Every finding on record at Bridgewood Health Care Center

Kansas City, Missouri · CCN 265822

61 findings across 44 inspections, in the inspector's own words, 52 of them at actual harm or above.

Data as of September 30, 2026, released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Inspection of August 24, 2026

1 finding

F609D · No harm, potential for more than minimal, isolated

Review of the facility's policy, Abuse and Neglect Policy, dated 6/12/24 showed:-It was the policy of this facility to report all allegations of abuse to have been reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulation within the prescribed time frames. 1. Review of Resident #2's quarterly Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 8/18/26, showed the following:-Depression (a common and serious mood disorder that causes ongoing sadness and a loss of interest in things you once enjoyed);-Anxiety (a normal human emotion characterized by feelings of tension, worried thoughts, and physical changes like a fast heartbeat);-Schizophrenia (a serious mental illness that causes a loss of contact with reality, affecting how a person thinks, feels, and behaves);-BIMS score was 13 indicating he/she was cognitively intact. Review of Resident #2's care plan dated 8/11/26 showed:-He/She had impaired cognitive function or impaired thought process.-He/She frequently called the state agency rambling on the phone about mistreatment related to staff not buying him/her items that he/she wanted.-He/She makes false claims against staff including abuse and neglect. Review of Resident #3's quarterly MDS dated [DATE] showed:-He/She had the following diagnoses:--Bipolar Disorder (a mental health condition that causes extreme shifts in a person's mood, energy, and activity levels);--Schizophrenia;--Psychosis (a mental state that causes a disconnection from reality, making it hard for a person to tell what is real and what is not);-His/Her Brief Interview for Mental Status (BIMS) score was 10 indicating he/she was moderately cognitively impaired. Review of Resident #3's care plan dated 4/10/26 showed:-He/She had a long history of mental illness and frequent psychiatric hospital admissions.-He/She had a history of behavioral challenges that required protective oversight in a secure setting.-He/She had a Guardian to assist in decision making related to mental illness.-He/She had a behavior of acting in a submissive manner to a peer.-He/She was at risk for harm/injury related to imitating the peer's risky behaviors.-He/She had impaired cognitive function or impaired thought processes and would speak childlike. Review of Resident #2's Nurses' Note dated 8/23/26 at 1:30 P.M. written by Licensed Practical Nurse (LPN) A showed the Director of Nursing (DON) met privately with the resident regarding a reported incident involving a staff member. Review of Resident#2's Nurses' Note dated 8/23/26 at 5:24 P.M. written by LPN A showed the resident had reported to the state agency that on Saturday he/she had been physically abused by a facility staff;Note: Several unsuccessful attempts were made to speak to LPN A regarding the Nurses Note entries. During an interview on 8/24/26 at 9:00 A.M. the Administrator said:-He/She was made aware of the allegation of abuse on Sunday 8/21/26 at about 8:30 A.M.;-The resident said he/she had called in a report to the state agency, so he/she felt it had already been reported.-He/She started an investigation for abuse. During an interview on 8/24/26 at 10:30 A.M. Resident #3 said:-He/She and Resident #2 were beat up by a facility staff member;-Resident #2 was thrown around his/her room and punched and kicked by the Certified Nursing Assistant (CNA) A;-CNA A also punched him/her but he/she was not able to remember where he/she was hit;-There were no marks on his/her body.;-Staff were trying to remove him/her from Resident #2's room;-He/She did not tell anyone about the incident. During an interview on 8/24/26 at 10:45 A.M. Resident #2 said:-On Saturday night at supper time CNA A came into his/her room to make Resident #3 leave his/her room;-When they declined CNA A started to pull Resident #3 out of his/her room;-They started to fight and the CNA A punched him/her in the forehead, chest, and kicked him/her in his/her genitals; -He/She threw a couple of punches;-He/She called the state agency to report the abuse. During an interview on 8/24/26 at 2:00 P.M. the Director of Nursing (DON) said:-He/She was made aware of the allegation of abuse at about 9:00 A.M. on Sunday 8/21/26;-He/She was aware of the two-hour window for reporting to the state agency for an allegation of possible abuse;-He/She had not reported the abuse allegation.During a follow up interview on 8/24/26 at 2:30 P.M. the Administrator said he/she was aware of the facility's policy on reporting abuse, the allegation should have been reported within two hours to the state but he/she had not reported it.

Inspection of July 31, 2026

2 findings

F740D · No harm, potential for more than minimal, isolated

4 findings

F600H · Actual harm, pattern

Based on observation, interview and record review, the facility failed to protect seven sampled residents (Resident #1, Resident #13, Resident #6, Resident #5, Resident #2, Resident #9 and Resident #16) from physical abuse. On 1/18/26 Resident #1 punched Resident #13 in the back of the head. On 1/27/26 Resident #1 hit Resident #6 on the head with a mop stick after Certified Nurses Aide (CNA) E had asked Resident #6 to help. Resident #6 then punched Resident #1 multiple times in the face and head. Resident #6 had a bruise and raised area on the left side if his/her forehead. Resident #1 had scratches and red marks on his/her face. Resident #6 was upset CNA E had asked for his/her assistance and wanted this to stop. On 1/31/26 Resident #1 punched Resident #5 in his/her head. Resident #5 then punched Resident #1 in the face and head. Resident #1 had a bleeding laceration to his/her lower lip. On 2/1/26 Resident #1 pushed Resident #2 down on the floor resulting in Resident #2 a right rib fracture. On 2/13/26 Resident #10 pushed Resident #9 out of his/her wheelchair onto the ground and then Resident #10 kicked Resident #9 on the shoulder and head, resulting in a contusion to Resident #9's left shoulder. On 2/19/26, Resident #15 punched Resident #16 in the face and body resulting in Resident #16 having a bruised and bloody nose and a rib contusion. On 2/22/26 Resident #18 took Resident #17 to the ground and held the resident there in a headlock which caused Resident #17 pain in the left rib area. The facility census was 134. Review of the facility Abuse and Neglect Policy, dated 6/12/24, showed:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.-Physical Abuse is purposeful beating, striking, wounding, or injuring any resident of any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner.-Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management.-Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. 1.Review of Resident #1's admission record showed he/she was admitted on [DATE] with the following diagnoses:-Asperger's Syndrome (a neurodevelopmental condition characterized by difficulties with social interaction, nonverbal communication, and restricted, repetitive patterns of behavior).-Paranoid Schizophrenia (a chronic mental health disorder characterized by intense, irrational delusions and auditory hallucinations).-Major Depressive Disorder (a serious mental health condition characterized by persistent, intense feelings of sadness, worthlessness, and a loss of interest in activities).-Anxiety Disorder (a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life).-Mild Intellectual Disability (a neurodevelopmental condition characterized by mild limitations in learning, social, and practical life skills).-Impulse Disorder (a mental health condition characterized by an inability to resist urges or impulses that may harm oneself or others).-Obsessive Compulsive Personality Disorder (a chronic mental health condition characterized by a pervasive, rigid preoccupation with orderliness, extreme perfectionism, and mental/interpersonal control).-Schizoaffective Disorder (a chronic mental health condition combining schizophrenia symptoms-such as hallucinations, delusions, and disorganized thinking-with major mood disorder symptoms like mania or depression-Dissociative Identity Disorder (a complex mental health condition where a person's identity fragments into two or more distinct, alternating personality states). Review of Resident #1's Quarterly Minimum data set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 1/8/26, showed he/she was severely cognitively impaired and had behaviors. Review of Resident #13's admission record showed he/she was admitted on [DATE] with the following diagnoses:--Schizophrenia.--Anti-social personality disorder (characterized by persistent disregard of the rights of other people, failure to comply with laws and social customs, and irresponsible and reckless behavior). Review of Resident #13's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of resident #1's Admin/Registered Nurse (RN) Investigation, dated 1/18/26 at 12:00 A.M., showed:-Resident #1 and Resident #13 were involved in an incident.-Resident #1 had a discolored right eye because of the incident.-Resident #1 stated that he/she was beat up by Resident #13 and was punched in the face by Resident #13.-Resident #13 stated that Resident #1 attacked and punched him/her and then Resident #1 fell to the ground and hit his/her head. -This incident was not marked as abuse. Review of resident #1's Psychosocial Post-Incident Impact Note (SPN), dated 1/19/26 at 2:18 P.M., showed:-He/She was the aggressor in the incident.-He/She had a bump on the right side of head. Review of resident #1's Incident note, dated 1/19/26 at 5:59 P.M., showed:-Resident #1 fell and hit face on handrail in hallway following pushing match with Resident #13. -Resident #1 received a bruise on his/her right eye. -An X ray was obtained. During an observation and interview on 2/23/26 at 2:00 P.M., Resident #13 said:-Resident #1 got mad at him/her because he/she wouldn't give Resident #1 a hug. -Resident #1 started yelling and screaming at him/her. -He/She started to walk away from Resident #1 when resident #1 started punching him/her from behind. -He/She then placed Resident #1 in a hold and when he/she let Resident #1 go, Resident #1 fell and hit his head. -Resident #1 was still trying to fight him/her while he/she was on the ground, and he/she had to place his/her foot on Resident #1's chest and belly and then Resident #1 finally calmed down and got up and walked away.-He/She noticed that Resident #1 had a black eye after the incident but could not recall how he/she received the black eye. During an interview on 2/27/26 at 2:00 P.M., Certified Nurse Assistant (CNA) D said:-He/She was the only witness to the incident. -Resident #13 was teasing Resident #1 and it made Resident #1 angry.-Resident #13 and Resident #1 started arguing and he/she told them to stop.-Resident #1 then attacked Resident #13 and Resident #13 tackled Resident #1 to the ground.-He/She attempted to break the residents up after the incident became physical. During an interview on 2/26/26 at 1:08 P.M., Director of Nursing (DON) said:- He/She had not done an abuse Registered Nurse Investigation to determine abuse yet. -The staff should be notifying the charge nurse and him/her immediately when behaviors happened.-Nursing staff should have implemented as needed medication and notified the doctor when behaviors were escalated before the behaviors escalated to abuse. -CNA D should have reported to the nurse Resident #13 was triggering Resident #1. During an interview on 2/26/26 at 1:08 P.M., Administrator said:-He/She and the Administrator Assistant have been doing the RNIs.-Abuse was defined as the willful infliction of harm. Example: someone who knowingly tried to harm someone else with or without an object, would be willful infliction of harm. -The incident that occurred on 1/18/26 between Resident #1 and Resident #13 should have been marked as abuse.-When a resident to resident incident occurred, staff should have intervened, deescalated, and followed the Crisis Prevention Institute (CPI-provides training in Nonviolent Crisis Intervention. It focuses on de-escalation strategies, verbal intervention, and safe, restrictive-conscious physical holding skills to manage agitated or aggressive residents while ensuring the safety of both staff and residents) guidelines.-In the incident that occurred between Resident #1and Resident # 13 on 1/18/26, CNA D did not call a code green until after the residents were fighting.-A code green should be called after residents become physical with each other during an incident. During an interview on 2/26/26 at 1:08 P.M., Chief Nursing Officer (CNO)-A code green should be called before the residents become physical to be proactive in preventing abuse.-CNA D should have called a code green prior to Resident #1 and Resident #13 escalating and becoming physical with each other. Review of Resident #6's admission record showed he/she was admitted on [DATE] with the following diagnoses:--Intermittent Explosive Disorder (a chronic mental health condition characterized by recurrent, sudden, and impulsive outbursts of verbal or physical aggression that are grossly disproportionate to the trigger).-- Mild Intellectual Disability.--Traumatic Brain Injury (a localized, mild brain injury caused by a direct blow, resulting in localized, non-diffuse, and sometimes, long-lasting symptoms). Review of Resident #6's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #1's Admin/RN Investigation, dated 1/27/26 at 10:00 P.M., showed:-Resident #1 and Resident #6 were involved in an incident.-Resident #6 along with staff attempted to get Resident #1 to comply with staff and go back to the unit. -Resident #1 picked up stick of mop or broom and struck Resident #6 on top of the head.-Resident #6 then pushed Resident #1 to the ground and began striking him/her several times in the face and head.-After several attempts staff were able to break up the altercation between Resident #6 and Resident #1.-Resident #6 had a small non discolored area to the top of his/her left forehead. -Resident #1 had scratches and red mark on his/her face, neck, and head. -This incident was not marked as abuse. Review of Resident #1's incident note, dated 1/27/26 at 10:00 P.M., showed:-Resident #1 stated that CNA E was being a bitch so he/she ran and kicked open door and ran out into dining room then attempted to go out into hangout.-CNA E followed Resident #1 into the dining room asked him/her to come back to the unit.-Resident #1 started cursing and yelling at CNA E then began to angrily run towards CNA E. -Resident #6 stepped in front of CNA E and asked Resident #1 to stop.-Resident #1 then went and kicked open the door to the hangout area.-CNA E and Resident #6 followed Resident #1 out to the hangout area. -Resident #1 then picked up a mop stick striking Resident #6 on top of the head. -Resident #6 in turn pushed Resident #1 to the floor then striking Resident #1 several times in the face and head. -Staff after several attempts were able to break up the altercation. -Resident #1 had superficial scratches and red marks on his/her face, neck, and head.-Resident #1 stated I'm not hurt, he/she tried to kill me, no one ever listens to me, I have all the power, and I can kill everybody. -Resident #1 refused neurological assessments stating nothing is wrong with me. I heal fast I told you I have all the power. Review of resident #1's skin assessment note, dated 1/27/26 at 10:14 P.M., showed that resident #1 had superficial scratches and red marks on his/her face. Review of resident #6's skin assessment note, dated 1/27/26 at 10:15 P.M., showed that Resident #6 had a small discolored raised area on top of his/her left forehead. Review of Licensed Practical Nurse (LPN) B written statement, dated 1/27/26 at 10:00 P.M., showed:-He/She observed CNA E and Resident #6 trying to deescalate and get Resident #1 to return to the unit. -He/She stated that resident #6 should not have been involved in deescalating a peer. Review of Resident #19's Annual MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 2/23/26 at 10:48 A.M., Resident #19 said:-He/She witnessed Resident #1 have escalated behaviors and kicking walls and doors prior to the incident.-He/She witnessed Resident #6 attempting to help CNA E deescalate Resident #1.-He/She often saw Resident #6 protecting staff from other residents when they were being violent. -He/She saw Resident #6 directly after being hit in the head by Resident #1 with a stick.-Resident #6 had a bruise and large bump on his/her head.-Resident #6 stated that his/her head hurt after the incident and he/she weas in pain. -He/She asked Resident #6 how resident #6 got hit with a stick by Resident #1 and Resident #6 told him/her that resident #6 was protecting CNA E from getting hit by Resident #1 and that is how Resident #6 was struck in the head with the stick. -Resident #6 stated that CNA E asked Resident #6 to stay with him/her and protect him/her from Resident #1. During an interview on 2/23/26 at 1:49 P.M., Social Services Designee A said:-He/She was not involved in the incident. -After the incident Resident #6 told him/her that resident #1 was attempting to hit CNA E with the broom stick and resident #6 protected CNA E from getting hit with the stick and Resident #6 was hit instead. Review of Resident #8's Annual MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 2/23/26 at 3:43 P.M., Resident #8 said:-He/she saw Resident #1 hit Resident #6 with a broom stick.-He/She saw Resident #6 grabbing his/her head after he/she was hit in the head with the broom stick.-Resident #6 told him/her that Resident #6 was in pain after being hit in the head by Resident #1 with a broom stick. -Resident #6 got hit in the head by resident #1 because resident #6 was protecting CNA E from getting hit by Resident #1. -None of the residents were cleared from the scene of the incident when it occurred. -Resident #6 was walking with CNA E and they were both trying to calm down Resident #1 when Resident #1 hit resident #6 in the head.-CNA E did not attempt to get resident #6 away from Resident #1.-CNA E wanted Resident #6 to protect CNA E from Resident #1 so that CNA E did not get beat up by Resident #1. During an interview on 2/26/26 at 11:52 A.M. Resident #6 said:-He/She was hit in the head with a mop stick by Resident #1 and then him/her and Resident #1 began to fight and fell to the ground. -The fight occurred because he/she was attempting to help CNA E calm resident #1 down and it made Resident #1 mad at him/her. -CNA E asked him/her to help calm down Resident #1 because CNA E feared Resident #1. -He/She felt like staff asked him/her a lot to help calm other residents down and it put him/her in danger. -He/She has asked staff not to use him/her to calm other residents down because he/she felt like it made him/her a target with the other residents. -His/Her head hurt after being hit with the broom stick by Resident #1, but it felt better now. -He/She had a large bump on his/her head for several days after being hit with the broom stick. During an interview on 2/27/26 at 1:52 P.M., CNA E said:-He/She witnessed this incident and was the CNA directly involved in the incident.-Resident #1 was escalated and having angry behaviors his/her entire shift.-He/She reported Resident #1's behaviors to the charge nurse and informed the charge nurse that he/she was scared that Resident #1 was going to hurt themself or someone else if something was not done to calm him/her down.-He/she felt that his/her presence was making Resident #1 more angry so he/she attempted to walk away from Resident #1.-Resident #6 followed him/her as they walked away from Resident #1. -When he/she and Resident #6 started to walk away from Resident #1, Resident #1 became angrier and kicked the door to the hangout smoke deck area and entered the smoke deck.-He/She and Resident #6 then went out to the smoke deck to get resident #1 to return into the facility.-Upon entering the smoke deck resident #1 picked up what appeared to be a broken off mop stick and hit resident #6 in the head with the stick.-Resident #6 then defended himself/herself and started punching resident #1 numerous times in the face and head.-He/She then yelled out Code green.-The only person that responded to the code green to help him/her was another CNA and he/She could not recall who the other CNA that responded was. -By the time anyone else arrived at the code green, he/she already broke up the residents from fighting.-He/She knew that he/she should have told Resident #6 to not involve himself/herself in the attempt to deescalate Resident #1.-He/She did not tell Resident #6 to stop trying to help him/her deescalate Resident #1.-Resident #6 felt the need to protect him/her from resident #1 because there were no other staff protecting him/her.-She relied on the nursing staff to deescalate Resident #1 before the behaviors escalated to abuse.-He/She and other staff members were scared when Resident #1 was escalated because Resident #1 had violent behaviors and that was why Resident #6 felt the need to protect him/her. -This was not the first incident of resident #6 feeling the need and protecting staff from other residents when other residents are escalated and being violent toward them. -He/She never asked resident #6 to protect him/her but he/she also did not ask resident #6 to stop trying to protect him/her. During an interview on 2/26/26 at 1:08 P.M., Administrator said:-The incident that occurred on 1/27/26 between Resident #1 and Resident #6 should have been marked as abuse.-On 1/27/26 Resident #1 hit Resident #6 in the head with a broken mop stick and the hit in the head caused Resident #6 an injury.-Resident #6 got hit in the head by Resident #1 because resident #6 inserted himself/herself into the situation. -CNA E should have separated the two resident and not allowed Resident #6 to be involved with the incident. -He/She would not expect staff members to have been asking residents for help or protection from other residents. -CNA E should have reported to the nurse that they were triggering Resident #1and been removed from Resident #1's care. Review of Resident #5's admission record showed he/she was admitted on [DATE] with the following diagnoses:-Paranoid Schizophrenia.-Major Depressive Disorder.-Persistent Mood Disorder (a mental health condition characterized by significant, sustained, and disruptive disturbances in a person's emotional state, such as extreme sadness (depression), excessive elation (mania), or both).-Mild Intellectual Disability.-Generalized Anxiety Disorder.-Post Traumatic Stress Disorder (PTSD-a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event). Review of Resident #5's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #1's Admin/RN Investigation, dated 1/31/26 at 4:50 P.M., showed:-Resident #1 struck Resident #5 in the head.-Resident #5 then struck Resident #1 back.-Resident #1 had a scant amount of blood on his/her left lower lip.-Resident #5 stated that a staff member was trying to enter the lobby area and resident #1 was in the staff members way.-Resident #5 told Resident #1 to come with them as Resident #5 was walking by.-Resident #1 then hit Resident #5 in the head and called Resident #5 the devil. -There may have been an intent to harm by both residents. -This incident was not marked as abuse. Review of Resident #1's behaviors note, dated 1/31/26 at 5:52 P.M., showed:-Resident #1 was running through the dining room and attempted to go into the administrator's office. -Resident #5 told Resident #1 to get away from there.-Resident #1 then punched Resident #5 in the right ear. -A code green was called, and the two residents were separated. -Resident #1 had an abrasion to his/her right eye and had a split lip on the bottom left side. Review of the resident #1's skin assessment note, dated 1/31/26 at 5:58 P.M., showed:-The resident had two new skin issues.-The resident had a laceration on his/her lower left lip that measured 1 centimeter (cm) in length. -The resident had an abrasion on his/her right eye. Review of resident #5's behaviors note, dated 1/31/26 at 6:18 P.M., showed:-He/she was trying to stop Resident #1 from going into the administrator's office when Resident #1 punched him/her in the right side of his/her face.-A code green was called, and the two residents were separated. Review of resident #1's Psychosocial Post-Incident Impact Note (SPN), dated 1/31/26 at 8:01 P.M., showed:-The resident was the aggressor in the incident. -The resident stated that everyone was trying to kill him/her. During an interview on 2/16/26 at 12:35 P.M., Resident # 5 said:-Resident #1 was blocking the door from a staff member being able to go through the door and he/she told resident #1 to move out of the way and walk with him/her.-Resident #1 got mad at what he/she said to him/her and punched him/her in the head.-He/She hit Resident #1 back in the face and head.-He/She was unsure how many times he/she hit Resident #1 in the face.-He/She wanted to hit Resident #1 more, but resident #1 started running from him/her and staff got in between them. During an interview on 2/20/26 at 10:45 A.M., with Certified Medication Technician (CMT) A said:-He/She witnessed Resident #1 and Resident #5 fighting toward the end of the incident. -When he/she arrived at the incident, Resident #5 had a grip on Resident #1's clothing and CNA F was attempting to separate the residents. -The residents both punched each other prior to him/her arriving to the incident. During an interview on 2/23/26 at 9:40 A.M., LPN A said: -He/She was the nurse on duty when the incident occurred. -Resident #1 went up and hit Resident #5 out of the blue and stated he/she was trying to protect the staff because Resident #5 was the devil.-Resident #5 then punched Resident #1 and started to chase Resident #1 around the dining room.-CNA F intervened and grabbed and hugged Resident #5 to deescalate the incident.-Resident #1 had a bloody lip after the incident from Resident #5 punching him/her in the lip. -Resident #1 had a black eye on the right side from resident #5 punching Resident #1 in the eye. During an interview on 2/23/26 at 10:48 A.M., Resident #19 said:-He/She witnessed Resident #1 punch Resident #5 in the head and then Resident #5 started punching Resident #1 back several times in the face. -Staff did not clear the residents from the dining area where the residents were fighting, and he/she witnessed the entire fight.-Resident #1 had a bloody lip after the fight. During an interview on 2/23/26 at 1:49 P.M. with Social Services Designee A said:-He/She was not aware of the incident until he/she looked at the reports and found out about the incident after the fact.-He/She was unaware if a psychosocial assessment was completed on the residents after this incident. -He/She was unaware if either resident had a negative psychosocial outcome from the incident.-He/She was unaware if any residents that witnessed the incident had any negative psychosocial outcome from the incident. During an interview on 2/23/26 at 2:13 P.M., CNA F said:-He/She witnessed Resident #1 punch Resident #5 in the head and then Resident #5 started punching Resident #1 back in the face.-He/She helped break up the residents fight and separate the residents. -He/She noticed that Resident #1 was bleeding from his/her lip and had a black eye from the fight. During an interview on 2/26/26 at 1:08 P.M., Administrator said the incident that occurred on 1/31/26 between Resident #1 and Resident #5 was abuse. Review of Resident #2's admission record showed he/she was admitted on [DATE] with the following diagnoses:-Bipolar Disorder (a chronic mental health condition characterized by intense, extreme shifts in mood, energy, and activity levels, ranging from high-energy mania to deep, hopeless depression).-Paranoid Schizophrenia.-Schizophrenia.-Major Depressive.-Violent Behavior (any physical, verbal, or written action, including threats, intimidation, or property damage-intended to cause physical harm, fear, or injury to individuals or groups). Review of Resident #2's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of resident #1's Admin/RN Investigation, dated 2/2/26 at 3:45 P.M., showed:-Resident #1 and Resident #2 were in a resident to resident incident.-Resident #1was running down the men's unit front hall and unprovoked hit Resident #2 in his/her ribs. -Resident #2 complained of rib pain after the incident. -An Xray was completed on 2/4/26 and showed that Resident #2 had a rib fracture to the 11th rib. -Resident #2 was sent to the emergency room for evaluation of the rib fracture. -Resident #2 returned from the hospital with new orders for a lidocaine pain patch (a topical, local anesthetic adhesive patch that numbs a specific, localized area of skin to relieve pain) and Naproxen (a non-steroidal anti-inflammatory drug (NSAID) used to relieve pain, inflammation, swelling, stiffness, and fever) for pain.-The incident was a result of abuse. Review of resident #2's After Visit Hospital Summary, dated 2/4/26 at 12:15 P.M., showed:-The resident had a diagnosis of rib fracture.-The rib fracture injury was a result of a physical assault. -The resident was in pain.-The resident was given a lidocaine patch and naproxen for pain at 11:27 A.M. During an interview on 2/9/26 at 1:00 P.M., LPN A said:-He/She was not a witness to this incident, but it was reported to him/her by CNA A. -He/She was the charge nurse on duty the day of the incident.-He/She was outside on a break when the incident occurred.-The abuse incident was already over before he/she returned from his/her break. -He/She knew that Resident #1 was having increased behaviors on the day of the incident prior to the incident occurring.-Resident #2 reported to him/her that he/she had rib pain. -The Xray results showed that Resident #2 had a fractured rib on the right side.-He/She then send Resident #2 to the hospital for evaluation of his/her fractured rib.-The resident returned from the hospital with new orders for pain medication. During an interview on 2/9/26 at 1:30 P.M., Administrator Assistant said:-He/She was not a witness to the resident to resident altercation and was not in the building when it occurred.-It was reported to him/her that Resident #1 punched Resident #2 in the ribs and as a result, Resident #2 had a rib fracture.-It was reported to him/her that the incident was non provoked by Resident #2 and Resident #1 was the aggressor. -Resident #2 complained of rib pain after the incident occurred.-This incident was marked as abuse. During an interview on 2/9/26 at 2:30 P.M., Resident #2 said:-He/She remembered getting hit and pushed by Resident #1 and getting his/her ribs hurt. -He/She was standing in the hallway and Resident #1 ran up to him/her out of nowhere and punched him in the side of the stomach and then pushed him/her down on the floor.-He/She was not sure why Resident #1 punched him/her or pushed him/her down.-He/She was not a fighter and did not like to fight.-He/She was scared when Resident #1 punched and pushed him/her down.-He/She still had pain in his/ribs. During an interview on 2/9/26 at 4:00 P.M., Social Services Designee said:-He/She was at work the day the incident occurred but did not witness the incident. -It was reported to him/her that Resident #1 was having increased behaviors on this day but he/she did not here about the behaviors until after the altercation occurred.-Resident #2 sustained a fractured rib from the incident. -Resident #2 disclosed to him/her after the incident that he/she wanted an Xray and that he thought his ribs were broken. -Resident #2 reported to him/her after the incident that he/she was in pain. During an interview on 2/13/26 at 10:15 A.M., CNA C said:-He/She was here the day the incident occurred. -He/She was working on the front hall, which was where Resident #1 resided. -He/She left the unit to get some cereal for another resident when the incident occurred. -When he/she returned to the unit, Resident #2 reported to him/her that Resident #2 attacked him/her and he/she was in pain. -He/She notified the nurse what Resident #2 reported to him/her. During an interview on 2/13/26 at 3:30 P.M., resident #1's guardian said:-Resident #1 had baseline delusions but has recently gotten worse.-He/She was notified with every incident that Resident #1 has been involved with. -He/She believed the incidents to be a result of abuse and escalated behaviors.-He/She would expect the residents to have a safe environment and effective protective oversight by the facility. During an interview on 2/13/16 at 3:40 P.M, Psychiatric Nurse Practitioner A said: -He/She considered all of these incidents to be abuse. -He/She expected all of the resident's to be free from abuse and live in a safe environment. During an interview on 2/26/26 at 1:08 P.M., Administrator said the incident that occurred on 2/1/26 between Resident #1 and Resident #2 was abuse. 2. Review of Resident #9's undated facesheet showed he/she admitted [DATE] with the following diagnosis: -Cerebral Infarction.-Bi-Polar Disorder.-Major Depressive Disorder.-Schizoaffective Disorder. Review of Resident #9's quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #10's undated facesheet showed he/she admitted [DATE] with the following diagnosis: -Schizoaffective Disorder.-Major Depressive Disorder. -Bipolar Disorder.-Hallucinations-Personal History of other Mental and Behavioral Disorders Review of Resident #10's quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #9's progress note, dated 2/13/26 at 6:40 P.M., showed: -He/She was in the hallway when Resident #10 had come up to Resident #9, punched Resident #9 and Resident #9's wheelchair fell over. -Staff intervened and separated when Resident #10 then kicked Resident #9 in the back of the head. -Resident #9 complained of pain to the left shoulder and was sent to the hospital. Review of Resident #10's progress notes, dated 2/13/26 at 6:59 P.M., showed:-He/She hit Resident #9 while Resident #9 was sitting in hallway. -Resident #10 hit and kicked Resident #9 in the back of Resident #9's head. Resident #9's wheelchair fell over. Review of the facility RNI, dated 2/13/26, showed: -Physical Aggression not involving the head between Resident #9 and Resident #10. -Responded to code green on medical unit. Resident #9 was lying on the floor in front of his/her wheelchair. Staff surrounded Resident #9 and completed an assessment. Resident #9 wanted off the floor and to press charges against Resident #10. -The event was a behavior based on Resident #10's poor impulse control, poor communication, and not being able to link consequences to actions. Resident #10 did not intend to harm Resident #9. Resident #10 said he/she pulled Resident #9 out of his/her wheelchair because Resident #10 was mad. -Resident #9 was sent to the hospital. -The incident was not the result of abuse and not reportable. Review of Resident #9's hospital after visit summary, dated 2/13/26, showed: -He/she was seen for neck pain. -He/she had a shoulder contusion. -He/she was provided a lidocaine (a fast acting pain relief) for pain. During an interview on 2/23/26 at 9 A.M., Resident #10 said: -Resident #9 had stolen from him/her and flipped him/her off. -He/She pushed Resident #9 from behind and knocked Resident #9 out of his/her wheelchair to the floor. -He/She did not remember who held him/her back. -He/She kicked Resident #9 once in the shoulder. During an interview on 2/23/26 at 10:24 A.M., Resident #9 said: -Resident #10 had run him/her down and tackled him/her. -He/she had left side paralysis which was why Resident #10 tackled him/her out of his/her wheelchair. Resident #10 kicked him/her in the shoulder and kicked him/her in the head. -He/she said the wheelchair flipped over on the side and bent the spokes on the foot pedal causing him/her to have a loaner wheelchair. -His/Her left shoulder hurt. -He/She went to the hospital. -He/She was mad his/her wheelchair was broke. During an interview on 2/23/26 at 10:58 A.M., LPN C said: -He/she was on the front hall and hall and heard commotion. When he/she responded Resident #9 was on the ground and Resident #10 had kicked Resident #9 in the head. During an interview on 2/23/26 at 11:15 A.M., CMT C said: -He/she was at the medication cart by the nursing station when he/she saw Resident #10 come from the [NAME] hall heading toward Resident #9. Resident

