Every finding on record at Crestwood Health Care Center

Based on observation, interview and record review, the facility failed to ensure food was served at a safe temperature. The facility stored dairy products and eggs in a malfunctioning refrigerator for one week after a repair technician recommended the refrigerator be replaced. The refrigerator temperature was observed in the 60-degree range and the milk measured at 58.5 degrees Fahrenheit (F). Staff were observed serving the milk during a meal service. This deficient practice had the potential to affect all residents who ate at the facility. The census was 141. Review of the facility's Resident Food: Storage and Sharing policy, last reviewed 9/23/25, showed:-Purpose: The purpose of this policy is to ensure that resident's food storage is safe with sanitary storage, handling and consumption;-Procedure:--Refrigerators will be kept clean and within the regulation temperature guidelines of 32-40 degrees. If the temperature falls beyond the regulated guidelines, the food will be discarded;--Each refrigerator will have a thermometer in the freezer and refrigerated compartments;--Each refrigerator will have a temperature log and will be documented daily. Review of the facility's Refrigerator Temperature Record, dated July 2026, showed:-On 7/6/26 at 5:30 A.M., temperature of -19 degrees (F). At 12:00 P.M., 0 degrees (F);-On 7/7/26 at 5:30 A.M., temperature of -27 degrees (F). At 12:00 P.M., 30 degrees (F);-On 7/8/26 at 5:30 A.M., temperature of 36 degrees (F). At 12:00 P.M., 30 degrees (F);-On 7/9/26 at 6:00 A.M., temperature of 21 degrees (F). At 12:00 P.M, 30 degrees (F);-On 7/10/26 at 5:30 A.M., temperature of 30 degrees (F). During an interview on 7/10/26 at 12:36 P.M., the Dietary Manager (DM) said they had issues with the refrigerator, but it was functioning. A technician came out recently and put coolant in the refrigerator, but they were still having issues. It had been broken for about a week. She came in one day and noticed the refrigerator was warm. She threw away the milk when she discovered the problem and did not serve any milk to the residents. She continued to take temperatures of the refrigerator, and they were within range. The walk-in refrigerator was connected to the walk-in freezer. There were no issues with the freezer. She kept the freezer door open so the cold air could reach the refrigerator. Observation of the walk-in refrigerator on 7/10/26 at 12:48 P.M., showed the walk-in refrigerator was connected to the freezer. The freezer door was propped open. No thermometer was inside the refrigerator or on the door. Approximately four boxes of milk sat on the floor of the refrigerator, next to the door. One box of health shakes sat under a shelf and a crate of eggs sat on the floor of the refrigerator. The temperature was taken using a digital thermometer. After approximately three minutes, the temperature inside the refrigerator read 68.2 degrees (F). The DM also took the temperature with the facility's digital thermometer, and the temperature read 68 degrees (F). The temperature of the milk was taken with a digital thermometer and read 58.5 degrees (F). The DM also took the milk's temperature, and it read 59.6 degrees (F). The health shakes temperatures were taken and read 57 degrees (F) on both thermometers. During an interview on 7/10/26 at 12:55 P.M., the DM said the temperature of the milk and cold beverages should be below 40 degrees (F). Serving warm milk could result in illness. She threw the milk, health shakes and eggs away. The technician came out twice regarding the refrigerator and said he needed a part. They were waiting for the part to arrive. She told the administrator and corporate office of the issues, and they discussed replacing the refrigerator, but she had not heard anything further. They were aware the refrigerator was broken. When asked about the temperatures taken previously, she said the temps were in range when the refrigerator was closed for several hours. Observation on 7/10/26 at 1:08 P.M., showed two residents ate lunch in the main dining room. Both residents were served milk and a health shake. The dietary staff confiscated the milk and health shakes from the residents. The administrator and dietary staff removed the milk and health shakes from the hall trays. During an interview on 7/10/26 at approximately 1:15 P.M., the administrator said she was aware of the refrigerator was not functioning properly and would obtain the information from the technician. Review of the technician's note, dated 7/10/26 at 2:32 P.M., showed:-Below are the technician's notes from the service call, dated 7/6/26;-I found the unit unable to meet set point temperature. I found the condenser coil plugged. I cleaned the condenser coil. I found the refrigerant pressure to be low. With a flashing liquid line sight glass, I added four pounds of R404a refrigerant and cleared the sight glass. I noted the unit was able to meet and maintain set point but when the system would pump down, the suction side took approximately eight to 10 minutes to pump down. With the condition of the system, I would recommend the system be replaced over replacing the compressor and liquid line filter drier. During an interview on 7/10/26 at 2:56 P.M., the administrator said dairy products and eggs were thrown away. The technician's recommendations should have been followed up on when the facility was made aware of the issue. Cold products should not exceed 40 degrees (F). Serving milk and eggs at inappropriate temperatures could cause foodborne illnesses. 3074056

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when Certified Nursing Assistant (CNA) A punched the resident in the head several times and had a physical altercation with the resident. The resident fought back, and the altercation was approximately 10 seconds long. The sample size was four. The census was 146. The Administrator was notified on 06/26/26 of the past non-compliance. The facility responded appropriately when the incident occurred. The facility sent CNA A home immediately after incident and began an investigation. The facility provided training and in-services for all staff regarding abuse and neglect, de-escalation techniques, tap-out procedure, and residents' rights on 06/18/26 through 06/24/26. The deficiency was corrected on 06/24/26. Review of the facility's Resident's Rights policy, revised 06/12/24, showed:-Purpose: To ensure that resident rights are protected;-Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Facility must protect and promote rights of each resident, including each of the following rights;-Freedom from abuse: Resident has the right to be free from verbal, sexual, mental, and physical abuse, corporal punishment and involuntary seclusion. Review of the facility's Abuse and Neglect policy, dated 06/12/24, showed:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations;-Verbal abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. This includes using profanity or speaking in demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence;-Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Review of Resident #1's record showed:~Diagnoses of Chronic Obstructive Pulmonary Disease (chronic long term lung disease the worsens overtime), schizoaffective disorder (mental Illness characterized by symptoms of delusions, disorganized thinking, and hallucinations), bipolar (a mental illness characterized by symptoms of grandiosity, delusions, hyper activity periods and periods of depression), and chronic congestive heart failure. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/16/26, showed:~Cognition intact;-Required supervision and/or set up assistance with activities of daily living. Review of the resident's care plan, dated 06/16/26, showed:~Resident with cognitive limitations and/or illness. At risk for abuse, neglect, intimidation, and financial exploitation due to limited awareness of rights and fear of retaliation, leading to underreporting of concerns and delayed identification, of potential abuse. Date initiated 03/20/26; Revision 03/30/26;~Resident has the potential to be physically aggressive due to poor impulse control. He/she will be physically aggressive towards peers when he/she does not get what he/she wants. Date initiated 08/13/25; Revision 08/13/25. Review of the facility's investigation report, dated 06/23/26, showed:-Date and approximate time of incident: 06/23/26 at 10:00 P.M.;-Type of incident: Alleged Abuse;-Persons involved: Resident #1 and CNA A; -Date and time notified: 06/23/26 at 11:00 P.M.;-Investigative Narrative:The nurse was at the nurse's station assisting another resident when I looked over, and I saw what looked like a staff trying to break up an altercation. The nurse then went closer to the window and called a code green (behavior emergency) and went to assist staff. Nurse had got staff down to the end of the hall, and resident sitting in his/her wheelchair saying he/she wanted to go back down the hall and beat his/her ass. Resident was assisted into his/her room. Resident was assessed and had no raised, red, or bruised areas noted. Resident stated I was trying to get to the nurse's station to get to that b***h at the nurse's station so I could kick her a**. Neurological (neuro) checks (frequent assessment of mental status and neurological changes after head injury occurs for 72 hours) initiated. Physician, management team, and the authorities notified. Police department here and informed of incident. Resident placed on 1: 1 monitoring. Message left for the Public Administrator. Staff wrote a statement and was sent home immediately. Witness statements received. Both witnesses stated CNA A was trying to stop the resident from going to the nurses' station due to peer being out there with nurse. Resident had just had a verbal altercation with peer. Both witnesses also stated as soon as they saw them fighting, they went to separate and called a code green. When CNA A attempted to remove the resident's hand from the doorframe, the resident bit her in the back and broke the skin. Per CNA A, the resident also hit him/her in the head.-Conclusion/ Outcome of the investigation:Staff admitted she started hitting the resident back and hit him/her on the top of the head twice. CNA A further stated the resident stood up and pushed him/her against the wall. During an interview on 06/25/26 at 3:00 P.M., CNA A said he/she was returning from his/her break and had to slide him/herself between the unit doors that he/she barely opened because the resident was trying to leave the locked unit. CNA B was shouting don't let the resident out; so CNA A followed what was being shouted. The Resident yelled at CNA A not to close the door on his/her hand, as the resident tried to force his/her way out the doors. CNA A tried to move the resident's hand, and the resident then bit down on CNA A's lower back and wasn't letting go. CNA A started fighting the resident, and the resident was swinging and hitting him/her too. They were separated after a few seconds. CNA A reported what happened to the charge nurse on duty, and then CNA A was sent home. CNA A said he/she was defending him/herself and just reacted without thinking. Review of CNA A's employee file showed he/he had been a CNA for approximately 10 years. CNA A's date of hire was 06/01/26, and he/she was trained on abuse on 06/01/26. During an interview on 06/26/26 at 10:00 A.M., Registered Nurse (RN) D said he/she was on duty when the incident happened. He/She was told to call a code green and then proceeded to the unit. The resident and CNA A were separated. RN D brought the resident to his/her room and did a body assessment. The Resident was not hurt and continued to yell at staff, wanting to get to CNA A to kick his/her ass. The resident had some scratches and bruising on his/her head. RN D did not feel this was premeditated abuse, and it was a person defending themselves when a resident had latched down on the staff member's back, biting and not letting go. CNA A was sent home pending investigation, was not injured and had some minor abrasions. During an interview on 06/26/26 at 11:00 A.M., CNA B said CNA A was returning from break, and the resident was trying to exit the locked unit. CNA B yelled at CNA A to stop the resident from going through the doors because the resident was trying to force his/her way out of them. The resident had her/his hand on the door frame. CNA A tried to move the resident's hand, and this is when the resident said Don't smash my hand and bit CNA A on the back. CNA A began hitting the resident in the face. The resident was swinging back, and CNA B began yelling code green. CNA B and CNA C separated CNA A and the resident, the incident lasted about 10 seconds. The resident was fighting back and hitting CNA A with punches, and neither party obtained serious injuries. The nurse arrived immediately, and the resident went to his/her room to be assessed. CNA A was sent home after being assessed to have no injuries. During an interview on 06/26/26 at 11:30 A.M., CNA C said when CNA A was coming through the doors, he/she tried to remove the resident's hand from the doorframe. The resident said Don't smash my hand and bit CNA A. Then CNA A began hitting the resident, and a fight followed. CNA C and CNA B separated CNA A and the resident. CNA A was sent home, and the resident was placed on 1:1 monitoring. During an interview on 06/26/26 at 12:00 P.M., the resident said he/she is not fearful and glad the staff member is not coming back. The resident still wants to kick the staff member's ass. During an interview on 06/26/26 at 1:00 P.M., the Director of Nursing (DON) said the employee had been terminated for abuse. The DON confirmed the in-servicing completed, and felt this was a knee jerk reaction response by the CNA. The staff member was removed from building immediately pending investigation, and the resident was examined. Both the resident and the staff member had minor in injuries. 3053070

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when a Certified Nursing Assistant (CNA A) yelled and used profanity at the resident, then grabbed and pushed the resident to the ground. The sample size was four. The census was 141.The administrator was notified on 5/22/25, of the past non-compliance. The facility responded appropriately when the incident occurred. CNA A left the facility and resigned. A witness, CNA G, was terminated. The facility provided training and in-services for all staff regarding abuse and neglect, de-escalation techniques, tap-out procedure, and residents' rights. The deficiency was corrected on 5/20/26. Review of the facility's Resident's Rights policy, revised 9/21/25, showed:-Purpose: To ensure that resident rights are protected;-Resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Facility must protect and promote rights of each resident, including each of the following rights;-Freedom from abuse: Resident has the right to be free from verbal, sexual, mental, and physical abuse, corporal punishment and involuntary seclusion. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed:-Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations;-Verbal abuse: The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. This includes using profanity or speaking in demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence;-Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/9/26, showed:-Cognitively intact;-No hallucinations or delusions;-No rejection of care;-No impairment to both lower and upper extremities;-Diagnoses included seizure disorder, depression, and bipolar disorder (mental health condition that causes extreme shifts in mood, energy and activity levels). Review of the facility's investigation report, dated 5/20/26, showed:-Date and approximate time of incident: 5/20/26 at 11:55 A.M.,-Type of incident: Physical aggression involving head;-Persons involved: Resident #1 and CNA A;-Date and time notified: 5/20/26 at 1:00 P.M.;-A loud noise heard coming from 600 hall the writer went to investigate and saw Resident #1 sitting on floor, Indian style, stating that staff pushed him/her. CNA A had exited the building, resident stated he/she was calling his guardian. The resident said, CNA A told him/her to shut the fuck up. CNA A then grabbed the resident and pushed him/her to the ground. During an interview on 5/22/26 at 10:25 A.M., Licensed Practical Nurse (LPN) B said when he/she and Registered Nurse (RN) F responded to the loud noise behind 600 hall, Resident #1 was by the door, crying and told them that CNA A put his/her hands on him/her. CNA A quickly left the facility, and they were not able to ask questions. LPN B said he/she was not certain if Code [NAME] (code called when a resident exhibiting aggressive behaviors) was called. He/She said it happened too fast. CNA A had already left the facility. LPN B never witnessed and was not aware of any history of CNA A being abusive and inappropriate to any residents. He/She did not observe CNA A being distracted or had signs of irritation. During an observation and interview on 5/22/26 at 10:44 A.M., the resident said on Wednesday, 5/20/26, sometime before lunch, CNA A put his/her hands on him/her and kept saying shut the fuck up. He/She said the CNA grabbed his/her shirt, almost choking him/her, and pushed him/her in the chest caused him/her to hit his/her head on the door. He/She was asking questions and did not know why the CNA became angry. Another staff member (CNA G) saw and heard CNA A yell at the resident but did not do anything. The resident said he/she had nightmares that night after the incident. He/She did not want the facility to report the incident to the police department. The resident showed a photo of his upper chest from his/her cellphone, showing some redness. The resident said there were no major injuries, and he/she was doing fine but did not want to see CNA A anymore. The resident said he/she was on the phone with his/her guardian during the incident and the guardian heard the staff yelling at the resident. During an interview on 5/22/26 at 11:13 A.M., CNA A said the resident was upset and restless that day, prior to the incident. He/She said another resident pulled the fire alarm, so the facility was doing resident headcounts and not allowing anybody to go out and smoke. Resident #1 did not like it when he/she was told of the situation and kept following the CNA around. The CNA said, I lost my cool, and pushed the resident. He/She denied choking the resident but grabbed his/her shirt in the chest area. He/She was aware of de-escalation techniques, proper approach to residents with behaviors, and was trained for abuse policy, and residents rights. He/She said he/she should have avoided the situation and let the nurse know instead of putting his/her hands on the resident. During an interview on 5/22/26 at 11:31 A.M., RN C said he/she expected the staff to report if residents were having behaviors. He/She would remind the staff how to de-escalate the situation and never hurt any resident. During altercations between staff and resident, RN C said he/she would expect staff to separate the individuals immediately, and the nurse to assess the resident, making sure the resident was safe from further injuries. During an interview on 5/22/26 at 11:47 A.M., CNA D said he/she had witnessed resident to resident altercation in the facility but no staff to resident altercations. He/She would de-escalate the situation by separating the individuals. He/She would call for help and not leave the residents, making sure residents were safe. Code [NAME] should be called. He/She would report the incident to the nurse immediately. During an interview on 5/22/26 at 11:59 A.M., CNA E said he/she would attempt to de-escalate the residents during increased behaviors. If the behaviors continued, he/she would call Code Green, and stay with the resident to avoid further behaviors and altercation. If being provoked by residents, he/she would walk away and let other staff know. He/She would report the situation to the nurse in charge. During an interview on 5/22/26 at 12:12 P.M., Social Services (SS) said that he/she heard a very loud noise. When he/she went to 600 hall, RN B and RN F had already responded. The resident was right by the door, standing up. When SS asked the staff, they said they did not see what happened. The resident said the staff choked him. SS said a staff said that the resident was on CNA A's face prior to the physical contact. SS expected the staff to know when to tap out when residents had increased behaviors. SS expected staff to avoid altercation with residents and remember their trainings on de-escalation techniques. During an interview on 5/22/26 at 1:16 P.M., CNA G said he/she was in another resident's room on 600 hall when the he/she heard a commotion. When he/she came out to check, CNA A and Resident #1 were yelling at each other. CNA told the resident, Shut the fuck up, then the resident responded, make me. CNA A then pushed the resident against the door. CNA G walked up to them and tried to get CNA An off the resident. The resident slid off and fell on the floor. CNA A had his/her hands on the resident's shoulders. Then CNA A got off and left the facility. CNA G said it happened too fast. He/She did not get a chance to talk to CNA A and call Code Green. CNA G was terminated after the incident. He/She was told by the Administrator that he/she did not put everything in his/her statement. He/She did not have similar incidents in the past and did not know how to respond at that moment. He/She should have called Code [NAME] and intervened immediately. During an interview on 5/22/26 at 2:45 P.M., the Director of Nursing (DON) and Administrator said they expected the staff to walk away from a situation when residents were having behaviors. She expected the staff to take a break, and ask for assistance, and report to the supervisor or DON when the situation escalated. When the DON called and notified CNA A that he/she was being suspended pending investigation, CNA A decided to resign. He/She admitted grabbing and pushing the resident. The Administrator said CNA G was terminated due to leaving out information during the investigation. Incident #3019870

Based on observation, interview, and record review, the facility failed to ensure food was appropriately labeled, dated, and/or sealed in an appropriate manner to prevent cross contamination and preserve food quality. The facility failed to ensure the dish machine and sanitizing sink were equipped with sufficient concentration of sanitizing solution to effectively clean and sanitize dishware. These deficient practices had the potential to affect all residents who ate at the facility. The census was 141.Review of the facility's Food Storage policy, undated, showed:-Frozen Meat/Poultry and Foods: Store items promptly at 0 degrees Fahrenheit (F). Foods shall be stored in their original containers if designed for freezing. Foods to be frozen shall be stored in airtight containers or wrapped in heavy-duty aluminum foil, plastic film, or special laminated papers. Label and date all food items;-Fresh Vegetables: Store at temperature of 41 degrees F or less;-Dry Storage: Any open products shall be placed in seamless plastic or glass containers with tight fitting lids or plastic bags. Open products may also be sealed by utilizing plastic film or tape;-Label and date all storage containers as follows: The received date should already be on it. Date when opened. Date when the item expires. 1. Observation of the facility's kitchen, on 4/26/26 at 8:15 A.M., showed:-The dry storage area contained an open, undated, and unsealed large bag of flour, an undated open bottle of caramel topping, an open and undated container of chili powder, a partially covered clear container containing oats, dated 3/3/26, and open bags of cornflakes, chips, yellow cake mix, muffin mix, and brown sugar sealed with plastic wrap and undated;-The prep area contained an open and undated container of powder sugar;-The shelf on the bottom of the stove contained an open and undated bottle of barbeque sauce;-The freezer contained open, undated, and unsealed boxes of cobbler crust, pizza dough, breaded cod, and cookie dough;-The refrigerator contained an undated and partially open container of mayonnaise, an open and undated container of relish, an open and undated container of lunch meat, and nine cartons of milk with a 'best used by' date of 4/25/26. Observation of the dry storage room on 4/29/26 at 7:40 A.M., showed an open, undated and unsealed bag of grits, and open bags of corn flakes and brown sugar, sealed with plastic wrap and undated. Observations of the kitchen on 4/29/26 at 8:50 A.M., showed the refrigerator contained two open and undated cartons of Med Pass (fortified nutritional supplement) and one open and undated carton of milk. The freezer contained open, undated and unsealed boxes of sausage, pork chops, and rolls, and an undated, torn plastic bag filled with carrots. During an interview, the Dietary Manager (DM) said when food is opened, it should be dated and the food should be sealed. Med Pass should not be stored in the kitchen refrigerator; it should be stored in the nurse's refrigerator. The freezer and refrigerator temps should be checked twice daily and documented on the log. 2. Review of the facility's Recording of Dish Machine Temperature policy, undated, showed:-Low temperature dish machine: the concentration of the sanitary solution during the rinse cycle is 50-100 parts per million (PPM, the unit of measurement used to ensure chemical sanitizers in the final rinse cycle are concentrated enough to kill microorganisms) with chlorine test strips;-When the chemical sanitizing dispenser is broken or not working correctly on the cold temp machine, appropriate amount of sanitizer, per manufacturer directions, can be manually added to the dish machine at each rinse cycle. Check for the correct amount of sanitizer at each rinse cycle with appropriate litmus paper;-Record PPM on temperature machines three times daily. Review of the facility's Low Temperature Dishwasher Form, dated April 2026, showed:-Record temperature and PPM, where applicable once before each meal period;-Breakfast and lunch: One of 28 opportunities to document wash temperature and PPM were blank;-Dinner: Six of 27 opportunities to document wash temperature and PPM were blank. Observation and interview on 4/29/26 at 8:40 A.M., showed the DM placed a chlorine test paper strip in the water located in the dishwasher reservoir during the final rinse cycle. She said she was not getting a reading. The dishwasher is tested three times a day. During the interview, the DM asked Dietary Aide (DA) S if he/she obtained a reading on the test strip. DA S said he/she she did not know how to do the test. The DM attempted to complete the test a few more times and was unable to get a reading. She did not know why there was no reading because she could see the chemical coming out of the hose connected to the dishwasher. Review of the facility's Pot Sink Sanitation Record, dated April 2026, showed:-Columns to document time, PPM, and checked by for breakfast, lunch, and dinner;-Time not documented 19 of 26 opportunities;-PPM not documented 20 of 26 opportunities;- Checked by not documented 26 of 26 opportunities. Observation and interview on 4/29/26 at 8:30 A.M., showed the placed paper towels in the bottom of the third (sanitizing) sink of the 3-vat sink and filled the sink with water that came from a clear hose connected to a container with chemicals in it. The DM tore a piece of test strip off a roll of strips that had instructions to dip the strip in water for 10 to 15 seconds before reading. The DM dipped the test strip into the water and the tip of the strip turned green. The DM dipped the strip into the water several times and the strip did not change colors. The DM said maybe there was not enough sanitizer in the sink. During an interview on 4/29/26 at 11:35 A.M., the Dishwasher Repair Representative (dishwasher repairman from an outside company) said the dishwasher's squeeze tube was bad and required replacement. On the sanitizer sink, someone had placed the hose for the sanitizer in the wrong container. 3. During an interview on 4/29/26 at approximately 10:15 A.M. the Regional Dietary Manager said food should be dated when opened and sealed when stored. 4. During an interview on 5/1/26 at 1:00 P.M., the Administrator said she expected food to be stored in a safe and sanitary condition. Dishes should be appropriately sanitized. She expected staff to follow the facility's policies and procedures.

Based on observation, interview, and record review, the facility failed to ensure 26 of 46 resident rooms, 17 of 46 bathrooms, and a shower room were adequately equipped with a functional call system that would allow residents to call for staff assistance. The census was 31. The census was141.Observations on 4/30/26 at 11:20 A.M., showed a test of call lights as follows:-On the 100 hall, call lights not functional in resident rooms 101, 105, 109, and 110, the 100 hall shower room, and the shared bathrooms of rooms 105/107 and 111/113;-On the 200 hall, call lights not functional in resident room [ROOM NUMBER] and the shared bathrooms of rooms 205/207 and 209/211;-On the 300 hall, call lights not functional in resident rooms 301, 302, 307, 309, 308, 311, 310, 312 and 313, and the shared bathrooms of rooms 302/304, 307/309, 311/313, 310/312;-On the 400 hall, call lights not functional in resident rooms 403, 404, 406 and 407, and the shared bathrooms of rooms 401/403 and 406/407;-On the 500 hall, call lights not functional in resident rooms 501, 510 and 513, and the bathrooms of resident rooms [ROOM NUMBER];-On the 600 hall, call lights not functional in resident rooms 601, 602, 605, 610, and 612, the lounge room of 613, the shared bathrooms of 601/603, 600/602, and 605/607, and the bathroom in room [ROOM NUMBER]. During an interview on 4/26/26 at 9:00 A.M. Certified Nurse Aide (CNA) B said he/she was aware the call light in room [ROOM NUMBER] was not working. It was reported to Maintenance but once they fix it, it just breaks again. During an interview on 4/30/26 at 11:20 A.M., the Maintenance Supervisor said he was not aware the call lights were not functioning. He expected nursing staff to notify Maintenance when something was not working so it could be addressed. During an interview on 5/1/26 at 1:00 P.M. the Administrator said if an item needed to be repaired, she expected staff to report it to Maintenance so they could address it. She expected the call lights to be functional throughout the facility.

Based on observation, interview, and record review, the facility failed to ensure staff provided adequate supervision when one resident (Resident #78) eloped from the facility at approximately 6:00 A.M. and staff were not aware the resident was missing until they received notification from a hospital that the resident arrived to the hospital at 8:06 A.M. The facility failed to ensure staff responded appropriately and in accordance with facility policy when one resident (Resident #63) pulled the fire alarm. The sample was 31. The census was 141.Review of the facility's Fire Alarm Pulls and Risk for Elopement Response policy, undated, showed:-Purpose: To ensure the safety of all residents by providing clear procedures for staff response when a fire alarm is pulled, including immediate actions to identify potential elopement and ensure all residents are accounted for;-Immediate actions when a fire alarm is pulled:--Check the fire alarm panel immediately;--Staff must go to the panel immediately to identify which pull station or zone was activated;--Respond to the location identified on the panel;--Staff must immediately go to the exact location of the activated pull station to determine if there is an active fire or hazard;--One staff must immediately exit the door closest to the activated pull station and walk the exterior perimeter of the facility in that area, look for any resident who may have exited the building, and report finding immediately to the charge nurse;--Remaining staff will follow standard fire response procedures;--Nursing staff must initiate an immediate headcount: Staff must physically lay eyes on residents-not just check rooms and confirm that all residents are accounted for;--If any resident is not accounted for and no resident is located during the exterior sweep and nursing confirms a resident is missing during the headcount: The Code [NAME] (missing person) policy must be implemented immediately. This includes facility wide notification, initiation of search procedure per policy and notification of administrator and additional parties;--Important reminders: Fire alarms are not only a fire risk-they are also an elopement risk. Every alarm must be treated as a potential missing resident event until proven otherwise. Delays in response can result in serious harm. Review of the facility's Elopements and Wandering Residents policy, dated last reviewed 6/12/24, showed:-The facility is equipped with door locks/alarms to help avoid elopements;-Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner;-Adequate supervision will be provided to help prevent accidents or elopements;-Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol:--Code [NAME] = Elopement from facility;--The designated facility staff will look for the resident;--If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office. 1. Review of Resident #78's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/26, showed:-Cognitively intact;-No behaviors exhibited;-Diagnoses included Alzheimer's disease, depression, bipolar disorder (mood disorder with extreme moods swings), psychotic disorder, schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), and schizoaffective disorder bipolar type (mental health condition that is marked by a mix of schizophrenia symptoms and mood disorder symptoms). Review of the resident's care plan, in use at the time of the survey, showed:-Problem, dated 4/13/26: Resident eloped from 100 hall;-Goal: Resident will not elope through next review;-Intervention: Resident placed on 600 hall. Elopement assessment updated and picture placed in the book. Social Services (SS) to meet with resident daily to assist with decreasing anxiety related to his/her delusions;-Problem, dated 4/14/26: Resident is at risk of elopement due to history of elopement from prior secure facility and/or expresses a desire to elope from facility;-Goal: The Resident will not elope from facility through next review;-Interventions: Complete elopement assessment on admission, readmission and quarterly. Face checks will be completed by facility protocol. Resident's photo and information will be kept in elopement book. Review of the resident's progress note, dated 4/13/26 at 2:51 P.M., showed elopement. Patient last seen at approximately 7:00 A.M. At 12:30 P.M., receptionist brought to the nurse's attention the hospital had called and needed information on the resident that had arrived there. Director of Nurses (DON) and Administrator notified immediately. A thorough search of the unit and facility grounds was initiated immediately. Resident then noted absent from the facility. The hospital representative said the resident had arrived there at 8:06 A.M., after being picked up by emergency medical services (EMS) and transported to the hospital. Resident was evaluated while there and was diagnosed with schizoaffective disorder, which is already specified as a prior diagnosis in his/her medical history. Patient arrived back at the facility at 2:10 P.M. An initial head-to-toe assessment performed. No visible injuries. Mental status and range of motion within normal limits according to prior assessments. Resident asked once how did you get out? Resident stated that he/she had gone out of 400 hall's door. During an interview on 4/27/26 at 11:04 A.M., the resident said he/she waited for the nurse to get busy and when there were a lot of people around, he/she exited the building out the 400 hall door. The door made a sound when it opened. He/She walked to the bus terminal and got an ambulance to take him/her to the hospital. Review of the facility's investigation, dated 4/14/26, showed:-Date and approximate time of incident: 4/14/26 at 12:30 P.M.-Type of incident: Elopement;-Investigative narrative report: The receptionist brought to the nurse's attention the hospital called and needed information on the resident. An immediate head count was started, and the resident was found to be not in the building. The hospital representative said the resident arrived at the hospital at 8:06 A.M. after being picked up by the ambulance at a transit station on a main road. Ambulance attendant stated resident requested to go to a specific hospital because he/she wanted to visit his/her family member and meet Saint [NAME]. Resident was evaluated while at the hospital. Patient arrived back at the facility at 2:10 P.M. Resident asked once he/she returned to facility how did you get out? Resident stated that he/she had gone out of 400 hall's door. Stated he/she wanted to visit his/her family at the hospital. Interview with multiple staff members and residents. Resident was last seen around 6:00 A.M. at the nurse station;-Conclusion/outcome of the investigation: Allegation substantiated. Review of the typed interviews completed by the Administrator, undated, showed:-The Administrator interviewed the day shift aides on the 100 hall: Certified Nurse Aide (CNA) I, CNA J, and CNA K. All three CNAs stated they did not see the resident when they did rounds, but they did not tell the nurse because they just assumed the resident was in the hospital;-Day shift Certified Medication Technician (CMT), CMT L, said he/she did not see the resident;-Licensed Practical Nurse (LPN) M interviewed three alert residents who were awake and at the nurse's station at the time of incident, said they did not hear the 400 hall door go off;-Night shift CNA N, said he/she was down by the laundry room on 4/13/26 at around 6:00 A.M., and did not hear the door alarm go off. During an interview on 4/30/26 at 11:29 A.M., CNA P said the resident was up all night long, he/she was combative, and he/she wanted to see his/her family member, who was in the hospital. At 6:00 A.M., CNA P took the residents out to smoke while the other aide provided care for the other residents. After the residents smoked, CNA P returned to the hall and assisted other residents with care. Between the hours of 6:00 A.M. and 6:30 A.M., all the alarms on all the halls start going off. If someone pushed the egress door bar for longer than three seconds, it would open. He/She did not realize the resident was not there when he/she returned to the hall. During an interview on 4/30/26 at 7:13 A.M. LPN O said two nurses work on the night shift. They tried to be sure one nurse was at the nurse's station. With the combination of all the staff, residents are rounded on every hour. If a resident was not in their room, between the hours of 11:00 P.M. and 5:00 A.M., he/she would ask other staff if they knew where the resident was. If they could not determine where the resident was, a head count would be done and the whole facility would be checked. If they still could not find the resident, they would notify the Administrator and police. Between the hours of 5:00 A.M. and 7:00 A.M., the residents are beginning to move about. On 4/13/26, he/she was not assigned to the 100 hall, but he/she knew the resident was there during the night because the resident needed to be redirected during the night. When the nurse left the nurse's station at 6:15 A.M. to provide care for another resident, the resident was at the nurse's station. When LPN O returned to the nurse's station, he/she finished charting and left at the end of his/her shift. Around 2:00 P.M., he/she received a text message from the DON asking when the last time was, he/she saw the resident. The resident used the busy time of the day to leave. Some of the exit doors don't seal well and the alarms are unreliable. Staff could be desensitized to the alarms if the alarm sounded. During an interview on 4/30/26 at 8:15 A.M. LPN E said he/she rounded on the residents every two to three hours and the CNAs round every two hours. If a resident was not in their room, he/she would look for the resident. If they could not find the resident, he/she would notify the Administrator. At around 6:00 A.M., all the alarms start going off because the residents come out into the common areas and go out to smoke. The door on the 400 hall will open if the egress bar is pushed/held for 15 seconds. LPN E worked the night shift and the day shift. The CNAs did not report the resident was missing or the resident missed breakfast. He/She did not know the resident was not in the facility until the receptionist reported the hospital called and wanted information on the resident. When the resident returned to the facility, the resident said he/she went out the 400 hall door. During an interview on 5/1/26 at 1:00 P.M., the DON said they found out the resident was not in the facility when the hospital called the facility. The resident left the facility around 6:00 A.M. and exited out the 400 hall door. The resident was looking for his/her family member. The door has an alarm on it. There were conflicting stories about whether the alarm sounded or not. When an alarm sounds, staff should go and see what is going on and they should check inside and outside looking to see if someone may have exited the building, and initiate a head count and do face checks. If a resident was unaccounted for, it should be reported. The Administrator said staff should check the alarms on the doors to be sure they are working. Staff should round on residents every two hours. The entire team completes face checks every two hours. Since there were conflicting stories about whether the alarm sounded or not when the resident eloped, an outside company came and checked the doors, and they were functioning. She expected staff to follow the facility's policies and procedures. 2. Review of Resident #63's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Other behavioral symptoms not directed towards others occurred 1 to 3 days;-Diagnoses included anxiety, depression, bipolar disorder), schizophrenia, Asperger syndrome (autism spectrum), mild intellectual disabilities, and borderline personality disorder (a mental health condition marked by extreme mood swings, impulsive behaviors, and unstable relationships). Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident has negative behaviors of breaking windows, pulling fire alarms, elopement, cutting, breaking back of toilet;-Goal: The resident an increase in positive behaviors through the review date;-Interventions included:--Coping skills: Blank;--Needed supports: Counseling, structured environment, alcohol abuse treatment, drug abuse treatment, outside support network, and coping skills training;--Resident's support system: Blank;--Triggers: Blank. Observation on 4/26/26 at 11:46 A.M., showed the fire alarm sounded. The Social Services Assistant (SSA) went to the fire panel and opened the case. The panel showed the alarm at room [ROOM NUMBER]. SSA pressed Silence on the panel and walked toward the 300 hall. When the SSA was approximately 10 feet from the fire panel, staff could be heard yelling, False alarm, it was a resident, he/she pulled the alarm. Approximately three staff members entered the 300 hall and went to the end of the hallway. Other staff on various hallways continued passing noon meal hall trays and passing medications, and did not cease activities to respond to the fire alarm. No overhead announcement made regarding the location of the triggered fire alarm. During an interview on 4/26/26 at 12:00 P.M., the SSA said when the fire alarm sounded, she went to the fire panel and hit the switch to silence the alarm. Then, she took the key to the 300 hall pull station. Once she got on the 300 hall, someone told her that a resident pulled the fire alarm, but she could not recall who told her this. She could tell by looking at the pull station the resident pulled the alarm. She called the front desk using her personal cell phone to notify them not to send out EMS/fire department. During an interview on 4/26/26 at 12:50 P.M., the Maintenance Director said he was in his office when he heard the fire alarm sound. He met the nurse with the key at the panel. No rounds were made because we knew the resident was acting out. The resident has set off the fire alarm five or six times since he has been at the facility, for about a month. During an interview on 4/26/26 at 1:15 P.M., the DON said the resident had a history of pulling the fire alarm. The resident was upset because he/she wanted his/her hair braided and the staff told the resident he/she would have to wait. He/She went back to his/her room, broke a light, and pulled the fire alarm. During an interview on 5/1/26 at 1:00 P.M., the Administrator said when the fire alarm sounded, the front desk should make an announcement as to where the location of the fire alarm was activated. She expected staff to follow the facility's policies and procedures and respond appropriately to the alarm. 29831052981901

