Every finding on record at Carroll House

Based on observation, interview, and record review, the facility failed to protect two resident's (Resident #18 and Resident #7) right to be free from physical abuse. On 6/15/25 LPN A followed Resident #18 into an unoccupied resident room rolled him/her out of the bed onto the floor multiple times and LPN A walked the resident backwards which resulted in the resident falling and sustaining a fracture of the right tibial plateau (a break in the top portion of the shinbone near the knee joint, that often occurs due to high-energy impacts such as falls). The resident was sent to the local hospital and transferred to another hospital for surgical evaluation. In addition, staff failed to protect Resident #7's right to be free from abuse when Resident #27 hit him/her on the back of the head. The facility census was 56. The Administrator was notified on 7/11/2025 at 2:30P.M. of an Immediate Jeopardy (IJ) which began on 6/15/2025. The IJ was removed on 7/14/2025 as confirmed by surveyor onsite verification. Review of the facility's undated Abuse and Neglect policy showed:- Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental, or physical condition cause harm, pain or mental anguish. - Corporal punishment, which is physical punishment, is used as a means to correct or control behavior. - Convivence is defined as the result of any action that has the effect of altering a residents behavior. that is not in the residents best interest. - Manual method means to hold or limit a residents voluntarily movement by using body contact as a method of physical restraint. - Mistreatment means inappropriate treatment of a resident. - Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. -The resident has the right to be free from abuse including freedom from involuntarily seclusion and physical or chemical restraint not required to treat the residents medical symptoms. Review of the facility's undated Resident Rights policy showed:-Residents have the right to be free from all abuse;-Residents shall not be subjected to physical, sexual, or emotional injury or harm.-Residents have a right to care which maintains or enhances the quality of life.Review of the facility's Person-Centered Interventions Behavior Management Program, dated 2022, includes:- When addressing a resident in crisis approach the person with a calm demeanor, avoid getting into a power struggle, utilize empathy and try to understand the residents point of view, respect the residents personal space and stand a little further back than arms reach (if you are too close to the person in crisis, then he/she may believe that you are being aggressive and that could further intensify the escalation of the event, Keep your hands to your side so the resident can see you have nothing you will use against them.- Person Centered Interventions includes guidance for a 2 to 3 person and did not include a physical de-escalation technique that could be used by only one staff member.1. Review of Resident #18's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/21/25, showed:-No cognitive impairment;-The resident had delusions;-The resident received antipsychotics (a class of medications primarily used to treat mental health disorders) daily;-Diagnoses included, schizophrenia, bipolar disorder, anxiety, and depression.Review of the resident's care plan, dated 05/29/25, showed:-The resident is at risk for falls;-The resident has behaviors;-Staff are directed to maintain a safe environment.Review of the nurse progress notes showed:-06/15/2025 at 04:00 A.M., the resident came to nurses station became verbally aggressive to LPN A. The resident said he/she will sleep where he/she chooses and went to room that was not the resident's room. LPN A went to the other room where the resident was in bed with the covers pulled over his/her head and pulled the covers down to verify it was the resident. The resident sat up in the bed and started grabbing, punching and scratching LPN A. LPN A utilized PCI technique, securing the resident's arms and lowering the resident to the floor onto his/her knees as the resident was kicking and screaming;-06/15/25 at 04:15 A.M., the Assistant Director of Nursing (ADON) went to the resident's room and the resident said his/her right knee hurt. The resident's knee was swollen; -06/15/25 at 05:31 A.M., the resident was sent to the hospital;-06/15/2025 at 08:17 A.M., the resident's guardian called and said resident was being sent to another hospital due to a fractured tibial plateau;-06/18/2025 at 05:47 P.M., the resident was re-admitted to the facility with diagnosis of right tibial plateau fracture.Review of the facility's Event Investigation dated, 06/15/25, showed:-At approximately 04:00 A.M., the resident became physically aggressive toward LPN A;-The resident initiated the altercation by pulling LPN A's hair and punching and scratching LPN A's head and arms;- LPN A implemented PCI technique and brought the resident safely to his/her knees to manage the aggression;- During this time the resident continued to resist by kicking his/her legs; -Certified Medication Technician (CMT) C and Certified Nurses Aide (CNA) A assisted the resident to bed. Observations and interviews with Resident #18 on 07/01/25 at 09:35 A.M. and 7/2/25 at 10:00A.M., showed: -The resident sat in a wheelchair with a brace in place to his/her right leg;-The resident said LPN A had got into it with him/her and broke his/her leg;-The resident said he/she was not usually in a wheelchair, but he/she had to be until the fracture is healed;-The resident said his/her right knee hurts, but pain medications help; -The night before the altercation with staff he/she had slept in a spare room, because his/her roommate snored;-He/she thought it was okay to sleep in another room;-On 06/15/25 at around 04:00 A.M., he/she walked to the empty room and LPN A followed him/her into the empty room;-LPN A told the resident he/she needed to get back into his/her bed;-LPN A went around the bed and started pulling up the sheets that the resident was laying on top of;-LPN A pulled the sheets up and rolled the resident out of bed and he/she got back into the bed and LPN A did it again multiple times; -The last time LPN A rolled him/her off the bed he/she got up and sat up on the bed and LPN A got in his/her face so he/she started punching and scratching LPN A;- He/she said, I should not have done that, but LPN A got in my face and All I wanted to do was sleep;-LPN A went to get CMT C and CNA A, because he/she was not able to stand up and could not put any weight on his/her right foot; - CMT C and CNA A helped him/her back to his/her room and into bed because his/her knees hurt; -He/She went to the hospital for a few days;-The hospital told resident he/she had a broken knee cap;- LPN A apologized and said he/she did not know she hurt him/her; - He/she is afraid of LPN A and a LPN A was still working at the facility. During an interview on 07/02/25 at 01:34 P.M., LPN A said:-On 06/14/25 the resident said he/she wanted to be moved to 400 hall and off the 200 halls, because the resident's roommate snored; -The resident went to an empty room and laid down;-The administrator told LPN A to get the resident to sleep in his/her own bed;-The administrator told LPN A not to let the resident sleep in another bed again;-On 06/15/25 at around 04:00 A.M., the resident came to the nurses station holding a pillow and said he/she could not sleep and he/she started down the hall to an empty room;-The resident went into an empty room and LPN A followed the resident;-The resident got in bed and covered up his/her head;-LPN A took the cover off the resident's head and told the resident he/she had to go back to the other room, because the administrator said he/she needed to sleep in his/her own room;-The resident stood up and started hitting LPN A;-The resident stepped toward LPN A and LPN A grabbed both of the residents' wrists and put them behind his/her back;-LPN A was facing the resident and walked the resident backwards toward the closed bathroom door;-When the resident and LPN A got to the closed bathroom door the resident went down to the floor and hit his/her knees and then the resident said ouch and that his/her knee hurt;-LPN A said he/she did not remember exactly how the resident got down to his/her knees;-The resident did not specify which knee was hurt at this time;-He/She did not pull the covers up and roll the resident out of the bed on to the floor at any time;-CNA A came down to the resident's room, because he/she said he/she heard some noise and the resident was setting on the floor at this time with his/her legs out in front of him/her.-CMT C came to the room and CNA A and CMT C assisted the resident back to bed;-The resident was complaining of knee pain;-The ADON had arrived at the facility and came to assess the resident;-He/She did not intentionally hurt the resident;-He/She did not want the resident to hurt himself/herself or others;-He/She should have left the room to get help and not try to de-escalate the resident alone;-The resident had a right to be safe at the facility. During an interview on 07/02/25 at 02:30 P.M., the Administrator said:-LPN A called the night that the incident happened and said the staff had dealt with the behavior;-He/She told LPN A to try to keep the resident in his/her own bed because that was the resident's bed;-LPN A said the resident had been up at the nurse's desk throughout the night;-The resident went into an empty room and LPN A followed/her;-The resident got in the room before LPN A did and had been covered up from head to toe;-LPN A took the covers down from the resident's head and the resident jumped up and went toward LPN A;-The resident started hitting/smacking LPN A;-LPN A said she used PCI training, but LPN A did not give any details;-LPN A said he/she got the resident to calm down by using PCI training;-LPN A said the resident fell down while the PCI technique was being administered and the resident complained of knee pain; -He/She did not feel this was abuse;-LPN A tried to keep the resident from harming himself/herself or others;-It was an unfortunate accident with no intent of abuse;-The resident had the right to be safe and free from accidents.During an interview on 07/02/25 at 03:47 P.M., CNA A said:-On 06/15/25 at around 04:00 A.M., LPN A did not call for help while he/she was in the resident's room;-He/She went to the resident's room, because he/she heard a sound like a trash can fell over;-When he/she got the resident's room the resident was sitting on the floor in front of the bed;-He/She has not seen LPN A be rude or rough with the residents;-The resident can be combative at times.During an interview on 07/02/25 at 04:12 P.M., CMT C said:-On 06/15/25 at around 04:00 A.M., LPN A did not call for help while he/she was in the resident's room;-CNA C told him/her to come to the resident's room;-The resident was sitting on the floor next to the bed;-The resident said LPN A hurt him/her;-He/she did not report the incident to anyone;-He/She had not seen LPN A be rude or rough with the residents;-The resident can be combative at times;-After CMT C entered the resident's room the resident told him/her LPN A hurt him/her;-The resident did not say how LPN A hurt him/her.During an interview on 07/02/25 at 04:43 P.M., the resident's physician said:-He was aware of the situation leading up to the fall;-The resident was combative with cares;-The resident was sent to the hospital for knee pain and found to have a right tibial plateau fracture.During an interview on 07/02/25 at 04:55 P.M., the resident's guardian said:-She was aware of the of situation;-The resident was combative with cares;-The facility did not report the resident was in pain;-She expects the resident to be safe and pain free.During an interview on 6/27/25 at 11:30 and 7/10/25 at 2:18P.M. the Ombudsman said:-The resident told her a staff member broke his/her knee;-The resident said he/she went to the hospital;-The resident did not say he/she was in pain at the time of the incident.2. Review Resident #7's Quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Diagnoses included: stroke, dementia and seizure disorder.Review of the resident's care plan, updated 06/22/25, showed staff educated the resident on not moving other residents' wheelchairs and to ask for staff assistance.Review of Resident #27's Annual MDS, dated [DATE], showed:-Severe cognitive impairment;-Verbal behaviors directed toward others;-Independent with the use of a wheelchair for mobility;-Diagnosis included, multiple sclerosis, thyroid disorder and high cholesterol.Review of the resident's care plan, dated 06/27/25, showed:-Used a wheelchair for mobility;-Impaired decision making.Review of the facility's investigation, dated 06/22/25, showed:-Resident #7 asked Resident #27 to move so he/she could get around him/her;-Both residents sat in wheelchairs;-Resident #7 moved Resident #27's wheelchair and went around him/her in the hall;-Resident #27 hit resident #7 with an open hand in the back of the head.Review of Licensed Practical Nurse (LPN) B written statement, dated 06/22/25, showed:-He/She sat at the nurses desk;-He/She observed Resident #7 go around Resident #27 in the hall;-Resident #27 reached out and slapped resident #7 with an open hand on the back of the head;-Resident #27 told Resident #7 to not come around him/her on this hall.Review of Resident #27 nurse's notes, dated 6/22/25 at 06:30 P.M., showed:-LPN B witnessed Resident #27 reach out and slap Resident #7 in the back of the head;- Resident #27 told Resident #7 do not come around him/her on this hall;-Resident #27 said Resident #7 was a [NAME].During an interview on 07/02/25 at 08:21 A.M., LPN B said:-He/she was at the nurse's desk on 06/22/25;-Resident #7 moved Resident #27's wheelchair and went around Resident #27:-Resident #27 reached out and slapped Resident #7 in the back of the head after he/she got around him/her;-Resident #27 told Resident #7 to not come around him/her on this hall;-Resident #27 said Resident #7 was a [NAME];-Resident #7 did not complain of pain;-Resident #7 did not say he/she was afraid of Resident #27.During an interview on 07/03/25 at 08:55 A.M., the Administrator said: -Resident #27 hit Resident #7 on the back of the head;-Resident #27 hit Resident #7, because Resident #7 moved his/her wheelchair;-Resident #27 told Resident #7 to stay off his/her hall;-Abuse is willful and intended;-Hitting is considered a form of abuse;-Resident #7 did not complain of pain;-Resident #7 did not say he/she was afraid of Resident #27;-He/She expected Resident #7 to be free from abuse;-He/She expected all residents to be free form abuse.During an interview on 07/03/25 at 08:58 A.M., the DON said:-Resident #27 hit Resident #7 on the back of the head;-Resident #27 hit Resident #7, because Resident #7 moved his/her wheelchair;-Resident #27 told Resident #7 to stay off his/her hall;-Abuse is willful and intended;-Hitting is considered a form of abuse;-He/She expected Resident #7 to be free from abuse;-He/She expected all residents to be free form abuse.MO256314At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review the facility failed to protect the rights of a resident's ability to make confidential phone calls to the state abuse and neglect hotline for three of the three sampled residents, Residents #16, #109, and #18, when the facility's provided phones would not allow any outgoing call to dial the Missouri abuse and neglect hotline number. This had the potential to impact all residents of the facility who wished to make a phone call to the Missouri abuse and neglect hotline. The facility census was 56. Review of the facility's policy titled, Residents Rights, undated, showed:-Residents have the right to exercise their rights. Encouragement and assistance is provided for the exercise of the resident's right as a resident and as a citizen. Residents may voice grievances and recommend changes to facility staff or to outside representatives free from restraint, interference, coercion, discrimination or reprisal.-Residents have the right to confidentiality. All information related to a resident's medical, personal, social, or financial affairs shall be treated confidentially;-The right to privacy in medical treatment, personal care, telephone and mail communications, visits and meetings of family and of resident groups. Residents should be treated with consideration and respect, with full recognition of their dignity and individuality;-The right to communicate freely, that residents may associate with and communicate privately with persons of their choice and send and receive mail unopened.1. Review of Resident #16's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/10/25 showed:-Cognition intact;-Independent with activities of daily living;-Diagnoses: high blood pressure and psychiatric mood disorder. During an observation of Resident #16 on 6/30/25 at 10:00 A.M., showed the facility phone would not reach the hotline, it would drop the call after a partial ring. During an interview on 6/30/25 at 10:00 A.M., the resident said:-He/she was not able to call the toll free abuse and neglect hotline phone number;-He/she was not allowed by the facility to use his/her personal phone due to guardian restricting resident from having a personal cell phone;-He/she was not allowed by the facility to access the internet on his/her personal devices for one month;-He/she would need to borrow another resident's personal phone to call the hotline, as all the facility phones will not go through to the state hotline phone number;-This upsets him/her and would like to be able to make a phone call, if needed. 2. Review of Resident #18's Quarterly MDS, dated [DATE] showed: -No cognitive impairment;-The resident had delusions;-The resident received antipsychotics (a class of medications primarily used to treat mental health disorders) daily;-Diagnoses included, schizophrenia, bipolar disorder, anxiety, and depression. Review of the resident's care plan, dated 05/29/25, showed:-The resident was at risk for falls;-The resident had behaviors;-Maintain a safe environment. During an observation of Resident #18 on 6/30/25 at 2:56 P.M., showed the facility phone would not reach the hotline, it would drop the call after a partial ring. During an interview with Resident #18 on 6/30/25 at 2:56 P.M., said:-He/she was not able to make phone calls to the state hotline as the calls seem to be blocked or cut off when he/she calls it; -He/she would have to ask to use another resident's personal phone in order to reach the hotline;-He/she reported the concern to staff, but nothing was done to fix the issue, was unsure of the date; -He/She felt angry when he/she could not call the hotline the night his/her knee was broken. During an interview with Resident #18 on 07/01/25 at 09:28 A.M., the resident said:-The facility blocked the state hot line on the resident's phone;-When the number was called it rang once and then nothing happened;-He/She tried the number four or five times and it did not work;-He/she tried to call on the resident's phone and the phone at the nurses desk and none of them worked;-There was a code used to dial long distance and he/she used that and it still did not work;-He/She wanted to call the state hotline the night his/her knee got broke, but he/she could not because the number did not work;-He/She felt angry when he/she could not call the hotline the night his/her knee was broken. 3. Review of Resident #109's Care plan, dated 6/24/25, showed:-Post traumatic stress disorder;-Cognition intact, but has attention deficit;-Psychiatric disorder;-Goal was for resident to not harm self or others. During an observation of Resident #109 on 6/30/25 at 1:15 P.M., showed the facility phone would not reach the hotline, it would drop the call after a partial ring. During an interview on 6/30/25 at 1:15 P.M., the resident said:-He/she is not able to use the facility phones to call out for help; -When he/she tried to call the abuse and neglect line, the facility phone would not work - Not being able to make calls to the hotline frustrates him/her and makes him/her feel helpless. -He/She told Certified Medication Technician (CMT) A about the phone not working but nothing had been done; -He/She had a right to call the state anytime he/she would like. 4. Observation of the Administrator on 6/30/25 at 1:00 P.M., showed:-The administrator attempted to call the hotline from his/her office unsuccessfully;-The administrator attempted to call the hotline from the all three of the residents (Resident #16, #109, and #18) phones unsuccessfully;-The administrator attempted to call the hotline from his/her personal cell phone and the call was successful;-The administrator attempted to make a call using the code prefix on the residents (Resident #16, #109, and #18) phone calls unsuccessfully;-The administrator had other staff try making a call to the hotline number from the resident's three phones and they were all three unsuccessful.Observation on 07/01/25 at 2:57 P.M., this surveyor tested the facility hand-held phone and the two desk phones that residents are allowed to use. All three phones did not successfully call the abuse and neglect hotline number.Observation on 07/01/25 at 2:59 P.M., this surveyor tested the hotline number using a personal cell phone and the call to the abuse hotline went through.Observation on 07/02/25 at 10:02 A.M., this surveyor tested the facility handheld phone and the two desk phones that residents are allowed to use. None of the calls went through to the abuse hotline.Observation on 07/03/25 at 9:00 A.M., this surveyor tested the facility handheld phone and the two desk phones that residents are allowed to use. None of the calls went through to the abuse hotline.Observation on 07/03/25 at 9:05 A.M., this surveyor tested the hotline number using a personal cell phone and the call to the abuse hotline went through. Observation on 07/03/25 at 10:35 A.M., showed the administrator dialed the state abuse hotline phone number on the phones at the nurse's desk and the number could not be reached. During an interview on 6/30/25 at 1:00 P.M., the Administrator said he/she attempted to dial the hotline from his/her office and the call dropped after one partial ring. The Administrator said that all residents can ask the nurses to use the desk phones and then they can dial the hotline number. He/She attempted to dial out from the two desk phones that residents can use and the resident's land line for public use and the call to the hotline dropped after one ring. The Administrator then attempted to call the same phone number with his/her own personal phone and the call went through. He/she said that there is a code used for long distance calls, but not needed for 1-800 numbers. The Administrator said the residents should be allowed to make and receive calls in private. During an interview on 6/30/25 at 3:00 P.M., the Assistant Director of Nursing (ADON) dialed the abuse and neglect hotline phone number from his/her office and received one partial unanswered ring and then a dead phone line. The ADON said that he/she had not needed to try dialing the hotline before but did not understand how it was not working in the building. She said there is a code to enter before long distance calls are made however the code is not working with the state hotline phone number. She then attempted to call a different number using the code, the phone number for Emergency Service calls and did not get through successfully either. The ADON Attempted to call the emergency phone service without using the code and it did not go through, and the call dropped. During an interview on 6/30/25 at 3:15 P.M., the Director of Nursing (DON) tried to dial the abuse and neglect hotline from his/her office and received one partial unanswered ring and then a dead phone line. He/she said that this phone line is confusing. He/she stated residents should be able to make and receive calls in private when needed. During an interview on 07/03/25 at 11:05 A.M., CMT A said:-Resident #109 told him/her the abuse hotline was not working, and was not sure how long it had been like this; -CMT A did not tell anyone;-CMT A thought the Director of Nursing (DON) and the Administrator already were aware of the phone not working;-He/She should have told the administrator immediately.During an interview on 07/03/25 at 11:18 A.M., the Administrator said:-She was just made aware the abuse hotline was not able to be accessed from the facility phones;-She expected staff to tell her immediately if the abuse hotline was not working;-The resident's should have easy access to the abuse hotline at anytime. During an interview on 7/03/25 at 11:30 A.M., the Administrator and the DON said residents have the right to call the abuse hotline from a facility phone and it should be a successful call. They did not believe that they should have to borrow a phone from another resident to place the call. The Administrator was not sure how long this had been going on. MO256236

