Every finding on record at Clara Manor Nursing Home

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when Certified Medication Technician (CMT) A put the palm of his/her hand over the resident's mouth and squeezed really hard, resulting in a scratch on the resident's right cheek, a circular bruise on the resident's left cheek, and the resident stating he/she was scared to death. The resident told two staff members and the facility failed to protect the resident by allowing CMT A to continue working his/her shift until 9:00 P.M. Twelve residents were selected for review. The facility census was 89 residents. The Administrator was notified on 11/18/25 at 1:20 P.M. of Immediate Jeopardy (IJ) which began on 11/12/25. The IJ was removed on 11/19/25. Review of the facility's undated policy titled, Policy Regarding Abuse and Neglect of Facility Residents, showed:-All suspicious crime including abuse shall be reported to the Administrator immediately. -Follow chain of command in the absence of the Administrator for reporting.-All suspected incidents must be investigated immediately.-The suspected victim must be protected immediately.-Employees who were involved with the suspects shall be suspended or terminated immediately.-Employees who were involved with the incident shall be suspended upon investigation.-All suspicious crime including abuse must be reported to law enforcement and/or the state surveyor agency in a timely manner.-Anything that appears even remotely suspicious should be reported immediately including all unexplained incidents of physical and/or verbal abuse.-Report to the charge nurse on duty, which in turn will report to the Administrator and/or Director of Nursing (DON), and physician.-The definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.-The definition of physical abuse was the use of physical force that may result in bodily injury, physical pain, or impairment. 1. Review of the facility's in-services showed CMT A attended an abuse in-service on 6/25/25. Review of Resident #1's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 10/14/25, showed the resident was cognitively intact. Review of the resident's undated face sheet showed he/she admitted on [DATE] his/her diagnosis included: cerebral infarction (blood flow to the brain is blocked resulting in brain tissue death), anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), and depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life). Review of the facility's investigation completed by the Administrator dated 11/17/25 at 6:45 P.M. showed: -Resident #1 stated CMT A grabbed his/her face after he/she was attempting to steal cigarettes off the medication cart.-Resident #1 was alert and oriented to person, place, and time.-Resident #1 was able to answer questions appropriately.-Resident #1 used a wheelchair for ambulation throughout the facility.-On 11/12/25 at 7:30 P.M.,--The Administrator received a message from the AIT stating Resident #1 stated he/she was assaulted by CMT A.--The Administrator instructed staff to give written/verbal statements and give them to the AIT.--The Administrator contacted CMT A and stated that he/she needed to leave and time out due to a reported accusation of abuse.--CMT denied abusing Resident #1-On 11/13/25:--Resident #1 was noted to have two areas of red/dark red ecchymosis (medical term for a bruise) on his/her jawline and neck approximately 2 centimeters (cm) x 3 cm and a scratch on his/her right side of his/her face.--The DON called the Administrator to inform him/her of the bruises he/she saw on Resident #1. Review of the resident's undated care plan showed:-He/She received an anti-depressant medication for depression.-He/She required extensive assistance with locomotion using a wheelchair.-An update, dated 11/12/25, bruising was present on his/her left side of his/her face and a scratch was on his/her right side of his/her face with bruising. Review of CMT A's timecard report showed he/she worked 2:55 P.M. to 9:06 P.M. on 11/12/25. During an interview on 11/17/25 10:10 A.M., Resident #1 said:-On 11/12/25, CMT A left the medication cart unlocked, so he/she looked for cigarettes on the cart.-CMT A took ahold of the resident's face by putting the palm of his/her hand over the resident's mouth with his/her thumb on the right side of the resident's face and his/her four fingers on the left side of the resident's face and squeezed really hard.-CMT A scared him/her to death when it happened.-CMT A was talking to him/her, but he/she doesn't remember what CMT A said to him/her.-He/She tried to get CMT A's hand off his/her face. He/She used his/her hand to try to pull CMT A's hand off his/her face.-CMT A sent him/her back toward his/her room by pushing him/her in his/her wheelchair nine million miles an hour down the hall;-There were some other residents around when it happened, but he/she did not know who they were.-He/She didn't want to tell anyone what happened, because he/she didn't want CMT A to get even madder at him/her.-On 11/12/25, Licensed Practical Nurse (LPN) A noticed the bruise and scratch on his/her face and asked him/her what happened. -He/She started crying and told LPN A what happened.-He/She also told the Administrator in Training (AIT) and the Administrator.-He/She felt safe now that CMT A was no longer at the facility.-The Administrator told him/her CMT A would not be coming back and he/she responded, good, I don't want to be around him/her. Review of the resident's nurse's note, dated 11/13/25 at 9:30 A.M. and completed by the DON, showed:-He/She observed a purple 2 (cm) x 2 cm bruise to the left side of the resident's face and a scratch 3.1 cm x 0.1 cm to the right side of his/her face with bruising.-He/She notified the doctor and the Administrator. Review of the text sent by the Administrator to CMT A on 11/13/25 at 10:17 A.M., showed the Administrator texted CMT A he/she was suspended pending investigation of an alleged abuse of a resident and that he/she would provide further details as he/she received them. Observation on 11/17/25 at 10:10 A.M., showed Resident #1 had a red scratch on his/her right cheek that was about a 3 cm long and a circular bruise on the left side of his/her face that was 2 cm in length and 2 cm in width and the resident demonstrated how CMT A placed his/her right hand over his/her face. During an interview on 11/17/25 at 12:00 P.M., Resident #8 (annual MDS dated [DATE], showed the resident was cognitively intact) said:-He/She was standing at the nurses' station facing the inside of the nurses' station on the evening of 11/12/25.-The medication cart was down the hall to his/her right.-He/She saw Resident #1 open one drawer of the medication cart and take something out of it, but could not tell what it was. -He/She saw Resident #1 try another drawer and it was locked. -Resident #1 was facing the medication cart and was turned a little to the left, so he/she could see Resident #1's face. -He/She told CMT A Resident #1 was getting into the unlocked medication cart. -CMT A went to Resident #1 from behind and put his/her hands on both of Resident #1's wheelchair handles that were on the back of his/her wheelchair and told Resident #1 not to do that and to move on.-CMT A turned the resident to the right, away from him/her.-At this point he/she could not see Resident #1's face, because he/she was headed down the hall toward his/her room.-CMT A pushed Resident #1 forward a little bit down the hall towards his/her room. During an interview on 11/17/25 at 11:50 A.M., CMT A said:-He/She backed Resident #1 away from the cart by pulling back on the two wheelchair handles and turned to the right to go toward his/her room.-He/She told Resident #1 to go on about his/her way and stay out of the medication cart.-Resident #1 always has his/her head down, so he/she couldn't say if Resident #1 already had any bruises or scratches.-The resident was cooperative and propelled himself/herself away from the medication cart.-He/She did not touch Resident #1.-The Administrator did not tell him/her to leave the evening of 11/12/25.-The Administrator told him/her via a text the next morning on 11/13/25 at 10:17 A.M. that he/she was on suspension.-His/her normal hours are 3:00 P.M. to 11:00 P.M.-He/She left at 9:00 P.M. on 11/12/25, because he/she helped work as a Certified Nurse Aide (CAN) on the floor.-When he/she helps on the floor, he/she gets to leave at 9:00 P.M. -He/She administered all the residents' medications before 9:00 P.M. before leaving on 11/12/25. During an interview on 11/18/25 at 10:39 A.M., Resident #2 (quarterly MDS dated [DATE] showed the resident was cognitively intact) said:-He/She was smoking with Resident #1 on the evening of 11/12/25.-Resident #1's eyes were red and it looked like he/she had been crying.-Resident #1 had bruising on his/her face.-Resident #1 said CMT A grabbed his/her face.-He/She told Resident #1 to come with him/her to report it.-Resident #1 went crazy and said he/she didn't want to report CMT A, because he/she was afraid.-He/She told LPN A what Resident #1 said.-He/She and Resident #1 went to the AIT and reported the incident to him/her.-This incident made him/her feel scared and that he/she and other residents were not safe. Review of LPN A's written statement, dated 11/12/25, showed:-Around 6:00 P.M., Resident #2 told him/her that Resident #1 said a nurse grabbed his/her face, leaving marks.-He/She went to see Resident #1.-Resident #1 had red and bruised areas on his/her left cheek and an abrasion to his/her right cheek.-He/She informed the DON and went to tell the AIT.-Resident #1 and Resident #2 were in the AIT's room talking to him/her. During an interview on 11/18/25 at 11:03 P.M., LPN A said:-Resident #2 came to him/her and said Resident #1 said one of the nurses grabbed him/her.-He/She went to the AIT and reported it to him/her.-He/She looked at Resident #1 and he/she had a red mark on his/her left cheek mark and a scratch on his/her right cheek.-He/She asked Resident #1 what happened.-Resident #1 said that CMT A grabbed him/her.-He/She wrote the skin assessment findings on a scratch piece of paper and gave it to the AIT.-Resident #1 does a lot of scratching all over his/her body.-If CMT put his/her hand on Resident #1's face, that was not an appropriate response and that would be abuse.-He/She had no idea if anyone witnessed the incident.-He/She doesn't know when the incident happened. Review of the AIT's written statement, dated 11/12/25, showed:-Around 6:15 P.M., Resident #2 brought Resident #1 into my office and stated that CMT A attacked him/her, because he/she touched the med cart.-Resident #1 said Resident #8 witnessed it.-Resident #1 had marks on both of his/her cheeks and the left side of his/her face looked swollen. During an interview on 11/17/25 at 1:10 P.M., the AIT said:-He/She was in his/her office on 11/12/25 around 6:15 P.M. when Resident #2 wheeled Resident #1 to his/her door.-Initially, Resident #1 said he/she didn't want to say anything.-Resident #1 said CMT A grabbed him/her, because he/she went into the medication cart.-Resident #1 started crying.-He/She noticed redness on both sides of Resident #1's face and his/her left cheek looked swollen.-He/She sent a text message to the Administrator to let him/her know about the allegation.-Resident #1 said Resident #8 was there during the incident.-He/She did not talk to Resident #8.-He/She asked the staff on Resident #1's floor if they were aware of anything that happened.-CNA A said he/she had nothing to report.-LPN B said he/she thought the resident's face was red from him/her scratching and picking at himself/herself.-CMT A said nothing happened.-He/She thinks CMT A left around 9:00 P.M. on 11/12/25. -This was the first experience he/she had with an abuse allegation and did not know what he/she was supposed to do other than notify the Administrator.-LPN B was the charge nurse upstairs so he/she didn't know anything about sending CMT A home. During an interview on 11/19/25 at 3:33 P.M., CNA A said:-He/She didn't see Resident #1 by the medication cart during the evening shift (on 11/12/25).-Sometime after dinner on 11/12/25, he/she came out from giving a resident a shower when CMT A told him/her that he/she just put Resident #1 to bed and asked CNA A to check on Resident #1 to see if he/she was still in bed.-When he/she went into Resident #1's room, he/she was in his/her wheelchair and was getting in bed.-Resident #1 had blood on his/her pants and shirt.-It looked like the blood came from his/her face.-He/She asked Resident #1 what happened and he/she did not want to tell him/her what happened.-He/She told the resident that he/she had to tell the nurse.-The resident told him/her not to worry about it.-He/She reported the bleeding to LPN A. During an interview on 11/17/25 at 11:23 A.M., the Administrator said:-Resident #1 told Resident #2 on 11/12/25 about the incident with CMT A and they both went to the AIT the evening of 11/12/25 to report it. -The AIT reported the incident with CMT A to him/her by text on 11/12/25 around 6:00 P.M. and he/she read the text around 7:30 P.M.-He/She called CMT A soon after 7:30 P.M. and told CMT A he/she needed to clock out and leave.-CMT A timed out at 9:07 P.M. on 11/12/13, probably after finishing the medication pass.-CMT A was gone on 11/13/25, so he/she knew Resident #1 was safe.-The DON called him/her on 11/13/25 between 8:30 A.M. and 9:00 A.M. and said he/she saw bruising on Resident #1's face.-He/She arrived after 9:00 A.M. on 11/13/25.-He/She knows the abuse happened.-Resident #1 initially said he/she was too scared to tell the Administrator.-He/She interviewed Resident #1 and Resident #1 said he/she was going to the medication cart to steal some cigarettes and the CMT came out of nowhere and grabbed his/her face hard and scared him/her to death.-When the AIT interviewed CMT A, he/she denied anything happened.-He/she told CMT A to leave over the phone. The charge nurse reported it to the AIT, the AIT said it was his/her first experience and did not know he/she was supposed to do other than notify the Administrator. No one made CMT A go home. During an interview on 11/18/25 at 10:20 A.M., the DON said:-He/She did the skin assessment on the resident as part of his/her investigation on the morning of 11/13/25.-He/She did not know the resident reported the incident to the AIT on 11/12/25.-CMT A should have been sent home immediately when the allegation of abuse was first reported on 11/12/25.-Putting a hand over the resident's mouth and causing a scratch and bruising was abuse.-When he/she saw the scratch/bruising the next morning (11/13/25), it was the first time he/she knew anything about the incident. -He/She called the Administrator on 11/13/25 after he/she saw the resident and reported the scratch and bruising on the resident. During an interview on 11/18/25 at 1:19 P.M., the Administrator said:-He/She did not keep a phone log to show when he/she called CMT A because it took up too much space.-Dinner was usually served around 5:00 P.M. and the incident was after dinner.-He/She concluded that CMT A abused the resident. During an interview on 11/18/25 at 8:13 A.M., Resident #1's primary care physician said she would expect the staff to not put their hand over the resident's face and abuse the resident. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). 2668352 and 2667668

Based on interview and record review, the facility failed to report to local law enforcement an allegation of abuse of Resident #1 by Certified Medication Technician (CMT) A. Twelve residents were selected for review. The facility census was 89 residents. Review of the facility's undated policy titled, Abuse and Neglect showed the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review of the facility's undated policy titled, Policy Regarding Abuse and Neglect of Facility Residents, showed:-Instructions to coordinate with local law enforcement entities to determine what actions are considered crimes in the political subdivision.-The suspected victim must be protected immediately.-Employees who were involved with the suspects shall be suspended or terminated immediately.-Employees who were involved with the incident shall be suspended upon investigation.-All suspicious crime including abuse must be reported to law enforcement in a timely manner. Review of the facility's undated policy titled, Policy for Investigating and Reporting of Abuse and Neglect showed instructions to report abuse after investigation to law enforcement. 1. Review of Resident #1's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 10/14/25, showed the resident was cognitively intact. Review of the resident's undated face sheet (dated as printed on 11/17/25) showed he/she was admitted to the facility on [DATE] with the following diagnoses: cerebral infarction (blood flow to the brain is blocked resulting in brain tissue death), anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), and depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life). During an interview on 11/17/25 at 10:10 A.M., the resident said:-On 11/12/25, CMT A left the medication cart unlocked, so he/she was looking for cigarettes on the cart.-CMT A took ahold of the resident's face by putting the palm of his/her hand over the resident's mouth with his/her thumb on the right side of the resident's face and his/her four fingers on the left side of the resident's face and squeezed really hard.-CMT A scared him/her to death when it happened.-CMT A was talking to him/her, but he/she doesn't remember what CMT A said to him/her.-He/She tried to get CMT A's hand off his/her face. He/She used his/her hand to try to pull CMT A's hand off his/her face.-CMT A sent him/her back toward his/her room by pushing him/her nine million miles an hour down the hall.-He/She didn't want to tell anyone what happened, because he/she didn't want CMT A to get even madder at him/her.-Licensed Practical Nurse (LPN) A noticed the bruise and scratch on his/her face and asked him/her what happened. -He/She started crying and told LPN A what happened.-He/She also told the Administer in Training (AIT) and the Administrator.-He/She felt safe now that CMT A was no longer at the facility.-The Administrator told him/her CMT A would not be coming back and he/she responded, good, I don't want to be around him/her. Review of the facility's investigation completed by the Administrator, dated 11/17/25 at 6:45 P.M., showed:-Resident #1 stated CMT A grabbed his/her face after he/she was attempting to steal cigarettes off the medication cart.-Resident #1 was alert and oriented to person, place, and time.-Resident #1 was able to answer questions appropriately.-Resident #1 used a wheelchair for ambulation throughout the facility.-On 11/12/25 at 7:30 P.M.,--The Administrator received a message from the AIT stating Resident #1 stated he/she was assaulted by CMT A.--The Administrator contacted CMT A and stated that he/she needed to leave and time out due to a reported accusation of abuse.--CMT A denied abusing Resident #1-On 11/13/25:--Resident #1 was noted to have two areas of red/dark red ecchymosis on his/her jawline and neck approximately 2 centimeters (cm) x 3 cm and a scratch on his/her right side of his/her face.--The Director of Nursing (DON) called the Administrator to inform him/her of the bruises he/she saw on Resident #1. Review of CMT A's timecard report dated 11/6/25-11/19/25 showed he/she worked 2:55 P.M. to 9:06 P.M. on 11/12/25. Observation on 11/17/25 at 10:10 A.M., showed the resident had a red scratch on his/her right cheek that was about a 3 cm long and a circular bruise on the left side of his/her face that was 2 cm in length and 2 cm in width and demonstrated how CMT A placed his/her right hand over his/her face. During an interview on 11/17/25 at 11:23 A.M., the Administrator said:-He/She knew CMT A abused Resident #1.-They did not notify the police of CMT A abusing Resident #1.-Resident #1 told Resident #2 on 11/12/25 about the incident with CMT A and they both went to the AIT the evening of 11/12/25 to report it. -The AIT reported the incident with CMT A to him/her by text on 11/12/25 around 6:00 P.M. and he/she read the text around 7:30 P.M.-He/She called CMT A soon after 7:30 P.M. and told CMT A he/she needed to clock out and leave.-CMT A timed out at 9:07 P.M. on 11/12/13, probably after finishing the medication pass. During an interview on 11/18/25 at 10:20 A.M., the DON said he/she did not think about notifying the police. During an interview on 11/18/25 at 1:19 P.M., the Administrator said:-He/She concluded that CMT A abused the resident.-It was his/her responsibility to complete the investigation per the facility policy.

Based on observation, record review, and interviews, the facility failed to store, prepare and serve food in accordance to professional standards of food service safety when staff failed to date, label, and store food items correctly, failed to maintain environmental and cleanliness standards for the kitchen, failed to adhere to proper standards for personal hygiene and handwashing, and failed to perform daily temperature checks on kitchen equipment. The facility census was 88. Review of facility's Dietary Department Policy, undated, showed:- All dietary services personnel shall at all times wear clean, washable clothes, they are required to keep their hands and fingernails clean at all times;- Staff shall store, prepare, distribute and serve food under sanitary conditions and in a manner that protects it against contamination and spoilage in accordance with food service requirements of Missouri regulations;- Food spoils at room temperature in two hours;- Containers of food are stored on clean surfaces, off the floor, and in a manner to protect them from contamination;- Effective procedures are established for the cleaning of all equipment and work areas;- Procedures for hand washing will be posted in appropriate areas;- Toxic items shall be properly stored, used and disposed of properly;- Hand washing facilities, including hot and cold water, soap in dispenser, and individual paper towels shall always be available in the dietary department;- Facility personnel entering the dietary area will be responsible for the same standards of cleanliness as those required of the dietary staff;- Food in unlabeled contains shall not be accepted or retained;- Weekly checks for labeling and for expired foods will be accomplished;- Temperature checks will be done daily;Request for facility's leftover policy was not provided;Observation in the kitchen on 10/14/25 at 10:00 A.M., showed:Stand-up Refrigerator near ice machine:- Grease and food stains on vents under refrigerator doors;- Juice containers, 15 jugs, no date on when made or use by date, sitting inside of refrigerator;- Three sandwiches in plastic bags no dates or labels on bags;- Two Styrofoam cups unlabeled, 8oz each with no use by dates;- Leftover cheese slices re-sealed with no use by date or label;- 20 individual servings of tarter sauce prepared in-house with no labels or use by dates;- 20 individual servings of cocktail sauce prepared in-house with no labels or use by dates;- Four 32 oz containers of soy milk expired June 2025;- No thermometer in the refrigerator and outside temperature gage is broken;Observation in the kitchen on 10/14/25 at 10:15 A.M., showed:- Kitchen area baseboards near the steam line had heavy dirt on tiles covering a 15 x 6 area near the floor. Corner tile was broken and heavy with dirt over exposed wall area; Stand-up Refrigerator near microwave and bread toaster:- Heavy oily grime on top of refrigerator exterior door, top lip;- Heavy food stains and rust on front of entire refrigerator and freezer doors;- Ground beef large sealed roll, defrosting inside of refrigerator with no label or dates;- Leftover minestrone soup dated 10/11 has no use by date;Walk-in Refrigerator:- Three packages of re-sealed sliced turkey no use by dates or labels;- Black mold-like substance covering the back wall of the refrigerator over a 2' by 2' area;- Sign on front of refrigerator door reads All items must have receipt date and use by date on the package otherwise the item will we disposed of;Walk-in Freezer: - One case of nutritional chocolate shake stored on the floor of the freezer;Dry Storeroom:- 15 gallon plastic storage bins of flour, sugar, and yellow corn meal had no labels and no dates;- Orange gelatin 24oz package resealed with no open or use by dates;- Three bags of brown gravy mix resealed with no open or use by date;- One bag of cane sugar resealed with no open or use by date;Observation in the kitchen on 10/16/25 at 8:50 A.M., showed:- No hand soap at the hand washing station in the kitchen;- Non-kitchen staff member enters the kitchen without washing hands and uses ice scoop to get ice out of the ice machine and load a container;- Dietary Aide (D) came into the kitchen from dumping trash and did not wash hands. Observation in the kitchen on 10/16/25 at 9:00 A.M., showed:- Dietary Aide (D) eating in the kitchen from a tray;Stand-up Refrigerator near ice machine:- One sandwich in a plastic bag without a label or use by date;- 15 juice jugs unlabeled and without a use by date; - Styrofoam cup 8oz with an unknown liquid and no use by date;Stand-up Refrigerator near bread toaster:- Log of meat defrosting on bottom rack, no label or use by date;- One package of turkey unsealed, sliced 32oz plastic bag, not dated with use by date;- Grated carrots 5 pound package unopened with no receipt date or expiration date on bag;Observation in the kitchen on 10/15/25 at 9:45 A.M., showed:- Heavy dirt and oily grime on bottom shelf underneath sink next to the ice team machine covering a 2' x 5' area;- 128 fluid oz hand sanitizer plastic container stored on a shelf underneath the rear area of the three sink cleaning station next to food times of liquid smoke and 1.32 gallons of balsamic vinegar;- 1.32 gallon jug of balsamic vinegar is covered in dirt and dried grime;- Two plastic bags of 32oz bath and body wash stored on the other side of the balsamic vinegar and liquid smoke;- The overhead of the grill area had visible streaks of grease coming from the overhead baffles covering a 12 foot area;Observation in the kitchen on 10/16/25 at 11:30 A.M., showed:- Food debris stains and crumbs from breakfast on two steam line food containers lids;- Stove top not cleaned, baked burnt food encrusted on the burner area of all six burners;- Six sausage links in a metal bin from today's breakfast meal that ended at 8:30 A.M., sitting uncovered on the kitchen preparation table;- Plate of fried eggs uncovered sitting on back table of kitchen from today's breakfast meal that ended at 8:30 A.M.;- Three ceiling tiles over and near the food preparation area had strings of hanging dust one inch in length; - Dietary Aide (D) left the kitchen to the outside trash area and returned to the kitchen to work in the dishwashing area without washing his/her hands and then went to the kitchen preparation area to help stage desserts for the lunch time meal;- Three tier storage cart in kitchen with containers of peanut butter and jelly on the top tier has rusted shelves on each level of the cart. Each rusted tier is two foot by one foot area; Observation in the kitchen on 10/16/25 at 12:15 P.M., showed:- Dietary Aide (B) returning to the kitchen from the dining room with gloves hands, touching the sweaty back of Dietary Aide (C) while passing each other in the kitchen. Dietary Aide (B) without washing hands upon entering kitchen or changing gloves prepares BBQ condiment for a resident by pouring sauce into a plastic 2oz cup;- Industrial fan sitting on shelf running with visible dust caked on exhaust screen grill blowing air directly onto uncovered desserts on foot cart which is also uncovered;- Dietary Aide (B) re-entered the kitchen from outside corridor, took off gloves and put on new gloves without washing hands and started handling food trays and touching food with gloved hands;Observation in the kitchen on 10/16/25 at 12:40 P.M., showed:- Dietary Aide (A) wearing gloves and placing smoked beef from serving line to all individual plates served using his/her hands and not using any tongs or kitchen tools;- Dietary Aide (A) while filling food trays from the steam line was wearing a soiled shirt Record Review of stand up Refrigerator and stand up Freezer near microwave and bread toaster on 10/16/25 at 11:45 A.M., showed:- Last temperatures taken and recorded show 10/13/25 with no temperatures taken on 10/14 through 10/16/25;During an interview on 10/16/25 at 1:20 P.M., the DM said:- The jugs of juice are made fresh daily and are to be used the same day they are made and then disposed of at the end of the day;- The Styrofoam cups contain Kool-Aid for the residents to drink;- The temperature gage on the stand-up refrigerator is broken but staff uses the thermometer inside the refrigerator to take temperatures daily;- Anyone entering the kitchen, especially staff should wash their hands immediately;- Staff should wash their hands between glove changes;- Staff should come to work in clean jeans and a shirt which are comfortable fitting without holes and not frayed. Exposed skin should be covered to avoid burns and for sanitary reasons;- Staff are allowed to eat in the staff break room or in the dining room and should not eat food in the kitchen;- There should be hand soap and paper towels at the hand washing station in the kitchen at all times;- Food containers or packages that are opened should contain a label with the date of when it was opened/resealed, food item name, and use by date;- The staff doesn't label the juice containers since we don't keep them as leftovers even though they are stored in the refrigerator;- Leftover beef should be kept for two days, one day for chicken, no leftover seafood, and two days for pork;- Condiments are changed out every three days;During an interview on 10/17/25 at 10:30 A.M., the Administrator said:- She would not expect dust to be hanging from the overhead in the kitchen over food preparation areas;- She would not expect an industrial fan which is dirty to be blowing on uncovered food and this is something that she has spoken to staff about before to not use those fans in the kitchen;- She would not expect black mold to be on the wall surfaces of the refrigerator;- She would expect staff to use kitchen tongs or some sort of equipment where they were not touching the meat with their hands when serving it to residents;- She would expect staff to take daily temperatures of the refrigerator and freezer;- She would expect staff to wash their hands between gloves changes;- She would expect leftovers to be resealed, dated and have a use by date on the packaged item;- She would expect kitchen surfaces to be free of built-up food debris and dirt;- She would not expect breakfast items to be left out uncovered and unrefrigerated in the kitchen for three hours;

Based on interview and record review, the facility failed to ensure they employed a Registered Nurse (RN) for eight consecutive hours per day, seven days per week. The facility census was 88. The facility did not provide the requested nurse staffing policy.Review of the staffing sheets for May 2025 showed no RN scheduled for eight consecutive hours on 05/02, 05/10, 05/11, 05/22 and 05/23.During an interview on 10/17/2025 at 02:40 P.M., the Administrator said they should have RN coverage eight hours a day, seven days a week.

Based on interview and record review, the facility failed to ensure four of the 18 sampled Residents (Resident #2, #6, #8, and #12) reviewed for unnecessary medications, and/or their representative were informed of the risks and benefits of a physician ordered antipsychotic, antidepressant, or anti-anxiety medication. The facility census was 88. Review of the facility's Resident Rights Dignity and Privacy policy, undated, showed:- Residents have a right to know about their medical condition and treatments;- Make decisions about their medical care and activities;- Have the right to be informed of all aspects of your care, to participate in planning your care and treatment, including any changes in care and treatment;- Have the right to refuse treatment and to be informed of the consequences of such refusal.1. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/17/25, showed:- Resident had severe cognitive impairment;- Diagnosis: coronary artery disease, diabetes, anxiety disorder, depression, bipolar disorder, and psychotic disorder;- High risk drug classes: antipsychotic, antidepressant, and hypoglycemic.Review of Resident's Care Plan, dated 9/15/25, showed:- Resident receives an anti-psychotropic medication for a delusional disorder;- Educate resident/family/caregivers about risks , benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given.Review of Resident's Order Summary Report, dated 10/16/25, showed Abilify Oral Tablet 10 milligrams (antipsychotic medication),one tablet daily for delusions was started on 8/7/25. Record review of Resident's Medical Records showed there was no documentation of informed consent for the use of antipsychotic medications for the resident.2. Review of Resident #6's Annual MDS, dated [DATE], showed:- Resident had moderate cognitive impairment;- Diagnosis: cancer, hypertension, depression, and schizophrenia;- Medications included antipsychotic and a antidepressant.Review of Resident's Order Summary Report, dated 10/16/25, showed Quetiapine Fumarate oral tablet 200 milligrams (antipsychotic), once daily at bedtime for mood disorder ordered on 7/28/25.Record review of Resident's Medical Records showed no documentation of informed consent for the use of antipsychotic medications for the resident. 3. Review of Resident #8's Annual MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnosis: atrial fibrillation (heart rhythm disorder), hypertension, GERD (acid reflux), kidney disease, diabetes, cerebral palsy, stroke, and depression;- High risk drug classes: antianxiety, antidepressant, opioid, and hypoglycemic;Review of Resident's Care Plan, dated 8/19/25, showed:- Resident uses anti-anxiety medication for anxiety disorder. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Buspar;- Resident receives an antidepressant medication. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Celexa and Wellbutrin.Review of Resident's Order Summary Report, dated 10/16/25, showed:- Order date 7/26/25 Bupropion HCL ER oral tablet extended release 150 milligrams (antidepressant), once daily for depressive disorder;- Order date 7/26/25 Buspirone HCL oral tablet 15 milligrams (anti-anxiety), three times daily for anxiety disorder;- Order date 7/26/25 Citalopram Hydrobromide oral tablet 40 milligrams (antidepressant), once daily for major depressive disorder.Record review of Resident's Medical Records showed no documentation of informed consent for the use of anti-anxiety or antidepressant medications for resident.During an interview on 10/15/25 at 10:05 A.M., the Resident said:- He/she did not recall being counseled on the risks and benefits of taking anti-anxiety or antidepressant medications;4. Review of Resident #12's Quarterly MDS, dated [DATE], showed:- Resident had severe cognitive impairment;- Diagnoses: cancer, hypertension, non-Alzheimer's dementia, depression, and psychotic disorder;- High risk drug classes: antipsychotic, anticonvulsant, and antidepressant.Review of Resident's Order Summary Report, dated 10/16/25, showed:- Order date 8/76/25 Seroquel oral tablet 25 milligrams (antipsychotic), once daily for depression;- Order date 7/25/25 Sertraline HCL oral tablet 50 milligrams (antidepressant), once daily for major depressive disorder.Record review of Resident's Medical Records showed no documentation of informed consent for the use of antipsychotic or antidepressant medications for the resident;During an interview on 10/17/25 at 9:30 A.M., the Administrator said:- There currently is no process for obtaining informed consent from residents for the use of psychotropic, anti-anxiety or antidepressant medications.