Based on observation, interview and record review, the facility failed to protect resident funds from misappropriation by not implementing a check and balance system. During cash disbursements, the facility allowed cash and receipt books to be issued to staff for distribution without reconciliation of funds and receipts upon return. This deficient practice enabled the business manager to alter receipts and remove funds from the cash box without detection, resulting in the potential for and actual misappropriation of resident money for 33 residents (#6, #8, #11, #14, #17, #27, #35, #38, #41, #42, #47, #52, #54, #56, #60, #64, #78, #79, #86, #93, #96, #100, #112, #114, #120, #127, #129, #132, #136, #140, #150 and #151) of the 101 resident's facility managed funds. The sample size was 32. The census was 141.Review of the facility's General Information Regarding Responsibilities of Holding Resident Funds policy, dated 3/1/17, showed:--The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility, using complete and separate accounting principles, which precludes any commingling of resident funds with facility funds;--Personal funds of the resident shall be used exclusively for the resident, which must be authorized in writing. The individuals who can authorize such transactions may be the resident, his/her legal guardian, or a legal representative (who may not be an employee at the facility, including the administrator);--The resident trust bank account should have at least two facility personnel as check signers. One such person is the Administrator and the other(s) should be chosen at the discretion of the Administrator. However, no one who handles the petty cash box, the checkbook, the posting of transactions, or assists residents in shopping for personal items should be a signer on the account; -Making Withdrawals from the Resident Trust Account:-- All checks written out of the trust account should be prepared by the Resident Trust Clerk and signed by the Administrator or other designated signer and should always be accompanied by a check request or other supporting documentation. All checks written out of the resident trust account should be copied prior to deposit or disbursement and attached to the appropriate documentation;--The checkbook balance should be updated each time a check is written. Deposits must also be entered into the checkbook;--Family members or friends who do not have legal access to a resident's account but wish to purchase clothing or personal items for a resident can do one of the following:1. Purchase the items needed and bring in the receipts to the Resident Trust Clerk. The clerk will then verify that a) the resident requested the items by signing the check request form and b) the resident has sufficient funds to reimburse the purchases.2. Have the resident sign a check request form to make the check payable to the individual wanting to purchase the items. The Resident Trust Clerk must verify the funds are available before writing the check. -Resident Trust Petty Cash:--The facility will maintain a resident petty cash fund for resident trust transactions only. The petty cash clerk will be a facility employee designated by the Administrator at each facility. The petty cash clerk will be someone other than the Resident Trust clerk and the Administrator and will not be authorized to sign checks. Requests for amounts larger than fifty dollars ($50) should be directed to the Resident Trust Clerk;--When a resident requests a cash withdrawal from his/her personal funds, the petty cash clerk will first verify the funds are available. This is to be done by obtaining an Open Balance report from the Resident Trust Clerk;-- A three part withdrawal receipt must be completed at the time of disbursement. The receipt should list the resident's name, date, amount of withdrawalal, and the person disbursing the funds. The resident must sign the receipt. lf the resident is unable to sign or can only mark an X, the receipt must be signed by two (2) facility staff members;--The petty cash clerk gives the resident the original receipt and the two duplicates are kept in the petty cash box;--On a daily basis usually at the end of the day, the Resident Trust clerk must enter into PCC all transactions into and out of the petty cash box;--When the petty cash box needs to be replenished the Resident Trust clerk must reconcile the cash left in the box with PCC;--The Resident Trust Clerk will file a copy of the check in the monthly Resident Trust file for the month for audit. -Resident Statements:--A detailed written account of all transactions affecting each resident's trust account shall be maintained and made available upon request.--The Resident Trust Clerk is responsible for sending out quarterly statements to the resident and his/her guardian or legal representative;--Make copies of all statements and date stamp them with the date they were mailed. Resident Trust Clerk will complete and sign the mailing confirmation and present to administrator to sign before emailing to Director of Business office. Review of the facility's Resident Rights policy, last reviewed on 9/21/25, showed:-Purpose: To ensure that resident rights are protected;-Protection of Resident Funds:--Accounting and Records. Facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to Facility on Resident's behalf. 1. Review of Resident # 6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/31/26, showed:-Diagnoses included Alzheimer's disease, Parkinson's disease with dyskinesia (involuntary, erratic and uncontrollable movements), schizophrenia (a chronic and severe brain disorder that affects a person's ability to interpret reality, think logically, manage emotions and relate to others);-Cognition moderately impaired. Review of Resident's Patient Trust (PT) ledger, dated 5/1/25 through 3/20/26, showed:-Withdrawals from 5/1/25 through 7/8/25 were in dollars range of four to five dollars;-Withdrawals from 7/9/25 through 3/16/26 showed an increase in larger withdrawals ranging $24 to $40. Review of Resident's PT withdrawal receipts, showed:-Receipt #0251102, dated 7/28/25, for $34, was missing a resident signature;-Receipt #374127, dated 8/15/25, for five dollars and #251128, dated 1/30/26, for $35 showed inaccurate resident signature;-Receipt #251007, dated 1/27/26, showed in the numeric box $4 scratched out and replaced with $35 and written line amount four was crossed out and replaced with thirty-five;-Receipt #537690, dated 2/19/26, showed discrepancies in the resident name and no detail for the withdrawal of $30;-Discrepancies in handwriting located in the numeric box and the written line amount for the following receipts: --Receipt #117102, dated 10/25/25, was altered from $4 to $34;--Receipt #117021, dated 10/29/25, was altered from $4 to $24;--Receipt #117102, dated 10/25/25, was altered from $4 to $34;--Receipt #123279, dated 11/6/25, was altered from $4 to $24;--Receipt #133280, dated 11/14/25, was altered from $4 to $34;--Receipt #121113, dated 11/20/25, was altered from $4 to $34;--Receipt #132608, dated 11/21/25, was altered from $4 to $34;--Receipt #122609, dated 12/3/25, was altered from $4 to $34;--Receipt #122677, dated 12/4/25, was altered from $4 to $34;--Receipt #127002, dated 12/10/25 was altered from $4 to $34;--Receipt #127065, dated 12/11/25, was altered from $4 to $34;--Receipt #127116, dated 12/12/25, was altered from $4 to $34--Receipt #116605, dated 12/15/25, was altered from $4 to $34;--Receipt #122801, dated 12/22/25, was altered from $4 to $34;--Receipt #451115, dated 1/15/26, was altered from $4 to $34;--Receipt #451227, dated 1/19/26, was altered from $4 to $24;--Receipt #250531, dated 1/20/26, was altered from $4 to $34;--Receipt #451253, dated 1/22/26, was altered from $4 to $34;--Receipt #116917, dated 1/23/26, was altered from $4 to $34;--Receipt #251045, dated 1/28/26, was altered from $5 to $35;--Receipt #251104, dated 1/29/26, was altered from $4 to $24;--Receipt #251146, dated 2/2/26, was altered from $4 to $34;--Receipt #122979, dated 2/3/26, was altered from $4 to $34;--Receipt #537613, dated 2/18/26, was altered from $4 to $34;--Receipt #537690, dated 2/19/26, was altered from $4 to $34;--Receipt #537701, dated 2/20/26, was altered from $4 to $24;--Receipt #537805, dated 2/26/26, was altered from $4 to $34;--Receipt #534809, dated 3/3/26, was altered from $4 to $40;--Receipt #334809, dated 3/4/26, was altered from $3 to $34;--Receipt #334862, dated 3/5/26, was altered from $4 to $34;--Receipt #334907, dated 3/6/26, was altered from $4 to $34;--Receipt #516803, dated 3/9/26, was altered from $4 to $34;--Receipt #516876, dated 3/10/26, was altered from $4 to $34;--Receipt #517012, dated 3/13/26, was altered from $4 to $34; 2. Review of Resident # 8's quarterly MDS, dated [DATE], showed:-Diagnoses included Alzheimer's disease with early onset, schizophrenia, cognitive communication deficit;-Intact cognition. Review of Resident's PT ledger, dated 5/1/25 through 3/20/26, showed:-Withdrawal dated 11/6/25 in the amount of $36.00 had no receipts to verify withdrawal;-Withdrawal dated 11/28/25 in the amount of $36.00 had no receipts to verify withdrawal;-Withdrawal dated 12/4/25 in the amount of $35 had no receipts to verify withdrawal;-Withdrawal dated 12/8/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 12/12/25 in the amount of $36.00 had no receipts to verify withdrawal;-Withdrawal dated 12/15/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 12/19/25 in the amount of $36.00 had no receipts to verify withdrawal;-Withdrawal dated 12/22/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 12/30/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 12/31/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 1/2/26 in the amount of $36.00 had no receipts to verify withdrawal;-Withdrawals dated 1/5/26 through 1/9/26, totaled in the amount of $146.00 had no receipts to verify withdrawals;-Withdrawal dated 1/13/26 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 1/15/26 in the amount of $45.00 had no receipts to verify withdrawal;-Withdrawal dated 1/16/26 in the amount of $26.00 had no receipts to verify withdrawal;-Withdrawal dated 1/19/26 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 1/21/26 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawals dated 1/22/26 through 2/3/26, totaled in the amount of $303.00 had no receipts to verify withdrawals;-Withdrawal dated 2/4/26 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 2/6/26 in the amount of $26.00 had no receipts to verify withdrawal;-Withdrawals dated 2/13/26 through 2/24/26, totaled in the amount of $177.00 had no receipts to verify withdrawals;-Withdrawal dated 2/26/26 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 2/27/26 in the amount of $26.00 had no receipts to verify withdrawal;-Withdrawal dated 3/1/26 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawals dated 3/3/26 through 3/10/26, totaled in the amount of $180.00 had no receipts to verify withdrawals;-Withdrawal dated 3/12/26 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 3/13/26 in the amount of $36.00 had no receipts to verify withdrawal. Review of Resident's PT withdrawal receipts, showed:-Discrepancies in handwriting located in the numeric box and the written line amount for the following receipts: --Receipt #121019, dated 11/18/25, was altered from $4 to $35; $4 in the numeric box and four in written line amount were scratched out and replaced with $35 in numeric box and thirty-five in written line amount;--Receipt #121129, dated 11/20/25, was altered from $5 to $25. 3. Review of Resident #11 quarterly MDS), dated [DATE], showed:-Diagnoses included schizoaffective disorder, bipolar disorder (a mental health condition characterized by dramatic shifts in mood);-Intact cognition. Review of Resident's PT ledger, dated 5/1/25 through 3/20/26 showed:-Withdrawal dated 7/29/25 in the amount of $300.00 had no receipts to verify withdrawal;-Withdrawal dated 1/15/26 in the amount of $300.00 had no receipts to verify withdrawal. 4. Review of Resident #14 's quarterly MDS, dated [DATE], showed:-Diagnoses included schizophrenia;-Intact cognition. Review of Resident's PT withdrawal receipts, showed:--Receipt #122913, dated 12/24/25, in the amount of $27; not signed by resident;--Receipt #374012, dated 8/12/25, in the amount of $27; not signed by resident;--Receipt #846141, dated 7/16/25, in the amount of $27; not signed by resident;--Receipt #0251031, dated 7/24/25, in the amount of $29; not signed by resident;--Receipt #374012, dated 8/12/25, in the amount of $27; not signed by resident;--Receipt #606767, dated 9/15/25, in the amount of $25; not signed by resident;--Receipt #0059798, dated 9/22/25, in the amount of $45; not signed by resident;--Receipt #606767, dated 10/29/25, in the amount of $27; not signed by resident;--Receipt #126857, dated 1/5/26, in the amount of $27; not signed by resident;--Receipt #321310, dated 1/6/26, in the amount of $29; not signed by resident;--Receipt #251256, undated, in the amount of $27; not signed by resident;--Receipt #251317, dated 1/9/26, in the amount of $27; not signed by resident;--Receipt #451095, dated 1/15/26, in the amount of $27; not signed by resident;--Receipt #451216, dated 1/19/26, in the amount of $27; not signed by resident;--Receipt #250544, dated 1/20/26, in the amount of $27; not signed by resident;--Receipt #250593, dated 1/21/26, in the amount of $27; not signed by resident;--Receipt #116982, dated 1/26/26, in the amount of $27; signature section blank;--Receipt #251016, dated 1/27/26, in the amount of $27; not signed by resident;--Receipt #251147, dated 2/2/26, in the amount of $27; not signed by resident;--Receipt #122980, dated 2/3/26, in the amount of $27; not signed by resident;--Receipt #537614, dated 2/3/26, in the amount of $27; not signed by resident;--Receipt #977891, dated 2/17/26, in the amount of $27; not signed by resident;--Receipt #537614, dated 2/18/26, in the amount of $27; not signed by resident;--Receipt #537693, dated 2/19/26, in the amount of $27; signature section blank;--Receipt #537703, dated 2/20/26, in the amount of $27; not signed by resident;--Receipt #337921, dated 2/25/26, in the amount of $27; not signed by resident;--Receipt #537806, dated 2/26/26, in the amount of $27; not signed by resident;--Receipt #537845, dated 2/27/26, in the amount of $27; not signed by resident;--Receipt #337811, dated 2/28/26, in the amount of $27; not signed by resident.-Discrepancies in handwriting located in the numeric box and the written line amount for the following receipts: --Receipt #117116, dated 10/20/25, was altered from $7 to $27;--Receipt #121126, dated 11/20/25, was altered from $7 to $27;--Receipt #116853, undated, was altered from $7 to $27;--Receipt #122863, dated 12/23/25, was altered from $7 to $27. 5. Review of Resident #17 's quarterly MDS, dated [DATE], showed:-Diagnoses included psychotic disorder with delusions due to unknown physiological condition, schizophrenia unspecified;-Intact cognition. Review of the resident's Patient Trust (PT) ledger, dated 5/31/25 through 3/16/26, showed:-Withdrawal dated 10/8/25 in the amount of $50.00 had no receipts to verify withdrawal;-Withdrawal dated 1/23/26 in the amount of $400.00 had no receipts to verify withdrawal. Review of Resident's Post Shopping form copy, dated 10/8/25, showed:-Staff complete: Business Office Manager;-List of items purchased: were blank;-Section listed: Cash from resident: $650.00; showed was altered; with a written note showed $500 gift card and $150 cash was used in transaction;-Total Spent: $439.57; Total Change: $210.43; Change given to resident: was marked with an X, with a handwritten note that said: But has more shopping request so $150.00 will be used toward shopping; no receipt to verify purchases were made with the $150.00;-Resident signature: showed resident signed;-Staff signature: Business Office Manager;-Included one receipt:--Walmart dated 11/4/25, in the amount of $368.64 that showed a purchase of iphone 13, screen protector, phone case; resident was given an Android [NAME]-phone. 6. Review of Resident # 27's Quarterly MDS, dated , 2/28/26, showed:-Diagnoses included schizophrenia, antisocial personality disorder;-Intact cognition. Review of the resident's Patient Trust (PT) ledger, dated 5/31/25 through 3/16/26, showed:-Withdrawal dated 10/22/25 in the amount of $400.00 showed discrepancies with gift card purchase;-Withdrawal dated 11/18/25 in the amount of $200.00 had no receipts to verify withdrawal;-Withdrawal dated 12/1/25 in the amount of $250.00 had no receipts to verify withdrawal;-Withdrawal dated 12/16/25 in the amount of $250.00 had no receipts to verify withdrawal;-Withdrawal dated 2/24/26 in the amount of $400.00 had no receipts to verify withdrawal;-Withdrawal dated 3/5/26 in the amount of $400.00 had no receipts to verify withdrawal. Review of Resident's store receipts, showed:-On 10/22/25, three gift cards from Dollar Tree were purchased in the amounts of $150.00, $300.00, and $100.00 totaled in the amount of $550.00; location of gift cards unknown;-On 10/23/25, Walmart receipt in the of $55.96, showed resident did not acknowledge purchase. Review of Resident's Post Shopping form copy, undated, showed:-Staff complete: Business Office Manager;-List of items purchased: were blank;-Section listed: Cash from resident: $300.00; Total Spent: $267.91; Total Change: $32.09; Change given to resident;-Staff signature: Business Office Manager;-Included two receipts:--Walmart dated 1/30/26, in the amount of $141.06 that showed a purchase of Airpods 4;--Walmart dated 1/4/26, was unreadable for the amount and purchase detail. Review of Resident's computer withdrawal receipt, dated 1/16/26, showed the amount of $600.00 had no receipts to verify purchases. 7. Review of Resident #35 's quarterly MDS, dated [DATE], showed:-Diagnoses included schizophrenia, social phobia unspecified;-Intact cognition. Review of Resident's PT withdrawal receipts, showed:-Receipt #032123, dated 7/9/25, for $24, altered resident signature and incomplete receipt detail;-Receipt #846090, dated 7/15/25, for $26, altered resident signature and incomplete receipt detail;-Receipt #305412, dated 7/31/25, for $35, altered resident signature.-Discrepancies in handwriting located in the numeric box and the written line amount for the following receipts: --Receipt #117046, dated 10/29/25, was altered from $4 to $34;--Receipt #123304, dated 11/7/25, was altered from $4 to $34;--Receipt #121133, dated 11/20/25, was altered from $4 to $34;--Receipt #132745, dated 11/28/25, was altered from $4 to $34;--Receipt #127025, dated 12/10/25, was altered from $4 to $24;--Receipt #122961, dated 12/24/25, was altered from $5 to $35;--Receipt #116801, dated012/30/25, was altered from $4 to $34. 8. Review of Resident # 38's quarterly MDS, dated [DATE], showed:-Diagnoses included schizophrenia, major depressive disorder;-Intact cognition. Review of Resident's PT ledger, dated 5/1/25 through 3/20/26 showed:-Withdrawal dated 8/12/25 in the amount of $20.00 had no receipts to verify withdrawal;-Withdrawal dated 8/18/25 in the amount of $15.00 had no receipts to verify withdrawal;-Withdrawal dated 8/26/25 in the amount of $20.00 had no receipts to verify withdrawal;-Withdrawal dated 9/2/25 in the amount of $10.00 had no receipts to verify withdrawal;-Withdrawal dated 9/15/25 in the amount of $45.00 had no receipts to verify withdrawal;-Withdrawals dated 10/27/25 through 10/30/25, totaled in the amount of $90.00 had no receipts to verify withdrawal;-Withdrawal dated 11/14/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 11/19/25 in the amount of $5.00 had no receipts to verify withdrawal;-Withdrawal dated 11/21/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 11/28/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawals dated 12/4/25 through 12/5/25, totaled in the amount of $50.00 had no receipts to verify withdrawals;-Withdrawals dated 12/11/25 through 12/12/25, totaled in the amount of $50.00 had no receipts to verify withdrawals;-Withdrawals dated 12/16/25 through 12/30/25 totaled in the amount of $195.00 had no receipts to verify withdrawals;-Withdrawals dated 1/2/26 through 1/9/26 totaled in the amount of $180.00 had no receipts to verify withdrawals;-Withdrawal dated 1/13/26 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawals dated 1/15/26 through 1/19/26, totaled in the amount of $105.00 had no receipts to verify withdrawals;-Withdrawal dated 1/21/26 in the amount of $35.00 had no receipts to verify withdrawal; -Withdrawals dated 1/26/26 through 1/30/26, totaled in the amount of $140.00 had no receipts to verify withdrawals;-Withdrawal dated 2/3/26 in the amount of $5.00 had no receipts to verify withdrawal;-Withdrawal dated 2/19/26 in the amount of $15.00 had no receipts to verify withdrawal;-Withdrawal dated 2/23/26 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 2/25/26 in the amount of $25.00 had no receipts to verify withdrawal. Review of Resident's PT withdrawal receipts, showed:-Discrepancies in handwriting located in the numeric box and the written line amount for the following receipts: --Receipt #846162, dated 7/16/25, was altered from $4 to $24;--Receipt #117038, dated 10/29/25, was altered from $5 to $35. 9. Review of Resident # 41's comprehensive MDS, dated [DATE], showed:-Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, schizoaffective disorder bipolar type;-Cognition moderately impaired. Review of Resident's PT ledger, dated 5/1/25 through 3/20/26, showed:-Withdrawal dated 5/27/25, in the amount of $36.00, has no receipt to verify withdrawal;-Two Withdrawals dated 6/30/25, in the amount of $45.00 each, has no receipt to verify withdrawals;-Withdrawal dated 7/1/25, in the amount of $500.00, has no receipt to verify withdrawal;-Withdrawal dated 8/11/25 in the amount of $800.00 had no receipts to verify withdrawal;-Withdrawal dated 8/12/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 8/19/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawals dated from 10/22/25 through 10/23/26 totaling in the amount of $90.00 had no receipts to verify withdrawals; -Withdrawals dated from 10/27/25 through 10/30/26 totaling in the amount of $128.00 had no receipts to verify withdrawals;-Withdrawals dated from 11/13/25 in the amount of $100.00 had no receipts to verify withdrawal;-Withdrawals dated from 11/18/25 in the amount of $45.00 had no receipts to verify withdrawal;-Withdrawals dated from 11/20/25 through 11/21/25 totaling in the amount of $70.00 had no receipts to verify withdrawals;-Withdrawals dated from 12/3/25 through 12/4/25 totaling in the amount of $80.00 had no receipts to verify withdrawals;-Withdrawals dated from 12/16/25 in the amount of $300.00 had no receipts to verify withdrawal;-Withdrawals dated from 12/17/25 through 3/13/26 totaling in the amount of $1075.00 had no receipts to verify withdrawals. Review of Resident PT withdrawal receipts showed:-Receipt #176678, dated 7/7/25, for $45, missing resident signature;-Receipt #0348128, dated 7/8/25, for $45, missing resident signature;-Receipt #621107, dated 7/21/25, for $45, missing resident signature;-Receipt #621149, dated 7/22/25, for $45, missing resident signature;--Receipt #032118, dated 7/9/25, for $45; receipt wasn't filled out completely - amount disputed;-Discrepancies in handwriting located in the numeric box and the written line amount for the following receipts: --Receipt #621023, dated 7/17/25, was altered from $5 to $45 and inaccurate resident signature. During an interview on 4/28/26 at 10:10 A.M., the resident said he/she did not withdrawal more than four to five dollars each time except when he/she purchased cigarettes. The resident said he/she did not remember withdrawing $500.00 to go shopping, but would like to go if someone would take him/her. 10. Review of Resident # 42's quarterly MDS, dated [DATE], showed: -Diagnoses included schizophrenia;-Intact cognition. Review of Resident's PT ledger, dated 5/1/25 through 3/20/26, showed:-Withdrawal dated 6/2/25 in the amount of $10.00 had no receipt to verify withdrawal;-Withdrawal dated 7/1/25 in the amount of $400.00 had no receipt to verify withdrawal. 11. Review of Resident # 47's quarterly MDS, dated [DATE], showed:-Diagnoses included mild intellectual disabilities, personal history of traumatic brain injury, cognitive communication deficit, paranoid schizophrenia;-Cognition severely impaired. Review of Resident's PT ledger, dated 5/1/25 through 3/20/26, showed:-Withdrawal dated 6/24/25 in the amount of $500.00 had no receipt to verify withdrawal;-Withdrawal dated 11/18/25 in the amount of $33.00 had no receipt to verify withdrawal;-Withdrawal dated 12/1/25 in the amount of $35.00 had no receipt to verify withdrawal;-Withdrawal dated 12/3/25 in the amount of $23.00 had no receipt to verify withdrawal;-Withdrawal dated 12/8/25 in the amount of $23.00 had no receipt to verify withdrawal;-Withdrawal dated 12/9/25 in the amount of $24.00 had no receipt to verify withdrawal;-Withdrawal dated 12/15/25 in the amount of $23.00 had no receipt to verify withdrawal;-Withdrawal dated 12/19/25 in the amount of $24.00 had no receipt to verify withdrawal;-Withdrawal dated 12/24/25 in the amount of $23.00 had no receipt to verify withdrawal;-Withdrawal dated 12/30/25 in the amount of $33.00 had no receipt to verify withdrawal;-Withdrawal dated 1/8/26 in the amount of $23.00 had no receipt to verify withdrawal;-Withdrawal dated 1/26/26 in the amount of $24.00 had no receipt to verify withdrawal;-Withdrawal dated 1/27/26 in the amount of $24.00 had no receipt to verify withdrawal;-Withdrawal dated 1/29/26 in the amount of $24.00 had no receipt to verify withdrawal;-Withdrawal dated 2/2/26 in the amount of $34.00 had no receipt to verify withdrawal;-Withdrawal dated 2/6/26 in the amount of $24.00 had no receipt to verify withdrawal;-Withdrawal dated 2/17/26 in the amount of $24.00 had no receipt to verify withdrawal;-Withdrawal dated 3/4/26 in the amount of $34.00 had no receipt to verify withdrawal;-Withdrawal dated 3/5/26 in the amount of $34.00 had no receipt to verify withdrawal;-Withdrawal dated 3/9/26 in the amount of $300.00 had no receipt to verify withdrawal;-Withdrawal dated 3/10/26 in the amount of $24.00 had no receipt to verify withdrawal;-Withdrawal dated 3/13/26 in the amount of $24 had no receipt to verify withdrawal. 12. Review of Resident # 52's quarterly MDS, dated [DATE], showed:-Diagnoses included schizoaffective disorder, bipolar type, autistic disorder;-Intact cognition. Review of Resident's PT ledger, dated 5/1/25 through 3/20/26, showed a withdrawal dated 1/22/26 in the amount of $29.00 had no receipt to verify withdrawal. 13. Review of Resident # 54's quarterly, MDS, dated [DATE], showed:-Diagnoses included bipolar disorder unspecified, autistic disorder;-Intact cognition. Review of Resident's PT ledger, dated 5/1/25 through 3/20/26, showed:-Withdrawal dated 12/16/25 in the amount of $200.00 had no receipts to verify withdrawal;-Withdrawal dated 10/22/25 in the amount of $34.00 had no receipts to verify withdrawal;-Withdrawal dated 10/30/25 in the amount of $ 34.00 had no receipts to verify withdrawal;-Withdrawal dated 11/18/25 in the amount of $44.00 had no receipts to verify withdrawal;-Withdrawal dated 11/21/25 in the amount of $24.00 had no receipts to verify withdrawal;-Withdrawal dated 11/28/25 in the amount of $34.00 had no receipts to verify withdrawal;-Withdrawal dated 12/5/25 in the amount of $24.00 had no receipts to verify withdrawal;-Withdrawals dated from 12/11/25 through 1/6/26 totaling in the amount of $204.00 had no receipts to verify withdrawals;-Withdrawals dated from 1/13/26 through 1/16/26 totaling in the amount of $106.00 had no receipts to verify withdrawals;-Withdrawal dated 1/22/26 in the amount of $34.00 had no receipts to verify withdrawal;-Withdrawals dated from 1/27/26 through 1/30/26 totaling in the amount of $97.00 had no receipts to verify withdrawals; -Withdrawal dated 2/4/26 in the amount of $24.00 had no receipts to verify withdrawal;-Withdrawals dated from 2/13/26 through 2/17/26 totaling in the amount of $49.00 had no receipts to verify withdrawals;-Withdrawals dated from 2/25/26 through 3/3/26 totaling in the amount of $123.00 had no receipts to verify withdrawals;-Withdrawals dated from 3/5/26 through 3/6/26 totaling in the amount of $48.00 had no receipts to verify withdrawals;-Withdrawal dated 3/10/26 in the amount of $25.00 had no receipts to verify withdrawal. Review of Resident's PT withdrawal receipts showed:-Discrepancies in handwriting located in the numeric box and the written line amount for the following receipts: --Receipt #123295, dated 11/7/25, was altered from $4 to $44;--Receipt #122713, dated 12/4/25, was altered from $4 to $24;--Receipt #132827, dated 12/5/25, was altered from $4 to $24;--Receipt #132895, dated 12/8/25, was altered from $4 to $24. 14. Review of Resident # 56's quarterly MDS, dated [DATE], showed:-Diagnoses included cerebellar stroke syndrome, schizophrenia unspecified;-Cognition moderately impaired. Review of Resident's PT ledger, dated 1/1/25 through 3/31/26, showed:-Withdrawal dated 7/31/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 8/19/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 1/19/26 in the amount of $34.00 had no receipts to verify withdrawal. 15. Review of Resident # 60's quarterly MDS, dated [DATE], showed:-Diagnoses included paranoid schizophrenia, unspecified intellectual disabilities;-Intact cognition. Review of Resident's PT ledger, dated 5/1/25 through 3/20/26, showed:-Withdrawal dated 7/28/25 in the amount of $34.00 had no receipts to verify withdrawal;-Withdrawal dated 9/5/25 in the amount of $30.00 had no receipts to verify withdrawal;-Withdrawal dated 10/6/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 10/29/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 10/30/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 11/6/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 11/14/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 11/18/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 11/20/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 11/21/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 12/3/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 12/4/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawal dated 12/8/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 12/15/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 12/16/25 in the amount of $25.00 had no receipts to verify withdrawal;-Withdrawal dated 12/19/25 in the amount of $35.00 had no receipts to verify withdrawal;-Withdrawals dated from 12/23/25 through 1/2/26 totaling in the amount of $100.00 had no receipts to verify withdrawals;-Withdrawals dated from 1/5/26 through 1/15/26 totaling in the amount of $250.00 had no receipts to verify withdrawals;-W

Based on interview and record review, the facility failed to ensure quarterly statements were distributed to residents and/or their responsible parties. This deficient practice affected all 101 residents whose funds were handled by the facility. The census was 141. Review of the facility's Resident Rights policy, last review date 9/21/25, showed the facility will keep a written account of all funds and provide resident or resident's designee or guardian a quarterly accounting of all financial transactions made on behalf of the resident. Review of the resident funds records provided by the facility, showed no documentation of quarterly statements. During an interview on 4/28/26 at 11:00 A.M., the Administrator said the facility managed 101 resident accounts. The Business Office Manager was responsible for sending out the quarterly statements, but did not send out the quarterly statements. The Administrator expected a written account of the residents' funds to be provided to the resident/resident representative quarterly.

Based on interview and record review, the facility failed to ensure the Nurse Aide (NA) registry verifications were checked before allowing four employees to work and provide care to residents (Employees AAA, CCC, DDD, and EEE). The census was 141.Review of the facility's Background Investigations policy, revised on 12/27/24, showed:-Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company;-The Human Resource department will conduct all applicable background investigation(s) on each individual making applications for employment with this company and on any current employee if such background investigation is appropriate for position for which the individual has applied;-For all applicants applying for a position as a certified nurse aide, the human resources department will contact the nurse aide registry of the state in which the individual is certified and/or previously employed to verify that the applicant's certification is in good standing;-The facility will not employ individuals who:--Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;--Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property;--Have a disciplinary action in effect against his or her professional license in a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of resident, or misappropriation or resident property;--All inquiries regarding background investigations should be directed to the Director of Human Resources or Administrator. 1. Review of Employee AAA's employee file, showed:-Date of hire (DOH) - 6/24/25;-No documentation of NA registry verification was checked. 2. Review of Employee CCC's employee file, showed:-DOH - 3/13/26;-No documentation of NA registry verification was checked. 3. Review of Employee DDD's employee file, showed:-DOH - 4/3/26;-No documentation of NA registry verification was checked. 4. Review of Employee EEE's employee file, showed:-DOH - 1/12/26;-No documentation of NA registry verification was checked. 5. During an interview on 5/1/26 at 2:21 P.M., Human Resources (HR) personnel said she only checked nursing staff for the NA registry verification. She was not aware that non-nursing staff were supposed to be checked for NA registry. HR personnel said all four sampled employees' NA registry was checked during the survey when she was made aware by the DON. 6. During an interview on 5/1/26 at 1:00 P.M., the Administrator and the Director of Nurses (DON) said all the employees' onboarding requirements should be completed upon hire. HR was responsible for making sure the NA registry verifications were checked for newly hired employees.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate did not exceed five percent or greater. Five errors were observed out of 25 opportunities, with a 20 percent error rate (Residents #5, #16, #23, and #102). The sample was 38. The census was 141.Review of the facility's Medication Administration policy, revised 6/26/24, showed:-Purpose: Medications are administered by licensed staff and as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. It is the policy of the facility to ensure the safe and effective administration of all medications by utilizing practice guidelines;-Policy:-Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, and right documentation;-Administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. Review of the facility's Administration of Insulin policy, reviewed 5/14/24, showed:-Purpose: To provide timely administration of insulin to meet the needs of each resident and to prevent adverse effects. The facility uses insulin pens to improve the accuracy of insulin dosing, provide increased resident comfort;-Policy: -Administration of insulin:--All insulin will be administered in accordance with physician orders; -Insulin Pens:--Insulin pens are to be primed prior to each use to avoid collection of air in the insulin reservoir. 1. Review of Resident #5's medical record, showed diagnoses included diabetes. Review of the resident's electronic physician order sheet (ePOS), showed an order, dated 1/1/26, for Humalog (fast acting insulin) [NAME], three times a day, inject per sliding scale:-100 to 150: Inject 2 units;-151 to 200: Inject 4 units;-201 to 250: Inject 6 units;-251 to 300: Inject 8 units;-301 to 350: Inject 9 units;-Above 400: Inject 12 units and call the physician. Observation and interview on 4/29/26 at 7:55 A.M., showed Licensed Practical Nurse (LPN) E obtained the resident's fasting blood glucose (FBG, a measurement of sugar in the blood). Per the glucometer, the result was 211. LPN E said per physician order, the resident would receive 6 units of Humalog. LPN E applied gloves, obtained the resident's Humalog pen, and dialed 2 units and pressed the plunger. LPN E then removed the gloves, sanitized his/her hands, applied clean gloves, then applied the insulin needle to the end of the insulin pen. LPN E dialed 6 units on the insulin pen and administered the insulin to the resident. LPN E said he/she did not prime the insulin needle prior to administration of the insulin. He/She did not know he/she needed to prime the needle prior to administration. 2. Review of Resident #16's medical record, showed diagnoses included chronic pain, stroke, high blood pressure, dysphagia (difficulty swallowing), and paralysis of the right side. Review of the resident's ePOS, showed an order, dated 6/13/25, for gabapentin (used to treat nerve pain) 100 milligrams (mg), take one capsule three times a day for pain. Observation and interview on 4/29/26 at 12:20 P.M., showed Certified Medication Technician (CMT) F obtained the resident's gabapentin medication card and reviewed the physician order. CMT F dispensed one capsule into his/her bare hand. CMT F opened the capsule with bare hands and emptied the medication into a plastic cup. Multiple medication beads from the opened capsule touched CMT F's fingertips while being poured into the cup. CMT F filled the cup with fluid, stirred the fluid, and assisted the resident to drink the mixture. CMT F said he/she had forgotten to apply gloves before opening the medication capsule and a few medication beads touched his/her fingers. Gloves should be worn when handling medications. 3. Review of Resident #23's medical record, showed diagnoses included tremors, seizures, and schizophrenia (a mental health disorder that affects how a person thinks, feels and behaves). Review of the resident's ePOS and Medication Administration Record (MAR) for April 2026, showed, an order, dated 2/20/25 for Austedo (used to treat uncontrolled tremors) 12 mg tablet and 6 mg tablet, take one tablet of 12 mg and 6 mg twice daily. Scheduled for 7:00 A.M. and 3:00 P.M. Observation and interview on 4/29/26 at 10:28 A.M., showed CMT G obtained the resident's 12 mg and 6 mg Austedo medication cards. CMT G dispensed one tablet of each medication into a plastic medication cup and administered the medication to the resident. CMT G said the medication was ordered to be administered at 7:00 A.M., for the morning dose. He/She had been late to begin the morning medication pass. Medications should be administered within an hour of the ordered time. 4. Review of Resident #102's medical record, showed diagnoses included paranoid personality disorder, bipolar disorder, (a mood disorder resulting in emotional highs and lows), and substance abuse history. Review of the resident's ePOS and MAR for April 2026, showed an order, dated 4/22/25, for olanzapine (used to treat psychosis and bipolar disorders) 15 mg disintegrating tablet, take one at bedtime daily. Scheduled for 7:00 P.M. Observation and interview on 4/28/26 at 5:00 P.M., showed CMT H obtained the resident's olanzapine 15 mg medication card. CMT H reviewed the physician order, dispensed one tablet into a small plastic cup, and administered the medication to the resident. CMT H ensured the medications were swallowed and documented the administration into the resident's medical record. CMT H said the medication was ordered to be taken at 7:00 P.M. He/She started the evening medication pass early to complete other tasks. Medications should not be administered more than an hour before the ordered administration time. 5. During an interview on 5/1/26 at 2:00 P.M., the Director of Nursing (DON) said she expected staff to administer medications as ordered. Medications can be administered an hour before or an hour after the physician-ordered administration time. Staff should not use ungloved bare hands to touch or handle medications. Insulin pen needles should be primed prior to administration of the insulin.

Based on interview and record review, the facility failed to ensure care was provided in accordance with professional standards of practice by not following physician's orders when staff administered the wrong medication to one resident (resident #92). The sample size was 31. The census was 141. Review of the facility's Transcription of Orders/Following Physician's Orders policy, revised 5/18/24, showed:-The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed;-To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders;-Clarification of Physician's Orders will be obtained if the order is either unclear or the nurse is uncomfortable in implementation of the Physician's Orders;-The RCC (Resident Care Coordinator)/Unit Manager/Designated Nurse will review all electronic MARs/TARs (Medication Administration Record/Treatment Administration Record) and compare all medications to the medications available for each resident in the facility weekly to ensure availability;-The Physician is expected to sign all of their orders electronically in the Electronic Health Record. Review of the facility's Medication Administration policy, revised 6/26/24, showed:-Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with the professional standards of practice, in a manner to prevent contamination or infection;-It is the policy of this facility to ensure the safe and effective administration of all medications by utilizing best practice guidelines;-Ensure the six rights of medication administration are followed;--Right resident;--Right drug;--Right dosage;--Right route;--Right time;--Right documentation;-Review MAR to identify medication to be administered;-Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Review of Resident #92's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/6/26, showed:-admitted on [DATE];-Cognitively intact;-Diagnoses included anxiety, depression, and Schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions);-Medications included antipsychotic, antianxiety, and antidepressant. Review of the resident's MAR, dated 4/1/26 through 4/30/26, showed:-On 4/7/26, an order of Hydroxyzine HCl (antianxiety) oral tablet 50 milligrams (mg), to give 50 mg by mouth three times a day for paranoia;-The medication was discontinued on 4/24/26;-The medication was administered from the morning of 4/7/26 through 4/23/26 at bedtime;-On 4/24/26, there was an order of the same medication, dose, and frequency for generalized anxiety disorder;-The medication was started on 4/24/26 at noon;-On 4/24/26, an order for Hydralazine HCl oral tablet 50 mg, to give one tablet by mouth two times a day for HTN (hypertension, high blood pressure);-The medication was started on the morning of 4/25/26. Review of the resident's progress note, dated 4/24/26 at 10:15 A.M., showed Licensed Practical Nurse (LPN) M documented he/she received a report by Certified Nurse Assistant (CNA) about a discrepancy with medication. The resident had an order for Hydroxyzine 50 mg by mouth three times a day for paranoia. Hydralazine was dispensed by pharmacy. The resident was assessed, and vital signs were checked. The LPN noted no adverse reactions. The medical physician ordered Hydralazine for high blood pressure. The psychiatric Nurse Practitioner (PNP) ordered to continue to monitor mood and behaviors. During an interview on 4/26/26 at 11:25 A.M., the resident said he/she was told the day before by staff that there was a medication error. He/She was upset and asked for all the medications ordered by his physician. He/She did not have any reactions and did not feel anything unusual. During an interview on 4/29/26 at 9:49 A.M., LPN M said they obtained the residents' orders from the discharge summary report. They verified the orders with the physicians via telephone. The PNP came every week and reviewed the orders. The orders were entered into Point Click Care (PCC, the facility's electronic health records system), then the pharmacy received the orders. Resident #92 received Hydralazine 50 mg three times a day, instead of Hydroxyzine 50 mg three times a day. The pharmacy dispensed the wrong cards. When the physician was notified of the error, an order was to continue Hydralazine 50 mg two times a day since the resident had elevated blood pressure readings. LPN M said the medication cards should have been checked against the orders to administer the correct medication. During an interview on 4/29/26 at 10:10 A.M., the pharmacy technician (PT) said the residents' orders were entered into PCC by the facility to transmit the orders electronically. According to the pharmacy records, Resident #92's orders were Hydralazine 50 mg by mouth two times a day, and Hydroxyzine 50 mg by mouth three times a day. The resident's Hydralazine 50 mg was ordered and dispensed on 4/6/26 three times a day and was changed to two times a day on 4/24/26. An order of Hydroxyzine 50 mg three times a day was added on 4/24/26. Observation and interview on 4/29/26 at 10:35 A.M., showed the 500 hall medication cart had Hydralazine 50 mg cards with a fill date of 4/7/26, to be given by mouth three times a day. The morning dose had nine tablets left, while the evening dose had 10 tablets left. There were three more unopened cards (90 tablets), with fill date of 4/24/25, and another two more cards (60 tablets), with fill date of 4/24/26. There were three cards of Hydroxyzine 50 mg, one for each morning, noon, and evening doses, with fill date of 4/24/26. Certified Medication Technician (CMT) G said the resident was not supposed to take Hydralazine 50 mg tablet. The resident's order was for Hydroxyzine 50 mg tablet three times a day. The pharmacy sent Hydralazine 50 mg. The CMT said, it threw us all off, until another CMT caught the error. The resident had been taking Hydralazine three times a day, instead of Hydroxyzine, since admission until 4/24/26. He/She said they should have checked the orders and compared the MAR with the medication cards before administering the medications to the residents. CMT G said the resident was a little upset when they notified him/her about the error. No unusual behaviors were observed. During an interview on 4/30/26 at 1:00 P.M., the PNP said she was notified by the facility of the resident's medication error the day it was found out. She advised the staff to observe the resident's behaviors and to notify the medical physician. The resident could have potentially destabilized and would have increased behaviors. No report was received from the facility of the resident having increased behaviors. She expected the staff to use the rights of medication administration and follow the physician's orders. During an interview on 4/30/26 at 1:55 P.M. the Director of Nursing (DON) said she expected the staff to follow the resident's physician orders and follow the medication administration policy.

Based on observation, interview and record review, the facility failed to update a resident's comprehensive care plan following admission into hospice services (Resident #9). The sample size was 31. The census was 141.Review of the facility's Comprehensive Care plan policy, reviewed 10/31/24, showed:-Purpose: To develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment;-Person centered care: To focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives;-Policy:-The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility as outlined by the comprehensive care plan, shall be competent;-The comprehensive care plan will be developed within seven days after completion of the comprehensive Minimum Data Set ((MDS) a federally mandated assessment instrument completed by facility staff) assessment;-The comprehensive care plan will describe, at a minimum:--The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being;--The comprehensive care plan will be reviewed and revised by the team after each comprehensive and quarterly MDS assessment. Review of Resident #9's medical record, showed:-admitted to hospice services on 12/23/25;-Diagnoses included stroke, failure to thrive, protein calorie malnutrition, and difficulty swallowing. Review of the care plan, in use during the survey, did not address hospice admission or hospice care plan and the facility responsibility of care needs. During an interview on 5/1/26 at 9:26 A.M., the Regional MDS Coordinator said the care plan should have reflected the accuracy of the resident conditions. Hospice services should have been addressed on the care plan. The care plan should have addressed what services the hospice provider would address and what services the facility would provide. The care plan was used to direct resident care and should have been updated as the resident's needs changed. During an interview on 5/1/26 at 2:00 P.M., the Administrator and Director of Nursing (DON) said the care plans should be accurate and updated to reflect the needs of the resident. The care plan was individualized to reflect care services by outside providers, including hospice services. As the resident's needs changed the care plan should be updated to reflect the changes.

Based on interview and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff. This deficiency affected two of 31 sampled residents (Resident #9 and Resident #28). The census was 141.Review of the MDS care assessment summary policy, revised 11/6/23, showed: -Purpose: To understand the changes presented by Centers for Medicare and Medicaid Services (CMS) 3.0, to define the intent of each section of the MDS 3.0 and to ensure that MDS sections are completed accurately and in a timely manner by the assigned responsible parties. -Procedure: -Section J is to be completed by nursing staff. This section addresses any condition that impacts the resident's quality of life and functional status; -Used to identify the number of health conditions that impact the resident's functional status and quality of life; -Areas in the section to assess are dyspena (difficulty breathing), prognosis, problem conditions and falls. -As the information from the MDS correlates with the Care Assessment Areas (CAAs), the staff that is responsible for that section should be the staff entering that information; -After completing the MDS 3.0, the facility will use the CAA to further assess the triggered areas of concern by helping the staff to look for casual or confounding factors, some of which may be reversible; -CAAs need to document the casual risk factors or unique risk factors for decline or lack of improvement; -MDSs must be kept current and up to date. 1.Review of Resident #9's physician order sheet (POS), showed: -An order, dated 12/23/25: Admit to hospice services. Review of the resident's significant change MDS, dated [DATE], showed: -Moderately cognitively impaired; -Diagnoses included stroke, heart failure, dysphagia (difficulty swallowing) and protein calorie malnutrition. -Section J: Prognosis: -Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months: No; -The significant change MDS did not correctly identify the enrollment into hospice services. Review of the care plan, in use during the survey did not address the enrollment of hospice services. 2. Review of Resident #28's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high cholesterol, bipolar disorder (mental health condition characterized by mood swings from one extreme to another), schizophrenia (a serious mental health condition that affects how people think, feel and behave), and chronic obstructive pulmonary disease (COPD, incurable lung disease); -Diabetes Mellitus (DM, a condition that happens when your blood sugar is too high) was not included as an active diagnosis; -Hypoglycemic medication, including insulin (medication that helps lower blood sugar), was indicated as taken by the resident. Review of the resident's care plan in use at the time of survey, showed: -Problem: The resident was at risk for hyper/hypoglycemic episodes related to diagnosis of DM; -Goal: The resident will have no complications related to diabetes through the review date, -Interventions: DM medication as ordered by doctor. Monitor and document for side effects and effectiveness. Identify areas of noncompliance or other difficulties in resident's diabetic management. Review of the resident's electronic health records (EHR), showed no diagnosis of DM. The resident's electronic physician's orders sheet (ePOS), and Medication Administration Record (MAR), did not show an order for insulin. 3. During an interview on 5/1/26 at 9:26 A.M., the regional MDS coordinator said the facility used nurse assessment coordinators to complete resident questionnaires. The MDS is completed by reviewing the resident's medical record. The MDS should be accurate and reflect the current condition of the residents. 4. During an interview on 5/1/26 at 2:00 P.M., the Administrator and Director of Nursing (DON) said they expected the MDS to be accurate and reflect the care needs of the residents. Hospice should be accurate on the MDS as well as the medications that are administered. Ozempic is not an insulin class of medication.

Based on observation and interview, the facility failed to maintain a homelike environment when the facility failed to ensure one toilet in a [NAME] and [NAME] bathroom (bathroom situated and directly accessible from two separate rooms) was functional (Resident #12). In addition, the facility failed to ensure one resident's bed had clean linen (Resident#114). The sample was 31. The census was 141.Review of the facility's Safe and Homelike Environment Policy, dated 6/5/2024, showed:-Housekeeping and maintenance services will be provided as necessary to maintain a sanitaryand comfortable environment;-The facility will provide and maintain bed and bath linens that are clean and in good condition;- Minimize odors by disposing of soiled linens promptly and reporting lingering odorsand bathrooms needing cleaning to housekeeping department. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/26, showed:-Moderate cognitive impairment;-Required supervision or touch assistance for personnel and toilet hygiene;-No behaviors;-Diagnoses included high blood pressure, anxiety, bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)) and schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). Observation on 4/26/26 at 8:30 A.M., showed the resident had a [NAME] and [NAME] bathroom. The toilet was clogged with brown substances. During an interview on 4/26/26 at 9:00 A.M., Certified Nurse Aide (CNA) B said the facility was aware the toilet was clogged, and when they unclogged it, the residents would clog it again. The CNA identified Resident #12 as who clogged the toilet and said they tried to keep the paper towels out. The CNA said he/she told the nurse when the toilet was clogged. He/She was not aware of any interventions put in place to try to prevent the resident from clogging the toilet. Observations on 4/26/26 at 8:30 A.M., 4/27/26 at 11:39 A.M. and 4/28/26 at 1:44 P.M., showed the toilet was clogged. During an interview on 4/29/26 at 9:30 A.M., the Administrator said she would expect the CNA and the housekeeping staff to notify maintenance when the toilet was clogged. She was aware the resident was known for clogging the toilet with paper towels. She would have expected staff to have made frequent checks of the bathroom and if the toilet was clogged, it should be reported immediately to maintenance. Observation on 4/29/26 at 11:30 A.M. showed the toilet was unclogged. During an interview on 4/29 at 1:30 P.M. the Maintenance Director said he had not been at the facility very long and was still learning the facility. He was not aware the toilet was clogged until the Administrator talked to him about it and he immediately took care of it. 2. Review of Resident #114's quarterly MDS, dated [DATE], showed:-Cognitively intact;-No behaviors or rejection of care;-Required supervision or touch assistance for personal and toilet hygiene;-Independent with dressing;-Always continent of bowels and bladder;-Diagnoses included: Alzheimer disease, Traumatic Brain Injury (TBI), depression, Schizophrenia and post-traumatic stress disorder (PTSD). Review of the resident's care plan, in use at the time of survey showed:-Problem: Risk for self-care deficit: bathing, dressing, feeding;-Goal: Resident will participate in self-care activities;-Interventions: Encourage resident to participate in planning day-to-day care. Evaluate functional abilities. Evaluate resident's ability to perform activities of daily living (ADLs, grooming, dressing, toileting and bathing). Maintain consistent schedule with daily routine. Provide assistance with ADLs as needed. Observation and interview on 4/26/26 at approximately 11:00 A.M., showed the resident lay in bed. There was a large dried yellow ring on the bottom sheet. The residents' clothes were dry. Observation on 4/29/26 at 1:32 P.M. and 4/30/26 at 1:00 P.M., showed the resident was not in the room. There was a large dried yellow ring on the bottom sheet. During an observation and interview on 4/30/26 at 1:10 P.M., the Social Services Assistant (SSA) said both the residents and the CNA's changed the bed linen. If the residents could not change the sheets, the CNAs should have done it. The resident was unable to change his/her bed linen. She would not expect the resident's sheet to have a yellow ring on it. She would have expected the CNAs to make rounds and change the bed linens, as needed. During an interview on 4/30/26 at 8:15 A.M. Licensed Practical Nurse (LPN) E said the CNA's did rounds on residents every two hours. During their rounds they checked on the residents and provided ADL care. During an interview on 5/1/26 at 1:00 P.M., the Administrator said she was made aware of the residents' bed linen. The resident was given a shower, and the bed linens were changed. The CNAs were responsible for changing the bed linens on shower days and as needed. She would have expected staff to follow the facility's policies and procedures.

Based on interview and record review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN, -CMS-10055) or a denial letter at the initiation, reduction or termination of Medicare Part A benefits. The facility identified 11 residents, who discharged from Medicare covered Part A with benefits days remaining in the past six months. Three residents were sampled, and issues were found with all three residents (Resident #41, #12 and #35). The census was 141.Review of the facility's Advance Beneficiary Notices, dated 11/5/24, showed:--To ensure that the resident, or representative, has enough time to make a decision whether ornot to receive the services in question and assume financial responsibility, the notice shall beprovided at least two days before the end of a Medicare covered Part A stay or when all of PartB therapies are ending. The notices must not be provided while the resident/representative is under duress or in an emergency situation;--The notice shall be prepared with an original and at least two copies. The facilityshall retain the original and give a copy to the resident/representative;-The original notice shall be placed into the resident's financial file. The notice shall be retainedat least five years. Review of the list of Beneficiary Notice-Residents discharged Within the Last Six Months, completed by the facility, showed:-Resident #41 discharged from services on 12/23/25 and remained in the facility;-Resident #12 discharged from services on 12/21/25 and remained in the facility;-Resident #35 discharged from services on 2/16/26 and remained in the facility. During an interview on 4/29/26 at approximately 3:00 P.M. and on 4/30/26 at approximately 10:00 A.M., the surveyor requested the Beneficiary Notices for Resident #41, #12 and #35 from the Administrator. During an interview on 5/1/26 at approximately 1:00 P.M., the Administrator said she did not have the SNFABN for two out of the three residents. The third notice was not provided. She would expect the notices to be provided to the resident/resident representative when the residents were discharged from services and documented in the residents' medical record.

Based on observation, interview and record review, the facility failed to ensure residents who needed assistance with nail care, received timely nail care services. The delay in services resulted in long, jagged and unkempt toenails (Resident #107 and Resident #12). The sample was 31. The census was 141.Review of the nail care policy, revised 6/26/24, showed:-Purpose: To provide guidelines for the provision of care to a resident's nails for good grooming and health;-Policy: -Assessments of nails will be conducted on admission and readmission to determine the nail condition, needs, and preferences for nail care: -Report unusual or abnormal conditions of the nails to the physician and the responsible party (curling, color changes, separation from the nail bed, redness, bleeding, pain, odor, and infection); -Obtain history and preferences regarding podiatry; -Identify conditions that increase risk for foot or nail problems, such as diabetes, vascular disease, heart failure, renal disease or stroke; -Routine cleaning and inspection of nails will be provided during daily care on an ongoing basis; -Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly). Nail care will be provided between scheduled occasions as the need arises; -The resident's plan of care will identify: -The frequency of nail care to be provided; -The type of nail care to be provided; -The person responsible for providing nail care; -Principles of nail care: -Nails should be kept smooth to avoid skin injury; -Only licensed nurses shall trim or file nails of residents with diabetes; -If a resident has diabetes mellitus, renal failure or vascular disease, trimming should be preformed by a physician or practitioner; -Residents without complicating disease processes, may have the nails clipped by staff who have received education and training to provide the service within professional standards of practice and as per facility policy; -Each resident will have his/her own nail care equipment. Equipment will not be shared between residents. Clean equipment after each use and before storing. 1. Review of Resident #107's medical record, showed:-re-admitted : 11/4/24;-Diagnoses included irregular heat beat, anxiety, heart disease, delusional disorder (persistent, fixed false beliefs (delusions) lasting at least one month, kidney disease and venous insufficiency. Review of the electronic physician order sheet (ePOS), showed:-An order dated 11/4/24: May see the Podiatrist. Review of the quarterly Minimum Data Set (MDS) a federally required assessment instrument, completed by facility staff, dated 2/3/26, showed:-Moderate cognitive impairment;-Staff provide supervision and touch assistance for bathing;-Staff provide moderate assistance with applying footwear. Review of the care plan, in use during the survey, did not address the resident's nail care needs. Review of the podiatry visit note, dated 2/4/26, showed:-History of present illness: At risk foot care;-Advanced trophic changes: -Nail thickening on both feet; -Nails are yellow, discolored, crumbly. Multiple nails are long and curved;-Plan: Nails trimmed with a nail clipper. A file was also used;-Follow up: Exam in two to three months. Observations on 4/26/26 at 8:10 A.M., and at 11:43 A.M., showed the resident sat up in bed. Both of the resident's feet were exposed and had very dry and scaley skin. Multiple toenails were long, scaley and curved. During interviews on 4/27/26 at 9:09 A.M. and 2:30 P.M., the resident said he/she had seen the foot doctor previously to trim his/her toenails. He/She could not recall the last time the Podiatrist examined his/her toenails. He/She had dry feet and staff do not put lotion on his/her feet. He/She wanted to see the Podiatrist soon. Staff did not provide nail trimming or filing. Observation on 4/29/26 at 7:18 A.M., showed the resident sitting up in bed, with both feet exposed. Both feet were dry and flakey with long nails. 2. Review of Resident #12's ePOS, showed:-An order, dated: 11/19/24, may see podiatry. Review of the medical record, showed:-re-admitted : 12/15/25;-Diagnoses included diabetes, high blood pressure, schizophrenia (delusions or paranoid thoughts), heart attack, and dementia. Review of the care plan, revised 12/29/25, showed:-Problem: The resident is resistive to care due to delusional thoughts;-Goal: The resident will cooperate with care;-Interventions: Allow the resident to make decisions, educate the resident regarding refusal of care.-Problem: The resident has diabetes; -Goal: The resident will have no complications; -Interventions: Administer medications as ordered, and monitor for hypoglycemia (low blood sugar);-The care plan did not address diabetic foot care. Review of the skin check assessment, dated 4/27/26, showed:-No skin issues;-Foot evaluation completed;-No additional notes documented regarding foot care. Observation and interview on 4/29/26 at 8:09 A.M., showed the resident in bed with his/her feet exposed. The toenails of both feet were long, very thick and the nails were curled under some of the toes. The resident said his/her feet hurt so much. Staff had not provided nail trimming, and he/she had not seen the podiatrist since admission. During an interview on 4/29/26 at 8:10 A.M., Certified Nurse Aide (CNA) D said if a resident had long toe nails, staff should notify the Social Worker. The resident needed some assistance with daily care. He/She did not trim his/her own toenails. The resident frequently refused care. CNA D had not reported the long nails to the Social Worker and assumed the nurse was aware. 3. During an interview on 5/1/26 at 12:30 P.M., the Director of Social Services said nursing staff were responsible for notifying her if the resident needed to be seen by Podiatry. She will add the residents to the Podiatry list. She expected the nurses to perform nail filing between Podiatry appointments. 4. During an interview on 5/1/26 at 1:00 P.M., the Administrator and Director of Nursing said they expected the aides to report long nails to the charge nurse. The charge nurse should provide an assessment and file or trim the nails. Residents nails should be assessed weekly during the skin assessment. Residents with long nails should be scheduled with the Podiatrist. If a resident refused nail care, it should be documented and noted in the care plan. Residents with diabetes should be assessed by podiatry.

