250 mg by mouth two times a day for seizure. Review of the resident's MAR, dated July 2022, showed dilantin initialed as given. Review of the resident's lab reports from November 2021 to July 2022 showed: -11/3/2021 Less than 2.5 ug (micrograms)/mL. (Dilantin level reference range (normal values) is 10-20 microgram/milliliter (ug/mL). No changes noted in the dosage of dilantin. -5/25/2022 Less than 2.5 ug/mL, with a new order on 5/25/2022 to draw dilantin level, recheck in one week. -6/1/2022 Less than 2.5 ug/mL with orders received on 6/3/22 to increase dilantin to 120 ml BID (twice a day). -6/14/2022 Dilantin level of 7.1 ug/mL. Orders from the hospital to increase the dilantin to 250 mg BID. Record review of the resident's progress notes, dated 7/17/2022 showed: -The physician was notified of the resident's seizure activity. The physician gave the order to send to the emergency room (ER) for evaluation and treatment. Review of the local hospital medical records dated 7/17/22 showed: -This resident with a history of seizure disorder presented from the nursing home for evaluation of seizure activity. The resident has a known history of seizure disorder and has had multiple admissions this year for breakthrough seizure activity. Upon arrival to the ER he/she was found to have active seizure activity. His/her dilantin level was checked upon admission and was undetectable. -Neurology consultation has been requested. It is unclear at this time if he/she is actually been receiving his/her antiepliptic (seizure) medication from the nursing facility given his/her undetectable dilantin level. He/she was given a dose of IV (intravenous) Keppra (a medication used to treat seizures) and dilantin in the ER. Review of the lab results for Dilantin completed in theER on [DATE] showed a dilantin level of 5 ug/mL with the normal range of 10-20 ug/mL. Observation of the Home Bound Unit (HBU) medication cart on 7/18/2022 at 2:03 P.M., showed: -One bottle Dilantin 8 fl oz (237 mL) (Phenytoin) 125 mg/5 mL, dated 6/10/2022: Give 4.8 mL (120 mg) orally BID. Further observation showed there were no notations on the bottle to show the order had changed. -The bottle was approximately half full. During an interview on 7/19/2022 at 1:00 P.M. Pharmacist B said: -He/she was employed by the facility's previous pharmacy. -The resident's dilantin was filled on 6/10/2022. -If it was being administered as ordered, there were 24 days of medication in the bottle. -The dilantin should have been refilled approximately 7/4/2022. During an interview on 7/19/2022 at 9:57 A.M., Pharmacist A said: -This pharmacy started with the facility on 7/1/2022. -If the dilantin had been given as ordered, there were 24 days of medication the resident's bottle of dilantin. -The bottle should have been refilled around 7/4/2022. During an interview on 7/18/2022 at 2:03 P.M., Certified Medication Technician (CMT) A said: -He/she passed medication to the resident while he/she was living on the HBU. -The resident's bottle of dilantin was in the medication cart. -The bottle was received and opened on 6/10/2022. -When administering medication, he/she follows the order that's on the bottle. During an interview on 7/18/2022 at 3:15 P.M., Licensed Practical Nurse A said: -When passing medication, staff should follow the order on the MAR. -The order on the bottle of medication and the order on the MAR should match. -If the two orders do not match, staff should clarify the order with the physician or pharmacy. -If the order on the bottle has changed, staff should write a note on the bottle. -Staff should also make a note on the bottle when it was opened. During an interview on 7/18/2022 at 3:25 P.M., Registered Nurse A said: -He/she cared for the resident while he/she resided on Maple hall. The resident tested positive for Covid and moved the HBU/Covid unit on 7/11/2022. -The resident was receiving dilantin while on Maple. -Sometimes the order on the bottle of dilantin would not match the MAR because the order for dilantin would change. -RN A looked in the medication cart, medication room, and nurses station and there were no additional bottles of dilantin for the resident. During an interview on 7/19/2022 at 7:35 A.M., CMT B said: -When passing medication, the CMT should follow the order on the MAR, not the order on the bottle. -If the order changes, staff should make a note on the bottle with the new order. During an interview on 7/19/2022 at 1:38 P.M., the Director of Nursing said: -When administering medication, staff should always follow the order on the MAR. -If the order on the container of medication did not match the order on the MAR, staff should clarify this with the charge nurse or physician. During an interview on 7/21/2022 at 1:18 P.M., the physician said: -He was not aware the resident had not been receiving the correct dose. He should have been notified if the staff had not been administering the correct dose. -The physician was aware that the resident had ongoing seizure activity. MO204100

Based on interview and record review, the facility failed to ensure residents are free from sexual abuse, when four residents (Resident #1, #2, #3 and #4), who are alert and oriented and independent with care, reported that the nurse would touch and rub their genitals using the excuse of providing incontinent care and treatments. The resident's reported that the actions of the nurse made them feel very uncomfortable and they felt violated. The facility census was 100. The Administrator was notified on 1/5/22 at 2:00 P.M. of an Immediate Jeopardy (IJ) which began on 1/2/22. The IJ was removed on 1/6/22 as confirmed by surveyor onsite verification. Review of the facility policy, dated 2021, on abuse, neglect, and exploitation showed: - The facility would provide protection for the health, welfare and the rights of each resident to prohibit and prevent abuse, neglect, and exploitation. - Defined abuse as willful infliction of injury and included sexual abuse. - Willful was defined as acting deliberately. - Sexual abuse was defined as non-consensual sexual contact of any kind with a resident. 1. Review of Resident #1's care plan, dated 11/18/21, showed: - The facility had the right to protect the resident's health and welfare. - The resident self-toileted. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/19/21, showed: - Cognitively intact; - Required supervision for cares; - Always continent of bladder and bowel; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 1/4/21 at 3:00 P.M., the resident said: - One night he/she was in the bathroom. - He/she did not call for help. - Licensed Practical Nurse (LPN) A came into the bathroom. - He/she had never seen LPN A before. - He/she said LPN A only did perineal (peri) care for male residents. - LPN A did not knock on the bathroom door and did not introduce him/herself. - LPN A took all the resident's clothes off and left him/her naked. - LPN A then said he/she was going to get wet wipes. - LPN A told the resident he/she had fecal matter on his/her balls. - LPN A told the resident he/she was going to look for shaving cream to clean the resident. - LPN A sprayed shaving cream on the resident's penis. - LPN A repeatedly stroked the resident's penis and gave up when the resident's penis did not get hard. - LPN A told the resident to get into bed without providing any clothing. - LPN A came back to the resident's room about an hour later. - LPN A patted the resident's penis and said okay. - LPN A made him/her very uncomfortable. - He/she reported the issue to a staff member who reported the issue to the Administrator (ADM). Review of the facility investigation, dated 1/4/22, by the ADM interviewing the resident showed: - The resident was in the bathroom. - LPN A asked the resident what was going on. - The resident told LPN A he/she was having diarrhea, but could handle it. - LPN A removed the resident's shirt and pants and said they were soiled. - LPN A started to clean the resident with wipes. - LPN A left the room and came back with shaving cream. - LPN A went too far, he/she rubbed the shaving cream on my butt, my penis, my balls, and my pubic hair. - LPN A put the resident in bed naked and covered him/her with a blanket. - LPN A returned a little later and said you're back in bed. - LPN A patted the blanket over the resident's penis and made him/her very uncomfortable. - LPN A told the resident he/she only liked to do peri-care on the male residents. 2. Review of Resident #4's admission MDS, dated [DATE], showed: - Cognitively intact; - Required supervision for cares; - Continent of bowel and bladder; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's care plan, dated 11/16/21, showed: - The resident had the right to privacy. - The resident was able to self-toilet. Review of the facility's investigation of the resident on 1/4/22 by the ADM showed: - LPN A came into the resident's room around 3:00 A.M. - LPN A woke up the resident and said he/she needed to fix the resident's bed, because the resident was laying wrong. - The resident sat up on the side of his/her bed. - The resident was wearing boxers and no shirt with a blanket covering his/her lap. - LPN A grabbed the wipes and brought them to the bedside table. - LPN A kept grabbing at the blankets and tried to grab at the resident. - The resident said I don't know what you are doing, but I want you to get out of my room right now. - LPN A washed his/her hands and left the room and did not return. During an interview on 1/5/22 at 9:25 A.M., the resident said: - LPN A woke him/her during the middle of the night. - He/she did not put on his/her call light. - LPN A said he/she did not like the way the resident was sleeping. - The resident said he/she normally slept with his/her knees outside the bed. - He/she had never fallen out of bed. - LPN A grabbed his/her blanket. - LPN A walked over to the sink after removing the resident's blanket and put wipes on the sink. - LPN A washed his/her hands. - LPN A grabbed the resident's knees. - The resident told LPN A he/she made him/her uncomfortable. - LPN A told the resident he/she seemed anxious and needed medication for anxiety. - The resident said he/she did not need anything. - LPN A then left the resident's room. 3. Review of Resident #2's care plan, dated 11/29/21, showed: - The resident required staff assistance of one for toileting. - The resident had a urinary catheter (a sterile tube inserted into the bladder to drain urine) and required catheter care. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Independent for cares; - Always continent of bowels; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility investigation, dated 1/4/22, by the ADM showed: - The resident stated he/she had a spastic bladder. - LPN A came to clean him/her up. - LPN A kept rubbing the resident's penis to clean it and rubbed it so much it was irritated. During an interview on 1/5/22 at 9:55 A.M., the resident refused to speak to the investigator. 4. Review of Resident #3's care plan,dated 5/13/21, showed: - The resident was dependant upon staff due to cognitive issues. - The resident self-toilets. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively impaired; - Independent or required supervision only for cares; - Always continent of bowel and bladder; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility investigation, dated 1/4/22, by the ADM showed: - LPN A made the resident uncomfortable. - LPN A woke him/her in the middle of the night and gave the resident a bath. - LPN A made the resident feel uncomfortable. During an interview on 1/5/22 at 10:00 A.M. the resident said: - LPN A woke him/her up in the middle of the night. - LPN A removed his/her clothing. - The resident had an infection on their penis. - LPN A treated the infection with a physician ordered cream. - LPN A made the resident feel uncomfortable. 5. During an interview on 1/5/22 at 10:30 A.M., Certified Nurse Assistant (CNA) A said: - He/she worked with LPN A. - LPN A performed peri care on only male residents that did not require peri care. - LPN A made him/her feel very uncomfortable. - He/she reported the issue to the ADM. During an interview on 1/11/22 at 7:10 A.M., LPN B said: - Staff reported to him/her that Resident #1 told him/her that LPN A inappropriately touched the resident. - He/she immediately reported the incident to the ADM. During an interview on 1/6/22 at 10:00 A.M., the ADM said: - As soon as the issue was reported to him/her, he/she ensured that residents were safe. - He/she ensured LPN A was not in the facility. - He/she notified the staffing coordinator that LPN A was not allowed in the building pending investigation. - He/she called the staffing agency and explained the allegations and stated that LPN A was suspended pending investigation. - He/she called the police and reported the issue. - He/she called the Elder Abuse hotline. - He/she called the Missouri Board of Nursing. - After thorough investigation, he/she banned LPN A from the facility permanently. During an interview on 1/6/21 at 10:30 A.M., LPN A said: - He/she would never inappropriately touch a resident. - He/she provided pericare for residents needing pericare. - Residents asked him/her for pericare. - Resident #4 was in danger of falling out of bed. - He/she repositioned the resident to prevent a fall. - He/she asked a resident if he/she needed a shower and provided the shower. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, 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 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 to be taken to address Class I violation(s). MO 1

Based on observation, interview, and record review, the facility failed to ensure residents received adequate assistance devices to prevent accidents. The facility to ensure staff identified a bariatric resident who was unable to safely be evacuated from the facility in the event of an emergency (Resident #71), when the facility did not have a mechanical lift rated to safely transfer the resident. The facility census was 104. The Administrator was notified on 12/15/21 at 4:16 P.M. of an Immediate Jeopardy (IJ) which began on 9/22/21. The IJ was removed on 12/16/21 as confirmed by surveyor onsite verification. A review of the facility policy of Care and Treatment of Bariatric Residents, dated 11/1/21, showed: -Bariatric residents have special needs. This facility will provide the necessary care and treatment that allows the bariatric resident to remain safe and attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. This policy also includes safety precautions for the caregiver to prevent injuries that may compromise the facility's ability to provide quality care. 1. Facility staff will identify equipment needs of the bariatric resident during the pre-screening and admission process. Equipment will be available upon admission for providing for the immediate needs of the resident. 2. The comprehensive assessment process will be utilized for identifying additional equipment needs. A person-centered care plan will be developed, based on specific factors identified in assessments and physician orders, and in accordance with the resident's goals and preferences. 3. Considerations for equipment needs include, but are not limited to: a. A bed in which the dimensions are appropriate for the resident's size and weight. b. Wheelchairs and other mobility aids. c. Resident lifts that can accommodate resident's size and weight. d. Shower chairs or commodes. e. Aids to facilitate safe bed mobility, such as ergonomic turn sheets and limb slings. 4. Facility staff will treat bariatric residents with dignity and respect. 5. Care will be provided with the number of staff needed to ensure safety of the resident and the staff. To promote dignity and respect, safety shall be the emphasis, not the resident's weight. 7. All employees are responsible for following established policies and procedures regarding the care and treatment of bariatric residents, and the appropriate use of mechanical devices for safe resident handling. Review of the facility's undated Emergency Preparedness policy regarding bariatric patients showed: -For the purpose of evacuation, a bariatric resident will be lowered from the bed, using a bedsheet, to the floor. The staff will then pull the bariatric resident to safety using the bedsheet. 1. Review of facility's weight summary showed Resident #71 weighed 4/1/21 439 pounds (lbs); - 5/7/21 477 lbs; - 6/7/21 489.6 lbs; - 7/1/21 488 lbs; - 8/10/21 494 lbs; - 9/22/21 509.8 lbs. Review of the resident's progress note, dated 9/22/21 at 3:43 P.M., showed: Restorative Aid (RA) A noted the resident had maxed weight limit for mechanical lift. Unable to safely weigh moving forward. Admin notified of issue. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandataed assessment tool, dated 10/27/21, showed: -Cognitively intact; -Extensive to total assistance with Activities of Daily Living (ADL), including dressing, bed mobility and bathing; -Limited Range of Motion to both upper extremities and both lower extremities; -No weight was recorded. Review of the resident's care plan, dated 11/3/21, showed: -Required assistance of 2 staff with bathing/showering twice weekly and as needed, using Hoyer lift. -Required a mechanical lift Hoyer with 2 staff assistance for transfers. Uses wheelchair propels self. -There were no problems or approaches addressing the resident's weight had exceeded the lift capacity and cannot be transferred from the bed. Observation on 12/14/21 at 9:37 A.M., showed the resident lying in bed, wearing hospital gown. His/her lower legs and feet appeared swollen and red with visible dry, flaky skin. During an interview on 12/14/21 at 9:37 A.M., the resident said: -He/she had not left the bed since August, as there was not a lift in the facility that can handle the resident's weight. -He/she would like to shower, but he/she cannot get out of bed. -The facility had given him/her a wheelchair to use, but he/she can't use it because it was not big enough and hurt to use it. -When asked how the facility would evacuate him/her during the event of an emergency, the resident said he/she wasn't sure and I'd guess I'd die. During an interview on 12/15/21 at 11:18 P.M., Certified Nurse Assistant (CNA) B said: -He/she was familiar with the resident. -He/she was unsure how the staff would evacuate the resident in the event of an emergency. He/she would unlock the breaks of the bed and push the bed out, if it fit through the door. -If the bed wouldn't fit through the door, he/she would use a Hoyer lift. -He/she was unsure what weight the lift was rated to. -CNA B reviewed the lift on the resident's unit. The sticker on the lift showed the lift was rated to 500 pounds. -CNA B said that there may be a higher rated lift elsewhere in the building, but was not sure. During an interview on 12/15/21 at 11:28 A.M., CNA D said: -The mechanical lift on the unit he/she worked on was rated to 450 pounds. -There may be a bigger bariatric lift somewhere in the building, but he/she was not sure. -He/she had worked with the resident a few times. -He/she was unsure if he/she had to evacuate the resident from the building how he/she would do so. During an interview on 12/15/21 at 12:57 P.M., Licensed Practical Nurse (LPN) B said: -If the resident needed to be evacuated from the facility, he/she would try to remove the bed from the room. -If the bed would not fit through the door, he/she is unsure how he/she would evacuate the resident, as there is no lift in the building rated for the resident's weight to safely transfer the resident. Observation of the resident on 12/15/21 at 2:10 P.M., showed: -Emergency Medical Services (EMS) were called to transfer to the resident to the hospital. -Six EMS responders were required to transfer the resident from bed to the ambulance stretcher. Observation of the the resident's room on 12/15/21 at 3:12 P.M., showed: -Bed frame width 48 inches; -Door frame width with the door on the hinges is 41.5 inches; -Door frame width without the door on the hinges is 43.5 inches. During an interview on 12/15/21 at 3:45 P.M., the Former Administrator said: -He/she was unaware there was not a lift in the facility that was not rated to safely transfer the resident. -If the resident did need to be evacuated from the facility, staff would need to call 911. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, 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 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 to be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for two of 24 sampled residents (Resident #84 and #88). Staff failed follow their policy for skin assessments and wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 104. Review of the facility policy for Wound Treatment Management dated 11/1/21 showed: -Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change; -In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse; -Treatment decisions will be based on: a. the etiology of the wound: pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage, surgical, incidental or atypical; b. the characteristics of the wounds; c. the location of the wound; d. goals and preferences of the resident/representation; -The facility will follow specific physician orders for providing wound care; -Treatments will be documented on the Treatment Administration Record (TAR); -The effectiveness of treatments will be monitored through ongoing assessments of the wound. The facility did not provide a policy for skin assessments. 1. Review of Resident #84's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff), dated 11/5/21 showed: -Unable to answer questions; -Extensive assistance of one staff for dressing, transfer, limited assistance of one staff member for walking, locomotion and dependent upon one staff member for personal hygiene; -Incontinent of bowel and bladder; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .); -At risk for pressure ulcers and no wounds marked. Review of the care plan for Diabetes Mellitus (DM) dated 5/17/21 showed in part: -Focus: the resident has DM; -Goal: the resident will have no complications related to DM through the review date with a revision date of 8/26/21; -Interventions/task: Inspect feet daily for open areas, sores, pressure areas, blisters, [CONDITION(S)] or redness; -Monitor/document/report as needed (PRN) any signs and/or symptoms of infection to any open area: redness, pain, heat, swelling or pus formation. Review of the weekly skin check dated 11/10/21 and 11/23/21 showed no wounds or open areas. Review of the medical record showed no weekly skin check for 11/17/21. Review of the bath sheets completed by staff dated 10/29/21 showed no wounds notes, 11/18/21 showed the resident refused. The facility was unable to provide any other bath sheets to show the resident received a bath or that nursing staff assessed the resident's skin. Review of the nurses notes dated 11/28/21 signed by Licensed Practical Nurse (LPN) B at 4:49 P.M. showed: -The resident's second toe on the right foot looks black and moist; -The right foot looks slightly swollen and red but not warm to the touch; -A black spot on the left toe was noted; -The resident appeared to have pain when providing care to the area. PRN Tylenol administered with effectiveness; -Notes faxed to the resident's physician. The Director of Nursing (DON) was aware. The family was notified. Review of the nurses notes dated 11/29/21 at 3:32 P.M., signed by LPN B, showed: -Physician was to order [MEDICATION(S)] (medication is used to treat a wide variety of bacterial infections) 500 milligrams (mg) four times a day (QID) for wound on second toe on the right foot. Review of the undated care plan for skin showed in part: -11/29/21: Focus: the right foot, second toe, is black/moist; there is a black spot on the toe on the left foot; -Goal: did not specify a goal for the areas to the feet; -Interventions/task: 11/29/21: the toe is to be cleaned with wound cleanser (WC) and Tylenol to be given for signs/symptoms of pain while treating the area. All parties were notified. Review of the physician's progress note dated 11/30/21 at 11:42 A.M. signed by Physician A showed: -Notified by nursing the resident had digital ulcers of the left foot. Examination of the right foot demonstrates the second toe has circumstantial dry gangrene (This type of gangrene involves dry and shriveled skin that looks brown to purplish blue or black. Dry gangrene may develop slowly. It occurs most commonly in people who have diabetes or blood vessel disease, such as atherosclerosis; is a dangerous and potentially fatal condition that happens when the blood flow to a large area of tissue is cut off. This causes the tissue to break down and die. Gangrene often turns the affected skin a greenish-black color.). Diminished capillary refill and cool, no odor, no discharge, no drainage. The duration is unknown, first documentation is 11/28/21. The resident is currently on [MEDICATION(S)] ( used to prevent heart attacks and strokes in persons with heart disease (recent heart attack), a recent stroke, or blood circulation disease, and [MEDICATION(S)] (used to lower cholesterol ) and weekly skin assessments. Review of the nurses notes dated 11/30/21 at 12:32 P.M. showed: -The physician came in to see the resident's toe on his/her right foot. The physician asked for the resident to be sent to the hospital for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Right foot is edematous (swelling) with mild redness and warm. Review of the nurses notes dated 11/30/21 at 10:04 P.M. showed: -Update on the resident's status at local hospital, the resident was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the hospital admission paperwork dated 11/30/21 showed: -Resident had a right foot wound. He/she was at a nursing home and they noticed his/her right second toe was black, two days ago; -Right, second toe appears ischemic (an inadequate blood supply to an organ or part of the body) in nature. Unable to assess pedal pulses (pulses found in the top of the foot); -X-ray results showed an infection in the second toe on the right foot; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Resident is not a candidate for surgical interventions at this time. Recommend conservative measures. Review of the nurses note, dated 12/7/21 at 3:48 P.M., showed: -The resident was readmitted to the facility from a local hospital. Spoke with nurse from the local hospital who said the resident had a CT (computed tomography scan - A procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body.) of the second toe of the left foot and no [CONDITION(S)] (inflammation of bone or bone marrow, usually due to infection.) was found. The resident was not a candidate for surgical amputation. New orders to cleanse the wound, apply [MEDICATION(S)], and then wrap the toe. Review of the the weekly skin check dated 12/8/21 showed: -Scabs to the left knee. Intact, dry dressing on the toes of the right foot. A scab from a blood blister on the fifth toe of the left foot. During an observation on 12/9/21 at 11:26 A.M. showed: -The resident lying in bed with his/her right foot wrapped with a Kerlix dressing. -LPN C removed the dressing to the foot; -The second toe to the right foot was black in color; -The resident moaned when the nurse removed the dressing and pulled his/her foot back. During an interview on 12/9/21 at 11:40 A.M. LPN C said: -He/she had only worked with the resident a couple of times, he/she does not normally work the hall where the resident resides; -He/she had not seen the resident's toe prior to this day. During an interview on 12/9/21 at 1:35 P.M., Certified Nurse Aide (CNA) A said: -He/she has worked the hall the resident lives on for about a month; -He/she had noticed the second toe on the right foot was black couple of weeks ago; -He/she reported this to a nurse, but he/she does not remember which nurse; -There is no place for CNA's to document when a resident has a skin condition. During an interview on 12/9/21 at 2:35 P.M., LPN B said: -He/she frequently works the hall the resident lives on; -He/she was the nurse who reported the black area on the second toe on the right foot to the physician on 11/28/21; -11/28/21 was the first time that the area was reported to him/her. During an interview on 12/10/21 at 10:18 A.M. the former Director of Nursing (DON) said: -He/she was unaware of the black area on the second toe on the right foot, until 11/28/21. During an interview on 12/10/21 at 12:42 P.M. LPN D said: -He/she had been the wound nurse several months ago, but resigned as he/she had not received any training and was being pulled to the floor to work as a nurse on the floor; -There is currently no wound nurse in the facility; -He/she was unaware of any skin issue for the resident, until the nurse found the area to the second toe on the right foot and the resident went to the hospital. -He/she is not aware of any other skin issues for the resident. Observation on 12/11/21 at 8:30 A.M. showed the resident slumped over in a dining room chair. A staff was attempting to arouse the resident. LPN D called for assistance and instructed the staff to call 911. Emergency medical services (EMS) arrived a few minutes later and the resident was transported to the hospital. Review of the hospital records dated 12/12/21 showed: -Resident has a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . History is limited due to the residents inability to communicate. Resident was minimally responsive with the nursing staff and he/she did not eat his/her breakfast which is unusual. He/she had a fever of 100 degrees. EMS was subsequently called. The resident was recently admitted to another hospital for a necrotic second digit of the right foot. He/she was deemed not a surgical candidate and was treated with IV (intravenous, an apparatus used to administer a fluid (as of medication, blood, or nutrients) intravenously) antibiotics and was discharged upon completion. -The resident appears to have a blister/wound to the left foot. The left fifth toe/lateral aspect (outer portion of the foot) shows skin loss with [CONDITION(S)] (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries). Tender to touch. -Hospital course: the resident was admitted for fever and altered mental status most likely due to [CONDITION(S)] (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin. If untreated, it can spread and cause serious health problems.) of the left foot. -Resident has [CONDITION(S)] (a disease in which the functioning of the brain is affected by some agent or condition (such as [CONDITION(S)] infection or toxins in the blood) most likely due to underlying infection versus worsening dementia Review of the medical record showed no documentation of the resident returning to the facility on [DATE]. Observation and record review on 12/13/21 at 8:43 A.M. showed: -A small dressing on the fifth toe on the left foot. There was a black area on the toe. The dressing was removed showing a small open area on the outer aspect of the fifth toe. The area was open with a scant amount of clear drainage. There was no documentation in the nurses notes of the open area and no documentation of the resident responsible party being not notified of the area. During an interview on 12/13/21 at 1:48 P.M. Physician A said: -He/she was first notified of the blackened toe on 11/27/21, he/she seen the resident on 11/30/21. The resident has severe Peripheral Vascular Disease (PVD), and he/she diagnosed the toe with dry gangrene and gave orders to be sent to the hospital. Resident returned to the facility. The resident is not a candidate for surgery. Review of the weekly skin check dated 12/14/21 showed an existing right foot/toe wound scattered bruising to both lower extremities, both upper extremities and back. No new wounds identified. During an interview on 12/14/21 at 3:22 P.M. LPN E said: -He/she had worked on the Village recently and had taken care of the resident; -He/she was not aware of any problems with his/her skin or having any wounds; -If a resident is gone for over 24 hours then the resident should be treated like a new admission. A skin assessment should be completed and documented in the nurses notes. If less than 24 hours, document that they went out and document that they came back. During an interview on 12/14/21 at 3:08 P.M. CNA C said: -He/she has been an aide for six years and works on Village; -The resident will say NO, regardless of what you say or ask, but can talk with him/her and he/she will let you take care of him/her; -He/she was aware of the wound to the second toe on the right foot; -A couple of weeks ago, his/her sock was off his/her foot and he/she seen his/her toe. The toe was little bit cracked in the middle. It looked like old old skin. A week before that he/she tried to put his/her shoe on and he/she complained of pain, he/she just thought his shoes were too small; -Evening shift does not take the resident's socks off, as they may get up and need socks to keep them from falling; -He/she has not seen his/her feet recently. During an interview on 12/14/21 at 2:53 P.M., LPN C said: -He/she is taking care of the resident today; -When a resident comes back from the hospital, the hospital usually sends a packet of paperwork about their hospital stay and orders; -The Unit Manager usually has the paperwork; -He/she does not have any paperwork from hospital; -He/she is unaware of any new wounds. -He/she does not have any new treatment orders other than the treatment to the second toe to the right foot. Review of the weekly skin check dated 12/15/21 showed: appears to have old scratches and abrasions on the left knee, no signs or symptoms of infection observed. Current dressing to foot in place. No new wounds identified. During an interview on 12/15/21 at 1:29 P.M. LPN D said: -The resident returned to the facility from the hospital on 12/13/21 with [CONDITION(S)] of the left foot, he/she did not have any new orders. The resident was suppose to go to hospice. Hospice said he/she does not qualify for hospice services; -On 12/9/21 a nurse aide came and showed him/her an abrasion like area to the fifth toe on the left foot. The resident has bruises from IV's that were given at the hospital; -He/she documented the information in Risk management tab in the electronic medical record. The Director of Nursing (DON) and the Administrator will look at the information that is documented in the Risk management tab. He/she cannot find the information in the Risk Management tab or in the nurses notes; -He/she notified the physician via a fax communication. The fax communication should be kept on a clip board until the physician answers the fax, then the fax is sent to medical records to be filed. The Fax machine on the Village does not work, so the nurses have to go to other halls to fax paperwork. He/she cannot find the fax that he/she sent to the doctor. He/she has not received any orders for the treatment to the area, he/she has just putting a dry dressing on the area; -He/she was not aware of the black area to the toe. Review of the medical record dated 12/12/21 through 12/22/21 showed: - No treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 12/15/21 at 10:00 A.M. Family Member A said: -He/she was made aware of the wound to the toe on the right foot a couple of weeks ago, the nurses then called the next day and told him/her that the resident was going to the hospital due to the wound; -He/she felt the decline in the wound happened quick. -He/she was not aware of any wound to the left foot until the hospital told him/her about the wound on the left foot when the resident was at the hospital on 12/12/21. During an interview on 12/15/21 at 1:59 P.M. the former Administrator said: -Nurses will document in the Risk Management area in Point Click Care (PCC), the electronic medical record. The Interdisciplinary Team (IDT) team will review the information to see if they need to add any information. The administration will then review the information and then lock it the entry in PCC. She can see an entry in the Risk Management section for the resident dated 12/10/21 of a new skin issue. An aide alerted the nurse that the resident had a new skin issue to 5th digit on the left foot, the wound was cleansed and dressed; -She would expect that a wound report would be competed , and reported to wound care plus (the outside wound care provider), and the Director of Nursing (DON) should have done the wound report. The DON would have been in charge of doing the wound assessment or assigning it out to be done; -The DON resigned on 12/13/21. During an interview on 12/20/21 at 10:00 A.M. LPN D said: -He/she does not have a treatment order for the wound on the left foot; -He/she has been putting on alginate dressing (Alginate dressings can absorb wound fluid in the dry form and form gels that can provide a dry wound with a physiologically moist environment and minimize bacterial infections, thereby promoting rapid re-epithelialization and granulation tissue formation) and border gauze; -He/she has asked for a wound care policy, but has not been provided one yet; -He/she does not know if the facility has a policy for wounds. During an interview on 12/20/21 at 10:00 A. M. LPN E said: -No wound assessments have been done on the resident's wounds; -He/she has asked for a wound care policy, but has not been provided one yet; -He/she does not know if the facility has a policy for wounds; -The facility does not have a wound nurse. Review of the nurses notes dated 12/20/2021 at 11:51 A.M. showed: -The Nurse Practitioner was in this shift and wrote new orders for wound cultures to both wounds on feet and new order for antibiotic. Family notified. Review of the resident's medical record dated 12/13/21 through 12/23/21 no documentation of wound assessments, no documentation of any open areas or wounds to the left foot. During an interview 12/22/21 4:22 P.M. the Interim Director of Nursing and Corporate Nurse B said: -The charge nurses complete the weekly skin check; -The wound assessment should consist of the actual wound measurements; -Weekly skin check is triggered in PCC (point click care, the facility electronic medical record) schedule; -If there is abnormal skin or wound, the nurses should notify the physician; -Residents who have existing wound only new wounds document on the skin assessment that the resident has a wound, if a new wound is found upon the skin assessment, then the nurse would document the wound and measurements; -The DON or nurse manager or charge nurse is responsible for weekly wound documentation. If the facility has a wound nurse, then the wound nurse would be responsible for the weekly documentation. The facility does not have a wound nurse at this time; -She is not aware of any new wound for the resident; - When a new area is found the nurses should notify the DON and document in Risk Management tab in PCC; -The Risk Management note goes to the DON, the DON is to ensure that the physician is notified, and orders are received; She expects the nurses should assess the residents and document when a resident returns from the hospital. During an interview on 12/22/21 at 5:00 P.M. Physician A said: -He/she would expect the facility to follow their policy and procedure for wound care and pressure ulcer care and treatment. He/she is aware that the facility does have a policy. 