F740G · Actual harm, isolated

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and behavioral health services for one sampled resident (Resident #1) who had a known behavioral health history and mental health diagnosis. The facility staff failed to implement the resident's plan of care, administer psychotropic medications and tests as ordered by the physician, implement behavioral health techniques for de-escalation to reduce the resident's behavior and maintain residents safety. As a result, the resident was involved in multiple resident to resident altercations that resulted in physical injury. On 1/18/26 Resident #1 punched Resident #13 in the back of the head. On 1/27/26 Resident #1 hit Resident #6 on the head with a mop stick. Resident #6 then punched Resident #1 multiple times in the face and head. Resident #6 had a bruise and raised area on the left side if his/her forehead and was upset. Resident #1 had scratches and red marks on his/her face. On 1/31/26 Resident #1 punched Resident #5 in his/her head. Resident #5 then punched Resident #1 in the face and head. Resident #1 had a bleeding laceration to his/her lower lip. On 2/1/26 Resident #1 pushed Resident #2 down on the floor resulting in Resident #2 a right rib fracture. 13 residents were sampled. The facility census was 133 residents.Review of the facility's Intensive Monitoring Policy, dated 4/30/24, showed:-The purpose of the policy was to ensure a system was in place for residents who required increased monitoring for crisis, behavioral and psychiatric issues.-Residents who required more intensive monitoring due to crisis, behavioral, or psychiatric symptoms would be monitored by the facility staff.-Intensive monitoring was defined as periodic hourly, every two hours, or every shift check by a facility staff member.-One-on-one monitoring was a designated employee assigned by a facility supervisor.-Residents who required intensive monitoring of one to one would have a dedicated staff member within eyesight.-Residents may require more intensive monitoring based on their crisis, behavioral, and psychiatric issues.-The level of intensive monitoring required would be identified by the specific situation or the resident assessment.-Residents who were showing poor impulse control including crisis, behavioral, psychiatric issues, such as, verbal and or physical aggression, elopement ideation, suicidal and or homicidal ideation and decompensation mentally or crisis may be placed on intensive monitoring or one to one or two to one monitoring at the discretion of the administrative staff and or the facility supervisor. -The facility's interdisciplinary team would address the resident's behavioral concerns and ensure interventions were in place to address the residents needs such as psychiatry follow up, counseling, and medical needs.-Once the resident was stabilized and or returned to prior level of functioning, the facility's interdisciplinary team met to discuss determination of discontinuation of intensive monitoring. -The facility staff would document the intensive monitoring in the residents Electronical Medical Record (EMR). Review of the facility Behavioral Health Services Policy, dated 10/31/24, showed:-It was the policy of the facility to ensure all residents received necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning.-Behavioral health encompasses a residents whole emotional and mental well-being, which included, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders.-The facility would consider the acuity of the resident population, including residents with mental disorders, psychosocial disorders, or substance use disorders, and those with a history of trauma and/or post-traumatic stress disorder, as reflected in the facility assessment.-All facility staff, including contracted staff and volunteers, would receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. -Education would be based on the role of the staff member and the residents needs identified through the facility assessment.-The social services director would serve as the facility's contact person for questions regarding behavioral services provided by the facility and outside sources such as physician, psychiatrist, or neurologist.-The assessment and care plan would include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice and safety.-Staff would monitor the resident closely for expressions or indication of distress.-Staff would accurately document the behaviors changes and potential triggers in the resident's record.-Staff would ensure appropriate follow up assessment, if needed.-Staff would evaluate resident and care plan routinely to ensure the approaches were meeting the needs of the resident. -Staff would share concerns with the Interdisciplinary Team (IDT) to determine underlying causes of mood and behaviors changes, including differential diagnosis. -Staff would use pharmacological interventions when non-pharmacological interventions were ineffective or clinically indicated. 1. Review of Resident #1's admission record showed he/she was admitted on [DATE] with the following diagnoses:-Asperger's Syndrome (a neurodevelopmental condition characterized by difficulties with social interaction, nonverbal communication, and restricted, repetitive patterns of behavior).-Paranoid Schizophrenia (a chronic mental health disorder characterized by intense, irrational delusions and auditory hallucinations).-Major Depressive Disorder (a serious mental health condition characterized by persistent, intense feelings of sadness, worthlessness, and a loss of interest in activities).-Anxiety Disorder (a group of mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life).-Mild Intellectual Disability (a neurodevelopmental condition characterized by mild limitations in learning, social, and practical life skills).-Impulse Disorder (a mental health condition characterized by an inability to resist urges or impulses that may harm oneself or others).-Obsessive Compulsive Personality Disorder (a chronic mental health condition characterized by a pervasive, rigid preoccupation with orderliness, extreme perfectionism, and mental/interpersonal control).-Schizoaffective Disorder (a chronic mental health condition combining schizophrenia symptoms-such as hallucinations, delusions, and disorganized thinking-with major mood disorder symptoms like mania or depression-Dissociative Identity Disorder (a complex mental health condition where a person's identity fragments into two or more distinct, alternating personality states). Review of the resident's Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 1/30/24 showed:-The resident had behavioral difficulties and/or mental illness symptoms requiring 24 hr. monitoring/management.-The resident had the following diagnoses:--Aspergers Syndrome--Paranoid Schizophrenia--Impulse Control Disorder--Attention Deficit Hyperactivity Disorder (ADHD-a neurodevelopmental disorder characterized by a persistent pattern of inattention, hyperactivity, and/or impulsivity that interferes with daily functioning, school, or work).--Mood Disorder (a mental health condition characterized by significant, long-term disturbances in emotional state, extending far beyond typical mood swings).--Psychotic Disorder (a set of symptoms indicating a loss of contact with reality, characterized primarily by hallucinations (seeing/hearing things not there) and delusions (false, fixed beliefs)).--Bipolar 1 Disorder (a severe mental health condition characterized by at least one manic episode lasting at least 7 days or being severe enough to require hospitalization).--Major Depressive Disorder.--Oppositional Defiant Disorder (a frequent and ongoing pattern of anger, irritability, arguing and defiance toward parents and other authority figures).--Pervasive Developmental Disorder (an umbrella term for a group of neurodevelopmental conditions characterized by significant, early-onset delays in social interaction, communication skills, and restricted or repetitive behaviors).--Anxiety Disorder--Mild Intellectual Disability--Obsessive Compulsive Disorder--Schizoaffective Disorder-The resident required psychiatric follow up and consultation.-The resident required medication administration, management, and monitoring.-The resident required a secure behavioral unit.-The resident was impatient and demanding.-The resident destroyed property.-The resident disturbed other residents.-The resident physically threatened other residents.-The resident struck other residents unprovoked.-The resident required 24-hour oversight for safety and nursing care.-The resident required medication administration and management.-The resident required psychiatric oversight.-The resident required monitoring of behavioral symptoms. -The resident required monitoring of medication therapeutic effects in managing mental health symptoms including labs. -The resident required assessment and planning for the level of supervision required to prevent harm to self and others. -A crisis plan was recommended due to the resident's history of aggression towards others. Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 1/8/26, showed he/she was severely cognitively impaired and had behaviors. Review of the resident's undated Care Plan showed:-The resident had behavioral challenges that required protective oversight in a secure setting.-Interventions included:--Counseling services to assist in developing coping skills.--1:1 intervention as needed.--Pharmaceutical Interventions as needed.-Per PASARR he/she had behaviors that included frequent and continuous telling, invading others space, verbal abuse, verbal threatening, physically threatening, striking others, and suspicion of others. -Triggers included:--When people were mean to him/her.--When people didn't understand him/her--When people yelled at him/her.--When he/she didn't get money on time.-Interventions included:--Smoking a cigarette.--Taking a shower.--People talking calmly to him/her.--Watching music videos.--Reading the Bible.--Listening to music. -Per PASARR, he/she needed provision of a structured environment.-Interventions included:--Provide instructions at his/her level of understanding.--Assess and plan for the level of supervision required to prevent harm to self/others.--Provide for individual personal space.--Establish consistent routines.--Provide schedule of daily tasks/activities.-The resident was at risk for the following signs/symptoms related to their diagnosis ofSchizophrenia: aggression, anxiety, inability to make decisions, delusions (fixedfalse beliefs that can't be reasoned with, fear, hallucinations (hearing, seeing, feeling, smelling things that are not there), hard time focusing, irritability, and staying to self. -Interventions included:-- Administering PRN (as needed) medication for anxiety or hallucinations per physician's order.--Avoiding arguing or getting defensive with him/her.--Being respectful, honest, and nonjudgmental with him/her at all times.--Notifying the charge nurse if the resident experienced any of the signs/symptoms of Schizophrenia.--Respecting his/her personal space.-The resident was at risk for the following signs and symptoms related to his/her diagnosis of Intellectual disability: difficulties talking or talking late, difficulty communicating or socializing with others, difficulty with problem-solving or logical thinking, Having problemsremembering things, Inability to connect actions with consequences, Inability to doeveryday tasks like getting dressed or using the restroom without help, Learning and developing more slowly than others, and had a lower-than-average scores on IQ test.-Interventions included:--Encouraging him/her to participate in social activities and groups.--Ensuring his/her environment is safe.--Offering behavior modification programs.--Providing him/her with diversional activities.--Providing positive reinforcement.--Use of calm and gentle approaches with him/her.-The resident was at risk of the following signs and symptoms related to the diagnosis Anxiety disorder such as cursing, hollering, leg shaking, moving around in or frequently getting up and down from the chair, nail biting, nervousness, pacing on the unit, restlessness, shaky voice, sweating, and toe tapping.--Interventions included:--Being aware of body stance and facial expressions when approaching him/her.--Closely watching him/her for signs of anxiety and act before he/she lost control.--Offering medication before he/she had a behavioral outburst.--Offering non-invasive coping mechanisms first to try to reduce his/her anxiety level. --Assisting with finding the cause of the anxiety. Review of the resident's Physician Order sheet (POS), dated January 2026, showed:-The resident had an active order for chlorpromazine HCl Injection Solution 25 MG/ML(Chlorpromazine HCl) Inject 50 mg intramuscularly every 12 hours as needed for Agitation: Anxiety. Review of the resident's Admin/Registered Nurse (RN) Investigation (RNI), dated 1/18/26 at 5:45 P.M., showed:-The resident kicked through the unit's front doors and entered the dining room. -The Activities Director/Staffing Coordinator was in the dining room when the resident entered. -The Activities Director/Staffing Coordinator sat the resident at a dining room table and gave the resident something to eat. -While in the dining room eating, the resident was triggered by a commercial that came on the television in the dining room. -The resident threw a bottle of shampoo at the television.-The Activities Director/Staffing Coordinator left the dining room while the resident remained in the dining room tend to another issue.-While staff was tending to another incident, the resident picked up a chair, placed the chair back on the ground, and then charged at Maintenance Staff A. -The Activities Director/Staffing Coordinator and Maintenance Staff A placed the resident in a hold (a gripping, supporting or containing a person with hands, arms or capacity), and both fell to the ground with along with the resident. -New interventions included:--A urinalysis test would be ordered for the resident.--A compete blood count (CBC) lab test would be ordered for the resident. --The resident's care plan would be reviewed and updated interventions added. Review of the resident's medical record showed no urinalysis test or complete blood count lab completed after this incident on 1/18/26. Further review showed the care plan was not reviewed or interventions added. Review of Resident #1's RNI, dated 1/18/26 at 12:00 A.M., showed: -Resident #1 and Resident #13 were involved in a resident-to-resident incident with Resident #1 as the aggressor.-Resident #1 had discolored skin to his/her right eye because of the incident.-Resident #1 stated that he/she was beat up and punched in the face by Resident #13.-Resident #13 stated that Resident #1 attacked and punched him/her and then the resident fell to the ground and hit his/her head. --New interventions included:--Assessment.--Staff education.--Resident education During an interview on 2/9/26 at 1:00 P.M., Licensed Practical Nurse (LPN) A said:-He/She was familiar with the resident and was the main charge nurse.-He/She witnessed the resident's behaviors on numerous occasions.-He/She was not aware that a urinalysis and CBC tests were supposed to be drawn on 1/18/26 per the resident's RNI. -He/She could not recall the resident was administered an as needed medication due to his/her escalated behaviors on 1/18/26. -The resident had a standing as needed medication order that staff could administer for his/her escalated behaviors when needed. Review of Resident #1's Psychosocial Post-Incident Impact Note (SPN), dated 1/19/26 at 2:18 P.M., showed: -He/She was the aggressor in the incident.-He/She had a bump on the right side of his/her head. Review of Resident #1's incident note, dated 1/19/26 at 5:59 P.M., showed: -Resident #1 fell and hit his/her face on handrail in hallway following a pushing match with Resident #13. -Resident #1 received a bruise to his/her right eye. -An X ray was obtained. Review of the residents Medication Administration Record (MAR), dated January 2026, showed Chlorpromazine for the resident's agitation was not administered to the resident on the date of the incident, 1/18/26. Review of the resident's Electronic Medical Record (EMR), dated 1/18/26 through 1/23/26, showed:-No care plan updates, or new interventions were completed by staff after the behavior incident on 1/18.-No behavior monitoring was documented by staff. -No nonpharmacological interventions were documented by staff.-No pharmacological interventions were documented by staff. -PASARR recommendations were not implemented such as:-The resident required monitoring of medication therapeutic effects in managing mental health symptoms including labs. -The resident required assessment and planning for the level of supervision required to prevent harm to self and others. -A crisis plan was recommended due to the resident's history of aggression towards others.-Facility staff did not document offering counseling services to the resident per the care plan.-No documentation facility staff implemented the care plan interventions of 1:1, pharmaceutical interventions, to smoke or shower, music or music videos, to read the Bible, or calm talk for the increased behaviors. During an interview on 2/9/26 at 1:30 P.M., Administrator Assistant said:-He/She completed the investigation for the incident on 1/18/26.-He/She was not sure why the interventions for the resident behaviors were not completed. -He/She expected that all the interventions in an incident investigation were to be completed. -He/She was not sure why the resident's care plan was not updated after the incident.-He/She thought it was the Social Services (SS) that updated the resident's care plan but was not sure.-He/She expected care plans to be updated after incidents of escalated behaviors that required an investigation.-He/She expected a resident's care plan interventions to be used when a resident was having escalated behaviors.-He/She was aware that the resident was care planned to have an as needed medication when his/her behaviors had escalated.-He/She was not sure why the nursing staff did not administer the resident's as needed medication when he/she needed it.-The facility was going to do some education on using interventions and as needed medications before the resident's behaviors got out of control. During an interview on 2/20/26 at 11:00 A.M., Maintenance Staff A said:-On 1/18/26, he/she heard a lot of commotion and witnessed the resident throwing something at the television in the dining area.-The resident then charged at him/her. -He/She and Activities Director/Staffing Coordinator placed a hold on the resident by each of them having one of the resident's arms placed above the resident's head.-Their hold on the resident was a Crisis Prevention Institute (CPI) approved hold. -During the hold, the resident and him/her fell to the floor.-There were no clinical staff or nurses monitoring the resident during his/her increased behaviors as was their protocol when the resident had behaviors. -Clinical staff arrived at the incident after a code green (facility wide call to ask for assistance) was called.-He/She witnessed the resident continue to have escalated behaviors for the rest of the day.-Staff were unable to handle the resident's behaviors. -He/She witnessed clinical staff allowing the resident to run around the facility and have escalated behaviors with no attempts to intervene on numerous occasions. -He/She witnessed the resident run around the facility hitting other residents, breaking things, doing what he/she wanted regardless of destructive behavior most days and nothing was done by staff to intervene or calm the resident down until he/she became physical with staff or other residents. -Most of the staff are female and they are fearful of the resident due to his/her violent behaviors. During an interview on 2/20/26 at 3:00 P.M., Activities Director/Staffing Coordinator said:-On 1/18/26, the resident busted through the door, and he/she sat the resident at a table in the dining room. -The resident had a shampoo bottle in his/her hand and threw the shampoo bottle at the television. -After the resident threw the shampoo bottle at the television, he/she got up and charged at Maintenance staff A.-Maintenance staff A performed a hold on the resident, and he/she stepped in to help get the resident under control.-The resident bit Maintenance staff A during the altercation.-The resident and Maintenance staff A both fell to the ground during the altercation. -There was no clinical or nursing staff present in the dining area at the time of the incident.-He/She called a code green.-Staff responded to the code green and helped get the resident and Maintenance staff A separated. -The resident continued to have increased behaviors and agitation after the incident.-He/She did not witness any clinical staff deescalating the resident before or after the incident. During an interview on 2/23/26 at 10:25 A.M., Certified Nurse Assistant (CNA) A said:-He/She did not directly witness the incident on 1/18/26 but responded when a code green was called.-He/She helped separate the resident and the staff members and took the resident outside on the smoke deck.-He/She was outside with the resident for 20 minutes. -A nurse did not come assess the resident after the incident while he/she had the resident on the smoke deck. -Once him/her and the resident returned into the facility, he/she brought the resident to see the nurse.-The resident continued to have escalated behaviors after the incident. -The nurse who responded to the incident did not attempt to deescalate the resident or give him/her an as needed medication for increased agitation. -The resident was not placed on any intense monitoring after the incident like their protocol after a resident behavior. -He/She was not given any interventions or special instructions to care for the resident after the incident.-He/She did not continue to sit with or monitor the resident. -He/She was not advised by the nurse to continue monitoring the resident. During an interview on 2/23/26 at 1:49 P.M., SS Designee A said:-He/She was here on 1/18/26 during the incident but did not see this incident when it occurred. -After the incident occurred, he/she made an attempt to talk to the resident, but he/she could not remember if he/she was able to do so.-Staff did not request him/her to help with the resident's escalated behaviors on 1/18/26. -He/She was unaware that the behavioral health policy stated SS served as the contact person for clinical staff to obtain behavioral health support. -He/She was rarely contacted by staff for behavioral health support when residents were having escalated behaviors.-He/She normally found out by his/her own record review if the incident required staff to fill out an incident report.-Residents should have received psychosocial assessments after each incident of escalated behaviors per facility practice. -He/She could not remember if a psychosocial assessment was completed on the resident after the incident. Review of Resident #13's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. During an observation and interview on 2/23/26 at 2:00 P.M., Resident #13 said:-Resident #1 got mad at him/her because he/she wouldn't give him/her a hug. -Resident #1 started yelling and screaming at him/her. -He/She started to walk away from the resident when he/she started punching him/her from behind. -He/She then placed Resident #1 in a hold and when he/she let him/her go, the resident fell and hit his/her head. -Resident #1 was still trying to fight him/her while Resident #1 was on the ground, and he/she had to place his/her foot on the resident #1's chest and belly and then Resident #1 finally calmed down and got up and walked away.-He/She noticed that Resident #1 had a black eye after the incident but could not recall how he/she received the black eye.-A code green was never called by staff until after the incident was over. -CNA D was present and witnessed Resident #1 attacking him/her. -CNA D just sat and watched it happen and never called a code or green or tried to stop the altercation between him/her and resident #1.-He/She looked at CNA D during the incident and said, why are you letting him/her attack other residents like this?-He/She reported to the Administrator that CNA D allowed Resident #1 to attack him/her and did nothing to intervene. During an interview on 2/27/26 at 2:00 P.M., CNA D said:-He/She was the only witness to the incident. -Resident #13 was teasing Resident #1 and it made Resident #1 angry.-Resident #1 was already having escalated behaviors and the teasing made the behaviors worse. -Resident #13 and Resident #1 started arguing and he/she told them to stop.-He/She did not call a code green during the argument. -Resident #1 then attacked Resident #13 and then Resident #13 tackled Resident #1 to the ground.-He/She attempted to break the residents up after the incident became physical.-He/She did not call a code green after the resident to resident became physical.-He/She called a code green after the resident's stopped fighting. -He/She was unsure what to do when the incident occurred.-He/She was unsure why he/she did not call a code green sooner. -He/She should have called a code green as soon as the residents started fighting. -Resident #1 continued to have escalated behaviors after the incident. -He/she asked for no other non-pharmacological interventions. -Resident #1 was not placed on intensive monitoring after the incident.-Resident #1 was not given any as needed medication after the incident. During an interview on 2/26/26 at 1:08 P.M., Director of Nursing (DON) said:-The staff should be notifying the charge nurse and him/her immediately when behaviors happen.-Nursing staff should have implemented the as needed medication and notified the doctor when behaviors were escalated before the behaviors escalated to abuse. -CNA D should have reported to the nurse that the resident was escalating. During an interview on 2/26/26 at 1:08 P.M., Administrator said:-He/She and the Administrator Assistant have been doing the RNIs.-When a resident-to-resident incident occurred, staff should have intervened, deescalated, and followed the CPI guidelines.-In the incident that occurred between Resident #1and Resident # 13 on 1/18/26, CNA D did not call a code green until after the residents were fighting.-A code green should be called before residents become physical with each other during an incident.-He/She would expect all staff to know how to deescalate and intervene with Resident #1.-He/She would expect nursing staff to be administering as needed medication to help prevent escalated behaviors from becoming physical. -He/She would expect staff who were working with Resident #1 to understand the resident's triggers and report any new behaviors to nursing staff. During an interview on 2/26/26 at 1:08 P.M., Chief Nursing Officer (CNO)- A code green should be called before the residents become physical to be proactive in preventing abuse.-CNA D should have called a code green prior to Resident #1 and Resident #13 escalating and becoming physical with each other. Review of Resident #1's Behavior Note, dated 1/23/26 at 2:02 A.M., showed:-The resident was having delusions.-The resident displayed physical aggression and was hitting towards others.-The resident displayed physical aggression and was pushing others.-The resident displayed physical aggression and was grabbing others.-The resident displayed verbal behaviors and was screaming, threatening others, and making disruptive sounds. Review of Resident #1's Medication Administration Record (MAR), dated January 2026, showed Chlorpromazine was not administered to the resident for increased agitation documented 1/23/26. Review of Resident #1's Electronic Medical Record (EMR), dated 1/23/26 through 1/27/26, showed:-No care plan updates, or new interventions were completed by staff. -No behavior monitoring was documented by staff on 1/23.-No nonpharmacological intervention was documented by staff.-No pharmacological intervention was documented by staff. -PASARR recommendations were not implemented such as monitoring of medication therapeutic effects, assessment and planning for the level of supervision to prevent harm to self and others, or develop a crisis plan for aggression towards others.-Facility staff did not document offering counseling services to the resident per the care plan.-No documentation facility staff implemented the care plan interventions of 1:1, pharmaceutical interventions, to smoke or shower, music or music videos, to read the Bible, or calm talk for the increased behaviors. Review of Resident #1's Admin/RN Investigation, dated 1/27/26 at 10:00 P.M., showed:-Resident #1 and Resident #6 were involved in an incident.-Resident #6 along with staff attempted to get Resident #1 to comply with staff and go back to the unit. -Resident #1 picked up stick of mop or broom and struck Resident #6 on top of the head.-Resident #6 then pushed Resident #1 to the ground and began striking him/her several times in his/her face and head.-After several attempts staff was able to break up the altercation between Resident #6 and Resident #1.-Resident #6 had a small non discolored area to the top of his/her left forehead. -Resident #1 had scratches and red mark on his/her face, neck, and head. -Interventions included:--Intensive monitoring. Review showed staff did not document how the intensive monitoring was supposed to be done. --Interdisciplinary team meeting would be scheduled.--Care plan would be reviewed and updated.--Staff education would be provided to clear areas when residents are having escalated behaviors. Review of Resident #1's incident note, dated 1/27/26 at 10:00 P.M., showed:-Resident #1 stated that CNA E was being a bitch so he/she ran and kicked open door and ran out into dining room then attempted to go out into hangout.-CNA E followed Resident #1 into the dining room asked him/her to come back to the unit.-Resident #1 started cursing and yelling at CNA E then began to angrily run towards CNA E. -Resident #6 stepped in front of CNA E and asked Resident #1 to stop.-Resident #1 then went and kicked open the door to the hangout area.-CNA E and Resident #6 followed Resident #1 out to the hangout area. -Resident #1 then picked up a mop stick and struck Resident #6 on top of the head. -Resident #6 in turn pushed Resident #1 to the floor then struck him/her several times in the face and head. -Staff after several attempts were able to break up the altercation. -Resident #1 had superficial scratches and red marks on his/her face, neck, and head.-Resident #6 had a bruise and raised area on the left side if his/her forehead. Resident #1 had scratches and red marks on his/her face. Resident #6 was upset CNA E had asked for his/her assistance and wanted this to stop. Review of Resident #6's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 2/26/26 at 11:52 A.M., Resident #6 said: -He/She was hit in the head with a mop stick by Resident #1 and then he/she and Resident #1 began to fight and fell to the ground. -The fight occurred because he/she attempted to help CNA E calm Resident #1 down and it made Resident #1 mad at him/her.-CNA E asked him/her to help calm down Resident #1 because CNA E feared the resident. -He/She felt like staff asked him/her a lot to help calm other residents down and it put him/her in danger. -He/She has asked staff not to use him/her to calm other residents down because he/she felt like it made him/her a target with the other residents. -He/She did not like being out in the middle of staff and Resident #1's problems.-There was not enough sta

F584E · No harm, potential for more than minimal, pattern

Based on observation, interview and record review, the facility failed to maintain sufficient supplies of wash cloths, hand towels, bath towels, and sheets for five sampled residents (Residents #7, #22, #10, #23, and #14) out of 23 sampled residents. The facility census was 134 residents. The facility did not have a policy regarding maintaining sufficient supplies of washcloths, hand towels, bath towels, or sheets. 1. During an interview on 2/20/26 at 10:41 A.M., Resident #7 said (Review of his/her Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning showed the resident was cognitively intact) he/she started washing his/her own clothes, towels, and sheets so that he/she had some and that if he/she didn't wash them, he/she didn't get any. During an interview on 2/23/26 at 9:31 A.M., Licensed Practical Nurse (LPN) A said:-They don't have enough supplies such as sheets and towels.-There was a flood and a lot of the towels were used to clean up and they were thrown away. During a tour of facility on 2/23/26 beginning at 10:42 A.M. with the Director of Nursing (DON):-On the men's unit, there were 11 sheets, five blankets, five towels in the storage closet, and no washcloths.-On the women's unit, there were no sheets, no blankets, no towels, and no washcloths in the storage closet.-On the medical unit, there were three towels, five sheets, no blankets, and no washcloths in the laundry room.-On the laundry cart in the laundry room, there were two flat sheets, two fitted sheets, four blankets, 10 washcloths that had black stains and were tattered, eight incontinence pads, and three gowns.-There were no items in the washing machine.-There were two blankets, one incontinence pad, and two sheets in the dryer.-There were no additional linens, towels, or washcloths anywhere else in the laundry room.-The DON said they had a pipe burst recently and he/she thought they ordered more supplies after the pipe burst.-The laundry worker said:--The washers were empty.--Staff had not brought anything else down to launder.--He/She delivered the loads of laundry he/she had to the men's unit and the medical around 8:00 A.M. and 10:00 A.M.--They don't have any other supplies than what were on the units and in the laundry room. During a tour of the medical unit on 2/23/26 beginning at 1:17 P.M., with the Maintenance Assistant:-The Maintenance Assistant said:--He/She didn't know why they were low on sheets and towels.--He/She took over the supervision of the laundry department on 2/18/26 because they did not have a laundry supervisor.--The lead housekeeper/laundry worker was responsible for the laundry.--The storage closets on the units should have a full rack of towels, washcloths, and sheets.-Resident #22 had no hand towels or washcloths in his/her room.-Resident #22 said (Review of his/her annual MDS dated [DATE] showed resident was severely cognitively impaired) they frequently did not have supplies like washcloths and hand towels.-Resident #10's room had no hand towels or washcloths on the bars for Resident #10 and for Resident #10's roommate. -Resident #10's bed had no sheets.-Resident #10 said (Review of his/her quarterly MDS dated [DATE] showed the resident was cognitively intact) they often did not have towels, washcloths, or sheets. -The laundry room on medical had five sheets, three towels, no washcloths, and no blankets.-Resident #23's room had no hand towels.-Resident #23 said (Review of his/her annual MDS dated [DATE] showed the resident was moderately cognitively impaired) they didn't get any kind of towels in their room. -Resident #14 said (Review of his/her quarterly MDS dated [DATE] showed the resident was moderately cognitively impaired) he/she has one fitted sheet and two towels that he/she keeps and washes himself/herself or otherwise he/she would not have any and that he used wipes for washing his/her face.-There were no hand towels in Resident #14's room. During an interview on 2/26/26 at 12:13 P.M., lead housekeeper/laundry worker A said:-They got an order in on 2/25/26.-He/She was not sure when they ordered the supplies.-They were low on fitted sheets and pillowcases.-He/She could put out enough towels and bedding for all of the residents and the majority of the time he/she doesn't get them back soon enough to get them washed and returned.-He/She washed whatever was sent down in the laundry. -They got flat sheets, wash cloths, and towels about a month ago.-It was common to have to replace these items monthly.-If there were items that he/she wouldn't use for himself/herself, he/she wouldn't send them up to have the residents use.-He/She worked 7:00 A.M. to 3:30 P.M. and went to each unit and stocked the closet. -The CNAs got what they need from the closets on the units. During an interview on 2/26/26 at 1:08 P.M., the Administrator said:-He/She and the Maintenance Assistant were responsible for ensuring there were enough supplies.-The Maintenance Assistant has been in that position for about a week and prior to that was just himself/herself.-They just made two big orders.-One of the orders came in on 2/25/26.-He/She would send the invoices (these were not received).-Lead housekeeper/laundry worker A had not reported any shortages of linens.-They should have had sufficient supplies on the units. Complaint #2739306