Based on interview, and record review, the facility failed to investigate an allegation of abuse when (Resident #18) reported to facility staff he/she had been abused by LPN A which resulted in the resident falling and sustaining a fracture of the right tibial plateau (a break in the top portion of the shinbone near the knee joint, that often occurs due to high-energy impacts such as falls). The facility census was 56.Review of the facility's undated Abuse and Neglect policy showed:- Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental, or physical condition cause harm, pain or mental anguish;- Corporal punishment, which is physical punishment, is used as a means to correct or control behavior; - Convivence is defined as the result of any action that has the effect of altering a resident's behavior. that is not in the residents best interest. - Manual method means to hold or limit a residents voluntarily movement by using body contact as a method of physical restraint;- Mistreatment means inappropriate treatment of a resident; - Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone;-The resident has the right to be free from abuse including freedom from involuntarily seclusion and physical or chemical restraint not required to treat the residents' medical symptoms; - The facility must take the following actions in response to an alleged violation of abuse:-Thoroughly investigate the alleged violation;-Prevent further abuse from occurring;-Take appropriate corrective action as a result of the investigation findings. Review of the facility's undated Resident Rights policy showed:-Residents have the right to be free from all abuse;-Residents shall not be subjected to physical, sexual, or emotional injury or harm;-Residents have a right to care which maintains or enhances the quality of life;-The policy did not address what an abuse or injury investigation would include.1. Review of Resident #18's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/21/25, showed:-No cognitive impairment;-The resident had delusions;-The resident received antipsychotics (a class of medications primarily used to treat mental health disorders) daily;-Diagnoses included, schizophrenia, bipolar disorder, anxiety, and depression.Review of the resident's care plan, dated 05/29/25, showed:-The resident was at risk for falls;-The resident had behaviors;-Maintain a safe environment.Review of the nurse progress notes showed:-06/15/2025 at 04:00 A.M., the resident came to nurses station, became verbally aggressive to LPN A. The resident said he/she will sleep where he/she chooses and went to room that was not the resident's room. LPN A went to the room where the resident was in bed with the covers pulled over his/her head and pulled the covers down to verify it was the resident. The resident sat up in the bed and started grabbing, punching and scratching LPN A. LPN A utilized PCI technique, securing the resident's arms and lowering the resident to the floor onto his/her knees as the resident was kicking and screaming;-06/15/25 at 04:15 A.M., the Assistant Director of Nursing (ADON) went to the resident's room and the resident said his/her right knee hurt. The resident's knee was swollen;-06/15/25 at 05:31 A.M., the resident was sent to the hospital;-06/15/2025 at 08:17 A.M., the resident's guardian called and said resident was being sent to another hospital due to a fractured tibial plateau;-06/18/2025 at 05:47 P.M., the resident was re-admitted to the facility with diagnosis of right tibial plateau fracture.Review of the facility's incident investigation, dated 06/15/25, showed:-At approximately 04:00 A.M., the resident became physically aggressive toward LPN A;-The resident initiated the altercation by pulling LPN A's hair and punching and scratching LPN A's head and arms;- LPN A implemented PCI technique and brought the resident safely to his/her knees to manage the aggression;- During this time the resident continued to resist by kicking his/her legs;-Certified Medication Technician (CMT) C and Certified Nurses Aide (CNA) A assisted the resident to bed; -The investigation did not include an interview with the resident;-LPN A was not interviewed or questioned by Administration regarding the about specific details of how the resident got hurt; -CNA A and CMT C were not interviewed by Administration regarding what happened, on the night the resident was hurt -The facility's investigation was not thorough regarding the staff's response to the resident and how the resident was injured. Observations and interviews with Resident # 18 on 07/01/25 at 09:35 A.M. and 7/2/25 at 10:00A.M., showed: -The resident sat in a wheelchair with a brace in place to his/her right leg; - The resident said he/she and LPN A had got into it with him/her and LPN A broke his/her leg; - The resident said he/she was not usually in a wheelchair, but he/she had to be until the fracture is healed; - The resident said his/her right knee hurts, but pain medications help; -The night before the altercation with staff he/she had slept in a spare room, because his/her roommate snored;-He/she though it was okay to sleep in another room. -On 06/15/25 at around 04:00 A.M., he/she walked to the empty room and LPN A followed him/her into the empty room;-LPN A told the resident he/she needed to get back into his/her bed;-LPN A went around the bed and started pulling up the sheets that the resident was laying on top of;-LPN A pulled the sheets up and rolled the resident out of bed and he/she got back into the bed and LPN A did it again multiple times;-The last time LPN A rolled him/her off the bed he/she got up and sat up on the bed and LPN A got in his/her face, so he/she started punching and scratching LPN A;- He/she said, I should not have done that, but LPN A got in my face and All I wanted to do was sleep;-LPN A went to get CMT C and CNA A, because he/she was not able to stand up and could not put any weight on his/her right foot.- CMT C and CNA A helped the resident back to his/her room and into bed because his/her knees hurt; - He/She went to the hospital for a few days;- The hospital told resident he/she had a broken knee cap;- He/she is afraid of LPN A and LPN A was still working at the facility. During an interview on 07/02/25 at 01:34 P.M., LPN A said:-On 06/14/25 the resident said he/she wanted to be moved to 400 hall and off the 200 hall because the resident's roommate snored;-The resident went to an empty room and laid down;-The administrator told LPN A to get the resident to sleep in his/her own bed;-The administrator told LPN A not to let the resident sleep in another bed again;-On 06/15/25 at around 04:00 A.M., the resident came to the nurses station holding a pillow and said he/she could not sleep and he/she started down the hall to an empty room;-The resident went into an empty room and LPN A followed the resident;-The resident got in bed and covered up his/her head:-LPN A took the cover off the resident's head and told the resident he/she had to go back to the other room, because the administrator said he/she needed to sleep in his/her own room;-The resident stood up and started hitting LPN A;-The resident stepped toward LPN A and LPN A grabbed both of the residents wrists and put them behind his/her back;-LPN A was facing the resident;-LPN A walked the resident backwards toward the closed bathroom door;-When the resident and LPN A got to the closed bathroom door the resident went down to the floor and hit his/her knees and then the resident said ouch and that his/her knee hurt;-LPN A said he/she did not remember exactly how the resident got down to his/her knees;-The resident did not specify which knee was hurt at this time;-He/She did not pull the covers up and roll the resident out of the bed on to the floor at any time;-CNA A came down to the resident's room because he/she said he/she heard some noise;-The resident was setting on the floor at this time with his/her legs out in front of him/her;-CMT C came to the room and CNA A and CMT C assisted the resident back to bed;-The resident was complaining of knee pain;-The ADON had arrived at the facility and came to assess the resident;-He/She did not intentionally hurt the resident;-He/She did not want the resident to hurt himself/herself or others;-The resident had a right to be safe at the facility. During an interview on 07/02/25 at 02:30 P.M., the Administrator said:-LPN A called him/her the night that the incident happened and said the staff had dealt with the residents behavior;-The resident went into an empty room and LPN A followed/her;-The resident got in the room before LPN A did and had been covered up from head to toe;-LPN A the took the covers down from head from the resident's head and the resident jumped up and went toward LPN A. During a follow up interview on 07/11/25 at 10:05 A.M., the DON said:-She did not question LPN A about specific details of how the resident got hurt; -She did not question CNA A and CMT C about what happened on the shift the night the resident was hurt; -She did not complete a thorough investigation regarding the incident and how the resident was injured. During a follow up interview on 07/11/25 at 10:18 A.M., the ADON said:-The resident said his/her right knee hurt;-The resident's right knee was swollen;-She gave the resident an ice pack;-The DON sent the resident to the hospital for pain and swelling to the right knee;-She did not report abuse to the administrator after the resident complained of pain and was not part of any investigation regarding the resident's knee pain;-The resident did not say how his/her knee was injured. During a follow up interview on 07/11/25 at 10:45 A.M., the Administrator said:-If she had known that LPN A grabbed the resident by the wrists she would have completed a more thorough investigation of the incident and resident's injury; -LPN A actions fall into the facility's definition of abuse;-She should have investigated the incident as potential abuse;-She did not obtain specific details from LPN A on what PCI technique LPN A used;-She did not interview the resident;-She did not interview CNA A and CMT C immediately after the incident and not just have them write a statement.During an interview on 7/23/24 at 9:47 A.M., the resident's physician said:-He was not aware LPN A grabbed the resident by the wrists and walked resident backwards;-With the allegation of abuse reported by the resident to CMT C he would expect the facility to fully investigate the allegation to determine if abuse occurred.

Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner when floors, and vents were covered in dirt and debris, and when equipment in the kitchen was covered in dust and when the dry storage contained outdated food and hazardous chemicals and when the facilty failed to ensure the dishwasher sanitizer was checked before meal service. This could potentially impact all residents by dirt or debris coming in contact with food and food preparation areas and food being served on contaminated dishes. Additionally outdated food can be potentially hazardous due to spoilage. The facility census was 53. Review of the facility's Safe Food Handling Policy, dated 5/20/15, showed: -All food items should be stored and tightly sealed with an identifying label and date. Review of the facilty's Storage of Dry Food and Supplies Policy, dated 5/20/15, showed: -The store room must be neat and orderly; -Store chemicals in an area separate from food storage. Review of the facilty's Dish Wash Policy, dated 5/20/15, showed: -Check chemical dispensers for adequate supply of chemical three times a day. The facilty did not provide the requested policy on cleaning of the vents in the kitchen. 1. Observation on 05/29/24 at 10:44 A.M., showed: - An open package of noodles dated 2024; -Vent by the plastic storage container with the cleaning rags was covered with dust and debris; -Trash can between the refrigerators was open and overflowing with food particles running down the sides; -Two empty card board boxes, a fan covered with dirt and debris, a bucket containing a black liquid with a mop standing in it next to a food storage rack; -A vacuum cleaner and scattered papers on the floor in front of the storage rack that contained [NAME] crackers coffee and cocoa; -A step ladder covered with dust setting next to the refrigerator; -The dishwasher sanitation log had no entries on 4/7/24, 4/24/24, 4/25/24. 4/31/24 and 5/9/24 through 5/29/24. -The floor in the dry storage room was dirty and sticky; -The trash can in the dry storage room was overflowing: -There was a can of unopened bleach powder and three gallons of germicidal bleach setting on a rack in the dry storage where other foods were stored; - Storage bin with sugar dated 3/15/22 and a storage bin containing flour dated 2/22/22; -Open package of rice with no date. During an interview on 5/29/24 at 1:22 P.M., the Dietary Manager (DM) said: - Maintenance is responsible for cleaning the vents in the kitchen; -He/She puts a maintenance order either in the binder or by word of mouth and that is how it is reported; -The vents should be cleaned at least every two or three months. He/She cleaned the vents the last time they were cleaned but could not remember when; -There should be no sticky substances on the floors in the kitchen; -Chemicals shouldn't be stored with food in the dry storage room; -The trash can should not be overflowing in the kitchen or in the dry storage room and the lid to the trash can should be closed. The trash cans should be clean free of food debris and dripping debris; -The stepladder should not be in the kitchen and if it is it should be clean; -The vacuum, the box fan covered in dust, the brooms and debris on the floor by where the [NAME] crackers were stored shouldn't be in the kitchen; -The sanitizer for the dishwasher should be checked three times a day before meal service; -The bins with the sugar and the flour in the dry storage should not be dated older than one year. During an interview on 5/29/24 at 1:50 P.M., the Registered Dietitian (RD) said: -He/She expected the kitchen to be clean and free of dirt and debris; -He/She expected the vents to be clean and free of debris and chemicals should not be stored in the dry storage room with food; -The trash should be emptied before it becomes overflowing the trash can lid should not stand open; -The dates on the sugar and flour should not be later than one year; -He/She expected the sanitizer concentration in the dishwasher to be recorded before every meal service; -The unnecessary clutter of the fan, the empty boxes and the brooms should be removed from the kitchen; -He/She expected the kitchen to be clean and sanitary. During an interview on 5/29/24 at 2:14 P.M., the maintence department said: -He/She was not sure how often the vents should to be cleaned in the kitchen; -The kitchen staff takes care of cleaning the vents in the kitchen; -Any work orders for maintence are put in a book but generally are given by word of mouth; -No work orders for cleaning the vents in the kitchen have been received. During an interview on 5/29/24 at 4:10 P.M., the Administrator said: -He/She expected the kitchen staff to keep the kitchen clean and sanitary; -He/She expected the kitchen staff to make sure the food is stored properly; -He/She expected the sanitizer in the dishwasher to be checked before meals; -The kitchen staff were responsible for reporting any repairs to maintenance.

Based on observation interview and record review, the facility failed to provide a dignified existence for three residents (Resident #2, #11 and #24) when the facility allowed multiple residents to remain in common areas with bare skin exposed with no staff intervention. This affected 3 out of 20 sampled residents. The facility census was 53. Review of the facility's undated Resident Rights Policy showed in part: -The resident shall be treated with consideration and respect and full recognition of their dignity and individuality. 1. Observation on 5/27/24 at 12:22 P.M. showed: -Multiple younger residents moving from table to table; -Multiple residents with their abdomen showing and upper buttocks showing; - Multiple residents yelling back an forth at each other and yelling at the kitchen; -The geriatric residents are staying seated while the younger residents are going up to the meal window yelling at the kitchen staff. 2. Review of Resident #2's Significant Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 4/3/24 showed: -Severe cognative impairment; -No mood behavior issues; -Maximum assist for Activities of Daily Living (ADL's -an individual's daily self-care activities such as eating, bathing, walking and transfers); -Incontinent of bowel and bladder; -Receives Hospice services; -Diagnoses included Alzheimer's Disease (a disease that affects the brain causing memory problems), arthritis, and high blood pressure. Review of the Resident's care plan dated 3/21/24, showed: -The resident requires the assistance of two staff for ADL's and transfers; -The resident has behaviors; -Avoid over stimulation; -Maintain a calm environment. During an interview on 05/28/2, at 04:24 P.M., the Resident's responsible party said: -It is very loud and busy at the facilty now and he/she is not sure the resident will be comfortable with the new residents; -Several of the residents are not dressed appropriately for this age group; -He/She had very little notice of the room change and that a group of younger, behavioral health residents would be moving into the facilty; -He/She has concerns that the new residents came so quickly and he/she is afraid that the younger residents will not interact the resident appropriately; -He/She has concerns that the new staff would not know how to take care of the resident; -He/She does not feel the resident would be as safe as he/she was in the past; -He/She is considering moving the resident because of this. 3. Review of Resident #11's Quarterly MDS, dated [DATE] showed: -Moderate cognative impairment; -Supervision for ADL's; -Occasionally incontinent of urine; -Diagnoses included heart failure, high blood pressure and high cholesterol. -Review of the resident's care plan dated 4/28/24, showed: -Provide the resident with support with ADL's; -The resident has anxiety; -The resident is a Do Not Resuscitate (DNR - medical order that instructs the health care provider to not no live resuscitative measures if a persons heart stops) code status. During an interview on 05/28/24 at 03:32 P.M., the resident said: -He/She has a lot of anxiety since the new younger residents moved in to the facilty; -He/She hates to go to the dining room now because the new residents are loud and yelling at each other; -The new residents need to pull their pants up and their shirts down; -He/She does not like to see all the exposed body parts when he/she goes to the dining room; -He/She used to keep the door to his/her room open but knows it is noisy and he/she doesn't feel safe; -The staff know he/she is concerned but nothing gets done. 4. Review of Resident #24's Quarterly MDS, dated [DATE] showed: -Moderate cognative impairment; -Supervision for ADL's; -Occasionally incontinent of urine; -Diagnoses included diabetes mellitus (too much sugar in the blood), high blood pressure and high cholesterol. -Review of the resident's care plan dated 12/28/23, showed: -Provide the resident support with ADL's; -The resident has pain; -The resident is a DNR code status. During an interview on 05/28/2, at 03:39 P.M., the resident said: -The new residents walk around with their bottoms and stomachs showing and he/she does not like that because it is disrespectful; -The staff tell them to pull their pants up but they fall back down again; -There was a fight in the dining room at supper last night:; -He/She feels like this is not his/her home anymore; -He/She sets next to a resident that talks all the time and it is upsetting and the staff will not move the resident; -He/She is nervous about leaving his/her door open because of the new residents. During an interview on 05/30/24 at 04:10 P.M., the Administrator said: -He/She expects that residents in the common areas and the dining room should be dressed appropriately; -All residents should treat each other with respect; -There should be no exposed skin. MO236514

