Every finding on record at Birch Pointe Health and Rehabilitation

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by staff when multiple staff members held one resident (Resident #1) down to obtain a urine sample while the resident screamed and resisted- trying to hit staff with their hands. The resident obtained bruising on his/her right pelvic area, left medial femoral area (the inner side of the thigh bone (femur) near the knee or hip), and right upper arm. The facility census was 107. The Administrator was notified on 08/03/26, at 8:57 P.M., of an Immediate Jeopardy (IJ) which began on 07/20/26. The immediacy was removed on 08/05/26, as confirmed by surveyor on-site verification. Review of the facility's policy titled, Preventing Resident Abuse, not dated, showed the following:-Preventing resident abuse is a primary concern for the facility. It is the facility goal to achieve and maintain an abusive-free environment;-The abuse prevention/intervention program includes, but is not necessarily limited to monitoring staff on all shifts to identify inappropriate behaviors toward residents (rough handling of residents, ignoring residents while giving care); involving attending physicians and the Medical Director when findings of abuse have been determined; and involving psychiatric medical professionals in aiding the staff to manage difficult or aggressive residents;-Encouraging all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. Review of the facility's policy titled, Resident's Rights, not dated, showed the following:-Residents may not be subjected to chemical or physical restraints for purpose of discipline or staff convenience;- Resident shall not be subjected to physical, sexual, or emotional injury or harm. 1.Review of Resident #1's face sheet (resident's information at a quick glance) showed the following:-admission date of 01/01/24;-Diagnoses included Alzheimer's disease, dementia (a general term for a number of neurological conditions that cause a decline in cognitive abilities), and anxiety. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 05/06/26, showed the following:-Severe cognitive impairment;-No physical or verbal behavioral symptoms directed toward others;-Physical symptoms such as hitting or scratching self, disrobing in public and verbal/vocal symptoms like screaming occurred in the last one to three days;-Used a wheelchair;-Dependent on staff for toileting, bathing, dressing, and personal hygiene. Review of the resident's care plan, revised 02/09/26, showed the following:-Resident had impaired cognitive function/dementia or impaired thought process;-Resident used psychotropic medications (medications that affect how the brain works, changing a person's mood, awareness, thoughts, feelings, or behavior) to treat target behaviors of anxiety and air hunger related to end-of-life process;-Resident at risk of pain due to decreased mobility and end-of-life disease process;-Resident is on pain medication therapy with morphine sulfate related to end-of-life process;-Resident had a deficit in expressive communication;-Staff to engage in conversion about a pleasant topic before initiating care;-Staff to use visual cues to help communicate;-Staff to provide cares prior to laying down;-Staff attempt non-pharmacological interventions such as repositioning, extra pillow, calm environment, and meet comfort needs;-Staff to allow resident time to respond and repeat as necessary;-Do not rush resident;-Staff to request clarification from the resident to ensure understanding, face resident when speaking, make eye contact, ask yes/no questions, and use brief , consistent words/cues and alternative communication tools as needed. Review of the facility's follow-up investigation, faxed to the regional office on 08/10/26, showed the following information:-On-site surveyor reported that resident was held down by five staff members during a straight catheter (a thin, flexible tube inserted temporarily through the urethra to drain urine from the bladder and removed immediately afterward) on 07/19/26;-Facility investigation determined a sixth staff member was present;-In summary all six staff members have confirmed their presence for catheterization of resident;-Employes named included Certified Nurse Aide (CNA) N, CNA M, CNA L, CNA P, Registered Nurse (RN) H, and RN I. Review of CNA L's typed phone interview summary, completed by the Director of Nursing (DON) and Assistant Director of Nursing (ADON), dated 08/03/26, showed the following information:-On 07/19/26, RN H told him/her to help him/her (RN H) with a straight catheterization on the resident;-CNA L went to help and there was RN I, CNA M, RN H, CNA N, and himself/herself in the room;-The resident had dementia and he/she did not know what was going on;-CNA L was not comfortable with all that was going on so he/she stood at the end of the resident's bed and asked them to stop and call the physician to get something for him/her to help calm him/her down;-RN I inserted the catheter four times then he/she was able to get the straight catheterization completed;-RN I had his/her hand spreading open the resident's perineal area, aggressively;-RN H had the resident's left restrained (the statement did not specify what the RN restrained);-RN I had the resident's right hip pushed down trying to straight catheterize him/her. During an interview on 08/03/26, at 4:40 P.M., CNA L said the following:-CNA L was working the 300 hall on the 07/19/26 overnight shift;-RN H needed assistance to collect a urine sample from the resident;-The resident was fighting staff while staff attempted to collect the urine sample;-Several staff members were in the resident's room, restraining the resident while RN I tried to collect the urine sample;-RN H was holding down the resident's right leg;-CNA M was trying to sooth the resident by talking to him/her and telling the resident to relax;-The resident screamed and tried to hit staff with his/her hands;-CNA L stood at the foot of the bed trying to soothe the resident by talking to him/her;-RN I was also trying to calm the resident down by talking to him/her;-CNA L suggested several times that staff stop and come back later to try again or to contact the doctor to see if the doctor could prescribe medication to calm the resident down;-CNA M also suggested to RN H and RN I that they stop and contact the doctor;-CNA L said the resident did not know what was going on, was over stimulated, and what staff were doing to collect the urine sample was over the top;-CNA L did not recall the time the incident took place only that it was in the middle of the night and it was dark outside;-CNA L reported the incident to one of the ADONs before he/she left work that morning;-It took staff 10 to 15 minutes to collect the urine sample from the resident;-On 07/25/26, CNA L told Licensed Practical Nurse (LPN) G how the resident received the bruises and LPN G said that staff had not documented anything in the resident's chart. Review of CNA M's phone interview summary, completed by the DON and ADON, dated 08/03/26 and 08/04/26, showed the following information:-On 7/19/26, RN H told him/her that he/she needed to do a straight catheterization on the resident;-The CNA told RN H that the resident was combative, and RN H told the CNA that he/she was going to have people hold the resident down;-The CNA was not comfortable doing that, but RN H was the charge nurse;-RN H wanted RN I to do the catheterization and grabbed RN I, CNA L, CNA N, CNA M, and himself/herself (RN H);-The RN had CNA N hold the resident's hands, CNA L held his/her legs, CNA M had the resident's hips, and RN I to catheterize him/her;-RN H was standing back barking orders;-Staff were trying to calm the resident down;-RN I was asked to do the resident's catheterization and he/she missed four times;-RN H told RN I to continue until he/she got urine;-RN I completed the catheterization and was able to get a little bit of urine;-CNA M told them he/she was not comfortable doing that and staff needed to try at adifferent time;-CNA M and CNA L, both asked them to stop several times and the RN did not;-On 08/04/26, CNA M added that CNA P was holding one of the resident's hands while CNA N held the resident's other hand. CNA M stood at the end of the bed. During an interview on 08/03/26, at 5:34 P.M., CNA M said the following:-On 07/19/26, RN H had to collect a urine sample from the resident;-RN H said it was going to be impossible to collect the urine sample, so he/she found other staff to help hold the resident down;-CNA M did not feel comfortable holding down a resident;-RN H told CNA M to hold the resident's heels because the heels don't bruise;-CNA M held the resident's right and left heels against the bed;-CNA N held the resident's right and left arms against the bed;-CNA L was trying to hold the residents legs apart;-RN I also tried to hold the resident's legs apart while trying to straight catheterize the resident;-RN I was nervous and inserted the tube four times before collecting the urine sample on the fifth attempt;-CNA L was pulling both the resident's knees trying to keep them apart;-RN I was pushing down on the resident's pelvic area with the palm of his/her hand;-CNA M told RN I to stop the procedure as it was hurting the resident;-The resident was resisting, trying to hit/scratch, and bite staff;-RN H said the reason for the urine sample was because of the resident's increased behaviors;-CNA M said he/she did not like to hold people down, saying the situation was very stressful;-CNA L, CNA N, and CNA M mentioned to RN H and RN I to try again later but RN H and RN I were determined to collect the urine sample;-When RN I was unable to collect the urine sample on the first try staff should have stopped and returned later to try again;-CNA M did not feel comfortable with what occurred and was told by RN H that he/she would document everything;-The resident had a bruise on her pelvic area about an hour after the sample was collected;-The bruise was from RN I pushing on the residents pelvis;-CNA L, CNA N, and CNA M reported the bruising to RN H and RN I;-On 07/20/26, CNA M told LPN G what had occurred the previous night;-LPN G reported the bruising to her supervisor as he/she was upset about the situation;-RN H and RN I should have tried a different approach or waited till the next day to try again;-It was not appropriate for staff to hold down a resident, insert the catheter several times while the resident was hitting, scratching and trying to bite staff members;-The way RN H and RN I kept attempting to collect the sample, not listening to the other staff, and not stopping is negligence on behalf of the RNs;-The incident was traumatizing for the resident;-The resident had bruising from his/her pelvic area and going down his/her thighs to the knees. During an interview on 08/05/26, at 10:40 A.M., CNA M said the following:-CNA P was also in the resident's room on the night staff collected the urine sample;-CNA P was holding one of the resident's hands and shoulder;-CNA M was talking gently to the resident trying to calm him/her down;-RN H and RN I told CNA M that they reported to administration the bruises on the resident;-Staff collected urine samples from residents during the night if the doctor ordered an emergency lab or it was easy to obtain the sample;-CNA M was under the assumption that RN H and RN I immediately reported the incident to the Administrator. Review of CNA N's phone interview summary, completed by the Administrator and witnessed by Human Resources (HR) staff, on 08/04/26, at approximately 1:12 P.M., showed the following information:-CNA N confirmed presence in the resident's room for a urinary catheterization but was unsure of the date;-CNA N reported six staff members were present: himself/herself, CNA M, CNA L, CNA P, RN H and RN I;-CNA N reported he/she was holding the resident's hand but only trying to comfort him/her and stroke his/her hair;-CNA N believed the event was abuse, but not by him/her. He/she believed the way otherstaff was holding the resident was aggressive compared to the way he/she was holding the resident. CNA N did not clarify that statement but reported the resident was having a fucking fit and they were holding him/her. It was traumatizing to CNA N;-CNA N denied reporting the event at time of occurrence. During an interview on 08/05/26, at 1:03 P.M., CNA N said the following:-The resident had exhibited behaviors of pulling out hair, taking off brief and clothes, and biting off pieces of the dirty brief and yelling;-On 07/19/26, after midnight, RN H rounded up the aides from the 300 and 400 hall;-RN H told the aides they had to help with collecting a urine sample from the resident;-Once in the resident's room, RN H told the aides where they needed to stand;-CNA N stood at the head of the resident's bed and was told to hold the resident's right hand;-CNA N was rubbing the resident's head, talking to him/her, and trying to distract the resident;-CNA L was standing on the left side of the resident's bed at the resident's hip area;-CNA L was holding the residents left leg/thigh area;-CNA L used two hands to hold the residents leg;-RN I was standing beside CNA L, using his/her elbows to keep the resident's legs apart while trying to collect the urine sample;-CNA M was at the foot of the bed on the right side, holding the resident's right foot to the mattress;-CNA P was standing on the right side of the resident's bed, across from CNA L, holding the residents right knee;-CNA P was talking to the resident trying to calm him/her down;-RN I was pushing on the resident's pelvic bone;-The resident would let out a squeal when RN I would push on the pelvic bone;-RN H came into the room and took CNA L's spot;-CNA L went to the foot of the bed and took out a flashlight to help RN I see better;-RN I attempted four times to collect the urine sample before being successful on the fifth try;-The incident took staff 10 to 15 minutes;-CNA M changed the resident's brief before shift change and noticed fingerprint marks and red area on the residents right thigh;-CNA M reported the marks and red area to RN H. RN H did not go and assess the resident;-CNA M told CNA A what had occurred overnight and it was CNA M's understanding that RN H documented and reported the incident to management. Review of CNA P's phone interview summary, completed by the Administrator and witnessed by HR staff on 08/04/26, at approximately 3:36 P.M., showed the following information:-CNA P confirmed presence in the resident's room for urinary catheterization but did not recall the date of the event;-The CNA reported six staff members were present himself/herself, CNA N, CNA M, CNA L, RN H, but was unsure of one staff member's name. The person's name he/she was unsure of was the nurse (RN I) doing the catheterization. Review of RN H's phone interview summary, completed by the DON and ADON, dated 08/03/26, showed the following information:-On 07/19/26, they could not keep clothes on the resident, and he/she was pulling out his/her hair, and made a baby doll out of the hair;-RN H thought he/she had three residents that night who were septic (a dangerous, life-threatening body reaction to an infection) and got stat (an urgent medical command meaning immediately) orders for blood and a urinalysis on all three residents;-Two of those residents were incontinent and had to be catheterized;-RN I was on 300 hall and RN H asked RN I to do the two straight catheterizations;-CNA L asked RN H to take his/her place while catheterizing the resident because he/she was having lower back pain;-There were two people on the resident's legs, one on each arm, and RN I was the one inserting the catheter, and was successful;-RN H was unable to state who was in the resident's room. During an interview on 08/03/26, at 4:59 P.M., RN H said the following:-When RN H received new orders from the doctor, RN H entered the order into the resident's medical record;-RN H received an order from the doctor to collect a urine sample from the resident;-The order did not specify how staff were to obtain the urine sample;-RN H asked RN I to collect the urine sample from the resident;-The resident was septic and would not stay in bed, or keep his/her clothes on, and had been pulling his/her hair out;-RN H went through the facility and rounded up as much help as he/she could to collect the urine sample from the resident;-RN H knew the resident would be combative and wanted all hands-on board;-RN H was not in the room when staff started the procedure;-There were six staff members in the room;-CNA L asked RN H to take his/her place holding the resident's left knee and leg;-RN H did not recall who the other three staff in the room were;-The resident was resisting during the procedure by calling out, trying to keep his/her knees together, and trying to hit staff members;-RN H checked on the resident several times and the resident was fine after the procedure;-No staff members suggested stopping the procedure and trying again later, or to call the doctor to see about getting medication to help calm the resident down;-The resident already received regular anxiety and pain medication;-On 07/24/26, LPN G asked RN H to help him/her complete a skin assessment on the resident;-The resident had purplish discoloration to both his/her inner thighs;-The bruises were from staff restraining the resident while collecting the urine sample on 07/20/26;-RN H did not see any other bruising due to the resident wearing a brief;-The restraining of the resident was appropriate to collect the urine sample;-The resident had high ammonia levels (elevated levels (hyperammonemia) often point to issues with how the liver or kidneys process waste products) which was causing the residents behaviors;-The resident's behavior had improved since staff collected the urine sample;-RN H documented the doctor's order for the collection of the urine sample;-RN H put the date and time on the collected urine sample, and felt that was sufficient documentation and did not document anything else in the resident's chart;-RN H did not document the resident's behavior prior to the urine collection due to not having enough time;-The behaviors were typical for the resident;-The resident had not been combative to cares in the past. Review of RN I's phone interview summary, completed by the DON and ADON, dated 08/04/26, showed the following information:-On 07/19/26, RN H told RN I he/she needed urine collected and the resident was not able to give a clean catch (a method used to collect a urine specimen);-RN I went with RN H and RN I cleaned up the resident and told him/her what they were going to do but the resident did not say anything to them;-RN H told RN I that he/she (RN H) did not think he/she would be able to get it in and RN I knew he/she could get in and out quickly without having any issues;-RN H, RN I, and a couple of the aides were in the room. During an interview on 08/06/26, at 8:10 A.M., RN I said the following;-RN I worked the 300 hall the night of 07/19/26;-RN H asked RN I for assistance collecting a urine sample on the resident;-RN H did not feel comfortable straight catheter the resident and asked RN I to do it;-RN I was not familiar with the resident and had not worked with him/her in the past;-RN H said the resident would be combative and RN I had experience working with combative patients;-There were four to five staff present in the resident's room to help RN I and keep everyone as safe as possible;-RN I did not know the names of the other staff in the room other than RN H;-The resident was very confused;-The resident did not understand what was going on and was trying to squeeze his/her legs together;-There were staff members on each side of the resident to hold the resident's legs apart while RN I collected the urine sample;-RN I was talking to the resident assuring him/her that he/she was ok;-Staff were holding the resident's arms to keep him/her relaxed enough to get the catheter in and out;-RN I did not remember any staff members at the residents' feet;-The resident was making noises but there were no signs the resident was in pain;-RN I placed his/her hand on the resident's peri-area and used his/her fingers to spread the area apart;-Staff were not squeezing or hurting the resident;-Staff were very safe as to not hurt the resident;-No staff suggested stopping the procedure and trying again later or contacting the doctor;-RN I was able to obtain the urine sample on the first try;-RN I did not go back and check on the resident after the incident;-RN I did not see the order for the urine analysis, but RN H told him/her there was one;-The doctor's order will state how staff are to collect the urine sample;-The facility does not have standing orders for residents;-Staff are to notify the physician regarding the resident's change of condition and the physician will tell staff how to proceed. Review of the resident's July 2026 Physician Order Sheet (POS) showed staff did not document a physician order for a urine analysis (test used to detect urinary tract infections). Review of the residents Lab Results Report, dated 07/24/2026, showed staff collected a urine sample from the resident on 07/20/2026, at 1:44 A.M. Observation on 08/01/26, at 12:20 P.M., of the resident showed the following:-CNA A and CNA C finished providing incontinent care to the resident;-The CNAs pointed out the bruising to the resident's inner left thigh;-The bruising ran from the resident's groin area down the inner left thigh to the residents left knee;-The bruising was yellow in color around a light purple area;-The CNAs said the resident's perineal area (the diamond-shaped region at the base of the pelvis located between the thighs) was also bruised;-The resident moaned and resisted when staff were moving the resident to provide care. Review of resident's skin audit, dated 08/03/26, showed the following:-The resident had bruising on the right iliac crest (thick, curved upper border of the ilium, the largest hip bone) (front);-The resident had bruising on the groin area;-The resident had bruising on the left thigh (front);-Staff did not document measurements of the bruises. Review of the Medical Director's progress note, dated 08/05/26, showed the following:-The resident was cooperative and pleasant today;-The resident had chronic weakness and debility;-The resident had impaired memory and cognition;-Right pelvic area had a 1.5 inches by 1 inch resolving ecchymoses (common bruise) noted;-Left medial femoral area had a 3.5 inch by 1.5 inch resolving ecchymoses noted;-Right upper arm had a 1 inch by 1 inch resolving ecchymoses noted;-Contracted knees. During an interview on 08/01/26, at 11:56 A.M., CNA A said the following:-CNA A worked on 07/21/26, and noticed the resident had massive bruising on her pelvic bone area and on his/her left inner thigh from the groin down to the knee;-He/She reported the bruising to RN B;-RN B said that overnight staff collected a urine sample and the resident became combative;-The overnight shift had to use straight catheterization to obtain a urine sample;-RN B told CNA A the bruise came from the staff holding down the resident while obtaining the urine sample;-The resident was nonverbal and unable to report pain to staff;-The resident will groan when staff touch the resident's left leg. During an interview on 08/01/26, at 12:29 P.M., CNA B said the following:-On 07/24/26, CNA B noticed bruising on the resident's left inner thigh and perineal area;-The resident's bruising on 07/24/26, was darker at that time than now;-CNA B was training and asked CNA A about the bruising and CNA A said that night shift had used straight catheterization to obtain a urine sample from the resident;-The resident became combative during the procedure and staff had to hold the resident down;-CNA A told CNA B that the nurse was aware of the bruising;-CNA B did not know if the nurse reported the bruising to management;-The resident gets upset when staff provide incontinent care and will scream and swing his/her arms around. During an interview on 08/03/26, at 3:01 P.M., CNA J said the following:-He/she was a shower aide;-He/she completed a shower sheet for each resident he/she showers;-He/she documented any skin tears, bruises, scratches, or wounds on the shower sheets;-He/she turned the shower sheet into the charge nurse, who then signs it;-CNA J gave the signed shower sheet to ADON K, who kept them in his/her office for two years;-The resident can be combative with cares, screaming and throwing hands around;-The resident's behaviors have increased over the last two weeks;-On 07/27/26, while showering the resident, CNA J noticed bruising in the resident's groin area and down the resident's left leg;-The bruises did not appear fresh. They were yellow/purplish in color and were big;-The bruises were new to CNA J so he/she contacted RN B to report them;-RN B said he/she was aware of the bruises and said that it took several staff members on the overnight shift to hold the resident down to obtain a urine sample;-The bruises on the resident were very alarming;-CNA J documented the bruising on the residents shower sheet. During an interview on 08/01/26, at 12:35 P.M., LPN D said the following:-The resident can be extremely combative and aggressive, swinging his/her arms around and screaming;-The resident was resistive to cares;-LPN D first heard about the resident's bruises in morning report. During an interview on 08/01/26, at 1:02 P.M., LPN E said the following:-The resident had an abrasion on her left knee that was being monitored;-LPN E was not aware of any bruising on the resident;-All residents have the right to refuse cares. During an interview on 08/03/26, at 2:05 P.M., RN B said the following:-RN B was not aware that night shift had collected a urine sample from the resident on 07/20/26;-On 07/21/26, LPN G told RN B that the resident had bruising in his/her groin area, lower abdomen, and inner thighs;-LPN G heard from RN H that six staff members held down the resident to collect a urine sample by straight catheterization;-LPN G said RN I assisted in the procedure;-RN B was horrified by the bruising on the resident;-On 07/30/26, while at the nurses' desk during shift change, LPN G called the DON, who was on call, to report that there was no documentation in the resident's chart regarding the bruises;-LPN G told RN B the DON told her We are working on it;-The resident's behavior got worse after the collection of the urine sample;-On 08/03/26, at shift change RN H said to RN B, of course the resident has bruising, it took six people to hold him/her down;-RN B considered staff holding down a resident to collect a urine sample while the resident is resisting, to be abuse. During an interview on 08/03/26, at 7:14 P.M., LPN G said the following:-The resident had behaviors that included slapping, yelling, screaming, and pulling his/her hair out;-The resident had bruising on his/her lower abdomen, pelvis, and on the left and right inner thighs down to the resident knees;-When LPN G saw the bruising last it was yellowing and purple;-LPN G knew of the bruises on the resident last week when he/she worked;-On 07/19/26, CNA M told him/her that multiple staff members restrained the resident to collect a urine sample;-On 07/24/26, LPN G asked RN H if he/she knew about the bruises and he/she did;-The CNA's that worked the overnight shift on 07/19/26, told her about the incident;-On 07/25/26, LPN G called the on-call nurse (DON) who said the bruises on the resident were not an injury of unknown origin and staff were aware of what happened;-The DON told LPN G that he/she would get a hold of RN H to document the incident and then the DON would contact LPN G to document his/her assessment;-CNA M held the resident's feet down;-CNA L, RN H, RN I, and CNA N were also involved in the incident;-It was obvious from the bruises the resident had how forceful the staff restrained him/her to obtain the urine sample;-LPN G did not know if staff restraining a resident to collect a urine sample was abuse but did feel that it was inappropriate;-The resident's behaviors had increased three to four days prior to the collection of the urine sample;-The staff receiving new orders from the doctor are to enter those orders in the resident's chart;-Staff are to document in a progress note the reasoning for the doctor order and family notification;-CNA's reported the resident was more apprehensive with cares after the incident;-CNA's reported having a harder time calming the resident down and getting him/her to understand what they were trying to do. During an interview on 08/03/26, at 7:01 P.M., ADON K said the following:-No staff reported any concern about the resident to ADON K;-ADON K was not aware of any bruising on the resident until this week;-ADON K heard over the weekend that staff collected a urine sample from the resident on 07/19/26;-Staff used a catheter to obtain the urine sample which could have caused bruises as well. During interviews on 08/01/26, at 1:17 P.M., on 08/03/26, at 7:58 P.M., and on 08/05/26, at 4:45 P.M., the DON said the following:-The resident required two people to assist with cares;-The resident had exhibited more behaviors with cares over the last couple of weeks;-The DON was not aware of the resident having any bruising;-When staff reported a new bruising on a resident a bump struck (event/investigation) was completed to find the origin of the bruising;-Staff should have a doctor's order prior to collecting a urine sample;-Staff should have a doctor's order stating to collect the urine sample by straight catheterization;-Staff should document all orders in the resident's medical chart prior to carrying out the orders;-The DON reviewed the resident's medical chart and did not locate a doctor's order to collect a urine sample by straight catheterization from the resident during the month of July 2026;-He/She was not aware of any bruising on the resident until 08/01/26;-No staff reported that staff members held down the resident to collect a urine sample;-He/She was not aware staff used the straight catheterization method to collect the urine sample from the resident;-Staff holding down a resident is an incident that required an investigation;-When staff receive a doctor's order staff should enter it in the resident's chart before staff carry out the order;-Staff should not collect a urine sample without a doctor's order. During an interview on 08/05/26, at 10:09 A.M., the Nurse Practitioner (NP) said the following:-The NP was at the facility once a week;-The resident had previously been receiving hospice services, but the resident discharged due to his/her condition stabilizing;-The resident had a history of behaviors that included yelling out because he/she was unable to say what she wanted/needed;-The resident had not exhibited aggressive behaviors;-The resident had past trauma from prior abuse, and the NP would be very hesitant to order a urine sample obtained by straight catheterization;-The NP referred the resident to hospice services after recent lab work showed the resident had elevated liver enzymes;-The NP was at the facility on Monday (08/03/26), and staff had not reported any bruises or concerns staff had regarding the resident;-Staff had not contacted the NP regarding combative or aggressive behaviors from the resident;-The NP did not recall reports of changes in the residents behavior in the past;-If staff had contacted the NP regarding the resident's behavior while trying to collect a urine sample he/she would treat the resident without completing a urine analysis (checks the physical, chemical and microscopic properties of an individual's urine);-The facility did not have standing doctor orders for urine analysis;-Nurses at the facility did not have the authority to make the decision to collect a urine sample for analysis;-Staff should stop what they are doing when a resident begins resisting the care;-Staff members holding down a resident while the resident is resisting is abuse. During interviews on 08/04/26, at 1:47 P.M., and 08/05/26, at 12:09 P.M., the Medical Director (MD) said the following:-The resident had diagnoses including dementia, seizure disorder, anxiety, and depression;-The resident had behaviors related to the dementia diagnosis;-The resident has previously rec[TRUNCATED]

Based on observations, interviews, and record review, the facility failed to ensure food items were stored in accordance with professional standards of practice for food service safety when expired foods were found in kitchen storage areas. Review of the facility's policy titled, Food Receiving and Storage, revised ,d+[DATE], showed foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). 1. Observation and interview on [DATE], at 9:01 A.M., alongside the Certified Director of Food Service (CDFS), showed a refrigerator in the main kitchen had an opened five-pound container of cottage cheese with a best by date of [DATE]. The CDFS confirmed this food item was expired. Observation and interview on [DATE], at 9:02 A.M., alongside the CDFS, showed the dry storage room of the main kitchen had 15, 12-ounce cans of evaporated milk with best by dates of [DATE]. The CDFS confirmed the items were expired. Observation and interview on [DATE], at 10:18 A.M., alongside the CDFS, showed the walk-in refrigerator in the main kitchen had unsliced ham stored in a clear plastic bag with a use-by date of [DATE]. The CDFS confirmed the food item was expired.

