Every finding on record at Brunswick Health Care Center

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #34), in a review of 15 sampled residents, received care and services in accordance with professional standards of practice when staff failed to follow the manufacturer's recommendations for the administration of an eye drop and an inhaled medication. The facility census was 29. Review of the facility policy, Administration of Eye Medications, last revised 05/06/24, showed the following:-Administer eye medications as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions;-After instillation of medication, instruct the resident to close eyes slowly to allow for even distribution over the surface of the eye and apply gentle pressure to the tear duct for one minute or by gently closing eye for three minutes. Review of the facility policy, Administration of Dry Inhalant Medications, last revised on 05/14/24, showed the following:-Medications are administered as prescribed in accordance with current nursing principles and practices;-Allow the resident to rinse mouth with warm water when required per manufacturer recommendations and spit out. Review of the facility policy, Medication Administration, last revised on 06/26/24, showed the following:-Medications are administered as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection;-General medication administration process included administration of medication as ordered in accordance with manufacturer specifications. Review of the website, rxabbvie.com, manufacturer of cyclosporine ophthalmic emulsion (an eye drop used to treat chronic dry eyes), last updated 2024, showed to instill one drop of cyclosporine ophthalmic emulsion twice daily in each eye, approximately 12 hours apart. Apply firm, downward pressure over the inner corner of the eye to allow for distribution of the medication in the eye. Review of the website, Breztri.com, last updated 10/2025, showed Breztri (an inhaled medication) can cause serious side effects, including fungal infection in the mouth or throat (thrush). Rinse the mouth with water without swallowing after using Breztri to help reduce the chance of getting thrush. Review of the website, Drugs.com, last updated 04/13/26, showed the following:-Cyclosporine ophthalmic emulsion, recommended administration: use nasolacrimal occlusion (apply firm, downward pressure over the inner corner of the eye) and close the eyelids for two minutes after administration; -Breztri aerosphere: after inhalation, rinse mouth with water without swallowing. 1. Review of Resident #34's physician order sheet (POS), dated April 2026, showed the following: -Cyclosporine ophthalmic emulsion 0.05%, instill one drop in both eyes every 12 hours; -Breztri aerosphere inhalation aerosol160-9-4.8 micrograms per actuation (mgc/ACT), two puffs orally, two times, twice daily. Review of the resident's comprehensive Minimum Data Set (MDS), a federally mandated assessment instrument to be completed by facility staff, dated 05/11/26, showed the following:-Cognitively intact; -Diagnosis of chronic obstructive pulmonary disease (COPD, lung disease). Observation on 05/04/26 at 09:45 A.M. showed the following: -Certified Medication Technician (CMT) C entered the resident's room and administered one drop of cyclosporine ophthalmic emulsion 0.05% in the resident's right eye; -CMT C did not apply nasolacrimal occlusion to the resident's right eye and did not have the resident close his/her eyes after he/she administered the cyclosporine ophthalmic emulsion per the manufacturer's recommendations; -CMT C administered one drop of cyclosporin ophthalmic emulsion 0.05% in the resident's left eye; -CMT C did not apply nasolacrimal occlusion to the resident's left eye and did not have the resident close his/her eyes after he/she administered the cyclosporine ophthalmic emulsion per the manufacturer's recommendations; -The resident used a tissue and dabbed the excess cyclosporine ophthalmic emulsion off his/her right eye and left eye; -CMT C handed the resident Breztri aerosphere inhalation aerosol device and the resident self-administered two puffs of the medication; -CMT C did not instruct the resident, or assist the resident, to rinse his/her mouth and spit after administration of the inhaled medication, per the manufacturer's recommendations. During an interview on 05/06/26 at 9:40 A.M., the resident said the following: -He/She was not aware it was necessary to hold pressure to the inner eye when the cyclosporin ophthalmic emulsion was administered or to close his/her eyes for two minutes, as recommended by the manufacturer; -Staff never applied pressure to the inner eye, or told him/her to close his/her eyes, after staff administered the eye drops; -He/She was aware of recommendations to rinse his/her mouth and spit after he/she used the Breztri inhaler, and was doing that at home before coming to the facility; -Staff did not instruct and/or assist him/her to rinse and spit after administration of the Breztri inhaler;-He/She did not ask for assistance to rinse and spit after the use of the inhaler because he/she already took a long time to take his/her medications, and he/she did not want to bother the staff with taking up more time. During an interview on 05/06/26 at 11:30 A.M., CMT C said the following: -He/She was not aware some eye drops required holding pressure to the inner eye following administration; -He/She was not aware of the manufacturer's recommendations for residents to rinse their mouth and spit after the use of Breztri to prevent thrush. During an interview on 05/06/26 at 12:45 P.M., CMT D said the following: -He/She was not aware some eye drops required holding pressure to the inner eye following administration; -He/She was not aware of the manufacturer's recommendations for residents to rinse and spit after the use of Breztri to prevent thrush. During an interview on 05/06/26 at 2:15 P.M., the Director of Nurses (DON) said the following: -She expected staff to follow manufacturer's recommendations when administering medications to residents; -She expected staff to apply pressure to the inner eye after the administration of an eye drop if it was clinically indicated; -She expected staff to have a resident rinse and spit after the use of inhaled medications if it was clinically indicated, such as with an inhaled steroid.

Based on observation, interview, and record review, the facility failed to practice acceptable infection control measures during medication administration for two residents (Residents #34 and Resident #13), when staff did not perform hand hygiene and touched the residents' medications without wearing gloves prior to administration and failed to wear gloves when administering eye drops and inhaled medications to one resident (Resident #34), in a review of 15 sampled residents. The facility census was 29. Review of the facility policy, Administration of Eye Medications, last revised on 05/06/24 showed the following:-Administer eye medications as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions;-Wash hands or utilize alcohol-based hand rub and apply gloves to administer medication. Review of the facility policy, Administration of Dry Inhalant Medications, last revised on 05/14/24, showed the following:-Medications are administered as prescribed, in accordance with current nursing principles and practices and only by persons legally authorized to do so;-Put on gloves to comply with standard precautions. Review of the facility policy, Medication Administration, last revised on 06/26/24, showed the following:-Medications are administered as ordered by physicians and in accordance with professional standards of practice in a manner to prevent contamination or infection;-General medication administration process included removal of medication from source, taking care not to touch medications with bare hands. 1. Review of Resident #34's Physician Order Sheet (POS), dated April 2026, showed the following: -Fluticasone propionate nasal suspension (a nasal spray used to treat allergy symptoms) 50 micrograms (mcg) per actuation (spray), give two sprays to both nostrils two times daily; -Gabapentin (a medication used to treat seizures and nerve pain) 300 milligrams (mg). Give two capsules by mouth, two times daily; -Ipratropium bromide nasal solution (a nasal spray used to treat allergy symptoms) 0.03%, two sprays in both nostrils twice daily; -Lansoprazole orally dissolving tablet (a medication used to treat gastroesophageal reflux disease) 30 mg by mouth two times twice daily; -Montelukast sodium oral tablet (a medication used to treat bronchospasm and allergies) 10 mg by mouth once daily; -Pred Forte ophthalmic suspension (an eye drop used to treat eye inflammation) 1%, instill one drop in right eye twice daily; -Propranolol oral tablet (a medication used to treat high blood pressure and heart irregularities) 60 mg by mouth twice daily; -Seroquel (an antipsychotic medication) 300 mg by mouth daily in the morning. Observation on 05/04/26 at 09:45 A.M. showed the following: -Certified Medication Technician (CMT) C stood at the medication cart in the hallway and removed the resident's prefilled medication packages from the medication cart; -CMT C did not perform hand hygiene and did not put on gloves; -CMT C pushed two capsules of gabapentin from the prepackaged medication card into his/her bare hand, then placed the tablets into the medication cup with the other medication; -CMT C pushed one lansoprazole tablet from the prepackaged medication card into his/her bare hand, then placed it into the medication cup with the other medications; -CMT C pushed one montelukast sodium tablet from the prepackaged medication card into his/her bare hand, then placed it into the medication cup with the other medications; -CMT C pushed one propranolol tablet from the prepackaged medication card into his/her bare hand, then placed it into the medication cup with the other medications; -CMT C pushed one Seroquel tablet from the prepackaged medication card into his/her bare hand, then placed it into the medication cup with the other medications; -CMT C entered the resident's room and handed the medication cup and a glass of water to the resident; -The resident poured the medications onto his/her upper chest area and took each medication one at a time;-Without performing hand hygiene and without wearing gloves, CMT C held a bottle of fluticasone nasal spray beneath the resident's nose and instilled two sprays of medication into the resident's right nare and then left nare. CMT C touched the resident's nasal bridge with his/her ungloved hands; -Without performing hand hygiene and without wearing gloves, CMT C touched the resident's lower right eyelid and placed one drop of Pred Forte 1% ophthalmic solution into the resident's eye; -Without performing hand hygiene and without wearing gloves, CMT C held a bottle of ipratropium nasal solution beneath the resident's nose and instilled two sprays of medication into the resident's right then left nare. CMT C touched the resident's nasal [NAME] with his/her ungloved hands; -The resident handed his/her water cup to CMT C, and he/she sat it on the bedside table; -CMT C returned to the medication cart and placed the eye drop and nasal medication bottles in a drawer on the cart. 2. Review of Resident #13's Physician Order Sheet, dated April 2026, showed the following: -Cholecalciferol (vitamin D supplement) 50 micrograms (mcg) by mouth in the morning, two times weekly;-Docusate sodium (a medication used to treat constipation) 200 mg by mouth daily in the morning;-Duloxetine hydrochloride (a medication used to treat depression and chronic pain) 30 mg delayed release, one capsule by mouth daily in the morning;-Eliquis (a blood thinning medication) 5 mg oral tablet, one my mouth two times daily. Observation on 05/05/26 at 06:30 A.M. showed the following: -CMT C stood at the medication cart in the hallway and removed the resident's prefilled medication packages from the medication cart; -CMT C did not perform hand hygiene and did not put on gloves; -CMT C pushed one cholecalciferol tablet from the prepackaged medication card into his/her bare hand, then placed it into a medication cup; -CMT C pushed one docusate sodium tablet from the prepackaged medication card into his/her bare hand, then placed it into the medication cup with the other medication; -CMT C pushed one duloxetine hydrochloride tablet from the prepackaged medication card into his/her bare hand, then placed it into the medication cup with the other medications; -CMT C pushed one Eliquis tablet from the prepackaged medication card into his/her bare hand, then placed it into the medication cup with the other medications; -CMT C handed the resident the cup of medications with a glass of water and the resident swallowed the medications. 3. During an interview on 05/06/26 at 11:37 A.M., CMT C said the following: -Staff should wash their hands or use hand sanitizer before and after administering medications to a resident; -Staff should not touch a resident's medication without wearing gloves; -He/She should wear gloves when administering eye drops and nasal inhalers or anytime he/she might touch the resident's skin;-He/She was in a hurry and did not think about what he/she was doing when he/she touched the residents' medications with his/her hands and did not wear gloves for the administration of eye drops and nasal inhalers. During an interview on 05/06/26 at 2:15 P.M., the Director of Nursing (DON) said the following: -Staff should not touch a resident's medication with their hands; -She expected staff to wear gloves when administering eye drops or nasal sprays, and staff should wash their hands or use hand sanitizer before and after contact with a resident;-She expected staff to follow hand hygiene and infection control practices during resident medication administration. During an interview on 05/06/26 at 2:30 P.M., the Administrator said she expected staff to follow hand hygiene and infection control practices when administering medications to residents.

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) eight consecutive hours a day, seven days a week and did not have a full-time director of nursing. The facility census was 36. Review of the facility's Registered Nurse (RN) Policy, revised on 4/30/24, showed the following:- Full time is defined as working 40 or more hours a week;-The facility will utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week;-The facility will designate a registered nurse to serve as the director of nursing on a full time basis. 1. Review of the nursing staff schedule, dated 7/1/25 through 7/5/25, showed no documentation of RN coverage on 7/1/25, 7/4/25, and 7/5/25. Review of the nursing staff schedule, dated 7/6/25 through 7/12/25, showed no documentation of RN coverage on 7/6/25, 7/7/25, 7/8/25, 7/9/25, 7/10/25, 7/11/25 or 7/12/25. Review of the nursing staff schedule, dated 7/13/25 through 7/19/25, showed no documentation of RN coverage on 7/13/25, 7/14/25, 7/15/25, 7/16/25, 7/17/25, 7/18/25 and 7/19/25. Review of the nursing staff schedule, dated 7/20/25 through 7/26/25, showed no documentation of RN coverage on 7/20/25, 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/25/25 and 7/26/25. Review of the nursing staff schedule, dated 7/27/25 through 7/31/25, showed no documentation of RN coverage on 7/27/25, 7/28/25, 7/29/25, 7/30/25 and 7/31/25. 2. Review of the nursing staff schedule, showed no documentation of hours for the Director of Nursing for 7/1/25 through 7/31/25. 3. During an interview on 7/31/25 at 2:44 P.M., the administrator said the following:-The interim DON was a corporate nurse, who had to share time with another facility that did not have a DON;-The interim DON was onsite two days a week; -She did not think the interim DON kept a record of the days she worked at the facility;-When the interim DON was onsite, she monitored medication orders, medication administration, medication and supply availability, presence of documentation, and documentation accuracy;-The facility was able to borrow a Licensed Practical Nurse (LPN) from another facility for coverage, but had not been able to borrow a registered nurse. During an interview on 7/31/25 at 3:00 P.M., the DON said the following:-She was a corporate regional nurse that started coverage for the facility on 6/28/25;-She was aware the facility was out of compliance, but they were working on finding replacements;-She had two facilities she was covering as director of nursing;-She was onsite at the facility twice a week, but last week she only made it in one day;-The days she was onsite, she checked medication orders, checked the administrations were recorded, checked documentation, and discuss the status and orders on the residents with wounds to make sure the wounds were healing and give instructions to the nurses to implement for wound care;-The facility did not have any other registered nurses to meet the eight hour per day coverage. Complaint 1761706

Based on interview and record review, the facility failed to ensure one resident (Resident #1), of 11 sampled residents, remained free from sexual abuse, when another resident with inappropriate sexual behaviors (Resident #2), sexually abused the resident in Resident #1's room. The facility census was 21. On 4/15/25 at 5:05 P.M., the administrator was notified of the immediate jeopardy (IJ) past non-compliance that occurred on 3/29/25. Corrective measures and an investigation began immediately. Resident #1's family and physician were notified of the allegation of abuse and the resident was placed one on one for safety until emergency medical services arrived to transport the resident to the hospital for assessment and evaluation. Resident #2 was placed on one on one supervision until local law enforcement arrived. Education on Sexual Harassment and Sexual Abuse policies was provided to all staff. The IJ was corrected on 3/31/25. Review of the facility's policy, Abuse and Neglect, revised on 6/12/24, showed the following: -It is the policy of this facility to report allegations of abuse/neglect/exploitation, or mistreatment, including injuries of unknown sources and misappropriation of property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations with prescribed time frames; -Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to the following: -Unwanted intimate touching of any kind especially of breasts or perineal area; -All types of sexual assault or battery, such as rape, sodomy and coerced nudity; -This also includes failure to intervene or attempt to stop or prevent non-consensual sexual activity or performance between residents. 1. Review of Resident #1's Face Sheet, undated, showed the following: -The resident's original admitted was 8/7/24; -The resident was his/her own responsible party. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 2/15/25 showed the following: -Cognitively intact; -Disorganized thinking continuously present and does not fluctuate; -No behavioral symptoms directed towards others exhibited (including hitting, kicking, pushing, grabbing or abusing others sexually); -Other behavioral symptoms not directed towards others (including public sexual acts) not exhibited; -The resident required substantial assistance with positioning in bed; -The resident was dependent on staff with transfers from bed to chair; -The resident had a urinary catheter; -Diagnoses included Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), cerebral palsy (a disorder that affects movement, balance and posture), epilepsy, Parkinson's disease (a brain disorder that causes movement problems, like shaking, stiffness and difficulty with standing), anxiety disorder and depression. Review of the resident's Grievance Report, dated 3/13/25, showed the following: -Date complaint/grievance occurred: 3/8/25 to 3/13/25; -Resident #2 was always touching Resident #1 on the shoulder. Resident #2 asked Resident #1 to go on a date with him/her and Resident #1 did not want to; -Resident #1 had to ask Resident #2 to stay out of his/her room. Resident #2 made him/her feel scared; -Form completed by Registered Nurse (RN) B; -Grievance follow up: Tried talking to Resident #2. He/She apologized and walked away. Review of the resident's Progress Note, dated 3/29/25 at 6:01 P.M., showed the following: -The resident just reported to an aide that Resident #2 came into his/her room earlier today. The charge nurse on the off going shift, Licensed Practical Nurse (LPN) A, and the oncoming shift nurse, LPN F, talked to the resident. The resident reported at 3:00 P.M., Resident #2 came into his/her room and put his/her fingers inside the resident's genitalia. Resident #1 told Resident #2, No, but the resident continued and said he/she (Resident #2) had permission to be in Resident #1's room, which the resident did not; -Resident #1 complained of pain in the genital area after the incident. The Assistant Director of Nursing (ADON) was notified to report the incident. LPN F made an emergency call to 911 and Emergency Medical Services (EMS). Review of the resident's Care Plan, revised on 3/31/25, showed the following: -The resident had a potential behavior problem related to inappropriate sexual comments. Anticipate and meet the resident's needs (date initiated 7/8/24); -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner divert attention and remove from situation and take to alternate location as needed; -The resident required assistance of two staff to turn and reposition him/her in bed every two hours and as necessary; -The resident was totally dependent on two staff for dressing; -On 3/29/25, the resident reported another resident came into his/her room earlier that day. The incident happened around 3:00 P.M., and the other resident put his/her fingers inside the resident's genitalia. Resident #1 told him/her, no but the resident continued and said he/she had permission to be in the resident's room; -The resident complained of pain between his/her legs, initiate post-incident psychosocial assessment. Completing every shift for three days and then daily for seven days; -Notified the physician, ADON, the Director of Nursing (DON), Administration, reported to the state agency and law enforcement; -Order received to send the resident to the emergency room for evaluation and treatment; -The resident was immediately placed one on one for oversight and kept away from the other resident. Review of the resident's Police Report, Sodomy or Attempted Sodomy/ Supplemental Narrative Report, dated 4/5/25 at 10:24 A.M., showed the following: -On 4/5/25 the resident was asked what happened last Saturday, 3/29/25; -Resident #1 said Resident #2 came in to his/her room at 3:00 A.M. while he/she was sleeping and kissed Resident #1 on the lips and lifted up his/her gown; -Resident #2 put his/her fingers inside the resident's genitalia and pushed deeper and deeper inside. Resident #1 said he/she told Resident #2 no, and to stop several times before he/she stopped; -Resident #1 was questioned about his/her relationship with Resident #2 and Resident #1 said Resident #2 just hooked onto him/her, they were not friends, and he/she didn't know him/her; -Resident #1 said Resident #2 had asked if he/she wanted to date and Resident #1 told him/her, no; -Resident #1 said the hospital did an exam of him/her and there was tearing and bleeding between his/her legs; -The resident was asked if he/she wanted to press charges and he/she said, yes. During an interview on 4/3/25 at 11:05 A.M. and 4/7/25 at 12:15 P.M., Resident #1 said the following: -At first, he/she enjoyed spending time with Resident #2. Resident #2 acted like he/she cared for him/her; -Resident #2 would touch him/her on the arm or shoulder, it made him/her feel good and Resident #2 sat with him/her during meals; -He/She and Resident #2 had watched movies in the facility sunroom. Resident #2 had kissed him/her and Resident #1 was fine with that; -On Saturday, in the night, around 3:00 A.M., he/she (Resident #1) was asleep in bed, and was awakened by Resident #2 kissing him/her on the lips; -Resident #2 pulled up his/her gown and put his/her fingers inside the resident's genitalia. Resident #1 was scared and stunned it happened so fast, he/she yelled for Resident #2 to stop, stop, stop, but he/she wouldn't; -Resident #2 was rough, and it hurt. He/She was afraid of Resident #2 now. 2. Review of Resident #2's Face Sheet, undated, showed the following: -admitted [DATE]; -The resident was his/her own responsible party. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No behavioral symptoms exhibited including physical behaviors (e.g., hitting, kicking, scratching or abusing others sexually), verbal behaviors or behaviors not directed towards others (physical symptoms such as hitting, scratching, pacing rummaging or sexual acts in public); -No wandering exhibited; -Independent with mobility; -No mobility device utilized. Review of the resident's Progress Note, dated 3/9/25 at 3:58 P.M., showed the following: -Resident #2 was at a table playing a game with Certified Nurse Assistant (CNA) E and another resident (Resident #1); -Resident #2 asked if he/she could take people out on dates and how he/she could go about it, the resident was directed to ask social services, but that it would have to be agreed upon; -Resident #2 asked a question about bringing someone into his/her room and told the staff member he/she was hot and attractive, and his/her body looked sculpted; -The staff member educated the resident and told him/her it was not appropriate to talk about staff members that way. Review of the resident's Progress Note, dated 3/18/25 at 6:30 P.M., showed Dietary Aide D said the resident came into the kitchen doorway and told him/her that he/she had a banging body and he/she wanted to kidnap him/her. Review of a Grievance Form, dated 3/18/25, untimed, completed by Dietary Aide D, showed the following: -Resident #2 said he/she had a banging body along with he/she would fuck him/her and that he/she looked at his/her ass; -Resident #2 also made a comment about kidnapping Dietary Aide D. Review of the resident's Medication Review report dated 3/30/25 showed the following: -Diagnoses included homeless, bipolar disorder, current episode depressed, mild (a mental health condition characterized by both periods of elevated mood, mania or hypomania) and periods of depression, with the current episode being a mild form of depression), adjustment disorder (an excessive emotional or behavioral reaction to a stressful life event or change) and anxiety; -Progesterone (can be used to reduce inappropriate sexual behaviors) for sexual disinhibition (loss of normal restraints or controls on sexual thoughts, impulses or behaviors) 100 milligrams (mg) one capsule at bedtime for sexual disinhibition (order date 3/11/25). Review of recorded facility camera footage, dated 3/29/25, showed the following: -At 3:03 P.M., Resident #2 walked down the hall and entered Resident #1's room and shut the door. No staff members were observed in the area at the time; -At 3:33 P.M., Resident #2 exited Resident #1's room. Review of the local law enforcement report, dated 3/29/25 at 6:24 P.M., showed the following: -On 3/29/24 at about 6:24 P.M., a report came into dispatch about a sexual assault that occurred at the facility. Staff at the facility advised to stay with the victim (Resident #1) and keep him/her separated from the suspect (Resident #2); -Arrived on scene at 7:53 P.M., was advised the victim had been transported to the hospital for a sexual assault exam. Questioned staff about Resident #1's mental status and was told he/she was alert and oriented to person, place, and time with occasional confusion; -Resident #1 gave a verbal statement that was written by Licensed Practical Nurse (LPN) A which included that around 3:00 P.M., Resident #2 went into Resident #1's room when he/she was asleep. He/She (Resident #2) gave the resident a kiss and put his/her fingers inside the resident's genitalia, it was hard, and Resident #1 told Resident #2 to stop, and he/she didn't. -Resident #1 told Resident #2 to stop again. Resident #2 kept going on and on. Resident #1 finally yelled stop, and Resident #2 finally stopped; Resident #2 wouldn't leave. Review of the resident's Care Plan, revised 3/31/25, showed the following: -The resident told a staff member that he/she was hot, attractive, and his/her body looked sculpted (date initiated 3/10/25); -The resident was educated on appropriate conversations that occur with staff and started on progesterone; -The resident had a problem with being verbally sexually inappropriate (date initiated 3/10/25); -Intervene as necessary to protect the rights and safety of other residents, divert attention. Remove from situation and take to alternate location as needed; -The resident was independent with activities of daily living (ADL); -The resident was a wanderer and significantly intruded on the privacy and activities of other residents (dated initiated 3/24/25); -Advised the resident he/she couldn't go down other hallways where he/she didn't live, the resident didn't verbalize an understanding and stated he/she would walk all the hallways, and he/she wasn't going into other rooms; -If wandering occurs attempt to offer favorite snacks; -Another resident (Resident #1) reported that the resident had entered his/her room and touched him/her (Resident #1) inappropriately (date initiated 3/30/25); -Local county law enforcement agency was called and notified to come to the facility; -The resident was placed on one-on-one supervision to ensure he/she was not found around the other resident (Resident #1); -The resident was taken with law enforcement for questioning over the incident. During an interview on 4/7/25 at 9:25 A.M. CNA E said the following: -Recently he/she was playing a game at a table in the dining room with Resident #1 and Resident #2; -Resident #2 made a comment about him/her (CNA E) being pretty and his/her body being sculpted. Resident #2 asked how residents could go about going on dates, CNA E wasn't sure if Resident #2 meant with residents or staff, he/she redirected Resident #2 and reported the incident to Registered Nurse (RN) B; -Resident #1 and Resident #2 sat together during meals, Resident #2 would pat Resident #1's shoulder or leg. Resident #1 didn't act like he/she liked it or didn't like it; -The week before the incident, Resident #1 asked to sit at another table, instead of sitting with Resident #2; -A few days later he/she asked to sit with Resident #2 again during meals; -He/She questioned Resident #1 about the seating arrangement and Resident #1 said he/she liked to sit with Resident #2. During an interview on 4/4/25 at 8:50 A.M. and 4/8/25 at 11:45 A.M. the Social Service Designee (SSD) said the following: -Resident #2 sat with Resident #1 at meals and would put his/her (Resident #1's) clothing protector on; -Resident #1 made a grievance against Resident #2 entering his/her room uninvited. SSD thought maybe Resident #2 wanted to visit, as many residents do in the facility, or because Resident #1 was aware Resident #2 had taken items from other residents, and Resident #1 didn't want him/her in his/her room; -He/She explained to Resident #1, Resident #2 could not enter his/her room uninvited, and he/she had to give him/her permission to do so; -He/She instructed Resident #1 to call for help or let staff know if there was an issue otherwise staff wouldn't know there was a problem; -He/She didn't ask Resident #1 why Resident #2 made him/her feel scared, as he/she (Resident #1) indicated on the grievance submitted to the SSD; -Resident #2 made inappropriate sexual comments towards staff regarding their appearance; -He/She had several grievances against Resident #2 for stealing other residents' items or going in their rooms; -He/She educated Resident #2 on not going in other resident's rooms or taking items that didn't belong to him/her. During an interview on 4/4/25 at 9:15 A.M. RN B said the following : -Resident #2 made a sexually inappropriate comment towards Dietary Aide D, the physician was notified and received an order for progesterone; -The physician followed up on medication effectiveness and RN B told the physician it was helping as he/she didn't notice any inappropriate sexual behaviors after being on the medication. During an interview on 4/7/25 at 11:45 A.M. and 4/8/25 at 2:04 P.M., the Director of Nursing (DON) said the following: -The facility did not know a lot about Resident #2 when he/she admitted to the facility; -Resident #2 was started on progesterone for inappropriate sexual comments made towards staff; -Resident #1 and Resident #2 sat together during meals and spent time together in the common area; -When Resident #1 told Resident #2 to stop and he/she didn't, that was considered sexual abuse/sexual assault. During an interview on 4/8/25 at 2:30 P.M. the Administrator said the following: -Resident #2 made inappropriate sexual comments towards staff and he/she was educated on this behavior not being appropriate; -The physician was notified and Resident #2 was started on progesterone; -She didn't have concerns with Resident #2 being sexually inappropriate with residents, it seemed directed towards the staff; -Resident #1 and Resident #2 sat together during meals and spent time together in the common area; -On 3/29/25, Resident #1 reported Resident #2 sexually assaulted him/her in his/her room; -She considered what Resident #2 did to Resident #1 was sexual assault and sexual abuse. MO251962 MO251922