2. Review of the facility's pain management policy, dated 11/1/21, showed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences. - Pharmacological interventions will follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: a. Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate [MEDICATION(S)] therapy for pain. b. Consider evidence-based practice tools to assist in the assessment of the resident's pain. c. Consider administering medication around the clock instead of PRN (pro re nata/on demand) or combining longer acting medications with PRN medications for breakthrough pain. d. Utilize the most effective and least invasive route for [MEDICATION(S)] administration (e.g. oral, rectal, topical, injection, infusion pump and/or transdermal) e. Use lower doses of medication initially and titrate slowly upward until comfort is achieved. f. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. g. Review clinical conditions which may require several analgesics and/or adjuvant medications; documentation will clarify the rationale for a treatment regimen and acknowledge associated risks. h. Opioids will be prescribed and dosed in accordance with current professional standards of practice and manufacturers ' guidelines to optimize their effectiveness and minimize their adverse consequences. i. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. j. Referral to a pain management clinic for other interventions that need to be administered under the close supervision of pain management specialists will be considered for residents with more advanced, complex or poorly controlled pain. - The policy directed staff to do the following for monitoring, reassessment and care plan revisions: a. Facility staff will reassess resident's pain management for effectiveness and/or adverse consequences (e.g., constipation, sedation, anorexia, change in mental status, [CONDITION(S)], respiratory depression, pruritus, nausea, vomiting, addiction and falling or drowsiness) at established intervals. b. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. c. If pain has resolved or there is no longer an indication for pain medication, the interdisciplinary team will work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics. Review of Resident #88's admission MDS, dated [DATE] showed: - A BIMS of 15 which indicated no cognitive impairment; - Feeling down, depressed or hopeless at least one day during the assessment period; no behaviors noted; - Independent with all ADLs with the exception of needing limited staff assistance for dressing and supervision with toilet use; did not walk in corridor or room; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Has been on a scheduled pain medication in the last five days, has not taken any PRN (as needed) pain medications; not experiencing any pain at the time of the assessment; - Has a chronic disease or condition that may result in a life expectancy of less than six months; - Received antianxiety medications four of the past seven days; antidepressants seven of the past seven days; received opioid (highly addictive narcotic pain medications) medications seven of the past seven days; - Hospice care. Review of the resident's quarterly MDS, dated [DATE], showed: - Received PRN pain medications; did not receive any non-medication interventions for pain; - Frequently experienced pain; pain has made it hard to sleep at night; pain has limited day-to-day activities; rated his/her pain at a 10; - Received antipsychotic medications two of the last seven days; antianxiety medications seven of the last seven days; antidepressants seven of the last seven days; opioid medications seven of the last seven days; - Hospice care. Review of the resident's entry MDS showed he/she readmitted from the hospital on 11/26/21. Review of the resident's undated care plan showed: - On a sedative/hypnotic medication related to [CONDITION(S)] ([MEDICATION(S)]). Interventions included: o Administer sedative/hypnotic medications as ordered by physician. Monitor/document side effects and effectiveness every shift. o Evaluate other factors potentially causing [CONDITION(S)], for example: environment (excessive heat, cold, or noise), lighting, inadequate physical activity, facility routines, [MEDICATION(S)]/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. o Monitor/Document/Report PRN for following adverse effects of sedative/hypnotic therapy: day time drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. o Report pertinent lab results to physician. - The resident uses anti-anxiety medications related to anxiety disorder. interventions included: o Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. o Monitor the resident for safety. The resident is taking ANTI-ANXIETY meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs. o Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. unexpected side effects: [CONDITION(S)], hostility, rage, aggressive or impulsive behavior, hallucination o Monitor/record occurrence of for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc. and document per facility protocol. o Psychiatry consults as needed - The resident uses antidepressant medication related to depression. Interventions included: o Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift o Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, o withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, [CONDITION(S)]; appetite loss, weight loss, nausea and vomiting, dry mouth, dry eyes o Psychiatry consults as needed; - The resident has chronic pain related to stroke with right side paralysis; 11/6/2021 Screaming about his nerve pain to his feet; Refuses pain patch at times. Interventions included: o 11/6/2021: screaming that his/her nerve pain in his/her feet are worse; physician/Hospice called and ordered dosage changes to his/her [MEDICATION(S)] (used to treat nerve pain)/[MEDICATION(S)] (treat pain and certain types of [CONDITION(S)]). Few HRS later was screaming again about the pain. Hospice notified and came out to exam him/her; received orders medication changes; see Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] o Administer [MEDICATION(S)] as per orders. o Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. o Evaluate the effectiveness of pain interventions Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. o Identify and record previous pain history and management of that pain and impact on function. Identify previous response to [MEDICATION(S)] including pain relief, side effects and impact on function. o Identify, record and treat The resident's existing conditions which may increase pain and or discomfort: paresthesia related to stroke o Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea and vomiting; dizziness and falls. Report occurrences to the physician. o Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. o Monitor/record/report to Nurse if resident complaints of pain or requests for pain treatment. o Notify Hospice and place on Dentist list o Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. o Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care. o Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to signs and symptoms or complaints of pain or discomfort. o The resident is able to: call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain. Review of the resident's December 2021 MAR/TAR showed: - [MEDICATION(S)] (a narcotic used to treat moderate to severe pain or a level of 4 to 10 on the pain scale) tablet 2 milligrams (mg), give one table by mouth as needed (PRN) for pain TID (three times a day)/ PRN; start date 11/26/21; - On 12/4/21, staff administered [MEDICATION(S)] for a pain level of 3; - On 12/5/21, staff documented the resident's pain level was a zero and they administered [MEDICATION(S)] at 4:31 A.M.; - On 12/7/21, staff administered Dilauded for a pain level of 10 at 8:00 A.M., then indicated the medication was effective; staff administered [MEDICATION(S)] again at 11:21 A.M. for a pain level of 10, three hours and 21 minutes after they administered the medication with an effective result. - On 12/14/21, staff administered [MEDICATION(S)] at 2:10 P.M., then again 5:41 P.M.; - On 12/20/21, staff administered [MEDICATION(S)] at 2:45 A.M., 10:15 A.M., 6:00 P.M. and again at 10:23 P.M., four times during this day; - On 12/21/2

This deficiency is uncorrected. For previous deficiencies, see the statement of deficiencies dated 10/27/21. Based on observation, interview, and record review, the facility failed to prevent one resident with a history of physically and sexually aggressive behaviors (Resident #81) from abusing multiple residents. The facility census was 89. Review of the facility policy for Abuse, Neglect, and Exploitation included the following: - It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. - Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. - An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. - Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. - Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. - Providing complete and thorough documentation of the investigation. - Taking all necessary actions as a result of the investigation, which may include, but are not limited to; analyzing the occurrences to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; defining how care provision will be changed and/or improved to protect residents receiving services; training of staff on changes made and demonstration of staff competency after training is implemented; identification of staff responsible for implementation of corrective actions; the expected date for implementation, and identification of staff responsible for monitoring the implementation of the plan. 1. Review of Resident #81's care plan for potential for a behavior problem related to agitation/delirium dated 12/31/21 showed: -Focus: potential for a behavior problem related to agitation and delirium, wanders in his/her wheelchair; -Goal: will have no aggressive behaviors through review; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; anticipate and meet the resident's needs; explain all procedures to the resident before starting; if reasonable, discuss the resident's behaviors. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 2/12/22 showed: -Unable to answer questions, unaware of the date, time and person; -No mood issues and no behaviors; -Extensive assistance of two staff for Activities of Daily Living (ADL's); -Five days of antipsychotic usage (a mediation used to control behaviors and mood); -Diagnoses of dementia, aphasia (inability to speak), manic depression (Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions). Review of the nurse's notes dated 1/26/22 at 12:52 P.M. showed: -Resident in the dining room, slapped another resident in the face. Resident sent to local hospital. Review of the nurse's notes dated 1/26/22 at 7:24 P.M. showed: -Resident returned from local hospital with no new orders. Continue to monitor. Review of the care plan for behaviors dated 12/31/21 showed no changes or additional approaches related to behavior after the 1/26/22 altercation. Review of the nurse's notes dated 1/29/22 at 8:43 A.M. showed: -At approximately 5:50 A.M., the resident was seen pushing another resident to the floor. This resident was removed from the dining room and sent to a local hospital. Review of the nurse's notes dated 1/29/22 at 11:30 P.M. showed: -The resident returned from the local hospital at 12:30 P.M. with no new orders Review of the care plan for behaviors dated 12/31/21 showed no changes or additional approaches related to behavior after the 1/29/22 incident. Review of the nurse's notes dated 1/31/22 at 5:27 P.M. showed: -The resident required re-direction following inappropriate contact with staff. He/she made contact with the buttocks of a female staff member. The resident was educated. Review of the nurse's notes dated 2/1/22 at 7:03 A.M. showed: -The resident has been seeking out female peers to sexually molest. Nurse has had to keep him/her in the line of sight at all times since 5:00 A.M. The resident had at least four near misses with four different residents. Staff was able to intervene quickly. Interim administrator notified and he/she came to the unit to address the resident's behaviors. Review of the nurse's note dated 2/1/22 at 8:59 A.M. showed: -The resident was found lying in bed with a female resident with his/her pants down. The resident was trying to pull the female resident's pants down. The resident was assisted back to his/her room. A female resident entered the resident's room, the resident became aggressive toward him/her as well. The resident sent to the local hospital for evaluation. Review of the nurses' note dated 2/1/22 at 12:54 P.M. showed: -Local hospital called to report the resident will be admitted to a psychiatric hospital. Review of the nurse notes dated 2/11/22 at 2:43 P.M. showed: -The resident was readmitted to the facility from psychiatric hospital. Review of the care plan for behaviors dated 12/31/21 showed no new approaches to address the sexually inappropriate behaviors toward residents and staff, or any new interventions from the recent psychiatric hospital admission. Review of the nurses notes dated 2/13/22 at 1:22 P.M. showed: -The resident was showing aggressive and inappropriate behavior toward nurses, Certified Nurse Aides (CNA's) and other residents and would not stop when asked to. Staff had to physically remove the resident's hands from touching inappropriately. The resident also slapped another resident in the face twice. The resident was sent to a local hospital for evaluation. Review of the care plan for behaviors dated 12/31/21 showed no new interventions to address the inappropriate behaviors of 2/13/22, the physical aggression towards another resident, or the recent hospitalization. Review of the social services note dated 2/24/22 at 8:57 A.M. showed: -Social Services communicated with the resident's guardian. The resident's guardian has expressed a need to have the resident moved to a behavior facility. Referrals have been sent. Review of the nurse's note dated 2/25/22 at 7:58 P.M. showed: -The resident has been doing sexual things again. He/she tried to grab another's back side this evening. He/she has had several behaviors taking briefs, trying to get in a cart, exit seeking for hours. He/she then started spitting on the floor in the hallway. He/she was then directed to his/her room by staff and told to stay in there. Review of the nurse's dated 2/26/22 and 2/27/22 showed: -9:40 A.M. - Upon arrival this nurse was informed the resident had been having behaviors. As directed by the Assistant Director of Nursing (ADON) this nurse placed a call to the guardian. With an approval to send the resident to the hospital. Resident left the facility at 9:34 P.M. for evaluation; -10:28 A.M. - nurse at the hospital called for report as to why the resident was at the hospital; -12:13 A.M. - the resident returned to the facility. Review of the nurse's notes dated 2/28/22 at 2:46 P.M. showed: -The resident sent to a hospital for evaluation related to sexual aggression, grabbing buttocks and private areas of other residents and staff. The resident also pulled the fire alarm and was exit seeking all shift. Review of the nurse's notes dated 3/1/22 showed: - 12:52 A.M. Spoke with the hospital's professional team with recommendations for the resident to return to the facility and see the facility's psychiatrist for a mediation adjustment; -3:24 A.M. the resident is transferred back to the facility. -9:23 A.M. the resident continues to grab at staff's buttocks and is going in other resident's rooms; -6:27 P.M. the resident was into everything this evening. Attempted to get into nursing station, in stuff on the cart. Kept going to the doors. Standing up from the wheelchair and having to be told to sit down as he/she was unstable on his/her feet. Review of the care plan for behaviors dated 12/31/21 showed no new interventions for the sexually aggressive behaviors, nor of the resident being sent to a psychiatric hospital. Review of the nurse's notes dated 3/5/22 showed: - 2:18 P.M. The resident came into the dining room and propelled next to another resident. He/she said something to this resident. The resident said something to him/her, then he/she slapped this resident with an open hand on the cheek two times. This writer immediately separated the two residents and took this resident to his/her room because he/she stated he/she was tired. The resident was sent to a local hospital for evaluation. -11:00 P.M. the resident returned from the hospital with no new orders. Review of the social services note dated 3/7/22 at 9:07 A.M. showed: -The IDT team met to discuss the resident's recent behaviors. Resident can display inappropriate touch of other people. He/she has been sent out for psychiatric hospitalization on 1/21/22, 1/29/22, 2/1/22, 2/27/22 and 2/28/22. Resident currently takes Risperdal (used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, irritability associated with autistic disorder) for bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). Quetiapine (Seroquel, an antipsychotic medicine that is used to treat schizophrenia (a serious mental disorder in which people interpret reality abnormally.) for unspecified dementia, bipolar disorder and mood. During the observation period of 3/21/22 through 3/23/22 showed the resident was on one on one observation by one staff member. Review of the behavior care plan dated 12/31/21 showed no changes or addition of interventions for the sexually aggressive behaviors, the admissions to the psychiatric hospitals, the medication used, or the one on one interventions used. Review of the nurse's notes dated 3/8/22 through 3/19/22 showed documentation of the resident's continued sexually inappropriate behaviors. Review of the care plan showed no documentation for any interventions in place for staff to utilize for the sexually inappropriate behaviors. During an interview on 3/23/22 at 2:00 P.M. the Corporate Nurse and Director of Operations said; -They were aware of the resident's physically aggressive behaviors and were attempting to find appropriate placement for the resident. They have sent out referrals to several facilities, but at this point no one will take the resident. During an interview on 3/24/22 at 2:00 P.M. the interim Director of Nursing said: -Staff should receive training for residents with behaviors through in-servicing from the management staff or training from outside educators on how to address the resident's behaviors. -Staff should identify the residents behavior, put interventions in place to address the behavior, update the care plan then educate the staff on the interventions.