Based on observation, interview, and record review, the facility failed to ensure an effective infection control and prevention program was maintained for six residents (Resident #101, #211, #212, #215, #359, and #54) of 25 residents reviewed for infection control when the facility failed to clean and disinfect patient care equipment in between resident use. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 09/2022, showed the following: -Resident-care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection and the Occupational Safety and Health Association (OSHA) Bloodborne Pathogens Standard. -Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment); -Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturers' instructions. 1. Review of Resident #101's Admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab showed the resident was admitted to the facility on [DATE]. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an Assessment Reference Date (ARD) of 01/25/25 and located in the EMR under the MDS tab, showed the facility assessed the resident as cognitively intact. During an observation on 02/11/25, at 9:16 A.M., in the resident's room, Certified Medication Technician (CMT) 1 obtained the resident's blood pressure using a wrist cuff on the resident's right wrist. CMT1 obtained the resident's oxygen saturation (O2) using a pulse oximeter checking multiple fingers. CMT1 administered the resident's medications and left the resident's room. CMT1 set the unclean wrist cuff and pulse oximeter on top of medication cart without a barrier and moved his/her med cart to doorway of of Resident #211's room. 2. Review of Resident #211's Admission Record, undated, located in the resident's EMR under the Profile tab showed the resident was admitted to the facility on [DATE]. Review of of the resident's admission MDS, with an ARD of 01/08/25, and located in the resident's EMR under the MDS tab, showed the facility assessed the resident to have a moderately cognitively impaired. During an observation on 02/11/25, at 9:24 A.M., CMT 1 picked up the unclean wrist cuff from the top of the medication cart and entered the resident's room. CMT1 obtained the resident's blood pressure using the wrist cuff on the resident's right wrist. CMT1 then obtained the resident's O2 reading using the pulse oximeter on his/her finger. CMT1 set the unclean wrist cuff and pulse oximeter on top of medication cart without a barrier and moved his/her medication cart to the doorway of Resident #212's room. 3. Review of Resident #212's Admission Record, undated, located in the resident's EMR under the Profile tab revealed of the resident was admitted to the facility on [DATE]. Review of the resident's admission MDS, with an ARD of 01/28/25 and located in the resident's EMR under the MDS tab, showed the facility assessed the resident to be moderately cognitively impaired. During an observation on 02/11/25, at 9:43 A.M., CMT1 picked up the unclean wrist cuff from the top of medication cart and entered the resident's room. CMT1 obtained the resident's blood pressure using a wrist cuff on the resident's right wrist. CMT1 attempted to obtain the resident's O2 reading using the pulse oximeter on multiple fingers. CMT1 administered the resident's medications to him/her and left the resident's room. CMT1 then set the unclean wrist cuff and pulse oximeter on top of med cart without a barrier and moved her med cart to doorway of next resident's room to take vitals and administer meds too. 4. During an interview on 02/11/25, at 9:50 A.M., CMT1 said staff receive training once a month and get reminders all the time on infection control. He/she will wipe down the patient care equipment after using it on 5 to 6 residents. He/she didn't clean the wrist cuff or pulse oximeter before or after those three residents, but would have if they were on isolation or precautions. 5. During an observation on 02/13/25, at 9:07 A.M., CMT5 picked up a wrist cuff from top of the med cart and entered the Resident #212's room. CMT5 then obtained the resident's blood pressure using wrist cuff on his/her right wrist and obtained his O2 reading with the pulse oximeter he/she pulled out of his/her pocket. CMT5 administered the resident's medications to him/her, left the resident's room, set the now unclean wrist cuff and pulse oximeter on top of medication cart without a barrier, and moved the medication cart to doorway of the next resident's room to take vitals and to administer medications. 6. Review of Resident #215's Admission Record, undated, located in the resident's EMR under the Profile tab showed the following: -admitted [DATE]; -Diagnoses included sepsis due to methicillin susceptible staphylococcus aureus (MRSA) and severe sepsis with septic shock. Review of the resident's admission MDS, with an ARD of 01/27/25 and located in the resident's EMR under the MDS tab, showed staff assessed the resident as cognitively intact. During an observation on 02/13/25, at 9:18 A.M., CMT5 donned PPE from the isolation cart outside he resident's doorway. The resident's door had signage of Contact Precautions posted to. The CMT stated, I don't know why he is on contact precautions. I believe it has something to do with his medical condition and why he is here at this facility. CMT5 picked up the wrist cuff and pulse oximeter from top of medication cart and entered the resident's room, leaving his door partially open. CMT5 obtained the resident's blood pressure using the wrist cuff on his/her right wrist and obtained his/her O2 reading with the pulse oximeter. CMT5 administered there resident's medications to him, doffed his/her PPE, set the wrist cuff on top of the medication cart without a barrier, put the pulse oximeter that he/she was holding into his/her pocket, washed his/her hands, exited the room, and closed the door. CMT5 moved the med cart to the doorway of next resident's room to take vitals and to administer medications. 7. Review of Resident #359's Admission Record, undated, located in the resident's EMR under the Profile tab showed the resident was admitted to the facility on [DATE]. During an observation on 02/13/25, at 9:25 A.M., CMT5 picked up the unclean wrist cuff from the top of the medication cart and entered the resident's room. CMT5 obtained the resident's blood pressure using the wrist cuff on his/her right wrist and obtained his/her O2 reading with the pulse oximeter he/she pulled out of his/her pocket. CMT5 administered the resident's medications to him, left the resident's room, set unclean wrist cuff and pulse oximeter on top of the medication cart without a barrier, and moved her medication cart to the doorway of next resident's room to take vitals and to administer medications. 8. During an interview on 02/13/25, at 9:35 AM, CMT5 said staff are supposed to clean patient care equipment before, after, and in between each use. He/she forgot and didn't clean them between the three residents. 9. During an interview on 02/11/25, at 1:34 P.M., Registered Nurse (RN) 1 said he/she used to be the CNA program trainer and he/she always taught them to clean any type of patient care equipment with the disinfecting Sani-cloths after every use. During an interview on 02/12/25, at 10:54 A.M., the Infection Preventionist (IP) said patient care equipment should be cleaned between residents or whenever equipment is taken into a resident room. They are all trained to clean them that way and to use the cleaning wipes from the container with purple top. We have racks hanging on the walls on a couple of halls that have the cleaning wipes so they're easily accessible to staff to clean with. During an interview on 02/12/25, at 10:40 AM, the Director of Nursing (DON) said my expectation was that staff are all responsible for infection control. Staff are to use standard practice of cleaning for all patient care equipment before and after use on a resident. We task the infection control training with the IP, but staff always constantly giving everyone reminders.

Based on observations, interviews, and record review, the facility failed ensure storage of medication per standards of practice and in a manner that prevented possible of expired medications/supplies when staff failed to remove expired medications/supplies from one of two medication storage rooms and two of four medication carts. Review of the facility's policy titled, Medication Labeling and Storage, dated 2001, showed the following: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. -If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observation on 02/13/25, at 9:07 A.M., with Licensed Practical Nurse (LPN) 4 of the medication cart at the nurses' station on Hall 400 showed one open box and one unopened box of Assure Prism blood glucose control solution with the expiration date of 12/07/24 were found in the first drawer of medication cart. LPN4 confirmed they were expired and removed them from the medication cart. Observation on 02/13/25, at 9:40 A.M., with LPN5 of the medication cart at the nurses' station on Hall 300 showed one open box of Assure Prism blood glucose control solution with the expiration date of 12/07/24 was found in the first drawer of the medication cart. LPN5 confirmed it was expired and removed it from the medication cart. Observation on 02/13/25, at 9:43 A.M., of the medication room at the nurses' station on Hall 300 was showed one open bottle of Docusate Sodium Liquid [stool softener laxative] that was not labeled with an open date and had an expiration date of 06/2024 was found on a shelf in the cabinet. LPN5 confirmed it was expired and removed it from the medication cart. During an interview on 02/13/25, at 9:43 A.M., LPN5 said he/she didn't know how long it had been up there, but staff don't use it. It's everyone's job to check for expired meds. Staff also have a monthly audit done when the pharmacy comes in the building. During an interview on 02/13/25, at 12:05 P.M., the Director of Nursing (DON) stated all the certified medication techs (CMT) and nurses are responsible for checking expiration dates. Our pharmacy comes in monthly and audits all the medication carts and medication rooms and removes all the expired meds too.

Based on record review and interview, the facility failed administer psychotropic drugs only when medically necessary when staff failed to educate the residents and/or residents' representatives of the risks and benefits prior to starting the drugs, failed to monitor and document adequate behaviors indication to use the drugs, failed offer nonpharmacological interventions, and failed to monitor adverse side effects for antipsychotic, antidepressant, and anti-anxiety medication use for four residents (Resident #54, #60, #64, and #80) of five residents reviewed for unnecessary medication use. Review the facility's policy for Antipsychotic Medication Use, revised July 2022, showed the following: -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; -For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are not sufficiently relieved by non-pharmacological interventions; -Residents (and/or resident representatives) will be informed of the recommendations, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. Residents (and/or representatives) may refuse medications of any kind; -The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications; -Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician. 1. Review of Resident #54's admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 01/04/21; -Diagnoses included bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and depressive and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an assessment reference date (ARD) of 01/11/25 and located in the resident's EMR under the MDS tab, showed the facility assessed that the resident did not exhibit mood or behavioral symptoms. The resident received antipsychotic, antianxiety, and antidepressant medication. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed psychotropic, antipsychotic, and anxiolytic [antianxiety] medications to treat/manage his/her bipolar with alteration in mood disorder, depression with anxiety, initiated 01/14/21 and revised 08/02/23, included the following interventions: -Monitor/document/report as needed (PRN) any adverse reactions of psychotropic medications including unsteady gait, tardive dyskinesia (a chronic, involuntary movement disorder that can develop as a side effect of long-term use of certain medications, typically antipsychotic drugs), EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and behavior symptoms not usual to the person initiated 08/02/23. -Administer medications as ordered by physician and monitor for side effects and effectiveness initiated on 01/14/21; -Alprazolam (used to treat anxiety disorders, panic disorders, and anxiety caused by depression) has a black box warning of risks from concomitant use with opioids. Abuse, misuse, and addiction dependence and withdrawal reactions, initiated on 08/02/23 and revised 10/26/23; -Fluxotine (antidepressant medication) had a black box warning of antidepressants increased the risk compared with placebo of suicidal thinking and behavior, initiated 06/10/22 and revised 10/26/23; -Monitor/document/report as needed adverse reactions to antidepressant therapy including change in behavior/mood/cognition, hallucinations/delusions. social isolation, suicidal thoughts, withdrawal, decline in ADL (activities of daily living) ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea and vomiting, dry mouth, dry eyes, initiated on 08/02/23. -Monitor/document/report as needed any adverse reactions to anti-anxiety therapy including 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, and blurred or double vision. Unexpected side effects included mania, hostility, rage, and aggressive or impulsive behavior, initiated on 08/02/23. -Quetiapine fumarate (atypical antipsychotic used to treat schizophrenia, bipolar disorder and depression) had a black box warning of increased mortality in elderly patients with dementia-related psychosis, initiated on 06/10/22 and revised on 10/26/23; -Resident with failed gradual dose reduction (GDR), suicidal thoughts. Clinically contradicted per psychiatric physician documentation due to bipolar disorder. Resident stated he/she felt like killing him/herself during attempted GDR. Resident is oriented, younger age for long term care placement, initiated on 08/02/23 and revised on 11/20/24; -Weekly and as needed visits with psychologist, initiated on 10/26/23 and revised 06/25/24. Review of the resident's Care Plan for risk for mood changes related to bipolar disorder, depression, and anxiety, initiated 01/14/21 and revised 12/13/23, showed the following interventions: -Monitor/record mood to determine if problems seem to be related to external causes, i.e. medications, treatments, concern over diagnosis. Review of the resident's record showed the staff did not care plan to include interventions of what target behaviors were being treating with the antipsychotic, antidepressant, and antianxiety mediation use. Review of the resident's Administration Report, for orders dated 12/01/24 to 02/28/25, and dated 02/12/25, showed the resident received phototropic medication by physician's order as follows: -An order, dated 12/04/22, for fluoxetine HCl capsule 40 milligram (mg), administer one capsule by mouth one time a day for depression/anxiety related to major depressive; -An order, dated 04/06/23, for alprazolam tablet 0.25 mg, administer one tablet by mouth three times a day related to generalized anxiety disorder; -An order, dated 04/06/23, for Seroquel oral tablet 300 mg, administer one tablet by mouth at bedtime related to bipolar disorder; -An order, dated 01/16/25, to observed symptoms not usual for the resident every shift for antipsychotic utilization. If observed, document in progress notes with physician and nurse practitioner notification. Review of the resident's medical record showed the facility monitored the adverse side effects for antipsychotic use; however, there was no documented evidence the facility monitored the adverse side effects for the antidepressant nor the antianxiety medication use. There was no documentation that the facility was monitoring the resident specified target behaviors for the antipsychotic, antidepressant, and antianxiety medication use and what non-pharmacological intervention were offered based on the target behaviors. There was no documentation regarding the the resident, nor was her representative being informed of the risks and benefits of her antipsychotic, antidepressant, or antianxiety medications before starting. During an interview on 02/11/25, at 3:39 P.M., the Director of Nursing (DON) said the facility did not have records documenting the daily target behaviors for the resident's psychotropic medication use. The facility only documented the exceptions for behavior motoring. If no documentation had been provided, no behavior would have been observed. The IDT (interdisciplinary team) routinely met once a week and documented the target behavior weekly, but not daily. After reviewing the resident's record, the DON said the facility combined all the adverse effects monitoring in the MAR (medication administration record) and did not have monitoring documentation by each drug class as the resident's care plan instructed. The facility's care plan for psychotropic medication use did not include interventions to monitor resident-specified target behaviors based on each drug class used. There was no consent record for the resident's psychotropic medication use. All the residents signed a consent to treat agreement upon admission, and the facility verbally notified residents or their families about the risks and benefits of the psychotropic medication. This may be documented in the progress notes, but the home does not have a standard form of consent listing the different risks and benefits of each antidepressant, antipsychotic, and antianxiety medication. 2. Review of Resident #64's admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 09/07/22; -Diagnoses included major depressive disorder, single episode, unspecified; other specified anxiety disorders; unspecified dementia; and psychotic disorder with delusions due to known physiological condition. Review of the resident's annual MDS, with an ARD of 01/08/25 and located in the resident's EMR under the MDS tab, showed the resident received antipsychotic, antidepressant, and antianxiety medications during the seven days prior to the ARD. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed a focus area for antidepressant medications with intervention to monitor for antidepressant and antianxiety medication side effects. Review of the resident's Orders, located in the EMR under the Orders tab, showed the following active orders: -Sertraline (an antidepressant), 100 mg, administer one tablet by mouth in the evening for depression related to major depressive disorder;. -Quetiapine (antipsychotic agent), 25 mg, administer one tablet by mouth at bedtime for depressive disorder; -Buspirone (an antianxiety), 10 mg, administer one tablet by mouth three times a day for anxiety related to other specified anxiety disorder; -Trazodone (an antidepressant), 50 mg, administer one tablet by mouth in the evening for depression related to major depressive disorder; -Desipramine (antidepressant), 25 mg, administer one tablet by mouth in the evening for chronic pain related to other chronic pain; -Observe symptoms not usual for the resident and if present document in progress note with physician/nurse practitioner notification every shift for antipsychotic utilization. (The Orders did not include an order for behavior monitoring or side effect monitoring for sertraline, bupropion, trazodone or desipramine.) Review of the resident's Pharmacy MRR (Medication Regimen Review)-Antidepressant, dated 11/27/24 showed the resident was prescribed multiple antidepressant medications, concomitant use could increase the risk for serotonin syndrome, and the clinical pharmacist advised to Please review and ensure adequate monitoring for adverse effects, including CNS (Central Nervous System) depression is in place if these medications are continued concomitantly. Review of the resident's MAR, dated December 2024, January 2025, and February 2025, showed staff did not document behavior monitoring or side effect monitoring for sertraline, bupropion, trazodone, or desipramine. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed no routine documentation related to behavior monitoring or side effect monitoring for antidepressant/antianxiety medications. 3. Review of Resident #60's admission Record, undated, located in the resident's EMR under the Profile tab, showed the following: -An admission date of 03/25/22; -Diagnoses included Alzheimer's Disease, anxiety disorder, and major depressive disorder. Review of the resident's quarterly MDS, with an ARD of 12/25/24 and located in the resident's EMR under the MDS tab, showed the resident had received antipsychotic and antidepressant medications, but not antianxiety medication, during the seven days prior to the ARD. Review of the resident's Care Plan, located in the resident EMR under the Care Plan tab, showed a focus area for antidepressant, antianxiety, and antipsychotic medications with the intervention to monitor for side effects and effectiveness. The Care Plan also included an intervention to monitor side effects and effectiveness PRN (as needed). Review of the resident's Orders, located in the EMR under the Orders tab, showed the following current orders: -Mirtazapine tablet (antidepressant), 15 mg, administer 2 tablet by mouth in the evening for appetite related to abnormal weight loss; -Seroquel tablet, 25 mg, administer 0.5 tablet by mouth in the evening related to major depressive disorder, recurrent, unspecified; -Sertraline tablet, 50 mg, administer 1.5 tablet by mouth in the evening related to anxiety disorder, unspecified; major depressive disorder, recurrent, unspecified; -Trazodone tablet, 50 mg, administer 1.5 tablet by mouth in the evening for insomnia related to insomnia; -Clonazepam tablet disintegrating (hypnotic agent) .5 mg, administer 1 tablet by mouth in the evening related to anxiety disorder, unspecified; -Observe symptoms not usual for the resident and if noted document in progress note with physician/nurse practitioner notification every shift for antipsychotic utilization (The Orders did not include an order for behavior monitoring or side effect monitoring for mirtazapine, sertraline, trazodone or clonazepam.) Review of the resident's MAR, dated December 2024, January 2025, and February 2025, and located in the resident's EMR under the Orders tab, showed no documentation of any behavior or side effect monitoring for mirtazapine, sertraline, trazodone, or clonazepam. Review of of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed no routine documentation related to behavior monitoring or antidepressant/antianxiety side effect monitoring. 4. Review of Resident #80's admission Record, undated, located in the resident's EMR under the Profile tab, showed the following: -admission date of 09/30/23; -Diagnoses included Alzheimer's Disease, anxiety disorder, and adjustment disorder with depressed mood, and dementia, severe, without behavioral disturbance. Review of the resident's significant change in status MDS, with an ARD of 11/13/24 and located in the resident's EMR under the MDS tab, showed the resident received antipsychotic, antianxiety, and antidepressant medications, but no hypnotic medication, during the seven days prior to the ARD. Review of the resident's Care Plan, located in the resident EMR under the Care Plan tab, showed focus areas for antidepressant, antianxiety, and antipsychotic medications with the intervention to monitor for side effects and effectiveness. The Care Plan also included an intervention to monitor for side effects and effectiveness PRN (as needed). The interventions for lorazepam included monitor for side effects and effectiveness every shift. Review of the resident's Orders, located in the EMR under the Orders tab, showed the following current orders: -Lorazepam tablet (hypnotic/antianxiety), .5 mg, administer 1 tablet by mouth three times a day related to generalized anxiety disorder; -Seroquel tablet, 25 mg, administer 25 mg by mouth in the evening for hallucinations; increased per failed attempt of GDR (gradual dose reduction)' -Duloxetine capsule delayed release sprinkle (antidepressant), 30 mg, administer 1 capsule by mouth one time a day related to visual hallucinations; -Trazodone tablet, 50 mg, administer mg by mouth at bedtime related to adjustment disorder with depressed mood' -Observe symptoms not usual for the resident and if yes document in progress note with physician/nurse practitioner notification every shift for antipsychotic utilization. (The Orders did not include an order for behavior monitoring or side effect monitoring for lorazepam, duloxetine, or trazodone.) Review of the resident's MAR, dated December 2024, January 2025 and February 2025, and located in the resident's EMR under the Orders tab, showed no behavior or side effect monitoring for lorazepam, duloxetine, or trazodone. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed no routine documentation related to behavior monitoring or antidepressant/antianxiety side effect monitoring. 5. During an interview on 02/13/25, at 2:25 P.M., the Clinical Pharmacist (Pharm D) said he/she would expect staff to monitor side effects and behaviors at least daily, particularly with residents on multiple psychotropic agents. The clinical pharmacist was unaware the facility had used PRN monitoring for psychotropic medications in the care plans. During an interview on 02/11/24, at 11:33 A.M. the Director of Nursing (DON) said behavior and side effect monitoring for psychotropic agents was documented in the MAR. During an interview on 02/11/25, at 3:39 P.M., the DON said behaviors and side effects were documented by exception or if the physician ordered specific monitoring after a medication change. The behaviors and side effects are discussed during IDT meetings.

Based on observation, interview, and record review, the facility failed to ensure residents received their scheduled showers for six resident nts (Resident (R) R6, R7, R10, R30, R39, and R66) reviewed for showers out of 34 sampled residents This failure could lead to decreased quality of life and dignity. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Staff to document each bathing and notify the supervisor if any resident refuses the shower/tub bath; -The bathing documentation requirement included the the date and time the shower/tub bath was performed and if the resident refused the shower/tub bath, the reason; -Notify the supervisor if the resident refuses the shower/tub bath. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised ,d+[DATE], showed the followng: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene. 1. Review of Resident #10's Admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab, showed the an admitted [DATE]. Review of of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, showed the following: -The facility assessed the resident as moderately cognitively impaired; -The resident was dependent on staff to completion of the shower task. Review of the residen'ts Point of Care (POC) documentation showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 9:57 A.M., the resident said he/she gets one shower a week and he/she would like to get two showers a week. He/she only gets one on Monday and not the Thursday shower. The shower aide gets pulled to work on the floor instead. 2. Review of Resident #30'sAdmission Record, undated, located in the resident's EMR under the Profile tab, showed an admitted [DATE]. Review of R30's quarterly MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident as cognitively intact; -The resident was being dependent on staff to complete showers. Review of of the resident's POC documentation showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE], -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 10:29 A.M., the resident said he/she had been at the facility about 13 months. He/she only got one shower a week and would like to get more than one shower. The facility does not two showers due to the shower aide being needed out on the floor instead. 3. Review of Resident #66's Admission Record, undated and located in the resident's EMR under the Profile tab of the EMR, showed an admitted [DATE]. Review of the resident's significant change in status MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident was cognitively intact; -The resident was dependent on staff to complete showers. Review of the resident's POC showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE] -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 10:17 A.M., the resident said he/she doesn't get his/her showers. There was one week he/she did not get a bath for one week. He/she would like to get two showers a week, but there's not enough staff to help out. One time they gave him/her a little shower. They took hium/her in there and put him/her under the water, let the water fall on him/her, and then took him/her out as quick as they took him/her in. They did not wash him/her and called that a shower. 4. Review of Resident #39's Admission Record, undated, located in the resident's EMR under the Profile tab, showed an admitted [DATE]. Review of the resident's annual MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed as cognitively intact. -The resident to used a wheelchair and was dependent on staff for tub or shower transfers and to shower or bath him/herself. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit with limited mobility related to cerebrovascular accident (CVA - stroke) with hemiplegia (one-sided muscle paralysis or weakness); -Initiated [DATE], resident required dependent assistance by x 2 staff with bathing; -Initiatiated [DATE], resident prefers to have a whirlpool once a week and a sponge bath for his/her 2x week Tuesday/Friday. He/she prefers to have them after lunch with no set days. He/she agreed to have 2 whirlpools a week until his skin is healed. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as his care plan stated each Tuesday, Friday, and as needed. During the interview on [DATE], at 11:28 A.M., the resident said his/her last shower was about two weeks ago, with no bathing in between. He/she placed a bath request to the bath aides about two weeks ago, but no staff ever gave him/her one. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident received a bed bath; -On [DATE], the reesident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a whirlpool bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident did nto receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the rsident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident refused a bath; -On [DATE], the residet received a bath. -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During the interview on [DATE], at 3:35 P.M., the DON reviewed the resident's records and the monthly Documentation Surveyor Report V2 report for the resident's no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON stated that if a resident refuses to bathe, the staff should re-offer and document it. 5. Review of Resident #7's Admission Record, undated, located in the resident's EMR under the Profile tab, showed an admitted [DATE]. Revive of the resident's quarterly MDS, with an ARD of [DATE], and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed was cognitively intact; -The resident did not exhibit behavioral symptoms including rejecting care; -The resident used a wheelchair and required staff's supervision to touch assistance including verbal cues for tub or shower transfers; -The resident required substantial to maximal assistance to shower or bath him/herself. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit related to weakness; -Initiated [DATE], the resident required max assistance by 1 staff with bathing/showering 2x a week (Tues/Friday) and as necessary. -Initiated [DATE], the resident was independent with toilet transfers due to grab bar and required supervision assisting with all other transfers. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as hi/her care plan stated each Tuesday, Friday, and as needed. During an interview on [DATE], at 10:17 A.M., the resident said he/she got bathed once a week, which was not okay. He/she liked to be bathed two times a week. The resident said he/she had spoken to a social worker about his/her bathing preference. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident refused a bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not recieve a scheduled shower; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not recieve a scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the residetn refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not received a scheduled bath; -On [DATE], the resident received a bed bath; -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During an interview on [DATE], at 3:35 P.M., the DON reviewed the resident's records and the monthly Documentation Surveyor Report V2 report for the resident's no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON said that if a resident refuses to bathe, the staff should re-offer and document it. 6. Review of Resident #6'sAdmission Record, undated, located in the resident's EMR under the Profile tab, showed an admitted [DATE]. Review of the resident's quarterly MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident as cognitively intact; -The resident did not exhibit behavioral symptoms including rejecting care; -The resident used a wheelchair and required partial to moderate assistance for tub or shower transfer and substantial to maximal assistance for shower or bath. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit due to hereditary ataxia (a group of inherited neurological disorders characterized by progressive incoordination and loss of balance); -Initiated [DATE], provide sponge bath when a full bath or shower cannot be tolerated; -Initiated [DATE], resident was max assistance of 1 staff with bathing/showering 2 times a week Mon/Thursday and as needed. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as his/her care plan stated each Monday, Thursday, and as needed. During an interview on [DATE], at 1:39 P.M., the resident said he/she only received one bath a week instead of two times a week. The resident also said each Monday and Thursday were his/her scheduled shower days and that his/her last bath was last Thursday ([DATE]), which was the only bath of that week. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident received a shower; -On [DATE], the resident did not receive scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a shower; -On [DATE], the resident refused a bath; -On [DATE], the reisdent received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident did nto receive a scheduled bath; -On [DATE], the resdient recieved a shower; -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During an interview on [DATE], at 3:35 PM, the reviewed the resident's records, including the monthly Documentation Surveyor Report V2 report for the residents' no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON said that if a resident refused to bathe, the staff should re-offer and document it. 7. During an interview on [DATE],5 at 8:59 A.M., Certified Nurse Aide (CNA) 1 said his/her primary job was being a shower aide. Residents were supposed to get two showers a week unless they refuse. They wouldn't get a shower though if he/she was pulled to the floor because they were short staffed. The CNA said he/she gets pulled to the floor on average two days a week. During an interview on [DATE], at 1:34 PM, Registered Nurse (RN) 1 said the shower aides will let him/her know if a resident refuses their shower. Staff will still try to give them a second shower on the make-up days. Wednesday and Sundays are make-up shower days. If a resident repeatedly refuses, then staff will let their power of attorney know. There are not any resideent who regularly refuses showers. All the residents have scheduled shower days, but sometimes staffing affects it. At times they do have to pull the shower aide to help out on the floor as an aide. During an interview on [DATE], at 12:17 PM, the DON said anytime a resident wants a shower on another day, the staff will accommodate them. The same goes if the shower aide gets pulled to the floor, staff will still give them a shower another day. During an interview on [DATE], at 2:05 PM, the Assistant Director of Nursing (ADON) said residents have two scheduled showers a week. He/she didn't know of any residents that were refusing showers. The shower aide was supposed to let the ADON know when a resident refused a shower.

