Every finding on record at Claru Deville Nursing Center

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program committee met at least quarterly with the required members present. This had the potential to affect all residents by limiting the facility's ability to identify and address quality of care and safety concerns. The facility's census was 67. Review of the facility's policy titled, Quality Assessment and Assurance (QAA), reviewed 01/26/26, showed:- This facility is committed to ensuring high-quality care and continuous improvement in resident outcomes through a structured QAA program. The QAA committee will oversee and support quality improvement efforts by identifying, analyzing, and addressing concerns related to clinical care, resident safety, and regulatory compliance;- The QAA committee shall include at a minimum, the Administrator, the Director of Nursing (DON) Services, the Medical Director or their designee, the Infection Preventionist (IP), and at least two other facility staff members;- The policy did not address the minimum frequency of meetings.Review of the facility's QAPI meeting documentation, provided by the Administrator, showed:- A QAPI meeting was held on 03/03/25, 04/07/25, and 05/05/25; - A Monthly QA Infection Control meeting was held on 10/29/25 with no documentation of the Medical Director, DON, or IP attending;- QAPI checklists for November 2025 completed with no documentation of the Medical Director, DON, or IP involvement;- QAPI checklists for December 2025 completed with no documentation of the Medical Director, DON, or IP involvement;- A QAPI meeting was held on 03/26/26 with no documentation of the Medical Director attending; - No documentation the QAPI program was implemented on a consistent and ongoing basis during this time period. During an interview on 04/24/26 at 10:30 A.M., the Administrator said she has the department heads fill out the QAPI checklists and they go over them. The regional nurse filled in as DON since she started in September, but the regional nurse did not attend the QAPI meetings. The facility went without a DON for a while. They had an Assistant Director of Nursing (ADON) for a while. The current DON started on 12/01/25 and finished IP training on 12/17/25. There was no IP before the current DON completed her training. She was just getting ready to start having meetings with the Medical Director present. The current Medical Director took over on 08/01/25.During an interview on 04/24/26 at 2:45 P.M., the Administrator said she would expect to have an ongoing QAPI program with an updated plan and meetings to be held at least quarterly with the required members present.

Based on observation, interview, and record review, the facility failed to demonstrate measures used to minimize the risk of Legionella (a bacteria naturally found in freshwater that can cause serious lung infections, most common Legionnaires' disease, which is a severe form of pneumonia) and other opportunistic pathogens in the building water system, by not providing a documented water management program. This deficient practice had the potential to affect all residents, staff and visitors. The facility's census was 67. Review of the facility's policy titled, Guideline to Develop a Water Management Program to Reduce Legionella Growth, undated, showed:- Purpose of guideline is to aid the facility in creating a site-specific water management system to reduce Legionella growth in the facility;- The facility will create a Water Management Committee which will consist of at least the Administrator, Director of Nursing, and the Maintenance Director;- The facility will conduct a facility risk assessment on an annual basis to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the water system.Observation on 04/21/26 at 9:30 A.M., showed the hot water turned off on the 200 Hall.During an interview on 04/22/26 at 2:50 P.M., the Administrator said the hot water had been out in certain areas, specifically on the 100, 200 and 300 Halls, since 04/16/26, due to waiting on a thermostatic valve to come in. The hot water was turned off to prevent the potential of residents being burned. The facility did not have a policy on what preventative measures to take but had a policy on Legionella. She was unsure what the water temperature range should have been, but believed it had to be below 140 degrees Fahrenheit. She said maintenance usually took care of the temperature checks and he/she had just quit.During an interview on 04/23/26 at 8:45 A.M., the Maintenance staff said he/she just started last week but the hot water had been turned off on the 100, 200 and 300 Halls due to leaking. The laundry, kitchen, 400, 500 and 600 Halls still had hot water. He/She had checked those temperatures. They had moved people around so there weren't many rooms left empty. The Maintenance staff said he/she would be checking temperatures and flushing rooms that were empty today. During an interview on 04/24/26 at 2:45 P.M., the Administrator, Director of Nursing and Registered Nurse Quality Assurance Support said they would expect the facility to have a process in place to prevent Legionella.

Based on interview and record review, the facility failed to demonstrate evidence of maintaining an ongoing effective, comprehensive, data-driven Quality Assurance Performance Improvement (QAPI) program that focuses on indicators of the outcomes of care and quality of life. This had the potential to affect all residents residing in the facility. The facility's census was 67. Review of the facility's policy titled, Quality Assessment and Assurance (QAA), reviewed 01/26/26, showed:- The facility is committed to ensuring high-quality care and continuous improvement in resident outcomes through a structured Quality Assessment and Assurance program. The Quality Measures (QM) committee will oversee and support quality improvement efforts by identifying, analyzing, and addressing concerns related to clinical care, resident safety, and regulatory compliance;- The QM committee is responsible for developing and implementing corrective plans of action, identifying deficiencies in care quality and regulatory compliance, creating and implementing corrective action plans to address identified issues, monitoring the effectiveness of corrective measures and making necessary adjustments, reviewing and analyzing quality data, regularly reviewing facility performance data, including metrics collected under the QAPI program, and analyzing data from drug regimen reviews to identify trends, errors, or adverse effects requiring intervention;- Members are responsible for upholding the standards of the QAPI program and fostering a culture of quality, accountability, and continuous improvement within the facility.Review of the facility's 2024 QAPI Plan showed:- The QAPI committee annually prioritizes activities, endorses or re-endorses policies and procedures, and continually monitors for improvement through the use of a QAPI self-assessment;- Physician oversight, direction, and involvement play an essential role in the QAPI process. The facility's Medical Director is the designated senior practitioner and advisor for all aspects of the QAPI program related to clinical care and safety. The Medical Director is accountable for providing leadership for, and is actively involved in the implementation of the QAPI program;- On a quarterly basis, data will be collected and reported to the QAPI Steering Committee from input from caregivers, residents, families, and others; adverse events; performance indicators; survey findings; and complaints;- The committee will consider and prioritize both external and internal elements affecting the long-term care industry and facility when selecting priorities of focus for the coming year;- A goal of reducing urinary tract infections (UTIs) by 20% by 12/31/25 with proper peri care and increased fluid intake;- No current QAPI Plan or goals.During an interview on 04/24/26 at 10:30 A.M., the Administrator said the regional nurse filled in as the Director of Nursing (DON) since she started in September. The regional nurse did not attend the QAPI meetings. The facility went without a DON for a while, and then they had an Assistant Director of Nursing (ADON) for a while. The current DON started on 12/01/25 and finished the Infection Preventionist training on 12/17/25. There was no IP before the current DON completed her training. She is just getting ready to start having meetings with the physician present. The current Medical Director took over on 08/01/25. She didn't update anything on the 2024 QAPI Plan because the Statement of Deficiencies from the last survey just said continue the plan, so that is what she did. She didn't update goals because she lacked a nurse. During an interview on 04/24/26 at 2:45 P.M., the Administrator said she would expect to have an ongoing QAPI program with an updated plan and goals and meetings to be held at least quarterly with the required members present.

Based on interview and record review, the facility failed to inform residents and/or their representatives, in advance of the risks and benefits of proposed care, before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for four residents (Residents #4, #10, #27, and #46) out of 17 sampled residents. The facility's census was 67. Review of the facility's Management of Psychotropic Medications and Unnecessary Medications policy, dated 04/28/25, showed: - The use of psychotropic medications will be carefully monitored to prevent unnecessary usage and will be prescribed only when clinically indicated, with full consideration of the resident's preferences and rights; - Prior to initiating or increasing a psychotropic medication, the resident or their legal representative will be fully informed of the proposed treatment, including the potential risks, benefits, and alternatives; - The resident will have the right to participate in the decision-making process and to accept or refuse treatment; - Before any psychotropic medication is prescribed or increased, the resident will be informed of their rights regarding treatment, including the right to accept or decline medication; - The facility will ensure the residents are given appropriate information in a manner they can understand, considering cognitive and language differences, and have the opportunity to ask questions; - Documentation of informed consent will be maintained for all psychotropic medications prescribed. 1. Review of Resident #4's medical record showed: - admitted on [DATE]; - Diagnoses of schizoaffective disorder (chronic mental health condition characterized by a combination of schizophrenia symptoms, such as hallucinations or delusions, and major mood disorder symptoms, including mania or depression), generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about every day, routine situations), bipolar disorder (a chronic mental health condition characterized by intense, fluctuating mood shifts), and insomnia (difficulty sleeping). Review of the resident's quarterly Minimum Data Set (MDS - a mandatory assessment completed by the facility), dated 03/26/26, showed: - Severe cognitive impairment; - The resident received antipsychotic (medication used to treat mental health disorders), antianxiety, and antidepressant medication in the seven-day lookback period. Review of the resident's physician order sheet (POS), dated 04/24/26, showed: - An order for lorazepam (anxiety medication), one milligram (mg) tablet three times a day for restlessness and agitation, dated 05/23/24; - An order for risperidone (an antipsychotic), two mg tablet daily for schizoaffective disorder, dated 05/23/24; - An order for trazodone (antidepressant), 150 mg tablet one time a day for insomnia, dated 05/23/24; - An order for haloperidol (an antipsychotic) five mg tablet two times a day for schizoaffective disorder, dated 03/17/26; - An order for Uzedy (an antipsychotic medication) 125 mg/0.35 milliliters (ml) subcutaneously (under the skin), every 24th of the month for schizoaffective disorder, dated 10/24/24. Review of the resident's progress notes showed: - On 03/17/26, a psychotropic consent for Haldol (haloperidol) decrease from 10 mg to five mg; - No psychotropic consents for lorazepam, risperidone, trazodone, or Uzedy. 2. Review of Resident #10's medical record showed: - admitted on [DATE]; - Diagnoses of dementia and other diseases classified elsewhere, unspecified severity with other behavioral disturbances (memory and thinking problems related to another disease process, along with behaviors such as agitation, aggression, wandering, or resistance to care), cerebral infarction, unspecified (a stroke caused by blocked blood flow to part of the brain; the exact type or location is not specified), mild cognitive impairment of uncertain or unknown etiology (mild problems with memory or thinking that are greater than normal aging, but not severe enough to be dementia; the cause is unknown), depression, unspecified (a mood disorder involving sadness, low motivation, or loss of interest, without a more specific type identified). Review of the resident's quarterly MDS, dated [DATE], showed: - Moderately impaired; - The resident received antipsychotic (medication used to treat mental health disorders), medication in the seven-day lookback period. Review of the resident's POS, dated 04/24/26, showed: - An order for Seroquel (an antipsychotic medication) 25 mg four times a day as needed related to restlessness and agitation, dated 12/21/25; - An order for quetiapine (an antipsychotic medication) 50 mg one tablet by mouth at bedtime related to dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, dated 12/21/25. Review of the resident's progress notes showed: - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the Seroquel and quetiapine medications. During an interview on 04/23/26 at 10:35 A.M., Registered Nurse (RN) A said Resident #10 was put on Seroquel when he/she was in the hospital, so she did not do a psychotropic consent for it. RN A said he/she didn't know he/she needed to do them for those situations. RN A thought he/she just had to do them for the residents that were put on them once they arrived to the facility or if the dosage was adjusted. During an interview on 04/24/26 at 8:34 A.M., the Director of Nursing (DON) said when residents were admitted to the facility with a psychotropic medication, they were completing consents. They were only doing them if a resident was put on them while in the facility or if they had a medication change while in the facility. 3. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnoses of bipolar (a chronic mental health condition characterized by intense, fluctuating mood shifts), and anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday, routine situations). Review of the resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - The resident received an antipsychotic and an antidepressant medication in the seven-day lookback period. Review of the resident's POS, dated 04/24/26, showed: - An order for aripiprazole (antipsychotic medication), four mg once a day for bipolar disorder, dated 03/18/26; - An order for escitalopram oxalate (an antidepressant medication), five mg once a day for anxiety, dated 03/18/26. Review of the resident's progress notes showed: - No documentation of psychotropic consents and no documentation that the risks and benefits were provided to the resident and/or their representative for the use of aripiprazole and escitalopram. 4. Review of Resident #46's medical record showed: - admitted on [DATE]; - Diagnoses of bipolar disorder, schizoaffective disorder, major depressive disorder (a serious mental health disorder characterized by persistent, severe sadness, low mood, or loss of interest in activities lasting at least two weeks), anxiety disorder, post-traumatic stress disorder (PTSD - a mental health condition triggered by experiencing or witnessing terrifying events), and borderline personality disorder (a serious mental health condition characterized by long-term instability in emotions, relationships, self-image and behavior). Review of the resident's quarterly MDS, dated [DATE], showed: - Moderately impaired; - The resident received antipsychotic, antianxiety, and antidepressant medications in the seven-day lookback period. Review of the resident's POS, dated 04/24/26, showed: - An order for depakote (a mood stabilizer) 750 mg, twice daily for schizoaffective disorder, dated 04/13/23; - An order for fluoxetine (an antidepressant) 60 mg, once daily for bipolar disorder, dated 04/13/23; - An order for haloperidol 10 mg, three times daily for schizoaffective disorder, dated 07/30/23; - An order for Seroquel 400 mg twice daily for schizoaffective disorder, dated 08/12/25. Review of the resident's progress notes showed: - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for Depakote, Seroquel or haloperidol. During an interview on 04/23/26 at 10:29 A.M., Registered Nurse (RN) A said he/she knew these consents were a new thing. He/She will complete them when there's a medication change, like if they go to the hospital and come back with a new order. Residents don't have consents done when they're admitted because the guardians knew they were already on those meds. During an interview on 04/24/26 at 2:45 P.M., the Administrator and DON said they would expect psychotropic medication consents to be completed for all residents who receive psychotropic medication. During an interview on 04/27/26 at 8:55 A.M., the DON said they were not completing the psychotropic medications consents on all residents with psychotropic medications but will be going forward.

Based on observation and interview, the facility failed to provide a homelike environment by failing to ensure the building was free from odors and adequate reusable dinnerware was available for the residents, which resulted in the use of disposable foam dishware. This affected one resident (Resident #53) out of 17 sampled residents and one resident (Resident #44) outside the sample. This had the potential to affect all residents. The facility's census was 67. The facility did not provide a policy regarding odors or the use of disposable dinnerware. 1. Observations on 04/21/26 at 12:14 P.M., 04/23/26 at 2:50 P.M., and 04/24/26 at 1:04 P.M., of the 600 Hall showed a strong odor of urine. 2. Observation of the test tray on 04/21/26 at 12:00 P.M., showed the tray included a foam bowl containing black-eyed peas. 3. Observation of the noon meal preparation on 04/24/26 at 10:00 A.M., showed a dietary aide placed desserts onto foam plates for the resident meal service. During an interview on 04/24/26 at 10:15 A.M., the Dietary Manager (DM) said the facility used foam plates, bowls, and other disposable dishware because there were not enough reusable supplies available. The facility previously had adequate dinnerware, but over time silverware, plates, cups, and other dinnerware had gone missing. She reported the concern to the Administrator and requested replacement supplies but had not been approved to order additional dishware. Staff had checked the resident rooms for missing items, but supplies had not been recovered. In the meantime, the facility continued using foam to supplement the meal services. During an interview on 04/24/26 at 10:35 A.M., Resident #53 said he/she sometimes received meals on foam plates. The foam plates could break when he/she ate salads, and that caused difficulty during meals. He/She would prefer regular plates and bowls. 4. Observation on 04/24/26 at 1:00 P.M., of the noon meal service in the dining room showed some residents were served their meal on reusable dinnerware, while others were served on foam dinnerware. During an interview on 04/24/26 at 1:00 P.M., Resident #44 said he/she would prefer to eat on regular dinnerware and not foam. During an interview on 04/24/26 at 2:45 P.M., the Administrator said she would expect proper dinnerware to be available to all residents for each meal service and would expect the building to be free from odors.