Based on interview and record review, the facility failed to ensure staff were employed with the appropriate competencies and skill sets to provide nursing care and related services to assure resident safety and attain the highest practicable mental and psychosocial well-being for their resident population when the facility accepted residents for admission with behavioral health needs that staff were not trained to care for. The facility census was 21. Review of the facility's Behavioral Health Services Policy, revised 10/31/24, showed the following: -Affected Personnel: All facility employees; -It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning; -All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based on the role of the staff member and resident needs identified through the facility assessment. Review of the facility's policy, Resident Referral Review Process, dated 12/1/22, showed the following: -When the facility receives a resident referral for admission, the Admission Coordinator will convene an Admission Team meeting immediately. This meeting will convene within 15 minutes of receiving the referral; -The members of the team must stop what they are doing and immediately attend the admission team meeting to review the referral; -The admissions coordinator will contact the referral sources and inform them of Admission Team's (Admissions Coordinator, Social Service Designee, Business Office Manager, Director of Nursing (DON) and Administrator) decision as rather to admit or not to admit the potential resident; -Referral decisions for medical referrals should be made in 15 minutes of the meeting; -Referrals for behavioral referrals should be made in two hours of receiving the referral, unless additional information was needed to make the decision; no longer than 24 hours after; -If the admissions team feels they cannot meet the resident's needs or the facility had no available bed for the referral, the admission coordinator will contact the referral source and inform them of the admissions team's decision to not admit; -The final decision as to whether to admit or not to admit the referral will be made by the Administrator. Review of the Facility's Assessment, dated 1/1/24 through 4/16/24, showed the following: -Average daily census was 31; -Diagnoses included psychiatric/mood disorders: alcohol abuse, alcohol dependence, anorexia, anxiety, bipolar disorder (a mental health condition characterized by both periods of elevated mood, mania or hypomania), hallucinations, insomnia, major depressive disorder, mood disorder (a mental health disorder affecting one's mental state), panic disorder, paranoid schizophrenia (mental health condition that can affect how a person thinks, feels and behaves), post-traumatic stress disorder (a mental health condition that develops after a traumatic event), psychiatric disorder with delusions (false beliefs); -When the facility received a referral for the care of a resident that staff are less familiar or when a resident develops a new diagnosis, condition or symptom that staff have not previously exposed to, the Interdisciplinary Team will immediately inform the DON, notify the Medical Director, review the company clinical library for related policy and procedures, utilize the regional nurse, utilize evidence based resources, utilize medical director for training, utilize vendors for training as needed, educate all involved staff and perform required competency related to new condition or procedure and consult company executive clinical leadership team as needed; -Average number of residents with special treatments/ acuity showed behavioral health needs was one; -Average number of residents with active or current substance use disorders was none; -Services and care offered based on our residents' needs included mental health and behavior, manage the medical conditions and medication related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, other psychiatric diagnoses, psychology and psychiatry by third party, psychosocial support by Social Worker (SW); -Staff training/education and competencies included providing a yearly calendar of educational experiences that cover pertinent and mandatory topics for the support and care needed for the resident population; -Nursing department required competency included person centered care and behavior management. Review of the list of residents admitted in the last 60 days with mental health diagnoses, provided by the facility, dated 4/8/25, showed the following: -Resident #3 admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia and paranoid personality disorder (a mental health disorder characterized by persistent pattern of mistrust and suspicion of others); -Resident #2 admitted the facility on 2/21/25. Diagnoses included bipolar disorder and adjustment disorder; -Resident #4 admitted to the facility on [DATE]. Diagnoses included bipolar disorder and anxiety disorder; -Resident #11 admitted to the facility on [DATE]. Diagnoses included unspecified psychosis not due to a substance or known physiological condition (a state where person's ability to distinguish between real and unreal experiences is impaired, leading to hallucinations (seeing or hearing things that aren't there) and delusions; -Resident #9 admitted to the facility on [DATE]. Diagnoses included delirium due to known psychological condition (a person's mental state, typically marked by confusion and disorientation, is caused by a preexisting mental health issue); -Resident #8 admitted to the facility on [DATE]. Diagnoses included undifferentiated schizophrenia (a diagnosis used when a person experiences of schizophrenia but don't fit into a clear specific subtype), other specified depressive disorders, social exclusion and rejection, major depressive disorder, bipolar disorder, current episode manic without psychosis features and delusional disorders (a state where an individual experiences a manic episode, characterized by elevated mood, energy and activity but doesn't experience delusions or hallucinations); -Resident #10 admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, personal history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), paranoid personality disorder, major depressive disorder, delusional disorder (a mental illness characterized by persistent, false beliefs, called delusions, that last for at least a month) and anxiety disorder. During an interview on 4/8/25 at 1:00 P.M. Certified Nurse Assistant (CNA) F said he/she had no formal training on caring for residents with mental health conditions. During an interview on 4/4/25 at 10:15 A.M. Licensed Practical Nurse (LPN) A said the following: -The facility was a basic long-term care facility, and recently they had admitted several residents with mental health conditions; -LPN A had not received formal training on caring for residents with mental health issues; -If the facility continued to admit residents with mental health issues, staff should have additional training, resources and education to care for those residents. During an interview on 4/8/25 at 1:00 P.M., the Activity Director said he/she had not received any formal training to care for mental health residents. During an interview 4/3/25 at 3:07 P.M. and 4/7/25 at 3:50 P.M. the Social Service Director (SSD) said the following: -She became the SSD in December 2024; -She had not received any formal mental health training; -The facility had admitted several residents with mental health conditions and she was not sure if she was doing the right thing to help residents with mental health issues; -Resident #2 was recently admitted to the facility. The resident was homeless and was basically dropped off at the facility by a ride-sharing service; -The facility knew very little about the resident and was unaware of his/her mental health conditions; -Resident #2 would steal and go in other rooms without permission, corporate staff told facility staff to educate the resident; -Staff attempted to educate Resident #2 and he/she would just walk away or ignore staff; -When staff tried to redirect Resident #2 he/she would retaliate by making a mess in another room or emptying his/her colostomy bag (bag that collects feces after a surgical procedure called a colostomy) in the sink or disconnecting the toilet; -There needed to be a better screening process before admitting residents to the facility. During an interview on 4/7/25 at 11:05 A.M., the Assistant Director of Nursing (ADON)/Admission Coordinator said the following: -He/She had not received any formal training on mental health; -The facility had admitted several residents with mental health diagnoses; -When he/she reviewed Resident #2's referral paperwork he/she missed the resident's mental health diagnoses, he/she basically reviewed the high points of the paperwork; -If he/she would have been aware of the resident's mental health diagnoses and that no medications were prescribed for symptom management, he/she would have questioned the resident's admission to the facility; -Corporate staff expected admission referrals be reviewed in 15 minutes and a prompt response on whether the facility would admit the resident; -Resident #3 continually made comments about wanting or needing to leave the facility. During an interview on 4/7/25 at 10:45 A.M. and 11:45 A.M. the Director of Nursing (DON) said the following: -She started working at the facility in December of 2024; -She had been a nurse for less than a year; -She had not received any formal training at the facility regarding mental health conditions; -She had concerns with the recent admission of residents with mental health conditions and the facility's ability to care for some of those residents due to the lack of training; -Corporate staff sent new admission referrals to the facility and the facility's administrative staff were to review the information and respond in 15 minutes whether they would accept the resident as an admission; -Resident #2's mental health diagnoses were missed when reviewing the information. The resident was not on any medications to manage his/her bipolar disorder. If that had been known, the facility would have questioned symptom management prior to accepting the resident; -Resident #2 had stolen clothing from other residents, stolen food from his/her roommate, used profanity towards staff when they tried to redirect him/her and was very manipulative; -She reached out to corporate staff and was adamant the resident needed to be transferred and was told to educate the resident on appropriate behavior and come up with interventions; -Resident #3's Level II screening (a process used to determine if an individual has a mental illness or intellectual disability and if a nursing facility is the most appropriate placement for them) indicated the resident needed a secured/behavioral unit, which the facility did not have. During an interview on 4/7/25 at 10:30 A.M. and 4/8/25 at 10:10 A.M. and 2:30 P.M., the Administrator said the following: -She had not received any formal mental health training; -The facility had admitted several residents recently with mental health conditions; -Facility staff had not received any formal mental health training; -Corporate staff sent all new admission referrals to the facility. The expectation was for referrals to be reviewed in 15 minutes and a decision made whether the facility would accept the resident as an admission; -Resident #2's mental health diagnoses got missed due to the rushed process of reviewing the referral information. The facility had limited information on him/her; -When she spoke with corporate staff about the resident's behaviors and what should be done to address those behaviors, she was told to educate the resident and document it.

Based on observation, interview and record review, the facility failed to ensure two residents (Resident #2 and #3), of 11 sampled residents with mental disorders, received individualized treatment and services to meet their needs. Residents displayed verbal, manipulative and aggressive behaviors on multiple occasions. The facility failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services to address the residents' psychosocial well-being. The facility census was 21. Review of the facility's Behavioral Health Services Policy, revised 10/31/24, showed the following: -Affected Personnel: All facility employees; -Purpose: It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning; -All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based on the role of the staff member and resident needs identified through the facility assessment; -Mental Disorder is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational or other important activities; -Background: Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, 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 will consider the acuity of the resident population. This includes residents with mental disorders, psychosocial disorders, or substance use disorders (SUDs), and those with a history of trauma and/or post traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), as reflected in the facility assessment; -A facility must ensure behavioral health services are provided: The facility will ensure necessary behavioral health services are person centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety; -Behavioral Health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being; -The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person centered-care; -The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, privacy, socialization, independence, choice and safety; -Complete PASARR (Pre-admission screening for serious mental disorders or intellectual disabilities and related conditions ), screening, obtain history from records; -Obtain history from medical records, the resident, and as appropriate resident's family and friends, regarding mental, psychosocial, and emotional health; -Assess and develop a person-centered care plan for concerns identified in the resident's assessment; -Share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes, including differential diagnosis; -Accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record; -Ensure appropriate follow-up assessment, if needed; -Discuss potential modifications to the care plan; -Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident; -The care plan shall have interventions that are person centered, evidence based, culturally competent, trauma-informed, and in accordance with professional standards of practice, reflect the resident's goals for care; -Use pharmacological interventions only when nonpharmacological interventions are ineffective or when clinically indicated; -Address any other individualized needs the resident may have related to the mental disorder or the substance abuse disorder; -The resident's care plan shall be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition. 1. Review of Resident #2's Face Sheet, undated, showed the following: -admitted was 2/21/25; -The resident was his/her own responsible party. Review of the resident's Progress Note, dated 2/23/25 at 9:38 A.M., showed the following: -The nurse went to administer morning medication to the resident in his/her room. The resident had cigarettes that had been used in a cup of water. The resident's room didn't smell like smoke, and there wasn't smoke in the room at the time; -The nurse asked the resident if he/she had been smoking in his/her room as residents couldn't smoke in the facility and the resident said go fuck with someone else and to leave him/her the fuck alone; -The nurse explained it was his/her job to keep him/her and other residents safe in the facility. The resident wasn't receptive to the information. Review of the resident's PASARR Level I Screening, dated 2/24/25, showed the following: -Previous address was homeless/shelter; -The resident didn't show any symptoms of a major mental illness, suspected or history of a major mental illness or an impairment due to a serious mental illness; -Within the last two years the resident had not experienced one psychiatric treatment episode that was more intensive than routine follow-up care or due to mental illness, experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or intervention by housing or law enforcement officials; -The resident did not have a substance related disorder; -No behavioral symptoms. Review of the resident's Progress Note, dated 2/24/25 at 5:10 P.M., showed the following: -Staff alerted the nurse the resident had smoke coming from his/her mouth and tracheostomy (a surgical procedure, where an opening was created in the trachea, when a person has difficulty breathing through the mouth for some reason) when he/she entered the room and there was a cigarette smoke smell in the hallway; -The resident was informed the facility was a non-smoking facility, and residents could not smoke cigarettes or vapes inside the facility; -The resident shook his/her head up and down as a response. Review of the resident's Progress Note, dated 2/25/25 at 12:40 A.M., showed the following: -The resident got upset with the nurse when he/she told the resident that he/she could not have an ice-cream shake with peanut butter. The resident demanded he/she wanted one; -The nurse said the resident could have a snack that was already prepared. The resident became angry and said that staff could make him/her a shake, but that staff didn't want to. Staff gave the resident a bowl of ice-cream and a spoonful of peanut butter. The resident said if staff could do that, they could make him/her a shake; -The resident came out of his/her room and said he/she wanted to buy a pack of cigarettes. Explained to the resident the nurse didn't smoke and he/she didn't have a pack of cigarettes; -The resident went outside and looked through the can of cigarette butts and went back to his/her room. Review of the resident's Progress Note, dated 2/25/25 at 8:39 A.M. showed the following: -It was passed on in report this morning from the night charge nurse the resident had been in other resident rooms looking for cigarettes and things to take. When the resident was redirected, the resident said to the nurse, lose your fucking attitude; -The resident was pleasant this morning but taking cigarettes from outside and bringing them inside and putting them on a tray in the dining room. When the resident was informed by the kitchen staff that this was not allowed, the resident rolled his/her eyes. The resident was not easily directed at this time. Review of the resident's Progress Note dated 2/25/25 at 8:48 A.M. showed a cigarette butt was found on the resident's tray in the dining room. Explained to the resident that cigarette butts weren't to be left on food trays. The resident rolled his/her eyes and walked away. Review of the resident's Progress Note, dated 2/25/25 at 9:30 A.M., showed the Social Service Designee (SSD), Director of Nursing (DON) and Unit Manager educated the resident on not smoking in his/her room, and the resident wasn't to enter other resident rooms unless asked to come in. The resident was also educated that he/she wasn't to take cigarettes etc. from any resident, if the resident needed something to ask staff. Review of the resident's Progress Note, dated 2/26/25 at 2:05 A.M., showed the resident picked up anything left on tables or in the kitchen. Review of the resident's Progress Note, dated 2/26/25 at 11:00 A.M,. showed the DON and Dietary Manager educated the resident that he/she could not empty his/her colostomy bag on the tray his/her food was delivered on and everything would need to be thrown away that stool was emptied on. Review of the resident's Behavior Note, dated 2/26/25 at 11:40 A.M. showed the resident had emptied his/her colostomy bag on dinner tray on multiple occasions. Education was provided to empty bag using a graduate container and to empty contents into the stool. Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff). dated 2/27/25, showed the following: -Moderate cognitive impairment; -No behavioral symptoms exhibited including physical behaviors (e.g., hitting, kicking, scratching or abusing others sexually), verbal behaviors or behaviors not directed towards others (physical symptoms such as hitting, scratching, pacing rummaging or sexual acts in public); -There was no evidence of an acute change in mental status from the resident's baseline; -Signs and symptoms of delirium, for example, being distractible or having difficulty keeping on track of what was said and disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) was present and this showed inattention, behavior fluctuated (comes and goes and changes in severity); -No wandering exhibited; -Independent with mobility; -No mobility device utilized. Review of the resident's Progress Note, dated 3/1/25 at 3:02 P.M., showed the resident requested the sign out book so he/she could leave and walk to the convenience store. Explained to the resident the nurse needed to call the Administrator and DON for approval. Instructed the resident to sign against medical advice (AMA) papers in case the resident didn't return. The resident became aggravated, explained to the resident if something happened to him/her it would protect the facility. The resident agreed to sign the paperwork and left the facility. The resident is his/her own responsible party per the face sheet. Review of the resident's Progress Note, dated 3/1/25 at 3:18 P.M., showed the resident had walked to an employee's home when out of the facility. The resident was brought back to the facility by the employee and the employees family member after the resident was told he/she could not be at an employee's home. Review of the resident's Behavior Note, dated 3/2/25 at 8:45 A.M., showed the resident came to nurse's station and said he/she was calling 911 and was going to have Emergency Medical Services (EMS) take him/her to the hospital for ostomy supplies. The nurse asked the resident what supplies the resident needed and if he/she could look for the supplies the resident needed. The resident agreed if he/she could have breakfast in his/her room, a cup of coffee, and ice cream right now. Staff accommodated the resident's wishes. The resident said receiving his/her pain pill every eight hours was way to long and it needed shortened. Staff said they would reach out to the physician. Review of the resident's Progress Note, dated 3/3/25 at 6:35 A.M., showed over the weekend maintenance had to come to the facility and spend six hours due to flooding in the resident's room as well as sink repairs. The float and a connecting arm were completely removed from the toilet tank. This allowed water to continuously flow onto the floor in the resident's room. Maintenance removed 80 gallons of water from the resident's floor, hallway and two adjoining rooms. Maintenance reported there was no way for the float from the back of the toilet tank to be missing unless removed. Also, cigarette butts were in the bowl of the toilet. Review of the resident's Progress Note, dated 3/9/25 at 3:58 P.M., showed the following: -Resident #2 was at a table playing a game with Certified Nurse Assistant (CNA) E and another resident (Resident #1); -Resident #2 asked if he/she could take people out on dates and how he/she could go about it, the resident was directed to ask social services, but that it would have to be agreed upon; -Resident #2 asked a question about bringing someone into his/her room and told the staff member he/she was hot and attractive, and his/her body looked sculpted; -The staff member educated the resident and told him/her it was not appropriate to talk about staff members that way. Review of the Grievance Report, made by Resident #1 regarding Resident #2, dated 3/13/25, showed the following: -Date complaint/grievance occurred: 3/8/25 to 3/13/25; -Resident #2 was always touching Resident #1 on the shoulder. Resident #2 asked Resident #1 to go on a date with him/her and Resident #1 did not want to; -Resident #1 had to ask Resident #2 to stay out of his/her room. Resident #2 made him/her feel scared; -Form completed by Registered Nurse (RN) B; -Grievance follow up: Tried talking to Resident #2. He/She apologized and walked away. Review of the resident's Social Service Progress Note, dated 3/14/25 at 9:09 A.M., showed the following: -Received several grievances from residents regarding Resident #2's behavior. The resident continued to act out if things didn't go his/her way. The resident continued to curse at staff and could be threatening; -Tried several times to talk to the resident about his/her behavior and the resident would apologize and continue to repeat the behavior. Will continue to monitor the resident. Review of the resident's Progress Note, dated 3/18/25 at 6:30 P.M., Dietary Staff D said the resident came into the kitchen doorway and told him/her that he/she had a banging body and he/she wanted to kidnap him/her. Grievance form filled out. Review of a Grievance Form, dated 3/18/25, untimed, completed by Dietary Aide D, showed the following: -Resident #2 said he/she had a banging body along with he/she would fuck him/her and that he/she looked at his/her ass; -Resident #2 also made a comment about kidnapping Dietary Aide D; -Follow-up: Talked to the resident about making inappropriate remarks to staff. Resident #2 said he/she would leave the staff member alone; -Date resolved was 3/19/25, dietary staff were educated to keep the kitchen door locked, so the resident could not enter the kitchen. Review of the resident's Medication Review Report, dated 3/30/25, showed the following: -Diagnoses included homeless, bipolar disorder (current episode depressed, mild (a mental health condition characterized by both periods of elevated mood, mania or hypomania) and periods of depression, with the current episode being a mild form of depression), adjustment disorder (an excessive emotional or behavioral reaction to a stressful life event or change) and anxiety; -Progesterone (can be used to reduce inappropriate sexual behaviors) for sexual disinhibition (loss of normal restraints or controls on sexual thoughts, impulses or behaviors) 100 milligrams (mg) one capsule at bedtime for sexual disinhibition (order date 3/11/25). Review of the resident's PASARR Level One Screening, dated 3/30/25, showed the following: -The resident showed signs and symptoms of a major mental illness. Signs/symptoms included sexually inappropriate, verbally aggressive and stealing; -Diagnoses included bipolar disorder, major depressive disorder, anxiety disorder, adjustment disorder and personal history of mental behavioral disorder; -Adaption to change: The individual had serious difficulty adapting to typical changes in circumstances associated with work, school, family or social interactions, agitation, exacerbated signs and symptoms associated with the illness or withdrawal from situations, self-injurious, self-mutilation, suicidal (ideation, gestures, threats, or attempts) physical violence or threats, appetite disturbance, delusions, hallucinations, serious loss of interest, tearfulness, irritability, or requires intervention by health health or judicial system; -Due to mental illness, experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community or interventions by housing or law enforcement officials; -The resident had a substance related disorder. The most recent substance abuse was unknown; -Upon review of cyber access, the resident had psychiatric diagnoses that had not been documented; -Being withdrawn/depressed: minimal symptoms noted; -Suspicious/paranoid/ aggressive (physical/verbal) behaviors: moderate symptoms noted; -Wandering, abnormal thought process and sexually inappropriate behaviors: maximal symptoms noted; -The resident had not been at the facility long enough to see a psychiatric provider. No psychiatric evaluation available; -Unstable mental condition monitored by a physician or mental health professional at least monthly or behavior symptoms are currently exhibited, or psychiatric conditions are recently exhibited; -Level of supervision: Every two-hour check; -No issues with cognition. During an interview on 4/3/25 at 1:30 P.M., Resident #11 said the following: -Resident #2 was his/her roommate for awhile; -Resident #2 stole his/her soda, popcorn and other items. Resident #2 was constantly making a mess with feces all over the room; -Resident #2 would always rub other resident's shoulders and heads, he/she thought it was inappropriate. Resident #2 touched the residents when staff weren't around; -He/She complained about Resident #2 and they moved him/her (Resident #2) to another room. During an interview on 4/3/25 at 11:05 A.M. and 4/7/25 at 12:15 P.M., Resident #1 said the following: -At first, he/she enjoyed spending time with Resident #2. Resident #2 acted like he/she cared for him/her; -Resident #2 would touch him/her on the arm or shoulder, it made him/her feel good and Resident #2 sat with him/her during meals; -He/She and Resident #2 had watched movies in the facility sunroom. Resident #2 had kissed him/her and Resident #1 was fine with that; -On Saturday, in the night, around 3:00 A.M., he/she (Resident #1) was asleep in bed, and he/she awakened by Resident #2 kissing him/her on the lips; -Resident #2 pulled up his/her gown and put his/her fingers inside the resident's genitalia. Resident #1 was scared and stunned it happened so fast, he/she yelled for Resident #2 to stop, stop, stop, but he/she wouldn't; -Resident #2 was rough, and it hurt. He/She was afraid of Resident #2 now; -Resident #2 told staff and he/she was sent out to the hospital. Review of the resident's Care Plan, revised 3/31/25, showed the following: -Staff alerted the charge nurse that the resident had smoke coming from mouth and trach. The resident was educated the facility was non smoking facility (date initiated 2/24/25); -Removal of connecting arm from float in toilet tank causing 80 gallons of water to be removed from the resident's floor as well as two adjoining room. Education was provided to the resident that if there was a problem with the toilet to alert staff so maintenance could be notified (date initiated 2/28/25); -The resident walked to an employees' residence. The resident was told by employees' family member to leave (date initiated 3/1/25); -Smoking a vape in the dining room. Reeducation on smoking policy (date initiated 3/9/25); -The resident told a staff member that he/she was hot, attractive, and his/her body looked sculpted. Staff member told the resident it was not appropriate to talk about staff members that way. Resident said, I am just saying and walked away. The resident was educated on appropriate conversations that occur with staff and started on Progesterone (date initiated 3/10/25); -The resident was a wanderer related to it's his/her right and significantly intruded on the privacy and activities of other residents. Educated not to go into therapy room without therapy personal related to safety, the resident verbalized understanding. (date initiated 3/24/25); -The resident doesn't verbalize understanding, the resident stated he/she was going to walk all the halls, he/she was not going into rooms (date initiated 3/28/25); -Another resident (Resident #1) reported the resident had entered his/her room and touched him/her (Resident #1) inappropriately. Local county law enforcement agency was called and notified to come to the facility. The resident was placed on one-on-one supervision to ensure he/she was not found around the other resident (Resident #1). The resident was taken with law enforcement for questioning over the incident (date initiated 3/30/25); -Advised the resident he/she couldn't go down other hallways where he/she didn't live; -The resident didn't verbalize an understanding and stated he/she would walk all the hallways, and he/she wasn't going into other rooms (revised 3/28/25); -If wandering occurs attempt to offer favorite snacks (dated initiated 3/31/25); -The resident had a problem with contraband in his/her possession, being verbally aggressive, being verbally sexually inappropriate, taking items that didn't belong to him/her related to diagnoses of bipolar and adjustment disorder (initiated 3/10/25 and revised on 3/31/25); -Administer medications as ordered, monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Assist the resident with developing appropriate methods of coping and interacting to include setting boundaries, redirection, and encouraging the resident to express feelings appropriately. Intervene as necessary to protect the rights and safety of other residents, divert attention. Remove from situation and take to alternate location as needed (date initiated 3/30/25). Review of the resident's medical record showed no evidence the resident was receiving psychiatric services and no additional monitoring was put in place. During an interview 4/3/25 at 3:07 P.M. and 4/7/25 at 3:50 P.M. the Social Service Designee (SSD) said the following: -She became the SSD in December 2024; -She had not received any formal mental health training; -The facility had admitted several residents with mental health conditions and she was not sure if she was doing the right thing to help residents with mental health issues; -Resident #2 was recently admitted to the facility. The resident was homeless and was basically dropped off by a ride-sharing service; -The facility knew very little about the resident and was unaware of his/her mental health conditions; -Resident #2 would steal and go in other rooms without permission, corporate told us to just educate him/her; -Staff attempted to educate Resident #2 and he/she would just walk away or ignore staff; -When staff tried to redirect Resident #2 he/she would retaliate by making a mess in another room or emptying his/her colostomy bag (bag that collects stool after a surgical procedure called a colostomy) in the sink or disconnecting the toilet; -The facility did not put any increased supervision of Resident #2 in place after his/her behaviors. The facility was not familiar with residents or situations like this; -There needed to be a better screening process before admitting residents to the facility; -She wasn't sure if the facility had psychiatric services available for the residents at the facility. 2. Review of Resident #3's PASARR Level II Evaluation, dated 1/31/25, showed the following: -Psychiatric evaluation 1/24/25, paranoid type delusional disorder (a mental illness characterized by the persistent belief that someone is being persecuted, harassed, or followed by others, even when there is no evidence to support these beliefs); rule out bipolar illness, mixed, with psychotic features (both manic and depressive symptoms are present and involves hallucinations (sensory experiences that appear real but are not actually present) or delusions (a false belief that persists despite evidence to the contrary) alongside the typical mood swings of bipolar disorder); -Psychiatric records, 2014: substance induced mood disorder, depression, Opioid dependency; -Historical symptoms or behaviors indicating a psychiatric disorder and time of onset: the resident was incarcerated which occurred in 2023. The resident was uncooperative, oppositional, disorganized in thought/behavior throughout his/her time in jail. The resident was agitated, yelling, and cursing at other inmates and jail staff. The resident was involved in physical altercations with others who were incarcerated on the mental health unit. The resident was unable to understand the charges due to his/her acute psychosis. He/She was committed to Department of Mental Health (DMH) for competency evaluation. The resident remained in jail from 9/11/23 to 1/23/25; -On 1/23/25 the resident received court ordered psychiatric treatment. Guardianship ad litem (a court appointed individual who represents the best interest of a incapacitated adult's well-being) was granted by the court on 1/31/25. Since admission the resident remained verbally abusive, cursing, yelling/screaming at staff for short periods of time, then will stop until the next staff member presents information the resident doesn't wish to hear; -Current psychiatric support/services included inpatient psychiatric treatment, medication administration/management/monitoring, secured behavioral unit, close observation/check every 15 minutes and group therapy/counseling; -The resident has memory impairment, difficulty with daily activities due to cognitive confusion/disorientation, however his/her delusional thought content and medication non-compliance issues are the primary issues in treatment currently; -Reason for nursing facility application or continued stay included assistance with activities of daily living (ADLs), medical treatment and/or monitoring, behavioral difficulties and/or mental illness symptoms requiring 24-hour monitoring or management, inadequate community/family support and required 24 nursing care and supervision; -Overt behaviors: refuses medications, frequent continuous yelling, intrusive, impatient/demanding, wandering, verbally abusive, verbally threatening, uncooperative with medical/nursing care or treatments, cursing/swearing, and being suspicious of others; -The individual's needs could be met in a nursing facility at this time; -The resident will require further stabilization on medications to address delusional and disorganized thinking. After found stable to transition from inpatient psychiatric setting, will require 24 hour a day nursing supervision and oversight to assure he/she and others are safe, to assure basic needs are met, and to ensure he/she had consistent access to ongoing psychiatric and medical follow-up and psychotropic medications. He/She required ongoing psychiatric and mental health follow up to promote maximum stability. The resident required a facility in which there are electronic or structural boundaries that prevent elopement. The resident will benefit from a safe, structured, skilled and supportive environment in which he/she can engage in social interaction with others his/her own age; -The individual needs specific services to address the individual's mental health and behavioral needs, monitoring of behavioral symptoms and trauma informed services, tools of choice or other positive behavioral support services; -Active psychosis and elopement attempts to be addressed in the nursing facility plan of care; -Crisis interventions include elopement precautions. Review of the resident's elopement evaluation, dated 2/18/25, showed he/she was an elopement risk. Review of the resident's Smoking and Safety Evaluation, dated 2/8/25, showed the following: -Supervision, designated smoking location, and smoking times are determined by the facility policy. This evaluation will be utilized for the resident's smoking care plan on admission and as indicated; -The resident used tobacco; -The resident followed the facility's policy on location and time of smoking; -Care Planning: the resident will adhere to the tobacco/smoking policies of the facility, conduct smoking safety evaluation on admission and as needed (PRN); -No clinical suggestions (using a smoking apron, staff to extinguish cigarette, resident deemed unsafe to smoke etc.) were indicated. Review of the resident's admission MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Psychosis not exhibited; -Signs or symptoms of delirium, inattention, disorganized thinking and or altered level of consciousness were not present; -Behavioral symptoms were not present; -No rejection of care; -Wandering not exhibited; -Supervision or touching assistance required with walking; -Wander/elopement alarm not used; -No psychological therapy (by any licensed mental health professional) administered to the resident in the last seven days. Review of the resident's Behavior Note, dated 3/8/25 at 10:57 P.M., showed the following: -The resident came to the nurses' station and asked for a cigarette. The resident came back in just a few minutes and gave the nurse back half of the cigarette and the lighter. In ten minutes, the resident came back and asked again for a cigarette. The resident was given the half of cigarette and lighter. Returned the lighter and came back in ten minutes and wanted another cigarette. Staff advised the resident that he/she was passing medication and the resident would have to wait as everyone was busy and the resident had smoked twice; -The resident started yelling and cursing at the nurse and stated that the nurse was sleeping with the resident's spouse, and they weren't divorced yet. The resident kept yelling and cursing. A Certified Nurse Assistant (CNA) assisted the resident back to his/her room. The resident laid down and had not came back out of his/her room. Review of the resident's Progress Note, dated 3/12/25 at 10:47 P.M., showed the following: -The resident was wandering about the facility, rocks back and forth while standing still and wants to smoke every 10-15 minutes. The nurse advised the resident that he/she couldn't smoke every 10 minutes. The resident was ok with that; -The resident was telling the kitchen staff they had stolen his/her spouse. The nurse tried to redirect the resident. Ativan (medication used for anxiety) given as ordered with results. The resident was resting in bed. Review of the resident's Behavioral Note, dated 3/20/25, at 6:49 P.M., showed the resident was pacing in the hall. The resident was hallucinating, speaking to imaginary people, the resident said he/she was going to be