Based on interview, and record review, the facility failed to promote each resident's right to self-determination of care when staff did not provide showers as preferred and care planned for six resident (Resident #6, #7, #10, #30, #39, and #66) reviewed for showers out of 34 sampled residents This failure could lead to decreased quality of life and dignity. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Staff to document each bathing and notify the supervisor if any resident refuses the shower/tub bath; -The bathing documentation requirement included the the date and time the shower/tub bath was performed and if the resident refused the shower/tub bath, the reason; -Notify the supervisor if the resident refuses the shower/tub bath. Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised ,d+[DATE], showed the following: -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene. 1. Review of Resident #10's Admission Record, undated, located in the resident's electronic medical record (EMR) under the Profile tab, showed the an admitted [DATE]. Review of of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of [DATE] and located in the EMR under the MDS tab, showed the following: -The facility assessed the resident as moderately cognitively impaired; -The resident was dependent on staff to completion of the shower task. Review of the resident's Point of Care (POC) documentation showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 9:57 A.M., the resident said he/she gets one shower a week and he/she would like to get two showers a week. He/she only gets one on Monday and not the Thursday shower. The shower aide gets pulled to work on the floor instead. 2. Review of Resident #30'sAdmission Record, undated, located in the resident's EMR under the Profile tab, showed an admitted [DATE]. Review of the resident's quarterly MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident as cognitively intact; -The resident was being dependent on staff to complete showers. Review of of the resident's POC documentation showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE], -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 10:29 A.M., the resident said he/she had been at the facility about 13 months. He/she only got one shower a week and would like to get more than one shower. The facility does not two showers due to the shower aide being needed out on the floor instead. 3. Review of Resident #66's Admission Record, undated and located in the resident's EMR under the Profile tab of the EMR, showed an admitted [DATE]. Review of the resident's significant change in status MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident was cognitively intact; -The resident was dependent on staff to complete showers. Review of the resident's POC showed the resident did not receive a scheduled shower or bed bath on the following dates: -On [DATE] -On [DATE]; -On [DATE]; -On [DATE]; -On [DATE]; -Staff did not document any resident refusals of their showers or bed baths. During an interview on [DATE], at 10:17 A.M., the resident said he/she doesn't get his/her showers. There was one week he/she did not get a bath for one week. He/she would like to get two showers a week, but there's not enough staff to help out. One time they gave him/her a little shower. They took him/her in there and put him/her under the water, let the water fall on him/her, and then took him/her out as quick as they took him/her in. They did not wash him/her and called that a shower. 4. Review of Resident #39's Admission Record, undated, located in the resident's EMR under the Profile tab, showed an admitted [DATE]. Review of the resident's annual MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed as cognitively intact. -The resident to used a wheelchair and was dependent on staff for tub or shower transfers and to shower or bath him/herself. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit with limited mobility related to cerebrovascular accident (CVA - stroke) with hemiplegia (one-sided muscle paralysis or weakness); -Initiated [DATE], resident required dependent assistance by x 2 staff with bathing; -Initiated [DATE], resident prefers to have a whirlpool once a week and a sponge bath for his/her 2x week Tuesday/Friday. He/she prefers to have them after lunch with no set days. He/she agreed to have 2 whirlpools a week until his skin is healed. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as his care plan stated each Tuesday, Friday, and as needed. During the interview on [DATE], at 11:28 A.M., the resident said his/her last shower was about two weeks ago, with no bathing in between. He/she placed a bath request to the bath aides about two weeks ago, but no staff ever gave him/her one. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a whirlpool bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bath. -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During the interview on [DATE], at 3:35 P.M., the DON reviewed the resident's records and the monthly Documentation Surveyor Report V2 report for the resident's no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON stated that if a resident refuses to bathe, the staff should re-offer and document it. 5. Review of Resident #7's Admission Record, undated, located in the resident's EMR under the Profile tab, showed an admitted [DATE]. Revive of the resident's quarterly MDS, with an ARD of [DATE], and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed was cognitively intact; -The resident did not exhibit behavioral symptoms including rejecting care; -The resident used a wheelchair and required staff's supervision to touch assistance including verbal cues for tub or shower transfers; -The resident required substantial to maximal assistance to shower or bath him/herself. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit related to weakness; -Initiated [DATE], the resident required max assistance by 1 staff with bathing/showering 2x a week (Tues/Friday) and as necessary. -Initiated [DATE], the resident was independent with toilet transfers due to grab bar and required supervision assisting with all other transfers. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as hi/her care plan stated each Tuesday, Friday, and as needed. During an interview on [DATE], at 10:17 A.M., the resident said he/she got bathed once a week, which was not okay. He/she liked to be bathed two times a week. The resident said he/she had spoken to a social worker about his/her bathing preference. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident refused a bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident refused a bath; -On [DATE], the resident received a bed bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident did not receive a scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident did not received a scheduled bath; -On [DATE], the resident received a bed bath; -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During an interview on [DATE], at 3:35 P.M., the DON reviewed the resident's records and the monthly Documentation Surveyor Report V2 report for the resident's no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON said that if a resident refuses to bathe, the staff should re-offer and document it. 6. Review of Resident #6'sAdmission Record, undated, located in the resident's EMR under the Profile tab, showed an admitted [DATE]. Review of the resident's quarterly MDS, with an ARD of [DATE] and located in the resident's EMR under the MDS tab, showed the following: -The facility assessed the resident as cognitively intact; -The resident did not exhibit behavioral symptoms including rejecting care; -The resident used a wheelchair and required partial to moderate assistance for tub or shower transfer and substantial to maximal assistance for shower or bath. Review of the resident's Care Plan, located in the resident's EMR under the Care Plan tab, showed the following: -Initiated [DATE], ADL self-care performance deficit due to hereditary ataxia (a group of inherited neurological disorders characterized by progressive incoordination and loss of balance); -Initiated [DATE], provide sponge bath when a full bath or shower cannot be tolerated; -Initiated [DATE], resident was max assistance of 1 staff with bathing/showering 2 times a week Mon/Thursday and as needed. Review of the resident's Care Plan Item/Task Listing Report, dated [DATE], showed the facility scheduled the resident to receive bathing as his/her care plan stated each Monday, Thursday, and as needed. During an interview on [DATE], at 1:39 P.M., the resident said he/she only received one bath a week instead of two times a week. The resident also said each Monday and Thursday were his/her scheduled shower days and that his/her last bath was last Thursday ([DATE]), which was the only bath of that week. Review of the resident's monthly Documentation Surveyor Report V2, dated [DATE] to [DATE], showed the following: -On [DATE], the resident received a shower; -On [DATE], the resident did not receive scheduled shower; -On [DATE], the resident received a shower; -On [DATE], the resident received a shower; -On [DATE], the resident refused a bath; -On [DATE], the resident received a shower; -On [DATE], the resident received a bed bath; -On [DATE], the resident did not receive a scheduled bath; -On [DATE], the resident received a shower; -Staff did not document the resident was offered an opportunity to receive a bath or shower when the resident refused or missed their regularly scheduled bathing day. During an interview on [DATE], at 3:35 PM, the reviewed the resident's records, including the monthly Documentation Surveyor Report V2 report for the residents' no-bathing days. The DON said there was no documentation that bathing was reoffered every day before the next scheduled bathing day. The DON said that if a resident refused to bathe, the staff should re-offer and document it. 7. During an interview on [DATE],5 at 8:59 A.M., Certified Nurse Aide (CNA) 1 said his/her primary job was being a shower aide. Residents were supposed to get two showers a week unless they refuse. They wouldn't get a shower though if he/she was pulled to the floor because they were short staffed. The CNA said he/she gets pulled to the floor on average two days a week. During an interview on [DATE], at 1:34 PM, Registered Nurse (RN) 1 said the shower aides will let him/her know if a resident refuses their shower. Staff will still try to give them a second shower on the make-up days. Wednesday and Sundays are make-up shower days. If a resident repeatedly refuses, then staff will let their power of attorney know. There are not any resident who regularly refuses showers. All the residents have scheduled shower days, but sometimes staffing affects it. At times they do have to pull the shower aide to help out on the floor as an aide. During an interview on [DATE], at 12:17 PM, the DON said anytime a resident wants a shower on another day, the staff will accommodate them. The same goes if the shower aide gets pulled to the floor, staff will still give them a shower another day. During an interview on [DATE], at 2:05 PM, the Assistant Director of Nursing (ADON) said residents have two scheduled showers a week. He/she didn't know of any residents that were refusing showers. The shower aide was supposed to let the ADON know when a resident refused a shower.

Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications when on one resident (Resident #54), of five residents reviewed for unnecessary medication use, receive opioid pain medication without assessment of the proper pain level, without documention of non-pharmalogical interventions attempted first, and without documented monitoring for side effects. Review of the facility's policy for Medication Therapy, revised April 2007, showed the following: -Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks; -Upon or shortly after admission, and periodically thereafter the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen to identify whether there is a clear indication for treating that individual with the medication; the dosage is appropriate; the frequency of administration and duration of use are appropriate; and potential or suspected side effects are present. Review of the National Library of Medicine's website, accessed on 02/16/25, under the Bookshelf tab in book selection, State Pearls for Hydrocodone page, last update 01/29/24, showed the following: -Hydrocodone is primarily used to treat severe chronic pain that requires opioid analgesia and is not effectively treated by non-opioid alternatives; -Clinicians should vigilantly monitor patients for pain relief, constipation, respiratory depression, and other potential adverse effects; -The most common adverse effects of hydrocodone included frequent constipation and nausea; -Additional adverse effects of hydrocodone included the severe respiratory depression, shortness of breath, respiratory tract infection, hypotension (low blood pressure), bradycardia (fast heart beat), and peripheral edema (swelling), headache, chills, anxiety, sedation, insomnia, dizziness, drowsiness, fatigue, pruritus (itching), diaphoresis (excessive sweating), rash, vomiting, dyspepsia (discomfort or pain in the upper abdomen, often after eating or drinking), gastroenteritis (an inflammation of the lining of the stomach and intestines), constipation, abdominal pain, urinary tract infection, urinary retention associated with prostatic hypertrophy (a non-cancerous enlargement of the prostate gland, which is located below the bladder in men), tinnitus (a condition where a person perceives ringing, buzzing, hissing, or other noises in their ears or head, even when there is no external source of sound), sensorineural hearing loss, and secondary adrenal insufficiency. 1. Review of Resident #54's Admission Record, dated 02/11/25, located in the resident's electronic medical record (EMR) under the Profile tab showed revealed the facility admitted the resident on 01/04/21 with diagnoses including chronic pain syndrome. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) with an assessment reference date (ARD) of 01/11/25, showed the facility assessed the resident had frequent pain, which occasionally affected his/her sleep. The resident received scheduled and as needed pain medication including an opioid. Review of the resident's Care Plan for chronic pain due to limited mobility, myopathy (a group of disorders that affect the muscles, causing weakness and other symptom), and polyneuropathies (disorders that affect multiple peripheral nerves, causing damage and dysfunction), initiated on 04/13/21, showed following interventions: -Administer medications as ordered by physician and monitor/document side effects and effectiveness each shift; -Assess pain on scale of 1 to 10 every shift; -Hydrocodone/APA had a black box warning of addiction, abuse, misuse, and life-threatening respiratory depression. Review of the resident's Administration Report, for order range 12/01/24 to 02/28/25, dated 02/12/25, showed the resident received Norco Tablet 10-325 milligrams (mg) (hydrocodone-acetaminophen), one tablet by mouth every 4 hours as needed for pain. The report showed the resident had received Norco when experiencing no pain and mild to moderate pain (scale 0 to 4) as follows: -From 12/01/24 to 12/31/24: 53 times. -From 01/01/25 to 01/31/25: 22 times. -From 02/01/25 to 02/11/25: 11 times. Review of of the resident's record showed there was no documentation that the staff offered nonpharmacological interventions for pain prior to administering Norco when the resident indicated mild to moderate pain. Staff did not document about whether the staff had been monitoring the opioid's adverse effects. During an interview on 02/11/25, at 3:42 P.M., the Director of Nursing (DON) reviewed the resident's record and said there was no documentation the opioid adverse effects were being monitored and the nonpharmacological interventions for pain were offered.

Based on interview and record review, the facility failed to provide documented evidence the facility documented residents' and/or their representatives grievances and provided grievance decisions/resolutions after grievances were voiced for two residents (Resident #60 and #91) of 34 sampled residents. Review of the facility's policy titled, Grievances and Complaints Policy and Procedure, revised 12/2016, showed the following: -The facility had adopted an internal grievance procedure providing for prompt and equitable resolution of complaints/grievances of all types, including but not limited to, those alleging any discriminatory action prohibited by or in violation of patient rights, applicable state and/or federal law, internal policies, rules, enactments, guidelines, codes, regulations, or initiatives issued or enacted by any and all entities holding jurisdiction over this facility; -Depending on the nature of the complaint/grievance, there may or may not be an official form that should be completed in accordance with applicable regulations. Regardless, all complaints should be in writing, containing the name of the person filing the complaint/grievance, the address and other contact information for the person filing, the name of the patient, a description of the act/actions/problem prompting the complaint/grievance, and the remedy or relief sought; -All complaints/grievances should be filed with the facility Grievance Official immediately upon discovery of the offense and no longer than 30 days following discovery; -The Grievance Officer will investigate the complaint, and forward to governing entities as required. The investigation will afford all interested persons and their representatives an opportunity to submit evidence relevant to the complaint/grievance. The investigator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and share them only with those who have a need to know; -The Grievance Officer is responsible for all of the following with relation to filed grievances: receiving and tracking, leading and investigating, maintaining confidentiality, issuing official decisions and regulations, coordinating with state and federal agencies, preventing further violations while investigating, documenting findings; and adhering to all applicable state and federal laws and regulations. -The person making the complaint/grievance will be notified by the Grievance Officer of the findings and the resolution of the complaint/grievance. Review of the facility's Grievance Form, revised 12/2016, showed at the bottom of the form boxes to be checked by the facility or the Grievance Officer that included the following: -Grievance recorded on Grievance Log. -Decision/Investigation outcome discussed with person filing grievance on [DATE] by [initials of person who discussed outcome]; -Grievance resolved/no further action to be taken, or unable to resolve. 1. During an interview on 02/10/25, at 10:11 A.M., Family Member (FM) 2 was in Resident #60's room. FM 2 indicated one of the biggest concerns was the door coming into the unit was always buzzing and going off. FM 2 said about 90% of the time it malfunctioned and the alarm goes off. At times, it has alarmed for up to 15 minutes. The lengthy time the alarm went off was because no one could get to it right away. FM 2 indicated filing a grievance over a year ago and nothing had happened. The Social Service Director (SSD) told him/her it was brought up in a meeting, but nothing has happened to fix it. Observation on 02/11/25, at 12:45 P.M., in the memory care unit, showed an ongoing issue with the door alarm. During lunchtime, the door alarm was repeatedly sounding, and staff members were actively managing the alarm by turning it off and on to stop the noise. During an interview on 02/11/25, at 12:47 P.M., License Practical Nurse (LPN) 1 confirmed he/she was aware of the door's buzzing problem. The LPN explained the issue could be managed by being careful about how the door was closed. During an interview on 02/12/25, at 3:08 P.M., the Maintenance Man discussed the dementia unit door issue. He explained the door's magnet sometimes shifted and turned sideways. To prevent problems, staff members were instructed not to slam the door, but instead to close it gently. The Maintenance Man indicated this had been a long-standing practice at the facility, stating, I was told it has been that way, and this is what we do. He also mentioned that he had not received any complaints about noise from the door. During an interview on 02/13/25, at 10:19 A.M., the Administrator discussed concerns about a door alarm system. According to the Administrator, people sometimes caused the door alarm to malfunction by allowing the door to slam, which created a gap that prevented the alarm from triggering. The Administrator stated during his time at the facility, they had adjusted the door multiple times. The door alarm was designed to sound when the door was not closed securely. If the door closed too slowly, it might trigger the alarm. The Administrator stated he knew who complained about the door and he has had multiple conversations about the issue. When asked to review any grievances and written resolutions, the Administrator denied the survey team their request. 2. Review of the facility's policy titled, Personal Property, revised September 2012 showed the resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. Review of Resident #91's Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab showed the resident was admitted to the facility on [DATE]. Review of the resident's quarterly Minimum Data Assessment (MDS), with an assessment reference date (ARD) of 12/04/24 and located in the resident's EMR under the MDS tab, showed the resident was not a candidate for a brief interview for mental status (BIMS) interview. The resident had short- and long-term memory problems. Review of of the resident's Inventory Sheet, dated 06/17/24 and located in the resident's EMR under the Misc [miscellaneous] tab, showed personal items inventoried upon admission. During an interview on 02/10/25, at 1:48 P.M., Family Member (FM) 3 said the resident had several pieces of missing clothes. The facility was responsible for doing the resident's laundry. FM 3 talked to nurses, case workers, and the Administrator about missing clothes. The resident had a dozen pants now down to four pants, no socks, fleece jacket, two blankets, and a gray hoodless jacket. FM 3 said she brought clothes for the resident and the facility was to label and add them to the rest of the resident's belongings. FM 3 said he/she had completed several grievances, and most of the grievances she never received anything back after filing them. During an interview on 02/12/25, at 4:02 P.M., the Social Services Assistant (SSA) said housekeeping labeled the clothes with a label maker. For the residents who resided on the short-term hall, at times he/she marked items with a marker. He/she said he/she did not know the process exactly to label personal items that are brought in from home. The facility would turn missing items into grievance if the items were not found. The forms the facility had were internal forms only and the person filing a grievance does not get a copy of the form. During an interview on 02/12/25, at 4:19 PM, the Social Service Director (SSD) stated the resident had a care plan meeting, and the family mentioned a fleece sweater, socks, and a couple pair of pants were missing. The family was not provided or offered to file a grievance. During an interview on 02/13/25, at 10:19 A.M., the Administrator denied the survey team the access to the grievances and/or documented resolutions.