This deficiency is uncorrected. For previous deficiencies, see the statement of deficiencies dated 10/27/21. Based on observation, interview, and record review, the facility failed to prevent one resident with a history of physically and sexually aggressive behaviors (Resident #81) from abusing multiple residents. The facility census was 89. Review of the facility policy for Abuse, Neglect, and Exploitation included the following: - It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. - Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. - An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. - Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. - Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. - Providing complete and thorough documentation of the investigation. - Taking all necessary actions as a result of the investigation, which may include, but are not limited to; analyzing the occurrences to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; defining how care provision will be changed and/or improved to protect residents receiving services; training of staff on changes made and demonstration of staff competency after training is implemented; identification of staff responsible for implementation of corrective actions; the expected date for implementation, and identification of staff responsible for monitoring the implementation of the plan. 1. Review of Resident #81's care plan for potential for a behavior problem related to agitation/[CONDITION(S)] dated 12/31/21 showed: -Focus: potential for a behavior problem related to agitation and [CONDITION(S)], wanders in his/her wheelchair; -Goal: will have no aggressive behaviors through review; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; anticipate and meet the resident's needs; explain all procedures to the resident before starting; if reasonable, discuss the resident's behaviors. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by staff, dated 2/12/22 showed: -Unable to answer questions, unaware of the date, time and person; -No mood issues and no behaviors; -Extensive assistance of two staff for Activities of Daily Living (ADL's); -Five days of antipsychotic usage (a mediation used to control behaviors and mood); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions). Review of the nurse's notes dated 1/26/22 at 12:52 P.M. showed: -Resident in the dining room, slapped another resident in the face. Resident sent to local hospital. Review of the nurse's notes dated 1/26/22 at 7:24 P.M. showed: -Resident returned from local hospital with no new orders. Continue to monitor. Review of the care plan for behaviors dated 12/31/21 showed no changes or additional approaches related to behavior after the 1/26/22 altercation. Review of the nurse's notes dated 1/29/22 at 8:43 A.M. showed: -At approximately 5:50 A.M., the resident was seen pushing another resident to the floor. This resident was removed from the dining room and sent to a local hospital. Review of the nurse's notes dated 1/29/22 at 11:30 P.M. showed: -The resident returned from the local hospital at 12:30 P.M. with no new orders Review of the care plan for behaviors dated 12/31/21 showed no changes or additional approaches related to behavior after the 1/29/22 incident. Review of the nurse's notes dated 1/31/22 at 5:27 P.M. showed: -The resident required re-direction following inappropriate contact with staff. He/she made contact with the buttocks of a female staff member. The resident was educated. Review of the nurse's notes dated 2/1/22 at 7:03 A.M. showed: -The resident has been seeking out female peers to sexually molest. Nurse has had to keep him/her in the line of sight at all times since 5:00 A.M. The resident had at least four near misses with four different residents. Staff was able to intervene quickly. Interim administrator notified and he/she came to the unit to address the resident's behaviors. Review of the nurse's note dated 2/1/22 at 8:59 A.M. showed: -The resident was found lying in bed with a female resident with his/her pants down. The resident was trying to pull the female resident's pants down. The resident was assisted back to his/her room. A female resident entered the resident's room, the resident became aggressive toward him/her as well. The resident sent to the local hospital for evaluation. Review of the nurses' note dated 2/1/22 at 12:54 P.M. showed: -Local hospital called to report the resident will be admitted to a psychiatric hospital. Review of the nurse notes dated 2/11/22 at 2:43 P.M. showed: -The resident was readmitted to the facility from psychiatric hospital. Review of the care plan for behaviors dated 12/31/21 showed no new approaches to address the sexually inappropriate behaviors toward residents and staff, or any new interventions from the recent psychiatric hospital admission. Review of the nurses notes dated 2/13/22 at 1:22 P.M. showed: -The resident was showing aggressive and inappropriate behavior toward nurses, Certified Nurse Aides (CNA's) and other residents and would not stop when asked to. Staff had to physically remove the resident's hands from touching inappropriately. The resident also slapped another resident in the face twice. The resident was sent to a local hospital for evaluation. Review of the care plan for behaviors dated 12/31/21 showed no new interventions to address the inappropriate behaviors of 2/13/22, the physical aggression towards another resident, or the recent hospitalization . Review of the social services note dated 2/24/22 at 8:57 A.M. showed: -Social Services communicated with the resident's guardian. The resident's guardian has expressed a need to have the resident moved to a behavior facility. Referrals have been sent. Review of the nurse's note dated 2/25/22 at 7:58 P.M. showed: -The resident has been doing sexual things again. He/she tried to grab another's back side this evening. He/she has had several behaviors taking briefs, trying to get in a cart, exit seeking for hours. He/she then started spitting on the floor in the hallway. He/she was then directed to his/her room by staff and told to stay in there. Review of the nurse's dated 2/26/22 and 2/27/22 showed: -9:40 A.M. - Upon arrival this nurse was informed the resident had been having behaviors. As directed by the Assistant Director of Nursing (ADON) this nurse placed a call to the guardian. With an approval to send the resident to the hospital. Resident left the facility at 9:34 P.M. for evaluation; -10:28 A.M. - nurse at the hospital called for report as to why the resident was at the hospital; -12:13 A.M. - the resident returned to the facility. Review of the nurse's notes dated 2/28/22 at 2:46 P.M. showed: -The resident sent to a hospital for evaluation related to sexual aggression, grabbing buttocks and private areas of other residents and staff. The resident also pulled the fire alarm and was exit seeking all shift. Review of the nurse's notes dated 3/1/22 showed: - 12:52 A.M. Spoke with the hospital's professional team with recommendations for the resident to return to the facility and see the facility's psychiatrist for a mediation adjustment; -3:24 A.M. the resident is transferred back to the facility. -9:23 A.M. the resident continues to grab at staff's buttocks and is going in other resident's rooms; -6:27 P.M. the resident was into everything this evening. Attempted to get into nursing station, in stuff on the cart. Kept going to the doors. Standing up from the wheelchair and having to be told to sit down as he/she was unstable on his/her feet. Review of the care plan for behaviors dated 12/31/21 showed no new interventions for the sexually aggressive behaviors, nor of the resident being sent to a psychiatric hospital. Review of the nurse's notes dated 3/5/22 showed: - 2:18 P.M. The resident came into the dining room and propelled next to another resident. He/she said something to this resident. The resident said something to him/her, then he/she slapped this resident with an open hand on the cheek two times. This writer immediately separated the two residents and took this resident to his/her room because he/she stated he/she was tired. The resident was sent to a local hospital for evaluation. -11:00 P.M. the resident returned from the hospital with no new orders. Review of the social services note dated 3/7/22 at 9:07 A.M. showed: -The IDT team met to discuss the resident's recent behaviors. Resident can display inappropriate touch of other people. He/she has been sent out for psychiatric hospitalization on [DATE], 1/29/22, 2/1/22, 2/27/22 and 2/28/22. Resident currently takes [MEDICATION(S)] (used to treat certain mental/mood disorders (such as [CONDITION(S)], [CONDITION(S)], irritability associated with autistic disorder) for [CONDITION(S)] (a mental health condition that causes extreme mood swings that include emotional highs ([CONDITION(S)] or hypomania) and lows (depression). [MEDICATION(S)] ([MEDICATION(S)], an antipsychotic medicine that is used to treat [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally.) for unspecified dementia, [CONDITION(S)] and mood. During the observation period of 3/21/22 through 3/23/22 showed the resident was on one on one observation by one staff member. Review of the behavior care plan dated 12/31/21 showed no changes or addition of interventions for the sexually aggressive behaviors, the admissions to the psychiatric hospitals, the medication used, or the one on one interventions used. Review of the nurse's notes dated 3/8/22 through 3/19/22 showed documentation of the resident's continued sexually inappropriate behaviors. Review of the care plan showed no documentation for any interventions in place for staff to utilize for the sexually inappropriate behaviors. During an interview on 3/23/22 at 2:00 P.M. the Corporate Nurse and Director of Operations said; -They were aware of the resident's physically aggressive behaviors and were attempting to find appropriate placement for the resident. They have sent out referrals to several facilities, but at this point no one will take the resident. During an interview on 3/24/22 at 2:00 P.M. the interim Director of Nursing said: -Staff should receive training for residents with behaviors through in-servicing from the management staff or training from outside educators on how to address the resident's behaviors. -Staff should identify the residents behavior, put interventions in place to address the behavior, update the care plan then educate the staff on the interventions.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse when the facility failed to protect residents who reside on a Special Care Unit (SCU), when one resident (Resident#1) who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to implement interventions after the incident on 10/15/21 to protect other residents. On 10/23/21 Resident #1 abused another resident (Resident #3) causing injury to the resident. The facility failed to ensure staff were aware of Resident #1's aggression and failed to ensure staff had access and knowledge of the resident's plan of care. The facility census was 103. The Administrator was notified on 10/26/21 at 4:30 P.M. of an Immediate Jeopardy (IJ) which began on 10/15/21. The IJ was removed on 10/27/21 as confirmed by surveyor onsite verification. Review of the facility policy, dated 2021, on Abuse, Neglect, and Exploitation showed: - The facility would provide protection for the health, welfare, and rights of each resident; - Abuse was defined as willful infliction of injury resulting in physical harm, pain, or mental anguish; - All staff will be educated on prevention of abuse; - The facility must provide a safe environment; - The facility must report and investigate all possible abuse; - The facility must protect residents from harm; - The facility must promptly respond to allegations of abuse; - The facility may require increased supervision of residents. Review of the facility staffing inservice, dated 7/19/21, on resident to resident altercation showed: - In the event of a resident to resident altercation staff must immediately separate the residents; - The aggressor must be placed on 1:1 supervision; - Staff must immediately report the issue to the Administrator (ADM) and the Director of Nursing (DON); - The aggressor must be sent out to the hospital for evaluation; - The aggressor must remain upon 1:1 supervision until a medication change has been performed and the first dose of medication; - If the hospital did not make any medication changes, the aggressor must remain on 1:1 until the facility psychiatrist made a medication change. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/3/21, showed: - Severe cognitive impairment; - Behaviors included delusions; - No physical behaviors; - Required supervision for cares; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Received antipsychotic and antidepressant medications. Review of Resident #1's care plan, dated 8/6/21, showed: - The resident was dependant upon staff for meeting needs due to required use of a walker; - The resident had the potential to be physically aggressive with staff and residents; - Staff are directed to analyze behavioral triggers and provided strategies to improve behavior. - No interventions for the aggressive behaviors. Review of Resident #2's admission MDS, dated [DATE], showed: - Memory problem with moderate cognitive impairment; - Required supervision for cares; - Behaviors included verbal and physical aggression towards others. - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Medications included antipsychotic and antidepressant medications. Review of Resident#2's care plan, dated 10/17/21, showed: - Staff discuss behavior and protect the safety of others. - Cognitive impairment due to dementia. - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's quarterly MDS, dated [DATE], showed: - Mild cognitive impairment; - No behaviors noted; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Received antidepressant medications. Review of Resident#3's care plan, dated 8/3/21, showed: - The resident had the potential for behaviors due to history of aggression. - The resident had the right be treated with dignity and respect. - The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's nurses notes, dated 10/9/21 at 6:25 A.M., by Registered Nurse (RN) D showed: - Resident #1 got into an altercation with Resident #2. - Resident #1 was going into other resident's rooms. - Resident #2 told Resident #1 to leave his/her room. - Both residents hit each other with open hands on the face, arms, and head. - Staff instructed both residents to stop hitting each other and separated. - No interventions were noted. Review of Resident #1's nurses notes by Licensed Practical Nurse (LPN) A, dated 10/15/21 at 2:55 P.M., showed: - Resident #1 and Resident #2 were hitting each other. - Resident #2 was yelling at Resident #1 to get out of his/her room. - Staff separated both residents and assessed the residents. - LPN A notified the DON. - The DON immediately called the resident's physician A who requested that staff transport the resident to the emergency department (ED) for evaluation and admission. - Resident #1 was transported to the ED by emergency medical services (EMS). Review of Resident #1's nurses notes, dated 10/15/21 at 6:51 P.M. by RN A showed: - ED nurse called and said Resident #1 was being returned to the facility. - RN A told the ED that physician A said the resident was to be admitted . - Resident #1 returned to the facility by EMS at 5:20 P.M. - Approximately 15 minutes after Resident #1 returned to the facility, Resident #1 was arguing with an unnamed resident (later identified as Resident #2). - Staff separated the residents. - RN A notified the DON who said to place Resident #1 on 1:1 supervision due to the resident's behavior. Review of Resident #1's medical record showed the following: - Staff did not complete one on one monitoring of the resident and instead completed 15 minute checks. - A check list for monitoring, dated 10/15/21 showing 15 minute checks were completed from 5:45 P.M. to 10:30 P.M. - Staff did not document checks past 10:30 P.M. on 10/15/21. - Staff did not notify the facility psychiatrist B. Review of Resident#1's care plan, updated on 10/15/21 showed: - The resident was transferred to the hospital for evaluation. - Resident was placed on [MEDICATION(S)] (medication used to treat psychiatric disorders) to treat impulse control. - No other interventions put in place for the resident's aggressive behaviors after the resident's resident to resident altercation. Observation and interview on 10/16/21 at 2:15 P.M., showed RN E on the locked unit, standing in the hall way. Resident #1 wandered back and forth through the halls, pressing on the panic bars on the three exit doors, and wandering into three different resident rooms. Two other residents redirected him/her from the resident rooms he/she attempted to enter. RN E said the resident had been aggressive and had hit another resident on the unit the previous day. RN E said he/she had come to the facility from a sister facility and he/she did not know where the Certified Nursing Assistant (CNA) who worked on the unit was; he/she was just trying to keep track of all the residents. As RN E stood in the hallway with two other residents close by, Resident #1 forcefully moved between the residents and surveyor. Review of Resident #1's medical records, dated 10/16/21 at 3:01 P.M. by RN