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to ensure the facility had an RN designated as the Director of Nursing (DON) on a full time basis. The facility census was 17. Review of the facility's policy titled Staffing, Sufficient and Competent Nursing, dated August 2022, showed the following: -Our Facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services with resident care plans and the facility assessment; -A registered nurse provides at least eight consecutive hours every 24 hours, seven days a week. Review of the Facility's Assessment, last updated/reviewed in April 2024, showed the facility did not have an active DON. Review of the facility's staffing schedule, dated November 2024, showed no RN and no DON coverage on 11/1/24, 11/2/24, 11/3/24, 11/4/24, 11/5/24 and 11/6/24. During an interview on 11/6/24 at 10:25 A.M. the facility's Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON) said the following: -The facility did not have a full time DON. The facility did have an interim DON, but he/she quit on 10/31/24; -The facility did not have any RN coverage as required. During an interview on 11/5/24 at 9:20 A.M. and 11/6/24 at 4:05 P.M. the Administrator said the following: -The facility did not currently have a full time DON; -The interim DON quit on 10/31/24; -The facility did not have any RN coverage since the interim DON's last day at the facility on 10/31/24; -She would expect the facility to have a full time DON and RN coverage as required.

Based on interview and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating, consisting of chest compressions and artificial respirations) certified staff were scheduled 24 hours a day seven days a week, failed to develop and implement a policy addressing CPR requirements for staff and failed to maintain documentation of CPR certifications for staff members. The facility had seven residents with full code status (residents requested to have full resuscitation efforts/CPR in the event of cardiac arrest). The facility census was 17. Review of the facility's CPR policy, dated February 2023, showed the following: -It is the policy of this facility to adhere to resident's rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding CPR; -CPR certified staff will be available within the facility at all times. 1. Review of the facility's code status report, dated [DATE], showed seven residents were designated as full code status. The facility provided a list of facility employees and agency staff employees' CPR certification cards that had worked since [DATE]. The staffing sheets were compared with the employees that had valid CPR certifications. Review of the facility's staffing sheets dated [DATE], compared to the list of CPR certified staff provided by the facility, showed the following shifts without a staff member who was CPR certified: -On [DATE], evening shift; -On [DATE], evening shift; -On [DATE], evening shift; -On [DATE], evening shift; -On [DATE], evening shift. Review of the facility's staffing sheets dated [DATE], compared to the list of CPR certified staff provided by the facility, showed the following shifts without a staff member CPR certified: -On [DATE], day shift; -On [DATE], day shift; -On [DATE], evening shift. During an interview on [DATE] at 10:25 AM the Assistant Director of Nursing (ADON) said the following: -She made out the schedule for each shift; -In the past she tried to schedule CPR certified staff each shift. She didn't know which staff members had a current CPR certification or an expired certification. New staff members did not have current certification; -A CPR certified staff member should be scheduled on each shift. During an interview on [DATE] at 9:20 A.M. and [DATE] at 4:05 P.M. the Administrator said the following: -She would expect each staff member to have an up to date CPR certification; -She would expect each shift to have at least one CPR certified staff member working per the regulation; -She was unaware many of the CPR certifications were expired or that the facility didn't have a copy of each staff members' current CPR certification; -She would have to compile a list of staff members to determine who was CPR certified. The list she had was incomplete or did not include all working staff at the facility. MO244247

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week and failed to ensure the facility had an RN designated as the Director of Nursing (DON) on a full time basis. The facility census was 22. 1. During an interview on 09/10/24 at 11:15 A.M., the Administrator said the facility did not have a policy for RN coverage. The facility followed the regulatory guidance. Review of the facility's staffing schedule, dated July 2024, showed no RN and no DON coverage on 7/01/24 through 7/07/24, 7/25/24, 7/26/24, and 7/29/24 through 7/31/24. Review of the facility's staffing schedule, dated August 2024, showed the following: -No RN coverage on 8/1/24 through 8/3/24, 8/7/24 through 8/9/24, 8/15/24 through 8/17/24, 8/23/24, and 8/28/24 through 8/31/24; -No DON coverage on 8/1/24 through 8/31/24. Review of the Facility's Assessment last updated/reviewed in August 2024 showed the following: -The facility did not have an active DON; -The DON position had been vacant for two months; -Prior to the two months, the facility had two licensed practical nurses (LPN) who served as nurse managers to help with the nursing department, but quit after a few months; -Currently, the Assistant Director of Nursing (ADON) was the interim DON. During an interview on 08/26/24 at 2:00 P.M., the Assistant Director of Nursing (ADON) said the following: -The facility did not have a full time DON; -She was an LPN acting as the DON until the facility hired a full time DON; -The facility did not have enough RNs to schedule per regulation, and there were days when no RN was scheduled. During an interview on 08/27/24 at 3:00 P.M., the Administrator said the following: -The facility did not currently have a full time DON; -He was unaware of how long the facility did not have a DON, but not for the three weeks he was the administrator; -The facility utilized a staffing agency for RN coverage; -He requested either RNs or LPNs from the staffing agencies,and took what the agencies sent as the facility needed to have a licensed nurse whether it was a RN or an LPN. MO241461

Based on observation, interview, and record review, the facility failed to implement effective pest control measures to eliminate pests, including flies from areas throughout the facility and in resident rooms. This effected multiple residents of the facility, including Resident #31, who had an open cancerous wound, that required medication to treat for infestation of maggots, Resident #5 who could not sleep due to flies and other residents during their meal service to the extent that they had to use fly swatters to deter the flies during their meal. The facility census was 35. Review of the facility policy, Pest Control Program, dated 11/1/23, showed the following: -It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; -Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats); -The facility will maintain a written documentation of monthly pest control observation and spraying; -The facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health; -The facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate. Review of the facility pest control log, dated June 2024, showed on 6/10/24, the maintenance director changed the glue traps in the kitchen and other rooms and changed the glue boards for flying insects. 1. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally assessment instrument to be completed by the facility, dated 4/12/24, showed the following: -Moderately impaired cognition; -Bed mobility-partial to moderate assist; -Occasionally incontinent of bladder; -Frequently incontinent of bowel; -No application of non-surgical dressing other than feet; -No other ulcers, wounds or skin issues. Review of the resident's progress notes, dated 4/28/24, showed staff documented when changing resident's dressing to left side of head per physician orders, writer noted maggots to top of wound site and back of wound site. Spoke with family nurse practitioner and hospice. Order to start albendazole (dewormer) 200 milligrams (mg) two times daily for two weeks and doxycycline (antibiotic)100 mg two times daily for ten days. Review of the resident's care plan, dated 4/30/24, showed the following: -Limited physical mobility: Provide supportive care, assistance with mobility as needed; -Presence of flies in the resident's room poses a risk to the resident's health and comfort: Control and minimize the presence of flies in the resident's room to ensure a clean and safe environment for the resident. Place the fly trap in a strategic location in the resident's room, educate staff on the purpose of the fly trap, regularly assess the resident's room for any factors that may attract flies and address them accordingly; no date for this intervention could be viewed; -Bladder/bowel incontinence: Used a urinal as needed (PRN). Review of the resident's progress notes, dated 5/3/24, showed staff documented the resident's wound to his/her left temporal cancer area measured 5.0 inches (in) x 5.0 in. x 3.5 centimeters (cm) in protrusion. Area red, beefy, with foul smell, moderate amount of bloody drainage and maggots noted. Currently on antibiotic therapy and Albendazole. Review of the resident's Physician Order Sheet (POS), dated June 2024, showed the following: -Diagnoses included (without dates of initiation): wound myiasis (parasitic skin infection caused by fly larvae or maggots, infesting open wounds), basal cell carcinoma (skin cancer) of skin/face, and legal blindness; -Apply Telfa (non-adherent pad) with Abdominal Pad (ABD-non-woven, thick, absorbent dressing) to left temporal mass daily and PRN (11/13/18). Review of the resident's progress notes, dated 6/17/24, showed the resident had a left temporal cancer wound. Area measures 14.0 cm by 16.0 cm by 3.5 cm inprotrusionn. Area red and beefy with copious amounts of bloody drainage. Foul smell. Many maggots noted. Observation on 6/20/24 at 9:55 A.M., showed the resident lay on his/her back in bed. The resident had an ABD dressing on his/her forehead. Three to five flies were on different parts of his/her body. The resident said, These flies are driving me crazy. The resident's top sheet had spots of blood. Ten flies were noted on the ceiling and privacy curtain. Fly strips hung from the ceiling on the left side of the resident's head and at the foot of the bed on the right side. Another strip hung from the ceiling corner near the first bed (nearest to the door). The strip near the resident's head was completely filled with flies and the other two were at least half full. The resident continually swatted at the flies with his/her hands. Observation on 6/20/24 at 12:22 P.M. showed the resident lay in his/her bed and picked at the wound dressing on his/her forehead. His/Her fingernails were tinged with blood from the wound. Bloody spots remained on the sheet. A strip of the wound was exposed as the dressing did not cover this portion. There were four to five flies on the resident and six flies on the ceiling and the privacy curtain. The same fly strips remained in the resident's room. Observation on 6/21/24 at 5:33 A.M. showed the resident lay on his/her back in bed with his/her eyes closed. Five flies were on the resident's body with two more on the wound dressing on the resident's head. Five flies were on the ceiling and on the privacy curtain. The resident swatted periodically (with his/her hand) at flies which swarmed around his/her head and landed on his/her body. His/Her eyes remained closed. Observation on 6/21/24 at 5:40 A.M., showed ten flies on the resident, privacy curtain and on the resident's overbed table. The top third of the resident's sheet had blood stains as the resident picked at back of head with his/her hands. Certified Nurse Assistant (CNA) C and CNA A entered the room. CNA C emptied dark urine from a graduate which sat uncovered on the resident's bedside table. CNA A removed the blood stained top sheet and placed it in a plastic bag. Observation on 6/21/24 at 11:28 A.M., showed the resident lay in his/her bed with his/her eyes closed. Flies sat on his/her left leg, right leg and right arm and one on the wound dressing where part of the wound was exposed. Three to five flies were on the ceiling and three more were on the privacy curtain and overbed table. During an interview on 6/20/24 at 10:59 A.M., Visitor A said the following: -He/She recently visited the facility and there were flies everywhere in the building; -There were so many flies in the resident's room; -The sticky fly traps in the resident's room were filled with flies; -The resident complained to him/her about the amount of flies in his/her room. During an interview on 7/12/24 at 8:11 A.M., the resident's nurse practitioner said the following: -He was notified many times of the presence of maggots in/on the resident's wound; -He would not expect to see maggots in/on a wound; -The facility should have implemented additional measures to eliminate the flies. 2. Observations on 6/20/24 in the dining room, before and during meal time, showed the following: -At 12:07 P.M., two flies flew around a dining table, near the conference where two residents sat; -At 12:08 P.M., two residents sat at a dining table near the nurse's desk where a fly sat on the table and another flew around the residents. A staff member waved his/her hand several times at the flies; -At 12:09 P.M., a fly landed on the nurse's desk; -At 12:15 P.M., two flies landed on a table (near the bird aquarium) where a resident sat in a G-chair; -At 12:16 P.M., three flies sat on the white columns in the dining room. During an interview on 6/20/24 at 11:25 A.M., CNA E said there was a problem with flies. The facility gave residents fly swatters and had hung some fly strips. Observation on 6/21/24 at 1:55 P.M. showed there were six flies on the white columns in the dining area. Observation on 6/20/24 at 11:58 A.M. in the dining room showed the following: -Resident #3 sat in his/her wheelchair at the dining room table; -Four flies crawled on and swarmed around his/her table; -Resident #3 had a fly swatter and attempted to swat (unsuccessfully) at the flies. Observation on 6/21/24 at 12:04 P.M. showed Resident #33 sat in his/her wheelchair in the dining room eating lunch and he/she attempted to swat at two flies that swarmed around his/her food. During an interview on 6/20/24 at 9:35 A.M., Resident #22 said the following: -He/She ate his/her meals in the dining room and there were flies in the dining room; -There were so many flies in the dining room, he/she called them pets. 3. Observation on 6/20/24 at 9:40 A.M. showed a fly landed on Resident #5 as he/she lay in bed. During an interview on 6/20/24 at 9:40 A.M., the resident said he/she saw a lot of flies in the facility and the flies bothered him/her constantly and could not sleep for the flies. The flies were even in the dining room were the residents ate. The facility should be spraying to get rid of the flies. 4. During an interview on 6/21/24 at 4:00 P.M., the maintenance director said the following: -He had installed fly strips after they were care planned for Resident #31; -They had turned on the fan outside of the back door to keep flies out; -Staff also used fly swatters to kill the flies; -The facility was installing another fan outside the front door next week which would help keep the flies out; -He installed a glue board in outlets throughout the facility and he had just added new fly strips in Resident #31's room. During an interview on 6/21/24 at 4:22 P.M., the Director Of Nursing said the following: -She was not aware of the number of flies in Resident # 31's room; -They had hung fly traps and used ultraviolet plug lights; -It would be the maintenance director's job to change the fly traps when needed during rounds; -The fly fly traps (ribbons) to be changed out as needed; -The facility had a lot of residents who smoked and went in and out of the front door; -She would not want the residents uncomfortable. MO237842