Based on interview and record review, the facility failed to provide care per standards of practice when facility staff failed to assess, monitor, care plan, and provide treatment for one resident (Resident #1) related to his/her surgical incision to his/her cervical (C) spine (back of neck) resulting in the incision dehiscing (surgical incision edges separated) and greenish-white drainage. The facility census was 111. Review of the facility policy/procedure titled, Wound Care, revised October 2010, showed the following: -The purpose of the procedure was to provide guidelines for the care of wounds to promote healing; -Staff to verify there is a physician's order for the procedure; -Staff to review the resident's care plan to assess for any special needs of the resident; -Staff to document all assessment data obtained when inspecting the wound (wound bed color, size, drainage, etc.); -Staff to document if the resident refused the treatment and the reason why; -Staff to notify the supervisor if the resident refused wound care; -Staff to report other information in accordance with the facility policy and professional standards of practice. 1. Review of Resident #1's face sheet showed the following: -admitted [DATE]; -Diagnoses included spinal stenosis (narrowing of the spaces between the disks) of the cervical (neck) region, encounter for surgical aftercare following surgery on the nervous system, abnormalities of gait and mobility, acute pain due to trauma, generalized anxiety disorder, obsessive compulsive disorder, and a history of falling. Review of the resident's hospital after visit summary, dated 07/25/24, showed the following: -Resident hospitalized from 07/03/24 to 07/25/24; -Procedures performed included cervical cord decompression (to relieve the pressure off the spine) and posterior and cervical fusion (surgical procedure to stabilize the spine in the neck region); -Discharge instructions for posterior cervical decompression showed neck brace to be worn at all times; -Incisional care said sutures in the incision will fall out on their own. Wash the area daily with warm, soapy water, and pat it dry. Keep the area clean and dry. You may cover it with a gauze bandage if it weeps or rubs against clothing. Change the dressing every day; -Call the physician immediately or seek immediate medical care if you have pain that does not get better after you take pain pills; have loose stitches; incision comes open; have blood or fluid draining from the incision; or have signs of infection such as increased pain, swelling, warmth, redness, red streaks leading from the site, swollen lymph nodes in the neck or armpits, or a fever. Review of the resident's admission summary progress note dated 07/25/24, at 12:10 P.M., showed the following in regards to the C-spine: -Resident arrived at the facility at this time via facility transport. Resident admitted to the hospital for a C-spine surgery on 07/03/24; -Resident's C-collar (a neck collar used to control head and neck movement) in place at all times related to recent surgical procedure. Review of the resident's July 2024 Physician Order Sheet showed staff did not document orders to assess, monitor, or treat the resident's surgical incision. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 07/29/24, showed the following: -Cognitively intact; -Recent surgery requiring skilled nursing facility (SNF) care with fusion of spinal bones; -Did not reject care; -Inattention and disorganized thinking continuously present; -Range of motion to bilateral (both sides) lower extremities impaired; -Used walker and wheelchair. Review of the resident's (facility) Nurse Practitioner progress note, dated 07/29/24, showed the following: -admitted to the hospital on 07/03/24 for further evaluation of global weakness in all his/her limbs as well as numbness in both upper extremities from the elbows down. The resident was taken to the operating room for a scheduled C 3-4 and C 4-5 laminotomy (removal of a portion of the vertebra to relief pressure), foraminotomy (surgical procedure to widen the opening in the spine where nerves exist), and decompression of spinal cord and nerve roots and posterior cervical fusion (surgical procedure to stabilize a portion of the spine) of C 3, C 4 and C 5 with lateral mass screws and rod on the right side only; -discharged to the facility on [DATE] for post-acute care; -Resident seen and examined today in the nursing facility. He/she was up in his/her wheelchair in the hall at the time of the visit; -Resident's cervical collar in place. The resident has a surgical incision to his/her posterior neck with silver dressing in place. Resident denied any specific complaints at that time. He/she denied pain or discomfort. Resident working with therapy and doing well; -Follow up with neurosurgery on 08/20/24; -Clean incision with soap and water and pat dry, wear cervical collar at all times; -Monitor for signs/symptoms of infection. Review of the resident's July 2024 Physician Order Sheet showed staff did not document orders to assess, monitor, or treat the resident's surgical incision. Review of the resident's nurse skin observation sheet, dated 07/29/24, showed surgical incision, post laminectomy (a removal of a portion of the vertebra to relieve pressure on the spine) with skin tears to left hand and small abrasion to bridge of the resident's nose. (The nurse did not document a full assessment and description of the incision.) Review of the resident's August 2024 Physician Order Sheet showed staff did not document orders to assess, monitor, or treat the resident's surgical incision. Review of the resident's social service progress note dated 08/05/24, at 11:40 A.M., showed the Admissions Coordinator documented the following: -Met with the resident to discuss discharge plans as staff stated the resident was not wanting to remain in LTC. Resident's medicare non-coverage letter explained to the resident. Resident stated was aware and would have family pick him/her up at the facility tomorrow, 08/06/24. -Resident was anxious about his/her neck collar that got wet. Notified therapy and nursing to assist the resident with the collar. Notified the resident the Social Service Director (SSD) would update the resident with home health information and any follow-up appointments. Review of the resident's nurse skin audit sheet, dated 08/05/24, showed surgical incision without redness. Skin tears to hand healing well without signs of infection and redness to resident's coccyx (tailbone area), blanchable. (The nurse did not document a full assessment and description of the incision.) Review of the resident's medical record showed staff did not document treatments completed to the resident's surgical incision, resident's refusal to allow for removal of the C-collar, physician notification of the incision care not provided or resident refusals, or full assessments and descriptions of the incision. Review of the resident's home health admission assessment, dated 08/07/24, showed the home health nurse documented the following: -The resident had a spinal surgery and stated that no one at the facility changed his/her dressing; -The resident had what appeared to be the original surgical dressing in place. The dressing was saturated with drainage and so was the collar; -The home health nurse called the facility to inquire what their wound care orders were and the facility said the sutures were to dissolve on their own and to leave open to air; -The home health nurse notified the resident of a large open wound; -The home health nurse also notified the surgeon and was able to schedule an appointment for the next day, 08/08/24; -Resident had an observable surgical wound to the upper spine that was open. Wounds size measured length of 4.5 centimeters (cm), width of 2.5 cm, and a depth of 0.3 cm with wound bed of 75% slough (collection of dead tissue and other debris that can build up in a wound, often appearing yellow, white, or tan) and tunneling (extending into the body tissues) 1.3 cm at 1 o'clock and 1.1 cm at 7 o'clock. During an interview on 08/22/24, at 10:30 A.M., the neurosurgeon's Nurse Practitioner (NP) said the following: -Facility staff should have followed hospital discharge instructions for wound care/monitoring of the resident's neck incision; -The C-collar was to remain in place, except for when the nurses were performing wound care; -On 08/07/24, the home health nurse sent the NP a photo of the resident's neck dressing and it appeared to be the type of dressing applied at the hospital prior to discharge, indicating the facility did not change the resident's incisional dressing; -On 08/08/24, the NP saw the resident in his/her office and the resident's neck incision had dehisced and the wound contained greenish-white drainage; -The NP cleansed and packed the wound and gave a new treatment orders for the home health nurse to treat the incision; -The NP consulted with the neurosurgeon, who did not feel the resident needed antibiotics for the wound at the surgical incision site, but did place the resident on antibiotics for an unrelated issue; -If the facility did not understand the hospital discharge instructions for treatment, they should have called the neurosurgery office for clarification of the orders; -Nurses at the facility should have assessed and performed incisional care to the neck incision at least daily while the resident was at the facility. Review of the resident's comprehensive care plan, showed the following incomplete care plan, date initiated 08/22/24 (post-discharge): -The resident has an alteration in muscoloskeletal status (SPECIFY) related to; -The resident will remain free of injuries of complications related to (SPECIFY) review date; -Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. (The care plan did not include any specifics related to the care/monitoring of the resident's surgical incision.) During an interview on 08/21/24, at 10:54 A.M., Licensed Practical Nurse (LPN) A said the following: -He/she assisted with the admission of the resident on 07/25/24: -He/she thought the resident's primary diagnosis upon admission was a laminectomy of the spine; -The nurse was not aware of any treatment order to the resident's neck incision upon admission; -He/she never saw the resident's neck without his/her collar on and the resident did not want the collar removed; -He/she, along with another nurse, completed the resident's admission assessment. The resident was anxious and refused to allow removal of his/her C-collar; -He/she cared for the resident on several different days after admission, but did not assess the resident's neck incision due to the resident's refusal to allow removal of his/her C-collar; -From the top of the C-collar, it looked like the resident had a patch over the back of his/her neck, but the nurse was unsure what was under the patch; -On one occasion, the resident wanted wet padding inside the C-collar changed after a shower, but the resident did not want the nurse to touch it. The resident went to therapy to have the padding changed out of his/her C-collar; He/she did not recall speaking with the resident's physician or nurse practitioner about the resident's neck or refusal to remove the C-collar; -The wound nurse worked Monday thru Friday each week at the facility and was responsible for resident skin treatments, including the treatment of surgical incisions; -If the wound nurse was not working, the nurses were responsible for the skin/surgical treatments; -After the resident discharged home, the Director of Nursing (DON) asked the nurse if he/she had ever removed the resident's brace and the nurse informed the DON the resident had refused to have the brace removed. During an interview on 08/21/24, at 11:15 A.M., LPN B said the following: -The resident admitted to the facility for rehabilitation after a cervical spine fusion and wore a C-collar; -The nurse was not aware of any orders for the resident for a skin treatment or incisional care; -The nurse was not aware the resident had an incision on his/her neck; -The resident refused to allow the nurse to remove his/her C-collar; -He/she probably could have done a better skin assessment on the resident; -The nurse did not think he/she notified anyone of the resident's refusal to allow removal of the C-collar, but should have notified the DON; -The wound care nurse usually performed care of resident surgical incisions, but the nurse was unsure if the wound nurse performed any incisional care for the resident during his/her stay at the facility; -Nurses were assigned weekly skin assessments for the residents, he/she tried to complete the assessments, but nurses were not consistently completing weekly skin assessments. During an interview on 08/21/24, at 11:35 A.M., Certified Nurse Assistant (CNA) C said the resident wore a neck collar at all times. He/she did not know the resident had an incision under the collar. During an interview on 08/21/24, at 11:39 A.M., Certified Medication Technician (CMT) D said the following: -The resident requested pain medications frequently and the CMT assumed the medication was for the resident's neck due to the neck brace; -The nurse usually asked about the resident's pain location and rating; -The CMT was unsure if the resident had a neck incision. During an interview on 08/21/24, at 12:17 P.M., LPN E said the following: -Upon admission, the admitting nurse was responsible for completing a head to toe skin assessment; -If he/she admitted a resident with a C-collar, he/she would look for a physician's order for the collar and assess the resident for any incision underneath the collar; -He/she would obtain a physician's order to assess the resident's incision for signs and symptoms of infection and for treatment orders to the incision; -He/she would notify the facility wound nurse about the resident's incision on admission. During an interview on 08/21/24, at 12:24 P.M., the Wound Nurse said the following: -He/she was responsible for resident weekly wound assessments and treatments for approximately the past year at the facility; -He/she generally performed the treatments Monday through Friday that required a dressing or monitoring, the nurses generally treated residents with superficial skin tears or abrasions; -The nurses were responsible for weekly skin assessments; -On admission, the charge nurses were responsible for completing head to toe skin assessments for all residents; -He/she looked at the resident's admission nurse assessment and the assessment did not show any skin concerns and therefore there was no reason for the Wound Nurse to see the resident; -After the resident's discharge, he/she heard from other staff the resident had a surgical dressing left in place on his/her neck; -If the resident refused to have his/her C-collar removed on admission. The nurse should notify the facility physician and the resident's surgeon and document the refusal in the progress notes; -If the resident was admitted following a C-spine surgery the nurses charting should be geared toward that and the nurses should assess the resident's incision every shift; -The facility would need to obtain orders for incisional care/monitoring every shift for signs and symptoms of infection from the physician; -To his/her knowledge, the resident had no orders related to his/her incision. During an interview on 08/21/24, at 12:55 P.M., the Occupational Therapist (OT) F said the following: -On one occasion, he/she assisted the resident with a shower and the resident's C-collar liner became wet; -The OT assisted the resident to bed and removed the front and back pieces of the collar and replaced the wet liner and then replaced the collar; -He/she did not visualize the back of the resident's neck or the incision during this time; -The resident never mentioned a dressing and the OT was not aware the resident had a neck incision. During an interview on 08/21/24, at 1:05 P.M., the DON said the following: -The wound nurse completed most resident skin treatments daily, Monday thru Friday; -If the wound nurse did not complete an ordered treatment, he/she would notify the charge nurse which resident treatments the nurses needed to complete that day; -Upon admission, the admitting nurse was responsible for head to toe skin assessments and notifying the Wound Nurse of any identified skin issues; -Upon admission, the nurse should visualize any surgical incisions, unless the hospital gave specific orders that the dressing was not to be removed, in which case the nurse would obtain orders from the physician to monitor the surrounding area for signs of infection every shift; -He/she interviewed several of the facility nurses and none of the nurses said they removed the C-collar. During interviews on 08/22/24, at 11:22 A.M. and 1:03 P.M., LPN G (Medicare Manager) said the following: -The nurse who admitted the resident should have placed an order on the resident's physician order sheet for treatment to the resident's neck incision since the order was listed on the hospital paperwork; -He/she documented the neck incision had no redness, but he/she did not visualized the incision, but rather the top edge of the dressing. During an interview on 08/22/24, at 2:15 P.M., LPN H said the following: -He/she was responsible for care plans; -The C-collar should listed on the resident's care plan; -If the resident's hospital paperwork contained special instructions related to care or monitoring of the surgical incision, LPN H would place the information on the care plan. During an interview on 08/22/24, at 2:20 P.M., the DON said the following: -Last week, a representative from former resident's home health agency came to the facility to inform the facility Administrator that the resident's neck incision dressing had not been changed during his/her time at the facility and when the home health nurse removed the dressing, the incision had dehisced; -Facility nurses should have clarified any orders on admission for treatment and/or monitoring of the resident's incision; -Staff should have included information in the resident's care plan regarding care and monitoring of the resident's C-collar and surgical incision. During an interview on 08/22/24, at 5:20 P.M., the Administrator said the following: -If a resident was admitted with a surgical incision, facility nurses should obtain a physician's order for monitoring and/or treatment of the incision; -If there is a discrepancy on the admission orders, the nurse should contact the primary care provider or surgeon's office for clarification; -Orders pertaining to the surgical incision should be on the care plan. MO00240762

Based on record review and interview, the facility staff failed to take steps to prevent further abuse and protect resident safety when staff failed to implement and care plan consistent and effective interventions for one resident (Resident #1) after resident-to-resident altercations with five residents (Resident #2, #3, #4, #5, and #6) resulting in continued altercations. The facility census was 99. Review of the facility's policy titled, Reporting Abuse, undated, showed the following: -The facility will not condone resident abuse by anyone, including staff members and other residents; -Physical abuse is defined as hitting, slapping, punching, kicking, etc. Review of the facility's policy titled, Preventing Resident Abuse, undated, showed the following: -Preventing resident abuse is a primary concern for the facility. It is the facility's goal to achieve and maintain an abuse-free environment; -The facility's abuse prevention program includes, assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect and assessing residents with signs and symptoms of behavior problems and developing and implementing care plans that can assist in resolving behavioral issues. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 03/22, showed the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; -Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; -When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers; -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; - The interdisciplinary team reviews and updates the care plan:when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment. 1. Review of Resident #1's face sheet (a snapshot of resident information) showed the following: -Initial admitted [DATE]; -Current admitted [DATE]; -Diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbances, generalized anxiety disorder, major depressive disorder, restlessness and agitation, excoriation (skin-picking) disorder, cognitive communication deficit, and hallucinations. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/03/24, showed the following: -Severe cognitive impairment; -The resident had hallucinations and delusions; -Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred one to three days of the review period; -Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) occurred one to three days of the review period; -The resident was independent with transfers. Review of the resident's care plan, revised 07/31/23, showed the following: -The resident had physical (hitting) and verbal (cursing, yelling) aggressive threatening behaviors due to dementia and poor impulse control; -Staff to administer Seroquel (an antipsychotic medication) 50 milligrams, two tabs in evening and as needed; -Educate staff to be aware of beginning signs early for potential development of altercations. Review of the resident's care plan, revised 05/07/24, showed the following: -Resident had a diagnosis of dementia unspecified; -Provide the resident with a program of activities that is meaningful and of interest like watching tv and/or listening to music; -Encourage and provide opportunities for exercise, physical activity. Review of the resident's nursing notes showed the following: -On 05/24/24, at 1:38 P.M., Resident #1 slapped another resident on the right shoulder with an open hand. The residents can't recall the event. There was no redness or bruising to either resident. The residents were immediately separated. Staff initiated 15-minute checks for the aggressor. There were no visual witnesses. Review of camera footage confirmed event; -On 05/24/24, at 1:45 P.M., the resident was observed approaching another resident who was seated in a chair near the nurses' station. Resident #1 leaned in close to the other resident and started yelling at him/her, It is 144 degrees outside! Go home or you will die! Staff intervened and separated the resident without further incident; -On 05/24/24, at 2:05 P.M., resident walked toward another resident asking, Do you have a room here? When peer answered yes, Resident #1 sat down in a chair beside him/her and with a raised voice said, Well, you better go to it. Resident #1 is currently being monitored on 15-minute checks. Staff immediately separated the residents. Both residents said they felt safe. Resident #1 said mind your own business and leave me alone when asked why he/she told peer to go to their room. The resident paced in the dining room in line of sight; -On 05/25/24, at 4:30 P.M., the resident continued to be monitored due to recent incident with another resident with no aggressive or inappropriate behaviors noted or reported. Resident ambulated ad lib (at will) with rollator-style walker and continued to pace the unit. Resident has been belligerent with staff and resists redirection; -On 05/26/24, at 4:28 P.M., the resident observed on multiple occasions this shift acting in an aggressive manner towards staff, another resident, and his/her responsible party. Resident also observed pacing through unit and being belligerent with staff with each interaction. Multiple times this shift, resident has attempted to strike or actually struck staff members with his/her rollator-style walker with redirection attempts not successful. The resident's walker had a malfunction to front left wheel, causing wheel to sit at an angle without turning. This caused resident to struggle using the walker for ambulation. Several times, the resident was approached and informed of the issue with the wheel and the risk of continuing to use the walker. This nurse asked to look at the wheel to determine what the issue was several times, to which the resident responded, Just leave me the hell alone, although resident allowed this nurse to assess the walker one time. While this nurse attempted to examine malfunctioned wheel, resident shoved the walker forward, striking this nurse in the face with the frame of the walker, at which time this nurse retreated from the resident's immediate area. When this nurse called resident's responsible party to notify him/her of the resident's behaviors, the responsible party informed him/her that the resident had struck him/her with his/her walker earlier this morning while he/she was visiting. The responsible party also said he/she was agreeable to the resident having a psychiatric evaluation completed due to increased behaviors and aggressive episodes; -On 05/26/24, at 1:06 P.M., Resident #5 sat in his/her wheelchair in the hallway. Resident #1 ambulated past the resident and slapped Resident #5 in the face. Staff did not visibly witness the strike, but it was audible to several staff members. Resident #5 immediately cried out for assistance and when asked by staff what had happened, he/she said, He/She slapped me! Right in the face! I didn't even do anything to him/her! Resident #1 said Get the hell away from me! I didn't do anything to him/her! The residents were immediately separated by staff. There was no injury; -On 05/29/24, at 4:21 A.M., staff noted on 05/28/24, at 8:30 A.M., Resident #5's hair was pulled/grabbed by Resident #1. Resident #1 was heard yelling, Get out of my room. When staff responded to scene both residents were in the doorway of their shared room. Resident #1 was holding on to Resident #5's hair. The residents were separated and Resident #1 started walking towards Resident #5. In efforts to redirect resident, staff stepped in front of wheelchair and grabbed the armrest. Resident #1 attempted to ram his/her wheelchair into the staff member's legs. Resident #1 then said, Let go of me or I'll knock the hell out of you. Resident #5 was questioned about incident and said, I was just trying to get by and he/she grabbed a hold of my hair and kept telling me to move. I told him/her to let go of me and she/he said he/she wasn't going to. I'm afraid he/she's going to do it again and if he/she does I'm going to get him/her back next time. What's wrong with him/her? Do you think he/she's missing something from his/her diet? Resident #1 said Yeah, I pulled him/her hair because he/she was in my way. I'll do it to you too. Get away from me and stop bothering me. Staff escorted Resident #5 to the nurses' station for one-on-one supervision until room change. Resident #5 denied any pain or discomfort. Staff implemented 15-minute checks Resident #1 until he/she's in bed for the night. Hot rack charting in place related to several resident-to-resident altercations where this resident was the aggressor. Resident remains on 15-minute checks until in bed for the night. A one time only dose of Seroquel 25 mg administered per physician. The resident's pacing/wandering has decreased. -On 05/29/24, at 9:30 A.M., during one-on-one monitoring for safety with a CNA, resident abruptly struck the face of a facility nursing aide student several times. Resident denied recollection of event when questioned; -On 05/29/24, at 9:23 A.M., the Director of Nursing (DON) said he/she spoke with Resident #1's responsible party regarding the resident's violent behavior and verbal threats towards peers and staff that required continual observation and one-on-one cares. As a result of these events and for the safety and well-being of all parties on the Memory Care Unit (MCU), an emergency discharge notice had been prepared and the facility would discharge the resident to his/her place of residence on this date. The resident's responsible party verbalized his/her understanding. The DON acknowledged that this may present a difficult circumstance for him/her to navigate considering the amount of time for preparation. The on-call provider was informed of increased behaviors and aggressive actions and a new order for a psychiatric evaluation was given. New order noted and carried out. Resident transported to hospital via ambulance without further incident at approximately 4:00 P.M.; -On 5/29/24, at 4:58 P.M., staff noted at 9:00 A.M., the physician was contacted that there was an incident of unknown origin with suspicion of resident-to-resident altercation. A witness said he/she saw Resident #6 being shooed out of Resident #1's room. Resident #1 was pushing a wheelchair into Resident #6 in a herding fashion. Resident #6 said He/She's trying to kill me. When asked if he/she was okay, Resident #6 showed new hematomas (is an abnormal collection of blood outside of a blood vessel or significant bruising) on his/her hands and said he/she beat me. Resident #1 said I better not talk about it. Go away. A skin assessment was completed on Resident #6 with a hematoma found on left hand, middle finger, wrapping to webbing of fingers and a hematoma on dorsum (back) of his/her right hand. Residents were immediately separated. A CNA is to stay with Resident #1 for one-on-one supervision; -On 05/29/24, at 12:19 P.M., staff noted the resident was discharged from the facility at 11:42 A.M., in the custody of his/her responsible party; -On 06/14/24, at 1:03 P.M., the Social Services Director (SSD) documented Resident #1's family appealed the decision that was made to do an emergency discharge. Resident #1 had hurt many residents in the MCU. The physician and staff had tried everything to help him/her not cause physical harm to other residents, but he/she continued to hurt residents and staff. The last time he/she physically hurt a resident, the decision had to made to do an emergency discharge. The DON and unit nurse had to make the decision he/she could no longer stay or come back to keeping other residents safe. SSD sent a response to the State why the facility did not feel it in the best interest for the safety of our other residents to have her come back. SSD sent the same letter to the Ombudsman and his/her responsible party; -On 06/20/24, at 3:59 P.M., the resident was admitted to the facility. Review of the resident's care plan showed staff update the care plan regarding any additional monitoring to protect other residents when the resident readmitted to the facility. Review of the resident's nursing notes showed the following: -On 06/21/24, at 3:00 P.M., staff noted the resident was alert and oriented to self only and verbalized needs to staff without difficulty. The resident paced the memory care unit and denied pain or discomfort. No aggression or inappropriate behaviors observed or reported at this time; -On 06/22/24, at 8:29 P.M., the resident paced laps on unit, opened residents' doors and leaving them open, which caused other residents' distress. Staff was unable to redirect the resident; -On 06/22/24, at 8:55 P.M., staff entered another resident's room and found Resident #1 in the room. Resident #1 was informed it was not his/her room and he/she walked towards the door. Resident #1 told him/her, I'm going to hit the hell out of you one of these days, and walked out of the room; -On 06/22/24, at 9:55 P.M., a certified nurse aide (CNA) redirected the resident out of the wrong room and resident said, move out of my way or I'm going to pounce you; -On 06/23/24, at 5:28 P.M., staff heard raised voices from down the hall. Upon investigation he/she found a resident in a wheelchair in the door to her room with Resident #1 attempting to pull the other resident's wheelchair out of the room while he/she said, you are in my room. Staff separated the residents and Resident #1 was informed where his/her room was. Resident #1 than went to his/her room and sat down on the bed. When interviewed regarding what occurred Resident #1 did not provide any new information that had not been provided by the other resident during the interview. Staff implemented immediate Intervention of residents separated and 15-minute location monitoring initiated for Resident #1; Review of the resident's care plan showed staff did not care plan regarding the resident's behaviors since admission or new interventions to protect other residents. Review of the resident's nursing notes showed the following: -On 06/23/24, at 10:18 P.M., a CNA reported that, Resident #1 was in Resident #2's room again. When he/she got to room Resident #2's room, Resident #2 was in his/her wheelchair in the doorway to his/her room. Resident #2 reported that Resident #1, pushed me out. He/she asked Resident #2 if Resident #1 had pushed him/her wheelchair or his/her body. Resident #2 rubbed his/her left forearm and said, with my body. The nurse entered the room and found Resident #1 sitting on Resident #2's bed. He/she Instructed Resident #1 to stand and leave the room because it is not his/her room. Resident #1 stood and walked out of the room with his/her wheeled walker. He/She took a few steps and started to turn around and come back. The nurse stopped the walker with his/her hand and the resident struck the nurse's right arm with an open hand and walked away. A physical assessment completed on both residents with no signs or symptoms of injury. Staff initiated 15-minute monitoring Resident #1. Staff notified the on-call provider for both residents and family/responsible party for both residents. Immediate intervention of Resident #1 removed from Resident #2's room and instructed not to return. Resident #2 was brought to the nurses' station and continued 15-minute checks on both residents. (Staff previously documents 15-checks implemented earlier on 06/23/24.) Review of the resident's care plan showed staff did not care plan regarding the resident's behaviors since admission or new interventions to protect other residents. Review of the resident's nursing notes showed the following: -On 06/24/24, at 5:50 A.M., staff noted hot rack charting related to two incidents in which this resident was the physical aggressor against another resident, the same resident both times. Resident rested well overnight in his/her bed with no further episodes of anxiety or aggression; -On 06/24/24, at 3:21 P.M., staff noted hot rack charting related to two incidents in which this resident was the physical aggressor. Resident is on 15-minute checks and walked with his/her walker around the unit. Resident ate breakfast and lunch. The resident is adjusting, but he/she was not friendly; -On 06/25/24 at 3:54 P.M., staff noted hot rack charting related to resident being physically aggressive with another resident. Resident is irritable when spoken too, however, he/ she was not aggressive towards resident nor staff this shift; -On 06/26/24, at 1:38 P.M., staff noted hot rack charting with continued to monitor for aggressive behavior with no such behavior noted or reported at this time. Resident ambulates ad lib with rollator-style walker and continuously paces the MCU; -On 06/26/24, at 1:35 P.M., staff noted Resident #1 was readmitted to MCU with a current order for Seroquel 25 mg twice daily. The resident continues to pick skin, trying to shoo bump others with his/her walker, yell out, speak rudely to staff, and aggressive/agitated with peers. There were two additional resident-to-resident altercations since being readmitted to memory care unit. Current interventions included sertraline (antidepressant), Depakote (antiepileptic than can be used as a mood stabilizer), participated in group activities parallel to others in group setting, one-on-one activities, and snacks. Interdisciplinary Plan to continue to monitor behaviors and intervene as needed. The physician does not feel resident is appropriate for gradual dose reduction of medication this time due to extent of skin picking, refusal of cares, and verbal threats towards others. (Staff did not address the 15-minute checks previously implemented.) Review of the resident's care plan, revised 06/27/24, showed the following: -Staff will continue to monitor the resident for aggression, location, and potential aggression toward others; -Staff to redirect resident from area where others are at risk; -Resident will not be involved in further altercations; -Staff to redirect resident from others that he/she has been known to have altercations previously. Review of the resident's nursing notes showed the following: -On 06/30/24, while in the dining room, the aides heard a resident call out for assistance on the other side of the dining room. Upon investigating, a resident said Resident #1 struck her. The residents were immediately separated. Resident #1 denied having struck the other and told this nurse, Go to hell. Staff notified administrative on-call and reviewed camera footage. Review of the footage showed Resident #1 was ambulating and attempting to go around the other resident, who was seated in his/her wheelchair. Resident #1 was unable to go around the other resident and attempted to move the other resident's wheelchair. A verbal altercation took place between the two residents and Resident #1 struck the other resident on the right shoulder with an open hand four times. The other resident began calling for help and Resident #1 walked away. Following the incident, a physical assessment attempted on Resident #1. Resident #1 was noncompliant and refused to allow this nurse to perform a physical assessment. Staff initiated 15-minute checks for location monitoring for Resident #1. Staff reported incident to on-call physician and the resident's responsible party; -On 07/01/24, at 12:54 P.M., staff noted on 06/30/24, at 8:43 A.M., while in the dining room, the aides heard a resident call out for assistance on the other side of the dining room. Upon investigating, a resident said Resident #1 struck him/her. Staff immediately separated the residents. Resident #1 denied having struck the other and told this nurse, Go to hell. Staff notified administrative on-call and reviewed camera footage. Review of the footage showed Resident #1 was ambulating and attempting to go around the other resident, who was seated in his/her wheelchair. Resident #1 was unable to go around the other resident and attempted to move the other resident's wheelchair verbal altercation took place between the two residents and Resident #1 struck the other resident on the right shoulder with an open hand four times, the other resident began calling for help and Resident #1 walked away. Following the incident, a physical assessment attempted on Resident #1. Resident #1 was noncompliant and refused to allow this nurse to perform a physical assessment. Staff initiated 15-minute checks for location monitoring for Resident #1. The incident reported on-call physician and the residents responsible party. Long term intervention of staff will monitor Resident #1's location at all times when he/she ambulates in close proximity of any other residents. Staff will be especially aware when the resident is in close location of residents who present as weaker, or more confused. The resident has been observed targeting this type of resident when he/she is agitated or anxious. Staff will add to care plan that staff will monitor the resident's location at all times when he/she ambulates in close proximity of any other residents and will be especially aware when he/she is in close location of residents who present as weaker, or more confused. The resident had been observed targeting this type of resident when he/she is agitated or anxious. Staff delivered a 30-day exit notice to resident and representative due to unsafe behaviors. Review of the resident's care plan, revised 07/01/24, showed the following -The resident had a resident-to-resident altercation; -The resident will not cause injury or receive injury from resident-to-resident altercations; -Physical assessment attempted and resident was noncompliant and refused; -Staff initiated 15-minute location monitoring from 8:45 A.M. to 5:45 A.M.; -Staff gave the resident's responsible party a 30-day exit notice due to unsafe behaviors; -Staff to monitor the resident's location at all times when he/she ambulates in close proximity of any other residents, Staff will be especially aware when he/she is in close location of residents who present as weaker, or more confused. The resident has been observed targeting this type of resident when he/she is agitated. Review of the resident's nursing notes showed the following: -On 07/02/24, at 9:44 A.M., staff noted hot rack charting related to medication change with no adverse reaction noted. Resident walks with his/her walker and has kept far away from other residents. Staff will continue to monitor; -On 07/02/24, at 10:23 P.M., staff noted hot rack charting related to resident being physically aggressive with another resident as well as recent start of Depakote. No adverse reaction to Depakote. No inappropriate behavior with any residents. Resident did refuse to allow vital signs to be obtained; -On 07/03/24, at 5:39 P.M., staff noted he/she was approached by a CNA who said a resident reported to him/her that he/she was struck by Resident #1. When interviewed, the other resident said that he/she was struck in the back while sitting in him/her wheelchair. Upon camera review, Resident #1 was observed to shake his/her hand at the other resident and then struck the other resident in the right shoulder. Immediate intervention was residents immediately separated. Resident #1 refused to allow a physical assessment. Staff initiated 15-minute location monitoring Resident #1; -On 07/04/24, at 3:29 A.M., staff noted hot rack charting related to recent start of Depakote and also for having an incident in which resident was physically aggressive with another resident. Resident #1 has not been aggressive with any residents; however, he/she was verbally aggressive with staff and staff were unable to redirect. Resident paced in hallway until 10:00 P.M. when he/she went to bed. Resident has rested well overnight; -On 07/04/24, at 10:38 A.M., staff noted on 07/03/24, at 4:15 P.M., the nurse was approached by a CNA who said a resident reported to him/her that he/she was struck by Resident #1. When interviewed, the other resident said he/she was struck in the back while sitting in his/her wheelchair. Upon camera review, Resident #1 was observed to shake his/her hand at the other resident and then struck the other resident in the right shoulder. Staff initiated 15-minute location monitoring for Resident #1. Staff notified Resident #1's responsible party of the incident. Resident's physician notified of incident. Long tem intervention of Resident #1 again placed on 15 minute locator monitoring. Staff is [NAME] about resident location and behavior. The facility continued with active attempt to find more compatible placement for resident. Staff added to the care plan resident again placed on 15 minute locator monitoring. Staff is [NAME] about resident location and behavior. Staff to continue with active attempt to find more compatible placement for resident. -On 07/04/24, at 11:32 A.M., staff noted said hot rack charting of continue to monitor for adverse effects of recent medication change with no adverse effects observed at this time. Resident #1 remained on 15-minute location monitoring due to recent altercation with another resident. Resident continued to pace the MCU with no aggressive behaviors noted at this time. Review of the resident's care plan, revised 07/04/24, showed the following: -Resident #1 was again placed on 15-minute locator monitoring; -Staff is [NAME] about resident location and behavior; -The facility continued to actively attempt to find more compatible placement for the resident. Review of the resident's nursing notes showed the following: -On 07/05/24, at 7:52 P.M., staff noted a dietary aide brought resident to the nurses' desk and said, He/She's trying to jump him/her. Upon review of cameras Resident #1 viewed standing aggressively over peer as peer is trying to get away in his/her wheelchair. The resident followed him/her using a wheeled walker. Resident #1 viewed striking him/her right forearm in the dining room. Immediate intervention of residents separated and new order for Zyprexa (antipsychotic medication) received and Seroquel increased to three times daily. Staff will monitor the resident closely and redirected when necessary; -On 07/06/24, at 12:05 A.M., staff noted the resident continued on hot rack charting for increase in Seroquel and new orders for Zyprexa and Depakote. The resident also continued on monitoring for aggression towards peers. The resident as viewed persistently going after peer as peer was attempting to get away and pacing hallways circling around to posture to peer as he/she passed. Staff monitors closely to keep residents separate. Will continue to monitor for changes in condition; -On 07/06/24, at 2:15 P.M., staff noted hot rack charting of resident continued to be monitored for adverse effects of recent medication changes. The resident was observed to pace the MCU continuously. Several times this shift, resident has entered into another resident's room and became belligerent with the room's occupant and staff when attempts to redirect resident to his/her own room are attempted. Staff notified administration and on-call provider of continued aggressive behavior. The nurse was instructed by administration to contact a psychiatric facility regarding possible transfer to that facility. The nurse was informed by the psychiatric facility that facility has placement available, and that the facility required medical clearance prior to admission, which could be performed at the hospital. Staff notified on-call provider of continuing aggressive behaviors and received new order to send resident to the hospital. Review of the resident's care plan, revised 07/07/24, showed the following: -Resident #1 has episodes of verbal and physical aggression including: yelling, cursing, verbally threatening, and physically hitting peers and staff; -The resident will have no increase in episodes of verbal/physical aggressive behavior this next review period; -Resident to remain separated from targeted resident with 15-minute location monitor until bedtime; -Staff to supervise for further indicators of aggression. Review of the resident's physician orders sheets, dated June 2024 and July 2024, showed staff did not document any specific behavior monitoring in place. 2. Review of Resident #2's face sheet showed the following: -admitted [DATE]; -Diagnoses included dementia, generalized anxiety disorder, and major depressive disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -The resident displayed no behaviors in the assessment period; -The resident required substantial assistance for transfers. Review of the resident's care plan, updated 12/11/23, showed the following: -The resident had impaired cognitive function/dementia or impaired thought processes; -Staff to use positive approach techniques including approach the resident from the front, use a wave and extend hand, then approach, modify hand position to engage the hand under hand technique, move to the side of the resident, and stay at eye level; -Present just one thought, idea question, or command at a time. Review of the resident's nurses' notes showed the following: -On 06/23/23, at 4:49 P.M., staff heard raised voices from down the hall. Upon investigation the nurse found a resident in a wheelchair in the door to his/her room with Resident #1 attempting to pull the other resident's wheelchair out of the room while he/she said, you are in my room. Resident #2 said He/She hit me. He/She threw water at me. He/She hit me with water, not her hand. If he/she had hit me with his/her hand, I would've hit her back; -On 06/23/24, at 10:18 P.M.,staff noted a CNA reported Resident #1 is in Resident #2's room again. When he/she got to room Resident #2's room, Resident #2 was in his/her wheelchair in the doorway to his/her room. Resident #2 reported that Resident #1, pushed me out. He/she asked Resident #2 if Resident #1 had pushed him/her wheelchair or his/her body. Resident #2 rubbed his/her left forearm and said, with my body. LPN E entered the room and found Resident #1 sitting on Resident #2's bed. He/she Instructed Resident #1 to stand and leave the room because it is not his/her room. Resident #1 stood and walked out of the room with his/her wheeled walker. He/She took a few steps and started to turn around and come back. The nurse stopped the walker with his/her hand and Resident #1 struck LPN E's right arm with an open hand and walked away. A physical assessment was completed on both residents with no signs or symptoms of injury. Staff initiated 15-minute monitoring was for Resident #1. Staff notified on-call provider and family/responsible party was notified for both residents. Immediate intervention was Resident #1 removed from Resident #2's room and he/she was instructed not to return. Resident #2 brought to the nurses' station and continued 15-minute checks on both re[TRUNCATED]