Based on interview and record review, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to two residents (Residents #10 and #66) out of two sampled residents who were discharged from Medicare Part A services with benefit days remaining and remained in the facility. The facility's census was 67.Review of the Form Instructions: Advance Beneficiary Notice of Non-coverage, dated 2024, showed:- Medicare requires Skilled Nursing Facility to issue the SNF ABN to original Medicare patients prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary or considered custodial;- The SNF ABN provides information to the patient so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility.1. Review of Resident #10's medical record showed:- The resident discharged from Medicare Part A services on 01/05/26;- The resident remained in the facility;- The facility failed to issue a SNF ABN to the resident.2. Review of Resident #66's medical record showed:- The resident discharged from Medicare Part A services on 04/01/26;- The resident remained in the facility;- The facility failed to issue a SNF ABN to the resident. During an interview on 04/23/26 at 2:00 P.M., the Business Office Manager (BOM) said she just does a Notice of Medicare Non-Coverage (NOMNC) when residents discharge from a Medicare Part A stay. She hasn't been doing ABNs for anyone and asked what ABN stood for. During an interview on 04/24/26 at 2:45 P.M., the Administrator and BOM said they would expect a SNF ABN to be issued when a resident's Medicare Part A stay ended and the resident remained in the facility. The BOM said the facility has had so few Medicare Part A stays that she had to ask what an ABN was.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and failed to provide a copy of the bed hold policy upon transfer to the hospital for four residents (Residents #3, #10, #27, and #55) out of 17 sampled residents. The facility also failed to notify the ombudsman (a trained advocate who investigates and resolves complaints made by or on behalf of residents in nursing homes, assisted living, and other residential care facilities) of the transfers. The facility's census was 67.The facility did not provide a policy. 1. Review of Resident #3's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident's representative was informed in writing, of the daily bed hold rate; - No documentation that a notification of transfer was provided to the ombudsman. 2. Review of Resident #10's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on the same day; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the resident's representative was informed in writing of the daily bed hold rate; - No documentation that a notification of transfer was provided to the ombudsman. 3. Review of Resident #27's medical record showed: - The resident transferred to the hospital on [DATE], and as of 04/24/26, had not returned; - A signed bed hold, dated 04/22/26; - No documentation the resident's representative was informed in writing of the daily bed hold rate. - No documentation that a notification of transfer was provided to the ombudsman. 4. Review of Resident #55's medical record showed: - Resident transferred to the hospital on [DATE] and returned to the facility 06/29/25; - No documentation that written notification of the transfer or a copy of the bed hold policy, including daily rate, was provided to the resident and/or the resident's representative at the time of the transfer; - No documentation that a notification of transfer was provided to the ombudsman. During an interview on 04/13/26 at 2:20 P.M., the Ombudsman said the facility had not been submitting their discharge and transfer notices through the new system, but they had received them prior. He/She received notice that they have a new social services person recently. During an interview on 04/24/26 at 12:50 P.M., the Administrator said she has no proof they have sent anything to the ombudsman because the previous social worker got fired for not doing it. They have not begun submitting them with the new process that started at the end of January. During an interview on 04/24/26 at 2:45 P.M., the Administrator said she would expect bed holds to have the bed hold rate included and would expect transfer notices and bed holds to be completed at the time of transfer and submitted to the ombudsman.

Based on observation, interview, and record review, the facility failed to implement care plans with specific interventions to meet individual needs for two residents (Residents #12 and #21) out of 17 sampled residents. The facility's census was 67.Review of the facility's policy, dated 10/01/15, showed it is the policy of the facility to use the most current Center for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS-a standardized comprehensive assessment completed by facility staff) Resident Assessment Instrument (RAI) Manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS, Care Area Assessment (CAAs-investigations triggered by the MDS), and resident care planning. 1. Review of Resident #12's medical record showed: - admission date of 09/01/25; - Diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and triggers may bring back memories, intense emotions and physical reactions). Review of the resident's care plan, revised 02/13/26, showed: - PTSD only mentioned as a diagnosis related to behaviors; - Did not address triggers or interventions on how to care for the resident. 2. Review of Resident #21's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, bipolar disorder (a mental health condition characterized by intense, fluctuating mood shifts ranging from manic highs to depressive lows), and anxiety. Review of the resident's care plan, revised 03/24/26, showed: - Resident had experienced trauma and had diagnoses of PTSD; - Resident may have fear, terror, dread, or helplessness due to traumatic event; - Did not address specific triggers or interventions on how to care for the resident. During an interview on 04/24/26 at 11:00 A.M., CNA B said he/she did not know what triggers or why Resident #21 has PTSD. He/She knows Resident #21 had a car accident because of what a family member said, when visiting. If Resident #21 has to wait for coffee, he/she gets upset but that's about it. He/She did not know any specifics related to the car accident Resident #21 had. During an interview on 04/24/26 at 11:20 A.M., CNA B said he/she thinks Resident #12 maybe had PTSD from when his/her family member pushed him/her and he/she hit his/her head on concrete. CNA B did not know for sure if that was why, but Resident #12 would talk about that at times. CNA B did not know if Resident #12 had any specific triggers. During an interview on 04/24/26 at 2:45 P.M., the Administrator and Director of Nursing said they would expect resident care plans to address triggers, interventions, and how to care for residents that are diagnosed with PTSD.

Based on observation, interview, and record review, the facility failed to obtain physician's orders for two residents (Residents #1 and #75) out of 17 sampled residents. The facility's census was 67.Review of the facility's policy titled, Physician's Orders, undated, showed:- Each resident must be under the care of a licensed physician authorized to practice medicine in this state and must be seen by the physician at least every sixty days;- Physician's orders must be signed by the physician and dated when such order was signed;- Physician orders must be reviewed and renewed. 1. Review of Resident #1's medical record showed:- admission date of 12/27/23;- Diagnoses of chronic pain, tremor (involuntary movement), and fracture of left acetabulum (deep cup shaped socket where the upper part of the hip sits for the ball and socket hip joint).Review of the resident's physician order sheet (POS), dated 04/23/26, showed no order for restorative therapy.Review of the resident's restorative nursing report showed:- Restorative therapy services provided seven times for the month of March 2026 on 03/04, 03/11, 03/16, 03/18, 03/23, 03/27 and 03/30;- Restorative therapy services provided once for the month of April 2026 on 04/08.Review of the resident's care plan, last reviewed 02/03/26, showed restorative care plan as follows: 3x/week restorative nursing program (RNP) to maintain gait and bilateral lower extremity (lower legs) strength.During an interview on 04/24/26 at 10:40 A.M., Resident #1 said he/she exercises and walks with staff sometimes.During an interview on 04/24/26 at 1:13 P.M., the restorative aide said he/she works with Resident # 1 two times a week, usually on Tuesdays and Thursdays. The therapist puts restorative therapy orders into the system. He/She said sometimes orders will fall off of the e-MAR (electronic medication administration record) and he/she thinks it might have to do with the time frames.2. Review of Resident #75's medical record showed:- admission date of 03/06/26;- Diagnoses of morbid obesity (excess of body fat that severely impairs physical function and increases risk for life-threatening conditions), chronic pain, muscle spasm, and acquired absence of the right leg below the knee.Review of the resident's POS, dated 04/21/26, showed no orders for the use of a continuous positive airway pressure (CPAP - a medical device that uses air pressure through a mask to keep the airways open while sleeping) or the cleaning of a CPAP or use of a trapeze (a medical mobility device consisting of a triangular handle hanging from an overhead metal frame, attached to a bed or freestanding) bar for bed mobility and transfers.Review of the resident's care plan, last reviewed 04/16/26, showed:- The resident uses a CPAP during hours of sleep, and to assist the resident with the CPAP as needed;- Trapeze bar above the bed for bed mobility and transfers.Observations of the resident showed:- On 04/21/26 at 11:45 A.M., the resident lay in bed with his/her CPAP on and a trapeze bar overhead attached to his/her bed;- On 04/23/26 at 1:00 P.M., the resident lay in bed with his/her CPAP on and a trapeze bar overhead attached to his/her bed.During an interview on 04/23/26 at 3:10 P.M., Resident #75 said he/she uses his/her CPAP when he/she sleeps. He/She has a company come in and clean the machine, but today staff messed with it, and it started smoking and is now giving an error code. The facility is getting a rental CPAP until it can be repaired or replaced.During an interview on 04/24/26 at 10:20 A.M., Resident #75 said he/she uses the trapeze bar multiple times a day every day to help reposition himself/herself and to get out of bed. He/She said it was brought from home and attached to his/her bed by staff.During an interview on 04/24/26 at 10:00 A.M., Registered Nurse (RN) G said the nurses should put orders in on admission for residents with trapeze bars and CPAPS. There should be an order for CPAP use, an order to clean the mask daily, an order to replace the tubing, and an order for settings. Therapy puts orders in for restorative nursing and the restorative aide documents the minutes.During an interview on 04/24/26 at 2:45 P.M., the Administrator and the Director of Nursing (DON) said they would expect a resident that receives restorative nursing, a resident with a CPAP, and a resident that has a trapeze to have orders for each.

Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for three residents (Residents #12, #21, and #46) with a diagnosis of post-traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) out of three sampled residents. The facility's census was 67. The facility did not provide a policy. 1. Review of Resident #12's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD and major depressive disorder (persistent low mood, loss of interest in pleasurable activities, and fatigue, lasting at least two weeks); - No trauma informed care assessment. Review of the resident's physician order sheet (POS), dated 04/24/26, showed: - An order for prazosin (medication to treat high blood and off-label for PTSD - related nightmares and sleep disturbances) 2 milligrams (mg) by mouth at bedtime for PTSD, dated 08/25/25. Review of the resident's care plan, revised 02/13/26, showed: - PTSD only mentioned as a diagnosis related to behaviors; - No triggers listed or interventions regarding how to care for the resident's trauma. 2. Review of Resident #21's medical record showed: - admitted on [DATE]; - Diagnoses of PTSD, bipolar disorder (a mental health condition characterized by intense, fluctuating mood shifts ranging from manic highs to depressive lows), and anxiety. - No trauma informed care assessment. Review of the resident's POS, dated 04/24/26, showed an order for Prazosin 3 mg daily for PTSD, dated 03/20/26. Review of the resident's care plan, revised 03/24/26, showed: - Resident had experienced trauma and diagnosed with PTSD; - No triggers listed or specific interventions regarding how to care for the resident's trauma. 3. Review of Resident #46's medical record showed: - admitted on [DATE]; - Diagnoses of bipolar disorder, schizoaffective (a mental health condition with symptoms of both schizophrenia and mood disorders) disorder, major depressive disorder, anxiety disorder, PTSD, and borderline personality disorder (a serious mental health condition characterized by long-term instability in emotions, relationships, self-image and behavior); - No trauma informed care assessment. Review of the resident's POS, dated 04/24/26, showed: - An order for depakote (a mood stabilizer) 750 mg twice daily for schizoaffective disorder, dated 04/13/23; - An order for fluoxetine (an antidepressant) 60 mg once daily for bipolar disorder, dated 04/13/23; - An order for haloperidol (an antipsychotic) 10 mg three times daily for schizoaffective disorder, dated 07/30/23; - An order for Seroquel (an antipsychotic) 400 mg twice daily for schizoaffective disorder, dated 08/12/25. Review of the resident's care plan, revised 01/29/26, showed: - Resident had experienced trauma related to sexual trauma during childhood; - Interventions included listening, determine readiness to discuss events, provide realistic feedback when resident attempts to use learned strategies to manage anxiety. During an interview on 04/23/26 at 10:40 A.M., the Administrator said the assessments for PTSD had been missed. During an interview on 04/24/26 at 11:45 P.M., Certified Nurse Aide (CNA) B said he/she did not know Resident #21 had PTSD or what the triggers were. He/She said a family member had said the resident had been in a car accident. If Resident #21 had to wait for coffee, he/she got upset, but that was about it. He/She did not know any specifics related to the car accident. During an interview on 04/24/26 at 12:00 P.M., CNA C said he/she thinks Resident #12 had PTSD from when his/her family member had pushed him/her, which caused him/her to hit head on concrete, but did not know if that was reason for PTSD. CNA C did not know if Resident #12 had any specific triggers.

Based on interview and record review, the facility failed to ensure three out of three sampled Certified Nurse Aides (CNAs) received an annual performance review. The facility's census was 67.The facility did not provide a policy regarding CNA annual performance reviews.1. Review of CNA D's personnel file showed:- Hire date of 04/01/25;- No documentation of an annual performance review.2. Review of CNA E's personnel file showed:- Hire date of 04/07/25;- No documentation of an annual performance review.3. Review of CNA F's personnel file showed:- Hire date of 03/21/25;- No documentation of an annual performance review.During an interview on 04/24/26 at 12:30 P.M., the Director of Nursing (DON) said performance reviews have not been getting done, but they are going to start doing them. She said she was unsure of how often they will be done, maybe yearly.During an interview on 04/24/26 at 2:45 P.M., the Administrator and DON said they would expect performance reviews to be completed at least yearly and to provide regular in-service education based on the outcome of the review.

Based on observation, interview, and record review, the facility failed to conduct a safety and maintenance assessment for the use of a trapeze bar (a medical mobility device consisting of a triangular handle hanging from an overhead metal frame, attached to a bed or freestanding) for one resident (Resident #75) out of one sampled resident. The facility's census was 67.The facility did not provide a policy regarding the use and maintenance of a trapeze bar.1. Review of Resident #75's medical record showed:- admitted on [DATE];- Diagnoses of morbid obesity (excess of body fat that severely impairs physical function and increases risk for life-threatening conditions), chronic pain, muscle spasm, and acquired absence of the right leg below the knee;- Care plan, last reviewed on 03/24/26, showed a trapeze bar above the bed for bed mobility and transfers;- No documentation of a trapeze bar safety assessment or maintenance assessment.Observations of the resident showed:- On 04/21/26 at 11:45 A.M., the resident lay in bed with a trapeze bar overhead and attached to his/her bed;- On 04/23/26 at 1:00 P.M., the resident lay in bed with a trapeze bar overhead and attached to his/her bed.During an interview on 04/24/26 at 10:20 A.M., Resident #75 said he/she uses the trapeze bar multiple times every day to help reposition himself/herself and to get out of bed. He/She said it was brought from home and attached to his/her bed by staff.During an interview on 04/24/26 at 9:30 A.M., the Administrator said she has talked to the Director of Operations, and they do not have a safety assessment or maintenance assessment for trapeze use.During an interview on 04/24/26 at 10:30 A.M., the Maintenance Director said he/she has only worked here for a short time and just recently moved to the maintenance department. He/She did not attach the trapeze bar to Resident #75's bed, but thinks it was probably put on by the previous maintenance director. The Maintenance Director said he/she has not done a maintenance assessment and didn't know that it was required.During an interview on 04/24/26 at 2:45 P.M., the Administrator and Director of Nursing (DON) said they would expect a safety assessment and maintenance assessment to be completed for the use of a trapeze bar.

Based on interview and record review, the facility failed to provide at least twelve hours of nurse aide in-service education per year to include dementia care (care of a resident with an impaired ability to remember, think or make decisions), care of cognitively impaired residents and/or abuse/neglect training for three of the three sampled Certified Nurse Aides (CNAs). The facility's census was 67.The facility did not provide a policy regarding CNA in-service requirements.1. Review of CNA D's in-service record showed:- A hire date of 04/01/25;- A total of nine in-services, dated 12/10/25; no length of time provided for each in-service;- No documented abuse/neglect, dementia care or the care of cognitively impaired residents training.2. Review of CNA E's in-service record showed:- A hire date of 04/07/25;- A total of nine in-services, dated 12/10/25; no length of time provided for each in-service;- No documented abuse/neglect, dementia care or the care of cognitively impaired residents training.3. Review of CNA F's in-service record showed:- A hire date of 03/21/25;- A total of nine in-services, dated 12/10/25, no length of time provided for each in-service;- No documented dementia care or the care of cognitively impaired residents training.During an interview on 04/24/26 at 12:30 P.M., the Director of Nursing (DON) said she, the Assistant Director of Nursing (ADON) or the Administrator provide in-services. She believes CNAs should have 12-15 hours of annual in-services to include resident rights, abuse and neglect, infection control, and all the basics. In-services should include who is attending, the topic, the date and the length of time of the in-service. She believes each of the in-services provided was around 15 minutes.During an interview on 04/24/26 at 2:45 P.M., the Administrator and DON said they would expect CNAs to have at least 12 hours of in-services per year to include dementia care, abuse/neglect prevention and the care of the cognitively impaired resident.