Based on observation, interview, and record review, the facility failed to implement effective pest control measures to eliminate pests, including flies from areas throughout the facility and in resident rooms. This effected multiple residents of the facility, including Resident #31, who had an open cancerous wound, that required medication to treat for infestation of maggots, Resident #5 who could not sleep due to flies and other residents during their meal service to the extent that they had to use fly swatters to deter the flies during their meal. The facility census was 35. Review of the facility policy, Pest Control Program, dated 11/1/23, showed the following: -It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; -Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats); -The facility will maintain a written documentation of monthly pest control observation and spraying; -The facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health; -The facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate. Review of the facility pest control log, dated June 2024, showed on 6/10/24, the maintenance director changed the glue traps in the kitchen and other rooms and changed the glue boards for flying insects. 1. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally assessment instrument to be completed by the facility, dated 4/12/24, showed the following: -Moderately impaired cognition; -Bed mobility-partial to moderate assist; -Occasionally incontinent of bladder; -Frequently incontinent of bowel; -No application of non-surgical dressing other than feet; -No other ulcers, wounds or skin issues. Review of the resident's progress notes, dated 4/28/24, showed staff documented when changing resident's dressing to left side of head per physician orders, writer noted maggots to top of wound site and back of wound site. Spoke with family nurse practitioner and hospice. Order to start albendazole (dewormer) 200 milligrams (mg) two times daily for two weeks and doxycycline (antibiotic)100 mg two times daily for ten days. Review of the resident's care plan, dated 4/30/24, showed the following: -Limited physical mobility: Provide supportive care, assistance with mobility as needed; -Presence of flies in the resident's room poses a risk to the resident's health and comfort: Control and minimize the presence of flies in the resident's room to ensure a clean and safe environment for the resident. Place the fly trap in a strategic location in the resident's room, educate staff on the purpose of the fly trap, regularly assess the resident's room for any factors that may attract flies and address them accordingly; no date for this intervention could be viewed; -Bladder/bowel incontinence: Used a urinal as needed (PRN). Review of the resident's progress notes, dated 5/3/24, showed staff documented the resident's wound to his/her left temporal cancer area measured 5.0 inches (in) x 5.0 in. x 3.5 centimeters (cm) in protrusion. Area red, beefy, with foul smell, moderate amount of bloody drainage and maggots noted. Currently on antibiotic therapy and Albendazole. Review of the resident's Physician Order Sheet (POS), dated June 2024, showed the following: -Diagnoses included (without dates of initiation): wound myiasis (parasitic skin infection caused by fly larvae or maggots, infesting open wounds), basal cell carcinoma (skin cancer) of skin/face, and legal blindness; -Apply Telfa (non-adherent pad) with Abdominal Pad (ABD-non-woven, thick, absorbent dressing) to left temporal mass daily and PRN (11/13/18). Review of the resident's progress notes, dated 6/17/24, showed the resident had a left temporal cancer wound. Area measures 14.0 cm by 16.0 cm by 3.5 cm inprotrusionn. Area red and beefy with copious amounts of bloody drainage. Foul smell. Many maggots noted. Observation on 6/20/24 at 9:55 A.M., showed the resident lay on his/her back in bed. The resident had an ABD dressing on his/her forehead. Three to five flies were on different parts of his/her body. The resident said, These flies are driving me crazy. The resident's top sheet had spots of blood. Ten flies were noted on the ceiling and privacy curtain. Fly strips hung from the ceiling on the left side of the resident's head and at the foot of the bed on the right side. Another strip hung from the ceiling corner near the first bed (nearest to the door). The strip near the resident's head was completely filled with flies and the other two were at least half full. The resident continually swatted at the flies with his/her hands. Observation on 6/20/24 at 12:22 P.M. showed the resident lay in his/her bed and picked at the wound dressing on his/her forehead. His/Her fingernails were tinged with blood from the wound. Bloody spots remained on the sheet. A strip of the wound was exposed as the dressing did not cover this portion. There were four to five flies on the resident and six flies on the ceiling and the privacy curtain. The same fly strips remained in the resident's room. Observation on 6/21/24 at 5:33 A.M. showed the resident lay on his/her back in bed with his/her eyes closed. Five flies were on the resident's body with two more on the wound dressing on the resident's head. Five flies were on the ceiling and on the privacy curtain. The resident swatted periodically (with his/her hand) at flies which swarmed around his/her head and landed on his/her body. His/Her eyes remained closed. Observation on 6/21/24 at 5:40 A.M., showed ten flies on the resident, privacy curtain and on the resident's overbed table. The top third of the resident's sheet had blood stains as the resident picked at back of head with his/her hands. Certified Nurse Assistant (CNA) C and CNA A entered the room. CNA C emptied dark urine from a graduate which sat uncovered on the resident's bedside table. CNA A removed the blood stained top sheet and placed it in a plastic bag. Observation on 6/21/24 at 11:28 A.M., showed the resident lay in his/her bed with his/her eyes closed. Flies sat on his/her left leg, right leg and right arm and one on the wound dressing where part of the wound was exposed. Three to five flies were on the ceiling and three more were on the privacy curtain and overbed table. During an interview on 6/20/24 at 10:59 A.M., Visitor A said the following: -He/She recently visited the facility and there were flies everywhere in the building; -There were so many flies in the resident's room; -The sticky fly traps in the resident's room were filled with flies; -The resident complained to him/her about the amount of flies in his/her room. During an interview on 7/12/24 at 8:11 A.M., the resident's nurse practitioner said the following: -He was notified many times of the presence of maggots in/on the resident's wound; -He would not expect to see maggots in/on a wound; -The facility should have implemented additional measures to eliminate the flies. 2. Observations on 6/20/24 in the dining room, before and during meal time, showed the following: -At 12:07 P.M., two flies flew around a dining table, near the conference where two residents sat; -At 12:08 P.M., two residents sat at a dining table near the nurse's desk where a fly sat on the table and another flew around the residents. A staff member waved his/her hand several times at the flies; -At 12:09 P.M., a fly landed on the nurse's desk; -At 12:15 P.M., two flies landed on a table (near the bird aquarium) where a resident sat in a G-chair; -At 12:16 P.M., three flies sat on the white columns in the dining room. During an interview on 6/20/24 at 11:25 A.M., CNA E said there was a problem with flies. The facility gave residents fly swatters and had hung some fly strips. Observation on 6/21/24 at 1:55 P.M. showed there were six flies on the white columns in the dining area. Observation on 6/20/24 at 11:58 A.M. in the dining room showed the following: -Resident #3 sat in his/her wheelchair at the dining room table; -Four flies crawled on and swarmed around his/her table; -Resident #3 had a fly swatter and attempted to swat (unsuccessfully) at the flies. Observation on 6/21/24 at 12:04 P.M. showed Resident #33 sat in his/her wheelchair in the dining room eating lunch and he/she attempted to swat at two flies that swarmed around his/her food. During an interview on 6/20/24 at 9:35 A.M., Resident #22 said the following: -He/She ate his/her meals in the dining room and there were flies in the dining room; -There were so many flies in the dining room, he/she called them pets. 3. Observation on 6/20/24 at 9:40 A.M. showed a fly landed on Resident #5 as he/she lay in bed. During an interview on 6/20/24 at 9:40 A.M., the resident said he/she saw a lot of flies in the facility and the flies bothered him/her constantly and could not sleep for the flies. The flies were even in the dining room were the residents ate. The facility should be spraying to get rid of the flies. 4. During an interview on 6/21/24 at 4:00 P.M., the maintenance director said the following:-He had installed fly strips after they were care planned for Resident #31; -They had turned on the fan outside of the back door to keep flies out; -Staff also used fly swatters to kill the flies; -The facility was installing another fan outside the front door next week which would help keep the flies out; -He installed a glue board in outlets throughout the facility and he had just added new fly strips in Resident #31's room. During an interview on 6/21/24 at 4:22 P.M., the Director Of Nursing said the following: -She was not aware of the number of flies in Resident # 31's room; -They had hung fly traps and used ultraviolet plug lights; -It would be the maintenance director's job to change the fly traps when needed during rounds; -The fly fly traps (ribbons) to be changed out as needed; -The facility had a lot of residents who smoked and went in and out of the front door; -She would not want the residents uncomfortable. MO237842

Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures for hand hygiene and changing gloves, to prevent the spread of bacteria or other infectious causing contaminates, and when indicated by professional standards of practice during personal care for four residents (Resident #3, #12, #15 and #30), in a review of 15 sampled residents. The facility failed to develop and implement a Legionella Prevention Program. The facility failed to ensure respiratory equipment remained free of contaminates for one sampled resident (Resident #19). The facility census was 31. Review of the facility's undated policy, Hand Hygiene, showed the following: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility; -Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR); -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom; -Use soap and water when hands are visibly dirty, hands are visibly soiled with blood or other body fluids, after caring for a resident with infectious diarrhea; -Use either soap and water or ABHR (ABHR is preferred) when coming on duty, between resident contacts (unless caring for a resident with infectious diarrhea - then hand washing with soap and water is required), before applying and after removing personal protective equipment including gloves, before and after handling clean or soiled dressings/linens/etc., before performing resident care procedures, when - during resident care - moving from a contaminated body site to a clean body site, after assistance with personal body functions like elimination/hair grooming/smoking, after sneezing/coughing/blowing or wiping nose, when in doubt. -The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves; 1. Review of Resident #30's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 3/16/24, showed the resident was dependent with toilet hygiene, dressing, personal hygiene, sit to lying, lying to sitting on side of bed and transfers. Observation on 4/17/24, at 6:15 A.M., showed the following: -The resident lay in his/her bed; -Nurse Aide (NA) K and NA L entered the resident's room, did not wash their hands, and put on gloves; -The resident had a strong smell of urine and the bed pad under the resident was saturated with urine past the resident's hips; -NA K and NA L turned the resident to his/her side; -NA K touched the resident's urine saturated pad and linen with his/her gloves and cleaned the resident's left buttock; -NA K and NA L removed the soiled linens from under the resident, and without changing their gloves, dressed the resident in clean clothing; -NA K touched the sling for the mechanical lift, the resident's clean bed linens, and the mechanical lift with soiled gloves; -NA K and NA L transferred the resident using the mechanical lift; -Wearing the same gloves he/she wore to provide perineal care, NA K brushed the resident's hair and put the resident's dentures in the resident's mouth. During an interview on 4/17/24, at 5:44 A.M., NA L said the following: -Staff were to clean their hands and put on gloves prior to providing care to residents; -Staff were to change their gloves if they touched something considered dirty before they touched clean items. 2. Review of Resident #19's quarterly MDS, dated [DATE], showed the following: -The resident had moderate cognitive impairment; -He/She received oxygen therapy. Review of the resident's physician orders, dated April 2024, showed an order for oxygen therapy at two liters per minute per nasal cannula continuously. Observation on 4/17/24 showed the following: -At 6:41 A.M., Certified Nurse Assistant (CNA) E brought the resident's concentrator to the dining room. The nasal cannula tubing dragged on the floor behind CNA E. The nasal prongs on the cannula slid across the dining room floor. CNA E picked up the nasal cannula tubing off the floor and placed it on the resident's table. (The resident wasn't in the dining room at this time.) CNA E plugged in the concentrator and left the nasal cannula tubing on the table. CNA E turned the oxygen concentrator on and left the table. -At 7:05 A.M., the resident put the nasal cannula that had been on the floor into his/her nose. 3. Review of Resident #12's care plan, revised 04/03/24, showed the following: -Activities of daily living focus - he/she has limited physical mobility related to stroke with residual hemiparesis; -Substantial assistance with toileting; -Extensive assistance with bed mobility. Review of the resident's annual MDS, dated [DATE], showed the following: -Dependent on staff to provide personal hygiene; -Substantial/maximum assist by staff for rolling left and right in bed; -Dependent on staff for chair/bed-to-chair transfer. Observation on 04/17/24, at 7:39 A.M., showed the following: -The resident lay in bed. A urinal sat containing urine sat on his/her bedside table; -CNA E and NA G entered the resident's room to get him/her up for the morning; -While wearing gloves, NA G took the urinal to the resident's bathroom and emptied the urinal in the toilet; -NA G returned to the resident's room, ran water in the urinal from the resident's sink, took the urinal back to the bathroom and emptied the urinal into the toilet; -NA G returned to the resident's room and placed the empty urinal on the resident's bedrail; -Without changing his/her gloves, NA G picked up the resident's clean pants from the back of the resident's wheelchair, picked up the resident's left foot and applied the pants to the resident's left leg; -CNA E performed front perineal care for the resident; -Wearing the same gloves, NA G performed front perineal care for the resident; -Without changing gloves, NA G assisted the resident to turn on his/her right side by touching the resident's left hip; -NA G then performed perineal care to the resident's buttocks. NA G ran out of peri-care wipes and went to the resident's drawers, opened the drawer with his/her gloves, got a new pack of wipes out of the drawer, closed the drawer, opened the new wipes and continued performing perineal care; -Without changing gloves, NA G touched and moved the mechanical lift pad from the back of the resident's wheelchair and started to place the lift pad under the resident; -Wearing the same gloves he/she wore to provide perineal care, CNA E assisted the resident to roll on his/her left side, attached the clean incontinent brief, and pulled up the resident's pants. During an interview on 4/18/24, at 1:50 P.M., CNA E said the following: -He/She should wash his/her hands before he/she performed cares, after he/she touched dirty linen, before he/she put on clean gloves, and before he/she left a resident's room; -He/She should change his/her gloves if they were soiled and after he/she provided care. During an interview on 4/18/24, at 1:56 P.M., NA G said the following: -He/She should wash his/her hands before and after he/she provided care and sometimes during care; -He/She should change his/her gloves each time they became dirty; -He/She did not realize he/she did not change his/her gloves when providing care for the resident; -His/Her gloves were soiled after dumping the urinal. He/She should have changed his/her gloves; -His/Her gloves were soiled after providing perineal care. He/She should have changed his/her gloves prior to touching the dresser and getting new wipes; 4. Review of Resident #15's annual MDS, dated [DATE], showed the following: -Always incontinent; -Dependent on staff with hygiene, transfers, toilet use, and bathing. Observation on 4/17/24, at 5:30 A.M., showed the following: -The resident lay in his/her bed; -NA K entered the resident's room, and without washing his/her hands, put on gloves; -The bed pad under the resident was wet and smelled like urine; -NA K cleaned the resident's perineal area between the resident's leg and the groin; -Without removing his/her gloves, he/she rolled the resident to his/her side, touching the resident; -NA K cleaned the resident's buttocks and touched the urine saturated pad with his/her gloves; -Without removing his/her gloves, NA K touched the resident's clean clothing, the sling for the mechanical lift, and the resident's clean incontinence brief. 5. Review of Resident #3's annual MDS, dated [DATE], showed the following: -Requires partial/moderate assistance from staff for toilet hygiene, going from sitting to standing, bed to chair and toilet transfers; -Dependent on staff for personal hygiene; -Frequently incontinent. Observation on 4/17/24, at 05:46 A.M., showed the following: -The resident lay in his/her bed; -The bed pad under the resident was visibly wet and smelled like urine; -NA L did not clean the resident's skin that was against the urine soaked pad and transferred the resident into his/her wheelchair; -The resident's bare buttocks sat directly on the wheelchair cushion; -NA L transferred the resident to the toilet, and assisted the resident to dress. NA L did not cleanse the resident's skin that had been against the urine soaked pad in the bed, or clean the cushion the resident sat on in the wheelchair; -NA L assisted the resident to transfer back into the wheelchair and to sit on the soiled wheelchair cushion. 6. Review of the facility's policy, Water Management Program, implemented 11/1/23, showed the following: -It is the policy to establish water management plans for reducing the risk of Legionella and other opportunistic pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) in the facility's water systems; -Water management plans refer to the documents that contain all the information pertaining to the development and implementation of the facility's water management activities for reducing risk of Legionella and other opportunistic pathogens; -Control measures are things done in the building water systems to limit growth and spread of Legionella, such as heating, adding disinfectant, or cleaning; -Control Limits are the maximum value, minimum value, or range of values that are acceptable for the control measures being monitoring to reduce the risk for Legionella growth and spread; -Control points are locations in the water systems where a control measure can be applied; -Definite healthcare-associated Legionnaires' disease refers to a case of Legionnaires' disease in a resident who spent the entire 10 days prior to onset of illness in the facility; -Possible healthcare-associated Legionnaires' disease refers to a case of Legionnaires' disease in a resident who spent only part of the 10 days before symptoms began in the facility; -A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing; a. Team members have been educated on the principles of an effective water management program, including how Legionella and other water-borne pathogens grow and spread. Education is consistent with each team member's role; b. The water management team has access to water treatment professionals, environmental health specialists, and state/local health officials; -The Maintenance Director maintains documentation that describes the facility's water system; -A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will consider the following elements: a. Premise plumbing: This includes water system components as described in the documentation of the facility's water system; b. Clinical equipment: This includes medical devices and other equipment utilized in the facility that can spread Legionella through aerosols or aspiration; c. At-risk population - This facility's entire population is at risk. High risk areas shall be identified through the risk assessment process; -Data to be used for completing the risk assessment may include, but are not limited to: a. Water system schematic/description; b. Legionella environmental assessment; c. Resident infection control surveillance data (i.e. culture results); d. Environmental culture results; e. Rounding observation data; f. Water temperature logs; g. Water quality reports from drinking water provider (i.e. municipality, water company); h. Community infection control surveillance data (i.e. health department data); -Based on the risk assessment, control points will be identified; -Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens; -Testing protocols and control limits will be established for each control measure; a. Individuals responsible for testing or visual inspections will document findings; b. When control limits are not maintained, corrective actions will be taken and documented accordingly; c. Protocols and corrective actions will reflect current industry guidelines (i.e. ASHRAE, OSHA, CDC); -The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will verify the program activity for which they are responsible; -The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate the effectiveness; - All cases of Legionella shall be reported to local/state health officials, followed by an investigation; a. The Infection Preventionist will investigate all cases of definite healthcare-associated Legionnaires' disease for the source of Legionella; b. The infection Preventionist will also investigate for the source of Legionella when two or more possible healthcare-associated Legionnaires' disease are identified; c. Elements of an investigation may include: Reviewing medical and microbiology records, actively identifying all new and recent residents with healthcare-associated pneumonia and testing them for Legionella using both culture of lower respiratory secretions and the Legionella urinary antigen test. Developing a line list of cases. Evaluating potential environmental exposures. Performing an environmental assessment. Performing environmental sampling, as indicated by the environmental assessment. Subtyping and comparing clinical and environmental isolates. Decontaminating environmental source(s). Working with local and/or state health department staff to determine how long heightened disease surveillance and environmental sampling should continue to ensure an outbreak is over. Reviewing and possibly revising the water management program, with input from local and/or state health department staff; -The facility will conduct an annual review of the water management program as part of the annual review of the infection prevention and control program, and as needed, such as when any of the following events occur: a. Data review shows control measures are persistently outside of control limits, b. A major maintenance or water service change occurs (including replacing tanks, pumps, heat exchangers, distribution piping, or water service disruption from the supplier to the building), c. One or more cases of disease are thought to be associated with the facility's systems, or; d. Changes occur in applicable laws, regulations, standards, or guidelines; -In the event of an update to the water management program, the water management team shall: a. Update the water system schematic/description, associated control points, control limits, and any pre-determined corrective actions; b. Train those responsible for implementing and monitoring the updated program; -Documentation of all the activities related to the water management program shall be maintained with the water management program binder for a minimum of three years; -The water management team shall report relevant information to the QAPI Committee. The facility did not provide any documentation to show the water management team conducted a risk assessment annually, and did not provide any documentation of any water management team meeting notes. During an interview on 4/16/24 at 1:05 P.M., the Infection Preventionist (IP) said she was not on a water management team and had never attended a water management team meeting . She had no knowledge of monitoring for Legionella exposure or Legionnaire's disease, and had not been educated as the policy said she would be as part of the team. She did not look at health acquired pneumonia cases screening for the Legionella antigen with sputum or urine test. During an interview on 4/16/24 at 4:34 P.M., the Maintenance Director said he monitored the water temperatures weekly to make sure the temperature was not over 120 degrees F in residents' rooms and under 165 degrees in the kitchen. He did not test the cold water. The facility did not have a water management team. He had never inspected water sources or vessels for sediment or biofilm. The facility did not check chlorine levels. He did not know what Legionella was or what to watch for. He had never reviewed ASHRAE guidelines. He didn't flush unused faucets or faucets in empty rooms. 7. During interviews on 4/17/24 at 10 :30 A.M. and 4/18/24 at 7:30 P.M., the Director of Nursing said the following: -Staff should wash their hands any time their hands were visibly soiled, after they provided cares, and when they changed their gloves; -S should change gloves if they were visibly soiled and any time they touch a different body part, such as when providing perineal care from front to back; -Staff should remove soiled gloves after pericare and before touching clean items; -She did not have training on Legionella and was not on the water management team. 42592 46506 50675

Based on observation, interview, and record review, the facility failed to ensure dietary equipment was free of an accumulation of grease, oil, dust, and debris; failed to ensure food items were sealed in the freezer and dry storage room; and failed to ensure the facility's ice machine drain contained a proper air gap. The facility census was 31. Review of the facility's dietary cleaning schedule showed, by-weekly deep clean stove/hood/grill/oven/filters. 1. Observations on 4/15/24 from 9:20 A.M. to 3:34 P.M., in the kitchen, showed the following: -In the white up-right freezer, a cardboard box contained an unsealed plastic bag of frozen biscuits; -In the dry storage room, a 5-pound unsealed plastic bag of natural cocoa powder; -Above the refrigerator unit next to the service hall kitchen door, an approximate 2-foot by 3-foot ceiling vent with a moderate buildup of dust and debris; -On east kitchen wall, a white rotary fan, located between a countertop with the microwave/mixer/blender and the three-compartment sink, had a moderate buildup of dust and debris; -A four bulb fluorescent light fixture inside the main kitchen door had a moderate buildup of dust and debris; -A four bulb fluorescent light fixture in front of the dishwasher and above the clean dish rack had a moderate buildup of dust and debris; -A four bulb fluorescent light fixture between the three-compartment sink and the food preparation table had a moderate buildup of dust and debris; -A four bulb fluorescent light fixture between the stovetop/oven/griddle and the food preparation table had a moderate buildup of dust and debris; -Four suppression nozzles and piping manifold inside the kitchen hood had a buildup of oily residue, dust and debris; -The vertical ductwork inside the kitchen hood above the stovetop/oven/griddle had an internal buildup of dust and debris. During an interview on 4/16/24 at 10:00 A.M., the dietary manager said the following: -Kitchen staff currently were to clean the identified areas monthly; -She expected these areas to be clean and free of oil, dust and debris; -She expected the kitchen hood suppression nozzles and piping manifold to be free of oil, dust, and debris; -She expected the vertical kitchen hood ductwork to be free of dust and debris; -She expected items in the freezers and in the dry food storage to be sealed. During an interview on 4/16/24 at 5:05 P.M., the administrator said the following: -She expected the kitchen/dietary equipment to be clean and free of oily buildup, dust, and debris; -She expected items stored in freezers and dry storage to be sealed. During an interview on 4/18/24 at 11:26 A.M., the registered dietician said the following: -She expected the kitchen/dietary equipment and area to be kept clean and free of dust, debris, and oily buildup; -She expected items in dry storage and freezers to be sealed. 2. Observation on 4/15/24 at 3:34 P.M., of the ice machine located in the kitchen, showed the following: -An approximately 1-inch plastic drain pipe exited the ice machine and ran along, down and through the kitchen floor into the basement mechanical room; -The ice machine drain pipe in mechanical room ran down and along the south wall and into the sump pump floor well, approximately 4-inches; -There was an air gap above the sump pump floor well. During an interview on 4/16/24 at 2:05 P.M., the Maintenance Director said he was unaware the end of the ice machine drain pipe was to be above the top edge of the sump pump well. During an interview on 4/18/24 at 11:26 A.M., the registered dietician said she expected the ice machine drain to have an air gap at the drain.