Based on observation, interview, and record review, the facility failed to provide a homelike environment in the dining room when basic utensils and condiments were not made available, sandwiches were served in plastic bags and residents were not asked what they wanted to eat before being served. Additionally, the facility failed to ensure a homelike environment in the resident hallways by not properly overseeing facility pets which caused unpleasant odors for two Residents (Residents #31 and #43). The facility census was 88.Review of the facility's Resident Rights-Dignity and Privacy Policy, undated., showed all Residents have the right to not have their life regulated beyond what is necessary in providing resident services;Request for policy covering Homelike Environment could not be provided;1. Review of Resident #13's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/1/25, showed:- Resident was cognitively intact:- Diagnosis: cancer, atrial fibrillation (heart rhythm disorder), heart disease, heart failure, hypertension, GERD (kidney disease), diabetes, anxiety disorder, depression, and epilepsy;During an interview on 10/17/25 at 8:53 A.M., the Resident said:- He/she expects the litter boxes to be filled with cat litter. He/she finds the smell unpleasant enough when they do have cat litter but when they are missing the litter it's a horrible smell and should not happen. It has happened on various occasions that there is no litter. 2. Review of Resident #43's Quarterly MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnosis: hypertension, kidney disease, depression, and anxiety disorder; Observation on 10/15/25 at 3:00 P.M. on the first-floor hallway, showed:- A litter box at the end of the south hall was empty. A facility cat entered the litter box and defecated. A strong odor was observed coming from the box and permeating the area covering15 square feet. During an interview on 10/17/25 at 9:15 A.M., the Resident said:- Cat litter boxes in the hallway are unsightly, unsanitary and he/she hated the smell of them. 3. Review of Resident #8's Annual MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnosis: atrial fibrillation (heart rhythm disorder), hypertension, GERD (acid reflux), kidney disease, diabetes, cerebral palsy, stroke, anxiety disorder, and depression;Observation on 10/17/25 at 9:30 A.M. on 1st floor hallway, showed the Resident was pushing his/her walker to his/her room with a single plastic spoon lying on the dirty seat cover of the walker. During an interview on 10/17/25 at 9:31 A.M., the Resident said:- He/she carried the spoon around to stir coffee throughout the day. Otherwise, he/she had to knock on the locked kitchen door on the ground floor to ask for a spoon since there are none available at the coffee station. There's cream and sugar that can be added to the coffee but nothing to stir the coffee once the condiments are added. There have been times when no one will answer the door to the kitchen and in those cases he/she can't get a spoon. If I was living at home I would have access to a metal spoon and any silverware I needed whenever I wanted. It's frustrating to go all the way downstairs just to get a spoon. 4. Review of Resident #51's Annual MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnosis: viral hepatitis and diabetes;During an interview on 10/15/25 at 9:02 A.M., the Resident said:- The kitchen staff don't ask what we want to eat before the meal, they just bring out the tray the same as for everyone else. Does not feel like home not having a choice on what I want to eat before it's served. Also the facility only gives him/her one napkin to use during the meal. If you want more you have to get a staff member's attention to go into the kitchen and get another napkin for him/her to use. The resident was frustrated that there are no napkins on the tables or bottles of condiments available to use. - Meals are served on plates but they are served on a tray like at a cafeteria and not at home. At home he/she doesn't eat on a tray, he/she eats with silverware and plates placed on a table. The condiment baskets have barely enough items in them and seldom match what is being served for the meal. 5. Review of Resident #77's admission MDS, dated [DATE], showed:- Resident is cognitively intact:- Diagnosis: GERD (acid reflux), thyroid disorder, epilepsy, anxiety disorder, bipolar disorder, schizophrenia, post traumatic stress disorder, and psychotic disorder;During an interview on 10/14/25 at 11:53 A.M., the Resident said:- He/she is not provided with any menu cards to order his/her menu items from. Doesn't feel like he/she had any choice on what food to eat that day, which doesn't feel like home. He/she placed spoon on empty cream and sugar packets because the staff doesn't provide a napkin until the meal is served. It doesn't feel very sanitary to rest the spoon on the table which doesn't feel that clean. It's very frustrating. - He/she can get a substitute, but it's normally just a peanut butter and jelly sandwich. It's served in a plastic bag which he/she would not do at home and it doesn't feel fresh. He/she can't tell how long it's been sitting in the refrigerator or when it was made. 6. Observation on 10/14/25 at 11:46 A.M., showed:- Each table had a basket condiment bowl but the bowl contents are not consistent from table to table. One bowl contained multiple salt and pepper packets, one bag of saccharin, no sugar and no creamer;- The dining room had self-serve water and coffee stations. There were no napkins for the residents and no spoons at the drink station or in dining room for residents to stir coffee or beverages.Observation on 10/14/25 at 12:30 P.M. in the dining room showed LPN B and CMT B sitting in the back of the dining room for the entire meal talking and CMT B administering medications as needed for residents at the table he/she was sitting at.During an interview on 10/14/25 at 12:35 P.M., LPN B said I don't need to ask residents if they wanted something else to eat even if they barely touched their meal. They are all alert and orientated and don't need assistance eating so if they want something else they just need to call out and I will get them what they want. Observation of the dining room on 10/15/25 at 11:59 A.M., showed:- [NAME] being served for today's meal. The condiment bowls had some jellies, salt, and pepper but nothing that would normally go on rice;- No spoons at the drink station for the residents to stir coffee;- Three residents drinking coffee with empty creme and/or sugar packets and no utensils to coffee;- Two residents served sandwiches in plastic bags on the food tray;- There are no condiments on the trays that are brought out to the residents;- One resident grabbed three butter packages from a condiment bowl for his/her rice. There were no more butter packages for the other two residents that were eating rice; During an interview on 10/17/25 at 10:10 A.M., the Administrator said:- She would expect that when rice is served to the residents that butter and soy sauce would be available on the tables;- Condiments should be on each tray that is brought out to the residents and condiments not used should go into the baskets on each table for other residents to use;- She would expect plastic ware to be available for residents and they would not have to knock on a locked kitchen door to get help for a spoon or napkin;- She would expect extra napkins on the table for residents so they would not have to ask staff for one each time they needed another napkin during the meal;- She would not expect residents to be served sandwiches in a plastic bag;- The cat litter boxes should be free of odors and full of cat litter. The facility orders the cat litter and picks it up but sometimes there is a lapse between it being cleaned out and the box being replenished with cat litter;- The staff are responsible for re-filling the cat boxes in the facility;

Based on observation, interview, and record review, the facility failed to ensure there were no expired stock medications in the medication carts, failed to ensure all stock medications were dated when opened, failed to label an inhaler with the resident's name for one of the 18 sampled residents (Resident #1), and failed to date opened pens of Insulin for two of the 18 sampled residents, (Resident #73 and #79). The facility census was 88.Review of the facility's Using Stock Medications policy, dated 2024, showed:- Check or place the appropriate labels on the container. Initial name, title, and date.Review of the facility's Insulin Administration policy, dated 2024, showed:- The nurse shall label the insulin with a date and initials upon opening;- The nurse shall dispose of the insulin after 28 days (or as recommended by the manufacturer) from the date labeled on the bottle.Review of the facility's policy, Storing Medications, dated 2024 showed:-Outdated, contaminated, or deteriorated drugs, and those in containers which were cracked, soiled or without secure closures were to be immediately withdrawn from stock.During an Observation and interview on 10/16/2025 at 7:58 A.M., Licensed Practical Nurse (LPN) A was passing medication using the two hall Certified Medication Technician (CMT) medication cart and showed:- Resident #73's Lantus insulin pen was opened and had no open date written on the tag on the pen;- LPN A said he/she would normally date the insulin pens when he/she opens them, but he/she doesn't usually use the CMT medication cart.During an Observation and interview on 10/16/2025 at 8:14 A.M., of LPN A passing medication using the two hall Certified Medication Technician (CMT) medication cart showed:- Resident #79's Lispro insulin pen was opened and had no open date written on the tag on the pen;- LPN A said, same as with the last pen, he/she would normally date the insulin pens.During an Observation and interview on 10/16/2025 at 8:36 A.M., LPN A passing medication using the two hall CMT medication cart showed:- One bottle of facility stock stool softener was unsealed and had not been dated when opened. The bottle had a 9/26 expiration date;- LPN A said he/she would date the bottles when opened normally, but this wasn't his/her usual medication cart.Observation and interview on 10/16/2025 at 9:20 A.M., CMT A passing medication using the two hall CMT medication cart showed:- Resident #1's Symbicort inhaler had no resident identifier on the actual inhaler. Resident name was on the box only;- CMT A said the inhaler should be labeled with the resident's name and then wrote the resident's name on the inhaler. He/She said the inhalers usually have a label on them from the pharmacy, but this one did not.During an Observation and interview on 10/16/2025 at 9:37 A.M., CMT A passing medication using the two hall CMT cart showed:- One bottle of facility stock B12 vitamin was unsealed and had not been dated when opened. The bottle had an 8/26 expiration date;- CMT A said the bottle should have had an opened date but does not.During an Observation and interview on 10/16/2025 at 9:48 A.M., CMT A passing medication using the two hall Certified Medication Technician (CMT) medication cart showed:- Two bottles of geri-tussin, one unsealed with no opened date and both bottles had an expiration date of 12/23; - One bottle of antacid tablets was unsealed with no opened date and had an expiration date of 6/25;- One bottle of milk of magnesia was unsealed with no opened date and had a 4/26 expiration date;- One bottle of zinc was unsealed with no opened date and had an expiration date of 4/25;- The CMT A said the staff try to look at the expiration dates and update the medication cart on the weekends. If the cart is out of a medication or a medication is expired the nurse would try to get or replace the medication. He/She did not notice the expired medications.During an Observation and interview on 10/16/2025 at 10:15 A.M., LPN B:- Was inspecting two hall medication room and noticed an expired, medication secured in the emergency kit in the medication room refrigerator;- LPN B said he/she didn't know where the emergency kit would go or who to give the emergency kit to for disposal;- The emergency kit had expired on 1/24 and contained one bottle of Lantus insulin, one bottle of Aspart insulin, and two foil packs of suppositories.- LPN B said the staff have been trying to get someone to come get the expired emergency kit, but no one knows who it goes to for disposal.During an Observation and interview on 10/16/2025 at 12:00 P.M., CMT A:- Was inspecting the two hall night shift CMT cart, noted four boxes of stock artificial tears that had an expiration date of 6/24;- CMT A said he/she normally tries to get rid of the expired medications and the staff would get ahold of the Administrator who has the keys to the supply room, and she can replace them. During an Observation and interview on 10/16/2025 at 3:20 P.M., LPN C:- Was inspecting the one hall day shift nurse's cart, and noted one package of glucagon that had an expiration date of 6/29/25;- LPN C said he/she would take care of it and get the expired glucagon replaced. During an interview on 10/17/2025 at 9:55 A.M., the Administrator said:- There should definitely not be expired medications in the medication carts or in the medication room refrigerators;- Regarding the expired emergency kit, she told LPN A, last week that it needed to be destroyed;- The insulin pens and the stock medications should be dated when they are opened;- The resident's inhalers should have their names on them. Usually, the pharmacy had a label on it already, but staff should make sure it is there. During an interview on 10/17/2025 at 11:11 A.M., LPN B said:- There should not be expired medications in carts or refrigerators;- The insulin pens and the stock medications should be dated when they are opened, and the resident's inhalers should have their names on them.

Based on observation, interview, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use proper Enhanced Barrier Precaution (EBP) signage for two residents with indwelling medical devices Resident #42 and #85 and when Certified Medical Technician (CMT) A failed to wash his/her hands and apply clean gloves before he/she administered medications for two residents Resident #79 and Resident #70. This affected four of the 18 sampled residents (Resident #42, #85, #79 and #70). The facility census was 88. Review of the facility's Enhanced Barrier Precautions policy, undated, showed:- Enhanced Barrier Precautions (EBP) are intended to be used for the duration of a resident's stay in a facility. A transition back to Standard Precautions alone might be appropriate for residents placed on EBP solely because of the presence of a wound or indwelling medical device when the wound heals or the device is removed;- Gowns and gloves are the minimum level of Personal Protective Equipment (PPE) required for these high-contact resident care activities. However additional PPE may be required;- An indwelling medical device provides a direct pathway for germs in the environment to enter the body and cause infection. Examples include indwelling urinary catheters, feeding tubes, and tracheostomy tubes;- EBP are indicated for residents with indwelling medical devices;- EBP is used when performing high-contact resident care activities including dressing, transferring, providing hygiene, and device care or use;- The facility provided a copy of the sign that should be applied near the resident's door that would remind staff to stop a utilize EBP for high-contact resident activities. 1. Review of Resident #42's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/12/25, showed:- Cognitive skills intact;- The resident required substantial assistance from staff for transfers, toilet use, showers, dressing, and personal hygiene;- Diagnoses included: neurogenic bladder (a condition where the nerves that control the bladder are damaged or malfunctioning, leading to problems with urination), osteoporosis (a condition that weakens bones, making them more prone to fractures), and high blood pressure. Review of the Resident's care plan, revised 10/9/25, showed:- The resident had a suprapubic catheter related to neurogenic bladder;- The resident required Enhanced Barrier Precautions (EBP) related to suprapubic catheter;- The nursing staff were to use EBP when performing high contact resident care activities including hygiene, changing linens, device care or use. Review of the Resident's Physician Order Sheet (POS), showed:- Prescriber order written on 9/19/25: EBP for residents with specific high-risk conditions, such as indwelling medical devices. Observation on 10/14/25 at 10:40 A.M., showed:- No EBP sign on or near the resident #42's door;- No EBP supply box inside or outside near the resident's room. 2. Review of Resident #85's care plan, dated 7/31/25, showed:- The resident had an indwelling foley catheter related to neurogenic bladder;- The resident required EBP related to foley catheter;- The nursing staff were to use EBP when performing high contact resident care activities including hygiene, changing linens, device care or use. Review of the Resident's Quarterly MDS, dated [DATE], showed:- Cognitive skills intact;- The resident used a wheelchair but was independent on all activities of daily living (ADL's);- Diagnoses included: neurogenic bladder and high blood pressure. Review of the Resident's Physician Order Sheet (POS), showed:- Prescriber order written on 9/19/25: EBP for residents with specific high-risk conditions, such as indwelling medical devices. Observation on 10/14/25 at 9:48 A.M., showed:- No EBP sign on or near resident #85's door;- No EBP supply box inside or outside near the resident's room. Observation on 10/15/2025 at 12:25 P.M., showed: - No EBP signs on or near resident #85 or #42's doors;- No EBP supply boxes inside or outside near the residents' rooms. During an interview on 10/16/2025 at 11:58 A.M. Licensed Practical Nurse (LPN) A said:- EBP would be used if it is a contagious respiratory issue, catheter, or something like that;- The staff would put signs outside the resident's door and a supply box outside the resident's room with gowns, gloves, and bags;- If there was a resident with a catheter the staff were supposed to utilize the PPE when providing cares;- There was supposed to be a sign and box outside the resident rooms if they have a catheter, but they are not there and he/she was not sure if the protocol had changed, but they used to be there. During an interview on 10/16/2025 at 3:25 P.M., Registered Nurse (RN) C said there should be EBP signs outside the rooms that require them. Observation on 10/17/25 at 8:44 A.M., showed the EBP signs have been placed beside the doors of resident #42 and #85. During an interview on 10/17/2025 at 9:55 A.M., the Administrator said:- If a resident had an order for EBP there should be a sign and a supply box outside the room;- She wasn't happy when she found out staff weren't utilizing the EBP signs and the supply boxes;- The EBP signs were up now but she thinks a staff member decided to take all the boxes downstairs and she was trying to locate them;- The residents with indwelling catheters, who are on dialysis, who have draining wounds, and a nephrostomy are the residents here with issues that would require EBP. During an interview on 10/17/2025 at 11:11 A.M., LPN B said:- If a resident had an order for EBP, there should be a sign and supply box outside the room;- The EBP should be utilized for residents who have catheters. Observation on 10/17/2025 at 11:57 A.M., showed:- The EBP signs and the EBP supply boxes had been recently placed per facility policy outside the resident rooms that required them. 3. Review of the facility's undated Hand Washing Policy, showed:-All care staff must apply proper hand washing before, after and between resident care;-Nursing staff must comply with hand washing policy;-Hand washing should be done when handling clean and contaminated, medication or treatment administration and after touching unsanitary objects. Review of Resident #79's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 07/22/25, showed:-No cognitive impairment;-Independent with Activities of Daily Living (ADL)s;-Diagnoses included schizophrenia, Post Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event) and diabetes. Review of Resident #79's care plan dated 7/22/25 showed a diagnosis of Diabetes. 4.Review of Resident #1's Quarterly MDS, dated [DATE]/25, showed:-Cognitively intact;-Substantial assist with ADLs;-Diagnosis included schizophrenia, high blood pressure and diabetes. Review of Resident #1's care plan dated 9/3/25 showed a diagnosis of diabetes. Observation on 10/15/25 at 12:21 P.M., showed:-CMT A walked down the hall with gloved hands;-CMT A held an insulin pen in his/her right hand and entered resident #79's room;-CMT A administered the insulin to resident #79;-CMT A did not remove his/her gloves or wash his/her hands before or after he/she gave resident #79 the insulin;-CMT A wore the same gloves and exited resident #79's room and walked up the hall to the medication cart;-CMT A opened the medication cart with the same gloved hands and placed resident #79's insulin pen in the cart;-CMT A used the same gloved hands and opened the second drawer of the medication cart;-CMT A used the same gloved hands and prepared resident #1's medications; -CMT A used the same gloved hands and opened the Medication Administration Records (MAR)s for the 200 hall and wrote resident #1's medications in the MAR;-CMT A entered resident #1's room and administered the resident's medications;-CMT A did not change his/her gloves or wash his/her hands before or he/she administered resident #1's medications;-CMT A wore the same gloves and exited resident #1's room and then went back to the medication cart;-CMT A failed to change gloves or wash/sanitize his/her hands before he/she administered resident #79's insulin and when he/she administered resident #1's medications. During an interview on 10/15/25 at 01:08 P.M., CMT A said:-He/She did not realize he/she had not changed gloves and/or washed hands between resident #79 and #1;-He/She should not walk down the hall with gloved hands;-He/She should have washed his/her hands and change gloves before she gave resident #79 his /her inulin;-He/She should have washed his/her hands and applied clean gloves before she gave resident #1 his/her medications. During an interview on 10/15/25 at 01:22 P.M. Licensed Practical Nurse (LPN) A said:-Staff should change gloves and wash hands in between residents;-Staff should not walk in the halls with gloves on;-He/She expected staff to practice good hand hygiene. During an interview on 10/16/25 at 1:25 P.M., Registered Nurse (RN) B said:-Staff should wash hands and apply clean gloves before and after each resident;-CMT A should not have walked down the hall with gloves already on. During an interview on 10/17/25 at 10:14 A.M., the Administrator said:-She expected CMT A to change his/her gloves and wash his/her hands before he/she gave resident #79 insulin;-She expected CMT A to wash his/her hands and apply clean gloves before he/she gave resident #1 his/her medication;-Staff should not have walked down the hall with gloved hands.

Based on observation, interview, and record review the facility failed to protect the resident's rights, when the facility did not post the State Survey Agency contact information for Residents (Residents #13, #38, and #86) and anyone else who wanted to file a complaint. The facility census was 88. Review of facility's Resident Rights-Dignity and Privacy policy, undated, showed:- All residents have the right to complain and be heard;- Residents have the right to free access to any representative of the state or federal government. 1. Review of Resident #38's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/30/25, showed:- The resident is cognitively intact;- Diagnosis: diabetes, cerebral palsy, anxiety disorder, bipolar disorder, and depression.During an interview on 10/17/25 at 8:15 A.M., the Resident said the only way to contact the state is to look up the number online from my computer. He/she doesn't recall the number being posted anywhere in the building. 2. Review of Resident #86's Minimum Data Set (MDS) information was not available. During an interview on 10/17/25 at 9:15 A.M., the Resident said He/she did not know where the state phone number was posted in order to make a complaint to the state agency regarding the facility. 3. Review of Resident #13's Annual MDS, dated [DATE], showed:- Resident was cognitively intact:- Diagnosis: cancer, atrial fibrillation (heart rhythm disorder), heart disease, heart failure, hypertension, GERD (kidney disease), diabetes, anxiety disorder, depression, and epilepsy.During an interview on 10/17/25 at 10:10 A.M., the Resident said he/she thought the phone number to contact the state was in the private telephone room that the residents use to make phone calls. He/she doesn't recall seeing it anywhere else.Observation of the facility on 10/16/25 at 2:25 P.M., showed there was no posted information regarding the state telephone number or how residents could file a complaint. During an interview on 10/17/25 at 10:30 A.M., the Administrator said the number to contact the state used to be posted in the private telephone room that the residents use and must have been taken down when the rooms were painted a few months ago. All residents should have access to the State Survey Agency information at any time and it should be posted.

Based on observation, interview, and record review the facility failed to protect the rights of residents, when the facility did not provide access to read or view the most recent State Survey Inspection conducted at the facility. This affected all residents. The facility census was 88.Review of the facility's undated Resident Rights-Dignity and Privacy Policy showed all Residents have the right to examine results of facility inspections including plans of correction.1. Review of Resident #86's Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, was not available. During an interview on 10/17/25 at 9:15 A.M., the Resident said he/she had not seen the state survey book and had not known where it was supposed to be kept for review. 2. Review of Resident #13's Annual MDS, dated [DATE], showed:- The Resident was cognitively intact:- Diagnosis: cancer, atrial fibrillation (heart rhythm disorder), heart disease, heart failure, hypertension, GERD (kidney disease), diabetes, anxiety disorder, depression, and epilepsy;During an interview on 10/17/25 at 10:10 A.M., the Resident said he/she does not know where the state survey book was located. Observation of the facility on 10/17/25 at 8:30 A.M., showed no posted signs on the ground floor, 1st floor, or 2nd floor of the facility indicating where the state survey book was located for the facility residents to review. During an interview on 10/17/25 at 10:30 A.M., the Administrator said the state survey book used to be at the front desk for residents to review. The Administrator did not know where it was currently located.

Based on observation, interview, and record review, the facility failed to ensure one Resident (Resident #77) remained free from smoke and fire hazards when the facility failed to prevent a resident from smoking in an unauthorized location in the facility. The facility census was 88.Review of facility's undated, Smoking Policy, showed;- Residents are to only smoke in posted designated areas during designated times posted on the first and second floors. An assigned staff member will monitor smoking activity;- Staff will make rounds every hour to monitor residents who are identified with risk behavior from history of smoking in non-designated areas;- If a resident is found to be noncompliant with the smoking policy, they will be placed on a 15 minute to an hourly monitoring process for 14 days;- Non-designated/prohibited smoking areas are Resident rooms, restrooms, shower rooms;- Designated Smoking Areas: Car port, Front Porch, Second Floor smoking area.1. Review of Resident #77's admission Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 8/7/25, showed:- Resident is cognitively intact:- Diagnosis: GERD (acid reflux), thyroid disorder, epilepsy, anxiety disorder, bipolar disorder, schizophrenia, post-traumatic stress disorder, and psychotic disorder;During an interview on 10/16/25 at 9:00 A.M., the Resident said, Resident #37 is my roommate and he/she smokes in the bathroom multiple times during the week, and it makes me nervous and scared! He/she was worried that roommate will start a fire in the room.Observation on 10/16/25 at 9:15 A.M. showed the smell of cigarette smoke coming from the Resident's bathroom was strong.2. Review of Resident #37's Quarterly MDS, dated [DATE], showed:- Resident was cognitively intact;- Diagnosis: hypertension, hip fracture, stroke, and anxiety disorder;Review of the resident's Care Plan, dated 7/15/25, showed the resident can smoke unsupervised. The resident should be instructed about smoking risks and hazards and about smoking cessation aids that are available. Notify the charge nurse immediately if it is suspected that the resident has violated facility smoking policy. Observation on 10/15/25 at 10:40 A.M. showed the resident outside his/her room with a pack of cigarettes poking out of his/her pocket;During an interview on 10/15/25 at 10:43 A.M., the Resident said, I sometimes smoke in the bathroom of my room, because it's so far to walk to the smoking area outside.During an interview on 10/16/25 at 2:20 P.M., Housekeeper A said he/she monitors resident rooms for smoking through the smell and observation of ashes or the yellowing of the walls. If he/she had an indication that a resident had smoked in an unauthorized location, he/she would contact the charge nurse. It had been six months or more since he/she had known of anyone smoking in their room.During an interview on 10/17/25 at 9:12 A.M., the Executive Assistant said:- He/she passes out cigarettes to residents and buzzes residents through the doors so they can smoke in designated smoking areas. Residents can smoke on the 2nd floor in an enclosed area that is locked during meals but otherwise is open to the residents at all times. Residents can smoke on the 1st floor outside seating area, or they can also smoke on the ground floor outside in the entrance parking lot. They are not allowed to smoke in their rooms or inside the facility except for the 2nd floor enclosed area. - The smoking policy had no constraints on when residents can smoke but they must smoke in designated areas. This would be a fire and safety hazard to smoke in their rooms. If anyone is suspected or caught smoking in their room, they are put on an hourly wellness check to see where they are in the building and to make sure, they are not smoking in an unauthorized area. Currently there are no residents on the hourly monitoring program. During an interview on 10/17/25 at 10:30 A.M., the Administrator said:- Residents are not allowed to smoke in their rooms or bathrooms;- Housekeeping monitors for smoke in resident rooms when they are doing their cleaning and will report to the charge nurse if they smell cigarette smoke;- Housekeeping will also look for cigarette butts, ashes, smells and yellowing of walls as indicators of residents smoking in their room.