F921E · No harm, potential for more than minimal, pattern

Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary and functioning environment when the sink in rooms 215 had discolored water standing in the sink causing a bad odor, the bedroom and bathroom floors had brown grime built up, and the heating unit was pulled away from the wall which were both causing distress to one sampled resident (Resident #4), failed to have a sink installed in the 200 hall bathhouse #1 which resulted in two medal poles to protrude from the wall and create an unsafe environment for all residents who resided on the 200 hall, failed to maintain sanitation in the 200 hall bathhouse #2 by having a toilet that was filled with a dark brown substance, and failed to maintain a HVAC (heating, ventilation, and air conditioning) unit in the Main Dining room that had no cover on it exposing the metal edges around the opening's sides that were bent up causing a sharp edge out of 19 sampled residents. The facility census was 133 residents.Review of the facility Safe and Homelike Environment Policy date 6/5/2024 showed:-In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment.-This included ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.-Environment refers to any environment in the facility that is frequented by residents, including the resident's rooms and bathrooms.-Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment.-The facility would minimize odors by disposing of soiled linens and reporting lingering odors and bathrooms needing cleaned to the housekeeping department. Review of the Housekeeping-Deep Cleaning policy revised dated 12/27/24 showed all areas should be monitored on a daily basis and all resident living areas and non-living areas should be clean and odor free. Review of the facility Resident Rights-Missouri Policy dated 9/21/25 showed:-Residents had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside facility.-Resident has the right to reside and receive services with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. 1.Review of Resident #4's admission Record showed he/she was admitted on [DATE] with diagnoses that include:-Schizoaffective Disorder, Bipolar type (is a mental illness that can affect your thoughts, mood and behavior).-Major Depressive Disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). -Agoraphobia with Panic Disorder (recurrent, unexpected panic attacks and intense fear of situations where escape might be difficult or help unavailable, leading to avoidance of places like crowds, public transport, or being alone).-Post-traumatic stress disorder (PTSD-is a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it).-Obsessive-compulsive personality Disorder (is a condition marked by an extensive preoccupation with perfectionism, organization and control). Observation on 2/9/26 at 9:15 A.M., of the resident's room showed:-The heating unit not attached and hanging from the wall.-The resident's bathroom sink was filled with standing brown water and had a bad odor.-The resident's bedroom floor was dirty and had brown grime built up on the floor and baseboards.-The resident's bathroom floor was dirty and had brown grime build up. During an interview on 2/9/26 at 9:20 A.M., Resident #4 said:-The heater has been unattached to his/her wall for over a month.-He/She reported the heater not being attached to the wall to the Director of Maintenance (DOM) and the Administrator.-He/She has not been able to use his/her sink for 2 weeks due to being plugged up.-He/she reported to the sink being plugged up and having an odor to the DOM and the Administrator. -His/Her room was always dirty and had grime on the floors.-Housekeepers never cleaned his/her room.-Both bathhouses on the unit were dirty and always had stopped up toilets.-The bathtub in bathhouse #1 was constantly running and was missing a sink.-He/She believed the unsanitary environment was making him/her sick. During an interview on 2/9/26 at 9:30 A.M., DOM said:-He/She was aware that the resident's heater was pulled from the wall.-The resident pulled the heater from the wall.-He/She was not aware that the resident's sink was plugged up. During an interview on 2/9/26 at 10:00 A.M., Administrator said:-The resident kept pulling his/her heater unit from the wall.-The resident kept putting items in his/her sink that causes the sink to get plugged up.-He/She was not aware that the heater unit was off the wall at that time.-He/She was not aware that the resident's sink was plugged up at that time.-Housekeeping cleaned the resident's rooms daily. 2. Observation of 200 hall bathhouse #1 on 2/9/26 at 2:00 P.M. showed:-No out of order sign was on the bathhouse door.-The bathhouse door was unlocked and able to be accessed.-The sink was missing, and poles were sticking out of the wall.-Tile was ripped from the wall behind the bathtub.-Bathtub plumbing was exposed behind the ripped out tile.-There was black substance on the back side of some of the broken tile.-The bathtub faucet was running. 3. Observation of 200 hall bathhouse #2 on 2/9/26 at 2:30 P.M., showed:-No out of order sign was on the bathhouse door.-The bathhouse door was unlocked and able to be accessed.-The toilet was filled with brown water and had a bad odor. During an interview on 2/9/26 at 11:30A.M., Certified Medication Technician (CMT) B said:-He/She is not aware of any bathtubs that were not properly working in the facility. -He/She was unaware of constant running bathtub water or toilets overflowing in the 200 bath houses. During an interview on 2/9/26 at 12:00 P.M., Certified Nurse Assistant (CNA) F said:-He/She has never witnessed continuous running of water in any bathtub, sink, or toilet.-It was the housekeeper's responsibility to keep the resident's rooms clean but they did not keep them clean like they should. -The housekeepers only deep cleaned the resident's rooms when state was in the building. -The residents did not have a clean-living environment in the facility.-He/She has witnessed resident's sinks overflowing and not draining. During an interview on 2/9/26 at 1:00 P.M., Licensed Practical Nurse (LPN) A said:-He/She was not aware of any sinks missing in the 200 hall bath houses. -He/She has not witnessed a continuous flow of water in the 200-hall bathtub.-He/She was not aware of any toilets in the 200 hall bath houses overflowing.-Housekeeping could be better about keeping the resident's rooms and bathroom cleaned. During an interview on 2/9/26 at 1:30 P.M. Administrator Assistant said:-He/She was not aware of any bath houses that do not have sinks or have continuous running baths or toilets. -Some of the residents will turn water on in the shower houses and leave the water running but other than that.-Housekeeping staff was responsible for keeping the resident's rooms cleaned.-Staff should be better about keeping the resident's rooms clean.-Maintenance was responsible for maintaining the heater units in the resident's rooms.-He/She was not aware of any resident's sinks being plugged up. During an interview on 2/13/26 at 2:40 P.M., Administrator said:-There was one shower on the women's unit that didn't work, and they were waiting on a part coming in the mail to fix it.- All the residents on the women's unit had an alternative shower to use.-He/She was not aware of any bathroom not having a sink.-He/She was not aware of any continuous running water in any of the bathtubs in the bath houses. -He/She was not aware of any toilets that have problems with overflowing. During an interview on 2/13/25 at 2:55 P.M., Housekeeping A said:-All resident's rooms were cleaned daily.-When resident rooms are cleaned, housekeepers also clean the resident's bathrooms.-When they cleaned the resident's rooms, that included sweeping and mopping the floors.-The floor techs were the ones responsible for stripping and waxing the floors. -When they did a deep cleaning, that was when the windows and base boards were cleaned. 4. Observation on 2/26/26 at 9:00 A.M. during a Life Safety Code (LSC) walk-through inspection with the DOM showed:-The top control panel of an HVAC (heating, ventilation, and air conditioning) unit in the Main Dining Room showed a rectangular panel opening at the north end of the unit was approximately (app.) 7 inches ( ) by 10 inches and had no cover on it exposing the metal edges around the opening's sides that were bent up causing sharp edge. Complaint Number: 2736619

Inspection of January 8, 2026

Based on observation, interview, and record review, the facility failed to ensure one resident was free from resident to resident abuse when Resident #28 was physically abused by three sampled residents (Resident #29 and Resident #33 and Resident # 30) during an altercation. Additionally, the facility failed to ensure Resident #22 was free from abuse when Resident #21 unplugged his/her call light so the resident could not call staff for assistance and hit the resident on top of the head and on the left forearm resulting in Resident #22 having three skin tears to his/her arm. The facility failed to ensure Resident #20 was free from abuse when Resident #19 slapped the resident after a earlier verbal altercation out of 35 sampled residents. The facility census was 166 residents. Record review of the facility policy titled, Abuse, Neglect, Grievance Procedures, dated 8/28/18, showed: -To outline procedures for reporting and investigating complaints of abuse, neglect and misuse of funds/property, to define terms of types of abuse/neglect and misappropriation of funds and property, and to ensure that a due process for appeals to the accused is outlined. -To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. -To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. -Mistreatment, neglect, or abuse of residents is prohibited by this facility. -This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. -Mental abuse includes either verbal or nonverbal conduct which causes, or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. -On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents and staffs understanding of individual resident care needs. -Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. 1. Record review of Resident 28's facility face sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Anxiety. -Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Psychosis (a mental disorder characterized by a disconnection from reality). -Post traumatic stress disorder (PTSD a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). -Schizophrenia (a disorder that affects a persons ability to think, feel and behave clearly). Record review of the resident's Preadmission Screening and Resident Review (PASRR a screening tool to determine placement for individual mental illness) Level II Assessment, dated 2/16/18, showed: -Schizoaffective disorder bipolar type. -PTSD. -Depression. -Borderline personality disorder (BPD-a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior). -Intellectual disability. -Suspicious thoughts. -Combative with staff. -Anxious and aggressive mood, hitting doors, suicidal/self harm ideation's and angry outbursts. Record review of resident's care plan, dated 1/13/22, showed: -The resident had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. -These behaviors include crying, verbal aggression, aggressive behavior, making stories up on staff. -Hyper fixated on his/her Mom, vending bucks, asking staff for money to buy him/her pop. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 4/22/22, showed his/her Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact, and: -The resident is independent with all ADL's (Activities of Daily Living - skills required to handle an individuals basic needs) -Behaviors noted were not directed toward others, such as wandering. Record review of the facility investigation, dated 5/25/22, showed: -On or about 1300 (1:00 PM), right after the noon meal on 5/25/22 on the front hall. -Resident peer altercation where Resident #28 was hit in the head. -Resident #30 threw water on Resident #28 because he/she called him/her a racial slur. -Resident #33 struck Resident #28 in the face. -Resident #29 also hit Resident #28 in the face. -Resident #31 observed the incident and tried to tell the one staff member that was in the vicinity, as other staff were still in the dining room. During an interview on 5/26/22 at 3:25 P.M., the resident said: -He/she fell on the floor the day before, after he/she had used racial slurs with other residents. -Resident #30 had jumped all over him/her. -He/she left the dining room early before the other residents and staff, and sat down in the first hall with his/her legs stretched out and crossed. -Resident #30 came down the hall and told him/her to move, he/she did not. Resident #30 climbed over his/her knees. -Resident #30 pushed him/her to the floor. -Resident #33 was mad and hit him/her in the head. -Resident #29 and Resident #30 hit him/her in the head. -He/she was afraid of the other resident, because of how he/she used racial slurs when he/she was angry. -He/she only said the racial slurs when mad and knew it made the other residents mad, but it did not give them the right to hit him/her. -He/she did not feel safe. Observation and interview on 5/26/22 at 3:36 P.M., with the resident, Licensed Practical Nurse (LPN) B, and the Assistant Administrator showed: -The resident had a purplish redness on the left side of his/her jawline. -The resident said he/she was hit on the left side of the face. -The Assistant Administrator said the facility video showed the resident fell to the side and was hit on the left side of the face. -LPN B described the area as a scratch that had come to the surface. During an interview on 5/27/22 at 11:35 A.M., the resident said: -Sometimes he/she says stuff to the other residents that he/she shouldn't, but that was just how he/she was raised. 2. Record review of of Resident #29's PASRR Level II Assessment, dated 12/6/17, showed: -Schizophrenia. -Bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs). -Borderline Personality disorder. -Impulse control disorder. -Intellectual disability (borderline). -Traumatic head injury. -Delusional. -Paranoid. -Persecutory and suspicious thoughts. -Aggressive and combative (hitting and spitting in staff's faces). Record review of the resident's facility face sheet showed resident admitted to the facility on [DATE]. Record review of the residents quarterly MDS, dated [DATE], showed his/her BIMS score was 14 which indicated the resident was cognitively intact, and -Resident is independent with all ADL's, -Exhibited delusions, -Exhibited verbal behavioral symptoms directed toward others, -Wandering. Record review of the resident's care plan, dated 3/9/22, showed: -The resident had manifestations of behaviors related to her/his mental illness that may create disturbances that affect others. -His/her behaviors included agitation, anger, behavior of faking a falls, complaints of jitters and physical aggression if he/she did not get his/her way, verbal/physical aggression, [NAME], trades and sells his/her personal belongings with peers and self harming behaviors, biting his/her finger, scratching his/her arm with his/her teeth and will hit self in the face. During an interview on 5/26/22 at 3:59 P.M., the resident said: -On 5/25/22 around 1 P.M., -He/she was angry and was pushed to the limit. -Resident #28 deserved it. -He/she and Resident #33 slapped Resident #28 in the face. -Resident #28 refused to move out of the way in the hallway and was name calling. -Resident #30 had thrown ice water on Resident #28, Resident #28 charged at Resident #30, Resident #30 pushed Resident #28 down, then he/she and Resident #33 charged at Resident #28 both had hit Resident #28 on the head. 3. Record review of Resident #30's facility face sheet showed the resident admitted to the facility 10/21/21 with diagnoses that included: -Depression. -Schizophrenia. Record review of the resident's PASRR Level II Assessment, dated 10/26/21, showed: -Traumatic Brain Injury. -Delusional regarding being pregnant. -Aggression. -Agitation. -Cursing and uncooperative behavior. -Grandiose delusions and sexually inappropriate behavior. -Poor insight and judgment. Record review of the resident's quarterly MDS, dated [DATE], showed his/her BIMS score of 15 which indicated the resident was cognitively intact and, -Independent with all ADL's. -No behaviors exhibited. During an interview on 5/26/22 at 3:49 P.M., the resident said: -On 5/25/22 at about 1:00 P.M., -Resident #28 was in the hallway and taking up half the hallway in the front hall. -Resident #28 saw him/her coming and refused to move. -Resident #28 made him/her skip over his/her legs while Resident #28 called him her racial slurs. -Resident #30 had a foam cup of ice and threw it on Resident #28. -Resident #28 came toward him/her and fell . -He/she heard the hits by the other residents; but he/she did not turn around. -He/she denied hitting or pushing Resident #28. 4. Record review of Resident #33's facility face sheet showed the resident admitted to the facility on [DATE] with diagnoses that included: -Anxiety. -Manic depression. -Schizophrenia. Record review of the resident's PASRR/[NAME] Level II Assessment, dated 2/16/21, showed: -Bipolar disorder. -Schizophrenia. -Cocaine abuse. -Catatonia (abnormality of movement and behavior arising from a disturbed mental state, typically schizophrenia). -Auditory hallucinations. -Paranoid delusions. -Thinks that if he/she speaks it will kill someone and becomes selectively mute. Record review of the resident's quarterly MDS, dated [DATE], showed his/her BIMS score of 15 which indicated the resident was cognitively intact., and -Independent with all ADL's, -Wandering behavior. Record review of the resident's care plan, dated 3/3/22, showed the resident had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. During an interview on 5/27/22 at 11:58 A.M.,the resident said: -Sometimes altercations happen with the front and back hall residents. -The facility staff have locked the doors between the two halls. -At meal time the front hall and the back hall were supposed to be separated. -At smoke time the front hall and back hall were supposed be separated. -When this happened on 5/25/22 around 1 P.M., the front hall and back hall were coming back from lunch and got mixed together. Resident #28 was already on the hall sitting on the floor. -It would not have happened if the residents from the two halls were not mixed together. -Whenever there was an altercation, the person who did it moves to the back hall, the bad hall. -If they just keep the two halls separate, the residents were good. 5. During an interview on 5/26/22 at 2:43 P.M., Housekeeper A said: -He/she was on the back hall and heard a commotion on 5/25/22 around 1 P.M. -The doors between the front hall and the back hall were open. -Resident #28 was on the front hall sitting on the floor. -Resident #30 had said excuse me and there was talking back and forth. -Resident #30 told Resident #28 he/she was blocking the door and threw a cup of ice on Resident #28. -Resident #28 stormed at Resident #30 called him/her a racial slur and fell to the floor. -He/she had his/her back to the front hall and was directing Resident #30 to continue walking to the back hall. -He/she did not see what had happened behind him/her on the front hall. 6. Record review of Resident #31's quarterly MDS, dated [DATE], showed his/her BIMS score of 15 which indicated the resident was cognitively intact. Record review of the resident's care plan, dated 3/18/22, showed: -The resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. -He/she had behaviors that include: hallucinations, verbal/physical aggression, attention seeking, self harm, insomnia and had been made to known to trade, sell or borrow items from peers such as personal items and clothing. During an interview with the resident on 5/27/22 at 11:45 A.M., he/she said: -He/she lived on the front hall. -The issues start, if the halls were together. -If the back hall and front hall were separated, there were no issues. -On 5/25/22 around 1 P.M., Resident #28 said a racial slur and Resident #30 threw water on him/her and Resident #30 fell down. -Resident #30, Resident #33, and Resident #29, were hitting Resident #28. They jumped him/her. 7. During an interview Certified Nurses Aide (CNA) A said: -He/she was on the back hall delivering meal trays to two resident rooms. -He/she did not see what had happened. -He/she heard hollering. During an interview on 5/26/22 at 4 P.M., the Assistant Administrator: -Both the front hall and the back hall eat in the dining room together. The front hall sit on one side and the back hall on the other side. -The back hall was supposed to be released from the dining room first and then the door between the two halls was closed. -The the front hall should be released and the dining hall door closed. -Yesterday Resident #28 went back onto the unit first, without any other resident or facility staff. -CNA A was on the back hall delivering room trays in the very back area. -Resident #28 resides on the front hall and should not have went back to the other halls. -The system was not performed as expected for dismissal from meal times. -The back hall residents should have been dismissed first, then the front hall residents should be dismissed. During an interview on 5/26/22 at 4:15 P.M., the Administrator said there was a break in the system. The back hall residents should have been dismissed then the front hall residents dismissed. During an interview on 5/27/22 at 12:30 P.M., the MDS Coordinator (the charge nurse on 5/25/22) said: -The front and back halls were separated for meal times and for smoke times. -This particular day, there must have been a few residents that didn't stay with their group when the trouble started. 8. Record review of Resident #21's facility face sheet showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Intracranial injury (traumatic brain injury). -Schizoaffective disorder. -Depression. Record review of the resident's admission MDS dated [DATE], showed he/she had preadmission screening and review. He/she had been evaluated by Level II PASRR and determine to not have a serious mental illness or mental retardation or related concern. Record review of the resident's quarterly MDS dated [DATE] showed he/she was moderately cognitively impaired. Record review of the resident's care plan dated 2/19/22 showed he/she: -Had manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. -Had behaviors of wandering. -Was to be moved to a more private area to voice concerns/feelings to assist in decreasing episodes of disturbing others. -Was administered and monitored with medications as ordered. -Required room changes related to peer to peer with room mate. Record review Resident #22's quarterly MDS dated [DATE] showed he/she was cognitively intact. Record review of the resident's care plan dated 5/10/22 showed he/she: -Had no behavioral care plan in place. -Had interventions for impaired coping included: --encouragement to verbalize feelings regarding fear and/or anxiety. --Encourage use of as needed medication to alleviate symptoms. --Staff to provide care in a confident, assured manner. During an interview on 5/20/22 at 3:52 P.M., the Administrator said: -The unit had heard arguing from Resident #21 and Resident #22's room, he/she entered the room, redirected the residents and left. -Resident #21 was on Resident #22's side of the bed. -Resident #21 had hit Resident #22 on the top of the head. -Resident #22 had used his/her left forearm to block Resident #21 resulting in -Resident #22 having three skin tears to his/her arm. -The physician was notified. -The resident was given a room change. -Local law enforcement was notified. Record review of the facility investigation dated 5/20/22 showed: -Resident #22 said Resident #21 unplugged his/her call light, so he/she would not call staff for assistance. -Resident #22 told Resident #21 to leave his/her bedside and he/she started to hit him/her. -He/she tried to block him/her with his/her left arm. -He/she said that was how he/she got this skin tear, my skin is fragile. -Resident #21 said that he/she actually unplugged Resident #22's call light. -He/she said he/she did it because Resident #22 was always complaining about him/her and he/she hit Resident #22 once. -Resident #21 was removed from the room and placed on one to one observation. -Assessment was completed on both residents. -No injuries, no complaints of pain or discomfort noted on Resident #21. -Resident #22 was noted to have three skin tears to his/her left forearm. -He/she denied any pain or discomfort, and refused to be sent to the hospital for evaluation and treatment. -Physician was notified and order was received to send Resident #21 out to the hospital for psychological evaluation and treatment. -Resident #21 returned to the facility the same day with no new orders. -Administrator, physician, psychiatrist and police were notified. During an interview on 5/23/22 at 3:30 P.M., Resident #22 said: -The staff were not doing their job, Resident #21 kept coming into his/her room. -Resident #21 would just stand there and look at him/her and then leave. -The other day Resident #21 had come into the room, tripped, ran into the bed until staff removed Resident #21 from his/her room. -Resident #21 tried to hit him/her and that was how he/she got the skin tears on his/her arm. -The staff were supposed to keep Resident #21 away. He/she had the police number in case he/she wanted to press charges. During an interview on 5/23/22 at 4:00 P.M., the MDS Coordinator said: -Resident #21 had a traumatic brain injury. -He/she believed Resident #21 thought Resident #22's room was still his/her room, even though the facility staff had moved Resident #21 way down the hall. During an interview on 5/23/22 at 3:00 P.M., Resident #21 said he/she may have hit Resident #22. 9. Record review of Resident #19's PASRR Level II Evaluation dated 12/1/17 showed he/she: -Was diagnosed with schizophrenia, mood disorder, impulse control disorder, depression, intellectual disability. -Was impatient/demanding. -Had frequent/continuous yelling. -Was physically threatening. -Struck others unprovoked. -Was monitoring for safety and assistance with personal care. -Required direct supervision. Record review of the resident's facility face sheet showed he/she was admitted to the facility on [DATE] with diagnoses of Bipolar disorder and post traumatic stress disorder. Record review of the resident's annual MDS assessment dated [DATE] showed he/she was moderately cognitively impaired. Record review of resident's care plan dated 2/16/22 showed he/she: -Had manifestations of behaviors related to mental illness, bipolar, schizoaffective disorder, hitting staff/peers and calling staff/peers names. -Had physical aggression with roommate hitting, pulling hair and yelling. -Was separated from peers for protective oversight, room moves as needed. -Has disturbed others, encouraged to go to a more private area to voice concerns/feelings to assist in decreasing episodes of disturbing others. -Was sent to emergency room for evaluation/treatment related to increased anxiety/hitting staff. Record review of Resident #20's quarterly MDS dated [DATE] showed he/she was moderately cognitively impaired. Record review the resident's care plan dated 4/25/22 showed he/she: -Had manifestations of behaviors related to mental illness that may create disturbances that affect others. -Had behaviors included wandering, refusing medications, elopement, wanting to go to front lobby. -Argumentative related to the resident believing he/she was not who he/she really was. -Requires intervention as necessary to protect the rights and safety of others. -Approach- be spoken to in a calm manner. Record review of the facility investigation dated 5/21/22 showed: -Resident #19 and Resident #20 were involved in an unwitnessed altercation. -Resident #19 was the aggressor. -Resident #19 exhibited increased anxiety and agitation, verbal aggression/outburst by cursing at staff and peers. -Resident #19 was placed on one to one observation with the Charge Nurse. -When Resident #19 calmed down he/she was taken off one to one observation. -He/she then walked to his/her room and slapped Resident #20. -Resident #19 was sent to the hospital for a psychological evaluation. -Resident #20 was assessed and had no injuries. -Resident #20 was sent to the hospital for evaluation. During an interview on 5/21/22 at 6:32 P.M., the Assistant Administrator said: -Resident #19 had a history of behaviors. -Resident #19 would randomly hit others without triggers related to his/her intellectual impairment. -Resident #19 had went to Resident #20 and slapped him/her with open palm. -Resident #19 just wanted to go the hospital and believed the more he/she goes to the hospital he/she will get to leave the facility. -Resident #19 was sent to the hospital. -The resident to resident incident was related to resident behaviors. During an interview with Resident #19 on 5/23/22 at 1:00 P.M., he/she said: -Yeah, I hit Resident #20. -He/she was sorry. -He/she was mad about something else, and he/she just took it out on Resident #20. During an interview with Resident #20 on 5/23/22 at 1:30 P.M., he/she said Resident #19 slapped him/her big time. MO00201662, MO00201438 and MO00201471