Based on observation, interview, and record review, the facility failed to post nurse staffing information that included the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care per shift, on a daily basis. The census was 141.Review of the facility's Nurse Staffing Posting Information policy, revised on 6/26/24, showed:-Purpose: It is the policy of this facility to make nurse staffing information readily available in a readable format to residents and visitors at any given time;-Policy:-The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information:--Facility name;--The current date;--Facility's current resident census;--The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:---Registered Nurses (RNs);---Licensed Practical Nurses (LPNs)/Licensed Vocational Nurses (LVNs);---Certified Nurse Aides (CNAs);--The facility will post the Nurse Staffing Sheet at the beginning of each shift;--The information posted will be:---Presented in a clear and readable format;---In a prominent place readily accessible to residents and visitors;--A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current;---The information shall reflect staff absences on that shift due to call-outs and illness;---After the start of each shift, actual hours will be updated to reflect such;---Staffing shall include all nursing staff who are paid by the facility (including contract staff);---Any staff not paid for by the facility, such as hospice staff or individuals hired by families, shall not be included;--Nursing schedules and posting information will be maintained in the Human Resources Department for review for a minimum of 18 months or as required by State law, whichever is greater;--The facility will, upon oral or written request, make the nurse staffing data available to the public for review at a cost not to exceed the community standard. Observation on 4/26/26 at approximately 8:05 A.M., showed no nurse staffing information posted at the facility's lobby or at the reception area. Observation on 4/30/26 at 8:58 A.M., showed the facility's Daily Staffing Hours sheet, dated 4/27/26, pinned in a cork board behind the reception area. During an interview, Receptionist C said he/she did not pay attention to the sheet. The Staffing Coordinator posted the staffing sheets. During an interview on 4/30/26 at 10:01 A.M., the Staffing Coordinator said she took the position a few months ago and was just made aware recently that the nurse staffing information had to be posted daily. She was too busy and forgot to post it daily. During an interview on 5/1/26 at 3:35 P.M., the Administrator said the nurse staffing information should be posted daily. The posting should be placed in public view. The board behind the reception area is not highly visible to the public or residents.

Based on interview and record review, the facility failed to provide on-going monitoring and close supervision of Resident #11, who had a history of being non-compliant with facility rules and policies by obtaining unauthorized and/or illegal drugs for both his/her own use as well as distribution to other residents. On [DATE], cardiopulmonary resuscitation (CPR, an emergency procedure used during cardiac or respiratory arrest that involves chest compressions, often combined with artificial ventilation, to preserve brain function and maintain circulation until spontaneous breathing and heartbeat can be restored) was initiated on Resident #11, Resident #1, and Resident #2 after an overdose. All three residents were sent to the hospital, and all three had drug screens that were positive for unauthorized and/or illegal substances. Review of the facility investigation/conclusion statement dated [DATE], showed the facility determined Resident #11 brought the unauthorized and/or illegal drugs into the facility and distributed them to Resident #1 and Resident #2. Resident #11 was readmitted to the facility on [DATE] and placed on one-on-one monitoring until [DATE]. On [DATE], Resident #11 exhibited behaviors that included being slow to respond and inappropriate laughter. Facility staff neglected to place Resident #11 on one-on-one monitoring and to obtain a drug screen at that time, not following facility policy. On [DATE], Resident #1, Resident #2, and Resident #3 were sent to the hospital, and all three residents' hospital drug screens were positive for unauthorized and/or illegal substances. The facility reviewed video footage from [DATE], which showed, Resident #1, Resident #2, and Resident #3 gave Resident #11 money that day and approximately one hour later, Resident #3 went into cardiac arrest (a life-threatening condition when the heart stops beating). CPR was initiated, and the resident was sent to the hospital where he/she was revived, but diagnosed with anoxic encephalopathy (a brain injury that occurs when the brain is completely deprived of oxygen, often due to events like cardiac arrest) and admitted to the hospital Hospice unit on [DATE]. Resident #1 and Resident #2 also exhibited symptoms of overdose that day and were sent to the hospital. All three residents' drug screens were positive for unauthorized and/or illegal substances. Resident #1 and Resident #2 said they had purchased the drugs from Resident #11 on [DATE]. In addition, Resident #29 tested positive for cocaine on [DATE] and said he/she had purchased it from Resident #11. Thirty-four residents were sampled, and problems were identified with five. (Residents #11, #3, #1, #2, and #29). The census was 133. The Administrator was notified on [DATE] at 11:39 A.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the Administrator became aware of the problem, and the facility began inservicing all staff on the Abuse and Neglect policy and procedure and Possession and Use of Illegal Drugs, Marijuana and Alcohol and Drug Screen and Searches policy. The IJ was corrected on [DATE].Review of the facility Abuse and Neglect policy dated [DATE] and revised on [DATE], showed:-Purpose: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;I. Neglect: Neglect is the failure of the facility, its 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;Policy:-Guidelines: The Facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences;-Identification: The facility will identify events, occurrences, patterns and trends that may constitute mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property as defined above;-Alleged violation: A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property;-Investigation: The facility will investigate all allegations and types of incidents as listed above in accordance to facility procedure for reporting/response as described below;-Protection: The facility will protect residents from harm during an investigation;-Reporting/Response: The facility will take all necessary corrective actions depending on the results of the investigation. The facility will analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences;-This Facility will identify and correct by providing interventions in which abuse, neglect or misappropriation of resident property is more likely to occur. This will include: assessment of the physical environment, which may make abuse or neglect more likely to occur, such as more secluded areas in the Facility, the deployment of staff on each shift in sufficient numbers to meet the resident's needs and that the staff are knowledgeable of resident care needs. Supervisors who identify inappropriate behaviors such as; derogatory language and neglectful care. Prevention will also include assessment care planning and monitoring of residents with needs or behaviors which may lead to conflict or neglect. The Facility will identify events, patterns and trends that may constitute abuse and investigate thoroughly, notifying the Administrator and the proper authorities;-This Facility desires to prevent abuse, neglect, and theft by establishing a resident sensitive and resident secure environment. This will be accomplished by comprehensive quality management approach involving the following: concern identification and follow-up. Resident and family concerns will be recorded, reviewed, addressed, and responded to using the Facility's complaint identification procedure. An essential element of customer satisfaction is a timely response back to the Facility or resident's concern expressed;-Resident Assessment: As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis;-Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway;-Resident who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the Facility.Review of the facility Residents - Possession and Use of Illegal Drugs, Marijuana and Alcohol and Drug Screen and Searches policy, dated [DATE] and revised on [DATE], showed:-Affected Personnel: All employees;-Purpose: To ensure that the Facility remains free from illegal drugs and substances as well as marijuana and alcohol. To define when and how a resident may be administered a drug screen or have their room searched;-Procedure:-I. Illegal Drugs or Substances, Marijuana and Alcohol are not permitted:1. The Facility is committed to maintaining a safe environment for every resident. Part of this commitment is attempting to maintain an environment that is free of illegal drugs, dangerous items and other related contraband;2. Use of illegal drugs creates a dangerous environment and may interfere with property prescribed medications;3. Marijuana (while legal) is not allowed in the Facility, it can interfere with properly prescribed medications;4. The use, consumption, possession, transportation, sale or distribution of unlawful or unauthorized drugs (including marijuana), inhalants, alcohol, or the abuse of prescribed drugs or alcohol by any resident while in the Facility or on Facility property is expressly prohibited and may result, in an immediate discharge. Illegal or controlled substances (other than a valid prescription) will be confiscated, and the appropriate law enforcement agency(s) may be notified;5. Contraband incudes weapons of any kind, any items which could be used as a weapon, illegal or unauthorized drugs (including marijuana), drug paraphernalia, or alcohol. The possession or sale of any contraband while on Facility premises is expressly prohibited;6. The Administrator and Director of Nursing (DON) shall educate staff and residents (as appropriate) on the signs and symptoms of illegal drug use.II. Staff Education:-Facility staff will have knowledge of signs, symptoms, and triggers of possible illegal substance use, which includes but is not limited to:1. Changes in resident behavior;2. Increased, unexplained drowsiness;3. Lack of coordination;4. Slurred speech;5. Mood changes;6. Loss of consciousness;III. Process When Suspicion of Ingestion of Illegal Substance:1. If a resident is suspected of taking an illegal drug or other substance (including Marijuana), the resident shall immediately be placed on one-on-one supervision and the DON or charge nurse and Administrator notified;2. If the resident shows any signs of distress or there are other concerns, 911 shall be called immediately;3. The nurse shall immediately evaluate the resident and obtain a complete set of vital signs, including a neurology check and oxygen saturation level;4. The resident's primary care physician shall immediately be contacted for instructions;5. If the resident is not being sent to the hospital, the protocol below for drug screens and searches will apply;IV. Drug Screen:1. In the event the Administrator or DON has reasonable suspicion that a resident has ingested illegal or unauthorized drugs, a drug screen may be administered;a. Drug screen is defined as a screen conducted by the Facility to determine if the resident as ingested illegal unauthorized drugs (including marijuana);b. Drug screen, as used in this policy, does not apply to any lab work ordered by a physician to provide care to the resident that may detect the presence of illegal substances;2. For the drug screen, the resident may be required to submit to a blood, urine, saliva, or other diagnostic test to detect alcohol and/or drugs in their system;5. If the resident has a guardian, the guardian will be contacted to obtain consent for the drug screen. This consent will be documented by a nurse;7. If the drug screen is positive, the resident's attending physician will be notified;V. Search of Resident's Room or Property;1. In the event the Facility's Administrator or DON has reasonable suspicion that contraband, illegal drugs or something that poses a safety risk to the resident or others in the Facility is in a resident's room, a search of the resident's room may be considered;2. The Facility should not act as an arm of law enforcement and may instead of a search (or if consent is not given for a search), the facility may make a referral to local law enforcement;4. If the resident has a guardian, the guardian will be contacted to obtain consent for the search. This consent will be documented by a nurse of Social Services;7. If suspected illegal drugs are found, the local police and the Department of Health and Human Services will be notified;VI. Suspected Contraband or Illegal Drugs:1. If suspected contraband or illegal drugs (including marijuana) are found, those items will be given to the Administrator, DON or Charge Nurse for inventory;4. If appropriate, an Administrative Investigation will be initiated;5. Possession of contraband or illegal drugs may be grounds for discharge from the Facility;VII. Increased Oversight: To protect the health and safety of residents, the facility will provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility.1. Review of the facility Investigation Timeline, dated [DATE], showed the following:-On [DATE] at 3:15 P.M., Code Blue (indicates a medical emergency) was called for Resident #1, who was in his/her room at the time. CPR was initiated and 911 was called due to the symptoms and the suspicion of drug ingestion;-At approximately 7:30 P.M., Code Blue was called for Resident #11, who was found unresponsive sitting in his/her wheelchair in the hallway on the 600 Hall. Resident did not respond to sternal rub (applying firm pressure to the sternum (chest bone) to provoke a response). Pulse was checked and absent. CPR was initiated, 911 called and upon emergency medical services (EMS) arrival Narcan (a medication administered to reverse or reduce the effects of opioids (a class of drugs that manage moderate to severe pain. Opioids have a high addiction potential) was administered due to symptoms and the suspicion of drug ingestion;-At approximately 9:00 P.M., Code Blue was called for Resident #2, who was found to be unresponsive in his/her room on his/her bed. Resident was lowered to the floor and CPR was initiated. 911 was called due to symptoms and suspicion, Narcan was administered. EMS arrived and resident was transported to the hospital;-Interventions to prevent reoccurrence included: Police were on scene with a drug K-9. Staff and resident education pertaining to facility policies. Care plans were updated to reflect education provided. All rooms in the facility were searched. Maintenance screwed the window screens down and started screen checks. All residents to complete a drug screen unless they refuse. New orders were received for residents to have random drug screens due to suspicion of illegal drug ingestion; -Conclusion: The facility immediately initiated a comprehensive investigation and implemented corrective measures following the suspected drug ingestion and overdose incidents on [DATE]. It was determined that the illegal substance(s) were brought into the facility by Resident #11 who then distributed the substances to two other residents. Resident #1 and Resident #2 consumed what they knew to be an illegal substance. Review of the facility Resident Investigation on Overdose - Resident Questionnaire, dated [DATE], showed:-Have you witnessed any residents with illegal drugs inside the facility? Two other residents, Resident #9 and Resident #33 answered yes and identified Resident #11. 2. Review of the facility Camera Footage - [DATE] report, showed:-2:07 P.M.: Activity Director on the hall passing out resident trust money for the day;-2:10 P.M.: Resident #3 receives his/her money and passes it to Resident #11 in his/her doorway;-2:11 P.M.: Resident #1 receives his/her money and goes directly into Resident #11's room;-2:17 P.M.: Resident #2 seen passing money through Resident #11's bedroom door;-2:18 P.M.: Resident #1, Resident #3, and Resident #11 sitting at table with money out. Resident #1 and Resident #3 seen giving money to Resident #11;-2:28 P.M.: Resident #11 goes down the hall to room [ROOM NUMBER] (recreation room) with a towel in his/her lap. He/She then places the towel in a barrel just inside 613's doorway;-2:41 P.M.: Resident #11 and Resident #1 go down to room [ROOM NUMBER] together;-2:43 P.M.: Resident #3 goes to room [ROOM NUMBER]. Resident #1 and Resident #11 are still in there;-2:46 P.M.: Resident #1 and Resident #3 leave room [ROOM NUMBER]. Both head to their own rooms;-2:48 P.M.: Resident #11 goes to his/her own room;-2:53 P.M.: Resident #11 leaves his/her room and heads down to Resident #1's room and looks in the room, then passes by and enters Resident #3's room;-2:57 P.M.: Resident #11 leaves Resident #3's room and heads back to his/her own room;-3:00 P.M.: Maintenance Assistant P enters hall to begin audit of windows and screens;-3:01 P.M.: Resident #11 looks inside Resident 1's room and then enters;-3:03 P.M.: Maintenance Assistant P enters Resident #1's room and rushes back out appearing to call for help. Resident #11 exits out of the room behind him/her;-Times stated are according to the camera footage programming, believed to be 20 minutes behind (the actual time);-On camera, we can clearly see Resident #2, Resident #3, and Resident #1 pass money to Resident #11. Resident #11 is then seen rolling in his/her wheelchair down to room [ROOM NUMBER]/recreation room with a towel in his/her lap. We see him/her place the towel into a barrel that is mostly off camera. Then Resident 3, Resident #1, and Resident #11 all make their way to room [ROOM NUMBER] and are in that room at the same time. It is not long after that we know Resident #3 and Resident #1 consumed the illegal substance. Resident #11 is seen going by both rooms as if he/she is checking on them before Resident #1 is found by Maintenance Assistant P;-At no point during our camera observations are staff observed passing anything suspicious between themselves or the residents;-During both of our investigations, it was reported that Resident #11's brother is supplying him/her with drugs. This was reported to the police in both investigations. Resident #11 has four brothers according to his/her guardian. We have never been able to obtain a description of this supposed brother. Per our video, it does appear that Resident #11 is accepting cash and then meeting the residents in room [ROOM NUMBER] where we assume illegal substances exchanged hands;-Signed by the Administrator. Review of the residents' questionnaires, dated [DATE], showed:-Have you ever witnessed any residents with illegal drugs inside this facility?-Resident #11: Refused to answer questions;-Resident #1, Resident #2, and Resident #13 all identified Resident #11.During an interview on [DATE] at 12:15 P.M., regarding the [DATE] camera footage, the Administrator said Resident #1 was seen giving money to Resident #11. That day Resident #1 denied taking anything. The next day Resident #1 said he/she gave Resident #11 money for the drugs fentanyl (an opioid (narcotic used to treat severe acute (sudden) or chronic pain) used to treat moderate to severe pain, but it can be misused, abused, and cause overdose deaths when obtained illegally), and maybe cocaine. Although the video did not show Resident #11 give anything to Resident #1, Resident #2, and Resident #3, thought Resident #11 had the drugs underneath the towel that he/she had in his/her lap. Resident #1, Resident #2, and Resident #11 were all placed on one-on-ones after the first incident on [DATE], but the one-on-ones had been removed prior to the [DATE] incident, and they were all on hall restriction (they were not allowed to leave the 600 hall) at that time. Resident #1, Resident #2, and Resident #11 had not been tested for illegal drugs since they had returned from the first incident that occurred on [DATE]. Resident #3 was still in the hospital, so they have not been able to interview him/her. The camera date was accurate, however the times on the video are not believed to be accurate.3. Review of Resident #11's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated [DATE], and located in the electronic medical record (EMR), showed:-Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Cognitively intact;-Inattention, Disorganized Thinking, Altered Level of Consciousness: Behavior not exhibited;-Hallucinations, Delusions: Behavior not exhibited;-Physical, Verbal, or Other Behavioral Symptoms: Behaviors not exhibited;-Rejection of Care: Behavior not exhibited;-Diagnoses of traumatic brain injury (an external force that has traumatically injured the brain) and schizophrenia (a psychotic disorder characterized by emotional responsiveness and disintegration of thought process);-High-Risk Drug Classes: Antipsychotics (a class of medications used to treat mental health conditions characterized by psychosis).Review of the resident's physician's order sheet (POS), located in the EMR, showed: no order for fentanyl or medical marijuana.Review of the resident's care plan, located in the EMR, showed:-[DATE], Problem: Potential to be verbally/physically aggressive related to a history of such and diagnoses of traumatic brain injury, schizophrenia, and impulsiveness. Goal: Will have fewer to no displays of physical aggression, threatening behavior. Interventions: Acknowledge resident's inappropriate behaviors, set clear, consistent and enforceable limits on his/her behavior. Provide physical and verbal cues to alleviate anxiety;-[DATE] and revised on [DATE], Problem: Resident has a Guardian to assist in decision making due to mental illness. Goal: The Guardian will assist in making decision. Interventions: Ensure Guardians wishes are followed. Guardian limitations of no off-site passes at this time. Guardian states family to come to facility for visitation without leaving grounds;-[DATE], Problem: This is resident's safety plan. Goal: Goals are to get out, get closer to the Lord, Study the word, praise the Lord. Interventions: I feel like my warning signs are: None. My past crisis moments include: I have to control my emotions, used drugs;-[DATE], Problem: Resident seen passing a marijuana vape to a resident. Goal: Resident will not use marijuana. Interventions: Resident will be on full all restriction for protective oversight until deemed appropriate to return to partial hall restriction by guardian/resident/IDT (interdisciplinary team). Residents on 600 hall will be smoked in smaller groups to maintain protective oversight. Resident educated on facility drug policy.Review of the resident's progress note, located in the EMR, showed:-[DATE] at 10:52 P.M.: At approximately 7:30 P.M., the Certified Medications Technician (CMT) called a code blue to 600 Hall. This resident was noted to be unresponsive at this time. Sternal rub was administered and resident did not respond. Lips were ashen in color and eyes were closed. Resident was not breathing at this time. At approximately 7:35 P.M., 911 was called, and resident was pulled out of his/her chair onto the floor and CPR was initiated. At approximately 8:00 P.M., paramedics arrived and took over. At approximately 8:15 P.M., management was notified and call placed to resident's guardian's answering service. At approximately 8:35 P.M., paramedics transported resident to hospital.Review of the resident's hospital record, located in the EMR, showed:-admission [DATE];-Chief Complaint: Drug Overdose;-Resident was found unresponsive by staff. CPR was started. Resident given Narcan with improvement to his/her respiratory status. On EMS arrival he/she is awake and responding to voice;-Review of the resident's drug screen collected on [DATE] at 1:14 A.M., showed the resident tested positive for cannabinoids (a group of chemicals or compounds found in the cannabis/marijuana sativa plant), cocaine and fentanyl. Review of the resident's care plan, located in the EMR, showed:-[DATE], Problem: Resident overdosed in his/her room. Goal: Resident will not use drugs. Interventions: Resident will be offered the narcotic anonymous (NA) program called In the Room. Resident will be offered counseling if not enrolled. Random drug screens as ordered;-[DATE], Problem: Resident Rights and Abuse and Neglect. Goal: Residents Rights and Abuse and Neglect policy will be upheld. Interventions: Resident was educated on Resident Rights and Abuse and Neglect and verbalize understanding;-[DATE], Problem: Resident is at risk for intentional or unintentional overdose due to history of depression, anxiety, confusion, access to medications, substance misuse, etc. Goal: Resident will not experience an overdose while in care. Interventions: Educate family/support system about overdose risks and prevention strategies. Education provided on Drug Policy for the facility, Screens and Searches entering the building, and Metal Wanding upon entering the building. Random drug screens with suspicion of using illegal drugs or as needed upon return from LOA (leave of absence) visits.Review of the resident's progress note, located in the EMR, showed:-[DATE] at 7:30 P.M.: Resident returned from hospital. Resident is one-on-one for monitoring, alert and oriented and lying in bed talking to roommate. Review of the resident's statement to the facility dated [DATE] at 8:30 A.M., showed: At first resident refused to talk. Resident appeared very angry. Resident said he/she got the drugs from this nurse (DON). Resident refused to answer any further questions.Review of the progress notes, located in the EMR, showed:-The resident remained on one-on-one monitoring until [DATE] at 7:59 P.M.;-[DATE] at 7:59 P.M. and documented by the DON: Removed off one on one due to no further behaviors.-[DATE] at 11:15 P.M.: When this resident came in from smoking resident appeared to be slower to respond, laughing inappropriately, and his/her eye lids were low. Resident went straight to his/her room once he/she saw this writer come on the hall. Management, physician and resident's guardian were notified;-[DATE] at 11:16 P.M. Late Entry and documented by the DON: This writer was on the phone with nurse when he/she was speaking to resident. Resident refused to make a statement or let the nurse do any assessment;-No documentation showing the facility initiated one-on-one monitoring or obtained a drug screen per the Possession and Use of Illegal Drugs, Marijuana and Alcohol and Drug Screen and Searches process when Suspicion of Ingestion of Illegal Substance is Suspected in response to the [DATE] at 11:15 P.M. nurses note.Review of the resident's progress notes showed:-[DATE] at 2:48 P.M.: Spoke to resident's deputy public administrator (DPA) and made aware of immediate discharge notice and place found at a sister facility. DPA is in agreement with this plan and agreeable with new placement.-[DATE] at 3:19 P.M.: Resident discharged to sister facility with medications and personal belongings.During an interview on [DATE] at 12:07 P.M., the DON said she did not instruct the nurse on [DATE] to place the resident on one-on-one monitoring and did not request a drug screen. Given the resident's history, she should have placed the resident on one-on-one pending a drug screen.4. Review of Resident #3's quarterly MDS dated [DATE], and located in the EMR, showed:-Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Cognitively intact;-Inattention, Disorganized Thinking, Altered Level of Consciousness: Behavior not exhibited;-Hallucinations, Delusions: Behavior not exhibited;-Physical, Verbal, or Other Behavioral Symptoms: Behaviors not exhibited;-Rejection of Care: Behavior not exhibited;-Diagnoses of anxiety disorder, depression, bipolar disorder (a mood disorder that causes cycles of rapid mood and behavioral changes) and schizophrenia;-High-Risk Drug Classes: Antipsychotics, antianxiety, and antidepressants.Review of the resident's care plan, located in the EMR, showed:-[DATE], Problem: Resident was found with marijuana in the building. Goal: Will not be found with marijuana in the building. Interventions: Resident educated on the negative effects of marijuana. Educate resident on the resident drug policy;-[DATE], Problem: Resident is at risk for intentional or unintentional overdose due to history of depression, anxiety, confusion, access to medications, substance misuse, etc. Goal: Resident will remain free from overdose or medication-related harm. Interventions: Educate family/support system about overdose risks and prevention strategies. Education provided on Drug Policy for the facility, Screens and Search entering the building, and Metal Wanding upon entering the building. Encourage resident participation in meaningful activities to reduce isolation and depression. Random drug screens with suspicion of using illegal drugs or as needed upon return from LOA visits;-[DATE], Problem: Resident had a positive drug screen ([DATE]) for marijuana and cocaine. Goal: Resident will be free from drugs. Interventions: Resident will be offered NA class through in In the Room. Drug use to be added to counseling sessions.Review of the resident's POS, located int the EMR, showed;-[DATE]: Oxycodone (an opioid pain medication used to treat moderate to severe pain) 5-325 milligram. Give one tablet by mouth every eight hours;-No order for medical marijuana or fentanyl.Review of the resident's hospital medical records, dated [DATE] through [DATE], showed:-Chief Complaint: Cardiac arrest. Coming to ED (emergency department) in cardiac arrest. EMS responded to a code blue while they were attending to another resident at the facility. Resident in PEA (pulseless electrical activity), unknown exactly how long resident was down. Proceeded with ACLS (advance cardiovascular life support) for 12 minutes with ROSC (return of spontaneous circulation) achieved, intubated (a procedure that's used when you can't breathe on your own. A tube is placed down the throat into the windpipe to make it easier to get air into and out of your lungs.) and brought to ED;-Drugs of Abuse Screen: Positive for: Oxycodone (would be expected due to physician's order), cannabinoids, cocaine and fentanyl; -Assessment and Plan: Functional Status: Poor; Decisional Capacity: Unreliable; Disease Extent: Serious and reversibility: Poor;-Disease-directed treatment options: Palliative (a specialized form of care for people living with serious illness. It helps relieve symptoms and stress, physical, emotional, spiritual, and practical, while improving quality of life.);-Hospice (end of life care) Eligibility: Based on current function, current medical issues, and prognosis models, the resident is eligible for Hospice;-discharged on [DATE].Review of the resident's Hospice admission record from the hospital, showed:-Date of admission: [DATE];-Inpatient Hospice History and Physical: High risk for complications and death due to advanced disease with limited life expectancy of days to a week. Symptoms requiring GIP Care (general inpatient care)/Chief Complaint: Uncontrolled pain, uncontrolled anxiety/psychosocial distress, uncontrolled restlessness/agitation, uncontrolled dyspnea (difficult breathing) and uncontrolled secretions;-Review of Systems: Unable to review due to mental status changes from terminal illness;-Physical Exam, General: Critically ill appearing, lying in bed. Pulmonary: Mechanically ventilated, no accessory muscle (the use of muscles other than the primary respiratory muscles to assist in breathing) use. Neurological: Nonfocal (not localized or concentrated in one specific area), generally weak; -Assessment/Plan: Hospice, diagnosis: anoxic encephalopathy. Progressive disease. No longer seeking treatment. Transitioned to Hospice. Focus of care is comfort and symptom management. Support patient and family with IDG (interdisciplinary group) during transition to end of life;-Plan: Continue comfort medications. Hospice following.5. Review of Resident #1's quarterly MDS dated [DATE], and located in the EMR, showed: -Makes Self Understood: Understood;-Ability To Understand Others: Understands;-Cognitively intact;-Inattention, Disorganized Thinking, Altered Level of Consciousness: Behavior not exhibited;-Potential Indicators of Psychosis: Delusions;-Physical, Verbal, or Other Behavioral Symptoms: Behaviors not exhibited;-Rejection of Care: Behavior not exhibited;-Diagnoses of anxiety, depression, psychotic disorder and schizophrenia;-High-Risk Drug Classes: Antipsychotics and antianxiety.Review of the resident's care plan, located in the EMR, showed:-[DATE], Problem: Independent with ADLs. Goal: Will have no decline in ADL performance. Interventions: Provide protective oversight

Based on interview and record review, the facility failed to ensure staff notified one resident's physician regarding the resident's low blood pressure. In addition, the resident had two antihypertensive medications ordered, and one of those two medications was administered while the resident was hypotensive (blood pressure below 90/60) (Resident #7). The sample was 33. The census was 133.Review of the facility Notification Of Changes Policy, dated [DATE], showed:-Purpose: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification;-Policy: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification;-Circumstances Requiring Notification:2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: Life threatening conditions, or clinical complications.Review of Resident #7's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff dated [DATE], showed:-Makes Self Understood: Understood;-Ability To understand Others: Understands;-Moderately impaired cognition;-Diagnoses of high blood pressure, Alzheimer's Disease, and schizophrenia (a psychotic disorder characterized by emotional responsiveness and disintegration of thought process). Review of the resident's care plan, located in the electronic medical record (EMR), showed:-[DATE], Problem: Hypertension (high blood pressure). Goal: Blood pressure will be within normal limits. Interventions: Evaluate blood pressure. Atenolol (medication/antihypertensive used to treat high blood pressure). Lorsartan potassium (medication/antihypertensive);-[DATE], Problem: Hypertension related to lifestyle choices, smoking. Goal: Will remain free of complications related to hypertension. Interventions: Give hypertensive medications as ordered. Monitor for side effect such as orthostatic hypotension and increased heart rate and effectiveness. Monitor/document/report PRN (as necessary) any signs/symptoms: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing;-Alteration in neurological status related to disease process Alzheimer's disease. Goal: Will be able to communicate needs daily through the review date. Interventions: Cueing, reorientation as needed. Give medications as ordered, monitor/document side effects and effectiveness;-Coronary artery disease (the reduction of blood flow to the heart due to build-up of plaque in the arteries) related to atrial fibrillation (irregular heartbeat/rate). Goal: Will be free from signs/symptoms of complications of cardiac problems. Interventions: Educate the resident/family/caregivers about factors which might precipitate irregular heart rate. Give all cardiac medications as ordered by the physician. Monitor and document side effects. Report adverse reactions to physician PRN. Review of the resident's physician's order sheet, located in the EMR, showed: -Lorsartan potassium 50 milligrams (mg) one tablet by mouth once daily for hypertension;-Atenolol 50 mg one tablet every 12 hours for hypertension;-Full code (in the event the heart stops working or have no pulse, staff will start cardio pulmonary resuscitation (an emergency procedure used during cardiac or respiratory arrest that involves chest compressions, often combined with artificial ventilation, to preserve brain function and maintain circulation until spontaneous breathing and heartbeat can be restored).Review of the resident's medication administration record dated [DATE] through [DATE], and located in the EMR, showed:-[DATE]: MP 7a (morning pass, liberalized), lorsartan potassium 50 mg. The Certified Medication Technician (CMT) initialed the medication had been administered;-[DATE]: 9:00 A.M., atenolol 50 mg, the CMT documented a blood pressure (BP) of 78/67 (normal BP is 120 (systolic)/80 (diastolic)) and entered a 5/hold/see progress notes.Review of the resident's weights/vitals tab, located in the EMR, showed the CMT documented: [DATE] at 10:56 A.M., BP 78/67.Review of the resident's progress notes, located in the EMR, showed:-No documentation regarding the resident's BP of 78/67;-[DATE] at 3:49 P.M. and documented by Registered Nurse (RN) F: 11:00 A.M., resident observed lying in bed talking to this writer and treatment nurse while taking medication and supplement. Resident verbally denied pain when asked. 11:48 A.M., code blue (a medical emergency), coffee ground emesis (vomit that resemble coffee grounds due to the presence of old, coagulated blood, indicating bleeding in the upper gastrointestinal tract that requires immediate medical attention). No pulse, no respiration, CPR initiated, 911 called. 12:24 P.M., resident pronounced dead.During an interview on [DATE] at 6:58 A.M., Licensed Practical Nurse (LPN) R said if a resident had a BP of 78/67, he/she would hold any BP medications and call the physician. He/She would document the BP and any new physician orders in the progress notes. If a CMT or Certified Nursing Assistant (CNA) obtained the BP, he/she would expect them to notify him/her immediately. During an interview on [DATE] at 7:50 A.M., the Director of Nurses (DON) said she would have expected the CMT to hold any antihypertensive medication and tell the nurse immediately of the low BP. The nurse should check the BP, and if it is that low, then call the physician for any new orders. This should be documented in the resident's progress notes. She expects staff to follow facility policies.During an interview on [DATE] at 9:35 A.M., RN F said that morning (9/17) the resident did not want to get up, which is unusual. He/She spoke to the resident who said he/she did not feel like getting up, but he/she said he/she felt fine. The CMT did not tell him/her the resident's BP was 78/67. The CMT should have told him/her. Had he/she known, he/she would have checked the resident's BP, and if it was that low, he/she would have ensured any antihypertension medications were held, and he/she would have called the physician. He/She would have documented any new order in the progress notes. During an interview on [DATE] at 12:13 P.M., the resident's physician and facility Medical Director said the CMT should have notified the charge nurse about the resident's BP of 78/67 and hold any antihypertension medications. If the CMT had notified the charge nurse, he would have expected the charge nurse to contact him. He would have ordered intravenous fluids, call emergency medical staff (EMS), and had sent the resident to the hospital for an evaluation. He is not sure had all of those things happened, that it would have changed the outcome for the resident. 2640283

Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when two residents (Residents #1 and #2) were involved in a resident-to-resident altercation. Resident #1 suffered a bloody lip as a result of Resident #2 hitting him/her in the mouth. The sample was 12. The census was 137.The Administrator was notified on 9/23/25 at 4:55 P.M., of the past non-compliance, which occurred on 9/16/25. The facility provided 1:1 for the residents and updated their care plans. The deficiency was corrected on 9/16/25. Review of the facility's Abuse and Neglect Policy, revised 6/12/24, showed:-It is the policy of this facility to report all allegations of abuse to the Administrator of the facility immediately and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames;-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations;-The facility will investigate all allegations and types of incidents;-The facility will take all necessary corrective actions depending on the results of the investigation;-Staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce chances of mistreatment for these residents;-Residents who allegedly mistreat another resident will be removed from contact with the resident during the investigation. The accused resident's condition shall be immediately be evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/29/25, showed:-Cognitively intact;-No behaviors exhibited;-Diagnoses included high blood pressure, chronic obstruction pulmonary disease (COPD, lung disease) and schizophrenia (a psychotic disorder or a group of disorders marked by severely impaired thinking, emotions, and behaviors). Review of Resident #1's care plan, in use during the survey, showed:-Problem: On 9/16/25, the resident was hit by peer (Resident #2) for wearing pink and possibly being gay;-Goal: Resident #1 will be free from alterations through next review;-Interventions: Social Services (SS) to meet with the resident regarding any ill effects of yesterday events. Neuro checks and 72-hour monitoring; Review of Resident #1's progress notes, dated 9/16/25 at 6:49 P.M., showed the resident was outside during smoke break when another resident walked up to him/her and punched him/her in the face. The resident was already on a 1:1 for behaviors so his/her 1:1 was able to separate the resident but not before Resident #2 was able to hit Resident #1 in his/her face. The resident was noted to be bleeding from his/her mouth and he/she also noted to have an abrasion to his/her right elbow. The resident denied pain or discomfort. The area to elbow was cleansed and a dressing was applied. Vitals- Temperature (T) 98.3, Pulse (P) 78, Respirations (R) 18, Blood Pressure (BP)132/86, O2 98%. The resident was alert and answered questions appropriately. A call was placed to resident's family member and guardian to notify of altercation. The Physician and Director of Nursing (DON) were notified. Review of Resident #2's quarterly MDS, dated [DATE], showed:-Cognitively intact;-Behaviors: Delusions;-Diagnoses included epilepsy (seizure disorder), anxiety disorder, depression, psychotic disorder, COPD and schizophrenia. Review of Resident #2's care plan, in use during the survey, showed:-Problem: On 9/16/25, the resident hit peer (Resident #1) due to him/her wearing pink and thinking he/she was gay;-Goal: Resident #2 will be free of physical altercations through next review;-Interventions: 1 on 1 until deemed safe. Psych was to review medications. Educated the resident that it was ok for anyone to wear pink and that they do not hit peers if they are gay. Review of Resident #2's progress notes, dated 9/16/25 at 6:50 P.M., showed staff went to Licensed Practical Nurse (LPN) C and reported that the resident stepped outside during smoke time and hit his/her peer, Resident #1 in the face. The resident stated Resident #1 was gay, and that he/she wore pink shirts, so Resident #2 hit him/her. The resident was assessed, and no injuries were noted. The resident denied complaints of pain or discomfort. Vitals: (T) 97.9, (P) 92, (R) 18, B/P-146/94, O2-97%. Call placed to the Physician, DON, and the resident's guardian. Review of the facility's investigation, dated 9/16/25, showed:-Certified Nurse's Aide (CNA) B reported to the DON that Resident #1 stepped outside to smoke and Resident #2 walked right up to Resident #1 and hit him/her in his/face. When the DON had gone to the hall, the residents had already been separated, and Resident #1 was standing at the nurses' station. Resident #2 was placed on one to one;-CNA A stated that he/she was outside with Resident #1 and when he/she opened the door to let the other residents out for some air, that was when Resident #2 hit Resident #1;-CNA B stated Resident #2 walked outside to smoke and instead of smoking, he/she started punching Resident #1 in the face. It was off guard and unexpected. Resident #1 did not swing back. He/She stated he/she did not know what Resident #2's problem was but he/she tried to pull Resident's d-ck off because he/she didn't do anything to Resident #2. Resident #1 also stated that he/she was just outside smoking and Resident #2 just started swinging, punching him/her in his/her face;-Resident #2 stated that he/she thought that Resident #1 was gay because he/she wore pink.-Conclusion/outcome of the investigation: Allegation substantiated;-Care plan changes and interventions: Resident #2: 1 on 1 until deemed safe. Psych was to review medications. Educated the resident that it was ok for anyone to wear pink and that they do not hit peers if they are gay. Resident #1: Social Services (SS) to meet with the resident regarding any ill effects of yesterday's events. Neuro checks and 72-hour monitoring. During an interview on 9/17/25 at 2:56 P.M., Resident #1 said he/she had been at the facility for about four or five months. It was an altercation with him/her and another resident. He/She was autistic, so it is hard for him/her to remember. The resident resides at the other end of the hall. The incident happened the day prior. They were outside smoking. He/She was minding his/her own business. The other resident had been bothering him/her since Resident #1 had been at the facility. Resident #2 walked up to him/her and hit/him her in his/her mouth. Resident #2 also hit him/her in his/her private area, right side of his/her temple, and also in his/her stomach. When Resident #2 hit him/her, he/she fell on the concrete and against the wall. He/She scraped his/her right elbow. Resident #2 hit him/her five to seven times. Two to three staff people broke it up. Resident #1 said he/she was sitting down in a chair on the patio under something like a gazebo when Resident #2 walked up to him/her and hit him/her. A code green was called, and a lot of staff came to assist. During an interview on 9/18/25 at 1:48 P.M., Resident #2 said he/she didn't know how long he/he had been at the facility. He/She had an altercation with Resident #1 about two days prior in the smoking area. The staff had been making fun of him/her. They were laughing and it had gotten worse and worse. The staff said that he/she had gotten punked. He/She thought they may have been talking about Resident #1 because he/she was the only closest gay person by his/her room. He/She turned around and walked outside and started swinging on Resident #1. Resident #1 didn't say anything to him/her. Resident #2 just walked up to Resident #1 and started hitting him/her. To show them he/she wasn't to be played with, he/she attacked Resident #1. One day, he/she would get his/her [NAME] (for attacking Resident #1). He/She was hitting Resident #1 in the face. He/She couldn't remember how many times he/she hit Resident #1. Resident #1 had a busted lip, that was it. When Resident #2 hit Resident #1, he/she fell on the ground. Resident #2 was placed on 1 to 1 and they were to check his/her medication levels. During an interview on 9/18/25 at 2:54 P.M., CNA A said he/she was working when the two residents had their altercation. He/She was doing the one-on-one monitoring with Resident #1. On the day of the altercation, neither of the residents, Resident #1 nor Resident #2, had an argument or anything with each other. He/She took Resident #1 outside to smoke, where he/she sat on a chair. The other residents wanted to go outside and smoke like they normally do. When CNA A put the code in to let the residents out, he/she was propping the door open. In the midst of him/her propping the door open to let the other residents out, Resident #2 walked past CNA A and went up to Resident #1 and just hit him/her. When he/she heard the first hit, CNA A 's back was turned and then he/she intervened. Resident #2 hit Resident #1 again at that time. CNA A thought Resident #1 had a cut on his/her elbow and might have been bleeding from his/her mouth. CNA A was the only staff outside because Resident #1 was his/her 1 to 1. There were more staff on the 600 hall because he/she believed there were three other 1 to 1's. After the incident, CNA A asked Resident #1 what happened and what did he/she do. He/She said nothing. CNA A said Resident #2 has moments when he/she blacked out. CNA A didn't have to call code green because he/she immediately intervened. He/She made Resident #1 leave the hall because he/she wasn't the aggressive one. Resident #1 went to the nurse for his/her arm and mouth. That was the first time the residents had an altercation with each other. During an interview on 9/18/25 at 3:09 P.M., CNA B said during the time of the altercation, he/she was passing out cigarettes. Resident #1 was already outside smoking. Resident #2 came out of his/her room to go out the back door. He/She was one of the last ones to get his/her cigarette. When he/she went out to get his/her cigarette, but before going outside, he/she asked if anyone was talking about him/her. People replied no. At that time, he/she got his/her cigarette, waked out the back door and punched Resident #1. CNA B was by the back door. Both Resident #1's and Resident #2's room was by the back door. Their rooms were next door to each other. They had three 1 to 1's. CNA A was Resident #1's 1 to 1 and CNA B was passing cigarettes. CNA B heard the incident first. As soon as he/she heard the boom boom, he/she ran out the back door. He/She called code green as soon as he/she heard it. The back door was right there by the room. Right outside the back door is where the incident had taken place. No one knew what Resident #2 was getting ready to do. That was why it had caught them off guard. It was totally unexpected. Both CNA A and CNA B intervened quickly. Resident #2 hit Resident #1 two or three times. Resident #1 did not swing back. Resident #1 fell on the ground when Resident #2 hit him/her. CNA B got Resident #1 off the ground. Resident #2 was instantly placed on 1 to 1. Resident #1 was taken off the hall and to the nurse's station and was left with the nurse at that time. The nurse was informed of what happened. No one had been sent out. Resident #1's lip was busted, and he/she was bleeding from the mouth. During interviews on 9/18/25 at 2:26 P.M., and 9/19/25 at 4:45 P.M. and 5:03 P.M., the Administrator said the resident-to-resident altercations are all behaviors. There was a period of about a week and two or three days when they didn't have an Activities Director so that seemed to be the time when more behaviors kicked in. They had activities but they didn't have as many as they used to have. It was her expectation that all residents are free from abuse. It is the Administrator's as well as everyone's responsibility to ensure that residents are free from abuse but ultimately it is the Administrator's responsibility. 2619269

Based on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated when another resident hit the resident in the face, resulting in a black eye and the need for sutures (Residents #1 and #2). The census was 138. The sample was 20. The administrator was notified on 1/9/25, of the past non-compliance. The facility responded appropriately when the incident occurred. The residents were separated and were sent to the hospital for evaluation. Care was provided to injuries and the rooms were changed so the residents no longer resided on the same hall. Continued education on abuse and neglect provided to staff. The deficiency was corrected on 1/2/25. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; -Physical abuse: Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Review of the facility's Resident's Rights policy, revised 7/5/23, showed: -Purpose: To ensure that resident rights are protected; -Resident has a right to a dignified existence, self-determination, and communication with and access to persons and serves inside and outside the facility. Facility must protect and promote rights of each resident, including each of the following rights; -Freedom from abuse: Resident has the right to be free form verbal, sexual, mental, and physical abuse, corporal punishment and involuntary seclusion. Review of the facility's investigation report, dated 1/2/25, showed: -Date of incident 12/31/24; -Persons involved: Resident #2 and Resident #1; -Date and time notified: 12/31/24 at 9:00 A.M.; -During a code green (code called when there is a resident exhibiting aggressive behaviors), Resident #1 was attempting to propel towards the incident the code green was called on despite being redirected and told to go to his/her room. A staff propelled the resident into Resident #2's room to remove him/her from harm's way. Moments later Resident #1 was wheeled out of the room backwards by a different staff and was noted with blood coming form above left eye. Resident #2 then came to the doorway yelling. He/She was aware there was a code being called but wanted Resident #1 out of his/her room. Licensed Practical Nurse (LPN) B said he/she was already on the hall dealing with another resident. He/She state while he/she was turning to walk down the hall, he/she saw Resident #1 in the doorway of Resident #2's room being cursed at loudly. When the resident was removed from the doorway, blood noticed coming from Resident #1's left eye. Review of Resident #2's medical record, showed: -A quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) dated 10/11/24, showed the resident cognitively intact with no behaviors; -A progress note dated 12/31/24 at 11:37 A.M., multiple staff were on the hall dealing with an altercation when incident occurred. Resident noted standing in front of another resident using a very selective choice of words after punching him/her in his/her face. (Laceration noted to opposed residents left eye). Residents separated immediately. Resident stated he/she was kicked, which caused him/her to punch resident in the face. When assessed no injuries to aggressor noted. Stated he/she was not hit, but he/she knocked the shit out of him/her. 911 called. Two emergency medical services (EMS) staff and two police arrived and transported the resident to the hospital for evaluation. Review of Resident #2's medical record, showed: -A quarterly MDS, dated [DATE], showed severe cognitive impairment. No behaviors. Uses a wheelchair; -A progress note dated 12/31/24 at 12:07 P.M., staff present at the time of incident, dealing with an altercation when incident occurred. Resident noted in a peers doorway, with blood coming from his/her left eye and being cursed at by aggressor. Residents separated immediately. When asked what happen, resident stated he/she hit me. Laceration noted to left eye when assessed, 911 called by writer. Vitals obtained, within normal limits according to prior assessments before altercation occurred. Two EMS and police arrived for transport to the hospital; -A progress note dated 12/31/24 at 10:15 P.M., resident remains at hospital emergency room (ER) at this time awaiting ambulance for transport back to facility. Sutures placed at ER to be removed in 3 to 5 days. No other orders received during report from ER nurse; -A progress note on 1/1/25 at 8:17 A.M., resident returned to facility. Appears to be 4 to 5 sutures below the left eyebrow, orders to remove in 3-5 days. Resident moved to a different room for protective oversite. States he/she is in no pain. Observation and interview on 1/9/25 at 7:49 A.M., showed Resident #2 sat in a wheelchair in his/her room. He/She said Resident #1 entered his/her room during a code green. He/She told Resident #1 to get out of his/her room and Resident #1 began to yell and then kicked him, so he/she punched him/her. He/She does realize what he/she did was wrong because not every resident in the facility is alert. Observation and interview on 1/9/25 at 7:55 A.M., showed Resident #1 lay in bed on his/her back. A dark bruise visible under the residents left eye. No sutures visible. He/She said he/she did not remember much but knows he/she got punched in the eye. He/She does not remember who did it or why. It does not hurt anymore. During an interview on 1/9/25 at 8:52 A.M., with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the ADON said she did complete the investigation into the incident between Resident #1 and Resident #2, but she was not witness to the incident. There were no staff present at the time. It was not found out until the resident was found to have an injury and staff began to ask questions, that there was an altercation. The DON said the investigation depended on what the residents involved had to say about the incident. The resident did get sutures, but they had already been removed. He/She only need two or three of them for a few days. During an interview on 1/9/25 at 12:10 P.M., the Administrator said residents have the right to be free from abuse, to include abuse from other residents. At the time the altercation took place, there was another altercation occurring on the hall. Resident #1 kept propelling towards the other altercation and was at risk, so a split decision was made to place him/her in a different resident's room. His/Her room was on the other side of the hall, and it was not possible to get the resident to his/her room without getting in the middle of the other altercation. Staff did what they felt was best at the time. MO00247310 and MO00247336

Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when one resident (Resident #4) was involved in a physical altercation with another resident (Resident #3). In two separate incidents, Resident #3 hit Resident #4 in the mouth when Resident #4 wandered into Resident #3's room. The sample size was 5. The census was 139. Review of the facility's Abuse and Neglect Policy, revised 1/5/23, included: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing (DON) or designee and outside persons or agencies To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. - Definitions: -Physical Abuse-Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior. -Policy: -III. Mistreatment, Abuse, or Neglect: -Mistreatment, neglect or abuse of residents is prohibited by this Facility. This includes physical abuse, sexual abuse. verbal abuse, mental abuse and involuntary seclusion. -Abuse includes deprivation of goods or services by staff that are necessary to attain or maintain physical, mental, and psychosocial well-being In these cases, staff has the knowledge and ability to provide care and services, but chose not to do it, or acknowledge the request for assistance from a resident, which results in care deficits to a resident. -This Facility is committed to protecting our residents from abuse by anyone including, but not limited to, Facility staff, other residents. consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. -VI. Prevention and Identification: The Facility will provide residents, family and staff, information on how and to whom they may report concerns, incidents and grievances without the fear of retribution and provide feedback on the concerns that they have expressed; -Environmental Assessment: Assess the environment for circumstances which may make abuse, neglect, or misappropriation of resident , items more likely to occur. Examples include, but are not limited to, resident's room far from the nurses station, in a room with all cognitively impaired residents, dimly lit areas; -Resident Assessment: As part of the resident social history assessment staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis; -Pattern Assessment: Review accident/incident reports, missing items reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other occurrences that may constitute abuse, neglect or theft. Based on an assessment of the reports, the Facility will further investigate and/or determine whether a change in Facility practices is warranted; -Staff Supervision: On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents and staffs understanding of individual resident care needs. Situations such as inappropriate language, insensitive handling, or impersonal care will be corrected as they occur. Incidents short of willful abuse will be handled through counseling, training, and if necessary or repeated, the Facility's progressive discipline policy. -VII. Reporting and Investigating Allegations: -Reporting to Supervisor/Administrator/DON: Employees and vendors are required immediately to report any occurrences of potential mistreatment including alleged violations, mistreatment, neglect, abuse, sexual assault, and injuries of unknown source and misappropriation of resident property they observe, hear about or suspect to a Supervisor or the Administrator. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential mistreatment to a Supervisor or the Administrator or to the Compliance Hotline. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated; -This Facility does not condone resident abuse by anyone, including employees, physicians, consultants volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors other residents, friends, or other individuals. It is the responsibility of employees, Facility consultants, attending physicians, family members, and visitors etc., to promptly report any incident or suspected incident of abuse/neglect/misappropriation of funds to Facility management immediately. If such incidents occur after hours the Administrator or designee and DON or designee will be notified at home or by cell phone and informed of any such incident; -Report to State, Law Enforcement, and Others; The facility must ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, or sexual assault including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation in made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency. While specific forms are not required, the DHSS (Department of Health and Senior Services) Initial Reporting Form and Follow-up investigation Form are attached. If the abuse involves alleged suspicion of crime, it must also be reported to local law enforcement within those time frames. See Elder Justice Act - Reporting Reasonable Suspicion of a Crime. The facility will also notify the resident or their guardian legal representative.; -Investigation: Upon learning of the report of abuse or neglect, the Administrator shall initiate an incident investigation. The nursing staff is additionally responsible for reporting and investigating the appearance of bruises, lacerations, or other abnormalities as they occur; -Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the Administrator or designee; -Appointing An Investigator: Once the Administrator or designee determines that there is a reasonable possibility that mistreatment occurred, the Administrator or designee will appoint a person to take charge of the investigation. The person in charge of the investigation will obtain a copy of any documentation relative to the incident. The investigation will include assessment of all residents involved and interventions to ensure protective oversight of all residents and involved residents in the Facility. Interventions could include; nursing staff separating alleged perpetrator and alleged victim including moving the residents to separate halls, Physician involvement, intensive monitoring of 15 minute face checks of the alleged perpetrator and alleged victim; this may include more intensive monitoring of 5 minute face checks based on the behavioral, psychiatric or medical needs of the resident, Legal Guardian notification, possible hospitalization or immediate discharge. More intensive monitoring will be determined by Administrative staff after an assessment of the resident is completed; -Confidentiality: The investigator shall do as much as possible to protect identities of any employees and residents involved in the investigation, until the investigation is concluded. After a conclusion based on the facts of the investigation is determined, internal reports, interviews and witness statements shall be released to those with a need to know. Even if the Facility Investigation is not complete, the Administrator will cooperate with any DHSS investigation. The Administrator or designee will keep the resident or guardian/resident representative informed of the progress of the investigation as appropriate; -Updates to Administrator: The person in charge of the investigation will update the Administrator or designee during the process of the investigation. The Administrator or designee will keep the resident or resident representative informed of the progress of the investigation; -Final Report: A final report of the Investigation will be sent to the Department of Public Health/DHSS no later than 5 days following the initial complaint or incident. All investigation results will be made available as required by law. The Administrator and all employees shall fully cooperate with any State agencies, law enforcement officials authorized to investigate allegations; -VIII. Protection of Residents: The Facility will take steps to prevent mistreatment while the investigation is underway; -Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the Facility. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/23/24, showed: -Severe cognitive impairment; -Hearing: Highly impaired; -Vision: Highly impaired; -Speech: None, Rarely/never understood, Rarely/never understands; -Mobility: Impairment one side lower extremity, no assistive device used; -Wandering: Behavior occurs daily; -Wandering: Does the wandering place the resident at significant risk of getting to potentially dangerous place? Blank; -Wandering: Does the wandering significantly intrude on the privacy of activities of others? Blank; -Physical Behavior directed towards others: Behavior not exhibited; -Verbal Behavior directed towards others: Behavior not exhibited; -Other Behavior not exhibited toward others: Behavior not exhibited; -How does resident's current behavior status, care, rejection, or wandering compare to prior assessment? Blank -Diagnoses include dementia, anxiety, and high cholesterol. Review of Resident #4's care plan, revised 11/8/23, showed: -Focus: Resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others. These behaviors include wandering into peer's rooms and laying on the bed and rummaging through items. Resident was a drummer throughout his/her life and swings his/her arms around putting him/her at risk for unintended injury; -Goal: Resident will minimize episodes of inappropriate behaviors that can affect others; -Interventions: Administer and monitor medications as ordered, Give positive feedback for good behavior, If resident is disturbing others, encourage him/her to go to a more private area to voice concerns/feeling to assist in decreasing episodes of disturbing others. Notify guardian /physician as needed. Provide 1:1 as needed per administration discretion. Review of Resident #4's care plan, revised 11/17/23, showed: -Focus: Resident has potential to be verbally/physically aggressive related to diagnosis of dementia and mild cognitive impairment; -Goal: resident will demonstrate effective coping skills through the review date; -Interventions: Assess and anticipate the resident's needs: food, thirst, toileting needs, comfort level, body positioning, paint. Provide physical and verbal cues to alleviate anxiety. Give positive feedback, assess verbalization of source of agitation, assist to set goals for more pleasant behavior., encourage seeking out of staff member when agitated. When resident becomes agitated: Intervene before agitation escalates. Guide away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. Review of Resident #4's care plan, initiated 2/24/24, showed: -Focus: On 2/23/24, Resident wandered into a peer's room and laid in his/her bed. Peer grabbed resident by the shirt to pull him/her out of bed and ripped his/her shirt; -Goal: Resident will have protective oversight through next review; -Interventions: Staff separated the residents. Skin assessment completed and red marks were noted to the right side of his/her chest. While staff was trying to obtain vital signs, resident refused and threw the equipment. Facility is making sure resident purchases snacks and drinks to keep in his/her room in hopes to minimize his/her wandering behaviors that lead to altercations. Facility has sent referrals to other facilities. Review of Resident #4's progress note, showed: -3/9/24 at 7:37 A.M., Continue on 1:1 monitoring. No abnormal behaviors noted. -3/10/24 at 3:07 P.M., Resident is very good with 1:1 activities. -3/11/24 at 4:14 A.M., Resident was sleeping in his/her room. Certified Nursing Assistant (CNA) went to check on the resident and found him/her in another resident's room with the left side of his/her lip swollen and with a small cut, the other resident had his/her hand in a fist. Call place to DON, Assistant Director of Nursing (ADON), and Administrator. Voice message left for each of them. -3/11/24 at 5:37 A.M., Physician notified of resident altercation and Administration aware of resident altercation. -3/11/24 at 5:40 A.M., DON notified of resident altercation. -3/11/24 at 6:23 A.M., Son/Daughter notified of resident's altercation. Review of Resident #4's care plan, showed no update on 3/11/24. Review of Resident #3's admission MDS, dated [DATE], showed: -Cognitively intact; -Hearing: Adequate; -Vision: Adequate; -Speech: Clear, Resident is understood and understands others; -Mobility: No upper or lower impairment, uses walker for mobility; -Wandering: Blank; -Physical Behavior directed towards others: Behavior not exhibited; -Verbal Behavior directed towards others: Behavior not exhibited; -Other Behavior not exhibited toward others: Behavior not exhibited; -Diagnoses include end stage renal disease (ESRD), arthritis, dementia, schizophrenia and cataracts. Review of Resident #3's care plan, initiated 1/19/24, showed: -Focus: Resident has potential to be verbally/physically aggressive related to diagnosis of schizoaffective disorder, unspecified dementia, violent behavior, restlessness and agitation; -Goal: Resident will demonstrate effective coping skills through the review date; -Interventions: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Provide physical and verbal cues to alleviate anxiety; give positive feeding, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff member when agitated. Give resident as many choices as possible about care and activities. Review of Resident #3's progress notes, showed: -3/11/24 at 4:26 A.M., Another resident was found in this resident's room with his/her left lip swollen and a small cut to it, this resident has his/her hand in a fist; -3/11/24 at 5:35 A.M., Physician notified of residents altercation and Admin aware of resident altercation; -3/11/24 at 5:43 A.M., DON notified of resident altercation; -3/11/24 at 3:05 P.M., Resident observed on the hall displaying increased agitation towards peers and staff. Code green (behavioral emergency) called. Staff answered, resident noted to charge at staff and displaying increased physical aggression. Resident then noted to throw things in his/her room. 911 called. EMS arrived at 2:50 P.M. Resident refused to speak with EMS. ADON came to unit where he/she was able to vent feelings and concerns. Resident continues to refuse to go to hospital for further treatment. Resident educated and encouraged to allow further treatment. Resident continues to refuse. Upper management and physician made aware. Resident educated that staff will place him/her in a different room. Resident stated understanding. No pain or discomfort noted at this time. New order Haldol (antipsychotic, used to treat nervous, emotional, and mental conditions) 5 mg by mouth (PO)/intramuscularly (IM) every 8 hours as needed (PRN). Staff will continue to monitor for protective oversight; -3/11/24 at 7:13 P.M., Resident was calm this evening. Resident was singing with staff and showed no signs of physical aggression. Review of Resident #4's progress note, showed: -3/12/24 at 7:54 A.M., Resident remains on 1:1 monitoring. During shift change resident wandered into another resident's room and was hit in the lip. Resident is being sent to the hospital for evaluation. No complaints of pain or discomfort voiced or noted at this time. Management guardian, doctor has been made aware. -3/12/24 at 4:12 P.M., Resident returned to facility per ambulance and two attendants. Resident showing no signs of agitation at this time. Resident has no new orders. Resident is voicing no complaints of pain or discomfort at this time. -3/12/24 at 10:42 P.M., Resident remains of 1:1 for protective oversight. Resident rested in his/her room most of the evening. No acute distress noted at this time. Resident ate well this evening and went to sleep. Review of Resident #4's care plan, revised 3/12/24, showed: -Focus: Resident is impulsive and grabs items within his/her reach often, especially food/drink items related to diagnosis of unspecified dementia and cognition impairment; -Goal: Ensure protective oversight is provided through next review; -Interventions: Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors by ensuring staff is providing intense monitoring. Monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. -Focus: On 3/12/24, Resident wandered into a peer's room and the peer struck him in the lip; -Goal: Resident will have no injury through next review; -Interventions: Staff intervened immediately and separated the residents. Staff will continue to monitor the resident for wandering behaviors. Referral is in progress to find a facility that can meet his/her needs. Skin assessment completed and no injures noted. Neurochecks initiated and within normal limits. Resident sent to the emergency room (ER) for a medical evaluation. Review of Resident #3's progress notes, showed: -3/12/24 at 7:02 A.M., Resident observed in his/her room displaying increased agitation toward peers/hitting another resident that had walked into his/her room in the lip. Code green called. Staff answered. Resident noted to charge at staff continuing to display increased physical aggression. Resident then noted refusing to go to the ER. Resident educated and encouraged to allow further treatment. Resident continue to refuse. Upper management and physician made aware. Resident educated that staff will place him/her in a different room if behaviors continue. Resident stated understanding. No pain or discomfort noted at this time. Staff will continue to monitor for protective oversight. Management, doctors made aware. No guardian listed at this time/self. -3/12/24 at 11:10 A.M., Resident continued to display progressed signs of agitation. Resident refused medications, refused injections on multiple attempts when asked. 911 called due to aggression which assisted (by) three EMS. Resident continued to be non-compliant, at this point being a threat to him/herself and others. Requiring an injection from EMS after a half an hour trying to convince the resident to go. Resident has been transferred to the hospital for further evaluation. Social service has been made aware that that resident needs to have guardianship. Management and doctors made aware. Vitals refused. -3/13/24 at 10:11 A.M., Resident arrived back to center from hospital with new orders verified by a nurse from the physician office. Resident is noted as his/her own responsible party and was made aware of new medication change. Review of Resident #3's care plan, initiated 3/12/24, showed: -Focus: On 3/12/24, peer wandered into resident's room and resident struck his/her peer; -Goal: Resident will have fewer behavioral episodes through next review; -Interventions: Staff intervened immediately and separated the residents. Resident was placed on 1:1 monitoring, and room moves were made. The resident refused assessment or any care. 911 was notified and responded. Resident refused to go to the ER and is his/her own person. EMS made several attempts to get him/her to the ER, but he/she continued to refuse. Room moves made. Resident continued to have codes throughout the shift. He/She became physically aggressive with staff. 911 called again and responded with St. Louis police department. 5 milligram (mg) Versed (benzodiazepine, sedative) given IM in right gluteal via EMS. Resident was finally calm and able to be transferred to the stretcher. He/she was sent to hospital ER for medical and psych evaluation. Review of the facility's investigation, for the 3/12/24 incident between Resident #4 and Resident #3, showed: -On 3/12/24, two staff members heard a noise and yelling from Resident #3's room. They heard Resident #3 telling someone to get out. Resident #4 then came out of Resident #4's room with a busted lip. Residents were immediately separated; -Resident #3 had no injury or complaints of pain; -Resident #4 had no active bleeding from lip. No complaints of or signs/symptoms of pain. Neuro checks define within normal limits (WNL); -Resident #4 unable to give a statement; -Resident #3 could not explain his/her actions; -CNA E stated he/she heard a noise from Resident #3's room and Resident #3 stating to get out. When CNA E got to the room, Resident #4 was coming out with a busted lip; -CNA F stated he/she heard yelling from the back of the hall. He/She went to see what was going on and saw Resident #4 with a busted lip; -Both residents were sent to the ER for evaluation; -Allegation was substantiated; -Resident #3 had a recent gradual dose reduction (GDR), chlorpromazine (antipsychotic, used to treat schizophrenia, bipolar disorder, and acute psychosis) was increased back to 25 mg twice a day; -Resident #4 was placed on 1:1 for protective oversight and was discharged to another facility on 3/13/24 to a more appropriate level of care. Review of the Nurse Practitioner (NP) follow up note, electronically signed 3/13/24 at 7:48 P.M., showed: -Chief complaint: Follow up ER -History of Present Illness: 3/11/24, Received call from Licensed Practical Nurse (LPN) A, Resident was involved in a peer-to-peer altercation. The peer came into resident's room. Resident with no injuries. 3/12/24 received a call from LPN B reporting that resident was in a peer-to-peer altercation this A.M. and has continued aggressive behaviors. Resident is his/her own person and does not want to go to the hospital but he/she is a threat to himself/herself and others, 911 was contacted and he/she will be escorted to the hospital. Resident returned from the ER today with a new order for hydroxyzine PRN anxiety. -Plan: Altercation with peer. Evaluated in ER. No acute injury or pain. Reviewed appropriate behaviors with patient. Verbalized understanding. Redirect as possible. Continues on hall restriction if ordered. Ok to continue hydroxyzine for anxiety. During an interview on 3/19/24 at 10:15 A.M., Certified Nursing Assistant (CNA) C said Resident #3 gets along pretty good with everyone. He/She just did not want Resident #4 in his/her room. Resident #4 should have been on a 1:1 but was not. The incident on 3/12/24 should not have happened. During an interview on 3/19/24 at 11:08 A.M., LPN D said the day of the incident on 3/12/24, he/she did not arrive to work at the facility until approximately 10:00 A.M. LPN D is not sure if Resident #4 was on 1:1 monitoring. The only odd occurrence was Resident #3 appeared upset later. He/She was upset when asked to change his/her room. They tried to send him/her out, but the resident refused. During an interview on 3/19/24 at 11:10 A.M. CNA E said he/she wrote a statement about the incident on 3/12/24. CNA E said he/she had just arrived that morning. Resident #4 did not have a 1:1 but he/she is not sure if the resident was supposed to. Resident #4 walked into a resident's room. CNA E got Resident #4 to leave that room. CNA E then went into the day room to check on residents in there. As CNA E left the day room, he/she heard Resident #3 hollering down the hall get out of my room. When he/she got down there, staff were already with Resident #3 and Resident #4, who had wandered down there. CNA E reported the incident to the night nurse since the incident occurred at shift change. During an interview on 3/19/24 at 11:20 A.M., LPN B said he/she was the assigned nurse for both residents on 3/12/24. LPN B said Resident #4 was supposed to be on a 1:1. When a resident is on a 1:1, they are supposed to always have a staff member with them that is no more than an arm length away. LPN B said this incident occurred during the change of shift and is not sure why the resident did not have someone with him/her. LPN B said he/she did not witness the incident. He/She responded to the Code [NAME] when it was called. LPN B said normally Resident #3 is calm but that day he/she was something else. Later, they called to get the resident taken to the hospital. It took three EMS and police to get him/her out of here. LPN B said the residents who are on 1:1 monitoring are listed on the 24 hour report sheet or nurses can print out the hot rack notes (part of the progress notes in the EMR) to know. During an interview on 3/19/24 at 11:50 A.M., the Administrator said Resident #4's lip was swollen after he/she was struck by Resident #3 on 3/12/24. The facility's investigation described Resident #4's lip as busted. During a review of the EMR with the Administrator and DON, the Administrator was not aware of the 3/11/24 incident with Resident #4 and Resident #3. The Administrator did not think the incident occurred on 3/11/24 just 3/12/24 but wanted to check to clarify if the information charted is correct. During an interview on 3/19/24 at 1:40 P.M. LPN A said the incident on 3/11/24 happened in the middle of the night around 3:00 A.M. Resident #4 should have been a 1:1 but the resident did not have one due to short staffing. There were two CNAs on the unit. One of the CNAs started to do another set of resident rounds. He/She thought Resident #4 was still asleep. This time, Resident #4 was not in his/her room. The CNA found Resident #4 in Resident #3's room. When the CNA walked in Resident #3's room, Resident #4 had a cut to his/her lip which was a little swollen. Resident #3 had his/her fist balled up. There was a little drop of blood on Resident #4's lip which the CNA wiped off. The CNA brought Resident #4 up to nurses station. The other CNA was in the day room with a different resident. LPN A is not sure what caused the cut on Resident #4's lip but believes when Resident #3 hit Resident #4, his/her lip probably got cut on his/her tooth. LPN A did not send either resident out to the hospital. He/She completed the neurochecks and kept a close eye on Resident #4. Resident #4 was not acting any differently. Resident #3 did not have any unusual behavior the rest of the shift. The incident was reported to management, the DON, the ADON, the physician, and the resident's son/daughter. The son/daughter was not happy. LPN A does not think the incident would have happened if Resident #4 was 1:1 like he/she was supposed to be. This is because Resident #4 would have never gotten to Resident #3's room. When a resident has a 1:1, they have a staff person with them at all times within arm's length. The other nurse who worked that night was on break when the incident occurred. That nurse called the Administrator. Both residents were normal the rest of the night. LPN A thought the CNA kept Resident #4 with him/her the rest of the night. The incident on 3/12/24 must have been a different incident. This incident did not happen at shift change. LPN A said Resident #4 needed to go to facility that could better meet his/her needs. During an interview on 3/19/24 at 2:44 P.M., the Administrator provided a list of residents on 1:1, dated 3/9/24, Resident #4 was not on there. The Administrator said the list is printed at the beginning of the week and done a week at a time. If an incident occurs after the list is made and a resident needs a 1:1, then that resident is added to the list. Resident #4 was added the day of the 3/12/24 incident. Resident #4 was kept on monitoring for the first 72 hours. He/She was not kept past the 72 because the incident was not behavior related. Resident #4 just wanders. During an interview on 3/19/24 at 3:25 P.M., the Administrator and DON said they do not think Resident #4 should have been on a 1:1 after the incident on 3/11/24. Resident #4 was on a 1:1 for almost a year. The DON said in the past, the facility's go to was to just place residents on a 1:1. The facility cannot do that with each and every person. They have to look at each incident and check intent and reason, then try other stuff before they go to the 1:1. The other thing with the 1:1 is that it requires a staff person continuously for 24 hours. The Administrator and DON said the incident on 3/11/24 should have been investigated. They expected staff to report it and then they send to DHSS and do a full investigation. MO00233067

See F760 cited at 7FZ112. Based on observation, interview and record review, the facility failed to ensure one resident (Resident #25) with a diagnosis of diabetes consistently received blood sugar level checks (measures the level of glucose (sugar) in the blood) and insulin administration. The facility failed to notify the physician of a blood sugar reading over 451, as ordered by the physician. On 12/23/23, the resident had a blood sugar level of 550. The resident was transferred to the hospital on 12/24/23 and diagnosed with diabetic ketoacidosis with coma associated with diabetes. The resident passed away on 12/25/23. Additionally, facility staff failed to clarify physician orders and obtain specific parameters for use when one resident (Resident #24) with a diagnosis of seizure disorder and a history of multiple seizures, was prescribed Valtoco (short-term treatment of seizure clusters), an as necessary (PRN) medication for seizures, and failed to consistently notify the resident's physician after every seizure. Last, staff failed to administer one resident's (Resident #23) medications as ordered and failed to document an explanation as to why the medications could not be administered on the medication administration record (MAR) and/or in the resident's progress notes. The sample size was 22. The census was 140. The administrator was informed on 2/5/24 of an Immediate Jeopardy (IJ), which began on 12/23/23. The IJ was removed on 2/6/24 as confirmed by surveyor on-site verification. Review of the facility's Blood Glucose Monitoring and Insulin Administration Policy, dated revised 6/29/23, showed: -Affected personnel: Registered Nurses (RN), Licensed Practical Nurses (LPN) and Certified Medication Technicians (CMT); -Purpose: To define accurate procedures to be followed when checking a blood sugar. To identify what measures will be taken in the event that a blood sugar falls out of the defined therapeutic range; -Procedure: If the resident's blood sugar is over 400, the physician will be notified by the charge nurse and orders will be followed. 1. Review of Resident #25's Admission Record, showed the resident was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic, metabolic disease characterized by elevated levels of blood glucose (blood sugar)). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/10/23, showed: -Cognitively intact; -Had a diagnosis of diabetes; -Received insulin injections. Review of the resident's care plan, showed: -Focus: At risk for alteration in health related to diabetes. Resident is on a regular low concentrated sweets diet (LCS, reduced carbohydrate diet) revised on 8/12/22; -Goal: The resident will have no complications related to diabetes through the review date, initiated on 12/11/21; -Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, initiated 12/11/21. Review of the resident's December 2023 Physician's Order Summary, showed: -Check and record blood sugar four times a day for diabetes, dated 8/17/23; -Dexcom G7 Receiver Device (Continuous Blood Glucose System Receiver). Inject 1 application intramuscularly one time a day related to diabetes, dated 8/17/23; -Dexcom G7 Sensor Miscellaneous (Continuous Blood Glucose System Sensor). Inject 1 application intramuscularly one time a day related to diabetes, dated 8/17/23; -Insulin Aspart FlexPen Subcutaneous Solution Pen injector (a short-acting insulin used to control blood sugar levels in the blood), 100 units per milliliter (ml). Inject subcutaneously (under all the layers of the skin) three times a day, as per sliding scale: --If blood sugar level is 200 - 250 = administer 3 units; --251 - 300 = 5 units; --301 - 350 = 7 units; --351 - 400 = 9 units; --401 - 450 = 11 units; --Over 451, Contact Physician, dated 10/31/23; -Lantus SoloStar Subcutaneous Solution Pen-injector (Insulin Glargine - a long-acting insulin used to control blood sugar levels in the blood), 100 units per ml. Inject 10 units subcutaneously every morning and at bedtime related to diabetes, dated 12/17/23. Review of the resident's December 2023 Accu check and insulin administration record, showed: -Lantus SoloStar Subcutaneous Solution Pen-injector 100 units per milliliter, inject 10 units subcutaneously every morning and at bedtime related to diabetes, dated 12/17/23, blank and not marked as provided on 12/9/23 at 7:00 P.M., and 12/17/23 at 7:00 P.M.; -Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 units per milliliter, inject subcutaneously three times a day, as per sliding scale: --if blood sugar level is 200 - 250 = administer 3 units; --251 - 300 = 5 units; --301 - 350 = 7 units; --351 - 400 = 9 units; --401 - 450 = 11 units; --Over 451, contact physician; dated 10/31/23. Review of the resident's December 2023 Accu check and insulin administration record, showed: - on 12/13/23 at 6:00 P.M., facility staff did not document the resident's blood sugar level or if insulin injection was required; - on 12/17/23 at noon, facility staff did not document the resident's blood sugar level or if insulin injection was required; - on 12/19/23 at 6:00 P.M., facility staff did not document the resident's blood sugar level or if insulin injection was required. Review of the resident's Nursing Progress Notes, showed: -No documentation as to why there was no recorded administration of the regularly scheduled Lantus insulin on 12/9/23 at 7:00 P.M. and 12/17/23 at 7:00 P.M.; -No documentation to show why blood sugar level or administration of sliding scale insulin was not documented on 12/13/23 at 6:00 P.M., 12/17/23 at noon, and 12/19/23 at 6:00 P.M. Nurse Practitioner note date of service 12/21/23: --Blood sugar 426 on 12/21/23 at 11:55 A.M.; --Diagnoses: Brittle diabetes (hard to control) and Type 2 diabetes mellitus with hyperglycemia (spike in blood sugar levels); --Plan: patient is brittle diabetic. He/She is very sensitive to insulin. Medications reviewed. Last visit increased Lantus to 10 units BID (twice daily). Follow up routine visit and as needed; Review of the resident's December 2023 Accu check and insulin administration record, showed on 12/22/23 at 6:00 P.M., facility staff did not document the resident's blood sugar level or if insulin injection was required. Review of the resident's Nursing Progress Notes, showed no documentation to show why blood sugar level or administration of sliding scale insulin was not documented on 12/22/23 at 6:00 P.M Review of the resident's December 2023 Accu check and insulin administration record, showed on 12/23/23 at 6:00 P.M., facility staff documented a blood sugar level of 550. The record showed sliding scale insulin was not administered on 12/23/23 at 6:00 P.M., due ot vitals outside of parameters for administration.The record did not include documentation the physician was notified of the blood sugar level of 550 or if any new orders were received. Review of the resident's Nursing Progress Notes, showed: -No documentation the physician was notified of the blood sugar level of 550 or if any new orders were received on 12/23/23 at 6:00 P.M.; -On 12/24/23 at 4:15 A.M, while doing routine rounds, the resident was breathing rapidly and lips were really dry. Vital signs were obtained: -temperature 96.4 (normal range between 97 F (Fahrenheit) and 99 F); -pulse 101- 105 (normal range 60 to 100 beats per minute); -respirations 32-28 (normal range from 12 to 16 breaths per minute); -blood pressure 87/52 (normal pressure is systolic (top number) of less than 120 and diastolic (bottom number) of less than 80 (120/80)); -blood sugar read HI >600. The nurse applied oxygen at 2 L (liter) per nasal cannula (a device that gives you additional oxygen through the nose); -12/24/23 at 4:31 A.M, call placed to resident's physician and reached the on-call physician. Made aware of what's going on with resident. Ok to send out 911. Resident is his/her own responsible party; -12/24/23 at 4:37 A.M., call placed to 911; -12/24/23 at 4:45 A.M.: Ambulance arrived at facility at 4:45 A.M.; -12/24/23 at 5:05 A.M.: Resident exited building with ambulance via stretcher. Review of the resident's Hospital Records, showed: -emergency room notes: --Chief complaint: hyperglycemia (elevated blood sugar level); --Transfer to the emergency department by EMS due to hyperglycemia. EMS states the patient's blood glucose level has been reading in the 500's since 4:00 P.M. on 12/23/23. Upon arrival at the emergency department the patient was unresponsive to verbal stimuli. The patient does respond to painful stimuli. The patient is hypotensive (abnormally low blood pressure). The patient suddenly started vomiting and likely aspirated (inhaling saliva, food, liquid, vomit and even small foreign objects into the lungs). The patient has a history of diabetes and diabetic ketoacidosis (DKA - A serious diabetes complication where the body produces excess blood acids (ketones)); -Final diagnoses: --Aspiration pneumonia of both lungs; --Altered mental status; --Diabetic ketoacidosis with coma associated with diabetes; --Acute kidney injury. During an interview on 1/24/24 at 1:49 P.M., CMT Y said: -CMTs performed the accu checks and insulin administration; -The resident's blood sugar was taken before dinner and at bedtime; -His/Her blood sugar always ran high; -Every time his/her blood sugar would run low or high, he/she would notify the nurse and let the nurse make the final decision on if to contact the physician or not; -He/She did not know if the physician was notified on 12/23/23, but was sure it was out of range; -He/she always asked the nurse what to do before giving insulin; -He/she did not remember if the resident received any insulin on 12/23/23; -Looking at the administration record, he/she got the long-lasting insulin but not the sliding scale due to the nurse needing to contact the physician to get an order for the dose to be administered; -He/She did not remember who the nurse was but was sure he/she told the nurse. During an interview on 1/24/24 at 3:05 P.M., LPN X said: -He/She did not recall 12/23/23, and the resident's blood sugar being elevated; -The resident had a history of refusing insulin; -If the CMT had notified him/her of the elevated blood sugar he/she would have contacted the physician for new orders; -He/She would normally make a note in the resident's progress notes any time he/she would contact the physician; -There should never be a blank on the administration record, there should always be some kind of documentation; -He/She expected the CMT to notify him/her immediately if there is a blood sugar level out of range. During an interview on 1/23/24 at 1:17 P.M., LPN A said: -CMTs performed the accu checks and administer insulin; -If the CMT was not certified, then the nurse would do it; -The CMT should notify the nurse immediately if the blood sugar level was not in range; -A blood sugar level of 550 was out of range and the nurse should be notified immediately; -The nurse would then reach out to the physician and put any new orders in place; -The CMT could not hold insulin due to the blood sugar level being out of range; -The MAR should be signed out when any medication was administered. During an interview on 1/25/24 at 10:17 A.M., Nurse K said: -The nurse/CMT should always record the accu check level and insulin administration; -If a blood sugar level was not obtained or insulin not administered, the expectation was to mark why; -CMTs were responsible for obtaining blood sugar levels and administering insulin; -He/She expected CMTs to notify him/her immediately if a blood sugar level was out of range; -A blood sugar level of 550 was out of range and needed to be called to the physician for new orders; -Any physician contact or new orders should be documented in the resident's chart. If a resident had a blood sugar out of parameters, he/she would call the physician, get an order for a one-time insulin administration, chart it, administer the insulin and the go back 20-30 minutes later to check on the resident, then document the follow up check. During an interview on 12/25/24 at 10:45 A.M., Nurse N said: -There should never be any blanks on the administration record, there were always options to pick from; -If it was blank, it was assumed it was not performed/administered; -Blood sugar levels and insulin administration were performed by the CMTs; -He/She expected the CMT to notify him/her immediately if a blood sugar level was out of range; -He/she would need to call the physician and get an order for insulin administration based on the blood sugar level; -A blood sugar level of 550 was out of range and required physician notification; -Any physician contact or new orders should always be documented in the resident's progress notes. During an interview on 1/25/24 at 12:57 P.M., the Director of Nursing (DON) said: -He/She expected staff to follow all physician orders; -He/She expected the MAR to be signed out when medication was administered, and that included blood sugar levels and insulin administration; -If there was a blank on the administration record, it meant the insulin was not administered; -The CMT must notify the nurse immediately if there was a blood sugar level out of range and the nurse would then notify the physician for new orders; -Any physician contact should be documented in the resident's progress notes; -Any new orders should be documented on the MAR and in the resident's progress notes; -If a blood sugar level was higher than the parameters, the nurse should go back and check on the resident in at least one hour and document the follow up; -He/She was going to change the process and give the blood sugar level checks and insulin administration tasks back to the nurses. 2. Review of Resident #24's annual MDS, dated [DATE], showed: -Makes Self Understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Understands, clear comprehension; -Diagnoses of seizure disorder or epilepsy (a brain disorder that causes recurring, unprovoked seizures), manic depression/bipolar disease (extreme mood swing) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's diagnoses located in the resident's medical record, showed a diagnosis of epileptic seizures related to external causes, not intractable (difficult to manage/alleviate, keep under control) with status epilepticus (a seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes). Review of the resident's care plan, initiated on 5/26/21 revised on 12/5/23, showed: -Focus: Risk for falls related to psychotropic drug (a drug that affects behavior, mood, thoughts, or perception) use, seizures, and head injury. Resident wears helmet for seizures. -Goal: Will be free from falls through review date; -Interventions: Anticipate and meet the resident's needs. To wear helmet while up. Review of the resident's physician's order sheet (POS), included the following orders: -Start Date: 9/11/23: Valtoco (diazepam (Valium)) benzodiazepine/anticonvulsant (a class of agents that work in the central nervous system) used to treat seizure clusters (seizures that occur in groups/clusters over a number of hours/days) 20 milligrams (mg) nasal liquid therapy pack 10 mg/0.1 milliliters (ml) (diazepam (anticonvulsant)), 0.2 ml in both nostrils every 4 hours PRN for seizures related to epileptic seizures. Discontinue Date: 12/14/23 (The order did not contain specific parameters for use- including if the medication should be administered after one seizure or more.); -Start Date: 12/17/23: Valtoco 20 mg dose nasal liquid therapy pack 10 mg)/0.1 ml, 0.2 ml in both nostrils every 4 hours PRN for seizure activity (The order did not contain specific parameters for use- including if the medication should be administered after one seizure or more.); -Start Date: 12/18/23: Lacosamide (Vimpat/anticonvulsant) 200 mg two times a day (BID) for anticonvulsant; -Start Date: 12/18/23: Valporic acid (used to treat various types of seizure disorders) 250 mg, two capsules (500 mg) BID anticonvulsant; -Start Date: 1/4/24: Levetiracetam (Keppra/anticonvulsant) 250 mg, five tablets (1250 mg) BID for epilepsy. Observation of the facility medication cart on 1/24/24 at 9:00 A.M., showed two boxes of Valtoco, each containing two spray devices. One box was sent to the facility from the pharmacy on 4/19/23, and contained one of two doses. The second box was sent to the facility from the pharmacy on 9/15/23, and contained two of two doses. Review of the Valtoco manufacturer's instructions found in the medication box received from the facility pharmacy, showed: -Indications for usage: Valtoco is a benzodiazepine indicated for the acute (sudden/immediate) treatment of intermittent, stereotypic episodes of frequent seizure activity (i.e. seizure clusters, acute repetitive seizures) that are distinct from a patient's usual seizure pattern in patients with epilepsy six years of age and older; -How to use Valtoco: Use Valtoco exactly as prescribed by your healthcare prescriber; -Valtoco is given in the nose only. Valtoco comes ready to use. If needed a second dose may be given at least 4 hours after the first dose. Do not give more than two doses to treat a seizure cluster; -Instructions for use: Safely secure the person. If the person appears to be having a seizure, gently help them to the floor and lay them on their side in a place where they cannot fall. The person can be on either their side or back to receive Valtoco. One dose equals two nasal spray devices. Each device sprays one time only. After giving Valtoco keep or move the person onto their side, facing you, so that you can watch them closely. According to the Valtoco manufacturer's website, seizure clusters, are episodes of frequent seizure activity, that occur 2 or more times within a 24-hour period. Review of the resident's December 2023 progress notes, showed: -12/8/23 at 5:32 P.M., documented by Nurse B: It was brought to my attention as nurse that this resident had a seizure lasting 1 minute. Resident lowered to the floor by nursing staff. Resident shows no signs or symptoms of loss of consciousness upon cessation of seizure. Resident transferred off the floor with the help of two staff members, transferred to a wheelchair and propelled to room by staff. Call placed to physician. May transport to hospital for further evaluation. Emergency Medical Services (EMS) arrived and transported resident to hospital. Resident responding and respirations even and unlabored. Resident remains stable upon departure; -No documentation Valtoco nasal spray was administered; -12/8/23 at 10:30 P.M.: Resident returned from hospital with no new orders. Vimpat and Keppra order faxed to pharmacy for physician order update. Resident remains stable upon return; -12/12/23 at 6:38 P.M.: Resident walking down the hall and yelled out. Resident then fell , but did not hit his/her head. Resident had seizure activity noted for about 1 minute. Resident then stood up. Resident responding verbally, and denies complaints of pain. Resident placed at nurse's station for protective oversight. Physician notified; -No documentation Valtoco nasal spray was administered; -12/13/23 at 11:32 P.M.: This writer heard resident yell out as he/she did before he/she had a seizure. Before staff could get to resident he/she fell forward hitting his/her face on the floor. Blood noted to right side of face, his/her mouth and chin. Upon assessing he/she was noted to be alert and responding appropriately. 911 was called and resident was sent to hospital for an evaluation. Physician was notified. Resident returned to facility with no new orders; -No documentation Valtoco nasal spray was administered; -12/14/23 at 12:19 P.M., documented by Nurse K: Code blue called. Resident found unresponsive and actively having a seizure. Resident was bleeding from right upper lip and left lower chin. Resident actively seized for 5 minutes. Oxygen saturation ranged from 93%-97% (normal range 95%-100%) until EMS arrived. Resident's eyes were not equal or accommodating to light during this period. Resident sent to hospital to receive care. Physician notified; -No documentation Valtoco nasal spray was administered; -12/17/23 at 2:34 P.M.: Resident started on Valporic Acid and stopped Briviact (anticonvulsant). Resident saw neurologist and suggested follow-up on 1/3/23; -12/29/23 at 6:00 A.M.: Resident observed to be displaying seizure activity while seated in a chair. Area made safe for resident for the duration of seizure activity lasting approximately 1 minute. When activity discontinued resident made comfortable and allowed to rest. Resident remains on intensive monitoring for protective oversight; -No documentation the resident's physician was notified; -No documentation Valtoco nasal spray was administered; -12/29/23 at 9:18 A.M., documented by Nurse K: Resident observed to be displaying seizure activity while sitting on bed. Area made safe for resident for the duration of seizure activity lasting approximately 1 minute. When activity discontinued resident made comfortable and allowed to rest. Resident remains on intensive monitoring for protective oversight. Morning medications given. No seizure activity since then; -No documentation the resident's physician was notified; -No documentation Valtoco nasal spray was administered. Review of the resident's MAR, dated 12/1/23 through 12/31/23, showed: -Valtoco 20 mg one spray in both nostrils every 4 hours as needed for seizures related to epileptic seizures; -No initials showed staff administered the Valtoco the entire month of December. Review of the resident's January 2024 progress notes, showed: -1/3/24 at 9:00 A.M.: Certified Nursing Assistant (CNA) approached nurse station at this time propelling resident in wheelchair making this nurse aware resident appeared to have had change in condition while sitting at dining room table during breakfast. Immediately assessed resident noted with head down, calling name with no response, noted rise and fall of chest with eyes open and spontaneous jerking noted. This nurse and CNA assisted resident to room and in bed safely as resident unable to sit up in wheelchair. During assessment resident noted to stare off and to begin spontaneous jerking with no response when nurse called out during assessment. Episode lasted about 30 seconds and resident began to respond when name called. Call to 911 to make aware of needed transport for emergent evaluation. Call placed to physician. Ambulance arrived to facility, resident remained awake with Registered Nurse Supervisor at bedside noting one seizure episode since this nurse left bedside. Resident left facility at that time via ambulance; -No documentation Valtoco nasal spray was administered; -1/3/24 at 9:30 A.M., documented by Nurse B: This nurse summoned to dining room regarding this resident, upon entering the dining room this nurse noted resident sitting in chair at table lethargic and responding little to verbal stimuli. This nurse asked resident how he/she felt, the resident dropped his/her head and did not respond. Rise and fall of chest noted evenly, resident's vital signs and oxygen saturation within normal limits. Call placed to physician with new orders to send to the hospital for further evaluation. EMS arrived and transferred resident to hospital for further evaluation. Resident had neurologist appointment scheduled this shift. Neurologist appointment postponed until a further day; -No documentation Valtoco nasal spray was administered; -1/3/24 at 5:33 P.M., documented by Nurse B: Resident returned from hospital with new orders to increase Keppra to 1,250 mg two times a day. MAR updated, resident remained stable upon return; -1/14/24 at 12:33 P.M., documented by Nurse K: Resident found in hallway having a seizure. Seizure lasted approximately three minutes. Helmet was in place at the time of the incident. No injury noted. Physician notified, said to monitor; -No documentation Valtoco nasal spray was administered; -1/15/24 at 1:03 A.M.: Resident had seizure activity this evening of inexact length of time. The seizure activity happened from the time the resident's roommate went to the dining room to heat ramen noodles for resident and returned back to the room. Upon entering this writer observed resident lying crosswise on bed, his/her body was stiff and rigid and he/she was making a loud snoring noise. This activity lasted approximately 1.5 minutes before seizure activity was over. This writer verified with CMT resident's medications required for seizure activity; -No documentation the resident's physician was notified. -No documentation Valtoco nasal spray was administered; -1/15/24 at 5:54 A.M.: While on 600 hall passing medication, was called to resident's room by his/her roommate saying the resident was having a seizure. Writer was two doors away and as writer got to the resident's room the seizure activity was stopping and resident was coming out of it. Seizure lasted 30-50 seconds (estimated). Will continue to monitor; -No documentation the physician was notified. -No documentation Valtoco nasal spray was administered; -1/15/24 at 9:25 A.M., documented by Nurse K: Resident found in hallway having a seizure at 7:00 A.M. medication pass. Seizure lasted approximately 3 minutes. Helmet was in place at time of incident. No injury noted. Physician notified and made aware of multiple occurrences since 1/14/24. Physician stated to monitor and the next occurrence send the resident out; -No documentation Valtoco nasal spray was administered; -1/15/24 at 11:13 A.M., documented by Nurse K: Diazapam was administered in left nostril during seizure. Review of the resident's medication signature sign out sheet, showed one dose of Valtoco was administered on 1/15/24. Review of the resident's MAR, dated 1/1/24 through 1/31/24, showed: -Valtoco 20 mg one spray in both nostrils every 4 hours as needed for seizures related to epileptic seizures; -No documentation staff administered the Valtoco on 1/15/24. During an interview on 1/24/24 at 8:32 A.M., Nurse K said he/she had worked at the facility for about three years. The resident had a lot of seizures. He/She had not given the resident Valtoco nasal spray. He/She did not think the resident had had an order for the medication too long. CMTs could not administer Valtoco, only nurses. The medication should have been given when the resident had a seizure. Nurse K had not received any previous directives to not administer the medication when the resident had a seizure. He/She was present on 1/15/23, when the resident had a seizure and Nurse B administered the medication. He/She did not know why Nurse B did not initial the medication had been administered as given on the MAR on 1/15/24. Nurses are responsible to initial a medication was administered on the MAR for any medication administered. During an interview on 1/24/24 at 8:57 A.M., Nurse B said he/she had worked at the facility for about four months. Only nurses were allowed to administer Valtoco. He/She administered the Valtoco on 1/15/24 because the resident had a seizure. Even though the resident had had several seizures, that was the first time he/she had administered the Valtoco. He/She was not sure why he/she had not administered the Valtoco prior to 1/15/24. If a medication was administered, it should be initialed as given. If a medication can't be administered there should be an explanation as to why either on the MAR or in the progress notes. He/She should have initialed the medication on 1/15/24. During an interview on 1/24/24 at 10:31 A.M., the resident's physician said she did not order the Valtoco. She said the resident's neurologist ordered the medication. She would expect staff to administer the Valtoco as ordered and/or per the manufacturer's guidelines. During an interview on 1/25/24 at 1:00 P.M., the DON said she expected staff to administer any medication including Valtoco per the physician's orders. Any medication administered should be initialed as administered on the MAR. If a medication cannot be administered, she expected staff to document a reason why on the MAR or in the progress notes. 3. Review of Resident 23's quarterly MDS, dated [DATE], showed: -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Diagnoses of high blood pressure, diabetes mellitus (DM), hyperlipidemia (high cholesterol/elevated levels of lipids (fatty compounds) in the blood), anxiety, depression, manic depression/bipolar disease and schizophrenia. Review of the resident's care plan, last revised on 2/14/22, showed: -Focus: History of behavioral challenges; -Goal: Resident will have no serious injuries due to behaviors; -Interventions: Pharmaceutical interventions as needed. Administer medications as ordered; -Focus: Potential to be verbally/physically aggressive related to diagnosis of schizophrenia; -Goal: Will not harm self or others; -Interventions: Administer medications as ordered; -Focus: At risk for impaired cognitive (thought) function due to schizophrenia, bipolar depression and anxiety; -Goal: Will remain at current level of cognitive function; -Interventions: Administer medications as ordered; -Focus: At risk for alteration in health and hyperglycemic (high)/hypoglycemic (low) episodes related to DM; -Goal: Will have no complications related to DM; -Interventions: Diabetes medications as ordered by physician. Glucose monitoring; -Focus: At risk for adverse reactions related to psychotropic medications due to major depression and schizophrenia; -Goal: Will remain free of psychotropic drug related complications; -Interventions: Administer psychotropic medications as ordered by the physician; -Focus: At risk for alteration in neurological status related to diagnosis of restless leg syndrome; -Goal: Will remain with optimal status and quality of life within limitations imposed by neurological deficits; -Interventions: Give medications as ordered. Review of the resident's POS, showed the following orders: -No Start Date: Blood glucose before breakfast in the morning for DM; -Start Date: 2/14/22: Benztropine 1 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to schizophrenia; -Start Date: 2/14/22: Buspirone 10 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to paranoid schizophrenia; -Start Date: 2/17/22: Fluphenazine 10 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to schizophrenia; -Start Date: 2/14/22: Risperidone 2 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to unspecified psychosis (an acute or chronic mental state marked by loss of contact with reality); -Start Date: 7/26/22: Topiramate 100 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to schizophrenia; -Start Date: 7/14/23: Atorvastatin 40 mg, 1 tablet at 6:00 P.M. for high cholesterol; -Start Date: 7/14/23: Mirtazapine 15 mg, 1 tablet daily at 6:00 P.M. for anxiety; -Start Date: 7/14/23: Pramipexole 0.5 mg, 1 tablet at 6:00 P.M. for restless leg syndrome (a long-term disorder that causes a strong urge to move one's legs); -Start Date: 7/14/23: Trazodone 100 mg, 1 tablet at 6:00 P.M. for insomnia (difficult falling asleep);<BR