Based on interview and record review, the facility failed to protect one out of six sampled residents (Resident # 1) from physical abuse. On 6/22/25, around 1:30 A.M., Certified Nurse Aide A became aware of Resident #1 and #2 getting into an altercation at the 2nd floor nursing station. Resident #1 wanted to get some ice and Resident #2 blocked the area with his/her wheelchair and would not let him enter. Resident #1 stated he cursed and threw a small amount of the remaining water in his water pitcher on Resident #2. Resident #2 yelled at Resident #1 and stated Resident #1 had called him/her racial names and threw water at him/her. Resident #1 went back to his own room. After Resident #1 left, Resident #2 told CNA A he/she was going to call his/her cousin and put a wood under his/her ass. The nurse aide advised Resident #2 to calm down and return to his/her room for the night. The facility failed to provide intervention and monitoring after the verbal incident per policy. Resident #2 went to the smoking area on the 2nd floor. Around 2:24 A.M., Resident #2 entered Resident #1's room. Resident #1 was awakened by Resident #2 striking him with a folding chair. Resident #2 then grabbed Resident #1's cell phone and placed it in his/her waistband and then forcefully grabbed Resident #1's scrotum, holding onto it while Resident #2 tried to wheel himself out of the room his/her room- which was next door. Resident #1 had bruising on his bilateral forearms and his right upper leg. Resident #1 said he was in excruciating pain from his scrotum being squeezed and was very angry that it occurred. The facility census was 86.The Administrator was notified on 6/25/25 at 2:40 P.M. of Immediate Jeopardy (IJ) which began on 6/22/25. The IJ was removed on 6/25/25.Review of the facility's undated Abuse and Neglect Policy showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.-Physical abuse was the use of physical force that may result in bodily injury, physical pain or impairment and could include: punishing, slapping, hitting, shoving, striking with or without an object, pinching, kicking, burning. -All residents would be protected from abuse, neglect or mistreatment. Review of the facility's undated Behavior Management Program policy showed:-Behavior symptoms in this policy was defined as an indication or characteristic of a negative physical or psychosocial out come which could indicate negative interactions or negative attitude that resulted in unpleasant atmosphere that disturbed others.-Resident who exhibited behavior symptom concerns would be monitored and/or treated to prevent incidents per the Quality Assurance (QA) decision on how often, what and where, and when the behavior was to be monitored.-Residents who often had outburst behaviors, aggression, verbal and/or physical abusive behavior should be monitored for safety. (The process of monitoring was decided individually per case by the QA committee or safety committee.)1. Review of Resident #1's admission Record Face Sheet showed the resident admitted to the facility on [DATE]. Review of Resident #1's quarterly Minimum Data Set (MDS-a standardized assessment tool that measured health status in nursing home residents), dated 4/16/25, showed the resident assessed as cognitively intact.Review of Resident #2's admission Record Face Sheet showed the resident admitted to the facility on [DATE], with the following diagnoses:-Schizophrenia, unspecified (a disorder that affected a person's ability to think, feel and behave clearly).-Major depressive disorder (a mental disorder characterized by persistently sad mood or loss of interest in activities, causing significant impairment of daily life).-Persistent mood affective disorder (a chronic low-grade depressed mood that lasts at least two years in adults).-Psychoactive substance abuse (abuse of substances that affect the brain).-Cannabis abuse.-Suicidal ideations (thinking or planning to kill one's self).-Insomnia (a disorder that makes it difficult to sleep).Review of Resident #2's quarterly MDS, dated [DATE], showed the resident assessed as cognitively intact.Review of Resident #1's Nurse's Notes, dated 6/22/25 at 2:24 A.M., showed: -Certified Nursing Assistant (CNA) B heard Resident #2 in Resident #1's room on the same hall, fighting, screaming, and throwing objects.-Resident #3 came to the nurses' station saying Resident #2 was in Resident #1's room and hit him with a chair.-CNA B went to the scene and called Licensed Practical Nurse (LPN) A to tell LPN A he/she was down the hall, two residents were fighting, and he/she needed help.-LPN A arrived immediately to Resident #2 in the hallway in his/her wheelchair, holding Resident #1's cell phone and refusing to get it out of his/her waistband and give it back.-CNA B stated after Resident #2 hit Resident #1 with the chair, he/she snatched the phone and when Resident #1 attempted to retrieve the phone, Resident #2 grabbed Resident #1's genitals. -Resident #1 began hitting Resident #2 on the head. -Resident #2 would not give back the phone.-Resident #1 was pushing Resident #2's wheelchair out of his room and hitting Resident #2 on the head.-Staff asked Resident #1 to stop and let the staff handle it, but he kept pushing Resident #2 into the room.-Both residents were then behind the door of Resident #2's room.-During the altercation, CNA B called 911.-Witness and Resident #1 stated the other resident was in this resident's room and struck Resident #1 with a chair and took his phone.Review of Resident #2's Nurse's Note, dated 6/22/25 at 2:25 A.M., showed: -LPN A was notified by CNA B that Resident #3 came to alert staff at the nurses' station of his/her roommate and Resident #2 fighting in the room.-LPN A came down toward Resident #1's room and saw him pushing Resident #2 down the hall in his/her wheelchair saying, Give me my phone. Resident #2 kept saying no.-Resident #1 began hitting Resident #2 in the side of the head. -Staff attempted to intervene and convince Resident #1 to stop and allow the staff to handle the situation.-Resident #1 would not stop and Resident #2 stated he/she was not giving the phone back.-Resident #1 pushed Resident #2 in his/her wheelchair to his/her room next door, pushed Resident #2 into the room, and attempted to retrieve his/her phone.Review of the facility's preliminary summary of investigation started on 6/23/25 showed:-LPN A stated Resident #1 repeatedly hit Resident #2 in the face.-He/She stated he/she was called to Resident #2's room.-He/She stated CNA B told him/her Resident #1 was requesting his phone back from Resident #2.-Upon further investigation it was found on 6/22/25 after 1:30 A.M., both residents were at the 2nd floor nursing station. Resident #1 wanted to get some ice and Resident #2 blocked the area with his/her wheelchair and would not let him enter.-Resident #1 stated he cursed and threw a small amount of the remaining water in his water pitcher on Resident #2.-Resident #2 yelled at Resident #1 and stated Resident #1 had called him/her racial names and threw water at him/her.-CNA A was sitting in the room next to the nursing station.-Upon interview, Resident #1 said Resident #2 was talking to him in a rude way, so he opened his water pitcher and threw a little water on Resident #2.-Resident #1 stated Resident #2 began to yell and curse at him, so he left and went back to his own room.-CNA A said after Resident #1 left, Resident #2 said he/she was going to call his/her cousin and put a wood under his/her ass.-CNA A advised Resident #2 to calm down and return to his/her room for the night.-Resident #2 went to the smoking area on the 2nd floor.-Before 2:24 A.M., Resident #2 entered Resident #1's room.-Resident #1 stated he was sleeping in his bed and was awakened by something hard hitting him.-Resident #1 stated Resident #2 hit him with a white folding chair several times and demanded his phone.-Resident #1 said he was defending himself under the covers of his bed and blocking the chair from hitting him. He called for his roommate, Resident #3, to help him.-Resident #3 stated he/she heard Resident #1 call for help and got up to stop Resident #2 from hitting Resident #1 with the chair. He/She was able to grab the chair and took it with him/her when he/she left the room to go get help.-He/She found CNA B and had him/her go with him/her to the room.-Resident #1 stated Resident #2 got ahold of his cell phone and would not return it.-CNA B stated he/she entered the room and saw Resident #1 hitting Resident #2 stating, Let go of my fucking dick! CNA B said the resident said this a few more times.-CNA B told Resident #2 to let go, but he/she would not.-CNA B said Resident #2 pulled Resident #1 by the scrotum to the hallway and into the room of Resident #2.-CNA B continued to ask Resident #2 to let go of Resident #1 and return the cell phone, but he/she refused.-Resident #1 stated he was asking for his phone to be returned.-CNA B stated Resident #1 hit Resident #2 in the face several times, but Resident #2 would not let go of Resident #1's scrotum.-CNA B asked both of them to stop, but they would not. He/She was afraid to intervene and was unable to deescalate them. He/She went down the hallway to get additional help from staff.-Resident #1 said he was bleeding from both arms. -In Resident #2's room, Resident #2 blocked the door and would not let Resident #1 leave the room.-Resident #1 said he was in excruciating pain from Resident #2 squeezing his scrotum and not letting go of him. He stated he hit Resident #2 in the face a few times.-According to Resident #2's nursing notes and interviews with Residents #1 and #2, LPN A and CNA B came to Resident #2's room.-CNA B said they returned to the room after possibly a minute, when he/she went to get the charge nurse.Review of Resident #1's Weekly Skin Assessment, dated 6/23/25, showed he had areas on bilateral forearms with scabs and red, discolored bruising and dark red bruising on bilateral forearms.Observation and interview on 6/23/25 at 10:45 A.M., showed Resident #1:-Resident #1 had multiple dark red and red blotches and scabs on both forearms and a reddened area on his right thigh.-He was laying in bed and Resident #2 came in and started hitting him with a chair and said, You deserved it!-He had some bruising on both arms and his left leg from where he tried to shield himself.-He could not get out of bed.-His roommate came and took the chair away from Resident #2.-He sat up on his bed and Resident #2 grabbed his scrotum and his phone.-Resident #2 kept trying to hide his phone in his/her waistband.-He had never had a fight with Resident #2 before; he never really talked to him/her.-He started hitting Resident #2 to get him/her to let go of his scrotum. -His roommate went and got the nurse.-The nurse (CNA B) came in the room and told him to stop hitting and CNA B told Resident #2 to let go of him.-CNA B grabbed Resident #1's arm and Resident #1 told CNA B not to touch Resident #1.-Resident #2 wouldn't let go of his scrotum so CNA B went to get more help. CNA B was only gone for a couple seconds.-Resident #2 dragged him to his/her room by the scrotum and threw his phone on the bed.-He told Resident #2 to let go and when he/she did not, he hit him/her.-The police had already been called.-He said his scrotum was sore, but did not take any pain pills.-Earlier, possibly around 1:30 A.M., he/she had gone to the ice machine and Resident #2 was blocking him/her from getting ice.-He/She thought his cup was empty and was not purposefully throwing water on Resident #2.-He/She had asked to get through and was just messing with Resident #2.-Now that Resident #2 was gone, he/she felt safe at the facility.During an interview on 6/23/25 at 11:00 A.M., CNA B said:-He/She had finished cleaning up another resident and Resident #3, who was Resident #1's roommate, came to him/her and said Resident #2 had hit Resident #1 with a chair while he was laying down.-When he/she got to the residents, Resident #2 had ahold of Resident #1's scrotum and Resident #1 was on the floor and was hitting Resident #2. -He/She told Resident #1 to stop and he said he wouldn't until Resident #2 released his scrotum.-He/She told Resident #2 to let go of Resident #1's scrotum and he/she would not.-He/She called 911, because it appeared Resident #2 was bleeding by the mouth and there was blood on the floor.-He/She tried to grab Resident #1's arm and told Resident #2 to let go of Resident #1.-Resident #2 tried to wheel him/herself back to his/her room with Resident #1's phone. -Resident #1 kept saying to give him back his phone.-Resident #2 rolled him/herself out of the room and they went to his/her room, while he/she was holding on to Resident #1's scrotum.-Resident #2 said Resident #1 started it earlier when he/she threw water on him/her. CNA A had separated them.During an interview on 6/23/25 at 12:10 P.M., LPN A said:-He/She did not witness the entire event.-The hallway had been quiet and he/she got a call from CNA B Resident #1 and Resident #2 were having a fight in the hallway.-He/She saw Resident #1 pushing Resident #2's wheelchair.-Resident #2 was grabbing Resident #1's scrotum and his phone was tucked in the left side of his/her waistband.-Resident #2 was laughing and said he/she was not going to give his phone back.-Resident #1 would say he wanted his phone back.-He/She did not know who started the fight, but assumed Resident #2 started it, because Resident #1 would typically stick to himself.-He/She was trying to separate the residents and not let them get in Resident #2's room and close the door behind them.Review of Resident #3's quarterly MDS, dated [DATE], showed he/she was cognitively intact.During an interview on 6/23/25 at 1:30 P.M., Resident #3 said:-Resident #2 snuck into his/her room, which he/she shared with Resident #1, around 2:30 A.M. on 6/22/25.-He/She woke up because Resident #1 was shouting, Get your ass over here!-Resident #2 was in his/her wheelchair and had a chair which he/she was swinging.-Resident #2 had brought the chair in with him/her. It was white plastic with a metal frame.-Resident #1 had his arms up and was shielding himself. -He/She grabbed the chair and took it into the hallway.-He/She then went to get a staff person to assist.-He/She saw Resident #2 grab Resident #1's phone and his scrotum and would not let go. -Resident #1 was hitting Resident #2 because he/she would not release him.-Resident #2 seemed like he/she was out of it on some kind of a drug. His/her eyes were glazed and there was nobody home.During an interview on 6/24/25 at 3:00 P.M., Psychiatric Nurse Practitioner A said:-Resident #2 attacking Resident #1 was abuse.-He/She did not think the staff would have known this might happen, since Resident #2 had calmed down from earlier incidents in the day. During an interview on 6/27/25 at 4:00 P.M., the Director of Nursing (DON) said he/she thought the incident was abuse when Resident #2 hit Resident #1 with a chair. During an interview on 6/27/25 at 4:15 P.M., the Administrator said:-Resident #2 attacking Resident #1 was intentional and abuse. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).MO00256231

Refer to F740 Event ID 66SW12 Based on observation, interview and record review, the facility failed to effectively manage behaviors by not providing appropriate behavior interventions for one sampled resident (Resident #76) when the resident physically assaulted and injured Resident #69 by hitting him/her in the face causing pain, swelling, and redness. The facility census was 86 residents. Review of the facility's Behavior Management Program, undated, showed: -A behavior symptom was defined as an indication or characteristic of a negative physical or psychosocial outcome which may have resulted in disturbing of others. -A behavior could also inhibit the resident in attaining or maintaining his/her highest practical well-being. -The purpose of the policy was to promote a healthy environment that provided comfort to all residents. -The staff may detect early changes in mental or psychosocial status for appropriate interventions, which included: medication regimen, activities, counseling, visits (not specified) or social therapy. -Residents who exhibit behavior symptom concerns were monitored and/or treated to prevent incident. -Monitoring included checking for patterns and occurrence. -Residents who exhibited behavior concerns that fluctuated should be observed or monitored for increased/decreased and factors that contribute to elevate behavior symptoms. -Residents who often exhibited outburst behaviors, aggression, verbal and/or physical abusive behavior were monitored for safety, based on each individual and decided by the safety committee or Quality Assurance (QA) team. -Residents who exhibit fluctuated behavior or new behavior symptoms or indicators: --Monitor for underlying medical conditions and notify the Director of Nursing (DON) to revise the care plan. --Daily observation and documentation on each resident's behavior flow sheet determined by the charge nurse. --All staff were responsible to communicate and recommend what behavior needs to be monitored. 1. Review of Resident #76's Face Sheet, undated, showed: -The resident was admitted to the facility on [DATE]. -His/Her diagnoses included: --Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), single episode. --Other psychoactive substance abuse (a strong desire or sense of compulsion to take the substance). --Generalized anxiety disorder (a constant about everyday issues and situations). Review of the resident's initial care plan dated 1/10/24 showed the resident: -Had a history of drug use/abuse. --The goal was the resident would understand the expectations of the facility, no drug use, and sign a contract. --The only intervention was the resident would understand that breaking the contract would result in discharge. ---NOTE: This care plan was not updated or revised. Review of the resident's Pre-Admission Screening/Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness, intellectual disability/developmental disability, and/or related condition who reside in a Medicaid Certified nursing facility), dated 6/13/24, showed: -The resident qualified for care. -The resident had a serious mental illness. -The resident had a history of Schizophrenia (a serious mental illness that affected how a person thought, felt and behaved). -The resident needed continued support and services. --Monitoring of behavioral symptoms. --Tools of choice or other positive behavioral support services. --Mental status to be monitored for signs/symptoms of depression, changes in mood, agitation and aggression. --Anger management may be helpful by teaching coping skills to deal with his/her emotions appropriately. --Staff to provide support and redirection as needed. -Resident would like to see a psychologist. Review of the resident's care plan showed: -There were no updates to the initial care plan of any new focus areas or interventions that addressed the resident's mood, mental status, and anger management. -There were no interventions that showed how to provide support and redirection to the resident. Review of the resident's Psychiatric Periodic Evaluation dated 10/3/24 showed: -The form was completed by an outside Psychiatric provider. -Was a psychiatry evaluation and medication management at the facility. -The resident denied feeling depressed or anxious. -The resident said the recent medication changes had helped his/her anxiety. -Staff noted no concerns, no new psychiatric issues or complaints. -Labs and medications list were reviewed, continue to monitor for changes and medication adjustment as needed. -Monitor for depression symptoms and document. -Psychological service to improve coping skills. -Safety concerns were addressed, staff were instructed regarding communication and redirection needed in caring for psychiatric and mental health residents. -Continue to monitor closely, redirect to promote safety, and utilize nursing intervention and behavioral modification. -Continue to offer activities, social events, group initiating, and resident one-on-one when needed. -Encourage sleep-wake cycle. -Monitor for changes in mood or behaviors and notify psychiatry if agitation or resident symptoms worsen. Review of the resident's care plan showed: -There were no updates, new focus areas, or new interventions that addressed safety concerns, communication, redirection, behavior modification, or placing the resident on 1:1 monitoring. Review of the resident's progress notes dated 10/24/24 showed: -The resident was agitated, kicking and screaming. -The resident was taken to the hospital for evaluation and treatment of increased agitation and aggressiveness. -The social worker notified the Administrator and Director of Nursing (DON) of the resident's behaviors and being admitted to the hospital. Review of the resident's care plan showed: -There were no updates or new focus areas initiated following the resident's hospitalization for behaviors. -There were no updates or new focus areas that addressed the resident's behaviors and interventions including 1:1 monitoring. Review of the resident's Psychiatric Periodic Evaluation dated 10/31/24 showed: -Psychiatric medication regimen was reviewed. -Continue current psychiatric medications. -Continue to monitor response and make adjustments as needed. -Resident could benefit from psychological services to enhance coping skills. -Monitor for changes in mood or behaviors. -No new psychiatric concerns/complaints noted. Review of the resident's Psychotherapy Progress Note dated 10/31/24 showed: -Was completed by an outside psychological provider. -Staff reported resident behaviors of fighting with others, emotionally labile, fighting with staff. -Therapist focused on the resident's current mental health status and progress towards management of mood and anxiety symptoms. -Therapist encouraged the resident to set short-term goals that involved only him/her and did not depend on anyone else's involvement in his/her life. -Therapist encouraged the resident to focus on attainable and short-term goals to manage mood and anxiety. -Therapist encouraged the resident to let staff know of needs as needed. -Therapist will follow up in one to three weeks. Review of the resident's progress notes dated 11/6/24 showed: -The resident was aggressively knocking on other resident's doors, yelling and screaming at them saying they owed him/her money. -The facility social worker notified the DON. -The facility social worker and DON talked with the resident. -The resident was placed on the list to be seen by psychology. Review of the resident's care plan showed: -There were no updates or new focus areas that addressed the safety of the resident or others. -There were no updates or new focus areas that addressed the resident's aggression, -There were no updates or new focus areas that addressed the resident's behaviors. -There were no updates or new focus areas that addressed the resident's behaviors and interventions including 1:1 monitoring. -There were no new interventions that addressed behavior modification when the resident became aggressive. Review of the resident's progress notes showed: -There was no documentation that mentioned changes in care needed following episodes of increased aggression and increased behaviors. -There was no documentation that mentioned psychology or psychiatry were notified of the resident's increased behaviors and aggression. Review of the resident's Psychotherapy Progress Note dated 11/7/24 showed: -The resident refused psychotherapy services. -The therapist will follow up in one to three weeks. Review of the resident's progress notes dated 11/7/24 showed: -The social worker and the DON talked with the resident. -The DON notified the psychiatrist of the resident's increased behaviors and asked for medication management and adjustment as needed. Review of the resident's Psychotherapy Progress Note dated 11/21/24 showed: -The resident refused psychotherapy services and said his/her mind was all crazy and he/she couldn't think. -The therapist will follow up in one to three weeks. Review of the resident's Psychotherapy Progress Note dated 11/27/24 showed: -The resident was extremely agitated and unreasonable. -The resident expressed distrust with residents and staff. -The resident expressed significant agitation and frustration. -The resident expressed thoughts of suicide, but did not report a plan. -Therapist attempted to reduce the resident's emotional distress and to problem solve around the crisis. -The resident reported disinterest in hospitalization . -The resident's distress and agitation were lessened with the opportunity to express difficult emotion with the therapist. -At the end of the session, the resident denied thoughts of suicide. -The therapist reported to the resident that his/her original expression of suicide would be shared with the staff. -The therapist discussed the resident's presentation and safety planning with the Administrator, DON, charge nurse, and floor nurses. --Issues of safety were discussed with all. Review of the resident's care plan showed: -There were no updates or new focus areas that addressed the safety of the resident or others. -There were no updates or new focus areas that addressed the resident's aggression, -There were no updates or new focus areas that addressed the resident's behaviors. -There were no new interventions that addressed behavior modification when the resident became aggressive. -There were no updates or new focus areas that addressed the resident's behaviors and interventions including 1:1 monitoring. Review of the resident's progress notes showed there was no documentation that mentioned changes in care needed following episodes of increased aggression and increased behaviors. Review of the resident's Psychiatric Periodic Evaluation, dated 11/28/24, showed: -Psychiatric medication regimen was reviewed. -Staff noted increased behavioral concerns as others were afraid of the resident because of his/her aggressive posture on the unit. -No new psychiatric issues or complaints were observed during the visit. -Mental status examination included: --Perseveration, pressured speech, coherent with loud tone and value speech. --Mood was noted to be irritable. --Affect was suspicious and irritable. --No response to hallucinations. --Poor concentration, insight, and judgement. -Start Seroquel (an antipsychotic used to treat hallucinations) 25 milligrams (mg) twice a day. Review of the resident's Psychiatric Periodic Evaluation, dated 12/19/24, showed: -Psychiatric medication regimen was reviewed. -The resident reported auditory hallucinations. -Staff noted increased behavioral concerns with anxiety and agitation. -No new psychiatric issues or complaints were observed during the visit. -Mental status examination included: --Perseveration, pressured speech, coherent with loud tone and value speech. --Mood was noted to be irritable. --Affect was suspicious and irritable. -Start Hydroxyzine (an antihistamine used to treat anxiety and agitation) 50 mg three times a day. Review of the resident's care plan showed: -There were no updates or new focus areas that addressed the safety of the resident or others. -There were no updates or new focus areas that addressed the resident's hallucinations. -There were no new interventions that addressed behavior modification when the resident became aggressive. Review of the resident's progress notes showed there was no documentation that mentioned changes in care needed with episodes of hallucinations and increased aggression. Review of the resident's Physician Orders, dated January 2025, showed the resident was ordered: -Sertraline (medication used to treat depression); 150 mg daily (order updated on 11/7/24). -Buspirone (medication used to treat anxiety disorders); 5 mg twice a day (order updated on 11/7/24). -Quetiapine (medication used to treat hallucinations) 25 mg twice a day (order started on 11/29/24). -Hydroxyzine (medication used to treat agitation) 50 mg three times a day (order started on 12/19/24). Review of the resident's Psychotherapy Progress Note dated 1/3/25 showed: -The resident reported significant distress over current level of functioning. -The resident expressed his/her mind was racing. -The resident reported auditory hallucinations and explained them as hearing voices of people he/she knew just talking, both day and night all the time. -The resident reported poor sleep with difficulty falling and staying asleep. -The therapist encouraged the resident to let staff know of needs as needed and appropriate. -The resident would benefit from continued psychotherapeutic support maintain current level of progress and stability. -The therapist discussed the resident's presentation and plan of care with the unit nurse, nurse manager, and the social worker. Review of the resident's care plan showed: -There were no new focus areas or interventions that addressed the resident's increased behaviors. -There were no new focus areas or interventions that addressed the resident's increased aggression towards other resident's and staff. Review of the resident's progress notes showed: -There was no documentation that addressed if changes in care were needed following episodes of increased aggression, hallucinations, and increased behaviors. -There was no documentation that addressed psychology or psychiatry was notified of the resident's increased behaviors, hallucinations, and increased aggression. Review of the resident's Psychotherapy Progress Note dated 1/9/25 showed: -The resident initially presented with agitation and anxiety. -The resident described his/her disappointment with his/her current family situation. -The resident had feelings of isolation and resentment. -The therapist helped the resident problem solve around preparing broken relationships. -The therapist determined the resident had periodic intermittent drops in mood and increased anxiety due to various personal issues, acute and chronic health conditions, strained family relationship dynamics, and ongoing situational stressors and challenges. -The therapist discussed the resident's recent presentation and plan of care with unit nurse, nurse manager, and the facility social worker. Review of the resident's care plan dated 1/13/25, showed: -The resident had a history of drug use/abuse. -The resident had potential for sad mood related to depression. --Administer medications as ordered. --Allow the resident to express feelings. --Behavioral health consults as needed. --Encourage the resident to attend activities of his/her choice. --Psychiatry consultation as needed. -The resident was at risk for increased behaviors related to a history of auditory hallucinations. --Administer medications as ordered. --Assist the resident to develop more appropriate methods of coping and interacting. --Encourage the resident to express feelings appropriately. --Caregivers were to provide opportunity for positive interactions, attention. --Stop and talk with him/her as passing by. --Monitor behavior episodes and attempt to determine underlying cause. --Consider location, time of day, persons involved, and situations. --Document behavior and potential causes. --Monitor behavior episodes and attempt to determine underlying cause. -The interventions / recommendations from the psychologist and psychiatrist were not added to the care plan. During an interview on 1/13/25 at 3:19 P.M., Resident #76 said: -He/She thought Resident #69 was going through his/her belongings. -He/She hit Resident #69 in the face. During an interview on 1/13/25 at 8:45 A.M., Resident #69 said: -Resident #76 said he/she kidnapped his/her children. -He/She was sleeping when Resident #76 came in his/her room and hit him/her in the face. -Resident #76 harassed him/her every day about going into Resident #76's room and taking his/her belongings, which never happened. -He/She talked to staff about Resident #76's behavior and they told him/her to stay away from Resident #76. -Resident #76 also bothered other residents, saying they went into his/her room and took belongings. -He/She felt safe now that Resident #76 was gone. During an interview on 1/13/25 at 9:15 A.M., Resident #72 said: -Resident #76 yelled a lot at the residents and had paranoid episodes, saying people were in his/her room taking his/her items. -Resident #76 was crazy, he/she threatened to beat up people. -Resident #76 was violent. Staff told him to stay in his/her room. -He/She heard Residents #69 and Resident #76 argue on Friday night (1/10/25), but did not see anything. -He/she felt safe without Resident #76 around. During an interview on 1/13/25 at 9:25 A.M., Resident #37 said: -Resident #76 was unruly in the evenings. -Staff told Resident #76 to return to his/her room when he/she acted up. -On Friday he/she saw Resident #76 go into Resident #69's room. -He/She could not see the head of the bed behind the curtain, but he/she saw the motion of Resident #76 swing his/her arms as if he/she had hit Resident #69. -He/She felt safe now that Resident #76 was gone. -Staff tried to stop Resident #76 from hitting Resident #69. -He/She thought Resident #76 was going to hit the staff. -The staff ended up calling the police. During an interview on 1/13/25 at 9:35 A.M., Resident #11 (Resident #76's roommate) said: -Resident #76 was paranoid a lot. -He/She never saw anyone in their room. -He/She did not see what happened on Friday. During an interview on 1/14/25 at 11:16 A.M., Resident #29 said: -He/She had seen Resident #76's explosive behaviors before Friday. -He/She was afraid of the resident and felt safer now that Resident #76 was gone. -He/She noticed that staff stayed with Resident #76 during his/her explosive behaviors and tried to keep him/her busy. During an interview on 1/13/25 at 9:43 A.M., Certified Nursing Assistant (CNA) B said: -He/She was not working Friday night. -Resident #76 had some paranoia, anger issues which increased over the last few months. -He/She reported behaviors to the nurse, he/she was unsure if anything was done. During an interview on 1/13/25 at 9:59 a.m., CNA A said: -Resident #76 had behaviors like pacing, sweating, and cussing at other residents. -He/She reported behaviors to the nurse. -Resident #76 was usually fine on the day shift, but was informed by staff and residents of his/her behaviors on the evening and night shifts. During an interview on 1/14/25 at 9:41 A.M., CNA A said: -When Resident #76 first arrived at the facility there were no behaviors. The last few months his/her behaviors increased. -Resident #76 went out of the building and returned angry, mad and paranoid. -Other resident's expressed being afraid of Resident #76. -He/She reported Resident #76's behaviors to the nurse. -He/She talked to Resident #76 to try to calm him/her down and he/she told the nurse about the resident's behaviors. During an interview on 1/14/25 at 9:54 A.M., CNA B said: -When Resident #76 first got to the facility there were no issues. -The last few months Resident #76 started showing more behaviors like cussing at other residents, accusing other residents of being in his/her room, yelling at staff and residents and pacing, generally paranoid. -He/She told the nurse about the behaviors. During an interview on 1/14/25 at 10:08 A.M., License Practical Nurse (LPN) A said: -When Resident #76 would start showing paranoia he/she would tell Resident #76 to go back to his/her room and calm down. -Resident #76 acted up on the night shift, because they didn't know how to handle the resident. -He/She separated the resident from other residents when he/she started to act up. -He/She did not report the behaviors because he/she was able to handle them. During an interview on 1/14/25 at 10:24 A.M., LPN B said: -Residents #76 and Resident #69 exhibited several hours of verbal altercations, including cussing at each other. -Resident #76 said he/she was going to kill Resident #69 while pacing in the hall. -He/She separated the residents, directing them to remain on separate sides of the hall. -Resident #76 was sweating and acting paranoid. -Resident #76 believed people were tapping into his/her phone. -Resident #76 believed Resident #69 was in his/her room. -Twice Resident #76 tried to enter Resident #69's room, accusing Resident #69 of taking things from his/her room. -Resident #76 threatened LPN B at which time LPN B called the police. -When police arrived Resident #76 physically assaulted the police as well as the paramedics. -Paramedics administered a sedative and the resident was removed in handcuffs. During an interview on 1/14/25 at 10:59 A.M., Certified Medication Technician (CMT) A said: -He/She was working Friday night during the incident. -The charge nurse told him/her that Resident #76 was being volatile. -He/She did not see anything that happened until the police arrived. -There were 11 officers and paramedics who responded to the 911 call. -Resident #76 had to be put in restraints. -Several residents told him/her they were afraid of Resident #76. -Resident #76 was usually easily redirected. -Resident #76 tended to be more aggressive toward people he/she believed to be more vulnerable. During an interview on 1/14/25 at 1:20 P.M., the DON said: -No residents or staff reported anything to him/her about Resident #76's behaviors. -Resident #76 went to the hospital last month, but that was the first time Resident #76 ever exhibited behaviors, that he/she was aware of. During an interview on 1/14/25 at 1:20 P.M. the Administrator said: -He/She was not made aware of any previous behaviors by Resident #76. -Resident #76 was sent out to the hospital last month for behaviors, but to his/her knowledge that was the only previous issue with his/her behaviors. -He/She would expect staff to separate the resident from other residents, place on one on one observation, someone should have been watching the resident, and call the police as the resident was very intimidating. MO00247856

Refer to F600 Event ID 66SW12 Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #69) was free from physical abuse, when on 1/10/25 at approximately 10:00 P.M., Resident #76 willfully hit Resident #69 on his/her face, resulting in swelling and pain. Resident #72 stated Resident #76 had threatened to beat up people and was violent. The facility census was 86 residents. An Abuse/Neglect policy was requested from the facility, but was not provided. Review of the facility's Abuse and Neglect Educational Material; Policy Regarding Abuse and Neglect of Facility Residents, undated showed: -Resident rights protected them from physical and mental abuse. -Abuse was defined as a willful infliction of injury. -Physical force that may result in physical pain or impairment included: --Pushing, slapping, hitting, shoving, striking with or without an object, pinching kicking or burning. 1. Review of Resident #76's Face Sheet, undated, showed: -The resident admitted to the facility on [DATE]. -His/Her diagnoses included: --Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), single episode. --Other psychoactive substance abuse (a strong desire or sense of compulsion to take the substance) --Generalized anxiety disorder (a constant about everyday issues and situations). Review of the resident's care plan dated 1/13/25 showed: -The resident had potential for sad mood related to depression. -The resident was at risk for increased behaviors. --Monitor behavior episodes and attempt to determine underlying cause. Review of the resident's Physician Orders, dated January 2025, showed: -Buspirone (medication used to treat anxiety disorders); 5 mg twice a day. -Quetiapine (medication used to treat hallucinations) 25 mg twice a day. -Hydroxyzine (medication used to treat agitation) 50 mg three times a day. During an interview on 1/13/25 at 3:19 P.M., Resident #76 said: -He/She thought Resident #69 was going through his/her belongings. -He/She hit Resident #69 in the face. -He/She was unsure if anyone else was around when it happened. -The police came and arrested him/her and took him/her to the hospital. 2. Review of Resident #69's Face Sheet, undated, showed: -The resident admitted on [DATE]. -The resident's diagnoses included: --Schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and actions). --Major Depressive Disorder --Persistent Mood Disorder (a continuous, long-term form of depression). Review of the resident's Care Plan, dated 11/21/24, showed: -The resident was resistant to cares. -The resident received antidepressant medication. -The resident had chronic pain in the lower back. During an interview on 1/13/25 at 8:45 A.M., the resident said: -Resident #76 said he/she kidnapped his/her children. -He/She was sleeping when Resident #76 came in his/her room and hit him/her in the face. -He/She had swelling and pain on the left side of his/her face. -He/She asked for pain medication and an ice pack and received it. -He/She did not want to go to the hospital. -Resident #76 harassed him/her every day about going into Resident #76's room and taking his/her belongings, which never happened. -He/She talked to staff about Resident #76's behavior and they told him/her to stay away from Resident #76. -Resident #76 also bothered other resident's, saying they went into his/her room and took belongings. -He/She felt safe now that Resident #76 was gone. Observation on 1/13/25 at 8:45 A.M. showed: -A small amount of swelling in Resident #69's left cheek. 3. During an interview on 1/13/25 at 9:00 A.M., Resident #59 (roommate of Resident #69) said: -Resident #76 was in their room. -He/She saw Resident #76 go over to the other side of the room, but the curtain was drawn and did not see what happened. During an interview on 1/13/25 at 9:15 A.M., Resident #72 said: -Resident #76 yelled a lot at the residents and had paranoid episodes, saying people were in his/her room taking his/her items. -Resident #76 threatened to beat up people. -Resident #76 was violent. Staff told Resident #76 to stay in his/her room. -He/She heard Resident#69 and #76 argue on Friday night (1/10/25), but did not see anything. -He/she felt safe without Resident #76 around. During an interview on 1/13/25 at 9:25 A.M., Resident #37 said: -Resident #76 was unruly in the evenings. -Staff told Resident #76 to return to his/her room when he/she was acting up. -On Friday he/she saw Resident #76 go into Resident #69's room. -He/She could not see the head of the bed behind the curtain, but he/she saw the motion of Resident #76 swing his/her arms as if he/she had hit Resident #69. -He/She felt safe now that Resident #76 was gone. -Staff tried to stop Resident #76 from hitting Resident #69. -He/She thought Resident #76 was going to hit the staff. -The staff ended up calling the police. During an interview on 1/13/25 at 9:35 A.M., Resident #11 (Resident #76's roommate) said: -Resident #76 was paranoid a lot. -He/She never saw anyone in their room. -He/She did not see what happened on Friday. During an interview on 1/14/25 at 9:41 A.M., CNA A said: -Resident #76 went out of the building and returned and he/she was angry, mad and paranoid. -Other resident's expressed being afraid of Resident #76. -He/She reported Resident #76's behaviors to the nurse. -On Friday Resident #76 was pacing and sweating a lot towards the end of his/her shift, around 7:00 P.M. -He/She talked to Resident #76 to try to calm him/her down and he/she told the nurse about the resident's behaviors. -Resident #76 said Resident #69 kidnapped his/her kids. -He/She tried to talk to Resident #76 and he/she calmed down a little. During an interview on 1/14/25 at 9:54 A.M., CNA B said: -Resident #76 and #69 used to be friendly with each other. -Recently they had arguments and disagreements, but nothing that went beyond that. During an interview on 1/14/25 at 10:02 A.M., Resident #69 said: -He/She was having pain in his/her back. -He/She still had pain in his/her face and jaw. -He/She had not reported it to the nurse, but was going to contact his/her doctor himself/herself. During an interview on 1/14/25 at 10:24 A.M., LPN B said: -He/She was working Friday night. -Residents #76 and #69 exhibited several hours of verbal altercations, including cussing at each other. -Resident #76 said he/she was going to kill Resident #69 while pacing in the hall. -He/She separated the resident's, directed them to remain on separate sides of the hall. -The other staff on shift were helping with other residents. -Resident #76 was sweating and acted paranoid. -Resident #76 believed people tapped into his/her phone. -Resident #76 believed Resident #69 was in his/her room going through his/her things. -He/She assured Resident #76 that Resident #69 was not in the room and explained how the setting on his/her phone worked to show that no one was tapping into their phone. -The resident returned to his/her room and LPN B returned to his/her duties. -Resident #69 came off the elevator saying he/she had gone down to smoke when Resident #76 hit him/her in the face. -Nursing staff came off the elevator with Resident #76 and instructed them both to remain on separate ends of the hall. -He/She went to Resident #69's room and assessed his/her injury. -He/She saw light redness and swelling, and the resident refused care, and asked for just an ice pack. -Twice Resident #76 tried to enter Resident #69's room, accusing Resident #69 of taking things from his/her room. -Resident #76 threatened LPN B at which time LPN B called the police. -When police arrived Resident #76 physically assaulted them as well as paramedics. -Paramedics administered a sedative and the resident was removed in handcuffs. During an interview on 1/14/25 at 10:59 A.M., Certified Medication Technician (CMT) A said: -He/She was working Friday night during the incident. -The charge nurse told him/her that Resident #76 was being volatile. -He/She did not see anything that happened until the police arrived. -Resident #76 had to be put in restraints. During an interview on 1/14/25 at 1:20 P.M., the Director of Nursing (DON) said: -Staff received quarterly training on abuse and neglect. -The DON and administrator were responsible for providing and documenting training which was offered monthly. -No residents or staff reported anything to him/her about Resident #76's past behaviors that would have indicated a problem. -Resident #76 went to the hospital last month but that was the first time he/she ever exhibited behaviors, that he/she was aware of. During an interview on 1/14/25 at 1:20 P.M. the Administrator said: -He/She was not made aware of issues between Resident #69 and Resident #76. -He/She expected the staff to separate the residents and when the issues continued to put Resident #76 on a one-on-one monitoring. -Someone should have been watching the resident. -Resident #76 was sent out to the hospital last month for behaviors, but to his/her knowledge that was the only previous issue with his/her behaviors. MO00247856