Based on interview, observation, and record review, the facility failed to provide protective oversight for two residents (Resident #1 and #3) with psychiatric diagnoses and a history of self harm who resided on the secured behavioral unit. On 02/25/25, Resident #3, who had and had a history of ingesting batteries, swallowed two AA batteries, which resulted in transfer to the emergency room (ER) and a procedure to remove the battery. On 02/26/25 at 12:44 P.M., Resident #1 became agitated and made threats of self harm by swallowing items. Resident #1 was placed on 15 minute checks, continued to make self harm threats, and ingested two AA batteries at 3:49 P.M., which resulted in an ER transfer. The facility did not provide documentation or evidence the 15 minutes checks were completed for Resident #1. The facility also failed to keep the environment free of accident hazards by not securing all of the rooms on the secured behavioral unit, when Resident #2 opened an unlocked clean utility room with four safety razors, a large bundle of plastic grocery bags, and two 12 cup coffee carafes full of hot coffee. Resident #2 had a history of ingesting harmful items. The facility census was 74. The administration was notified on 02/27/25 at 6:51 P.M., of an Immediate Jeopardy (IJ) which began on 02/25/25. The IJ was removed on 02/27/25, as confirmed by surveyor onsite verification. The facility did not provide a policy regarding accidents/incidents. 1. Review of Resident #3's face sheet showed: - admitted [DATE]; -Diagnoses of schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), insomnia, anxiety, bipolar disorder (a mental health condition characterized by extreme mood swings, including periods of intense happiness or irritability (mania) and periods of deep sadness or hopelessness (depression)), suicidal ideations, suicide attempt, personality disorder (a mental health condition that involves long-lasting, disruptive patterns of thinking, behavior, mood and relating to others), borderline personality (a mental illness that severely impacts a person's ability to regulate their emotions), and post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event). Review of the resident's Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure individuals are not inappropriately placed in nursing homes), dated 12/02/24, showed; - Diagnoses of schizoaffective disorder, major depressive disorder, personality disorder, bipolar disorder, PTSD, mood disorder (a mental health problem that primarily affects a person's emotional state), attention deficit hyperactivity disorder (a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and/or impulsivity that interfere with daily functioning), reactive attachment disorder (a rare and severe mental health condition that affects children's ability to form healthy attachments with caregivers), and oppositional defiant disorder (a behavioral disorder characterized by persistent patterns of angry/irritable mood, argumentative/defiant behavior, and vindictiveness); - Resident unable to care for self due to recent hospitalization due to swallowing batteries, flat affect, and urge to harm self; - In September, the resident swallowed two batteries and stated to psychiatry the continued desire to harm self. On 10/05 (2024?), he/she swallowed batteries again; - Resident had a mental health disability as defined by PASRR; - Resident was withdrawn, depressed, paranoid, labile (emotional, involves sudden and extreme mood swings) mood, positive suicide attempt by overdose, history of self harm, received Department of Mental Health (DMH) services intermittently since childhood; - Resident had behavioral difficulties or mental illness symptoms requiring 24 hour monitoring; - Provision of structured environment, low stimulation, assess and plan for level of supervision required to prevent harm to self or others; - Crisis intervention to include suicidal precautions. Plan to identify clear steps to be taken to support individual during crisis, specify who to contact for assistance, how staff will work together, as well as identify physician, and law enforcement; - Support services of referral to DMH; - Community based psychiatric treatment required include: medication education and psychiatric follow up; - Resident's needs at this time could be met in a nursing facility; - Resident required following supports and services: behavioral support plan, structured environment, crisis intervention services, medication therapy, activity of daily living (ADL) program, and personal support network. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 02/11/25, showed: - Cognition intact; - Clear speech and able to understand - Independent with eating; - Independent for all ADLs and mobility. Review of the resident's revised Care Plan, dated 02/18/25, showed: - Resident had a court appointed guardian; - Resident had impaired psychosocial skills as evidenced by behaviors; - Resident had impaired decision making/poor judgment and resided on a secured behavior unit; - Resident had experienced trauma with a diagnosis of PTSD; - Resident was at risk to harm self or others. Resident was at risk of elopement. There was a history of self harm and suicide attempt by overdose. Resident had frequent suicidal thoughts and self injury behaviors, multiple suicide attempts, severe self mutilating behaviors, overdose, and history of swallowing glass and batteries; divert resident's behavior by using coping skills, don't confront resident, allow resident to explore feelings, report any suicidal thoughts or self harming to the nurse immediately. - On 08/26/24, the resident swallowed a AA battery from the TV remote and was sent to the ER. The resident transferred to another hospital due to trying to jump out of the ambulance several times during the transport. Resident placed on 1:1 until 09/01/24 upon return; - On 09/20/24, the resident told a CNA he/she had swallowed a battery. A battery was missing from the TV remote. The resident was sent to the ER and transferred to another hospital for a procedure to remove the battery. The resident returned from the hospital and found his/her belonging removed from the room. The resident became aggressive, threw the side table, water pitcher, and attempted to punch the wall. Two Certified Nurse Aides (CNAs) put the resident into a primary restraint technique (PRT - a method designed for one person to safely and effectively restrain a person without causing pain or injury) hold and the physician gave orders for two injections. Resident to be placed on 15 minute checks upon return; - On 02/25/25, the resident reported to staff he/she asked another resident for batteries that he/she then swallowed. They were AA batteries. The resident was placed on 1:1 and sent to the ER where a procedure occurred and the batteries were removed. Resident placed on 1:1 upon return; - The resident received psychotropic (drugs that affect the brain and nervous system, influencing mood, behavior, and mental processes. They are used to treat a wide range of mental health conditions) medications. Monitor for side effects and report to physician if observed: Poor coordination, dry mouth, increased heart rate, urinary retention, agitation, hallucinations, orthostatic hypotension, drowsiness, blurred vision. Review of the resident's Nurse's Notes showed: - On 02/25/25 at 1:59 P.M., the resident reported to staff that he/she asked another resident for some batteries and swallowed two AA batteries. Complained of feeling upset, agitated, and had an urge to swallow the batteries. The resident was placed 1:1, called the physician, and sent to the ER; - On 02/25/25 at 5:54 P.M., the ER called and reported they found two batteries the resident swallowed in x-ray and was being sent to another hospital for further treatment; - On 02/26/25 at 8:36 A.M., the hospital called and reported the procedure was completed and both batteries removed. The resident would be discharged back to the facility. 2. Review of Resident #1's PASSR, dated 10/27/21, showed: - Resident met the federal definition of serious mental illness but didn't require specialized services; - Resident met the federal definition of intellectual disability but didn't require specialized services; - Resident met the skilled nursing facility admission requirements; - Diagnoses of schizoaffective (a condition characterized by abnormal thought processes and deregulated emotions), bipolar disorder (a mental disorder that causes unusual shifts in mood), depression, adult victim of sexual abuse, intellectual disability, Asperger's (a developmental disorder that falls under the broader category of autism spectrum disorder ), and elopement risk; - Resident had auditory hallucinations (where you hear, see, smell, taste or feel things that appear to be real but only exist in your mind) and nightmares of abuse, poor insight, referral notes of paranoia (an unfounded and/or exaggerated mistrust of others), disorganization, nonsensical speech; - Current psychiatric support services at time of evaluation included outpatient psychiatric follow up and a secured behavioral unit; - One overdose suicide attempt; - Resident was childlike; - Support and/or services needed include: community based psychiatric treatment, behavioral support/supervision, day programing/treatment/partial hospital program, financial assistance, medical follow up, individual counseling, medication education, referral to department of mental health, residential services, skills training, and social work services; - Due to nature of trauma and recent elopement from a residential care facility, the nursing facility was the least restrictive setting. Would need long term trauma based therapy; - If admitted to a nursing facility, needed assessment and implementation of behavioral support plan to include monitoring of behavioral symptoms and provision of behavioral supports; - It was recommended the resident received behavior unit services for structure and stability; - Crisis intervention should include safety plan to address elopement behaviors, stress reactions related to trauma, and plan with clear steps to support resident during a crisis situation; - Recommended services to include: behavioral support plan, structured environment, crisis intervention services, discharge planning, medication therapy, ADL program, and personal support network. Review of the resident's face sheet showed: - admitted [DATE]; - Diagnoses of bipolar disorder, major depressive disorder (long-term loss of pleasure or interest in life), and anxiety (persistent worry and fear about everyday situations). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognition intact; - Verbal behavior directed toward others; - Other behavior not directed toward others; - Wandering; - Clear speech and able to understand; - Independent with eating with a mechanically altered diet; - Independent for all ADLs and mobility. Review of the resident's Care Plan, last reviewed on 12/03/24, showed: - Required an anti-anxiety medication; - Required an anti-depressant medication; - Resident experienced trauma; - Resident had behavior symptoms and resided on a secured behavioral unit due to behaviors. Resident was at risk of harm to self or others and elopement. Resident had an overdose suicide attempt, scared of male peers, and was childlike; - On 09/14/24, the resident reported to staff another resident triggered him/her talking about suicide. The resident brought a glass covering from a light in the bedroom to staff and said he/she was considering using it to slit his/her wrists. Staff encouraged resident to focus on progress and not be influenced by others. Resident placed on 15 minute checks; - On 11/17/24, the resident became upset because another peer had extra soda. The resident cursed at staff and slammed his/her door. The resident pointed out an abrasion to the left wrist when checked on. Said he/she did it last night, but didn't look fresh and no blood present. Staff asked resident about reason of being upset and spoke with resident. Staff encouraged coping skills to be used. Items removed from room that could be a safety hazard and placed on 15 minute checks. Resident is using a marker to draw on arm instead of something to scratch it; - On 12/22/24, the resident tore off the right index finger fingernail related to being upset over another person. Resident educated by staff on not harming self and possible infection from injury; - On 12/27/24, the resident had an increase in behaviors and had become verbally and physically aggressive toward staff, peers, and not easily re-directed. Notified physician who ordered a medication change; - On 01/23/25, the resident had a nightmare and became upset. Staff spoke to resident about nightmare not being real and resident being safe. Resident calmed down; - On 01/29/25, the resident reported using a coloring pencil to self harm to the left wrist resulting in a 1 centimeter (cm) superficial cut. Staff spoke with resident, encouraged to focus on self and use coping skills. Coloring pencils removed from resident; - Divert resident's behavior by using coping skills, don't confront resident, allow resident to explore feelings, report any suicidal thoughts or self harming to the nurse immediately. - Resident required psychotropic medications related to diagnoses of bipolar disorder, restlessness, and agitation; - Resident had a legal guardian. Review of the resident's Nurse's Notes showed: - On 02/26/25 at 9:56 A.M., the resident worked with therapy before a smoke break and missed it. When the resident returned to the unit, the resident demanded staff to take him/her to smoke. Before staff could respond, the resident slammed his/her door and was verbally aggressive. The nurse redirected the resident with 1:1 conversation and took the resident to smoke; - On 02/26/25 at 12:44 P.M., the resident had increased behavioral outbursts made self harm threats of swallowing pens and pencils. When asked why, the resident said, I don't know, I just do. The pens and pencils were removed from the resident's possession. The resident was placed on 15 minute checks and in the dining room eating lunch. The resident appeared calm with a normal affect; - On 02/26/25 at 3:49 P.M., the resident came to staff, smiled, and said, I swallowed a battery. The nurse asked why since he/she didn't have a history of swallowing batteries, and the resident said, I don't know, I just did. The resident said it was AA batteries from his/her radio. The nurse looked in the radio and found no batteries in it or any his/her room. The Director of Nursing (DON) and the physician were notified with an order to send to the ER for treatment. The guardian was notified of the transfer; - On 02/26/25 at 5:09 P.M., the resident returned from the ER with instructions to allow the resident to pass the batteries. The resident was placed on 15 minute checks for monitoring. Batteries were removed from his/her room. Resident denied any active self harming thoughts at that time; - On 02/27/25 at 1:37 A.M., the resident complained of stomach pain earlier in the shift; - On 02/27/25 at 9:13 A.M., the resident said he/she wanted to kill him/herself and would do whatever it took to do it. The resident placed on 1:1 until not suicidal. Review of the resident's 15 minute checks showed: - No documentation from when the resident returned from the hospital on 02/26/25 at 5:09 P.M., through 02/27/25 at 6:00 A.M. During an interview on 02/27/25 at 11:00 A.M., Resident #1 said he/she was on 1:1 because he/she had been bad. He/She swallowed batteries from his/her radio. The hospital said he/she had to pass them. During an interview on 02/27/25 at 11:10 A.M., Certified Nursing Assistant (CNA) A said he/she was Resident #1's primary 1:1 for the day shift on 02/26/25. Resident #1 threatened to self harm multiple days resulting on 1:1. The resident swallowed two AA batteries on 02/26/25. The resident went to the ER. During an interview on 02/27/25 at 4:56 P.M., CNA E said he/she worked last night and did 15 minute checks when Resident #1 returned. Resident #1 swallowed batteries, went to the hospital, and returned. CNA E came in on 02/27/25 at 6:00 P.M., and said Resident #1 was never on 1:1. CNA E said the 15 minute checks were not documented, but should have been. During an interview on 02/27/25 at 11:20 A.M., CNA B said Resident #1 was on 1:1 for self harm by swallowing batteries. Resident #1 went to the hospital and was currently figuring out emotions and why he/she did the action. During an interview on 02/27/25 at 11:25 A.M., CNA C/Unit Coordinator said Resident #1 was placed on 1:1 on the morning of 02/26/25, due to getting into an argument with another resident who told him/her to kill himself/herself and to swallow more batteries. Resident #1 became suicidal and was placed on 1:1. When swallowed the batteries on 02/26/25, the staff sent the resident to the ER. He/She saw no care instructions for the resident. The nurse told him/her to watch Resident #1's fecal material for the passing of the batteries. He/She couldn't find the documentation of the 15 minute checks when Resident #1 returned from the hospital. During an interview on 02/27/25 at 6:00 P.M., CNA F said Resident #1 was monitored last night after returning from the hospital. He/She wasn't aware of any 15 minute checks on Resident #1, but did 10 to 15 checks just because of coming back from the hospital from self harm. Resident #1 had to pass the batteries. No documentation of the checks were done last night, because no one said to do them. He/She had no training provided at this facility. During an interview on 02/27/25 at 2:30 P.M., CNA C/Unit Coordinator said the charge nurse made the decision on if a resident was placed on 15 minute checks or 1:1. The resident stayed on that monitoring for usually 72 hours and it should be documented in the nurse's notes. He/She wasn't aware of any policy and procedure regarding resident checks, but the whole unit was on 30 minute checks unless it was increased individually. If a resident had verbal threats of self harm or harm to others, they were placed on 15 minute checks. If that escalated to physical harm, then it was moved to 1:1 until they returned to their baseline. During an interview on 02/27/25 at 2:45 P.M., the Assistant Director of Nursing (ADON) said the charge nurse decided if a resident was on a 15 minute check or 1:1. There wasn't a policy or procedure for the nurse to follow. If the nurse was not sure, they were able to call the DON or ADON for directions. The point was to keep the resident safe with the least restrictive environment. During an interview on 02/27/25 at 3:45 P.M., CNA B said if a resident expressed a desire to harm themselves, then he/she let the nurse know and kept the resident in sight. During an interview on 02/27/25 at 3:55 P.M., CNA C/Unit Manager said if a resident expressed a desire to self harm, he/she redirected and started coping skills. If the resident couldn't be redirected, the nurse was notified. Most of the residents liked to write their feelings down. During an interview on 02/27/25 at 4:38 P.M., Licensed Practical Nurse (LPN) D said he/she was told in report Resident #1 had swallowed two batteries. Resident #1 went to the hospital and they sent him/her back to pass the batteries. Resident #1 was on 15 minute checks and the staff checked the residents that often anyway on the secured behavioral unit. 3. Observation on 02/27/25 at 3:58 P.M., of the secured behavioral unit showed: - Resident #2 opened an unlocked clean utility room door with four safety razors in a tub above the sink, a large bundle of plastic grocery bags, and two 12 cup coffee carafes full of hot coffee; - Another door beside the clean utility room was open and a bucket of mop water sat in it; - Multiple tubes of toxic acrylic paint sat on the counter in the dining room. During an interview on 02/27/25 at 4:33 P.M., CNA G said the water in the mop bucket on the secured behavior unit had a triple-multisurface cleaner poured into it. During an interview on 02/27/25 at 6:00 P.M., CNA F said Resident #2 had a history of swallowing items and batteries 4. During an interview on 02/27/25 at 5:00 P.M., CNA C/Unit Coordinator said an administrator from another facility came and did some training on self-harm, behaviors, and de-escalation. Resident #2 had a history of swallowing items and batteries. Generally, Resident #3 would talk real slow and then start cursing and become loud. That's when he/she was going to self harm. No razors should be in the clean utility room. The clean utility room door should be locked and staff should ensure the door was locked after exiting. He/She had the keys to the clean utility closet but all staff knew to lock it. The utility room with the mop bucket was left unlocked and the water should be just regular water because the residents like to mop their rooms to feel productive. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the 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). Complaint MO249053