Based on observation, interview, and record review, the facility failed maintain an effective infection control program when staff failed to properly dispose of used Personal Protective Equipment (PPE - gloves, gowns and masks) and failed to don the appropriate PPE when entering isolation rooms with residents positive with Coronavirus Disease 2019 (COVID-19); when staff failed to implement source control when the facility had resident positive for COVID-19; and when staff failed to separate and appropriately handle hall trays and cleaning supplies removed from isolation rooms with residents positive with COVID-19. The facility census was 93. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 05/08/23, showed the following: -The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency; -Healthcare facilities should have a plan for how SARS-CoV-2 (COVID-19) exposures in a healthcare facility will be investigated and managed and how contact tracing will be performed; -Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking. sneezing, or coughing. Masks and respirators also offer varying levels of protection to the wearer. People, particularly those at high risk for severe illness, should wear the most protective mask or respirator they can that fits well and that they will wear consistently; -Source control options for health care personnel (HCP) include a NIOSH approved particulate respirator with N95 filters (a safety device that covers the nose and mouth and helps protect the wearer from breathing in some hazardous substances. An N95 mask protects a person from breathing in 95% of small particles in the air) or higher; a respirator approved under standards used in other countries that are similar to NIOSH approved N95 filtering face piece respirators; a barrier face covering that meets ASTM F3502-21 requirements including workplace Performance and Workplace Performance Plus masks; OR a well-fitting facemask; -When used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment, they should be removed and discarded after the patient care encounter and a new one should be donned; -Source control is recommended more broadly in the following circumstances: by those residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over (e.g., no new cases of SARS-CoV-2 infection have been identified for 14 days); or facility-wide or, based on a facility risk assessment, targeted toward higher risk areas (e.g., emergency departments. Urgent care) or patient populations (e.g., when caring for patients with moderate to severe immunocompromised) during periods of higher levels of community SARS-CoV-2 or other respiratory virus transmission; or have otherwise had source control recommended by public health authorities (e.g., in guidance for the community when COVID-19 hospital admission levels are high). Review of the facility's policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, dated 04/2022, showed the following: -The facility follows recommended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility; -This policy is based on current recommendations for standard precautions and transmission-based precautions, environmental cleaning, and social distancing for COVID-19; -While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including hand hygiene, respiratory hygiene, appropriate use of PPE, transmission-based precautions (where indicated), monitoring and reporting of respiratory infections, environmental cleaning (with EPA-registered disinfectants approved for use against SARS-CoV-2), and laundry practices; -To address asymptomatic and pre-symptomatic transmission, universal source control is being implemented when there is a COVID-19 outbreak in the facility, otherwise facemasks are optional for staff, residents, and visitors. Anyone entering the facility is required to have a face covering regardless of symptoms. Cloth face coverings are appropriate for visitors and residents. Cloth face coverings for source control are not considered PPE. Staff should wear a facemask at all times when in the facility if facility is in an outbreak status; -Standard precautions are utilized when caring for all residents. Review of the facility's policy titled Personal Protective Equipment, revised 10/2018, showed the following: -Personal protective equipment appropriate to specific task requirements is available at all times; -Personal protective equipment provided to personnel includes, but is not necessarily limited to, gowns/aprons/lab coats (disposable, cloth, and/or plastic), gloves (sterile, non-sterile, heavy-duty and/or puncture-resistant), masks, and eye wear (goggles and/or face shields); -Not all tasks involve the same risk of exposure, or the same kind or extent of protection. The type of PPE required for a task is based on the type of transmission-based precaution, the fluid or tissue to which there is a potential exposure, the likelihood of exposure, the potential volume of material, the probable route of exposure, and the overall working conditions and job requirements; -A supply of protective clothing and equipment is maintained at each nurses' station. PPE required for transmission-based precautions is maintained outside and inside the resident's room, as needed; -Training on the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals. Review of the facility's policy titled Personal Protective Equipment - Using Face Masks, revised 09/2010, showed the following: -Objectives are to prevent transmission of infectious agents through the air, protect the wearer from inhaling droplets, prevent transmission of some infections that are spread by direct contact with mucous membranes, prevent the splashing of blood or body fluids into the mouth or nose, and prevent exposure to viruses from blood or body fluids; -Put the mask on before entering the room and after cleaning hands. -Be sure that face mask covers the nose and mouth while performing treatment or services for the patient; -Before changing a face mask, wash hands. -Do not remove the mask while performing treatment or services for the patient; -Follow established handwashing techniques; -Use a mask when providing treatment or services to a patient who has a communicable respiratory infection and when providing treatment or services to a patient and the use of a mask is indicated. -Obtain a mask, wash your hands, remove the mask from its container (Note: if gowning procedures are necessary, put the mask on before putting on gown.), place the mask over the nose and mouth and avoid any unnecessary handling of the mask; -Removing the mask: wash hands, remove the mask from the face, discard the mask into the designated waste receptacle inside the room, and wash hands. Review of the facility's sign for the sequence for donning and doffing personal protective equipment (PPE) showed the following: -The type of PPE used will vary based on the level of precautions required; e.g., standard and contact, droplet or airborne infection isolation; -Sequence for donning PPE is as follows: Gown - cover torso from neck to knees, arms to end of wrists and wrap around the back. Fasten in back of neck and waist. Mask or respirator - secure ties or elastic bands at middle of head and neck. Fit flexible band to nose bridge. Fit snug to face and below chin. Fit-check respirator. Goggles or face shield - place over face and eyes and adjust to fit. Gloves - extend to cover wrist of isolation gown; -Use safe work practices to protect self and limit the spread of contamination. Keep hands away from face, limit surfaces touched, change gloves when torn or heavily contaminated, and perform hand hygiene; -Sequence for removing personal protective equipment. Except for respirator, remove PPE at doorway or in anteroom (a small room between areas of contamination and treatment areas). Remove respirator after leaving patient room and closing door. Gloves - the outside of gloves is contaminated; grasp outside of glove with opposite gloved hand and peel off. Hold removed glove with gloved hand. Slide fingers of ungloved hand under remaining glove at wrist. Peel glove off over first glove. Discard gloves in waste container. Goggles or face shield - the outside of goggles or face shield is contaminated. To remove, handle by head band or ear pieces. Place in designated receptacle for reprocessing or in waste container. Gown - gown front and sleeves are contaminated. Unfasten ties. Pull away from neck and shoulders, touching inside of gown only. Turn gown inside out. Fold or roll into a bundle and discard. Mask or respirator - Front of mask/respirator is contaminated, do not touch. Grasp bottom, then top ties or elastics and remove. Discard in waste container; -Perform hand hygiene immediately after removing all PPE. Review of a sign placed on COVID-19 isolation rooms for droplet precautions showed everyone must clean their hands, including before entering and when leaving the room, make sure their eyes, nose and mouth are fully covered before room entry or remove face protection before room exit. Review of the facility's policy titled Coronavirus Disease (COVID-19) - Cleaning and Disinfecting, revised 09/2022, showed the following: -Standard cleaning and disinfection practices in accordance with the Centers for Disease Control and Prevention, measures are implemented when areas, material or equipment have likely been contaminated by a person with COVID-19; -Management of laundry, food service utensils, and medical waste are performed in accordance with routine procedures; -Once the resident has been discharged or transferred, staff, including environmental services personnel, should refrain from entering the vacated room without all recommended PPE until 24 hours has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use. 1. Observations on 11/28/23, at 8:32 A.M., showed the following: -Nursing Assistant (NA) N donned a surgical mask and gloves and entered isolation room [ROOM NUMBER] with a food tray; -NA N exited the room, doffed the gloves and mask and laid them on the PPE cart outside isolation room [ROOM NUMBER]; -He/she did not perform hand hygiene, donned new gloves, and surgical mask only, picked the soiled mask and gloves up off the PPE cart and entered room [ROOM NUMBER] to throw the soiled mask and gloves into the red bagged trash inside this room; -He/she continued into room [ROOM NUMBER] without removing the newly soiled gloves, performing hand hygiene or donning clean gloves; -He/she did not don a gown, eye protection, or N95 mask when entering room [ROOM NUMBER] or 322; -He/she exited room [ROOM NUMBER] carrying a hall tray and wearing the surgical mask and gloves and placed the tray on the hall cart; -He/she then doffed the surgical mask and gloves, used his/her elbow to open the door of room [ROOM NUMBER], placed the gloves and mask in the trash inside room [ROOM NUMBER] and performed hand hygiene. Observation on 11/28/23, at 12:23 P.M., showed the following: -NA N donned a gown, gloves, and surgical mask, and entered room [ROOM NUMBER]. He/she did not don a N95 mask or eye protection; -He/she later donned a gown, gloves and surgical mask and entered room [ROOM NUMBER]. He/she did not don a N95 or eye protection; -LPN C donned a gown, gloves, and N95 mask, and entered room [ROOM NUMBER]. He/she did not don eye protection. Observation on 12/01/23, at 10:16 A.M., showed the Housekeeping Supervisor exited room [ROOM NUMBER], which was a COVID-19 isolation room. He wore his gloves out of the room, touched the door handle, door frame and an empty cardboard box. He grabbed a red bag and placed it in the empty box, opened the door to room [ROOM NUMBER] again, and placed the box with a red bag inside the room. He then continued to walk down the hallway wearing the same gloves. During an interview on 11/29/23, at 8:57 A.M., Licensed Practical Nurse (LPN) C said the following: -Before entering a COVID-19 isolation room, he/she performed hand hygiene, donned a gown, gloves, goggles and N95 mask; -When he/she exited, he/she doffed all of the PPE and placed in the trash inside the room, performed hand hygiene and donned a new mask. During an interview on 11/30/23, at 12:11 P.M., Registered Nurse (RN) H said the following: -When staff entered an isolation room, they should put on a gown, mask and gloves and when they exit they should remove the PPE in the room, place in red bag and sanitize their hands; -Staff should not place used PPE on the PPE cart because it would contaminate all that is on the cart and bringing the used PPE out into the hallway could spread the virus. During an interview on 12/01/23, at 9:05 A.M., the Infection Preventionist (IP) said the following: -When staff enter a COVID-19 isolation room they should sanitize their hands, don gown, gloves, N95 mask and eye protection and when they exit they should doff the PPE, place in red bag in the resident's room, and sanitize their hands; -Staff should not enter COVID-19 isolation room only wearing surgical mask and should not doff the mask and gloves, exit the room and place the dirty PPE on the PPE cart. If the room they exited did not have a red bag for PPE, they should place in a regular trash bag, tie it up and leave in the room until they get the proper red bag receptacle in that room. During an interview on 12/01/23, at 9:52 A.M., the Director of Nursing (DON) said the following: -When staff entered a COVID-19 isolation room, they should wear a N95 mask, eye protection, gown and gloves and when they exited the room they should doff the PPE before they leave the room and sanitize their hands; -Staff should not enter those rooms wearing just a surgical mask and gloves; -Staff should not place a dirty mask and gloves after exiting an isolation room on top of the PPE cart because that would cause cross contamination. If they did not have what they needed in the isolation room, they could activate the call light and request the item or double bag the dirty PPE and leave in the room until they could get a red bag receptacle into the room. During an interview on 12/01/23, at 11:36 A.M., the Administrator said the following: -When entering COVID-19 isolation rooms, staff should don N95 mask, gown, and gloves and they should doff before leaving the room and place the PPE in the trash inside the room; -Staff should not exit isolation room and place dirty mask and gloves on PPE cart. This could spread the infection. 2. Observation and interview on 11/27/23, at 8:40 A.M., showed the following: -The administrator said the facility had three residents who tested positive for COVID-19 on two separate areas of the facility; -No staff wore face masks for source control in any area of the facility. Observations on 11/27/23, from 8:40 A.M. to 4:15 P.M., showed no staff wore face masks for source control on the two areas or halls where the COVID-19 positive residents resided. During an interview on 11/28/23, at 11:55 A.M., Administrative Assistant BB said the following: -When a resident tested positive for COVID-19, staff moved the resident to another area of the facility and placed them in isolation; -When visitors entered the facility, he/she would let them know if the facility had COVID-19 positive residents; -Source control depended on the number of residents who tested positive for COVID-19; -If a resident had COVID-19, staff and visitors were encouraged to wear masks in those rooms; -Last week, the Administrative Assistant asked the infection preventionist (IP) for more training regarding the facility's COVID-19 protocol. The IP told him/her he would provide that education the following week. During an observation interview on 11/28/23, at 12:00 P.M., Certified Medication Technician (CMT) Z said the following: -The CMT stood near the dining room preparing medications for administration. The CMT was not wearing a face mask; -The facility currently had five people who tested positive for COVID-19. The five residents resided on two different areas of the facility; -Staff did not wear masks for source control until the facility was in outbreak status which occurred when multiple residents, residing on all halls, tested positive. During an interview on 11/28/23, at 12:05 P.M., CMT AA said the following: -The CMT stood near the dining room preparing medications for administration. The CMT was not wearing a face mask; -Staff wore face masks in the halls for source control when administrative staff told them to. Observation on 11/28/23, at 3:05 P.M., showed the following: -The barrier doors separating the foyer from the resident care areas were closed. On the door hung a sign with the image of a red stop sign that gave the following information/instructions: Droplet Precautions: Everyone must clean their hands, including when entering and when leaving the room. Make sure eyes, nose, and mouth are fully covered; -A small white three drawer storage cart sat to the side of the barrier doors. It contained gloves and masks for staff to apply before entering the resident care areas. Observation and interview on 11/28/23, at 3:07 P.M., showed the following: -The Dietary Manager (DM) wore a surgical type face mask which covered his/her nose and mouth; -The DM said, while in a care plan meeting, she received a message on the secured messaging app that directed staff to wear face masks any time they worked on the two areas COVID-19 positive residents resided. The DM did not know what prompted the change from not wearing masks to wearing masks. Observation and interview on 11/28/23, at 3:08 P.M., showed the following: -The Activity Director (AD) wore a surgical type face mask which covered his/her nose and mouth; -The AD said about an hour ago, the IP told her to wear a face mask when she worked in the resident care areas where COVID-19 positive residents resided; -The AD did not know what prompted the change. Observation and interview on 11/28/23, at 3:10 P.M., showed the following: -LPN Q sat at the nurses' station in one of the resident care areas. The LPN did not have a face mask covering his/her mouth or nose. When asked about his/her mask, the LPN said he/she just returned from outside and forgot to put it on. The LPN found his/her surgical type face mask and put it on; -The LPN said, about an hour ago, the IP told staff to wear face masks when working in the COVID-19 positive areas. The new directive occurred due to the number of COVID-19 positive residents residing in the facility. The facility now had five residents who tested positive. Observation and interview on 11/28/23, at 3:12 P.M., showed the following: -LPN Y sat at the nurses' station in one of the resident care areas. The LPN wore a surgical type face mask that covered his/her nose and mouth; -The LPN said the facility now had five COVID-19 positive residents and one resident in the hospital with pneumonia caused by COVID-19. During an interview on 11/29/23, at 8:57 A.M., LPN C said he/she considered a COVID-19 outbreak when the facility had multiple residents on multiple units positive for COVID-19. During an interview on 12/01/23 at 1:11 P.M., the DON said the following: -When a facility had two or more residents test positive for COVID-19, the facility was considered in outbreak status. The CDC recommendations included staff wearing face masks as source control when a facility had an outbreak of COVID-19; -The facility administration did not implement source control for the two resident areas where COVID-19 positive residents resided because the residents resided in controlled areas; -A few months ago, the facility had positive Covid-19 residents, but the infection was contained to the locked unit; -When the unit was out of outbreak status, the facility had a resident who resided on another area, test positive. Staff moved that resident to another area attempting to cluster any COVID-19 positive residents to a specific area; -Over the holiday weekend, two residents who resided on the non-specific area, tested positive. One resident refused to move to another area of the facility. Staff determined moving the second resident to another area of the facility would be detrimental to his/her psychosocial well-being. Both of those residents resided in private rooms; -On 11/28/23, another resident tested positive. At that time, the facility decided since they could not cluster the residents to a specific area, they would require all staff to wear face masks in those two resident care areas; -Staff should wear masks if there was a facility acquired COVID-19 positive resident, but Administration did not advise staff to wear masks when the first resident tested positive for Covid-19. During an interview on 12/01/23, at 2:48 P.M., the Administrator said according to the CDC, masking was recommended for source control, but it was just a recommendation. Since the first residents who tested positive were moved to specific area, they did not implement source control; -Staff were not wearing masks for source control until 11/28/23 when another resident (the fifth) tested positive. 3. Observation on 11/28/23, at 8:32 A.M., showed the following: -NA N exited COVID-19 isolation room [ROOM NUMBER] and placed the resident's hall tray on the hall tray cart. The hall tray was not placed inside a bag and had no separation from the other hall tray already on the cart. The NA pushed the cart to the end of the hall and left it in the hallway by room [ROOM NUMBER]; -The hall tray contained regular silverware, cups, plate and plate cover, not disposable items. During an interview on 11/29/23, at 8:38 A.M., NA B said the following: -When he/she removed a hall tray from a COVID-19 isolation room, he/she placed the tray in a red bag so the kitchen staff knew how to handle the trays; -Staff should not bring trays out of COVID-19 isolation rooms not bagged because this could spread the virus to other residents and staff. Observation on 11/28/23, at 12:40 P.M., showed the following: -A housekeeper exited room [ROOM NUMBER] while wearing N95 mask, gown, and gloves. The housekeeper threw a rag into his/her cart and placed trash from the room into the trash receptacle on his/her cart; -He/she removed a broom and dust pan from the cart and reentered room [ROOM NUMBER]. The resident could be heard coughing while the housekeeper was in the room cleaning; -He/she exited the room again wearing the PPE and placed the broom and dust pan back on the cart; -He/she obtained the mop and mop pad and reentered the room; -He/she exited the room again and doffed the PPE before he/she exited and placed the mop back on the cart and the mop pad inside the cart; -He/she placed a wet floor sign on the name plate to the room, pushed the cart approximately 50 foot down the hallway and then performed hand hygiene; -He/she did not sanitize the broom, mop or the dustpan. During an interview on 11/29/23, at 8:57 A.M., LPN C said the following: -When staff took a hall tray out of a COVID-19 isolation room, they should red bag it so the kitchen staff know the tray came from an isolation room; -Staff should not place hall trays from COVID-19 isolation rooms on the hall cart, not red bagged, because this could spread the COVID-19 virus. During an interview on 11/29/23, at 10:00 A.M., Dietary Aide (DA) T said the following: -He/she waited until all of the dishes were washed before he/she ran the COVID-19 isolation trays through the dishwasher and wore gloves when handling these trays due to COVID-19 being contagious. Observation on 11/30/23, at 11:13 A.M., showed the door to a COVID-19 positive resident's room was open. Inside the room, the housekeeping supervisor cleaned the floor with a microfiber broom. He continued to use the broom to clean the floor outside of the room, in front of the isolation cart. He then dragged the microfiber broom head along the floor to the empty room next door. During an interview on 11/30/23, at 12:03 P.M., DA R said he/she knew a tray came from a COVID-19 isolation room if the tray was red bagged. During an interview on 11/30/23, at 12:11 P.M., Registered Nurse (RN) H said the following: -Staff should place hall trays from COVID-19 isolation rooms in a regular trash bag to prevent the spread of the virus; -The bag let kitchen staff know the tray was contaminated; -Staff should not place hall trays from isolation rooms on the cart uncovered and pushed to the end of the hall because this could spread the virus. During an interview on 12/01/23, at 8:37 A.M., RN H said the following: -When housekeeping cleaned a COVID-19 isolation room, they should place the mop pad in a bag before they leave the room. They should not mop out into the hallway and drag the mop down the hallway because this could spread the virus. During an interview on 12/01/23, at 8:48 A.M., the DM said the following: -Staff should put hall trays from COVID-19 isolation rooms in a bag. The bag can be red or clear; -When staff placed trays in bags, his/her staff knew how to handle them; -Kitchen staff waited until all dishes were washed before handling the isolation room trays. The staff put on gloves while they handled the trays to protect themselves; -After they washed the trays from the COVID-19 isolation rooms, they drained the dishwasher, sanitized the dishwasher and then drained the dishwasher again; -If nursing staff did not place the trays in bags, his/her staff did not know they came from an isolation room and could wash them with the other dishes. This could cause cross contamination and possibly spread the virus to kitchen staff or other residents; -He/she was responsible for ensuring kitchen staff knew how to handle hall trays from COVID-19 isolation rooms and the DON or Administrator was responsible for ensuring other staff knew the process. During an interview on 12/01/23, at 8:56 A.M., Housekeeper S said the following: -When he/she cleaned a COVID-19 isolation room, he/she put on a gown, gloves and N95 mask. He/she could not go in and out of the room so he/she took what he/she needed to clean the room inside and closed the door; -When he/she was done cleaning, he/she placed the rag and mop head used in the laundry in the room. If he/she brought the mop head out, he/she placed in a yellow bag prior to placing it in his/her cart; -He/she took all the PPE off inside the room and placed in the red bag trash inside the room; -Staff should not throw the used mop pad or rag inside the cart without placing them in a bag; -Staff should sanitize the broom and mop when they left an isolation room as well; -Staff should not mop inside an isolation room and then mop outside the room and drag the mop down the hallway. This could cross contaminate and make others sick; -Staff should not wear gloves outside the room and should sanitize their hands before they touch anything when they leave an isolation room. They should not push their cart down the hall and then sanitize their hands. During an interview on 12/01/23, at 9:05 A.M., the IP said the following: -When staff took hall trays out of a COVID-19 isolation room, they should be bagged in either a red or clear trash bag; -Staff should not bring the hall tray out not bagged, place it on the hall tray cart and push it down the hall. This could cause cross contamination and dietary would not know which trays came from an isolation room; -He/she, the DON, and staff development were responsible for ensuring staff knew proper infection control techniques; -When housekeeping cleaned a resident's room, they should not go in and out of the room multiple times; -Housekeeping should leave their mop pad and rag to clean the room in the COVID-19 laundry in the resident's room. They should not bring these out of the room, not bagged and just throw in their cart no bagged; -Housekeepers should not mop inside the room, then continue to mop outside the room and then drag the mop down the hallway. This could contaminate the hallway and other staff could carry the virus to other residents' rooms; -He/she, staff education coordinator, and the Housekeeping Supervisor were responsible for ensuring housekeeping staff knew proper infection control. During an interview on 12/01/23, at 9:44 A.M., the Housekeeping Supervisor said the following: -When housekeeping staff entered a COVID-19 isolation room, they don a gown, gloves and N95 mask. They grab all of the cleaning supplies they need and enter the room and stay in the room until the room was cleaned; -When they finish, they place the mop pad and rags in a bag, place it outside the door along with their mop, broom and cleaning supplies. They doff the PPE inside the room and place in the trash and then sanitize their hands; -Once outside the room, they sanitize the mop, broom and cleaning supplies and placed the bagged rags and mop pads into their cart. They should do this to not contaminate anything else; -Staff should not exit these rooms with their gloves on, should not throw their rag and mop pad in their cart not bagged and should not mop from inside the room out into the hallway and then drag the mop down the hall. This could cause an outbreak; -He/she was responsible for ensure housekeeping staff knew the proper infection procedures. During an interview on 12/01/23, at 9:52 A.M., the DON said the following: -Staff should double bag hall trays when they bring them out of COVID-19 isolation rooms. They should place them in a red bag and not just an ordinary trash bag; -Staff should not bring a hall tray out of a COVID-19 isolation room not bagged, place it on the hall tray cart and push it down to the end of the hall. This could spread the virus; -The kitchen staff knew the precautions to use if the hall tray was red bagged and if the hall tray was not bagged, the virus could spread to staff and other residents; -He/she was responsible for ensuring nursing staff knew how to handle hall trays from COVID-19 isolation rooms and the charge nurse should oversee this as well; -When housekeeping cleaned a COVID-19 isolation room, they should don a gown, N95 mask, gloves and eye protection and follow their cleaning protocol; -Housekeeping staff should not bring the mop pad and rags out of the room and throw them in their cart unless they were double bagged in yellow bags; -Housekeeping staff should not wear gloves outside the isolation rooms and should not mop the floor of the isolation room, then out in the hall and then drag the mop down the hall. This could cause cross contamination; -The Housekeeping Supervisor was responsible for ensuring housekeeping staff knew proper infection control protocols and the IP and DON ensured the Housekeeping Supervisor knew proper infection control techniques. During an interview on 12/01/23, at 11:36 A.M.,