This deficiency is uncorrected. Please see the Statement of Deficiencies dated 03/19/24 for previous examples. Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents was free from physical abuse (Resident #101). The resident is legally blind and hard of hearing. On 4/28/24 at approximately 7:30 P.M., the resident asked Dietary Aide (DA) A for coffee, and DA A said the resident could not have coffee because the kitchen was almost closed. During the conversation, the resident put his/her hands up while talking. DA A grabbed the resident's wrists and then grabbed the resident's throat. Floor Technician (FT) B intervened and separated DA A and Resident #101. Certified Nurse's Aide (CNA) C was in the doorway to the smoking room and yelled out Code Green (behavioral emergency to notify additional staff). Certified Medication Technician (CMT) D heard the Code Green and brought the resident to his/her room. After the incident, DA A went to the smoking room with other residents. DA A remained in the facility and clocked out at his/her regular time at 8:00 P.M. The facility staff failed to ensure the safety of the other residents on the evening of the incident. The census was 146. The administrator was informed on 5/3/24 of an Immediate Jeopardy (IJ), which began on 4/28/24. The IJ was removed on 5/3/24 as confirmed by surveyor on-site verification. Review of the facility's Abuse and Neglect Policy, dated revised 1/5/23, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed; -Physical Abuse - Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior; -Mistreatment, neglect, or abuse of residents is prohibited by this Facility. This includes physical abuse, sexual abuse, verbal abuse, mental abuse and involuntary seclusion; -This Facility is committed to protecting our residents from abuse by anyone including, but not limited to, Facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -This Facility does not condone resident abuse by anyone, including employees, physicians, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. It is the responsibility of employees, Facility consultants, attending physicians, family members, and visitors etc., to promptly report any incident or suspected incident of abuse/neglect/misappropriation of funds to Facility management immediately. If such incidents occur after hours the Administrator or designee and Director of Nursing or designee will be notified at home or by cell phone and informed of any such incident; -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices, such as: --Dealing with aggressive residents; --Reporting allegations with fear of reprisal; --Recognizing signs of burnout, frustrations or stress that may lead to abuse; --The definition that constitutes abuse, neglect and misappropriation of resident property; -During orientation of new employees, the facility will cover at least the following topics: --Sensitivity to resident rights and resident needs and what constitutes physical, sexual, verbal and mental abuse; --Staff obligations to prevent and report abuse; --How to assess, prevent and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff; --How to recognize and deal with burnout, frustration and stress that may lead to inappropriate responses or abusive reactions to residents; --Reporting abuse and their obligations under law when receiving an allegation of abuse; -On an annual basis, staff will receive a review of the above topics; -Upon learning of the report of abuse or neglect, the Administrator shall initiate an incident investigation. The nursing staff is additionally responsible for reporting and investigating the appearance of bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the Administrator or designee; -The Facility will take steps to prevent mistreatment while the investigation is underway: -Employees of this Facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the Facility pending the results of the investigation and review by the Administrator; -Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home. Review of Resident #101's admission record showed the resident admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), hearing loss, legal blindness and dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/29/24, showed: -Cognitively intact; -Ability to hear (with hearing aid or hearing appliances if normally used): Adequate. No difficulty in normal conversation, social interaction, listening to TV; -Hearing Aid or other hearing appliance used: No; -Speech Clarity: Unclear Speech: Slurred or mumbled words; -Ability to express ideas and wants, consider both verbal and nonverbal expression: Usually understood. Difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to understand others, understanding verbal content, however able (with hearing aid or device if used): Understands. Clear comprehension; -Ability to see in adequate light: Moderately impaired. Limited Vision, not able to see newspaper headlines but scan identify objects; -Corrective Lenses: No; -How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy? Never; -Psychosis: None; -Behavioral Symptoms: --Physical behavioral symptoms directed towards others: Behavior not exhibited; --Verbal behavioral symptoms directed towards others: Behavior not exhibited; --Other behavioral symptoms not directed toward others: Behavior not exhibited; -Rejection of Care: Behavior not exhibited; -Wandering: Behavior not exhibited. Review of the resident's current care plan, showed: -Focus: At risk for behavior problems related to schizophrenia and bipolar disorder; -Goal: Ensure protective oversight is provided through next review; -Interventions: Anticipate and meet the resident's needs, caregivers to provide opportunity for positive interaction, attention, stop and talk with him/her as passing by, if reasonable discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable; -Focus: At risk for a deficit in communication problem related to dx of legal blindness and hearing loss. Has decreased sensory perception. Is best at communicating face to face and has a Russian ethnicity. He/She uses hearing aides and glasses; -Goal: Will be able to make basic needs known on a daily basis through the review date; -Interventions: Be conscious of resident position when in groups, activities, dining room to promote proper communication with others; Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed; Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. Review of DA A's Abuse and Neglect Policy Acknowledgment (located in his/her personnel file), showed: -The statement: I am acknowledging that I have received, read, understand and had the opportunity to ask questions concerning the Abuse and Neglect policy; -Signed by DA A; -Dated: 4/23/24, five days prior to the incident. Review of the video evidence, dated 4/28/24, showed: -The resident was noted in the dining room walking towards the kitchen area and DA A walked to stand in front of Resident #101; -At time stamp 00:09, DA A grabbed for the resident using his/her right hand, the resident grabbed DA A's right hand with his/her left hand; -At time stamp 00:11, DA A grabbed towards resident's right shoulder/neck area with his/her left hand, then also moved his/her right hand to the resident's throat with the resident still trying to hold the right hand back; -At time stamp 00:15, the resident was able to step back and push DA A's hands off his throat; -At time stamp 00:16, FT B stepped in between DA A and the resident. FT B did not remove the resident from the situation or request DA A to move away from the resident; -At time stamp 00:25, FT B turned his back on DA A and the resident and started walking away; -At time stamp 00:26, CMT D was approaching at this time. DA A started stepping forwards again towards the resident; -At time stamp 00:28, CMT D put his/her arm out and blocked DA A from moving towards the resident and motioned for him to walk away and started speaking with the resident; -At time stamp 00:32, DA A was no longer visible in the video. FT B was walking towards the direction of DA A; -At time stamp 00:34, FT B stood between the resident and the direction DA A walked; -At time stamp 00:49, CMT D was still standing in the same place in the dining room talking with the resident, and the video ended. Review of DA A's Individual Employee Time Cards showed he/she clocked out at 8:00 P.M. Review of the resident's electronic progress notes for the months of April 2024 and May 2024, showed: -4/28/24 at 8:00 P.M.: Resident alert and up ad lib. Resident continues monitoring for meal consumption. Resident in dining room for dinner. Consumed 100% dinner. Staff will continue to monitor for protective oversight; -4/29/24 at 7:18 A.M.: Late Entry: Resident stated on 4/28/24 staff member put (his/her) hands around my neck and choked me. Head to toe skin assessment. No apparent injury noted. No bruising or discoloration noted. Placed call to the resident's physician and guardian and made them aware of incident. Administrator, Director of Nurses (DON) and Social Service aware. No complaints of pain or discomfort at the present time. -Skin assessment on 4/29/24 at 10:25 A.M.: Skin warm and dry, skin color within normal limits and turgor is normal; -4/29/24 at 6:20 P.M.: Continues on observation. No acute distress noted. Denies pain or discomfort; -4/30/24 at 7:22 A.M.: Continues on observation. No acute distress noted. Denies pain or discomfort; -4/30/24 at 8:53 A.M.: Administrator spoke with the guardian regarding the staff to resident incident that occurred on 4/28/24. The guardian was happy to hear how the facility handled the situation. The guardian was very understanding and empathetic; -4/30/24 at 9:06 A.M.: Law enforcement was notified of the staff to resident incident that occurred on 4/28/24; -4/30/24 at 9:53 A.M.: Resident's guardian notified Social Services Director (SSD) of an assault on resident by staff member. Allegation was investigated and law enforcement was called in. SSD spoke with resident on how he/she was feeling; resident appeared to be doing fine and stated he/she was doing ok. SSD will follow up with resident over the next 72 hours; -4/30/24 at 12:44 P.M.: Resident remains on close monitoring at this time. Resident is up ad lib to meals and group. No change in level of functioning. Resident able to voice feelings and concerns with staff. Resident denies pain or discomfort at this time. Neurologic (neuro, refers to a person's nervous system function including mental status, coordination, ability to walk, and how well the muscles, sensory systems, and deep tendon reflexes ) checks (an assessment tool to determine a patient's neurologic function) remains in place. Staff will continue to monitor for protective oversight; -4/30/24 at 11:25 P.M.: Resident alert and up ad lib. Resident continues monitoring for altercation. Neuro checks completed and within normal limits for resident's baseline. Resident not noted to have any increased agitation or aggression this shift. Denies pain. Staff will continue to monitor for protective oversight; Review of the facility's Administrator/Registered Nurse (RN) Investigation dated 4/30/24, showed: -Date of incident: 4/29/24; -Type of incident: Alleged abuse; -Person(s) involved in the incident: --Resident #101; --DA A; -Witnesses: --FT B; --CNA C; --CMT D; -Statements received from witnesses: Yes; -Statement received from affected person(s): Yes; -Supportive intervention documentation attached: Yes; -Guardian notified of the incident: Yes; -By whom: Social worker; -Date and time notified: 4/29/24 at 2:00 P.M.; -Physician notified of incident: Yes; -By who: RCC; -Date and time: 4/29/24 at 2:30 P.M.; -Documentation of incident completed: Yes; -By who: RCC; -Disciplinary action required: Yes; -Narrative Note: the resident went to the kitchen door attempting to get coffee and was unsuccessful as DA A sent him/her away from the door. The resident walked to the back of the dining room then came back up to the dietary door where the alleged abuser was standing. The resident walked up asking DA A for coffee again when DA A started to take a stance with the resident, causing the resident to move his/her hands towards DA A. DA A then attempted to grab the resident in the neck area. Another resident was standing there and he/she was able to get the resident to move back from DA A. CMT D walked into the dining room and noticed that DA A was holding the resident's arms. CMT D then rushed up to see what was going on and officially removed the resident away from DA A. CMT D began to question DA A and was told that the resident wanted coffee and was told that there was none left, DA A added that the resident then came back trying to gain entrance into the kitchen so DA A was attempting to stop the resident. CMT D did not see DA A's hands around the resident's neck. CMT D simply thought it was a misunderstanding. CMT D also took the time to educate DA A, who is a new worker and had been working in the facility for maybe a week. The resident's sibling actually called the Social Worker on 4/29/24, to ensure that the facility knew what had occurred. We then started a full investigation. Head to toe assessment done on the resident showed no injuries; -Conclusion/Outcome of the Investigation: All other residents were interviewed to ensure they are safe and that they felt safe. Abuse and neglect in-service also began again, in light of what happened. We also interviewed staff that may have seen this event and carried out disciplinary actions. I went to assess the resident again for any physical or mental wound. He/She appears to be ok. None noted at this time. The resident is VERY hard of hearing which poses a problem as well. If he/she can't hear to understand and in this case the staff was new, it can cause an issue for the resident and staff; -Care plan changes and interventions: Facility will follow up on the resident's hearing aides to see why he/she doesn't have them and get them. Will speak to his/her family as well; -Employee witness statement obtained; -The care plan must reflect new interventions as a result of this behavior emergency crisis: See about why he/she is not wearing hearing aids. -Signed by the Administrator and DON, dated 5/1/24. Review of DA A's Employee/Witness statement, dated 4/29/24, showed: -Resident 101 walked up to DA A in the kitchen door asking for coffee. He/She told the resident it was empty. In that moment, the resident demanded DA A to move out of the way. When he/she didn't move, the resident grabbed his/her arm with strength force. DA A grabbed the resident's neck as protecting himself/herself. DA A heard a co-worker call Code Green (a call for emergency assistance related to a physical encounter in progress), but he/she did not see the people coming to help. But the situation did calm down and they took the resident to a different area as he/she went to the smoking room. Review of CMT D's Employee/Witness Statement, dated 4/29/24, showed: -CMT D was on his/her way to the dining room to get some ice to pass medications. While there a resident called Code Green. Upon arrival, he/she saw the staff holding the resident by the arm. CMT D rushed over to stop then and asked the staff what happened. DA A told CMT D that the resident wanted some more coffee. DA A told the resident that there was no more coffee but the resident did not believe DA A said the resident tried to get into the kitchen. CMT D took the resident to the 600 hall (a locked unit) to cool off because the resident was angry. Review of FT B's Employee/Witness Statement, dated 4/30/24, showed: -All FT B saw was DA A and the resident having a problem. the resident was trying to get in the back of the kitchen because he/she was upset because there wasn't any more coffee. So, DA A was standing there and he/she grabbed the resident's arm. Review of CNA C's Employee/Witness Statement, dated 4/30/24, showed: -On Sunday, May 28 (DHSS verified with writer this was supposed to read April, not May), while smoking the residents, he/she heard yelling and looked up. CNA C saw DA A had a hold of the resident, so he/she yelled a Code Green. A couple of other staff came to intervene and separated the two. He/she did not hear what started the incident because he/she was busy smoking population. Review of the resident's record, showed: -5/1/24 at 11:21 A.M.: Late Entry: Psychosocial Post-Incident Impact Note: the resident was involved in an incident as the victim. --the resident was asked do you feel safe? Yes --the resident was asked do you have any after effects from incident? No --the resident was asked do you have any other needs or items that you would like addressed? No; -5/1/24 at 1:54 P.M.: Remains on observation. -5/1/24 at 10:15 P.M.: Last day observation no concerns were voiced; -5/2/24 at 10:52 P.M.: Staff will continue to monitor for protective oversight. During an interview on 5/2/24 at 1:45 P.M., the resident said: -He/She is very hard of hearing; -He/She was legally blind and could not read a written question; -DA A grabbed him/her around the throat for asking for coffee; -He/She was not hurt at the time, just surprised; -He/She knows one thing, he/she will never ask for coffee again if this is what is going to happen; -He/She feels safe in the facility since DA A no longer works at the facility. During an interview on 5/2/24 at 2:35 P.M., DA A said: -One of the residents walked up to him/her by the kitchen door requesting coffee; -DA A told the resident there was no more coffee; -The resident told DA A to move out of his/her way. The resident was going to try to go in the kitchen; -DA A told the resident no; -The resident raised his/her arms and then DA A raised his/her arms; -DA A then grabbed the resident's neck and was in defense mode; -He/She had not been properly trained. He/She had orientation and started the next day in the kitchen; -In orientation, he/she learned if a resident attacks you, you can defend yourself; -They didn't teach to ask for help or verbally de-escalate. They taught us nothing and then he/she started the next day; -He/She was told to tell residents who ask that there was no more coffee; -The kitchen was being closed as it was almost 8:00 P.M.; -DA A doesn't make coffee and was told not to by the Supervisor; -He/She said the residents get coffee at breakfast, lunch and dinner; -The resident showed aggressiveness by raising his/her arms; -He/She resident grabbed DA A's arm and he/she was showing strength; -DA A showed his/her defense move and grabbed the resident's neck; -When asked if they discussed abuse -verbal and physical at orientation, he/she said they didn't get into any details; -If he/she had proper training he/she wouldn't be going through this; -He/She was never told the proper protocol; -When asked if he/she would consider his/her actions physically abusive, he/she said you can't skip to that part when asking about his/her actions. This was a reaction to the resident showing his/her physical strength. During an interview on 5/2/24 at 3:23 P.M., CMT D said: -He/She was on the CMT cart and walking to the kitchen for ice when he/she heard someone yell out Code Green; -CMT D noted DA A holding the resident by the throat; -CMT D ran over and told DA A You can't hold (him/her) like that; -The resident was a little angry and upset, so CMT D took him/her onto 600 unit (locked unit) to cool off; -The resident said he/she asked DA A for coffee and DA A refused to give him/her any coffee; -DA A told CMT D the resident asked for coffee, there wasn't any left and he/she told this to the resident. The resident still kept trying to get past DA A into the kitchen. DA A said he/she grabbed the resident in self-defense; -CMT D did not report the incident to Administration because he/she saw Nurse E in the dining room performing blood sugar checks when he/she entered the dining room; -CMT D assumed Nurse E would write up the incident and notify Administration when Nurse E finished blood sugar checks. During an interview on 5/2/24 at 3:34 P.M., CNA C said: -He/She stood in the doorway of the smoking room, when he/she heard a commotion coming from the dining room. He/She looked up and saw DA A with his/her hands on the resident; -He/She could not tell where DA A had a hold of the resident; -He/She yelled a Code Green; -He/She saw two staff members intervene. He/She did not intervene because he/she could not leave the residents unattended while smoking; -DA A left the dining room after staff intervened and entered the smoking room with smoking residents; -CMT D took the resident away from the dining room; -He/She did not talk with DA A when he/she entered the smoking room and did not attempt to stop him/her from entering the smoking room; -He/She does not know how long DA A stayed in the smoking room with the residents; -He/She did not report the incident because he/she thought the staff who intervened would tell the nurse and report it. During an interview on 5/2/24 at 3:50 P.M., FT B said: -He/She stood in the dining room and witnessed the altercation; -The resident was trying to get coffee and go past DA A into the kitchen; -The resident grabbed DA A's arm and DA A had his/her hands on the resident's throat when FT B went to intervene; -FT B got between them and separated them; -CMT D came in then to assist, but he/she did not see the incident; -CNA C yelled out a Code Green from the smoking room; -FT B did not have a walkie talkie on him/her to make a Code Green announcement; -CMT D took the resident to his/her room and DA A went into the smoking room; -There were residents in the smoking room; -He/She did not stop DA A from entering the smoking room; -FT B did not ask DA A why he/she grabbed the resident by the throat and DA A did not offer a reason; -It was not acceptable for staff to grab a resident by the throat; -He/She did not report the incident because someone else called the Code Green, so he/she wasn't aware that he/she needed to report it; -He/She assumed the person who yelled Code Green would report it and it would be on video and they would question him/her about it; -He/She received abuse and neglect in-servicing earlier in April. During an interview on 5/3/24 at 10:39 A.M., RN E said: -He/She was in the dining room performing blood sugar levels at the time of the incident; -He/She was not sure what time this occurred; -He/She did not witness the incident; -The dining room was loud and he/she did not hear the incident or the staff yell out Code Green; -No one reported the incident to him/her; -He/She did not assess the resident after the incident; -To his/her knowledge, the other nurse on duty, Nurse F, was not notified and did not assess the resident either; -Staff should have notified him/her or Nurse F of the incident; -If he/she was notified, he/she would have pulled DA A off the floor immediately and sent him/her home; -He/She would not have allowed DA A to enter the smoking room with other residents due to the potential for additional resident harm; -He/She would have performed a head to toe assessment on the resident had he/she been notified; -He/She would have then notified administration, the resident's physician and family; -He/She did not work the next day and did not know about the incident until the DON called on 4/29/24 to ask if he/she was aware of the situation and what actions were taken, if any. During an interview on 5/3/24 at 10:48 A.M., the DON said: -He/She was not aware of the incident until the resident's family member called the SW and the SW notified him/her; -The Administrator was already on his/her way into the facility at the time of notification; -The facility began the investigation immediately; -He/She assessed the resident and no injuries were noted; -He/She and the Administrator watched the video and it was evident what happened, so DA A was called and terminated immediately; -Staff statements were taken and resident interviews were performed; -The resident's physician was notified and his/her family member was called back with an update; -The police were called and DA A was arrested for assault; -Staff had been previously in-serviced on abuse/neglect and when to report on 4/17/23, so they should have known to report it; -It was not acceptable for DA A to stay in the facility after the incident or to enter the smoking area with other residents present; -It is not acceptable for staff to place their hands on a resident's throat under any circumstances; -DA A was recently hired and educated on the Abuse and Neglect policy during orientation. During an interview of 5/2/24 at 12:30 P.M., the Administrator said: -The incident occurred on Sunday 4/28/24, but was not sure what time; -The facility administration was unaware of the incident until the resident's sibling called and notified them of the incident; -DA A was new to the facility and had only worked a few days at the time of the incident; -Staff was present when the incident occurred and did not report the incident to administration; -Staff present did receive disciplinary action, a final warning due to the severity of the incident; -There was video of the incident; -DA A was terminated immediately after viewing the video; -The police were called and DA A was charged with simple assault and arrested. At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the 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 to be taken to address Class I violation(s). MO00235393 MO00235415

This deficiency is uncorrected. Please see the Statement of Deficiencies dated 03/19/24 for previous examples. Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents was free from physical abuse (Resident #101). The resident is legally blind and hard of hearing. On 4/28/24 at approximately 7:30 P.M., the resident asked Dietary Aide (DA) A for coffee, and DA A said the resident could not have coffee because the kitchen was almost closed. During the conversation, the resident put his/her hands up while talking. DA A grabbed the resident's wrists and then grabbed the resident's throat. Floor Technician (FT) B intervened and separated DA A and Resident #101. Certified Nurse's Aide (CNA) C was in the doorway to the smoking room and yelled out Code [NAME] (behavioral emergency to notify additional staff). Certified Medication Technician (CMT) D heard the Code [NAME] and brought the resident to his/her room. After the incident, DA A went to the smoking room with other residents. DA A remained in the facility and clocked out at his/her regular time at 8:00 P.M. The facility staff failed to ensure the safety of the other residents on the evening of the incident. The census was 146. The administrator was informed on 5/3/24 of an Immediate Jeopardy (IJ), which began on 4/28/24. The IJ was removed on 5/3/24 as confirmed by surveyor on-site verification. Review of the facility's Abuse and Neglect Policy, dated revised 1/5/23, showed: -Purpose: To outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, and to define terms of types of abuse/neglect and misappropriation of funds and property. To ensure immediate reporting of all abuse allegations to the Administrator or designee and the Director of Nursing or designee and outside persons or agencies. To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed; -Physical Abuse - Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes handling a resident with any more force than is reasonable for a resident's proper control, treatment or management. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Physical abuse also includes corporal punishment, which is physical punishment used as a means to correct or control behavior; -Mistreatment, neglect, or abuse of residents is prohibited by this Facility. This includes physical abuse, sexual abuse, verbal abuse, mental abuse and involuntary seclusion; -This Facility is committed to protecting our residents from abuse by anyone including, but not limited to, Facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals; -This Facility does not condone resident abuse by anyone, including employees, physicians, consultants, volunteers, and staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. It is the responsibility of employees, Facility consultants, attending physicians, family members, and visitors etc., to promptly report any incident or suspected incident of abuse/neglect/misappropriation of funds to Facility management immediately. If such incidents occur after hours the Administrator or designee and Director of Nursing or designee will be notified at home or by cell phone and informed of any such incident; -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices, such as: --Dealing with aggressive residents; --Reporting allegations with fear of reprisal; --Recognizing signs of burnout, frustrations or stress that may lead to abuse; --The definition that constitutes abuse, neglect and misappropriation of resident property; -During orientation of new employees, the facility will cover at least the following topics: --Sensitivity to resident rights and resident needs and what constitutes physical, sexual, verbal and mental abuse; --Staff obligations to prevent and report abuse; --How to assess, prevent and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff; --How to recognize and deal with burnout, frustration and stress that may lead to inappropriate responses or abusive reactions to residents; --Reporting abuse and their obligations under law when receiving an allegation of abuse; -On an annual basis, staff will receive a review of the above topics; -Upon learning of the report of abuse or neglect, the Administrator shall initiate an incident investigation. The nursing staff is additionally responsible for reporting and investigating the appearance of bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the Administrator or designee; -The Facility will take steps to prevent mistreatment while the investigation is underway: -Employees of this Facility who have been accused of mistreatment will be immediately removed from contact with any residents and must leave the Facility pending the results of the investigation and review by the Administrator; -Employees accused of possible mistreatment shall not complete the shift and will immediately be sent home. Review of Resident #101's admission record showed the resident admitted to the facility on [DATE] with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), hearing loss, legal blindness and dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/29/24, showed: -Cognitively intact; -Ability to hear (with hearing aid or hearing appliances if normally used): Adequate. No difficulty in normal conversation, social interaction, listening to TV; -Hearing Aid or other hearing appliance used: No; -Speech Clarity: Unclear Speech: Slurred or mumbled words; -Ability to express ideas and wants, consider both verbal and nonverbal expression: Usually understood. Difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to understand others, understanding verbal content, however able (with hearing aid or device if used): Understands. Clear comprehension; -Ability to see in adequate light: Moderately impaired. Limited Vision, not able to see newspaper headlines but scan identify objects; -Corrective Lenses: No; -How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy? Never; -Psychosis: None; -Behavioral Symptoms: --Physical behavioral symptoms directed towards others: Behavior not exhibited; --Verbal behavioral symptoms directed towards others: Behavior not exhibited; --Other behavioral symptoms not directed toward others: Behavior not exhibited; -Rejection of Care: Behavior not exhibited; -Wandering: Behavior not exhibited. Review of the resident's current care plan, showed: -Focus: At risk for behavior problems related to schizophrenia and bipolar disorder; -Goal: Ensure protective oversight is provided through next review; -Interventions: Anticipate and meet the resident's needs, caregivers to provide opportunity for positive interaction, attention, stop and talk with him/her as passing by, if reasonable discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable; -Focus: At risk for a deficit in communication problem related to dx of legal blindness and hearing loss. Has decreased sensory perception. Is best at communicating face to face and has a Russian ethnicity. He/She uses hearing aides and glasses; -Goal: Will be able to make basic needs known on a daily basis through the review date; -Interventions: Be conscious of resident position when in groups, activities, dining room to promote proper communication with others; Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed; Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. Review of DA A's Abuse and Neglect Policy Acknowledgment (located in his/her personnel file), showed: -The statement: I am acknowledging that I have received, read, understand and had the opportunity to ask questions concerning the Abuse and Neglect policy; -Signed by DA A; -Dated: 4/23/24, five days prior to the incident. Review of the video evidence, dated 4/28/24, showed: -The resident was noted in the dining room walking towards the kitchen area and DA A walked to stand in front of Resident #101; -At time stamp 00:09, DA A grabbed for the resident using his/her right hand, the resident grabbed DA A's right hand with his/her left hand; -At time stamp 00:11, DA A grabbed towards resident's right shoulder/neck area with his/her left hand, then also moved his/her right hand to the resident's throat with the resident still trying to hold the right hand back; -At time stamp 00:15, the resident was able to step back and push DA A's hands off his throat; -At time stamp 00:16, FT B stepped in between DA A and the resident. FT B did not remove the resident from the situation or request DA A to move away from the resident; -At time stamp 00:25, FT B turned his back on DA A and the resident and started walking away; -At time stamp 00:26, CMT D was approaching at this time. DA A started stepping forwards again towards the resident; -At time stamp 00:28, CMT D put his/her arm out and blocked DA A from moving towards the resident and motioned for him to walk away and started speaking with the resident; -At time stamp 00:32, DA A was no longer visible in the video. FT B was walking towards the direction of DA A; -At time stamp 00:34, FT B stood between the resident and the direction DA A walked; -At time stamp 00:49, CMT D was still standing in the same place in the dining room talking with the resident, and the video ended. Review of DA A's Individual Employee Time Cards showed he/she clocked out at 8:00 P.M. Review of the resident's electronic progress notes for the months of April 2024 and May 2024, showed: -4/28/24 at 8:00 P.M.: Resident alert and up ad lib. Resident continues monitoring for meal consumption. Resident in dining room for dinner. Consumed 100% dinner. Staff will continue to monitor for protective oversight; -4/29/24 at 7:18 A.M.: Late Entry: Resident stated on 4/28/24 staff member put (his/her) hands around my neck and choked me. Head to toe skin assessment. No apparent injury noted. No bruising or discoloration noted. Placed call to the resident's physician and guardian and made them aware of incident. Administrator, Director of Nurses (DON) and Social Service aware. No complaints of pain or discomfort at the present time. -Skin assessment on 4/29/24 at 10:25 A.M.: Skin warm and dry, skin color within normal limits and turgor is normal; -4/29/24 at 6:20 P.M.: Continues on observation. No acute distress noted. Denies pain or discomfort; -4/30/24 at 7:22 A.M.: Continues on observation. No acute distress noted. Denies pain or discomfort; -4/30/24 at 8:53 A.M.: Administrator spoke with the guardian regarding the staff to resident incident that occurred on 4/28/24. The guardian was happy to hear how the facility handled the situation. The guardian was very understanding and empathetic; -4/30/24 at 9:06 A.M.: Law enforcement was notified of the staff to resident incident that occurred on 4/28/24; -4/30/24 at 9:53 A.M.: Resident's guardian notified Social Services Director (SSD) of an assault on resident by staff member. Allegation was investigated and law enforcement was called in. SSD spoke with resident on how he/she was feeling; resident appeared to be doing fine and stated he/she was doing ok. SSD will follow up with resident over the next 72 hours; -4/30/24 at 12:44 P.M.: Resident remains on close monitoring at this time. Resident is up ad lib to meals and group. No change in level of functioning. Resident able to voice feelings and concerns with staff. Resident denies pain or discomfort at this time. Neurologic (neuro, refers to a person's nervous system function including mental status, coordination, ability to walk, and how well the muscles, sensory systems, and deep tendon reflexes ) checks (an assessment tool to determine a patient's neurologic function) remains in place. Staff will continue to monitor for protective oversight; -4/30/24 at 11:25 P.M.: Resident alert and up ad lib. Resident continues monitoring for altercation. Neuro checks completed and within normal limits for resident's baseline. Resident not noted to have any increased agitation or aggression this shift. Denies pain. Staff will continue to monitor for protective oversight; Review of the facility's Administrator/Registered Nurse (RN) Investigation dated 4/30/24, showed: -Date of incident: 4/29/24; -Type of incident: Alleged abuse; -Person(s) involved in the incident: --Resident #101; --DA A; -Witnesses: --FT B; --CNA C; --CMT D; -Statements received from witnesses: Yes; -Statement received from affected person(s): Yes; -Supportive intervention documentation attached: Yes; -Guardian notified of the incident: Yes; -By whom: Social worker; -Date and time notified: 4/29/24 at 2:00 P.M.; -Physician notified of incident: Yes; -By who: RCC; -Date and time: 4/29/24 at 2:30 P.M.; -Documentation of incident completed: Yes; -By who: RCC; -Disciplinary action required: Yes; -Narrative Note: the resident went to the kitchen door attempting to get coffee and was unsuccessful as DA A sent him/her away from the door. The resident walked to the back of the dining room then came back up to the dietary door where the alleged abuser was standing. The resident walked up asking DA A for coffee again when DA A started to take a stance with the resident, causing the resident to move his/her hands towards DA A. DA A then attempted to grab the resident in the neck area. Another resident was standing there and he/she was able to get the resident to move back from DA A. CMT D walked into the dining room and noticed that DA A was holding the resident's arms. CMT D then rushed up to see what was going on and officially removed the resident away from DA A. CMT D began to question DA A and was told that the resident wanted coffee and was told that there was none left, DA A added that the resident then came back trying to gain entrance into the kitchen so DA A was attempting to stop the resident. CMT D did not see DA A's hands around the resident's neck. CMT D simply thought it was a misunderstanding. CMT D also took the time to educate DA A, who is a new worker and had been working in the facility for maybe a week. The resident's sibling actually called the Social Worker on 4/29/24, to ensure that the facility knew what had occurred. We then started a full investigation. Head to toe assessment done on the resident showed no injuries; -Conclusion/Outcome of the Investigation: All other residents were interviewed to ensure they are safe and that they felt safe. Abuse and neglect in-service also began again, in light of what happened. We also interviewed staff that may have seen this event and carried out disciplinary actions. I went to assess the resident again for any physical or mental wound. He/She appears to be ok. None noted at this time. The resident is VERY hard of hearing which poses a problem as well. If he/she can't hear to understand and in this case the staff was new, it can cause an issue for the resident and staff; -Care plan changes and interventions: Facility will follow up on the resident's hearing aides to see why he/she doesn't have them and get them. Will speak to his/her family as well; -Employee witness statement obtained; -The care plan must reflect new interventions as a result of this behavior emergency crisis: See about why he/she is not wearing hearing aids. -Signed by the Administrator and DON, dated 5/1/24. Review of DA A's Employee/Witness statement, dated 4/29/24, showed: -Resident 101 walked up to DA A in the kitchen door asking for coffee. He/She told the resident it was empty. In that moment, the resident demanded DA A to move out of the way. When he/she didn't move, the resident grabbed his/her arm with strength force. DA A grabbed the resident's neck as protecting himself/herself. DA A heard a co-worker call Code [NAME] (a call for emergency assistance related to a physical encounter in progress), but he/she did not see the people coming to help. But the situation did calm down and they took the resident to a different area as he/she went to the smoking room. Review of CMT D's Employee/Witness Statement, dated 4/29/24, showed: -CMT D was on his/her way to the dining room to get some ice to pass medications. While there a resident called Code Green. Upon arrival, he/she saw the staff holding the resident by the arm. CMT D rushed over to stop then and asked the staff what happened. DA A told CMT D that the resident wanted some more coffee. DA A told the resident that there was no more coffee but the resident did not believe DA A said the resident tried to get into the kitchen. CMT D took the resident to the 600 hall (a locked unit) to cool off because the resident was angry. Review of FT B's Employee/Witness Statement, dated 4/30/24, showed: -All FT B saw was DA A and the resident having a problem. the resident was trying to get in the back of the kitchen because he/she was upset because there wasn't any more coffee. So, DA A was standing there and he/she grabbed the resident's arm. Review of CNA C's Employee/Witness Statement, dated 4/30/24, showed: -On Sunday, May 28 (DHSS verified with writer this was supposed to read April, not May), while smoking the residents, he/she heard yelling and looked up. CNA C saw DA A had a hold of the resident, so he/she yelled a Code Green. A couple of other staff came to intervene and separated the two. He/she did not hear what started the incident because he/she was busy smoking population. Review of the resident's record, showed: -5/1/24 at 11:21 A.M.: Late Entry: Psychosocial Post-Incident Impact Note: the resident was involved in an incident as the victim. --the resident was asked do you feel safe? Yes --the resident was asked do you have any after effects from incident? No --the resident was asked do you have any other needs or items that you would like addressed? No; -5/1/24 at 1:54 P.M.: Remains on observation. -5/1/24 at 10:15 P.M.: Last day observation no concerns were voiced; -5/2/24 at 10:52 P.M.: Staff will continue to monitor for protective oversight. During an interview on 5/2/24 at 1:45 P.M., the resident said: -He/She is very hard of hearing; -He/She was legally blind and could not read a written question; -DA A grabbed him/her around the throat for asking for coffee; -He/She was not hurt at the time, just surprised; -He/She knows one thing, he/she will never ask for coffee again if this is what is going to happen; -He/She feels safe in the facility since DA A no longer works at the facility. During an interview on 5/2/24 at 2:35 P.M., DA A said: -One of the residents walked up to him/her by the kitchen door requesting coffee; -DA A told the resident there was no more coffee; -The resident told DA A to move out of his/her way. The resident was going to try to go in the kitchen; -DA A told the resident no; -The resident raised his/her arms and then DA A raised his/her arms; -DA A then grabbed the resident's neck and was in defense mode; -He/She had not been properly trained. He/She had orientation and started the next day in the kitchen; -In orientation, he/she learned if a resident attacks you, you can defend yourself; -They didn't teach to ask for help or verbally de-escalate. They taught us nothing and then he/she started the next day; -He/She was told to tell residents who ask that there was no more coffee; -The kitchen was being closed as it was almost 8:00 P.M.; -DA A doesn't make coffee and was told not to by the Supervisor; -He/She said the residents get coffee at breakfast, lunch and dinner; -The resident showed aggressiveness by raising his/her arms; -He/She resident grabbed DA A's arm and he/she was showing strength; -DA A showed his/her defense move and grabbed the resident's neck; -When asked if they discussed abuse -verbal and physical at orientation, he/she said they didn't get into any details; -If he/she had proper training he/she wouldn't be going through this; -He/She was never told the proper protocol; -When asked if he/she would consider his/her actions physically abusive, he/she said you can't skip to that part when asking about his/her actions. This was a reaction to the resident showing his/her physical strength. During an interview on 5/2/24 at 3:23 P.M., CMT D said: -He/She was on the CMT cart and walking to the kitchen for ice when he/she heard someone yell out Code Green; -CMT D noted DA A holding the resident by the throat; -CMT D ran over and told DA A You can't hold (him/her) like that; -The resident was a little angry and upset, so CMT D took him/her onto 600 unit (locked unit) to cool off; -The resident said he/she asked DA A for coffee and DA A refused to give him/her any coffee; -DA A told CMT D the resident asked for coffee, there wasn't any left and he/she told this to the resident. The resident still kept trying to get past DA A into the kitchen. DA A said he/she grabbed the resident in self-defense; -CMT D did not report the incident to Administration because he/she saw Nurse E in the dining room performing blood sugar checks when he/she entered the dining room; -CMT D assumed Nurse E would write up the incident and notify Administration when Nurse E finished blood sugar checks. During an interview on 5/2/24 at 3:34 P.M., CNA C said: -He/She stood in the doorway of the smoking room, when he/she heard a commotion coming from the dining room. He/She looked up and saw DA A with his/her hands on the resident; -He/She could not tell where DA A had a hold of the resident; -He/She yelled a Code Green; -He/She saw two staff members intervene. He/She did not intervene because he/she could not leave the residents unattended while smoking; -DA A left the dining room after staff intervened and entered the smoking room with smoking residents; -CMT D took the resident away from the dining room; -He/She did not talk with DA A when he/she entered the smoking room and did not attempt to stop him/her from entering the smoking room; -He/She does not know how long DA A stayed in the smoking room with the residents; -He/She did not report the incident because he/she thought the staff who intervened would tell the nurse and report it. During an interview on 5/2/24 at 3:50 P.M., FT B said: -He/She stood in the dining room and witnessed the altercation; -The resident was trying to get coffee and go past DA A into the kitchen; -The resident grabbed DA A's arm and DA A had his/her hands on the resident's throat when FT B went to intervene; -FT B got between them and separated them; -CMT D came in then to assist, but he/she did not see the incident; -CNA C yelled out a Code [NAME] from the smoking room; -FT B did not have a walkie talkie on him/her to make a Code [NAME] announcement; -CMT D took the resident to his/her room and DA A went into the smoking room; -There were residents in the smoking room; -He/She did not stop DA A from entering the smoking room; -FT B did not ask DA A why he/she grabbed the resident by the throat and DA A did not offer a reason; -It was not acceptable for staff to grab a resident by the throat; -He/She did not report the incident because someone else called the Code Green, so he/she wasn't aware that he/she needed to report it; -He/She assumed the person who yelled Code [NAME] would report it and it would be on video and they would question him/her about it; -He/She received abuse and neglect in-servicing earlier in April. During an interview on 5/3/24 at 10:39 A.M., RN E said: -He/She was in the dining room performing blood sugar levels at the time of the incident; -He/She was not sure what time this occurred; -He/She did not witness the incident; -The dining room was loud and he/she did not hear the incident or the staff yell out Code Green; -No one reported the incident to him/her; -He/She did not assess the resident after the incident; -To his/her knowledge, the other nurse on duty, Nurse F, was not notified and did not assess the resident either; -Staff should have notified him/her or Nurse F of the incident; -If he/she was notified, he/she would have pulled DA A off the floor immediately and sent him/her home; -He/She would not have allowed DA A to enter the smoking room with other residents due to the potential for additional resident harm; -He/She would have performed a head to toe assessment on the resident had he/she been notified; -He/She would have then notified administration, the resident's physician and family; -He/She did not work the next day and did not know about the incident until the DON called on 4/29/24 to ask if he/she was aware of the situation and what actions were taken, if any. During an interview on 5/3/24 at 10:48 A.M., the DON said: -He/She was not aware of the incident until the resident's family member called the SW and the SW notified him/her; -The Administrator was already on his/her way into the facility at the time of notification; -The facility began the investigation immediately; -He/She assessed the resident and no injuries were noted; -He/She and the Administrator watched the video and it was evident what happened, so DA A was called and terminated immediately; -Staff statements were taken and resident interviews were performed; -The resident's physician was notified and his/her family member was called back with an update; -The police were called and DA A was arrested for assault; -Staff had been previously in-serviced on abuse/neglect and when to report on 4/17/23, so they should have known to report it; -It was not acceptable for DA A to stay in the facility after the incident or to enter the smoking area with other residents present; -It is not acceptable for staff to place their hands on a resident's throat under any circumstances; -DA A was recently hired and educated on the Abuse and Neglect policy during orientation. During an interview of 5/2/24 at 12:30 P.M., the Administrator said: -The incident occurred on Sunday 4/28/24, but was not sure what time; -The facility administration was unaware of the incident until the resident's sibling called and notified them of the incident; -DA A was new to the facility and had only worked a few days at the time of the incident; -Staff was present when the incident occurred and did not report the incident to administration; -Staff present did receive disciplinary action, a final warning due to the severity of the incident; -There was video of the incident; -DA A was terminated immediately after viewing the video; -The police were called and DA A was charged with simple assault and arrested. At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the on-site visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the 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 to be taken to address Class I violation(s). MO00235393 MO00235415