Based on observation, interview, and record review, the facility failed to protect residents on the secured behavioral unit from abuse through deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This deficiency affected three sampled residents (Resident #11, #61, and #68) on the secured behavioral unit, resulting in humiliation and embarrassment for those residents and back pain for Resident #68 from sleeping on a mattress on the floor and had the potential to affect all residents on the secured behavioral unit. The facility also failed to protect one resident's (Resident #11) right to be free from physical abuse when Certified Nurse Assistant (CNA) A physically forced Resident #11 to the ground and physically restrained Resident #11 while on the ground, making Resident #11 feel humiliated. The facility's census was 74. The administration was notified on [DATE] at 3:15 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's policy, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, undated, showed: - It is the policy of this facility that each resident will be free from abuse; - Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion; - The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms; - Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility; - No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection; - The facility will strive to educate staff and other applicable individuals in techniques to protect all parties; - All employees of this facility are mandated reporters; - All employees who have been alleged to commit abuse will be suspended immediately pending investigation; - If the allegation is substantiated, there is a potential that the employee will be terminated, added to the Employee Disqualification List and not allowed to work in a nursing home, disciplined by their licensing agency and charged with a crime. Review of the document Resident Rights, signed by all staff upon hire and annually, undated, showed: - A resident has the right to participate in their care. Residents are entitled to take part in planning their care and in being informed of all aspects of their care. Residents may refuse any treatment they do not want; - A resident has the right to keep their possessions. Residents may retain personal possessions as space permits, unless to do so would infringe on the rights of others; - A resident has the right to be free from abuse. Residents shall not be subjected to physical, sexual, or emotional injury or harm. 1. Observation on [DATE] at 12:13 P.M. showed a printed paper posted on Resident #11's bathroom door which read: - Actions and Consequences, you all are aware of the rules, they are now set in place. So, if you have one of these actions there will be consequences and we will be following through with each one of them. - The document was then divided into two columns, one labeled Action the other Consequences. The Consequences column had two options for each action depending on a resident's smoking status; - Action: Arguing with another resident. Consequence: Sent to room to work on coping skills; - Action: Arguing with staff, not listening. Consequence: Resident loses one smoke break; - Action: Arguing with staff, not listening. Consequence: Resident loses one day of snack cart; - Action: Cursing out staff. Consequence: Resident loses two smoke breaks; - Action: Cursing out staff. Consequence: Resident loses a week of snack cart; - Action: Hitting a staff member or a resident. Consequence: Resident loses smoke break for 48 hours; - Action: Hitting a staff member or a resident. Consequence: Resident loses snack cart for two weeks; - Action: Stealing from another resident. Consequence: Resident loses two smoke breaks; - Action: Stealing from another resident. Consequence: Resident loses snack cart for a week; - Action: Attention seeking Self-Harming behavior. Consequence: Resident loses belongings and smoke break for the day and is to wear a gown with pants; - Action: Attention seeking Self-Harming behavior. Consequence: Resident loses belongings and snack cart for the week and is to wear a gown with pants; - Action: Refusing medication. Consequence: Resident loses everything until medication is taken; - Action: Taking off a resident tray or sharing food. Consequence: Resident loses smoke break for 24 hours; - Action: Taking off a resident tray or sharing food. Consequence: Resident loses snack cart for the week; - Action: Resident refusing shower for two days. Consequence: Resident loses smoke break until shower is taken; - Action: If a resident stands where staff is charting after staff has redirected. Consequence: Resident loses one smoke break, and snack cart for the day; - Action: Resident not listening to being sent to room, due to behavior on the hall and not shutting the door when asked. Consequence: Resident will lose all privileges for the rest of the day; - Action: Resident sharing anything without staff approval. Consequence: Resident loses one smoke break; - Action: Resident sharing anything without staff approval. Consequence: Resident loses one snack cart day; - Action: Resident going past the double doors with the phone after being reminded. Consequence: Resident loses one smoke break; - Action: Resident going past the double doors with the phone after being reminded. Consequence: Resident loses one snack cart day; - Action: Resident not following directions or listening to the staff when asked of something. Consequence: Resident loses one smoke break; - Action: Resident not following directions or listening to the staff when asked of something. Consequence: Resident loses one snack cart; - Action: Resident keeping things in their room, that are not allowed. Consequence: Resident loses one smoke break per item found in room; - Action: Resident keeping things in their room, that are not allowed. Consequence: Resident loses snack cart days per item found in room. Review of Resident #11's medical record showed: - admitted on [DATE]; - Diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and nicotine dependence (a chronic brain disorder that causes a person to compulsively need nicotine, a substance found in tobacco products and includes withdrawal symptoms like restlessness, agitation, increased hunger, insomnia, constipation, or diarrhea); - Per the Preadmision Screening and Resident Assessment (PASARR) Level II screening (a comprehensive assessment of current and historical treatment): Resident has history of depression, anxiety, paranoia, agitation, aggression, mood swings, non-compliance with medication and treatment, impulsive behaviors, poor decision making, racing thoughts, irritation, anger outbursts, poor sleep at times, poor appetite at times, at a previous facility was found walking on the road, non-compliance with rules, suicidal ideation - thought of hanging self, history of suicidal attempt, punching walls, and marijuana use. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated [DATE], showed: - No cognitive impairment; - Exhibited hallucinations in the seven-day look back period; - Independent with activities of daily living (ADLs); - The resident routinely received antipsychotic medication in the seven-day look back period. Review of the resident's care plan, revised [DATE], showed: - Resident at increased risk for behavioral/mood problems due to history of behaviors. At risk to harm self or others. At risk to elope from facility; - History of physical violence. - Unit Coordinator got approval per guardian directive that if resident has a behavior, staff can take away any open hall activities and a smoke break and do room searches for safety reasons; - Unit Coordinator spoke with resident's guardian in regard to the unit policies and procedures and went over each one with the guardian. The guardian agreed with the unit policies and procedures, and states she gives verbal consent and to add these to resident's guardian directives; - Care plan did not address actions/consequences list. Review of the resident's Physician's Order Sheet (POS), dated [DATE], showed: - An order for nicotine gum, two mg, give one piece four times a day as needed for nicotine withdrawal, dated [DATE]; - An order for nicotine lozenge; four mg, may have one lozenge buccal (in the cheek) every two hours as needed between 11:00 P.M. and 7:00 A.M. for nicotine withdrawal, dated [DATE]; - An order for Latuda (antipsychotic medication), 120 mg, give one tablet with 20 mg tablet to equal 160 mg daily, for bipolar disorder, dated [DATE]; - An order for Latuda, 40 mg, give one tablet with 120 mg tablet to equal 160 mg daily, for schizophrenia, dated [DATE]; - An order for Trileptal (anticonvulsant medication), 150 mg, give one tablet by mouth twice daily, for schizophrenia, dated [DATE]; - An order for carbamazepine (anticonsulvant used to treat bipolar disorder), 100 mg, give one chewable tablet by mouth twice daily, for mood disorder, dated [DATE]; - An order for chlorpromazine (antipsychotic medication), 50 mg, give 50 mg by mouth daily, for schizophrenia, dated [DATE]; - An order for Abilify Maintena suspension (antipsychotic medication), 400 mg, give 400 mg intramuscularly every 28 days, for mood disorder, dated [DATE]; - An order for Geodon solution (antipsychotic medication), 20 mg/ml, give one ml intramuscularly every 12 hours as needed for behaviors, dated [DATE]; - An order for trazodone (antidepressant medication), 50 mg, give one tablet at bedtime as needed, for insomnia, dated [DATE]. Review of the resident's Medication Administration Record (MAR), dated [DATE] through [DATE], showed no administration of either nicotine gum or nicotine lozenges for nicotine withdrawal. Review of the resident's progress notes showed: - On [DATE] at 11:11 A.M., Resident this morning screaming and yelling at all staff and guardian on the phone. Resident was redirected several times and ignored redirection. Resident stating that staff and Director of Nursing (DON) is the reason why he/she cannot advance to another facility. Resident yelling and screaming at staff still nurse came down and tried to redirect. Redirection ignored once again. Resident currently calmed down at this time; - On [DATE] at 5:35 P.M., Resident had behavioral outburst this morning of yelling, cussing, and being verbally aggressive towards staff. Staff was able to redirect resident with 1:1 conversation, after conversation, resident calmed down and has had no behaviors since; - On [DATE] at 11:07 P.M., Resident had outbursts most of the day. The resident voiced that he/she was upset about losing his/her smoke break. Resident later became extremely loud and began cussing and yelling. Staff alerted this nurse upon arrival in room, resident was resistant to a Geodon (antipsychotic medication) injection, but eventually stated he/she would take one. Injection given in right deltoid (shoulder muscle) without difficulty; - On [DATE] at 2:32 P.M., Resident standing at the end of the hallway looking outside the window and screaming how he/she wants to die, wants to leave, hates his/her guardian. DON was speaking with this resident. Resident expressed wanting the PRN (as needed) Geodon to help him/her calm down. The DON spoke with this resident regarding possible placement at behavior hospital and resident expressed he/she wanted to do that. The DON stated she would look into it. Resident let this nurse give him/her PRN Geodon in right deltoid, tolerated well. Resident went back to his/her room to calm down. - On [DATE] at 5:37 P.M., Resident this evening around 4:00 P.M. started to have increase in behavioral outburst and show signs and symptoms of manic behavior and had started to punch the walls and attempted to attack staff. Resident also making homicidal ideations towards staff and others and becoming more violent and showing signs and symptoms of becoming a danger to himself/herself and others. Staff attempted to re-direct resident, but resident was not responding to redirection. Nurse notified psychiatric physician of increase in resident's behaviors and that he/she was not responding to re-direction and that PRN Geodon had been administered a few hours prior. New order given for resident to be sent to the emergency room for psychiatric evaluation and treatment as indicated; - On [DATE] at 4:17 P.M., Resident called facility. Unit Coordinator answered. Resident stated to Unit Coordinator that I need you to pack my shit. I am being discharged from the facility. Unit Coordinator stated that he/she knew nothing of that and that if resident was being discharged that it would most likely be back to the facility. Resident stated No, if I go back to the facility, it's not going to be pretty for you! I will tear that entire place up and destroy you and the facility! I cannot live there anymore and I will not. Do you hear me? Unit Coordinator tried to speak, but resident just continued to get louder and then hung up the phone. Unit Coordinator called guardian and guardian stated, Oh well, all I can say is good luck. Review of the facility's Incident Investigation, dated [DATE], showed: - At 9:30 P.M. on [DATE], Resident #11 and CNA A were arguing back and forth on the 500 hall. Resident #11 punched CNA A in the left side of the face and CNA A took Resident #11 to the ground and held the resident until the nurse was able to give a PRN (as needed) injection and the resident calmed down; - No injuries to the resident or complaints of pain at this time; - Resident #11 was escorted to his/her room and CNA A was taken off the hall and made to leave the facility. Review of the facility's In-service Training Record, dated [DATE], showed CNA A was present for Abuse and Neglect Training, which included the Abuse Policy and a handout titled Freedom from Abuse, Neglect, Misappropriation, and Exploitation. Review of Resident #11's progress note, recorded as a late entry by Licensed Practical Nurse (LPN) B on [DATE] at 2:56 A.M. showed: - LPN B heard yelling from the 500 hall unit. Upon entering the unit, he/she observed this resident and CNA A arguing. LPN B was able to calm the situation down for a minute and was walking with the resident back to his/her room as he/she and CNA A were still yelling back and forth; - Resident #11 turned around and went back to CNA A, where he/she acted like he/she was going to urinate on CNA A's feet. Resident #11 then stood up and exchanged words with CNA A, then punched CNA A on left side of face; - Resident #11 was taken to the ground and this nurse obtained an order for Geodon (antipsychotic medication) injection that was given; - Resident #11 was held until he/she said he/she would not be aggressive towards staff anymore. LPN B walked the resident back to his/her room; - CNA A then showed LPN B that Resident #11 had busted CNA A's lip when Resident #11 hit CNA A and bit CNA A's left forearm and drew blood from bite mark; - LPN B had CNA A wash his/her arm with soap and water and then use alcohol pads to bite mark. The DON was notified and other appropriate persons. Will continue to monitor. Review of the resident's behavior notes from the behavior binder showed: - On [DATE], Resident was fine and laughing this morning with Unit Coordinator. Resident asked Unit Coordinator for his/her smoke break back. Unit Coordinator stated per guardian, resident lost smoke breaks for assaulting a staff member. Resident started screaming and cussing at Unit Coordinator. Resident called guardian screaming and yelling, demanding guardian to get him/her out of this facility or shit was about to be really bad for everyone here. Resident started screaming and cussing at guardian. Guardian hung up the phone. Resident yelling at Unit Coordinator demanding that Unit Coordinator give resident back his/her smoke breaks that per guardian, resident lost due to resident assaulting a staff member twice. Unit Coordinator stated that those are the consequences for his/her actions. Resident stated I would hit you in your fucking face if I wouldn't lose a smoke break because of it. Observation of the resident on [DATE] at 1:30 P.M. showed the resident, wearing his/her own clothes, appearing agitated, pacing on the hall, speaking about religion, tithing, and giving his/her money to television evangelists and how he/she hates his/her guardian, while other residents were outside smoking. During an interview on [DATE] at 12:13 P.M., Resident #11 said he/she had an altercation with Certified Nursing Assistant (CNA) A and he/she punched CNA A in the face. CNA A put him/her in a head lock and threw him/her to the ground and CNA A sat on him/her. He/She can still go out and get fresh air during smoke break times. They have an actions and consequences list on the bathroom door. Some residents ruin things for other residents. The resident's toilet was flooding, so he/she yelled that they needed a plunger and blankets. CNA A was complaining about it being clogged. Resident #11 and CNA A got into it because the toilet overflowed. This was a Friday morning and CNA A also worked Saturday. It was at 3:52 P.M. when he/she asked for another roll of toilet paper. CNA A said he/she just gave Resident #11 a roll yesterday. CNA A said he/she uses too much toilet paper. He/She uses about a roll a day. He/She bitched about it. CNA A talked about it on smoke break and told Resident #11 that CNA A's family of nine doesn't use that much. CNA A came into Resident #11's room and didn't knock. CNA A said, You're still mad about the toilet paper? He was telling CNA E about the incident and Resident #11 felt humiliated and now he/she can't smoke for three days. He/She got toe to toe with CNA A, and CNA A pointed at his/her room and told him/her to go to his/her room. He/She punched CNA A and CNA A got him/her in a head lock and threw him/her to the ground and CNA A sat on him/her. Resident #11 told LPN B to get an injection because he/she knew he/she needed it. CNA A was sitting on his/her butt and he/she was up on her elbows and CNA A was pushing his/her head back down. During an interview on [DATE] at 3:06 P.M., CNA J/Unit Coordinator said staff get training about how to take down a resident properly, but CNA A did not have that training and he/she will not be coming back. During an interview on [DATE] at 11:00 A.M., the Assistant Director of Nursing (ADON) said that when employees are hired, they get abuse/neglect training and it's documented in the payroll system. Agency staff do written training when they are hired. During a telephone interview on [DATE] at 3:48 P.M., CNA E said he/she was working the locked unit the night the incident occurred between Resident #11 and CNA A. Resident #11 came out in the hall from his/her room and had a verbal altercation with CNA A. CNA E believes Resident #11 was upset with CNA A about a previous toilet paper situation where CNA A did not want to give the resident toilet paper because CNA A believed the resident was using too much. CNA A and Resident #11 were a good distance apart on the hall yelling at each other; they weren't up in each other's face at this point. The resident was so loud that LPN B and another CNA outside the locked unit at the nurses station heard them and LPN B came back on the unit. LPN B had his/her hands on the resident's shoulders attempting to redirect the resident back to his/her room. The resident was still yelling at CNA A, who was still responding to the resident yelling. Resident #11 came back around and came at CNA A and punched him/her in the mouth. CNA A grabbed the resident around his/her shoulder and neck area and tackled the resident to the floor. The resident was lying flat on the floor on his/her stomach with his/her hands on the ground. CNA A wasn't really kneeling on the resident, but instead half-way straddling the resident's back. CNA A had his/her right hand on the resident's right shoulder holding him/her there. LPN B left the locked unit to obtain an injection for behaviors, came back and gave the resident the injection. LPN B asked if the resident was going to go back to his/her room if CNA A let the resident up, to which the resident replied he/she would. The resident returned to his/her room, they pulled CNA A off the hall and CNA E worked the rest of the night. CNA E picks up shifts at this facility quite often, but has only worked on the locked unit a couple of times. He/She believed the facility offers training for these types of situations, but the facility has not offered a class to him/her since he/she has worked there. During a telephone interview on [DATE] at 2:25 P.M., LPN B said he/she heard the resident yelling, so he/she walked back to the unit. When he/she first arrived on the unit, CNA A and Resident #11 were arguing, which is not uncommon for the resident. He/She was able to redirect Resident #11 and were going back to the resident's room to sit and chat about what was going on, and LPN B got the resident about halfway down the hall and Resident #11 and CNA A were still arguing. Resident #11 ran up to CNA A and pulled his/her pants down and said that because CNA A didn't want to give Resident #11 any more toilet paper that he/she was going to piss on CNA A's shoes. Resident #11 didn't do that, but instead slugged Resident #11. CNA A got Resident #11 in a hold around his/her neck and took the resident down. On the way down, Resident #11 bit CNA A's arm. After that, LPN B was able to give Resident #11 an injection. The facility provides training on how to take a resident down. LPN B does not have the training, but quite a few of the agency CNAs have the training. LPN B works at the facility about two to three days a week. LPN B was aware of the Actions/Consequences program and that staff would take belongings or smoke breaks away. LPN B could see how some residents could possibly view the program as a punishment. LPN B did not feel that behaviors were escalated except for Resident #11, who really did not like consequences at all. Resident #11 had a lot of behaviors. During a telephone interview on [DATE] at 4:53 P.M., CNA A said Resident #11 was becoming aggravated and aggressive over an incident with some toilet paper. CNA A asked Resident #11 why he/she needed more toilet paper because CNA A had previously given Resident #11 some. CNA A had found out that Resident #11 had also gotten two other rolls from someone else and either Resident #11 or Resident #11's roommate had clogged the toilet with a roll the morning before. Resident #11 came out of his/her room when everyone else was asleep and was hollering and CNA A was trying to coerce Resident #11 back to his/her room to calm down so the resident could talk about it when he/she was calmer. Anything CNA A would do or say to calm the resident down didn't help. LPN B had Resident #11 walking back to his/her room, and then the resident came running back at CNA A and threatened to pee on CNA A's foot. Resident #11 got up in CNA A's face and punched him/her in the face and bloodied CNA A's lip. The resident's arms were down by his/her waist after this happened. CNA A then got behind Resident #11 and had his/her hands at the resident's elbows and gently tried to take the resident by his/her arms in order to sit the resident down as gently as possible to keep him/her from hurting himself/herself or anyone else. On the way down, Resident #11 bit CNA A on the forearm. After the resident bit CNA A, CNA A sat the resident down on his/her bottom and rolled the resident over onto his/her stomach. LPN B came back to give Resident #11 a shot and LPN B asked the resident if he/she was going to come after anyone and the resident said no, so CNA A let Resident #11 go and Resident #11 walked back to his/her room. CNA A was sent home after that. CNA A had not had any type of training either from the facility, a previous employer, or the staffing agency through which he/she is employed. CNA A believed the house staff receives training, but they never mentioned anything to him/her about receiving training. CNA A was working about four days a week at the facility, but feels he/she wasn't able to pick up as many shifts recently until the incident happened. CNA A said the facility had in services, but they occurred when he/she wasn't there. During an interview on [DATE] at 4:43 P.M the DON said CNA A started picking up shifts at the facility in July of 2023. The only training/inservice CNA A participated in was the one on abuse and neglect on [DATE], which was provided during survey. The facility typically does not include agency staff in trainings unless it is for Person-Centered Interventions (PCI - a training for two-person team and three person defensive hold). Agency staff have certain trainings they have to complete through the staffing agency to keep their accounts active, but she does not have access to those things other than to know if CNA A passed or failed them. 2. Review of Resident #61's medical record showed: - admitted [DATE]; - Diagnoses of schizophrenia, restlessness and agitation, and oppositional defiant disorder (a condition characterized by a persistent pattern of defiant, angry, and irritable behavior towards authority figures, such as parents, teachers, or caregivers); - Per the PASARR Level II screening: Resident with history of overdose on opiates to end life, held gun to his/her head, poor insight/judgment, looseness of association, flight of Ideas, thought broadcasting, poor sleep, grandiose delusions, decreased appetite, depressed mood, elevated anxiety level, irritability, decreased energy, feelings of helplessness/hopelessness/guilt, self-isolation, excessive worry, panic attacks, heart racing, and sweating. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Physical (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal (e.g., threatening others, screaming at others, cursing at others) behavioral symptoms directed toward others, other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) and wandering all occurred one to three days in the seven-day look back period; - Independent with ADLs; - The resident received antipsychotic, antianxiety, and antidepressant medication in the seven-day look back period. Review of the resident's care plan, revised [DATE], showed: - The resident resides on the secured behavioral unit due to history of behaviors. At risk to harm self or others. At risk for elopement; - Care plan does not address actions/consequences list. - History of acting like a police officer/threatening to arrest staff/and making/pointing finger guns at staff; reported that he/she was a volunteer fireman and police explorer; - Whatever the resident listens to/watches on YouTube, that is what he/she becomes next (during recent power failure, the resident put on a jacket, acted as if he/she was a security guard, checked all perimeters, and reported to staff that all was secured; - History of overdose of opiates to end life; held gun to his/her head; - Poor insight/judgment; looseness of association; flight of ideas; thought broadcasting; poor sleep; grandiose delusions; decreased appetite; depressed mood; elevated anxiety level; irritability; decreased energy; feelings of helplessness/hopelessness/guilt; self-isolation; excessive worry; panic attacks; heart racing; sweating; crying spells; presents with grandiose bravado demeanor; behaving in an intimidating manner; delusions; likes to stand close to people and be in their space; sleeping excessively; and suicidal ideation; - History of threatening to elope if staff at previous facility did not send him/her to the hospital. Also hit and kicked staff at previous facility; - Resident's preferred coping skills are exercise, listening to music, talking to someone close to him/her, smiling at five people, and playing with modeling clay. Review of the resident's POS, dated [DATE], showed: - An order for trazodone, 100 mg, give one tablet by mouth at bedtime, for insomnia, dated [DATE]; - An order for risperidone (antipsychotic medication), one mg, give one tablet by mouth twice a day, for schizophrenia, dated [DATE]; - An order for divalproex extended release (anticonvulsant medication used as a mood stabilizer), 500 mg, give 1000 mg by mouth once daily, for schizophrenia, dated [DATE]; - An order for zoloft (antidepressant medication), 100 mg, give 200 mg by mouth once daily, for major depressive disorder, dated [DATE]; - An order for Invega Sustenna (antipsychotic medication), 234 mg/1.5 ml, give 234 mg intramuscularly every 21 days, for schizophrenia, dated [DATE]; - An order for Geodon solution, 20 mg/ml, give 20 mg intramuscularly one time, for restlessness and agitation, dated [DATE]; - An order for Ativan solution (antianxiety medication), two mg/ml, give two mg intramuscularly one time, for restlessness and agitation, dated [DATE]; - An order for Geodon solution, 20 mg/ml, give 20 mg intramuscularly one time, for restlessness and agitation, dated [DATE]. Review of the resident's progress notes showed: - On [DATE] at 5:30 P.M., resident threatening to hit staff and hovering over staff on hall. Staff told resident to stop hovering over them. Resident did not like that and got mad, yelling at staff. Resident went into office and grabbed scissors. Resident tried to cut right thumb. There is a small mark on resident's finger. Unit Coordinator instructed to remove resident's belongings from room to prevent resident from harming himself/herself in any other way. When staff tried to pack resident's belongings up, resident got mad and tried attacking staff. Staff initiated defense team with staff support and handled appropriately. No injuries present. Staff put resident's belongings in office and locked office. - On [DATE] at 3:52 P.M., Resident started having a behavioral outburst, was cussing at staff, being verbally aggressive to staff, and making threatening statements to staff. Staff attempted to verbally redirect resident. Resident was not easily redirectable at this time. Nurse notified psychiatric physician of resident's current behavior. New order given for Geodon injection. With CNAs present, nurse administered injection to left deltoid with no complications; - On [DATE] at 11:15 A.M., Resident was having a behavioral outburst, and showing signs and symptoms of attention seeking behaviors. Nurse went to speak with resident with other staff present. When asked why he/she was upset, resident stated I want all my shit back. Staff reminded resident that he/she was making suicidal ideation (SI) statements and for his/her safety, that not all items could be returned at this time. Resident then started to laugh and smile and then states Well, I am SI now. Nurse asked resident if he/she had a plan, and resident stated Well, No. This nurse tried to redirect resident with 1:1 conversation. Resident was not responding well to 1:1 conversation. Resident then stated If you even tr [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure and promote an environment that promoted maintenance or enhancement of each resident's quality of life, recognizing each resident's rights, failed to protect and promote the rights of the resident, failed to allow the resident to exercise his or her rights as a resident of the facility without coercion, interference, discrimination, or reprisal from the facility, and failed to ensure the residents were able to exercise their rights as a resident of the facility and were free of restraints when 3 of 22 residents (Residents #11, #61 and #68) were placed in a secured unit without evaluation for appropriate placement and their resident rights were removed per the guardians' directions, based on a list of actions and consequences. The facility's census was 74. Review of the document Resident Rights, signed by all staff upon hire and annually, undated, showed: - A resident has the right to participate in their care. Residents are entitled to take part in planning their care and in being informed of all aspects of their care. Residents may refuse any treatment they do not want; - A resident has the right to keep their possessions. Residents may retain personal possessions as space permits, unless to do so would infringe on the rights of others; - A resident has the right to exercise their rights. Encouragement and assistance will be provided for the exercise of the resident's right as a resident and as a citizen. Residents may voice grievances and recommend changes to facility staff or to outside representatives free from restraint, interference, coercion, discrimination, or reprisal; - A resident has the right to be free from abuse. Residents shall not be subjected to physical, sexual, or emotional injury or harm; - A resident may associate with and communicate privately with persons of their choice and send and receive mail unopened; - A resident may or may not engage in social, religious, and community activities of their choice, unless a physician determines that such activity would be harmful. 1. Observation on 01/14/25 at 12:13 P.M. showed a printed paper posted on Resident #11's bathroom door which read: - Actions and Consequences, you all are aware of the rules, they are now set in place. So, if you have one of these actions there will be consequences and we will be following through with each one of them. - The document was then divided into two columns, one labeled Action the other Consequences. The Consequences column had two options for each action depending on a resident's smoking status; - Action: Arguing with another resident. Consequence: Sent to room to work on coping skills; - Action: Arguing with staff, not listening. Consequence: Resident loses one smoke break; - Action: Arguing with staff, not listening. Consequence: Resident loses one day of snack cart; - Action: Cursing out staff. Consequence: Resident loses two smoke breaks; - Action: Cursing out staff. Consequence: Resident loses a week of snack cart; - Action: Hitting a staff member or a resident. Consequence: Resident loses smoke break for 48 hours; - Action: Hitting a staff member or a resident. Consequence: Resident loses snack cart for two weeks; - Action: Stealing from another resident. Consequence: Resident loses two smoke breaks; - Action: Stealing from another resident. Consequence: Resident loses snack cart for a week; - Action: Attention seeking Self-Harming behavior. Consequence: Resident loses belongings and smoke break for the day and is to wear a gown with pants; - Action: Attention seeking Self-Harming behavior. Consequence: Resident loses belongings and snack cart for the week and is to wear a gown with pants; - Action: Refusing medication. Consequence: Resident loses everything until medication is taken; - Action: Taking off a resident tray or sharing food. Consequence: Resident loses smoke break for 24 hours; - Action: Taking off a resident tray or sharing food. Consequence: Resident loses snack cart for the week; - Action: Resident refusing shower for two days. Consequence: Resident loses smoke break until shower is taken; - Action: If a resident stands where staff is charting after staff has redirected. Consequence: Resident loses one smoke break, and snack cart for the day; - Action: Resident not listening to being sent to room, due to behavior on the hall and not shutting the door when asked. Consequence: Resident will lose all privileges for the rest of the day; - Action: Resident sharing anything without staff approval. Consequence: Resident loses one smoke break; - Action: Resident sharing anything without staff approval. Consequence: Resident loses one snack cart day; - Action: Resident going past the double doors with the phone after being reminded. Consequence: Resident loses one smoke break; - Action: Resident going past the double doors with the phone after being reminded. Consequence: Resident loses one snack cart day; - Action: Resident not following directions or listening to the staff when asked of something. Consequence: Resident loses one smoke break; - Action: Resident not following directions or listening to the staff when asked of something. Consequence: Resident loses one snack cart; - Action: Resident keeping things in their room, that are not allowed. Consequence: Resident loses one smoke break per item found in room; - Action: Resident keeping things in their room, that are not allowed. Consequence: Resident loses snack cart days per item found in room. Review of Resident #11's medical record showed: - admitted on [DATE]; - Diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and nicotine dependence (a chronic brain disorder that causes a person to compulsively need nicotine, a substance found in tobacco products and includes withdrawal symptoms like restlessness, agitation, increased hunger, insomnia, constipation, or diarrhea). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 11/05/24, showed: - No cognitive impairment; - Independent with activities of daily living (ADLs). Review of the resident's care plan, revised 11/11/24, showed: - Resident at increased risk for behavioral/mood problems due to history of behaviors. - Unit Coordinator got approval per guardian directive that if resident has a behavior, staff can take away any open hall activities and a smoke break and do room searches for safety reasons; - Unit Coordinator spoke with resident's guardian in regard to the unit policies and procedures and went over each one with the guardian. The guardian agreed with the unit policies and procedures, and states she gives verbal consent and to add these to resident's guardian directives. - Resident smokes cigarettes; - Nicotine lozenge four milligrams (mg). May have one lozenge every two hours as needed for nicotine withdrawal between 11:00 P.M. and 7:00 A.M. May not consume during smoking hours; - Divert resident's behavior by encouraging use of coping skills. The resident often uses journaling, drawing, helping others, or painting as coping skills; - Do not confront, argue against, or deny resident's hallucinations. Explore resident's underlying feelings rather than the content of the hallucinations (e.g. anxiety, fear, etc.); - Maintain a calm, slow, understandable approach with resident; - Respect resident's needs for privacy and space. Avoid unnecessary touching. - On 12/16/23, Per guardian phone calls must be supervised; - On 02/22/24, Resident upset the Unit Coordinator would not allow him/her to email his/her family. Resident had lost his/her privileges to use the Internet due to previous behaviors; - On 05/16/24, Per guardian, resident lost smoking privilege at 6:30 P.M. smoke break; - On 08/10/24, Resident has been argumentative with staff and yelling down the hall at other residents when they are about to go outside for smoke break during facility scheduled time. Resident is upset over not being able to smoke per guardian; - On 08/11/24, Resident states that he/she did nothing wrong and feels like he/she is in jail. Educated resident on reasons that privileges were taken per guardian and resident began to curse at the nurse. Review of the facility's Behavior Binder showed: - On 01/14/25, Resident #11 asked Unit Coordinator for his/her smoke break back. Unit Coordinator stated per guardian, resident lost smoke breaks for assaulting a staff member. Resident started screaming and cussing at Unit Coordinator. Resident called guardian screaming and yelling. Review of Resident #11's medical record showed a lack of physician evaluation to establish how the resident's mental health could benefit from restricted smoke breaks as a behavioral health intervention, restricted Internet use, lack of privacy, and secured on a locked unit. During an interview on 01/14/25 at 12:13 P.M., the resident said they have an actions and consequences list on the bathroom door. Resident #11 said he/she had punched CNA A in the face after a verbal altercation. The resident felt humiliated and now he/she can't smoke for three days. 2. Review of Resident #61's medical record showed: - admitted [DATE]; - Diagnoses of schizophrenia, restlessness and agitation, and oppositional defiant disorder (a condition characterized by a persistent pattern of defiant, angry, and irritable behavior towards authority figures, such as parents, teachers, or caregivers); - Per the PASARR Level II screening: Resident with history of overdose on opiates, poor insight/judgment, looseness of association, flight of ideas, thought broadcasting, poor sleep, grandiose delusions, decreased appetite, depressed mood, elevated anxiety level, irritability, decreased energy, feelings of helplessness/hopelessness/guilt, self-isolation, excessive worry, panic attacks, heart racing, and sweating. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Physical (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal (e.g., threatening others, screaming at others, cursing at others) behavioral symptoms directed toward others, other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) and wandering all occurred one to three days in the seven-day look back period; - Independent with ADLs; - The resident received antipsychotic, antianxiety, and antidepressant medication in the seven-day look back period. Review of the resident's care plan, revised 11/29/24, showed: - The resident resides on the secured behavioral unit due to history of behaviors. At risk to harm self or others. At risk for elopement; - On 06/13/24, Unit Coordinator spoke with guardian and resident is only allowed to have one incoming and one outgoing call per day; - On 06/17/24, Per resident's court appointed guardian resident's family may call the resident on Sundays at 2:00 P.M. They can talk for up to 15 minutes and the calls are to be monitored. He/She is not allowed phone calls with anyone else at this time. If the family member treats staff rudely again, all calls will be stopped for 30 days. The Unit Coordinator told the resident's guardian, If the resident calls his/her family once a day there might be an increase in behaviors. Resident #61's calls to his/her family will start with them talking one time per week and can increase if no behaviors follow; - On 07/19/24, Resident came out of room, upset, over not talking to family on phone; - On 09/10/24, Resident upset and pacing back and forth. Resident said he/she was mad because he/she was told he/she could not talk to his/her family for a long time; - On 12/02/24, Resident is allowed to talk to his/her mother on the phone on speaker in front of staff supervised once per day for fifteen minutes as long as he/she has good behavior the day of and day prior to his/her phone call. Review of the resident's progress notes showed: - On 01/12/25 at 5:30 P.M., Resident #11 was agitated an went into office and grabbed scissors. Resident tried to cut right thumb. There is a small mark on resident's finger. Unit Coordinator instructed staff to remove resident's belongings from room to prevent resident from harming himself/herself in any other way. When staff tried to pack resident's belongings up, resident got mad and tried attacking staff. Staff initiated defense team with staff support and handled appropriately. No injuries present. Staff put resident's belongings in office and locked office; - On 01/15/25 at 11:15 A.M., Resident was having a behavioral outburst, and showing signs and symptoms of attention seeking behaviors. Nurse went to speak with resident with other staff present. When asked why he/she was upset, resident stated I want all my shit back. Review of Resident #61's medical record showed a lack of physician evaluation to establish how the resident could benefit from restricted contact with his/her family, removal of all his/her possessions including clothing, lack of privacy and secured on a locked unit. Observations of Resident #61 showed: - On 01/14/25 at 1:33 P.M., the resident walked in the hall wearing a hospital gown and pants; - On 01/15/25 at 1:32 P.M., the resident lay in bed with covers over his/her head; - On 01/15/25 at 2:53 P.M., the resident sat on the floor in the hall wearing a hospital gown and pants. During an interview on 01/14/25 at 1:33 P.M., Resident #61 said he/she is wearing a hospital gown because he/she was self-harming by trying to cut his/her arm. He/She would like to wear his/her own clothes. He/She has some clothes in the office, but they won't let him/her wear them until he/she quits self-harming. That's the Unit Coordinator's rule. On 01/15/25 at 2:53 P.M., Resident #61 said wearing a hospital gown made him/her feel bad. 3. Review of Resident #68's medical record showed: - admitted [DATE]; - Diagnoses of borderline intellectual functioning (on the border between normal intellectual functioning and intellectual disability), suicide attempt, borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions), and poisoning by multiple unspecified drugs; - Per the PASARR Level II screening: Resident has history of sexual abuse. Resident has verbalized feeling guilt and overwhelming sadness and experiences auditory and visual hallucinations. The voices are angry with him/her and tell him/her he/she deserved what happened. He/She also verbalized having difficulty dealing with coping with his/her aunt's terminal illness. He/She has overdosed on all of his/her medications multiple times in the past and prior to this admission. He/She has a history of self-abuse by cutting, with the last reported incident several months ago. Staff use distraction and visualization when the resident is experiencing suicidal ideations. Review of the resident's quarterly MDS assessment, dated 10/10/24, showed: - No cognitive impairment; - Independent with ADLs; - The resident received antipsychotic and antidepressant medications in the seven-day look back period. Review of the resident's care plan, revised 10/25/24, showed: - Resident resides on the secured behavioral unit due to history of behaviors. At risk to harm self or others. At risk to elope from facility; - History of suicidal ideations and multiple suicide attempts by overdosing on medications; - History of self abuse/mutilating by cutting; - Chronic self-injurious behaviors; - Homicidal statements that he/she felt like hurting someone; - Experienced nightmares, isolation, and anxiety; - On 01/07/24, Guardian has emailed Unit Coordinator and stated that resident is to have no contact whatsoever with his/her parents at this time. Guardian will let Unit Coordinator know when contact will be allowed again; - On 02/09/24, CNA reported resident exhibiting suicidal thoughts. Facility got orders to send out for eval. POA and case manager notified. Case manager giving permission for resident to be sent out and stated that facility may take away his/her items due to behavior; - On 02/28/24, Resident stated he/she was depressed and missed talking to his/her family. Deputy from resident's legal guardian's office explained to resident that his/her guardian did not want resident to have phone conversations with his/her family for 30 days after admission to the facility, so that he/she could have an adjustment period and history of getting upset after phone calls from his/her family; - On 03/11/24, Unit Coordinator talked to resident's guardian about his/her behaviors over the weekend. Resident is not allowed to see his/her family until his/her guardian approves; - On 03/15/24, Resident refused medication and did some yelling this morning. Unit Coordinator told the resident he/she will not be able to participate in today's festivities per his/her guardian. Review of the resident's progress notes showed: - On 01/07/25 at 3:26 P.M., Guardian has emailed Unit Coordinator and stated that he/she wants resident to have no contact whatsoever with his/her parents at this time. Guardian will let Unit Coordinators know when he/she will allow contact again. During an interview on 01/14/25 at 1:36 P.M., Resident #68 said he/she is wearing a hospital gown because he/she was self-harming (scratching really hard on the inside of his/her wrist). Once he/she quits, he/she will get his/her clothes back. He/She would really like to wear his/her clothes. On 01/15/25 at 1:16 P.M., Resident #68 said he/she has had to wear the hospital gown for two weeks. He/She said it makes him/her feel embarrassed when he/she has to wear a hospital gown. Observations of Resident #68 showed: - On 01/14/25 at 12:06 P.M., the resident lay on a mattress in the floor with the cover pulled over his/her head. - On 01/15/25 at 1:16 P.M., the resident sat on the mattress on the floor wearing a hospital gown; - On 01/15/25 at 4:26 P.M., the resident's mattress was on the floor; - On 01/16/25 at 8:44 A.M., the resident's mattress was on the floor. Review of Resident #68's medical record showed a lack of physician evaluation to establish how the resident could benefit from restricted communication to his/her family, wearing a hospital gown instead of normal clothes for an extended period of time and keeping his/her mattress on the floor for an extended period of time. During an interview on 01/15/25 at 3:00 P.M., Resident #68 said his/her bed was taken away as a consequence of self-harming. He/She is the only one on the unit who sleeps on the floor like that. He/She feels like a hobo and his/her back is starting to hurt from it. 4. During a telephone interview on 01/22/25 at 2:25 P.M., Licensed Practical Nurse (LPN) B was aware of the Actions/Consequences program and that staff would take belongings or smoke breaks away following the program. LPN B could see how some residents could possibly view the program as a punishment. During an interview on 01/15/25 at 11:40 A.M., CNA I said the actions and consequences program was in place when he/she began working at the facility over a month ago. CNA I said he/she had been instructed to enforce the consequences. There is a Behavior Book where staff is to keep track of which residents have had what taken away and for how long. CNA I said he/she feels the consequences can escalate behaviors for some residents. During an interview on 01/15/25 at 11:55 A.M., CNA J/Unit Coordinator said the actions and consequences program started in December 2023. Resident's guardians and responsible parties have all signed off on it as well. Staff are expected to enforce the program. CNA J explained the process as when a staff member sees a resident exhibiting one of the actions, they are to come to CNA J and report what they saw and then discuss and agree on what consequence to take. A summary of each consequence is sent to the resident's guardians/responsible party. They approve by signing the form and sending it back, and it is kept on file. CNA J said staff track behaviors and consequences in the Behavior Book. CNA J said some resident's behaviors are escalated by the consequences. During an interview on 01/15/25 at 12:10 P.M., the DON said she started working at the facility two years ago and the Foundation Program (name of the action/consequence list) was in place when she got here. The residents all have copies of the actions and consequences list, and all resident's guardians are aware, and we have either verbal or written consent. The CNAs will report actions to the Unit Coordinator and the Unit Coordinator keeps track of which residents receive what consequence in a binder. The DON believes the program has been very beneficial. When the prior Unit Coordinator was here, the unit was in utter chaos. The DON said some residents can be triggered by the consequences. During an interview on 01/17/25 at 4:35 P.M., the Administrator, DON, and ADON said they would expect residents to retain their personal items that they are allowed to have and for the behavioral program to not infringe on resident rights. During a telephone interview on 01/27/25 at 8:37 A.M., CNA J/Unit Coordinator said there was no tracking tool for behaviors. Staff would just go through the behavior binder to see how it was. He/She is there six days a week. Staff would give report for the next shift and that's how they would know who had consequences. Staff would ask the nurse when residents should get their items back because the nurse was always notified. Resident #11 lost his/her smoke breaks for punching and biting CNA A on 01/11/25 and the next day Resident #11 was acting like she wanted to fight other staff, so he/she got 48 hours of smoke breaks taken away on 01/12/25. Resident #61 threatens things every day, like he/she would start scratching himself/herself when a pen, then staff would take that away. Then Resident #61 would say he/she was going to find something else to kill himself/herself with. He/She had a pair of pants and was trying to choke himself/herself and that was when we gave him/her the gown. Staff notified the guardian and the guardian was going to try to get the resident into a Department of Mental Health place, but the guardian said she couldn't find a place. CNA J cannot remember when Resident #61's action began and when the consequence should have ended. When Resident #61 and #68 know that they are getting their items back, they will try the same things again. Staff were trying to keep them safe because staff can't do 1:1 with everyone on the hall. CNA J cannot remember when Resident #68's action began and when the consequence should have ended. The longest the residents get items taken away is 72 hours. Residents will try to choke themselves with their pants and break hangers and eat them. Resident #68's mattress was on the floor because the resident would attempt to cut himself/herself with the springs on the bed. CNA J cannot remember when this happened, but Resident #68 had only been without a frame for about five days. During an interview on 02/05/25 at 11:34 A.M., the DON said all employees sign the Resident Rights form upon hire and annually. She also has the agency staff sign it as well on their first shift. She just started having agency sign these in June of last year. During an interview on 02/06/25 at 8:09 A.M., the DON said the only criteria the facility has for working on the behavior unit is staff must be at least [AGE] years old. The facility staffs two CNAs and the Unit Coordinator most days and that is preferred, but when call outs happen that is not always an option so sometimes it's one CNA and the unit coordinator, who is also a CNA. During an interview on 02/06/25 at 10:48 AM, the DON said there are no written policies regarding the behavior unit at this time, however that is something we are working on and hope to have in place in the near future. The DON said the facility uses a contracted training for staff which encompasses behavioral health, but it is not required to be obtained before working on the unit. The DON said the beds on the locked behavior unit are nursing home beds and the residents residing on that unit are qualified to be in a nursing home. They are placed on the unit to ensure ease of care for their particular needs.