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all residents.The facility census was 31. During an interview on 4/18/24, at 1:15 P.M., the Administrator said the facility did not have a policy for RN coverage. The facility followed the regulatory guidance. Review of the Payroll Based Journal (PBJ) report (the facility is mandated to report staffing hours to the Centers for Medicare and Medicaid Services (CMS) and those hours are reviewed and calculated into a report) dated 10/1/23-12/31/23, showed the following dates when the facility did not have any documented RN hours: -11/6/23; -11/7/23; -11/8/23; -11/12/23; -11/14/23; -11/15/23; -12/15/23; -12/18/23; -12/24/23; -12/28/23; -12/29/23; -12/31/23. Review of the facility's payroll and agency staffing, dated 2/15/24-4/15/24, showed the following: -2/17/24 no RN hours; -2/18/24 no RN hours; -2/24/24 no RN hours; -2/25/24 no RN hours; -3/3/24 no RN hours; -3/5/24 6.12 RN hours; -3/10/24 no RN hours; -3/16/24 no RN hours; -3/17/24 no RN hours; -3/18/24 no RN hours; -3/23/24 no RN hours; -3/28/24 5.73 RN hours; -3/30/24 no RN hours; -3/31/24 no RN hours; -4/5/24 RN hours started at 10:25 P.M. to 12:00 A.M. (1 hour and 35 minutes); -4/7/24 RN hours started at 10:31 P.M. to 12:00 A.M. (1 hour and 29 minutes); -4/9/24 3.73 RN hours; -4/12/24 RN hours started at 8:20 P.M. to 12:00 A.M. (3 hours and 40 minutes); -4/13/24 RN hours 12:00 A.M. to 7:21 A.M. (7 hours 21 minutes); -4/14/24 no RN hours. During an interview on 4/16/24, at 10:21 A.M., the Director of Nursing said the facility did not have full RN coverage. The facility did not have RN coverage everyday. During an interview on 4/15/24, at 1:28 P.M., the Administrator said the facility has had days with no RN coverage. MO232587

Based on observation, interview and record review, the facility failed to provide four residents (Resident #15, #25, #27 and #30), of eight sampled residents, with the assistance of activities of daily living (ADL) care that the residents required. Resident #15 and #30 were not provided appropriate perineal care, Resident #27 and #30 were not offered bathing as scheduled and Resident #25 was not provided with feeding assistance when needed. The facility census was 31. Review of the facility policy, Quality of Life, dated June 2023, showed the following: -The community environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being; -Residents whom are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming, and personal and oral hygiene; -Residents are provided with appropriate care and services including: a. Hygiene; b. Mobility; c. Elimination; d. Dining, including meals and snacks, e. Communication; -The resident or representative refuse care and treatment to restore or maintain functional abilities after efforts are given to educate about such or offer alternatives; -If a resident or representative refuses care and treatment which may contribute to a decline, then complete the following: a. Inform and/or educate the resident or responsible party of the benefits and risks of not accepting such interventions; b. Document such in the record, including the interventions identified in the care plan and in place to minimize functional loss that were refused; c. Document substitute interventions that were tried with consent or refused, and; d. Attempt to find the underlying cause of the refusal if related to depression, behavioral or dementia care; -Utilize ADL reports, paper or electronic to assess ADL decline over time. Update care plan appropriately and interventions as needed. 1. Review of Resident #15's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/18/23, showed the following: -Cognition not assessed, cannot do interview because resident is rarely understood; -Diagnosis include hemiplegia (paralysis one side of body) affecting right dominant side; cerebral vascular accident (stroke), parkinson's, back pain related to cervical disc issue; -Always incontinent; -Range of motion (ROM) impairment of one upper extremity; -Dependent on staff with hygiene, toilet use, and bathing; Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No behaviors. Observation on 4/17/24, at 5:30 A.M., showed the following: -The resident lay in bed; -Nurse Assistant (NA) K and NA L entered the resident's room; -The resident's right hand was contracted, the resident did not fully extend his/her legs and they were bent at the knee and hip; -The resident's pad on the bed was wet from incontinence of urine; -NA K provided peri-care and cleaned the area between the resident's leg and groin with a disposable cloth but did not cleanse the resident's genital area. During an interview on 4/17/24 at 6:05 A.M. NA K said staff are expected to cleanse every area where urine or feces touches the resident's skin when providing perineal care. 2. Review of Resident #27's face sheet showed the resident's family member was the resident's durable power of attorney. Review of the resident's care plan, dated 10/18/23, showed the resident refused bathing. The plan did not list any interventions staff was to try/do in the event the resident refused. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent with bathing and personal hygiene; -Occasionally incontinent. Review of the facility's bath schedule showed the resident's bath days were Mondays and Thursdays on the day shift (twice a week). Review of the resident's bath record, in the resident's electronic medical record (EMR), dated 2/1/24-2/29/24, showed the resident had a bath on 2/1/24. Review of the resident's daily bath sheets, (paper sheets) dated 2/1/24-2/29/24, showed the following: -No documentation the resident received, was offered or refused a bath on 2/5/24; -No documentation the resident received, was offered or refused a bath on 2/8/24; -No documentation the resident received, was offered or refused a bath on 2/12/24; -On 2/15/24, staff documented the resident refused a bath; -On 2/19/24, the resident received a bath (18 days since last documented bath); -On 2/22/24, staff documented the resident refused a bath; -On 2/26/24, staff documented the resident refused a bath; -No documentation the resident received, was offered or refused a bath on 2/29/24. The resident received one bath out of eight scheduled baths in February. Review of the resident's bath record in the resident's EMR, dated 3/1/24-3/31/24, showed staff did not document any baths for the resident. Staff documented the bathing activity did not occur. Review of the resident's daily bath sheets, dated 3/1/24-3/31/24, showed the following: -On 3/4/24, staff documented the resident refused a bath; -On 3/5/24, the resident received a bath (15 days since last documented bath); -On 3/7/24, staff documented the resident refused a bath; -On 3/11/24, the resident received a bath (six days since last documented bath); -No documentation the resident received, was offered or refused a bath on 3/14/24; -No documentation the resident received, was offered or refused a bath on 3/18/24; -On 3/21/24, staff documented the resident refused a bath; -On 3/25/24, staff documented the resident refused a bath; -No documentation the resident received, was offered or refused a bath on 3/28/24. The resident received two baths out of eight scheduled baths in March. Review of the resident's bath record in the resident's EMR, dated 4/1/24-4/18/24, showed staff did not document any baths for the resident. Staff documented the bathing activity did not occur. Review of the resident's daily bath sheets, dated 4/1/24-4/18/24, showed the following: -No documentation the resident received, was offered or refused a bath on 4/1/24; -On 4/4/24, the resident received a bath (24 days since his/her last documented bath on 3/11/24); -On 4/7/24 and 4/8/24, the resident received a bath; -No documentation the resident received, was offered or refused a bath on 4/11/24; -No documentation the resident received, was offered or refused a bath on 4/15/24; -On 4/17/24, staff documented the resident refused a bath. The resident received three baths out of five scheduled baths thus far (up to the 17th) in April. Observation on 4/15/24 at 12:45 P.M., showed the resident at the dining room table with an unkempt appearance. The resident's fingernails were long with brown debris under his/her fingernails. The resident had a urine smell and dry flaky skin. During an interview on 4/15/24 at 3:37 P.M., the resident's family member said the following: -He/She has come to the facility several times and found the resident saturated in urine or with dried feces on him/her; -Often he/she finds the resident with feces under his/her fingernails; -He/She does not want the resident to lay in urine for extended periods; -The resident has gone weeks without a shower. Staff say the resident refuses, but he/she feels staff ask the resident in a way to get a no answer because they don't have time to give the resident a shower; -In March, the resident went over two weeks without any kind of bath. Observation on 4/16/24 at 10:16 A.M., showed the resident in his/her bed with an unkempt appearance. The resident's fingernails were long with brown debris under his/her fingernails. The resident had a urine smell and dry flaky skin. Review of the resident's medical record showed no documentaion in the record, including the interventions staff was to do in the event of refusals, no documentation of substitute interventions that were tried with consent or refusal, and no documentation to show staff attempted to find the underlying cause of the refusals. 2. Review of Resident #30's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of Alzheimer's disease; -No behaviors or rejection of care; -Dependent with toileting hygiene and shower/bathe; -Requires substantial/maximal assistance with dressing and bed mobility; -Requires partial/moderate assistance with personal hygiene; -Always to frequent incontinent of bowel and bladder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses included urinary tract infection in the last 30 days. -Dependent on staff for toilet hygiene, shower/bathe, dressing, personal hygiene, sit to lying, lying to sitting on side of bed and transfers. Review of the facility's bath schedule showed the resident's bath days were Sundays and Thursdays on the evening shift (twice a week). Review of the resident's bath record in the resident's EMR, dated 3/1/24-3/31/24, showed the following: -Resident received a bath on 3/3/24; -No documentation the resident received, was offered or refused bathing on 3/7/24; -Resident received a bath on 3/10/24 (seven days later); -No documentation the resident received, was offered or refused bathing on 3/14/24; -No documentation the resident received, was offered or refused bathing on 3/17/24; -No documentation the resident received, was offered or refused bathing on 3/21/24; -No documentation the resident received, was offered or refused bathing on 3/24/24; -Resident received a bath on 3/28/24 (18 days later); -Resident received a bath on 3/31/24. Review of the resident's daily bath sheets, dated 3/1/24-3/31/24, showed no documentation the resident received or refused a bath from 3/1/24 through 3/31/24. The resident received four baths out of nine scheduled baths in March. Review of the resident's bath record in the resident's EMR, dated 4/1/24-4/18/24, showed the following: -No documentation the resident received, was offered or refused bathing on 4/4/24; -No documentation the resident received, was offered or refused bathing on 4/7/24; -Resident received a bath on 4/11/24; -No documentation the resident received, was offered or refused bathing on 4/14/24; -No documentation the resident received, was offered or refused bathing on 4/18/24. Review of the resident's daily bath sheets, dated 4/1/24-4/18/24, showed on 4/7/24 the resident received a bath. The resident received two baths out of five scheduled baths thus far (up to the 18th) in April. Observation on 4/16/24 at 11:45 A.M., showed the resident in the dining room at his/her table with an unkempt appearance. The resident smelled of urine and had dry flaky skin. Observation on 4/17/24, at 6:15 A.M., showed the following: -The resident lay in his/her bed; -NA K and NA L entered the resident's room; -The resident had a strong smell of urine and his/her pad on the bed was visibly saturated with urine up past the resident's hips; -The resident had long toenails extending past the resident's toes and long fingernails; -The resident had dry flaky skin; -NA K and NA L turned the resident to his/her side and cleaned the left buttock that was against the wet pad but did not clean the right buttock; -The NAs proceeded to remove the soiled linens and dress the resident; -NA K and NA L did not perform perineal care to the resident's front perineal area; -NA K and NA L did not clean all areas of the resident's skin that was in contact with urine. Review of the resident's medical record showed no documentation in the record, including the interventions staff was to do in the event of refusals, no documentation of substitute interventions that were tried with consent or refusal, and no documentation to show staff attempted to find the underlying cause of the refusal. During an interview on 04/18/24 at 1:56 P.M., NA G said due to call-ins in the past two days, all of the residents scheduled to receive a bath did not get one. NA G and CNA E were the only two aides scheduled for the past two days due to call-ins. During an interview on 5/6/24, at 4:15 P.M., NA F said the following: -The facility often only had two aides and it was impossible to get to everyone quickly; -The facility was short staffed. During an interview on 04/18/24 at 1:50 P.M., Certified Nursing Assistant (CNA) E said the following: -Residents were scheduled to receive showers/bed baths two times a week; -If staff called in (did not come to work as scheduled), there was not enough staff to get all of the cares done and to give the residents showers/baths; -Staff call-in frequently. 4. Review of Resident #25's face sheet showed the resident had diagnoses that included unspecified protein-calorie malnutrition, dementia. Review of the resident's medical record showed his/her weight on 1/18/24 was 125 pounds (lb). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnoses of dementia; -Upper extremity impairment on both sides; -Required partial/moderate assistance with eating. Review of the resident's medical record showed his/her weight on 3/1/24 was 122.5 lbs. Review of the resident's care plan, dated 3/1/24, showed the resident needed help to eat and drink. Record review of the resident's medical record showed the following: -Weight on 4/1/24 was 118.5 lbs. -The resident had a six pound weight loss in 75 days. Observation of the dining room on 04/15/24 at 12:00 P.M. showed the following: -Resident #25 sat in a wheelchair at a table with two other residents (#27 and #30); -CNA E assisted Residents #27 and #30 with their noon meal; -Resident #25's plate was untouched with no food items eaten. No one assisted Resident #25 with her meal. During an interview on 04/15/24 at 12:45 P.M., CNA E said CNA I was to assist the resident with eating, but CNA I was on his/her break. Observation on 04/15/24 at 12:45 P.M. thru 1:05 P.M., showed the resident sat in the dining room without feeding assistance. The resident had contracted hands (a condition that causes one or more fingers to bend toward the palm of the hand). The resident fed him/herself 1/3 of his/her glass of tea, 2/3 of his/her nutritional shake, and all of his/her pudding . The resident's plate including all of his/her meat, all of his/her vegetables and all of his/her macaroni, was untouched. During an interview on 04/16/24 at 09:50 A.M., the resident said he/she needed help to eat. Staff helped him/her when someone was around. If no one was around, he/she did not get help to eat. During an interview on 04/17/24 at 12:26 P.M., Hospitality Aide (HA) M, (family member of the resident), said the resident needed help eating. He/She usually fed resident. He/She was not at the lunch meal on 4/15/24. He/She expected staff to help the resident whenever he/she needed help and when he/she was not there. During an interview on 04/16/24 at 09:35 A.M., CNA I said he/she assisted the resident yesterday (4/15/24) at lunch. CNA I said the resident took one bite of everything then refused the rest of the meal (during the continuous observation by the state agency (SA) of the noon meal on 4/15/24, no observation was made of CNA I attempting to assist the resident or the resident refusing assistance). During an interview on 04/16/24 at 09:30 A.M. Licensed Practical Nurse (LPN) A said the resident needed help to eat and/or encouragement to eat. During an interview on 04/18/24, at 7:30 P.M., the Director of Nursing (DON) said the following: -She expected staff to give showers as scheduled; -She would expect nail care and shaves to be performed during a shower/bath; -If there were no call-ins, there was enough staff scheduled to provide all cares; -It would be difficult to complete showers, shaving, nail care, and provide all cares needed with just two CNAs working the floor; -The past two days, there were only two CNAs working the floor; -Showers did not get completed the past two days due to call-ins. 46506

Based on observation, interview, and record review, the facility failed to update interventions in the resident's care plan to reflect current safety and care needs for three residents (Resident #1, #16, and #19), in a review of 15 sampled residents. The facility census was 31. Review of the facility's Care Plan Revision Upon Status Change policy, undated, showed the following: -The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change; -Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff) Coordinator, the physician, and the resident representative, if applicable; b. The care plan will be updated with the new or modified interventions; c. Staff involved in the care of the resident will report resident response to new or modified interventions; d. Care plans will be modified as needed by the MDS Coordinator or other designated staff member; e. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 1. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -The resident had severe cognitive impairment; -He/She experienced inattention, disorganized thinking, and altered level of consciousness; -He/She had verbal and other behavioral symptoms not directed toward others; -He/She wandered; -He/She was independent with eating; -He/She needed setup assistance for toileting hygiene; -He/She needed supervision with personal hygiene. Review of the resident's physician orders, dated January 2024, showed the following: -Metformin HCL (antidiabetic agent) 500 milligrams (mg) give one tablet orally twice a day related to pancreatic cancer; -Vemlidy (antiviral medication) 25 mg give one tablet orally daily related to viral hepatitis B. Review of the resident's care plan, updated 1/2/24, showed the following: -The resident continued to have falls when going to the restroom and then trying to find the bed again, after toileting; -Bells on the restroom door, room door, bed, and call light; -The staff educated the resident to bells and that the bells help him/her to find where he/she is in the room. Review of the resident's nurse note, dated 1/6/24 at 5:52 A.M., showed the following: -The staff found the resident on the floor between his/her bed and the restroom door; -The resident had an abrasion on his/her back; -The resident said he/she was trying to go to the restroom and fell back; -The staff put non-slip socks on the resident's feet and administered Tylenol (pain reliever) for headache. Review of the resident's care plan, dated 1/6/24, showed the resident continued to have falls in his/her room after toileting. No new interventions were added to the care plan to address the resident's fall on 1/6/24. Review of the resident's nurse note, dated 1/26/24, showed the following: -The staff provided all meals on a red plate with an inside edge to prevent food spillage and increase intake; -The staff encouraged the resident to try all foods on the plate and if he/she did not like a food, the staff would offer the resident an alternative; -Continue to monitor weight weekly. Review of the resident's care plan, last updated 1/26/24, showed the following: -The resident walked without aids, however when out of his/her room, the resident did better when someone held his/her hand, guiding the resident where to go; -The care plan did not include the resident was prescribed an antiviral medication for viral hepatitis B infection or a hypoglycemic; -The care plan did not include the resident required setup assistance with toileting hygiene. Review of the resident's weekly Medicare meeting note, dated 1/30/24, showed the following: -The resident received physical therapy and occupational therapy services three times a week; -Occupational therapy goals were self-feeding, toileting, and bed mobility with tactile/auditory cues for locating bathroom/bed/toilet; -Physical therapy goals were to improve the resident's bilateral lower extremity strength and activity tolerance to improve gait and balance to decrease risk of fall. Review of the resident's physician orders, dated February 2024, showed consistent carbohydrate, finger food diet. Review of the resident's nurse's note, dated 2/2/24, showed the resident had five episodes of hollering out and wandering. Review of the resident's nurse note, dated 2/5/24 at 4:07 P.M., showed the following: -The staff found the resident on the floor in his/her bathroom; -The resident sustained an injury above the left eyebrow that was 5 centimeters (cm) long; -The nurse practitioner applied ten sutures to the injury. Review of the resident's nurse's note, dated 2/7/24, showed the nurse received an order to transport the resident to a psychiatric unit for further evaluation due to increased behaviors. Review of the resident's psychiatric hospital safety plan, dated 2/21/24, showed the following: -When to seek help: 1. Sudden loud noises; 2. Interrupting the resident during a conversation; 3. Yelling and cursing. -Coping strategies: 1. Talking about trivia; 2. Talking about the resident's military service; 3. Music from the 70's. -Making the resident's environment safe; 1. Take medications as prescribed; 2. Approach and communicate appropriately due to the resident being blind and deaf. Review of the resident's summary page, undated, showed the following: -The resident was readmitted on [DATE]; -He/She had a medical power of attorney; -Diagnoses: viral hepatitis B (viral infection that attacks the liver and can cause both acute and chronic disease), malignant neoplasm (cancer) of head of pancreas, legal blindness, left ear hearing loss, major depressive disorder (common and serious medical illness that negatively affects how you feel, the way you think and how you act), and traumatic hemorrhage of cerebrum (bleeding on a section of the brain caused by trauma). Review of the resident's nurse note, dated 2/21/24 at 7:25 P.M., showed the staff found the resident on the floor between the bed and the air conditioner. Review of the resident's interdisciplinary fall huddle note, dated 2/23/24, showed the following: -Bells are in place; -The staff toileted the resident every two hours and had the resident dressed and out for meals; -The administration educated the staff that the resident needed to be first in the dining room and last out to be monitored more closely. Review of the resident's care plan, updated 2/23/24, showed the following: -The resident was at risk for falls; -The staff anticipated and met the resident's needs; -The staff maintained a clear pathway, free of obstacles; -The staff avoided rearranging furniture; -The care plan did not include staff were to toilet the resident every two hours, staff were to dress the resident and take him/her to the dining room first and take him/her out of the dining room last in order to monitor him/her more closely; -The fall from 2/5/24 had not been addressed on the care plan. Review of the resident's care plan, updated on 3/5/24, showed the following: -Maintain a clear pathway, free of obstacles; -Avoid rearranging furniture; -The fall from 2/21/24 and the recommendations from the resident's psychiatric stay had not been addressed on the care plan. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident had severely impaired cognition; -He/She had verbal and other behavioral symptoms not directed towards others one to three days of the assessment; -He/She rejected care one to three days in the assessment; -He/She wandered one to three days in the assessment that intrudes on others; -He/She required setup assistance with eating; -He/She required supervision with toileting hygiene; -He/She required moderate assistance with personal hygiene. Review of the resident's care plan, last updated 3/11/24, showed the following: -At risk for impaired cognitive function/dementia or impaired thought process related to disease process; -Bells to identify call light, restroom door, and door out into hallway; -Administer medications as ordered, monitor/document for side effects and effectiveness; -Because of traumatic brain injury, it was hard for the resident to process information; -The care plan did not include the resident's coping strategies of talking about trivia, talking about military service, or music from the 70's; -The care plan was not updated to show a change in the MDS to include wandering, required supervision with toileting hygiene, or moderate assistance with personal hygiene. -The care plan did not include consistent carbohydrate finger food with regular consistency from the physician orders; -The care plan did not include falls on 2/21/24, 2/5/24, or 1/31/24. Review of the resident's nurse note, dated 3/21/24 at 3:57 A.M., showed the staff found the resident on the floor next to his/her bed with the emergency call light ripped from the wall and in the resident's hand. Review of the resident's nurse note, dated 3/21/24, showed the following: -A resident across the hall screamed and the facility staff found the resident naked and wandering in the other resident's room; -The resident said, I am going to the kitchen to get some chocolate. Review of the resident's nurse fall charting, dated 3/30/24, 1:19 P.M., showed the staff witnessed the resident lose balance and slide into another resident, then slid to the floor. Review of the resident's nurse note, dated 4/1/24, showed the following: -The resident was unsteady on his/her feet; -He/She had a wheelchair that he/she got around in the facility. Review of the resident's care plan, last updated 3/11/24, showed no documentation to include the resident occasionally used a wheelchair to go from his/her room to the dining room for meals, the facility implemented a toileting schedule for the resident, or the staff were supposed to check on the resident at a minimum of every two hours if not every hour. Review of the resident's weekly Medicare note, dated 4/2/24, showed Occupational Therapy recommended a bed/chair alarm for safety and a functional maintenance program for nursing. staff to continue. Review of the resident's fall huddle interdisciplinary team note, dated 4/8/24, showed the staff was re-educated on the importance of the toileting schedule and to check on the resident at a minimum of every two hours if not every hour. Review of the resident's care plan meeting note, dated 4/8/24, showed the following: -The resident had a functional maintenance program in place; -An easy touch call light was purchased for the resident making it easier to summon help and the therapy staff reported the resident was educated in the use and seemed to understand the concept; -The falls from 3/21/24 and 3/30/24 had not been addressed on the care plan. Review of the resident's nurse note, dated 4/13/24 at 5:20 AM., showed the following: -The resident fell on [DATE]; -The resident's gait was very unsteady; -He/She did not stay in bed and continued to wander around and continued to be a major fall risk; -The staff put the resident in his/her wheelchair and brought the resident up to the dining room to be watched. Review of the resident's fall nurse note, dated 4/13/24 at 2:00 P.M., showed the following: -The staff found the resident on the floor; -The nurse administered Tylenol (non-steroidal anti-inflammatory) for possible pain due to agitation from the resident; -The staff changed the resident's brief due to being damp and a night gown was put on the resident. Observation in the dining room on 4/15/24 at 11:52 A.M., showed Licensed Practical Nurse (LPN) A fed the resident, told him/her what was on the spoon before putting it up to his mouth, and the food was on a red plate. Observation in the dining room on 4/16/24 at 6:00 A.M., showed Nurse Aid (NA) K walked with the resident with him/her holding onto NA K's arm, then Certified Nurse Aid (CNA) E brought a wheelchair up behind the resident, the resident was instructed to sit down, then CNA E took the resident to the dining room table via wheelchair. During an interview on 4/16/24 at 9:10 A.M., Certified Medication Technician (CMT) D said the following: -Some days the staff took the resident to the dining room via wheelchair and some days the staff walked with the resident to the dining room with the resident holding onto the staff member's arm. Observation in the dining room on 4/17/24 at 6:55 A.M., showed the following: -LPN A cued the resident to eat and used a spoon to feed the resident; -LPN A took the resident to his/her room via wheelchair. During an interview on 4/17/24 at 6:55 A.M., LPN A said, the resident did not stay seated in the wheelchair and was too unsteady to be left alone. 2. Review of Resident #19's summary page, undated, showed the following: -The resident was admitted on [DATE]; -He/She had a durable power of attorney; -Diagnoses included high blood pressure and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). Review of the resident's nurse's note, dated 3/3/23, showed the resident fell from transferring self from wheelchair to bed without locking the breaks on his/her wheelchair. Review of the resident's nurse's note, dated 3/6/23, showed the following: -The resident used a light for assist with transfers to use the bathroom; -He/She attempted to transfer from wheelchair to the toilet without locking brakes; -The staff reminded the resident to lock wheelchair brakes; -The resident voiced concern of the wheelchair no longer being left by his/her bed and had to use the call light for assist with transfers. Review of the resident's nurse's note, dated 8/3/23, showed the following: -A staff member found the resident on the floor by his/her bed; -The resident said, she did not know how he/she fell , and the wheelchair just moved out from underneath him/her; -He/She only locked the wheelchair brakes prior to transferring; -He/She took himself/herself to the bathroom, only locked one brake on the wheelchair, so the staff member reminded the resident to lock both brakes prior to transferring Review of the resident's annual MDS, dated [DATE], showed the following: -The resident had moderately impaired cognition; -He/She required supervision with oral hygiene, toileting hygiene, upper body dressing, sitting to lying in bed, lying to sitting on bed, sitting to standing in bed, and toilet transfer; -He/She required setup with rolling left and right in bed; -He/She required moderate assistance to put on/take off footwear and propel self in wheelchair 50 feet with two turns. Review of the resident's care plan, last updated 12/6/23, showed the following: -The resident was able to toilet self; -He/She was independent with upper body dressing; -He/She told the staff when he/she needed assistance with toileting; -He/She did not have any recent falls; -The care plan did not include the resident required supervision with oral hygiene, toileting hygiene, upper body dressing, sitting to lying in bed, lying to sitting on bed, sitting to standing in bed, toilet transfer; -The care plan did not include the resident required setup assistance with rolling left and right in bed or required moderate assistance to propel self in wheelchair 50 feet with two turns; -The care plan did not include the resident's fall risk or the falls of 3/3/23 or 8/3/23, or keep the wheelchair away from the resident's bed while he/she was in bed. Review of the resident's nurse's note, dated 1/24/24, showed the resident had a fall on 1/18/24 and the resident's roommate picked him/her up and helped the resident get back into the wheelchair. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had moderately impaired cognition; -He/She was independent with oral hygiene, toileting hygiene, personal hygiene, sitting to lying in bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and propelling self in wheelchair; -He/She required supervision with upper body dressing, lower body dressing, put on/take off footwear, and rolling left and right in bed; -He/She received occupational and physical therapy. Review of the resident's nurse note, dated 3/31/24, showed the following: -Staff found the resident sitting on the floor between the bed and window; -The resident said, I was trying to get some candy. Review of the resident's care plan meeting note, dated 4/4/24, showed the following: -Staff used a dry erase board to communicate with the resident due to hearing loss; -Social Services had concerns with the resident's behavior towards others; -The family member explained to the resident that he/she was not to curse at others and try to work on his/her tone of voice. Review of the resident's nurse note, dated 4/4/24, showed the resident yelled at another resident over the window blinds being raised and staff talked with the resident about the incident. Review of the resident's care plan, last updated 4/15/24, showed the following: -The resident was able to toilet himself/herself; -He/She was independent with upper body dressing; -He/She told the staff when he/she needed assistance with toileting; -He/She did not have any recent falls; -The care plan did not include supervision with upper body dressing, lower body dressing, put on/take off footwear, rolling left and right in bed, or occupational and physical therapy; -The care plan did not include resident falls on 1/18/24 or 3/31/24, use of a dry erase board to communicate with the resident due to hearing loss or increase of verbal behaviors. 3. Review of Resident #16's summary page, undated, showed the following: -The resident was admitted on [DATE]; -Diagnoses included alcohol abuse, high blood pressure, atherosclerotic heart disease (type of thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery), chronic obstructive pulmonary disease, and dorsalgia (back pain); -Doxycycline (antibiotic) 100 milligrams give one tablet orally twice a day for 10 days related to pneumonia (started 4/15/24). Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She fell within the last month and within the last two to six months prior to admission. Review of the resident's nurse notes, dated 3/30/24, showed the following: -The resident was admitted status post hospitalization for pneumonia; -He/She continued on an antibiotic for pneumonia. Review of the resident's nurse's note, dated 4/5/24, showed the nurse received a new order for Ativan (anti anxiety medication) 1 mg orally daily for five days related to alcohol withdrawal. Review of the resident's fall nursing note, dated 4/8/24, showed the following: -A staff member found the resident on his/her knees between the recliner and the resident's bed, grippy socks on, and the resident had just toileted; -The resident said there was a slick spot on the floor in front of the bed that caused him/her to slip and fall forward onto his/her knees, and the resident caught himself/herself with the recliner and edge of bed. Review of the resident's fall huddle, dated 4/8/24, showed the staff were to make sure the floors were cleaned daily, updated housekeeping, and resident was already wearing grippy socks. Review of the resident's care plan, last updated on 4/10/24, showed the care plan did not include the resident's fall on 4/8/24 with interventions, alcohol withdrawal monitoring with signs and symptoms, or treatment for pneumonia. During an interview on 4/18/24 at 11:25 A.M., LPN A said the following: -The MDS Coordinator #1/Medical Records (MDSC 1/MR) and the Assistant Director of Nursing/Infection Preventionist (ADON/IP) staff members were responsible for updating all resident care plans; -Falls, change in diet, change in ADL performance, bedrails, high-low bed implementation were items that needed to be updated on the care plan; -If there were psychiatric recommendations, then LPN A provided a copy to MDSC 1/MR; -Interventions to prevent falls for Resident #1 included a flat call light that was easier for the resident to find and use, tuck bed sheets under the foot of the bed to prevent falls from tripping hazard, non-skid socks, toilet the resident every two hours, and the staff encouraged the resident to eat in the dining room because he/she triggered for weight loss and staff could encourage the resident to eat; -Interventions the staff used when the resident had negative behaviors included the staff took the resident back to his/her room, encouraged the resident to listen to staff, and allow him/her to lay in bed; -The administrative staff decided to install automatic locking breaks on Resident #19's wheelchair that locked when the resident stood up; -He/She gave changes and/or updates to the MDSC 1/MR and didn't know why the care plan was not updated. During an interview on 4/15/24, at 11:55 A.M., Minimum Data Set Coordinator (MDSC) 1 said she completed all of the care plans except the Infection Preventionist/Assistant Director of Nursing completed the wound information and if the resident had any infection. Activity staff completed the activity care plan and dietary staff completed the nutrition care plan. She had not had formal training for care plans. During an interview on 4/18/24 at 7:30 P.M., the Director of Nursing said the expectation was she would update care plans with each fall, and she would implement new interventions every time a fall occurred after discussion during the IDT meeting.