Refer to F623 Event ID 66SW Based on interview and record review, the facility failed to provide an appropriate discharge notice for one sampled resident (Resident #76) out of 36 sampled residents, when the Discharge Notice issued to the resident had incorrect contact information for the Ombudsman, incorrect contact information in order for the resident to appeal the discharge, and did not have the correct discharge location listed on the notice. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed: -The purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. -Involuntary discharges must: --Be reviewed by the Safety Committee. --The physician shall be consulted. --Can be immediate in the case of emergency due to: ---The safety of individuals at the facility was endangered due to clinical or behavioral status of the resident. --Issue a discharge notice letter to the resident, including the reason for the discharge, that included a 30-day notice or immediate discharge. --The Administrator sent the notice to the resident/Durable Power of Attorney (DPOA) and the local Ombudsman (an advocate for residents of nursing homes), which included the following: ---Reason for discharge. ---Effective date of discharge. ---Location to which the resident was discharged . ---A statement that the resident had the right to appeal. ---The name, mailing address, and telephone number of the Ombudsman. ---NOTE: The policy did not address the need for resident or authorized facility personnel signatures. 1. Review of Resident #76's Face Sheet, undated, showed: -The resident was admitted to the facility on [DATE]. -His/Her diagnoses included: --Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), single episode. --Other psychoactive substance abuse (a strong desire or sense of compulsion to take the substance). --Generalized anxiety disorder (a constant worry about everyday issues and situations). Review of the resident's Notice of Discharge (Immediate notice), dated 1/11/25, showed: -The resident was immediately discharged for: -In The reason for your discharge section of the form Licensed Practical Nurse (LPN) B wrote: --discharged due to extreme violent behavior, drug use, causing a safety issue and being a danger to self or other residents, physically and verbally. -The discharge letter did not have a signature of facility staff, physician, or resident. -The effective date was 1/11/24 at 12:14 A.M. -NOTE: there were no signatures on the notice by the resident or authorized facility personnel. During an interview on 1/14/25 at 10:24 P.M., LPN B said: -He/She contacted the police and the Administrator and was instructed to provide the resident with an immediate discharge. -He/She did not sign the form and handed it to the police to take for the resident. During an interview on 1/14/25 at 10:24 A.M., LPN A said: -The Administrator and the Director of Nursing (DON) were responsible for preparing and sending out discharges and notices. During an interview on 1/14/25 at 12:24 P.M., Social Services Director (SSD) B (from Facility B), said: -He/she had not received a referral from Facility A for any resident, including Resident #76. -He/She checked his/her fax, email and phone records and was unable to find a referral. During an interview on 1/14/25 at 1:20 P.M., the Administrator said: -He/She was responsible for initiating the discharge for the resident. -The Administrator and the resident should sign the discharge notice. -He/She spoke to LPN B on the phone and had him/her provide the paperwork to the resident. -LPN B gave the discharge notice to the resident in person. -The resident was in handcuffs and sedated and was unable to sign the form. During an interview on 1/14/25 at 2:15 P.M., Administrator B (from Facility B) said: -He/She had not heard from Administrator A in the last few days. -He/She was unaware of any referral from Facility A. During a phone interview on 1/17/25 at 3:00 P.M. the Ombudsman said: -The facility discharge letter was incorrect. --The letter had no discharge location. --The Ombudsman information that was 4 years old was incorrect. --The contact information for the appeals unit was from two years ago and invalid. -The Administrator does not plan to let the resident return. MO00247856

Refer to F622 Event ID 66SW12 Based on interview and record review, the facility failed to plan, coordinate, and provide a safe and appropriate discharge when the facility initiated an immediate discharge for one sampled resident (Resident #76) out of 36 sampled residents. The resident's discharge notice stated the transfer location was Facility B, however, the resident was transported to the hospital via Emergency Medical Services. Facility B was unaware the resident was to be discharged to them. The facility census was 86 residents. Review of the facility's Discharge and Transfer Resident policy, dated 12/21/24, showed: -The purpose of the policy was to ensure the appropriate procedure for transferring and discharging a resident. -All residents who were discharged out of the facility under any circumstance was given an order from the attending physician. -Provide written instruction with verbal explanation regarding care, treatment, use of medications or devices to the resident upon discharge. -Order to discharge included the date and time of physician notification. -Involuntary discharges must: --Be reviewed by the Safety Committee. --The physician shall be consulted. --Can be immediate in the case of emergency due to: ---The safety of individuals at the facility was endangered due to clinical or behavioral status of the resident. --Issue a discharge notice letter to the resident, including the reason for the discharge, that included a 30-day notice or immediate discharge. --The Administrator would send the notice to the resident/Durable Power of Attorney (DPOA) and the local Ombudsman (an advocate for residents of nursing homes), which included the following: ---Reason for discharge. ---Effective date of discharge. ---Location to which the resident was discharged . ---A statement that the resident had the right to appeal. ---The name, mailing address, and telephone number of the Ombudsman. 1. Review of Resident #76's Face Sheet, undated, showed the resident admitted to the facility on [DATE] with the following diagnoses: -Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), single episode. -Other psychoactive substance abuse (a strong desire or sense of compulsion to take the substance). -Generalized anxiety disorder (a constant about everyday issues and situations). Review of the resident's Notice of Discharge (Immediate notice), dated 1/11/25, showed: -The resident was immediately discharged for: --The safety of individuals in the facility was endangered due to clinical or behavioral status of the resident. --The health of individuals in the facility was otherwise endangered. --The discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility. -In The reason for your discharge section of the form Licensed Practical Nurse (LPN) B wrote: --discharged due to extreme violent behavior, drug use, causing a safety issue and being a danger to self or other residents, physically and verbally. -Police and fire department onsite. -The notice indicated the discharge was discussed with the resident and would be going to a different facility (Facility B). -The effective date was 1/11/25 at 12:14 A.M. Review of the resident's Physician Order Sheet dated January 2025 showed: -No order for discharge. During an interview on 1/14/25 at 10:24 P.M., LPN B said: -The resident had several hours of verbal altercations with other residents. -The resident was being paranoid and yelled at other residents and staff. -The resident was physically aggressive toward police officers and paramedics. -The resident was handcuffed by the police, sedated by the paramedics, and taken to local hospital. -The resident hit another resident and started to come after staff. -He/She contacted the police and the Administrator and was instructed to provide the resident with an immediate discharge. During an interview on 1/14/25 at 10:24 A.M., LPN A said: -The Administrator and the Director of Nursing (DON) were responsible for preparing and sending out discharges and notices. During an interview on 1/14/25 at 1:20 P.M., the Administrator said: -He/She was responsible for initiating the discharge for the resident. -He/She spoke to LPN B on the phone and had him/her provide the paperwork to the resident. -LPN B gave it to the resident in person. -He/She made arrangements for the resident to go to Facility B once released from the hospital. -He/She contacted the Administrator at Facility B on the phone and made the arrangements. -The Ombudsman received a report at the end of the month with all the discharges. -The resident was in handcuffs and sedated at the time of discharge and was unable to sign the form. During an interview on 1/14/25 at 12:24 P.M., Social Services Director (SSD) B (from Facility B), said: -He/she had not received a referral from Facility A for any resident, including Resident #76. -He/She checked his/her fax, email and phone records and was unable to find a referral. During an interview on 1/14/25 at 2:15 P.M., Administrator B (from Facility B) said: -He/She had not heard from Administrator A in the last few days. -He/She was unaware of any referral from Facility A. During a phone interview on 1/17/25 at 3:00 P.M. the Ombudsman said: -The ombudsman office had filed an appeal. -He/she had contacted the facility Administrator, notified of the intent to appeal the discharge. -The facility discharge letter was incorrect. --The letter had no discharge location. --The Ombudsman information was 4 years old and was incorrect. --The contact information for the appeals unit was from two years ago and invalid. -The Administrator said he/she did not plan to let the resident return. MO00247856

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #69) was free from physical abuse, when on 1/10/25 at approximately 10:00 P.M., Resident #76 willfully hit Resident #69 on his/her face, resulting in swelling and pain. Resident #72 stated Resident #76 had threatened to beat up people and was violent. The facility census was 86 residents. An Abuse/Neglect policy was requested from the facility, but was not provided. Review of the facility's Abuse and Neglect Educational Material; Policy Regarding Abuse and Neglect of Facility Residents, undated showed: -Resident rights protected them from physical and mental abuse. -Abuse was defined as a willful infliction of injury. -Physical force that may result in physical pain or impairment included: --Pushing, slapping, hitting, shoving, striking with or without an object, pinching kicking or burning. 1. Review of Resident #76's Face Sheet, undated, showed: -The resident admitted to the facility on [DATE]. -His/Her diagnoses included: --Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), single episode. --Other psychoactive substance abuse (a strong desire or sense of compulsion to take the substance) --Generalized anxiety disorder (a constant about everyday issues and situations). Review of the resident's care plan dated 1/13/25 showed: -The resident had potential for sad mood related to depression. -The resident was at risk for increased behaviors. --Monitor behavior episodes and attempt to determine underlying cause. Review of the resident's Physician Orders, dated January 2025, showed: -Buspirone (medication used to treat anxiety disorders); 5 mg twice a day. -Quetiapine (medication used to treat hallucinations) 25 mg twice a day. -Hydroxyzine (medication used to treat agitation) 50 mg three times a day. During an interview on 1/13/25 at 3:19 P.M., Resident #76 said: -He/She thought Resident #69 was going through his/her belongings. -He/She hit Resident #69 in the face. -He/She was unsure if anyone else was around when it happened. -The police came and arrested him/her and took him/her to the hospital. 2. Review of Resident #69's Face Sheet, undated, showed: -The resident admitted on [DATE]. -The resident's diagnoses included: --Schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and actions). --Major Depressive Disorder --Persistent Mood Disorder (a continuous, long-term form of depression). Review of the resident's Care Plan, dated 11/21/24, showed: -The resident was resistant to cares. -The resident received antidepressant medication. -The resident had chronic pain in the lower back. During an interview on 1/13/25 at 8:45 A.M., the resident said: -Resident #76 said he/she kidnapped his/her children. -He/She was sleeping when Resident #76 came in his/her room and hit him/her in the face. -He/She had swelling and pain on the left side of his/her face. -He/She asked for pain medication and an ice pack and received it. -He/She did not want to go to the hospital. -Resident #76 harassed him/her every day about going into Resident #76's room and taking his/her belongings, which never happened. -He/She talked to staff about Resident #76's behavior and they told him/her to stay away from Resident #76. -Resident #76 also bothered other resident's, saying they went into his/her room and took belongings. -He/She felt safe now that Resident #76 was gone. Observation on 1/13/25 at 8:45 A.M. showed: -A small amount of swelling in Resident #69's left cheek. 3. During an interview on 1/13/25 at 9:00 A.M., Resident #59 (roommate of Resident #69) said: -Resident #76 was in their room. -He/She saw Resident #76 go over to the other side of the room, but the curtain was drawn and did not see what happened. During an interview on 1/13/25 at 9:15 A.M., Resident #72 said: -Resident #76 yelled a lot at the residents and had paranoid episodes, saying people were in his/her room taking his/her items. -Resident #76 threatened to beat up people. -Resident #76 was violent. Staff told Resident #76 to stay in his/her room. -He/She heard Resident#69 and #76 argue on Friday night (1/10/25), but did not see anything. -He/she felt safe without Resident #76 around. During an interview on 1/13/25 at 9:25 A.M., Resident #37 said: -Resident #76 was unruly in the evenings. -Staff told Resident #76 to return to his/her room when he/she was acting up. -On Friday he/she saw Resident #76 go into Resident #69's room. -He/She could not see the head of the bed behind the curtain, but he/she saw the motion of Resident #76 swing his/her arms as if he/she had hit Resident #69. -He/She felt safe now that Resident #76 was gone. -Staff tried to stop Resident #76 from hitting Resident #69. -He/She thought Resident #76 was going to hit the staff. -The staff ended up calling the police. During an interview on 1/13/25 at 9:35 A.M., Resident #11 (Resident #76's roommate) said: -Resident #76 was paranoid a lot. -He/She never saw anyone in their room. -He/She did not see what happened on Friday. During an interview on 1/14/25 at 9:41 A.M., CNA A said: -Resident #76 went out of the building and returned and he/she was angry, mad and paranoid. -Other resident's expressed being afraid of Resident #76. -He/She reported Resident #76's behaviors to the nurse. -On Friday Resident #76 was pacing and sweating a lot towards the end of his/her shift, around 7:00 P.M. -He/She talked to Resident #76 to try to calm him/her down and he/she told the nurse about the resident's behaviors. -Resident #76 said Resident #69 kidnapped his/her kids. -He/She tried to talk to Resident #76 and he/she calmed down a little. During an interview on 1/14/25 at 9:54 A.M., CNA B said: -Resident #76 and #69 used to be friendly with each other. -Recently they had arguments and disagreements, but nothing that went beyond that. During an interview on 1/14/25 at 10:02 A.M., Resident #69 said: -He/She was having pain in his/her back. -He/She still had pain in his/her face and jaw. -He/She had not reported it to the nurse, but was going to contact his/her doctor himself/herself. During an interview on 1/14/25 at 10:24 A.M., LPN B said: -He/She was working Friday night. -Residents #76 and #69 exhibited several hours of verbal altercations, including cussing at each other. -Resident #76 said he/she was going to kill Resident #69 while pacing in the hall. -He/She separated the resident's, directed them to remain on separate sides of the hall. -The other staff on shift were helping with other residents. -Resident #76 was sweating and acted paranoid. -Resident #76 believed people tapped into his/her phone. -Resident #76 believed Resident #69 was in his/her room going through his/her things. -He/She assured Resident #76 that Resident #69 was not in the room and explained how the setting on his/her phone worked to show that no one was tapping into their phone. -The resident returned to his/her room and LPN B returned to his/her duties. -Resident #69 came off the elevator saying he/she had gone down to smoke when Resident #76 hit him/her in the face. -Nursing staff came off the elevator with Resident #76 and instructed them both to remain on separate ends of the hall. -He/She went to Resident #69's room and assessed his/her injury. -He/She saw light redness and swelling, and the resident refused care, and asked for just an ice pack. -Twice Resident #76 tried to enter Resident #69's room, accusing Resident #69 of taking things from his/her room. -Resident #76 threatened LPN B at which time LPN B called the police. -When police arrived Resident #76 physically assaulted them as well as paramedics. -Paramedics administered a sedative and the resident was removed in handcuffs. During an interview on 1/14/25 at 10:59 A.M., Certified Medication Technician (CMT) A said: -He/She was working Friday night during the incident. -The charge nurse told him/her that Resident #76 was being volatile. -He/She did not see anything that happened until the police arrived. -Resident #76 had to be put in restraints. During an interview on 1/14/25 at 1:20 P.M., the Director of Nursing (DON) said: -Staff received quarterly training on abuse and neglect. -The DON and administrator were responsible for providing and documenting training which was offered monthly. -No residents or staff reported anything to him/her about Resident #76's past behaviors that would have indicated a problem. -Resident #76 went to the hospital last month but that was the first time he/she ever exhibited behaviors, that he/she was aware of. During an interview on 1/14/25 at 1:20 P.M. the Administrator said: -He/She was not made aware of issues between Resident #69 and Resident #76. -He/She expected the staff to separate the residents and when the issues continued to put Resident #76 on a one-on-one monitoring. -Someone should have been watching the resident. -Resident #76 was sent out to the hospital last month for behaviors, but to his/her knowledge that was the only previous issue with his/her behaviors. MO00247856

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #69) was free from physical abuse, when on 1/10/25 at approximately 10:00 P.M., Resident #76 willfully hit Resident #69 on his/her face, resulting in swelling and pain. Resident #72 stated Resident #76 had threatened to beat up people and was violent. The facility census was 86 residents. An Abuse/Neglect policy was requested from the facility, but was not provided. Review of the facility's Abuse and Neglect Educational Material; Policy Regarding Abuse and Neglect of Facility Residents, undated showed: -Resident rights protected them from physical and mental abuse. -Abuse was defined as a willful infliction of injury. -Physical force that may result in physical pain or impairment included: --Pushing, slapping, hitting, shoving, striking with or without an object, pinching kicking or burning. 1. Review of Resident #76's Face Sheet, undated, showed: -The resident admitted to the facility on [DATE]. -His/Her diagnoses included: --Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), single episode. --Other psychoactive substance abuse (a strong desire or sense of compulsion to take the substance) --Generalized anxiety disorder (a constant about everyday issues and situations). Review of the resident's care plan dated 1/13/25 showed: -The resident had potential for sad mood related to depression. -The resident was at risk for increased behaviors. --Monitor behavior episodes and attempt to determine underlying cause. Review of the resident's Physician Orders, dated January 2025, showed: -Buspirone (medication used to treat anxiety disorders); 5 mg twice a day. -Quetiapine (medication used to treat hallucinations) 25 mg twice a day. -Hydroxyzine (medication used to treat agitation) 50 mg three times a day. During an interview on 1/13/25 at 3:19 P.M., Resident #76 said: -He/She thought Resident #69 was going through his/her belongings. -He/She hit Resident #69 in the face. -He/She was unsure if anyone else was around when it happened. -The police came and arrested him/her and took him/her to the hospital. 2. Review of Resident #69's Face Sheet, undated, showed: -The resident admitted on [DATE]. -The resident's diagnoses included: --Schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and actions). --Major Depressive Disorder --Persistent Mood Disorder (a continuous, long-term form of depression). Review of the resident's Care Plan, dated 11/21/24, showed: -The resident was resistant to cares. -The resident received antidepressant medication. -The resident had chronic pain in the lower back. During an interview on 1/13/25 at 8:45 A.M., the resident said: -Resident #76 said he/she kidnapped his/her children. -He/She was sleeping when Resident #76 came in his/her room and hit him/her in the face. -He/She had swelling and pain on the left side of his/her face. -He/She asked for pain medication and an ice pack and received it. -He/She did not want to go to the hospital. -Resident #76 harassed him/her every day about going into Resident #76's room and taking his/her belongings, which never happened. -He/She talked to staff about Resident #76's behavior and they told him/her to stay away from Resident #76. -Resident #76 also bothered other resident's, saying they went into his/her room and took belongings. -He/She felt safe now that Resident #76 was gone. Observation on 1/13/25 at 8:45 A.M. showed: -A small amount of swelling in Resident #69's left cheek. 3. During an interview on 1/13/25 at 9:00 A.M., Resident #59 (roommate of Resident #69) said: -Resident #76 was in their room. -He/She saw Resident #76 go over to the other side of the room, but the curtain was drawn and did not see what happened. During an interview on 1/13/25 at 9:15 A.M., Resident #72 said: -Resident #76 yelled a lot at the residents and had paranoid episodes, saying people were in his/her room taking his/her items. -Resident #76 threatened to beat up people. -Resident #76 was violent. Staff told Resident #76 to stay in his/her room. -He/She heard Resident#69 and #76 argue on Friday night (1/10/25), but did not see anything. -He/she felt safe without Resident #76 around. During an interview on 1/13/25 at 9:25 A.M., Resident #37 said: -Resident #76 was unruly in the evenings. -Staff told Resident #76 to return to his/her room when he/she was acting up. -On Friday he/she saw Resident #76 go into Resident #69's room. -He/She could not see the head of the bed behind the curtain, but he/she saw the motion of Resident #76 swing his/her arms as if he/she had hit Resident #69. -He/She felt safe now that Resident #76 was gone. -Staff tried to stop Resident #76 from hitting Resident #69. -He/She thought Resident #76 was going to hit the staff. -The staff ended up calling the police. During an interview on 1/13/25 at 9:35 A.M., Resident #11 (Resident #76's roommate) said: -Resident #76 was paranoid a lot. -He/She never saw anyone in their room. -He/She did not see what happened on Friday. During an interview on 1/14/25 at 9:41 A.M., CNA A said: -Resident #76 went out of the building and returned and he/she was angry, mad and paranoid. -Other resident's expressed being afraid of Resident #76. -He/She reported Resident #76's behaviors to the nurse. -On Friday Resident #76 was pacing and sweating a lot towards the end of his/her shift, around 7:00 P.M. -He/She talked to Resident #76 to try to calm him/her down and he/she told the nurse about the resident's behaviors. -Resident #76 said Resident #69 kidnapped his/her kids. -He/She tried to talk to Resident #76 and he/she calmed down a little. During an interview on 1/14/25 at 9:54 A.M., CNA B said: -Resident #76 and #69 used to be friendly with each other. -Recently they had arguments and disagreements, but nothing that went beyond that. During an interview on 1/14/25 at 10:02 A.M., Resident #69 said: -He/She was having pain in his/her back. -He/She still had pain in his/her face and jaw. -He/She had not reported it to the nurse, but was going to contact his/her doctor himself/herself. During an interview on 1/14/25 at 10:24 A.M., LPN B said: -He/She was working Friday night. -Residents #76 and #69 exhibited several hours of verbal altercations, including cussing at each other. -Resident #76 said he/she was going to kill Resident #69 while pacing in the hall. -He/She separated the resident's, directed them to remain on separate sides of the hall. -The other staff on shift were helping with other residents. -Resident #76 was sweating and acted paranoid. -Resident #76 believed people tapped into his/her phone. -Resident #76 believed Resident #69 was in his/her room going through his/her things. -He/She assured Resident #76 that Resident #69 was not in the room and explained how the setting on his/her phone worked to show that no one was tapping into their phone. -The resident returned to his/her room and LPN B returned to his/her duties. -Resident #69 came off the elevator saying he/she had gone down to smoke when Resident #76 hit him/her in the face. -Nursing staff came off the elevator with Resident #76 and instructed them both to remain on separate ends of the hall. -He/She went to Resident #69's room and assessed his/her injury. -He/She saw light redness and swelling, and the resident refused care, and asked for just an ice pack. -Twice Resident #76 tried to enter Resident #69's room, accusing Resident #69 of taking things from his/her room. -Resident #76 threatened LPN B at which time LPN B called the police. -When police arrived Resident #76 physically assaulted them as well as paramedics. -Paramedics administered a sedative and the resident was removed in handcuffs. During an interview on 1/14/25 at 10:59 A.M., Certified Medication Technician (CMT) A said: -He/She was working Friday night during the incident. -The charge nurse told him/her that Resident #76 was being volatile. -He/She did not see anything that happened until the police arrived. -Resident #76 had to be put in restraints. During an interview on 1/14/25 at 1:20 P.M., the Director of Nursing (DON) said: -Staff received quarterly training on abuse and neglect. -The DON and administrator were responsible for providing and documenting training which was offered monthly. -No residents or staff reported anything to him/her about Resident #76's past behaviors that would have indicated a problem. -Resident #76 went to the hospital last month but that was the first time he/she ever exhibited behaviors, that he/she was aware of. During an interview on 1/14/25 at 1:20 P.M. the Administrator said: -He/She was not made aware of issues between Resident #69 and Resident #76. -He/She expected the staff to separate the residents and when the issues continued to put Resident #76 on a one-on-one monitoring. -Someone should have been watching the resident. -Resident #76 was sent out to the hospital last month for behaviors, but to his/her knowledge that was the only previous issue with his/her behaviors. MO00247856