Based on observation, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for three sampled residents (Residents #11, #61 and #68) out of 22 residents who reside on the secured behavior unit. The facility failed to care plan resident specific interventions and did not assess the affect of the use of an actions/consequences list requested by the guardian. The facility did not develop a behavior plan or crisis intervention plan for residents as indicated by the pre-admission behavioral health screening. The unit enforced a program of negative consequences should a resident exhibit behaviors. The facility census was 74. The facility did not provide any policies or procedures regarding locked behavior unit staffing needs, specialized training needed to work on the locked behavior unit or criteria for admission to the locked behavior unit. The facility did not provide any mental health behavior training program for staff working on the locked behavioral unit. Review of the Facility Assessment, last updated 7/20/24 showed: - An average of 20-22 residents are receiving care on a locked behavioral unit; - An average of 20 residents requires a special level of behavioral mental health from facility staff; - Services and care offered to residents based on their needs included: - Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior; - Identify and implement interventions to help support individuals with issues such as dealing with anxiety; - Care of someone with cognitive impairment; - Care of individuals with depression, trauma/PTSD and other psychiatric diagnoses, intellectual or developmental disabilities; 1. Observation on 01/14/25 at 12:13 P.M. showed a printed paper posted on Resident #11's bathroom door which read: - Actions and Consequences, you all are aware of the rules, they are now set in place. So, if you have one of these actions there will be consequences and we will be following through with each one of them. - The document was then divided into two columns, one labeled Action the other Consequences. The Consequences column had two options for each action depending on a resident ' s smoking status; - Action: Arguing with another resident. Consequence: Sent to room to work on coping skills; - Action: Arguing with staff, not listening. Consequence: Resident loses one smoke break; - Action: Arguing with staff, not listening. Consequence: Resident loses one day of snack cart; - Action: Cursing out staff. Consequence: Resident loses two smoke breaks; - Action: Cursing out staff. Consequence: Resident loses a week of snack cart; - Action: Hitting a staff member or a resident. Consequence: Resident loses smoke break for 48 hours; - Action: Hitting a staff member or a resident. Consequence: Resident loses snack cart for two weeks; - Action: Stealing from another resident. Consequence: Resident loses two smoke breaks; - Action: Stealing from another resident. Consequence: Resident loses snack cart for a week; - Action: Attention seeking Self-Harming behavior. Consequence: Resident loses belongings and smoke break for the day and is to wear a gown with pants; - Action: Attention seeking Self-Harming behavior. Consequence: Resident loses belongings and snack cart for the week and is to wear a gown with pants; - Action: Refusing medication. Consequence: Resident loses everything until medication is taken; - Action: Taking off a resident tray or sharing food. Consequence: Resident loses smoke break for 24 hours; - Action: Taking off a resident tray or sharing food. Consequence: Resident loses snack cart for the week; - Action: Resident refusing shower for two days. Consequence: Resident loses smoke break until shower is taken; - Action: If a resident stands where staff is charting after staff has redirected. Consequence: Resident loses one smoke break, and snack cart for the day; - Action: Resident not listening to being sent to room, due to behavior on the hall and not shutting the door when asked. Consequence: Resident will lose all privileges for the rest of the day; - Action: Resident sharing anything without staff approval. Consequence: Resident loses one smoke break; - Action: Resident sharing anything without staff approval. Consequence: Resident loses one snack cart day; - Action: Resident going past the double doors with the phone after being reminded. Consequence: Resident loses one smoke break; - Action: Resident going past the double doors with the phone after being reminded. Consequence: Resident loses one snack cart day; - Action: Resident not following directions or listening to the staff when asked of something. Consequence: Resident loses one smoke break; - Action: Resident not following directions or listening to the staff when asked of something. Consequence: Resident loses one snack cart; - Action: Resident keeping things in their room, that are not allowed. Consequence: Resident loses one smoke break per item found in room; - Action: Resident keeping things in their room, that are not allowed. Consequence: Resident loses snack cart days per item found in room. Review of Resident #11's medical record showed: - admitted on [DATE]; - Diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and nicotine dependence (a chronic brain disorder that causes a person to compulsively need nicotine, a substance found in tobacco products and includes withdrawal symptoms like restlessness, agitation, increased hunger, insomnia, constipation, or diarrhea). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 11/05/24, showed: - No cognitive impairment; - Exhibited hallucinations in the seven-day look back period; - Independent with activities of daily living (ADLs); - The resident routinely received antipsychotic medication in the seven-day look back period. Review of the resident's Level II screening (a comprehensive assessment of current and historical treatment), dated 03/17/21, showed: - Resident has history of depression, anxiety, paranoia, agitation, aggression, mood swings, non-compliance with medication and treatment, impulsive behaviors, poor decision making, racing thoughts, irritation, anger outbursts, poor sleep at times, poor appetite at times, at a previous facility was found walking on the road, non-compliance with rules, suicidal ideation - thought of hanging self, history of suicidal attempt, punching walls, and marijuana use; - Resident needs a Behavioral Plan in place for ongoing assessment for mental status changes, including mood and thought process. The resident's previous behavior plan in place during hospital placement included 1. A safe day with no emergency procedures due to unsafe behaviors that are not redirectable. 2. No threats of harm or unsafe behaviors that are not redirectable within 3 attempts. 3. Ability to go to a quieter/safer area to calm down when agitated. If she meets all the above for the entire day, she will earn 1 soda the following day. See hospital records. Ensure safety of sharps due to history of ingesting. Review of the resident's care plan, revised 11/11/24, showed: - Resident at increased risk for behavioral/mood problems due to history of behaviors. At risk to harm self or others. At risk to elope from facility; - History of physical violence. - Unit Coordinator got approved per guardian directive that if resident has a behavior, staff can take away any open hall activities and a smoke break and do room searches for safety reasons; - Unit Coordinator spoke with resident's guardian in regard to the unit policies and procedures and went over each one with the guardian. The guardian agreed with the unit policies and procedures, and states she gives verbal consent and to add these to resident's guardian directives. The care plan did not address resident specific interventions and did not address the use of an actions/consequences list. The facility did not provide a behavior plan as indicated by the Level II screening. The facility did not provide a crisis intervention plan for behaviors. During an interview on 01/14/25 at 12:13 P.M., Resident #11 said he/she had an altercation with Certified Nursing Assistant (CNA) A and he/she punched CNA A in the face. They have an actions and consequences list on the bathroom door. Resident #11 said because he/she hit the nurse he/she can't smoke for three days. Resident #11 said it was humiliating. During a telephone interview on 01/27/25 at 8:37 A.M., CNA J/Unit Coordinator said Resident #11 lost his/her smoke breaks for punching and biting CNA A on 01/11/25 and the next day Resident #11 was acting like she wanted to fight other staff, so he/she got 48 hours of smoke breaks taken away on 01/12/25. 2. Review of Resident #61's medical record showed: - admitted [DATE]; - Diagnoses of schizophrenia, restlessness and agitation, and oppositional defiant disorder (a condition characterized by a persistent pattern of defiant, angry, and irritable behavior towards authority figures, such as parents, teachers, or caregivers); Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Physical (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal (e.g., threatening others, screaming at others, cursing at others) behavioral symptoms directed toward others, other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) and wandering all occurred one to three days in the seven-day look back period; - Independent with ADLs; - The resident received antipsychotic, antianxiety, and antidepressant medication in the seven-day look back period. Review of Resident Level II screening, dated 12/16/22 showed: - Resident with history of overdose on opiates to end life, held gun to his/her head, poor insight/judgment, looseness of association, flight of Ideas, thought broadcasting, poor sleep, grandiose delusions, decreased appetite, depressed mood, elevated anxiety level, irritability, decreased energy, feelings of helplessness/hopelessness/guilt, self-isolation, excessive worry, panic attacks, heart racing, and sweating; - The need for the facility to establish a daily behavior plan for Resident #61 to facilitate his getting up and actively participating In the program, regardless of level of sleep need. It Is recommended the facility obtain a copy of his ISP from [NAME] Regional Office to Identify areas in which he requires education and urging/encouragement to work toward less restricted level of care. Review of the resident's care plan, revised 11/29/24, showed the resident resides on the secured behavioral unit due to history of behaviors. At risk to harm self or others. At risk for elopement. The care plan did not address resident specific interventions and did not address the use of an actions/consequences list. The facility did not provide a behavior plan as indicated by the Level II screening. The facility did not provide a crisis intervention plan for behaviors. Review of the resident's progress notes showed: - On 01/12/25 at 5:30 P.M., resident threatening to hit staff and hovering over staff on hall. Staff told resident to stop hovering over them. Resident did not like that and got mad, yelling at staff. Resident went into office and grabbed scissors. Resident tried to cut right thumb. There is a small mark on resident's finger. Unit Coordinator instructed floor staff to remove resident's belongings from room to prevent resident from harming himself/herself in any other way. When staff tried to pack resident's belongings up, resident got mad and tried attacking staff. Staff initiated defense team with staff support and handled appropriately. No injuries present. Staff put resident's belongings in office and locked office; During an interview on 01/14/25 at 1:33 P.M., Resident #61 said he/she had to wear a hospital gown because he/she was self-harming by trying to cut his/her arm and staff took everything out of his/her room. He/She would like to wear his/her own clothes. Resident #61 said his/her clothes are locked in the office, but they won't let him/her wear them until he/she quits self-harming. That's the Unit Coordinator's rule. During an interview on 01/15/25 at 2:53 P.M., Resident #61 said wearing a hospital gown made him/her feel bad. He/She was thinking of self-harming and had been working on coping skills. During a telephone interview on 01/27/25 at 8:37 A.M., CNA J/Unit Coordinator said Resident #61 threatens things every day, like he/she would start scratching himself/herself with a pen, then staff would take that away. Then Resident #61 would say he/she was going to find something else to kill himself/herself with. He/She had a pair of pants and was trying to choke himself/herself and that was when we gave him/her the gown. Staff notified the guardian and the guardian was going to try to get the resident into a Department of Mental Health place, but the guardian said she couldn't find a place. 3. Review of Resident #68's medical record showed: - admitted [DATE]; - Diagnoses of borderline intellectual functioning (on the border between normal intellectual functioning and intellectual disability), suicide attempt, borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions), and poisoning by multiple unspecified drugs. Review of the resident's quarterly MDS assessment, dated 10/10/24, showed: - No cognitive impairment; - Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), and rejection of care occurred one to three days during the seven-day look back period; - Independent with ADLs; - The resident received antipsychotic and antidepressant medications in the seven-day look back period. Review of Resident #68's Level II screening, dated 11/19/23, showed: - Resident has history of being sexually abused. Resident has verbalized feeling guilt and overwhelming sadness and experiences auditory and visual hallucinations. The voices are angry with him/her and tell him/her he/she deserved what happened. He/She also verbalized having difficulty dealing with coping with his/her aunt's terminal illness. He/She has overdosed on all of his/her medications multiple times in the past and prior to this admission. He/She has a history of self-abuse by cutting, with the last reported incident several months ago. Staff use distraction and visualization when the resident is experiencing suicidal ideations; - The resident's needs could be met in a nursing facility; - The resident needs the following support services: - Obtain Individual Support Plan (ISP), Individual Treatment Plan (ITP), Behavior Heath Plan (BHP) from the Department of Mental Health, or other such entity; - Monitoring of behavioral needs; - Trauma informed services; - Tools of Choice or other Positive Behavioral Support service. Review of the resident's care plan, revised 10/25/24, showed: - Resident resides on the secured behavioral unit due to history of behaviors. At risk to harm self or others. At risk to elope from facility; - History of suicidal ideations and multiple suicide attempts by overdosing on medications; - History of self abuse/mutilating by cutting; - Chronic self-injurious behaviors; - Homicidal statements that he/she felt like hurting someone; - Experienced nightmares, isolation, and anxiety; - 03/31/24: Resident having behavioral outburst, and showing signs and symptoms of attention seeking behavior as he/she has a history of behavior. Resident acting as if he/she will use zipper off his/her clothes to harm self, and making suicidal statements. Staff removed resident's clothing and resident given hospital gown related to resident attempting to use items off his/her clothes to harm self with. Resident not cooperative at first and was yelling and being tearful but no tears present noted. Resident became agitated and physically aggressive toward staff. The care plan did not address resident specific interventions and did not address the use of an actions/consequences list. The facility did not provide a behavior plan as indicated by the Level II screening. The facility did not provide an ISP, ITP or BHP. The facility did not provide a crisis intervention plan for behaviors. During an interview on 01/14/25 at 1:36 P.M., Resident #68 said he/she is wearing a hospital gown because he/she was self-harming (scratching really hard on the inside of his/her wrist). Once he/she quits, he/she will get his/her clothes back. He/She would really like to wear his/her clothes. During an interview on 01/15/25 at 1:16 P.M., Resident #68 said he/she has had to wear the hospital gown for two weeks. He/She said it makes him/her feel embarrassed when he/she has to wear a hospital gown. During an interview on 01/15/25 at 3:00 P.M., Resident #68 said his/her bed was taken away as a consequence of self-harming. He/She is the only one on the unit who sleeps on the floor like that. He/She feels like a hobo and his/her back is starting to hurt from it. During a telephone interview on 01/27/25 at 8:37 A.M., CNA J/Unit Coordinator said there was no tracking tool for behaviors. Staff were trying to keep them safe because staff can't do 1:1 with everyone on the hall. CNA J cannot remember when Resident #68's action began and when the consequence should have ended. The longest the residents get items taken away is 72 hours. Resident #68's mattress was on the floor because the resident would attempt to cut himself/herself with the springs on the bed. CNA J cannot remember when this happened, but Resident #68 had only been without a mattress for about five days. Observations of Resident #68 showed: - On 01/14/25 at 12:06 P.M., the resident lay on a mattress in the floor with the cover pulled over his/her head; - On 01/15/25 at 1:16 P.M., the resident sat on the mattress on the floor wearing a hospital gown; - On 01/15/25 at 4:26 P.M., the resident's mattress on the floor; - On 01/16/25 at 8:44 A.M., the resident's mattress on the floor. During an interview on 01/15/25 at 11:40 A.M., CNA I said the actions and consequences program was in place when he/she began working at the facility over a month ago. CNA I said he/she had been instructed to enforce the consequences. There is a Behavior Book where staff is to keep track of which residents have had what taken away and for how long. CNA I said he/she feels the consequences can escalate behaviors for some residents. During an interview on 01/15/25 at 11:55 A.M., CNA J/Unit Coordinator said the actions and consequences program started in December 2023. Resident's guardians and responsible parties have all signed off on it as well. Staff are expected to enforce the program. CNA J explained the process as when a staff member sees a resident exhibiting one of the actions, they are to come to CNA J and report what they saw and then discuss and agree on what consequence to take. A summary of each consequence is sent to the resident's guardians/responsible party. They approve by signing the form and sending it back, and it is kept on file. CNA J said staff track behaviors and consequences in the Behavior Book. CNA J said some resident's behaviors are escalated by the consequences. Interviews with the DON: - On 01/15/25 at 12:10 P.M., the DON said she started working at the facility two years ago and the Foundation Program was in place (name for the action/consequence list) when she got here. The residents all have copies of the actions and consequences list, and all resident's guardians are aware, and we have either verbal or written consent. The CNAs will report actions to the Unit Coordinator and the Unit Coordinator keeps track of which residents receive what consequence in a binder. The DON believes the program has been very beneficial. When the prior Unit Coordinator was here, the unit was in utter chaos. The DON said some residents can be triggered by the consequences; - On 02/06/2025 at 10:48 AM, the DON said there are no written policies regarding the behavior unit at this time, however that is something we are working on and hope to have in place in the near future. The DON said the facility uses a contracted training for staff which encompasses behavioral health, but it is not required to be obtained before working on the unit; - On 02/06/2025 at 10:48 AM, the DON said the beds on the unit are nursing home beds and the residents residing on that unit are qualified to be in a nursing home. They are placed on the unit to ensure ease of care for their particular needs.