A, showed: - The resident wandering the hall. - Two unnamed CNAs tried to change the resident. - The resident pulled one of the CNA's hair and slapped the CNA. - The resident tried to bite the CNA. - Did not document any behavioral interventions. Review of Resident #3's nurses notes, dated 10/23/21 at 6:15 P.M. by LPN D, showed: - Resident #3 told LPN A that Resident #1 struck him/her in the face three times with his/her wrist after Resident #1 entered his/her room. - Resident #3 had bruising and a hematoma on the left outer eye. - Resident #3 requested to file a police report and then go to the ED. Review of nurses notes, dated 10/23/21 at 7:19 P.M., by the DON showed: - Resident #1 allegedly struck another resident in the resident's room. - Apparently Resident #1 sought out the resident. - The DON sent Resident #1 to the ED for evaluation and emergency discharge. During an interview on 10/25/21 at 3:35 P.M., Certified Medication Technician (CMT) B said the following: - He/she was working the SCU on 10/23/21. - Resident #1 came out of Resident #3's room. - Resident #3 said the [OBSCENITY] ing [OBSCENITY] hit him/her in the eye. - Resident #1 went into everyone's room. - Some residents got angry when another resident went into his/her room. - The facility did not have any interventions in place to encourage Resident #1 not to go into other residents' rooms. - One CNA sat with Resident #1 until EMS arrived. - He/she tried to redirect Resident #1 as often as possible. - Resident #1 did not always know the location of his/her room. Observation on 10/26/21 at 8:35 A.M., of Resident #3 showed the resident with an approximately 2 centimeter (cm) purple area around the left eye. During an interview on 10/26/21 at 8:35 A.M., Resident #3 said: - Staff did not keep Resident #1 from frequently wandering in residents' rooms. - Resident #1 would get in his/her bed and be aggressive when asked to leave. - Resident #1 hit him/her in the left eye three times on 10/23/21. Review of Resident #1's medical records from a local hospital, dated 10/23/21 at 7:25 P.M., showed: - The resident was brought to the ED for a mental health evaluation. - The ED attempted to return the resident to the facility after finding no acute illness. During an interview on 10/25/21 at 11:26 A.M., LPN B said: - He/she was assigned to provide care to residents on the SCU, including Resident #1 the week before the 10/23/21 incident occurred. - He/she just started working for the facility. - He/she was not trained in dealing with aggressive residents and was not told the resident had aggressive behaviors During an interview on 10/25/21 at 11:27 A.M., CMT said: - He/she was assigned to provide care to residents on the SCU, including Resident #1. - He/she starting working at the facility on 10/24/21. - He/she did not receive any orientation before caring for residents. - He/she did not know the resident had aggressive behaviors. During an interview on 10/25/21 at 11:28 A.M., CNA A said: - He/she was assigned to provide care to residents on the SCU, including Resident #1 on 10/23/21. - He/she worked for an agency. - Staff gave a change of shift report, but did not discuss change of behaviors in the shift report. - He/she did not know how to access the residents' care plans. - He/She did not receive any orientation to the facility or the SCU and was not informed that Resident #1 had aggressive behaviors. During an interview on 10/25/21 at 11:30 A.M. CNA B said: - He/she was assigned to provide care to residents on the SCU, including Resident #1. - He/she occasionally worked on the SCU. - He/she did not know how to access the residents' care plans. During an interview on 10/25/21 at 11:50 A.M., LPN C said: - He/she normally worked on the SCU. - Resident #1 often wandered into other resident's rooms and upset the other residents. - He/she redirected the resident when the resident wandered into other resident's rooms. - The only intervention was redirecting. - The resident's behaviors were not discussed in report. During an interview on 10/25/21 at 3:30 P.M., CNA I said: - He/she worked on the SCU. - Resident #1 often got into other residents' beds. - Other resident frequently became angry when Resident #1 got in their beds. - The facility staff did not have any strategies to prevent Resident #1 from going into other resident's rooms. - He/She did not know about the resident to resident incidents. During an interview on 10/25/21 at 3:58 P.M., CNA D said: - He/she started working at the facility several months ago. - At times, he/she worked on all the units in the facility. - He/she did not know where to find residents' care plans. - He/She received no training on what interventions the resident had in place for aggressive behaviors. During an interview on 10/26/21 at 6:26 A.M., RN B said: - He/she worked on the SCU. - He/she did not receive any orientation when he/she started working at the facility - He/she did not know where to find residents' care plans. - He/She did not know the resident had aggressive behaviors or what to do if the residents had aggressive behaviors. During an interview on 10/26/21 at 6:29 A.M., CNA E said: - He/she worked for the facility. - He/she frequently worked on the SCU. - He/she did not know how to access resident's care plans. - Resident #1 frequently went into other residents' rooms. - He/she tried to redirect Resident #1. - The facility did not change anything after the resident to resident altercation. During an interview on 10/26/21 at 8:00 A.M., CNA G said: - He/she frequently worked on the SCU. - Resident #1 was very aggressive with other residents. - He/she redirected Resident #1 frequently. During an interview on 10/26/21 at 8:25 A.M., CMT C said: - He/she worked for an agency. - He/she had worked on the SCU. - There had been several incidents of aggression with Resident #1. - He/she was afraid of Resident #1 due to the resident's aggressive behavior. - Resident #1 often refused to take his/her medications. - He/she received no training when he/she started at the facility. - He/she did not know how to access residents' care plans. During an interview on 10/26/21 at 8:50 A.M., LPN C said: - Resident #1 was frequently aggressive. - Resident #1 walked a lot and swung his/arms while walking. - There were frequent resident to resident altercations due to Resident #1's swinging arms. - He/she redirected the resident, but frequently that did not work. During an interview on 10/26/21 at 8:55 A.M., CNA H said: - He/she worked all over the facility including the SCU. - Resident #1 frequently was agitated. During an interview on 10/27/21 at 5:40 A.M., LPN H said: - He/she worked for a staffing agency. - He/she did not receive any orientation when working at the facility or the SCU. - He/she was not told in report that Resident #1 was aggressive. During an interview on 10/26/21 at 12:15 P.M. physician A said: - Resident #1 had increasing agitation. - He/she increased his/her medications. - He/she discussed with the facility the use of nonmedication behavior interventions. - He/she sent Resident #1 to the ED on 10/15/21 and requested that the resident be admitted for behavior management. - Instead the ED sent the resident back to the facility with no interventions. - Resident #1 was tranquil in the ED, but was aggressive and yelling as soon as the resident arrived back at the facility. During an interview on 10/26/21 at 2:15 P.M., physician B said: - Staff did not inform him/her that Resident #1 was aggressive. - He/she evaluated for the behavioral issues on 10/17/21 and did not find the resident aggressive at that time. During an interview on 10/26/21 at 1:05 P.M., MDS Coordinator said: - He/she updated resident care plans after discussing new resident issues. - He/she made care plan updates and notified the resident's charge nurse. - The charge nurse should notify the oncoming nurse of care plan changes. - Care plan updates trigger and update the CNA care plans. - He/she said he/she should have added interventions after the first resident to resident's altercation. During an interview on 10/25/21 at 2:05 P.M., the DON said: - Resident #1 assaulted Resident #3 on 10/23/21. - He/she told the staff to contact EMS. - He/she thought staff communicated with the on coming staff with a written sheet. - He/she did not know how agency staff received orientation to the facility. During interviews on 10/25/21 at 2:25 P.M. and 10/26/2021 at 1:20 P.M., the ADM said: - Resident #1 was placed on 15 minute checks some time by the charge nurse, but not on 10/15/21. - Staff should have provided one on one monitoring until the next day. - The ADM said staff did not put any interventions into place to prevent Resident #1 attacking other residents. - Resident #1 should have been placed on 1:1 supervision due to his/her behaviors. - Care plan updates should be reviewed during change of shift report. - The ADM expected all licensed staff to update the care plan. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, 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 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 to be taken to address Class I violation(s).

Based on observations, interviews, and record reviews, the facility failed to implement measures to treat and prevent pressure ulcers (PU) ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one residents (Resident #1) who developed an Unstageable PU (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to the resident's right ankle; failed to assess and monitor one resident (Resident #2) with a history of pressure ulcers and failed to implement to treat and prevent PU and follow physician's orders for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's documentation did not reflect the PU for Resident #1, when staff charted the resident's skin was within normal limits and no skin concerns on daily skilled notes. The facility census was 77. Review of the facility policy for Wound Evaluation dated 9/18 showed: -The purpose of this procedure is to provide guidelines for the evaluation of current or new wounds; -Evaluation of wounds will be performed on admission, weekly and on discovery; -Evaluation is the formal process in which wound characteristics assessed and documented: local - the anatomical location of the wound(s); size - measurement of the length, width and depth (if any) of the wound(s) in centimeters (cm); staged if a PU - staging per policy; type of the wound if not a PU - arterial, vascular, surgical, trauma or skin tear; onset date for PU - the date the PU was discovered initially as a Stage II (stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid.) or higher or the date the PU deteriorated to a Stage 2 or higher. The PU retains the same date even if deterioration past a Stage 2 occurs; wound bed - percentage of granulation (Granulation tissue is vascularized tissue that forms as chronic inflammation evolves. The new capillaries make the tissue appear pink and granular), percentage of eschar (a dry, dark scab or falling away of dead skin), percentage of slough (shed or remove (a layer of dead skin) and color; drainage - the color, amount and type of drainage: purlent (consisting of, containing, or discharging pus), green, clear, serous (mostly clear or slightly yellow thin plasma that is just a bit thicker than water), serosanguineous (drainage that contains or consists of both blood and serous fluid), small, medium, large copious, thick or thin; odor - presence of absence of wound or drainage odor; tunneling/undermining (occurs when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge) (when present); infection - presence or absence or signs of local wound infection, [CONDITION(S)] (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries), induration (Localized hardening of soft tissue of the body. The area becomes firm, but not as hard as bone), purulent drainage (Evaluate drainage for signs and symptoms of infection after cleaning); healing (when present) - presence of granulation tissue (fragile beefy red healing tissue composed of small blood vessels and connective tissue) or epithelialization tissue (thin slivery [MEDICATION(S)] tissue); surrounding skin - color, appearance and integrity of: denuded (loss of the epidermis (the outermost layer of skin, provides a waterproof barrier and creates our skin tone.), caused by exposure to urine, feces, body fluids, wound exudate or friction), dry, rolled, macerated (occurs when skin is in contact with moisture for too long), intact, red, or pink; pain - the presence of absence of and severity of pain if present; -Wound evaluations are completed upon admission (if wounds are present). Upon discovery and at least week. Wound assessments may be completed by the facility Nursing staff or the designated Wound Care Company; -Evaluation results are communicated to the members of the care team through documentation, care plan meetings, and care planning; -If there is no wound progression, a treatment change should be considered. If there is no change in treatment, documentation should occur as to why the current treatment maintained; -Wounds are observed during dressing changes. The Nurse will note in the progress notes of the wound has worsened or deteriorated and the physician will be notified; -The care plan will be created/updated accordingly. 1. Review of Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -Visit conducted via telehealth; -admitted [DATE], from hospital following urosepsis (develops as a complication of a urinary tract infection ([CONDITION(S)]); -tested positive for COVID-19 ( a new disease, caused by a novel (or new) coronavirus that has not previously been seen in humans) on 6/19/20; -Skin dry no skin concerns noted; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument, completed by staff, date 7/28/20, showed: -Total dependence on staff for activities of daily living (ADL)'s such as dressing, moving in and out of his/her room, bed mobility, transfers, and extensive assistance from staff for eating; -At risk for PU -No unhealed PU; -Weight 157 pounds (lbs). Review of the resident's monthly skin evaluation notes dated 8/9/20, showed: -Skin intact no PU. Review of the resident's shower sheets for August 2020, showed: -No open areas or skin concerns. Review of the resident's daily skilled nurses notes dated 8/31/20, showed: -At 2:35 A.M., dressing to right ankle; -At 2:00 P.M., wound nurse evaluated wound. Review of the resident's Physicians order sheet (POS) dated September 2020, showed: -Start date 9/1/20, med pass (fortified nutritional shakes) 90 milliliters (ML) three times daily with meals; -Start date 9/1/20, Vitamin C (supplement that can promote the healing process of wounds) 500 milligrams (mg) one tablet daily; -Start date 9/1/20, Zinc (supplement that can promote the healing process of wounds) 220 mg one tablet daily; -Start date 9/1/20, cleanse wound to right outer ankle with wound cleanser. Apply santyl (removes dead tissue from wounds so they can start to heal) alginate (highly absorbent dressing), and cover with a gauze dressing daily; -Skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film) to left heel daily; -Start date 9/1/20, pressure relieving boots on at all times. Review of the resident's care plan updated 9/1/20, showed: -Potential for impairment to skin related to incontinence and decreased mobility; -Open area to left heel; -Skin assessments daily with cares. Review of the resident's Treatment Administration Record (TAR) dated September 2020, showed: -Staff initialed daily dressing changes to the resident's right ankle and skin prep to the resident's left heel which indicates the treatments were done; -Three times daily staff initialed 80 percent (%) of the time pressure boots were on at all times. Review of the resident's wound care notes dated 9/1/20, at 10:20 A.M., showed: -Wound to left heel and right outer ankle. Discoloration of left heel where it appears blister has reabsorbed. Skin soft and thin appearing no drainage measuring 4.0 centimeters (cm) by 4.5 cm. No [CONDITION(S)] (swelling) to the area. Right outer ankle wound measuring 2.5 cm by 2.3 cm. Moist yellow slough noted covering the wound bed. Small amount of serous (mostly clear or slightly yellow drainage) noted. Order received for santyl and skin prep to left heel. Pressure relieving boots and cushion placed in resident's bed. Resident right foot tends to lean to the left causing internal pressure to the ankle area. Review of the resident's shower sheets for September 2020, showed: -9/2/20, wound to right ankle treatment in progress; -9/4/20, no skin issues noted; -9/8/20, no skin issues noted; -9/11/20, open area to right ankle; -9/15/20, open area to right ankle; -9/18/20, no skin issues noted; -9/22/20, open area to right ankle; -9/29/20, open area to right ankle. Review of the resident's wound care notes dated 9/7/20, at 9:30 A.M., showed: -Weekly assessment completed. Area to left heel measuring 3.0 cm by 4.0 cm area remains intact. Right outer ankle measuring 2.5 cm by 2.3 cm. Continues to have moist yellow slough covering wound bed no signs or symptoms of infection no odor noted. Moderate amount of serous light tannish drainage. Review of the resident's monthly skin evaluation notes dated 9/9/20, showed: -Open area to right outer ankle treatment in progress. Review of the resident's wound care notes dated 9/14/20, no time charted showed: -Wound assessment completed area to left heel measuring 3.5 cm