Based on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan, specific to the resident, for four residents (Resident #2, #12, #15 and #16), in a review of 15 residents and one additional resident (Resident #37). The facility was 31. A request for a facility policy for comprehensive care plans and revisions of care plans was requested and none provided. 1. Review of Resident #2's summary page, undated, showed the following: -The resident was admitted on [DATE]; -He/She was his/her own responsible party; -Diagnoses included high blood pressure, heart failure, peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel), chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs), and asthma (disease in which the airways clog and narrow, making it hard to breathe), erythema intertrigo (common inflammatory skin condition that is caused by skin-to-skin rubbing that is intensified by heat and moisture), pyogenic arthritis (infection in the joint fluid and joint tissues), convulsions, morbid (severe) obesity (overweight), Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), Alzheimer's disease (type of dementia that affects memory, thinking and behavior), obstructive sleep apnea (occurs when the throat muscles relax and block the airway), cerebral palsy (group of movement disorders that can cause problems with posture, manner of walking, muscle tone, and coordination), and edema (swelling caused by too much fluid trapped in the body's tissues). Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/1/24, showed the following: -The resident was cognitively intact; -He/She was dependent on staff for upper body dressing, and lower body dressing; -He/She had scheduled pain medication for pain; -He/She received a diuretic, opioid, and hypoglycemic medications. Review of the resident's nurse's note, dated 3/14/24, showed the resident used a bed pan, oxygen at two liters/minute via nasal cannula, and had a large bed. Review of the resident's care plan, started on 3/20/24, showed the following: -The resident had limited physical mobility; -He/She had a pressure ulcer or potential for pressure ulcer development related to immobility; -Weekly head to toe skin assessment; -Turn and reposition every two hours; -The care plan did not include the resident had a bariatric bed, used a bed pan, had supplemental oxygen therapy, experienced pain, pressure ulcer prevention devices, skin wounds, had Alzheimer's disease, type II diabetes mellitus (long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), or Parkinson's disease. Review of the care plan, last updated on 4/1/24, showed the following: -The resident had a skin infection; -He/She would show improvement with signs and symptoms within 48 hours of starting antibiotic; -Ensure adequate nutrition to support immune function and promote tissue repair and wound healing; -Conduct a thorough assessment of the affected skin area, noting characteristics such as redness, warmth, swelling, pain, and presence of drainage or pus; -The care plan did not include the resident had a bariatric bed, used a bed pan, had supplemental oxygen therapy, experienced pain, pressure ulcer prevention devices, skin wounds, had Alzheimer's disease, type II diabetes mellitus (long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), or Parkinson's disease. Review of the resident's nurse's note, dated 4/8/24, showed the resident requested pain medication for right shoulder pain rated at 7/10. Review of the resident's nurse's note, dated 4/9/24, showed the following: -The resident had an episode of not responding when spoken to that lasted for a few seconds; -The resident's oxygen saturation was 84% on room air (normal range 92-100%); -The nurse put oxygen at three liters per minute per nasal cannula; -The staff put the resident in bed with head of bed elevated. Review of the resident's nurse note, dated 4/11/24, showed the following: -The resident continued with wounds to buttocks/gluteal, self-inflicted wound from the resident scratching, healing stage varies based on the resident's behavior; -He/She was on weekly weight monitoring; -He/She had a wheelchair cushion in place and a low air loss mattress. Review of the resident's weekly skin note, dated 4/12/24, showed the following: -Right gluteal fold noted with 4.0 centimeters (cm) x 10 cm open area, red excoriated skin with maceration noted throughout; -Left gluteal fold measuring 7 cm x 10 cm, red excoriated skin; -Both buttocks were bright red and missing top layer of skin; -Areas were self-inflicted from the resident scratching at self; -Triple butt cream applied to areas. Observation in the resident's room on 4/15/24 at 9:55 A.M., showed the following: -The resident laid in a bariatric bed; -He/She had dark areas surrounded by redness on the left lower leg; -He/She had an oxygen concentrator with oxygen cannula/tubing. Review of the resident's physician orders, dated April 2024, showed the following: -Brivaracetam (anticonvulsant) 150 mg give one tablet orally twice a day (started on 3/13/24); -Clonazepam (benzodiazepine) 0.5 mg give one tablet orally twice a day (started on 3/13/24); -Depakote DR (anticonvulsant) 250 mg give two tablets orally three times a day (started on 3/13/24); -Donepezil HCL (treat dementia related to Alzheimer's disease) 5 mg give two tablets orally at bedtime (3/13/24); -Gabapentin (anticonvulsant) 300 mg give one capsule twice a day (started on 3/13/24); -Mirapex ER (antiparkinsonism agents) 0.75 mg give one tablet orally twice a day (started on 3/13/24); -Spironolactone (potassium-sparing diuretic) 50 mg give one tablet orally daily (started on 3/13/24); -Symbicort inhalation aerosol (bronchodilator) 80-4.5 micrograms/actuation inhale two puffs twice a day (started on 3/13/24); -Tramadol (opioid) 50 mg give one tablet orally every six hours as needed for pain (started on 3/13/24); -Tramadol 50 mg give half a tablet orally twice a day (started on 3/13/24); -Tylenol #3 (opioid) give one tablet orally every six hours as needed for pain (started on 4/10/24); -CPAP on at bedtimes with current settings as needed per resident's request (started on 3/13/24); -May have oxygen at 3 liters per minute per nasal cannula to keep oxygen saturation above 92% (started on 3/13/24); -Voltaren gel (nonsteroidal anti-inflammatory) 1% apply to bilateral shoulders topically three times a day (started on 3/13/24). Review of the resident's medical record, showed the care plan did not include the resident had a bariatric bed, used a bed pan, had supplemental oxygen therapy, experienced pain, air mattress on the bed, skin wounds, had Alzheimer's disease, type II diabetes mellitus (long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), or Parkinson's disease. 2. Review of Resident #12's care plan, dated 10/04/23, showed the following: -The resident was at risk for psychosocial impairment due to disease process; -The resident was at risk for mood problem related to disease process; -No focus area related to activities. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Able to understand and be understood by others; -Activity preferences that were important to the resident: snacks between meals, choose his/her own bedtime, have family/friends involved in decisions about care, having books/newspapers/magazines to read, be around animals such as pets, keeping up with the news and going outside when weather permits; -Activity preferences that are somewhat important to the resident: choose what to wear, choose between a tub bath/shower/bed bath, and listening to music; -Activity preferences were answered by the resident; -Review of the Care Area Assessment (CAA's) of the MDS showed activities triggered as an area and should be addressed on the care plan. Review of an additional care plan provided by the facility, dated 04/03/24, showed no focus area related to activities. Observation on 04/15/24, at 10:39 A.M., showed the resident lay awake in his/her bed watching television. During an interview on 04/15/24 at 10:39 A.M., the resident said he/she did not participate in activities by his/her choice and spent the majority of his/her time in his/her room. 3. Review of Resident #16's summary page, undated, showed the following: -The resident was admitted on [DATE]; -High risk for falls: -He/She was his/her own responsible party; -Diagnoses included alcohol abuse, nicotine dependence, and atherosclerotic heart disease (common condition that develops when a sticky substance called plaque builds up inside your arteries). Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She had a history of falls one month and two to six months prior to admission; -He/She received anticoagulant and antibiotic medications. Review of the resident's nurse's note, dated 3/29/24, showed the resident recently stopped drinking alcohol, no signs or symptoms of delirium tremens (severe, life-threatening form of alcohol withdrawal). Review of the resident's nurse's note, dated 3/30/24, showed the following: -The resident's lung sounds were diminished with occasional rubs; -He/She received an antibiotic for pneumonia; -He/She received Eliquis (anticoagulant) for deep vein thrombosis (occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs) ; -He/She smoked and had a history of alcohol use. Review of the resident's nurse's note, dated 4/5/24, showed the nurse practitioner ordered Ativan (anti anxiety medication) 1 milligram (mg) orally daily for five days related to alcohol withdraw. Review of the resident's nurse's note, dated 4/8/24, showed the following: -The staff found the resident on his/her knees between the recliner and bed in his/her room; -He/She wore grippy socks and had just toileted; -He/She said there was a slick spot on the floor in front of the bed that caused him/her to slip and fall forward to his/her knees, the resident was able to catch himself/herself with the recliner and edge of bed. Review of the resident's fall huddle interdisciplinary team note, dated 4/8/24, showed the intervention was to make sure the floors were cleaned daily, updated housekeeping. Review of the resident's baseline care plan, last updated 4/10/24, showed the following: -The resident had nutritional problem related to alcohol abuse, high blood pressure, atherosclerotic heart disease, chronic obstructive pulmonary disease, and gastroesophageal reflux disease; under normal body mass index; on high protein diet-supplement received; -The care plan did not include the resident's fall of 4/8/24 with intervention, he/she was prescribed an antibiotic twice for pneumonia, he/she smoked, or to monitor for bleeding related to anticoagulant use. Review of the resident's physician orders, undated, showed the following: -Doxycycline hyclate (antibiotic) 100 mg give one tablet orally twice a day for ten days for pneumonia (started on 4/15/24); -Eliquis (anticoagulant) 5 mg give one tablet orally twice a day for atherosclerotic heart disease (started on 4/5/24); During an interview on 4/16/24 at 8:59 A.M., the resident said the following: -He/She could go smoke when he/she wanted; -He/She could take himself/herself out, light his/her own cigarette, and come back without assistance. Review of the resident's medical record, showed the comprehensive care plan did not include the following: -The resident was high risk for falls, assessed on 3/29/24; -He/She had a fall on 4/8/24 with intervention; -He/She was prescribed an antibiotic twice for pneumonia; -He/She smoked cigarettes in the designated resident smoking area; -The staff need to monitor the resident for bleeding related to anticoagulant medication. 4. Review of Resident #15's annual MDS, dated [DATE], showed the following: -Cognition not assessed, cannot do interview because resident was rarely understood; -Diagnoses included hemiplegia (paralysis one side of body) affecting right dominant side, CVA (stroke), back pain, cervical disc degeneration (degeneration of the spine in the neck region), -Long and short term memory was a problem; -Slurs or mumbles words; -Usually understands, may miss intent of conversation; -Behaviors not directed towards others daily; -Rejection of care one to three days out of the last seven days; -No scheduled, PRN (as needed) pain medication, or non homological interventions for pain; -Had the following indicators of pain or possible pain in the last five days: non-verbal sounds, vocal complaints of pain, facial expressions, and protective body movements; -Limited range of motion in one upper extremity; -Dependent on staff with hygiene, transfers, toilet use, bathing; -Substantial/maximum assistance rolling left and right; -Two or more non-injury falls since last assessment -On Section V the resident triggered for pain and staff marked they would proceed to care plan for pain. Review of the resident's care plan, dated 10/18/23, showed it did not include pain or any interventions to address pain control. Review of the resident's quarterly MDS, dated [DATE], showed staff did not answer the pain section of the MDS. Observation on 4/17/23, at 5:30 A.M., showed the following: -The resident lay in his/her bed; -Nurse Assistant (NA) L and NA K rolled the resident from side to side in bed to perform perineal care and dress the resident; -The resident's right arm was contractured and the resident kept his/her elbow bent and his/her hand clenched; -The resident's legs were stiff and when the NA's moved the resident's legs he/she would grimace in pain and moan. Review of the resident's quarterly MDS, dated [DATE], showed staff did not answer the pain section of the MDS. Staff identified the resident had a diagnosis of pain and signs of pain. Pain was not addressed in the resident's plan of care. 5. Review of Resident #37's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Bilateral lower extremity limitations; -Wheelchair was used for mobility; -Dependent on staff for sitting to lying position change, lying to sitting on the side of the bed position changes and chair/bed-to-chair transfers. Review of the resident's care plan, dated 01/15/24, showed the following: -Falls: the resident was at risk for falls due to cognitive impairment; -Staff would anticipate and meet resident needs; -No indication on the care plan of lower extremity limitation, mobility status, transfer status or assistance needed for transfers. Review of a second care plan for the resident and provided by the facility dated 04/17/24, showed the resident was at risk for falls with no identification of why the resident was at risk, and with no goals or interventions noted. Observation on 04/17/24, at 7:23 A.M., showed the following: -The resident lay awake and dressed in bed; -Certified Nursing Assistant (CNA) E and NA) G assisted the resident to a sitting position with manual assistance and the use of a gait belt; -CNA E and NA G assisted the resident to a standing position with manual assistance and the use a a gait belt and the resident's walker; -CNA E and NA G assisted the resident to pivot transfer to his/her wheelchair; -NA G pushed the resident to the dining room for breakfast. During an interview on 04/17/24, at 7:35 A.M., CNA E said the resident could not transfer himself/herself and required staff assistance for the transfer and to be pushed to and from any place he/she needed to go. During an interview on 4/15/24, at 11:55 A.M., MDS Coordinator (MDSC) 1 said she was the liaison to MDSC 2 who completed the residents' MDS assessments offsite. MDSC 1 completed all of the interviews and corresponded with MDSC 2 via email. MDSC 1 did not review MDSC 2's assessments because she had limited knowledge and was not trained. MDSC 1 also completed all of the residents' care plans except the Infection Preventionist/Assistant Director of Nursing completed the wound information and if they have any infection, activities completed the activity care plan and dietary completed the nutrition care plan. She had not had formal training for MDS assessments and care plans. During an interview on 4/16/24 at 11:39 A.M., MDSC 2 said MDSC 1 completed all of the required interviews with the residents, and the BIM (cognitive section). Therapy does all of section GG. MDSC 2 took over in December 2023, prior to that another 3rd party company completed the facility's MDS assessments. During an interview on 04/18/24, at 7:30 P.M., the Director of Nursing (DON) said she would expect care plans to be up-to-date and complete. 42592 46506 50675

Based on interview and record review, the facility failed to complete required pre-employment screenings for five of eight sampled employees hired since the previous survey. The facility failed to request a criminal background check for four employees, complete an Employee Disqualification List (EDL) check for four employees, and complete a Nurse Aide (NA) registry check for two employees, prior to hire. The facility census was 31. 1. Review of Activity Aide N's employee file showed the following: -Date of hire 01/03/24; -Criminal background check requested on 03/09/24 (66 days after hire date); -EDL check completed on 02/08/24 (36 days after hire date). 2. Review of the Director of Nursing's (DON) employee file showed the following: -Date of hire 02/12/24; -Criminal background check requested on 03/08/24 (25 days after hire date); -EDL check completed on 03/08/24 (25 days after hire date). 3. Review of Speech Therapist O's employee file showed the following: -Date of hire 12/17/23; -No criminal background check request on file; -No EDL check on file; -NA registry check completed, but no date provided for when it was completed. 4. Review of the Administrator's employee file showed the following: -Date of hire 08/01/23; -Criminal background check completed on 08/03/23 (two days after hire date); -Criminal background check received on 08/04/23 (three days after hire date); -EDL check completed on 08/03/23 (two days after hire date); -NA registry check completed on 08/03/23 (two days after hire date). 5. Review of Licensed Practical Nurse (LPN) P's employee file showed the following: -Date of hire 11/10/22; -Criminal background check requested on 11/07/22; -No record of criminal background check received. 6. During interviews on 04/16/24 at 4:24 P.M. and 04/18/24 at 1:15 P.M., the Administrator said the following: -There was no corporate policy regarding completing criminal background checks, EDL checks, or NA registry checks; -The corporation follows the state guidelines related to each area; -The employee's hire date was the same as the start date; -She was responsible for completing the criminal background checks, EDL, and NA registry checks; -The criminal background check, EDL, and NA registry checks should be completed at least two days prior to the employees' start date.

Based on observation and interview, the facility failed to provide a clean, comfortable environment by failing to ensure the shower room and ceiling vents were clean and in good repair. The facility census was 31. 1. Observation on 4/15/24 at 1:10 P.M. and on 4/17/24 at 7:45 A.M., in the shower room on Cardinal hall, showed black marks on the floor near the shower stall. The shower basin had a large crack between the wall and the floor, the seam in the corner appeared black, and the tiles above the basin showed the grout was black for three of the tiles. The floor in the shower basin had brown stains by the drain. During an interview on 4/24/24 at 1:05 P.M., the Director of Nursing (DON) showed the following: -Staff were to notify maintenance if repairs were needed. -Nursing was to clean the shower room if they or the resident left a mess in the shower room. -Staff could contact housekeeping to provide extra cleaning. 2. Observations on 4/15/24 between 9:18 A.M. and 3:23 P.M., showed the following: -In the west hall shower room, the 8-inch by 8-inch ceiling vent, located by the door, had a heavy accumulation of lint and debris. The 6-inch by 6-inch ceiling vent with attached light had a moderate accumulation of lint and debris; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust and debris; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust and debris; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust and debris; -In occupied resident room [ROOM NUMBER], the bathroom ceiling vent had a moderate accumulation of dust and debris. During an interview on 4/15/24 at 9:18 A.M. and on 4/16/24 at 3:15 P.M., the maintenance director said maintenance staff was responsible for cleaning the ceiling vents. He cleaned the vents about every 45 days or when staff or residents told him they were dirty. He had overlooked cleaning the ceiling vents in the west hall shower room. 42592

Based on observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for four residents (Residents #15, #27, #30 and #36), in a review of 15 sampled residents, who all had diagnosis of dementia, were cognitively impaired, and dependent on staff for assistance with activities of daily living. Staff woke and dressed the residents early in the morning without consideration of the resident's preferences for waking and for staff convenience. The facility census was 31. Review of the facility policy, Quality of Life, dated June 2023, showed the following: -The community environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being; -Residents whom are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition, grooming and personal and oral hygiene; -Residents are provided with appropriate care and services including: a. Hygiene; b. Mobility; c. Elimination, and d. Dining, including meals and snacks, e. Communication. Review of the facility policy, Resident Rights, dated July 2023, showed the following: -Employees shall treat all residents with kindness, respect, and dignity. -Our facility will make every effort, to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. 1. Review of Resident #15's annual Minimum Data Set (MDS), a federally mandated assesment completed by staff, dated 10/18/23, showed the following: -Cognition not assessed, cannot do interview because resident is rarely understood; -Diagnosis include hemiplegia (paralysis one side of body) affecting right dominant side; cerebral vascular accident (stroke) Parkinson's (disorder of the central nervous system that affects movement, often including tremors), back pain related to cervical disc issue; -Dependent on staff with hygiene, transfers, toilet use, and bathing. Review of the resident's care plan, dated 10/18/23, showed the resident has a history of cognitive impairment. The resident can make simple needs known. The resident is dependent on staff for toileting, transfers, hygiene, and requires partial to moderate assistance with dressing. The care plan did not address the resident's preference on when to get up in the mornings. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No behaviors; -Presence of pain left blank. Observation on 4/17/24, at 5:30 A.M., showed the following: -Resident in his/her bed with eyes closed; -Nurse Assistant (NA) K and NA L entered the resident's room and turned the light on; -NA L woke the resident; -The resident said it doesn't feel like its time; -NA L told NA K the resident said he/she would get up but it doesn't feel like the right time; -The NA's got the resident dressed and used the mechanical lift to get him/her out of bed; -The NA's did not give the resident a choice about getting up; -Staff propelled the resident out to the dining room (breakfast was not to be served until 7:30 A.M.). 2. Review of Resident #36's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of dementia; -Usually understood and usually understands. Review of the resident's care plan, dated 4/26/23, showed the following: -The resident's memory isn't good; -Offer simple choices; -Explain what is happing to the resident. The care plan did not address the resident's preference on when to get up in the mornings. Review of the residents quarterly MDS, dated [DATE], showed the following: -Supervision/cues from staff for upper body dressing, toilet transfer, ambulate 51-150 feet; -Partial/moderate assistance from staff with toileting hygiene, lower body dressing and footwear; -Substantial/maximal assistance from staff with shower/bathe. Observation on 4/17/24, at 6:00 A.M., showed the following: -Resident in bed with his/her eyes closed; -NA L went into the resident's room, turned the light on and asked him/her if he/she is ready to get up; -The resident said no, but I guess I will; -The NA assisted the resident to the bathroom and to get dressed; -The resident said I want to lay back down; -The NA told the resident once he/she was dressed and ready for the day he/she could lay down for a while; -After the resident was dressed in clothes and shoes, staff assisted the resident back to bed. During an interview on 4/17/24, at 6:04 A.M., NA L said the resident doesn't like to get out of bed. The resident can be feisty when you try to get him/her up so you have to watch out. 3. Review of Resident #30's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of Alzheimers; -No behaviors or rejection of care; -Dependent with toileting, transfers, hygiene, and shower/bathe; -Requires substantial/maximal dressing, footwear, and bed mobility; Review of the resident's care plan, dated 12/14/23, showed the following: -The resident once was very sociable, now quiet and will give short answers to questions; -Respect the resident's wishes; -Requires help with dressing, grooming, toileting, and transfers. The care plan did not address the resident's preference on when to get up in the mornings. Review of the resident's quarterly MDS, dated [DATE], showed the resident is dependent with toilet hygiene, shower/bathe, dressing, footwear, personal hygiene, sit to lying, lying to sitting on side of bed, and transfers. Observation on 4/17/24, at 6:15 A.M., showed the following: -The resident in his/her bed with eyes closed; -NA K and NA L entered the resident's room, turned the light on and said it's time to get up; -The resident replied no; -NA K and NA L dressed the resident anyway; -NA K and NA L transferred the resident using the mechanical lift; -After cares were completed and the resident dressed for the day, staff took the resident to the dining room (breakfast was not to be served until 7:30 A.M.). 4. Review of Resident #27's face sheet showed the resident's had a durable power of attorney. Review of the resident's care plan, dated 10/18/23, showed the resident required partial/moderate to dependent assistance with dressing. The resident had limited physical mobility related to Alzheimer's disease and cognitive impairment. The care plan did not address the resident's preference on when to get up in the mornings. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent with bathing, transfers and personal hygiene. 5. Review of a resident roster showed Resident #15, #27, #30 and #36 all resided on Cardinal Lane. During an interview on 4/17/24, at 5:44 A.M., NA L said the following: -There was no list of residents to get up or a list of what time residents want to get up; -On night shift, the NA/certified nurse aides (CNA's) are expected to get up all the residents on this hall (referring to Cardinal Lane); -The night shift was not allowed to leave until the residents were are all up; -The night shift was supposed to end at 6:00 A.M.; -Some resident's fight staff, especially Resident #27 and Resident #36; -Resident #36 will usually lay back down after they get him/her up; -Resident #15 and Resident #30 do not like to get up, but they will, they just complain about it; -He/She tried to get Resident #27 up this morning but he/she tried to hit him/her (NA L) so he/she told the charge nurse that day shift would have to try to get him/her up later. During an interview on 4/17/24, at 6:15 A.M., Registered Nurse (RN) T said the following: -The aides on night shift get the residents up on Cardinal hall; -They are expected to get them all up unless there is an issue, otherwise day shift will not have time to get everyone out for breakfast. During an interview on 4/17/24, at 1:30 P.M., the Director of Nursing said she is not sure if there is a get up list or how the aides know who to get up in the morning. If a resident didn't want to get up, staff should try later. During an interview on 4/17/24, at 3:09 P.M., the Administrator said he/she did not know the night shift aides were supposed to get up everyone on Cardinal hall before they leave. If a resident does not want to get up, he/she would expect staff to try later.