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #25) with a diagnosis of diabetes consistently received blood sugar level checks (measures the level of glucose (sugar) in the blood) and insulin administration. The facility failed to notify the physician of a blood sugar reading over 451, as ordered by the physician. On 12/23/23, the resident had a blood sugar level of 550. The resident was transferred to the hospital on 12/24/23 and diagnosed with diabetic ketoacidosis with coma associated with diabetes. The resident passed away on 12/25/23. Additionally, facility staff failed to clarify physician orders and obtain specific parameters for use when one resident (Resident #24) with a diagnosis of seizure disorder and a history of multiple seizures, was prescribed Valtoco (short-term treatment of seizure clusters), an as necessary (PRN) medication for seizures, and failed to consistently notify the resident's physician after every seizure. Last, staff failed to administer one resident's (Resident #23) medications as ordered and failed to document an explanation as to why the medications could not be administered on the medication administration record (MAR) and/or in the resident's progress notes. The sample size was 22. The census was 140. The administrator was informed on 2/5/24 of an Immediate Jeopardy (IJ), which began on 12/23/23. The IJ was removed on 2/6/24 as confirmed by surveyor on-site verification. Review of the facility's Blood Glucose Monitoring and Insulin Administration Policy, dated revised 6/29/23, showed: -Affected personnel: Registered Nurses (RN), Licensed Practical Nurses (LPN) and Certified Medication Technicians (CMT); -Purpose: To define accurate procedures to be followed when checking a blood sugar. To identify what measures will be taken in the event that a blood sugar falls out of the defined therapeutic range; -Procedure: If the resident's blood sugar is over 400, the physician will be notified by the charge nurse and orders will be followed. 1. Review of Resident #25's Admission Record, showed the resident was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic, metabolic disease characterized by elevated levels of blood glucose (blood sugar)). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/10/23, showed: -Cognitively intact; -Had a diagnosis of diabetes; -Received insulin injections. Review of the resident's care plan, showed: -Focus: At risk for alteration in health related to diabetes. Resident is on a regular low concentrated sweets diet (LCS, reduced carbohydrate diet) revised on 8/12/22; -Goal: The resident will have no complications related to diabetes through the review date, initiated on 12/11/21; -Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, initiated 12/11/21. Review of the resident's December 2023 Physician's Order Summary, showed: -Check and record blood sugar four times a day for diabetes, dated 8/17/23; -Dexcom G7 Receiver Device (Continuous Blood Glucose System Receiver). Inject 1 application intramuscularly one time a day related to diabetes, dated 8/17/23; -Dexcom G7 Sensor Miscellaneous (Continuous Blood Glucose System Sensor). Inject 1 application intramuscularly one time a day related to diabetes, dated 8/17/23; -Insulin Aspart FlexPen Subcutaneous Solution Pen injector (a short-acting insulin used to control blood sugar levels in the blood), 100 units per milliliter (ml). Inject subcutaneously (under all the layers of the skin) three times a day, as per sliding scale: --If blood sugar level is 200 - 250 = administer 3 units; --251 - 300 = 5 units; --301 - 350 = 7 units; --351 - 400 = 9 units; --401 - 450 = 11 units; --Over 451, Contact Physician, dated 10/31/23; -Lantus SoloStar Subcutaneous Solution Pen-injector (Insulin Glargine - a long-acting insulin used to control blood sugar levels in the blood), 100 units per ml. Inject 10 units subcutaneously every morning and at bedtime related to diabetes, dated 12/17/23. Review of the resident's December 2023 Accu check and insulin administration record, showed: -Lantus SoloStar Subcutaneous Solution Pen-injector 100 units per milliliter, inject 10 units subcutaneously every morning and at bedtime related to diabetes, dated 12/17/23, blank and not marked as provided on 12/9/23 at 7:00 P.M., and 12/17/23 at 7:00 P.M.; -Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 units per milliliter, inject subcutaneously three times a day, as per sliding scale: --if blood sugar level is 200 - 250 = administer 3 units; --251 - 300 = 5 units; --301 - 350 = 7 units; --351 - 400 = 9 units; --401 - 450 = 11 units; --Over 451, contact physician; dated 10/31/23. Review of the resident's December 2023 Accu check and insulin administration record, showed: - on 12/13/23 at 6:00 P.M., facility staff did not document the resident's blood sugar level or if insulin injection was required; - on 12/17/23 at noon, facility staff did not document the resident's blood sugar level or if insulin injection was required; - on 12/19/23 at 6:00 P.M., facility staff did not document the resident's blood sugar level or if insulin injection was required. Review of the resident's Nursing Progress Notes, showed: -No documentation as to why there was no recorded administration of the regularly scheduled Lantus insulin on 12/9/23 at 7:00 P.M. and 12/17/23 at 7:00 P.M.; -No documentation to show why blood sugar level or administration of sliding scale insulin was not documented on 12/13/23 at 6:00 P.M., 12/17/23 at noon, and 12/19/23 at 6:00 P.M. Nurse Practitioner note date of service 12/21/23: --Blood sugar 426 on 12/21/23 at 11:55 A.M.; --Diagnoses: Brittle diabetes (hard to control) and Type 2 diabetes mellitus with hyperglycemia (spike in blood sugar levels); --Plan: patient is brittle diabetic. He/She is very sensitive to insulin. Medications reviewed. Last visit increased Lantus to 10 units BID (twice daily). Follow up routine visit and as needed; Review of the resident's December 2023 Accu check and insulin administration record, showed on 12/22/23 at 6:00 P.M., facility staff did not document the resident's blood sugar level or if insulin injection was required. Review of the resident's Nursing Progress Notes, showed no documentation to show why blood sugar level or administration of sliding scale insulin was not documented on 12/22/23 at 6:00 P.M Review of the resident's December 2023 Accu check and insulin administration record, showed on 12/23/23 at 6:00 P.M., facility staff documented a blood sugar level of 550. The record showed sliding scale insulin was not administered on 12/23/23 at 6:00 P.M., due ot vitals outside of parameters for administration.The record did not include documentation the physician was notified of the blood sugar level of 550 or if any new orders were received. Review of the resident's Nursing Progress Notes, showed: -No documentation the physician was notified of the blood sugar level of 550 or if any new orders were received on 12/23/23 at 6:00 P.M.; -On 12/24/23 at 4:15 A.M, while doing routine rounds, the resident was breathing rapidly and lips were really dry. Vital signs were obtained: -temperature 96.4 (normal range between 97 F (Fahrenheit) and 99 F); -pulse 101- 105 (normal range 60 to 100 beats per minute); -respirations 32-28 (normal range from 12 to 16 breaths per minute); -blood pressure 87/52 (normal pressure is systolic (top number) of less than 120 and diastolic (bottom number) of less than 80 (120/80)); -blood sugar read HI >600. The nurse applied oxygen at 2 L (liter) per nasal cannula (a device that gives you additional oxygen through the nose); -12/24/23 at 4:31 A.M, call placed to resident's physician and reached the on-call physician. Made aware of what's going on with resident. Ok to send out 911. Resident is his/her own responsible party; -12/24/23 at 4:37 A.M., call placed to 911; -12/24/23 at 4:45 A.M.: Ambulance arrived at facility at 4:45 A.M.; -12/24/23 at 5:05 A.M.: Resident exited building with ambulance via stretcher. Review of the resident's Hospital Records, showed: -emergency room notes: --Chief complaint: hyperglycemia (elevated blood sugar level); --Transfer to the emergency department by EMS due to hyperglycemia. EMS states the patient's blood glucose level has been reading in the 500's since 4:00 P.M. on 12/23/23. Upon arrival at the emergency department the patient was unresponsive to verbal stimuli. The patient does respond to painful stimuli. The patient is hypotensive (abnormally low blood pressure). The patient suddenly started vomiting and likely aspirated (inhaling saliva, food, liquid, vomit and even small foreign objects into the lungs). The patient has a history of diabetes and diabetic ketoacidosis (DKA - A serious diabetes complication where the body produces excess blood acids (ketones)); -Final diagnoses: --Aspiration pneumonia of both lungs; --Altered mental status; --Diabetic ketoacidosis with coma associated with diabetes; --Acute kidney injury. During an interview on 1/24/24 at 1:49 P.M., CMT Y said: -CMTs performed the accu checks and insulin administration; -The resident's blood sugar was taken before dinner and at bedtime; -His/Her blood sugar always ran high; -Every time his/her blood sugar would run low or high, he/she would notify the nurse and let the nurse make the final decision on if to contact the physician or not; -He/She did not know if the physician was notified on 12/23/23, but was sure it was out of range; -He/she always asked the nurse what to do before giving insulin; -He/she did not remember if the resident received any insulin on 12/23/23; -Looking at the administration record, he/she got the long-lasting insulin but not the sliding scale due to the nurse needing to contact the physician to get an order for the dose to be administered; -He/She did not remember who the nurse was but was sure he/she told the nurse. During an interview on 1/24/24 at 3:05 P.M., LPN X said: -He/She did not recall 12/23/23, and the resident's blood sugar being elevated; -The resident had a history of refusing insulin; -If the CMT had notified him/her of the elevated blood sugar he/she would have contacted the physician for new orders; -He/She would normally make a note in the resident's progress notes any time he/she would contact the physician; -There should never be a blank on the administration record, there should always be some kind of documentation; -He/She expected the CMT to notify him/her immediately if there is a blood sugar level out of range. During an interview on 1/23/24 at 1:17 P.M., LPN A said: -CMTs performed the accu checks and administer insulin; -If the CMT was not certified, then the nurse would do it; -The CMT should notify the nurse immediately if the blood sugar level was not in range; -A blood sugar level of 550 was out of range and the nurse should be notified immediately; -The nurse would then reach out to the physician and put any new orders in place; -The CMT could not hold insulin due to the blood sugar level being out of range; -The MAR should be signed out when any medication was administered. During an interview on 1/25/24 at 10:17 A.M., Nurse K said: -The nurse/CMT should always record the accu check level and insulin administration; -If a blood sugar level was not obtained or insulin not administered, the expectation was to mark why; -CMTs were responsible for obtaining blood sugar levels and administering insulin; -He/She expected CMTs to notify him/her immediately if a blood sugar level was out of range; -A blood sugar level of 550 was out of range and needed to be called to the physician for new orders; -Any physician contact or new orders should be documented in the resident's chart. If a resident had a blood sugar out of parameters, he/she would call the physician, get an order for a one-time insulin administration, chart it, administer the insulin and the go back 20-30 minutes later to check on the resident, then document the follow up check. During an interview on 12/25/24 at 10:45 A.M., Nurse N said: -There should never be any blanks on the administration record, there were always options to pick from; -If it was blank, it was assumed it was not performed/administered; -Blood sugar levels and insulin administration were performed by the CMTs; -He/She expected the CMT to notify him/her immediately if a blood sugar level was out of range; -He/she would need to call the physician and get an order for insulin administration based on the blood sugar level; -A blood sugar level of 550 was out of range and required physician notification; -Any physician contact or new orders should always be documented in the resident's progress notes. During an interview on 1/25/24 at 12:57 P.M., the Director of Nursing (DON) said: -He/She expected staff to follow all physician orders; -He/She expected the MAR to be signed out when medication was administered, and that included blood sugar levels and insulin administration; -If there was a blank on the administration record, it meant the insulin was not administered; -The CMT must notify the nurse immediately if there was a blood sugar level out of range and the nurse would then notify the physician for new orders; -Any physician contact should be documented in the resident's progress notes; -Any new orders should be documented on the MAR and in the resident's progress notes; -If a blood sugar level was higher than the parameters, the nurse should go back and check on the resident in at least one hour and document the follow up; -He/She was going to change the process and give the blood sugar level checks and insulin administration tasks back to the nurses. 2. Review of Resident #24's annual MDS, dated [DATE], showed: -Makes Self Understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Understands, clear comprehension; -Diagnoses of seizure disorder or epilepsy (a brain disorder that causes recurring, unprovoked seizures), manic depression/bipolar disease (extreme mood swing) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's diagnoses located in the resident's medical record, showed a diagnosis of epileptic seizures related to external causes, not intractable (difficult to manage/alleviate, keep under control) with status epilepticus (a seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes). Review of the resident's care plan, initiated on 5/26/21 revised on 12/5/23, showed: -Focus: Risk for falls related to psychotropic drug (a drug that affects behavior, mood, thoughts, or perception) use, seizures, and head injury. Resident wears helmet for seizures. -Goal: Will be free from falls through review date; -Interventions: Anticipate and meet the resident's needs. To wear helmet while up. Review of the resident's physician's order sheet (POS), included the following orders: -Start Date: 9/11/23: Valtoco (diazepam (Valium)) benzodiazepine/anticonvulsant (a class of agents that work in the central nervous system) used to treat seizure clusters (seizures that occur in groups/clusters over a number of hours/days) 20 milligrams (mg) nasal liquid therapy pack 10 mg/0.1 milliliters (ml) (diazepam (anticonvulsant)), 0.2 ml in both nostrils every 4 hours PRN for seizures related to epileptic seizures. Discontinue Date: 12/14/23 (The order did not contain specific parameters for use- including if the medication should be administered after one seizure or more.); -Start Date: 12/17/23: Valtoco 20 mg dose nasal liquid therapy pack 10 mg)/0.1 ml, 0.2 ml in both nostrils every 4 hours PRN for seizure activity (The order did not contain specific parameters for use- including if the medication should be administered after one seizure or more.); -Start Date: 12/18/23: Lacosamide (Vimpat/anticonvulsant) 200 mg two times a day (BID) for anticonvulsant; -Start Date: 12/18/23: Valporic acid (used to treat various types of seizure disorders) 250 mg, two capsules (500 mg) BID anticonvulsant; -Start Date: 1/4/24: Levetiracetam (Keppra/anticonvulsant) 250 mg, five tablets (1250 mg) BID for epilepsy. Observation of the facility medication cart on 1/24/24 at 9:00 A.M., showed two boxes of Valtoco, each containing two spray devices. One box was sent to the facility from the pharmacy on 4/19/23, and contained one of two doses. The second box was sent to the facility from the pharmacy on 9/15/23, and contained two of two doses. Review of the Valtoco manufacturer's instructions found in the medication box received from the facility pharmacy, showed: -Indications for usage: Valtoco is a benzodiazepine indicated for the acute (sudden/immediate) treatment of intermittent, stereotypic episodes of frequent seizure activity (i.e. seizure clusters, acute repetitive seizures) that are distinct from a patient's usual seizure pattern in patients with epilepsy six years of age and older; -How to use Valtoco: Use Valtoco exactly as prescribed by your healthcare prescriber; -Valtoco is given in the nose only. Valtoco comes ready to use. If needed a second dose may be given at least 4 hours after the first dose. Do not give more than two doses to treat a seizure cluster; -Instructions for use: Safely secure the person. If the person appears to be having a seizure, gently help them to the floor and lay them on their side in a place where they cannot fall. The person can be on either their side or back to receive Valtoco. One dose equals two nasal spray devices. Each device sprays one time only. After giving Valtoco keep or move the person onto their side, facing you, so that you can watch them closely. According to the Valtoco manufacturer's website, seizure clusters, are episodes of frequent seizure activity, that occur 2 or more times within a 24-hour period. Review of the resident's December 2023 progress notes, showed: -12/8/23 at 5:32 P.M., documented by Nurse B: It was brought to my attention as nurse that this resident had a seizure lasting 1 minute. Resident lowered to the floor by nursing staff. Resident shows no signs or symptoms of loss of consciousness upon cessation of seizure. Resident transferred off the floor with the help of two staff members, transferred to a wheelchair and propelled to room by staff. Call placed to physician. May transport to hospital for further evaluation. Emergency Medical Services (EMS) arrived and transported resident to hospital. Resident responding and respirations even and unlabored. Resident remains stable upon departure; -No documentation Valtoco nasal spray was administered; -12/8/23 at 10:30 P.M.: Resident returned from hospital with no new orders. Vimpat and Keppra order faxed to pharmacy for physician order update. Resident remains stable upon return; -12/12/23 at 6:38 P.M.: Resident walking down the hall and yelled out. Resident then fell , but did not hit his/her head. Resident had seizure activity noted for about 1 minute. Resident then stood up. Resident responding verbally, and denies complaints of pain. Resident placed at nurse's station for protective oversight. Physician notified; -No documentation Valtoco nasal spray was administered; -12/13/23 at 11:32 P.M.: This writer heard resident yell out as he/she did before he/she had a seizure. Before staff could get to resident he/she fell forward hitting his/her face on the floor. Blood noted to right side of face, his/her mouth and chin. Upon assessing he/she was noted to be alert and responding appropriately. 911 was called and resident was sent to hospital for an evaluation. Physician was notified. Resident returned to facility with no new orders; -No documentation Valtoco nasal spray was administered; -12/14/23 at 12:19 P.M., documented by Nurse K: Code blue called. Resident found unresponsive and actively having a seizure. Resident was bleeding from right upper lip and left lower chin. Resident actively seized for 5 minutes. Oxygen saturation ranged from 93%-97% (normal range 95%-100%) until EMS arrived. Resident's eyes were not equal or accommodating to light during this period. Resident sent to hospital to receive care. Physician notified; -No documentation Valtoco nasal spray was administered; -12/17/23 at 2:34 P.M.: Resident started on Valporic Acid and stopped Briviact (anticonvulsant). Resident saw neurologist and suggested follow-up on 1/3/23; -12/29/23 at 6:00 A.M.: Resident observed to be displaying seizure activity while seated in a chair. Area made safe for resident for the duration of seizure activity lasting approximately 1 minute. When activity discontinued resident made comfortable and allowed to rest. Resident remains on intensive monitoring for protective oversight; -No documentation the resident's physician was notified; -No documentation Valtoco nasal spray was administered; -12/29/23 at 9:18 A.M., documented by Nurse K: Resident observed to be displaying seizure activity while sitting on bed. Area made safe for resident for the duration of seizure activity lasting approximately 1 minute. When activity discontinued resident made comfortable and allowed to rest. Resident remains on intensive monitoring for protective oversight. Morning medications given. No seizure activity since then; -No documentation the resident's physician was notified; -No documentation Valtoco nasal spray was administered. Review of the resident's MAR, dated 12/1/23 through 12/31/23, showed: -Valtoco 20 mg one spray in both nostrils every 4 hours as needed for seizures related to epileptic seizures; -No initials showed staff administered the Valtoco the entire month of December. Review of the resident's January 2024 progress notes, showed: -1/3/24 at 9:00 A.M.: Certified Nursing Assistant (CNA) approached nurse station at this time propelling resident in wheelchair making this nurse aware resident appeared to have had change in condition while sitting at dining room table during breakfast. Immediately assessed resident noted with head down, calling name with no response, noted rise and fall of chest with eyes open and spontaneous jerking noted. This nurse and CNA assisted resident to room and in bed safely as resident unable to sit up in wheelchair. During assessment resident noted to stare off and to begin spontaneous jerking with no response when nurse called out during assessment. Episode lasted about 30 seconds and resident began to respond when name called. Call to 911 to make aware of needed transport for emergent evaluation. Call placed to physician. Ambulance arrived to facility, resident remained awake with Registered Nurse Supervisor at bedside noting one seizure episode since this nurse left bedside. Resident left facility at that time via ambulance; -No documentation Valtoco nasal spray was administered; -1/3/24 at 9:30 A.M., documented by Nurse B: This nurse summoned to dining room regarding this resident, upon entering the dining room this nurse noted resident sitting in chair at table lethargic and responding little to verbal stimuli. This nurse asked resident how he/she felt, the resident dropped his/her head and did not respond. Rise and fall of chest noted evenly, resident's vital signs and oxygen saturation within normal limits. Call placed to physician with new orders to send to the hospital for further evaluation. EMS arrived and transferred resident to hospital for further evaluation. Resident had neurologist appointment scheduled this shift. Neurologist appointment postponed until a further day; -No documentation Valtoco nasal spray was administered; -1/3/24 at 5:33 P.M., documented by Nurse B: Resident returned from hospital with new orders to increase Keppra to 1,250 mg two times a day. MAR updated, resident remained stable upon return; -1/14/24 at 12:33 P.M., documented by Nurse K: Resident found in hallway having a seizure. Seizure lasted approximately three minutes. Helmet was in place at the time of the incident. No injury noted. Physician notified, said to monitor; -No documentation Valtoco nasal spray was administered; -1/15/24 at 1:03 A.M.: Resident had seizure activity this evening of inexact length of time. The seizure activity happened from the time the resident's roommate went to the dining room to heat ramen noodles for resident and returned back to the room. Upon entering this writer observed resident lying crosswise on bed, his/her body was stiff and rigid and he/she was making a loud snoring noise. This activity lasted approximately 1.5 minutes before seizure activity was over. This writer verified with CMT resident's medications required for seizure activity; -No documentation the resident's physician was notified. -No documentation Valtoco nasal spray was administered; -1/15/24 at 5:54 A.M.: While on 600 hall passing medication, was called to resident's room by his/her roommate saying the resident was having a seizure. Writer was two doors away and as writer got to the resident's room the seizure activity was stopping and resident was coming out of it. Seizure lasted 30-50 seconds (estimated). Will continue to monitor; -No documentation the physician was notified. -No documentation Valtoco nasal spray was administered; -1/15/24 at 9:25 A.M., documented by Nurse K: Resident found in hallway having a seizure at 7:00 A.M. medication pass. Seizure lasted approximately 3 minutes. Helmet was in place at time of incident. No injury noted. Physician notified and made aware of multiple occurrences since 1/14/24. Physician stated to monitor and the next occurrence send the resident out; -No documentation Valtoco nasal spray was administered; -1/15/24 at 11:13 A.M., documented by Nurse K: Diazapam was administered in left nostril during seizure. Review of the resident's medication signature sign out sheet, showed one dose of Valtoco was administered on 1/15/24. Review of the resident's MAR, dated 1/1/24 through 1/31/24, showed: -Valtoco 20 mg one spray in both nostrils every 4 hours as needed for seizures related to epileptic seizures; -No documentation staff administered the Valtoco on 1/15/24. During an interview on 1/24/24 at 8:32 A.M., Nurse K said he/she had worked at the facility for about three years. The resident had a lot of seizures. He/She had not given the resident Valtoco nasal spray. He/She did not think the resident had had an order for the medication too long. CMTs could not administer Valtoco, only nurses. The medication should have been given when the resident had a seizure. Nurse K had not received any previous directives to not administer the medication when the resident had a seizure. He/She was present on 1/15/23, when the resident had a seizure and Nurse B administered the medication. He/She did not know why Nurse B did not initial the medication had been administered as given on the MAR on 1/15/24. Nurses are responsible to initial a medication was administered on the MAR for any medication administered. During an interview on 1/24/24 at 8:57 A.M., Nurse B said he/she had worked at the facility for about four months. Only nurses were allowed to administer Valtoco. He/She administered the Valtoco on 1/15/24 because the resident had a seizure. Even though the resident had had several seizures, that was the first time he/she had administered the Valtoco. He/She was not sure why he/she had not administered the Valtoco prior to 1/15/24. If a medication was administered, it should be initialed as given. If a medication can't be administered there should be an explanation as to why either on the MAR or in the progress notes. He/She should have initialed the medication on 1/15/24. During an interview on 1/24/24 at 10:31 A.M., the resident's physician said she did not order the Valtoco. She said the resident's neurologist ordered the medication. She would expect staff to administer the Valtoco as ordered and/or per the manufacturer's guidelines. During an interview on 1/25/24 at 1:00 P.M., the DON said she expected staff to administer any medication including Valtoco per the physician's orders. Any medication administered should be initialed as administered on the MAR. If a medication cannot be administered, she expected staff to document a reason why on the MAR or in the progress notes. 3. Review of Resident 23's quarterly MDS, dated [DATE], showed: -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Diagnoses of high blood pressure, diabetes mellitus (DM), hyperlipidemia (high cholesterol/elevated levels of lipids (fatty compounds) in the blood), anxiety, depression, manic depression/bipolar disease and schizophrenia. Review of the resident's care plan, last revised on 2/14/22, showed: -Focus: History of behavioral challenges; -Goal: Resident will have no serious injuries due to behaviors; -Interventions: Pharmaceutical interventions as needed. Administer medications as ordered; -Focus: Potential to be verbally/physically aggressive related to diagnosis of schizophrenia; -Goal: Will not harm self or others; -Interventions: Administer medications as ordered; -Focus: At risk for impaired cognitive (thought) function due to schizophrenia, bipolar depression and anxiety; -Goal: Will remain at current level of cognitive function; -Interventions: Administer medications as ordered; -Focus: At risk for alteration in health and hyperglycemic (high)/hypoglycemic (low) episodes related to DM; -Goal: Will have no complications related to DM; -Interventions: Diabetes medications as ordered by physician. Glucose monitoring; -Focus: At risk for adverse reactions related to psychotropic medications due to major depression and schizophrenia; -Goal: Will remain free of psychotropic drug related complications; -Interventions: Administer psychotropic medications as ordered by the physician; -Focus: At risk for alteration in neurological status related to diagnosis of restless leg syndrome; -Goal: Will remain with optimal status and quality of life within limitations imposed by neurological deficits; -Interventions: Give medications as ordered. Review of the resident's POS, showed the following orders: -No Start Date: Blood glucose before breakfast in the morning for DM; -Start Date: 2/14/22: Benztropine 1 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to schizophrenia; -Start Date: 2/14/22: Buspirone 10 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to paranoid schizophrenia; -Start Date: 2/17/22: Fluphenazine 10 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to schizophrenia; -Start Date: 2/14/22: Risperidone 2 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to unspecified psychosis (an acute or chronic mental state marked by loss of contact with reality); -Start Date: 7/26/22: Topiramate 100 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to schizophrenia; -Start Date: 7/14/23: Atorvastatin 40 mg, 1 tablet at 6:00 P.M. for high cholesterol; -Start Date: 7/14/23: Mirtazapine 15 mg, 1 tablet daily at 6:00 P.M. for anxiety; -Start Date: 7/14/23: Pramipexole 0.5 mg, 1 tablet at 6:00 P.M. for restless leg syndrome (a long-term disorder that causes a strong urge to move one's legs); -Start Date: 7/14/23: Trazodone 100 mg, 1 tablet at 6:00 P.M. for insomnia (difficult falling asleep); -Start Date: 8/25/23: Metfor

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #25) with a diagnosis of diabetes consistently received blood sugar level checks (measures the level of glucose (sugar) in the blood) and insulin administration. The facility failed to notify the physician of a blood sugar reading over 451, as ordered by the physician. On 12/23/23, the resident had a blood sugar level of 550. The resident was transferred to the hospital on [DATE] and diagnosed with diabetic ketoacidosis with coma associated with diabetes. The resident passed away on 12/25/23. Additionally, facility staff failed to clarify physician orders and obtain specific parameters for use when one resident (Resident #24) with a diagnosis of seizure disorder and a history of multiple seizures, was prescribed Valtoco (short-term treatment of seizure clusters), an as necessary (PRN) medication for seizures, and failed to consistently notify the resident's physician after every seizure. Last, staff failed to administer one resident's (Resident #23) medications as ordered and failed to document an explanation as to why the medications could not be administered on the medication administration record (MAR) and/or in the resident's progress notes. The sample size was 22. The census was 140. The administrator was informed on 2/5/24 of an Immediate Jeopardy (IJ), which began on 12/23/23. The IJ was removed on 2/6/24 as confirmed by surveyor on-site verification. Review of the facility's Blood Glucose Monitoring and Insulin Administration Policy, dated revised 6/29/23, showed: -Affected personnel: Registered Nurses (RN), Licensed Practical Nurses (LPN) and Certified Medication Technicians (CMT); -Purpose: To define accurate procedures to be followed when checking a blood sugar. To identify what measures will be taken in the event that a blood sugar falls out of the defined therapeutic range; -Procedure: If the resident's blood sugar is over 400, the physician will be notified by the charge nurse and orders will be followed. 1. Review of Resident #25's admission Record, showed the resident was admitted to the facility on [DATE], with diagnoses that included diabetes (a chronic, metabolic disease characterized by elevated levels of blood glucose (blood sugar)). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/10/23, showed: -Cognitively intact; -Had a diagnosis of diabetes; -Received insulin injections. Review of the resident's care plan, showed: -Focus: At risk for alteration in health related to diabetes. Resident is on a regular low concentrated sweets diet (LCS, reduced carbohydrate diet) revised on 8/12/22; -Goal: The resident will have no complications related to diabetes through the review date, initiated on 12/11/21; -Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, initiated 12/11/21. Review of the resident's December 2023 Physician's Order Summary, showed: -Check and record blood sugar four times a day for diabetes, dated 8/17/23; -Dexcom G7 Receiver Device (Continuous Blood Glucose System Receiver). Inject 1 application intramuscularly one time a day related to diabetes, dated 8/17/23; -Dexcom G7 Sensor Miscellaneous (Continuous Blood Glucose System Sensor). Inject 1 application intramuscularly one time a day related to diabetes, dated 8/17/23; -Insulin Aspart FlexPen Subcutaneous Solution Pen injector (a short-acting insulin used to control blood sugar levels in the blood), 100 units per milliliter (ml). Inject subcutaneously (under all the layers of the skin) three times a day, as per sliding scale: --If blood sugar level is 200 - 250 = administer 3 units; --251 - 300 = 5 units; --301 - 350 = 7 units; --351 - 400 = 9 units; --401 - 450 = 11 units; --Over 451, Contact Physician, dated 10/31/23; -Lantus SoloStar Subcutaneous Solution Pen-injector (Insulin Glargine - a long-acting insulin used to control blood sugar levels in the blood), 100 units per ml. Inject 10 units subcutaneously every morning and at bedtime related to diabetes, dated 12/17/23. Review of the resident's December 2023 Accu check and insulin administration record, showed: -Lantus SoloStar Subcutaneous Solution Pen-injector 100 units per milliliter, inject 10 units subcutaneously every morning and at bedtime related to diabetes, dated 12/17/23, blank and not marked as provided on 12/9/23 at 7:00 P.M., and 12/17/23 at 7:00 P.M.; -Insulin Aspart FlexPen Subcutaneous Solution Pen injector 100 units per milliliter, inject subcutaneously three times a day, as per sliding scale: --if blood sugar level is 200 - 250 = administer 3 units; --251 - 300 = 5 units; --301 - 350 = 7 units; --351 - 400 = 9 units; --401 - 450 = 11 units; --Over 451, contact physician; dated 10/31/23. Review of the resident's December 2023 Accu check and insulin administration record, showed: - on 12/13/23 at 6:00 P.M., facility staff did not document the resident's blood sugar level or if insulin injection was required; - on 12/17/23 at noon, facility staff did not document the resident's blood sugar level or if insulin injection was required; - on 12/19/23 at 6:00 P.M., facility staff did not document the resident's blood sugar level or if insulin injection was required. Review of the resident's Nursing Progress Notes, showed: -No documentation as to why there was no recorded administration of the regularly scheduled Lantus insulin on 12/9/23 at 7:00 P.M. and 12/17/23 at 7:00 P.M.; -No documentation to show why blood sugar level or administration of sliding scale insulin was not documented on 12/13/23 at 6:00 P.M., 12/17/23 at noon, and 12/19/23 at 6:00 P.M. Nurse Practitioner note date of service 12/21/23: --Blood sugar 426 on 12/21/23 at 11:55 A.M.; --Diagnoses: Brittle diabetes (hard to control) and Type 2 diabetes mellitus with hyperglycemia (spike in blood sugar levels); --Plan: patient is brittle diabetic. He/She is very sensitive to insulin. Medications reviewed. Last visit increased Lantus to 10 units BID (twice daily). Follow up routine visit and as needed; Review of the resident's December 2023 Accu check and insulin administration record, showed on 12/22/23 at 6:00 P.M., facility staff did not document the resident's blood sugar level or if insulin injection was required. Review of the resident's Nursing Progress Notes, showed no documentation to show why blood sugar level or administration of sliding scale insulin was not documented on 12/22/23 at 6:00 P.M Review of the resident's December 2023 Accu check and insulin administration record, showed on 12/23/23 at 6:00 P.M., facility staff documented a blood sugar level of 550. The record showed sliding scale insulin was not administered on 12/23/23 at 6:00 P.M., due ot vitals outside of parameters for administration.The record did not include documentation the physician was notified of the blood sugar level of 550 or if any new orders were received. Review of the resident's Nursing Progress Notes, showed: -No documentation the physician was notified of the blood sugar level of 550 or if any new orders were received on 12/23/23 at 6:00 P.M.; -On 12/24/23 at 4:15 A.M, while doing routine rounds, the resident was breathing rapidly and lips were really dry. Vital signs were obtained: -temperature 96.4 (normal range between 97 F (Fahrenheit) and 99 F); -pulse 101- 105 (normal range 60 to 100 beats per minute); -respirations 32-28 (normal range from 12 to 16 breaths per minute); -blood pressure 87/52 (normal pressure is systolic (top number) of less than 120 and diastolic (bottom number) of less than 80 (120/80)); -blood sugar read HI >600. The nurse applied oxygen at 2 L (liter) per nasal cannula (a device that gives you additional oxygen through the nose); -12/24/23 at 4:31 A.M, call placed to resident's physician and reached the on-call physician. Made aware of what's going on with resident. Ok to send out 911. Resident is his/her own responsible party; -12/24/23 at 4:37 A.M., call placed to 911; -12/24/23 at 4:45 A.M.: Ambulance arrived at facility at 4:45 A.M.; -12/24/23 at 5:05 A.M.: Resident exited building with ambulance via stretcher. Review of the resident's Hospital Records, showed: -emergency room notes: --Chief complaint: hyperglycemia (elevated blood sugar level); --Transfer to the emergency department by EMS due to hyperglycemia. EMS states the patient's blood glucose level has been reading in the 500's since 4:00 P.M. on 12/23/23. Upon arrival at the emergency department the patient was unresponsive to verbal stimuli. The patient does respond to painful stimuli. The patient is hypotensive (abnormally low blood pressure). The patient suddenly started vomiting and likely aspirated (inhaling saliva, food, liquid, vomit and even small foreign objects into the lungs). The patient has a history of diabetes and diabetic ketoacidosis (DKA - A serious diabetes complication where the body produces excess blood acids (ketones)); -Final diagnoses: --Aspiration pneumonia of both lungs; --Altered mental status; --Diabetic ketoacidosis with coma associated with diabetes; --Acute kidney injury. During an interview on 1/24/24 at 1:49 P.M., CMT Y said: -CMTs performed the accu checks and insulin administration; -The resident's blood sugar was taken before dinner and at bedtime; -His/Her blood sugar always ran high; -Every time his/her blood sugar would run low or high, he/she would notify the nurse and let the nurse make the final decision on if to contact the physician or not; -He/She did not know if the physician was notified on 12/23/23, but was sure it was out of range; -He/she always asked the nurse what to do before giving insulin; -He/she did not remember if the resident received any insulin on 12/23/23; -Looking at the administration record, he/she got the long-lasting insulin but not the sliding scale due to the nurse needing to contact the physician to get an order for the dose to be administered; -He/She did not remember who the nurse was but was sure he/she told the nurse. During an interview on 1/24/24 at 3:05 P.M., LPN X said: -He/She did not recall 12/23/23, and the resident's blood sugar being elevated; -The resident had a history of refusing insulin; -If the CMT had notified him/her of the elevated blood sugar he/she would have contacted the physician for new orders; -He/She would normally make a note in the resident's progress notes any time he/she would contact the physician; -There should never be a blank on the administration record, there should always be some kind of documentation; -He/She expected the CMT to notify him/her immediately if there is a blood sugar level out of range. During an interview on 1/23/24 at 1:17 P.M., LPN A said: -CMTs performed the accu checks and administer insulin; -If the CMT was not certified, then the nurse would do it; -The CMT should notify the nurse immediately if the blood sugar level was not in range; -A blood sugar level of 550 was out of range and the nurse should be notified immediately; -The nurse would then reach out to the physician and put any new orders in place; -The CMT could not hold insulin due to the blood sugar level being out of range; -The MAR should be signed out when any medication was administered. During an interview on 1/25/24 at 10:17 A.M., Nurse K said: -The nurse/CMT should always record the accu check level and insulin administration; -If a blood sugar level was not obtained or insulin not administered, the expectation was to mark why; -CMTs were responsible for obtaining blood sugar levels and administering insulin; -He/She expected CMTs to notify him/her immediately if a blood sugar level was out of range; -A blood sugar level of 550 was out of range and needed to be called to the physician for new orders; -Any physician contact or new orders should be documented in the resident's chart. If a resident had a blood sugar out of parameters, he/she would call the physician, get an order for a one-time insulin administration, chart it, administer the insulin and the go back 20-30 minutes later to check on the resident, then document the follow up check. During an interview on 12/25/24 at 10:45 A.M., Nurse N said: -There should never be any blanks on the administration record, there were always options to pick from; -If it was blank, it was assumed it was not performed/administered; -Blood sugar levels and insulin administration were performed by the CMTs; -He/She expected the CMT to notify him/her immediately if a blood sugar level was out of range; -He/she would need to call the physician and get an order for insulin administration based on the blood sugar level; -A blood sugar level of 550 was out of range and required physician notification; -Any physician contact or new orders should always be documented in the resident's progress notes. During an interview on 1/25/24 at 12:57 P.M., the Director of Nursing (DON) said: -He/She expected staff to follow all physician orders; -He/She expected the MAR to be signed out when medication was administered, and that included blood sugar levels and insulin administration; -If there was a blank on the administration record, it meant the insulin was not administered; -The CMT must notify the nurse immediately if there was a blood sugar level out of range and the nurse would then notify the physician for new orders; -Any physician contact should be documented in the resident's progress notes; -Any new orders should be documented on the MAR and in the resident's progress notes; -If a blood sugar level was higher than the parameters, the nurse should go back and check on the resident in at least one hour and document the follow up; -He/She was going to change the process and give the blood sugar level checks and insulin administration tasks back to the nurses. 2. Review of Resident #24's annual MDS, dated [DATE], showed: -Makes Self Understood: Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Understands, clear comprehension; -Diagnoses of seizure disorder or epilepsy (a brain disorder that causes recurring, unprovoked seizures), manic depression/bipolar disease (extreme mood swing) and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's diagnoses located in the resident's medical record, showed a diagnosis of epileptic seizures related to external causes, not intractable (difficult to manage/alleviate, keep under control) with status epilepticus (a seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes). Review of the resident's care plan, initiated on 5/26/21 revised on 12/5/23, showed: -Focus: Risk for falls related to psychotropic drug (a drug that affects behavior, mood, thoughts, or perception) use, seizures, and head injury. Resident wears helmet for seizures. -Goal: Will be free from falls through review date; -Interventions: Anticipate and meet the resident's needs. To wear helmet while up. Review of the resident's physician's order sheet (POS), included the following orders: -Start Date: 9/11/23: Valtoco (diazepam (Valium)) benzodiazepine/anticonvulsant (a class of agents that work in the central nervous system) used to treat seizure clusters (seizures that occur in groups/clusters over a number of hours/days) 20 milligrams (mg) nasal liquid therapy pack 10 mg/0.1 milliliters (ml) (diazepam (anticonvulsant)), 0.2 ml in both nostrils every 4 hours PRN for seizures related to epileptic seizures. Discontinue Date: 12/14/23 (The order did not contain specific parameters for use- including if the medication should be administered after one seizure or more.); -Start Date: 12/17/23: Valtoco 20 mg dose nasal liquid therapy pack 10 mg)/0.1 ml, 0.2 ml in both nostrils every 4 hours PRN for seizure activity (The order did not contain specific parameters for use- including if the medication should be administered after one seizure or more.); -Start Date: 12/18/23: Lacosamide (Vimpat/anticonvulsant) 200 mg two times a day (BID) for anticonvulsant; -Start Date: 12/18/23: Valporic acid (used to treat various types of seizure disorders) 250 mg, two capsules (500 mg) BID anticonvulsant; -Start Date: 1/4/24: Levetiracetam (Keppra/anticonvulsant) 250 mg, five tablets (1250 mg) BID for epilepsy. Observation of the facility medication cart on 1/24/24 at 9:00 A.M., showed two boxes of Valtoco, each containing two spray devices. One box was sent to the facility from the pharmacy on 4/19/23, and contained one of two doses. The second box was sent to the facility from the pharmacy on 9/15/23, and contained two of two doses. Review of the Valtoco manufacturer's instructions found in the medication box received from the facility pharmacy, showed: -Indications for usage: Valtoco is a benzodiazepine indicated for the acute (sudden/immediate) treatment of intermittent, stereotypic episodes of frequent seizure activity (i.e. seizure clusters, acute repetitive seizures) that are distinct from a patient's usual seizure pattern in patients with epilepsy six years of age and older; -How to use Valtoco: Use Valtoco exactly as prescribed by your healthcare prescriber; -Valtoco is given in the nose only. Valtoco comes ready to use. If needed a second dose may be given at least 4 hours after the first dose. Do not give more than two doses to treat a seizure cluster; -Instructions for use: Safely secure the person. If the person appears to be having a seizure, gently help them to the floor and lay them on their side in a place where they cannot fall. The person can be on either their side or back to receive Valtoco. One dose equals two nasal spray devices. Each device sprays one time only. After giving Valtoco keep or move the person onto their side, facing you, so that you can watch them closely. According to the Valtoco manufacturer's website, seizure clusters, are episodes of frequent seizure activity, that occur 2 or more times within a 24-hour period. Review of the resident's December 2023 progress notes, showed: -12/8/23 at 5:32 P.M., documented by Nurse B: It was brought to my attention as nurse that this resident had a seizure lasting 1 minute. Resident lowered to the floor by nursing staff. Resident shows no signs or symptoms of loss of consciousness upon cessation of seizure. Resident transferred off the floor with the help of two staff members, transferred to a wheelchair and propelled to room by staff. Call placed to physician. May transport to hospital for further evaluation. Emergency Medical Services (EMS) arrived and transported resident to hospital. Resident responding and respirations even and unlabored. Resident remains stable upon departure; -No documentation Valtoco nasal spray was administered; -12/8/23 at 10:30 P.M.: Resident returned from hospital with no new orders. Vimpat and Keppra order faxed to pharmacy for physician order update. Resident remains stable upon return; -12/12/23 at 6:38 P.M.: Resident walking down the hall and yelled out. Resident then fell, but did not hit his/her head. Resident had seizure activity noted for about 1 minute. Resident then stood up. Resident responding verbally, and denies complaints of pain. Resident placed at nurse's station for protective oversight. Physician notified; -No documentation Valtoco nasal spray was administered; -12/13/23 at 11:32 P.M.: This writer heard resident yell out as he/she did before he/she had a seizure. Before staff could get to resident he/she fell forward hitting his/her face on the floor. Blood noted to right side of face, his/her mouth and chin. Upon assessing he/she was noted to be alert and responding appropriately. 911 was called and resident was sent to hospital for an evaluation. Physician was notified. Resident returned to facility with no new orders; -No documentation Valtoco nasal spray was administered; -12/14/23 at 12:19 P.M., documented by Nurse K: Code blue called. Resident found unresponsive and actively having a seizure. Resident was bleeding from right upper lip and left lower chin. Resident actively seized for 5 minutes. Oxygen saturation ranged from 93%-97% (normal range 95%-100%) until EMS arrived. Resident's eyes were not equal or accommodating to light during this period. Resident sent to hospital to receive care. Physician notified; -No documentation Valtoco nasal spray was administered; -12/17/23 at 2:34 P.M.: Resident started on Valporic Acid and stopped Briviact (anticonvulsant). Resident saw neurologist and suggested follow-up on 1/3/23; -12/29/23 at 6:00 A.M.: Resident observed to be displaying seizure activity while seated in a chair. Area made safe for resident for the duration of seizure activity lasting approximately 1 minute. When activity discontinued resident made comfortable and allowed to rest. Resident remains on intensive monitoring for protective oversight; -No documentation the resident's physician was notified; -No documentation Valtoco nasal spray was administered; -12/29/23 at 9:18 A.M., documented by Nurse K: Resident observed to be displaying seizure activity while sitting on bed. Area made safe for resident for the duration of seizure activity lasting approximately 1 minute. When activity discontinued resident made comfortable and allowed to rest. Resident remains on intensive monitoring for protective oversight. Morning medications given. No seizure activity since then; -No documentation the resident's physician was notified; -No documentation Valtoco nasal spray was administered. Review of the resident's MAR, dated 12/1/23 through 12/31/23, showed: -Valtoco 20 mg one spray in both nostrils every 4 hours as needed for seizures related to epileptic seizures; -No initials showed staff administered the Valtoco the entire month of December. Review of the resident's January 2024 progress notes, showed: -1/3/24 at 9:00 A.M.: Certified Nursing Assistant (CNA) approached nurse station at this time propelling resident in wheelchair making this nurse aware resident appeared to have had change in condition while sitting at dining room table during breakfast. Immediately assessed resident noted with head down, calling name with no response, noted rise and fall of chest with eyes open and spontaneous jerking noted. This nurse and CNA assisted resident to room and in bed safely as resident unable to sit up in wheelchair. During assessment resident noted to stare off and to begin spontaneous jerking with no response when nurse called out during assessment. Episode lasted about 30 seconds and resident began to respond when name called. Call to 911 to make aware of needed transport for emergent evaluation. Call placed to physician. Ambulance arrived to facility, resident remained awake with Registered Nurse Supervisor at bedside noting one seizure episode since this nurse left bedside. Resident left facility at that time via ambulance; -No documentation Valtoco nasal spray was administered; -1/3/24 at 9:30 A.M., documented by Nurse B: This nurse summoned to dining room regarding this resident, upon entering the dining room this nurse noted resident sitting in chair at table lethargic and responding little to verbal stimuli. This nurse asked resident how he/she felt, the resident dropped his/her head and did not respond. Rise and fall of chest noted evenly, resident's vital signs and oxygen saturation within normal limits. Call placed to physician with new orders to send to the hospital for further evaluation. EMS arrived and transferred resident to hospital for further evaluation. Resident had neurologist appointment scheduled this shift. Neurologist appointment postponed until a further day; -No documentation Valtoco nasal spray was administered; -1/3/24 at 5:33 P.M., documented by Nurse B: Resident returned from hospital with new orders to increase Keppra to 1,250 mg two times a day. MAR updated, resident remained stable upon return; -1/14/24 at 12:33 P.M., documented by Nurse K: Resident found in hallway having a seizure. Seizure lasted approximately three minutes. Helmet was in place at the time of the incident. No injury noted. Physician notified, said to monitor; -No documentation Valtoco nasal spray was administered; -1/15/24 at 1:03 A.M.: Resident had seizure activity this evening of inexact length of time. The seizure activity happened from the time the resident's roommate went to the dining room to heat ramen noodles for resident and returned back to the room. Upon entering this writer observed resident lying crosswise on bed, his/her body was stiff and rigid and he/she was making a loud snoring noise. This activity lasted approximately 1.5 minutes before seizure activity was over. This writer verified with CMT resident's medications required for seizure activity; -No documentation the resident's physician was notified. -No documentation Valtoco nasal spray was administered; -1/15/24 at 5:54 A.M.: While on 600 hall passing medication, was called to resident's room by his/her roommate saying the resident was having a seizure. Writer was two doors away and as writer got to the resident's room the seizure activity was stopping and resident was coming out of it. Seizure lasted 30-50 seconds (estimated). Will continue to monitor; -No documentation the physician was notified. -No documentation Valtoco nasal spray was administered; -1/15/24 at 9:25 A.M., documented by Nurse K: Resident found in hallway having a seizure at 7:00 A.M. medication pass. Seizure lasted approximately 3 minutes. Helmet was in place at time of incident. No injury noted. Physician notified and made aware of multiple occurrences since 1/14/24. Physician stated to monitor and the next occurrence send the resident out; -No documentation Valtoco nasal spray was administered; -1/15/24 at 11:13 A.M., documented by Nurse K: Diazapam was administered in left nostril during seizure. Review of the resident's medication signature sign out sheet, showed one dose of Valtoco was administered on 1/15/24. Review of the resident's MAR, dated 1/1/24 through 1/31/24, showed: -Valtoco 20 mg one spray in both nostrils every 4 hours as needed for seizures related to epileptic seizures; -No documentation staff administered the Valtoco on 1/15/24. During an interview on 1/24/24 at 8:32 A.M., Nurse K said he/she had worked at the facility for about three years. The resident had a lot of seizures. He/She had not given the resident Valtoco nasal spray. He/She did not think the resident had had an order for the medication too long. CMTs could not administer Valtoco, only nurses. The medication should have been given when the resident had a seizure. Nurse K had not received any previous directives to not administer the medication when the resident had a seizure. He/She was present on 1/15/23, when the resident had a seizure and Nurse B administered the medication. He/She did not know why Nurse B did not initial the medication had been administered as given on the MAR on 1/15/24. Nurses are responsible to initial a medication was administered on the MAR for any medication administered. During an interview on 1/24/24 at 8:57 A.M., Nurse B said he/she had worked at the facility for about four months. Only nurses were allowed to administer Valtoco. He/She administered the Valtoco on 1/15/24 because the resident had a seizure. Even though the resident had had several seizures, that was the first time he/she had administered the Valtoco. He/She was not sure why he/she had not administered the Valtoco prior to 1/15/24. If a medication was administered, it should be initialed as given. If a medication can't be administered there should be an explanation as to why either on the MAR or in the progress notes. He/She should have initialed the medication on 1/15/24. During an interview on 1/24/24 at 10:31 A.M., the resident's physician said she did not order the Valtoco. She said the resident's neurologist ordered the medication. She would expect staff to administer the Valtoco as ordered and/or per the manufacturer's guidelines. During an interview on 1/25/24 at 1:00 P.M., the DON said she expected staff to administer any medication including Valtoco per the physician's orders. Any medication administered should be initialed as administered on the MAR. If a medication cannot be administered, she expected staff to document a reason why on the MAR or in the progress notes. 3. Review of Resident 23's quarterly MDS, dated [DATE], showed: -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands; -Diagnoses of high blood pressure, diabetes mellitus (DM), hyperlipidemia (high cholesterol/elevated levels of lipids (fatty compounds) in the blood), anxiety, depression, manic depression/bipolar disease and schizophrenia. Review of the resident's care plan, last revised on 2/14/22, showed: -Focus: History of behavioral challenges; -Goal: Resident will have no serious injuries due to behaviors; -Interventions: Pharmaceutical interventions as needed. Administer medications as ordered; -Focus: Potential to be verbally/physically aggressive related to diagnosis of schizophrenia; -Goal: Will not harm self or others; -Interventions: Administer medications as ordered; -Focus: At risk for impaired cognitive (thought) function due to schizophrenia, bipolar depression and anxiety; -Goal: Will remain at current level of cognitive function; -Interventions: Administer medications as ordered; -Focus: At risk for alteration in health and hyperglycemic (high)/hypoglycemic (low) episodes related to DM; -Goal: Will have no complications related to DM; -Interventions: Diabetes medications as ordered by physician. Glucose monitoring; -Focus: At risk for adverse reactions related to psychotropic medications due to major depression and schizophrenia; -Goal: Will remain free of psychotropic drug related complications; -Interventions: Administer psychotropic medications as ordered by the physician; -Focus: At risk for alteration in neurological status related to diagnosis of restless leg syndrome; -Goal: Will remain with optimal status and quality of life within limitations imposed by neurological deficits; -Interventions: Give medications as ordered. Review of the resident's POS, showed the following orders: -No Start Date: Blood glucose before breakfast in the morning for DM; -Start Date: 2/14/22: Benztropine 1 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to schizophrenia; -Start Date: 2/14/22: Buspirone 10 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to paranoid schizophrenia; -Start Date: 2/17/22: Fluphenazine 10 mg, 1 tablet daily at 7:00 A.M., 12:00 P.M., and 6:00 P.M. related to schizophrenia; -Start Date: 2/14/22: Risperidon