Based on interview and record review, the facility failed to ensure the Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee developed and implemented an appropriate plan of action to correct identified quality deficiencies. This had the potential to affect all residents in the facility. The facility's census was 74. The facility did not provide a QAPI policy or any documentation related to a QAPI program. During an interview on 01/15/25 at 12:30 P.M., the Assistant Director of Nursing (ADON) said they don't have QAPI meetings. During an interview on 01/16/25 at 3:36 P.M., the Administrator said he has no QAPI policy or plan. He knows he should be doing something more formal. They do have a daily stand up meeting. During an interview on 01/17/25 at 4:35 P.M., the Administrator, Director of Nursing (DON), and ADON said they would expect to have a QAPI policy, QAPI plan, and a program to monitor and track any quality deficiencies and have Performance Improvement Plans (PIPs) in place for those deficiencies.

Based on interview and record review, the facility failed to have a Quality Assurance and Performance Improvement (QAPI, a program to improve the processes for the delivery of health care and quality of life for the residents) program in place with policies and protocols describing how the facility will identify and correct its own quality deficiencies. This deficient practice had the potential to affect all residents in the facility. The facility's census was 74. The facility did not provide a QAPI policy or any documentation related to a QAPI program. During an interview on 01/15/25 at 12:30 P.M., the Assistant Director of Nursing (ADON) said they don't have QAPI meetings. During an interview on 01/16/25 at 3:36 P.M., the Administrator said he has no QAPI policy or plan, nor does he have a list of the QAPI committee members. He knows he should be doing something more formal. They do have a daily stand up meeting. During an interview on 01/17/25 at 4:35 P.M., the Administrator, Director of Nursing (DON), and ADON said they would expect to have a QAPI policy, QAPI plan, and a program to monitor and track any quality deficiencies and have Performance Improvement Plans (PIPs) in place for those deficiencies. They would also expect to have QAPI meetings at least quarterly with the required members including the Medical Director, Administrator, DON, Infection Preventionist, and two other staff members.