Based on interview and record review, the facility failed to maintain and follow policies and procedures for immunization of residents against pneumococcal disease as required. The facility failed to provide and document provision of pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine for 14 of 16 sampled residents (Residents #1, #2, #4, #7, #11, #13, #17, #20, #21, #24, #27, #32, #34, and #142) and four additional residents (Residents #5, #8, #15, and #19) of which six residents (Residents #1, #4, #5, #8, #19, and #21) developed pneumonia. The facility also failed to offer and vaccinate eligible residents with the pneumococcal vaccine with recommended doses of the pneumococcal vaccine as indicated by the Centers for Disease Control and Prevention (CDC) recommendations. The facility census was 41. Review of the facility policy, Influenza and Pneumococcal Immunizations, revised 9/1/17, showed the following: -The facility shall ensure that: (i) Before offering the pneumococcal immunization, each resident, or resident's legal representative receives education regarding the benefits and potential side effect of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; (iv) The resident's medical record includes documentation that indicated, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; (B) The the resident either received the pneumococcal immunization or did not received the pneumococcal immunization due to medical contraindication or refusal; (v) Exception - as an alternative, based on an assessment and practitioner recommendation, a second pneumococcal immunization may be given after five years following the fist pneumococcal immunization, unless medically contraindicated or the resident or resident's legal representative refuses the second immunization; (vi) As there are two types of pneumococcal vaccines, (PPSV and PCV13), documented specific types of vaccines received prior to admission is very difficult. Our facility shall use the following protocol to establish a baseline: If NOT specified as to the type of vaccine received prior to admission AND it was received greater than three years ago (prior to September 1, 2014) than it shall be presumed to be the PPSV and therefore upon proper immunization consent, the facility shall first immunize with the PCV 13. After one year, a second PPSV may be administered if the initial immunization occurred before the age of 65 and the attending physician believes the individual falls into a high-risk group. If the vaccine is known for sure to be either the PPSV or PCV13, then the opposite vaccine shall be administered, as long as it has been at least one year between immunizations. Review of the facility policy, Protocol for Pneumococcal Immunization, revised 9/1/17, showed the following: -The Director of Nursing services shall be responsible for the immunization of the residents within this facility; -Upon admission, in coordination with the completion of the Minimum Data Set (MDS), section W, each resident shall be assessed for possible need for both the influenza and the pneumococcal immunization; -Upon admission, through medical history intake, the resident or legal representative is asked of the history of the pneumococcal vaccine; -If it is determined that the resident has never received the pneumococcal vaccine, the primary physician is contacted; -If there is no contraindications to receiving the immunization, the order is received and transcribed in the medical record; -The director shall document in the nurses notes that either the resident or the resident's legal representative has been educated regarding the benefits and potential side effects of the immunization; -If the immunization is not given, this shall also be documented in the nurses notes. Review of the CDC's recommendations for pneumococcal vaccine timing, dated 4/1/22, showed the following: -CDC recommends pneumococcal vaccination for adults [AGE] years old or older; -For adults who have never received a pneumococcal vaccine, or those with unknown vaccination history, one dose of PCV 15 (15-valent pneumococcal conjugate vaccine) or PCV 20 (20-valent pneumococcal conjugate vaccine) should be administered; -If PCV 20 is used, their pneumococcal vaccinations are complete; -If PCV 15 is used, follow with one dose of PPSV 23 (23-valent pneumococcal polysaccharide vaccine) with a recommended interval of at least one year; -For adults who have previously received PPSV 23 but who have not received any pneumococcal conjugate vaccine (PCV), one does of PCV 15 or PCV 20 may be administered with an interval of at least one year; -For adults [AGE] years or older without an immunocompromising condition, [CONDITION(S)], or cochlear implant, who have previously received PCV13 at any age, it is recommended to receive one dose of PPSV 23 at or after [AGE] years of age (at least one year after PCV13 was received). Their pneumococcal vaccinations are complete; -For adults [AGE] years or older with an immunocompromising condition who have previously received a PCV13 at any age, CDC recommends two doses of PPSV 23 before age [AGE] years and one dose of PPSV 23 at the age of 65 or older. Administer a single dose of PPSV23 at least 8 weeks after the PCV13 was received. -If the patient was younger than [AGE] years old when the first dose of PPSV23 was given and has not turned [AGE] years old yet, administer a second dose of PPSV23 at least five years after the first dose of PPSV23. This is the last dose of PPSV23 that should be given prior to [AGE] years of age. -Once the patient turns [AGE] years old and at least five years have passed since PPSV23 was last given, administer a final dose of PPSV23 to complete their pneumococcal vaccinations. 1. Review of Resident #4's face sheet showed the following: -He/She was over [AGE] years old; -His/Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's vaccination history showed the family reported the resident had received a pneumococcal vaccination in the past, but was unsure of the date. Review of the resident's medical record showed no evidence the resident received any type of pneumococcal vaccination and no evidence the facility offered the vaccine to the resident. Review of the facility infection preventionist tracking log showed the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/12/22, showed the pneumococcal vaccination was not offered. During an interview on 10/5/22, at 8:43 A.M., the resident's responsible party said he/she would prefer the resident be up-to-date on pneumococcal vaccinations, and would want the facility to give recommended vaccinations to the resident. 2. Review of Resident #5's Immunization Tracker, undated, showed the resident received a PPSV 23 in October 2007. Review of the Infection Preventionist's log, dated January 2022, showed the resident was diagnosed with pneumonia on 12/31/21, 1/13/22, and 1/26/22. Review of the resident's quarterly MDS, dated [DATE], showed the following: -admitted [DATE]; -The resident was over the age of 65; -The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's medical record showed no evidence the facility offered or the resident received a pneumococcal vaccine per CDC guidelines after October 2007, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine to the resident or his/her representative. During interview on 10/12/22 at 1:11 P.M., the resident's family member said the facility did ask permission to give the resident a pneumococcal vaccine, but he/she was unable to remember when this occurred. He/She said he/she gave the facility permission to give the resident the pneumococcal vaccine, but the facility didn't provide any information on the vaccine. 3. Review of Resident #19's Immunization Tracker, undated, showed the resident received PPSV 23 on 10/01/10 and PCV 13 on 11/19/15. Review of the Infection Preventionist's log showed the resident was diagnosed with pneumonia on 2/21/22 and 6/28/22. Review of the resident's MDS, dated [DATE], showed the following: -admitted [DATE]; -The resident was over the age of 65; -The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Infection Preventionist's log showed the resident was diagnosed with pneumonia again on 9/16/22. Review of the resident's medical record showed no evidence staff offered the resident the pneumococcal vaccination per CDC guidelines, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine to the resident or his/her representative. 4. Review of Resident #21's face sheet showed the following: -He/She was admitted on [DATE]; -He/She was over the age of 65; -His/Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's vaccination history showed the resident was up to date per hospital medical records. (Review showed no dates were documented to show when the resident received the vaccinations or which vaccinations the resident received.) Review of resident's nurse's notes, dated 9/16/22, showed the resident was diagnosed with pneumonia and started on oral antibiotic therapy. 5. Review of Resident #142's face sheet showed the following: -He/She was admitted on [DATE]; -He/She was over [AGE] years of age; -His/Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's vaccination history showed the resident had never had a pneumococcal vaccination. Review of the resident's medical record showed the resident had not received any type of pneumococcal vaccination. Review showed no documentation staff provided pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine to the resident. During an interview on 9/28/22, at 1:47 P.M., the resident said the following: -He/She was his/her own person (responsible party); -He/She had not ever been given a pneumonia vaccine; -The facility had not offered him/her a pneumonia vaccine; -He/She would like to get the pneumonia vaccine. 6. Review of Resident #7's face sheet showed the following: -admitted [DATE]; -The resident was over the age of 65; -The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's admission MDS, dated [DATE], showed the resident was not up to date with pneumococcal vaccination, and the vaccination was not offered. Review of the resident's Immunization Tracker, undated, showed the resident's family member reported the resident received the pneumococcal polysaccharide years ago (no date provided). The specific type of immunization was not documented. Review of the resident's medical record showed no evidence the facility offered or the resident received a pneumococcal vaccination while a resident at the facility, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine to the resident or his/her representative. During interview on 10/12/22 at 12:59 P.M., the resident's responsible party said he/she didn't remember the facility offering the resident a pneumococcal vaccine nor offering any education regarding the vaccine. He/She thought the resident was up to date with his/her vaccinations. 7. Review of Resident #11's face sheet showed the following: -admitted [DATE]; -The resident was over the age of 65; -The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's Immunization Tracker, undated, showed the resident's family member reported one dose of pneumococcal polysaccharide over three years ago. The specific type of vaccination was not documented. Review of the resident's medical record showed no evidence the facility offered or the resident received a pneumococcal vaccination after admission, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine to the resident or his/her representative. 8. Review of Resident #17's face sheet showed the following: -admitted [DATE]; -The resident was over the age of 65; -The resident was his/her own responsible party. Review of the resident's quarterly MDS, dated [DATE], showed his/her pneumococcal vaccination was not up to date and he/she had not been offered the pneumococcal vaccine. Review of the resident's undated Resident Immunization Tracker showed '1971' was handwritten in the date received or date refused column for the pneumococcal vaccine (no other information was listed specific to the type of vaccine received or refused). Review of the resident's medical record showed no documentation the facility offered or the resident received a pneumococcal vaccine, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine to the resident. 9. Review of Resident #32's face sheet showed the following: -admitted [DATE]; -The resident was over the age of 65; -The resident was his/her own responsible party. Review of the resident's quarterly MDS, dated [DATE], showed his/her pneumococcal vaccination was not up to date and he/she had not been offered the pneumococcal vaccine. Review of the resident's medical record showed no evidence the facility offered or the resident received a pneumococcal vaccine, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine to the resident. 10. Review of Resident #34's face sheet showed the following: -admitted [DATE]; -The resident was over the age of 65. Review of the resident's admission MDS, dated [DATE], showed his/her pneumococcal vaccination was not up to date and he/she had not been offered the pneumococcal vaccine. Review of the resident's undated Resident Immunization Tracker in the pneumococcal vaccine section showed 'believed to be no' was handwritten in the Date Received or Date Refused column. Review of the resident's medical record showed no evidence the facility offered or the resident received a pneumococcal vaccine since admission to the facility, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine to the resident or his/her representative. 11. Review of Resident #20's undated Resident Immunization Tracker in the pneumococcal vaccine section showed 'January 2021' was handwritten in the Date Received or Date Refused column with no other information listed specific to the type of vaccine received. Review of the resident's face sheet showed the following: -admitted [DATE]; -The resident was over the age of 65; -The resident was his/her own responsible party. Review of the resident's medical record showed no evidence the facility offered or the resident received a pneumococcal vaccine while a resident in the facility, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine to the resident. 12. Review of Resident #2's face sheet showed the following: -He/She was admitted on [DATE]; -He/She was over age 65. Review of the resident's undated vaccination history, undated, showed the resident had always refused in the past per family prior to the resident's admission. Review of the resident's admission MDS, dated [DATE], showed the pneumococcal vaccination was not up to date and had not been offered. Review of the resident's medical record showed no evidence the facility offered or the resident received a pneumococcal vaccine while a resident in the facility, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine to the resident or his/her representative. 13. Review of Resident #24's face sheet showed the following: -He/She was admitted to facility on 8/17/20; -He/She was over age 65. Review of resident's physician's orders, dated 6/28/22, showed an order to administer pneumococcal vaccinations per facility policy if not contraindicated. Review of the resident's vaccination history showed the resident received the PCV13, but there was no date documented. (Review showed no documentation staff offered the resident or the resident received or refused the PPSV 23 vaccination after administration of PCV13.) Review of the resident's medical record showed no documentation staff provided pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine to the resident or his/her representative. 14. Review of Resident #15's vaccination history showed the resident received the PCV13 in November 2016. Review of Resident #15's quarterly MDS, dated [DATE], showed the resident was over age 65; Review of the resident's medical record showed no documentation the facility offered or the resident received a pneumococcal vaccination per CDC guidelines after receiving the PCV13 in November 2016, and no documentation staff provided pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine to the resident or his/her representative. 15. Review of Resident #13's immunization tracker, undated, showed he/she received the PPSV23 and PCV13 in 2014. Review of the resident's face sheet showed the following: -admitted [DATE]; -The resident was over the age of 65. Review of the resident's medical record showed no evidence staff offered the resident the pneumococcal vaccination per CDC guidelines, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine to the resident or his/her representative. 16. Review of Resident #27's vaccination history showed the resident received a PPSV23 on February 2015 and PCV13 on 5/24/16. Review of the resident's face sheet showed the following: -He/She was admitted on [DATE]; -He/She was over [AGE] years old; -His/Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's medical record showed no evidence staff offered the resident the pneumococcal vaccination per CDC guidelines, and no documentation the facility provided pertinent information regarding the pneumococcal vaccine to the resident or his/her representative. During an interview on 10/5/22 at 8:35 A.M., the resident's responsible party said he/she would prefer the resident be up-to-date on pneumococcal vaccinations, and would want the facility to give recommended vaccinations to the resident. 17. Review of Resident #8's admission MDS, dated [DATE], showed the following: -admitted [DATE]; -The resident was over the age of 65; -The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Immunization Tracker, undated, showed the resident's family member refused the pneumococcal vaccine (no date documented). Review of the Infection Preventionist's log, dated September 2022, showed the resident was diagnosed with pneumonia on 9/19/22. Review of the resident's medical record showed no documentation the facility provided pertinent information regarding the pneumococcal vaccine to the resident or his/her representative. 18. Review of Resident #1's face sheet showed the following: -He/She was admitted on [DATE]; -He/She was over age 65; -His/Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's vaccination history showed the resident refused the pneumococcal vaccination on 3/31/22. Review of the resident's medical record showed no documentation staff provided pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine to the resident or his/her representative. Review of the resident's quarterly MDS dated [DATE], showed the following: -Cognition was intact; -Pneumococcal vaccination was offered and declined. Review of resident's nurse's notes, dated 9/22/22, showed resident was diagnosed with pneumonia and started on oral antibiotic therapy. Review of resident's nurse's notes, dated 9/23/22, showed the resident was hospitalized for pneumonia. 19. During an interview on 9/28/22 at 2:50 P.M., the previous Infection Control Preventionist said the following: -The Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) A were in charge of resident vaccinations; -He/She was never responsible for tracking resident vaccinations; -He/She did not look to see and/or track if residents who had been diagnosed with pneumonia were up to date with pneumonia vaccinations. During an interview on 9/28/22 at 3:20 P.M., the current Infection Preventionist said the following: -The ADON used to track pneumococcal vaccination status for residents; -After the ADON left, he/she thought everyone was following through with tracking the residents' vaccination status; -There has not been a real system for tracking pneumococcal vaccination status for a while. During an interview on 9/29/22 at 11:45 A.M., the ADON said the facility used to have a check list that indicated vaccination status with dates the vaccines were administered. She recently returned to the facility and was responsible for vaccinations, but delegated this task to LPN A. LPN A was to track and offer the vaccinations as needed. She was unaware why LPN A was not offering the vaccinations. During an interview on 9/29/22, at 3:17 P.M., LPN A said the following: -The prior DON tracked the pneumococcal vaccination status of residents; the prior DON had been gone since July 2022; -He/She had not been monitoring pneumococcal vaccination status for residents as it has not been assigned to him/her to track at the present time. During an interview on 9/29/22 at 3:20 P.M., the medical director said he expected the facility to follow the CDC's guidelines regarding pneumococcal vaccinations. The facility should work with residents and residents' families and offer and administer the vaccinations if needed/consented. During an interview on 9/29/22 at 6:12 P.M., the administrator said she expected staff to ensure residents were up to date with pneumococcal vaccinations per CDC guidelines and to offer vaccinations if they were not up to date. Staff should offer education regarding the vaccines to residents.