Based on interview and record review, the facility failed to ensure each resident received adequate supervision for three residents (Residents #4, #15 and #3). The facility failed to immediately report and investigate when Resident #4 did not return to the facility from the day program. Facility staff on the secured unit was aware the resident was not at the facility and waited approximately eight hours to report the resident missing. The resident was found by a good samaritan approximately nine hours after the facility reported the resident missing. The resident reported he/she was assaulted and injected intravenous drugs. The facility failed to provide adequate supervision and interventions for Resident #15, who displayed self-harm behaviors multiple times and eloped from the facility. The facility failed to ensure staff were aware of a resident's leave of absence (LOA) after staff failed to report it (Resident #3). In addition, the facility failed to ensure there was protective oversight on three out of three secured units. The census was 136. The administrator was notified on 7/5/22 at 3:47 P.M. of an Immediate Jeopardy (IJ) which began on 6/22/22 . The IJ was removed on 7/12/22 as confirmed by surveyor onsite verification. Review of the facility's Intensive Monitoring/Visual Checks policy, updated 3/25/22, showed: -Purpose: To ensure a system is in place for residents who require increased monitoring for behavioral/psychiatric and medical issues; -Procedure: Residents who require more intensive monitoring due to medical behavioral/psychiatric symptoms will be monitored on visual face checks by the licensed nurse and/or designee, and Certified Nurse Aide (CNA) and/or designee. The licensed nurse monitoring shall include a visual assessment of clinical symptom changes and abnormalities; -Definition of intensive monitoring: The definition of intensive monitoring is defined as periodic (hourly, every two hours, or shiftly) check by a licensed nurse. A face check is defined by the employee visually seeing the face of the resident; -Residents may require more intensive monitoring based on their medical and behavioral/psychiatric needs; -One to one monitoring: New admissions to the specialized units will be placed on intensive monitoring one to one (with in eyesight of staff at all times) if deemed necessary by the administrator, Director of Nursing, or program director, the one to one monitoring can only be removed by the administrative staff; -Residents who are showing poor impulse control including verbal/physical aggression, elopement ideations, suicidal/homicidal ideations, decompensation mentally or medically may also be placed on one to one or two to one (within eyesight of staff at all times) monitoring at the discretion of the administrative staff; -A one to one or two to one will be determined at the severity of the behavior or medical condition and at the discretion of the Chief Operating Officer, Regional Director, Administrator, Director of Nursing, Management Team, and Physician; -Residents who require intensive monitoring of one to one will always have a dedicated staff member within eyesight; -When a Regional Director requests or approves that a resident is placed on one-on-one, that Regional Director must be informed when the facility believes the resident should be removed from the one-on-one. The Regional Director will then confer with the Executive [NAME] President and Chief Operating Officer who will approve the resident being taken off the one-on-one intensive monitoring. The Regional Director will inform the facility when the resident may be removed from the one-on-one; -One delegated staff member can monitor two residents in the same room if both residents require intensive monitoring related to medical or fall risks. This must be approved by the administrator. This cannot be implemented for two residents that are behavioral; -Face Checks: All residents on each unit will be monitored by visual checks at least every two hours or may be provided more intensive monitoring every hour. Special units will not be unattended at any time; -Upon hire, licensed and registered nurse will be required to review, agree and sign the nurse census call-in protocol. Signed form should be placed in employee file; -Residents may require, based on behavior/medical issues, a more intensive monitoring which would require a license nurse to visually check the resident more often than every two hours; -Certified Nurse Aide (CNAs) can be provided direction to monitor the resident in timely manner at the discretion of administration for a medical or behavior decompensation; -Documentation: All documentation of face checks, one to one, or other intensive monitoring will be done in point click care under the face checks task. The attached monitoring sheets should only be used in the event that PCC is unavailable. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/18/22, showed the following: -Cognitively intact; -Independent for bed mobility, transfers, walking in room and corridor, locomotion on unit, dressing and toilet use; -Physical impairment of both lower extremities; -Supervision only for locomotion off unit and eating; -Wandering not exhibited; -Diagnoses of viral hepatitis, anxiety, bipolar (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), and schizophrenia (a psychotic disorder or group of disorders marked by severely impaired thinking, emotions, and behaviors). Review of the resident's electronic medical record (EMR) showed a quarterly elopement assessment, dated 1/21/22, which said the resident was not an elopement risk. Review of the resident's care plan, dated 8/14/21, showed: -Focus: Impaired cognitive function or impaired thought process related to disease process of schizophrenia disorder, bipolar disorder, anxiety, and suicidal ideation; -Goal: Resident will maintain current level of cognitive function through review date; -Interventions: Monitor/document/report as needed any changes in cognitive function. Specifically changes in decision making ability, memory, recall and general awareness or mental status. Review of the resident's progress notes, dated 6/22/22, showed: -10:22 P.M., Upon shift, nurse was notified that resident was sent out with day program. Upon end of shift rounds, nurse noticed resident was still not present. Nurse and staff immediately conducted a room to room search. Resident was not found. Upon confirmation that resident was missing. Nurse staff called Director of Nursing (DON); -10:31 P.M., DON and next of kin notified. During an interview on 6/29/22 at 10:45 A.M., the DON said Resident #4 left around 9:00 A.M. on Monday, Wednesday, and Friday for his/her day program and returns at approximately 1:00 P.M. During an interview on 6/29/22 at 11:50 A.M., Licensed Practical Nurse (LPN) N said the resident left the faciity on [DATE] between 9:30 A.M. and 9:45 A.M. Typically he/she returns between 2:00 P.M. and 2:30 P.M., but it was not unusual for the resident to return after LPN N leaves after his/her shift which ends around 3:00 P.M. to 3:30 P.M. LPN N said he/she worked that morning and he/she told the evening nurse in report that the resident was not at the facility. LPN N said the resident had not mentioned planning anything and was not acting unusual the day before or that morning. LPN N said the resident had been fine and it was not unusual for the resident to get back later. During an interview on 6/30/22 at 1:00 P.M., LPN T said he/she was assigned to the resident on the evening shift of 6/22/22. The LPN arrived at the facility at 3:00 P.M. for his/her shift. He/she said that he/she was told in report the resident was on Outside Pass (OSP) and had not returned. The LPN said he/she was not told when the resident should be expected to return. LPN T said he/she was not familiar with the resident leaving. He/she had never worked on a day when the resident went to the day program. LPN T said he/she does hourly rounds with the CNA and knew the resident was not there the entire shift. Around 9:00 P.M., LPN T said he/she wanted to make sure he/she knew if the resident was or was not going to return since the resident had until 11:00 P.M. The resident could come back until 12:00 A.M., but the LPN's shift ended at 11:00 P.M. LPN T said he/she did not want to end his/her shift without the resident returning to the facility. The LPN said he/she did not talk to any residents to see where the resident could be. LPN T said that he/she should have reported the resident missing earlier in his/her shift. During an interview on 7/1/22 at 12:30 P.M., CNA U said he/she has worked at the facility since last October. He/she said the resident rounds are done every hour or more. CNA U said he/she worked the day the resident eloped from the day program. CNA U said he/she told the evening shift the resident had not returned when he/she left after 3:00 P.M. The oncoming CNA said he/she would check. During an interview on 7/2/22 at 1:20 P.M., Certified Medication Technician (CMT) C said he/she was the evening shift CMT on 6/22/22. He/she was told, by the day shift staff, in report the resident went to the day program and was supposed to be gone for another hour. CMT C said he/she kept asking where the resident was and told the nurse. He/she was not sure when the nurse decided to call someone. The other residents were saying Resident #4 ran away. CMT C said he/she was not sure why the nurse did not cal,l but looking back, he/she should have said something sooner or gone over the nurse's head. Review of the resident's progress notes, dated 6/23/22, showed: -8:50 A.M., Arrived at facility, accompanied by facility staff. He/she was placed on intense monitoring and will remain on it at this time. Resident denied any complaints. Complete assessment performed. Guardian and physician were notified of the resident's arrival; -10:30 A.M., Resident sent to hospital via cab accompanied by staff member; -10:54 P.M., Resident returned from hospital at 8:50 P.M. via taxi with 1-1 staff escort. Resident continues 1:1 monitoring for intensive monitoring. Staff continues to monitor for protective oversight. A review of the summary of the self-report provided with the investigation showed: -On 6/22/22 at approximately 10:36 P.M., LPN R called and said Resident #4 was not in the facility. The facility surveillance noted the resident went out with his/her day program in their van at approximately 9:00 A.M. as he/she does every Monday, Wednesday, and Friday. The resident was noted to have an ID badge on his/her person and there were two other people in the van when it arrived. This visit was approved by the resident's guardian. The resident did not return from today's visit. The statements received from the evening shift verified that he/she was not listed at the facility. The resident did not take his/her medicine. The Initial resident interviews said that the resident has been planning this elopement for some time. -On 6/23/22 at approximately 6:00 A.M., the resident was recognized by a good samaritan after seeing the resident's picture on the news. Around this same time the resident had contacted our facility to tell us where he/she was. Staff went to the gas station and police released the resident into our custody. The resident was sent to the hospital for a medical evaluation since the resident said he/she smoked crack cocaine and injected heroin. The resident also said he/she was sexually assaulted. Review of the resident's statement of what occurred, no time recorded, showed the resident left the facility at 9:00 A.M., transported by the day program's van. There was a driver and an aide when the van left the facility. When the resident arrived at the day program, he/she said that he/she just walked away. There were no checks. The resident met another acquaintance from the day program. The resident said they walked for a while on Grand avenue. They then went into an abandoned building where they smoked a dime size rock of crack cocaine. The resident said then the other person left him/her and the resident met three more people in the alleyway. The resident agreed to have sex with one of them in exchange for heroin which he/she injected in him/herself. The resident said that person brought along a friend, and that friend had non-consensual sex with him/her. As the resident was leaving the home, he/she said he/she fell down a flight of stairs, receiving only minor scratches and bruising. The resident then met back up with the original person later on. They smoked another dime rock mixed with tobacco. They walked around until they found an unlocked car and slept there for the night. When the resident woke up, he/she and the other person walked to the gas station where he/she was identified by the good samaritan. During an interview on 6/29/22 at 9:00 A.M., CNA Q said he/she was the one that answered the phone when the resident called the facility the morning after he/she eloped. The resident called the facility at around 7:00 A.M. The resident told the CNA where he/she was, so CNA Q could send help. During an interview on 6/29/22 at 11:30 A.M., Resident #4 said he/she just decided that day to leave. It was not preplanned. During an interview on 6/30/22 at 12:00 P.M., the resident's guardian said he/she is located at the day program that the resident was attending. The guardian said the resident has a badge and when he/she arrives at the day program, he/she swipes in and goes to the recovery center clubhouse. On 6/22/22, he/she swiped in but did not go in the clubhouse. The day the resident did not return to the facility, the facility called the guardian at 10:45 P.M. The guardian said he/she would have expected to receive a call around 5:00 or 5:30 P.M. The day program van leaves there around 2:00 P.M. or 2:30 P.M., so the resident should arrive back at the facility around 3:00 P.M. or 3:30 P.M. The resident should never arrive any later if arriving by the van. If he/she were to come later, they would have to personally take him/her and they would let the facility know. If there was a late activity such as a movie, then they would let them know when to expect him/her later. During an interview on 6/30/22 at 2:30 P.M., the DON and the social worker said the resident typically returns after 2:00 P.M. and has been going to the day program for a month and a half to two months. They said if/when a resident does not return, what happens was different with every case. When asked if the resident has been getting back by 2:00 P.M., would it be fair to say the resident would be expected back by shift change, around 3:00 P.M.? The social worker said he did not think so. They are notified if the resident goes on an outing. The back time is spontaneous. They may drive the resident around. The social worker said he has never personally gotten a call saying the resident was going to return late. He would expect to be notified that the resident did not return when when the sun goes down, dinner time, around 6:00. Then it would be alarming at that point. It was a unique case because it was a new nurse who was not sure what time the resident normally returns. The DON said he would expect the nurse to ask that if he/she was not sure. 2. Review of Resident #15's admission MDS, dated [DATE], showed: -Diagnoses included high blood pressure, acid reflux, renal failure, hyperlipidemia, manic depression, and schizophrenia; -BIMS score of 15 out of 15; (A BIMS score of 15 shows the resident is cognitively intact); -Had delusions; -Physical behaviors occurred 1 to 3 days; -Verbal behaviors occurred 1 to 3 days; -No wandering; -Independent with bed mobility, transfers, dressing, toileting and hygiene. Review of the resident's elopement risk assessment, dated 4/1/22, showed the resident was not at risk for elopement. Review of the resident's care plan, dated 4/1/22 and updated on 6/28/22, showed: -Focus: Resident was at risk of elopement due to a history of elopement and verbally expresses desire to elope from facility and has the physical capability to do so; -Goal: The resident will be monitored closely and remain safe through next review; -Interventions: Complete elopement assessment on admission, re-admission, and quarterly; -Face checks/intensive monitoring will be completed per facility protocol; -On 6/28/22, the resident attempted to elope from the facility. Resident pulled fire alarm in the dining room and ran through the front door to the main street. Staff called a code white and immediately responded. Resident spoke with staff outside and agreed to come back to the facility. Police notified and responded immediately. Guardian and physician notified. New order to send resident to emergency room for further evaluation; -Resident's photo and information will be kept in elopement book; -Focus: Resident had potential to be physically/verbally aggressive and has a history of self-harm related to diagnosis of bipolar disorder and schizoaffective disorder. He/she will hit his/her head on the wall and punch walls when agitated; -Goal: The resident will demonstrate effective coping skills through the review date; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; -Assess and address for contributing sensory deficits; -Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain; -Communication: Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; -Give the resident as many choices as possible about care and activities; -Monitor/document/report as needed (PRN) any signs and symptoms of resident posing danger to self and others; -On 6/25/22, multiple residents reported to charge nurse that the resident was in the dining room saying how he/she put a cigarette out on his/her right arm. Charge nurse assessed resident and noted an approximately 0.5 centimeter (cm) blister on his/her right forearm. Charge nurse asked the resident what happened and the resident replied, Oh I had a little mishap. Charge nurse then asked the resident to go on the hall so that nurse could look at it closer and get his/her vitals. Charge nurse was talking to the resident on the hall where he/she admitted to burning his/herself with a cigarette. Resident stated, when I am upset the only thing I find satisfying is pain. Charge nurse also noted three new holes in the wall next to his/her bed. Charge nurse asked resident what he/she was upset about and the resident stated, I am tired of being locked up. Charge nurse explained that responding the way that he/she did was not going to get him/her out of this place and in order to get out of here was to figure out a coping mechanism that will not be destructive or self-harming. Resident agreed with that. Call placed to physician, Director of Nursing (DON), and attempted to notify guardian with no answer and no voicemail to leave a message. Psych physician also notified and says he/she will be here on Monday; -On 6/29/22 charge nurse was notified by CNA that resident took medallion off his/her chain and slit wrist. Upon assessment, resident was standing in the hallway holding wrist and stated, you all are the devil and are trying to kill me. Upon wound assessment, nurse noted several superficial scars on resident's wrist. Nurse attempted to treat wounds and resident refused. Guardian, psych physician, physician notified. New order for resident to be directly admitted to hospital; -When the resident becomes agitated: Intervene before agitation escalates; guides away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Further review showed staff did not add any interventions after these incidents. Review of the resident's medical record, dated 6/25/22, showed: -A progress note, dated 6/25/22 at 10:15 P.M., showed multiple residents reported to charge nurse that the resident was in the dining room saying how he/she put a cigarette out on his/her right arm. Charge nurse assessed resident and noted an approximately 0.5 cm blister on his/her right forearm. Charge nurse asked the resident what happened and the resident replied, Oh I had a little mishap. Charge nurse then asked the resident to go on the hall so that nurse could look at it closer and get his/her vitals. Charge nurse was talking to the resident on the hall where he/she admitted to burning his/herself with a cigarette. Resident stated, when I am upset the only thing I find satisfying is pain. Charge nurse also noted three new holes in the wall next to his/her bed. Charge nurse asked resident what he/she was upset about and the resident stated, I am tired of being locked up. Charge nurse explained that responding the way that he/she did was not going to get him/her out of this place and in order to get out of here is to figure out a coping mechanism that will not be destructive or self-harming. Resident agreed with that. Call placed to physician, DON, and attempted to notify guardian with no answer and no voicemail to leave a message. Psych physician also notified and says he/she will be here on Monday. Physician said to apply Silvadene cream to area; however, blister has not burst yet; -The resident's behavior monitoring and interventions log, dated 6/25/22 at 7:25 P.M., staff documented the resident showed no behaviors. -The resident's electronic 1:1 monitoring log, dated 6/25/22, showed the resident was not on 1:1 monitoring. -The resident's electronic resident safety log, dated 6/25/22, showed no documentation of any suicidal, homicidal or elopement ideation. -Further review of the resident's record showed there was no interventions put in place after this incident. Review of the resident's medical record, dated 6/26/22, showed: -A progress note, dated 6/26/22 at 10:21 P.M., showed resident continues on IFU (investigation follow up) for putting cigarettes out on his/her arm. Resident was voicing no complaints of pain. No signs and symptoms of infection; -The resident's electronic behavior monitoring and interventions log, dated 6/26/22 at 3:00 A.M. and 10:59 P.M., showed staff documented the resident showed no behaviors; -The resident's electronic 1:1 monitoring log, dated 6/26/22, showed the resident was not on 1:1 monitoring; -The resident's electronic resident safety log, dated 6/26/22, showed staff documented the resident showed no signs of suicidal, homicidal or elopement ideation. Review of the resident's medical record, dated 6/27/22, showed: -A progress note, dated 6/27/22 at 11:30 A.M., showed IFU continues for wound to the right forearm noted. Resident voices no concerns at this time. No complaints of pain, no behaviors noted. Will continue to monitor; -The resident's electronic behavior monitoring and interventions log, dated 6/27/22 at 5:23 A.M. and 9:49 A.M., showed staff documented the resident showed no behaviors; -The resident's electronic 1:1 monitoring log, dated 6/27/22, showed the resident was not on 1:1 monitoring; -The resident's electronic resident safety log, dated 6/27/22, showed staff documented the resident showed no signs of suicidal, homicidal or elopement ideation. Review of the resident's medical record, dated 6/28/22, showed: -A progress note, dated 6/28/22 at 7:20 P.M., showed resident noted to be agitated and banging on the door to hall. This writer along with Resident Care Coordinator (RCC) spoke with resident and allowed resident to vent his/her feelings. Resident came out for his/her meal with no issues. After supper resident was noted to attempt to cut him/herself with a plastic fork. Redirected resident, then resident pulled the fire alarm and pushed the lobby door and ran out of the facility. Staff were right behind resident trying to stop him/her. 911 was called and the resident was allowed to vent and was brought back into the facility and taken to the smoke room to smoke and vent. Officers here now and escorted to the smoke room where the resident was venting his/her feelings. Resident stated that he/she was in pain due to him/her having cancer and he/she misses his/her friends. Call placed to resident's guardian, physician, and psych physician. ADON here and notified DON. Call placed to hospital and report given; -The resident's electronic behavior monitoring and interventions log, dated 6/28/22 at 8:18 A.M., showed staff documented the resident showed no behaviors; -The resident's electronic 1:1 monitoring log, dated 6/28/22, showed the resident was not on 1:1 monitoring; -The resident's electronic resident safety log, dated 6/28/22, showed staff documented the resident had signs of elopement ideation and suicidal ideation. The resident showed no signs of homicidal ideation. -Further review showed no interventions put in place after the elopement for elopements/behaviors. Review of the resident's medical record, dated 6/29/22, showed: -Progress notes, dated 6/29/22 at 6:34 A.M., showed resident arrived back from hospital at 5:20 A.M. via ambulance. Resident came back with no new orders. Resident alert, calm and cooperative. Zero suicidal/homicidal/elopement ideations voiced or attempted. Denies pain. Zero agitation present. Will continue to monitor for protective oversight; -At 10:56 P.M., at approximately 10:15 P.M., nurse was notified by CNA that resident took the medallion off of his/her chain and slit wrist. Upon nurse assessment, resident was standing in the hallway holding wrist. Resident stated, you all are the devil and are trying to kill me. Wound assessment nurse noted several superficial scars on the resident's wrist. Nurse attempted to treat wounds, resident refused. Resident also stated he/she is tired of us; -The resident's electronic behavior monitoring and interventions log, dated 6/29/22 at 5:42 A.M., showed staff documented the resident showed no behaviors; -The resident's electronic 1:1 monitoring log, dated 6/29/22, showed the resident was not on 1:1 monitoring; -The resident's electronic resident safety log, dated 6/29/22, showed staff documented the resident showed no signs of suicidal, homicidal or elopement ideation. -Further review showed no interventions put in place after the elopement for elopements/behaviors. During an interview on 6/29/22 at 8:30 A.M., the DON said the resident eloped. He/she pulled the alarm and went out the front door. He/she was found on the side walk in front of the facility. The resident was brought back in. The DON was unaware which fire alarm was pulled, if it was inside the secured unit or not, and who witnessed it. Review of the resident's medical record, dated 6/30/22, showed: -A progress note, dated 6/30/22 at 8:20 P.M., showed resident recently sent to the hospital for behavior; -The resident's electronic behavior monitoring and interventions log, dated 6/30/22 at 1:58 A.M., showed staff documented the resident showed no behaviors; -The resident's electronic 1:1 monitoring log, dated 6/29/22, showed the resident was not on 1:1 monitoring; -Further review showed no intervention put in place. -The resident's electronic resident safety log, dated 6/29/22, showed staff documented the resident showed no signs of suicidal, homicidal or elopement ideation. During an interview on 6/29/22 at 12:20 P.M., the Assistant Director of Nursing (ADON) was asked where the elopement book was located. He said he was not sure and will ask one of the old nurses here. The ADON then left the nurses station to go find someone. At 12:30 P.M., the ADON placed the elopement book on the counter at the nurse's station. He said it was up here, he just could not tell because the book was sitting upright and the label is on the front of the book. He said Resident #15 was not in the book yet and a resident should probably be placed in the elopement book within a day of their elopement. During an interview on 6/30/22 at 3:30 P.M., the DON said the resident attempted to cut him/herself and was sent out to the hospital. He/she did not have any additional information regarding the resident's self-harm or the the elopement that occurred on 6/29/22, and the investigation was still on-going. During an interview on 7/1/22 at 10:00 A.M., CNA E said the resident burned him/herself outside during the smoke break, but no one knew anything until the resident reported what he/she did. CNA E was not aware of any interventions that were put into place. On the day the resident eloped, CNA E was told by a nurse the resident could not come off the unit. It was an agency nurse, so CNA E did not know who it was. The resident was mad and said, they should take me to the hospital. CNA E left the unit to take his/her break, but when he/she returned the resident was observed at the nurse's station. He/she displayed behaviors during that time. CNA E had to return to the secured unit, but staff was at the nurse's station with the resident. CNA E took the residents on the secured unit outside to smoke. When CNA E was outside with the residents smoking, he/she saw the resident run across the parking lot as staff ran after him/her. The resident stopped at the end of the lot and surrendered. Staff walked the resident back inside. CNA E said an employee let the resident leave the unit when he/she was on break. He/she did not know who the employee was, and the resident was not on 1:1 monitoring. CNA E had no knowledge of any elopement or risk of elopement prior to the incident. He/she did not have any prior knowledge of any attempts of self-harm. CNA E was told that the resident pulled the fire alarm and went out of the front door. The resident was always quiet and CNA E said that the resident had been at the facility for a while, and it was the first time he/she witnessed behaviors. During an interview on 7/7/22 at 11:25 A.M., QLA D said he/she never had a problem with the resident. He/she worked on the secured unit with the resident and never had any issues with self-harm. The resident never really came out of his/her room other than to eat, go to group and talk on the phone. The resident had reported that he/she burned their arm with a cigarette. The resident said it was an accident. It was reported to the nurse. If a resident attempts to self-harm, they are usually on 1:1 monitoring. They may get sent back to the secured unit, but they are still on 1:1 monitoring. QLA D did not believe the resident was placed on 1:1 monitoring or any other inventions put in place. During an interview on 7/11/22 at 12:20 P.M., the Social Services Director (SSD) said when the resident was first admitted , he/she did weird stuff like stand over his/her roommate when they slept, but the staff was able to redirect that behavior. That was the only thing. The SSD said he did not know where the elopement came from. The SSD was told the resident burned him/herself with the cigarette, pulled the fire alarm, and banged his/her head. Most of the behaviors happened over the weekend, so the SSD was not in the facility. The resident should had been placed on 1:1 monitoring because of the self-harm. Any resident who displays self-harm is placed on 1:1 monitoring. If they are sent out to the hospital, they are still placed on 1:1 monitoring when they return. There was a lack of supervision on the secured unit. During an interview on 7/12/22 at 12:34 P.M., the Regional Director said she would expect residents to be assessed if they self-harm. The facility is expected to have interventions in place and start an investigation. The nurse should complete an assessment to show if the resident was at baseline and the resident should had been transported to the hospital after he/she burned him/herself with the c

Based on interview and record review, the facility failed to thoroughly investigate, in accordance with their policies and procedures, a staff-to-resident incident which resulted in an allegation of abuse from Resident #506. Per facility policy, nursing staff also failed to thoroughly assess the resident, who experienced difficulty breathing, after two staff members witnessed Administrator-in-training (AIT) X lying on top of the resident (who was supine/lying face up on the floor) while holding the resident's arms on the floor. The resident's face was covered by the resident's shirt. In addition, the facility failed to keep one resident free from abuse when one resident (Resident #69), who resided on a secured behavior unit, obtained, ingested and tested positive for [MEDICATION(S)] (a powerful synthetic opioid [MEDICATION(S)] for severe pain that is similar to [MEDICATION(S)] but is 50 to 100 times more potent) on 5/28/21. The sample was 26. The census was 132. Review of the facility's policy titled Abuse and Neglect Policy, reviewed 7/8/20, showed every resident had the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Every resident also had the right to be free from verbal, sexual, physical or mental abuse, corporal punishment, and involuntary seclusion. Mistreatment, neglect or abuse of residents was prohibited by the facility. Physical abuse was defined as purposefully beating, striking, wounding or injuring any consumer or any manner whatsoever of mistreating or maltreating a consumer in a brutal or inhumane manner. Physical abuse included handling a consumer with any more force than was reasonable for a consumer's proper control, treatment or management. Upon learning of a report of abuse or neglect, the administrator was to initiate an incident investigation. If the resident complained of physical injuries or if harm was suspected, then staff was to contact the resident's physician for further instructions. The facility was to immediately call 911 to involve the police department, when there was physical abuse involving physical injury inflicted on a resident by a staff member or visitor. Review of the facility's policy titled Behavioral Emergency Policy reviewed 2/26/21, showed the purpose was to provide safe treatment and humane care to the resident in a behavioral crisis and outline steps to follow in order to correctly care for the resident in a behavioral crisis, to ensure that the resident was not being coerced, punished or disciplined for staff convenience. If the resident exhibited extreme behaviors such as suicidal, homicidal, self-mutilation, elopement or resident-to-resident altercations, then the licensed nursing staff/team leader/resident care coordinator (RCC) would assess the resident exhibiting such behaviors. Ensuring the safety of the resident and others was the first priority. A one-to-one monitoring of the resident was to be initiated by staff under the direction of the licensed nurse. In the event that the resident was unable to be redirected or was requesting an as needed (PRN) medication for mood stabilization, the resident would receive the PRN medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation of the behavior emergency in the registered nurse investigation was to include evaluation of the resident's behavior with consideration for precipitating events or environmental triggers and other related factors in the medical record, with enough specific detail of the actual situation to permit underlying cause identification to the extent possible. If the resident required medication or the utilization of approved crisis allevations lessons and methods (CALM, a system of de-escalation, prevention and safety procedures designed for use in nursing homes, hospitals and schools) techniques, then staff was to assess the resident, closely monitor his/her vital signs and notify the physician of any changes or concerns regarding the resident's condition. Behavioral emergency=code green. The licensed practical nurse (LPN) or registered nurse (RN) must be present during the entire use of approved CALM hold techniques. There were only two reasons that staff was to utilize approved CALM hold techniques; when a resident was in imminent danger of harming him/herself or when a resident was in imminent danger of harming others. Approved CALM hold techniques were never to be utilized for punitive reasons, discipline or for staff convenience. Staff was never to threaten the use of CALM as a scare tactic or a threat. A code green did not denote that approved CALM hold techniques were automatically utilized. After every code green which required utilization of approved CALM hold techniques, the director of nursing (DON) or designee was to complete a RN investigation of the occurrence regarding the resident's behavior and staff responses. All behavioral emergency code green reviews filled out by the responding staff were to become part of the RN investigation to ensure that the behavioral crises was handled professionally, that it could not have been avoided and was handled by CALM certified staff using appropriate techniques following the policies of the facility. Any resident who requires approved CALM hold techniques must have complete skin assessment with vital signs monitored for 72 hours. The physician and legal guardian were to be notified of assessment findings and other concerns regarding the resident's behavior emergency crisis. 1. Review of Resident #506's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/1/21, showed the following: -Cognitively intact; -Weight: 148 pounds, 63 inches tall; -Required supervision of personal hygiene and bathing; -No mobility devices; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, updated 12/10/20, showed the following: -The resident is alert and oriented times three (person, place and time), able to make his/her needs known, has impaired cognition and decision-making with limited judgment/insight; -The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she had periods of restlessness with repetitive pacing, verbal/physical aggression and demanding behavior; -The resident experiences paranoia which impacts his/her behavior. The resident will act out aggressively against staff or other residents, while in a paranoid state; -During periods of agitation, staff is to allow the resident to vent his/her fears and frustrations; -When addressing the resident, get his/her attention using a calm tone and volume. Speak in short simple statements and instructions. Allow him/her time to process and respond; -Do not argue with the resident. Speak to the resident in a calm tone. Attempt to redirect him/her, when he/she is exhibiting a behavior. Approach the resident with his/her permission, in a gentle manner and explain what you are trying to do; -The resident takes antipsychotics for management of mood/behavioral symptoms which may affect his/her cognitive ability. He/she is at risk for falls and adverse drug reactions. Review of the facility's undated investigation summary, showed on 5/15/21, at approximately 10:00 P.M., the resident got upset with AIT X. The resident wanted AIT X to take him/her to the laundry area to get clean linen. AIT X told the resident that he/she would take the resident in a little bit. The resident got upset, after seeing another staff member take a peer off of the hall, before the resident got to leave. The resident yelled at AIT X, calling AIT X a no good mother[OBSCENITY] , went into his/her room and slammed the door. AIT X knocked on the resident's door, entered the room to check on the resident and noted that the resident was in the restroom. AIT X did not indicate that the resident was further agitated. AIT X went back out into the hallway and a few moments later, the resident came out of his/her room yelling at AIT X, calling him/her a piece of[OBSCENITY] AIT X attempted to de-escalate and redirect the resident, who continued to yell and advanced toward him/her. The resident then started to swing at AIT X, who called for a code green to be announced. AIT X attempted to block the resident's right arm from hitting him/her. The resident made contact with AIT X's face with the left arm. While the code green was being called, AIT X continued to try and block the resident from striking him/her. During this event, the two of them fell to the floor. As they fell , the Hall Monitor (Dietary Aide FF) responded to the code green to assist with redirection. The resident continued to try to kick, hit and spit on staff. AIT X was able to secure one of the resident's arms, while the Hall Monitor secured the other arm. More staff members responded to the code green and the charge nurse took over as team leader. AIT X was tapped out of the code green, in an attempt to de-escalate the resident. AIT X went to the front conference area to await further instruction. Staff assisted the resident off of the floor and provided 1:1 attention for the resident to verbalize and ventilate his/her feelings, which enabled him/her to calm down. The charge nurse completed a head-to-toe assessment and neurochecks with no injuries noted. The nurse did not note any pain. The resident's vital signs were as follows: temperature 98.6 (normal range: 97.8-99.1 degrees Fahrenheit), pulse 95 (normal range: 60-100 beats per minute), blood pressure 125/94 (normal range: 90/60 millimeters/Hg (millimeters of mercury)-120/80 mm/Hg), and oxygen saturation on room air 99% (normal range: 95%-100%). Summary of incident investigation findings: The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she could become easily agitated and strike out, when his/her expectations were not met. AIT X attempted to redirect the resident without success. The resident took an aggressive approach toward staff, by attempting to hit AIT X, who then tried to block the resident from making contact. While AIT X was trying to block the resident's strikes, they both fell to the floor. Staff notified the administrator of the altercation at approximately 10:30 P.M. The administrator went to the facility and began the investigation. Staff notified the police department. AIT X wrote his/her statement and was suspended, pending an investigation. Staff contacted the resident's physician, did not receive any new orders and placed the resident under 1:1 supervision for protective oversight. Staff attempted to reach the resident's legal guardian and left a voicemail message. Administration provided a self-reporting of the incident to the Missouri Department of Health and Senior Services within two hours of the altercation. Plan of action: educational needs- educate staff on the behavior emergency policy, CALM techniques, resident triggers. AIT X was removed from his/her assignment at the facility. Review of the resident's progress note, dated 5/16/21 at 6:33 A.M., showed the resident was displaying increased agitation related to a resident-to-staff altercation. Staff called a code green. Upon entering the unit, LPN EE saw the resident lying on the floor in the doorway of his/her room with AIT X on top of the resident holding the resident down. LPN EE stepped in and asked AIT X to remove him/herself from the situation, so LPN EE could intervene. Staff helped the resident off of the floor. The resident was able to vent the frustrations and concerns, which led to the aggression. LPN EE completed a full body assessment, did not note any bruising or bleeding and educated the resident on asking to speak to LPN EE when upset. Staff was educated on proper CALM techniques. Review of the resident's undated written statement, regarding the incident, showed he/she was talking to AIT X about going to get his/her clothes. A staff person from the laundry department happened to open the door to the locked unit and another resident went with him/her, instead of Resident #506. Resident #506 and AIT X started arguing, because AIT X would not allow Resident #506 to go. The resident was arguing that it was not fair. AIT X got really smart with the resident and said that the resident could wait until the next day. When the resident got sarcastic, AIT X called a code green and took him/her to the floor. The resident started struggling with AIT X, who pulled the resident's shirt over the resident's face, slapped him/her in the face and stuck a finger in the resident's throat. AIT X kept the shirt over his/her face, until the nurse entered the unit. Review of Resident #517's undated written statement showed, when Resident #506 was on the floor, Resident #517 saw AIT X strike Resident #506 twice. Review of LPN EE's written statement, dated 5/16/21, showed staff called a code green for 600 hall. LPN EE entered the unit. AIT X was on top of the resident. The two of them were yelling back and forth. As LPN EE got closer, he/she saw that AIT X was stuffing the resident's shirt into his/her mouth. LPN EE asked AIT X to tap out and allow the other staff present to take control, in order to defuse the situation. Review of Certified Medication Technician (CMT) GG's written statement, dated 5/16/21, showed he/she responded to the code green called for 600 hall on 5/15/21. The resident was face up on the floor, held down by two staff members. One of them was holding the resident's shoulders down and the other was holding down the resident's legs. The resident's shirt was covering his/her face. The staff members holding the resident down said it was because the resident was spitting on them. The resident said that staff (AIT X) hit him/her. The resident was cursing at staff and saying that he/she would get the staff person fired. They tapped the staff person out and asked him/her to leave the unit. Further review of the facility's incident investigation and the resident's medical records, did not show documentation of 72 hour vital signs on the resident per the behavioral emergency policy. The investigation summary did not indicate that the issues of AIT X covering the resident's face with the resident's shirt and/or stuffing the shirt into the resident's mouth, the resident's allegations of AIT X striking him/her and pressing a finger into the base of his/her neck or the appropriateness/risk for harm caused by the manner in which the CALM technique was utilized by staff were investigated. No findings regarding those issues were included in the investigation summary. Review of the administrator's e-mail, sent 7/20/21 at 2:12 P.M., showed she could not find an incident report or code green review sheets for this incident. According the administrator, AIT X completed his/her CALM training on 4/7/21. In response to a request for incident witness statements, she attached to the e-mail statements for all staff who witnessed the incident, with the exception of AIT X and Hall Monitor/Dietary Aide FF. Review of AIT X's abuse and neglect policy acknowledgement, dated 10/1/17, showed he/she acknowledged that he/she received, read, understood and had the opportunity to ask questions concerning the abuse and neglect policy. Review of AIT X's Missouri commercial driver's license showed he/she weighed 240 pounds and was 5 feet 11 inches tall. During interviews on 7/13/21 at 2:30 P.M. and 7/30/21 at 11:08 A.M., AIT X said on the day in question, he/she was sitting at the end of the hall in secured unit 600, when Resident #506 asked to go to the laundry. AIT X told him/her to wait until staff returned from assisting with snack time. A certified nurse aide (CNA) entered the unit and another resident asked if he/she could go and heat up some food. AIT X granted that resident permission to leave the unit with the CNA. Resident #506 got mad saying, that was our aide. He/she started cursing and went into his/her room. AIT X followed and asked if the resident was alright. The resident said, just leave me alone. I'll be fine. AIT X explained that the CNA was not assigned to unit 600 and promised the resident would be allowed to go to the laundry, when the assigned CNA returned. AIT X went back out into the hall. The resident came out, still angry and cursing while walking towards AIT X fast. Several times, AIT X asked the resident not to curse at AIT X. The resident suddenly swung his/her right arm, attempting to hit AIT X, who turned sideways, leaned back and caught the arm. The resident tried to pull away and AIT X shouted for someone to announce code green over the intercom. With his/her left hand, the resident slapped AIT X in the face twice. They fell down. AIT X believed that either the resident pulled them down or leaning backwards caused AIT X to lose his/her balance. AIT X was still holding the resident's right arm in both of AIT X's hands like a baseball bat. Hall Monitor/Dietary Aide FF and CMT GG entered the unit. The resident was lying on his/her back. Dietary Aide FF held the resident's left arm. AIT X then told Dietary Aide FF and CMT GG that they could not hold the resident on his/her back. The resident was wearing an oversized T-shirt. One arm had slipped out of the sleeve and the shirt had slid up over his/her face. AIT X did not pull the shirt over the resident's face or stuff it into his/her mouth. The resident never spit, but was talking crazy and threatening to spit. AIT X never laid on top of the resident, he/she was off to the side on the floor. At one point, he/she was up on his/her knees, holding the resident's right arm. Others came and told AIT X to leave the unit, because the resident was fixated on him/her. They said, you're the trigger. You need to leave. AIT X went out into the front lobby of the facility. AIT X never lost his/her temper, did not strike the resident or press a thumb into the base of the resident's neck. He/she was suspended and never called back to work at the facility. He/she completed CALM training during the first week in April of this year. AIT X had previously read the resident's care plan and was familiar with the interventions listed. AIT X had worked with the resident at several other facilities and was knowledgeable about the resident's care needs. During interviews on 7/7/21 at 9:30 A.M. and 7/16/21 at 7:03 A.M., the resident said on the day in question, he/she was sitting down, waiting to go and get his/her laundry. The resident had to wait for someone to return. It was taking a long time. He/she grew frustrated and stood up, complaining to AIT X, how long does it take to get your laundry and come back? AIT X ordered him/her sit back down. The resident refused. AIT X got into his face saying, you want me to call a code on you? I'll kick your ass! The resident still refused to sit down saying, come on in my room and do it. AIT X called a code green and performed a takedown on the resident without any other staff present. AIT X was lying on top of the resident and holding down the resident's arms. It was hard for the resident to breathe with AIT X on top of him/her. AIT X pulled the resident's shirt over his/her face and struck the resident on the side of the face. The resident swatted at AIT X, who then pressed a finger into the base of the resident's neck, in the front, so hard that it caused a bruise to form. The shirt was stretched so much that the resident could see shadows through it. He/she saw Dietary Aide FF approach, but Dietary Aide FF did not do much. He/she just held one of the resident's arms. Staff never turned the resident onto his/her stomach. The resident did not spit. He/she did not recall his/her shirt being stuffed into his/her mouth. During an interview on 7/30/21 at 1:11 P.M., Resident #517 said he/she witnessed the incident and saw AIT X bear down on Resident #506's throat and slap him/her a couple of times. Resident #517 could not recall any other details of the incident. The day after the incident, Resident #506 developed a bruise below the neck but above the upper sternum from being held. The bruise was a dark purple which looked black. In general, AIT X was not nice to residents in the unit. However, he/she was not mean to them. AIT X just did not have much patience with residents. During an interview on 7/15/21 at 3:08 P.M., Dietary Aide FF said on the day in question, he/she was returning from a break and about to continue his/her 1:1 supervision assignment, when he/she heard the code green announcement and entered unit 600. AIT X had already taken the resident down and was lying on top of the resident and holding the resident's arms down. The resident's shirt rode up as he/she struggled, attempting to free him/herself. LPN EE entered and moved to pull the shirt off of the resident's face. AIT X said, Don't move the shirt, because he'll spit at you. LPN EE urged AIT X to get up off of the resident. Dietary Aide FF assisted by holding down the resident's left arm. AIT X moved off to the side and held down the resident's right arm. With the shirt off of his/her face, the resident started spitting. They rolled the resident onto his/her stomach and CMT GG held the resident's head. The resident was arguing with AIT X, who was angry but not saying anything. Initially, AIT X did not want to leave. With urging from LPN EE, he/she left the unit. Dietary Aide FF did not see AIT X strike the resident, press his/her thumb into the resident's neck or stuff the shirt into the resident's mouth. During an interview on 7/15/21 at 11:35 A.M., CMT GG said prior to the incident, he/she was not on unit 600. CMT GG heard someone yelling, code green. When he/she entered the unit, AIT X was not lying on top of the resident. The resident was face up on the floor and AIT X was kneeling over the resident, holding down both arms. The resident was fighting and spitting. His/her shirt was not over his head or in his/her mouth. Dietary Aide FF was holding the resident's legs. The resident kept saying that AIT X had choked him/her, but there was no visible bruising. They turned the resident onto his/her stomach. Each of them held one part of the resident's body: one person held his arms, legs and head. They held the resident that way for five minutes and then released him/her. During an interview on 7/15/21 at 2:30 P.M., LPN EE said he/she was at the nurse's station on the day in question, when Dietary Aide FF came out of unit 600 and yelled, code green. LPN EE entered the unit and saw the resident lying on the floor, in the doorway of his/her room, with his/her legs out in the hallway. AIT X appeared to be angry and was on top of the resident, forcibly attempting to stuff the top portion of the resident's shirt (neck/collar) into the resident's mouth. The resident was not gagging, but tried turning away his/her face. AIT X and the resident were arguing, going back and forth. AIT X's actions were making the situation worse; he/she had the resident's arms pinned to the floor. The resident could not lift his/her arms. He/she was screaming and yelling, attempting to get up. Initially, AIT X refused to get off of the resident. When LPN EE attempted to pull the resident's shirt back down, AIT X said the resident would spit in LPN EE's face. LPN EE had to move between them and use an arm to urge AIT X, who had moved on the resident's left side, to get up. Dietary Aide FF was present in the room, but staff never turned the resident onto his/her stomach. Once AIT X got off of the resident, the resident got up and was completely calm. He/she had started to calm down, as soon as he/she saw LPN EE. The two of them had that kind of relationship. LPN EE told AIT X to let him/her talk to the resident. AIT X did not want to leave, so LPN EE had someone walk him/her off of the unit and took the resident into the resident room. Prior to that day, LPN EE had not wanted AIT X working with the resident, because AIT X was short-tempered and seemed to be on a power trip. One time, LPN EE needed to bring the resident off of the unit for something. AIT X said no, the resident was not coming off of my unit. LPN EE had to remind AIT X that LPN EE was the charge nurse for the unit. During an interview on 7/20/21 at 10:25 A.M., the administrator said it was not appropriate for a staff person to tell a resident that he/she would call a code green, if the resident did not sit down and be quiet. If an agitated resident walked away and went into his/her room, it was not appropriate for the staff person to follow him/her, unless the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It was never appropriate for a staff person to lie on top of a resident. Stuffing the resident's shirt into the resident's mouth was unacceptable, even if the resident was spitting at staff, because it could obstruct his/her breathing. The facility ensured all staff received CALM training, prior to working on locked resident units. After an incident in which staff employed CALM techniques, staff were to fill out an emergency code green review sheet. The administrator agreed to provide copies of witness statements for AIT X and the other staff who witnessed the incident as well as documentation of AIT X's CALM training. During an interview on 7/16/21 at 1:30 P.M., the DON said it was never acceptable for a single staff person to perform a CALM takedown without assistance from other staff trained in the technique. Doing so posed a high risk of harm to the resident. Lying on top of a resident could hinder his/her breathing. If a staff person observed another staff person engaging in those behaviors, then that staff person should tap out their co-worker and immediately report it to supervisory and/or administrative staff. Proper procedure was for the staff person who was the target of the code green needed to leave, so that his/her co-workers could de-escalate the resident. During an interview on 7/16/21 at 7:30 A.M., Facility Advisory Nurse/RN C said appropriate CALM technique consisted of the following: verbal de-escalation was the first step. If a resident required physical intervention, then staff was to perform a two-man hold with the resident standing or sitting between them. Each staff member was to exert pressure via a hand-over-hand hold on the he resident's arm and wrist. Taking a resident down to the floor required the participation of five staff. With the resident's arms extended and their joints intact, staff was to apply pressure to the resident's shoulders as other staff members held and supported each of the resident's leg with their hands on the thigh and lower leg/shin. Providing support, the group would then guide the resident down to the floor onto his/her stomach with a pillow under the resident's head, which should be turned to one side. Once the resident was on the floor, staff was to keep the resident's arms and legs spread. At no point was it appropriate for a staff member to be on top of the resident. That could result in bruising or occluding of the resident's airway. It was also inappropriate to hold the resident's head straight back, because that could also occlude his/her airway. Keeping the resident's head sideways would be an appropriate way to prevent him/her from banging his/her head on the floor. It was not appropriate to stuff the resident's shirt into his/her mouth, because it could occlude his/her airway. Appropriate CALM technique never involved covering the resident's face with his/her shirt. During an interview on 7/21/21 at 11:32 A.M., Physician W said a staff person should never lie on top of a resident or stuff a resident's shirt into his/her mouth. If lying on a resident resulted in pressure being applied to the resident's neck, then it could block his/her airway. Heavy pressure on the chest could lead to the resident experiencing difficulty breathing. No one should be on top of a resident, unless that resident was attempting to self-harm or kill him/herself. 2. Review of Resident #69's preadmission screening/resident review (PASARR) Level II screening (a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Reports paranoid delusions and hallucinations. History of incarceration due to substance abuse and driving while intoxicated. Review of the resident's face sheet, showed the following: -admitted to a secured unit room in the facility on 4/24/21; -Had a legal guardian; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's departmental notes, dated 4/25/21 at 10:17 A.M., showed the facility admitted the resident. The resident was ambulatory, alert and oriented times three (to person, place and time), denied complaints of pain or discomfort, denied thoughts or feelings of harm to self or others. No suicidal, homicidal or elopement ideations. Resident is polite and smiling. Review of the resident's social service note, dated 4/30/21, showed the resident transferred from another facility. Resident had a long history of drug abuse and addiction. Resident stated he/she last used in 2017. Review of the resident's admission MDS, dated [DATE], showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's departmental notes, dated 5/28/21 at 8:16 A.M., showed at approximately 6:15 P.M. on 5/27/21, code blue was called to resident's room. Resident noted to be laying in bed with the head of bed elevated, oxygen on per nasal cannula. Staff reported that they witnessed the resident kneeling down and then went unresponsive. 911 called. Pupils dilated and eyes rolled upwards. Resident did not respond to sternal rub or verbal stimuli. Resident given nasal [MEDICATION(S)] (nasal spray, the first nasal formulation of [MEDICATION(S)] to be FDA approved for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Approximately 6:25 (5 minutes after [MEDICATION(S)] was administered), resident became responsive at approximately 6:30 P.M. Review of the hospital note, dated 5/28/21, showed EMS gave [MEDICATION(S)], after which he/she regained consciousness. The resident admitted to snorting unknown substance which he/she found on the floor at the facility. His/her urine toxic screen is consistent with [MEDICATION(S)] intake. During an interview on 6/4/21 at 2:11 P.M., the resident said he/she paid a staff member, whose name he/she didn't remember, for two pills and a chunk of white powder. The resident said he/she made the purchase in his/her room. During an interview on 7/14/21 at 11:22 A.M., the social service director (SSD) said the resident has a history of substance abuse. The resident said he/she had a problem with drugs, and marijuana was his/her drug of choice. The SSD was familiar with the incident that occurred. The resident had been at the facility for [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents by not following their protocols for resident monitoring on the 600 hall locked unit for one resident (Resident #1) who had verbalized a desire to leave the facility. Staff failed to ensure Resident #1 returned inside after the 9:00 P.M. smoke break on [DATE]. In addition, staff failed to monitor the residents per facility protocol. The certified nursing assistants (CNAs) and licensed nurses for the 3:00 P.M. to 11:00 P.M. and 11:00 P.M. to 7:00 A.M. shifts incorrectly documented the resident was in the facility during hourly resident checks after the 9:00 P.M. smoke break. The facility failed to identify the resident as missing until approximately 6:30 A.M. on [DATE], when the certified medication technician (CMT) could not locate the resident for morning medications. The resident climbed an approximate 6 foot fence to get out of the facility smoking area. He/she walked approximately half a mile away to a gas station, where police were called and the resident was sent to the hospital. The resident was located by the facility at the hospital on [DATE] at approximately 8:30 A.M. The census on the locked unit was 21, and approximately 13 of the 21 residents smoke. The census was 140. The administrator was notified on [DATE] at 3:53 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 Monitoring of Residents on Visual Face Checks policy, dated [DATE], showed: -Affected Personnel: All facility staff; -Purpose: To ensure a system is in place for residents who require increased monitoring for behavioral/psychiatric and medical issues. Monitoring staff on units with residents who require more intensive monitoring; -Procedure: Residents who require more monitoring due to medical, behavioral/psychiatric symptoms will be monitored on visual face checks; -Residents may require more intensive monitoring based on their medical and behavioral/psychiatric needs. The resident will be assessed to determine the reason for the intensive monitoring, the length of time for intensive monitoring and the frequency of the intensive monitoring. This will be completed by administrative staff; -Residents who are showing poor impulse control including verbal/physical aggression, elopement ideations, suicidal/homicidal ideations, decompensation mentally and medically may also be placed on one to one (1:1, within eyesight of staff at all times) monitoring at the discretion of the Administrative staff; -Residents may require based on behavior/medical issues a less intensive monitoring which would require staff to visually check the resident more often than every 15 minutes; -All residents on each unit will be monitored by visual checks at least within 30 minutes; -If a unit has 12 or more residents that require less intensive monitoring of more than 15 minutes then staffing for the unit will include an additional staff member at all times; -Visual face checks will be documented on the 1:1 monitoring form and reviewed daily by the administrator/designee and or the Director of Nursing (DON)/designee including the 15 and 5 minute face checks and the 1:1 monitoring. Review of Resident #1's Preadmission Screening and Resident Review (PASRR, a tool used to screen residents for evidence of serious mental illness and/or intellectual disabilities, developmental disabilities, or related conditions to determine appropriateness of placement in a nursing facility and to calculate a resident's service needs) level 2 evaluation, dated [DATE], showed: -Records indicate [DIAGNOSES REDACTED]. Records indicate mild mental [MEDICAL CONDITION] and borderline intellectual functioning. [MEDICAL CONDITION] at age 14 with resulting poor impulse control and cognitive issues, per referral documentation. Left eye [MEDICAL CONDITION] due to gunshot wound (pellet gun), history of inhalant abuse. Records indicate history of auditory hallucinations on regular basis, insight and judgement impaired, cognitive issues, confused; -Overt behaviors: Frequent/continuous yelling, pacing, impatient/demanding, wandering, physically threatening, suspicious of others; -Cognitive skills/adaptive functioning: -Makes good decisions: No; -Stays on task: No; -Follows complex directions: No. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admitted [DATE]; -No mood concerns identified; -Exhibited hallucinations, delusions; -Physical behaviors and rejection of care exhibited ,[DATE] days; -Wandering behavior not exhibited; -No mobility devices required; -[DIAGNOSES REDACTED]. -Smoker; -Took antipsychotic and antidepressant medications. Review of the resident's 5-day MDS, dated [DATE], showed: -Readmitted [DATE]; -Moderate cognitive impairment; -Ambulates independently; -[MEDICAL CONDITION] not exhibited; -Behavioral symptoms not exhibited; -Wandering behavior not exhibited; -[DIAGNOSES REDACTED]. Review of the resident's facility medical record, showed: -A smoking assessment, dated [DATE], showed: -Is a smoker; -Does the resident have a history of poor judgement regarding safety of themselves or others? No; -Is the resident able to move freely without assistance? Yes; -Does the resident show good insight and judgement? Yes; -Is the resident compliant with the facility rules? Yes; -Is the resident an elopement risk? No; -Is the resident currently allowed to go off the unit unsupervised? No; -Is the resident safe to smoke unsupervised? Yes; -An order, dated [DATE], for [MEDICATION NAME] (anti-anxiety medication) 2 milligrams (mg) by mouth four times daily as needed (PRN) for 14 days; -A certified nurse aide (CNA) care plan, undated, showed: -Elopement: No; -Face checks every 15 minutes; -Behavioral: High. Physically aggressive, verbally aggressive, non-compliant, combative. Review of the resident's care plan, printed [DATE], and in use at the time of the abbreviated survey showed: -Problem, onset date of [DATE]: Resident can be verbally inappropriate, often with references of delusions/hallucinations. He/she can be very intrusive with disregard for other's personal space, has periods of impulsiveness/restlessness, and can be physically/verbally aggressive with staff/peers; -Approaches include: -Monitor resident for signs/symptoms of mood/behavior disturbances of persistence. Document and report observations to the physician; -Provide resident with other outlets for frustration and anxiety; -During period of anxiety/agitation, reduce environmental stimulation to a minimum or remove resident from the source of agitation; -Administer PRN medications as ordered; -Update [DATE]: Noted physical aggression toward staff. PRN given and resident placed on 1:1; -Update [DATE]: Noted agitation with staff, threatening behavior, yelling, unable to control. He/she ran across the hall and tried to attack peer, who closed the door on him/her and resident hit the door instead. He/she ran back to his/her room and proceeded to punch his/her roommate, hitting them in the nose. Resident given PRN and was sent to hospital for evaluation; -Update [DATE]: Resident was outside smoking when he/she and a peer started displaying increased agitation, leading to physical aggression. PRN medication given; -Problem, onset date of [DATE]: Resident has impaired decision making with limited judgement/insight related to his/her [DIAGNOSES REDACTED]. He/she has periods of delusions/hallucinations that may further impact his/her cognitive skills; -Approaches include: -Give verbal cueing/reminders as needed with daily tasks and for protective oversight; -Monitor for any changes in his/her mood/behavior pattern, refer as needed for psychiatric evaluation; -Assess for changes in his/her cognitive pattern that may further impact his/her communication abilities; -Assess for changes with his/her baseline level of functioning and refer to evaluation as needed. Review of the facility's self-report to the Department of Health and Senior Services, received on [DATE], showed Resident #1 was reported as missing from the facility on [DATE] at 6:50 A.M. Staff contacted police and searched for the resident at local businesses. A gas station attendant said a person matching the resident's description was in the gas station around 1:00 A.M. The police were notified and the resident was taken to a local hospital for evaluation after making delusional statements about bugs crawling all over him/her. Review of Google Maps, showed: -Distance from facility to the gas station: 0.5 miles; -Walking time: 10 minutes. Observation on [DATE] at approximately 9:15 A.M., showed the facility located on a hilly two lane road with a speed limit of 25 miles per hour (mph). A partial sidewalk on the same side of the facility ended and resumed, and the resident would have to pass several side streets and driveways. The resident would have to turn left at the end of the two lane road, onto a four lane road with a speed limit of 45 mph and a sidewalk leading to the gas station. The gas station located approximately 0.1 miles from a six lane interstate. During an interview on [DATE] at 9:30 A.M., the administrator said Resident #1's room was on the 600 hall, a locked unit. Staff should check the residents every hour. When residents receive smoke breaks on the unit, one staff should go outside to the courtyard, while the other staff lets residents outside. One staff remains outside with residents during the smoke break, while the other staff remains inside to monitor residents who do not smoke. Once the smoke break is over, the staff outside with the residents should count them as they return to the building. On [DATE], CNA A was assigned to the 600 hall for the 3:00 P.M. to 11:00 P.M. shift. Upon reviewing the facility's surveillance footage, the administrator saw CNA A let the residents, including Resident #1, go outside for the evening smoke break around 9:00 P.M. Maintenance Assistant (MA) L remained inside with non-smoking residents. When CNA A let the residents back inside the building, Resident #1 did not return. Staff should have counted the residents as they came back inside. CNA A sat in a chair right outside of Resident #1's room and marked the hourly monitoring checks as having been completed for the resident; however, Resident #1 was not in his/her room. When the CMT arrived to pass medication on [DATE] at 6:30 A.M., he/she could not locate the resident and called a Code White, notifying all staff that a resident was missing. Staff searched the area nearby for the resident, and located a gas station attendant who reportedly saw the resident just before 1:00 A.M. According to the gas station attendant, Resident #1 exhibited irrational behavior, so the police were notified and the resident was taken to a local hospital. Staff contacted the hospital and verified Resident #1 was there and had no injuries. Resident #1 returned to the facility on [DATE] between 11:00 A.M. and 12:00 P.M. When the administrator interviewed the resident about what happened, he/she said he/she thought someone would see him/her outside and would let him/her back in. He/she waited in the courtyard for hours, then hopped the fence and walked to the gas station where he/she died . Resident #1 was not an elopement risk prior to the incident on [DATE], but now he/she is. The administrator said Resident #1 was not the cause of the problem, and the incident was a people failure. CNA A should have checked on the residents hourly, and should not have lied on the hourly monitoring log. Ultimately, the charge nurse is responsible because he/she should have checked the residents as well. Review of the 1 Hour CNA Intensive Monitoring Checks for the 600 hall, dated [DATE], showed: -Place a check in the box signifying that the resident was seen face to face. If the resident is not seen on the unit, use key to signify location; -Checkmarks and slashes in the boxes next to Resident #1's name hourly, from 7:00 A.M. on [DATE] to 5:00 A.M. on [DATE]; -By signing below, I confirm that I have visually checked all residents on my assigned unit and all residents are accounted for; -CNA A signed for the 3:00 P.M. to 11:00 P.M. shift; -CNA K signed for the 11:00 P.M. to 7:00 A.M. shift. Review of the 1 Hour Licensed Nurse Intensive Monitoring Checks for the 600 hall, dated [DATE], showed: -Place a check in the box signifying that the resident was seen face to face. If the resident is not seen on the unit, use key to signify location; -Slashes and dashes in the boxes next to Resident #1's name hourly, from 7:30 A.M. on [DATE] to 6:30 A.M. on [DATE]; -By signing below, I confirm that I have visually checked all residents on my assigned unit and all residents are accounted for; -Nurse I signed for the 3:00 P.M. to 11:00 P.M. shift; -Nurse H signed for the 7:00 P.M. to 7:00 A.M. shift. Observation of the 600 hall on [DATE] at 10:20 A.M., showed: -Entry to the unit from the facility required keypad entry. Door alarm functioned properly; -Resident #1's room at the end of the hall, just before the exit door to the outdoor courtyard. A chair placed in the area between the exit and Resident #1's room; -Exit from the unit to the outdoor courtyard required keypad entry. Door alarm functioned properly; -The 600 hall outdoor courtyard fully enclosed by a wooden fence, over 6 feet high; -Chairs placed in the middle of the grass in the courtyard. Observation of the resident on [DATE], showed: -At approximately 10:20 A.M., he/she stood at the medication cart on the 600 hall, yelling profanities. He/she wore pajama pants and a t-shirt with a hospital bracelet on one wrist. Minutes later, he/she sat in the indoor smoking room, yelling profanities at him/herself; -At 10:50 A.M., the resident lay in bed in his/her room and said he/she was not here right now. During an interview on [DATE] at approximately 10:25 A.M., CNA J said two staff should be assigned to the 600 hall at all times. Smoke breaks are four times a day and one staff must go outside with the residents and count them as they come in. During the smoke break, the other staff member has to stay on the unit to monitor the other residents. Resident #1 stays in his/her room most of the time. He/she does not usually go outside for smoke breaks and when he/she does, he/she sits in the grass and looks at the sky. Staff is responsible for making sure residents are where they are supposed to be. CNAs complete hourly checks on the residents, which are documented on 1 Hour CNA Intensive Monitoring Check forms. If a resident is not where they are supposed to be, staff must call a Code White to notify other staff of a missing resident. During an interview on [DATE] at approximately 12:10 P.M., CNA M said the 300 hall is also a locked unit for residents. There should be two staff working on the unit, but CNA M was the only one working on the unit that day. Many of the residents on the 300 hall are smokers. At the end of the hall, there is an enclosed courtyard where the residents smoke. Keypad entry is required to exit the unit and enter the courtyard. For smoke breaks, CNA M has to stand at the exit to the courtyard, where he/she can see the 300 hall and the courtyard patio. The rule is residents cannot leave the patio during smoke breaks because staff cannot see them. Several residents on the unit are at risk for elopement. During an interview on [DATE] at approximately 1:42 P.M., the DON said the CNA assigned to a hall is responsible for checking residents hourly, and completing hourly monitoring forms. These forms are reviewed by medical records or the administrative assistants to check for accuracy. Nurses should do rounds every two hours. They are expected to complete their own rounds to verify residents are where they should be. The administrator said approximately 19 out of 21 residents on the 600 hall are smokers. During an interview on [DATE] at 10:02 A.M., CNA A said the 600 hall required two staff at all times because anything can happen when there is one person. All of the residents on the 600 hall have behaviors or significant mental health issues. Thirteen out of 21 residents on the 600 hall smoke. The facility is short-handed, requiring staff to work 16 hour shifts. After ,[DATE] shifts, people are basically brain dead. On [DATE], CNA A had just done three double shifts in a row and was scheduled on the 600 hall from 7:00 A.M. to 3:00 P.M., and from 3:00 P.M. to 11:00 P.M. During the day shift, Resident #1 was frustrated and said he/she wanted to go home, so CNA A requested the CMT give the resident a PRN medication. During the evening shift, CNA A was the only person assigned to the 600 hall. MA L came to the hall to help watch the residents who remained inside during smoke breaks. For the last smoke break of the day, CNA A passed cigarettes to the residents as they exited to the courtyard, and then went outside with them to supervise. Resident #1's room is right next to the exit door, so he/she is the first one called for smoke breaks. He/she usually goes outside with the other residents for smoke breaks. When the break was over, CNA A thought he/she saw Resident #1 go back inside, but made a mistake. CNAs should monitor the residents every hour, but CNA A did not double check to make sure Resident #1 was back in his/her room before his/her shift ended at 11:00 P.M. When CNA A arrived for work on [DATE] at 6:30 A.M., staff said the resident was missing. He/she must have gotten on top of the furniture (an old dresser, chairs, and beds) stacked against the fence in the 600 hall courtyard in order to climb over the fence. The furniture had been stacked against the fence for a month or so. The fence around the courtyard is too high for someone to jump over. During an interview on [DATE] at 11:10 A.M., the administrator said surveillance footage from [DATE] could not be provided because the footage erases over itself. She had time to watch it after the incident, but now the footage was gone. Review of the resident's narcotic record, showed: -An order, dated [DATE] for [MEDICATION NAME] (anti-anxiety medication) 2 mg, three times daily PRN; -Administered on [DATE] at 8:00 A.M. and 8:00 P.M. Observation and interview on [DATE] at 8:09 A.M., showed Resident #1 face down on the bed in his/her room. The resident said he/she smokes cigarettes and likes to go outside. The other day, he/she got left outside and that's when (he/she) died . He/she could not remember what happened next. He/she has jumped the fence in the courtyard one time. He/she could not remember where he/she went, but that's when (he/she) died . During an interview on [DATE] at 10:03 A.M., the administrator said Resident #1 was with the facility before and was more independent. His/her family became guardian and removed him/her from the facility and took him/her off his/her medications a year or so ago. When Resident #1 returned to the facility, he/she was no longer appropriate for general population because he/she was a different person and staff needed to get to know him/her again. His/her PASRR indicated it would be safer for the resident to be on the locked unit rather than in the general population. He/she does not do well with larger environments. Placement on the locked units is based on the individual resident. Residents are placed on the locked unit because of elopement risk, behaviors, or because they function better in smaller settings. Resident #1 was not an elopement risk prior to [DATE], but now he/she is. At this time, a copy of the facility's policy about locked unit placement was requested. During an interview on [DATE] at approximately 10:10 A.M., CNA C said he/she was not working on [DATE], when Resident #1 was left outside, but did hear about it. Resident #1 said he/she jumped over the 6 foot wooden fence by running and jumping onto it. CNA C believes the resident because he/she is good at basketball and wrestling. The resident does not want to be at the facility and wants to be home with his/her family. Staff never know what they will get from the resident; one minute he/she is happy, and the next minute he/she is crying. CNA C has not seen any stacks of furniture in the courtyard that could have been used by Resident #1 to jump the fence. Staff on the 600 hall should be doing visual face checks with the residents every 15 minutes or every hour. During an interview on [DATE] at 10:14 A.M., Nurse H said he/she started work at 7:00 P.M. on [DATE], and was not assigned to the 600 hall until 11:00 P.M. He/she helped pass snacks on the 600 hall before 9:00 P.M. and saw Resident #1 in his/her room, in bed. During report, Nurse H did not receive any information that Resident #1 expressed ideations of leaving that day. If the resident made statements about wanting to leave, this should have been communicated to the nurse. CNAs are on the locked units at all times, so Nurse H relies on them to monitor the residents. CNAs should be doing 15 minute and hourly face checks on the residents. Nurses should be doing hourly face checks as well; however, he/she did not do hourly face checks on the night of [DATE] because he/she was relying on the CNAs to monitor. During an interview on [DATE] at 10:24 A.M., Nurse I said on the evening of [DATE], he/she was assigned to three halls, two of which are locked units, including the 600 hall. That night, the facility was short-staffed and things were hectic. Nurse I performed CNA duties on the 200 hall, which had one CNA assigned to it. He/she also helped dietary prepare meal trays because the kitchen was short-handed. CNA A and MA L were assigned to the 600 hall. The CNA should have been doing hourly face checks with the residents by checking off the monitoring sheet after physically laying eyes on the residents. CNA A should have ensured all residents were accounted for during rounds. If a resident did not come back inside after a smoke break, but the monitoring was checked off, the documentation is not accurate. Nurse I relies on the CNAs to be his/her eyes and ears on the halls. He/she trusted CNA A was ensuring residents were where they should be. Nurses should also do hourly face checks and utilize the monitoring checklist. He/she did not check that all residents on the 600 hall were accounted for on [DATE] because he/she assumed the CNA was monitoring the hall like he/she should be. When Nurse I received report on [DATE], staff did not report any issues with Resident #1, such as voicing the desire to leave. If a CNA hears a resident make such a comment, it is expected that they report it to the nurse, so they can take appropriate action. During an interview on [DATE] at 8:41 A.M., CNA K said he/she usually works on the 600 hall. On [DATE], he/she worked a double and was assigned to the 600 hall for the night shift, 11:00 P.M. to 7:00 A.M. When his/her night shift started, there were supposed to be two aides on the 600 hall. CNA K thought there were already two staff on the 600 hall, so he/she worked on a computer off the unit. He/she returned to the 600 hall around 1:00 A.M. or 2:00 A.M., and found out that one of the aides had been moved to a different hall. CNA K forgot his/her clipboard with the hourly monitoring checklist and ended up doing something else instead of hourly face checks on the residents. At around 7:00 A.M., he/she went to fill out the hourly monitoring sheet and found another employee had already filled it out. Shortly after, the CMT arrived on the unit and staff discovered the resident was missing. When CNA A let the residents out to smoke on the evening of [DATE], it was probably too dark to see Resident #1 was still outside. CNAs should be doing hourly face checks with the residents, which means physically laying eyes on them. To his/her knowledge, Resident #1 does not have a history of elopement. During an interview on [DATE] at 10:50 A.M., the Medical Director said if the facility implements hourly checks on residents, it is expected that staff follow through with completing the checks. It is unacceptable for staff to falsify documentation of hourly checks. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy J level. Based on observation, interview and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 233