Based on observation, interview, and record review the facility failed to follow their policy when the facility did not provide four residents a written notice regarding a room change, including the reason for the room change, before the facility moved the resident to another room (Resident # 3, Resident #2, Resident #11 and Resident #24), of the 14 sampled residents . These residents did not want to be moved and were emotionally upset about the room changes. The facility's census was 53. Review of the facility policy, Room Change, dated 2017 showed: -It is the policy of this facility to promote a resident's right to make choices and to promptly receive written notice of a room change or change in an assigned roommate. The facility supports the resident's right to refuse a room change made solely for the staff's convenience. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of the facility staff, the resident, family and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate and ask questions about the move. The room change or roommate assignment change notice will be issued as much as in advance as possible upon knowledge of the need for change. Documentation of the notice and response will be included in the medical record. The notice contains the reason for the room or change, the effective date of the change and the location to which the resident will be moved. 1. Review of Resident #3 Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 4/18/24 showed: -Brief Interview of Mental Status (BIMS) of 15, Indicated no cognitive deficit. -No behaviors -Moderate to dependence of staff for activities of daily living (ADL's: tasks completed in a day to care for oneself such as bathing, toileting, personal hygiene) -Diagnoses of Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration.), diabetes mellitus(a group of diseases that result in too much sugar in the blood) , anxiety disorder (a feeling of fear, dread, and uneasiness), and obstructive sleep apnea (occurs when the throat muscles relax and block the airway while sleeping). Review of the resident's medical record showed: -Nurse progress notes on 5/03/2024 at 1:16 P.M. resident's daughter and resident were notified of move/room change next week by Assistant Director of Nursing (ADON). His/her family mentioned possibly changing to a private pay room. -There was no written notice of room moves. During an interview on 5/28/24 at 9:40 A.M. Resident #3 said: - He/She had to move out of his/her room so multiple new residents could move in. -He/She was previously on the 400 hall. -He/She was not given written notice. -He/She was not given a choice about moving rooms. -He/She was told one day and moved rooms 2 days later. -This had all been very distressing for him/her. 46706 2. Review of Resident #2's Significant Change MDS dated [DATE], showed: -Severe cognative impairment; -No mood behavior issues; -Maximum assist for ADL's; -Incontinent of bowel and bladder; -Receives Hospice services; -Diagnoses included Alzheimer's Disease, arthritis, and high blood pressure. Review of the resident's care plan dated 3/21/24, showed: -The resident requires the assistance of two staff for ADL's and transfers; -The resident has behaviors; -Avoid over stimulation; -Maintain a calm environment. Review of the resident's medical record showed: -Nurses note dated 5/3/24 showed the resident's responsible party was notified by phone of the room move; -No written notice of the room move was found. During an interview on 05/28/24 at 04:24 P.M., the resident's responsible party said: -The facility called on 5/3/24 and said they where moving the resident to another hall so they could keep the new residents on the same hall; -The facilty did not give the resident a choice of rooms or to move; -He/she did not receive a written notice; He/she would have liked some time to talk this over more with the facilty. 3. Review of Resident #11's Quarterly MDS, dated [DATE] showed: -Moderate cognative impairment; -Supervision for ADL's; -Occasionally incontinent of urine; -Diagnoses included heart failure, high blood pressure and high cholesterol. -Review of the resident's care plan dated 4/28/24, showed: -Provide the resident with support with ADL's; -The resident has anxiety; -The resident is a Do Not Resuscitate (DNR - medical order that instructs the health care provider to not no live resuscitative measures if a persons heart stops) code status. Review of the resident's medical record showed: -Nurses note dated 5/3/24 showed he resident's family was notified by phone of the room move; -No written notice of the room move was found. During an interview on 05/28/24 at 03:32 P.M., the resident said: -The Assistant Director of Nursing (ADON) called on a Friday and the facilty moved him/her to another room on a Monday; -The facilty provided the resident with no written notice; -His/her family was called but nothing in written was provided to either of them; -He/she was not given a choice of a room or the choice to move; -The facilty just said his/her new room would be a certain number; -He/she would have like more notice before the room change. 4. Review of Resident #24's Quarterly MDS, dated [DATE] showed: -Moderate cognative impairment; -Supervision for ADL's; -Occasionally incontinent of urine; -Diagnoses included diabetes mellitus (too much sugar in the blood), high blood pressure and high cholesterol. -Review of the resident's care plan dated 12/28/23, showed: -Provide the resident with support with ADL's; -The resident has pain; -The resident is a DNR code status. Review of the resident's medical record showed: -Nurses note dated 5/3/24 showed he resident's responsible party was notified by phone of the room move; -No written notice of the room move was found. During an interview on 05/28/24 at 03:39 P.M., the resident said: -The staff told him/her to get ready to move to another room and only gave us a few days notice; -The staff did not let him/her choose a room the facilty told him/her the room he/she would be in; -He/she did not receive a written notice of the room move; During an interview on 05/30/24 at 02:25 P.M., the resident's family member said: - He/she did not receive a written notice of the facilty was going to move the resident; - He/she was verbally notified of the room move while at the facilty; - The facilty did not give the resident a choice of a room or the choice to move at all, the facilty said they were moving the resident; - He/she would have liked advanced notice in writing. During an interview on 05/30/24 at 04:10 P.M., the Administrator said: -The notification of the room moves are documented in the nurses notes of the residents that were here prior to the new residents admitting; -Residents should be provided a a written notice regarding a room change, including the reason for the room change, before the facility moved the resident to another room.

The facility failed to provide a comfortable and home -like environment for four of 20 sampled residents ( Resident #2, #11, #22 and #24) when they failed to ensure sound levels were not loud and uncomfortable in the dining room, when a resident was yelling and staff failed to intervene, and when the facility failed to ensure the door to the smoking area did not slam shut when residents went in and out and caused distress for one resident (resident #24). The facilty census was 53. Review of the facility's undated Resident Rights Policy showed: -The resident shall be treated with consideration and respect and full recognition of their dignity and individual preferences. The facility did not provide the requested policy regarding a comfortable and homelike environment. 1. Observation on 5/27/24 at 12:22 P.M. showed: -Multiple younger residents moving from table to table; - Multiple residents yelling back an forth at each other and yelling at the kitchen staff; -The geriatric residents stay seated while the younger residents are going up to the meal window yelling at the kitchen staff. 2. Review of Resident #2's Significant Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 4/3/24 showed: -Severe cognitive impairment; -No mood behavior issues; -Maximum assist for Activities of Daily Living (ADL's, an individual's daily self-care activities such as eating, bathing, walking and transfers); -Incontinent of bowel and bladder; -Receives Hospice services; -Diagnoses included Alzheimer's Disease (a disease of the brain that affects memory and reasoning), arthritis, and high blood pressure. Review of the Resident's care plan dated 3/21/24, showed: -The resident required the assistance of two staff for ADL's and transfers; -The resident had behaviors; -Avoid over stimulation; -Maintain a calm environment. During an interview on 05/28/24 at 04:24 P.M., the Resident's responsible party said: -It is very loud and very busy at the facilty now. - He/She has concerns that the new residents came so quickly and he/she was afraid the younger residents will not interact with the resident appropriately; - He/She said he/she talked to an employee and a lot of their staff are being replaced by the staff from another facilty and do not know how to take care of mental health residents; -He/She said he/she had concerns that the people would not know how to take care of the resident; -The resident has the right to a home like environment. 3. Review of Resident #11's Quarterly MDS, dated [DATE] showed: -Moderate cognitive impairment; -Supervision for ADL's; -Occasionally incontinent of urine; -Diagnoses included heart failure, high blood pressure and high cholesterol. -Review of the Resident's care plan dated 4/28/24, showed: -Provide the resident with support with ADL's; -The resident has anxiety; -The resident is a Do Not Resuscitate (DNR - medical order that instructs the health care provider to not no live resuscitative measures if a persons heart stops) code status. During an interview on 05/28/24 at 03:32 P.M., the Resident said: -He/She has a lot of anxiety since the new residents moved in; -Meals are late he/she hates to go to the dining room because he/she has to set by those people; -He/She needs help at meals and the old staff would take the time to help him/her but the new staff said they do not have time; -He/She used to keep the door to his/her room open but does not feel like it is safe to do so anymore; -The door to the smoke area keeps slamming shut and he/she can hear it even with his/her door shut; -His/Her family is going to move him/her out of the facility because he/she just can't take it. 4. Review of Resident #22's Annual MDS, dated [DATE] showed: -Moderate cognative impairment; -No mood or behavior issues; -Maximum assist for ADL's; -Diagnoses included Cerebral palsy (disorder of movement, muscle tone or posture) high blood pressure and anxiety. Observation of the dining room on 5/28/24 at 1:15 P.M., showed: -Resident #179 was pacing on 200 hall and was talking on the phone, yelling loudly and cursing; -Residents are sitting in the dining room nearby and were looking at the resident pacing and yelling on 200 hall; -Staff are sitting at the dining room tables assisting residents with eating; -The staff did nothing to intervene and no staff responded to resident #179 that was yelling on 200 hall; -Resident #22 asked to be removed from the dining room because of the noise and told staff it increased his/her anxiety and he/she did not eat. During an interview on 5/29/24 at 11:17 A.M., Certified Nurses Aide (CNA) A said: -He/She had no education about dealing with mental health residents; -He/She was setting at a table when Resident #179 got upset and was yelling and he/she didn't do anything because he/she didn't know what to do; -He/She was afraid to say anything incase Resident #179 flipped out on him/her; -It really overstimulated Resident #22 and he/she was crying and acting out then he/she yelled because he/she was so upset with the other residents yelling; - A lot of our geriatric residents have left because of the new residents. During an interview on 5/30/24 at 11:31 A.M., CNA B said: -He/She was here when Resident #179 got upset and he/she did not know what to; -He/She received no training; 5. Review of Resident #24's Quarterly MDS, dated [DATE] showed: -Moderate cognative impairment; -Supervision for ADL's; -Occasionally incontinent of urine; -Diagnoses included diabetes mellitus (too much sugar in the blood), high blood pressure and high cholesterol. -Review of the resident's care plan dated 12/28/23, showed: -Provide the resident with support with ADL's; -The resident has pain; -The resident is a DNR code status. Observation of 300 hall on 5/28/24, from 1:35 P.M. to 1:46 P.M., showed: -Resident #24 is in his/her room setting in a chair; -Multiple residents standing in the hall near the resident's room by the smoke room door; -Multiple residents walk out into the smoking area and the door loudly slams shut behind them; -1:39 P.M., a resident comes back inside from the smoke area and the door loudly slams shut; -1:41 P.M., a resident comes back inside from the smoke area and the door loudly slams shut; -1:42 P.M., a resident comes back inside from the smoke area and the door loudly slams shut; -1:45 P.M., a resident comes back inside from the smoke area and the door loudly slams shut; -1:46 P.M., a resident comes back inside from the smoke area and the door loudly slams shut. During an interview on 05/28/24 at 03:39 P.M., the resident said: -The resident that sets next to him/her at meals talk all the time and it upsets him/her and the staff will not move him/her. -The big problem is out side his/hers room is the door to their smoking area and the door slams hard every time someone goes in and out; -He/She goes to bed around 7:00 P.M. and the door is still slamming; -The slamming door makes him/her nervous; -He/She has told the staff about his/her concerns but nothing has been done so far. During an interview on 05/30/24 at 10:40 A.M., the resident said: -He/She is hearing the door close to the smoke area; -He/She has told the staff again but doesn't not remember who; -He/She liked things the way they were at the facility before the new residents came. During an interview on 5/30/24 at 11:31 A.M., CNA B said: -Some of the residents choose to stay in their rooms because of the noise and too much going on around them; -It gets pretty loud sometimes and he/she does not know how to make it any quieter or any better. During an interview on 05/30/24 at 04:10 P.M., the Administrator said: -He/She expects to have peaceful quiet areas in the facilty; -If the noise level is loud the staff ask the residents to turn down the noise level; -We try to keep the loud residents together and we cannot tell them they can't yell; -No one should be that uncomfortable in their own home.

Based on observation, interview and record review, the facility failed to assure resident Minimum Data Set assessments were completed accurately and timely for three of 14 sampled residents (Residents #177, #78 and #80 ). The facility census was 53. Review of the facility provided Minimum Data Set and Care Planning Guidelines, dated 10/1/2015 included; It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual, any published Interim RAI manual errata documents and applicable federal guidelines as the authoritative guide for completion of the MDS, CAAs and resident care planning. 1. Review of Resident #177's face sheet showed: - The resident admitted to the facility on [DATE]; - Diagnoses included: Schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), falls, pain in the right wrist, shortness of breath, generalized abdominal pain, nausea, diarrhea, pain, depressive episodes, low back pain, cough, bipolar disorder, migraine headaches, chronic obstructive pulmonary disease (a group of diseases that affect the lungs), diabetes mellitus (lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels), and anxiety. Review of the resident's medical record showed: -No completed MDS in the resident chart. -No care plan in his/her chart. 44395 2. Review of Resident #78 Face sheet showed: -He/she admitted to the facility 5/7/24 -Diagnoses of Schizoaffective Disorder, Edema (swelling) , Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Morbid Obesity (more than 80 to 100 pounds above their ideal body weight), Paranoid Personality Disorder (a mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate reason to be suspicious) , Pervasive Developmental disorder (characterized by delays in the development of social and communication skills) , Insulin dependent Diabetes Mellitus, Anxiety, Schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly). Review of the resident's medical record showed: -No completed MDS in the resident chart. -No care plan in his/her chart. 3. Review of Resident #80 Face sheet showed: -He/she admitted to the facility on [DATE] Diagnoses of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions.), difficulty walking, Cognitive Communication Deficit (difficulty understanding what is said, or inability to respond in a timely fashion), Glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), seizures (a sudden, uncontrolled burst of electrical activity in the brain), dermatitis (a common condition that causes swelling and irritation of the skin) , Kidney failure (a condition in which one or both of your kidneys no longer work on their own), Schizoaffective Bipolar type (a mental disorder characterized by episodes of mania (extreme highs) and sometimes major depression (severe lows)). Review of the resident's medical record showed: -Entry tracking record completed 5/8/24 -No completed MDS in the resident chart. -No care plan in his/her chart. 4. During an interview on 05/30/24 at 10:00 A.M. the MDS Coordinator said: -Admission MDS Assessments should be completed within 14 days and submitted within 21 days. -If the MDS was started it would show in progress in the medical record. During an interview on 05/30/24 at 4:10 P.M. with the Director of Nursing and the Administrator : -The DON said admission MDS should be completed in 14 days. Residents who admitted on [DATE]th, 8th, or 9th should have had a completed MDS. -The administrator said residents should have had a MDS completed within 14 days of admission.

Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for three of 14 sampled residents (Residents #8, #78 and #80). The census was 53. Review of the facility provided Minimum Data Set and Care Planning Guidelines, dated 10/1/2015 showed: It is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual, any published Interim RAI manual errata documents and applicable federal guidelines as the authoritative guide for completion of the MDS, CAAs and resident care planning. 1. Review of Resident #8 Admission MDS 5/1/24 showed: -admitted [DATE]; -Brief Interview of Mental Status (BIMS) of 14, indicated No cognitive deficits. -Vision was severely impaired , he/she wore corrective lenses; -Assist of 1-2 staff for Activities of Daily Living (ADL's: tasks completed in a day to care for oneself); -Continent of bowel and bladder; -Diabetic foot ulcers (wounds that are caused by the diabetes disease process); -Pressure reduction devices for the bed and chair; -Diagnoses of Unspecified fracture of right acetabulum (broken hip), fracture of the great toe, repeated falls, Constipation, Anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe.), hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis ( inability to move on one side of the body) following cerebral infarction (stroke), hypertension, Diabetes Mellitus (A group of diseases that result in too much sugar in the blood) with diabetic neuropathy (nerve damage that can occur if you have diabetes), chronic kidney disease(CKD: gradual loss of kidney function.), atrial fibrillation (a rapid and irregular heart beat), and peripheral vascular diseases (condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the medical record showed no comprehensive care plan for Resident #8. 2. Review of Resident #78 Face sheet showed: -He/She admitted to the facility 5/7/24; -Diagnoses of Schizoaffective Disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), edema (swelling) , Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), morbid obesity (more than 80 to 100 pounds above their ideal body weight), paranoid personality disorder (a mental health condition marked by a long-term pattern of distrust and suspicion of others without adequate reason to be suspicious) , pervasive developmental disorder (characterized by delays in the development of social and communication skills), insulin dependent Diabetes Mellitus lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels). anxiety, schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly). Review of the resident's medical record showed: -No completed MDS in the resident chart. -No care plan in his/her chart. 3. Review of Resident #80 Face sheet showed: -He/she admitted to the facility on [DATE]; Diagnoses of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions.), difficulty walking, cognitive communication deficit (difficulty understanding what is said, or inability to respond in a timely fashion), glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye), Parkinson's Disease, seizures (a sudden, uncontrolled burst of electrical activity in the brain), dermatitis (a common condition that causes swelling and irritation of the skin) , kidney failure (a condition in which one or both of your kidneys no longer work on their own), and schizoaffective bipolar type (a mental disorder characterized by episodes of mania (extreme highs) and sometimes major depression (severe lows)). Review of the resident's medical record showed: -Entry tracking record completed 5/8/24 -No completed MDS in the resident chart. -No care plan in his/her chart. During an interview on 05/30/24 at 10:00 A.M. the MDS Coordinator said: -Admission MDS Assessments should be completed within 14 days and submitted within 21 days. -If the MDS was started it would show in progress in the medical record. -Care Plans are completed after the MDS, within 7 days. During an interview on 05/30/24 at 4:10 P.M. with the Director of Nursing and the Administrator: -The DON said admission MDS should be completed in 14 days. Care plans are completed 7 days after the MDS is completed. -The administrator said residents should have had a MDS completed within 14 days of admission and a care plan within another 7 days. The process is 21 days total.

Based on record review and interview, the facility failed to review and update their facility-wide assessment to determine what resources are necessary to care for their residents competently during day to day operations and emergencies. The facility census was 53. The facility did not provide the requested policy regarding maintaining a facility assessment. 1. Review of the facility's 802/Matrix (a tool used by facilty staff to identify pertinent care areas for residents living in the facilty), dated 5/27/24 showed: -32 residents with behavior health needs; -The facilty census was 53. Review of the facility assessment, provided by the facility, showed: -The name of the administrator was incorrect; -Assessment review date with the Quality Assurance and Assessment/ Quality Assurance and Performance Improvement (QAA/QAPI) committee was 12/14/22; -Annual review date was 2/2/23; -The average daily census was 20; -Three residents with behavior health needs; -The information provided was incorrect. During an interview on 5/30/2024 at 4:10 P.M., the Administrator said: - The facility assessment has not been updated to reflect recent changes at the facility, including change of administrator; -The facility assessment should be completed within seven to fourteen days after a change; - It is the Administrator's responsibility to ensure the facility assessment is reviewed regularly and updated as needed.

Based on observation and interviews the facility failed to maintain infection control when two of 14 sampled resident's (Resident #177 and #178), nebulizer machines (a machine that turns liquid medication into a mist and is inhaled) and tubing were resting on the floor without a barrier. Additionally Resident #178's continuous positive airway pressure (CPAP) mask was observed resting on the floor and not on a barrier. The facility census was 53. The facility did not provide a policy regarding placement of nebulizer machines and CPAP mask's. 1. Review of Resident #177 record showed the following: -The resident was admitted to the facility on [DATE]; - Diagnoses included: Chronic obstructive pulmonary disease (COPD, a group of diseases that affects breathing), cough, and anxiety; - No Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff) or care plan had been completed; - A physicians order dated 5/21/24 for ipratropium- albuterol (a medication used to help make breathing easier and administered with a nebulizer machine) solution for nebulization 0.5 milligram (mg) -3 mg per vial. Administer 1 vial with the nebulizer machine every 6 hours as needed. Observation on 5/28/24 at 9:43 A.M. showed the resident's nebulizer machine sitting directly on the floor. The tubing and mouthpiece were lying on the floor. There was no barrier. During and interview and observation on 5/29/24 at 7:57 A.M. showed: - The resident's nebulizer machine on the floor with the tubing and mouth piece on the floor; - The resident said the nebulizer on the floor was the most convenient place for him/her because he/she did not have a table to set the nebulizer machine on; - If he/she had a table, he/she would store it on the table. 2. Review of Resident #178's record showed the following: - The resident was admitted to the facility on [DATE]; - Diagnoses included: Shortness of breath, cough and anxiety; - The resident's baseline care plan showed the resident used a CPAP machine; - No MDS or comprehensive care plan; - Physician's order dated 5/26/24 for ipratropium-albuterol 0.5 mg-3 mg per vial. Give 1 vial with a nebulizer machine every 6 hours as needed; - Physician's order dated 5/16/24 to clean the CPAP weekly on Sundays, including the head gear and tubing, filter, and distilled water chamber. Observation on 5/28/24 at 9:08 A.M. showed: - The resident's nebulizer machine, tubing and mouth piece on the floor with no barrier; - The resident's CPAP mask was lying on the floor with no barrier. Observation on 5/29/24 at 10:22 A.M. showed: - The resident's CPAP mask on the floor without a barrier; - The resident's nebulizer machine and tubing was lying on the floor with no barrier. During an interview on 5/29/24 at 11:00 A.M. the resident said he/she stored the nebulizer machine and his/her CPAP mask on the floor because he/she did not have a table to store them on. 3. During an interview on 5/30/24 at 9:3.1. the Infection Preventionist said: - He/She expected all nebulizer machines with their tubing and CPAP masks to be off of the floor; - There should be an elevated surface available for the resident to store those items; - Nebulizer tubing, mouth pieces and CPAP masks should not touch the floor and should be wrapped in a disposable bag. During an interview on 5/30/24 at 4:10 P.M., the administrator and Director of Nursing (DON) said nebulizer machine, tubing and CPAP masks should be in a bag and not on the floor.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year, failed to provide nurse aide's annual individual performance review or evaluation and competency,and failed to implement a tracking system for monitoring training hours. This effected two of two sampled nurse aides (Certified Nurse Aide; (CNA) D and CNA E) and had the potential to effect all staff and residents. The facility's census was 53. The facility did not provide a policy on education and competency. 1. Record review of the in-service records for CNA D showed: - A hire date of 6/15/2021; -Had less than twelve hours of in-service education per year; -No annual competency for 2023. 2. Record review of the in-service records for CNA E showed: -A hire date of 11/3/2023 with a previous hire date of 4/10/2014; -Had less than twelve hours of in-service education; -No annual competency. During an interview on 05/30/24 at 4:10 P.M. with the Director of Nursing and the Administrator said: -The Administrator said she started work at this facility a week ago; -Staff absolutely need training, particularly on how to deal with psychiatric illness and behaviors; -Registered Nurse (RN) A puts out booklets for education he/she wants the staff to have; -The DON and she will track training; -Competency should be completed annually or quarterly if there was an issue; -The DON said she began working at the facility a week ago; -She was not sure what education had been provided previously; -There was no tracking system for individual staff; -Competency should be completed at least yearly or as needed.

Based on interview and record review, the facility failed to clarify the status of the Resident #11's Do Not Resuscitate Order (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) when the resident's responsible party signed the revocation provision of the DNR, with out changing the order on the resident's Physician's Order Sheet (POS) to Full Code Status. This affected one resident (Resident #11). The facilty census was 53. Review of the facilty's Advanced Directive Policy, dated March 2015, showed: -The social services designee will inquire of the resident and/or his/her family members about the existence of any written advanced directives information; -Advanced directive shall be displayed prominently in the medical record under the advanced directive tab. 1. Review of the resident's DNR showed: - 10/16/23, The resident's responsible party signed the revocation provision, revoking the resident's DNR code status. Review of Resident #11's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 4/28/24 showed: -Moderate cognative impairment; -Supervision for ADL's; -Occasionally incontinent of urine; -Diagnoses included heart failure, high blood pressure and high cholesterol. -Review of the resident's care plan dated 4/28/24, showed: -admitted [DATE]; -Provide the resident with support with ADL's; -The resident has anxiety; -The resident is a DNR. Review of the residents POS dated 5/1/24 showed: -Order Start date 10/16/23: Code Status - DNR. During an interview on 05/30/24 at 09:55 A.M., Administrator said: -Social Services usually takes care of this and he/she is not here today; -If the resident is a DNR there should be an order on the POS that states the resident is a DNR; -If the revocation provision is signed that means the resident is no longer a DNR but is a full code and live saving measures would be given; -He/She expects the Social Service Director to ensure any discrepancy on the DNR is clarified; -He/She expects the DNR form to be filled out correctly.

Based on observation, interview, and record review the facility failed to train staff to adequately care for one resident (Resident #179) with behavioral health care needs, causing Resident #22 to feel unsafe within the facility. The facility census was 53. The facility did not provide a policy on education and competency. Review of education records for Certified Nurse Aide (CNA) A and B for August 2023-May 2024 showed no education on psychiatric illness and interventions. 1. Review of Resident #179 medical record showed: -admitted on [DATE]; -Diagnoses of: Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Post Traumatic Stress Disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), Autism (developmental disorder that affects how people interact with others, communicate, learn, and behave); -No base line care plan, no comprehensive care plan, no Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff). 2. Review of Resident #22 Annual MDS dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 12, indicated slight cognitive loss; -No behaviors; -Maximum assistance to dependence on staff for Activities of Daily Living (ADL's: tasks completed in a day to care for oneself); -Diagnoses of Cerebral Palsy (a group of conditions that affect movement and posture; caused by damage that occurs to the developing brain, most often before birth), Anxiety (a feeling of fear, dread and uneasiness), Hypertension (high blood pressure) and spastic quadriplegia (a permanent nerve and muscle disorder causing limitations with severe involvement of the legs and arms and floppiness of the neck.); 3. Observation on 05/28/24 at 1:15 P.M. showed -Resident #179 was pacing the 200 hall; -He/She was yelling loudly, and cursing into the telephone; -Multiple residents were sitting in the dining room, completing the noon meal, and watching resident #179; -CNA A was sitting at a dining table assisting residents to eat and observed resident #179 multiple times, and did not respond; -CNA B was sitting at a dining table assisting residents to eat and observed resident #179 multiple times and did not respond; -Resident #22 asked CNA B if he/she could assist him/her to his/her room. -CNA B assisted Resident #22 to his/her room and returned to the table. He/She did not respond to resident #179 pacing, cursing and yelling. During an interview on 5/29/24 at 9:34 A. M . Resident #22 said: -He/She had to be taken from the dining room because it was too loud and upsetting. During an interview on 5/29/24 at 11:04 A.M. CNA C said: -He/She transferred to this facility from another facility; -He/She had a quick reminder of how to use gloves and infection control prior to moving to the facility; - He/She did not get any further training. During an interview on 5/29/24 at 11:17 A.M. CNA A said: -He/She has been working at the facility for the last 8 to 9 months; -He/She was not provided any education on care of residents with psychiatric conditions; -He/She was sitting at the middle table when Resident #179 got upset and was yelling; -He/She did not do anything because he/she did not know what to do; -He/She was afraid to say anything to Resident #179 in case he/she flipped out; -It was really over stimulating. Resident #22 was crying and had to be taken to his/her room and did not finish his/her meal. During an interview on 5/30/24 at 11:31 A.M. CNA B said: -He/She was at a dining room table when resident #179 was pacing, yelling and cursing on the phone; -He/She did not know what to do to intervene; -He/She had no training for behavior management and psychiatric conditions. During an interview on 5/30/24 at 4:10 P.M. with the Administrator and the Director of Nursing (DON): The Administrator said: - Staff absolutely need training how to deal with agitated residents and psychiatric disorders; -He/She is unsure what education staff have completed; - Registered Nurse A completes all education; -He/She and the DON will track all training; -He/She expects competency to be completed at least every 12 months, or quarterly as needed for issues. The DON said: He/She did not know what education had been completed prior to his/her arrival last week; -Competency should be completed annually. MO236514