Based on interview and record review, the facility failed to ensure that all allegations of possible abuse were thoroughly and timely investigated when staff failed to document investigations of alleged abuse involving five residents (Resident #3, Resident #25, Resident #40, Resident #66 and Resident #82) out of a sample of 24 residents. The facility census was 93. Review of the facility's policy titled Abuse Prevention Program, revised December 2016, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms; -Administration will protect residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; -Administration will identify and assess all possible incidents of abuse; -Administration will investigate and report any allegations of abuse within timeframe as required by federal requirements; -Administration will protect residents during abuse investigations. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017 showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ('abuse') shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 1. Review of Resident #'82's face sheet (admission data) showed the following: -admitted [DATE] and readmitted [DATE]; -Diagnoses included unspecified dementia, mild with agitation, anxiety disorder and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/13/23, showed the following: -Moderately impaired cognitive skills; -The resident had no behaviors. Review of the resident's care plan, 11/23/23 , showed dementia and impaired thought. Review of the resident's progress note dated 11/27/23, at 6:56 P.M., showed Licensed Practical Nurse (LPN) J documented the resident reported another resident touched his/her butt and ran his/her hand up his/her leg. Upon follow up by this nurse, resident recants statement and states he/she did not touch him/her inappropriately, the resident did not feel threatened, violated, sexually abused, just annoyed by his/her presence. LPN J educated the resident on appropriate ways to communicate emotions and needs. The facility will educate nursing staff to intervene when necessary when both residents are in common areas at the same time. During an interview on 11/28/23, at 4:19 P.M., LPN J said last night, on 11/27/23, the resident told him/her Resident #3 slapped his/her butt and groped his/her leg. LPN J reported this to the Director of Nursing (DON) immediately. The DON reviewed the facility cameras and found the resident was in the dining room and Resident #3 braised the back of Resident #82's knee with his/her fingertips. LPN J asked Resident #82 and told him/her staff reviewed the cameras and it showed Resident #3 braised back of his/her leg. Resident #82 said Resident #3 drives him/her crazy and did not think the resident touched his/her butt. LPN J said would consider this an allegation of abuse. The facility staff reviewed the cameras to determine if this incident happened. During an interview on 11/28/23, at 8:50 P.M., LPN K said he/she heard in the nursing report that Resident #82 said Resident #3 came up behind him/her and grabbed his/her butt and ran his/her hand down the back of his/her leg. Facility staff reviewed the facility cameras and asked Resident #82 again about the incident and Resident #82 said it did not happen like that. During an interview on 11/29/23, at 9:08 A.M., the resident said he/she stood up at the nurses' station and Resident #3 walked by him/her. He/she thinks Resident #3 touched his/her leg. During an interview on 11/28/23, at 4:49 P.M., Certified Medication Technician (CMT) L said Resident #82 said this morning at around 6:00 A.M., when he/she came on shift, that Resident #3 was a hand full. Resident #82 said the resident hit him/her on the butt and he/she let everyone know. CMT L said the nurses said it is an increased behavior. He/she would consider this an allegation of sexual abuse due to Resident #3 touched Resident #82 without consent. During an interview on 11/28/23, at 5:10 P.M., Registered Nurse (RN) M said when he/she came on shift this morning, he/she heard from the charge nurse who had floated that there had been an allegation, but once the investigation was initiated and completed last night, Resident #82 said Resident #3 tried to smack his/her butt. During an interview on 11/30/23, at 12:19 P.M., the DON said staff followed up with one more alert resident who said they felt safe. During an interview on 11/30/23, at 12:19 P.M., the Administrator said the following: -The resident recanted the statement. Staff reviewed the facility cameras with no physical touching; -He would consider this an allegation of abuse; -The nurse followed up with the resident who said he/she was annoyed with the resident; -The resident is high functioning and he trusts the resident. The resident said nothing happened. Review of DHSS records showed the facility did not provide copy of an investigation of the allegation prior to 11/30/23. 2. Review of Resident #3's face sheet showed the following: -admitted on [DATE]; -Diagnoses included Alzheimer's disease, anxiety disorder, and psychotic disorder with delusions due to known physiological condition. Review of the resident's annual MDS assessment, dated 09/07/23, showed the following: -Severely impaired cognitive skills; -Physical behavior symptoms toward others marked occurred four to six days, but less daily; -Other behaviors symptoms not directed toward others, but less daily. Review of the resident's care plan, revised 08/02/23 showed the following: -The resident has impaired cognitive function/dementia; -The resident uses psychotropic medications to treat and manage his/her depression with psychotic with delusions diagnosis; -The resident uses anti-anxiety medication due to dementia with behavioral and psychotic disorder with anxiety. During a phone interview on 11/28/23, at 8:57 P.M., Certified Nurse Aide (CNA) O said the following: -The resident follows the residents and tries to play with their butts; -The resident is in a wheelchair and follows other residents; -He/she did not observe the resident touch other residents inappropriately, but has heard other residents say he/she tried to touch his/her butt. During an interview on 11/28/23, at 4:10 P.M., CNA P said the following: -Last week, the resident groped a person's butt last week. A family member came up and said the resident was inappropriate; -A couple of weeks ago, the CNA reported the resident touched Resident #25's butt; -RN M said he/she would check into it. During interviews on 11/28/23, at 4:49 P.M., and on 11/29/23, at 9:44 A.M., CMT L said the following: -The resident likes residents of the opposite sex and follows them; -He/she sees the resident touch a resident's butt once per week and reports it to the charge nurse; -The resident purposely goes and pinches residents' butts with a grin on his/her face; -He/she reports the incidents to the nurses each time who say to watch the resident and keep away from other residents. During an interview on 11/30/23, at 12:19 P.M., the DON said staff followed up with one more alert resident who said they felt safe. Review of DHSS records showed the facility did not provide copy of investigation of the allegation prior to 11/30/23. 3. Review of Resident #50's face sheet showed the following: -admitted on [DATE]; -Diagnoses included Alzheimer's disease, unspecified dementia and cognitive communication deficit. Review of the resident's quarterly MDS assessment, dated 11/20/23, showed the following: -Severely impaired cognitive skills; -No behaviors. Review of the resident's care plan, revised 11/17/23, showed the following: -The resident has impaired cognitive function/dementia or impaired thought process; -Staff to cue, reorient, and supervise the resident as needed. During an interview on 11/29/23, at 2:16 P.M., Staff Person U said the Resident #3 touched the resident's breast last week. He/she reported the incident to a nurse who no longer worked at the facility. He/she did not report this incident to the DON or Administrator. During an interview on 11/30/23, at 12:19 P.M., the DON said she did not hear or investigation reports of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear or investigate reports of this allegation of abuse. Review of DHSS records showed the facility did not provide copy of investigation of the allegation prior to 11/30/23. 4. Review of Resident #25's face sheet showed the following: -admitted on [DATE]; -Diagnoses included unspecified dementia and anxiety disorder. Review of the resident's admission MDS assessment, dated 10/29/23, showed the following: -Severely impaired cognitive skills; -Physical behaviors directed toward others - one to three days; -Verbal behaviors directed toward others - one to three days; -Wandering occurred one to three days. Review of the resident's care plan, dated 11/07/23, showed the resident has impaired cognitive function/dementia or impaired thought processes. During interviews on 11/29/23, at 9:44 A.M. and 12:50 P.M., CMT L said the following: -On 11/12/23, at 11:30 A.M., the resident came over to Resident #66's dining room table. Resident #66 touched Resident #25's nipple and twisted it. The resident jerked his/her arm up and stepped back. Resident #66 grabbed the resident's wrist and pulled Resident #25 toward him/her. CMT L intervened and separated the residents; -CMT L reported this incident to two different nurses; -One nurse said he/she did not want to hear it because he/she did not want to chart on it; -CMT L did not report this incident to the DON and Administrator and should have reported it to administration staff; -No other staff witnessed the incident between the residents. During an interview on 11/29/23,at 9:19 A.M., CNA F said the following: -CNA O reported in the nursing report a week ago that staff found Resident #25 naked on top of Resident #3's in his/her bed; -He/she has not observed the incidents; -A charge nurse said this incident is already charted and documented. Review of the resident record showed staff did not document regarding resident found in another resident's bed naked. During an interview on 11/29/23, at 10:54 A.M., LPN Q said he/she heard the resident strips off his/her clothes and walks down the hall. He/she heard staff found the resident in one of the resident's beds undressed, but did not remember what room. During an interview on 11/30/23, at 9:45 A.M., CMT D said he/she was told the resident was pulled out of Resident #3's bed. He/she thinks there was an instance where Resident #3 did not have any clothes on, but the residents were just laying there two or three weeks ago and nothing inappropriate. During an interview on 11/30/23, at 12:19 P.M., the DON said she did not hear or investigate the reports of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear or investigate the reports of this allegation of abuse. Review of DHSS records showed the facility did not provide copy of investigation of the allegation prior to 11/30/23. 5. Review of Resident #66's face sheet showed the following: admitted [DATE]; Diagnoses included Alzheimer and major depressive disorder. Review of the resident's annual MDS assessment, dated 10/07/23, showed the following: -Severely impaired cognitive skills; -No behaviors. Review of the resident's care plan, reviewed 07/17/23. showed the following: -Impaired cognitive function/dementia with impaired thought process related to Alzheimer's disease; -Use positive approach technique. During an interview on 11/29/23, at 9:44 A.M., CMT L said the resident touched Resident #25's nipple and twisted it on 11/12/23, at 11:30 A.M., and he/she reported it to two different nurses. During an interview on 11/30/23 at 12:19 P.M., the DON said she did not hear or investigate of this allegation of abuse. During an interview on 11/30/23 at 12:19 P.M., the Administrator said he did not hear or investigate this this allegation of abuse. Review of DHSS records showed the facility did not provide copy of investigation of the allegation. prior to 11/30/23. 6. During an interview on 11/28/23, at 4:19 P.M., LPN J said the charge nurse initially starts the abuse investigation. The DON and Administrator review the facility cameras and investigate. 7. During an interview on 11/28/23, at 5:10 P.M. RN M said the following: -The DON or Administrator immediately starts an abuse investigation; -Staff should investigate the allegation of abuse until resolved or further actions. 8. During an interview on 11/30/23, at 12:19 P.M., the DON said the following: -There is a checklist in a folder at each nurses station regarding abuse; -The charge nurse initiates an assessment of the resident; -The interdisciplinary team approach interviews the resident, other staff members, and witnesses. 9. During an interview on 11/30/23, at 12:19 P.M., the Administrator said the following: -The charge nurse initiates an assessment of the resident; -The interdisciplinary team approach interviews the resident, other staff members, and witnesses. MO00228139, MO00228141, MO00228142, MO00228143 and MO00228171

Based on interviews and record review, the facility failed to ensure allegations of possible abuse were reported immediately to management and within two hours to the State Survey Agency (Department of Health and Senior Services - DHSS) when staff received allegations of possible abuse involving five residents (Resident #3, Resident #25, Resident #50, Resident #66, and Resident #82) out of 24 sampled residents. The facility census was 93. Review of the facility's policy titled Abuse Prevention Program, revised December 2016, showed the following: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms; -Investigate and report any allegations of abuse within timeframe as required by federal requirements. Review of the facility's policy titled Abuse Investigation and Reporting, revised July 2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: -Two hours if the alleged violation involves abuse or has resulted in serious bodily injury. 1. Review of Resident #'82's face sheet (admission data) showed the following: -admitted [DATE] and readmission of 03/19/23; -Diagnoses included unspecified dementia, mild with agitation, anxiety disorder, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/13/23, showed the following: -Moderately impaired cognitive skills; -The resident had no behaviors. Review of the resident's care plan, dated 11/23/23, showed the following: -The resident has impaired cognitive function/dementia, or impaired thought processes; -Provide the resident with a homelike, therapeutic environment. Review of the resident's progress note dated 11/27/23, at 6:56 P.M., showed Licensed Practical Nurse (LPN) J documented the resident reported another resident touched his/her butt and ran his/her hand up his/her leg. Upon follow up by this nurse, resident recants statement and states he/she did not touch him/her inappropriately. The resident did not feel threatened, violated, sexually abused, just annoyed by his/her presence. LPN J educated the resident on appropriate ways to communicate emotions and needs. The facility will educate nursing staff to intervene when necessary when both residents are in common areas at the same time. During an interview on 11/28/23, at 4:19 P.M., LPN J said last night, on 11/27/23, the resident told him/her another resident (Resident #3) slapped his/her butt and groped his/her leg. LPN J reported this to the Director of Nursing (DON) immediately. The DON reviewed the facility cameras and found the resident was in the dining room and Resident #3 braised the back of Resident #82's knee with his/her fingertips. LPN J asked Resident #82 and told him/her staff reviewed the cameras and it showed Resident #3 braised back of his/her leg. Resident #82 said Resident #3 drives him/her crazy and did not think the resident touched his/her butt. LPN J said he/she would consider this an allegation of abuse. The facility staff reviewed the cameras to determine if this incident happened. During an interview on 11/28/23, at 8:50 P.M., LPN K said he/she heard in the nursing report that Resident #82 said Resident #3 came up behind him/her and grabbed his/her butt and ran his/her hand down the back of his/her leg. Facility staff reviewed the facility cameras and asked Resident #82 again about the incident and Resident #82 said it did not happen like that. LPN K said this is the only time he/she has heard about Resident #3 being inappropriate. During an interview on 11/29/23, at 9:08 A.M., the resident was in his/her room and appeared in no distress. The resident said he/she stood up at the nurses' station and Resident #3 walked by him/her. He/she thinks Resident #3 touched his/her leg. During an interview on 11/28/23, at 4:49 P.M., Certified Medication Technician (CMT) L said Resident #82 said this morning at around 6:00 A.M., when he/she came on shift, that Resident #3 was a hand full. Resident #82 said the resident hit him/her on the butt and he/she let everyone know. CMT L said the nurses said it is an increased behavior. He/she would consider this an allegation of sexual abuse due to Resident #3 touched Resident #82 without consent. During an interview on 11/28/23, at 5:10 P.M., Registered Nurse (RN) M said when he/she came on shift this morning, he/she heard from the charge nurse who had floated that there had been an allegation, but once the investigation was initiated and completed last night, Resident #82 said Resident #3 tried to smack his/her butt. During an interview on 11/30/23, at 12:19 P.M., the Administrator said the following: -The resident recanted the statement. Staff reviewed the facility cameras with no physical touching; -He would consider this an allegation of abuse; -The nurse followed up with the resident who said he/she was annoyed with the resident; -The resident is high functioning and he trusts the resident. The resident said nothing happened; -He has a two hour window to report an allegation of abuse to the state and did not report this allegation due to the resident said it did not happen. Review of DHSS records showed the facility did not self-report the allegation of possible abuse prior to 11/30/23. 2. Review of Resident #3's face sheet showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease, anxiety disorder, and psychotic disorder with delusions due to known physiological condition. Review of the resident's care plan, revised 09/05/23, showed the following: -The resident has impaired cognitive function/dementia; -The resident uses psychotropic medications to treat and manage his/her depression with psychotic with delusions diagnosis; -The resident uses anti-anxiety medication due to dementia with behavioral and psychotic disorder with anxiety. Review of the resident's annual MDS assessment, dated 09/07/23, showed the following: -Severely impaired cognitive skills; -Physical behavior symptoms toward others marked occurred four to six days, but less daily; -Other behaviors symptoms not directed toward others, but less daily. During an interview on 11/28/23, at 8:57 P.M., Certified Nurse Aide (CNA) O said the following: -The resident follows the residents and tries to play with their butts; -The resident is in a wheelchair and follows other residents; -He/she did not observe the resident touch other residents inappropriately, but has heard other residents say 'he/she tried to touch my butt. During an interview on 11/28/23, at 4:10 P.M., CNA P said the following: -Last week, the resident groped a person's butt last week. A family member came up and said the resident was inappropriate; -A couple of weeks ago, a CNA reported the resident touched Resident #25's butt; -RN M said he/she would check into it. During interviews on 11/28/23, at 4:49 P.M., and on 11/29/23, at 9:44 A.M., CMT L said the following: -The resident likes to follow residents of the opposite sex; -He/she sees the resident touch a resident's butt once per week and reports it to the charge nurse; -The resident purposely goes and pinches residents' butts with a grin on his/her face; -He/she reports the incidents to the nurses each time who say to watch the resident and keep away from other residents. Review of the resident's record showed staff did not document reporting these allegations of possible abuse. Review of DHSS records showed the facility did not self-report the allegations of possible abuse prior to 11/30/23. 3. Review of Resident #50's face sheet showed the following: -admitted [DATE]; -Diagnoses included Alzheimer's disease, unspecified dementia, and cognitive communication deficit. Review of the resident's quarterly MDS assessment, dated 11/20/23, showed the following: -Severely impaired cognitive skills; -No behaviors. Review of the resident's care plan, revised 11/17/23, showed the following: -The resident had impaired cognitive function/dementia or impaired thought process; -Staff to cue, reorient, and supervise the resident as needed. During an interview on 11/29/23, at 2:16 P.M., Staff Person U said Resident #3 touched the resident's breast last week. He/she reported the incident to a nurse who no longer works at the facility. He/she did not report this incident to the DON or Administrator. During an interview on 11/30/23, at 12:19 P.M., the DON said she did not hear reports of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear reports of this allegation of abuse. Review of the resident's record showed staff did not document reporting this allegation of possible abuse. Review of DHSS records showed the facility did not document reporting this allegation of abuse prior to 11/30/23. 4. Review of Resident #25's face sheet showed the following: -admitted [DATE]; -Diagnoses included unspecified dementia and anxiety disorder. Review of the resident's admission MDS assessment, dated 10/29/23, showed the following: -Severely impaired cognitive skills; -Physical behaviors directed toward others - one to three days; -Verbal behaviors directed toward others - one to three days; -Wandering occurred one to three days. Review of the resident's care plan, dated 11/07/23, showed the resident had impaired cognitive function/dementia or impaired thought processes. During interviews on 11/29/23, at 09:44 A.M. and 12:50 P.M., CMT L said the following: -On 11/12/23, at 11:30 A.M. the resident came over to Resident #66's dining room table and Resident #66 touched Resident #25's nipple and twisted it. The resident jerked his/her arm up and stepped back. Resident #66 grabbed the resident's wrist and pulled Resident #25 toward him/her. CMT L intervened and separated the residents; -CMT L reported this incident to two different nurses; -One nurse said he/she did not want to hear it because he/she did not want to chart on it; -CMT L did not report this incident to the DON and Administrator and should have reported it to administration staff; -No other staff witnessed the incident between the residents. During an interview on 11/29/23, at 9:19 A.M., CNA F said the following: -CNA O reported in the nursing report a week ago that staff found Resident #25 naked on top of Resident #3's in his/her bed; -He/she has not observed the incidents; -A charge nurse said this incident is already charted and documented. Record review of the resident's record showed staff did not document an incident of resident found in another resident's bed naked. During an interview on 11/29/23, at 10:54 A.M., LPN Q said he/she heard the resident strips off his/her clothes and walks down the hall. He/she heard staff found the resident in one of the resident's beds undressed, but did not remember what room. During an interview on 11/30/23, at 9:45 A.M., CMT D said he/she was told the resident was pulled out of Resident #3's bed. He/she thinks there was an instance where Resident #3 did not have any clothes on, but the residents were just laying there two or three weeks ago and nothing inappropriate. During an interview on 11/30/23, at 12:19 P.M. the DON said she did not hear of reports of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear reports of this allegation of abuse. Review of the resident's record showed staff did not document reporting these allegations of possible abuse. Review of DHSS records showed the facility did not self-report the allegations of possible abuse prior to 11/30/23. 5. Review of Resident #66's face sheet showed the following: -admitted [DATE]; -Diagnoses included Alzheimer and major depressive disorder. Review of the resident's annual MDS assessment, dated 10/07/23, showed the following: -Severely impaired cognitive skills; -No behaviors. Review of the resident's care plan, reviewed 07/17/23. showed the following: -Impaired cognitive function/dementia with impaired thought process related to Alzheimer's disease; -Use positive approach technique. During an interview on 11/29/23, at 9:44 A.M., CMT L said the resident touched Resident #25's nipple and twisted it on 11/12/23, at 11:30 A.M., and he/she reported it to two different nurses. During an interview on 11/30/23, at 12:19 P.M., the DON said she did not hear of this allegation of abuse. During an interview on 11/30/23, at 12:19 P.M., the Administrator said he did not hear reports of this allegation of abuse. Review of the resident's record showed staff did not document reporting this allegation of possible abuse. Review of DHSS records showed the facility did not self-report the allegation of possible abuse prior to 11/30/23. 6. During an interview on 11/28/23, at 4:10 P.M. CNA P said the following: -Types of abuse include physical, mental, emotional, and sexual; -Staff should report to the charge nurse immediately an allegation of abuse; -The facility should call the state within two hours with an allegation of abuse. 7. During an interview on 11/28/23, at 4:19 P.M., LPN J said the following: -Types of abuse include physical, mental and sexual; -Staff should report to the DON and Administrator immediately of an allegation of abuse; -The facility should call the state within two hours with an allegation of abuse. 8. During an interview on 11/28/23, at 4:49 P.M., CMT L said the following: -Types of abuse include verbal, physical, and sexual which could include inappropriate touching; -Staff should report to the charge nurse immediately of an allegation of abuse; -The facility should call the state under two hours with an allegation of abuse; -Nurses should notify the DON or on-call nurse with an allegation of abuse; -Nursing staff pass on in nursing report of allegations of abuse. 9. During an interview on 11/28/23, at 5:10 P.M., RN M said the following: -Types of abuse staff should monitor include physical, resident to resident abuse, staff to resident abuse, sexual, emotional and verbal; -Staff should separate the individuals with any allegation of abuse if observed or reported; -Staff should call the administration immediately of an allegation of abuse; -The facility should report to the state within two hours of an allegation of abuse. 10. During an interview on 11/29/23, at 9:19 A.M., CNA F said the following: -Types of abuse include sexual, physical, and resident-to-resident abuse; -Staff should separate residents from each other if abuse is observed or reported; -Staff should report to the charge nurse immediately of an allegation of abuse; -The facility should report to the state within two hours of an allegation of abuse. 11. During an interview on 11/29/23, at 10:54 A.M., LPN Q said the following: -Types of abuse include verbal, physical, sexual which is inappropriate touching; -Staff should separate the residents if abuse is observed or reported and notify the administrator as soon as possible; -The facility should notify the state within two hours of an allegation of abuse. 12. During an interview on 11/30/23, at 12:19 P.M., the DON said the following: -Types of abuse include neglect, misappropriation, physical, emotional, mental and sexual; -She expects staff to report to the charge nurse, DON, and Administrator immediately with an allegation of abuse; -There is a checklist in a folder at each nurses station regarding abuse; -The facility should notify the state in two hours with an allegation of abuse; -The facility encourages all disciplines to report immediately to the charge nurse if resident behaviors of touching other residents inappropriately. 13. During an interview on 11/30/23, at 12:19 P.M., the Administrator said the following: -Types of abuse include neglect, misappropriation, physical, emotional, mental, and sexual; -The facility should notify the state in two hours with an allegation of abuse. MO00228139, MO00228141, MO00228142, MO00228143 and MO00228171