Based on observation, interview and record review, the facility failed to effectively manage behaviors by not providing appropriate behavior interventions for one sampled resident (Resident #76) when the resident physically assaulted and injured Resident #69 by hitting him/her in the face causing pain, swelling, and redness. The facility census was 86 residents. Review of the facility's Behavior Management Program, undated, showed: -A behavior symptom was defined as an indication or characteristic of a negative physical or psychosocial outcome which may have resulted in disturbing of others. -A behavior could also inhibit the resident in attaining or maintaining his/her highest practical well-being. -The purpose of the policy was to promote a healthy environment that provided comfort to all residents. -The staff may detect early changes in mental or psychosocial status for appropriate interventions, which included: medication regimen, activities, counseling, visits (not specified) or social therapy. -Residents who exhibit behavior symptom concerns were monitored and/or treated to prevent incident. -Monitoring included checking for patterns and occurrence. -Residents who exhibited behavior concerns that fluctuated should be observed or monitored for increased/decreased and factors that contribute to elevate behavior symptoms. -Residents who often exhibited outburst behaviors, aggression, verbal and/or physical abusive behavior were monitored for safety, based on each individual and decided by the safety committee or Quality Assurance (QA) team. -Residents who exhibit fluctuated behavior or new behavior symptoms or indicators: --Monitor for underlying medical conditions and notify the Director of Nursing (DON) to revise the care plan. --Daily observation and documentation on each resident's behavior flow sheet determined by the charge nurse. --All staff were responsible to communicate and recommend what behavior needs to be monitored. 1. Review of Resident #76's Face Sheet, undated, showed: -The resident was admitted to the facility on [DATE]. -His/Her diagnoses included: --Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), single episode. --Other psychoactive substance abuse (a strong desire or sense of compulsion to take the substance). --Generalized anxiety disorder (a constant about everyday issues and situations). Review of the resident's initial care plan dated 1/10/24 showed the resident: -Had a history of drug use/abuse. --The goal was the resident would understand the expectations of the facility, no drug use, and sign a contract. --The only intervention was the resident would understand that breaking the contract would result in discharge. ---NOTE: This care plan was not updated or revised. Review of the resident's Pre-admission Screening/Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness, intellectual disability/developmental disability, and/or related condition who reside in a Medicaid Certified nursing facility), dated 6/13/24, showed: -The resident qualified for care. -The resident had a serious mental illness. -The resident had a history of Schizophrenia (a serious mental illness that affected how a person thought, felt and behaved). -The resident needed continued support and services. --Monitoring of behavioral symptoms. --Tools of choice or other positive behavioral support services. --Mental status to be monitored for signs/symptoms of depression, changes in mood, agitation and aggression. --Anger management may be helpful by teaching coping skills to deal with his/her emotions appropriately. --Staff to provide support and redirection as needed. -Resident would like to see a psychologist. Review of the resident's care plan showed: -There were no updates to the initial care plan of any new focus areas or interventions that addressed the resident's mood, mental status, and anger management. -There were no interventions that showed how to provide support and redirection to the resident. Review of the resident's Psychiatric Periodic Evaluation dated 10/3/24 showed: -The form was completed by an outside Psychiatric provider. -Was a psychiatry evaluation and medication management at the facility. -The resident denied feeling depressed or anxious. -The resident said the recent medication changes had helped his/her anxiety. -Staff noted no concerns, no new psychiatric issues or complaints. -Labs and medications list were reviewed, continue to monitor for changes and medication adjustment as needed. -Monitor for depression symptoms and document. -Psychological service to improve coping skills. -Safety concerns were addressed, staff were instructed regarding communication and redirection needed in caring for psychiatric and mental health residents. -Continue to monitor closely, redirect to promote safety, and utilize nursing intervention and behavioral modification. -Continue to offer activities, social events, group initiating, and resident one-on-one when needed. -Encourage sleep-wake cycle. -Monitor for changes in mood or behaviors and notify psychiatry if agitation or resident symptoms worsen. Review of the resident's care plan showed: -There were no updates, new focus areas, or new interventions that addressed safety concerns, communication, redirection, behavior modification, or placing the resident on 1:1 monitoring. Review of the resident's progress notes dated 10/24/24 showed: -The resident was agitated, kicking and screaming. -The resident was taken to the hospital for evaluation and treatment of increased agitation and aggressiveness. -The social worker notified the Administrator and Director of Nursing (DON) of the resident's behaviors and being admitted to the hospital. Review of the resident's care plan showed: -There were no updates or new focus areas initiated following the resident's hospitalization for behaviors. -There were no updates or new focus areas that addressed the resident's behaviors and interventions including 1:1 monitoring. Review of the resident's Psychiatric Periodic Evaluation dated 10/31/24 showed: -Psychiatric medication regimen was reviewed. -Continue current psychiatric medications. -Continue to monitor response and make adjustments as needed. -Resident could benefit from psychological services to enhance coping skills. -Monitor for changes in mood or behaviors. -No new psychiatric concerns/complaints noted. Review of the resident's Psychotherapy Progress Note dated 10/31/24 showed: -Was completed by an outside psychological provider. -Staff reported resident behaviors of fighting with others, emotionally labile, fighting with staff. -Therapist focused on the resident's current mental health status and progress towards management of mood and anxiety symptoms. -Therapist encouraged the resident to set short-term goals that involved only him/her and did not depend on anyone else's involvement in his/her life. -Therapist encouraged the resident to focus on attainable and short-term goals to manage mood and anxiety. -Therapist encouraged the resident to let staff know of needs as needed. -Therapist will follow up in one to three weeks. Review of the resident's progress notes dated 11/6/24 showed: -The resident was aggressively knocking on other resident's doors, yelling and screaming at them saying they owed him/her money. -The facility social worker notified the DON. -The facility social worker and DON talked with the resident. -The resident was placed on the list to be seen by psychology. Review of the resident's care plan showed: -There were no updates or new focus areas that addressed the safety of the resident or others. -There were no updates or new focus areas that addressed the resident's aggression, -There were no updates or new focus areas that addressed the resident's behaviors. -There were no updates or new focus areas that addressed the resident's behaviors and interventions including 1:1 monitoring. -There were no new interventions that addressed behavior modification when the resident became aggressive. Review of the resident's progress notes showed: -There was no documentation that mentioned changes in care needed following episodes of increased aggression and increased behaviors. -There was no documentation that mentioned psychology or psychiatry were notified of the resident's increased behaviors and aggression. Review of the resident's Psychotherapy Progress Note dated 11/7/24 showed: -The resident refused psychotherapy services. -The therapist will follow up in one to three weeks. Review of the resident's progress notes dated 11/7/24 showed: -The social worker and the DON talked with the resident. -The DON notified the psychiatrist of the resident's increased behaviors and asked for medication management and adjustment as needed. Review of the resident's Psychotherapy Progress Note dated 11/21/24 showed: -The resident refused psychotherapy services and said his/her mind was all crazy and he/she couldn't think. -The therapist will follow up in one to three weeks. Review of the resident's Psychotherapy Progress Note dated 11/27/24 showed: -The resident was extremely agitated and unreasonable. -The resident expressed distrust with residents and staff. -The resident expressed significant agitation and frustration. -The resident expressed thoughts of suicide, but did not report a plan. -Therapist attempted to reduce the resident's emotional distress and to problem solve around the crisis. -The resident reported disinterest in hospitalization. -The resident's distress and agitation were lessened with the opportunity to express difficult emotion with the therapist. -At the end of the session, the resident denied thoughts of suicide. -The therapist reported to the resident that his/her original expression of suicide would be shared with the staff. -The therapist discussed the resident's presentation and safety planning with the Administrator, DON, charge nurse, and floor nurses. --Issues of safety were discussed with all. Review of the resident's care plan showed: -There were no updates or new focus areas that addressed the safety of the resident or others. -There were no updates or new focus areas that addressed the resident's aggression, -There were no updates or new focus areas that addressed the resident's behaviors. -There were no new interventions that addressed behavior modification when the resident became aggressive. -There were no updates or new focus areas that addressed the resident's behaviors and interventions including 1:1 monitoring. Review of the resident's progress notes showed there was no documentation that mentioned changes in care needed following episodes of increased aggression and increased behaviors. Review of the resident's Psychiatric Periodic Evaluation, dated 11/28/24, showed: -Psychiatric medication regimen was reviewed. -Staff noted increased behavioral concerns as others were afraid of the resident because of his/her aggressive posture on the unit. -No new psychiatric issues or complaints were observed during the visit. -Mental status examination included: --Perseveration, pressured speech, coherent with loud tone and value speech. --Mood was noted to be irritable. --Affect was suspicious and irritable. --No response to hallucinations. --Poor concentration, insight, and judgement. -Start Seroquel (an antipsychotic used to treat hallucinations) 25 milligrams (mg) twice a day. Review of the resident's Psychiatric Periodic Evaluation, dated 12/19/24, showed: -Psychiatric medication regimen was reviewed. -The resident reported auditory hallucinations. -Staff noted increased behavioral concerns with anxiety and agitation. -No new psychiatric issues or complaints were observed during the visit. -Mental status examination included: --Perseveration, pressured speech, coherent with loud tone and value speech. --Mood was noted to be irritable. --Affect was suspicious and irritable. -Start Hydroxyzine (an antihistamine used to treat anxiety and agitation) 50 mg three times a day. Review of the resident's care plan showed: -There were no updates or new focus areas that addressed the safety of the resident or others. -There were no updates or new focus areas that addressed the resident's hallucinations. -There were no new interventions that addressed behavior modification when the resident became aggressive. Review of the resident's progress notes showed there was no documentation that mentioned changes in care needed with episodes of hallucinations and increased aggression. Review of the resident's Physician Orders, dated January 2025, showed the resident was ordered: -Sertraline (medication used to treat depression); 150 mg daily (order updated on 11/7/24). -Buspirone (medication used to treat anxiety disorders); 5 mg twice a day (order updated on 11/7/24). -Quetiapine (medication used to treat hallucinations) 25 mg twice a day (order started on 11/29/24). -Hydroxyzine (medication used to treat agitation) 50 mg three times a day (order started on 12/19/24). Review of the resident's Psychotherapy Progress Note dated 1/3/25 showed: -The resident reported significant distress over current level of functioning. -The resident expressed his/her mind was racing. -The resident reported auditory hallucinations and explained them as hearing voices of people he/she knew just talking, both day and night all the time. -The resident reported poor sleep with difficulty falling and staying asleep. -The therapist encouraged the resident to let staff know of needs as needed and appropriate. -The resident would benefit from continued psychotherapeutic support maintain current level of progress and stability. -The therapist discussed the resident's presentation and plan of care with the unit nurse, nurse manager, and the social worker. Review of the resident's care plan showed: -There were no new focus areas or interventions that addressed the resident's increased behaviors. -There were no new focus areas or interventions that addressed the resident's increased aggression towards other resident's and staff. Review of the resident's progress notes showed: -There was no documentation that addressed if changes in care were needed following episodes of increased aggression, hallucinations, and increased behaviors. -There was no documentation that addressed psychology or psychiatry was notified of the resident's increased behaviors, hallucinations, and increased aggression. Review of the resident's Psychotherapy Progress Note dated 1/9/25 showed: -The resident initially presented with agitation and anxiety. -The resident described his/her disappointment with his/her current family situation. -The resident had feelings of isolation and resentment. -The therapist helped the resident problem solve around preparing broken relationships. -The therapist determined the resident had periodic intermittent drops in mood and increased anxiety due to various personal issues, acute and chronic health conditions, strained family relationship dynamics, and ongoing situational stressors and challenges. -The therapist discussed the resident's recent presentation and plan of care with unit nurse, nurse manager, and the facility social worker. Review of the resident's care plan dated 1/13/25, showed: -The resident had a history of drug use/abuse. -The resident had potential for sad mood related to depression. --Administer medications as ordered. --Allow the resident to express feelings. --Behavioral health consults as needed. --Encourage the resident to attend activities of his/her choice. --Psychiatry consultation as needed. -The resident was at risk for increased behaviors related to a history of auditory hallucinations. --Administer medications as ordered. --Assist the resident to develop more appropriate methods of coping and interacting. --Encourage the resident to express feelings appropriately. --Caregivers were to provide opportunity for positive interactions, attention. --Stop and talk with him/her as passing by. --Monitor behavior episodes and attempt to determine underlying cause. --Consider location, time of day, persons involved, and situations. --Document behavior and potential causes. --Monitor behavior episodes and attempt to determine underlying cause. -The interventions / recommendations from the psychologist and psychiatrist were not added to the care plan. During an interview on 1/13/25 at 3:19 P.M., Resident #76 said: -He/She thought Resident #69 was going through his/her belongings. -He/She hit Resident #69 in the face. During an interview on 1/13/25 at 8:45 A.M., Resident #69 said: -Resident #76 said he/she kidnapped his/her children. -He/She was sleeping when Resident #76 came in his/her room and hit him/her in the face. -Resident #76 harassed him/her every day about going into Resident #76's room and taking his/her belongings, which never happened. -He/She talked to staff about Resident #76's behavior and they told him/her to stay away from Resident #76. -Resident #76 also bothered other residents, saying they went into his/her room and took belongings. -He/She felt safe now that Resident #76 was gone. During an interview on 1/13/25 at 9:15 A.M., Resident #72 said: -Resident #76 yelled a lot at the residents and had paranoid episodes, saying people were in his/her room taking his/her items. -Resident #76 was crazy, he/she threatened to beat up people. -Resident #76 was violent. Staff told him to stay in his/her room. -He/She heard Residents #69 and Resident #76 argue on Friday night (1/10/25), but did not see anything. -He/she felt safe without Resident #76 around. During an interview on 1/13/25 at 9:25 A.M., Resident #37 said: -Resident #76 was unruly in the evenings. -Staff told Resident #76 to return to his/her room when he/she acted up. -On Friday he/she saw Resident #76 go into Resident #69's room. -He/She could not see the head of the bed behind the curtain, but he/she saw the motion of Resident #76 swing his/her arms as if he/she had hit Resident #69. -He/She felt safe now that Resident #76 was gone. -Staff tried to stop Resident #76 from hitting Resident #69. -He/She thought Resident #76 was going to hit the staff. -The staff ended up calling the police. During an interview on 1/13/25 at 9:35 A.M., Resident #11 (Resident #76's roommate) said: -Resident #76 was paranoid a lot. -He/She never saw anyone in their room. -He/She did not see what happened on Friday. During an interview on 1/14/25 at 11:16 A.M., Resident #29 said: -He/She had seen Resident #76's explosive behaviors before Friday. -He/She was afraid of the resident and felt safer now that Resident #76 was gone. -He/She noticed that staff stayed with Resident #76 during his/her explosive behaviors and tried to keep him/her busy. During an interview on 1/13/25 at 9:43 A.M., Certified Nursing Assistant (CNA) B said: -He/She was not working Friday night. -Resident #76 had some paranoia, anger issues which increased over the last few months. -He/She reported behaviors to the nurse, he/she was unsure if anything was done. During an interview on 1/13/25 at 9:59 a.m., CNA A said: -Resident #76 had behaviors like pacing, sweating, and cussing at other residents. -He/She reported behaviors to the nurse. -Resident #76 was usually fine on the day shift, but was informed by staff and residents of his/her behaviors on the evening and night shifts. During an interview on 1/14/25 at 9:41 A.M., CNA A said: -When Resident #76 first arrived at the facility there were no behaviors. The last few months his/her behaviors increased. -Resident #76 went out of the building and returned angry, mad and paranoid. -Other resident's expressed being afraid of Resident #76. -He/She reported Resident #76's behaviors to the nurse. -He/She talked to Resident #76 to try to calm him/her down and he/she told the nurse about the resident's behaviors. During an interview on 1/14/25 at 9:54 A.M., CNA B said: -When Resident #76 first got to the facility there were no issues. -The last few months Resident #76 started showing more behaviors like cussing at other residents, accusing other residents of being in his/her room, yelling at staff and residents and pacing, generally paranoid. -He/She told the nurse about the behaviors. During an interview on 1/14/25 at 10:08 A.M., License Practical Nurse (LPN) A said: -When Resident #76 would start showing paranoia he/she would tell Resident #76 to go back to his/her room and calm down. -Resident #76 acted up on the night shift, because they didn't know how to handle the resident. -He/She separated the resident from other residents when he/she started to act up. -He/She did not report the behaviors because he/she was able to handle them. During an interview on 1/14/25 at 10:24 A.M., LPN B said: -Residents #76 and Resident #69 exhibited several hours of verbal altercations, including cussing at each other. -Resident #76 said he/she was going to kill Resident #69 while pacing in the hall. -He/She separated the residents, directing them to remain on separate sides of the hall. -Resident #76 was sweating and acting paranoid. -Resident #76 believed people were tapping into his/her phone. -Resident #76 believed Resident #69 was in his/her room. -Twice Resident #76 tried to enter Resident #69's room, accusing Resident #69 of taking things from his/her room. -Resident #76 threatened LPN B at which time LPN B called the police. -When police arrived Resident #76 physically assaulted the police as well as the paramedics. -Paramedics administered a sedative and the resident was removed in handcuffs. During an interview on 1/14/25 at 10:59 A.M., Certified Medication Technician (CMT) A said: -He/She was working Friday night during the incident. -The charge nurse told him/her that Resident #76 was being volatile. -He/She did not see anything that happened until the police arrived. -There were 11 officers and paramedics who responded to the 911 call. -Resident #76 had to be put in restraints. -Several residents told him/her they were afraid of Resident #76. -Resident #76 was usually easily redirected. -Resident #76 tended to be more aggressive toward people he/she believed to be more vulnerable. During an interview on 1/14/25 at 1:20 P.M., the DON said: -No residents or staff reported anything to him/her about Resident #76's behaviors. -Resident #76 went to the hospital last month, but that was the first time Resident #76 ever exhibited behaviors, that he/she was aware of. During an interview on 1/14/25 at 1:20 P.M. the Administrator said: -He/She was not made aware of any previous behaviors by Resident #76. -Resident #76 was sent out to the hospital last month for behaviors, but to his/her knowledge that was the only previous issue with his/her behaviors. -He/She would expect staff to separate the resident from other residents, place on one on one observation, someone should have been watching the resident, and call the police as the resident was very intimidating. MO00247856

Based on observation, interview and record review, the facility failed to effectively manage behaviors by not providing appropriate behavior interventions for one sampled resident (Resident #76) when the resident physically assaulted and injured Resident #69 by hitting him/her in the face causing pain, swelling, and redness. The facility census was 86 residents. Review of the facility's Behavior Management Program, undated, showed: -A behavior symptom was defined as an indication or characteristic of a negative physical or psychosocial outcome which may have resulted in disturbing of others. -A behavior could also inhibit the resident in attaining or maintaining his/her highest practical well-being. -The purpose of the policy was to promote a healthy environment that provided comfort to all residents. -The staff may detect early changes in mental or psychosocial status for appropriate interventions, which included: medication regimen, activities, counseling, visits (not specified) or social therapy. -Residents who exhibit behavior symptom concerns were monitored and/or treated to prevent incident. -Monitoring included checking for patterns and occurrence. -Residents who exhibited behavior concerns that fluctuated should be observed or monitored for increased/decreased and factors that contribute to elevate behavior symptoms. -Residents who often exhibited outburst behaviors, aggression, verbal and/or physical abusive behavior were monitored for safety, based on each individual and decided by the safety committee or Quality Assurance (QA) team. -Residents who exhibit fluctuated behavior or new behavior symptoms or indicators: --Monitor for underlying medical conditions and notify the Director of Nursing (DON) to revise the care plan. --Daily observation and documentation on each resident's behavior flow sheet determined by the charge nurse. --All staff were responsible to communicate and recommend what behavior needs to be monitored. 1. Review of Resident #76's Face Sheet, undated, showed: -The resident was admitted to the facility on [DATE]. -His/Her diagnoses included: --Major Depressive Disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest), single episode. --Other psychoactive substance abuse (a strong desire or sense of compulsion to take the substance). --Generalized anxiety disorder (a constant about everyday issues and situations). Review of the resident's initial care plan dated 1/10/24 showed the resident: -Had a history of drug use/abuse. --The goal was the resident would understand the expectations of the facility, no drug use, and sign a contract. --The only intervention was the resident would understand that breaking the contract would result in discharge. ---NOTE: This care plan was not updated or revised. Review of the resident's Pre-Admission Screening/Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness, intellectual disability/developmental disability, and/or related condition who reside in a Medicaid Certified nursing facility), dated 6/13/24, showed: -The resident qualified for care. -The resident had a serious mental illness. -The resident had a history of Schizophrenia (a serious mental illness that affected how a person thought, felt and behaved). -The resident needed continued support and services. --Monitoring of behavioral symptoms. --Tools of choice or other positive behavioral support services. --Mental status to be monitored for signs/symptoms of depression, changes in mood, agitation and aggression. --Anger management may be helpful by teaching coping skills to deal with his/her emotions appropriately. --Staff to provide support and redirection as needed. -Resident would like to see a psychologist. Review of the resident's care plan showed: -There were no updates to the initial care plan of any new focus areas or interventions that addressed the resident's mood, mental status, and anger management. -There were no interventions that showed how to provide support and redirection to the resident. Review of the resident's Psychiatric Periodic Evaluation dated 10/3/24 showed: -The form was completed by an outside Psychiatric provider. -Was a psychiatry evaluation and medication management at the facility. -The resident denied feeling depressed or anxious. -The resident said the recent medication changes had helped his/her anxiety. -Staff noted no concerns, no new psychiatric issues or complaints. -Labs and medications list were reviewed, continue to monitor for changes and medication adjustment as needed. -Monitor for depression symptoms and document. -Psychological service to improve coping skills. -Safety concerns were addressed, staff were instructed regarding communication and redirection needed in caring for psychiatric and mental health residents. -Continue to monitor closely, redirect to promote safety, and utilize nursing intervention and behavioral modification. -Continue to offer activities, social events, group initiating, and resident one-on-one when needed. -Encourage sleep-wake cycle. -Monitor for changes in mood or behaviors and notify psychiatry if agitation or resident symptoms worsen. Review of the resident's care plan showed: -There were no updates, new focus areas, or new interventions that addressed safety concerns, communication, redirection, behavior modification, or placing the resident on 1:1 monitoring. Review of the resident's progress notes dated 10/24/24 showed: -The resident was agitated, kicking and screaming. -The resident was taken to the hospital for evaluation and treatment of increased agitation and aggressiveness. -The social worker notified the Administrator and Director of Nursing (DON) of the resident's behaviors and being admitted to the hospital. Review of the resident's care plan showed: -There were no updates or new focus areas initiated following the resident's hospitalization for behaviors. -There were no updates or new focus areas that addressed the resident's behaviors and interventions including 1:1 monitoring. Review of the resident's Psychiatric Periodic Evaluation dated 10/31/24 showed: -Psychiatric medication regimen was reviewed. -Continue current psychiatric medications. -Continue to monitor response and make adjustments as needed. -Resident could benefit from psychological services to enhance coping skills. -Monitor for changes in mood or behaviors. -No new psychiatric concerns/complaints noted. Review of the resident's Psychotherapy Progress Note dated 10/31/24 showed: -Was completed by an outside psychological provider. -Staff reported resident behaviors of fighting with others, emotionally labile, fighting with staff. -Therapist focused on the resident's current mental health status and progress towards management of mood and anxiety symptoms. -Therapist encouraged the resident to set short-term goals that involved only him/her and did not depend on anyone else's involvement in his/her life. -Therapist encouraged the resident to focus on attainable and short-term goals to manage mood and anxiety. -Therapist encouraged the resident to let staff know of needs as needed. -Therapist will follow up in one to three weeks. Review of the resident's progress notes dated 11/6/24 showed: -The resident was aggressively knocking on other resident's doors, yelling and screaming at them saying they owed him/her money. -The facility social worker notified the DON. -The facility social worker and DON talked with the resident. -The resident was placed on the list to be seen by psychology. Review of the resident's care plan showed: -There were no updates or new focus areas that addressed the safety of the resident or others. -There were no updates or new focus areas that addressed the resident's aggression, -There were no updates or new focus areas that addressed the resident's behaviors. -There were no updates or new focus areas that addressed the resident's behaviors and interventions including 1:1 monitoring. -There were no new interventions that addressed behavior modification when the resident became aggressive. Review of the resident's progress notes showed: -There was no documentation that mentioned changes in care needed following episodes of increased aggression and increased behaviors. -There was no documentation that mentioned psychology or psychiatry were notified of the resident's increased behaviors and aggression. Review of the resident's Psychotherapy Progress Note dated 11/7/24 showed: -The resident refused psychotherapy services. -The therapist will follow up in one to three weeks. Review of the resident's progress notes dated 11/7/24 showed: -The social worker and the DON talked with the resident. -The DON notified the psychiatrist of the resident's increased behaviors and asked for medication management and adjustment as needed. Review of the resident's Psychotherapy Progress Note dated 11/21/24 showed: -The resident refused psychotherapy services and said his/her mind was all crazy and he/she couldn't think. -The therapist will follow up in one to three weeks. Review of the resident's Psychotherapy Progress Note dated 11/27/24 showed: -The resident was extremely agitated and unreasonable. -The resident expressed distrust with residents and staff. -The resident expressed significant agitation and frustration. -The resident expressed thoughts of suicide, but did not report a plan. -Therapist attempted to reduce the resident's emotional distress and to problem solve around the crisis. -The resident reported disinterest in hospitalization . -The resident's distress and agitation were lessened with the opportunity to express difficult emotion with the therapist. -At the end of the session, the resident denied thoughts of suicide. -The therapist reported to the resident that his/her original expression of suicide would be shared with the staff. -The therapist discussed the resident's presentation and safety planning with the Administrator, DON, charge nurse, and floor nurses. --Issues of safety were discussed with all. Review of the resident's care plan showed: -There were no updates or new focus areas that addressed the safety of the resident or others. -There were no updates or new focus areas that addressed the resident's aggression, -There were no updates or new focus areas that addressed the resident's behaviors. -There were no new interventions that addressed behavior modification when the resident became aggressive. -There were no updates or new focus areas that addressed the resident's behaviors and interventions including 1:1 monitoring. Review of the resident's progress notes showed there was no documentation that mentioned changes in care needed following episodes of increased aggression and increased behaviors. Review of the resident's Psychiatric Periodic Evaluation, dated 11/28/24, showed: -Psychiatric medication regimen was reviewed. -Staff noted increased behavioral concerns as others were afraid of the resident because of his/her aggressive posture on the unit. -No new psychiatric issues or complaints were observed during the visit. -Mental status examination included: --Perseveration, pressured speech, coherent with loud tone and value speech. --Mood was noted to be irritable. --Affect was suspicious and irritable. --No response to hallucinations. --Poor concentration, insight, and judgement. -Start Seroquel (an antipsychotic used to treat hallucinations) 25 milligrams (mg) twice a day. Review of the resident's Psychiatric Periodic Evaluation, dated 12/19/24, showed: -Psychiatric medication regimen was reviewed. -The resident reported auditory hallucinations. -Staff noted increased behavioral concerns with anxiety and agitation. -No new psychiatric issues or complaints were observed during the visit. -Mental status examination included: --Perseveration, pressured speech, coherent with loud tone and value speech. --Mood was noted to be irritable. --Affect was suspicious and irritable. -Start Hydroxyzine (an antihistamine used to treat anxiety and agitation) 50 mg three times a day. Review of the resident's care plan showed: -There were no updates or new focus areas that addressed the safety of the resident or others. -There were no updates or new focus areas that addressed the resident's hallucinations. -There were no new interventions that addressed behavior modification when the resident became aggressive. Review of the resident's progress notes showed there was no documentation that mentioned changes in care needed with episodes of hallucinations and increased aggression. Review of the resident's Physician Orders, dated January 2025, showed the resident was ordered: -Sertraline (medication used to treat depression); 150 mg daily (order updated on 11/7/24). -Buspirone (medication used to treat anxiety disorders); 5 mg twice a day (order updated on 11/7/24). -Quetiapine (medication used to treat hallucinations) 25 mg twice a day (order started on 11/29/24). -Hydroxyzine (medication used to treat agitation) 50 mg three times a day (order started on 12/19/24). Review of the resident's Psychotherapy Progress Note dated 1/3/25 showed: -The resident reported significant distress over current level of functioning. -The resident expressed his/her mind was racing. -The resident reported auditory hallucinations and explained them as hearing voices of people he/she knew just talking, both day and night all the time. -The resident reported poor sleep with difficulty falling and staying asleep. -The therapist encouraged the resident to let staff know of needs as needed and appropriate. -The resident would benefit from continued psychotherapeutic support maintain current level of progress and stability. -The therapist discussed the resident's presentation and plan of care with the unit nurse, nurse manager, and the social worker. Review of the resident's care plan showed: -There were no new focus areas or interventions that addressed the resident's increased behaviors. -There were no new focus areas or interventions that addressed the resident's increased aggression towards other resident's and staff. Review of the resident's progress notes showed: -There was no documentation that addressed if changes in care were needed following episodes of increased aggression, hallucinations, and increased behaviors. -There was no documentation that addressed psychology or psychiatry was notified of the resident's increased behaviors, hallucinations, and increased aggression. Review of the resident's Psychotherapy Progress Note dated 1/9/25 showed: -The resident initially presented with agitation and anxiety. -The resident described his/her disappointment with his/her current family situation. -The resident had feelings of isolation and resentment. -The therapist helped the resident problem solve around preparing broken relationships. -The therapist determined the resident had periodic intermittent drops in mood and increased anxiety due to various personal issues, acute and chronic health conditions, strained family relationship dynamics, and ongoing situational stressors and challenges. -The therapist discussed the resident's recent presentation and plan of care with unit nurse, nurse manager, and the facility social worker. Review of the resident's care plan dated 1/13/25, showed: -The resident had a history of drug use/abuse. -The resident had potential for sad mood related to depression. --Administer medications as ordered. --Allow the resident to express feelings. --Behavioral health consults as needed. --Encourage the resident to attend activities of his/her choice. --Psychiatry consultation as needed. -The resident was at risk for increased behaviors related to a history of auditory hallucinations. --Administer medications as ordered. --Assist the resident to develop more appropriate methods of coping and interacting. --Encourage the resident to express feelings appropriately. --Caregivers were to provide opportunity for positive interactions, attention. --Stop and talk with him/her as passing by. --Monitor behavior episodes and attempt to determine underlying cause. --Consider location, time of day, persons involved, and situations. --Document behavior and potential causes. --Monitor behavior episodes and attempt to determine underlying cause. -The interventions / recommendations from the psychologist and psychiatrist were not added to the care plan. During an interview on 1/13/25 at 3:19 P.M., Resident #76 said: -He/She thought Resident #69 was going through his/her belongings. -He/She hit Resident #69 in the face. During an interview on 1/13/25 at 8:45 A.M., Resident #69 said: -Resident #76 said he/she kidnapped his/her children. -He/She was sleeping when Resident #76 came in his/her room and hit him/her in the face. -Resident #76 harassed him/her every day about going into Resident #76's room and taking his/her belongings, which never happened. -He/She talked to staff about Resident #76's behavior and they told him/her to stay away from Resident #76. -Resident #76 also bothered other residents, saying they went into his/her room and took belongings. -He/She felt safe now that Resident #76 was gone. During an interview on 1/13/25 at 9:15 A.M., Resident #72 said: -Resident #76 yelled a lot at the residents and had paranoid episodes, saying people were in his/her room taking his/her items. -Resident #76 was crazy, he/she threatened to beat up people. -Resident #76 was violent. Staff told him to stay in his/her room. -He/She heard Residents #69 and Resident #76 argue on Friday night (1/10/25), but did not see anything. -He/she felt safe without Resident #76 around. During an interview on 1/13/25 at 9:25 A.M., Resident #37 said: -Resident #76 was unruly in the evenings. -Staff told Resident #76 to return to his/her room when he/she acted up. -On Friday he/she saw Resident #76 go into Resident #69's room. -He/She could not see the head of the bed behind the curtain, but he/she saw the motion of Resident #76 swing his/her arms as if he/she had hit Resident #69. -He/She felt safe now that Resident #76 was gone. -Staff tried to stop Resident #76 from hitting Resident #69. -He/She thought Resident #76 was going to hit the staff. -The staff ended up calling the police. During an interview on 1/13/25 at 9:35 A.M., Resident #11 (Resident #76's roommate) said: -Resident #76 was paranoid a lot. -He/She never saw anyone in their room. -He/She did not see what happened on Friday. During an interview on 1/14/25 at 11:16 A.M., Resident #29 said: -He/She had seen Resident #76's explosive behaviors before Friday. -He/She was afraid of the resident and felt safer now that Resident #76 was gone. -He/She noticed that staff stayed with Resident #76 during his/her explosive behaviors and tried to keep him/her busy. During an interview on 1/13/25 at 9:43 A.M., Certified Nursing Assistant (CNA) B said: -He/She was not working Friday night. -Resident #76 had some paranoia, anger issues which increased over the last few months. -He/She reported behaviors to the nurse, he/she was unsure if anything was done. During an interview on 1/13/25 at 9:59 a.m., CNA A said: -Resident #76 had behaviors like pacing, sweating, and cussing at other residents. -He/She reported behaviors to the nurse. -Resident #76 was usually fine on the day shift, but was informed by staff and residents of his/her behaviors on the evening and night shifts. During an interview on 1/14/25 at 9:41 A.M., CNA A said: -When Resident #76 first arrived at the facility there were no behaviors. The last few months his/her behaviors increased. -Resident #76 went out of the building and returned angry, mad and paranoid. -Other resident's expressed being afraid of Resident #76. -He/She reported Resident #76's behaviors to the nurse. -He/She talked to Resident #76 to try to calm him/her down and he/she told the nurse about the resident's behaviors. During an interview on 1/14/25 at 9:54 A.M., CNA B said: -When Resident #76 first got to the facility there were no issues. -The last few months Resident #76 started showing more behaviors like cussing at other residents, accusing other residents of being in his/her room, yelling at staff and residents and pacing, generally paranoid. -He/She told the nurse about the behaviors. During an interview on 1/14/25 at 10:08 A.M., License Practical Nurse (LPN) A said: -When Resident #76 would start showing paranoia he/she would tell Resident #76 to go back to his/her room and calm down. -Resident #76 acted up on the night shift, because they didn't know how to handle the resident. -He/She separated the resident from other residents when he/she started to act up. -He/She did not report the behaviors because he/she was able to handle them. During an interview on 1/14/25 at 10:24 A.M., LPN B said: -Residents #76 and Resident #69 exhibited several hours of verbal altercations, including cussing at each other. -Resident #76 said he/she was going to kill Resident #69 while pacing in the hall. -He/She separated the residents, directing them to remain on separate sides of the hall. -Resident #76 was sweating and acting paranoid. -Resident #76 believed people were tapping into his/her phone. -Resident #76 believed Resident #69 was in his/her room. -Twice Resident #76 tried to enter Resident #69's room, accusing Resident #69 of taking things from his/her room. -Resident #76 threatened LPN B at which time LPN B called the police. -When police arrived Resident #76 physically assaulted the police as well as the paramedics. -Paramedics administered a sedative and the resident was removed in handcuffs. During an interview on 1/14/25 at 10:59 A.M., Certified Medication Technician (CMT) A said: -He/She was working Friday night during the incident. -The charge nurse told him/her that Resident #76 was being volatile. -He/She did not see anything that happened until the police arrived. -There were 11 officers and paramedics who responded to the 911 call. -Resident #76 had to be put in restraints. -Several residents told him/her they were afraid of Resident #76. -Resident #76 was usually easily redirected. -Resident #76 tended to be more aggressive toward people he/she believed to be more vulnerable. During an interview on 1/14/25 at 1:20 P.M., the DON said: -No residents or staff reported anything to him/her about Resident #76's behaviors. -Resident #76 went to the hospital last month, but that was the first time Resident #76 ever exhibited behaviors, that he/she was aware of. During an interview on 1/14/25 at 1:20 P.M. the Administrator said: -He/She was not made aware of any previous behaviors by Resident #76. -Resident #76 was sent out to the hospital last month for behaviors, but to his/her knowledge that was the only previous issue with his/her behaviors. -He/She would expect staff to separate the resident from other residents, place on one on one observation, someone should have been watching the resident, and call the police as the resident was very intimidating. MO00247856