Based on record review and interviews, the facility failed to ensure that a resident to resident altercation that was investigated as abused was reported to the Department of Health and Senior Services (DHSS) within the required two hour time frame when Resident 1 slapped Resident #2 in the face on 12/18/23. The facility census was 21. Review of the reporting abuse and neglect policy dated November 2016 showed: - The facility staff were to report abuse allegations to DHSS within two hours after the allegation was made; - All employees of the facility are mandated reporters of abuse and neglect; - All allegations of abuse will meet the two hour reporting timeframe requirement even if it occurs during night shift, on the weekend, or during a holiday. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by the facility staff) Dated 11/5/23 showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 0, indicating sever cognitive impairment; - He/She had physical and verbal behaviors during the assessment period; - He/She was able to ambulate with a walker, and dependent on staff for personal cares; - His/Her diagnoses included: Dementia with behaviors (a disease that affects the brain, the residnet's ability to remember and impaired reasoning), insomnia (difficulty getting to sleep or staying asleep), and anxiety. Review of the resident's behavior care plan dated 11/16/23 showed: - The staff were directed to avoid over stimulation of the resident; - The staff were directed to divert the resident's behavior by offering the resident snacks; - The staff were to maintain a calm environment for the resident and redirect the resident when he/she had physical or verbal outbursts. 2. Review of Resident #2's quarterly MDS dated [DATE] showed: - He/She had a BIMS score of 14, indicating little to no cognitive impairment; - The resident was dependent to the wheel chair and on staff for showers; - The resident's diagnoses included: Stroke with left upper and lower extremity weakness, body weakness and depression. Review of the resident's Activities of Daily Living (ADL) care plan dated 2/9/23 showed he/she required the assistance of one staff member to shower. 3. Review of the medical record showed the following: - 12/18/23 11:50 A.M. Licensed Practical nurse A documented Resident #1 became agitated after staff took Resident #2 to the shower. Resident #1 attempted to follow Resident #2 and the staff member to the shower, the staff member told Resident #1 he/she could not follow Resident #2 into the shower room. Resident #1 slapped Resident #2 in the face. Staff seperated the residents immediately. Resident #2 did not have any injuries. 4. During an interview on 12/25/23 at 5:45 A.M. Certified Nurse Aid (CNA) A said: - He/She asked Resident #2 if he/she wanted a shower during the evening of 12/18/23; - Resident #1 was nearby and he/she said he/she would give Resident #2 a shower; - CNA A told Resident#1 he/she could not help with Resident #2's shower; - Resident #1 became agitated and with an open hand, slapped Resident #2 across the face; - Staff intervened and seperated the resident's; - He/She reported the incident to LPN A. During an interview on 12/25/23 at 6:31 A.M. Resident #2 said: - He/She was going to the shower; - Resident #1 hit/him/her across the face; - The resident did not know why Resident #1 was upset; - He/She was startled when Resident #1 hit him/her. During an interview on 12/25/23 at 6:55 A.M. The Assistant Director of Nursing (ADON) and Administrator said: - We discussed the incident, but did not think to report it to DHSS. - We should have reported the incident to DHSS with two hours of receiving the abuse allegation. During an interview on 12/26/23 at 10:50 A.M. the DON said he/she should have reported the incident to DHSS within two hours since there was an allegation of abuse. MO229224

Based on interview and record review, the staff failed to ensure the physician signed the resident's purple Outside of Hospital Do Not Resuscitate (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, CPR, if the resident's breathing sops or if a resident's heart stops beating) for one of eight sampled residents, (Resident #1) and failed to ensure two physicians signed the incapacitation form for Resident #8 and #5. The facility census was 16. Review of the facility's undated policy for advance directive showed, in part: - The facility will respect advance directives in accordance with state law; - Upon admission of a resident, the social services designee will inquire of the resident, and /or his/her family members, about the existence of any written advance directives; - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 1. Review of Resident #1's OHDNR order sheet showed; - The resident signed the form on [DATE]; - The physician did not sign the form. Review of the resident's quarterly Minimum Data Set, (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE] showed; - Cognitive skills moderately impaired; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's undated care plan, showed: - The resident was a Do Not Resuscitate (DNR). During an interview on [DATE] at 4:09 P.M., Licensed Practical Nurse (LPN) C said: - The purple OHDNR forms should be signed by the physician; - If the physician had not signed it, then he/she would consider the resident to be a full code. During an interview on [DATE] at 4:24 P.M., the Social Services Designee said: - He/she had been in the current position for about a year; - He/she tried to make sure the family or responsible party has signed it and then sends it to the physician to be signed; - Should make sure the physician has signed the form. During an interview on [DATE] at 2:58 P.M., the Director of Nursing (DON) said: - The OHDNR forms should be signed by the physician; - Social Services is responsible to make sure it has been completed. 2. Review of the facility's policy for completion of capacity verification form, revised [DATE] showed, in part: - The purpose is to assist facility staff and resident's medical providers in determining if a resident has the capacity to consent to or the withholding of care, medication, or medical procedures; - The policy does not state when there should one or two physicians to declare the resident incapacitated. Review of the Missouri statue 404.825. dated [DATE] showed: - Examination of patient required, content. - Unless the patient expressly authorizes otherwise in the power of attorney, the powers and duties of the attorney in fact to make health care decisions shall commence upon a certification by two licensed physicians based upon an examination of the patient that the patient is incapacitated and will continue to be incapacitated for the period of time during which treatment decisions will be required and the powers and duties shall cease upon certification that the patient is no longer incapacitated. One of the certifying physicians may be the patient's attending physician. The certification shall be made according to accepted medical standards. The determination of incapacity shall be periodically reviewed by the attending physician. The certification shall be incorporated into the medical records and shall set forth the facts upon which the determination of incapacity is based and the expected duration of the incapacity. 3. Review of Resident #8's OHDNR form, showed: - The resident's representative signed the form on [DATE]; - The physician signed the form on [DATE]. Review of the resident's capacity form showed: - One physician signed the form on [DATE]. Review of the resident's medical chart showed the Durable Power of Attorney (DPOA), did not specify if there should be one or two physicians to declare the resident incapacitated. Review of the resident's undated care plan, showed;- The resident was a DNR. Review of the resident's quarterly MDS, dated [DATE], showed: - The resident's cognitive status was not addressed; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Review of Resident #5's OHDNR form, showed: - The resident's representative signed the form on [DATE]; - The physician signed the form on [DATE]. Review of the resident's capacity form showed: - One physician signed the form on [DATE]. Review of the resident's medical chart showed the Durable Power of Attorney (DPOA), did not specify if there should be one or two physicians to declare the resident incapacitated. Review of the resident's undated care plan, showed; - The resident was a DNR. Review of the resident's quarterly MDS, dated [DATE], showed: - a Brief Interview for Mental Status score of zero, which indicated severe cognitive impairment; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 4:09 P.M., LPN C said: - He/she thought it had to be two physicians to declare the resident incapacitated. During an interview on [DATE] at 4:24 P.M., the Social Services Designee said: - He/she sends the incapacity form for the physician to sign; - The physician will either sign the form or come and see the resident and decide if the resident is incapacitated; - Once the physician had deemed the resident incapacitated, then it is sent to another physician for a signature; - There should be two physicians to declare the resident incapacitated. During an interview on [DATE] at 2:58 P.M., the DON said: - There should be two physicians to declare a resident incapacitated; - Social Services is responsible to make sure it has been completed.

Based on observation, interviews, and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary notice of Non-coverage (SNF ABN), CMS- for two sampled residents (Resident #3 & 16). The facility census was 16. Review of undated facility policy showed: -Please refer to Medicare claims Processing Manual, chapter 30 for general notice rquirements and detailed information about SNFABN. Information on the ABN (Form CMS-R-131) can be found on the ABN webpage: http://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html -A.) SNF's will continue to use the ABN Form CMS-R-131 when applicable for Medicare Part B items and services. -Completing the SNFABN -The SNFABN is available for download by selecting the 'FFS SNFABN' link from the menu on the wepage http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html. The SNFABN is a CMS-approved model notice and should be replicated as closely as possible when used as a mandatory notice. Failure to use this notice or significant alterations of the SNFABN could result in the notice being invalidated and/or the SNF being held liable for the care in question. 1. Review of the medical records for Resident #16 showed: -Notice of Medicare Non-Coverage (NOMNC) CMS- form provided and signed on 10/24/22. - Advanced Beneficiary Notice (ABN) form CMS-R-131 (3/11) dated 10/24/22. -No docmentation of SNF ABN CMS- form provided. 2. Review of the medical record for Resident #3 showed: -NOMNC CMS- form provided and signed on 7/29/22. -No documentation of SNF ABN CMS- form provided. -Used ABN form CMS-R-131 (3/11) dated 7/29/22. During an interview on 10/26/22 at 12:13 P.M., Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff) Coordinator said: -He/she was not aware of form SNF ABN CMS- . -He/she have not been using SNF ABN CMS- when providing beneficiary notices. -He/she was told to use. -He/she has always provided forms CMS-R-131 and NOMNC CMS- forms with beneficiary notices. During an interview on 10/26/22 at 12:16 P.M., Administrator said: -He/she was unaware that facility was using wrong form with beneficiary notices -His/her understanding was that ABN form CMS-R-131 was required to be provided to residents discharging from therapy.