Based on interview and record review, facility staff failed to verify a resident's code status and failed to provide basic life support timely, including cardio-pulmonary resuscitation (CPR - an emergency procedure that is performed when a person's heartbeat or breathing has stopped), for one resident (Resident #95) of a sample of two residents who was found unresponsive. The facility census was 93. Review of the facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation, revised ,d+[DATE], showed the following: -If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/Basic Life Support (BLS) shall initiate CPR unless the resident is a known that a Do Not Resuscitate (DNR - order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g., rigor mortis)); -If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR; -If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives; -If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR. Instruct a staff member to activate the emergency response system (code) and call 911. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. 1. Review of Resident #95's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -The resident was full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive); -The resident had a responsible party; -Diagnoses included epilepsy (a brain disorder that causes recurring, unprovoked seizures), depression, anxiety, and dementia. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated [DATE], showed the following: -The resident had severe cognitive impairment; Review of the resident's care plan, revised [DATE], showed the following: -The resident lacked capacity to understand and make decisions regarding healthcare due to dementia and had the following Advance Directives and Durable Power of Attorney for health care decisions. The resident would have healthcare decisions made for him/her in accordance with any written advance directives if known and in accordance with the resident's best interests. Arrange for care plan conference with healthcare providers and resident's healthcare surrogate or healthcare agent to review the resident's current status and to make healthcare decisions at least quarterly and more often as needed; -The resident's code status was full code. If the resident's heart stops beating or the resident stops breathing, CPR would be initiated per the resident's/responsible party's wishes. Check to make sure that full code was listed as the resident's code status on the resident's profile/face sheet. Provide opportunity for the resident to discuss feelings and to ask questions related to end of life decisions as needed. Review code status with the resident/responsible party quarterly or as needed. Review of the resident's Physician's Order Sheet (POS), dated ,d+[DATE], showed the following: -An order, dated [DATE], for CPR full code. Review of the resident's physician's progress note dated [DATE], at 5:56 A.M., showed the following: -Resident had been at baseline for 2:30 A.M. rounds. At approximately 5:15 A.M., certified nursing assistants (CNA) went into the resident's room to do morning cares and the resident was unresponsive. This nurse went in to assess the resident and noted that he/she was pale, skin cold to the touch and not breathing. The resident was noted to be deceased by two nurses listening for heart and lung sounds. While preparing to notify family, it was noted that the resident was a full code. Compressions were initiated at 5:25 A.M. Staff called Emergency Medical Services (EMS) and the resident was declared deceased at 5:30 A.M. by EMS. Staff notified the resident's family member, the resident's Nurse Practitioner, and Director of Nursing (DON). During an interview on [DATE], at 2:09 P.M., CNA F said the following: -He/she started work on [DATE], at approximately 6:15 A.M., and was told in report that the resident bled out in their sleep and passed away around 6:01 A.M. The CNA who gave him/her report said they walked into the room, saw blood everywhere and started CPR. During an interview on [DATE], at 2:41 P.M., Licensed Practical Nurse (LPN) G said the following: -When he/she assessed the resident after the resident was found unresponsive, he/she believed there was no chance of resuscitation because the resident was cold to the touch, blue, and had started to become stiff; -He/she asked a CNA to grab his/her stethoscope and another nurse was walking by the room at the time. He/she and the other nurse listened to the resident and the resident had no pulse and was not breathing; -He/she went and looked at the resident's chart approximately five minutes after the resident was found unresponsive and noticed the resident was full code and the other nurse then started compressions and he/she called 911; -The nurse started compressions because legally they were required to since the resident was a full code; -He/she did exactly what he/she was supposed to because there was absolutely no chance of reviving the resident. During an interview on [DATE], at 9:52 A.M., the DON said the following: -The resident was full code; -The nurse should have verified the resident's code status prior to verifying signs of life; -The nurse did not check the resident's code status until ten minutes after the resident was found unresponsive. The nurse should have checked the resident's code status immediately; -He/she was responsible for ensuring staff know the proper procedure when a resident was found unresponsive. During an interview on [DATE], at 12:23 P.M., LPN A said he/she found the resident's code status in the electronic medical documentation program (EMR). During an interview on [DATE], at 8:38 A.M., Nursing Assistant (NA) B said he/she looked in EMR to verify a resident's code status. During an interview on [DATE], at 8:57 A.M., LPN C said he/she verified a resident's code status by looking in the EMR. During an interview on [DATE], at 2:00 P.M., the Activities Assistant said the following: -If he/she found a resident unresponsive, he/she checked their pulse, yelled for a nurse and if the resident was full code, started compressions until someone told him/her different; -He/she verified a resident's code status in the EMR. During an interview on [DATE], at 2:03 P.M., Certified Medication Technician (CMT) D said the following: -If a resident was unresponsive, he/she immediately notified the nurse and checked the resident's code status; -If the resident was full code, he/she grabbed the crash cart and followed the nurse's instructions from there. During an interview on [DATE], at 2:05 P.M., LPN E said the following: -If a CNA or CMT found a resident unresponsive, they should notify the charge nurse; -The charge nurse verified the resident's code status and assessed the resident for a pulse and if the resident was breathing; -The charge nurse instructed another staff member to notify EMS and started compressions if the resident's code status was full code and was not breathing or had no pulse; -He/she verified a resident's code status in the EMR. During an interview on [DATE], at 2:09 P.M., CNA F said the following: -He/she knew a resident's code status by asking the charge nurse; -If a resident was unresponsive, he/she called for the charge nurse, verified code status, and started CPR. During an interview on [DATE], at 2:41 P.M., LPN G said the following: -If a CNA found a resident unresponsive, they notified the nurse immediately; -The nurse assessed the resident, verified the code status as soon as possible, and, if the resident was full code, started CPR. During an interview of [DATE], at 8:37 A.M., Registered Nurse (RN) H said the following: -If a CNA or CMT found a resident unresponsive, they activated the emergency response and notified the nurse; -Any nursing staff could check the resident's code status in the EMR and someone should check the code status while the nurse assessed the resident with a stethoscope; -If the resident was full code, staff grabbed the crash cart and started compressions and breaths while another staff member called 911; -Facility nurses could not declare a resident deceased , but EMS could; -If a resident, who was full code, was cold, blue in color and started to get stiff, he/she still started compressions until EMS pronounced the resident deceased . During an interview on [DATE], at 9:52 A.M., the DON said the following: -If a CNA or CMT found a resident unresponsive, they called for help and initiated CPR if the resident was full code; -The charge nurse or CMT verified code status immediately; -If a resident was full code, nursing staff should start CPR even if the resident was cold, blue in color and starting to become stiff; -Staff should call 911, and any staff member could do this; -CPR should not be stopped until EMS took over. During an interview on [DATE], at 11:36 A.M., the Administrator said the following: -If staff found a resident unresponsive, they should immediately check the resident's code status and if the resident was full code, start CPR while another staff called 911.

Based on record review and interview, the facility failed to give written information to the resident and/or resident's representative of the facility's bed-hold policy for one resident (Resident #94) who was transferred out to the hospital. A sample of three residents' closed records was selected for review in a facility with a census of 93. Review of the facility's policy titled Bed-Hold Charge, undated, showed the following: -In the absence of the resident from the facility, a daily bed-hold charge will be made until the personal effects of the resident are removed from the facility or a stop bed-hold agreement is signed; -Bed-hold provisions vary according to whether the resident is private or medicare, or medicaid for hospital/therapeutic leave so long as the facility occupancy rate is 97% or higher in accordance with state regulations, up to a maximum of 12 therapeutic leave days in a six month period; -If the resident's insurance covers the bed-hold period, the resident will not be billed separately for the amount covered. 1. Record review of Resident #94's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included acute kidney failure and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Review of the resident's physician order dated 10/18/23, at 9:28 A.M., showed an order to transfer the resident to the hospital for a behavioral evaluation. Review of the resident's progress notes showed the following: -On 10/18/23, at 10:29 A.M., a nurse documented the Assistant Director of Nursing (ADON) messaged nursing staff to send the resident back to the hospital for behaviors. The resident left the facility with emergency medical services at 11:50 A.M.; -On 10/18/2023, at 5:35 P.M., social service staff documented the resident's current placement was less then 24 hours and the resident was transferred back out to the hospital. Review of the resident's medical record showed staff did not document providing documentation of the bed hold policy to the resident or resident's representative at discharge to the hospital. During an interview on 12/01/23, at 12:14 P.M., the Business Office Manager (BOM) said the following: -She is responsible for sending the bed hold policy to the resident and/or representative; -She reviews discharges every morning; -She did not send the bed hold policy for the resident; -The facility had a lot of admissions and discharges for the month of October 2023 and she missed it; -She prints a copy of the bed hold policy and mails it to the resident or to the guardian. During an interview on 12/01/23, at 12:30 P.M., the Administrator said the BOM is responsible for sending the bed hold policy and should have sent it to the resident's responsible party.

Based on record review and interview, the facility failed to promote resident self-determination when staff failed to provide routine baths or showers to one resident (Resident #42) and failed to consistently provide oral care assistance for one resident (Resident #91), with known dental issues, out of a sample of 24 residents. The facility had a census of 93. Review of the facility's policy titled, Activities of Daily Living (ADLs - dressing, grooming, bathing, eating, and toileting), Supporting, revised March 2018, showed the following: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming and oral care). 1. Review of the facility's policy titled, Bath,Shower/Tub, revised February 2018, showed the following: -The purposes of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -If the resident refused the shower/tub bath, document the reason why and the intervention taken; -Notify the supervisor if the resident refused the shower/tub bath. Review of Resident #42's face sheet (admission data) showed the following: -admitted [DATE]; -Diagnoses included anxiety disorder, reduced mobility, and major depressive disorder. Review of the resident's annual Minimum Data Set (MDS - a federally required assessment completed by facility staff), dated 09/09/23, showed the following: -Cognitive skills intact; -No behaviors; -No rejection of care; -Dependent on staff for shower/bath. Review of the resident's care plan, revised on 09/06/23, showed the following: -The resident has an ADL self-care performance deficit with limited physical mobility, alteration in musculoskeletal status related to muscle weakness, foot drop, and muscle wasting atrophy (decrease in size of an organ or tissue); -The resident prefers shower during the daytime hours with no specified preferred day of the week; -Staff to provide sponge bath when a full bath or shower cannot be tolerated; -The resident is dependent assistance of one staff. Review of the resident's September 2023 shower documentation showed the resident received a shower on the following days: -On 09/01/23; -On 09/11/23 (10 days after the prior shower); -On 09/12/23; -On 09/19/23 (7 days after the prior shower); -On 09/29/23 (10 days after prior shower). Review of the resident's October 2023 shower documentation showed the resident received a shower on the following days: -On 10/14/23 (15 days after prior shower); -On 10/27/23 (13 days after prior shower); -On 10/28/23. Review of the resident's November 2023 shower documentation showed the resident received a shower on the following days: -On 11/12/23 (15 days after prior shower); -On 11/21/23 (whirlpool) (9 days after prior shower). Review of the resident's progress notes, dated 08/18/23 through 11/29/23, showed staff did not document any refusal by the resident's of scheduled showers. During an interview on 11/30/23, at 9:12 A.M., the resident said the following: -He/she keeps track of his/her received showers on his/her phone; -The resident normally receives showers on Tuesday and Friday; -He/she refused a shower once awhile ago, but had not refused since then; -The last shower he/she received was on 11/12/23; -Not getting a regular shower made the resident feel dirty; -He/she would like to have a shower on the scheduled days; -He/she would like a shower at least once per week. During an interview on 11/30/23, at 10:05 A.M., Licensed Practical Nurse (LPN) E said the following: -Staff have not told him/her the resident refuses showers; -He/she has known the resident for sometime and he/she did not refuse showers. The resident may request another time for a shower, but not refuse; -He/she assigns an aide when he/she is the charge nurse on the 400 hall; -Staff should notify the charge nurse if a resident refuses a shower; -The nurse should talk with the resident and ask if a different time of day would be better for the shower; -The nurse aides complete a shower sheet and enter the shower in the computer; -The aides should document in the computer if a resident refused or received a shower. During an interview on 11/30/23, at 10:36 A.M., Certified Nurse Aide (CNA) V said the following: -The resident will refuse a shower if it is close to an activity time; -Staff had a shower list; -Aides documented completed showers in the computer; -Aides completed the shower sheets located at the nurses desk; -Nurses reviewed the shower sheets for skin issues; -Aides should report to the nurse if a resident refuses a shower and enter a note in the computer; -Staff should offer a resident a shower again on the next scheduled day if refuses. During an interview on 11/30/23, at 10:54 A.M., CNA W said the following: -The resident did not typically refuse showers; -Staff assigned the aides showers in the morning; -The nurses made the shower assignments; -If a resident refused a shower, aides should offer the resident a shower a few more times that day; -Staff should document on the shower sheet, computer and tell the nurse if a resident refuses. During an interview on 12/01/23 at 12:17 P.M., the Assistant Director of Nursing (ADON) said the following: -The aides give residents showers based on the shower books which show the days; -Weekends are make up days for residents who refuse; -She audits showers and refusals every few days; -Staff should document showers in the computer; -She checks the shower sheets weekly and documents the showers staff did not chart in the computer; -Aides come back later to the resident on the same day if a resident refuses a shower; -Aides should document if a resident refuses a shower and notify the nurse; -Nurses should document in the progress notes if a resident refuses a shower. During an interview on 12/01/23, at 1:11 P.M., the Director of Nursing (DON) said the following: -The resident did not refuse showers and has never complained about showers; -Staff give showers according to resident preference; -Staff should document in the computer if a resident refuses a shower. During an interview on 12/01/23, at 12:30 P.M., the Administrator said the following: -The resident is habitual with his/her refusal of showers; -Staff checked daily for showers; -Staff should attempt to reschedule if a resident refuses a shower; -Shower schedule is twice per week. 25513 2. Review of the facility's Routine Dental Care policy, revised April 2007, showed the following: -The nursing care staff will conduct ongoing oral health assessments to assure that each resident receives adequate oral hygiene. -The facility's routine dental care includes, but is not limited to an initial evaluation of the resident's dental needs; daily dental and oral hygiene plan of care; and preventive care and treatment. Review of Resident #91's face sheet showed the following: -Initial admission on 08/07/23 and readmitted to the facility on [DATE]; -Diagnoses included dysphagia following cerebral infarction (difficulty swallowing after a stroke), cachexia (condition causing muscles to waste away), muscle weakness (generalized), muscle wasting, and atrophy (wasting or thinning of muscle mass). Review of the resident's current care plan, revised on 11/20/23, showed the following: -The resident had his/her own teeth that were broken and with cavities and gum inflammation; -The resident required extensive assist of one staff with personal hygiene and oral care; -Discuss oral health concerns with resident/responsible party. Observation and interview with the resident on 11/27/23, at 2:25 P.M., showed the resident had missing, broken, and discolored teeth. The resident said he/she knew he/she had dental issues, but at that time he/she experienced no mouth or gum pain. The resident said he/she ate most meals in his/her room, in bed. During an interview on 11/30/23, at 10:36 A.M., CNA V said the following: -Aides assisted residents with oral care in the morning and as needed. Aides documented it in the electronic medical record; -He/she assisted residents with oral care if they needed it or if their mouth was dirty; -He/she usually worked on another hall, but had cared for Resident #91 in the past. He/she had not assisted the resident with oral care today (11/30/23). During an interview on 11/30/23, at 10:54 A.M., CNA W said the following: -Aides assisted residents with oral care when they assisted residents up in the morning; -He/she also asked residents if they needed assistance with oral care; -If a resident stayed in bed, he/she tried to assist that resident with oral care after meals; -Staff documented oral care in electronic medical record along with other activities of daily living; -He/she had not personally assisted Resident #91 with oral care, but would if the resident asked. During an interview on 11/30/23, at 12:17 P.M., CNA X said the following: -Staff assisted residents with oral care when staff got residents up in the morning; -Staff documented providing oral care in the electronic medical record; -Oral care consisted of cleaning residents' dentures or brushing their teeth with toothpaste; -The CNA did not usually work on Resident #91's hall and had not assisted him/her with oral care including today (11/30/23). During an interview on 11/30/23, at 12:37 P.M., LPN C said the following: -Staff assisted residents with oral care in the morning or after meals; -Oral care consisted of cleaning dentures, brushing teeth, and flossing; -Resident #91's teeth were not in good condition, but they did not affect the resident's eating. Review of the resident's electronic health records (EHR), dated 11/01/23 to 11/30/23, showed staff documented they provided oral care to the resident two to three times daily. The documentation did not specify the type of oral care provided. During an interview on 12/01/23, at 8:44 A.M., the resident said the following: -Staff assisted him/her with oral care once or twice per week at his/her request. They did not provide oral care every day. -He/she could brush his/her own teeth, but needed staff to give him/her the supplies. During an interview on 12/1/23, at 11:30 A.M., Registered Nurse (RN) H said the following: -Staff assisted residents with oral care every morning and after meals and was part of regular care; -If a resident refused oral care, the aides notified the nurse; -Staff documented oral care and any refusals in the electronic medical record. During an interview on 12/01/23, at 11:45 A.M., LPN E said that following: -The aides assisted residents with oral care every shift and documented it in the electronic medical record; -Oral care consisted of brushing teeth and dentures, making sure no food remained in the mouth between meals, and keeping the mouth clean; -Resident #91's teeth were in poor condition. During an interview on 12/01/23, at 1:11 P.M., the DON said the following: -Aides or nurses could assist residents with oral care; -Staff should assist resident with oral care before and after meals; -Oral care included denture care, checking the mouth for pocketing, brushing teeth in the morning and evening, and per residents' preferences; -Staff documented oral care in electronic medical record; -Resident #19's teeth were in poor condition, staff should assist him/.her with oral care. During an interview on 12/1/23, at 2:48 P.M., the Administrator said staff should assist residents daily with oral care.

Based on interview and record review, the facility failed to communicate and collaborate, consistent with professional standards of practice, with the dialysis (a process of filtering and removing waste products from the bloodstream when the kidneys can no longer sufficiently do so) center for one resident (Resident #73), out of a sample of two residents, when staff did not consistently send and receive communication with the dialysis facility regarding each dialysis session. The facility census was 93. Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with, revised October 2010, showed the following: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The facility will ensure that residents who require dialysis receive such services, consistent with professional standards of proactive, the comprehensive person-centered care plan, and the resident's goals and preferences; -Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including how the care plan will be developed and implemented and how information will be exchanged between the facilities. 1. Review of Resident #73's face sheet (a document that gives a patient's information at a quick glance) showed the following: - admitted [DATE]; - Diagnoses included acute kidney failure, edema (swelling), diabetes, and depression. Review of the resident's Physician Order Sheet (POS), showed the following: -An order, dated 06/19/23, to complete nursing communication with dialysis assessment Tuesday, Thursday, and Saturday (send copy with patient to be completed by dialysis). One time a day every Tuesday, Thursday, and Saturday for pre dialysis and in the afternoon every Tuesday, Thursday, Saturday for post dialysis. Review of the resident's care plan, revised 10/06/23, showed the following: -Monitor resident for adverse reactions from dialysis and notify nurse; -Dialysis assessment communication form to be completed prior to dialysis and upon returns as ordered by the MD (medical director); -Resident to attend all of his/her dialysis appointments. Review of the resident's nursing shared communication with dialysis assessment (electronic file), showed the nursing staff did not complete the communication with dialysis assessments from 08/22/23 through 12/01/23. During an interview on 11/30/23, at 10:16 A.M., Certified Nursing Assistant (CNA) I said social services handles dialysis communications. During an interview on 11/30/23, at 10:43 A.M., the RN/Clinical Instructor said the following: -Social services sets up transportation for residents to receive dialysis; -The shared communication with dialysis form is on the electric file and filled out by the nurses, printed, and sent with the resident to dialysis; -Sometimes dialysis fills out the rest of the communication form and returns it with the resident; -The completed form goes in the screen box at the nurse's desk; -Where the form goes after picked up from the screen box, he/she did not know; -The communication form is important so the nurse knows how the resident did at dialysis and if there are any concerns. During an interview conducted on 11/30/23, at 10:46 A.M., Licensed Practical Nurse (LPN) E said the following: -The dialysis communication form is paper and sent with the resident when going to dialysis; -The dialysis communication form goes in the screen box at the nurse's desk, when the resident returns to the facility, -The purpose of the form is for the facility and the provider to share information regarding the residents care. During an interview on 11/30/23, at 11:46 A.M., the Assistant Director of Nursing (ADON) said the following: -The resident should take the communication form with them to dialysis; -Very seldom does the dialysis center return the communication form; -They had difficulty getting the form back from dialysis; -The communication form goes in the screen basket at the nurses' desk when returned; -The ADON collects the forms every 24 to 48 hours; -The ADON scans the returned communication form into the resident's electronic file; -The resident goes to dialysis four to five days a week because he/she is not always able to receive dialysis; -The nursing staff hears about the resident's dialysis treatment by word of mouth from the transport driver; -The ADON has asked for communication forms from the dialysis center and has not received them; -If the resident is not able to receive dialysis, the nurse should document that in the residents nurse notes. During an interview on 11/30/23, at 2:56 P.M., the transport driver said the following: -The driver has been providing transportation for the resident consistently for two years; -The nurses do not send any document/form with the resident when he/she goes to dialysis; -When the dialysis center runs test they will send the residents results back with the resident to give to the nursing staff; -The dialysis center calls the facility routinely to keep the facility up to date on the residents care. During an interview conducted on 11/30/23, at 3:49 P.M., the Director of Nursing (DON) said the following: -The nurse should send the resident with the dialysis communication form along with a medication list when requested; -The dialysis center has not been returning the communication form; -The nurse should communicate new orders through phone call or fax; -The charge nurse should complete the communication with dialysis form, print the form, and send with the resident; -If the communication with dialysis form is not received when the resident returns from dialysis, the charge nurse should call the dialysis center for verbal report and document that information in the residents nursing notes; -The ADON scans the completed communication with dialysis form into the resident's electronic chart, then put in the screening basket at the nurse's desk; -Social Services is responsible for scheduling transportation to dialysis for the resident. During an interview on 12/01/23, at 12:30 P.M., the Administrator said the following: -The expectation of dialysis is out of his scope; -The electronic medical record has a communication tool; -They should be able to print out the communication with dialysis form and send with the resident.