Inspection of March 16, 2022

2 findings

F600K · Immediate jeopardy, pattern

2 findings

F323J · Immediate jeopardy, isolated

Based on observation, interview and record review, the facility staff failed to provide adequate protective oversight and supervision for one resident (Resident #25) diagnosed with [REDACTED]. Resident #25 left the facility unnoticed by staff when the licensed charge nurse on the evening shift of [DATE] opened the locked key coded courtyard door to let the resident out onto the resident smoking area which was, at that time unsupervised by staff. The resident crossed the courtyard and entered an area that was not illuminated, obtained a chair, scaled a fence and climbed onto the facility roof then eloped from the facility. The facility licensed nursing staff failed to accurately perform hourly resident face checks. The facility care staff failed to accurately perform fifteen minute resident face checks. The facility staff were unaware the resident was missing until a care staff member pulled the resident's bed covers back on [DATE] at 8:40 A.M. and discovered the resident was not in his/her bed. The facility staff could not locate the resident. The facility staff failed to accurately follow the facility's Hourly Census Report Protocol and Elopement Protocol policy and procedure which included failure to notify the police of the resident's elopement. The facility staff found the resident approximately eight miles from the facility on [DATE]. The facility staff also failed to follow the facility's "Abuse, Neglect, Grievance Procedures" policy to ensure one sampled resident (Resident #26) was protected from further aggression, from one other sampled resident (Resident #27) of 14 sampled residents immediately following a resident-to-resident altercation. The facility census was 155 residents. 1. Record review of the facility's Elopement Protocol dated [DATE], a copy of which was kept in the Elopement Books (facility notebooks for policy and individual resident reference information in the event of a resident elopement which are kept at each nurse's station and at the reception desk) showed: -Purpose: An elopement will be defined as any time a resident is missing from the facility or there is a possibility that a resident has left the facility without appropriate supervision and their whereabouts are unknown. -Procedure: - 1. The first person aware of an elopement will call a "Code White" to the area of the believed elopement, if known. - 2. If the resident is believed to possibly still be inside the facility, the first person to be aware of the missing resident is to page for all units to search room to room for the resident. All rooms, closets, bathrooms and work areas are to be searched. - 3. As soon as pages have been made, the Administrator is to be called immediately. - 4. If the resident has in fact left the facility, notify the resident's family or guardian. The person to notify the family or guardian will be designated by the Administrator. - 5. The charge nurse on duty will initiate facility grounds search. The Charge Nurse on duty will call the police to report the elopement when the resident is not found in the building or grounds. The Charge Nurse will provide the police department with the following information pertaining to the resident: a. Name b. Sex c. Age d. Time discovered missing e. Where resident was last seen and when f. Physical description (picture if available) -Height, race, color of hair, and color of eyes g. Physical impairments h. Mental impairments i. Language spoken j. Color and type of clothing worn k. If resident is harmful to self or others l. Home address of any known friends or relatives - 6. The Administrator will initiate the emergency call list and coordinates the search. - 7. As each person on the call list is notified they will call the next person and then go to the facility to assist with the search. - 8. After the resident has been located and returned to the facility: a. Notify the family or guardian b. Notify all persons involved in the search c. Perform a full body assessment d. Obtain vital signs e. Document all findings f. Notify physician g. Complete investigation elopement form. h. Initiate every 15 minute face checks protocol upon return for attempted/actual elopement. - 9. Notification of state agencies will be at the discretion of the Administrator/designee. Record review of the facility's Hourly Census Report Protocol (the procedure for licensed charge nurses to call a cell phone number and leave a message regarding the hourly resident census), undated, showed: -This is the protocol you must use when calling in your hourly census report. -The hourly report must be left no later than 15 minutes after each hour. -Also when you leave your message this is what is needed to be stated by you in your report: --This is only to be stated the first time you leave the report each shift: "I understand if I falsify this report, I will lose my job. Also I will be reported to the Department of Health Services." --Also add the bottom part along with this first report. --This is what you will state in your report every time except for the first call of the shift, Example: "My name is (blank),I'm the license nurse on the men's, medical, women's unit. This is my 10 A.M. report. I have done a eye to eye check on every resident on men's, medical, women's unit, at this time I am confirming that all my residents are here and accounted for except (examples of resident names, locations and reason for being away from the facility/off the unit). Record review of facility inservice records dated [DATE] showed an inservice that covered topics including protective oversite and completing five minute, 15 minute, and hourly resident checks and was attended by Licensed Practical Nurse (LPN) F and LPN G, Certified Nursing Assistant (CNA) A, CNA B, and CNA C. Record review of a list of facility residents who were considered by the facility staff to be at risk for elopement, dated [DATE], showed: -Two residents were considered to be at high risk for elopement. -12 residents were considered to be at medium risk for elopement. -All the remaining 141 residents at the facility were considered to be at low to no risk for elopement. Record review of Resident #25's Pre-Admission Screening and Resident Review (PASRR, a required form used by the Missouri Department of Health and Senior Services (DHSS) to meet the federal mandate, 42CFR483.SubpartC, and reviewed by the Missouri Department of Mental Health (DMH) if screening requirements are met to determine level of services appropriate for residents with serious mental illness or mental retardation; and the PASRR assessment is to be used by facilities to coordinate and formulate the resident's care plan and treatment services), Level II Screening report, dated [DATE], and kept as part of the resident's facility medical record showed: If the resident was found to meet the state/federal definition for serious mental illness and was not in need of specialized services, the nursing facility, according to federal law, was mandated to incorporate any lesser intensity services recommended into the resident's plan of care. -The resident had a Public Administrator/legal guardian. -The reason for the resident's nursing facility admission was unsafe behaviors, aggressive behaviors, sexually inappropriate behaviors, possible medication non-compliance and substance use. -The resident's documented historical and current psychiatric [DIAGNOSES REDACTED]. to function in society), antisocial traits (a pattern of disregard for and violation of the rights of others, and history of polysubstance abuse (excessive use of at least three groups of substances with no single substance predominating). -The resident had at a past placement become sexually inappropriate with a staff member. -The resident had multiple failed placements. -The resident had a history of [REDACTED]. -The resident had a long history of mental health treatment including numerous inpatient psychiatric hospitalization s and outpatient treatment. -Symptoms and behaviors indicating a psychiatric disorder included cursing staff, responding to unseen stimuli, exhibiting racing thoughts, and verbal aggression toward staff. -Psychiatric treatment included medication therapy, administration and monitoring, inpatient psychiatric treatment, Department of Mental Services Community Psychiatric Rehabilitation Center (CPRC). -Precautions included assault and elopement risk. -The resident had a history of [REDACTED]. -Medical [DIAGNOSES REDACTED]. -Recommendations included: --Continued medication therapy to alter the manifestations of his/her psychiatric illness. --Development of a personal support network, --Continuation of guardianship to assist him/her with finances and healthcare decisions. --A secured unit; the resident had a history of [REDACTED]. Record review of the resident's psychiatric evaluation for his/her [DATE] hospital admission showed: -He/she was admitted to the hospital psychiatric unit because of combative behavior at his placement facility, because he/she was a danger to others and because he/she was given an immediate discharge and could not take care of himself/herself. -He/she had [DIAGNOSES REDACTED]. to function in society) not otherwise specified (NOS, a clinically significant problem in personality functioning that does not fit into any of the other existing personality disorder categories of a disruption in relatedness). Record review of the facility's New Hire Orientation Concerning the Resident Environment (signed by Licensed Practical Nurse (LPN) A on [DATE] and located in his/her facility personnel file showed): -The facility has both geriatric and special needs residents. -Nursing homes are no longer just for the aged and many now provide services to those who have other challenging needs, after all they are people too. -The special needs (sometimes called behavior) residents could range in age from [AGE] years old and up. -Many have both a physical [DIAGNOSES REDACTED]. -The facility assists these people who have been stricken with challenging issues and the special needs residents can have a [DIAGNOSES REDACTED]. -When you combine the effect of the mental diseases and the medications for mental and/or physical diseases these residents can become confused, wouldn't you? -Sometimes the confusion will cause these residents to want to leave the facility, but of course they are at the facility under orders from a doctor and some could be hurt or even killed if left on the streets to take care of themselves. -Some of the residents may say things to you that are generally not acceptable in society and may insult your gender, race, hair style, hair color, clothing, body parts, physical attributes or anything else they feel like saying. -Many will attempt to befriend you so they can get you to help them leave the facility without a doctor's approval. -In the event that any of these things occur, be certain to tell your supervisor right away and in particular if a special needs resident talks about eloping from the facility or hurting themselves or others. -While there are some things we can do to assist with some of these behaviors, we must also keep in mind that these residents are not "normal" and some behaviors are expected after all that is in part why they are here. -We will provide you with training in both how to work with these residents and how to protect yourself in the event that should be necessary. -While many times the residents become like family to staff, occasionally a resident can become frustrated and can attempt to harm themselves or others. -"Your job in part along with the other staff members is to be sure no one including the residents are injured should such an event occur." -Part of the training we provide you is a program called Crisis Alleviation Lessons and Methods (CALM ) which you could use anytime in your day. -These techniques are to help make you more alert of your options and to show you what to do if a resident should become unruly. -If you feel you want to help these challenged individuals with navigation their lives back to a better place then let's talk further. If not, we understand and wish you well in your search for other employment. -We are here to help these people who are less fortunate than we are and need others who are willing to do the same and take their issues in stride. Record review of Resident #25's medical record "Face Sheet", dated [DATE], showed: -He/she was admitted to the facility on [DATE]. -He/she had [DIAGNOSES REDACTED]. -He/she had a legal guardian. Record review of the resident's Elopement Risk assessment dated [DATE], showed: -He/she was fully ambulatory (able to walk about). -He/she was alert and oriented to person, place and time. -He/she was content with his/her placement. -He/she had a history of [REDACTED]. -The behavior section was marked to say he/she had no behaviors. -He/she received two or more antipsychotic/mood altering medications. -He/she had two or more dementia/mental illness diseases. -The resident's total score was 15, representing that he/she was a low elopement risk. Record review of the resident's Elopement/Wandering assessment dated [DATE], showed: -He/she was physically able to leave the building on his/her own. -He/she was not disoriented to place. -He/she had impaired decision making (as listed in the Minimum Data Set (MDS, a federally mandated assessment tool required to be completed by facility staff and used for care planning). -He/she did not make statements about going home. -He/she did not display persistent anger at family, staff, residents or current placement. -He/she had no history of wandering. -He/she had no current behavior of wandering. -He/she was currently at risk for elopement. Record review of the resident's 'Resident Smoking Assessment' dated [DATE], showed: -He/she was a smoker. -He/she had a legal guardian. -His/her legal guardian had given permission for him/her to smoke. -His/her legal guardian had not given permission for him/her to smoke unsupervised. -He/she was alert and oriented to person, place and time. -He/she was physically able to hold a cigarette, matches/lighter without assistance. -He/she was physically able to extinguish his own/her own cigarette without assistance. -He/she did not have a history of fire starting/pyromania. -He/she had a history of [REDACTED]. -He/she was physically able to extinguish a lit cigarette/ash that had fallen on him/her. -He/she was able to call for help. -He/she was able to move freely without assistance. -He/she did not have a medical condition that contributed to the contraindication of smoking independently. -He/she had been educated on the risks of smoking. -He/she did not show good insight and judgment. -He/she was compliant with the facility rules. -He/she was a medium elopement risk. -He/she was not currently allowed to go off his/her living unit unsupervised. Record review of the resident's facility "Initial Psychosocial History" report, dated [DATE], showed: -His/her previous placement was a nursing home. -He/she had a legal guardian. -He/she had not seen his/her living parent in [AGE] years; his other parent was deceased . -He/she had a history of [REDACTED]. -He/she had a [DIAGNOSES REDACTED]. -He/she had a child of preschool age who lived with the child's other parent. -He/she had increased anxiety, decreased energy, decreased motivation, delusional thinking, paranoia/suspicion and stated his/her medications were too strong. -The medical and psychiatric history - "needs for the following and currently having an impact on the resident's physical, mental and psycho-social wellbeing," section had a check mark next to alcohol/drug abuse. -"High elopement risk" was written in the special considerations section. -Social services received and reviewed the resident's guardian paperwork, PASSR and code status, and met with nursing to communicate all his/her care needs. Record review of the resident's social services progress notes dated [DATE], showed: -He/she was admitted to the facility on [DATE] from a psychiatric hospital located in the eastern portion of the state. -He/she had a [DIAGNOSES REDACTED]. -He/she was a resident of a long-term care facility before his hospitalization . -He/she had some combative behaviors and was taken to the hospital due to his/her behaviors. -He/she had a history of [REDACTED]. -He/she had a long history of mental illness according to his/her hospital records. -He/she had delusional thinking and disorganized thoughts. -He/she used to live in an apartment. -He/she then stopped taking his/her medications and started getting agitated and paranoid and then eloped from his/her apartment. -He/she was then sent back to a structured setting again. Record review of the resident's admission MDS dated [DATE], showed: -He/she made himself/herself understood and understood others. -He/she was cognitively intact. -He/she had mood symptoms of difficulty with sleep, -His/her behavior section was not marked to indicate behavioral symptoms. -He she was independent in bed mobility, transfer, and walking. -He/she was independent with supervision for eating, dressing, personal hygiene and bathing. -He/she was continent of bladder and bowel. -He/she had active medical [DIAGNOSES REDACTED]. -He/she received antipsychotic medication. Record review of the resident's care plan dated [DATE], showed: -A problem/need that he/she was at risk for elopement related to a history of elopement attempts. -A goal that he/she would receive the protective oversight necessary to maintain safety and well-being. -Staff approaches: --He/she would be placed in the elopement book at the receptionist's desk along with his/her medical record Face Sheet (a record of important individual resident identification and contact information) and his/her picture. --Always approach him/her in a calm, non-judgmental manner and attempt to find out why he/she is wanting to leave. --Allow and encourage him/her to verbalize his/her feelings and attempt to redirect him/her. --Investigate any environmental factors which may be affecting his/her feelings and desire to elope. --Notify Administrator, Director of Nursing (DON), physician, and guardian of any elopement attempts, --If allowed to leave, ensure that his/her family/responsible party signs him/her out from the facility with expected time of return. --If at any time he/she cannot be located and is believed to have eloped, notify local law enforcement immediately to assist with search, providing a description of his/her clothing worn, and pertinent medical history, --Provide intense monitoring/15 minute checks/5 minute checks/1 on 1 as appropriate to level of risk for elopement. Record review of the resident's undated Elopement Risk sheet (a sheet with the resident's photo and identifying information/description which was kept in the elopement books), undated, showed: -A photo of the resident. -His/her name. -His/her date of birth. -His/her room number. -His/her height. -His/her weight. -His/her hair color. -His/her eye color. -He/she did not wear glasses. -He/she did not use dentures. -He/she could walk. Interview and record review of the resident's Nurse's Notes dated [DATE] at 8:05 P.M., showed: -The resident was admitted to the facility male locked behavior unit. -He/she was alert, oriented to person, place and time and able to make his/her needs and wants known. -He/she answered questions appropriately. -He/she was up as he/she wished and walked with a steady manner. -He/she denied thoughts of suicide/homicide or elopement. -He/she was placed on intensive monitoring. -During an interview on [DATE] at 11:50 A.M., the Administrator said intensive monitoring was the hourly licensed nurse observations, the 15 minute or five minute Certified Nurse Assistant (CNA) observations or the one staff person to one resident observations. -He/she was oriented to the unit and expressed his/her understanding verbally. Record review of the resident's Elopement Risk assessment dated [DATE], showed: -He/she was "fully ambulatory" (able to walk about). -He/she was alert and oriented to person, place and time. -He/she was content with his/her placement. -There was no score for the history of elopement section, including for history of elopement from a residential care facility (RCF)/home. -The behavior section was marked to show he/she had no behaviors. -The resident's total score was eight, representing that he/she was a low elopement risk. Record review of the resident's Elopement/Wandering assessment dated [DATE], showed: -He/she was physically able to leave the building on his/her own. -He/she was not disoriented to time. -He/she had impaired decision making (as listed on his/her MDS). -He/she did make statements about going home. -He/she did not display persistent anger at his/her family, staff, residents, or current placement. -He/she had no history of or current wandering. -He/she was currently at risk for elopement. Record review of the resident's Nurse's Notes dated [DATE] at 3:00 P.M., showed: -He/she was up as he/she wished with a steady gait (manner of walking). -He/she was able to make his/her needs known, denied pain or distress, was compliant with taking his/her medications, independent with activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting) and got up for his/her meals. Interview and record review of the resident's Nurse's Notes dated [DATE] untimed, showed: -The resident got into a verbal altercation with another resident. -He/she was separated from others and allowed to voice his/her feelings. -The LPN spoke with the assistant Administrator and the resident was placed on intensive monitoring. -During an interview on [DATE] at 11:50 A.M., the Administrator said that in addition to the hourly licensed nurse observations, the 15 minute or five minute CNA observations or the one staff person to one resident observations, the resident's intensive monitoring at that time would have included moving him/her to a separate location from the resident with whom he/she had the conflict for protective oversight and safety. Interview and record review of the resident's Nurse's Notes dated [DATE] at 12:30 A.M., showed: -The resident was verbally aggressive with and spit twice at the LPN charge nurse. -The assistant Administrator was notified of the incident. -The resident was placed on 1:1. -During an interview on [DATE] at 11:50 A.M., the Administrator defined 1:1 as one dedicated staff person constantly observing and staying near one resident. -He/she was allowed to stay in bed on the front hall (the resident's room was on the back hall of the Men's Unit) for the night to keep him/her from the resident with whom he/she had the earlier incident. Record review of the resident's Nurse's Notes dated [DATE] at 3:00 A.M., showed: -The resident was resting in his/her temporary bed on the front hall of the Men's Unit with 1:1 coverage for protective oversight. -He/she was still saying he/she was going to beat the other resident in the head when he/she returned to his/her unit. Record review of the resident's Nurse's Notes dated [DATE] at 3:00 P.M., showed: -The resident was removed from intensive monitoring. -No behaviors were noted. -He/she was up for meals and was calm and cooperative with staff. Record review of the resident's physician progress notes [REDACTED]. -The resident had multiple chronic medical conditions, was ambulatory (walked), is readmitted , he/she reported he/she went to jail and now is being readmitted , complained of feeling ill with flu-like illness, and also complained of foot pain from an old injury. -Major Problem included COPD, viral hepatitis, paranoid schizophrenia, and high blood pressure; the facility staff reported no concerns at this time. -Social History: The resident is currently a resident in a long term care facility locked unit. -The resident was at his/her baseline mental/neurologic status. -The resident's behavior was appropriate. -The Physician agreed with the resident's current level of care. -Assessment and Plan: Prescription drugs managed per physician's orders [REDACTED]. Record review of the resident's Nurse's Notes dated [DATE] at 11:00 P.M., showed: -The resident had no behaviors at that time and no complaints of pain. -He/she walked with a steady gait and had no shortness of breath. -He/she went out to smoke with other residents with staff supervision (the location was not documented). Record review of the resident's Nurse's Notes dated [DATE] untimed, showed: -The resident was observed by the CNA making rounds to have a cigarette lighter and two cigarettes in his/her position. -The CNA informed the LPN who then questioned the resident, asking him why he/she had not turned in the lighter and cigarettes since he/she knew his/her smoking privileges were supervised. -The resident made several different statements regarding the lighter and cigarettes. -The LPN asked the resident for the lighter and cigarettes and the resident denied having them. -The resident's guardian was notified; a statement was obtained from the CNA and turned into the Administrator for investigation. -The resident was placed on five minute checks for the reminder of the evening. Record review of the resident's Resident Smoking Assessment update dated [DATE], showed: -The resident's had a recent change in his/her smoking status. -On [DATE], the resident's smoking status was changed to independent. Record review of the resident's Nurse's Notes dated [DATE] untimed, showed: -He/she was assessed for independent smoking and was safe to smoke independently. -He/she was able to light and extinguish cigarettes. -He/she was to smoke on the front courtyard smoking area; resident and staff informed; administrative staff and the Director of Nursing (DON) aware. Record review of the resident's Resident Smoking assessment dated [DATE], showed: -He/she had a legal guardian who had given permission for him/her to smoke; the resident's legal guardian had not given permission for him/her to smoke unsupervised. -He/she was oriented to person, place and time. -He/she was able to hold a cigarette, matches/lighter without assistance. -He/she was physically able to light his own/her own cigarette without assistance. -The yes/no response to the question regarding if the resident had a history of [REDACTED]. -The yes/no response to the question regarding if the resident had a history of [REDACTED]. -He/she was physically able to extinguish a lit cigarette/ash that has fallen on themselves or others. -He/she was able to call for help. -He/she was able to move freely without assistance. -He/she did not have a medical condition that contributed to the contraindication of smoking independently. -He/she had been educated on the risks of smoking. -He/she did not show good insight and judgment. -The yes/no response to the question regarding if the resident was compliant with the facility rules was blank. -He/she was an elopement risk. -At that time, the resident was assessed to not be safe to smoke unsupervised. Record review of the resident's psychiatrist's Long Term Psychiatric Management Progress Note, dated [DATE], showed: -His/her mood and behavior were stable. -His/her affect was blunted (a disturbance in mood seen in schizophrenia manifested by shallowness and a severe reduction in the expression of feeling). -His/her insight was limited/impaired. -His/her judgment was limited/impaired. -He/she had a poverty of speech (a symptom of schizophrenia, characterized by brief and empty replies to questions; minimal verbal communication that lacks the additional unprompted content characterized by normal speech) and hallucinations. Record review of the resident's Nurse's Notes dated [DATE] at 12:20 P.M., showed: -The resident was noted with increased verbal aggression towards a staff member. -He/she was difficult to redirect and was allowed to verbalize his/her feelings and concerns with the Men's Unit Resident Care Coordinator (RCC) A and the Director of Nursing (DON). -He/she spit on staff. -He/she continued on intensive monitoring. -Administrative staff, the DON, and the resident's guardian were made aware of the resident's behavior. Record review of the resident's physician's orders [REDACTED]. -His/her [DIAGNOSES REDACTED]. -His/her physician ordered medications that included: --Benztropine 2 milligrams (mg) twice daily for extrapyramidal side effects (EPS - a group of symptoms that can occur in persons taking antipsychotic medications including tremor, inner restlessness and the inability to sit or stand still, abnormal movements or postures, slowing of thought processes, slowing of movement and muscular rigidity), --Haloperidol decanoate (long-acting form of the antipsychotic haloperidol in sesame oil which is given by intramuscular injection and results in slow and sustained release of haloperidol) 100 mg/milliliter (ml), inject 0.75 ml intramuscularly (IM - injected into a muscle) every two weeks (75 mg) for schizophrenia. --Oxcarbazepine 300 mg, one tablet three times daily for mood disorder. --Haloperidol 5 mg, one tablet every four hours as needed for psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). --Hydroxyzine 50 mg, one tablet every six hours as needed for anxiety. Record review of a facility resident sheet (used to identify an individual residents' risk/care factors including; elopement, and independent vs. supervised smoking) dated [DATE], showed the resident: -Was identified a low elopement risk, -Was identified as an independent smoker. Record review of the resident's social services progress notes quarterly assessment dated [DATE], showed: -He/she had been doing well since his/her admission. -He/she had some behaviors and was otherwise doing well. -He/she was followed by the facility psychiatrist. -He/she did not

F323J · Immediate jeopardy, isolated

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". A complaint investigation related to supervision to prevent accidents and hazards was investigated from 8/13-8/15/12. Based on observation, interviews and record review completed during this investigation it was determined the facility had implemented corrective action to address and lower the violation at this time. Facility staff had received training regarding the facility policy and procedures. The facility inserviced staff and review of sampled resident's medical record showed proper implementation of polices related to face to face resident checks. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.0261 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Inspection of January 24, 2012