Based on interview and record review, the facility failed to maintain quarterly Quality Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committee meetings with the required members. The facility's census was 74. The facility did not provide a QAPI policy or any documentation related to a QAPI program. During an interview on 01/15/25 at 12:30 P.M., the Assistant Director of Nursing (ADON) said they don't have QAPI meetings. During an interview on 01/16/25 at 3:36 P.M., the Administrator said he has no QAPI policy or plan, nor does he have a list of the QAPI committee members. He knows he should be doing something more formal. During an interview on 01/17/25 at 4:35 P.M., the Administrator, Director of Nursing (DON), and ADON said they would expect to have a QAPI policy, QAPI plan, and a program to monitor and track any quality deficiencies and have Performance Improvement Plans (PIPs) in place for those deficiencies. They would also expect to have QAPI meetings at least quarterly with the required members including the Medical Director, Administrator, DON, Infection Preventionist, and two other staff members.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from neglect when the staff failed to assess and provide prompt medical treatment when the resident complained of pain after a fall that resulted in fractures to the resident's tibia and fibula (the two long bones in the lower leg) and to the left humeral (upper arm bone) bones. The facility census was 68. The Administration was notified on 05/11/2023 at 3:00 P.M. of a Past Non-compliance Immediate Jeopardy (IJ) which occurred on 04/28/2023. Staff informed the facility administration of the incident on 04/30/2023 at which time the facility started an investigation. The investigation resulted in the termination of Licensed Practical Nurse (LPN) A. The facility also inserviced on abuse, neglect, reporting timely and the chain of command. The IJ was corrected on 05/10/23. Review of the facility's Overview of the Regulation, Abuse and Neglect policy, dated 2017, showed: - Residents are to be free of any and all types of abuse, neglect, misappropriation and exploitation; - The facility must have policies, procedures and education for new and existing staff about freedom from abuse; - Facility staff must know how and when to report suspected abuse; - Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; - If any staff witnesses or are informed of abuse, they must first protect the resident, intervene and stop the abuse. Review of Resident #1's medical record showed: - Date of admission of 07/20/22; - Diagnoses of paranoid schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), insomnia (difficulty sleeping), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety disorder (persistent worry and fear about everyday situations), nightmare disorder (a pattern of repeated frightening and vivid dreams that affects your quality of life), post traumatic stress disorder (PTSD) (a person has difficulty recovering after experiencing or witnessing a terrifying event), borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions). Review of the resident's care plan, updated 04/25/23, showed: -The resident resided on a secured behavioral unit; -The resident at risk of harming self and others and for elopement; -An intervention to assess whether his/her behavior endangers the resident and/or others and to intervene if necessary. Review of the resident's nurses notes for 04/28/23 through 05/01/23 showed: - On 04/28/23 at 06:45 P.M., Licensed Practical Nurse (LPN) A documented the resident lay on the floor after staff took the resident down because the resident was punching the walls. LPN A contacted the psychiatrist and received an order for a psychiatric injection. After receiving the injection, the resident refused to get up off the floor due to the pain in his/her left knee and left shoulder. LPN A told the resident that the refusal to get up was a behavior and he/she would not be gotten up out of the floor. Against LPN A's judgement, two staff assisted resident out of the floor and into a chair; - No entry on 04/29/23 related to a post fall assessment or complaints of pain; - On 04/30/23 at 11:03 A.M., the resident remained in bed all day and staff reported he/she was total care all day related to complaints of pain to his/her left upper and lower extremities. Upon assessment, moderate bruising was present to the left upper extremity and his/her range of motion (ROM) has declined. He/she reported a pain level of a 10 out of 10. The resident had some edema present to the left knee and the ROM to the knee was also decreased. The resident reported the inability to stand or to ambulate. The resident presentation indicated discomfort. X-rays were ordered; - No documentation of the date or time the resident was sent out to the emergency room ; - On 05/01/23 at 12:35 AM, the resident arrived back at facility per ambulance. The report given from the emergency room showed the resident had a left humerus fracture, a left tibial plateau fracture, and a left fibula fracture. The resident was non-weight bearing. Review of the resident's left tibia/fibula x-ray report, dated 4/30/23, showed: - Acute comminuted fractures (a bone that is broken in at least two places) through the lateral tibia plateau (the flat top portion of the tibia bone that runs from the knee to the ankle); - Acute comminuted fractures involving the proximal (closer to the center of the body) metaphysis (the trumpet-shaped end of a long bone) and the head of the fibula. Review of the resident's left shoulder x-ray report, dated 4/30/23, showed: - An acute fracture through the humeral head (the large rounded head of the humerus) and neck regions. Review of the facility's investigation, dated 05/01/23 and started on 04/30/23, showed: - Resident #1 had self-harming and other harming behaviors resulting in Certified Medication Technician (CMT) B performing an approved behavioral crisis physical intervention (a physical hold used during a behavioral crisis) on 04/28/23; - CMT B and the resident lost their balance which resulted in both falling to the floor; - The resident reported pain in his/her left leg immediately; - The resident told LPN A the fall broke his/her leg; - CMT B told LPN A that he/she heard a snap and a crack when the resident fell ; - The resident refused to stand after the fall; - Certified Nursing Assistant (CNA) D said the resident told LPN A he/she could not stand. LPN A said, I'm not picking your ass up out of the floor and if you refuse to get up, I'll get you a damn pillow. You can sleep on the floor; - LPN E's witness statement showed the resident complained of left knee pain and could not bear weight. LPN E said a thorough assessment of the left leg was completed with pitting edema (swelling) noted at the knee. Palpation of the knee showed no pain. Staff assisted the resident into a chair. LPN E assessed the resident on the morning of 04/29/23, and did not feel there were any significant findings and did not document. The resident was given Tylenol for pain. The facility felt at no time did the staff willingly neglect the resident. Observation of Resident #1 on 05/11/23 at 9:30 A.M., showed staff pushed the resident in a wheelchair on the locked unit. The resident sat in a high back wheelchair with an extended foot/leg rest that kept the left leg straight. The left leg had an immobilizer on it that extended above and below the knee down to the ankle. The left ankle, foot and lower leg had noted swelling. The resident did not move his/her left arm. The resident had yellow to light purple bruising down his/her left upper arm, shoulder, and onto the chest. During an interview on 05/11/23 at 9:30 A.M., the Director of Nursing (DON) said Resident #1 had behaviors and hit the wall (4/28/23). The resident drew back in an attempt to hit CMT B and staff reacted with a primary restraint technique (PRT) (an approved behavioral crisis physical intervention). CMT B lost his/her balance and both fell sideways. There were no signs of a fracture and LPN A felt the resident was not truthful about his/her pain. Within two days, the resident had bruising and staff obtained an order for an x-ray. The resident's left leg and left shoulder were broken. The resident had osteopenia (a decrease in bone mineral density which can cause bones to fracture more easily) and took multiple calcium depleting psychiatric medications. Staff performed the PRT correctly. LPN A refused to be interviewed. Resident #1 had an orthopedic appointment on 05/12/23. During an interview on 05/11/23 at 9:45 A.M., Resident #1 said due to his/her behaviors, CMT B had to perform a PRT on 04/28/23. CMT B had control of the resident's right side, but not the left, and they ended up falling after the resident tried to swing CMT B around. The resident couldn't get up due the left leg pain and immediately told CMT B and LPN A his/her left leg was broken. LPN A laughed and said the resident was fine. LPN A told the resident to get up and if he/she didn't, then he/she would be written up and could sleep on the floor. LPN A never assessed him/her for injuries. On Sunday, 04/30/23, was the first time a nurse even looked at him/her. His/her only concern was that LPN A ignored his/her pain and laughed at him/her. During an interview on 05/11/23 at 11:30 A.M., CMT B said he/she tried to talk Resident #1 down verbally, but that didn't work so CMT B performed the PRT (4/28/23). CMT B's left foot was behind the resident's left foot and when the resident swung his/her body, CMT B's foot prevented the resident's foot from pivoting and both fell down. He/she thought the resident's left leg looked abnormal and he/she immediately complained of pain. CMT B heard a crack and pop and told LPN A. There was swelling to the left leg and the knee was kind of turned inside with the foot out about 20 degrees. CMT B told LPN A something wasn't right four to five times in the first 30 minutes after it happened. The resident was not able to bend the leg or get up. CMT B never saw LPN A assess the resident. The resident refused to get out of bed, bear weight, and was fully mobile prior to the incident. During an interview on 05/11/23 at 12:25 P.M., CNA C said Resident #1 heard voices that were telling him/her to hurt him/herself and others. CNA C went to find LPN A. CMT B heard CNA C and went back to the unit to assist. CMT B asked the resident to stop hitting the wall. CMT B performed the PRT, had control of Resident #1's right side but didn't have control of the left side, and they fell . The resident could only bear weight to the right leg. On 04/29/23 between 2:30 A.M. and 3:00 A.M., the resident asked to be carried to the bathroom. LPN A offered a urinal and the resident refused it. The resident complained of a lot of pain. CNA C never saw LPN A assess Resident #1 but did see him/her in the hall when CNA C left to assist another resident. During an interview on 05/11/23 at 2:05 P.M., CMT B said LPN A administered a psychiatric injection to the resident while he/she lay on the floor. He/she released the resident when they both fell and the resident said, Let me go. The resident voiced his/her pain very plainly to everyone, including LPN A. During an interview on 05/11/23 at 2:52 P.M., CNA D said he/she didn't see the fall. Afterwards, Resident #1 was propped up against CNA D's legs. LPN A yelled at the resident to get off the floor. CNA D told LPN A he/she couldn't get the resident up because the resident was hurt. LPN A said, I'm not going to pick your ass up out of the floor, I'll get a pillow and you can sleep here. CNA D and CNA F lifted the resident into a wheelchair and then onto the bed. He/she went to do the paperwork for the incident but LPN A said not to do it because he/she would take care of it and document it as a behavior. LPN A never assessed the resident for injuries even though he/she was saying his/her left leg was broken and refused to get up. During an interview on 05/11/23 at 2:15 P.M., the DON said it was expected that an assessment be performed by a nurse after any altercation, PRT or a fall. An assessment should have been completed on Resident #1, especially with the complaint of pain. She received a text that a PRT had been performed on the resident and LPN A called the doctor to obtain an order for a psychiatric injection. She was not notified about Resident #1 falling or complaining of pain. She did not become aware of the injury until 04/30/23. None of the staff saw LPN A assess the resident after the incident. Resident #1 denied LPN A assessed him/her after the injury. LPN A was agency staff but had been working shifts since at least June 2022. She did not have any documentation about the PRT in the agency book that was given to the agency staff as she did not want them to perform it if they were not trained. The staff were expected to contact her if a PRT was performed. Had LPN A notified her of the incident, an x-ray would have been ordered or the resident would have been sent to the emergency room . During an interview on 05/11/23 at 3:30 P.M., the Administrator said it was expected the DON let him know of abnormal events like falling with a PRT and an injury. Had the DON known about the injury, they would have ensured care had been provided. Anytime staff placed their hands on a resident, a resident falls, or a resident complains of pain, an assessment should be completed by a nurse. MO00217777 & 217879

Based on observation, interview and record review, the facility failed to obtain and provide effective pain management for one (Resident #4) with severe pain in a sample of 12 residents. Staff also failed to follow the facility pain management policy and protocol and failed to obtain and administer medication for one (Resident #5) in the sample. The facility failed to administer medication to one additional (Resident #17) outside the sample. The facility census was 37. 1. Record review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/17/12, showed the resident was cognitively independent for decision making and had frequent pain with moderate intensity. Review of the resident's physician's orders [REDACTED]. The physician had ordered [MEDICATION NAME] 5-325 milligrams (mg) (treats mild to moderate pain) every six hours as needed (PRN) for pain on 7/04/12. Review of the plan of care, last up-dated 7/24/12, showed resident had potential for pain due to recent left [MEDICAL CONDITION] that required surgical repair. The long term goal is to prevent chronic pain and relieve acute pain within one hour of the intervention. Record Review of the POS [REDACTED].M.. During an interview on 8/03/12 at 3:15 P.M., Resident #4 said his/her pain pills were not working and the nurse told him/her to tell the physician and he would order a pain patch. The resident said he/she had not received the patch over the weekend. The nurse had told him/her the pharmacist was not available over the weekend to fill the order. The pain pills take the edge off but said this was the worst pain he/she had ever experienced and looked forward to getting the patch. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - 08/01/12 one time and marked as effective, no pain scale was used; - 08/03/12 one time and marked as effective, no pain scale was used; - 08/05/12 two times and marked as effective, no pain scale was used; - 08/06/12 one time and marked as effective, no pain scale was used. Record review showed a nurse's note, dated 08/04/12 at 12:19 P.M., said the [MEDICATION NAME] not yet received from pharmacy. The medication may not be available until 08/06/12 as the pharmacy is closed on weekends and does not deliver medications. The pharmacy will be contacted 08/06/12 in the A.M. regarding delivery of [MEDICATION NAME]es. During an interview on 8/06/12 at 3:38 P.M., Licensed Practical Nurse (LPN) I said the DON called the pharmacy about the resident's [MEDICATION NAME] and the pharmacy said they let the order slip by them over the weekend. LPN I said nursing staff should have followed-up on why the patch had not been received. During an interview on 8/07/12 at 7:58 A.M., Resident #4 said the pain is usually a #10 in his/her back and left hip and with the [MEDICATION NAME] pills the pain only goes down to a #7 on the pain scale. A pain scale that is a #0 indicates no pain and a #10 indicates the worst pain possible. Review of the MAR, dated August 2012, showed the [MEDICATION NAME] was received and applied on 8/06/12 at 16:30 P.M. Observation on 8/08/12 at 9:53 A.M., showed the resident complained of pain. Certified Medication Technician (CMT) J told the resident he/she had all the medication ordered. The Administrator said to the resident he/she should tell the physician the next time he comes. Staff did not check the [MEDICATION NAME] placement. During an interview on 08/08/12 at 10:32 A.M., the Administrator said he/she found the resident's pain patch on the floor of the resident's room and staff reapplied the patch with tape. During an interview on 08/09/12 at 5:43 A.M., Resident #4 said since the pain patch had been taped on, he/she had less pain and rated his/her pain at a #2 on the #0 to #10 pain scale. The resident said with the patch he/she slept all night without being awakened by pain. Review of the facility pain management policy and protocol, dated 07/05/05, showed: - If a resident reports pain during the initial screening, a comprehensive assessment and further evaluation is done; - Chronic pain is to be treated with regularly schedule pain medications. An as needed dosing is appropriate only as an adjunct to routine medications; - When pain interventions do not relieve pain, the physician will be notified and additional measures considered; - A pain management book will be kept a nurse's station and contains a list of resident's on pain management program and a pain screening and pain assessment form; - The pain assessment form instructs staff to use the pain scale to assess pain and to notify physician if resident scores one or higher on the severity scale. Staff failed to follow the facility pain management policy by not using a pain scale to assess the resident's pain, not notifying the physician of resident's continuing pain, and not obtaining medication as ordered by the physician. 2. Record review of the August 2012 physician order [REDACTED]. The POS included an order for [REDACTED]. Record review of Resident #5's MAR, dated August 2012, showed an physician's orders [REDACTED]. August 1st through August 6th was circled as not given. During an interview on 8/07/12 at 1:34 P.M., CMT D said the medication was not here to give, staff ordered the medication but it did not come, staff called the pharmacy and the medication still does not come. It happened sometimes with that pharmacy. During an interview on 8/07/12 at 2:51 P.M., the DON said the medication treats the resident's [MEDICAL CONDITION] and should have been obtained for the resident. The DON said he/she could not see where the [MEDICATION NAME] was ordered. 3. Observation on 08/06/12 at 12:42 P.M. showed CMT D administered noon medications. He/she failed to administer [MEDICATION NAME] Ultra eye drops (dry eye lubricant) ordered for Resident #17, one drop in each eye four times a day. During an interview on 08/06/12 at 12:50 P.M., CMT D said he/she did not see the medication when he/she flipped the pages of the medication administration record. During an interview on 08/09/12 at 8:30 A.M., the Director of Nurses (DON) said all medications must be administered as ordered by the physician. Review of the facility undated medication pass technique instructions, showed staff must review the five rights with the administration of each medication which includes the right medication.