Based on interview and record review, the facility failed ensure staff provided necessary services for all dependent residents to maintain grooming and personal hygiene when the staff failed to document routine offers of bathing or showering and failed to address resident's preferences for shower/baths in the resident's care plan for one resident (Resident #1). The facility had a census of 94. Review of the facility's policy titled Bath, Shower/Tub, revised February 2018, showed the following: -The purpose of the procedure is to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident skin; -Staff should document the date and time the bath was performed; -Staff should document the name and title of the individual(s) who assisted the resident with the bath; -Staff should document how the resident tolerated the bath; -Staff should document if the resident refused the bath, and what interventions were taken by staff; -Staff should notify the supervisor if the resident refuses the bath; -Report other information in accordance with facility policy and professional standards of practice; (The policy did not address the frequency for bathing or care planning resident's bathing preference.) 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included stroke and retention of urine. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/28/23, showed the following information: -Moderately impaired cognition; -Required extensive assistance with dressing, toilet use, and personal hygiene; -Dependent on staff for bed mobility and transfers; -Used a wheelchair for mobility; -Had an indwelling catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid); -Totally dependent on staff for bathing. Review of the resident's care plan, updated 04/18/23, showed the following: -The resident had difficulty caring for himself/herself due to a history of stroke, and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in his/her legs. (Staff did not care plan the resident's preference for how often to have a bath or shower. Staff did not care plan how many staff were required to assist with bathing or showers.) Review of the resident's electronic bathing record showed the following: -On 04/17/23 staff recorded assisting the resident with a bed bath (24 days after the resident was admitted to the facility); -On 04/20/23, staff recorded not applicable under type of bathing; -On 05/01/23, staff recorded not applicable under type of bathing; -On 05/04/23, staff recorded not applicable under type of bathing; -On 05/15/23, staff recorded not applicable under type of bathing; -On 05/17/23, staff recorded assisting the resident with a shower (one month after the last documented shower). During an interview on 08/01/23, at 9:47 A.M., Certified Nurse Assistant (CNA) A said there is a shower and bathing schedule made for all residents. Most residents get two baths or showers a week and CNAs electronically record when a resident has a shower or bath. During an interview on 08/01/23, at 9:5 A.M., Licensed Practical Nurse (LPN) B said he/she had not heard any recent concerns about residents not receiving sufficient baths or showers. He/she said each resident usually gets two showers or baths per week. During an interview on 08/01/23, at 2:38 P.M., the Director of Nursing (DON) said the following: -Residents are scheduled to have a bath or shower at least two times per week; -Staff can record the showers electronically on the kiosks/electronic bathing record, or sometimes on paper bath sheets; -For residents who refuse a bath at a certain time, staff should retry and re-approach the resident at a different time; -She was unable to say what occurred when staff put not applicable on the electronic bath records for the resident for the dates of 04/20/23 through 05/15/23. She could not say whether a bath had been offered or refused. She said staff should not be recording not applicable, as it has no indication as to what occurred. Review showed the facility did not provide paper bath sheets for the resident. During an interview on 08/01/23, at 4:27 P.M., the Administrator said staff should not be recording not applicable, because it has no meaning as to whether a bath was even offered to a resident. MO00218005

Based on interview, observation, and record review, the facility failed to obtain timely catheter (flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care orders, failed to obtain an order and document an indwelling catheter change, and failed to obtain a timely urine specimen when a resident had symptoms of a urinary tract infection and contact the physician on the delay for one resident (Resident #1). The facility also failed to follow physician's orders when staff inserted a different sized catheter than ordered for two residents (Resident #1 and #2). The facility's census was 94. Review of the facility's catheter procedure, revised October 2010, showed the following: -Staff should verify there there is an order for the procedure; -Review the resident's care plan to assess for any special needs of the resident; -Assemble the equipment and supplies as needed; -Equipment necessary for the procedure included a catheter tray, size (of the catheter) specified in the order; -Document the date and time the procedure was performed, who performed the procedure, all assessment data collected during the procedure (color, clarity, character), the size of the catheter inserted and the amount of fluid used to insert the balloon, in the resident's record; -Notify the physician of any abnormalities. Review of the facility's agreement for portable imaging services, dated 11/03/20, showed the provider will provide courier service at a mutually agreed upon time daily (Sunday through Saturday) to pick up specimens from the facility. 1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted [DATE]; -Diagnoses included stroke and retention of urine. Review of the resident's March 2023 through July 2023 Physician Order Sheet (POS) showed an order, dated 03/27/23, for indwelling catheter output every shift. (Staff did not obtain orders regarding catheter care). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/28/23, showed the following information: -Moderately impaired cognition; -Required extensive assistance with dressing, toilet use, and personal hygiene; -Dependent on staff for bed mobility and transfers; -Used a wheelchair for mobility; -Had an indwelling catheter; -Received an antibiotic five out of the last seven days. Review of the resident's March 2023 through July 2023 POS showed the following: -An order, dated 03/29/23 (to start 4/24/23), to change the resident's 16 French (fr - diameter of the catheter)/10 cubic centimeters (cc - the size of the balloon) indwelling catheter, on the evening shift, every month on the 24th; -An order, dated 03/29/23, may flush catheter with sterile water (water that is free of all microorganisms) as needed (PRN) every 8 hours for indwelling catheter care. Review of the resident's care plan, updated 04/18/23, showed the following: -The resident was dependent on staff for toilet use; -Monitor and document intake and output as per facility policy; -Monitor for signs of discomfort with urination and frequency; -Change catheter monthly; -The resident had a diagnosis of urinary retention. (Staff did not care plan catheter care.) Review of the resident's April 2023 Treatment Administration Record (TAR) showed the following: -An order, dated 03/29/23, to change the resident's 16fr/10cc catheter every month on the 24th; -On 04/24/23, a nurse documented changing the resident's catheter. Review of the resident's physician assistant (PA) progress note, dated 04/27/23, showed the following: -The resident reported significant catheter pain. The resident said the catheter needed changed; -The resident's indwelling catheter currently had no output (at approximately noon). Aides reported they had not emptied it this day; -The PA asked nursing to reposition/replace the catheter. The nurse received approximately 400 cc of urine output when replaced. Staff will send urine for UA due to very cloudy with foul odor. Review of the resident's March 2023 through July 2023 POS showed the following: -An order, dated 04/27/23, for a urinalysis with reflex laboratory testing performed subsequent to initial test results to culture and sensitivity (C&S-a culture is a test to find germs (such as bacteria or a fungus) that can cause an infection. A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection) one time for urinary tract infection (UTI). Review showed the staff did not document regarding obtaining the first specimen and reason for delay. Review of the resident's progress note dated 05/01/23, at 10:05 A.M., showed a nurse documented the PA reordered the UA with reflex to culture due to the laboratory did not collect the previous specimen. Review of the resident's March 2023 through July 2023 POS showed an order, dated 05/01/23, for a urinalysis with reflex to culture for UTI (four days after the initial order). Review of the resident's progress note dated 05/01/23, at 9:48 P.M., showed a nurse documented the resident said it felt like his/her catheter was not working right. The nurse attempted to flush the catheter without any luck. The nurse changed the indwelling catheter and used an 18fr/10cc catheter. The resident's urine was very thick, cloudy and had a foul odor. (The resident's physician's order was for a 16fr/10cc catheter.) Staff did not document obtaining the second specimen. Review of the resident's UA results, dated 05/02/23, and C&S results, dated 05/05/23, showed the following: -The resident's urine contained blood, leukocytes (a specific type of white blood cell), white blood cells, red blood cells and bacteria (the reference range of each of the findings was negative/not present) ; -The C&S showed the presence of Proteus mirabelis (bacterium that is a frequent cause of catheter-associated urinary tract infections) greater than 100,000 colony forming units (cfu)/milliliter (ml) (estimates the number of microbial cells (bacteria, fungi, viruses etc.) in a specimen) (cultures with greater than 100,000 cfu/ml of one type of bacteria usually indicate infection) Review of the resident's May 2023 TAR showed the following: -An order, dated 03/29/23, to change the resident's 16fr/10cc catheter every month on the 24th (the order did not include a PRN order); -On 05/25/23, a nurse documented changing the resident's catheter (the nurse did not document changing the resident's catheter on 05/01/23 as noted in the nurses' notes). Review of the resident's March 2023 through July 2023 POS showed an order, dated 06/19/23, for indwelling catheter care every shift and as needed with soap and water or wipes for infection control. During an interview on 08/01/23, at 11:25 A.M., the Assistant Director of Nursing, Long-Term Care (ADON-LTC), said she was the admitting nurse for the resident when the resident first came to the facility. She remembers that the resident would sometimes have a urinary tract infections (UTI), which were treated. The resident would sometimes have discomfort with his/her catheter. At that time, staff would flush the catheter and that would usually relieve the discomfort. If there were still problems, staff would change (replace) the catheter, and that would usually provide the resident with relief. During interviews on 08/01/23, at 2:38 P.M. and 4:48 P.M., and on 08/03/23, at 1:13 P.M., the Director of Nursing (DON) said the following: -The resident admitted to the facility with a catheter. He/she did not admit with specific catheter size or frequency orders due to a pending urology appointment. When the resident returned from that appointment (on 03/29/23), he/she had recommendations from the urologist that included frequency of catheter changes and to flush the catheter as needed; -The facility contracted with a laboratory company. A technician picked up urine specimens Monday through Friday; -The DON did not think staff changed the resident's catheter on 04/27/23. The nurse did not document the change in the resident's progress notes or TAR. Staff did not have to change a catheter to obtain a urine sample; -The DON did not know why the laboratory technician did not pick up the resident's urine specimen on 4/28/23. The nurse contacted the PA when he/she noticed the laboratory did not pick up the previous specimen (05/01/23). Staff would not need to contact the PA or physician sooner since a technician only picked up Monday through Friday. If the resident's condition was unstable, the facility would send the resident to the hospital if they could not wait until the next business day for pick up; -The nurse who changed the resident's catheter on 05/01/23 should have documented the change in the resident's TAR. If the resident did not have a PRN order to change his/her catheter, the nurse should have called the physician to obtain an order. If he/she could not obtain the correct size of catheter, he/she should have contacted the physician. The nurse should not have used a non-ordered size of catheter. 2. Review of Resident #2's face sheet showed the following information: -admitted [DATE]; -Diagnoses included congestive heart failure (inability of the heart to pump blood and oxygen to all necessary areas of the body), difficulty walking, and disorders of the bladder and urinary tract. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Total dependence on staff for toileting and personal hygiene; -Had an indwelling catheter Review of the resident's POS, dated August 2023, showed the following: -An order, dated 03/23/23, for supra pubic catheter (catheter enters the bladder directly through the abdomen) 16fr/10cc balloon. Change catheter PRN (as needed) for leakage obstruction or patient removal. Observation on 08/01/23, at 12:30 P.M., of the resident's suprapubic catheter showed showed the resident had a catheter in use with the size 16fr with a 5 cc balloon. During an interview on 08/01/23, at 12:40 P.M., the ADON-LTC said she didn't know why the resident had a catheter size that was different from what was ordered by the doctor. She said, if the facility does not have the correct-sized catheter, they can usually ask another facility for one the correct size and obtain it the same day. If that still isn't possible, the facility can go and buy the correct size. She said staff should not use a catheter for a resident that is not the same size as the one in the physician's order. 3. During an interview on 08/01/23, at 9:47 A.M., Certified Nurse Aide (CNA) A said CNAs are trained on catheter care and cleaning, but catheters are only changed by nurses. 4. During an interview on 08/01/23, at 9:55 A.M., Licensed Practicing Nurse (LPN) B said once an order for a UA is given by the doctor, one of the nurses should be obtaining a urine sample (specimen) as soon as possible. Then the lab would be contacted for pick up, if they were not already scheduled to come to the facility. 5. During interviews on 08/01/23, at 2:38 P.M. and 4:48 P.M., and on 08/03/23, at 1:13 P.M., the Director of Nursing (DON) said the following: -All residents should have orders upon admission for catheter care at least every shift and as needed, and to monitor output every shift as needed; -Although past standards of care recommended catheter changes every month, that changed and now catheter changes occurred according to physician orders and based on the specific needs of the resident; -The physician ordered the size of the catheter and staff should follow physician's orders related to size and frequency. -Staff documented changing a resident's catheter on the TAR and in the resident's progress notes. All catheter change orders should include a PRN order in case the catheter became clogged or dislodged; -The resident admitted to the facility with a catheter. He/she did not admit with specific catheter size or frequency orders due to a pending urology appointment. When the resident returned from that appointment (on 03/29/23), he/she had recommendations from the urologist that included frequency of catheter changes and to flush the catheter as needed; -The facility contracted with a laboratory company. A technician picked up urine specimens Monday through Friday. -The DON did not think staff changed the resident's catheter on 04/27/23. The nurse did not document the change in the resident's progress notes or TAR. Staff did not have to change a catheter to obtain a urine sample; -The DON did not know why the laboratory technician did not pick up the resident's urine specimen on 4/28/23. The nurse contacted the PA when he/she noticed the laboratory did not pick up the previous specimen (05/01/23). Staff would not need to contact the PA or physician sooner since a technician only picked up Monday through Friday. If the resident's condition was unstable, the facility would send the resident to the hospital if they could not wait until the next business day for pick up; -The nurse who changed the resident's catheter on 05/01/23 should have documented the change in the resident's TAR. If the resident did not have a PRN order to change his/her catheter, the nurse should have called the physician to obtain an order. If he/she could not obtain the correct size of catheter, he/she should have contacted the physician. The nurse should not have used a non-ordered size of catheter. 6. During an interview conducted on 8/1/23, at 4:48 P.M., the Administrator said staff should follow physician's orders. MO00218005 36974

Based on interview and record review, the facility failed to follow physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] #10) . The facility census was 100. 1. Record review showed the facility policy did not provide a policy regarding how facility staff should enter medication or treatment orders. Record review of Resident #10's face sheet (a brief resident profile sheet) showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's hospital discharge instructions, dated 4/28/2022, showed the following: -Wound/Incision Care Instructions: Change dressing and clean incision daily; -Continue wound VAC (a type of therapy to help wounds heal) until canceled by surgeon later on; -Two week follow up outpatient; -Needs a two week follow-up for wound VAC therapy. Record review of the resident's Order Summary Report showed the following: -An order, dated 4/28/2022, to cleanse the surgical site on the left foot with wound wash, place foam to the wound bed (bottom of the wound), cover with an ABD pad (a highly absorbent dressing that provides padding and protection for large wounds), and secure with Kerlix (a woven, rolled gauze) every day. (The order summary report did not address the wound VAC.) Record review of the resident's Treatment Administration Record (TAR), dated 4/1/2022 to 5/31/2022, showed the following: -A treatment order, dated 4/28/2022, to cleanse the left amputation surgical site with wound wash, place foam to the wound bed, cover and secure with Kerlix every day for surgical wound care. (Staff did not add an order regarding the wound VAC to the TAR.) Record review of the resident's care plan showed staff did not address the resident's surgical wound or a wound VAC. Record review of the resident's Skin and Wound Evaluation Form, dated 4/28/2022, showed the following: -Staff documented a surgical wound to the resident's left foot was present on admission; -Staff documented the wound was closed by 10 sutures (stitches); -Staff documented the wound exhibited dehiscence (partial or complete separation of the outer layers of the joined incision); -Staff documented the wound measured 1.0 centimeters (cm) length x 1.8 cm width; -Staff documented the wound had no evidence of infection; -Staff documented the wound had moderate exudate (drainage) and no swelling; -Staff documented the resident experienced intermittent pain of 2 on a 0-10 scale; -Staff documented the provider was notified. (Staff did not document notifying the surgeon or regarding the wound VAC.) Record review of resident's TAR, dated 4/1/2022 to 5/31/2022, showed the following: -On 4/29/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.) -On 4/30/2022, staff documented the resident was out of the facility so no treatment was performed; -On 5/1/2022, staff documented performing the wound treatment to cleanse the left amputation surgical site with wound wash, place foam to the wound bed, cover and secure with Kerlix every day for surgical wound care. (Staff did not document regarding a wound VAC.) Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 5/1/2022, showed the following: -The resident was moderately cognitively impaired; -He/she had a recent surgery requiring skilled nursing facility care; -He/she had a surgical wound requiring surgical wound care. Record review of resident's TAR, dated 4/1/2022 to 5/31/2022, showed the following: -On 5/2/2022, staff documented the previous shift performed the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.); -On 5/3/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.); -On 5/4/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.) Record review of the resident's Skin and Wound Evaluation Form, dated 5/4/2022, showed the following: -Staff documented a surgical wound to the resident's left foot that was present on admission; -Staff documented the wound was closed by 10 sutures; -Staff documented the wound exhibited dehiscence; -Staff documented the wound measured 1.0 cm length x 1.8 cm width; -Staff documented the wound had evidence of infection, which included increased drainage and increased pain; -Staff documented the wound had moderate seropurulant (a light green, brown, yellow, or tan fluid) exudate and no swelling; -Staff documented the resident experienced intermittent pain of 4 on a 0-10 scale; -Staff documented the resident stated the area was very tender and hurt much of the time; -Staff documented the dressing was saturated; -Staff documented the surrounding edges of the wound were a dark, reddish brown; -Staff documented the wound had turquoise colored drainage saturating the dressing when changed. -Staff documented the physician was notified and an order was obtained for a wound culture with sensitivity (a test to find germs that can cause infection, and which antibiotics respond best to the germs). (Staff did not document notifying the surgeon or regarding the wound VAC.) Record review of resident's TAR, dated 4/1/2022 to 5/31/2022, showed the following: -On 5/5/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.); -On 5/6/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.); -On 5/7/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.); -On 5/8/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.); -On 5/9/2022, staff documented the resident was hospitalized ; -On 5/10/2022, staff documented the resident was hospitalized ; -On 5/11/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.). Record review of the resident's Skin and Wound Evaluation Form, dated 5/11/2022, showed the following: -Staff documented a surgical wound to the resident's left foot was present on admission; -Staff documented the wound was closed by 10 sutures; -Staff documented the wound exhibited dehiscence; -Staff documented the wound measured 3.6 centimeters (cm) length x 3.0 cm width; -Staff documented the wound had no evidence of infection; -Staff documented the wound had heavy serous (thin, watery) exudate and no swelling; -Staff documented the surrounding tissue was denuded (the loss of the upper layer of tissue due to exposure of urine, feces, body fluid, wound exudate, or friction), excoriated (superficial loss of tissue), fragile, and macerated (white, wet, waterlogged tissue); -Staff documented the resident experienced continuous pain of 5 on a 0-10 scale; -Staff documented the dressing was saturated and leaking; -Staff documented the wound was deteriorating; -Staff documented the provider was notified. (Staff did not document notifying the surgeon or regarding the wound VAC.) Record review of resident's TAR, dated 4/1/2022 to 5/31/2022, showed the following: -On 5/12/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.); -On 5/13/2022, staff documented performing the wound treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff did not document regarding a wound VAC.); -On 5/14/2022, staff documented the resident was hospitalized . During interviews on 5/16/2022, at 9:55 A.M. and 12:20 P.M., Registered Nurse (RN) H said he/she does wound care and if he/she is not at the facility, the charge nurse on the hall is responsible for the wound care. He/she did wound care for the resident and he/she was originally supposed to have a wound VAC, but the day the resident was discharged from the hospital the order was discontinued because of the resident's sutures and the wound coming open. RN H said if he/she is unclear about orders for a resident, or if there are not orders for a resident, staff should call the physician to obtain orders. The Assistant Director of Nursing (ADON) usually put in the admitting orders. He/she did call the facility physician, but did not call the surgeon regarding the wound. During interviews on 5/16/2022, at 4:15 P.M. and 4:46 P.M., Licensed Practical Nurse (LPN) F said the admission nurse puts the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If staff is unsure about an order, all the physicians have standing orders for staff to use. Staff can also call the hospital to clarify an order if an order is unclear, call a physician to clarify an order, or to obtain an order if one is missing. During interviews on 5/16/2022, at 12:15 P.M. and 4:21 P.M., LPN L said the admission nurse may do some of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If there are orders the nurse is unsure about, or if the resident is missing orders, staff should call and get clarification. He/she does not remember if the resident had a wound VAC. During an interview on 5/16/2022, at 4:55 P.M., the Admissions Nurse/Care Plan Coordinator/Social Services Designee said if she has time to enter new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She does not remember entering orders for the resident. Wounds should be entered on the resident's care plan and if a resident has a wound VAC it should be on the resident's care plan. During an interview on 5/16/2022, at 2:12 P.M., the ADON said she expects staff to follow physician orders for wound care. She believes the staff went by what they were told in report from the hospital instead of the discharge orders. During an interview on 5/16/2022, at 5:30 P.M., the Administrator said he expects staff to follow physician orders. During an interview on 5/23/2022, at 4:20 P.M., the resident's surgeon said he/she expects staff to follow the wound orders as written and would expect staff to apply the wound VAC as ordered and leave it on until the follow-up appointment. He/she would have expected staff to call him/her if the resident was having problems with the wound. He/she said not applying the wound VAC could cause deterioration to the wound. 2. Record review of the facility policy titled Neurological Assessment, dated October 2010, showed the following: -Staff should perform neurological assessments for the following: -Upon physician orders; -When following an unwitnessed fall; -Subsequent to a fall with a suspected head injury; -When indicated by a resident's conditions; -Staff should perform neurological checks with the frequency as ordered or per falls protocol. Record review showed the facility policy did not provide a policy addressing how often neuro-checks should be performed. Record review of the facility form titled Nursing Neurological Assessment showed the following: -Assessments included assessment date and time; temperature; route the temperature was taken; pulse; respirations; blood pressure; position during blood pressure; resident orientation; level of consciousness; assessment of pupils; ability to respond to simple commands; verbalization; pain assessment; and evaluation of movement, sensation, and grip intact to arms and legs. Each assessment to be signed and dated by staff; -Staff to complete an initial assessment, then every 15 minutes x 4, then every 30 minutes x 4, then hourly x 4, then every eight hours x 8. Record review of Resident #10's admission MDS, dated [DATE], showed the following: -The resident required extensive assistance of two persons for transfers; -He/she used a wheelchair for mobility; -The resident had no falls prior to admission. Record review of the resident's current care plan showed the following: -An entry, dated 5/2/2022, that showed the resident had an actual fall; -Monitor/document/report as needed (PRN) for 72 hours for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation; -Neuro-check x (frequency). (Staff did not specify the frequency.) -Take vital signs lying/sitting/standing x 1 in first 24 hours. -An entry, dated 5/2/2022, that showed the resident was (Specify High, Moderate, Low) risk for falls. Record review of the resident's Progress Notes showed facility staff did not document a fall on 5/12/2022. Record review of the resident's Neurological Assessment Form, dated 5/12/2022, showed the following: -An initial assessment completed at 6:45 P.M.; -The first fifteen minute assessment completed at 7:00 P.M.; -The second fifteen minute assessment completed at 7:15 P.M.; -The third fifteen minute assessment completed at 7:30 P.M.; -The fourth fifteen minute assessment completed at 7:45 P.M.; -The first thirty minute assessment completed at 8:15 P.M.; -The second thirty minute assessment completed at 8:45 P.M.; -The third thirty minute assessment completed at 9:15 P.M.; -The fourth thirty minute assessment completed at 9:45 P.M.; -The first one hour assessment completed at 10:45 P.M.; -The second one hour assessment completed at 11:45 P.M.; -The third one hour assessment completed on 5/13/2022, at 12:45 A.M.; -The fourth one hour Assessment completed on 5/13/2022, at 1:45 A.M Record review of the resident's Progress Note dated 5/13/2022, at 6:59 A.M., showed the following: -Resident was found lying on his/her left side at the foot of his/her bed, with his/her left upper extremity pinned under him/her. He/she had an abrasion (scrape) on his/her right forehead on the bruise he/she got from the last fall. It appears as if he/she tried to get up and walk and started to trip over his/her catheter tubing. The on-call provider was notified and said to apply a pressure dressing and monitor the site. Record review of the resident's Neurological Assessment Form, dated 5/12/2022, showed the following: -Staff continued with the previous neurological assessments: -The first eight hour assessment completed on 5/13/2022, at 10:00 A.M.; -The second eight hour assessment completed on 5/13/2022, at 8:00 P.M.; -The third eight hour assessment completed on 5/14/2022, at 12:00 A.M.; Record review of the resident's Neurological Assessment Forms showed facility staff did not restart neuro-checks after the documented fall on 5/13/2022, at 6:59 A.M., per standards of practice. During an interview on 5/16/2022, at 1:30 P.M., RN M said during the overnight hours of 5/13/2022 and early morning 5/14/2022, The resident had rolled out of bed multiple times. He/she was aware of two times and the resident hit his/her head the second time. The day before on 5/13/2022, at 6:59 A.M., the resident had fallen and hit his/her head. The RN said he/she was unable to get the residents wound to stop bleeding, so he/she applied a pressure dressing per directions of the provider. The resident was having behaviors that were not typical, such as hitting at staff, but his/her vital signs were within normal range. After the resident's second fall early that morning, he/she had a cut on his/her forehead that the RN could not get to stop bleeding so he/she sent the resident to the Emergency Department. The RN said every time the resident fell , a new set of neuro-checks was started. The neuro-checks were documented on paper and kept at the nurses' station. Record review of the resident's Progress Notes showed facility staff did not document sending the resident to the Emergency Department or the multiple falls between 5/13/2022 and 5/14/2022. During an interview on 5/16/2022, at 12:15 P.M., LPN L said if a resident falls, staff should assess the resident, make sure they are safe, and start neuro-checks if the fall was unwitnessed or if the resident hits his/her head. If the resident was already on neuro-checks and falls again, the neuro-checks should start over with the new fall. During an interview on 5/16/2022, at 12:20 P.M., RN H said if a resident falls, staff should immediately assess the resident, take their vital signs, contact the physician if needed, contact the responsible party, start neuro-checks if the resident hits his/her head or if the fall is unwitnessed, and if the resident falls while they are already having neuro-checks done, staff should restart neuro-checks over. During an interview on 5/16/2022, at 1:00 P.M., LPN F said if a resident falls, staff should make sure the resident is safe, get vital signs, do an assessment, call the family, call the physician if needed, and start neuro-checks if the resident hits his/her head or if the fall is unwitnessed. If the resident has another fall while already on neuro-checks, staff should restart neuro-checks. During an interview on 5/16/2022, at 1:15 P.M., CNA O said if a resident falls, staff should make sure they are safe, call for a nurse to come and assess the resident, and take the resident's vital signs. The nurse will call the physician if needed, call the responsible party, and do an incident report. If the fall is unwitnessed or the resident hits his/her head, neuro-checks should be started and done per protocol. If the resident has another fall, the neuro-checks should start over. During an interview on 5/16/2022, at 1:45 P.M., CMT N said if a resident falls, staff should not move the resident until the nurse assesses the resident. Staff should check vital signs, and start neuro-checks if the resident hits his/her head or if the fall is un-witnessed. If a resident was already getting neuro-checks, and had another fall, staff should restart neuro-checks if needed. During an interview on 5/16/2022, at 2:10 P.M., the ADON said if a resident falls, she expects staff to start neuro-checks if the fall is unwitnessed or if the resident hits his/her head. Staff should assess the resident for injury, notify the physician if needed, contact the family, and send the Emergency Department if needed. If a resident is already on neuro-checks and has another fall that is unwitnessed or involving a head injury, the staff should restart the neuro-checks. During an interview on 5/16/2022, at 3:20 P.M., the Physician Assistant said if a resident has an unwitnessed fall or hits his/her head, she would expect staff to perform neuro-checks per protocol. If the resident is already having neuro-checks performed and has another unwitnessed fall or hits his/her head, she would expect staff to restart neuro-checks. During an interview on 5/16/2022, at 5:15 P.M., the Administrator said he expected staff to perform neuro-checks per facility protocol. If a resident has a fall while he/she is already getting neuro-checks, the Administrator expects staff to restart the neuro-checks. MOO 209