4 findings

F319J · Immediate jeopardy, isolated

Based on record review, interview and observation, facility staff failed to use de-escalation techniques that resulted in a one person physical intervention when the facility policy requires a minimum of five staff to perform a physical intervention for one resident (Resident #1) of seven sampled residents. The facility administrative staff failed to provide appropriate training for new staff to safely implement and follow procedures of the CALM (Crisis Alleviation Lessons and Methods, a de-escalation and physical intervention method with residents who are a danger to themselves or others) program, Behavioral Emergency Policy, and the Behavior Emergency Guidelines. The facility failed to ensure staff were competent and comfortable in the use of the CALM program, failed to provide inservice training to all staff two times per month on a portion of the CALM procedure as required by the facility policy and procedure. In addition, the facility failed to train staff on how to use the facility's intercom system to request staff assistance when a resident was having a behavioral emergency for three resident's (Resident #1, Resident #3 and Resident #6). The facility staff failed to follow the facility's Supportive Techniques Oversight Protection (STOP) Determination Review program (the goal of the STOP program is to eliminate high potential residents from being injured or suffering from an adverse reaction related to known history or physical ailments resulting from the use of approved CALM techniques) assessment for two residents (Resident #1, and Resident #6), and did not complete an assessment for one resident (Resident's #3). The facility failed to have adequate amount of staff available on the back men's unit when a resident charged at a certified nurse's aide (CNA) and the CNA used a one person physical method of restraint. The facility staff failed to document and investigate the resident's physical intervention for one resident (Resident #6). The facility failed to notify the resident's guardian regarding the resident's behavior emergency and subsequent physical intervention for two residents (Resident #1 and #6). The facility census was 154 residents. Record review of the facility's Crisis Alleviation Lessons and Methods (CALM) Workbook, a product of Crisis Management Solutions, Inc., not dated, showed: -Page 11; De-escalation is the most often overlooked stage of crisis escalation. De-escalation occurs when the client begins to regain control. The De-escalation stage is the goal of each and every one of our de-escalation efforts. -Page 23; A Crisis Response Team should be made up of specifically trained in crisis response. Ideally, the team should consist of 6-8 people...The role of the crisis response team (CRT) is to evaluate each specific crisis situation and develop a plan for behavior management. The CRT: --Assesses the crisis event --Attempts to verbally de-escalate the patient --Assures the milieu is safe. --Looks for turning point of the event when physical intervention is required. --Provides assistance to the leader. -Page 29; Client Assessment: --When it becomes necessary to physically control a client, the risk and emotional trauma to both the client and staff member increases. Consider the following: ---Does the client have pre-existing medical condition? ---Does the client have a history of emotional, sexual or physical abuse? ---What traumatic events have happened in the client's life that might cause re-trauma? ---When staff decide to use restraints as a form of control, the risk for patient or staff injury increases and the therapeutic relationship will be negatively affected. --When a patient is restrained, utmost attention must be placed on the clients breathing system, that allows for expansion and compression of the chest. At not time during the restraint should a client's breathing system be obstructed. --Common pitfalls which contribute to breathing interference are sitting on the client's back or chest lying across or putting pressure on the client's back or chest, failure to recognize an obese or heavy client may have respiratory compromise lying on their stomach, failure of staff to listen to the client and take them seriously when they say they are having difficulty breathing. -Page 29; CALM Concept: --The therapeutic value of restraints is to ensure the patient does not harm themselves or others. Restraints are used as a form of control and calming when all other methods do not work. Record review of the facility's undated "Behavioral Emergency Policy" showed the following, in part: - Purpose: To provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis. To ensure the resident is not being coerced, punished or disciplined for staff convenience. - Procedure: It is the Policy of Reliant Care Management to provide a safe environment and provide humane care to all residents. If the resident exhibits extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident to resident altercations the following steps will occur: - The licensed nursing staff/Team Leader/Resident Care Coordinator (RCC) will assess the resident who is exhibiting such behaviors, ensuring that safety of the resident and others is the first priority. A one-to-one monitoring of the resident will be initiated at this time under the direction of the licensed nurse. - Each resident who has an increased potential for aggressive behavior to self or others, or shows a history of harm to self or others will have an assessment completed upon admission or prior to the use of approved supportive calm takedown techniques. The resident who displays or is assessed as having physical/medical limitations and is assessed to be clinically inappropriate to use approved CALM supportive takedown techniques will be placed on the Behavior Management/Care List with the acronym "STOP". Other supportive methods to control behaviors will be outlined in a the plan of care individually for those residents in a behavior emergency crisis. - The guardian will be notified at this time. - The Physician will be notified. - The DON/ADON/RN/designee will complete an RN investigation within 24 hours of the behavioral emergency. This may include a PRN Intervention Form and notification of state agencies in the event that criteria are met. Record review of the facility's "Behavior Emergency Guidelines" showed the following, in part: - Behavioral Emergency =Code Green- The LPN or RN must be present during the usage approved CALM techniques of any resident who poses imminent danger to self or others. - There are only two reasons that the approved CALM techniques will be used. The reasons are as follows: -- When a resident is in imminent danger of harming themselves. -- When a resident is in imminent danger of harming others. - NOTE: A Code Green can be called to be proactive in ensuring that enough qualified staff is present and to warrant the potential need of utilizing CALM technique. - Approved CALM techniques are never used as punishment or for punitive reasons; Residents are never threatened by the use of the CALM as a scare tactic or a threat by staff. - Anytime a Code Green is called, the Nurse must be present to take control of the situation. If approved CALM techniques are used, then the Nurse must stay with the resident the entire time. The Nurse is ultimately in charge of the Code Green and all staff responding will follow the Nurse's direction as the "Team Leader". - When a Code Green is called, staff will respond promptly and professionally. A Code Green does not denote that approved CALM techniques will automatically be used. The central purpose of calling a Code Green is recognizing that the resident has become or has the potential to become a danger to themselves or someone else. Calling a Code Green also ensures that all staff is readily available to utilize CALM technique if necessary. - Any staff that responds to a Code Green where CALM techniques are used, all staff must fill out a Behavioral Emergency Review Sheet/Code Green Review. This will include writing about the events that lead up to the Code Green, if CALM techniques were properly used, and any concerns regarding the CALM techniques used. - After every Code Green that requires the use of approved CALM techniques, the DON/Designee will complete an investigation of the occurrences regarding the behavior and the staff responses. Remember that any resident who requires CALM techniques must meet the criteria, which must be documented. - Anytime CALM hold techniques are used, the Physician and Legal Guardian must be notified. - All Behavioral Emergency Reviews/Code Green Reviews filled out by the responding staff will become part of the investigation to ensure that the behavioral crisis was handled professionally, and that it could not have been avoided, and was handled by CALM certified staff using appropriate techniques, following the policies of the facility. Record review of the facility's "Supportive Techniques Oversight Protection (STOP) Determination Review" (a facility review form used to determine if the CALM technique and/or five person take down method could be utilized on a resident) not dated showed: -Determination would be based on the review of the resident's: --Preadmission Screening and Resident Review (PASRR, a required form used by the Missouri Department of Health and Senior Services (DHSS) to meet the federal mandate, 42 CFR 483. Subpart C, and reviewed by the Missouri Department of Mental Health (DMH) if screening requirements are met to determine level of services appropriate for residents with serious mental illness or mental [MEDICAL CONDITION]). --History and physical. --Psychosocial history. --Current and past diagnosis. --Nursing assessment. -The goal of the STOP program was to eliminate high potential residents from being injured or suffer from adverse reactions related to known histories or physical ailments resulting from the use of CALM techniques. -The determination would be completed on all residents. -The final decision of the STOP program would be at the discretion of the administrative staff of the facility and based on the individual assessment. -If the resident was added to the STOP program (eligible or ineligible for the CALM techniques), then an individualized supportive plan of care would be developed. Record review of the facility's undated CALM Certification policy and procedure showed the following: - Purpose: To set guidelines for employees of the facility to become CALM certified. To provide safe treatment and humane care to the resident in a behavioral crisis. - Procedure: CALM stands for Crisis Alleviation Lessons and Methods. -- After time of hire, all employees working with behavioral residents will become CALM certified. -- All employees working with behavioral residents will be CALM certified within 90 days of hire. -- All CALM certified employees will maintain a current CALM certification and attend a CALM refresher course yearly for CALM hold techniques, as well as de-escalation techniques, which will be reviewed in in-services as needed to ensure that employees maintain knowledge and preparedness in the event that CALM hold techniques should be utilized. It is stressed that CALM hold techniques only be utilized in the event that a resident would become a danger to themselves or others. -- CALM will be taught only by certified CALM instructors that have attended the instructor trainer course. -- The Administrator and Director of Nursing will be responsible for educating the staff on updates of facility CALM policies and procedures during the scheduled in-services bi-weekly/monthly and as needed to ensure that the CALM practices are being utilized correctly. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff), dated 11/4/11, showed the resident: -Was able to express his/her wants and needs, and able to understand others. -Was cognitively intact. -Had [MEDICAL CONDITION] (fixed false beliefs). -Had minimal depression. -Wandered daily. -Required supervision with walking on and off the unit, dressing, eating, hygiene, and bathing. -Was independent with bed mobility, transfers, and toilet use. -Was always continent. -Had [DIAGNOSES REDACTED].'s ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Has coughing or choking during meals or when swallowing medications. -Weighed 126 pounds. -Has taken antipsychotic and antianxiety medications. Record review of the resident's face sheet showed the resident: -Was admitted on [DATE], and readmitted on [DATE]. -Had additional [DIAGNOSES REDACTED]. -Had a guardian. Record review of the resident's care plan dated 8/16/10, showed a problem due to receipt of nectar thick liquids, has a history of [MEDICAL CONDITION], interventions included the following: -Monitor the resident for signs and symptoms of aspiration, check lung sounds and temperature recording abnormal finding with significant changes reported to the physician. -The resident has [DIAGNOSES REDACTED]. -Staff are to monitor the resident in the main dining room for any chewing/swallowing difficulties or any complaint of pain or discomfort. Record review of the resident's care plan problem/need regarding the resident being an active smoker, dated 8/16/10 showed interventions that included: -Post the smoking schedule for the resident to view and remind him/her of smoke times if needed. -All smoking and lighting materials will be kept locked at the nurse's station and distributed by staff at the scheduled times. -Monitor the resident for the need for a smoking jacket due to tremors and potential for self-injury/burns. -Keep the resident's physician and guardian informed of any non-compliance with the facility smoking policy. -Monitor the resident so that he/she doesn't have any smoking materials on his/her person or in his/her room and check the resident when he/she returns from outside pass. Record review of the resident's care plan problem regarding difficulty in making decisions, and [DIAGNOSES REDACTED]. -Assist the resident in decision making when possible if he/she presents difficulty in making appropriate choices. -Educate the resident when poor decisions are made, offer alternatives that could have been better. -The resident is to be on the face and room checks per facility protocol. -The resident is to reside on the locked unit of the facility. -Staff is to monitor the resident when he/she is off the unit due to the risk of elopement. -Interact with the resident in a non-judgmental manner at all times and allow the resident to vent his/her feelings, provide support and encouragement when possible. Record review of the resident's care plan problem regarding the resident's behavior of verbal and physical abuse towards staff and peers and the resident is on the STOP program (a program to eliminate high potential residents from being injured or suffering from an adverse reaction related to known histories or physical ailments resulting from the use of approved CALM techniques), dated 1/27/11, and updated 7/7/11, showed interventions that included in part: -Do not argue with the resident when engaging him/her in conversation. Use calm and quiet voice when communicating with the resident to avoid behaviors. -Reinforce to the resident the unacceptability of his/her verbal/physical abuse towards staff and peers. -Remove the resident from public areas when behavior is disruptive. (Words marked through and dated 7/7/11, using calm technique/held if indicated.) -Redirect the resident when he/she is displaying inappropriate behaviors, educating the resident on what is expected behavior. -Monitor the resident for significant changes is cognition, mood/behavior or gait disturbance every shift and report to physician as needed. -The resident prefers to be called by a nickname and has the potential to become verbally abusive and will upset easily if he/she is called what he/she believes to be the wrong name. Staff should abide by the resident's choice to avoid escalating his/her behaviors. -Approach the resident warmly and positively when engaging him/her in conversation. -Allow the resident the opportunity to make choices and participate in his/her direct care. -Provide the resident with one to one attention as needed to be able to safely voice or vent his/her feelings, frustrations and concerns. Provide positive support and encouragement when possible. Record review of the resident's STOP Determination Review (Supportive Techniques Oversight Protection) form dated 1/7/11 and one dated 7/7/11, showed the resident was placed on the STOP program. Record review of the resident's nurse's notes dated 11/14/11, showed: -The resident was attempting to go out the doors and was aggressive physically and verbally toward staff. -The resident was escorted back to his/her room by two staff to vent and calm. The physician and guardian were made aware. Will continue to monitor. Record review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME] 2 milligram (mg) tablet three times daily for extrapyramidal symptoms (EPS, various uncontrolled movements). -[MEDICATION NAME] 25 mg/milliliter (ml) intramuscularly inject 2 ml's intramuscularly (IM) every two weeks (50 mg) for [MEDICAL CONDITION]. -[MEDICATION NAME] 1 mg tablet, take three times daily for [MEDICAL CONDITION]. -[MEDICATION NAME] acid 250 mg/5 ml syrup, take 10 ml's three times per day for mood disorder (500 mg ). -[MEDICATION NAME] 15 mg one tablet three times daily for [MEDICAL CONDITION]. -Health shakes one by mouth four times daily for supplement. -Carnation instant breakfast one can twice daily with meals for weight loss. -[MEDICATION NAME] 2 mg tablet, every six hours as needed for anxiety. Record review of the resident's nurse's notes dated 1/15/12, at 2:20 P.M., documented by Registered Nurse (RN) A, House Supervisor, showed: -Notified at 2:20 P.M., that resident cannot be located, Code White announced- resident located by the police immediately- two staff members picked the resident up at 124 th and Charlotte and returned the resident to the facility at 3:15 P.M. -The resident was agitated and wanted to stay in the front lobby, the resident was given a soft drink and he/she calmed down. -The resident had an abrasion of five centimeter (CM) to forehead noted upon his/her return to the facility. No other skin impairment noted. -The resident had cigarettes and lighter, attempted to burn another staff member with lighter. -The resident tripped in process of trying to burn the staff member, lighter and cigarette confiscated. The resident was assisted to his/her feet and escorted with two man walk to his/her room. -The resident was placed on 1:1 monitoring for protective oversight. -The DON was notified of occurrence. Record review of the resident's nurse's notes dated 1/15/12, at 4:00 P.M., documented by RN A, House Supervisor, showed: -The resident's brother and the Administrator were notified. Record review of the resident's nurse's notes dated 1/15/12 at 8:00 P.M., documented by RN A, House Supervisor, showed: -The resident was cooperative now and has been allowed to smoke under supervision. Record review of the resident's nurse's notes dated 1/15/12, at 10:00 P.M., documented by RN A, House Supervisor, showed a message was left for the resident's physician regarding the resident's elopement, forehead abrasion, resident's trip on the carpet, no injury from the resident's trip/fall on carpet. The RCC cleansed the forehead wound with cleanser. Record review of the resident's RN Investigation Report, completed by RN A, House Supervisor, and signed off on by the Administrator, dated 1/15/12, showed in part: -Staff involved in the incident, CNA F, CNA G, and the Life Enhancement Director, witnessed by the receptionist. -Disciplinary action required, yes, as per administration which may include termination. -Investigation narrative note: --Notified at 2:20 P.M. that the resident's family member was here to visit and the resident was unable to be located. Code white announced. Police were in the building having been called by another resident for a different issue. Police reported they had just found a person at 124th and Charlotte. This person was the resident. -CMT B and LPN B drove to the area and met the police. The resident willingly got into their vehicle and was escorted back to the facility with the police following. -The resident walked into the lobby without assistance. -Noted the resident had approximately 5 cm abrasion to his/her forehead. -The resident was agitated and not ready to return to his/her room. The resident requested to sit in the lobby and the resident calmed down when the receptionist gave him/her a soft drink which his/her family member had left for the resident. -The resident then told the receptionist he/she wanted to smoke and when the receptionist told the resident he/she would call a CNA to take him/her back to the unit to smoke at smoke break, the resident started cussing, yelling and started hitting the door. -The receptionist got the Life Enhancement Director to assist and the resident was found smoking a cigarette in the lobby. -A "Code Green" was called overhead during this time period by the receptionist. The Code Green could not be overheard in the front hall of the men's unit (which is where both the RCC and RN A, House Supervisor were standing). -Employees were running to the front lobby. Upon the RN House Supervisor arrival, both the resident and the Life Enhancement Director were on the floor and two other staff members were assisting the Life Enhancement Director. -It was reported that the resident had gotten his/her feet tangled up on the carpet and both the resident and staff landed on the floor. The cigarette and lighter were confiscated. -The resident was escorted back to his/her room with two man ambulatory escort. -The resident was placed on 1:1 monitoring for protective oversight. -The resident was allowed to go to back porch with supervision to smoke two cigarettes. The resident calmed down after the cigarettes. -The resident's skin was assessed and was intact except for 5 cm abrasion to his/her forehead. -The DON was notified when it was first noted the resident was missing and again upon his/her return. The DON was also notified of the smoking incident in the front lobby. -At 4:00 P.M., the resident's family member was notified of the elopement and of the resident's return, and the abrasion to his/her forehead. -The Administrator was notified by the DON of the occurrences. At 6:00 P.M., the Administrator was present reviewing the video and interviewing staff. -Corrective action needed: --The Administrator was informed that staff cannot hear overhead paging at all on the front hall of the Men's unit. The Administrator stated this is due to a need to maintain peacefulness of this area. Shall encourage paging nursing staff as well as using overhead page for future need to contact staff for emergencies. Record review of the Resident's Code Green Review sheet, completed by the Life Enhancement Director, dated 1/15/12, showed: -Situation requiring staff support: aggressive physical behavior, threat or imminent harm to others, and unredirectable behavior which posed threat of harm to self or others. -Narrative: The resident was aggressive towards the secretary threatening and banging on the doors. The receptionist came into the dining room and got the Life Enhancement Director. The Life Enhancement Director proceeded to the lobby. The Life Enhancement Director observed the resident smoking a cigarette and holding a lighter in the other hand. The Life Enhancement Director asked the resident to put the cigarette out and the resident refused and began cussing and threatening to kick, hit and burn staff with the cigarette and lighter. The Life Enhancement Director grabbed the resident's hand and tried to remove the lighter, the resident tried to burn the Life Enhancement Director with the cigarette. The Life Enhancement Director grabbed both of the resident's hands from the rear to keep the resident from kicking him/her in the private area and biting him/her on the arms. The resident's feet got tangled up on the carpet and both he/she and the Life Enhancement Director fell to the floor. Other staff arrived and restrained the resident's legs and arms until the resident calmed down and the lighter and the cigarette could be removed. After a few minutes the resident was picked up and escorted to the men's front hall without further incident. Record review of a written statement by the Maintenance Employee A, undated, part of the Code Green review packet, showed: -Between 3:00 and 4:30 P.M., the resident arrived back to the building as he/she was in the lobby after attacking the Life Enhancement Director. -The Maintenance Employee A showed up to assist the Life Enhancement Director in neutralizing and detaining the resident. -Shortly after, the Life Enhancement Director and the Maintenance Employee A escorted the resident back to the unit and to his/her room. Record review of a written statement by Dietary Aide A, part of the Code Green Review packet, dated 1/15/12, showed: -A code green was called in the lobby. When Dietary Aide A arrived the resident was already on the ground, the only thing Dietary Aide A did was grab the resident's legs. Record review of a written statement by Dietary Aide B, part of the Code Green Review packet, dated 1/20/12, showed: -Dietary Aide B walked out into the front hall area and really did not notice what was going on and walked back into the kitchen. Then staff were notified there was a Code Green, and he/she walked back out of the kitchen and saw the resident on the ground with a lighter. -The Life Enhancement Director tried to secure the lighter while making sure the resident remained calm, the Life Enhancement Director secured the lighter then walked the resident out to his/her room. Record review of a written statement by the Receptionist, dated 1/15/12, showed in part: -Between 2:20 P.M. and 2:45 P.M. -The resident's Guardian came to visit the resident on 1/15/12 at 2:20 P.M. The receptionist called the front hall and a female CNA answered the phone, the receptionist told the CNA to bring the resident up to the lobby. The CNA said okay. About 10 minutes passed, and the receptionist called the unit phone and there was no answer so the receptionist chirped (used a cell phone to send a "chirping" noise) CMT A to let them know the resident's Guardian was still waiting for the resident. CMT A said that the CNA went to get the resident and was bringing him/her up. The third time the receptionist had to chirp the Men's Unit RCC, whoever answered he/she did not know where the resident was. The Men's Unit RCC stated over the chirper that he/she did not know where the resident was and the resident's Guardian overheard this information. The Guardian got upset wondering where the resident was at. The Life Enhancement Director came up to the Receptionist desk, and told the receptionist that there was an issue on the men's back hall and the resident could come up once they got it cleared back there. The resident's Guardian left. Then the Men's Unit RCC called a "Code White". The police were in the building and one of the police officers told the nurses they found the resident. Two staff went to pick the resident up. The resident was brought back by the two staff. The Men's Unit RCC asked if the resident could sit up front, and the receptionist said okay. The receptionist gave the resident a soda that the Guardian had left the resident. The resident was fine until about ten minutes later and the resident wanted to smoke. The resident wanted to smoke and the receptionist told the resident that he/she needed a nurse or a CNA to take the resident out. The resident got mad and started cussing. There were visitors in the lobby so the receptionist wanted to get the resident back on the unit. The receptionist went to get the Life Enhancement Director and he/she came right out and they found the resident smoking a cigarette in the lobby. The resident was told he/she could not smoke in the lobby and tried to burn the Life Enhancement Director with the lighter and cigarette. The receptionist called a "Code Green" because there was a scuffle and staff did not respond. The receptionist had to clear the lobby of visitors and other residents. Observation of the video surveillance dated 1/15/12, starting at 3:35:01 until 3:45 P.M., showed: -At 3:35:01 the resident in yellow shirt was sitting in a chair in the lobby facing towards the camera. The resident appears to have something in his/her hand taking it to his/her mouth. Four other residents and one family member are also in the lobby. One unknown resident is at the lobby desk and blocks the view of the resident at times. -At 3:39:15 the resident stands up from the chair, goes toward the front lobby doors, appearing to want out and looks back and forth toward the reception desk. -At 3:39:35 the receptionist leaves the desk and goes off camera toward the locked doors between the lobby and the dining room. The resident remains at the front door. -At 3:39:43 the resident returns to sitting in the chair in the lobby. -At 3:39:51 the resident puts his/her hands to his/her face and there is a flash of light as if the resident may have lit a cigarette. -At 3:40:00 two residents move from the sitting area of the lobby toward the locked doors between the lobby and the dining room. -At 3:40:24 the receptionist returns on camera headed toward the lobby desk. -At 3:40:25 the Life Enhancement Director appears on camera coming from the locked doors between the lobby and the dining room. The Life Enhancement Director heads towards the resident who remains seated. -At 3:40:35 the Life Enhancement Director is standing over the resident. -At 3:40:38 the Life Enhancement Director bends over the resident and appears to try to get the resident's hands. The Life Enhancement Director then goes behind the chair the resident is sitting in and reaches for the resident's hands. -At 3:40:42 the Life Enhancement Director is behind the resident, has the residents hands behind the resident's back. The resident tries to stand up but appears to lose his/her balance and sits back down. The Life Enhancement Director is bent over the resident from behind the resident grabbing at the residents hands. -At 3:40:50 the Life Enhancement Director has the resident's hands behind his/her back and in one motion the Life Enhancement Director comes from behind the chair with the resident standing in front of the chair. The Life Enhancement Director has the resident's hands behind his/her back, they appear to be struggling a bit. Both take 3-4 steps forward. -At 3:40:55, the Life Enhancement Director pivots his/her left leg behind him/her and gets the resident off balance moving the same way as the Life Enhancement Director pivoted and both go to the floor. The Life Enhancement Director was on his/her hands and knees, the resident was on his/her right side. -At 3:41:03 the receptionist walking toward the situation and toward the other residents and family in the lobby. -At 3:41:12 the Life Enhancement Director was kneeling behind the resident and the resident remains on his/her right side. -At 3:41:15 the Life Enhancement Director puts his/her weight on the resident's back and the resident is now on his/her stomach. -At 3:41:35 the Life Enhancement Director adjusts his/her body weight and appears to be holding himself/herself up with his/her arms but remains over the r

F319J · Immediate jeopardy, isolated

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". A monitoring visit was completed on 2/9/12. Based on observation, interviews and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. There have been no inappropriate CALM techniques used since that time, the facility management team has retrained all nursing staff at the facility with the eight hour CALM training focusing on deescalation techniques. The management team still needs to retrain the ancillary staff on the CALM technique, focusing on deescalation techniques. The have also inservice all staff on the STOP system. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.0261 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

F323J · Immediate jeopardy, isolated

Based on record review, interview and observation the facility staff failed to provide adequate oversight and supervision for one resident (Resident #1), of seven sampled residents, from leaving the facility without facility staff knowledge for approximately four hours on 1/15/12. The facility staff failed to follow facility policy and procedure and go outside to supervise residents who were smoking, failed to accurately perform 15 minute face checks when staff falsely documented a resident was present for 2:30 hours. The facility staff failed to provide an accurate and true account of the incident in the residents medical record and subsequent initial facility investigation. The facility staff were unaware the resident was missing until the resident's family member arrived at the facility to visit with the resident at 2:20 P.M. on 1/15/12. Once the facility staff could not locate the resident, the facility staff failed to follow the facility elopement policy and procedure, failed to initiate a facility wide search timely. The police found the resident one and one half miles from the facility. Once the resident was returned to the facility, the facility staff failed to follow facility policy and procedure and place the resident on 1:1 intensive monitoring after his/her return to the building and remained in the front lobby. The facility census was 154 residents. Record review of the facility policy and procedure regarding Elopement Protocol, undated, showed: -Procedure: - 1. The first person aware of an elopement will call a "Code White" to the area of the believed elopement, if known. - 2. If the resident is believed to possibly still be inside the facility, the first person to be aware of the missing resident is to page for all units to search room to room for the resident. All rooms, closets, bathrooms and work areas are to be searched. - 3. As soon as pages have been made, the Administrator is to be called immediately. - 4. If the resident has in fact left the facility, notify the resident's family or guardian. the person to notify the family or guardian will be designated by the Administrator. - 5. The charge nurse on duty will initiate facility grounds search. The Charge Nurse on duty will call the police to report the elopement when the resident is not found in the building or grounds. The Charge Nurse will provide the police department with the following information pertaining to the resident: a. Name b. Sex c. Age d. Time discovered missing e. Where resident was last seen and when f. Physical description (picture if available) -Height, race, color of hair, and color of eyes g. Physical impairments h. Mental impairments i. Language spoken j. Color and type of clothing worn k. If resident is harmful to self or others l. Home address of any known friends or relatives - 6. The Administrator will initiate the emergency call list and coordinates the search. - 7. As each person on the call list is notified they will call the next person and then go to the facility to assist with the search. - 8. After the resident has been located and returned to the facility: a. Notify the family or guardian b. Notify all persons involved in the search c. Perform a full body assessment d. Obtain vital signs e. Document all findings f. Notify physician g. Complete investigation elopement form. h. Initiate every 15 minute 15 minute face checks protocol upon return for attempted/actual elopement. - 9. Notification of state agencies will be at the discretion of the Administrator/designee. Record review of the facility policy and procedure regarding Room/safety Check sheets, undated, showed, in part: -Purpose: The purpose of this policy is develop a system to assess residents for suicidal, homicidal and elopement ideations and also monitor the safety and security of the environment in which the resident resides. -Procedure: --Each resident that states they are experiencing any suicidal, homicidal, or elopement ideations will be placed on 1:1 immediately and interventions will take place to ensure protective oversight of the resident. This may include more intensive monitoring such as 2:1 or hospitalization . --The physician will be notified and doctor's orders will be followed when the system indicates that the resident has answered yes to any of the assessed ideations. Record review of the facility policy and procedure regarding Monitoring of Residents not dated, showed: -Purpose: To ensure a system is in place for residents who require increased monitoring for behavioral/psychiatric and medical issues. To monitor staffing on units with residents who require more intensive monitoring. -Procedure: Residents who require more intensive monitoring due to medical behavioral/psychiatric symptoms will be monitored on visual face checks. --Resident may require more intensive monitoring based on their medical and behavioral/psychiatric needs. --New admissions to the behavioral units will be placed on intensive monitoring one to one (with in eyesight of staff at all times) if deemed necessary by the Administrator, Director of Nursing (DON), or Program Director, the one to one monitoring can only be removed by the Administrative staff. --Residents who are showing poor impulse control including verbal/physical aggression, elopement ideations, suicidal/homicidal ideations, decompensation mentally or medically may also be placed on one to one or two to one (with in eyesight of staff at all times) monitoring at the discretion of the Administrative staff. --A one to one or two to one will be determined at the severity of the behavior and at the discretion of the Administrator, DON, Management Team and Physician. --The resident that is requiring a two to one monitoring will most likely be discharged to a higher level of care. --Residents may require based on behavior/medical issues a less intensive monitoring which would require staff to visually check the resident more often than every fifteen minutes. --Residents who require intensive monitoring of one to one will have a dedicated staff member at all times within eye sight. --Residents may be moved off of the less intensive monitoring of more than fifteen minutes at the discretion of the Administrator. Record review of the facility policy and procedure regarding Intensive Monitoring Charge Nurse/Team Leader Accountability Sheet, undated, showed: -Purpose: To ensure that a system is in place which better monitors protective oversight of residents by holding the charge nurses/team leader accountable for reviewing the intensive monitoring check sheets twice a shift at random. -Procedure: The charge nurse/team leader of each unit will be held accountable to actively participate in the intensive monitoring of every resident on the unit. This will be achieved by: -1. Each charge nurse/team leader will be expected on a every shift basis to review intensive monitoring sheets and ensure through observation that the assigned staff are completing eye to eye face checks for their designated length of time. This will be completed at random two times per shift. See attached sheet for charge nurse to sign with randomized times. One sheet is to be complete for each unit daily. -2. The charge nurse/team leader will be responsible to complete random checks on every resident on their assigned unit and ensure that eye to eye contact is being made by trained staff. This will be completed by the charge nurse/team leader doing rounds with the assigned trained staff member responsible for the checks. After the rounds are completed, the charge nurse/team leader will initial at the top of the intensive monitoring sheet by the time the rounds were completed. -3. The DON/Resident Care Coordinator (RCC)/designee will monitor to ensure that charge nurses/team leaders are following the policy and signing random checks at least twice a shift and timing at the correct time corresponding to the time they did the rounds with the trained staff. -4. This process will need to be added to the Quality Assurance monthly. The Administrator/DON/designee will need to ensure compliance of policy by staff. 1. Record review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff), dated 11/4/11, showed the resident: -Was able to express his/her wants and needs, and able to understand others. -Was cognitively intact. -Had delusions (fixed false beliefs). -Had minimal depression. -Wandered daily. -Required supervision with walking on and off the unit, dressing, eating, hygiene, and bathing. -Was independent with bed mobility, transfers, and toilet use. -Had [DIAGNOSES REDACTED]. to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Has coughing or choking during meals or when swallowing medications. -Weighed 126 pounds. -Has taken antipsychotic and antianxiety medications. Record review of the resident's face sheet showed the resident: -Was admitted on [DATE], and readmitted on [DATE]. -Had additional [DIAGNOSES REDACTED]. -Had a guardian. Record review of the resident's elopement risk assessments completed over the past year: -Dated 1/31/11, showed a score of 13, which was a low elopement risk -Dated 4/15/11, showed a score of 17, which was a medium elopement risk. -Dated 7/12/11, showed a score of 17, which was a medium elopement risk. -Dated 11/2/11, showed a score of 16, which was a medium elopement risk. Record review of the resident's elopement/wandering assessments over the past year dated 1/27/11, , 4/15/11, 7/12/11, and 11/2/11, showed: -The resident was physically able to leave the building on his/her own. -The resident had impaired decision making. -The resident makes statements about "going home". -The resident had a history of [REDACTED]. -The resident has a current behavior of wandering. Record review of the resident's care plan problem/need regarding the resident being an active smoker, dated 8/16/10 showed interventions that included: -Post the smoking schedule for the resident to view and remind him/her of smoke times if needed. -All smoking and lighting materials will be kept locked at the nurse's station and distributed by staff at the scheduled times. -Monitor the resident for the need for a smoking jacket due to tremors and potential for self-injury/burns. -Keep the resident's physician and guardian informed of any non-compliance with the facility smoking policy. -Monitor the resident so that he/she doesn't have any smoking materials on his/her person or in his/her room and check the resident when he/she returns from outside pass. Record review of the resident's care plan problem regarding difficulty in making decisions, and [DIAGNOSES REDACTED]. -Assist the resident in decision making when possible if he/she presents difficulty in making appropriate choices. -Education the resident when poor decisions are made, offer alternatives that could have been better. -The resident is to be on the face and room checks per facility protocol. -The resident is to reside on the locked unit of the facility. -Staff is to monitor the resident when he/she is off the unit due to risk of elopement. -Interact with the resident in a non-judgmental manner at all times and allow the resident to vent his/her feelings, provide support and encouragement when possible. Record review of the resident's care plan problem elopement, dated 8/16/11, showed interventions that included: -Staff will investigate any environmental factors which may be effecting the residents feeling and need to elope. -Activities will involve the resident to his/her personal preference. -Staff will redirect the resident when he/she is attempting to leave the facility or unit. -Staff will help redirect the resident when he/she is attempting to leave the facility. -The resident's picture will be in the front desk elopement book. -Staff will approach the resident in a calm and gentle voice. -Nursing will notify his/her guardian, physician and director of nursing and the Administrator with any attempts to elope. Record review of the resident's nurse's notes dated 11/14/11, showed: -The resident was attempting to go out the doors and was aggressive physically and verbally toward staff. -The resident was escorted back to his/her room by two staff to vent and calm. The physician and guardian were made aware. Will continue to monitor. Record review of the resident's physician's orders dated 1/15/12 to 2/14/12, showed the physician had ordered: -Cogentin 2 milligram (mg) tablet three times daily for extrapyramidal symptoms (EPS, various uncontrolled movements) -Fluphenazine 25 mg/milliliter (ml) intramuscularly inject 2 ml's intramuscularly (IM) every two weeks (50 mg) for schizophrenia. -Ativan 1 mg tablet, take three times daily for schizophrenia. -Valproic acid 250 mg/5 ml syrup, take 10 ml's three times per day for mood disorder (500 mg ). -Zyprexa 15 mg one tablet three times daily for schizophrenia. -Health shakes one by mouth four times daily for supplement. -Carnation instant breakfast one can twice daily with meals for weight loss. -Ativan 2 mg tablet, every six hours as needed for anxiety. Record review of the resident's medication administration record (MAR) dated 1/15/12 to 2/14/12, showed on 1/15/12, the certified medication technician (CMT) A documented the resident refused all medications at 8:00 A.M., 12:00 P.M., and 4:00 P.M., this would have included the residents Cogentin three times, Ativan three times, and Valproic acid three times, Zyprexa three times. Record review of the resident's 15 minute face checks documented on a facility form with all residents on that unit, documented by CNA G, dated 1/15/12, showed: -The resident was present and accounted for every fifteen minutes from 6:00 A.M. through 1:15 P.M., and then again from 3:45 P.M. through 5:45 P.M. -There are blank spaces from 1:30 P.M., 1:45 P.M., 2:00 P.M., 2:15 P.M., 2:30 P.M., 2:45 P.M. 3:00 P.M., 3:15 P.M. and 3:30 P.M. Record review of the resident's nurse's notes dated 1/15/12 at 1:15 P.M., documented by Resident Care Coordinator (RCC) A, men's unit, showed: -The resident went out to smoke at the side of the front men's unit at designated smoke area with a staff member, certified nurse's assistance (CNA) F asked CNA G to keep an eye on the resident smoking while he/she went to use the toilet (Off the unit). When CNA G went out, he/she just saw two residents smoking and he/she went to the other side to see if anyone was left outside, he/she did not see anybody, he/she came back and made a head count and realized this resident did not come back to the unit. -In the mean time, the RCC was at the back doing paperwork when the front desk called and asked to take the resident to the front for a visitor. The resident had eloped. -The resident was apprehended three blocks from the facility. -When the resident came back he/she was very angry and agitated and did not want to be assessed. The resident had an abrasion to the right side of his/her face. Record review of the resident's nurse's notes dated 1/15/12, at 2:20 P.M., documented by Registered Nurse (RN) A, House Supervisor, showed: -Notified at 2:20 P.M., that resident cannot be located, Code White announced- resident located by the police immediately- two staff members picked the resident up at 124 th and Charlotte and returned the resident to the facility at 3:15 P.M. -The resident was agitated and wanted to stay in the front lobby, the resident was given a soft drink and he/she calmed down. -The resident had an abrasion of five centimeter (CM) to forehead noted upon his/her return to the facility. No other skin impairment noted. -The resident had cigarettes and lighter, attempted to burn another staff member with lighter. -The resident tripped in process of trying to burn the staff member, lighter and cigarette confiscated. The resident was assisted to his/her feet and escorted with two man walk to his/her room. -The resident was placed on 1:1 monitoring for protective oversight. -The DON was notified of occurrence. Record review of the resident's nurse's notes dated 1/15/12, at 4:00 P.M., documented by RN A, House Supervisor, showed: -The resident's brother and the Administrator were notified. Record review of the resident's nurse's notes dated 1/15/12, at 8:00 P.M., documented by RN A, House Supervisor, showed: -The resident was cooperative now and has been allowed to smoke under supervision. Record review of the resident's nurse's notes dated 1/15/12, at 10:00 P.M., documented by RN A, House Supervisor, showed a message was left for the resident's physician regarding the resident's elopement, forehead abrasion, resident's trip on the carpet, no injury from the resident's trip/fall on carpet. The RCC cleansed the forehead wound with cleanser. Record review of the resident's RN Investigation Report, completed by RN A, House Supervisor, and signed off on by the Administrator, dated 1/15/12, showed in part: -Staff involved in the incident, CNA F, CNA G, and the Life Enhancement Director, witnessed by the receptionist. -Disciplinary action required, yes, as per administration which may include termination. -Investigation narrative note: --Notified at 2:20 P.M. that the resident's family member was here to visit and the resident was unable to be located. Code white announced. Police were in the building having been called by another resident for a different issue. Police reported they had just found a man at 124 th and Charlotte. This man was the resident. --CMT B and LPN B drove to the area and met the police. The resident willingly got into their vehicle and was escorted back to the facility with the police following. --The resident walked into the lobby without assistance. --Noted the resident had approximately 5 cm abrasion to his/her forehead. --The resident was agitated and not ready to return to his/her room. The resident requested to sit in the lobby and the resident calmed down when the receptionist gave him/her a soft drink which his/her family member had left for the resident. --The resident then told the receptionist he/she wanted to smoke and when the receptionist told the resident he/she would call a CNA to take him/her back to the unit to smoke at smoke break, the resident started cussing, yelling and started hitting the door. --The receptionist got the Life Enhancement Director to assist and the resident was found smoking a cigarette in the lobby. --The Life Enhancement Director attempted to get the resident to stop smoking and the resident attempted to burn the Life Enhancement Director with the cigarette and lighter, the resident started kicking and attempted to bite the Life Enhancement Director. --Video Camera indicates the residents went to the smoking area at 10:38 A.M., and did not return. CNA G was observed on the video camera talking to another resident when the resident went to the smoking area at 10:38 A.M. --CNA G was responsible for doing 15 minute face checks on the 28 men on the front hall. CNA G documented up until 1:15 P.M. listing that the resident was in various parts of the building (Common area, dining room, etc.) during the time period that the resident was gone from the facility. CNA F was the other aide working with CNA G. --Upon review, CNA G and CNA F were surprised to find out that the resident had eloped in the morning. CNA G recalls taking some resident out on the smoke break and there were times these residents were smoking unsupervised while staff were caring for other residents or when a staff member was in the bathroom (CNA F) and the other staff member (CNA G) was at the desk. CNA G reporters he/she had propped the back smoking area door open with a "wet floor" sign when he/she left to assist CNA F with another resident. The camera review indicates the resident had walked out the door during a time when CNA G was standing near the door talking to another resident. --At 8:00 P.M., the resident told RN A, House Supervisor and Men's Unit RCC that sometime after breakfast, the resident climbed the fence in the back yard as he/she wanted to go visit his/her father. The resident demonstrated to them how he/she was able to place his/her feet on the three lateral wood slats to get over the fence and he/she stated he/she scraped his/her forehead in the process when going over the other side. The resident stated he/she had a good time while out of the facility and he/she was smiling and laughing in telling the story. -Summary of Findings: --The resident eloped from the facility at 10:38 A.M. The resident admitted to climbing the fence when residents were allowed outside smoking without direct supervision. He/she sustained a 5 cm abrasion to the forehead but otherwise suffered no injuries. The resident was not realized by staff to be missing until 2:20 P.M., when his/her brother came to visit. Staff had falsified 15 minute face check records on this resident. Guardian notified of resident's elopement and forehead abrasion. The guardian expressed understanding was glad resident was safe. The physician was notified via voice mail. -Corrective Action Needed: --Staff on the men's unit were in-serviced about need to remain with residents at all times during their smoke breaks. Staff are to do head counts of residents who are going out to smoke both before and after smoke breaks. The head count will be signed (see attached in-service sheet and copy of head count verification sheet.) --Recommend that staff not prop open doors to the smoke break area. May need to have push button installed outside because presently if staff outdoors and the door is shut, staff are unable to get back in the building without someone opening the door from the other side. --Recommend if possible have three CNAs on the front hall. Recommend CNA divide up the face checks among staff rather than have one CNA responsible to check all 28 residents with 15 minute face checks. --Disciplinary action will be needed to staff for not following protocol of observing residents when smoking and falsifying record of 15 minute face checks. Record review of an e-mail document that was part of the facility's investigation, dated 1/16/12 at 12:15 A.M., sent by RN A, House Supervisor to the Administrator, showed: -"We probably need to check with Maintenance Director about those three lateral wood pieces because the resident demonstrated to the men's unit RCC and I how easy it was to scale that fence!" -Sent by RN A, House Supervisor on Admission Coordinator's computer. -A hand written note at the bottom of the e-mail says- "Gate had been broken at sometime and replaced backwards during wind storm. Gate repaired." No signature or initials on this note. Record review of the facility's visitor's sign-in sheet, dated 1/15/12 showed the residents Guardian signed in at 2:20 P.M. and left at 2:40 P.M. Record review of a written statement completed by CNA F, dated 1/15/12, showed: -Around 10:00 or 10:30 A.M., he/she asked CNA G to assist him/her in a residents room that had a bowel movement. -CNA F needed assistance with this resident because when doing peri care the resident moves around so much it takes two CNAs' to complete the peri care. Record review of a written statement completed by CNA G, dated 1/15/12, showed: -CNA G took two residents out to smoke at 10:30 A.M. CNA F called for help and since he/she was the only other CNA working the front hall, he/she left the two resident's outside unattended and went to help CNA F. -When they were done with caring for the resident, CNA G went back to the smoke area and let the two residents back inside. CNA G reported he/she stepped out to make sure that was all of the residents and walked around the building and came back inside. Record review of a written statement completed by CMT B, dated 1/15/12, showed, in part: -The CMT was on the Woman's unit on 1/15/12 when about 3:00 P.M., the Men's Unit RCC came over with a CNA from Medical Unit looking for a resident. The CMT looked for the resident outside. The police were in the building on another matter. Then one of the police officers said that two police officers had found the resident at 124 th and Charlotte. -At that time, the Men's Unit RCC asked the CMT and LPN B if they could get the resident and they did. -They brought the resident back to the building and the resident sat down in the lobby. The Men's Unit RCC was in the lobby at that time. -Before getting back to the building, the CMT asked the resident how he/she got out of the building. The resident told the CMT, he/she climbed over the fence when they were out there smoking at 10:30 A.M. Record review of a written statement by the Receptionist, dated 1/15/12, showed in part: -Between 2:20 P.M. and 2:45 P.M. -The resident's Guardian came to visit the resident on 1/15/12 at 2:20 P.M. The receptionist called the front hall and a female CNA answered the phone, the receptionist asked the CNA to bring the resident up to the lobby. The CNA said okay. About 10 minutes passed, and the receptionist called the unit phone and there was no answer so the receptionist chirped (used a cell phone to send a "chirping" noise) CMT A to let them know the resident's Guardian was still waiting for the resident. CMT A said that the CNA went to get the resident and was bringing him/her up. The third time the receptionist had to chirp the Men's Unit RCC, who answered said that he/she did not know where the resident was. The Men's Unit RCC stated over the chirper that he/she did not know where the resident was and the resident's Guardian overheard this information. The Guardian got upset wondering where the resident was at. The Life Enhancement Director came up to the Receptionist desk, and told the receptionist that there was an issue on the men's back hall and the resident could come up once they got it cleared back there. The resident's Guardian left. Then the Men's Unit RCC called a "Code White". The police were in the building and one of the police officers told the nurses they found the resident. Two staff went to pick the resident up. The resident was brought back by the two staff. The Men's Unit RCC asked if the resident could sit up front, and the receptionist said okay. The receptionist gave the resident a soda that the Guardian had left the resident. The resident was fine until about ten minutes later and the resident wanted to smoke. The resident wanted to smoke and the receptionist told the resident that he/she needed a nurse or a CNA to take the resident out. The resident got mad and started cussing. There were visitors in the lobby so the receptionist wanted to get the resident back on the unit. The receptionist went to get the Life Enhancement Director and he/she came right out and they found the resident smoking a cigarette in the lobby. The resident was told he/she could not smoke in the lobby and tried to burn the Life Enhancement Director with the lighter and cigarette. The receptionist called a "Code Green" because there was a scuffle and staff did not respond. The reception had to clear the lobby of visitors and other residents. Record review of the written statement completed by LPN B, dated 1/15/12, showed: -At 3:00 P.M., the Men's Unit RCC came on the medical unit looking in the room of residents. LPN B asked what was going on, and the Men's Unit RCC said he/she was looking for the resident because his/her Guardian was here to visit. -LPN B asked how long they had been looking for the resident and the Men's Unit RCC said about five minutes. LPN B told the Men's Unit RCC to call a "Code White" on the intercom and he/she did. -The police were in the building for a separate incident and asked was the resident still missing. They told the police officer yes, and about a minute later he/she said two officers found the resident at 124 th and Charlotte. The officer asked if there were any staff that could pick the resident up. LPN B volunteered and asked CMT B to come with him/her because he/she was not exactly sure where the resident was at. -LPN B got to the resident and the police had everything out of the resident's pockets. The resident got into the car and the police followed them back to the facility. -They brought the resident into the building and the Men's Unit RCC and RN A, House Supervisor were in the front office. Record review of the facility in-service information regarding Face Checks and Smoke Breaks, dated 1/15/12, showed: -Head counts need to be done of the smokers before and after smoke breaks on both the front and back hall residents on the Men's unit. These head counts need signed by staff member. -The DON will be reviewing these head counts. -Staff member must be present during all smoke breaks. -Do not prop open doors at any time. -When doing face checks, make sure you see the resident. If the resident cannot be located, contact charge nurse immediately so others can help search for the resident. Record review of the facility Daily Staffing Sheet, dated 1/15/12, showed: -Two CNA's were assigned to the front hall of the men's unit and two CNA's were assigned to the back hall of the men's unit. -The men's unit RCC was charging the entire men's unit, front and back hall, and there was a CMT assigned to pass medications to the entire men's unit. Record review of the facility census sheet on 1/15/12, showed the men's unit had 28 residents on the front hall and 40 residents on the back hall. During an interview on 1/19/12, at 10:30 A.M., Hospital RN said: -He/she admitted the resident at 2:35 A.M. on 1/18/12 on their medical unit, not the psychiatric unit. -The resident was sent to their hospital because he/she tried to elope from the facility and had aggressive behavior. -When the resident got there, he/she did not clear medically, they found he/she had pneumonia. The resident had some scrapes on him that were a few days old. -The resident had a scrape over his/her right eyebrow. The resident said, "they grabbed him/her and threw me to the ground because I forgot I could not smoke there." It looked like a rug burn, but open, older wound edges. He/she was also saying he/she was John Elway at the time. The abrasion was 2.5 cm x 1 cm. -They have the resident with 1:1 supervision so he/she does not elope. During an interview on 1/19/12, at 11:00 A.M., the Vice President Clinical Services, Administrator, and the DON said: -On 1/15/12, the resident eloped from the facility. The resident's Guardian came to visit the resident and the staff could not locate the resident. -The police located the resident at 124 th and Charlotte sitting on someone's front porch with cigarettes. -When the resident returned to the building, he/she had an abrasion on his/her forehead. -The resident told them the abrasion happened when he/she was scaling the fence. -The resident got agitated when he/she was returned to the building and did not want to return to the men's unit. The resident stayed in the lobby and drank a soda that his/her Guardian had brought. That calmed the resident down. -After a time, the resident wanted to smoke, beat on the front door, and then lit a cigarette in the front lobby, was involved in a physical intervention in the lobby and then returned to the unit. -Facility staff have been suspended and terminated due to this occurrence on 1/15/12. -The resident should have been put on 1:1 monitoring once he/she returned to the building but was not placed on 1:1 monitoring until he/she was returned to the secured unit. -They found upon review of their video surveillance that the residents on the front hall of the men's unit were not properly supervised during a smoke break at 10:30 to 10:38 A.M. on 1/15/12. The video showed the resident never came back in the building after that. -The resident was gone from the building from 10:38 A.M. until 2:20 P.M. with