by 4.0 cm. area intact no drainage. Right outer ankle measuring 2.0 cm by 1.5 cm santyl continues beginning to see granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) to wound bed. Edges surrounding area intact epithelial tissue (manifests as light pink with a shiny pearl appearance) noted around the edges minimal serous drainage noted on dressing no sign or symptoms of infection. Physician updated interventions remain in place. Review of the resident's wound care notes dated 9/21/20, no time charted showed: -Wound assessment completed. Left heel unstageable has been resolved. Right outer ankle measuring 2.0 cm by 1.5 cm wound classified as unstageable because of slough that has been debrided. Wound bed clean and healthy pink. Feet elevated when up all interventions in place. Review of the resident's wound care notes dated 9/29/20, no time charted showed: -Wound assessment completed. Area to right ankle continues to improve area measuring 1.3 by 1.0 cm area filling in with granulation tissue. Serous drainage noted on dressing. Review of the resident's monthly skin evaluation notes dated 9/30/20, showed -Open area to right outer ankle treatment in progress Review of the resident's POS dated October 2020, showed: -Start date 9/1/20, med pass (fortified nutritional shakes) 90 milliliters (ML) three times daily with meals; -Start date 9/1/20, Vitamin C 500 mg one tablet daily; -Start date 9/1/20, Zinc 220 mg one tablet daily; -Start date 9/1/20, cleanse wound to right outer ankle with wound cleanser. Apply santyl and cover with a gauze dressing daily; -Skin prep to left heel daily; -Start date 9/1/20, pressure relieving boots on at all times. Review of the resident's TAR dated October 2020, showed: -10/1/20 thru 10/6/20, staff initialed daily dressing changes to the resident's right ankle and skin prep to the resident's left heel which indicates the treatments were done; -10/1/20 thru 10/6/20, staff initialed pressure boots were on at all times. Review of the resident's shower sheets for October 2020, showed: -10/2/20, wound to right ankle; -10/6/20, wound to right ankle. Review of the resident's daily skilled nurses notes dated 10/5/20, at 4:59 A.M., showed: -Skin within normal limits checked; -PU/Injury left blank; -No skin concerns documented. Review of the resident's daily skilled nurses notes dated 10/6/20, at 4:33 A.M., showed: -Skin within normal limits checked; -PU/Injury left blank; -No skin concerns documented. Review of the resident's daily skilled nurses notes dated 10/7/20, at 4:18 A.M.,showed: -Skin within normal limits checked; -PU/Injury left blank; -No skin concerns documented. Review of resident's admitting emergency room report note dated 10/7/20, at 1:06 P.M., showed: -Presented very hypothermic (medical emergency that occurs when your body loses heat faster than it can produce heat, causing a dangerously low body temperature) probable pneumonia with [CONDITION(S)] and possible beginning of urosepsis; -Large ankle wound with concern for exposed bone probable osteomylitis (an infection in a bone) magnetic resonance imaging (MRI) (scans produce detailed images of the organs and tissues in the body) results pending; -Started on intravenous antibiotics to cover for possible osteomylitis as well. Review of resident's hospital discharge report dated 11/3/20, at 10:40 A.M., showed: -MRI confirmed [CONDITION(S)] orthopedics performed incision and drainage (I &D) on 10/15/20, wound vac (a system may help your wound heal more quickly by draining excess fluid from the wound) left in place. Infectious disease consulted for antibiotics for osteomylitis. Review of Resident #1's discharge MDS, date 10/7/20, showed: -At risk for PU -No unhealed PU. During an interview on 11/10/20, at 2:00 P.M., Certified Nurse's Aides (CNA) A said: -Resident #1 is totally dependent on staff for his/her activities of daily living (ADL)'s; -He/she had a wound to the right ankle after the wound developed he/she wore boots at all times; -He/she required staff assistance to reposition and this was done every two hours. During an interview on 11/10/20, at 2:30 P.M., Registered Nurse (RN) A said: -Resident #1 was moved several times while in the facility due to COVID-19; -He/she did not recall the resident having wounds. During an interview on 11/10/20, at 4:30 P.M., Licensed Practical Nurse (LPN) A said: -He/she is the wound care nurse and he/she does weekly wound measurements and treatments; -During the week the charge nurses doing the daily dressing changes; -A PU is classified as an unstageable because of slough /esghar; -The resident did not have any PU when he/she admitted to the facility; -On 9/1/20, staff identified an Unstageable PU to the resident's right ankle; -The facility's wound care protocol includes implementing increased protein such as med pass, Vitamin C, Zinc, pressure relieving devices, and wound care; -On 9/21/20, the resident's left heel unstageable PU had been resolved; -On 9/29/20, the resident's unstageable PU had been debrided and was significantly improved. During an interview on 11/10/20, at 4:40 P.M., the Director of Nursing (DON) said: -The facility documentation showed the PU to the resident's right ankle was improving. 2. Review of Resident #2 care plan for impaired skin integrity dated 5/13/20 showed: -Stage 4 PU to the coccyx and red area to the right heel; -Goal: wounds will show signs of healing and remain free from infection, will not develop additional skin integrity problems or wound, the red area to the right heel will be resolved; -Approaches: Administer medication as ordered; administer supplements as ordered to promote wound healing; administer treatments as ordered and monitor for effectiveness; apply barrier cream after peri care; indwelling catheter inserted to aide with wound healing; assess, record and monitor wound healing weekly. Measure length, width and depth where possible. Review of the annual MDS dated [DATE] showed: -Alert and oriented and able to answer questions; -Requires extensive assistance of one staff member for ADL's; -Indwelling catheter (a tube placed in the bladder to drain urine) and incontinent of bowels; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .; -Stage 4 PU. Review of the Weekly Wound Report dated 5/18/20 signed by LPN A showed: -Stage 4 PU to coccyx, area healing, measured 0.7 cm by 0.8 cm by 0.5 cm. Review of the Weekly Wound Report no further measurements documented. Review of the nurses' notes dated 5/25/20 signed by the LPN A showed: -Wound assessment completed. Area to coccyx measuring 0.8 cm by 0.8 cm by 0.2 cm. Wound bed is clean and moist and improving. Review of the nurses' notes dated 5/26/20 through 6/21/20 showed no documentation of wound measurements, or the condition of the stage 4 PU to the coccyx. Review of the nurse's notes dated 6/21/20 at 7:30 P.M. showed the resident was transferred to the hospital. The documentation did not include a skin assessment. During an interview on 12/3/20 at 4:30 P.M. the LPN A said: -She was out of the facility from the end of May until the first of July 2020; -She measures and documents on all wounds and PU weekly; -She does not know if the wounds or PU was measured while she was off work. 3. Review of Resident #4's baseline care plan dated 9/18/20 showed: -Altered skin integrity/potential for: -Prevent any skin breakdown or injury; -Heal or improve current skin issues; -Follow facility skin protocol; -Immediately report any skin redness to the nurse; -Report any skin breakdown to the charge nurse; -Provide incontinent care as needed. Review of the admission assessment dated [DATE] showed: -Soft, white area to coccyx, measured 2 cm by 3 cm. Review of the comprehensive MDS dated [DATE] showed: -admitted on [DATE]; -Difficulty with decisions; -Extensive assistance of one staff for ADL's; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -No PU noted on assessment. Review of the undated Nurse Information Kardex (a tool used by Certified Nurse Aides to direct care ) showed: -Apply barrier cream and use a chair cushion; -No further prevention noted to aide in preventing PU or aide in healing PU. Review of the nurses' notes dated 10/5/20 at 4: 59 P.M. signed by LPN A showed: -The resident had an area of concern to the coccyx. Assessment completed. The resident has circular white soft are to the sacral region between upper buttocks. Wound bed clean and intact. Edges and surrounding area intact. Denies any pain or discomfort. Received an order to apply Alginate (a type of absorbent wound dressing). Incontinent of bowel and bladder. Needs assistance with repositioning. Review of the nurse's notes dated 10/14/20 at 10: 33 P.M. signed by LPN A showed: -Wound assessment completed. Area on the sacrum/coccyx area measured 4.0 cm by 3.5 cm. Wound bed intact with light tannish moist slough with small area of light brown noted. Small amount serous drainage noted on old dressing. Edges with small amount granulation noted. Review of the Weekly Wound Measurements dated 11/16/20 completed by LPN A showed: -Stage 3 PU (involve full-thickness skin loss potentially extending into the subcutaneous tissue layer.), measured 4.8 cm by 1.8 cm with moderate serous drainage, Review of the nurses' notes dated 11/23/20 at 10:09 A.M. signed by LPN A showed: -Wound assessment completed. Area measured 3.3 cm by 2 cm by 2.0 cm. Undermining noted with a depth of 2.5 cm. Edges and surrounding area intact. 10% moist light yellow slough in the wound bed. Granulation noted throughout the wound bed. Slight odor noted with dressing changed. Moderate amount of serous fluid noted. Continue with Santyl (is applied to skin ulcers to help remove dead skin tissue and aid in wound healing). Low air loss mattress is in place. Resident lays side to side and remains in bed. Incontinent of bowel and bladder. Observation on 12/3/20 at 2:00 P.M. showed: -The resident in the bed with the head and foot of the bed elevated, the resident was in the middle of the bed on his/her right side; -The bed was saturated with yellow urine; -Licensed Practical Nurse (LPN) B and CNA B lowered the bed, provided incontinent care and rolled the resident further to the right side. There was no dressing to the PU to the coccyx. The PU was approximately the size of a half dollar and was approximately 1 inch deep, white tissue was exposed inside the PU. LPN B, with a soiled glove reached inside of the PU and removed a piece of dressing from the wound. During an interview on 12/3/20 at 2:15 P.M. LPN B said: -The resident does not get out of bed, he/she cannot straighten his/her left leg. The resident did not have the PU upon admission. During an interview on 12/4/20 at 2:00 P.M. LPN A said: -The resident had a white area to his/her coccyx upon admission, the area continued to get worse and is now a Stage 4 PU; -Treatments should be done as ordered by the physician; -Dressings should be reapplied if they come off or are soiled. During an interview on 12/4/20 at 2:00 P.M. the DON said: -He would expect the nurses to complete wound assessments weekly and document when a PU is not healing; -He would expect the CNA's to notify the nurses when a dressing comes off or is soiled. MO 464 MO 762

Based on observation, interview, and record review, facility staff failed to thoroughly investigate an injury of unknown origin for one of three sampled residents (Resident #1) and failed to thoroughly investigate an allegation of staff-to-resident abuse when one resident (Resident #1) reported a staff member hit him/her on the face. Staff did not remove the alleged perpetrator (AP) from resident care pending an investigation, and instead assigned the AP to work and provide direct care to residents on a locked dementia unit without completing an investigation. Facility staff also failed to identify possible abuse and neglect by not treating one resident's (Resident #2) allegations of staff mistreatment as abuse and instead investigated the resident's report as a grievance. The facility census was 130. 1. Review of the facility's undated Resident Abuse policy showed: - It is inherent in the nature and dignity of each of the residents at the Company (facility) that he/she be afforded basic human rights, including the right to be free from abuse, neglect, and mistreatment. The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED]. - Employees of the Company are charged with a continuing obligation to treat residents so they are free from abuse, neglect, and mistreatment. No employee may at any time commit an act of physical, psychological, or emotional abuse against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal. - Physical Abuse: Striking the resident with a part of the body or with any object; non-therapeutic shoving, pushing, pulling, or twisting any part of a resident's body; physical contact intentionally or through carelessness that results in or likely to result in physical pain, injury or psychological pain to a resident; psychological harm including level of fear, anxiety, agitation or emotional distress in a resident; - Verbal abuse includes statements made to a resident which result in ridicule or humiliation of the resident. - All employees have the duty to respect the rights of all residents. Any employee who witnesses or has knowledge of an act of abuse to a resident is obligated to report such information to the clinical nurse in charge, director of clinical services, and/or executive director. An employee shall be deemed to have violated his/her obligation if he/she does any of the following: makes a false or misleading or incomplete report of abuse; falsifies the records related to the incident of abuse; harasses or otherwise retaliates against any resident, employee, or other person who discloses information or participates in an investigation of an act of abuse. - All reported events, bruises, skin tears, falls, inappropriate or abusive behavior, will be investigated by the director of clinical services; - The abuse coordinator is responsible for reporting to the appropriate officials in accordance with Federal and State regulations. The abuse coordinator of the company will endeavor to protect the rights of the resident and the employees. The administration recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened. Thus while the administration reserves the right to suspend a suspect pending investigation, such suspension is not to be deemed as an assessment of guilt; - Immediately upon report of an incident to the individual in charge, the subject(s) shall be segregated from the resident. The factual basis for and credibility of the allegation shall be ascertained and the abuse coordinator shall be notified. The abuse coordinator shall then notify the director of clinical services, and the suspect(s), to the department director when applicable. - If the charge appears on it's face to be credible, then the suspect(s) shall be suspended without pay pending the investigation. - The clinical nurse in charge shall perform and document a thorough nursing assessment, and notify the attending physician. - An incident report shall be filed by the individual in charge who received the report in conjunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion. - The abuse coordinator and/or director of clinical services shall take statements from the victim, the suspect(s), and all possible witnesses including other employees in the vicinity of the alleged abuse. Upon completion of the investigation, a detailed report shall be prepared and any suspect(s), once he/she has been identified, will be suspended pending the investigation. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/23/14, showed staff assessed the resident as: - diagnosed with [REDACTED]. - Did not have behaviors; - Did not have a [MEDICAL CONDITION] or disorganized thinking; - Did not complete a brief interview for mental status (BIMS, used to determine cognitive status); - Could remember the names of staff and their faces; - Did not have a long term memory problem; - Had problems with short term memory. Review of the resident's laboratory test results, dated 12/17/14, showed: - The resident's platelet count (indication of risk for bleeding and bruising) was within normal range. Review of certified nurse aide (CNA) B's work schedule showed: - He/she worked the night shift on HBU (hall the resident resides on) on 12/19/14, 12/23/14, and 12/24/14 into the morning of 12/25/14. Review of the resident's nurses' notes, dated 12/26/14, showed staff documented: - A note on the shower sheet showed staff identified a bruise on the resident; - Assessment showed a large, bruised, discolored area; blue, purple, green and gray on the right back, posterior arm and shoulder area, measured 29 by six (did not indicate type of measurement); - Discolored right hip/flank area, blue, purple, green and gray, measured 12 by six (did not indicate type of measurement); - Resident denied pain and laid on the right side, even when turned to the left; - Increased anxiety and restlessness in the past few days and required [MEDICATION NAME] (pain medication) and [MEDICATION NAME] (antianxiety medication); - Faxed the physician and notified the durable power of attorney (DPOA). Observation on 12/27/14 at 10:30 A.M., showed: - Resident #1 asleep in bed; - The residents right cheek bone had a discolored area approximately the size of a half dollar. During an interview on 12/27/14 at 10:38 A.M., the director of nursing (DON) said: - Nursing staff are expected to assess residents with an injury of an unknown origin to see if the resident was harmed; - Ask the resident if he/she knew what happened; - Expected staff to try and determine the cause of the bruise; - Check history of bruising and medications. During an interview on 12/27/14 at 10:38 A.M., the administrator said: - The bruise under the resident's arm could have been caused from a bed shear or a lift pad. Observation on 12/29/14 at 11:30 A.M., showed: - Bruising on the resident's right upper torso, running from the mid-side of his/her body through the under arm and down the back side of the resident's right arm; - Approximately 14 inches long and varied in width from three to five inches; - Blue, purple, gray, and brown in color; - Bruising above the resident's right hip area, approximately six inches long and four to five inches wide; appeared older and more faded than the bruise on the arm and upper torso; blue, green, gray and brown in color. During an interview on 12/29/14 at 12:20 P.M., the resident said: - He/she did not know how he/she got a bruise under his/her right arm; - He/she got a black right eye from CNA B hitting him/her in the face during care; - "Around a week ago", two staff members, CNA A and CNA B came into his/her room to assist him/her with care; - CNA B ripped the resident's clothes off and became rough with him/her during care and positioning; - CNA B hit him/her in the right eye; - CNA B said he/she hit the resident by accident; - He/she did not think it was an accident and told CNA B that he/she better not be rough with him/her again; - He/she did not report CNA B. Observation on 12/29/14 at 12:25 P.M., showed: - Oxygen tubing taped to the resident's right cheek and two nickel sized blue areas below the cheek on the right side of the resident's face. During an interview on 12/29/14 at 12:45 P.M., the resident's Durable Power of Attorney (DPOA) said: - He/she did not know the resident obtained a bruise under the arm and upper torso and face; - He/she usually visited daily, but did not the last two days because he/she came down with the flu; - The facility did not notify him/her the resident obtained a bruise. Review of the physician's report from Behavioral Medicine, dated 12/29/14 at 1:40 P.M., showed: - The resident had moderate confusion; - Did not have [MEDICAL CONDITION]; auditory hallucinations, [MEDICAL CONDITION] or delusions; - Alert and oriented times two of three; - Fair insight. During an interview on 12/29/14 at 4:15 P.M., the DON, social service designee (SSD) and administrator said: - They did not know of any residents with injuries of an unknown origin in the facility; - This surveyor informed all three staff members at this time of the accusations made by the resident; - The SSD identified the staff members described by the resident based on the resident's description of the CNA's and the CNA's assigned to the resident's unit. - The SSD said the resident seemed very lucid at times and at other times he/she had some confusion; - The SSD said the residents DPOA had not been invoked and he/she is able to make decisions. Review of the investigation report completed by the SSD titled "Interview with Residents on HBU, due to concerns with Certified CNA," dated 12/29/14, showed: - The resident's roommate said two staff talked to the resident "like a dog"; the tone they used sounded "hateful"; they worked the late evening or night shift; - The resident was unable to recall when this occurred. During an interview on 12/30/14 at 10:15 A.M., the DON said; - The initial assessment of the bruise under the resident's right arm and upper torso by nursing indicated the bruise appeared to be from a bed shear; - Her investigation showed the resident obtained the bruise from laying on her remote control in bed; - She did not talk with CNA B yet but planned on talking with him/her today prior to CNA B's scheduled shift tonight; - CNA B did not work last night and would not work until he/she talked with the CNA B; - She called the facility last night prior to CNA B's shift and made sure CNA B did not work and was not scheduled to work; - The SSD said she interviewed several of the residents that live on the same hall as Resident #1 and they all denied any problems. During a phone interview on 12/30/14 at 11:30 A.M., CNA B said: - He/she just woke up from sleeping because he/she worked the night shift at the facility "last night." - He/she said he/she did not work with the resident; - He/she worked on the Village (locked dementia unit); - He/she did not know the resident made any allegations about him/her - CNA B denied he/she would ever harm any resident; - All the residents loved him/her and he/she did nothing wrong to the resident; - He/she worked the night before staff identified the bruise on the Resident #1; - Other staff members told him/her the bruise looked old. During an interview on 12/30/14 at 11:40 A.M., the DON said: - She has never heard CNA B speak inappropriately in the past; - She did not know CNA B worked "last night." During an interview on 12/30/14 at 11:45 A.M., the SSD said: - She did not know CNA B worked last night. - The facility suspends involved staff pending any abuse and neglect investigation. During an interview on 12/30/14 at 12:45 P.M., the DON said; - She said she did not understand the surveyors were reporting an allegation of possible abuse or she "would not have allowed CNA B to work" During an interview on 12/30/14 at 1:00 P.M., the SSD said; - She started the investigation as soon as surveyors left the facility at 4:30 P.M., - She interviewed residents who live on the same hall and asked them about the interactions with staff; - The resident's roommate said he/she has seen staff speak to Resident #1 "like a dog" using a "mean tone." - The roommate did not identify the staff because he/she did not see them and only heard them. - She understood the surveyor reporting that CNA B had allegedly hit Resident #1. The SSD said she started her investigation immediately and gave her completed report to the DON at approximately "5:00 P.M" During an interview on 12/30/14 at 1:50 P.M., Licensed Practical Nurse (LPN) A said: - He/she did not think the resident's bruise on the right side was caused by a bed sheer; - He/she did the initial nursing assessment of the bruise after he/she saw a bath sheet that indicated a new bruise on the resident. During an interview on 12/30/14 at 5:00 P.M., the administrator said; - Staff reassigned CNA B away from Resident #1 but did not remove him/her from the schedule. Instead staff assigned CNA B to work with resident's that live on the dementia unit; - CNA B did not work "around the time" the facility identified the bruise under the resident's arm; - During this time, surveyors reviewed the CNA staffing sheets with the administrator which showed CNA B worked the day before staff identified the resident's bruise on her right side; During an interview on 12/31/14 at 11:00 A.M., the administrator said; - The DON called the facility before CNA B's shift and asked who was working. During this time, staff reported to the DON that CNA B was not scheduled to work on 12/29/14. During an interview on 12/31/14 at 5:30 P.M., an anonymous resident said: - He/she heard CNA B and CNA A talk "mean" to Resident #1; - He/she did not report the incident to staff "because she was afraid of what would happen and that staff would not believe him/her" During an interview on 1/5/15 at 10:50 A.M., LPN A said; - He/she assessed the resident's bruise on 12/26/14 and completed a report; - He/she did not ask the resident how he/she got the bruise. - He/she only asked the resident if it hurt. - He/she gave the report to the DON and did not question the issue after that; - He/she never suspected abuse, but did not know how or why the resident got the bruise; - Abuse and neglect issues included physical abuse such as bruising and should be reported to the DON; - The surveyor asked if he/she reported abuse and neglect or an injury of an unknown origin to the DON and nothing was done about it, what would he/she do and LPN A said he/she did not know. 3. Review of Resident #2's MDS, dated [DATE], showed: - admitted to the facility on [DATE]; - Came to the facility from home; - Received physical therapy five times a week; - Did not have behavior problems; - BIMS score of 15, indicating the resident was cognitively intact. Review of the grievance form filled out by the resident, dated 12/18/14, showed the resident wrote the following: - Bath aide (BA) with black hair and a pony tail, yanked my clothes off and caused a skin tear, hurt my sore bottom and told me to hurry; - Several hours later, while waiting to use the restroom in the hall, the BA asked where I was going; - The BA said read the sign and I would be waiting a long time because nobody would help me; - I pushed the call light and a pleasant staff member helped me to the same restroom and told me I did the right thing the first time. - Facility staff documented that no action was taken and the grievance was unfounded. Review of nurse's notes regarding Resident #2 dated 12/18/14, showed: - The administrator asked the resident to tell her what happened with the BA the day before; - The resident said while in the shower room he/she began removing his/her shirt and the BA said "we have to hurry" and made a skin tear and his/her bandage came off. - The resident said he/she did not get dressed fast enough. - The resident said after getting dressed, he/she sat outside the shower room and BA asked "What do you want?" - The resident told BA he/she needed to use the bathroom; - The BA said "Can you read?" and then said "You need to go to your room and turn on your light." - The administrator asked the resident if it was possible that BA was asking him/her to turn on his/her light so other staff would know he/she needed to use the bathroom; - The resident said the BA came in the room and walked past him/her and assisted the roommate to the bathroom; - The administrator asked if it was possible the BA did not hear the resident and the resident said yes; - The resident said he/she told the BA he/she felt the BA was rude and the BA stopped at the door and said he/she was not rude; - The resident said that BA was loud and boisterous; - The administrator rarely got complaints about the BA, and wondered if it was a misunderstanding; - The resident said no, it was not a misunderstanding. During an interview on 12/30/14 at 11:00 A.M., the resident said: - When he/she was admitted to the facility a few weeks ago, the Physical Therapist (PT) told him/her part of the physical therapy included dressing and removing his/her clothing; - The first time he/she took a shower at the facility, he/she followed the instruction of PT and attempted to remove his/her shirt. The BA asked "What are you doing?" He/she explained to the BA, PT told him/her to dress and undress him/herself as part of physical therapy. The BA said in a "mean" tone that the BA gave all the showers in the facility and he/she did not have time for that. - The BA ripped at his/her shirt causing the resident to hit his/her arm on the shower chair and get a skin tear on his/her arm. - As he/she waited in the hall to use the hall bathroom, the BA asked what he/she was doing. The resident said he/she was waiting to use the restroom. The BA pointed to the sign and in a "mean" tone said "Can't you read, this restroom is not for residents"; - After he/she reported what the BA did and said staff that were nice to him/her now ignored him/her; - The administrator spoke with him/her and said he/she must be sensitive because all the other residents like the BA; - He/she cried his/herself to sleep for several nights. During an interview on 1/5/15 at 10:20 A.M., the administrator said: - She investigated this as a grievance issue not abuse. - Abuse investigations includes looking at physical, verbal, financial, and emotional abuse; - If staff are accused of abuse or neglect, they should be separated from the residents and if the allegations could possibly be true, the employee should be suspended pending the results of the investigation. - If the employee was not at the facility, then they were contacted about the allegations and if staff could not get a hold of the employee by phone, they would meet the staff member at the facility prior to the start of their shift to discuss the allegation(s). NOTE: At the time of the investigation, the violation was determined to be at the immediate and serious jeopardy level "J". Based on record review, interview, and observation completed during the onsite visit, it was determined the facility had implemented corrective actions to address and lower the violation at that time. During the onsite visit, the Department of Health and Senior Services (DHSS) surveyors determined the facility was re-educating all facility staff on the Abuse and Neglect policy and procedure and staff were receiving this education prior to working their next shift. The education addressed Witnessing Abuse and Neglect, Types of Abuse and Neglect, Who to Report Abuse and Neglect to, How Soon to Report Abuse and Neglect and if Staff are Afraid to Report Abuse and Neglect in Fear of Retaliation. Interviews and record review confirmed the administrator and DON had already begun this staff re-education for each staff person currently on duty and will re-educate all other staff prior to working their next shift. The administrator had also re-educated the DON on the facility policy of Abuse and Neglect. In addition to the staff education, the facility interviewed every resident in the facility with a BIMS score above nine to assure resident safety and this interview included "have any staff mistreated you, hit or threatened you while you have been at the facility and are you fearful of any staff." Final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. On 12/31/14, the severity of the deficiency was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interviews and record reviews, facility staff failed to follow their change of condition policy and procedure and notify one sampled residents' (Resident #1) physician in a timely manner of the yellow/brown/green-colored sputum/drainage from the resident's tracheotomy (trach, a surgical opening through the neck into the airway for breathing) and staff failed to give a daily antibiotic ordered as STAT (immediately) for 11 hours. The resident was admitted to the hospital's intensive care unit in critical condition. The facility census was 135. 1. Review of Hospital A's physicians' notes, discharge summary, and laboratory report dated 11/11/13 to 11/13/13, facility staff provided, showed: - Hospital C transferred Resident #1 to Hospital A on 10/4/13, with [MEDICAL CONDITION] and a trach. - The resident improved and was weaned from the ventilator (a machine that moves air into and out of the lungs). - Severe advanced [MEDICAL CONDITION] ([MEDICAL CONDITION], a group of diseases that affects breathing) stable and off the ventilator. - Recent [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA, a bacteria that is resistant to many antibiotics and can cause severe problems including pneumonia) pneumonia or [MEDICAL CONDITION] (inflammation of the passages that carry air to the lungs) [MEDICAL CONDITION] positive sputum cultures. Completed a ten-day treatment of [REDACTED]. -[MEDICAL CONDITION] colonization (when a person carries [MEDICAL CONDITION] on their skin but does not have an infection). - [MEDICAL CONDITION] (allows the person to breathe through the mouth) as tolerated. [MEDICAL CONDITION] ultimately be removed in the future if the resident continues to improve.