Based on observation, interview and record review, the facility failed to protect two sampled residents (Resident #1 and #6 ) from physical abuse. On 7/3/24 at approximately 8:10 P.M., Resident #2 who smelled strongly of alcohol entered Resident #6's room and hit him/her in the mouth without provocation, causing a small cut on the resident's lower lip. On 7/22/24 at approximately 9:00 A.M., Resident #2, who smelled strongly of alcohol, became agitated and struck Resident #1 with closed fists in both cheeks approximately one inch below each eye, causing four centimeter cuts requiring a hospital emergency room visit to apply two stitches for each cut out of 10 sampled residents. The resident census was 85 residents. Review of the facility's policy for Abuse and Neglect, revised in 2022 showed: -The purpose of the policy was to ensure the residents' rights were respected and honored and to provide protection from all forms of abuse and/or neglect. -Each resident had the right to be free from abuse. -The facility was responsible to prevent resident abuse. Residents were not to have been subjected to abuse by anyone, including other residents. -Abuse was defined as the willful infliction of injury resulting in physical harm, pain or mental anguish, with physical abuse resulting in bodily injury, physical pain, or impairment. -Physical abuse included hitting, slapping, punching and kicking. -Some examples of physical abuse were bruises, black eyes, lacerations/cuts and broken bones. 1. Review of Resident #2's Preadmission Screening and Resident Review (PASRR, DA-124C, a required form to be submitted for any client who requests admission to a Medicaid certified bed regardless of the client's payment source; this includes dually certified beds both Medicare and Medicaid), dated 10/25/23, showed he/she had the following diagnoses: -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Alcohol abuse. -Psychoactive substance abuse-(use of a variety of drugs or other agent that affects normal mental functioning as mood, behavior, or thinking processes). Review of Resident #2's quarterly Minimum Data Set (MDS-a federally mandated assessment tool competed by facility staff and used for care planning) dated 6/27/24 showed he/she: -Was cognitively intact. -Showed no issues with mood or negative behaviors. Review of Resident #6's facility Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Stress fracture of his/her left ankle. -Anxiety. -Alcohol abuse. Review Resident #6's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -Was unable to walk and used a wheelchair to ambulate and perform his/her daily activities. During an interview on 7/26/24 at 11:00 A.M., Licensed Practical Nurse (LPN) A said: -On 7/3/24 Resident #2 had smelled strongly of alcohol and stating his/her cell phone had been stolen. -The resident was getting angry and jumped off his/her bed and lunged at him/her as if he/she was going to hit him/her. -He/she called 911. -LPN C reported that Resident #2 went into Resident #6's room and hit him/her in the mouth, splitting open the resident's lower lip. -The police came but stated there was no room in the jail so Resident #2 went to the hospital. During an interview on 7/26/24 at 12:42 P.M., Resident #6 said: -He/she was sitting in his/her room watching television when Resident #2 just walked in and hit him/her in the mouth stating, you killed your roommate!. -The police came and put Resident #2 in hand cuffs, but the police said they had not room in the jail so the resident would have to go to the hospital. -He/she asked to press assault charges, but no police ever came to take his/her statement. -He/she just stayed away and stopped hanging out with Resident #2. During an interview on 7/26/24, at 3:30 P.M., LPN C said on 7/3/24 between 8:00 P.M. and 9:00 P.M. Resident #2 punched Resident #6 and cut open his/her bottom lip. 2. Review of Resident #1's facility Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Spinal stenosis-(narrowing of the spinal canal). -Heart disease. -Alcohol abuse. Review of Resident 1's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -Was unable to walk and used a wheelchair to ambulate and perform his/her daily activities. Review of Resident #2's Nurse's Notes dated 7/22/24 at 9:10 A.M., showed: -The resident came to LPN B asking for a cup of water. -LPN B told him/her that the water on his/her medication cart was not cold and the resident might want to check on the other medication cart. -The resident acted angry so he/she got a cup of cold water and took it to him in his/her room. -He/she became angry telling him/her that the cup was too small. -A couple of minutes later, he/she heard loud banging and a thud coming from the resident's room as if the resident was kicking his/her room door. -A minute later, Resident #1 came out of the room blood dripping down his/her cheeks stating his/her roommate, Resident #2 had beat him/her up. -Resident #2 was taken away to calm down while Resident #1's injuries were attended to. Review of Resident 1's Nurse's Notes dated 7/22/24 at 9:30 A.M., showed: -The resident came into the hallway with blood on his/her face, both the left and right sides. -He/she stated that Resident #2 hit him/her several times. -The resident showed he/she had lacerations to both his/her upper right cheeks. -The lacerations were cleaned but the bleeding continued so emergency medical services (EMS) were called to examine the residents. Review of Resident 1's Nurse's Notes dated 7/22/24 at 12:25 P.M., showed: -The resident's physician saw the resident and encouraged him/her to go to the emergency room for stitches to his/her cheeks. -The resident agreed to go to the hospital and was transported by EMS for evaluation and treatment. Review of Resident 1's Nurse's Notes dated 7/22/24 at 6:45 P.M., showed: -He/she returned from the emergency room with stitches to each laceration covered by steri-strips (a thin, adhesive bandage used to assist with keeping lacerated skin together and protect a wound). -His/her right eye was swollen and discolored. During an interview on 7/25/24 at 12:30 P.M., LPN B said: -He/she had heard a commotion coming from Resident #2 and Resident #1's room which sounded like banging or someone kicking the door. -He/she walked down to the room and the door was closed as the banging continued. -He/she did not hear anyone yelling and thought that Resident #2 was just kicking the door to his/her room since he/she was angry. He/she did not enter the room. -A minute later, Resident #1 came out of the room with blood coming from both of his/her cheeks, stating that Resident #2 had beat him/her up. -Resident #2 was taken from the room to calm down. -Resident #1 after contact with the physician was transported to the ER for stitches. During an interview on 7/25/24 at 1:40 P.M., Certified Nursing Assistant (CNA) A said he/she was in the shower room nearby when the incident occurred and heard the banging, but no yelling, so had no idea what was going on. Observation and interview on 7/25/24 at 2:00 P.M., with Resident #1 showed: -He/she was in the bathroom when Resident #2 came in asking for water. -He/she told Resident #2 to hold on a second and Resident #2 just started pounding on me! -He/she did not yell for help as he/she thought it could make things worse. -Resident #2 hit him/her in both cheeks with both fists. -Resident #2 had never been physically aggressive with him/her but he/she had yelled and called him/her names including the N word. -He/she was never afraid of Resident #2 and wasn't afraid of him/her if he/she returned to the facility. -He/she knew the resident drank too much and blamed it all on the alcohol. -The resident was up in his/her wheelchair. -He/she had two steri-strips covering each laceration on his/her cheeks. -Two approximately four-centimeter (cm) lacerations were noted below each eye. -Both lacerations appeared to have two stitches each. -Slight bruising was noted around the left laceration. -No swelling was noted on either cheek. 3. During an interview on 7/29/24 at 3:15 P.M., Nurse Practitioner (NP) A said: -He/she was responsible for the resident' medical care. -He/she was not aware that Resident #2 was becoming violent or that he/she was leaving the facility, drinking and then harming other residents. -He/she would have made sure the psychiatric NP knew and possible changed up his/her treatment plan and/or medications. -He/she would have expected the facility to notify him/her of all changes in resident's conditions. -He/she was not aware Resident #2 hit any residents. -He/she would have expected a staff member notify him/her. -It was not appropriate for Resident #2 to hit another resident During an interview on 7/31/24 at 1:30 P.M., the Director of Nursing (DON) said: -He/she would have expected the facility staff to keep all residents safe from abuse. -When Resident #2 injured and hit Resident #6 and #1 it was considered abuse. During an interview on 7/31/24 at 1:55 P.M., the Administrator said: -He/she would have expected the staff to intervene when Resident #2 became agitated in order to prevent any violent behaviors. -He/she would have expected the staff remove the vulnerable resident from the agitated resident. -He/she did not feel abuse could be concluded as per his/her investigation he/she found the event was not witnessed. -Resident #2 did not have blood on his/her knuckles. -Resident #1 could have accidentally hit his/her own face on something as both the lacerations were equal in size and in the same place bilaterally. -He/she did not necessarily feel it was abuse without a witness and both residents smelled of alcohol. MO00239366

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical abuse and provide intervention and assessment after a resident to resident altercation, where one sampled resident (Resident #5) threw hot water onto another sampled resident (Resident #4), resulting in second degree burns. The facility census was 72 residents. Record review of the facility Abuse and Neglect Policy not dated showed: -All residents will be protected from abuse; -The victim must be protected by separating and removing the suspect; -Observe and assess the resident's condition including physical, mental and psychosocial assessments; -All incidents must be investigated immediately; -Complete an incident report; -Report the abuse to the regulatory body, law enforcement, responsible party and attending physician. -Plan to prevent further abuse and/or neglect in response to an assessment of: --Adequate staffing and education so staff understand the Abuse and Neglect Policy; --The environment - support of individual safety, function and well being; --Individual needs and risk of abuse and/or neglect. Record review of the facility's Physician Notification Policy dated (YEAR) showed: -Prompt notification to the physician of resident status or change in condition; -Nursing staff must conduct an assessment and notify the resident's attending physician when: --Fall, injury and any incident; --Mood or behavior that requires medical intervention; --Resident refusal of treatment and/or medications 3 consecutive times; -Facility staff are to notify the physician within 24 hours if: --Accident/Incident involving injuries; --Deterioration in the health, mental condition and/or psychosocial status of life-threatening nature. 1. Record review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. -Major [MEDICAL CONDITION] (persistent depressed mood or loss of interest in activities, causing significant impairment in daily life); -[MEDICAL CONDITION] (uncontrolled drinking and preoccupation with alcohol) and -Psychoactive substance abuse (is chemical substance that changes brain function and results in alterations in perception, mood, consciousness, cognition or behavior). Record review of Resident #5's Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by facility staff for care planning) dated 11/21/18, showed he/she: -Was cognitively intact; -Had no behaviors listed. Record review of Resident #4's Face Sheet showed he/she was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Record review of the Resident #4's Admission MDS dated [DATE], showed he/she: -Was cognitively intact; -Had constant behavior of inattention; -Rejected care (taking medication) 1 to 3 days; -Was not coded for Paranoid [MEDICAL CONDITION]. Record review of Resident #4's Care Plan dated 11/29/18 showed he/she: -Had a Behavior-Resistant Care, where he/she refused to see the facility doctor; -Was provided counseling for safety measures, using simple instructions to direct mobility and locomotion; -Was explained and/or obtained the Against Medical Advice (AMA) for that risk of practice; -Had [MEDICAL CONDITION] agents for psych purpose; -Was provided [MEDICATION NAME] (antipsychotic) as ordered; -Was monitored with observations and screen for side effects; -Was monitored on medications and the physician should be notified if needed; -Was documented frequently, only as instructed by the Director of Nurses (DON) or Charge Nurse; -Was to have communication through intra-nursing department to ensure consistent and continuous follow-up; -Had taken medication in front of staff; -No changes were made to the resident's care plan. Record review of Resident #4's Nurse's Note dated 1/20/19 at 8:30 A.M., showed: -Staff called to dining area; -Resident #4 took his/her cane and struck Resident #5; -Resident #4 threw hot coffee on Resident #5; -The residents were separated afterwards; -Resident #5 has open cuts on his/her face and hand, with small bleeding; -Resident #5 refused to go to hospital; -Resident #4 started cursing staff and went to his/her room; -Resident #4 took the mattress off his/her bed and stripped the bed; -Resident #4 threw his/her personal items all over his/her room and floor; -The police, caseworker and DON were called and a message was left for Resident #4's son; -Resident #4 sent to the hospital; -No assessment was completed on Resident #4 for injuries before being sent to the hospital. Record review of Resident #5's Nurse's Note dated 1/20/19 at 8:30 A.M., showed: -Resident #5 was attacked in the dining area by Resident #4; -Resident #5 stated Resident #4 hit him/her with a cane, scratched his/her face and threw hot coffee on him/her; -Resident #5 changed clothes and scratches were treated; -Resident #5 smelled of alcohol; -The physician was notified of the situation. Record review of the Resident #4's Hospital Medical Records dated 1/20/19 showed he/she: -Was anxious, agitated and crying; -Had first and second [MEDICAL CONDITION]-3% of his/her right ear, right neck, right chest, right shoulder and left back. Record review of the Resident #4's Nurse's Note dated 1/20/19 at 10:30 A.M., showed: -The hospital requested the last 48 hour of notes; -The physician was notified. Record review of Resident #5's Nurse's Note dated 1/20/19 at 2:00 P.M., showed the DON was notified of incident by Registered Nurse (RN) A. During an interview on 1/20/19 at 2:05 P.M., RN A said: -He/she was unaware [MEDICAL CONDITION] Resident #4; -Maybe Resident #4 got them during the fight down stairs; -Resident #4 threw a cup of coffee on Resident #5; -Resident #4 hit Resident #5 with a cane; -He/she had sent Resident #4 out; -He/she called the DON. Observation of Resident #5 on 1/20/19 at 2:35 P.M., showed he/she: -Had scratches down the right side of his/her nose and cheek; -Had scratches on his/her right hand; -Had finger nail marks on his/her left hand. During an interview on 1/20/19 at 2:46 P.M., Licensed Practical Nurse (LPN) A said: -Resident #4 did not hit Resident #5 with the cane; -Resident #4 did scratch Resident #5; -Resident #6 was there and prevented Resident #4 from hitting Resident #5. Observation on 1/20/19 at 3:05 P.M., showed the coffee temperature were 139.8 degrees Fahrenheit in the dining room area. During an interview on 1/20/19 at 3:05 P.M., the DON said: -Resident #4 stayed by him/herself a lot; -He/she did not know the resident was burned; -Resident #4 wore his/her hair long; -Resident #4 had not showered at the facility; -Resident #4's last shower at the facility was 1/9/19; -Resident #4 left the facility every day; -Resident #4 has asked about staying at another facility he/she was at before. Record review of Resident #5's Statement of Events dated 1/20/19 no times noted showed: -Resident #5 went to get a cup of tea; -Resident #4 already had a cup of coffee and was stirring it; -Resident #4 threw the stir sticks in the sugar; -Resident #5 told Resident #4 that we live here and that Resident #4 should not do that; -Resident #4 hit Resident #5 with his/her cane; -Resident #4 then threw his/her coffee at Resident #5; -Resident #5 turned around and said what; -Resident #4 started scratching Resident #5's face and hands; -Resident #6 stepped between Resident #4 and Resident #5 and everything stopped. During an interview on 1/22/19 at 11:35 A.M., the DON said: -Resident #4 started refusing medication on 1/10/19; -Resident #4 threw coffee on Resident #5, but did not hit Resident #5; -Resident #6 took the cane away from Resident #4; -Resident #4 was sent to the hospital for evaluation and treatment; -He/she was called about an incident around 8:00 A.M.; -Neither RN A nor LPN A had filled out the incident report; -He/she started the investigation when he/she arrived at the facility; -He/she had not called the state, because the state was already at the facility; -He/she did not know about Resident #4'[MEDICAL CONDITION] notified by the state; -RN A should of assessed Resident #4 before being sent out to the hospital; -RN A and LPN A should of started the investigation right away; -LPN A did assess and interview Resident #5 for injuries and treated Resident #5's injuries. During an interview on 1/22/19 at 1:16 P.M., Resident #5 said: -Resident #4 scratched the right side of his/her face and left hand; -Resident #4 hit him/her with a cane; -The coffee did not burn him/her; -He/she did not throw coffee on Resident #4; -He/she was half awake; -He/she gets hot water every morning for hot tea in a insulated pink cup; -The police came and he/she is pressing charges against Resident #4; -If Resident #6 (another resident in the area) had not taken the cane away from Resident #4 he/she would have been hit more. During an interview on 1/22/19 at 2:30 P.M., RN B said: -He/she separated Resident #4 and Resident #5, assessed for injuries and interviewed everyone involved; -Notification was made to the Administrator, DON, physician, responsible parties and the state; -Resident #4 was a difficult resident to care for and refuses his/her medications. Observation on 1/24/19 at 10:40 A.M., showed Resident #4: -[MEDICAL CONDITION] his/her right ear, down the right side of his/her neck, on his/her shoulder, chest and under his/her right breast; -Had a blister on his/her right cheek; -[MEDICAL CONDITION] red and purple in color; -The hospital had applied a treatment and dressing to the burns. During an interview on 1/24/19 at 10:40 A.M., the Resident #4 said: -Resident #5 before breakfast in the smoke room, was up in his/her face, said he/she was going to get him/her kicked out of the facility or have him/her arrested; -He/she raised his/her cane to protect him/herself from Resident #5; -He/she did not hit Resident #5; -He/she then went downstairs to the dining room to get coffee; -He/she had put the stir sticks on the condiment cart; -Resident #5 followed him/her downstairs to the dining room; -Resident #5 started yelling at him/her; -He/she yelled back at Resident #5; -Resident #5 came at him/her; -He/she put his/her cane up in the air to stop Resident #5; -Resident #6 (another resident in the area) took the cane away from him/her; -He/she did scratch Resident #5; -Resident #5 threw hot water on him/her; -The police arrested him/her and took him/her to the hospital. During an interview on 1/25/19 at 10:56 A.M., Resident #7 said: -Resident #4 and Resident #5 had argued; -Resident #4 swung the cane at Resident #5 and almost hit him/her; -Resident #5 went upstairs; -He/she did not see any coffee or hot water thrown; -It all happened so fast; -He/she was just trying to keep from getting hit. During an interview on 1/25/19 at 11:23 A.M., RN A said: -RN A had to calm down Resident #4 on Saturday (1/19/19); -Resident #4 started in right away again on Sunday morning (1/20/19); -He/she did not see the incident happen; -The information was second hand; -Someone said Resident #4 attacked Resident #5; -Resident #5 said Resident #4 hit him/her; -Others said Resident #4 did not hit Resident #5; -Resident #4's behavior had been escalating; -He/she did not see any marks on resident #4's neck; -He/she did not assess Resident #4 before being sent out to the hospital; -He/she did not see Resident #4's clothes were wet; -Resident #4 was cursing and yelling when brought up from down stairs; -Resident #4 went to his/her room and threw his/her personal items all over the room; -He/she called the DON and reported the incident; -He/she called 911 for EMS and the police; -He/she did not call the state, that was the DON's job; -He/she did not start the investigation until the DON arrived at the facility. During an interview on 1/25/19 at 11:42 A.M., Resident #6 said: -He/she had went to get coffee for another resident; -Resident #4 and Resident #5 were arguing; -Resident #5 told Resident #4 he/she was going to get him/her out of the facility; -Resident #4 pushed the condiment tray into Resident #5; -The tray hit Resident #5 in the leg; -Resident #4 raised the cane and shook the cane at Resident #5; -He/she took the cane away from Resident #4; -He/she then turned around and handed the cane to Certified Mediation Technician (CMT) B; -Resident #4 and Resident #5 were at the dining room door at this time; -Resident #4 and Resident #5 were pulling each other's hair; -Resident #4 then scratched Resident #5's face; -He/she and CMT B separated Resident #4 and Resident #5; -He/she did not see any coffee or hot water thrown at Resident #4; -He/she did get wet on his/her back during the incident; -Resident #4's hair was in a ponytail; -He/she did not see Resident #4's neck; -Resident #5's story kept changing as the day went on; -RN A showed up and the incident was calmed down. During an interview on 1/25/19 at 12:07 P.M., CMT B said: -Resident #4 wore his/her hair up in a bun or pony tail after it dried; -He/she had not seen any marks on Resident #4's neck; -Resident #4 had a temper and would explode for no reason; -He/she tried to calm Resident #4 down when upset; -Resident #4 did not like many young people; -Resident #4 would take his/her medication sometimes for CMT B. During an interview on 1/25/19 at 12:46 P.M., CNA A said: -He/she did not see the altercation happen; -He/she went to the dining room to get 2nd floor breakfast trays, when he/she observed Resident #4's neck was real red and his/her shirt was wet; -Resident #5 had scratches on his/her face; -He/she left the dining room and took the breakfast trays up stairs; -RN A and LPN A were already downstairs in the dining room; -Resident #5 filled the facility water cup up with hot water every morning for hot tea; -EMS came and took Resident #4 before CNA A had seen him/her again. Observation on 1/25/19 at 1:10 P.M., showed: -Coffee and hot water are brewed from the same machine; -The hot water temperature was 140 degrees Fahrenheit; -Large decanters of coffee and hot water were placed in the dining room throughout the day; -Every resident had access to self serve his/her own coffee and hot water at all times. During an interview on 1/25/19 at 2:18 P.M., Administrator said: -The DON did notify him/her of the incident on 1/20/19 in the morning; -The DON called again when state entered the building. During an interview on 1/25/19 at 3:51 P.M., Nurse Practitioner (NP) said: -He/she expected the staff to assess both residents right away for injuries after a resident to resident altercation; -He/she was not notified of the resident to resident incident until 1/21/18 at 6:00 A.M. Monday morning; -He/she assessed Resident #5's scratches on the face and arm. Record review of the facility Summary of Investigation, dated 1/25/19 showed: -Per reports from residents involved and review of camera footage; -At approximately 7:58 A.M., on 1/20/19 Resident #4 and Resident #5 were in a verbal altercation; -The verbal altercation between Resident #4 and Resident #5 became physical in the dining room downstairs; -Resident #4 knocked over the beverage accessory cart; -Resident #6 took a cane from Resident #4; -Resident #4 threw his/her coffee on Resident #5; -Resident #5 then chased after Resident #4; -Resident #5 threw hot water on Resident #4's right side from behind; -Resident #4 then charged after Resident #5; -Resident #4 hit and scratched Resident #5; -Resident #6 once again separated Resident #4 and Resident #5 while more help arrived; -Resident #4 went back upstairs to his/her room; -Resident #4 was throwing things around his/her room and continued to escalate; -RN A called the police, and the DON; -Resident #4 was taken to the hospital; -RN A and LPN A said Resident #4 did not complain of any injuries or pain; -Resident #5 had scratches to the face and arm; -Resident #5 said his/her right arm hurt where he/she was hit with the cane; -The DON instructed the nurses to get an x-ray of Resident #5's right arm; -At approximately 3:00 P.M., DON received a call from RN A; -State was in the building regarding Resident #4's burns; -The DON came to the facility to answer question related to the complaint; -The DON said this was the first time he/she had heard about Resident #4's injuries; -The DON had RN A begin to gather statements from all involved in the incident; -The DON was not able to see camera footage at that time; -On Tuesday 1/22/19, camera footage was reviewed; -The DON saw inconsistencies in the version of events Resident #5 said had happened; -Resident #5 said he/she did not retaliate against Resident #4; -Resident #5 did pour his/her beverage on Resident #4; -The beverage was the source of [MEDICAL CONDITION] Resident #4; -Resident #4 will not be readmitted into the facility due to higher level of care that the facility cannot provide; -Resident #5 chose to leave the facility on his/her own accord and he/she left against Medical Advise (AMA) on 1/25/19. During an interview on 1/27/19 at 9:24 A.M., LPN A said: -He/she heard over the intercom help was needed in the dining room; -He/she responded to the dining room and took Resident #5 to interview him/her and assess for any injury; -RN A took Resident #4 upstairs to interview him/her and assess for any injury; -After assessing Resident #5 he/she went upstairs to check on Resident #4; -Resident #4 was in his/her room and it was a mess and he/she had thrown things everywhere; -Resident #4 had his/her shirt off, so he/she left so the resident could have privacy while changing; -The police came and took Resident #4 to the hospital for evaluation and treatment; -He/she asked Resident #5 to write out a statement; -Resident #5 could not write out a statement, because he/she was under the influence of something; -He/she wrote the statement for Resident #5 and read the statement back to him/her and then the resident signed the statement. During an interview on 1/28/19 at 12:52 P.M., CMT B said: -Resident #5 came up stairs and told CMT B that Resident #4 had hit him/her; -He/she went and told RN A about the incident; -Resident #5 went back down stairs when CMT B went to tell RN A; -CMT B went downstairs using the elevator; -When the door opened CMT B had observed Resident #4 and Resident #5 in another altercation; -Resident #6 was trying to separate Resident #4 and Resident #5; -Resident #6 handed CMT B Resident #4's cane; -He/she set the cane aside and continued to separate the residents; -The dining room was a mess with condiments everywhere on the floor and -He/she did not see any water on the floor. MO 920