F323J · Immediate jeopardy, isolated

At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". A monitoring visit was completed on 2/9/12. Based on observation, interviews and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. There have been no elopements since the onsite investigation. The management team has inserviced all staff to properly supervise resident's while they are smoking, on the intensive monitoring policy, and the code white policy and procedure. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.0261 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Inspection of November 3, 2011

2 findings

F314G · Actual harm, isolated

This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 11/3/11. Based on observation, interview, and record review, the facility staff failed to follow the facility's policy and procedure on wound care management; failed to follow current physician's orders [REDACTED].#8 and #21); and failed to develop and update care plans for wound management for three residents (Residents #10, #21, and #22) out of four residents sampled for wound management. The facility census was 159 residents. Record review of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) showed: - A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. - A pressure ulcer can occur wherever pressure has impaired circulation to the tissue. Critical steps in pressure ulcer prevention and healing include identifying the individual resident at risk for developing pressure ulcers, identifying and evaluating the risk factors and changes in the resident's condition, identifying and evaluating factors that can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. Review of the undated information from Primaris (Missouri's federally designated Quality Improvement Organization) showed the following Pressure Ulcer Classifications definitions: - Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk). - Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (necrotic/avascular tissue in the process of separating from the viable portions of the body, and usually light colored, soft, moist, and stringy). May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, [MEDICAL CONDITION] (inflammation of the skin), maceration (the softening of a tissue) or excoriation (to tear or wear off the skin). - Stage III - Full thickness tissue loss. Subcutaneous (under the skin) fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation). The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (back of the head) and malleolus (rounded protuberances on each side of the ankle) do not have subcutaneous tissue, and Stage III ulcers can be shallow. - Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. This often includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] (bone infection almost always caused by a bacteria and over time, the result can be destruction of the bone itself) possible. Exposed bone/tendon is visible. - Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (dead matter which may be yellow, tan, gray, green or brown in color) and/or eschar in the wound bed. Review of Primaris's Systems Investigative Audit: Pressure Ulcer Prevention/Treatment (used to evaluate the decision-making process and adequacy of the facility's process in the prevention of pressure ulcers and appropriateness of treatment protocols) dated May 2008, showed the following guidelines: - Residents are screened within 24 hours of admission for risk of skin breakdown using a standardized risk-screening tool, - An appropriate pressure ulcer prevention or treatment care plan should be put into place within the first 24 hours of admission for all residents whether high or low risk, - Appropriate skin/wound assessments/reassessments should be done at appropriate intervals according to determined levels of risk and current clinical practice guidelines including: - Full skin assessments at least weekly with detailed documentation, according to clinical practice guidelines of wound condition if present, - At least daily monitoring of pressure sites and areas of skin changes, and - Progress of wound healing is reassessed every two to four weeks and the treatment plan re-evaluated if no evidence of progress noted. - The care plan should incorporate the following care needs as well as all identified risk factors: - Needs for turning/positioning were identified, - Positioning/pressure relief product needs identified and utilized consistently and properly, - Nutritional assessment completed and identified needs included in the care plan, - Individualized skin care needs identified and included in the care plan, and - Interventions included from all disciplines for either pressure ulcer prevention or treatment. - Care plan interventions implemented as indicated, - Care plan consistently evaluated and revised based on current resident assessed needs, - Documentation of skin condition, intervention for risk factors, and treatment of existing pressure ulcers and evaluation of effectiveness was timely, consistent, and follows recommended clinical practice guidelines. - An appropriate system for communication to all direct-care staff skin risk factors, interventions and changes in the plan of care was in place and functioned properly, - Responsibility and accountability was assigned for each phase of the pressure ulcer prevention/treatment process (those designated as responsible and accountable for monitoring the processes of pressure ulcer prevention/treatment carried out their responsibilities in a timely manner), - Policy and protocols are updated and communicated to all staff according to current clinical practice guidelines, - The quality assurance committee had processes in place to track and identify patterns and to determine the root cause of skin breakdown events such as: - Identified solutions were system-oriented, and - Content of staff education was determined by competency evaluations and identified areas of weakness. - If resident self-determination was a contributing factor in pressure ulcer development, reasonable counsel, education and alternatives were provided. Review of Primaris's July, 2008 Pressure Ulcer Prediction, Prevention and Treatment Pathway showed instructions to complete a head-to-toe skin assessment upon admission and weekly, and: If the resident does not have a pressure ulcer: - Document the overall skin condition including color, temperature, moles, bruises, incisions, scars, intact skin and burns, - Report anything abnormal to the physician, - Obtain a treatment order from the physician if appropriate, - Notify the family, and - Proceed to completion of a risk assessment to identify risk factors and care plan interventions. If the resident has a pressure ulcer: -Document the length, width, depth, location, stage, exudate, tunneling, necrosis, granulation, undermining, sinus tracts, and pain, - Report the findings to the physician, - Obtain a treatment order from the physician, - Notify the family, and - Proceed to completion of a risk assessment to identify risk factors and care plan interventions. Complete a skin risk assessment and determine if the resident is at risk or not. If the resident is not at risk repeat the skin risk assessment at least every 90 days and with significant changes or per facility protocol, and complete a care plan for a potential skin problems. If the resident is at risk: - Care plan an actual skin problem if they have a current skin problem and care plan the potential for a skin problem if they do not have a current skin problem. - Complete the care plan problem statement, - Address possible risk factors such as bed/chair mobility, - Possible interventions for bed mobility might include developing a turning and repositioning schedule, providing a pressure reducing/relieving device, and a therapy consult, - Possible interventions for chair mobility might include repositioning schedules, providing a pressure-relieving cushion, and assessment of chair fit, - To prevent friction and/or shear, possible interventions might include padding to prevent skin contact, providing booties/heel protectors, elevating the heels, placing the head of bed in the lowest position possible unless contraindicated by medical condition, and providing positioning devices, - Possible interventions for bowel and bladder incontinence might include providing peri-care after each incontinence, cleaning as soon as possible after soiling, applying barrier cream, and providing incontinent pads or briefs, - Possible interventions for moisture might include removing the incontinence brief while in bed, and providing moisture barrier, - Possible interventions for nutrition and body weight might include weekly weights, a Dietician consult, labs, food supplements, speech therapy, vitamin/medication supplements, hydration, and an assessment for chewing and swallowing problems. - Other resident-specific risk factors (include any/all interventions related to identified specific risk factors). Review of the U.S. Department of Health and Human Services Clinical Practice Guideline Treatment of Pressure Ulcers 15 th Edition, dated December 1994, showed: - The assessment of an individual with a pressure ulcer is the basis for planning treatment, evaluating treatment effects, and communicating with other caregivers. - Initially, the clinician should determine the location, stage and size of the pressure ulcer and whether sinus tracts, undermining, tunneling, exudates, necrotic tissue, granulation tissue and [MEDICATION NAME] are present. - Pressure ulcers should be assessed at least once a week, but deterioration either in the patient's overall condition or in the pressure ulcer itself mandates more immediate reassessment as well as a reevaluation of the treatment plan. - A written plan for the use of positioning devices should be developed and implemented. - An individually prescribed seat cushion should be used. - A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. Review of The Agency for Health Care Policy and Research's Clinical Practice Guideline Number 3, dated May 1992, showed the following information: - Prevention of pressure ulcers in adults at risk is the overall goal of this guideline; - Most can be prevented and those Stage I pressure ulcers that do form need not worsen; - Recommendations target four goals: Identifying at risk individuals who need preventive interventions and the specific factors placing them at risk, maintaining and improving tissue tolerance to pressure in order to prevent injury, protecting against the adverse effects of external mechanical forces (pressure, friction, and shear), and reducing the incidence of pressure ulcers through educational programs; - Interventions should be monitored and documented; - Results of the interventions and the care being rendered and the adjustment in the interventions as indicated by the outcomes should be documented; - Individuals in bed assessed to be at risk for developing pressure ulcers should be repositioned at least every two hours if consistent with the overall patient goals; - A written schedule for systematically turning and repositioning the individual should be used; - Uninterrupted sitting by at-risk individuals in chairs or wheelchairs should be avoided; - The individual should be repositioned, shifting the points under pressure, at least every hour or be put back to bed; - Individuals who are able to move should be taught to shift weight every 15 minutes; - For individuals who sit in wheelchairs or on other sitting surfaces, the use of a pressure reducing device is indicated; - All individuals at risk should have a systematic skin inspection at least once a day paying close attention to the bony prominences and the results of the inspection should be documented. Review of The National Pressure Ulcer Advisory Panel's Pressure Ulcer Prevention Points revised 2007, showed the following information: - Consider all bed-bound and chair-bound persons or those whose ability to reposition is impaired to be at risk for pressure ulcers; - Use a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors; - Assess all at risk patients/residents at the time of admission to health care facilities, at regular intervals thereafter and with a change in condition. A schedule is helpful and should be based on individual acuity (clinical severity) and the patient care setting; - Residents in long term care should be assessed on admission, weekly for four weeks, then quarterly and whenever the resident's condition changes; - Identify all individual risk factors such as decreased mental status, exposure to moisture, incontinence, device related pressure, friction, shear, immobility, inactivity, and nutritional deficits, to guide specific preventive treatments and modify the care according to the individual factors; - Perform a head-to-toe skin assessment at least daily, especially checking pressure points such as the sacrum (lower portion of the backbone), ischium (bony area on the buttocks when seated), trochanters (bony area from the hip joint), heels, elbows, and the back of the head; - Reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent with the overall goals of care; - Consider postural alignment, distribution of weight, balance, stability, and pressure redistribution when positioning persons in chairs or wheelchairs; - Use a written repositioning schedule; - Place at risk persons on a pressure-redistributing mattress and chair cushion surfaces; - Teach chair-bound persons, who are able to shift their weight every 15 minutes. Review of the facility's policy and procedure on Skin Integrity assessment dated [DATE], showed its purpose was to ensure that all resident's skin is assessed on a regular basis and that any skin issues are addressed promptly and effectively. All residents will be assessed for skin integrity issues at least, but not limited to, two times a week by two different disciplinary staff members. Any skin assessments done must be reviewed by the Resident Care Coordinator (RCC) or designee. Any skin abnormalities will be reported in writing to the Wound Nurse or designee when found and forward a copy to the Director of Nursing (DON). The policy instructed: - All residents that are admitted or readmitted will have a Braden Scale (a type of wound assessment tool) and Malnutrition Assessment completed by the RCC or designee and repeated upon quarterly review. - The dietician will do an assessment upon admission/readmission to assess nutritional needs and reassess quarterly and as needed (PRN). - All residents will have a thorough skin assessment by the Licensed Practical Nurse (LPN) at the following times without exception: When a new admission/readmission, complete the admission assessment form, and when out on pass longer than four hours for any reason (complete the out on pass form). - Weekly by the LPN and then again by the Certified Nurse's Assistant (CNA) on bath day, the CNA is to document on the back of the activities of daily living (ADL) form and the LPN will use that attached for B. - The RCC or designee will review the skin assessment done by the LPN within 24 hours of admission/readmission. - The RCC or designee will review the skin assessment done on a resident for out on pass on the same day or at the first available time he/she returns to work it occurs upon the weekend. - All skin abnormalities will be reported on the attached form A. - A treatment will be set up as protocols are outlined and appropriate at time of discovery. The treatment will be reviewed by the Wound nurse or designee at his/her next working day. - All diabetic's feet will be examined weekly by the LPN/RN (Registered Nurse) and documented separately. - All documentation will be reviewed weekly by care team at the Quality Assurance (QA) meeting. - All physicians involved in care of the resident will be kept informed of all assessments with concern. Record review of the facility's policy and procedure on Wound Management dated 2/9/11, showed its purpose was to ensure that all skin integrity issues are documented appropriately. The Wound nurse or designee will measure weekly of all abnormal skin conditions. This nurse will make the judgment on treatments for wounds and will communicate changes to families and physicians. He/she will refer any skin issues to Specialized Wound Management (SWM) as appropriate and make rounds with the Nurse Practitioner weekly. This nurse will contact Advance Tissue of any resident that had Part B Medicare and that has a treatment order for reimbursement. The policy also instructed that: - Treatments will be set up per protocol as outlined and appropriate. The Wound Nurse will assess treatment at his/her earliest convenience and will make changes as needed. - Any deviance from set protocols must be approved by the Wound Nurse or designee, unless otherwise set up by the physician; upon which time the wound nurse must be notified of changes. - Specialized Wound Management will be notified by the Wound Nurse or designee when a new area is found and it will be up to the Nurse Practitioner to determine if they will pick up for services. - A dietary consult will be requested upon the time of a new area reported. - The following lab orders will be drawn at the earliest convenience upon time of new area reported: A complete blood count, basic metabolic profile, pre-[MEDICATION NAME], and [MEDICATION NAME] (labs used to help determine a resident's nutritional status). - Advanced Tissue will be notified when new area is found and treatment is set up if the resident has Part B Medicare by the Wound Nurse or designee. - This nurse will prepare the wound report for the meeting and give reports weekly to the DON, Administrator, RCC, the dietary supervisor and the MDS (Minimum Data Set) Coordinator. - The Wound Nurse or designee will keep the physician and family informed of changes in the wound or the resident's response to treatment. He/she will be responsible for all transcription of orders from physicians and Specialized Wound Management. - The Wound nurse or designee will be responsible to keep supplies stocked from central supply or Advanced Tissue for any dressing changes. Central Supplies will work with this designee to ensure supplies are readily available. Record review of the facility's undated policy and procedure for Preventing and Caring for Decubitus Ulcers, showed it's purpose was to ensure that residents are protected from developing a pressure area or to ensure that residents receive the appropriate treatment if they develop a pressure area. The procedure directed staff to: - Keep the resident's skin clean and dry. - Turn and position residents who are helpless every two hours or more frequently if needed. - Encourage residents that sit in wheelchairs to raise themselves up every 15 minutes if possible; if not assist them to raise themselves up, assist the residents in Geri-chairs to reposition themselves to prevent pressure areas also. - When turning residents, use a draw sheet or turning sheet to prevent shearing or the skin. Always use two people to turn a resident if they are unable to assist. - Make sure that any special care mattresses or positioning devices are used correctly. - Keep skin soft by using A & D ointment or any good moisture barrier cream. - Wash the peri area and dry thoroughly. - Change soiled linens and wet linens quickly. - Keep the bed wrinkle-free and all sheets and pads smooth. - Caution: Avoid massage over bony prominences. - Encourage good nutrition with your residents and fluid intake. - Avoid over padding the beds. - Elevate the feet of a bedridden resident to reduce pressure on the heels. - Use heel and elbow protectors to reduce friction to frail skin. - Keep skin from touching skin with the feet and legs. - Use pillows to provide support and positioning. - Evaluate and maintain urinary and fecal incontinence. - Avoid putting the resident directly on their wounds. - Try to prevent contractures. Review of the facility's policy regarding Wound Care Dressings dated 1/1/00, showed it's purpose was to help eliminate the spread of infection, to help ensure the comfort and cleanliness of the resident, and to replace soiled dressings and clean ones so there is no contamination of the wound. It's procedure instructed staff to do the following: - Any adhesive should be removed by pulling it parallel to the skin surface. Moistening the adhesive, if necessary may facilitate its removal. - A dressing which is adherent to the wound, may be more readily removed if moistened with peroxide. - An ointment, preferably ordered by the physician, would protect a draining wound. - Adhesive should not be used on residents with [MEDICAL CONDITION]. Use the non-[MEDICATION NAME] type. - Explain the procedure to the resident. - Wash your hands thoroughly. - Take the dressing supplies to the room and prepare a clean working area at the resident's bedside on overbed table. Never on the resident's bed. - Screen the resident for privacy and turn back linen as necessary. - Take off soiled dressing with a gloved hand and place in small plastic bag. Note: Gloves are needed for sterile dressings. Clean dressings may be applied without using gloves or instruments. - Put on fresh dressing sterilely with instruments or sterile gloves. - When finished, discard soiled dressings and clean up instruments used and return materials to their proper place. - Chart the time the treatment was done, the amount and type of drainage, whether sutures, clips, drains, etc. were removed or are still in place and who performed dressing change. - Reinforce dressings are to be watched carefully for excessive drainage or bleeding. If in doubt, circle the area and put time on it so as to be able to tell if it is spreading. - If using a dressing or treatment cart, never take it into a resident's room; only take needed supplies in a resident's room. - Never leave excess dressings in room, unless an isolation resident. - Double bag all dressings with excessive drainage. - Sterile dressings done by RN or LPN. Record review of the facility's undated policy regarding transcription of orders/following physician's orders [REDACTED]. - Upon receiving a physician's orders [REDACTED]. - If the order was received via phone or verbal, a carbon copy telephone order sheet will be filled out and the top copy will be given to medical records to be sent to the ordering physician to be signed. - The telephone order carbon copy sheet must include the name of the resident, the order, the date and the nurse's signature that reviewed the order. - Once the order is transcribed on the right side of the physician's orders [REDACTED]. - Any changes in medication are to be addressed on the left side of the POS where the medications are listed. If medications are discontinued, then the medication is to be crossed through with "d/c" and the date that the medication was discontinued. All medication orders are to be transcribed on the Medication Administration Record [REDACTED]. The nurse then will contact the corresponding pharmacy either via fax or phone. All medication changes are to be started within 24 hours of the new order. If the medication is not available, then the physician must be notified. - After laboratory testing, diagnostic testing, or other services are ordered, the nurse will sign that the order was received and fill out the corresponding requisition for the specific services to be obtained. - Any new orders that are not on the physician's orders [REDACTED]. - Clarification of physician orders [REDACTED]. - The RCC/Unit Director/LPN/DON/designee will audit all physician's orders [REDACTED]. On weekends, the RN supervisor will check all charts in the facility to ensure that all new orders received have been transcribed accurately and implemented. - The RCC/Unit Director/LPN/DON/RN Supervisor/designee will document the audit on the "Daily physician's orders [REDACTED]. Record review of the facility's document dated 12/20/11 regarding care planning showed the following information: - The MDS/Care Plan Coordinator will review new orders for treatments and carry over any new orders to the Care Plans within 72 hours of order changes. - Medical Records will review new orders in the physician's orders [REDACTED]. - When treatment orders have been changed, two licensed nurses will verify treatment orders have been transcribed correctly from the order to the physician's orders [REDACTED]. - The facility does not have a current care plan policy and procedure. The facility's goal is to follow the federal guidelines for care plans using MDS 3.0. - Physician A will review all phone orders, lab test results, and wound reports each time he/she is in the building. He/she will be in the facility at least twice a week. 1. Record review of Resident #21's face sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. - [MEDICAL CONDITION] disorder (a mental condition that causes loss of contact with reality and mood problems); - Paralysis (loss or impairment of the ability to move a body part, usually as a result of damage to its nerve supply); - [MEDICAL CONDITION] (a decrease in hemoglobin in the blood to levels below the normal range); - [MEDICAL CONDITION] disorder (mood disorders characterized usually by alternating episodes of depression and mania); - [MEDICAL CONDITION] (a form of liver inflammation that causes primarily a long-[MEDICATION NAME] (chronic) disease); and - [MEDICAL CONDITION] (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). Record review on 12/19/11 at 4:15 P.M. of the resident's care plan dated 10/27/11, showed the resident had a wound to his/her right hip/thigh; and approaches included to: - Apply Santyl (an ointment used for the debridement of pressure ulcers) and gauze; - Apply Puracol (a collagen wound dressing) to the wound; - Provide meals and snacks; - Give medication as ordered; - Monitor the resident's Foley catheter (a tube passed through the urethra into the bladder to drain urine) and [MEDICAL CONDITION] (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen); - Reposition frequently due to paralysis. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff used in the care planning process) dated 11/03/11, showed the resident: - Was cognitively intact; - Was independent with bed mobility, transferring, dressing, and toilet use; - Had impaired range of motion of both lower extremities; - Used a wheelchair for mobility; - Was at risk for developing pressure ulcers; - Had two unhealed unstageable pressure ulcers with necrotic (localized death of living cells as from interruption of blood supply or infection) tissue; - Had no other ulcers, wounds, or skin problems; - Had a pressure reducing device for his/her bed and chair; - Had nutrition or hydration intervention to manage skin problems; - Received ulcer care; - Received application of nonsurgical dressings other than to his/her feet; - Received application of ointments/medications other than to his/her feet; Record review of the resident's Wound Care Specialists' team assessment and treatment orders dated 12/16/11 showed the following information: - The resident had a Stage III pressure wound which was located on the left ischium (forms the lower and back part of the hip bone), and measured 1.1 centimeters (cm) in length, 0.7 cm in width, and 0.2 cm in depth. -- The wound tissue was 100 percent granulation tissue (any soft pink fleshy projections that form during the healing process in a wound). -- There was a small amount of serous (watery, clear, or slightly yellow/tan/pink drainage) exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) with no odor. -- The surrounding skin was normal in color and moisture. -- The treatment order was for staff to cleanse the wound with wound cleanser of the facility's choice, apply Puracol to the wound bed, cover with gauze, and change daily and as needed. - The resident had a Stage III pressure wound which was located on the right ischium and measured 3.5 cm in length, 1.5 cm in width, and 0.2 cm in depth. -- The wound tissue was 75 percent granulation tissue and 25 percent slough tissue. -- There was a small amount of serous exudate with no odor. -- The surrounding skin was normal in color and moisture. -- The treatment order was for staff to cleanse the wound with wound cleanser of the facility's choice, apply Puracol to the wound bed, cover with gauze, and change daily and as needed. - The resident had a Stage III pressure wound which was located on the right gluteal fold (thigh/buttock area) and measured 2.5 cm in length, 4.5 cm in width, and 0.2 cm in depth. -- The wound tissue was 100 percent slough tissue. -- There was a small amount of serous exudate with no odor. -- The surrounding skin was normal in color and moisture. -- The treatment order was for staff to cleanse the wound with wound cleanser of the facility's choice, apply Santyl to the wound bed approximately nickel thick, cover with Vaseline gauze, cover or wrap loosely with gauze, and change daily and as needed for soiling. - Th