- Transfer to skilled nursing facility. Review of the facility's change in resident condition policy and procedure, dated as revised 1/3/13, showed: - The clinical nurse will recognize and appropriately intervene in the event of a change in the resident's condition. - The physician/family/responsible party will be notified as soon as possible. - The clinical nurse will communicate to the nurse manager/supervisor any change in resident condition as it occurs. - This will also be communicated in the 24-hour report as well. During an interview on 12/2/13, at 2:50 P.M., the facility's infection control nurse said: - The facility's policy was to put any resident admitted with a history [MEDICAL CONDITION] on isolation and do weekly cultures until they obtained two consecutive negative culture results. When the facility received the second negative culture report, staff took the resident off isolation. - Resident #1 had a history of [REDACTED]. - A resident may [MEDICAL CONDITION] without an infection; we do not [MEDICAL CONDITION] unless the resident had an infection. During an interview on 11/27/13, at 12:40 P.M., Licensed Practical Nurse (LPN) A said: - The facility staffed two nurses on the hall on the day and evening shift, a desk nurse and a treatment nurse. - The desk nurse transcribed physicians' orders, contacted physician as needed, sent residents to the hospital as needed, gave narcotics as needed, and gave report to the next shift. The treatment nurse did assessments and treatments [MEDICAL CONDITION]. Both nurses charted in the nurses' notes as needed. Review of the admission data tool, dated 11/13/13, showed LPN D documented: - Alert to person, short and long-term memory problems, severely impaired decision making ability; - Productive cough with a small amount of white sputum; - Lung sounds clear; - Capped trach; - Oxygen at 2 liters per minute (LPM). Review of the admission orders [REDACTED] -[MEDICAL CONDITION] each shift and as needed; - Oxygen 2 LPM via nasal cannula (NC, a device to administer oxygen through the nose) - No antibiotic order. Review of the admission care plan, dated 11/13/13, showed: - Respiratory: airway maintenance,[MEDICAL CONDITION], oxygen as ordered, monitor oxygen saturation when symptomatic and/or as ordered. - Monitor for signs and symptoms of infection and give medications as ordered. During an interview on 12/2/13, at 11:30 A.M., and 12/3/14, at 1:53 P.M., LPN D said: - He/she worked the evening shift and admitted the resident on 11/13/13. - He/she cleaned the resident'[MEDICAL CONDITION] the gauze dressing. The gauze was wet with sputum and the sputum did not have any color. - The resident's sputum was clear and normal on admission and he/she did not see the resident cough. - He/she gave the night shift report and did not remember the resident having an antibiotic order. During a telephone interview on 12/2/13, at 11:30 P.M., Registered Nurse (RN) B said he/she worked the night shift from 11:00 P.M. on 11/13/13, to 7:00 A.M. on 11/14/13. That night the resident did not cough and had no secretions from the trach. Review of the 24-hour report sheet, used to report from shift to shift, dated 11/14/13, showed for the 7:00 A.M. to 3:00 P.M. shift: antibiotic on hold, sputum culture obtained,[MEDICAL CONDITION] positive nasal culture. During an interview on 12/3/13, at 10:20 A.M., LPN C said: - LPN D admitted the resident on the 11/13/13, evening shift and gave report to the night shift. - RN B gave him/her report the morning of 11/14/13, and he/she documented the report on the 24-hour report sheet. - On 11/14/13, at about 8:30 A.M., the assistant director of nursing (ADON), the infection control nurse, and medical records staff made rounds and said the resident had [MEDICAL CONDITION] positive sputum culture in the hospital, not a positive nasal culture. - He/she did not know anything about an antibiotic on hold. The resident had no orders for antibiotics on the hospital discharge orders or the admission orders [REDACTED]. - Staff did the resident's nasal culture on 11/13/13, and received the negative [MEDICAL CONDITION] nasal culture report on 11/15/13. Review of a physician's telephone order, dated 11/14/13, directed staff to obtain weekly sputum cultures [MEDICAL CONDITION] until the resident had two consecutive negative sputum cultures. During an interview on 12/2/13, at 11:55 A.M., RN C said: - The facility had a policy that put new admissions on isolation until they received [MEDICAL CONDITION] culture reports. - On 11/14/13, he/she worked as the day shift treatment nurse and collected the resident's sputum culture after he/she [MEDICAL CONDITION]. - The resident had a frequent productive cough with yellow to brown sputum. - RN C defined a frequent cough as once every couple of minutes. He/she did not suction the resident because the resident did not have an order to suction. - He/she told LPN C the resident had yellow to brown-colored sputum because LPN C was the desk nurse and gave report to the next shift. Review of RN C's nurse's note, dated 11/14/13, at 1:22 P.M., showed: - Oxygen at 2 LPM/NC; - Lungs clear; -[MEDICAL CONDITION] completed and capped, frequent coughs producing yellow/brown-colored sputum, able to clear throat. Review of the 24-hour report sheet, dated 11/14/13, for the 7:00 A.M. to 3:00 P.M. shift showed staff did not document the resident's frequent coughs or the yellow/brown-colored sputum. During an interview on 12/2/13, at 3:55 P.M., LPN C said: - He/she did not remember RN C telling him/her anything about yellow/ brown-colored sputum. - He/she did not report the yellow/brown-colored sputum to the next shift because RN C did not tell him/her anything. - He/she only contacted the physician once to clarify the calcium [MEDICATION NAME] (antacid) order but not about anything else. - He/she never did the resident'[MEDICAL CONDITION] and never knew about the yellow, green, or brown-colored sputum, so he/she did not tell anyone about it. Review of the 24-hour report sheet, dated 11/14/13, for the 3:00 P.M. to 11:00 P.M. shift showed staff did not document anything about a cough or sputum. Review of the 24-hour report sheet, dated 11/14/13, for the 11:00 P.M. to 7:00 A.M. shift, showed staff did not document the resident's productive cough and clear sputum. Review of the 24-hour report sheet, dated 11/15/13, showed on the 7:00 A.M. to 3:00 P.M. shift staff documented sputum culture sent and nasal culture negative. During an interview on 12/2/13, at 2:25 P.M., LPN G said: - At 9:00 P.M. he/she did the resident'[MEDICAL CONDITION]. When he/she removed the gauze around [MEDICAL CONDITION] the inner cannula and he/she noticed a greenish drainage around the trach. - He/she did not tell Physician A about the green-colored drainage. - Green drainage can mean many things; it can mean an infection or other things, but I'm not a doctor so I do not know what it means. Review of LPN G's nurse's note, dated 11/15/13, at 9:00 P.M., showed: - He/she did not document the greenish-colored drainage around the resident's trach. - Spoke with Physician A earlier and no new orders given. Review of the 24-hour report sheet, dated 11/15/13, showed on the 3:00 P.M. to 11:00 P.M. shift, staff did not document the greenish-colored drainage around the resident's trach. During a telephone interview on 12/2/13, at 11:30 P.M., RN B said: - He/she worked from 11:00 P.M. on 11/15/13, to 7:00 A.M. on 11/16/13. - He/she did the resident'[MEDICAL CONDITION], the resident had a productive cough, and the sputum had changed to green in color. - He/she reported the resident's change in sputum to the day shift nurses so they could assess and contact the physician. - There was not much sputum but it had changed from clear the night before to green. - He/she always gave report to all the day shift nurses but may not write everything on the 24-hour report sheet. Review of RN B's nurse's note, dated 11/16/13, at 2:00 A.M., showed: - Resting quietly with eyes closed, continuous oxygen at 2 LPM/NC, and no signs or symptoms of respiratory distress. - Has productive (cough) with slight greenish-colored production. Review of the 24-hour report sheet, dated 11/15/13, for the 11:00 P.M. to 7:00 A.M. shift showed staff did not document the resident's productive cough and/or the slight greenish-colored sputum. During an interview on 12/2/13, at 11:30 A.M., and 12/3/14, at 1:53 P.M., LPN D said: - He/she worked the evening shift on 11/14/13 and 11/15/13 on the resident's hall. - No staff ever told him/her the resident coughed colored sputum. During an interview on 12/2/13, at 1:40 P.M. and 12/3/12, at 11:40 A.M., LPN A said: - On 11/16/13, he/she worked as the day shift desk nurse and did not recall that RN B told him/her anything about green-colored sputum. - During his/her shift the resident coughed and expelled yellow-colored sputum from around the trach. The yellow-colored sputum looked like the color of resident's tube feeding (liquid nutrition given through a tube into the stomach). - He/she did not notify anyone about the yellow-colored sputum because the resident did not have a lot of sputum. Review of LPN A's nurse's note, dated 11/16/13, at 12:00 noon, showed: - Productive cough with yellow colored sputum. Review of the 24-hour report sheet, dated 11/16/13, for the 7:00 A.M. to 3:00 P.M. shift, showed staff did not document the resident's yellow-colored sputum from the trach. During an interview on 12/1/13, at 9:25 A.M., RN A said: - He/she worked from 6:30 A.M. to 11:00 P.M., on 11/16/13, and cleaned the resident'[MEDICAL CONDITION] the resident had thick, green-colored mucus. - Green-colored mucus means infection. - He/she did not notify the physician on 11/16/13, about the green-colored mucus because he/she wanted to wait for the culture results. Review of RN A's nurse's note, dated 11/16/13, at 6:40 P.M., showed: -[MEDICAL CONDITION] done with thick, green-colored mucus noted [MEDICAL CONDITION]. Review of the 24-hour report sheet, dated 11/16/13, for the 3:00 P.M. to 11:00 P.M. shift, showed staff did not document the resident's green-colored mucus from the trach. During an interview on 12/3/13, at 11:40 P.M., LPN A said: - He/she worked as the day shift desk nurse the weekend of 11/16/13. - RN A did not tell him/her the resident's green-colored sputum. - He/she would have called the physician if anyone had reported the resident had green or yellow-colored sputum because that meant infection. - There are issues that staff can fax to the physician that can wait until the next day for a response and there are issues that need attention now. Green-colored sputum needs attention now. During an interview on 12/1/13, at 9:25 A.M., RN A said: - On 11/17/13, he/she worked from 6:30 A.M. to 11:00 P.M., and provided the resident's care. He/she noticed the resident had coarse crackles throughout both lungs and he/she suctioned thick, green-colored phlegm from the trach. The coarse crackles cleared after he/she suctioned the resident. He/she changed [MEDICAL CONDITION] and cleaned the inner cannula. The resident continued to produce a moderate amount of thick, green mucus after suctioning. Review of RN A's nurse's note, dated 11/17/13, at 10:20 A.M., showed: - Upon assessment at 7:30 A.M., the resident had course lung sounds throughout. The resident tried to cough up the phlegm unsuccessfully. Suctioned thick, green-colored phlegm from the trach.[MEDICAL CONDITION] and inner cannula changed. Lung sounds clearer after suctioning. [MEDICAL CONDITION] and resident able to produce moderate amount of thick, green-colored phlegm on his/her own after suctioning. Oxygen on at 2 LPM/NC and no shortness of air or respiratory distress noted. During an interview on 12/2/13, at 1:40 P.M., LPN A said: - He/she sent a fax to the physician regarding the residents pain management needs but he/she did not inform the physician about the resident's thick, green-colored mucus because he/she did not know about the mucus. Review of the 24-hour report sheet, dated 11/17/13, for the 7:00 A.M. to 3:00 P.M. shift, showed no staff documented the resident's coarse crackles throughout both lungs, and/or that staff suctioned thick, green-colored phlegm from the trach, and/or that the resident continued to produce a moderate amount of thick, green-colored mucus after suctioning. During an interview on 12/1/13, at 9:25 A.M., RN A said: - On 11/17/13, at 4:00 P.M., the laboratory called and said [MEDICAL CONDITION] culture was positive [MEDICAL CONDITION]. He/she paged the physician because the lab called with the culture results. Nurse Practitioner (NP) A called and ordered [MEDICATION NAME] (antibiotic) 750 mg daily for seven days STAT. NP A said STAT and anytime a physician gave him/her an antibiotic order the physician ordered it STAT. - He/she faxed the STAT [MEDICATION NAME] order to the pharmacy and then called to assure they received the order. Pharmacy staff said they would send the [MEDICATION NAME] with the 8:00 P.M. delivery. - The facility had [MEDICATION NAME] tablets in the E-Kit (a supply of medications provided and refilled by the pharmacy) but not the liquid. He/she did not want to crush the [MEDICATION NAME] tablets because it was difficult to get the entire dose out of the med cup so he/she wanted to wait for the liquid. Review of NP A's telephone order, dated 11/17/13, showed: - Isolation precautions [MEDICAL CONDITION] positive trach; - [MEDICATION NAME] 750 mg solution per tube daily for seven days [MEDICAL CONDITIONS] (STAT). During an interview on 11/27/13, at 3:45 P.M., LPN D said: - On 11/17/13, evening shift, the pharmacy delivered the [MEDICATION NAME] and he/she set it on the nurses' cart since it was a [DEVICE] medication and he/she was not assigned to the nurses' cart. Review of the pharmacy proof of delivery, dated 11/17/13, showed LPN D received the [MEDICATION NAME] at 6:57 P.M. During an interview on 11/27/13, at 3:55 P.M., LPN E said: - He/she worked the evening and night shift on 11/17/13. - He/she did not know NP A ordered the [MEDICATION NAME] STAT. - He/she suctioned dark, yellow-colored, thick mucus from the resident'[MEDICAL CONDITION] 5:30 A.M. to 6:00 A.M. on 11/18/13. - He/she gave the first dose of [MEDICATION NAME] on 11/18/13, at 6:00 A.M., because he/she did not want to wake the resident during the night. Review of the 24-hour report sheet, dated 11/17/13, for the 11:00 P.M. 7:00 A.M. shift showed staff did not document the resident's coarse lungs and/or that staff gave the first dose of [MEDICATION NAME] on 11/18/13 at 6:00 A.M. During an interview on 12/1/13, at 12:00 noon, RN A said: - He/she did not tell LPN E that NP A ordered the [MEDICATION NAME] STAT because the facility had a policy to give the first dose of an antibiotic on the shift staff received the order, so it was a mute point. - The resident had medications ordered for 8:00 P.M., 10:00 P.M. and midnight, and you do not need to wake him/her to give tube meds. During an interview on 11/27/13, at 12:40 P.M., 12/2/13, at 1:40 P.M., and 12/3/13, at 11:40 A.M., LPN A said: - LPN E gave him/her report the morning of 11/18/13, and did not tell him/her anything about the resident's change in condition. - After report he/she started his/her regular morning rounds and did not get to the resident's room until 7:30 A.M. He/she found the resident in bad respiratory distress. He/she gave [MEDICATION NAME], increased the oxygen from 2 LPM to 3 LPM, and suctioned thick, green-colored mucus from the trach. He/she was able to clear [MEDICAL CONDITION] mucus then paged the physician. - If LPN E said anything about a change in condition he/she would have gone to the resident's room right away. - He/she saw NP B and asked him/her to see the resident. NP B said to give a breathing treatment and if not improved send to the emergency room (ER). He/she started the breathing treatment and about half way through the NP B said to send the resident to the ER. - He/she told NP B that the resident was fine yesterday because no staff told her the resident had thick, green-colored mucus for days. During an interview on 12/2/13, at 4:50 P.M., NP B said: - He/she made rounds at the facility three or four days a week. - Physician A made rounds to see new patients and do a history and physical on Mondays or Tuesdays. - Staff should send a fax to the physician's office with any resident's change in condition from eating less than usual, increased sputum or change in sputum color, anything that is a change from resident's normal. Depending on the change, he/she would either respond that day or see the resident the next day. Staff should call the office with any critical change in condition. - The morning of 11/18/13, LPN A stopped him/her and said the resident had a big change and was in respiratory distress. - LPN A said he/she suctioned thick, green-colored mucus from the resident's trach. - No staff told NP B about the resident's yellow, green, or brown-colored mucus/drainage before 11/18/13. - Staff said the resident declined overnight, which made him/her wonder if the resident had an antibiotic ordered and if staff gave the antibiotic, why a big change overnight. - He/she saw the resident and gave the order to send him/her to the ER for evaluation. Review of NP B's progress note, dated 11/18/13, showed: - Staff requested he/she see the patient for increased shortness of air and labored respirations. - Staff report large amount thick, green-colored sputum suctioned this morning. - Culture last week positive [MEDICAL CONDITION], recent pneumonia in hospital, orders given for [MEDICATION NAME] 750 mg daily for seven days, worse today per staff. - Breathing treatment given and reassessed after 20 minutes. Oxygen at 4 LPM [MEDICAL CONDITION], using abdominal accessory muscles and labored respirations in bed. - Respiratory distress; sent to ER and report called to physician. During an interview on 12/3/13, at 10:00 A.M. and 12:15 P.M., the director of nursing said: - Staff should document a description of the mucus when a resident had a productive cough. - During the physician's office hours staff should send a fax to the physician with any change in resident condition and should continue to send a fax if the physician did not respond in a couple of hours. After office hours staff should page the physician with any resident change in condition. - Staff should call the physician when a resident had any signs and symptom of an infection. - She expected staff to follow physician's orders [REDACTED]. - Staff should start an antibiotic, ordered as daily, as soon as possible. Review of the Hospital B's ER records, dated 11/18/13, showed: -[MEDICAL CONDITION] immediately as it was plugged off with thick, yellow purulent (containing pus) secretions; - Oxygen at four liters per minute per trach; - Tachypnea (rapid breathing) at 36 breaths per minute (normal adult breathing rate was 12-20 per minute); - White blood count of 16.3 (normal was 4.2 to 10.0); - The physician admitted the resident to the intensive care unit with a condition of critical. Review of the hospital's history and physical, dated 11/18/13, showed: - Pneumonia; - Acute [MEDICAL CONDITION], possibly related to fluid depletion. MO