Based on observation, interview and record review, the facility failed to follow physician's orders for a Registered Dietician (RD) consultation once weight loss was identified, to monitor the resident's weight loss and implement interventions to address weight loss once it became significant for two sampled residents (Resident #53 and #59) out of 18 sampled residents. The facility census was 70 residents. Record review of the facility Weight Management -Unplanned weight Change policy and procedure, revised (YEAR), showed: -The Director of Nursing (DON)/ Assistant Director of Nursing (ADON) will be responsible to establish monthly/weekly weight schedule; -The appointed nursing staff is responsible to obtain weights for each resident according to the schedule; -Staff who is responsible for weighing will compare the current weight and the previous weight and shall re-weigh if there is a 5 pound (lb.) variance; -The weight record shall be communicated to the Quality Assurance Committee or weight committee upon completion; -Residents who exhibit weight gain or weight loss of more than 5% in a 30 day period; 7.5% in a 90 day period or 10% in a 180 day period shall be assessed by a licensed nurse for causative factors, contributing factors and risks; referred to the RD for further evaluation; notified to the physician for medical intervention and referred to the weight committee for reviewing and revising the care plan; -The charge nurse will be responsible for documentation, progress, implementation of treatment; -Documentation of exceptions shall reflect the changes in status, condition, implementation of the care plan or physician's orders; -A resident who is observed declining in feeding ability or refusing to eat; consuming less percentage of intake, exhibiting wounds will be evaluated by the weight committee and -The weight committee will meet at least monthly or more frequently if needed to monitor for progress and successful implementation in order to develop and revise the care plan. All weight gain or loss within the parameter of concerns above will be documented on the weight gain/weight loss assessment sheets. 1. Record review of Resident #53's Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated [DATE], showed he/she: -Was alert and oriented with no behavioral symptoms; -Was independent with transfers and ambulation, but had lower extremity impairment on both sides; -Was independent with eating and had no chewing or swallowing difficulty; -Received a therapeutic diet; -Did not have significant weight loss and -Weighed 169 pounds (lbs). Record review of the resident's monthly Weight Record showed: -May (YEAR) =167.6 lbs; -June (YEAR) =170.6 lbs and -July (YEAR) =169.4 lbs. Record review of the resident's Quarterly Nutritional Progress Note dated [DATE], showed he/she remained on a low-concentrated sweets (LCS) with no added salt (NAS) diet, consumed ,[DATE]% of meals and fed himself/herself. It showed the resident's weight was stable at this time and there were no dietary concerns. The RD would continue to monitor. Record review of the resident's Quarterly Nutritional Evaluation dated [DATE], showed he/she was on a regular, LCS, NAS diet and his/her weight was 169.4 lbs. Record review of the RD annual Assessment (Diet History and Initial Screening) dated [DATE], showed: -The resident was 5' 2 (height) and weighed 169.4 lbs. His/her BMI was 31.0; -The resident received a regular, LCS, NAS diet; -The resident was missing a few teeth, but had most of his/her own teeth that were in good condition and there were no complaints with chewing or swallowing; -The resident needed some staff encouragement during dining; -The RD reviewed the resident's labs and noted the resident's potential risks were related to his/her medications but found no current problems; -The resident's estimated nutritional needs showed the resident protein, fluid and energy levels were normal and there was no nutritional problem noted and -The RD documented he/she reviewed the resident's medications and noted the resident had a recent upper respiratory infection. The resident's skin was intact, the resident's BMI was adequate and his/her weight was stable. There were no new nutritional recommendations and the RD would continue to follow the current plan of care. Record review of the resident's Nursing Notes showed: -There was only one nursing note documented from [DATE] to [DATE]. The note, dated [DATE] showed the nurse Practitioner visited and increased the resident's pain medication orders. There were no notes that documented the resident's eating patterns or change in eating habit. There was no documentation showing the resident was starting to lose weight and there was no change in the resident's health noted that was attributed to weight loss and -On [DATE], the nurse documented the Nurse Practitioner visited the resident today and gave a new order for a RD consult due to weight loss. Record review of the resident's (MONTH) Weight Record showed the resident weighed 166.2 pounds (lbs). (a loss of 3 lbs within 30 days). Record review of the resident's Physician's Order Sheet (POS) dated (MONTH) (YEAR), showed a physician's order dated [DATE] for RD consult due to weight loss. Record review of the resident's Dietary Notes showed there were no notes showing dietary was notified of the resident's weight loss, or of the physician's order dated [DATE], for a RD consult due to weight loss. There was no documentation showing any dietary interventions that showed how the facility was going to address the resident's weight loss. Record review of the resident's Nursing Notes showed nursing staff documented on falls the resident had from [DATE] to [DATE]. None of the notes showed any correlation with the resident's meal intake or weight loss. The resident was sent to the hospital after falling on [DATE] (returned on [DATE]) and [DATE] (returned on [DATE]) and both of those hospitalization s were related to falls and did not address the resident's weight loss. Record review of the resident's Physician's Note dated [DATE] showed the resident's physician completed a physical examination of the resident and reviewed his/her labs, medications and medical record. The physician documented that he/she took the resident off of several medications that were possibly related to the resident's falls, however there were no notes showing there were any gastric problems or problems with the resident's ability to eat. The resident's weight loss was not addressed. Record review of the resident's (MONTH) Weight Record showed the resident weighed 155.0 lbs (a loss of 11 lbs. or 6.74% in 30 days, this is significant weight loss). Record review of the resident's Nursing Notes from [DATE] to [DATE] showed he/she was being treated for [REDACTED]. There were no notes showing the nursing staff followed up with the RD or Dietary Manager regarding the resident's weight loss, meal intake or any interventions to try to stabilize the resident's weight. Record review of the resident's Physician's Note dated [DATE] showed the physician documented he/she completed a physical evaluation of the resident and reviewed the resident's medical record (including labs and medications). The physician documented the resident had no significant weight change. He/she documented the resident had recent falls and medication changes and the resident seemed to be more alert. He/she documented that the resident's urinary infection was resolved. There were no orders related to the resident's continued weight loss or recommendation for the RD to complete an evaluation of the resident. There was no documentation to show the resident's weight loss was planned or expected. The resident's weight loss was not addressed. Record review of the resident's Nursing Notes from [DATE] to [DATE] showed there were no notes addressing or related to the residents weight loss, interventions to try to prevent further weight loss or efforts made to notify the RD to perform a nutritional evaluation on the resident to address the resident's weight loss. Record review of the resident's (MONTH) Weight Record showed the resident weighed 150.0 lbs. (a loss of 16 lbs or 9.75% in 90 days is significant weight loss). Record review of the resident's Malnutrition risk dated [DATE], showed the resident had a score of 6 (a total score above 10 is high risk). Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was alert and oriented with no behavioral symptoms; -Was independent with transfers, ambulation, and eating; -Had no chewing or swallowing problems and received a therapeutic diet and -Had a significant weight loss over the past 6 months and was not on a planned weight loss regimen. Record review of the resident's Care Plan updated [DATE], showed he/she was on a LCS NAS diet and ate in the main dining room, did not follow his/her diet and ate snack foods. It showed the resident has had recent and prior weight loss and the dietician and the resident's physician were aware. The intervention showed staff was to monitor his/her weight and consumption. There were no additional nutritional interventions documented. Record review of the resident's Dietary Progress note dated [DATE], showed the resident's weight is currently 166.2 lbs. It showed the resident consumes ,[DATE]% of his/her meals and feeds himself/herself. There were no issues noted. The note showed the resident's weight was down to 166.2 from the last quarterly review (July (YEAR) it was 169.0 lbs.). This weight did not reflect the resident's weight that was documented on the monthly weight record. Observation on [DATE] at 8:14 A.M., showed the resident was sitting in the dining room in his/her wheelchair eating a regular diet of fried eggs (two), hot cereal and toast with juice and coffee. The resident did not have any assistive devices and was able to eat independently without assistance. He/she was eating at this time and did not seem to have any difficulty chewing or swallowing his/her food. He/she was eating well. Observation on [DATE] at 8:26 A.M., showed the resident was sitting in the dining room in a chair, with his/her cane beside him/her. He/she was eating a regular diet of scrambled eggs, a muffin, hot cereal, coffee and orange juice. He/she was eating, drinking without any encouragement or assistance, and seemed to be eating well without difficulty chewing or swallowing. When he/she was finished eating, he/she left the dining room independently. During an observation and interview on [DATE] at 11:48 A.M., the resident was ambulating independently in his/her room and said he/she eats what he/she wants to eat, and if he/she does not want to eat then he/she does not eat. The resident said he/she did not mind losing some weight. The resident was not observed going to the dining room for lunch. During an interview on [DATE] at 7:35 A.M., Licensed Practical Nurse (LPN) A said: -The resident has been losing weight gradually over the last few months and his/her weight loss is not planned; -The resident was trying to lose weight initially, but the resident did not plan this most recent weight loss; -The resident had two recent hospitalization s, one in (MONTH) (YEAR) and one in (MONTH) (YEAR); -The resident had noticeable weight loss in (MONTH) (YEAR), and his/her primary care physician was notified about the resident's weight loss in August; -After looking in the resident's medical record, he/she said the resident was supposed to have a dietary consultation, and on (MONTH) 8, (YEAR), there was a physician's order for the resident to have a dietary consultation for weight loss.; -He/she was not aware that the resident had lost 11 pounds from (MONTH) to (MONTH) (YEAR) (166.2 in Aug to 155 in Sept); -After looking through the resident's medical record, he/she said he/she did not see where a dietary consultation had ever been completed by the RD; -The Dietary Consultant did not document the current weights on the resident's quarterly nutrition assessment and that documentation was incorrect; -The resident's weights are completed and documented monthly (and those weights were the correct weights for the resident); -The nurses were not responsible for documenting weights or monitoring the resident's weights; -The former Director of Nursing (DON) was responsible for documenting and reviewing resident weights, getting the physician orders for interventions related to weight loss and communicating with the Registered Dietician and dietary staff of any changes in the resident's weights, recommendations and physician's orders; -He/she was not aware of a weight committee or weekly weight meetings where they discussed residents with weight loss. He/she said they discuss resident weight loss during the shift change; -When they (the physician and/or RD) determined interventions for addressing the resident's weight loss, the DON would communicate those interventions to the nurse, and the nurse then implemented the orders/interventions; -He/she only monitors daily weights; -The DON should have caught the resident's weight loss and made sure the physician's orders were implemented for getting the RD to evaluate the resident; -He/she thought the RD was supposed to come to the facility on ce monthly, but she had not seen the RD monthly; -He/she did not know what the protocol for weight loss was because the former DON always handled that; -The resident eats independently without any assistance and ate what he/she wanted, but will give his/her food away at times; -The interim DON said that the resident was overweight, but there still should be some documentation about interventions implemented, or what was done about the resident's weight loss once weight loss was identified. He/she said there should be documentation in the dietary notes and there should have been a RD consultation as ordered by the resident's physician and -He/she said the resident's care plan should have been updated to show that the resident had significant weight loss and the interventions that were put in place to address it. He/she said it did not seem that anything was done once weight loss was identified. He/she said the dietary consultant/manager may have notes in his/her office that had not been put in the resident's medical record and it was possible the RD had not sent in his/her evaluation. He/she said he/she will try to contact the RD. During an interview on [DATE] at 9:04 A.M., the DON said the dietary consultant had the RD consultations for the past several months and would send them to the facility. Record review of the facility's Nutritional Care Form showing the dates the RD visited the facility and also showed the residents the RD saw when he/she visited the facility. The document showed: -The RD visited the facility on [DATE], [DATE], [DATE] and [DATE] and -Documentation showed the RD did not see the resident on any of the dates he/she visited the facility. Attempted to notify the resident's physician on [DATE] at 9:00 A.M., and on [DATE] at 9:00 A.M., and the resident's physician as not returned the phone calls as of [DATE]. 2. Record review of Resident #59's Admission Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. -Cardiovascular accident ([MEDICAL CONDITION], is the medical term for a stroke. A stroke is when blood flow to a part of your brain has been impaired by a blockage or rupture of an artery to the brain); -[MEDICAL CONDITION] (CAD, causes impaired blood flow in the arteries that supply blood to the heart) and -Paralysis (is complete or partial loss of function especially when involving the power of motion or of sensation in any part of the body) of the right side body, and [MEDICAL CONDITION] (involuntary body movement). Record review of the resident's Annual Dietary History and Initial Screening completed by the RD dated [DATE] showed he/she: -Had a diet order for a regular diet with no added salt; -Was to receive a house supplement every day with an ordered date of [DATE]; -The resident's weight was 129.6 pounds and -Diet and weight had been adequate with good food intake. Record review of the resident's Dietary progress note dated [DATE] showed the resident remained on a regular diet with no added salt with house shake three times a day. His/her weight was stable. The resident ate 50 to 85% of his/her meals. He/she had no special request for dietary at this time. Record review of the resident's Quarterly Nutritional re-evaluation dated [DATE] showed the resident: -Had a regular diet with no added salt; -Was also to have a House supplement shake, to be given three times a day; -Weight was 131.6 pounds and marked as he/she had no percentage of weight change and -Diet had met his/her nutrition needs. Record review of the resident's weekly weights from [DATE] to [DATE] showed: -On [DATE] his/her weight was 133.4 pounds and -On [DATE] his/her weight was 133.4 pounds. Record review of the resident's weekly weights from [DATE] to [DATE] showed: -On [DATE], his/her weight was 132.4 pounds; -On [DATE], his/her weight was 131.2 pounds; -On [DATE], his/her weight was 130.4 pounds; -On [DATE] his/her weight was 129.8 pounds; -On [DATE], his/her weight was 127.6 pounds and -For the month of (MONTH) showed weight loss of 4.8 pounds. Record review of the resident's POS for ,[DATE] showed the resident's diet order: -Was Regular diet with no added salt and had date of [DATE]; -House supplement Strawberry given once daily at lunch for weight loss had been ordered on [DATE] and -No documentation was found for referral to the RD for resident's weight loss or for monitoring of the resident weight weekly. Record review of the resident's nursing progress notes from [DATE] to [DATE] showed: -No documentation was found related to monitoring of the resident's poor eating habits and to his/her ongoing weight loss and -No documentation was found for a request for a referral to the RD or to the resident's physician related to the resident's weight loss or for monitoring of the resident weights weekly. Record review of the resident's weekly weights from [DATE] to [DATE] showed: -The resident was in the hospital from [DATE] to [DATE]; -On [DATE]/18 his/her weight was 126.8 pounds; -On [DATE] his/her weight was 125.8 pounds; -On [DATE] his/her weight was 124.0 pounds and -For the month of (MONTH) showed the resident had weight loss of 2.8 pounds. Record review of the resident (MONTH) monthly weight showed; The resident weight documented was 127.4 pounds and had a loss of 5 pounds in one month and -The monthly weight of 127.4 pounds did not match the documented weekly weights. Record review of the resident's physician progress notes [REDACTED]. showed the resident: -Appetite was satisfactory per the resident. No significant weight change reported; -Did not have the resident's current weight documented on the resident's physician progress notes [REDACTED].>-Had been well nourished and his/her skin warm and dry. The resident's mouth was moist. Record review of the resident's POS for ,[DATE] showed the resident's diet order: -Was Regular diet with no added salt; -Strawberry house supplement Strawberry given once daily at lunch for weight loss and -No documentation was found for referral to the RD for resident's weight loss or for monitoring of the resident weight weekly. Record review of the resident's nursing progress notes from [DATE] to [DATE] showed: -Last nursing progress note was dated [DATE] related to a visit from the Nurse Practitioner (NP) and received new orders for physical therapy and occupational therapy evaluation for weakness and unsteady gait. Referral sent to outside therapy group; -No documentation was found related to monitoring of the resident's poor eating habits and to his/her ongoing weight loss; -No documentation was found for a request for a referral to the RD or to the resident's physician related to the resident's weight loss or for monitoring of the resident weights weekly and -No documentation found related to resident not receiving the physician's order strawberry supplemental shake at lunch. Record review of the resident's Annual History and Physical physician progress notes [REDACTED]. showed the resident: -Appetite was satisfactory per resident. No significant weight change reported; -Did not have the resident's current weight documented on the resident's physician progress notes [REDACTED].>-Had been well nourished and his/her skin warm and dry. The resident's mouth was moist. Record review of the resident's weekly weights from [DATE] to [DATE] showed: -On [DATE] his/her weight was 126.2 pounds; -On [DATE] his/her weight was 124.0 pounds; -On [DATE]/,[DATE] his/her weight was 122.8 pounds; -On [DATE] his/her weight was 121.8 pounds; -On [DATE] his/her weight was as 121.6 pounds and -For the month of (MONTH) showed the resident had weight loss of 4.6 pounds. Review of the resident's weekly weights from ,[DATE] to ,[DATE] showed the resident had a 10.8 pounds weight loss in 3 months for a total of 7.5% weight loss. Record review of the resident's dietary progress note dated [DATE] showed the resident: -Was on a regular diet with no added salt diet, with a strawberry shake one time with lunch; -Eats his/her meals in the 2nd floor dining room; -Able to feed himself/herself; -Had no special problems for dietary at this time and -Had no documentation related to the resident recent weight loss. Record review of the resident's Quarterly Nutritional re-evaluation dated [DATE] showed the resident: -Nutritional re-evaluation was left un-answered expect for the diet information; -Diet order was a regular diet with no added salt; -House supplement shakes were to be given one time a day and -Weight for (MONTH) was not documented on the form and no documentation related to any weight change. Record review of the resident's Care Plan related to nutrition and weight that was last reviewed on [DATE] showed: -The resident's goal: Will not exhibit an fluctuation in his/her weight related to weight loss and weight gain (includes an 5% weight change in 30 days, or a 7.5% weight change in 90 days); -The resident had a history of [REDACTED]. -The resident's meal intake was to be monitored and to monitor the resident for signs and symptoms of hunger such as; shaking, cold, lethargic; -The facility staff were to provide snacks for the resident and to encourage meal participation or planned dietary compliance; -The resident eats his/her meals in the 2nd floor dining room; -He/she was able to feed himself/herself, the resident did have weakness on his/her right side and -The resident received a strawberry supplement shake at lunch. Record review of the resident's Quarterly MDS dated [DATE] showed: -Weight was 126 pounds and height was 60 inches; -The section of weight loss of 5% or more in the last month was marked yes; -Weight loss was not a physician prescribed weight loss regimen; -Was on a therapeutic diet; -Was independent with eating did not require supervision or setup and -Had impaired range of motion on one side of his/her body. Record review of the resident Malnutrition Risk assessment dated [DATE] showed the resident's had a score of 6, which indicated the resident was not a high risk for malnutrition or weight loss. Record review of the resident Monthly Nursing Summary dated [DATE] showed the resident had no documentation related to his/her weight loss and did not have a current weight listed in the summary. Record review of the resident's Nursing Progress Notes from [DATE] to [DATE] showed: -No documentation was found related to monitoring of the resident's poor eating habits and to his/her ongoing weight loss; -No documentation was found for a request for a referral to the RD or to the resident's physician related to the resident's weight loss or for monitoring of the resident weights weekly and -No documentation found related to resident not receiving the physician's order strawberry supplemental shake at lunch. Record review of the resident meal intake from [DATE] showed the resident ate 100% Breakfast, had no documentation for lunch, and only ate 25% of his/her dinner. Record review of the resident's weekly weights for (MONTH) [DATE] showed his/her weight was 122.4 pounds. Record review of the resident's medical record from [DATE] to [DATE] to including physicians order sheet, care plan, nurse progress notes and dietary notes showed the resident: -Had no documentation found related to ongoing monitoring of the resident's weight change over the last 3 months of 7.5% weight loss; -Had a weekly flow sheet with documented weekly weights that was done by licensed nursing staff; -Had no further follow-up documentation to be found related to his/her weight changes and -Had no new documentation or interventions was found from the facility addressing the resident decline in his/her weight over the past three months. During an interview on [DATE] at 8:40 A.M. the resident said: -He/she has not seen the RD for weight loss and he/she continued to lose weight; -He/she said he/she does not like the food offered at the facility, and he/she feels part of his/her weight loss was from the food offered and -Observation of the resident's room showed he/she had bowls of un-touched sugared cereal at bedside. During observation of the resident on [DATE] at 12:12 P.M. showed the resident: -Had regular lunch tray, with hamburger on bun, tater tots, green beans and ice cream; -Drinks were not offered until the meal arrived; -The resident did not have a health shake supplement on his/her tray; -The resident was only able to use his/her left arm and hand to assist cutting meat and preparing meal; -No special meal equipment was seen for the resident; -The resident only ate his/her ice cream, drank some Kool-Aid, ate few bites of green beans and tater tots; -No encouragement from staff to stay to finish his/her meal and -No assistance offered from staff to cut up or prepare food. Observation on [DATE] at 8:00 A.M. the resident: -Was trying to propel himself/herself away from the dining room; -He/she was redirected back to the dining room by staff and was verbal encouragement to eat more of his/her breakfast and -No hands on assistant provided for the resident. Record review of the resident meal intake from [DATE] to [DATE] showed: -On [DATE] he/she ate 50% of his/her breakfast and ate 25% of his/her lunch, no documentation for dinner; -On [DATE] he/she ate 50% of his/her breakfast and ate 45% of his/her lunch, no documentation for dinner; -On [DATE] he/she ate 100% of his/her breakfast and ate 10% of his/her lunch, no documentation for dinner; -On [DATE] he/she ate 25% of his/her breakfast and ate 25% of his/her lunch and he/she ate 75% of his/her dinner; -On [DATE] he/she ate 25% of his/her breakfast and ate 25% of his/her lunch, no documentation for dinner; -On [DATE] he/she ate 40% of his/her breakfast and ate 50% of his/her lunch, no documentation for dinner and -No documentation found on meal intake sheet related to the recording of the resident's intake of his/her physician order house supplement shake. Record review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED] -There was no physician's order for a strawberry supplement shake 1 time a day at lunch or three times a day with meals and -No documentation was found regarding the supplemental shakes in the resident's past MAR's and TAR's. During an interview on [DATE] at 1:25 P.M. CMT A said: -The resident's weights were done either weekly or monthly and -If there was a concern with the weight then information was placed in the communication book for the resident's physician to review, and follow up with dietary. Record review of the resident's MAR indicated [REDACTED].M. with CMT A showed: -No documentation of a physician's order for the strawberry supplement shake on the MAR; -The nursing staff and CNA's had been giving the resident the strawberry supplement shake three times a day with his/her meals; -The only documentation for resident on the supplemental drinks are under the fluid intake and the supplement drinks was included in the total liquids the resident's had drank during the meals; -Review with CMT A of the resident's POS showed a physician's order under the diet order was for strawberry supplement one time a day with lunch and -He/she said the resident like his/her drinks and has no problem with him/her drinking the supplements. During an interview on [DATE] at 1:50 P.M., LPN A said: -The resident likes his/her supplement shakes and drinks them three times a day with meals; -The resident has a lot of dislike in his/her foods; -If resident does not like something at meal time, he/she will get mad and not eat the meal; -Not aware if alternatives meals are offered to the resident; -The former DON would review the resident's weights weekly and as need if needed a referral for the RD or other recommendation; -The facility former DON left in (MONTH) (YEAR); -If the resident had a weight loss of 5 pounds, he/she would either let the resident physician know and send information down to dietary. Also notify the MDS coordinator; -He/she not aware on how to communicate with the RD and -He/she was not aware of a communication book for the RD on the second floor unit. During interview on [DATE] at 2:05 P.M., Dietary Manager (DM) said: -The dietary manger had only been at the facility for 30 days; -He/she receives Dietary Order Form from nursing staff for the resident's with diet recommendation; should include resident's name, the resident's physician name, recommendation for diet, room, what nursing staff sent it; -The Dietary Manger said he/she does not obtain the physician's orders for the RD visits or referrals and -The resident's dietary card showed had a Regular diet, NO added salt and a house supplement with every meal. Observation of the resident's room on [DATE] at 7:00 A.M. showed he/she had pop cans, two bowls of fruit loops, bag of candy in the bedside drawer and un-open can spaghetti O's and -In his/her refrigerator had expired carton of strawberry supplement shake dated ,[DATE]. Observation of the facility snack bulletin board located behind the nurse's station showed the resident's name under the 2:00 P.M. time to receive the strawberry supplemental shake at snack time. Observation of the resident during breakfast on [DATE] 8:00 A.M. showed: -He/she had two hard boiled eggs, bowl of dried cereal of fruit loops and toast. -Also had juice and milk; -The resident only ate the white part of the eggs and left the dining room and -The dietary card did not have anything about the resident's house supplement shake or

Based on observation, interview, and record review, facility staff failed to provide supervision for one (Resident #19) of three sampled residents who smoke cigarettes. Staff did not provide monitoring to ensure Resident #19 did not use oxygen while smoking to prevent potential hazard including combustion and possible fire. Additionally, staff did not ensure eight residents (Resident's #4, 110, 107, 113, 102, 111, 112, 114, and 115) smoked only in the facility designated area and disposed of smoking materials in a safe manner. Staff also failed to ensure Resident #115 did not smoke in his/her room including while the resident's roommate was present and wearing oxygen. Staff did not provide appropriate smoking receptacles (ash trays) in three additional areas used by staff and residents for smoking. Staff also failed to maintain the floor outside of resident room 209 in good repair to prevent a potential tripping hazard. Staff failed to ensure a medications were monitored and administered to resident in a safe manner for four residents (#103, #125, #12, and #113). Staff did not assess the cause of falls and provide services to prevent additional falls for one resident (#7) and did not instruct staff how transfer two residents (#7, #15). Staff did not provide nursing care and services for one resident (#12) with a history of alcohol abuse, who acts in an unsafe manner while in the community. The facility census was 86 residents. Record review of the facility's undated Smoking Policy showed the following: -Staff will make rounds every hour to monitor residents who are identified with risk behavior from a history of smoking in non-designated smoking areas; -If a resident is found to be non-compliant with the smoking policy, the Administrator or Director of Nursing (DON) will be notified; - If a resident is found to be noncompliant with the smoking policy, the staff will implement a Smoke Watch Log. The resident area of non-compliance will be monitored every 15 minutes until total compliance is confirmed. The Administrator and staff will monitor during daily rounds. 1. Record review of Resident #19's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 4/16/15, showed staff assessed the resident as: -Alert and oriented; -Used oxygen therapy. Record review of the Resident's Smoking Safety Assessment, dated 6/29/15, showed staff documented: -The resident was fully capable of understanding the facility's smoking rules, holding the cigarette properly, using an ash tray properly, turning off all oxygen related devices, and using the lighter properly; -On 6/9/15, the resident parked his/her wheelchair in the lobby area, turned off the oxygen cylinder, removed the nasal cannula, walked over to the smoking area and smoked a cigarette; -On 6/29/15, the resident said he/she did not like the Administrator following him/her around. The Administrator explained that was his/her way of assessing the resident; -The resident signed the smoking policy and procedure stating he/she reviewed the policy with facility staff, fully understood the smoking policy, and was responsible for compliance with the policy. Record review of the resident's annual MDS, dated [DATE], showed staff assessed the resident as: -Had clear speech, able to understand others, and was understood by others; -Cognitively intact; -Did not refuse care; -Independent in bed mobility, transfers, walking, locomotion, dressing, eating, toileting, personal hygiene and bathing; -Used a wheelchair; -Diagnoses included high blood pressure, renal (kidney) failure, stroke, seizure disorder, anxiety, depression, bipolar behavior, Chronic Obstructive Pulmonary Disease (COPD), and polysubstance abuse; -Used tobacco currently; -Was not identified as using oxygen; and -Had shortness of breath. Record review of the resident's Care Plan, dated 7/17/15, showed staff were instructed to: -Provide medications for COPD -Provide oxygen at 2 liters (L) per nasal cannula continuously; -Remind the resident to remove his/her oxygen and keep it out of the smoke room area; -Review and explain the smoking policy; -Encourage compliance with the smoking policy (designated places for smoking; combustible storage, etc.); -Encourage him/her not to smoke; -Encourage and remind him/her to turn off his/her oxygen while smoking. Further review of the resident's Care Plan showed staff assessed the resident at risk for potential injury and hazard related to non-compliance with the smoking policy. Observation on 9/11/15, showed the following: -At 8:11 A.M., the resident sat in his/her wheelchair and smoked a cigarette in the area outside the basement door with his/her oxygen cylinder still attached to the wheelchair and on; -Two other residents were in the area at the time, one of which smoked a cigarette, and no facility staff were present in the smoking area; -At 8:12 A.M., the surveyors went into the dining room and asked Certified Nurses Aide (CNA) B to come outside quickly because a resident was smoking with his/her oxygen cylinder on; -Between 8:13 A.M. and 8:14 A.M., CNA B politely asked the resident to give him/her the cigarette that was still lit, and the resident hesitated; -At 8:15 A.M., the resident kept insisting his oxygen was not turned on even though the portable oxygen tank showed the oxygen was set at 3 L per minute. The state surveyor asked CNA B to unhook the tubing to see if there the oxygen was on, and when unhooked the sound of releasing gas was heard; and -At 8:16 A.M., the state surveyor asked CNA B to put out the cigarette since the resident did not want to put out the cigarette himself/herself. During an interview on 9/11/15 at 8:24 A.M., Licensed Practical Nurse (LPN) B said he/she has not seen the resident smoke with his/her oxygen cylinder on before. During an interview on 9/11/15 at 8:29 A.M., Resident #116 said: -Resident #19 was at the smoking area when Resident #116 got to the smoking area; -Resident #19 went outside to smoke by himself/herself; -Resident #19 lit his/her cigarette just a little bit before the two surveyors walked in the door. During an interview on 9/11/15 at 8:34 A.M., Certified Medication Technician (CMT) C said: -He/she did not know the resident was outside smoking at the time; -He/she had not seen the resident smoke with the oxygen cylinder on before; -He/she believed the resident was aware of the risks; -When the resident smokes in the second floor smoke room, the resident leaves his/her wheelchair outside the smoke room by the nurse's station. During an interview on 9/11/15 at 8:37 A.M., CNA B said: -He/she did not know the resident was outside smoking at the time, -He/she had not seen any resident smoke with the oxygen cylinder in the smoking area; -In the past, he/she observed the resident leave his/her wheelchair outside the smoke room and go into the smoke room to smoke. During an interview on 9/11/15 at 9:13 A.M., Resident #19 said: -He/she was not aware that the his/her oxygen cylinder was on, -He/she had not smoked with the oxygen cylinder in the vicinity before; -The oxygen cylinder can blow up if he/she smoked with it on; -He/she went out there by himself/herself; -There was no facility staff out at the smoking area at the time. During an interview on 9/11/15 at 9:30 A.M., the Activity Director said: -He/she saw one resident go outside to smoke with the oxygen cylinder still attached to his/her chair sometime back in June 2015; -He/she did not tell the nursing staff. During an interview on 9/11/15 at 11:39 A.M., Registered Nurse (RN) B said the following: -Resident #19 went outside this morning and did what he wanted to do; -Staff do not supervise any residents while smoking. During an interview on 9/11/15 at 1:18 P.M., CMT C and CNA B said: -They were not aware they were supposed to encourage the resident not to smoke and to remind the resident to turn off oxygen while smoking; -They made sure that residents smoked in the correct area; -They did not see the resident outside on that morning. During an interview on 9/11/15 at 2:00 P.M., LPN B said: -The resident used oxygen; -The facility staff never had to monitor that resident before; -The facility staff did not have to go out with Resident #19 when he/she smoked; -That resident was alert and oriented. During an interview on 9/11/15 at 3:29 P.M., the Administrator said: -Resident #19 was not happy with being watched while he/she smoked. 2. Observations with the Maintenance Director on 9/8/15, showed: -At 3:14 P.M., numerous cigarette butts were stored in a plastic bag on the night stand, and cigarette butts were in the trash container with a plastic bag in it inside Resident #110's room; and -At 3:17 P.M., cigarette butts were in one ash tray that was not of safe design (an ash tray without a self-closing lid) in Resident #107's room. Observations with the Maintenance Director on 9/9/15, showed : -At 8:26 A.M., cigarette butts were in an ash tray that was not of safe design in Resident #113's room; and -At 8:29 A.M., cigarette butts were stored in a 12 ounce plastic container that was full in Resident #102's room. Observations and interviews with the Administrative Assistant, CNA D and the Social Service Designee (SSD) on 9/9/15, showed the following: -At 9:44 A.M., a plastic bag of cigarette butts was in Resident #110's room; CNA D said that resident stored cigarette butts like that for a long time; and Resident #110 said he/she did not smoke in the room, he/she crushed the cigarette butts to get the remaining tobacco out of them, and he/she did not believe it was a safety hazard; -At 9:49 A.M., there was a cigarette smoke odor in Resident #4's room; and CNA D said Resident #4 smoked in his/her room; -At 9:52 A.M., CNA D said Resident #111 smoked in his/her room in the past, and at the time of the observation of his/her room, Resident #111 said he/she had not smoked in his/her room before; -At 9:55 A.M., there was a 12 ounce plastic container full of cigarette butts stored in Resident #112's room; the Administrative Assistant said he/she did not know that residents stored the cigarette butts in an unsafe manner and he/she did not believe that these unsafe practices occurred until he/she saw them for himself/herself; and CNA D said staff spoke to the resident many times regarding the storage of cigarette butts; -At 9:57 A.M., cigarette butts were in two ash trays of unsafe design in Residents#113's and #114's room. During and interview on 9/9/15 at 9:57 A.M.: -Resident #113 said he/she did not smoke in the room but smoked outside, and Resident #114 said he/she only smoked outside; -Resident #113 said he/she saved the cigarette butts in a bag of tobacco that he/she has loose tobacco in, but he/she understood why cigarette butts had to be discarded properly. During an interview on 9/9/15 at 10:07 A.M., CNA D and the SSD said: -Some residents who have their own money get cigarettes on their own; -The staff with longer tenure have been educated about the dangers of residents having and using cigarettes and related articles in their rooms; -Newer staff needed to be informed of cigarette related issues; -CNA D said all residents who smoke have been informed of the rules; -The SSD said that residents who get caught smoking in their rooms have their cigarettes and lighters placed at the nurse's station, and residents do not have to sign a written warning. During an interview on 9/9/15 at 10:18 A.M., LPN B said he/she was not informed of which residents have a tendency to smoke in their rooms. 3. Observation and interview on 9/9/15 at 2:18 P.M., showed: -The cigarette smoke was smelled from Resident #115's room; -At 2:21 P.M., LPN C was notified and he/she went to the room to investigate; -Resident #115 said to the LPN said that he/she was not smoking; and in response, LPN C said he/she was not nose-blind and that he/she smelled smoke. During an interview on 9/11/15 at 3:49 P.M., Resident #115 said: -Resident #117 was in the room on 9/10/15 and smoked in the room; -Resident #115 said he/she did not remember if his/her roommate (Resident #20), who used an oxygen concentrator, was in the room when Resident #117 smoked in the room. During an interview on 9/11/15 at 3:55 P.M., Resident #117 said: -He/she does not smoke in his/her room; -He/she did not smoke in Resident #115's room; -Resident #115 lit the cigarette on the afternoon of 9/9/15 just before LPN C walked into the room. During an interview on 9/14/15 at 9:31 A.M., Resident #20 (Resident #115's roommate) said: -He/she uses an oxygen concentrator continuously due to his/her [DIAGNOSES REDACTED].>-There are times when his/her roommate smoked in the room while he/she used the oxygen concentrator. Observations from 9/8/15 through 9/15/15, showed a No smoking, Oxygen in use sign posted in the facility. During a phone interview on 9/21/15 at 3:00 P.M., LPN C said the following: -In the past Resident #107 had a guest who smoked in his/her room; -That guest was banned from the facility because the guest would not comply with the rules of no smoking in resident rooms; -On 9/9/15, when he/she went into Resident #115's room, there was a smoky haze present in the room; -Resident #115 told him/her that he/she smoked in the room at that time; -It bothered him/her from a safety standpoint when residents smoked in their rooms; -In four years, he/she never saw staff take any measure against residents if they smoked in their rooms. During an interview on 9/14/15 at 11:41 A.M., Registered Nurse (RN) B said: -Residents are given a verbal warning if staff catch them smoking in their rooms; -He/she is not sure how many times a resident has to get caught smoking in his/her room before a discharge procedure takes place; -If a residents is caught smoking in his/her room, then the Administrator should be notified; -He/she heard that Resident #115 smoked in his/her room before. During an interview on 9/14/15 at 12:52 P.M., the Administrator said: -He/she has to be informed of which residents smoke in their rooms by facility staff; -He/she informs the representative from a security consulting company about those residents so that the representative can speak with those residents about local ordinances and the possible consequences; -He/she will start discharge procedures for those residents on an individual basis; -Staff have not informed him/her of different incidences of smoking. 4. Observations with the Maintenance Director on 9/8/15, showed: -At 1:18 P.M., a self-closing ash tray in the first floor smoke room, that had no handle to open the lids for the ashes; -At 3:47 P.M., cigarette butts and ashes inside a trash container in the second floor smoke room. Observations and interview with the Maintenance Director on 9/9/15 from 8:34 A.M. through 8:44 A.M., showed: -One resident smoked on the front porch and five cigarette butts were on the ground; -The Maintenance Director said there used to be ash trays, but some residents placed paper in the ash trays; -Cigarette butts mixed with an empty cigarette pack in the ash try at the resident smoking area close to the parking lot; -No ash tray at the employee smoking area outside the kitchen. During an interview on 9/15/15 at 2:10 P.M., the Administrator said the following: -He/she did not have an exact number of completed smoking assessments but knew it was less than half; -That task was delegated to the previous Director of Nursing (DON) prior to 9/11/15; -That DON did not do any follow-up. 5. Observations on 9/8/15 at 3:29 P.M. and 9/11/15 at 2:47 P.M., showed an area of tile that was eight and one-fourth inches in size that was missing from the floor in the corridor outside resident room 209 and was a tripping hazard. During an interview on 9/11/15 at 2:48 P.M., the Maintenance Director said the tile outside resident room 209 has been missing for about two to three weeks. 6. Record review of Resident #103's Resident Admission Information sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Hypertension (HTN); -Peripheral Neuropathy (nerves to the extremities that are damaged or do not work properly); -Bipolar Disorder; -Diabetic Neuropathy. Record review of the resident's September 2015 Physician's Order Sheet (POS) and Medication Administration Record (MAR), showed physician's orders for the following medications: [REDACTED] -Citalopram 20 milligrams (mg) daily for depression; -Fiber-lax 625 mg two tablets daily for supplement; -Lasix 40 mg daily for hypertension; -Neurontin 300 mg three times daily for neuropathy; -Invokana 100 mg by mouth with breakfast for diabetes; -Januvia 100 mg by mouth daily for diabetes; -KCl (potassium) 20 milliequivalent (mEq) two tablets daily for potassium depletion; -Losartan 50 mg by mouth daily for hypertension; -Metformin 1000 mg by mouth twice daily for diabetes; -Metoprolol 25 mg by mouth twice daily for hypertension; -Oxycarbazepine 300 mg twice daily before meals for seizures; -Simvastatin 20 mg at bedtime for high cholesterol; -Tylenol 325 mg two tabs every six hours as needed for pain or fever; -Hydroxyzine 50 mg one tab four times daily as needed for itching; -Loperamide 2 mg two tabs after first loose stool then one tab every four hours as needed; -Prochlorperazine 10 mg, take one tab every eight hours as needed for nausea or vomiting. Observation on 9/8/15 at 11:53 A.M., showed a medication cup that contained two pills on the nightstand next to the resident's bed. One of the medications was white and another was an oval, beige colored medication. Observation on 9/10/15 at 6:28 A.M., showed CMT B: -Opened the top drawer of his/her medication cart, which contained three double-stacked, unmarked, paper medication cups; -CMT B removed top cup of the double-stacked, unmarked medication cups from the top drawer of the medication cart. The bottom cup contained an unidentified oval beige tablet; -CMT B identified the medication in the medication cup as Oxycarbazepine; -CMT B delivered the paper medication cup to Resident #103 for administration. Prior to the resident taking the medication, CMT B dropped the medication tablet in the trash; -At 6:40 A.M., CMT B returned to the medication cart and withdrew the resident's Oxycarbazepine 300 mg tablet from the resident's medication card; -CMT B did not lock the medication cart after replacing the resident's medication card in the medication cart; -CMT B left the medication cart unlocked and unattended to enter the resident's room to administer the medication to the resident; -The medication cart remained unlocked and unattended as CMT B performed blood sugar testing from 6:28 A.M. until 6:46 A.M.; -CMT B did not remove the trash can liner with the discarded medication when he/she left the resident's room. 7. Record review of Resident #125's Resident Admission Information Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -[DIAGNOSES REDACTED] (below normal function of the thyroid gland which regulated metabolism). Record review of the resident's POS and MAR, dated September 2015, showed a physician's order for Levothyroxine 50 micrograms (mcg) by mouth daily for [DIAGNOSES REDACTED] scheduled to be administered at 9:00 A.M. Observation on 9/10/15 at 6:52 A.M., showed CMT B: -Opened the top drawer of his/her medication cart, which contained three double-stacked, unmarked, paper medication cups; -CMT B removed top cup of the double-stacked, unmarked medication cups from the top drawer of the medication cart. The bottom cup contained an unidentified oval white tablet. During an interview on 9/10/15 at 7:03 A.M., CMT B said: -He/she prepares his/her morning medications at 3:00 A.M. by removing the medication from the medication card, placing the medication in a medication cup and covering the medication with another medication cup, then places the medications in his/her medication cart to be administered later in the morning; -He/she did this every shift to save time during morning medication pass; -He/she knew which medication cup belonged to which resident; -The medication cart should be locked at all times and should not be left unlocked and unattended; -He/she would wait for the resident to take the medication before leaving and would not leave the medication cup with the medication in the resident's room unattended; -He/she should have removed the trash can liner with the discarded medication when he/she left the resident's room. 8. Record review of Resident #12's Resident Admission Information sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Depression; -Diabetes; -Psychosis; -Anxiety. Record review of the resident's Hospital Discharge History and Physical, dated 10/27/14, showed: -The resident expressed suicidal ideation with a plan; -The resident reported to the hospital staff he/she would commit suicide by injecting 100 units of insulin in both his/her arms and would have a painless, silent death. Record review of the resident's Anxiety Care Plan dated 11/7/14 and updated on 2/6/15, 5/8/15, and 8/6/15 showed: -Encourage the resident to verbalize feelings. -Give positive feedback. -Offer diversional activities to redirect away from anxiety. -Make sure the resident takes his/her medications as ordered. -Report any changes to the resident's physician. Record review of the resident's Mood Care plan dated 11/7/14 and updated on 2/6/15, 5/8/15, and 8/6/15 showed: -He/she had a history of [REDACTED]. -Inform the staff about this care plan and the resident's behavior. -Assign a staff to monitor when this resident is in public places or common areas in the facility or around others. -Consult the resident's physician for medication evaluation if needed. Record review of the resident's admission MDS, dated [DATE], and quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact. -Ale to understand others and was understood by others. -Had no verbal or physical behaviors. -Reported feeling down, depressed, or hopeless several days during the assessment period. -Reported he/she did not have thoughts he/she would be better off dead or of hurting himself/herself in some way in the last two weeks. -admitted to the facility after making suicidal statements with a plan less than two weeks prior to the end of the assessment period. Record review of the resident's Nurses Notes,dated 3/14/15 - 9/14/15,showed staff documented: -On 4/2/15, the resident called the police reporting to be suicidal. He/she was taken by ambulance to an outside treatment facility. -On 4/9/15, the resident had a strong odor of alcohol and admitted to the staff he/she had been drinking alcohol. -On 4/20/15, the resident reported having suicidal thoughts to the staff. He/she was transferred to an outside treatment facility by ambulance. -On 4/22/15, the resident returned to the facility by a stranger after the resident reported to the stranger he/she could not find his/her way back to the facility. The resident had a strong alcohol odor. The resident was later found to be cursing at another resident and threatened the other resident. The police were called and after the resident became verbally abusive to the police officers was told he/she would be arrested and taken to jail if he/she did not calm down. The resident went to his/her room and complied with the police officers' request. -On 4/23/15, the resident threatened the facility staff in front of other residents and began roaring like a lion. Staff called 911 and the resident was transferred to the emergency room . The resident was intoxicated. -On 4/30/15, a local hospital called the facility to inform the staff the resident checked into the emergency room after becoming intoxicated and being in a physical altercation. The resident was described as beat up with a black eye. -On 7/13/15, another resident found Resident #12 outside the facility passed out by the dumpsters. The resident smelled strongly of alcohol and was transported to the emergency room . -On 7/21/15, other residents reported Resident #12 was belligerent to other residents in the first floor smoking area on 7/20/15. The resident was intoxicated and smelled of alcohol. Record review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Able to understand others and was understood by others; -Reported feeling down, depressed, or hopeless almost daily during the assessment period. Record review of the resident's Behavioral Health notes, dated 8/18/15, showed: -Facility staff referred the resident to behavioral health services for alcoholism. -Recommendation for the staff to encourage the resident with socialization. -The resident was very defensive about his/her problem areas. -The initial treatment plan included the resident refraining from alcohol use. -The resident denied suicidal ideation at that time. Record review of the resident's Assessment for Self-Administration of Insulin, dated 8/29/15, showed staff answered the question has the resident demonstrated harmful behaviors to himself/herself, and cannot self-administer a glucometer check with or without assistance by circling no. Record review of the resident's September 2015 POS and MAR showed: -Seroquel 300 mg at bedtime for schizophrenia; -Seroquel 50 mg every four hours as needed for agitation and/or anxiety; -Buspar 15 mg three times daily for anxiety. Record review of the resident's POS, dated September 2015, showed: -A physician's order for Novolog (a fast acting insulin) nine units subcutaneously (under the skin) before meals for diabetes; -No physician's order to self-administer his/her insulin. Record review of the resident's active medical record showed no behavior monitoring sheets. Additionally, staff could not locate any behavioral monitoring sheets. Observation on 9/10/15 at 11:45 A.M., showed: -The resident received a Novolog Insulin pen from LPN A; -The resident entered the shower room with the insulin pen alone; -The resident exited the shower room at 11:46 A.M. with the insulin pen, and returned the insulin pen to LPN A. During an interview on 9/8/15 at 9:10 A.M., Supplemental Resident #128 said: -Resident #12 often gets intoxicated and curses at the residents in the facility. -Resident #12 will become loud and yell when he/she returns to the facility intoxicated. -Resident #12 will threaten some other residents in the facility, however he/she has not threatened him/her. -He/she feels intimidated by Resident #12 due to his/her behaviors when he/she is intoxicated. -He/she has not reported to the facility he/she feels intimidated by the resident. During an interview on 9/8/15 at 10:00 A.M., Supplemental Resident #129 said: -Resident #12 often gets intoxicated and curses at the residents in the facility. -Resident #12 will threaten some other residents in the facility, however he/she has not threatened him/her. -He/she feels intimidated by Resident #12 due to his/her behaviors when he/she is intoxicated. -He/she has not reported to the facility he/she feels intimidated by the resident. During an interview on 9/8/15 at 10:30 A.M., the Administrator said: -Resident #12 has a history of leaving the facility and drinking alcohol. -The resident is his/her own responsible party. -Staff counseled the resident regarding his/her behaviors. -No other residents have reported feeling threatened or intimidated by Resident #12. During an interview on 9/9/15 at 1:25 P.M., Supplemental Resident #116 said: -Resident #12 often gets intoxicated and curses at the residents in the facility. -Resident #12 can be intimidating and threatening to other residents, however he/she has not acted that way towards him/her. -He/she feels intimidated by Resident #12 when Resident #12 is intoxicated. -He/she cannot remember if he/she has reported to the staff the way the resident makes him/her feel when the resident is intoxicated. During an interview on 9/15/15 at 9:50 A.M., LPN A said: -A resident with a past history of suicidal ideation with a plan to overdose on insulin should not be considered safe to self-administer insulin without a staff member to watch him/her at all times during the administration process; -He/she was unaware the resident had a history of [REDACTED]. -The resident should not have been assessed as safe to self-administer insulin. During an interview on 9/15/15 at 10:00 A.M., Registered Nurse (RN) A said: -Staff document the residents behaviors on the resident's nursing notes. -Staff should document each time the resident has a verbal or physical outbursts. -He/she has not witnessed Resident #12 be verbally or physically abusive to residents or staff. During an interview on 9/15/15 at 10:30 A.M., Licensed Practical Nurse (LPN) A said: -Staff document the residents behaviors on the resident's nursing notes. -Staff should document each time the resident has a verbal or physical outbursts. -He/she has not witnessed Resident #12 be verbally or physically abusive to residents or staff. -He/she has not had any reports from residents of being verbally or physically attacked by the resident nor has any resident reported feeling intimidated by Resident #12. 9. Record review of Resident #113's Resident Admission Information sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the resident's MAR, dated September 2015, showed physician's orders for the following medications: [REDACTED] -Neurontin (generic form of this medication is gabapentin) 600 mg four times daily (no diagnosis); -Hydroxyzine 50 mg by mouth three times daily for anxiety; -Lisinopril 10 mg by mouth daily (no diagnosis); -Quetiapine 300 mg by mouth at bedtime for bipolar; -Calcium 500 mg by mouth three times daily for indigestion. Observations on 9/9/15 at 8:25 and 9/9/15 at 9:57 A.M., showed a bottle labeled with gabapentin (used to treat pain and seizures) on top of the climate control unit next to Resident #113's bed. During an interview on 9/15/15 at 11:00 A.M., LPN C said: -The resident should not have medications in his/her room, and he/she was not assessed as being able to self-administer medications; -Rooms were checked periodically for medication bottles, but the facility cannot always control when a resident goes out to multiple physicians and obtains prescriptions from another source without telling the facility; -The resident did not have a physician's order to self-administer any medications. 10. During an interview on 9/15/15 at 9:30 A.M., RN A said: -Medications should not be pre-set in medication cups sitting in the medication cart prior to administration; -The medication cart should be locked at all times and should not be left unlocked and unattended; -Medications should not be discarded in the resident's trash. If a medication is accidentally thrown away in the resident trash can, the staff should remove the trash can liner when he/she exits the room; -A resident with a past history of suicidal ideation with a plan to overdose on insulin should not be considered safe to self-administer insulin without a staff member to watch him/her at all times during the administration process; -Staff