F314G · Actual harm, isolated

Based on observation, interview, and record review, the facility staff failed to follow the facility's policy and procedure on wound care management to include assessment, prevention, treatment, and monitoring of residents with wounds; failed to provide consistent skin assessments of resident's wounds; failed to implement preventative measures to prevent the development and healing of pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)); failed to follow current physician's orders for wound treatment; failed to follow the facility's infection control policy; and failed to develop and update care plans for the management of pressure ulcers for three residents (Residents #8, #9, and #10) out of eleven sampled residents. The facility staff failed to provide wound management which included keeping the resident clean and dry and repositioned every two hours that contributed to Resident #10 being transferred to the Wound Specialty Hospital in October, 2011 for aggressive wound treatment of [REDACTED]. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) pressure ulcer on the resident's right gluteal fold (a prominent fold on the back of the upper thigh that marks the upper limit of the thigh from the lower limit of the buttock) and contributed to the development of a new facility-acquired Stage II (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) pressure ulcer on the resident's right inner thigh in November, 2011; failed to follow re-admission physician's orders for placement of a urinary catheter (a tube passed through the urethra into the bladder to drain urine) for wound healing for one resident (Resident #10). The facility census was 155 residents. Record review of the State Operations Manual (SOM) revealed: Pressure Ulcers: Defined: -A pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). Although friction and shear are not primary causes of pressure ulcers, friction and shear are important contributing factors to the development of pressure ulcers. Overview: -A pressure ulcer can occur wherever pressure has impaired circulation to the tissue. Critical steps in pressure ulcer prevention and healing include: identifying the individual resident at risk for developing pressure ulcers, identifying and evaluating the risk factors and changes in the resident's condition, identifying and evaluating factors that can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. Risk Factors: -Many studies and professional documents identify risk factors that increase a resident's susceptibility to develop or to not heal pressure ulcers. Examples of these risk factors include, but not limited to: -Impaired/decreased mobility and decreased functional ability; -Co-morbid conditions, such as end stage [MEDICAL CONDITION] (kidney disease), [MEDICAL CONDITION] disease or diabetes mellitus (a condition in which the pancreas no longer produces enough insulin or when cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body); -Drugs such as steroids that may affect wound healing; -Impaired diffuse or localized blood flow, for example, generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency; -Resident refusal of some aspects of care and treatment; -Cognitive impairment; -Exposure of skin to urinary and fecal incontinence; -Under nutrition, [MEDICAL CONDITION], and hydration deficits; and -A healed ulcer. The history of a healed pressure ulcer and its stage (if known) is important, since areas of healed Stage III or IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcers are more likely to have recurrent breakdown. -Some residents have many risk factors for developing pressure ulcers, such as diabetic [MEDICAL CONDITION] (loss of feeling in the extremities), frailty, cognitive impairment, and under nutrition. Pressure Points and Tissue Tolerance (ability of the skin and its supporting structures to endure the effects of pressure without adverse effects): -Assessment of a resident's skin condition helps define prevention strategies. -Tissue closest to the bone may be the first tissue to undergo necrosis (localized death of living cells as from interruption of blood supply or infection). -An at-risk resident who sits too long on a non-cushioned surface may be more prone to get ischial (lower portion of the hip bone) ulceration. -Pressure ulcers may develop at other sites where pressure has impaired the circulation to the tissue. Repositioning: -Repositioning is a common, effective intervention for an individual with a pressure ulcer or who is at risk of developing one. Assessment of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident's need and goals. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. -Support Surfaces and Pressure Redistribution --Appropriate support surfaces or devices should be chosen by matching a device's potential therapeutic benefit with resident's specific situation. --Static pressure redistribution devices (e.g. solid foam, convoluted foam, gel mattress) may be indicated when a resident is at risk for pressure ulcer development or delayed healing. A specialized pressure redistribution cushion or surface, for example, might be used to extend the time a resident is sitting in a chair; however, the cushion does not eliminate the necessity for periodic repositioning. Review of Primaris's (Missouri's federally designated Quality Improvement Organization) undated Pressure Ulcer Classifications showed: Definitions: - Suspected Deep Tissue Injury (DTI) - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar (tan, brown or black). Evolution may be rapid exposing additional layers of tissue, even with optimal treatment. - Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk). - Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy). May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates DTI). This stage should not be used to describe skin tears, tape burns, perineal (the region between the anus and the external genitalia), [MEDICAL CONDITION] (inflammation of the skin), maceration (the softening of a tissue) or excoriation (to tear or wear off the skin). - Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation). Further description: The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (back of the head) and malleolus (rounded protuberances on each side of the ankle) do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III press ulcers. Bone/tendon is not visible or directly palpable. - Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] (bone infection almost always caused by a bacteria and over time, the result can be destruction of the bone itself) possible. Exposed bone/tendon is visible or directly palpable. - Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (dead matter which may be yellow, tan, gray, green or brown in color) and/or eschar in the wound bed. Review of Primaris's May, 2008 Systems Investigative Audit: Pressure Ulcer Prevention/Treatment (used to evaluate the decision-making process and adequacy of the facility's process in the prevention of pressure ulcers and appropriateness of treatment protocols) showed the following guidelines: - Residents are screened within 24 hours of admission for risk of skin breakdown using a standardized risk-screening tool, - An appropriate pressure ulcer prevention or treatment care plan should be put into place within the first 24 hours of admission for all residents whether high or low risk, - Appropriate skin/wound assessments/reassessments should be done at appropriate intervals according to determined levels of risk and current clinical practice guidelines (CPGs) including: - Full skin assessment at least weekly with detailed documentation, according to CPGs of wound condition if present, - At least daily monitoring of pressure sites and areas of skin changes, and - Progress of wound healing is reassessed every two to four weeks and treatment plan re-evaluated if no evidence of progress noted. - The care plan should incorporate the following care needs as well as all identified risk factors: - Needs for turning/positioning were identified, - Positioning/pressure relief product needs identified and utilized consistently and properly, - Nutritional assessment completed and identified needs included in the care plan, - Individualized skin care needs identified and included in the care plan, and - Interventions included from all disciplines for either pressure ulcer prevention or treatment. - Care plan interventions implemented as indicated, - Care plan consistently evaluated and revised based on current resident assessed needs, - Documentation of skin condition, intervention for risk factors, and treatment of [REDACTED]. - An appropriate system for communication to all direct-care staff skin risk factors, interventions and changes in the plan of care was in place and functioned properly, - Responsibility and accountability was assigned for each phase of the pressure ulcer prevention/treatment process (those designated as responsible and accountable for monitoring the processes of pressure ulcer prevention/treatment carried out their responsibilities in a timely manner), - Policy and protocols are updated and communicated to all staff according to current CPGs, - The quality assurance committee had processes in place to track and identify patterns and to determine the root cause of skin breakdown events such as: - Identified solutions were system-oriented, and - Content of staff education was determined by competency evaluations and identified areas of weakness. - If resident self-determination was a contributing factor in pressure ulcer development, reasonable counsel, education and alternatives were provided. Review of Primaris's July, 2008 Pressure Ulcer Prediction, Prevention and Treatment Pathway showed instructions to: - Complete a head-to-toe skin assessment upon admission and weekly, -- If the resident does not have a pressure ulcer: - Document overall skin condition including color, temperature, moles, bruises, incisions, scars, intact skin and burns, - Report anything abnormal to the physician, - Obtain treatment order from the physician if appropriate, - Notify the family, and - Proceed to completion of a risk assessment to identify risk factors and care plan interventions. -- If the resident has a pressure ulcer: -Document the length, width, depth, location, stage, exudate, tunneling, necrosis, granulation, undermining, sinus tracts, and pain, - Report the findings to the physician, - Obtain a treatment order from the physician, - Notify the family, and - Proceed to completion of a risk assessment to identify risk factors and care plan interventions. - Complete skin risk assessment and determine if the resident is at risk or not, -- If the resident is not at risk: - Repeat skin risk assessment at least every 90 days and with significant changes or per facility protocol, and - Complete a care plan for a potential skin problem. -- If the resident is at risk: - Care plan an actual skin problem if they have a current skin problem and care plan the potential for a skin problem if they do not have a current skin problem. - Complete the care plan problem statement, - Address possible risk factors: - Bed/Chair mobility, - Possible interventions for bed might include: - Turning and repositioning schedule, - Pressure reducing/relieving device, and - Therapy consult. - Possible interventions for the chair might include: - Repositioning schedules, - Pressure-relieving cushion, and - Assessment of chair fit. - Friction and/or shear, - Possible interventions might include: - Padding to prevent skin contact, - Booties/heel protectors, - Elevate heels, - Head of bed in lowest position possible unless contraindicated by medical condition, and - Positioning devices. - Bowel and bladder incontinence and moisture, - Possible interventions for incontinence might include: - Peri care after each incontinence, - Clean as soon as possible after soiling, - Barrier cream, and - Incontinent pads or briefs. - Possible interventions for moisture might include: - Remove incontinence brief while in bed, and - Moisture barrier. - Nutrition and body weight, - Possible interventions for nutrition and body weight might include: - Weekly weight, - Dietician consult, - Labs, - Food supplements, - Speech therapy, - Vitamin/medication supplements, - Hydration, and - Assessment for chewing and swallowing problems. - Other resident-specific risk factors (include any/all interventions related to identified specific risk factors). Review of the U.S. Department of Health and Human Services Clinical Practice Guideline treatment of [REDACTED]. -The assessment of an individual with a pressure ulcer is the basis for planning treatment, evaluating treatment effects, and communicating with other caregivers. -Initially, the clinician should determine the location, stage and size of the pressure ulcer and whether sinus tracts, undermining, tunneling, exudates, necrotic tissue, granulation tissue and [MEDICATION NAME] are present. -Pressure ulcers should be assessed at least once a week, but deterioration either in the patient's overall condition or in the pressure ulcer itself mandates more immediate reassessment as well as a reevaluation of the treatment plan. -A written plan for the use of positioning devices should be developed and implemented. -An individually prescribed seat cushion should be used. -A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. Review of The Agency for Health Care Policy and Research's (AHCPR) Clinical Practice Guideline Number 3, dated [DATE], showed the following information: - Prevention of pressure ulcers in adults at risk is the overall goal of this guideline; - Most can be prevented and those Stage I pressure ulcers (non-blanchable [DIAGNOSES REDACTED] - redness of the skin that does not subside when pressure is relieved) that do form need not worsen; - Recommendations target four goals: Identifying at risk individuals who need preventive interventions and the specific factors placing them at risk, maintaining and improving tissue tolerance to pressure in order to prevent injury, protecting against the adverse effects of external mechanical forces (pressure, friction, and shear) and reducing the incidence of pressure ulcers through educational programs; - Interventions should be monitored and documented; - Results of the interventions and the care being rendered and the adjustment in the interventions as indicated by the outcomes should be documented; - Individuals in bed assessed to be at risk for developing pressure ulcers should be repositioned at least every two hours if consistent with the overall patient goals; - A written schedule for systematically turning and repositioning the individual should be used; - Uninterrupted sitting by at-risk individuals in chairs or wheelchairs should be avoided; - The individual should be repositioned, shifting the points under pressure, at least every hour or be put back to bed; - Individuals who are able to move should be taught to shift weight every 15 minutes; - For individuals who sit in wheelchairs or on other sitting surfaces, the use of a pressure reducing device is indicated; - All individuals at risk should have a systematic skin inspection at least once a day paying close attention to the bony prominences and the results of the inspection should be documented. Review of The National Pressure Ulcer Advisory Panel's (NPUAP) Pressure Ulcer Prevention Points, revised 2007, showed the following information: - Consider all bed-bound and chair-bound persons or those whose ability to reposition is impaired to be at risk for pressure ulcers; - Use a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors; - Assess all at risk patients/residents at the time of admission to health care facilities, at regular intervals thereafter and with a change in condition. A schedule is helpful and should be based on individual acuity (clinical severity) and the patient care setting; - Residents in long term care should be assessed on admission, weekly for four weeks, then quarterly and whenever the resident's condition changes; - Identify all individual risk factors (decreased mental status, exposure to moisture, incontinence, device related pressure, friction, shear, immobility, inactivity, and nutritional deficits) to guide specific preventive treatments and modify the care according to the individual factors; - Perform a head to toe skin assessment at least daily, especially checking pressure points such as the sacrum (lower portion of the backbone), ischium (bony area on the buttocks when seated), trochanters (bony area from the hip joint), heels, elbows, and the back of the head; - Reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent with the overall goals of care; - Consider postural alignment, distribution of weight, balance, and stability, and pressure redistribution when positioning persons in chairs or wheelchairs; - Use a written repositioning schedule; - Place at risk persons on a pressure-redistributing mattress and chair cushion surfaces; - Teach chair-bound persons, who are able to shift their weight every 15 minutes. Record review of the CDC 2007 guidelines showed person-to-person transmission of infectious disease primarily occurs through unprotected contact with blood and body fluids; associated with a high rate of transmission; transmission in healthcare settings has been reported but is prevented by use of barrier precautions (refers to a method or device used to decrease contact with potentially infectious body fluids). Record review of the CDC's website showed the following information: - Hand hygiene is required regardless of whether gloves are used or changed. Failure to remove gloves after patient contact or between "dirty" and "clean" body-site care on the same patient must be regarded as nonadherences to hand-hygiene recommendations. - In a study in which experimental conditions approximated those occurring in clinical practice (321), washing and reusing gloves between patient contacts resulted in observed bacterial counts of ,[DATE].7 log on the hands after glove removal. - Therefore, this practice should be discouraged; handwashing or disinfection should be performed after glove removal. - Decontaminate hands after removing gloves. - Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: before patient contact; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings). Review of the facility policy and procedure on Skin Integrity Assessment, dated [DATE], showed: -The purpose: To ensure that all residents' skin is assessed on a regular basis and that any skin issues are addressed promptly and effectively. -Procedure: All residents will be assessed for skin integrity issues at least, but not limited to, two times a week by two different disciplinary staff member. Any skin assessments done must be reviewed by the Resident Care Coordinator (RCC) or designee. Any skin abnormalities will be reported in writing to the Wound Nurse or designee when found and forward a copy to the Director of Nursing (DON). --All residents that are admitted or readmitted will have a Braden Scale and [MEDICAL CONDITION] Assessment completed by the RCC or designee and repeated upon quarterly review. ---The dietician will do an assessment upon admission/readmission to assess nutritional needs and reassess quarterly and as needed (PRN). --All residents will have a thorough skin assessment by the Licensed Practical Nurse (LPN) at the following times without exception: ---New admission/readmission (admission assessment form) ---Out on pass longer than four hours for any reason. (Out on pass form.) --Weekly by the LPN and than again by the Certified Nurse's Assistant (CNA) on bath day, (CNA to document on back of the activities of daily living (ADL) form and the LPN will use that attached for B). ---The RCC or designee will review the skin assessment done by the LPN within 24 hours of admission/readmission. ---The RCC or designee will review the skin assessment done on a resident for out on pass on the same day or at the first available time he/she returns to work it occurs upon the weekend. --All skin abnormalities will be reported on the attached form A. --A treatment will be set up as protocols are outlined and appropriate at time of discovery. The treatment will be reviewed by the Wound nurse or designee at his/her next working day. --All diabetics feet will be examined weekly by the LPN/RN (Registered Nurse) and documented separately. --All documentation will be reviewed weekly by care team at the Quality Assurance (QA) meeting. --All physicians involved in care of resident will be kept informed of all assessments with concern. Record review of the facility policy and procedure on Wound Management, dated [DATE], showed: -Purpose: To ensure that all skin integrity issues are documented appropriately. -Procedure: Wound nurse or designee will measure weekly of all abnormal skin conditions. This nurse will make the judgement on treatments for wounds and will communicate changes to families and physicians. She/he will refer any skin issues to Specialized Wound Management (SWM) as appropriate and make rounds with the Nurse Practitioner weekly. This nurse will contact Advance Tissue of any resident that had Part B Medicare and that has a treatment order for reimbursement. --Treatments will be set up per protocol as outlined and appropriate. The Wound Nurse will assess treatment at her earliest convenience and will make changes as needed. --Any deviance from set protocols must be approved by the Wound Nurse or designee, unless otherwise set up by physician; Upon which time the wound nurse must be notified of changes. --Specialized Wound Management will be notified by Wound nurse or designee when a new area is found and it will be up to the Nurse Practitioner to determine they will pick up for services. --Dietary consult will be requested upon the time of new area reported. --The following lab orders will be drawn at the earliest convenience upon time of new area reported: ---Complete blood count, basic metabolic profile, pre-[MEDICATION NAME], and [MEDICATION NAME]. --Advanced Tissue will be notified when new area is found and treatment is set up if resident has Part B Medicare by Wound Nurse or designee. --This nurse will prepare the wound report for the WHIP meeting and give weekly to DON and Administrator weekly, RCC, dietary supervisor and the MDS (Minimum Date Set) Coordinator. --The Wound Nurse or designee will keep the physician and family informed of changes in wound or residents response to treatment. He/she will be responsible for all transcription of orders from physicians and SWM. --The Wound nurse or designee will be responsible to keep supplies stocked from central supply or Advanced Tissue for any dressing changes. Central Supplies will work with this designee to ensure supplies are readily available. Record review of the facility policy and procedure for Preventing and Caring for Decubitus Ulcers, not dated, showed: -Purpose: To ensure that residents are protected from developing a pressure area or to ensure that residents receive the appropriate treatment if they develop a pressure area. -Procedure: --Keep resident's skin clean and dry. --Turn and position residents who are helpless every two hours or more frequently if needed. --Encourage residents that sit in wheelchairs to raise themselves up every fifteen minutes if possible; if not assist them to raise themselves up, assist the residents in Geri chairs to reposition themselves to prevent pressure areas also. --When turning residents, use a draw sheet or turning sheet to prevent shearing or the skin. Always use two people to turn a resident if they are unable to assist. --Make sure that any special care mattresses or positioning devices are used correctly. --Keep skin soft by using A & D ointment or any good moisture barrier cream. --Wash peri area and dry thoroughly. --Change soiled linens and wet linens quickly. --Keep the bed wrinkle-free and all sheets and pads smooth. Caution: Avoid massage over bony prominences --Encourage good nutrition with your residents and fluid intake. --Avoid over padding the beds. --Elevate the feet of a bedridden resident to reduce pressure on the heels. --Use heel and elbow protectors to reduce friction to frail skin. --Keep skin from touching skin with the feet and legs. --Use pillows to provide support and positioning. --Evaluate and maintain urinary and fecal incontinence. --Avoid putting the resident directly on their wounds. --Try to prevent contractures. Review of the facility policy regarding Wound Care Dressings, dated [DATE], showed in part:: -Purpose: To help eliminate the spread of infection, to help ensure the comfort and cleanliness of the resident. To replace soiled dressings and clean ones so there is no contamination of the wound. -Procedure: --Any adhesive should be removed by pulling it parallel to the skin surface. Moistening the adhesive, if necessary may facilitate its removal. --A dressing which is adherent to the wound, may be more readily removed if moistened with peroxide. --An ointment, preferably ordered by the physician, would protect a draining wound. --Adhesive should not be used on residents with [MEDICAL CONDITION]. Use the non-[MEDICATION NAME] type. --Explain the procedure to the resident. --Wash your hands thoroughly. --Take the dressing supplies to the room and prepare a clean working area at the resident's bedside on overbed table. Never on the resident's bed. --Screen the resident for privacy and turn back linen as necessary. --Take off soiled dressing with gloved hand and place in small plastic bag. (Note: Gloves are needed for sterile dressings. Clean dressings may be applied without using gloves or instruments.) --Put on fresh dressing sterilely with instruments or sterile gloves. --When finished, discard soiled dressings and clean up instruments used and return materials to their proper place. --Chart time, treatment done, amount and type of drainage, whether sutures, clips, drains, etc. were removed or are still in place and who performed dressing change. --Reinforce dressings are to be watched carefully for excessive drainage or bleeding. If in doubt, circle the area and put time on it so as to be able to tell if it is spreading. --If using a dressing or treatment cart, never take into a resident's room. --Only take needed supplies in a resident's room. --Never leave excess dressings in room. (Unless isolation resident.) --Double bag all dressing with excessive drainage. --Sterile dressings done by RN or LPN. Record review of the facility policy regarding Wound Care, Sterile Dressing Change, dated [DATE], showed: -Purpose: To protect open wounds from contamination. To absorb drainage. -Procedure: --Explain the procedures to the resident. --Assess size of wound to be drained. --Wash hands. --Expose the area. --Put on clean disposable gloves. This prevents hands from contamination from soiled dressings. --Remove tape by pulling towards dressing and with gloved hand remove dressing. --Dispose soiled dressing in disposable bag. --Remove gloves by pulling them inside out. Dispose in bag. --Open individually wrapped sterile supplies. Place on beside table. Sterile dressings remain sterile while on or within sterile surfaces. --Open antiseptic solution and pour over sterile gauze. Physician will specify type of solution to be used. --Put on sterile gloves. --Cleanse wound with antiseptic solutions: ---Use separate swab for each cleansing stroke. ---Clean from least contaminated to most contaminated. --Use dry gauze to swab as in #12. --Apply antiseptic ointments if ordered using the same technique as cleaning. --Apply dry sterile dressings to wound site. (Note: Physician may order a wet to dry dressing. In that case, moisten the layer of dressing closest to the wound with sterile, normal saline and cover with a dry dressing. If the wound is to be packed, pack per physician's order and cover with dry dressing.) --Secure dressing with tape. --Remove gloves and dispose in bag. --Dispose of all supplies. --Assist the resident to a comfortable position. --Wash your hands. Record review of the facility's policy

Inspection of July 6, 2011

1 finding

F223J · Immediate jeopardy, isolated

Based on observation, interview, and record review, the facility staff failed to prevent emotional/mental abuse when staff compelled one sampled resident (Resident #14) out of 21 sampled residents to undergo a body cavity search on [DATE] without the consent of the resident, the resident's physician, and the resident's legal guardian. The facility census was 149 residents. Record review of the facility's Abuse, Neglect, and Grievance procedures dated [DATE] showed: -The policy was based on the Department of Mental Health regulations (Not long term care regulations). -Physical abuse: Purposefully beating, striking, wounding, or injuring any consumer or any manner whatsoever mistreating or maltreating a consumer in a brutal or inhumane manner. Physical abuse includes handling a consumer with any more force than is reasonable for a consumer with any more force than is reasonable for a consumer's property control, treatment, or management. -Verbal abuse: Using profanity or speaking in a demeaning, nontherapeutic, undignified, threatening manner in the consumer's presence. -When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the administrator or designee will notify: --The state licensing agencies responsible for surveying/licensing the facility. --The resident's representative. --Adult protective services. --Law enforcement. --The resident's physician. --The facility medical director. --Division of family services. -Note: The policy did not have any information related to emotional and mental abuse. Record review of the Missouri Protection and Advocacy Services (a federally mandated system in the state of Missouri which provides protection of the rights of persons with disabilities through legally based advocacy) "Legal Rights Handbook," [DATE] showed: -Rights of people in Medicaid/Medicare funded nursing homes include active treatment to help maintain and increase the resident's physical, mental and psychosocial well-being. Record review of the Centers for Medicare and Medicaid Services (CMS - the branch of the U.S. Department of Health and Human Services that maintains oversight of nursing homes for compliance with the Medicare health and safety standards through the survey process completed by individual State Survey Agencies) booklet, "Guide to Choosing a Nursing Home," revised [DATE] showed: -Residents of nursing homes have the same rights and protections as all United States citizens, -Residents have certain rights and protections under the law, -Residents have the right to freedom from abuse and neglect; residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion by anyone; the facility must investigate and report to the proper authorities all alleged violations and any injuries of unknown origin within five working days of the incident. 1. Record review of the Resident #14's Face Sheet showed the resident: -Was admitted to the facility on [DATE]. -Has a Public Administrator (court appointed legal guardian). -Had the following Diagnoses: [REDACTED]. --Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). --[MEDICAL CONDITION] ([MEDICAL CONDITION] - a disease process that decreases the ability of the lungs to perform ventilation). --Gastro [MEDICAL CONDITION] reflux disease (back-up of stomach acid/heartburn). --[MEDICAL CONDITION]: (an infection caused by [MEDICAL CONDITION] that attacks the liver and leads to inflammation). --Hypertension (HTN- high blood pressure). Record review of the resident's Preadmission Screening and Resident Review (PASRR, a required form used by the Missouri Department of Health and Senior Services (DHSS) to meet the federal mandate, 42CFR483.SubpartC, and reviewed by the Missouri Department of Mental Health (DMH) if screening requirements are met to determine level of services appropriate for residents with serious mental illness or mental [MEDICAL CONDITION]) dated [DATE] showed the resident: -Had the following Diagnoses: [REDACTED].). --[MEDICAL CONDITION] Disorder: (A mental illness characterized by recurring episodes of elevated or depressed mood, or of simultaneously elevated and depressed mood that alternate with, or occur together with, distortions in perception). -Had historical symptoms of physical aggression toward others, auditory hallucinations with command to harm herself/himself, running away, poor judgment, poor insight, and poor suicidal ideation. -Had verbal and physical aggression towards others. -Appeared to be mildly intellectually limited. -Required placement in a safe, structured, secure facility. Record review of the resident's Rights and Responsibilities form dated [DATE] showed the resident: -Shall not be subjected to emotional or physical harm. -Has the right to privacy and dignity. -Signed the document. Record review of the resident's Physician's Telephone Order Sheet dated [DATE] showed: -No smoking. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Nurse's Notes dated [DATE], showed the resident: -Had to be redirected away from the smoking area. Record review of the resident's Nurse's Notes dated [DATE] showed the resident: -Was very manipulative in attempting to obtain cigarettes. -Was difficult to redirect. Record review of the resident's Nurse's Notes dated [DATE] at 8:00 P.M. showed the resident: -Was redirected twice about going outside (smoking porch) and picking up cigarette butts. -The resident was searched and was found to have old food in his/her pockets. Record review of the resident's Nurse's Notes dated [DATE] at 9:00 P.M. showed: -The resident had to be redirected away from the smoking porch. Record review of the resident's Nurse's Notes dated [DATE] at 9:00 P.M. showed: -The resident continued to go outside (smoking porch) and pick up cigarette butts. Record review of the resident's Nurse's Notes dated [DATE] at an illegible time, showed: -The resident allowed peers to smoke in his/her room, but denied the incident. -The resident liked to go outside (smoking porch) and beg for cigarettes. -The resident had to be directed back to the unit several times. -The resident was stubborn. Record review of the resident's Nurse's Notes dated [DATE] at 10:00 P.M. showed: -The resident was very argumentative when redirected from going outside (smoking porch). Record review of the resident's Nurse's Notes dated [DATE] at 5:40 P.M. showed: -The resident had to be reminded to not go outside (smoking porch). Record review of the resident's Nurse's Notes dated [DATE] at 8:30 P.M. showed: -The resident's room smelled like cigarette smoke. -The resident was questioned about smoking in his/her room. -Contraband check was done. -The resident was very argumentative and not cooperative. -The resident removed a lighter from his/her private area. Record review of the resident's Nurse's Notes dated [DATE] at 4:15 P.M. showed: -The resident was not easily redirected. -The resident had to be told over and over not to go to the smoking porch. Record review of the resident's Nurse's Notes dated [DATE] at 9:00 P.M. showed: -The note was written by Licensed Practical Nurse (LPN) D. -The resident was found smoking in another resident's bathroom. -Cigarette butts were found in his/her possession. -The resident denied having a lighter. -A lighter was found in the resident's vagina and confiscated. -The resident became physically aggressive with the charge nurse. -There was no note stating the resident's physician and public administrator had been notified. Record review of the resident's RN Investigation Report completed by Registered Nurse (RN) A dated [DATE] showed: -RN A filled out the RN Investigation Report. -LPN D and Certified Nursing Assistant (CNA) P were the staff present during the search. -Investigative narrative: LPN D reported smelling smoke and noticed it was coming from a resident's bathroom. LPN D and another staff member searched the resident (Resident #14) and found a cigarette lighter inside the resident's vagina (a female internal body part). The resident told RN A she had been given two cigarettes and a lighter from a friend. The resident refused to say how she obtained the smoking materials. The resident was tearful and said, "Don't be mad at me." -The resident's physician and Public Administrator were not marked as being notified. Record review of the resident's Nurse's Notes dated [DATE] showed: -The resident repeatedly inquired about smoking and was not redirectable. -The resident had refused the nicotine patches and gum (smoking cessation products). Record review of the resident's Nurse's Notes dated [DATE] at 4:00 P.M. showed: -The resident was not allowed to smoke. -The resident has to be redirected many times away from the smoking area. Record review of the resident's Nurse's Notes dated [DATE] at 8:00 P.M. showed: -The resident was found smoking in another resident's bathroom. -The resident denied any other cigarettes and lighters in his/her room. -A cigarette and lighter check were done in the resident's room. -The resident admitted to using a blow dryer to smoke a cigarette. -The blow dryer was removed from the resident. Record review of the resident's Nurse's Notes dated [DATE] showed: -The resident continued to be non-complaint with smoking. -Had to be reminded constantly that he/she cannot smoke due to [MEDICAL CONDITION]. -The resident continues to beg for cigarettes from staff. Record review of the resident's Nurse's Notes dated [DATE] at 4:10 P.M. showed: -The resident continues to beg for cigarettes from staff. Record review of the resident's Nurse's Notes dated [DATE] showed: -The resident's Public Administrator and Physician A spoke to the resident about the risks of smoking. -Other staff members were present. -The resident wanted to smoke. -Physician A agreed to allow the resident to smoke at designated smoking times. Record review of the resident's Physician's Telephone Order Sheet dated [DATE] showed the following physician's orders [REDACTED]. -Please make the resident a Do Not Resuscitate (DNR-No Cardiopulmonary resuscitation, CPR, if the resident was to stop breathing or the heart was to stop beating). Record review of the resident's annual Minimum Data Set (MDS-a federally mandated tool required to be completed by facility staff) dated [DATE] showed the resident: -Did not have hallucinations or [MEDICAL CONDITION]. -Had [MEDICAL CONDITION]. -Did not have behaviors. -Did not have disorganized thinking. -Had intact cognition. -Was independent with bed mobility, transfers, walking, and eating. -Needed supervision only with dressing, personal hygiene, bathing, and toilet use. -Was continent of bowel and bladder. -Had the following Diagnoses: [REDACTED]. --Depression, --HTN, --GERD, --[MEDICAL CONDITION]. Record review of the resident's Care Plan dated [DATE] showed: -The resident was an active smoker. -The resident should abide by the smoking rules over the next 90 days. -The smoking schedule for the resident should be viewed. -All cigarettes and lighters should be locked at the Nurse's station and distributed by the staff at the scheduled times. -Monitor the resident for smoking and lighting materials in his/her room and on his/her person. -Keep physician and guardian notified on any non-compliance. Record review of the resident's quarterly MDS dated [DATE] showed the resident: --Did not have hallucinations or [MEDICAL CONDITION]. -Had [MEDICAL CONDITION]. -Did not have behaviors. -Did not have disorganized thinking. -Had intact cognition. -Was independent with bed mobility, transfers, walking, and eating. -Needed supervision only with dressing, personal hygiene, bathing, and toilet use. -Was continent of bowel and bladder. During an interview on [DATE] at 9:00 A.M., the resident said: -He/she only wanted to smoke cigarettes but the staff would not let him/her. -He/she had been searched by the staff on [DATE] but did not remember which staff members did the search. -The nurse asked if he/she could search and I told him/her they could search my room. -He/she had not given permission to search my private areas. -The staff members searched my room, searched my pockets, and "searched for lighters in my pussy". -The staff made him/her feel "real bad" and was "forced to have my pussy searched". "They made me put my hands up in my pussy" and "I was mad". "I didn't want them to do this to me". -He/she got physically aggressive during the search because he/she was mad. -The resident was upset, emotional, and angry during the interview. During an interview on [DATE] at 9:35 A.M., the Medical Records Director said: -He/she was involved in the search of the resident on [DATE]. -A Code Green had been called on the resident for a show of force by the staff. -The resident had no bottom clothing on and that was how the staff knew the resident had a lighter. -"We made him/her stick his/her hand up his/her private area to get the lighter out". --Note: He/she was not listed on the RN Investigation Report as a witness. During a telephone interview on [DATE] at 9:50 A.M., LPN D (was listed on the RN Investigation Report as a witness) said: -He/she was involved in the search of the resident on [DATE]. -He/she had been told by another resident that Resident #14 had a lighter. -The resident was in his/her room. -He/she asked the resident for the lighter many times. -The resident went into the bathroom and took off all of his/her clothes except for his/her bra to show he/she did not have a lighter. -He/she kept asking the resident for the lighter. -He/she felt up underneath the resident's bra under the resident's breasts for the lighter. -He/she had asked the resident if a room search could be done and the resident said "ok". -He/she did not ask the resident if he/she could touch the resident's breasts and bra to search for a lighter but the resident did not say no during the search. -The resident laid down on the bed and took the lighter out of his/her vagina himself/herself. -He/she put gloves on and picked up the lighter. -The resident was calm during the search of his/her room and body. -He/she always notified the physician and public administrator. -He/she did not notify the physician and public administrator before the search was done. During an interview on [DATE] at 11:00 A.M., the Social Services Director (SSD) said: -The staff should have asked the resident if he/she had a lighter. -The staff should have "given up" the search at that point. -The staff should have notified the resident's public administrator before searching the resident's room and the resident. -The staff did not have to ask permission to search the resident because the resident had a public administrator. During an interview on [DATE] at 11:30 P.M., the Director of Nursing (DON-had been in this position at the facility since [DATE]) said: -Searching a room is up to the facility. -When searching a resident's body you need to obtain permission from the resident or the resident's public administrator. -You do not have to have permission to search the resident's body if the public administrator gave permission. During a telephone interview on [DATE] at 8:10 A.M., Physician A said: -At first he/she had not let the resident smoke due to the [DIAGNOSES REDACTED]. -He/she had met with the resident and the resident's guardian and came to the decision to let the resident smoke due to increased behaviors of seeking cigarettes. -He/she had not been notified that the resident had hid a lighter in his/her vagina. -He/she had not been notified of the search of the resident. -He/she, along with the resident's public administrator, should have been notified immediately before the search was done. -The lighter would have caused no harm to the resident and would have come out of the resident's vagina on its own. -When the resident took his/her clothes off, the staff should have stopped what they were doing and called him/her for immediate guidance. -The staff should not have tried to continue to obtain the lighter and should have stopped the search. -Anytime a search was done, permission needed to be obtained from the resident first, especially when touching the resident. -The staff should have asked the resident before they touched his/her bra and breast area. -The facility should have followed the facility policies, procedures and the long term care regulations. During a telephone interview on [DATE] at 8:30 A.M., Public Administrator #3 said: -He/she had limited legal guardianship over the resident including psychological treatment and placement, but did not have authority over the residents medical issues. -The physician made the medical decisions on the resident. -He/she had met with the resident and the resident's physician (Physician A) and came to the decision to let the resident smoke due to increased behaviors of seeking cigarettes. -He/she had been made aware the resident had hid a lighter in his/her vagina, but not until a later time. -Anytime a search was done, permission needed to be obtained from the resident first, especially when touching the resident. -The facility should have followed the long term care regulations regarding the residents. During a telephone interview on [DATE] at 10:30 A.M., the Medical Director said: -Anytime a search was done, permission needed to be obtained from the resident first, especially when touching the resident. -If the resident had a foreign body in his/her vagina, the resident should be sent to the hospital for it to be removed. -The facility should have followed the facility policies, procedures and the long term care regulations. During a telephone interview on [DATE] at 7:49 A.M., CNA P (was listed on the RN Investigation Report as a witness) said: -He/she was involved in the search of the resident on [DATE]. -He/she arrived to the resident's room at the tail end of the search. -He/she did not remember if a Code Green had been called. -LPN D said to the resident multiple times, "Give me the lighter." -The resident finally admitted to having a lighter in his/her vagina. -The resident had laid down on the bed. -The resident was cursing at LPN D and said, "Hurry up." -He/she stood on one side of the resident's bed and LPN D stood on the other side of the bed. -He/she held the resident's legs open so LPN D could get the lighter out. -LPN D had gloves on and reached into the resident's vagina and removed the lighter. -LPN D did not have to reach up far in the resident's vagina to pull it out. -The resident did not fight during the search, but he/she held the resident's legs open in case the resident started to get combative. -After the lighter was removed, he/she left the room. During a telephone interview on [DATE] at 8:00 A.M., the Administrator (had been in this position at the facility since [DATE]) said: -He/she expected the staff to get permission from the resident to search them. -He/she expected the nurse to stay with the resident until the resident produced the lighter from his/her vagina. -He/she would have expected the nurse to remove the lighter from the resident's vagina as long as the resident consented. -He/she expected the staff to call the physician for consent to remove the lighter before putting his/her hand in the resident's vagina. -If the resident was physically and verbally aggressive during the search, he/she expected the staff to continue to search and remove the lighter from the resident's vagina. During a telephone interview on [DATE] at 8:13 A.M., the DON said: -He/she expected the staff to get permission from the resident to search them. -He/she was unaware the nurse removed the lighter from the resident's vagina. -He/she thought the resident had removed it himself/herself. -If the resident had a lighter in his/her vagina, he/she expected the staff to call the physician before removing the lighter from the resident's vagina. -If a resident became physically and verbally aggressive during the search, he/she expected the staff to stop the search and call the physician. -The physician should have been notified before the vaginal search. During a telephone interview on [DATE] at 8:53 A.M., RN A said: -He/she had filled out the RN Investigation Report on the incident (from [DATE]). -He/she was not present at the search of the resident. -He/she was notified about the search, but could not remember who removed the lighter from the resident's vagina. -No Behavioral Management Flow Sheets were used, it is only used if a takedown occurs. -He/she expected staff to obtain consent from the resident before a search. -If a resident became physically and verbally aggressive during the search he/she expected the staff to stop the search and call the physician. -He/she expected the staff to notify the resident's physician and/or guardian after the search. -He/she was unaware of what the physician's expectations were in a situation like this. -Should of had an individualized care plan for the resident based on behaviors. -He/she expected LPN D to notify him/her before the search was done. -LPN D notified him/her after the search was done. -After the incident, the resident was monitored more closely and was not allowed by or in the smoking room. -It was hard to monitor the resident because cigarettes and lighters were sold by other residents at the facility sometimes. At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". A monitoring visit was completed on [DATE]. Based on observation, interviews and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. There have been no body searches since the exit of [DATE], they have inserviced their staff but still need to go over the STOP and Level system and revamp. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a "D" level. This statement does not denote that the facility has complied with State law (Section 198.0261 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Inspection of January 25, 2011