Based on observation, interview, and record review, the facility failed to ensure safety and adequate monitoring were provided to prevent falls; failed to consistently implement and modify interventions as necessary, in accordance with current standards of practice; and failed to update care plans with interventions to prevent falls for two residents (Residents #1 and #2), in a review of four sampled residents. The facility's census was 41. 1. Review of the facility's Fall Reduction Policy, dated 11/26/13, showed the following: -Purpose: To ensure that optimal objectives and interventions are met to attempt to prevent a resident from falling; -Goal: To provide a mechanism of resident assessment that identifies the risk for falling with the focus on prevention, prompt intervention, investigation, and care plan updates; -Baseline assessments: Upon admission, all residents will be assessed for fall risk utilizing Fall Risk Assessment form. This assessment will be updated following the MDS schedule; -Upon completion of the Fall Assessment, all at risk residents shall be care planned to alert the staff of the fall risks; -If a resident demonstrates a decline in physical functioning, the nursing department shall request a physical therapy (PT) and/or occupational therapy (OT) screening. Should needed therapy intervention be identified, the attending physician shall be alerted so that an order can be received for an evaluation and treatment; -Should a resident fall, an all alert call is made for an in-house emergency response. If the resident is requiring immediate medical treatment, the following occurs: -A licensed staff member immediately assesses the scene of the accident/incident; -First aid is provided; -Vital signs are taken; -If the resident is complaining of any pain or obvious severe injury is present, the resident is back boarded and sent out via ambulance; -If the fall is without obvious trauma or head injury, then a complete assessment of the resident is completed prior to moving them from the floor; -Fall Huddle: -If the resident is stable, a fall huddle is held immediately and all responding staff shall evaluate the environment. Upon completion of the huddle, this information is analyzed (Refer to Root Cause Analysis (RCA)) to determine if the fall/incident was preventable and how to reduce the possibility of a repeated episode. The resident care plan will be revised/updated with the investigation information included. PT/OT and restorative programs will be reviewed for use for those residents with balance or gait problems. After each incident, the staff shall determine if a new intervention is needed to minimize a repeat fall. Options to consider may include soft mats next to the bed on the floor, personal alarms, mattress alarms, chair mat alarms, partial bed rails, low beds, alternate room assignment closer to the nurses' station, place resident in a wheel chair and move to the front dining room for better observation, or involve in an activity of interest; -Post Fall Root Cause Analysis (RCA): RCA is a process to find out what happened, why it happened, and to determine what can be done to prevent it from happening again; -Key points to RCA: 1. RCA is a useful process for understanding and solving problems; 2. Figure out what conditions and/or negative events were in place and preceded the fall; 3. Look at complex systems around the problem (fall, accident); 4. Identify key points of failure; 5. Determine solutions that address the root causes: internal, external, systemic; -Three areas to investigate for RCA of a fall: 1. Environmental/extrinsic conditions; 2. Internal/intrinsic conditions; 3. Operational/systemic; -Causation findings identified from the Fall Prevention Program: -External causes: noise, busy activity, lack of environment contrasts, placement of furniture, equipment and personal items; -Internal causes: poor balance, sleep deprivation, medications (type and amount), orthostatic blood pressure, endurance/strength, and the four Ps (pain, potty, position, panic); -Systemic causes: time of day, shift change/times, break times, day of week, location of fall, type of fall, routine assignments, staffing levels. -Top 10 Effective Fall Prevention Interventions: 1. Consistent staff that are held responsible for knowing the routines of the residents; 2. Determine cause of the fall-RCA; 3. Protect sleep; 4. Provide quiet, calm unrushed environment; 5. Engage resident in meaningful activities; 6. Offer opportunities to balance; 7. Toilet resident at resident needed times; 8. Relieve pain; 9. Reduce unnecessary medications-consider type, dose, frequency, noise accompanying medication care; 10. Contrast the environment-making items visible. 2. Review of Resident #1's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/6/17, showed the following: -[DIAGNOSES REDACTED]. -Cognition was moderately impaired; -Required extensive assistance of one staff for transfers and walking in the room; -Walking in the hallway occurred one to two times with physical assistance of one person; -Required extensive assistance of two or more staff for toileting; -Balance was not steady, only able to stabilize with human assistance during walking and turning; -Two or more falls without injury since the previous assessment on 12/12/16; -Two or more falls with injury since the previous assessment on 12/12/16. Review of the resident's Care Plan, dated 3/6/17, showed the following: -Sometimes stands better on legs than other times, depends on mood/wakefulness; -Sometimes requires one person to assist with transfer, but recently has been transferring on his/her own; -Propels self in wheelchair at times; -At risk for falls due to condition, recent falls, and medications; -Ensure the wheels on the bed and wheelchair are locked prior to transfer. The resident generally locks the wheels; -The resident will appear to be dozing and leaning forward at times. Some staff members have said this makes them nervous, but it is comfortable for the resident. Review of the resident's fall risk assessment, dated 3/8/17, shows a score of 15, indicating high risk for falls. Review of the resident's Physician order [REDACTED]. -[DIAGNOSES REDACTED] (cancer formed by malignant plasma cells) without reaching remission, generalized anxiety, and [DIAGNOSES REDACTED] (a rare disease that occurs from an abnormal protein deposit in body tissues and organs. Symptoms can include fatigue and weakness) -An order on 4/4/17 to decrease the resident's Fentanyl patch (topical narcotic pain medication that it slowly released through the skin over time) from 200 micrograms (mcg) an hour to 150 mcg/hour. Review of the incident report, dated 4/7/17 at 9:00 A.M., showed the following: -Staff responded to a noise in the dining room and found the resident on the floor in front of the wheelchair on his/her left side. The resident said he/she had fallen asleep and fell out of the wheelchair. The resident complained of knee pain. The resident was fully dressed with shoes on and the wheelchair was locked. The resident complained of dizziness; -Post Fall Interventions: Recent medication changes. Review of documentation from the weekly meeting with the Director of Nursing (DON) and Occupational Therapist (OT) showed the following: -On 4/7/17 at 9:00 A.M., staff found the resident on the floor of the dining room. The resident had fallen asleep and fell out of the chair; -Response: Offer to lay down. -Physical Therapy (PT)/OT: No-hospice Review of the resident's Care Plan showed an update, on 4/7/17, which said the resident was found on the floor in front of the wheelchair in the dining room. The resident was fully dressed with clothes on and wheelchair brakes locked. The resident had been dozing in the wheelchair earlier. The resident said, I fell asleep and I guess I fell out. Propels self in wheelchair. Tends to lean forward when resting/dozing. May straighten self briefly and then resume position when drowsy. (Review of the resident's care plan showed no evidence staff evaluated or implemented interventions to reduce the resident's risk from falling from his/her wheelchair.) Review of the resident's POS showed the following: -An order on 4/10/17 for Fentanyl patch to be 100 micrograms (mcg)/hour and decrease to 50 mcg/hour when the 100 mcg patches were gone; -An order on 4/13/17 to change hydroxyzine (antihistamine) from 25 milligrams (mg) by mouth (PO) every eight hours scheduled to every eight hours as needed (PRN). Review of the resident's Care Plan showed an update on 4/15/17 at 1:50 P.M. The resident was found on the floor in front of the recliner and obtained an abrasion to the left shoulder blade. Review of the resident's nurse's note, dated 4/15/17 at 1:53 P.M. showed staff found the resident on the floor. The resident obtained an abrasion to the left shoulder. There was no incident report found and no documentation from the weekly meeting with the DON and OT regarding the fall on 4/15/17. Review of the resident's medical record showed no evidence staff evaluated the potential cause for the fall and no evidence staff evaluated current interventions or implemented new interventions to prevent falls from the recliner. Review of the incident report, dated 4/16/17 at 4:30 A.M., showed the following: -The nurse responded to a noise in the resident's room and found the resident on the floor between the recliner and the wheelchair. The resident said he/she fell backward when trying to sit in the wheelchair. The wheelchair brakes were locked; -Post Fall Intervention: Locking equipment (bed, wheelchair). Review of documentation from the weekly meeting with the DON and OT showed the following: -On 4/16/17 at 4:30 A.M., staff found the resident on the floor of his/her room. The wheelchair brakes were locked; -Response: (left blank); -PT/ OT?: No-hospice. Review of the resident's Care Plan showed an update on 4/16/17 at 5:45 A.M. The resident was found on the floor between the recliner and the wheelchair. The resident said he/she fell back when trying to sit in the wheelchair. The wheelchair brakes were locked. Review of the resident's medical record showed no documentation staff evaluated current interventions or implemented new interventions to prevent the resident from falling. (The resident's wheelchair brakes were locked at the time of the fall on 4/16/17 at 4:30 A.M., however, the intervention staff documented on the incident report was locking equipment.) During an interview on 5/3/17 at 2:22 P.M., the DON said the intervention of locking equipment (bed, wheelchair) on the incident report in the post fall intervention section was a choice that could be automatically selected in the computerized system when staff completed the incident report and was not an individualized intervention. Review of the incident report dated 4/16/17 at 4:40 P.M. showed the following: -A visitor alerted staff the resident was on the floor of his/her room. The resident reported feeling dizzy and falling; -Post Fall Intervention: Encouraged fluids. Review of documentation from the weekly meeting with the DON and OT showed the following: -On 4/16/17 at 4:40 P.M., the resident was found on the floor of his/her room. The resident had been up walking around; -Response: (left blank); -PT/ OT?: No-hospice. Review of the resident's Care Plan showed an update on 4/16/17 at 4:40 P.M. The resident was found on the floor in the doorway of his/her room. The resident said he/she felt dizzy and fell . Review of the incident report, dated 4/26/16 at 11:50 P.M., showed the following: -Staff observed the resident fall from the wheelchair to the floor in the dining room. The resident was leaning forward and the wheelchair rolled out from under him/her; -Post Fall Intervention: Locking equipment (bed, wheelchair). Review of documentation from the weekly meeting with the DON and OT showed the following: -On 4/26/17 at 11:50 P.M., the resident got up from the wheelchair and lost his/her balance; -Response: (left blank); -PT/ OT?: (left blank). Review of the resident's Care Plan showed an update on 4/26/17 at 11:50 P.M. The resident was leaning forward to the point the chair rolled out from under him/her. (There was no intervention found on the Care Plan related to this fall.) During an interview on 5/3/17 at 2:12 P.M., the DON said the intervention of locking equipment (bed, wheelchair) for the falls on 4/16/17 and 4/26/17 referred to the manual locks on the bed and wheelchair. The resident received hospice services and hospice did not provide the automatic locking brakes/anti roll-back devices for wheelchairs. Review of the incident report, dated 4/27/17 at 2:50 A.M., showed the following: -Staff responded to a banging noise in the resident's room and found him/her on the floor in front of the door. The resident complained of right wrist pain; -Post Fall Intervention: The resident was brought to the nurse's station for observation. Other-camera. Review of the resident's Care Plan showed an update on 4/27/17 at 2:50 A.M. The resident was found on the floor of his/her room in front of the door. The resident complained of right wrist pain. An order was received for an X-ray of the right wrist. Review of the resident's medical record showed not evidence the facility evaluated the potential cause for the fall and did not include evidence the facility evaluated current interventions or implemented new interventions to prevent future falls. During an interview on 5/3/17 at 2:12 P.M., the DON said after the resident fell on [DATE], a camera was placed in the resident's room with a monitor located at the nurse's station to allow closer monitoring of him/her while the resident was in his/her room. The camera was removed a few hours later due to being needed for another resident. There were no further interventions implemented at that time. Review of the nurse's notes showed the following: -On 4/27/17 at 1:44 P.M., the resident received an X-ray of the right wrist in the facility at 9:00 A.M. A fracture was noted to the right wrist. At 9:55 A.M., the resident was transported to the hospital; -On 4/27/17 at 4:30 P.M., the hospital called and informed facility staff the resident would remain in the hospital for surgical repair of the right wrist fracture; -On 4/28/17 at 4:20 P.M., the hospital called and informed facility staff the resident was ready for discharge after right wrist surgical repair, plate placement, and casting. Observation on 5/3/17 at 10:05 A.M. showed the resident in a wheelchair propelling himself/herself in the hallway towards the dining room. The resident's right arm was in a cast. The resident propelled himself/herself into the dining room where he/she leaned forward in the wheelchair and closed his/her eyes. There were no staff members present within line of sight of the resident. The resident began leaning further forward and his/her wheelchair began to roll backwards. The resident appeared to be about to fall forward out of the chair when the surveyor requested the resident to sit up in the wheelchair. The resident did as requested and sat up in the wheelchair. The resident removed his/her house shoes and began propelling himself/herself through the dining room in bare feet. The resident stood up from the wheelchair on his/her own and began pushing the wheelchair out of the dining room and into the hallway. During an interview on 5/3/17 at 1:30 P.M., Certified Nurse Aide (CNA) B said to prevent falls for Resident #1, he/she tried to assist the resident when he/she was up walking alone and tried to check on him/her frequently and offer to lay the resident in bed or the recliner if he/she was sleepy. During an interview on 5/3/17 at 3:05 P.M., CNA C said to prevent falls for Resident #1, he/she tried to keep the resident in the wheelchair especially if the resident was really tired. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -[DIAGNOSES REDACTED]. -Cognition was moderately impaired; -Independent with transfers; -Supervision for walking in the room and hallway; -Balance was steady; -Two or more falls without injury since the previous assessment on 11/14/16. Review of the resident's Care Plan, last reviewed on 2/14/17, showed the following: -Fallen three times in the last three months; -At risk for falls due to medications and recent falls; -Ensure footwear is non-skid; -Inform the nurse of changes in gait, movement, or balance; -Check blood pressure regularly; -Ensure the wheels on the bed are locked; -Low bed against the wall to allow the resident to get out on the right side; -Mat on the floor next to the bed on the right side. Remove the mat during the day. Review of the incident report, dated 2/24/17 at 7:00 A.M., showed maintenance staff pulled the emergency light after finding the resident on the floor on his/her side. Nursing staff responded. The resident did not have on pants or undergarments and had on loose fitting shoes. A small amount of urine was observed on the floor; -Post Fall Intervention: Environmental factor. Consider therapy for strengthening. Review of the resident's medical record showed no documentation therapy staff evaluated the resident after the fall on 2/24/17. Review of documentation from the weekly meeting with the DON and OT showed there were no notes regarding the resident's fall on 2/24/17. Review of the resident's Care Plan showed an update on 2/24/17 at 7:10 A.M. The resident was found on his/her right side on the floor. The resident had on loose fitting shoes and was not wearing any pants or undergarments. There was a small amount of urine on the floor. (There was no evidence staff evaluated current interventions on the care plan or implemented new interventions to prevent the resident from falling.) Review of the incident report, dated 3/12/17 at 6:00 A.M., showed the following: -Staff found the resident on the floor in the doorway of the bathroom on his/her left side. The resident had a skinned left knee and shoulder; -Post Fall Intervention: Place bed in low position (intervention already in place on the resident's care plan, dated 2/14/17). Review of documentation from the weekly meeting with the DON and OT showed the following: -On 3/12/17 at 6:00 A.M., staff found the resident on the bathroom floor; -Actions: Transition to wheelchair. Review of the resident's Care Plan showed an update on 3/12/17 at 6:30 A.M. The resident was found on his/her left side on the floor of the doorway to the bathroom. The resident obtained a skinned area to the left knee and shoulder. Review of the resident's medical record showed no evidence staff evaluated the possible cause for the fall and no evidence to show staff evaluated current interventions or implemented new interventions to prevent future falls. Review of the resident's nurse's notes showed the following: -On 3/13/17 at 8:30 A.M., staff reported bruising to the resident's left shoulder area. The resident complained of pain and the physician was notified; -On 3/13/17 at 6:22 P.M., X-ray reports were received which showed a left clavicle fracture. Staff should transfer the resident with a gait belt and the resident was non-weight bearing to the left arm. Review of the incident report, dated 3/24/17 at 1:30 A.M., showed the following: -The resident was found on the floor of the bathroom on his/her right side; -Post Fall Intervention: Place bed in low position (intervention already in place on the resident's care plan, dated 2/14/17, and was also identified as an intervention following the resident's fall on 3/12/17.) Review of documentation from the weekly meeting with the DON and OT showed the following: -On 3/24/17 at 1:50 A.M., staff found the resident on the bathroom floor; -Response: Toilet at midnight; -PT/OT?: OT to evaluate and treat. Review of the resident's care plan showed an update on 3/24/17 at 1:40 A.M. The resident was found on his/her right side in front of the bathroom door. The walker was overturned in the doorway. No apparent injury. (There was no intervention found on the Care Plan related to this fall.) During an interview on 5/5/17 at 9:10 A.M., the DON said the intervention listed for the resident regarding the fall on 3/24/17 was for frequent monitoring. The DON's expectation was for staff to check on the resident every 15 to 30 minutes. The DON verbally instructed staff to complete these checks and there was no documentation kept of them. The frequent monitoring was discontinued after the resident appeared to improve. The DON was uncertain how long the resident remained on the more frequent monitoring. Review of the incident report, dated 3/27/17 at 3:45 A.M., showed the following: -The resident was found on the floor after sliding out of his/her recliner; -Post Fall Intervention: Frequent monitoring. Review of documentation from the weekly meeting with the DON and OT showed the following: -On 3/27/17 at 3:45 A.M., the resident slid out of the recliner and was found on the floor; -Response: (left blank); -PT/OT?: OT to evaluate and treat (repeated intervention from the fall on 3/24/17). Review of the resident's Care Plan showed an update on 3/27/17 at 3:45 A.M. The resident was found on the floor in front of the recliner. The resident denied knowing how he/she got there. It appeared the resident slid out of the recliner. (There was no intervention found on the Care Plan related to this fall.) Review of the resident's therapy documentation showed the resident began receiving OT services on 3/30/17. The resident did not receive any PT services. Review of the resident's nurse's note, dated 4/26/17 at 11:19 A.M., showed the nurse was called to the resident's room where he/she was found kneeling in front of the sink. The resident had cabinet doors open and was arranging several personal care items in baskets. The resident reported he/she got down to clean under the sink and could not get back up. Review of the resident's Care Plan showed an update on 4/26/17 at 11:20 A.M. The resident was found on one knee in front of the sink and had items form under the sink removed and surrounding the sink. The resident said he/she had gotten down there but could not get back up. There was no incident report found regarding this incident. During an interview on 5/3/17 at 1:30 P.M., CNA B said in order to the resident from falling, he/she tried to check on the resident frequently, keep the walker with the resident and ensure he/she used it. During an interview on 5/3/17 at 3:05 P.M., CNA C said to prevent falls for Resident #2, he/she tries to check on the resident frequently and keep the walker with the resident. If the resident was tired, CNA C would let him/her utilize the wheelchair. 4. During an interview on 5/3/17 at 2:22 P.M., the DON said the charge nurse at the time a fall occurs is responsible to complete an incident report which then goes to the DON and Administrator. The DON looks at the intervention listed to ensure it is appropriate. The DON started meeting weekly with the Occupational Therapist (OT) in February to go over falls and trouble shoot ideas and determine if the resident could benefit from therapy. Interventions were relayed to direct care staff verbally from the DON and the charge nurses would pass along the information in shift report. The DON also used a dry erase board to communicate fall interventions for resident to direct care staff. At the weekly meeting with the OT fall interventions were re-evaluated to see whether or not they were appropriate. During interview on 5/5/17 at 9:08 A.M., the DON said the facility had a fall committee that met every one to two months. The members included the DON, two CNAs, and the day shift charge nurse. The committee discussed the falls since the previous meeting and possible interventions were discussed. The DON met weekly with the OT to try and come up with fall interventions between the fall committee meetings. During an interview on 5/3/17 at 1:30 P.M., CNA B said he/she heard about resident falls from the charge nurse during shift report. During an interview on 5/3/17 at 3:05 P.M., CNA C said falls were discussed along with new interventions during change of shift report. Complaints MO 7 and MO 8

Based on interview and record review the facility failed to provide adequate supervision and monitoring of one resident (Resident #2), a resident with a history of aggressive behaviors and roommate conflicts, of three sampled residents, when the facility moved the resident into a room with another resident, (Resident #1) after a long period without a roommate. Two days after Resident #1 moved in with Resident #2, staff found Resident #2 cursing and standing over Resident #1 who laid on the floor. Staff found Resident #2 attempting to kick Resident #1 after the unwitnessed altercation. Resident #1 sustained a fractured coccyx as a result. The facility census was 52. 1. Review of Resident #2's care plan updates/revisions document with the entries signed by the Assistant Director of Nurses/Minimum Data Set/Care plan coordinator, dated 11/28/10 showed the following: -On 11/28/10 Staff unable to redirect the resident, the resident had anxiety, and tried to hit his/her roommate Resident #3 with his/her walker; -On 11/28/10 Resident #2 moved into an alternate room; -On 11/28/10 the resident cornered staff in a threatening manner, and was referred to a gero-psych unit at that time. Review of the the resident's history and physical dated 12/01/10 showed the resident had a history of [REDACTED]. The resident suffered from dementia and anxiety. Review of the resident's nurses notes dated 12/7/10 through 12/16/10 showed the following: -On 12/7/10 at 11:10 P.M. review of the hospital nurses notes provided by the facility showed the resident slapped a nurse while attempting to give him/her medications; - On 12/16/10 at 11:55 P.M. the resident yelled and cursed at staff. Review of the resident's care plan updates/revisions document with the entries signed by the ADON/MDS/Care plan coordinator, dated 12/16/10 showed the resident returned to facility from the hospital geriatric psych unit. Review of the resident's nurses notes dated 12/25/10 through 5/13/11 showed the following: - On 12/25/10 at 6:30 A.M. the resident hit a certified nursing assistant (CNA) staff member after attempts to redirect him/her from entering a resident's room; - On 1/1/11 at 10:25 P.M. the resident yelled and cursed at staff; - On 01/14/11 at 8:00 A.M. the resident was "verbally abusive" to all staff and residents in the dining room when being directed toward his/her table by staff; -On 1/29/11 at 12:30 P.M. the resident "verbally threatened" another resident for sitting in his/her dining room chair. Review of the resident's care plan updates/revisions document with the entries signed by the ADON/MDS/Care plan coordinator, dated 1/29/11 showed the resident verbally threatened another resident regarding a dining room chair. Review of the resident's history and physical dated 4/29/11 showed the resident with the following Diagnoses: [REDACTED]. -Mental disorders; -Alzheimer's (most common form of dementia); -Dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior). Review of the resident's physician orders [REDACTED]. -Xanax (an anti-anxiety sedative medication) as needed (PRN) for anxiety; -Aricept daily (a medication commonly used to treat Alzheimer's disease); -Seroquel twice daily (a medication commonly used to treat behaviors, abnormally excited or irritated mood). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 05/02/11, showed the facility assessment of the resident included the following: -Impaired vision; -Long term and short term memory problems; -Moderately impaired cognition and decision making abilities; -Short tempered and easily annoyed behavior; -Ambulates by self with setup only, walker for mobility; -[DIAGNOSES REDACTED]. -Resident on antipsychotic medication. Review of the resident's care plan dated 5/3/11 showed the facility identified problems and planned approaches including the following: -The resident had Alzheimer's and dementia; -Short and long term memory were not very good, staff to redirect the resident and keep a consistent routine; -The resident's vision was not very good, staff are to notify the eye doctor if needed; -The resident does not tolerate a roommate, was a very private person; -The resident does not like noise such as the radio or television; -Staff entering the room to turn down the bed aggravated the resident; -The resident can only tolerate the dining room for long enough to eat; -The resident curses and speaks to others in a belligerent tone, threatening manner, and takes antipsychotic medications; -Staff are to leave the resident alone to calm down when he/she becomes agitated, or provide PRN anti-anxiety medication; -The resident's environment to be kept as calm as possible; -The resident does not like activities, the resident prefers to be left alone. Review of the facility document care plan updates/revisions with the entries signed by the ADON/MDS/Care plan coordinator for the resident dated 5/11/11 through 5/13/11 showed the following: -No entry for dates for 5/11/11 and 5/12/11 during the introduction period of the new roommate for the resident, (roommate initiated 5/11/11); -On 5/13/11 an incident involving the new roommate, with the resident transferred from the facility. Review of the resident's nurses notes dated 5/13/11 at 8:05 A.M. showed the following: -The nurse was called to the room after staff heard cursing from the room of Resident #2 and Resident #1; -The nurse observed Resident #1 on the floor in the doorway, and Resident #2 with his/her arms braced in the doorway, standing above Resident #1 cursing profanity at Resident #1, with an apparent attempt to kick Resident #1; -Staff stepped between the residents, and walked Resident #2 back to his/her bed with the resident still cursing, and then attended to Resident #1. Review of Resident #1's nurse's notes dated 5/13/11 at 2200 (10:00 P.M.) showed the facility received the resident's x-ray results following the incident that same day. Results showed the resident with an irregularity suspicious for a nondisplaced fracture of the coccyx. Interview with Resident #3 (Resident #2's previous roommate) on 6/03/11 at 11:30 A.M. showed he/she said the following: -He/she had known Resident #1 and Resident #2 for many years; -He/she was Resident #2's roommate previously, but could not recall dates or time frames; -He/She considered Resident #2 to be confused, Resident #2 cursed at him/her and staff frequently; -Resident #1 was very quiet, and non aggressive. Interview with certified nursing assistant (CNA) A on 6/03/11 at 1:30 P.M. showed he/she said the following: -Resident #2 was very moody, and frequently agitated; -The resident ambulated well with a walker, could feed him/herself, and could dress him/herself with little staff assistance; -The resident was "very mean", and had Alzheimer's; -The resident was very territorial, and frequently agitated with staff entering his/her space; -He/She felt the resident should not have a roommate due to the resident's inability to get along with others; -He/She could not recall any special monitoring of Resident #1 or Resident #2 when they became roommates. Interview with Licensed Practical Nurse (LPN) B on 6/03/11 at 1:00 P.M. showed he/she said the following: -He/she had worked with Resident #2 for over a year, and Resident #1 since the resident's admission; -Resident #1 was quiet, had a reserved personality, with no history of provocative or aggressive behaviors; -Resident #2 was a "loner", liked the quiet, and had occasional aggressive behaviors; -The facility placed Resident #2 in a room by him/herself because of aggressive behaviors; -Resident #2 ambulated well with a walker, and required setup assistance with activities of daily living (ADL's); - Resident #2 was cognitively impaired, and suffered with Alzheimer's dementia; - Resident #2 was sent to a geriatric psychiatric inpatient care unit for an evaluation in December 2010 due to his/her verbally aggressive outbursts; -The resident had his/her medications adjusted, and had been reasonably well behaved since return from the hospital; -A few days after Resident #1 moved in with Resident #2, he/she was called to the room where Resident #2 was standing over Resident #1 yelling "Get him/her the hell out of here", and attempted to kick Resident #1; -Resident #1 sustained a fractured tailbone from the altercation; -The facility did not initiate or complete additional monitoring or checks after staff moved Resident #1 into Resident #2's room. Interview with the Assistant Director of Nursing (ADON), (also responsible for MDS assessments and care plans), on 6/03/11 at 2:00 P.M. showed she said the following: -Resident #2 had a labile personality, with mood swings; -Resident #1 had a docile personality, with no history of any behaviors; -Resident #1 had no history of physical aggression towards other residents; -Resident #2 had a verbal altercation with his/her previous roommate (Resident #3), possibly regarding noise levels, or a loud television; -The facility moved Resident #2 into a room by him/herself after problems with a previous roommate (Resident #3), because the census was low enough at that time; -Resident #2 did not like people in his/her room, and would often curse profanity at staff when they were in his/her room; -Resident #2 had varying levels of cognition due to Alzheimer's dementia; -Resident #2 ambulated well with a walker, and required setup assist with activities of daily living (ADL's); -A meeting between the DON, herself, and the administrator determined which resident would be a good fit as a roommate for Resident #2.; -Staff moved Resident #1 into the room with Resident #2 on 5/11/11; -The altercation between Resident #1 and Resident #2 occurred on 5/13/11; -No changes were made in Resident #2's or Resident #1's care plan when staff moved Resident #1 in with Resident #2. Interview with the DON on 6/6/11 at 3:15 P.M. showed she said the following: -Resident #2 had no behavior problems to her knowledge since his/her return to the facility in December 2010; -The resident had a problem with a roommate (Resident #3), in the past with television and noise incompatibility; -The resident had a "fast trigger" for behaviors, was verbally aggressive and frequently cursing at staff especially in the evening; -The resident had "good days and bad days" for behaviors; -The resident had no roommate from December 2010 through May 2011 because the facility was able to accommodate due to the facility census, until Resident #1 moved in as Resident #2's roommate; -A team meeting was held with the administrator and ADON to decide on a compatible roommate for Resident #2 when a bed was needed for a new admission to the facility; -The facility provided no additional monitoring when a roommate was introduced into Resident #2's routine, routine monitoring was done by staff during routine care of residents; -The facility made no change in the care plan when the facility introduced Resident #2 with a new roommate, Resident #1; -Resident #2's care plan reflected he/she did not do well with a roommate; -Resident #2's care plan reflected the resident's daily routine should be maintained; -Resident #2 was agreeable to a roommate during conversation with social services and the administrator; -Resident #2 had dementia, (and per facility assessment, moderately impaired cognition). Interview with the administrator on 6/03/11 at 10:10 A.M. and 6/6/11 at 3:38 P.M. showed she said the following: -Resident #2 had a history of [REDACTED]. -Resident #2 was in a room by him/herself because the facility census allowed after trouble with a previous roommate (Resident #3); -Resident #2 had recently been sent to a hospital based geriatric psychiatric unit in December 2010 for inpatient care evaluation and medication adjustment after physically threatening or intimidating an employee, and verbal outbursts; -Resident #1 was recently moved into Resident #2's room, due to full census and anticipation of a new admission; -Resident #2 had not exhibited aggressive behaviors in several months; -Resident #2 had agreed to allow a roommate when asked the day before the move; -Resident #2 suffered with dementia with varying levels of cognition; -Resident #2's care plan showed the resident does not do well with roommate and the resident's daily routine should be maintained; -Resident #1 had a quiet, reserved personality and had no history of provocative or aggressive behaviors; -She had a meeting with the DON to decide on a compatible roommate for Resident #2, Resident #1 was selected because he/she was quiet, and familiar with Resident #2; -Resident #2's care plan noted the resident did not do well with a roommate; -Care plan reflected that Resident #2's daily routine should be maintained; -A few days after moving Resident #1 into Resident #2's room, an unwitnessed altercation occurred with staff finding Resident #1 on the floor, with Resident #2 standing over the resident attempting to kick Resident #1; -Resident #1 complained of tail bone pain and was found to have sustained a possible fracture of that area; -The facility provided no additional supervision or monitoring of Resident #2 during the time frame when resident #2 and Resident #1 were roommates. Review of the undated facility Abuse Prevention policy showed the following: -Physical abuse is defined as hitting or displaying aggressive behavior towards a resident; -Abuse risk group include residents with dementia, history of psychological or behavior dysfunction; -The facility shall screen individuals that receive services to determine if the needs can be met by the facility; -The facility shall maintain the environment for safety and protection; -The DON is responsible for assessment, planning and monitoring of a resident with needs and behaviors which might lead to conflict, such as residents with a history of behaviors; -The DON shall deploy staff on each shift in sufficient numbers to meet needs of residents, and the staff has the knowledge required of individual needs. Complaint #