Based on observations, interviews, and record review, the facility failed to assure residents have the right to file grievances in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievances, the right to obtain a written decision regarding his or her grievance. This had the ability to affect all residents. The facility census was 16. Review of the facility policy for grievance protocol showed: -Purpose of the Grievance/complaint Report and Grievance Log is to provide a written record on each resident and family concern and to insure proper follow-up through the appropriate discipline. -The Social Services Director is responsible for the program although the Administrator is ultimately responsible for the proper implementation of the program. The social Service Director informs the Administrator of each incident. -Guidelines: Any member of the Social Services staff can complete the Grievance Complaint Report. The appropriate situations for use of the Grievance Complaint Report are: -Resident articles that are lost or cannot be located; continual concern of lost resident items. This would include laundry concerns. -Resident care or personal hygiene issues that cannot be immediately resolved. -Resident or family concerns with dietary issues: diet or temperature of the meals. -Any resident or family concern with a staff member. -Any resident or family issue that would require a resolution. -The Social Service Director will: -Obtain the original Grievance Complaint Report. -Record the grievance on the Monthly Grievance Log. -Inform the Administrator of the grievance. -Forward a copy of the grievance to the appropriate discipline. -The Administrator and Social Service Director evaluate the Monthly Grievance Log for trends or patterns and devise an Action Plant to correct the issues. -A new Grievance Log should be completed each month. It should be presented at the QAA Meeting quarterly. Observation in facility on 10/25/22 through 10/28/22 showed: -No contact information of grievance official with whom a grievance can be filed posted in facility. -No grievance forms available in facility During an interview on 10/26/22 at 8:37 A.M. Resident #12 said: -He/she has never completed a written grievance about her concerns; -He/she does not know how to file a grievance; -He/she currently voices complaints during resident council minutes. During an interview on 10/26/22 at 8:47 A.M. the Social Services Director said: -Grievance process includes residents voicing concerns during Resident Council meetings -When residents come to him/her with a grievance he/she fills out a form. -He/she reviews complaints with Director of Nursing and the Administrator and they discuss an intervention. -He/she does not know if grievance information is posted in facility as he/she just moved into social service position last March. -Grievance forms are not available for the residents or families; -He/she fills out grievance forms for residents During an interview on 10/28/22 at 9:42 A.M. Resident #2 said: -He/she is unsure if the facility has grievance forms available. -He/she does not know where grievance forms would be located at. -If he/she has a complaint he/she tells MDS Coordinator or Social Services Director Social or mentions it to Laundry staff. -He/she has provided verbal grievances to the Social Services Director -He/she is not sure what to do if Social Services Director is not present in facility to file grievance but he/she would probably tell the Nurse, Administrator, or MDS Coordinator. -He/she does not know of access to obtain a grievance form. -Social service director just fills out grievance forms. During an interview on 10/28/22 at 9:54 A.M., Social Services Director said -Staff and residents are educated about ways to voice grievances or concerns via the rights paper I give them -He/she tells residents during resident council if they have anything they can come to him/her. -He/she is new in position and does not know how family members or residents file grievances after hours or anonymously because he/she has never had one. He/she believes they would probably tell the charge nurse that is in facility and believes the charge nurse would then provide a note on or under his/her door or that they would contact the administrator by phone. -He/she states there are no forms posted in facility. During an interview on 10/28/22 at 9:54 A.M. with Certified Nurse Aide (CNA) A said: -He/she would talk to resident if they voiced a grievance or concern and see if there was anything he/she could do to help then would notify the nurse. -He/she is not sure if there is a form for grievances -He/she has never had to do a complaint form. During an interview on 10/28/22 at 10:01 A.M. with CNA B said: -He/she would go to the nurse if received a complaint or grievance. If nurse didn't handle situation then would go to the Director of Nursing. -He/she is not sure if facility has a grievance policy/ During an interview on 10/28/20 at 10:10 A.M. with CNA C said: -He/she would let a nurse know if received a complaint/grievance from resident or family member. -He/she does not know the process as she is not facility staff but rather agency staff. During an interview on 10/28/22 at 10:18 A.M. MDS Coordinator said: -He/she states grievances are to be reported to Social Services Director whom is the social worker and she takes it from there. -He/she receives communication from Social Services Director if nursing needs to do something to address the grievance/complaint. -He/she states family members will usually tell nurses if they have a complaint and also communicate to social services coordinator. -He/she also reports complaints to his/her supervisor like the Director of Nursing and Administrator, whomever it applies to. -If it is weekend or after hours complaints and grievances are communicated via the nurse. -There is not a way that he/she is aware that individuals can make anonymous complaints. During an interview on 10/28/22 at 10:25 A.M. Licensed Practical Nurse (LPN) B said: -If he/she received a complaint would take it to the appropriate person including the Director of Nursing or the MDS Coordinator. -He/she is not sure if there is a grievance/complaint form. -He/she would verbally pass on the complaint. During an interview on 10/28/22 at 2:58 P.M. Director of Nursing (DON) said: -Most residents and families go to the Social Services Director for grievances as he/she has been here forever. -Social Services Director was not aware of grievance process. The DON showed Social Services Director today grievance book in Administrator's office and the form for grievances. -Administrator explained to Social Services Director the grievance process of giving grievances to appropriate department heads. -Department heads are to fill out on grievance form the action they took and return to social services director. -Social Services Director has the grievance form now and plans to spend some time reviewing policy. -Social Services Director has had no training for her job role. -Grievance forms are not accessible to family members of residents. -Unsure if facility should have grievance forms accessible after hours. -Facility does not have method to submit grievance forms anonymously.

Based on interview and record review, the facility failed to ensure staff provided written notice of transfer or discharge to residents or their responsible party and the reasons for the transfer in writing in a language they understood. This affected two of eight sampled residents, ( Resident #8 and #5). The facility census was 16. Review of the facility's undated policy for discharge/transfer of a resident, showed, in part: - The purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Explain transfer and reason to the resident and /or representative and give copy of signed transfer or discharge notice to the resident and /or representative or person responsible for care. NOTE: if emergency transfer, transfer or discharge notice form may be completed later, but as soon as possible; - Complete transfer form, copy any portion of the medical record necessary for care of resident; - Send original of transfer form and portions of medical record that was copied with the resident. Review of the facility's undated emergency transfer notice showed: - It did not contain the following pertinent information: - The reason for the transfer; - Statement of appeal rights including name, address (mailing and e-mail), telephone number of the entity and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 1. Review of Resident #8's progress notes, dated 7/25/22 showed: - 12:02 A.M., upon entering the resident's room observed the resident to be lying face down on blankets on the floor. The resident had a bloody nose with swelling and redness to nose. Resident with complaint of pain while attempting to assess range of motion. Physician notified and received order to send resident to the emergency room (ER) for evaluation and treatment. Director of Nursing (DON) notified and the responsible party notified. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/17/22 showed: - Cognitive skills for daily decision making not addressed; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's medical chart showed no documentation of a letter of reason for the transfer/discharge to the hospital sent with the resident or to the responsible party. 2. Review of Resident #5's progress notes, dated 10/22/22 showed: -4:57 P.M. 3:35 P.M. Resident call light noted to be on, upon entering room resident noted to be on knees next to bed with right arm behind body. Resident's body held in position and resident assisted from left side to back. The right arm stabilized during reposition. Shirt cut off for assessment as so not to move right arm. Resident Range of Motion (ROM) to left arm bilateral lower extremity (BLE) noted within normal limits (WNL). No noted shortening or deformity with palpitation. Resident had no noted signs or symptoms of pain or discomfort. Res continued to repeat common. Resident right arm noted to have external rotation at the elbow. Resident noted to have abrasion to bilateral knees. No noted bruising or redness noted to face or bilateral arm. Resident's bed in low position and winged mattress in place resident does attempt to get out of bed at times without assistance against nursing advice. Primary care physician called and order received to transfer. Resident left on back while awaiting Emergency Medical Transport. 3:48 P.M. 911 called. 5:00 P.M. local ambulance arrived. Local hospice notified. 4:10 P.M. local ambulance left with the resident. Review of Resident #5's quarterly MDS, dated [DATE], showed: - a Brief Interview for Mental Status score of zero, which indicated severe cognitive impairment; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical chart showed no documentation of a letter of reason for the transfer/discharge to the hospital sent with the resident or to the responsible party. During an interview on 10/26/22 at 2:15 P.M., the MDS/CP Coordinator said: - When a resident is sent out to the hospital, we do not send a transfer or discharge letter, we just send the transfer form, a copy of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - She sends a copy of the residents who were sent out to the Ombudsman monthly. During an interview on 10/28/22 at 2:58 P.M., the Director of Nursing (DON) said: - When a resident is sent to the ER, we should send a discharge letter with the resident and to the responsible party and it should be in plain language they resident and family can understand.

Based on interview and record review, the facility failed to ensure staff provided a bed hold policy to residents or their responsible party when staff transferred two of eight sampled residents, (Resident #8 and #5) to the hospital. The facility census was 16. Review of facility's undated bed hold guidelines, showed, in part: - This facility will notify all residents and /or their representative of the bed hold guidelines; - This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave. 1. Review of Resident #8's progress notes, dated 7/25/22 showed: - 12:02 A.M., upon entering the resident's room observed the resident to be lying face down on blankets on the floor. The resident had a bloody nose with swelling and redness to nose. Resident with complaint of pain while attempting to assess range of motion. Physician notified and received order to send resident to the emergency room (ER) for evaluation and treatment. Director of Nursing (DON) notified and the responsible party notified. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/17/22 showed: - Cognitive skills for daily decision making not addressed; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's medical chart showed no documentation of the a bed hold policy or the with the resident. 2. Review of Resident #5's progress notes, dated 10/22/22 showed: -4:57 P.M. 3:35 P.M. Resident call light noted to be on, upon entering room resident noted to be on knees next to bed with right arm behind body. Resident's body held in position and resident assisted from left side to back. The right arm stabilized during reposition. Shirt cut off for assessment as so not to move right arm. Resident Range of Motion (ROM) to left arm bilateral lower extremity (BLE) noted within normal limits (WNL). No noted shortening or deformity with palpitation. Resident had no noted signs or symptoms of pain or discomfort. Res continued to repeat common Resident right arm noted to have external rotation at the elbow. Physician called and order received to transfer. 3:48 P.M. 911 called. 5:00 P.M. local ambulance arrived. Local hospice notified. 4:10 P.M. Local ambulance with resident. Review of Resident #5's quarterly MDS, dated [DATE], showed: - a Brief Interview for Mental Status score of zero, which indicated severe cognitive impairment; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical chart showed no documentation of a bed hold policy or bed hold letter sent with the resident. During an interview on 10/27/22 at 10:26 A.M., the MDS/CP Coordinator said: - If the resident is going to be gone longer than 24 hours, they call the responsible party and asked them to come in and sign the bed hold; - If the resident is going to the ER to be evaluated and treated, we don't do anything with the bed holds because they are already getting billed for that day. If it's longer than 24 hours they send the bed holds. During an interview on 10/28/22 at 2:58 P.M., the Director of Nursing (DON) said: - The bed holds should be signed before the resident leaves for the hospital.