1 finding

F314G · Actual harm, isolated

Based on observation, interview and record review, the facility staff failed to follow their policy on wound care; develop a care plan for the management of multiple pressure sores (a sore caused by unrelieved pressure resulting damage of underlying tissue) and surgical wounds; provide a pressure reducing device when the resident was out of bed; and provide consistent wound care management, treatment and measurements; contributing to the resident having to be transferred back to the wound care specialty hospital due to large amounts of purulent (pus), sanguineous (bloody), odorous drainage coming from his/her wounds; for one sampled resident (Resident #16) who was admitted to the facility on [DATE] from a wound care specialty hospital with twelve skin issues out of 17 sampled residents. Resident #16 was readmitted back to the facility on [DATE] for further wound care. The facility's census was 148. Review of Primaris' (Missouri's federally designated Quality Improvement Organization) undated Pressure Ulcer Classifications showed: Definitions: - Suspected Deep Tissue Injury (DTI) - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar (tan, brown or black). Evolution may be rapid exposing additional layers of tissue, even with optimal treatment. - Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk). - Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy). May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates DTI). This stage should not be used to describe skin tears, tape burns, perineal (the region between the anus and the external genitalia), [MEDICAL CONDITION] (inflammation of the skin), maceration (the softening of a tissue) or excoriation (to tear or wear off the skin). - Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation). Further description: The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (back of the head) and malleolus (rounded protuberances on each side of the ankle) do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III press ulcers. Bone/tendon is not visible or directly palpable. - Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] (bone infection almost always caused by a bacteria and over time, the result can be destruction of the bone itself) possible. Exposed bone/tendon is visible or directly palpable. - Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (dead matter which may be yellow, tan, gray, green or brown in color) and/or eschar in the wound bed. Review of Primaris' May 2008 Systems Investigative Audit: Pressure Ulcer Prevention/Treatment (used to evaluate the decision-making process and adequacy of the facility's process in the prevention of pressure ulcers and appropriateness of treatment protocols) showed the following guidelines: - Residents are screened within 24 hours of admission for risk of skin breakdown using a standardized risk-screening tool, - An appropriate pressure ulcer prevention or treatment care plan should be put into place within the first 24 hours of admission for all residents whether high or low risk, - Appropriate skin/wound assessments/reassessments should be done at appropriate intervals according to determined levels of risk and current clinical practice guidelines (CPGs) including: - Full skin assessment at least weekly with detailed documentation, according to CPGs of wound condition if present, - At least daily monitoring of pressure sites and areas of skin changes, and - Progress of wound healing is reassessed every two to four weeks and treatment plan re-evaluated if no evidence of progress noted. - The care plan should incorporate the following care needs as well as all identified risk factors: - Needs for turning/positioning were identified, - Positioning/pressure relief product needs identified and utilized consistently and properly, - Nutritional assessment completed and identified needs included in the care plan, - Individualized skin care needs identified and included in the care plan, and - Interventions included from all disciplines for either pressure ulcer prevention or treatment. - Care plan interventions implemented as indicated, - Care plan consistently evaluated and revised based on current resident assessed needs, - Documentation of skin condition, intervention for risk factors, and treatment of [REDACTED]. - An appropriate system for communication to all direct-care staff skin risk factors, interventions and changes in the plan of care was in place and functioned properly, - Responsibility and accountability was assigned for each phase of the pressure ulcer prevention/treatment process (those designated as responsible and accountable for monitoring the processes of pressure ulcer prevention/treatment carried out their responsibilities in a timely manner), - Policy and protocols are updated and communicated to all staff according to current CPGs, - The quality assurance committee had processes in place to track and identify patterns and to determine the root cause of skin breakdown events such as: - Identified solutions were system-oriented, and - Content of staff education was determined by competency evaluations and identified areas of weakness. - If resident self-determination was a contributing factor in pressure ulcer development, reasonable counsel, education and alternatives were provided. Review of Primaris' July 2008 Pressure ulcer prediction, prevention and treatment pathway showed instructions to: - Complete a head-to-toe skin assessment upon admission and weekly, - If the resident does not have a pressure ulcer: - Document overall skin condition including color, temperature, moles, bruises, incisions, scars, intact skin and burns, - Report anything abnormal to the physician, - Obtain treatment order from the physician if appropriate, - Notify the family, and - Proceed to completion of a risk assessment to identify risk factors and care plan interventions. - If the resident has a pressure ulcer: -Document the length, width, depth, location, stage, exudate, tunneling, necrosis, granulation, undermining, sinus tracts, and pain, - Report the findings to the physician, - Obtain a treatment order from the physician, - Notify the family, and - Proceed to completion of a risk assessment to identify risk factors and care plan interventions. - Complete skin risk assessment and determine if the resident is at risk or not, - If the resident is not at risk: - Repeat skin risk assessment at least every 90 days and with significant changes or per facility protocol, and - Complete a care plan for a potential skin problem. - If the resident is at risk: - Care plan an actual skin problem if they have a current skin problem and care plan the potential for a skin problem if they do not have a current skin problem. - Complete the care plan problem statement, - Address possible risk factors: - Bed/Chair mobility, - Possible interventions for bed might include: - Turning and repositioning schedule, - Pressure reducing/relieving device, and - Therapy consult. - Possible interventions for the chair might include: - Repositioning schedules, - Pressure-relieving cushion, and - Assessment of chair fit. - Friction and/or shear, - Possible interventions might include: - Padding to prevent skin contact, - Booties/heel protectors, - Elevate heels, - Head of bed in lowest position possible unless contraindicated by medical condition, and - Positioning devices. - Bowel and bladder incontinence and moisture, - Possible interventions for incontinence might include: - Peri care after each incontinence, - Clean as soon as possible after soiling, - Barrier cream, and - Incontinent pads or briefs. - Possible interventions for moisture might include: - Remove incontinence brief while in bed, and - Moisture barrier. - Nutrition and body weight, - Possible interventions for nutrition and body weight might include: - Weekly weight, - Dietician consult, - Labs, - Food supplements, - Speech therapy, - Vitamin/medication supplements, - Hydration, and - Assessment for chewing and swallowing problems. - Other resident-specific risk factors (include any/all interventions related to identified specific risk factors). Review of the U.S. Department of Health and Human Services Clinical Practice Guideline treatment of [REDACTED]. -The assessment of an individual with a pressure ulcer is the basis for planning treatment, evaluating treatment effects, and communicating with other caregivers. -Initially, the clinician should determine the location, stage and size of the pressure ulcer and whether sinus tracts, undermining, tunneling, exudates, necrotic tissue, granulation tissue and [MEDICATION NAME] are present. -Pressure ulcers should be assess at least once a week, but deterioration either in the patient's overall condition or in the pressure ulcer itself mandates more immediate reassessment as well as a reevaluation of the treatment plan. -A written plan for the use of positioning devices should be developed and implemented. -An individually prescribed seat cushion should be used. -A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. Review of the facility's undated "Pressure Ulcers Policy and Procedure," showed the following: Purpose - "The purpose of this policy is to provide a description of pressure ulcers and give protocols for providing care and treatment to the resident with a pressure ulcer." Definitions included: -A pressure ulcer is defined as an area of skin breakdown that develops when the skin and soft tissue is squeezed between the bones and the surface that is within contact of the body. -The most common area for pressure ulcers to develop are bony prominences (bones close to the skin), which include the hip, heel. buttocks, elbow, shoulder and the back of the head. -Several factor that can increase the risk for pressure ulcer are; -Being bedridden or confined to a wheelchair for long periods of time, -Fragile skin, -Chronic condition/diagnose that prevents are of the body from receiving proper blood flow, -An inability to move certain part of the body without assistance, -Malnourishment. Procedure: -Upon admission, weekly, and as needed (PRN) the resident will have a skin assessment completed by licensed nursing personnel/designee. -If a skin integrity issue is noted, the following people in the Interdisciplinary Team will be notified. -Residents that present with a Stage II pressure area can have the following implemented but not limited to: -Notification of the Interdisciplinary Team, -Pressure relieving device, -Turn and repositioning schedule. -Residents that present with a Stage III pressure area can have the following implemented but not limited to: -Notification of the Interdisciplinary Team, -The facility may also draw labs, utilize pressure relieving devices, or place the resident on a turn schedule as treatment measures ordered by the physician. -Residents that present with a Stage IV pressure area can have the following implemented but not limited to: -Notification of the Interdisciplinary Team, -The facility may also draw labs, utilize pressure relieving devices, or place the resident on a turn schedule as treatment measures ordered by the physician. -Residents that present with an unstageable area can have the following implemented but not limited to: -Notification of the Interdisciplinary Team, -Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. 1. Review of Resident #16's face sheet showed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Physician order [REDACTED]. : -multiple vitamins one tablet daily, -protein/soy supplement two scoops with meals, -wounds on buttocks, ischial, thigh, stump, and calf; cleanse with wound cleanser, then cover with [MEDICATION NAME] (brand name for a porous semi-transparent wound covering), Silver alginate (a wound dressing that is anti-microbial and absorbed wound drainage), and pad. Treatment to be done twice a week on Tuesday and Thursday. -zinc oxide; apply topically every 12 hours. Review of the resident's Nurses' Notes (NN) dated 11/10/10 at 4:30 P.M., showed the resident was admitted from a wound care specialty hospital, answered questions appropriately, was to be transferred by a mechanical lift only, was a paraplegic, was a left above the knee [MEDICAL CONDITION] and had the following wounds documented by Resident Care Coordinator (RCC) A: -right lateral ankle which measured 1.6 centimeter (cm) by 1.0, -right lateral calf which measured 14.8 cm by 6.0 cm, -right posterior calf which measured 9.5 cm by 6.5 cm, -right lateral and posterior thigh 26.0 cm by 20.8 cm, -four right hip wounds which measured 10.0 cm by 3.9 cm, 6.4 cm by 3.0 cm, 4.9 cm by 7.5 cm and 1.6 cm by 2.0 cm, -right lateral back "above the hip" 5.8 cm by 5.2 cm, -right buttock 10.5 cm by 8.0 cm by 0.6 cm, 2.5 cm by 1.2 cm, 5.5 cm by 2.5 cm by 0.4 cm, -left hip 35 cm by 7.6 cm, -left stump 12.4 cm by 5.2 cm by 0.3 cm. The Nurses' Notes showed the resident had a urinary catheter with clear yellow urine, and a [MEDICAL CONDITION] (an opening of a portion of the bowel this is surgically brought through the abdominal wall to drain feces) bag. Review of the facility's Weekly Wound Tracking form, dated 11/10/10, identified the following wounds on the resident: - "Stage 2" pressure wound on the right lateral ankle with an unknown date of onset, which measured 1.6 centimeters (cm) by 1.0 cm, with no undermining, or tunneling, treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -An "unstageable" pressure wound, also documented as a surgical wound, on the right thigh with an unknown date of onset. The wound measured 26.5 cm by 20.8 cm, with slough, no undermining or tunneling were present and treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, application of nonsurgical dressing and ointments/medications other than feet. - "Venous" (wound that develops due to poor circulation) wound on the right posterior calf with an unknown date of onset, which measured 9.5. cm by 6.5 cm, with no undermining or tunneling and treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Stage 2" pressure wound on the right hip with an unknown date of onset, which measured 1.0 cm by 3.9 cm with "granulation" noted on wound and no undermining or tunneling. Treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Stage 2" pressure wound on the right hip with an unknown date of onset, which measured 6.4 cm by 3.0 cm, no undermining or tunneling and treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Stage 2" pressure wound on the right hip with an unknown date of onset, which measured 4.9 cm by 7.5 cm with "granulation" noted on wound and no undermining or tunneling. Treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Stage 2" pressure wound on the right hip with an unknown date of onset, which measured 1.6 cm by 2.0 cm with "granulation" noted on wound and no undermining or tunneling. Treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Unstageable" pressure wound, also documented as a surgical wound, on the right hip with an unknown date of onset The wound measured 35.0 cm by 7.6 cm with "slough" noted on wound and no undermining or tunneling. Treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Stage 3" pressure wound on the right buttock with an unknown date of onset, which measured 10.5 cm by 8.0 cm by 0.6 cm with "granulation" noted on wound and tunneling on the "upper most part". Treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Stage 2" pressure wound on the right buttock with an unknown date of onset, which measured 2.5 cm by 1.2 cm with "granulation" noted on wound and no undermining or tunneling. Treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Stage 3" pressure wound on the right buttock with an unknown date of onset, which measured 5.5 cm by 2.5 cm by 0.4 cm with "granulation" noted on wound and no undermining or tunneling. Treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Stage 2" pressure wound on the right back with an unknown date of onset, which measured 5.8 cm by 5.2 cm with "granulation" noted on wound and no undermining or tunneling. Treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. -"Stage 3" venous wound on the left stump with an unknown date of onset, which measured 12.4 cm by 5.2 cm by 0.3 cm with "granulation" noted on wound and no undermining or tunneling. Treatments included pressure reducing device for chair and bed, turning and repositioning, ulcer care, and application of nonsurgical dressing and ointments/medication. *Note - The Weekly Wound Tracking form was signed by Registered Nurse (RN) A. The form, which was to be used for four weeks, showed no other documentation of tracking Resident #16's wounds. Review of the resident's Nutritional assessment dated [DATE] showed the Registered Dietician (RD) noted the resident was malnourished with multiple wounds and was a paraplegic. The RD recommendations were to add No Added Salt (NAS) to diet , to [MEDICATION NAME] (brand name for a nutritional supplement) one packet twice a day (BID), vitamin C 500 milligrams (mg) BID, zinc sulfate 200 mg for 14 days for wound healing. The RD also recommended diabetic health shakes between meals, laboratory blood work for pre-[MEDICATION NAME] (a marker for nutritional evaluation), [MEDICATION NAME] (a protein and required for healing tissue), and total protein (protein is required for healing tissue) . Review of the resident's POS showed an order dated 11/12/10 for Specialized Wound Management (SWM) to consult and treat the resident's wounds as indicated. Review of the resident's Treatment Administration Record (TAR) showed an order dated 11/10/10 instructing the staff to cleanse the resident's wounds on the buttock, ischia, thigh, stump and calf with wound cleanser, then cover with [MEDICATION NAME], silver alginate and a pad. The wound care was to be done BID on Tuesday and Thursday. The TAR showed documentation that the wound care was completed on 11/13/10. Review of the resident's laboratory results dated [DATE] showed the resident had a total protein level of 6.7 (within normal limits between 6.0 - 8.5) and [MEDICATION NAME] level of 3.2 (within normal limits between 3.0 - 5.5). Review of the resident's physician's orders [REDACTED]. The order noted the wound care was to be done on Monday, Thursday and as needed (PRN), and staff were to encourage the resident to change position frequently. The order was signed by the SWM consultant nurse. Prior to the onsite investigation, two copies of the resident's NN dated 11/17/10 through 12/21/10 were received; one labeled "Original" and one labeled "Revised." Record review of the resident's NN labeled "Original" showed on 11/17/10, untimed, the resident was seen by SWM nurse, new orders given, note signed by RCC B. Review of the resident's NN located in the current medical record showed: -on 11/17/10 at 12:00 P.M., the resident was seen by SWM nurse who recommended to continue current treatment orders, the note was signed by RCC A. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/19/10 showed the resident: -Had no memory loss, -Was independent with cognitive skills for daily decision making, -Had no behaviors, -Required extensive assistance with two staff for bed mobility, -Required total assistance with two staff for transfers and toilet use, -Did not ambulate, -Required extensive assistance with one staff for locomotion on and off the unit, dressing and personal hygiene. -Had an indwelling catheter and an ostomy, -Had a Stage I wound, -Was at risk for developing pressure ulcers, -Had one or more unhealed pressure ulcers at Stage I or higher, -Had a surgical wound(s), -Had one unstageable wound that was present on admission, -The longest length of an unhealed Stage 3 or 4 wound was 27 cm. -Skin and ulcer treatments included pressure reducing device for chair and bed, turning/repositioning program, nutrition or hydration intervention to manage skin problems, ulcer care, surgical wound care, and application of nonsurgical dressing other than feet. Review of the resident's SWM report dated 11/19/10 showed the resident had multiple donor skin grafts to the right lower extremity, and was a new left above the knee [MEDICAL CONDITION] which had skin grafts. The report noted the resident, in the past 60 to 90 days, had an episode of necrotizing fascitis (bacterial infection of the deep layers of skin and subcutaneous tissues) involving the peri area and back which required a high left above the knee amputation with extensive skin grafting. The report identified two wounds; -left hip above the knee amputation wound with skin grafts which had multiple granulating areas, with scant white, yellow slough. -right lower extremity skin graft with pink granulation, and moderate amount of serous drainage. The SWM nurse recommended to focus on nutrition to promote healing, a low-air loss mattress and to reposition the resident frequently. The staff were to continue current treatment orders; cleanse with wound care cleanser/normal saline, cover with [MEDICATION NAME] and silver alginate and apply a non-adherent dressing and a pad. Wound care was to be done every other day and PRN. The report noted the the wound care and pressure relief was reviewed with nursing, treatment nurse, Assistant Director of Nursing (ADON) and the Primary Care Physician (PCP). The short term goals was to promote granulation tissue and prevent infection. The report showed the SWM nurse was to follow-up in two weeks. *Note - This one page report does not identify the resident's other wounds and was not located on the resident's chart. *Note - The SWM nurse's recommendation for wound care to be done every other day was not the wound care order the SWM nurse wrote on 11/17/10 which was for wound care to be done Mondays and Thursdays. *Note - Upon request from the surveyor this report was faxed from the SWM company to the facility on [DATE]. Review of the resident's NN located on the current medical record showed on 11/26/10, untimed, the resident was transferred with a mechanical lift, was assisted with activities of daily living (ADL), had "several wounds noted on the resident's right buttock, right hip, left hip, left stump, skin grafts to right lower extremities, has a left above the knee amputation, and was a paraplegic. Wound care was completed as ordered and the resident repeatedly refused [MEDICATION NAME] injection. The resident was educated on the reason for [MEDICATION NAME] anticoagulant, the resident verbalized understand and stated "I have the right to refuse any treatment." Review of the resident's NN labeled "Original" showed: -on 11/26/10, untimed, the resident refused [MEDICATION NAME] (a medication used to prevent blood clots) injection and will continue to monitor. -on 11/28/10, untimed, "advised resident his/her dressing will be changed. Resident agitated, using foul, inappropriate language." After talking the resident, he/she said he/she would permit the dressing to be changed. *Note - Review of the resident's NN located in the current medical record showed no entry for 11/28/10. Review of the resident's NN located in the current medical record showed on 11/30/10 at 4:00 P.M., the resident was seen by his/her physician who recommended the resident be a direct admit to a wound care specialty hospital, due to large amount of purulent and sanguinous (bloody drainage) drainage with foul odor. Review of the resident's NN labeled "Original" on 11/30/10 at 4:00 P.M., the resident was seen by his/her physician who recommended the resident be a direct admit to a wound care specialty hospital, due to large amount of purulent and sanguinous drainage with foul odor. *Note - Review of the resident's entire medical record showed no additional wound measurements. Review of the resident's History and Physical from the wound care specialty hospital showed: -the resident was admitted from the facility to the hospital on [DATE], after being seen by his/her physician, -the resident had complaints of increasing back pain and increased drainage from his/her back wound, -the physician saw the resident at the facility and saw that the resident had a large amount of "pus and blood" with his/her wounds, -the resident was sent to the hospital for treatment of [REDACTED]. -the resident was a paraplegic, had diabetes, severe [MEDICAL CONDITION], had a left above the knee amputation twice, had necrotizing fascitis which involved the perineal area and the lumbar area, -the resident was to be admitted to the hospital, -the resident was to have cultures done on his/her blood, urine and wounds; and to be started on [MEDICATION NAME] (anti-bacterial) and [MEDICATION NAME] (anti-bacterial) intravenously. Review of the resident wound care records dated 12/1/10 from the wound care specialty hospital showed a Stage III sacral (area just above the base of the spinal column) wound which measured 6.0. cm by 9.5. cm by 0.3 cm. The wound had 90% granulation, some areas of slough and a moderate amount of serosanguineous (containing serum and blood)drainage. Review of the resident's hospital laboratory result dated 12/4/10 of wound cultures showed the following bacteria was identified [MEDICAL CONDITION] (MRSA), [MEDICATION NAME], corynebacterium and gram negative rod. Review of the resident's discharge orders from the wound care specialty hospital dated 12/21/10 showed the following wound care orders: -cleanse wounds on right hip with wound cleanser, apply Vaseline gauze, cover with pad and secure with tape. The wound care was to be done daily. -cleanse skin grafts on right lower extremity with wound cleanser, apply Vaseline gauze, cover with pad, wrap with Kerlix (brand name of a gauze wrap) and secure with tape. The wound care was to be done daily. -cleanse wound on left stump with wound cleanser, apply Vaseline gauze, cover with a pad and secure with tape. The wound care was to be done daily. -cleanse sacral wound with wound cleanser, apply alginate with silversorb, cover with a pad and secure with tape. The wound care was to be done daily. Review of the resident NN labeled "Original" showed on 12/21/10, at 1:45 P.M., the resident was readmitted to the facility from the speciality wound care hospital. Vital signs temperature 97.6, pulse 89, respirations 22, blood pressure 128/88, alert and oriented times three, neuro checks completed. pupils equal round and reactive to light and accomodation (PERRLA) intact, grips equal, answers questions appropriately, up with assistance of two staff, self propels in wheel chair, skin warm /dry to touch, color within normal limit, wounds noted on resident. Skin grafts on right lower extremities, above the knee amputation to left lower extremities, wounds on the left stump: 1) 10.2 x 4.0 x 0.1, 2) 1.1 x 1.8 , 3). 3.1 x 2.4 x .0.3; sacral wound: 6.6 x 8.4 x 1.4; wounds on the left buttock: 1.) 1.0 x 1.0, 2.) 0.5 x 0.5; wounds on right buttock: 6.4 x 6.8 x 0.2 , all measurements in centimeters (CM), small amount of sanguinous drainage to wounds, granulation tissue noted on all wounds, sacral wound noted with sloughing in the middle and moderate amount of purulent drainage and sanguinous drainage, minimal odor noted, no [MEDICAL CONDITION]. apical heart rate (AHR) 89, regular respiratory rate (RRR), capillary refill less than three seconds in nail bed, lungs clear to ausculation bilaterally (LCTAB), no respiratory distress noted, SPO2 98 % on room air, bowel sounds positive in all four quadrants, abdomen soft and non-tender, resident has 18 french Foley. Review of the resident's NN located in the current medical record showed on 12/21/10 at 1:45 P.M., the resident was admitted to the facility from the wound hospital via ambulance. Vital signs; temperature 97.6 degrees, pulse 89, respirations 22, blood pressure 128/88, alert and oriented times three, neuro checks completed, pupils equal, round reactive to light, accomodation intact, grips equal, answers questions appropriately, up with assistance of two staff with gait belt, self propels in wheel chair, intact skin warm and dry to touch with normal color, resident h

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