Based on observation, interview, and record review, facility staff failed to accurately assess a resident for pressure ulcer risk, failed to accurately document and monitor pressure ulcers, failed to notify the physician of a delay in treatment initiation, and failed to develop and implement interventions to prevent and treat pressure ulcers for one dependent sampled resident (Resident #1) out of 18 sampled residents. The facility's census was 86 residents. 1. Record review of Resident #1's admission Face Sheet showed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] ([MEDICAL CONDITION] - a disease process that decreases the ability of the lungs to perform ventilation); -High blood pressure; -[MEDICAL CONDITION] (the presence in the blood of an abnormally high concentration of fats or lipids in the blood); -Right [MEDICAL CONDITION]; -History of [MEDICAL CONDITION]. Record review of the resident's medical record from [DATE] showed the resident was admitted to the facility on [DATE] for post-surgical rehabilitation. Additionally, staff did not document they completed an admission assessment or a licensed nurse skin assessment upon admission. Further review of the resident's medical record showed the resident's physician did not complete a History and Physical or document a progress note. Record review of the resident's admission physician's orders [REDACTED]. Record review of the resident's nurse's notes, dated [DATE], showed staff documented the resident was admitted with complaints of pain to his/her right hip and leg, was continent of bladder and bowel, able to propel him/herself in the wheelchair, and weighed 90 pounds. Record review of the resident's Braden Scale for predicting pressure ulcer risk, dated [DATE], showed staff assessed the resident at low risk for developing pressure ulcers. Record review of the resident's nurse's notes on [DATE], showed he/she propelled himself/herself to the store and back in his/her wheelchair. Record review of the resident's Shower Review, dated [DATE], showed the resident did not have any open areas to his/her skin. The charge nurse signed the sheet. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated [DATE], showed staff assessed the resident as: -Moderately impaired cognitive skills for daily decision-making; -Totally dependent on facility staff for transfers, locomotion on and off the unit, personal hygiene, and bathing; -Required extensive assistance of facility staff for toileting; -Had impaired functional limitation in Range of Motion (ROM) to both lower extremities; -Was not at risk for developing pressure ulcers; -Did not have pressure ulcers; -Continent of bladder and occasionally incontinent of bowel; -Did not receive hospice care. Record review of the resident's Monthly Summary documented by the Certified Medication Technician (CMT), dated [DATE], showed staff documented the resident's skin was dry with no fragile, broken, decubitus (pressure sore/pressure ulcer) or abrasion (a wound consisting of superficial damage to the skin, such as a scrape that generally does not scar or bleed) areas and had good muscle tone. Record review of the resident's Braden Scale for predicting pressure ulcer risk, dated [DATE], showed staff assessed the resident at low risk for developing pressure ulcers. Record review of the resident's POS, dated [DATE], showed the resident's physician directed staff to: -Cleanse area to the resident's right shoulder with normal saline (salt water), apply Santyl (an ointment used for the debridement of pressure ulcers) ointment then Vaseline gauze (Fine mesh, absorbent gauze impregnated with white petroleum), cover with a dry dressing. Change daily and PRN (as needed). Record review of the resident's nurse's notes, dated [DATE] at 1:00 P.M., showed the resident was seen by the wound care team with wound care orders to his/her right shoulder wound. Record review of the resident's Wound Report, dated [DATE], showed a new Stage III pressure ulcer (full thickness skin loss, exposing the subcutaneous tissues and presents as a deep crater with or without undermining adjacent tissues) to the resident's right shoulder measuring 2.0 centimeters (cm) long x 1.5 cm wide x 0.1 cm deep. Record review of the resident's [DATE] Treatment Administration Record (TAR) showed: -A physician's orders [REDACTED]. -Staff did not document this treatment was started until [DATE]. -Staff did not document they administered the dressing change on [DATE] and [DATE]. Record review of the resident's nurse's notes, dated [DATE] on the 7:00 A.M. to 3:00 P.M. shift, showed staff documented the resident had another pressure ulcer on his/her left buttock. Record review of the resident's nurse's notes, dated [DATE] at 1:03 P.M., showed staff documented the resident: -Had health deterioration issues; -Was unable to care for himself/herself; -Had a pressure ulcer on his/her shoulder and buttock; -Had difficulty propelling himself/herself in his/her wheelchair; -Had a poor appetite; -Was unable to sit up erect due to contractures. Record review of the resident's POS, dated [DATE], showed the resident's physician directed staff to admit the resident to hospice care with a [DIAGNOSES REDACTED]. Record review of the resident's Shower Review, dated [DATE], showed staff documented the resident had an open area to his/her right shoulder and left ischium. The charge nurse signed the sheet and left the nursing assessment and interventions areas blank. Record review of the resident's Wound Report, dated [DATE], showed: -The Stage III pressure ulcer to the resident's right shoulder was not healed, the wound deteriorated and measured 2.0 cm long x 2.9 cm wide x 0.1 cm deep; - A new unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to the resident's right ischium that measured 2.1 cm long x 1.8 cm wide x 0.1 cm deep. Record review of the resident's significant change in status MDS, dated [DATE], showed staff assessed the resident as: -Moderately impaired cognitive skills for daily decision-making; -Totally dependent on facility staff for transfers, locomotion on and off the unit, personal hygiene, and bathing; -Required extensive assistance of facility staff for toileting; -Had impaired functional limitation in ROM to both lower extremities; -Was not at risk for developing pressure ulcers; -Did not have pressure ulcers; -Occasionally incontinent of bowel and bladder; -Received hospice care. Record review of the resident's Comprehensive Care Plan, dated [DATE], showed staff did not develop a pressure ulcer care plan for the resident. Record review of the resident's TAR, dated [DATE], showed staff documented: -A physician's orders [REDACTED]. -Staff documented they started the treatment on [DATE] (three days later). -Staff did not document they administered the dressing change on [DATE]. During an interview on [DATE] at 9:50 A.M., Licensed Practical Nurse (LPN) D said the reason the treatment to the resident's right ischium was not done from [DATE] to [DATE] was because hospice did not deliver the supplies. LPN D said he/she did not notify the resident's physician the treatment was not administered from [DATE] to [DATE]. Record review of the resident's Wound Report, dated [DATE], showed: -The Stage III pressure ulcer to the resident's right shoulder was not healed and measured 1.9 cm long x 2.5 cm wide x 1.0 cm deep (0.9 cm deeper than last measured on [DATE]); - The unstageable pressure ulcer to the resident's right ischium was not healed and measured 2.5 cm long x 2.5 cm wide x 0.1 cm deep (0.4 cm longer and 0.7 cm wider than last measured). Record review of the resident's POS, dated [DATE], showed the resident's physician directed staff to change the resident's treatment order to: -Cleanse area on right sacrum and hip with normal saline, apply Santyl ointment and Vaseline gauze, cover with a dry dressing, and change daily. Record review of the resident's [DATE] TAR showed: -A physician's orders [REDACTED]. -Staff documented the order was initiated on [DATE]. -Staff did not document they turned the resident the entire month. Record review of the resident's Hospice Report, dated [DATE], showed hospice staff documented the resident as: -Impaired skin integrity; -A wound to the right shoulder and ischium; -Redness to the resident's right hip; -Weight loss; -Decrease in appetite; -Increased fatigue; -Increased depression; -Warm, dry, pale skin; -Required extensive assistance with self-cares; -Required extensive assistance with positioning, transfers, and mobility; -Joint deformity; -Sat in his/her wheelchair leaned over to the right side; -Was unable to hold his/her head up; -Contractures to the neck and both lower extremities. Record review of the resident's Hospice Skin Issue form, dated [DATE], showed the hospice aide documented the resident had a wound to his/her right hip and bandaged areas on the right shoulder and ischium. Record review of the resident's Wound Report, dated [DATE], showed the wound physician documented: -The Stage III pressure ulcer to the resident's right shoulder was not healed and measured 1.6 cm long x 1.9 cm wide x 0.1 cm deep; - The unstageable pressure ulcer to the resident's right ischium was not healed and measured 2.6 cm long x 2.4 cm wide x 0.1 cm deep (0.1 cm longer than the last measurement on [DATE]); - A new unstageable pressure ulcer to the resident's right lateral (outer) hip measured 1.5 cm long x 1.6 cm wide x 0.1 cm deep. Record review of the resident's TAR, dated [DATE], showed: -Staff did not document they administered the dressing change (cleanse area on the right sacrum and hip, apply Santyl ointment and Vaseline gauze, and cover with a dry dressing) on [DATE] and [DATE]. Record review of the resident's Shower Review, dated [DATE], showed he/she had a healing open area to his/her right shoulder and open areas to his/her right hip and right ischium. The charge nurse signed the sheet and left the nursing assessment and interventions areas blank. Record review of the resident's nurse's notes, dated [DATE] at 2:00 P.M., showed his/her sacrum and hip areas are getting more open. Record review of the resident's Wound Report, dated [DATE], showed the wound physician did not document: -Wound status or measurements to the Stage III pressure ulcer to the resident's right shoulder; - Wound status or measurements to the unstageable pressure ulcer to the resident's right ischium; - Wound status or measurements to the unstageable pressure ulcer to the resident's right lateral hip. Record review of the resident's nurse's notes, dated [DATE] at 2:30 P.M., showed staff documented the resident: -Remained in bed during the shift; -Was barely able to get up for meals; -Had to be fed by staff; -Had a decline in his/her condition since admission. Record review of the resident's Hospice Skin Issue form, dated [DATE], showed the hospice aide documented the resident had: -Open areas to his/her right shoulder, right hip, right ischium and right ankle; -Red areas to his/her left and right mid back. Record review of the resident's Monthly Summary, dated [DATE], showed staff documented the resident's skin was dry with no fragile, broken, decubitus or abrasion areas and had good muscle tone. Record review of the resident's nurse's notes, dated [DATE] at 2:28 P.M., showed the resident's wound on his/her right hip was soaked with purulent drainage (contained pus). Record review of the resident's Wound Report, dated [DATE], showed the wound physician documented: -The Stage III pressure ulcer to the resident's right shoulder healed; - The unstageable pressure ulcer to the resident's right ischium was not healed and measured 2.0 cm long x 2.7 cm wide x 0.1 cm deep (0.3 cm wider than the last measurement on [DATE]); -The unstageable pressure ulcer to the resident's right lateral hip measured 2.9 cm long x 4.7 cm wide x 0.1 cm deep (0.9 cm longer and 2.3 cm wider than the last measurement on [DATE]). Record review of the resident's nurse's notes, dated [DATE] at 12:58 P.M., showed staff documented the resident refused breakfast and lunch and appeared dehydrated. Record review of the resident's nurse's notes, dated [DATE] at 2:00 P.M., showed staff documented the resident had wounds on his/her right ischium and right hip. A small amount of drainage was noted. Record review of the resident's nurse's notes, dated [DATE] at 2:00 P.M., showed the resident's wounds on his/her right ischium and right hip had brown drainage. Record review of the resident's Monthly Vital Sign Record showed staff documented the resident weighed 90 pounds upon admission, and his/her weight on [DATE] was 83.4 pounds. Record review of the resident's nurse's notes, dated [DATE] at 10:00 A.M., showed staff documented the wound team was in the facility to see the resident and noted the resident's hip surgery site was inflamed and discharging serous drainage. A new physician's orders [REDACTED]. Record review of the resident's Wound Report, dated [DATE], showed the wound physician documented: - The unstageable pressure ulcer to the resident's right ischium was not healed and measured 1.8 cm long x 1.6 cm wide x 0.1 cm deep; -The unstageable pressure ulcer to the resident's right lateral hip was not healed, measured 4.8 cm long x 6.5 cm wide x 0.1 cm deep, and exhibited purulent, sero-sanguineous drainage (containing blood and watery drainage). (The right hip pressure ulcer was 1.9 cm longer and 1.8 cm wider than the last measurement on [DATE] and exhibited the signs and symptoms of infection to the pressure ulcer). Record review of the resident's POS, dated [DATE], showed a new physician's orders [REDACTED].>-Cleanse area on right sacrum, apply Santyl ointment and Vaseline gauze, cover with a dry dressing, change daily and PRN; -Cleanse area to right hip with normal saline, apply silver alginate (absorbs wound exudate and form a gel-like covering over the wound, maintaining a moist wound environment and provides antimicrobial protection) and cover with an ABD pad, secure with a dry dressing, change daily and PRN. Record review of the resident's [DATE] TAR showed: -A physician's orders [REDACTED]. Staff did not document they administered the dressing change on [DATE] and [DATE]. -A physician's orders [REDACTED]. Staff did not document they administered the dressing change on [DATE] and [DATE]. -Staff did not document they turned the resident from [DATE] through [DATE]; During an interview on [DATE] at 9:50 A.M., LPN D said the wound treatments are not being performed on the weekends. Record review of the resident's nurse's notes, dated [DATE], showed staff documented the resident continued to have a poor appetite and ate 25%-50% of meals. Record review of the resident's Shower Review, dated [DATE], showed staff documented the resident did not have any open areas to his/her skin. The charge nurse signed the sheet. Record review of the resident's nurse's notes, dated [DATE] at 6:00 P.M. to 7:20 P.M., showed staff documented the resident cried out loudly for help with complaints of severe pain to his/her right hip and side. Record review of the resident's nurse's notes, dated [DATE] at 3:00 P.M., showed staff documented the area on the resident's right hip appeared bigger and deeper. Observation on [DATE] at 3:38 P.M., showed: -The resident lay in bed on his/her right side, naked with a single sheet partially covering his/her body; -The resident's right lower extremity was contracted to his/her chest; -A low air loss mattress (LAL) was in use with the air flow setting turned up to the firmest setting available making the bed hard. Observation on [DATE] at 7:58 A.M., showed: -The resident lay on his/her right side horizontally the bed with his/her right lower extremity contracted to his/her chest; -The resident was naked with a single sheet partially covering his/her body; -The resident's LAL mattress air flow setting was set at the firmest setting available, making the bed hard. Observation on [DATE] at 8:35 A.M., showed: -The resident lay on his/her back, leaning to the right side and positioned horizontally in the bed, with his/her right leg contracted to his/her chest; -The resident was naked with a single sheet partially covering the resident. Observation on [DATE] at 1:49 P.M., showed: -The resident lay on his/her back in bed with his/her head on the mattress; -The LAL mattress air flow setting was set at the firmest setting available, making the bed hard. Observation on [DATE] at 2:04 P.M., showed: -LPN D performed wound care on the resident's right ischium and right hip pressure ulcers; -An approximate 6 cm x 6 cm round, unstageable open area with a yellow base and exposed bone to the resident's right hip; -An approximate 2 cm x 2 cm round Stage II pressure ulcer with a yellow and pink base to the resident's right ischium; -The resident's incontinence pad was saturated with a brownish, moist stain. Record review of the resident's Shower Review, dated [DATE], showed the resident had a broken left hip and did not address any open areas to his/her skin. The charge nurse signed the shower sheet. Record review of the resident's nurse's notes, dated [DATE] at 9:20 P.M., showed staff documented: -The resident required total care by staff for ADL's and peri-care; -Had a poor appetite; -Could only sip liquids through a straw with frequent rest periods; -Nails and lips were cyanotic (a bluish color to the skin or mucus membranes that is usually due to a lack of oxygen in the blood). Observation on [DATE] at 6:22 A.M., showed: -The resident lay on his/her back horizontally in bed, leaning to the right side; -The resident's LAL mattress air flow setting was placed on the firmest setting available, making the bed hard. During an interview on [DATE] at 11:45 A.M., Hospice RN A said: -The resident had an open area to his/her right ischium and a reddened area to his/her right hip when hospice services began; -Hospice staff identified the open wound to the resident's right hip and notified the facility staff; -The resident was unable to use the bed side rails for repositioning and turning. Record review of the resident's Hospice Visit Report, dated [DATE], showed: -The resident lay on his/her back horizontally in bed; -The Hospice RN encouraged the facility staff to attempt repositioning; -Hospice will continue visits twice daily. During an interview on [DATE] at 8:10 A.M., LPN D said: -The facility nurses do not perform skin assessments on the residents unless there is a problem; -If there was a skin assessment performed on the resident on admission, it would have been in the chart; -He/she did not perform a skin assessment on the resident because the wound clinic and hospice were following his/her wounds. During an interview on [DATE] at 10:20 A.M., LPN D said: -He/she believed the CNA notified him/her in timely manner that the resident had a wound to his/her right hip; -He/she did not consider the wound to be open because the skin was just broken some. -The resident should have been identified as a high risk for pressure ulcers because he/she was wheelchair bound with contractures; -A skin assessment and Braden Scale assessment should have found the resident at risk for pressure ulcers, and that information should have been included in the resident's MDS and Care Plan; -The resident should have been repositioned every two hours but he/she liked to lay on his/her right side; -A resident with contractures should have been positioned so there was no extra weight on the contractures; -Hospice provided a high back chair because the resident could not hold his/her head up; -Hospice provided a low air loss mattress after the resident developed pressure ulcers; -The doctor should have been notified of any interventions that did not work and new orders should have been received. Observation on [DATE] at 8:27 A.M., showed: -The resident lay in bed on his/her right side, naked with a single sheet covering him/her; -LAL mattress setting was placed on the firmest setting possible, making the bed hard; -Had a dressing to his buttocks/sacrum area. During an interview on [DATE] at 9:15 A.M., the resident's Wound Doctor said: -The resident's pressure ulcers were unavoidable due to the resident's contractures and declined health; -The resident would need to be placed on a rotisserie and turned constantly to avoid pressure ulcers; -The right hip wound became infected and developed a huge abscess a few weeks ago; -The right hip pressure ulcer exhibited undermining when the abscess opened up; -The measurements for the right hip pressure ulcer at that time were 6.5 cm long x 5.3 cm wide x 0.6 cm deep with undermining measuring 12 cm x 12cm x .3 cm (1.7 cm longer and 0.5 cm deeper than the last measurement on [DATE] and new undermining of the wound); -The measurements for the right ischium at that time were 1.9 cm long x 1.2 cm wide x 1.2 cm deep (0.1 cm longer and 1.1 cm deeper than the last measurement on [DATE].). During an interview on [DATE] at 11:35 A.M., the Assistant Director of Nursing (ADON) said: -Licensed Nurses only performs skin assessments on admission and as needed based on any skin issues; -Licensed Nurses do not perform weekly skin assessments; -CNA's record skin assessments two times a week on the resident's bath sheets; -All nursing skin assessments should be found in the resident's chart; -Any and all changes in condition should be placed on the resident's Care Plan; -Declines in condition should prompt assessments to be updated. Record review of the resident's medical record from [DATE] through [DATE] showed: -The staff did not document the description of the resident's pressure ulcers after each dressing change; -Staff did not complete a Braden Scale assessment after the resident developed a pressure ulcer. Record review of the resident's nurses notes, dated [DATE], showed the resident died at 1:06 A.M. During an interview on [DATE] at 9:41 A.M., CNA A said the resident: -Was too weak to use the side rails to reposition or turn him/herself for the last two weeks or so; -Was supposed to be turned every two hours but preferred lying on his/her right side; -Could no longer lift his/her head or move his/her arms around; -Could no longer use a urinal and was totally incontinent. During an interview on [DATE] at 9:50 A.M., LPN D said: -The resident's physician should have been notified when the resident only wanted to lay on his/her right side. During an interview on [DATE] at 1:30 P.M., the ADON said: -The resident's Care Plan should have been updated to with the resident's pressure ulcers, and staff should have developed and implemented interventions; -He/she was responsible for updating Care Plans; -The MDS should have accurately reflected the resident's condition; -Care Plans should be updated as changes in condition occur. During an interview on [DATE] at 2:03 P.M., the Administrator said: -He/she expected contractures and declines in health to be addressed and interventions to maintain skin integrity to be implemented; -He/she expected skin assessments to be completed on admission and any time there is a decline in condition; -He/she expected the wound dressings to be changed daily per physician's orders [REDACTED].>-He/she was not aware the weekend staff did not perform wound care on the weekends; -He/she expected the Braden Scale to accurately reflect the resident's risk for skin breakdown; -He/she expected the MDS and the Care Plans to accurately reflect the resident's condition; -He/she expected the CNA's to accurately document skin condition on the bath sheets; -When a licensed nurse signs off on a bath sheet, he/she is signing that the resident was bathed, their skin was assessed and all information is correct; -He/she expected the licensed nurses to document wound appearance and any drainage noted in the nurse's notes with each dressing change; -He/she expected all staff members to report any skin issues prior to the appearance of an open wound; -He/she expected the staff to document when they reposition the residents, was not sure where the staff should document it, but it should be documented; -He/she expected the staff to identify and report skin issues to the licensed nurses in a timely manner; -He/she expected the resident's Monthly Summaries to be accurate and including any skin issues and any pressure ulcers; -He/she was not sure who should be completing the Monthly Summaries.