Based on observation, interview, and record review, the facility failed to provide appropriate interventions and adequate supervision to prevent one of ten sampled residents (Resident #3) from falling and obtaining a left hip fracture, when staff knew the resident's history of falls and knew the resident's spouse, who was also his/her roommate, had a history of [REDACTED]. The facility failed to monitor the resident's the use of psychotropic medications and possible need for a dose reduction, which put the resident at a greater risk for falls and injuries. The facility failed to coordinate care with the physician and hospice provider to assure the facility had the proper equipment and provided the proper education for staff on positioning to promote healing, comfort and alignment, which caused additional pain and suffering prior to the resident's death five days after the hip fracture. The facility census was 41. Review of the facility's policy on antipsychotic medications, dated 3/2012, showed: - Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition; - Residents will only receive antipsychotic medication when necessary to treat a specific condition for which they are indicated and effective; The attending physician and other staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions; - Nursing staff will document in detail an individual's target symptoms; - Antipsychotic medication will not be used if the resident only has one or more of the following symptoms, restlessness, impaired memory, wandering, poor self care, mild anxiety and nervousness. 1. Review of Resident #3's Health Care Power of Attorney, signed by the resident 2/19/13, showed: - My appointment of my healthcare proxy if my attending physician and another physician determine that I am no longer able to make decisions regarding my medical treatment, I direct my attending physician to follow health care instructions from my health care proxy, Family Member (FM) A. Review of the clinical hospice recertification note, dated 9/17/14, prior to the resident's admission to the facility provided by the facility as part of the resident's medical history, showed: - Resident had increased restlessness, confusion and restlessness, physician increased the resident's Seroquel (antipsychotic medication with sedating side effects) to 50 milligrams (mg) two times daily and Ativan (antianxiety medication with sedating side effects) 0.5 mg every six hours; - Resident had generalized weakness, fatigue, unsteady gait, recent falls, high risk for falls and preferred to use an assuasive device with ambulation. Review of the resident's medical record showed staff did not use a behavior monitoring tool to monitor behaviors for the use of psychotropic medications. Review of the resident's admission Bladder Incontinence Evaluation showed: - Poor vision, disoriented, multiple daily incontinent episodes; Review of the capacity verification (certification from a physician a person is no longer competent to make their own health care decisions), dated 10/31/14, showed: - Only one physician, the resident's primary care physician, certified the resident as not having the capacity to make health care decisions. Review of the facility's Advance Directive (a form used for a resident to express his/her wishes for when he/she is not longer able to verbalize them, and should only be completed by the resident) form, dated 10/31/14, showed: - The resident's non-invoked health care proxy, FM A, declined any healthcare measures to be initiated upon cessation of heartbeat, breathing or both; - Comfort measure only to be provided. Review of the undated care plan showed: - An admission date of [DATE]; - Mental wellness with the [DIAGNOSES REDACTED]. - Seroquel to assist with delusional disorder; - Assist with taking medications and report any mental status changes to the physician; - Mobility, unable to walk related to a unsteady gait, needed assist of one staff member with ambulation; - Frequently forgets to ask for assistance with ambulation, transfers independently. - Fall risk: ambulated him/herself frequently without assistance; balance and gait poor, frequently forgot he/she could not ambulate independently; fell several times at home; did not remember to call staff for assistance; safety alarm in place while resident in bed at the request of the family to alert staff when the resident attempted to get out of bed; FM B, who shared a room with the resident, would frequently remove the resident's bed alarm; monitor the alarm to make sure it was in the correct position and functioning properly; keep call light and personal items within reach; monitor for weakness, dizziness and behaviors; - Poor eyesight in the left eye related to frequent infections, keep room free of clutter and call light and personal items within reach. Review of the physician order [REDACTED]. - Ativan intensol range order 0.5 milliliters (ml) to 1 ml every one to two hours as needed for air hunger and anxiety; - Ativan 0.25 mg three times daily for anxiety; - Seroquel 50 mg two times daily. Review of the nurses' notes showed: - On 10/31/14, the resident admitted to the facility and came via private car with FM A; poor left eyesight related to pink eye; able to feed him/herself with set up; alert and oriented to self and family members; able to speak with delayed thought process and difficulty making his/her needs known; incontinent of bowel and bladder and wears a brief; ambulated with assist of one staff member and required assist with all activity's of daily living. Review of the hospice records showed: - On 10/31/14, fall risk assessment showed the resident was a high risk for falls; - On 10/31/14, slept 16 to 24 hours a day, did not have pain, independent with transfers and ambulation, coordination of care with facility staff; Review of the potential wanderer assessment, dated 11/1/14, showed: - Resident mobile, restless, paces, voiced desire to leave, confused and a high risk to wander. Review of the facility's fall risk assessment, dated 11/1/14, showed; - High risk for falls. Review of the side rail evaluation 11/1/14, showed: - Will get out of bed and wander; difficulty seeing out of right eye related to pink eye; - Gait problems with long distances, begins to shuffle. Review of the nurses' notes showed: - On 11/1/14, patient alarm required at bedtime per FM A's request; - On 11/3/14, patient alarm in place per the FM A's request; - On 11/4/14, no signs or symptoms of discomfort, difficulty making needs known to others; - On 11/5/14, no signs or symptoms of discomfort, change Ativan intensol scheduled medication to by mouth three times daily; - On 11/6/14, no signs or symptoms of pain or discomfort. Review of the hospice records showed: - On 11/6/14, wheelchair ordered and safety issues discussed with facility staff related to transfers, no complaints of pain and slept 16 to 24 hours a day with excessive daytime sleeping, high fall risk; Review of the nurses' notes showed: - On 11/7/14, at 4:15 A.M., resident observed on the floor, supine in front of the back side of the bed; resident stated he/she hit his/her head on the bed frame and his/her hip hurt; large knot noted on the back side of the resident's head; deep palpation of all joints with no abnormalities, but resident complained of hip pain when moved; at 4:35 A.M., notified the physician and orders given to give as needed morphine and monitor the resident; at 4:40 A.M., hospice nurse notified and instructed staff to give Ativan to reduce the resident's anxiety and the nurse would visit the resident later in the morning; at 8:30 A.M., resident complained of hip pain and morphine given; at 9:00 A.M., resident continued to complain of hip pain, but it was to early to give another dose of morphine, staff notified the physician; received new orders to increase the morphine from 10 mg every three hours as needed to 10 to 20 mg every two hours as needed and send the resident to the hospital for a x-ray of the left hip; at 10:00 A.M., hospice aware of new orders; at 11:00 A.M., the hospital called and said the resident did have a hip fracture and the family elected not to treat the fracture and return the resident to the facility with hospice care and comfort measures; at 1:40 P.M., the resident returned to the facility, with family present and moaned out with facial grimacing, morphine 20 mg given to the resident; at 4:00 P.M., received orders for the resident to stay on bed rest until the hip fracture healed. Review of the facility's fall investigation report, dated 11/7/14, showed: - Staff were not present when the incident occurred; - Bed alarm did not sound during the event; - Cause of fall: resident lost balance and was confused; - Severity level of the incident: minor. Review of the x-ray report dated 11/7/14, showed: - Displaced and angulated left intertrochanteric fracture of the left hip. Review of the hospice note, dated 11/7/14, showed: - Arrived at the facility and resident just finished x-ray to confirm left broken hip; - Facility staff awaiting orders for additional equipment for the resident; - After arrival to the facility the resident complained of pain with movement and moaned, 20 mg of morphine given prior to moving the resident to the bed; - Attempted to assist the assistant director of nursing (ADON) with removing the resident's pants; - The resident moaned and winced in pain with movement; - Received permission from the resident's family to cut his/her pants off to prevent movement. - Did not specifically mention an abductor pillow needed for the resident. Review of the care plan, dated 10/31/14, showed: - Updated 11/7/14, bed rest until left hip healed, needed assistance with all activity's of daily living; - Hospice care for the [DIAGNOSES REDACTED]. - Did not have pain, but morphine available if needed. Review of the neurological assessment (checks for neurological changes after a fall) completed after the fall showed: - On 11/7/14, staff completed 10 assessments and staff documented the resident did not have pain; - On 11/8/14, staff completed two assessments and documented the resident did not have pain; - On 11/9/14, staff completed two assessments and documented the resident did not have pain; - On 11/10/14, staff completed one assessment and documented the resident did not have pain. Review of the care plan, dated 10/31/14, showed: - Updated 11/11/14, Wong Baker (scale used to determine the amount of pain a person is having) pain scale for morphine dosing. Review of the medication administration record (MAR) for as needed medications showed: - On 11/7/14, staff administered morphine three times to the resident for hip pain and Ativan one time for anxiety. Review of the hospice records showed: - On 11/8/14, FM A asked about abductor pillow ordered to be put between the resident's legs related to left hip fracture, ordered on [DATE]. Staff to order if it did not get ordered, precipitating factors to pain included movement, morphine given for pain and intervention included positioning. Review of the nurses' notes showed: - On 11/10/14, resident yelled out with care and hip palpation, morphine given. Review of the hospice note showed: - On 11/10/14, abductor pillow ordered. Review of the MAR for as needed medications showed: - On 11/10/14, staff administered morphine to the resident five times for repositioning. Observation and interview on 11/10/14 at 11:00 A.M., the assistant director of nursing (ADON) said during the initial tour of the facility: - The resident fell last week, obtained a left hip fracture and did have pain with care after the fracture; - Two staff members entered the resident's room and after a few minutes the resident yelled out so loud this surveyor heard it through a closed door and sounded as if he/she were in pain. Review of the nurses' notes from 11/11/14, at 6:10 A.M., showed: - The resident complained of pain; as needed morphine given, facial grimacing noted. Observation on 11/11/14, at 8:40 A.M. showed: - The resident laid quietly in bed on his/her back and appeared comfortable and sleeping. Observation and interview on 11/11/14, at 9:25 A.M., showed: - Certified Nurse Aide (CNA) A and CNA B provided care to the resident; - During care, both CNAs rolled the resident onto his/her left hip; - The resident screamed out very loudly and exhibited facial grimacing until the CNAs completed the care and returned the resident to his/her back; - CNA A and B said no one instructed them to not turn the resident on his/her left side where his/her hip was fractured during care; - They rolled the resident on the left hip since the resident obtained the fracture the week before during care and positioning; - They were only instructed to log roll the resident and did not know the resident needed an abductor pillow in between his/her legs for positioning. Review of the nurses' notes on 11/11/14, at 11:45 A.M., showed: - Staff called the physician to see if pain medication could be scheduled due to increased pain and a physical therapy (PT) consult to assist staff with positioning for comfort; - Received order for morphine 10 mg every two hours scheduled and PT to evaluate for positioning. Review of the MAR for as needed medications showed: - On 11/11/14, staff administered morphine to the resident four times for repositioning. Review of the PT evaluation, dated 11/11/14, showed; - Evaluation for proper positioning device and education for staff on proper positioning of left lower extremity lateral bolster and abductor pillow (pie shaped pillow placed between the legs to assist with positioning, healing and alignment); - Resident presented with a frog-like leg position and increased pain when realigned in knee neutral position, after positioned the resident did demonstrate increased comfort with proper neutral position. Review of the mini in-service provided to staff by PT, dated 11/11/14, showed: - Discontinued use of positioning roll; abduction pillow in place. - Monitor and check placement every two hours and as needed. - Continue to avoid rolling resident to his/her left side. - Please notify charge nurse prior to repositioning. During an interview on 11/11/14, at 3:50 P.M., PT A said: - Rolling the resident on his/her left fractured hip would cause a lot of pain with the type of fracture the resident had; - He recommended an abductor pillow for a short period of time to assist with alignment of the hip, promote healing and provide comfort to the resident. During an interview on 11/11/14, at 5:00 P.M., FM A said: - He/she requested the facility keep the alarm on the resident at night because the resident frequently got up in the night at home and removed his/her incontinent brief and made a mess; - The resident mainly slept all day and night at home after hospice started the resident on Seroquel and Ativan; - Staff at the hospital told him/her it would be difficult to find a physician to treat the resident's hip fracture because of the resident's cancer and Hospice care being provided to the resident; - Surgery would be more painful to the resident; - Hospital staff did not present surgery as an option; - The resident yelled out from pain when the facility staff repositioned the resident; - He/she asked staff to remove the resident's spouse when they provided care because it upset the spouse related to the spouse's confusion; - The spouse acted like he/she wanted to hit staff when they provided care to the resident one time and doubled up his/her fist because he/she thought staff were hurting the resident; - The day the resident obtained the left hip fracture, a facility nurse told him/her the resident's alarm did not sound when the resident got out of bed and obtained the left hip fracture; - The resident's confused spouse went and found staff for help after the fall. During an interview on 11/12/14, at 10:30 A.M., the charge nurse, Licensed Practical Nurse (LPN) B said: - He/she did not know the resident took Seroquel, he/she did not do the admission; - Residents who take Seroquel should be monitored for side effects from the medication and the need for the use of the medication; - When the resident returned from the hospital after the fracture, he/she received orders for the resident to be on bed rest; - He/she did not ask for positioning instructions and if the resident needed an abductor pillow to keep the resident's hip aligned and the nurse from the doctor's office did not offer instructions; - He/she did not have a conversation with the family after the resident returned to the facility with the fractured hip about being told the resident could not have surgery because he/she received hospice care; - The hospital told him/her in report prior to the resident's arrival the family did not want the resident to have surgery; - Staff could roll the resident on the fractured left hip for care as long as they did not position the resident on his/her left hip; - He/she did not go to the in-service, but read the in-service; - He/she did not know of any interventions being provided for the resident prior to the fall with the exception of a safety alarm. Observation and interview on 11/12/14, at 11:06 A.M., showed: - The ADON said staff should never roll the resident on the left fractured hip, only position the resident slightly to the left to remove soiled linens if needed; - Staff finished providing care and the resident did not yell out and appeared comfortable when staff finished. During an interview on 11/12/14, at 11:50 A.M., the administrator said: - The resident received a left hip x-ray on an outpatient basis and did not see a physician at the hospital the day of the x-ray and did not see a physician since the fracture happened; - The facility did not know the hospital told the family the resident could not have surgery because he/she received hospice care and did not know who would have said that since the resident never saw a physician. Observation on 11/12/14, at 12:40 P.M., showed: - The resident lay quietly in bed on his/her back and appeared comfortable. During an interview on 11/12/14, at 3:00 P.M., the ADON said: - The resident seemed to be doing well with care and did not yell out when staff provided care after staff started using a abductor pillow and did not roll the resident on his/her left hip. Review of the MAR for as needed medications showed: - On 11/12/14, staff administered morphine to the resident two times for facial grimacing in addition to the scheduled 10 mg of morphine every two hours. Review of the nurses' notes dated 11/12/13, showed: - At 10:05 A.M., contacted the physician and requested orders for a urinary catheter to decrease discomfort with incontinent care; - Decreased food and fluid intake; - At 12:20 P.M., urinary catheter inserted with 500 milliliter return; - At 3:15 P.M., notified the physician of decreased by mouth intake, received orders to discontinue all medications except comfort medications; - At 7:00 P.M., resident awake and fidgeting, morphine given as ordered; - At 9:00 P.M., morphine given as ordered; - At 10:20 P.M., Resident did not have a pulse or respirations; - At 10:27 P.M., funeral home notified of the death. During an interview on 11/13/14, at 9:38 A.M., the ADON said: - The resident could walk with assist of one staff member prior to the hip fracture; - She talked with the night nurse who said he/she did not know why the resident's safety alarm did not go off; - She did not know if the resident's spouse went to find help when the resident fell ; - She talked with the FM A after the resident returned to the facility with the fractured hip, but she did not know the hospital told the family the resident could not have surgery because of receiving hospice care; - She requested that hospice to bring an abductor pillow on 11/8/14, and when she returned to work on 11/10/14, the resident did not have an abductor pillow; - She could not find one from a supplier and reached out to a friend who worked for an orthopedic (bone specialist) office who delivered the pillow the evening of 11/11/14. During an interview on 11/13/14, at 10:00 A.M., the director of nursing (DON) said: - Seroquel increased a resident's risk for falls and she expected the charge nurse caring for the resident to know if a resident received psychotropic medication to allow the nurse to assess for signs and symptoms of side effects of psychotropic medications; - The facility did check on the resident every fifteen minutes for the first few days after the resident's admission to the facility; - The facility did not document this but it was a standard of practice for the facility with all new admissions until they knew the resident's routine and they feel the resident was safe; - She expected staff to provide care to the resident in a way that avoided discomfort to the resident, only turning the resident slightly to the left if needed to provide necessary care; - She did not expect staff to position the resident or roll the resident on his/her left fractured hip; - The resident did much better with pain after staff added the abductor pillow and PT provided education to staff on positioning; - The facility used a daily behavior monitoring sheet to determine if psychotropic medications and dose reductions were needed, but the facility did not fill one out on the resident.