Based on observation, interview and record review, and in accordance with the Center for Disease Control (CDC) guidelines for the 2019 Novel Coronavirus Disease (COVID-19), the facility failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to follow their policy and/or CDC guidelines for how residents in the facility who develop COVID-19 will be handled. One resident who tested positive for COVID-19 had a roommate with a COVID-19 status of unknown (Resident #2 and #3). Facility staff failed to post signage outside the resident's room to indicate transmission based precautions and/or the type of personal protective equipment (PPE) needed. The resident positive for COVID-19 and the resident with an unknown COVID-19 status were located in their room within 6 feet of each other and neither wore a mask. The residents remained in the same room from 8/20/20 when the first positive test results came back and continued to remain in the room until 8/21/20, when brought to the facility's attention by the state surveyor. The facility failed to utilize a space in the facility dedicated to care for residents with confirmed COVID-19 that was separate from residents negative for COVID-19 to include proper signage to identify the area as isolation and/or what PPE was required in the area, for one resident positive for COVID-19 (Resident #6). In addition, the facility failed to follow their policy and ensure staff disinfected a multi-resident use Hoyer lift (mechanical total lift) before or after use (Resident #9). The census was 140. The administrator was notified on 8/21/20 at 3:53 P.M. of an Immediate Jeopardy (IJ) which began on 8/20/20. The IJ was removed on 8/25/20, as confirmed by surveyor onsite verification. Review of the CDC Preparing for COVID-19 in Nursing Homes, updated 6/25/20, showed: -Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19. As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP); -Regularly review CDC's Infection Control Guidance for Healthcare Professionals about COVID-19 for current information and ensure staff and residents are updated when this guidance changes; -Educate and train HCP, including facility-based and consultant personnel and volunteers who provide care or services in the facility; -Provide supplies necessary to adhere to recommended infection prevention and control practices: Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room; -Identify space in the facility that could be dedicated to monitor and care for residents with COVID-19: -This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19; -Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). Review of the CDC Responding to Coronavirus (COVID-19) in Nursing Homes, updated 4/30/20, showed: -Considerations for establishing a designated COVID-19 care unit for residents with confirmed COVID-19: -Determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit. Facilities that have already identified cases of COVID-19 among residents but have not developed a COVID-19 care unit, should work to create one unless the proportion of residents with COVID-19 makes this impossible (e.g., the majority of residents in the facility are already infected); -Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms; -To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit; -Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms; -Resident with new-onset suspected or confirmed COVID-19: -If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit; -Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Review of the facility's pandemic Coronavirus plan, updated on 4/30/20, showed: -Purpose: To provide a plan for surveillance and detection of the presence of pandemic Coronavirus in the facility. To ensure proper containment and treatment of [REDACTED]. -Procedure: Resident's that have tested positive for the Coronavirus will be triaged according to their medical comorbidities. The facility will follow physician's orders [REDACTED]. Resident's that test positive for the Coronavirus will be placed on isolation; -How does Coronavirus spread: Person to person and transmission between persons with someone who is infected and those secretions, such as droplets in a cough or sneeze but can also be spread through contact. Infected surfaces or objects such as touching a surface or object that has been infected with [MEDICAL CONDITION]; -Treatment: Droplet isolation- the resident should be placed in on isolation with any potential cases of Coronavirus until transported to an acute care setting. Review of the facility's undated infection control isolation room/COVID-19 policy, showed: -Purpose: To ensure in the event a resident becomes infected or is admitted with [MEDICAL CONDITION] is isolated away from others to prevent the spread of [MEDICAL CONDITION]; -Procedure: -The resident will be taken to the isolation room away from others where he/she will be further assessed; -The room designated in the facility is room [ROOM NUMBER]; -All managers will be notified as well as staff immediately and given further instructions on caring for the resident; -All staff will be in serviced as to what to do in the event they have to enter the room; -The proper barrels needed will be placed in the room so that all trash and linen can be placed in them before leaving the room; -The resident will remain in isolation for the duration of the period as ordered by the resident's physician and the CDC; -This procedure will stand for all residents that return or come from the hospital with the signs or symptoms whether they have the [MEDICAL CONDITION] or if attempting to rule [MEDICAL CONDITION] out. 1. Review of Resident #2's medical record, showed: -[DIAGNOSES REDACTED]. -Ambulates independently; -An order, dated 8/7/20, for [MEDICATION NAME] (cough syrup) 10 milliliter (ml) four times daily as needed; -A progress noted, dated 8/8/20 at 6:00 A.M., this writer started at 7:00 P.M. on 8/7/20. Was told resident had a temperature of 101.0. Also, had non-productive cough. Was told the physician was contacted and new order was given for cough medication; -A progress note, dated 8/20/20 at 10:09 P.M., resident resting in bed. Remains on isolation precautions related to COVID-19; -A COVID-19 test result, collected on 8/17/20 and dated 8/20/20 at 1:19 P.M., showed [DIAGNOSES REDACTED]-Cov-2 (COVID-19) detected; -A care plan, printed 8/21/20 and in use at the time of the abbreviated survey, showed: -Problem: Resident tested positive for COVID-19 and at this time is not exhibiting any symptoms of the disease; -Goal: To prevent the spread of infection; -Approaches included: -Isolation for 14 days, then re-test; -Monitor for temperature, shortness of breath, cough, runny nose, sore throat, etc. and report to physician promptly; -Staff/resident to wear mask; -Staff to wash hands before and after entering and leaving resident's room; -Resident to stay in room, requires redirection; -Staff to use infection control equipment in room; -Discard infection control equipment in barrels before leaving room and wash hands; -Educate staff and resident on infection control and why needed. During an interview on 8/21/20 at 8:30 A.M., the administrator said the facility received Resident #2's COVID-19 test results on 8/20/20, and he/she was positive for COVID-19. His/her roommate is Resident #3. Both residents will be placed on isolation together. Resident #3 was tested for COVID-19 on 8/20/20. At this time, the facility's infection control policy that addresses the different types of isolation and what PPE is required were requested. Review of Resident #3's medical record, showed: -[DIAGNOSES REDACTED]. -Limited assistance of one person required for locomotion and supervision required for transfers. Observation of the 100 hall on 8/21/20 at 9:02 A.M., showed: -Four signs posted on the double doors entering the 100 hall; -Wash hands; -No phone zone; -Stop if you have symptoms; -List of COVID-19 symptoms; -No signage regarding transmission-based precautions or PPE required; -A three-drawer caddy outside the double doors entering the 100 hall, contained a box of gloves, shoe covers, gowns, and two pairs of protective eye wear; -Certified Medication Technician (CMT) B stood at a medication cart in front of the 100 hall dining room on the inside of the double doors. He/she wore a gown, shoe covers, and surgical mask. During an interview on 8/21/20 at approximately 9:03 A.M., CMT B said shoe covers, goggles, and a gown should be worn on the 100 hall because Resident #2 tested positive for COVID-19. Observation of the room shared by Resident #2 and Resident #3, on 8/21/20 at approximately 9:08 A.M., showed: -The door to the room fully open; -No signage regarding transmission based precautions or PPE usage on the resident's door or outside of the room; -No PPE located outside of the resident's room; -Resident #2 seated on his/her bed, talking to self, and not wearing a mask; -Resident #3 seated on a chair next to Resident #2's bed, not wearing a mask, and approximately 4 feet away from Resident #2. Observation and interview on 8/21/20 at approximately 9:10 A.M., showed CMT B wore a surgical mask, gown, and shoe covers. He/she said the doors entering the 100 hall should have signs posted regarding PPE use and precautions. Outside of the room shared by Resident #2 and Resident #3, signs should be posted to notify staff if a resident is on isolation and what PPE is required. CMT B knew about Resident #2's positive COVID-19 test and what PPE to wear because staff told him/her. During an interview on 8/21/20 at 10:50 A.M., the facility's Medical Director (MD) said she saw Resident #2 a week ago. He/she previously had a cough that had improved, and his/her lungs were clear with no noted respiratory problems. The MD ordered the resident be tested for COVID-19, and the results were positive. Facility administration notified the MD of the positive test results on 8/20/20. During their conversation, the MD discussed moving Resident #2 to another room, or moving his/her roommate, Resident #3, who had not tested positive for [MEDICAL CONDITION]. The MD did not know the residents still remained in the same room. During her discussion with facility administration on 8/20/20, the MD recommended testing all residents on the 100, 200, and 300 halls for COVID-19, and a 14-day quarantine for residents with suspected cases. The facility declined her recommendations and will only be testing symptomatic residents. Most residents on the 100 hall are ambulatory and should wear masks when they are in the hall. Resident #2's room is on the 100 hall, but due to his/her severe mental [MEDICAL CONDITION], he/she will not wear a mask. The 100 hall should be made into an isolation unit to prevent the spread of COVID-19. Signs should be posted outside the rooms of any resident on precautions, and on the doors of the unit where precautions must be taken. Signs on the rooms and halls should show staff what PPE is required. Staff working on an isolation unit should wear N95 masks, face shields, gowns, and gloves when providing care. The facility should be following its infection control policies. During an interview on 8/21/20 at 11:26 A.M., the administrator and Director of Nursing (DON) said when a resident tests positive for COVID-19, they are placed on contact isolation in their rooms, and are not permitted to leave their room while on isolation. Droplet precautions are also implemented and staff should wear N95 face masks, gowns, face shields, gloves, and shoe covers while on an isolation unit. The 100 hall has been made into an isolation unit and there are now caddies containing PPE outside of the room where the resident tested positive for COVID-19. Signs should be posted on the hall and outside of the rooms where droplet precautions are implemented, to inform staff of what PPE is required. One resident, Resident #6, is already on isolation on the 200 hall after testing positive for COVID-19. The physician ordered Resident #2 be tested for COVID-19 due to a cough he/she had three weeks ago. It would be detrimental to move Resident #2 to the 200 hall because he/she would not have stayed in the room and would have fought with staff about moving. It was easier to keep him/her in his/her room. There were no other rooms on the 100 hall open. This is the first time the facility has had a positive COVID-19 case, so staff need to be educated on what type of transmission based precautions are needed and what to do if a resident tests positive. When asked what was being done to protect Resident #3 from getting COVID-19 from Resident #2, the administrator and DON said the residents have been roommates for a long time, and Resident #3 probably already has it. At this time, a copy of the facility's infection control policy that addresses the different types of isolation and what PPE is required was again requested. Review of the facility census report, showed room [ROOM NUMBER] identified as an isolation room and showed it was empty. During an interview on 8/21/20 at 2:55 P.M., the DON said she was not aware the resident had the temperature or non-productive cough documented in the progress notes, she would have to look further into that. She was surprised when the doctor wanted Resident #2 tested for COVID-19. When she asked the doctor why they were obtaining the test, the doctor said because the resident had a cough a while back. During an interview on 8/21/20 at 3:26 P.M., the administrator said Resident #6 is already on isolation after testing positive for COVID-19. If Resident #2 was moved into the same room, Resident #6 would try to take care of him/her and the two residents would not be compatible as roommates. Resident #2's roommate, Resident #3, has declined cognitive ability and requires monitoring when eating. Moving him/her to another room could potentially cause him/her to stop eating. Residents #2 and #3 have been roommates for a very long time. Both of them were placed on isolation together and Resident #3's COVID-19 test is pending. During an interview on 8/21/20 at 4:20 P.M., the DON said staff was in the process of moving Resident #2 to Resident #6's room. Resident #3 will remain in his/her room. The facility has started in-servicing staff in the building regarding precautions for COVID-19 and isolation. Further review of Resident #3's medical record, showed: -A nurse's note, dated 8/20/20 at 3:14 P.M., showed a call placed to the resident's family regarding COVID-19 test results on a different resident in the facility. A call placed to the physician and new order received to test Resident #3 for COVID-19. Test completed and resident showed no signs/symptoms of [MEDICAL CONDITION]; -A COVID-19 test result, collected on 8/20/20 and approved by the lab on 8/24/20 at 2:46 A.M., showed [DIAGNOSES REDACTED]-Cov-2 not detected. During an interview on 8/25/20 at approximately 11:05 A.M., the administrator and DON said Resident #3's COVID-19 test results came back negative for [MEDICAL CONDITION]. Resident #2's positive COVID-19 results were not received until the evening shift on 8/20/20. He/she was not moved to another room on the 100 hall because there were no empty rooms available. After receiving Resident #2's results, the DON had to prepare the 100 hall as an isolation unit before she had time to post signs regarding droplet precautions and PPE requirements. As of the abbreviated survey exit, on 8/26/20, no policies that address the different types of isolation and what PPE is required had been provided by the facility. 2. Review of Resident #6's medical record, showed: -[DIAGNOSES REDACTED]. -Independent with activities of daily living; -COVID-19 test results, dated 8/20/20, showed [DIAGNOSES REDACTED]-Cov-2 (COVID-19) detected. Review of the care plan, printed 8/21/20, and in use at the time of the abbreviated survey, showed: -Problem: The resident tested positive for COVID-19. He/she had no symptoms; -Goal: Prevent the spread of the infection; -Approaches: Isolate the resident for 14 days, monitor his/her temperature, shortness of breath, runny nose, changes in taste or smell and report changes to his/her physician, staff and the resident to wear a mask, the resident to stay in his/her room and staff to redirect, infection control equipment inside of the resident's room, staff to discard equipment used in barrels inside of the room before leaving the resident's room. During the entrance conference on 8/19/20 at 9:25 A.M., the Administrator said Resident #6 tested positive for COVID-19. The resident had been tested because a physical therapy assistant tested positive outside the facility and that staff member worked on the resident's hall. All of the residents on the 300 hallway were tested and when Resident #6's COVID-19 test results were reported as positive, the staff moved him/her to a room at the end of the 200 hall, the room is used and identified as the facility's isolation room. The facility retested the resident on 8/17/20. At the time of the entrance conference, the resident's second test results were not available. Observation on 8/19/20 at 10:20 A.M., of the 200 hallway, showed: -In the hall outside of the resident's room, a metal portable linen cart with an 8 x 11 yellow piece of paper on the lid, showed infectious linen; -A red plastic biohazard container located in the hallway, outside the resident's room; -On the resident's closed door, an 8 x 11 piece of paper showed Stop, contact precautions. Everyone must clean hands, when entering or leaving the room, apply gown and gloves at the door and use patient dedicated or disposable equipment, leave used material in the room and keep the door closed; -A three drawer isolation caddy outside of the room contained disposable gowns, gloves and red biohazard trash bags; -No defined COVID-19 care area and/or no signage at the entrance to the COVID-19 care area that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while in the area and that gowns and gloves should be added when entering resident rooms. Numerous residents noted to walk the length of the hallway, past the resident's room and past the biohazard trash can and bin. During an interview on 8/19/20 at 10:30 A.M., the facility's Medical Director said the facility had one resident that had a positive COVID-19 test result. The resident had no signs or symptoms and the facility retested him/her and the results were not back yet. Used isolation PPE barrels should not be in the hallway, the barrels should be inside of the isolation room to prevent potential infection spread. Several of the resident's in the facility wander the hallways and could easily touch the isolation barrels if the barrels are exposed in the facility hallways. Further observation of the resident's room on 8/19/20, showed: -At 12:10 P.M., Resident #6 opened his/her room door, he/she did not wear any mask, exited the room into the hallway and placed used linen from his/her room into the yellow infectious linen cart in the hallway. Licensed Practical Nurse (LPN) G wore a cloth face mask, not the required N95 or higher-level respirator or facemask if a respirator is not available, approached the resident in the hallway and told the resident he/she may not be in the hallway without a mask in place. The resident went into his/her room and closed the door; -At 12:55 P.M., the biohazard barrel and infection linen cart remained in the hall outside the resident's room. Three residents walked the length of the hallway, past the biohazard barrel and infection linen cart. No signage posted identifying the area as an isolation area. During an interview on 8/19/20 at 1:45 P.M., the DON said all isolation disposal barrels should be in the isolation room and not in the hall. If the barrels are exposed in the hallways, other facility residents could potentially touch the barrels and contract the illness. The facility had several residents that walked the hallways. 3. Review of the facility's undated multiuse equipment policy, showed: -Any equipment being used on more than one resident must be sanitized between each resident; -Electronic lifts: Staff should use chemical in the spray bottle to spray and wipe the lifts down between resident uses. Review of Resident #9's medical record, showed: -Severe cognitive impairment; -Total staff assistance needed for transfers and daily care; -Used a mechanical lift for all transfers; -[DIAGNOSES REDACTED]. Observation and interview on 8/19/20 at 11:16 A.M., showed CNA D and E obtained the Hoyer lift from the hallway and pushed the lift to the resident's bedside. The CNAs attached the Hoyer lift to the lift pad and transferred the resident into his/her chair. The Hoyer lift was not sanitized prior to transferring the resident. CNA D pushed the Hoyer lift into the hallway along the wall and re-entered the resident's room. CNA E walked out of the resident's room and exited the unit. He/she did not sanitize the lift before leaving the unit. CNA D exited the resident's room and entered a separate resident's room. LPN F entered into the resident's room to provide care, and left the resident's room. He/she said all lifts should be disinfected before and after resident use. The disinfectant is in the hallway bathrooms. The facility had been short staffed and the CNAs may have forgotten to wipe down the lift before moving on to care for other residents. During an interview on 8/19/20 at 11:20 A.M., CNA D said the facility had been short staffed. He/she forgot to wipe off the lift before or after use. CNA E assisted him/her with the resident's transfer, but CNA E had not been assigned to the hallway. The disinfectant that should be used on the lifts is in the hallway bathroom, but he/she did not have time to clean the lift related to being short staffed and he/she needed to assist other residents. During an interview on 8/19/20 at 1:45 P.M., the DON said all lifts should be disinfected and sanitized before and after each resident use. The disinfectant should be easily accessible to staff. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy J level. Based on observation, interview and record review, completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on interview and record review, the facility failed to provide protective oversight for residents who exhibited aggressive behaviors towards other residents and for residents who were targeted by aggressive residents, for five of seven sampled residents (Resident #30, #31, #28, #26 and #27). The census was 142. 1. Review of Resident #30's medical record, showed the following: -admitted on [DATE], with a [DIAGNOSES REDACTED]. -Prior to admission to the facility, the resident was hosptalized on [DATE], related to increased delusions, aggression and agitation. Review of the resident initial social service assessment dated [DATE], showed: -[DIAGNOSES REDACTED]. -History of physical and verbal aggression. Review of the resident nurse's notes, showed: -9/28/11 at 7:30 P.M., the resident became agitated and verbally aggressive; -10/22/11 at 4:30 P.M., the resident became agitated and physically aggressive towards another resident (unidentified resident); -10/25/11 at 10:30 A.M., the resident displayed increased agitation with property destruction, yelling and cursing, caused others to fall, and verbal aggression with threats; -10/25/11 at 11:00 A.M., the resident displayed increased agitation and property destruction. He/she was noncompliant with redirection. Crisis Alleviation Lessons & Methods (CALM) technique used. Review of the residen's care plan, dated 10/25/11, showed: -Increased aggressive behaviors, non-directable may apply calm technique; -Implement room changes to reduce stimuli and harm to other residents; -Provide a structured environment with continuity of care and caregivers; -Monitor for early signs of agitation, attempt to intervene by reducing environmental stimuli or with distraction. Review of Resident #31's medical record, showed: -admission date of [DATE], [DIAGNOSES REDACTED]. -Social service initial assessment note, dated 7/18/11, resident's history included prior hospitalization for physical and verbal aggression with [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 8/15/11, showed: -Protective oversight when dealing with new or difficult situations; -Discourage from poor decision making discussing possible consequences that may or can occur; -Monitor for early signs of agitation in attempt to intervene early to reduce stimuli; -Remove the resident from public areas for displays of increase aggressive behaviors for protective oversight. Review of the resident's nurse's notes, showed: -10/7/11 at 6:00 P.M., the resident became agitated; -10/12/11 with no time documented, the resident displayed increased agitation with physical aggression. The CALM technique was used (no indication of what form of CALM technique was used); -10/22/11 with no time documented, the resident became agitated and aggressive. He/she had bright red blood oozing from the left side of his/her head. The approximate length was 3 centimeters (cm) (no further description of how the resident sustained [REDACTED]. Review of the facility's investigation report, dated 10/22/11, showed: -Resident #30 in the common area talking loud to him/herself; -Resident #31 became annoyed at the resident talking loudly to him/herself; -Resident #31 pushed Resident #30 after repeatedly telling him/her to shut up; -Resident #30 reacted to being shoved by hitting Resident #31 in the face with an ash tray; -Code Green (CALM's hold technique), was called and both residents were separated; -Documentation showed the calm technique not used, just that the residents were physically pulled apart. During an interview on 11/1/11 at 3:05 P.M., Certified Nursing Assistant (CNA) Y said he/she was down the hall providing patient care when he/she heard the argument. When he/she arrived in the smoking area, CNA X had called a Code Green. Resident #30 was hitting Resident #31 with a red can that is used for an ash tray. Resident #31 was on the floor trying to protect him/herself. He/she had both of his/her arms up. CNA Y tried to tell Resident #30 to stop hitting Resident #31, but he/she didn't stop. CNA X went to the door and called a Code Green. During an interview on 11/2/11 at 7:20 A.M., CNA X said both residents were in the common area, and they sat next to each other. Resident #30 talked to him/herself and Resident #31 told him/her to shut up. Resident #31 pushed Resident #30. Resident #30 picked up the ash tray and hit Resident #31 in the face with it. After he/she hit Resident #31, CNA X left the area, keyed in a code into the wall key pad, opened the door and called a Code Green. Resident #30 was still hitting Resident #31 with the ash tray. Eventually Resident #30 put the ash tray down and begun hitting Resident #31 with his/her closed fist. By the time other staff arrived, Resident #30 had calmed down. Resident #31 was on the floor bleeding from his/her head. He/she was trying to defend him/herself, and he/she was crying. During an interview on 11/2/11 at 10:10 A.M. Resident #31 said Resident #30 was cursing him/her. He/she told Resident #30 to stop, but he/she wouldn't listen. So, Resident #31 barely shoved him/her. Resident #30 came at him/her with an ash tray and hit Resident #31 on the side of his/her head. During an interview on 11/2/11 at 10:15 A.M., the Director of Nursing (DON) said CNA X informed her that Resident #30 was talking loud and Resident #31 told him/her to shut up. Resident #31 shoved Resident #30. Resident #30 hit Resident #31 with an ash tray. CNA X should have separated the residents to try to diffuse the situation. CNA X would not be assigned to work the unit. CNA X was too soft-spoken. The CALM technique was used when residents were no longer redirectable. During and interview on 11/21/11 at 1:09 P.M. the Administrator said staff was expected to separate residents during an altercation to prevent harm. It was not acceptable to leave residents when an altercation was present. They were to be separated. 2. Review of Resident #28's medical records, showed: -admitted [DATE], admitting [DIAGNOSES REDACTED]. -Admission social service note, dated 8/18/11, history of suicidal and homicidal ideation, elopement and aggressive behavior. Review of the resident's nurse's notes, showed: -9/14/11 with no time documented, the resident displayed verbal aggression toward the staff; -On 10/15/11 at 1:30 P.M., displayed aggression and sustained lacerations the right side of his/her chin and mouth; -On 10/17/11 with no time documented, the resident displayed increased agitation and aggression. He/she was unable to be redirected. He/she was administered Ativan and Haldol by injection as ordered (no documentation of skin assessment or 15 minutes checks in his/her medical records related to this incident); Review of the resident's care plan, dated 10/17/11, showed: -Provide frequent face and safety checks for protective oversight; -Document behavior episodes and interventions used if behaviors persist, notify psych physician for further evaluation; -Monitor for any changes with mood/behavior patterns; -Assist with ways of improving or developing his/her coping skills to deal with new or difficult situations; -Did not assess and address the types of CALM techniques to be used during a behavioral crisis. Further review of the resident's nurse's notes, dated 10/20/11, showed the resident was sent to the hospital from his/her day program. The resident displayed suicidal and homicidal ideations. Review of Resident #26's medical record showed, an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the resident's care plan, dated 3/8/11, showed: -CALM techniques for non-directable behaviors; -Face checks and safe checks for protective oversight; -Assist/encourage ways to improve coping mechanisms to channel any mood or behaviors; -Monitor for any significant changes with baseline mood and behavior Review of the resident's nurse's notes, showed on 10/15/11 with no time documented, the resident displayed increased agitation with aggression. He/she was sent to the hospital for an evaluation (no documentation of type of aggression displayed). Further review of resident's care plan, showed an update on 10/18/11, for staff to encourage the resident to report any problems with peers to nursing staff. Further review of Resident #26's nurse's notes, showed -10/20/11 with no time documented, the resident displayed physical aggression towards the staff; -10/24/11 at 3:05 P.M., the resident returned from out site privilege. The resident refused to give his/her packaged medication to the staff, refused to be searched and became verbally aggressive, made threatening gestures towards the staff. The resident signed out and left the facility. He/she returned to the facility at 3:20 P.M. The county police were at the facility to ensure safety. The resident refused to go to the hospital for an evaluation. He/she was resistant with the county police. Review of Resident #27's medical records, showed: -admitted [DATE], [DIAGNOSES REDACTED]. -Nurse's note dated 8/29/11 at 9:15 A.M., the resident was physically aggressive with the staff; -No documentation of resident to resident altercation was found in the nurse's notes. Review of the resident's care plan, dated 11/9/11, showed: -Monitor for changes in mental status with abnormal findings documented and reported to physician; -Monitor for changes in mood and behavior with abnormal findings documented and reported to physician; -Provide frequent face and safety checks for protective oversight; -Encourage the resident to report any occurrence with peers to nursing staff to intervene early for protective oversight; -Displays of increased behaviors, remove from public areas for protective oversight; -Encourage the resident to refrain from involvement in other residents disputes and to report it to nursing staff immediately. During an interview on 11/10/11 at 7:50 A.M., Nurse O said he/she was in the dining room on 10/15/11, when Resident #28 entered and grabbed the broom and walked out. A few minutes later, he/she heard a Code Green called. He/she left the dining room and saw staff held Resident #28 up against the wall and the other unidentified staff kept the other residents from him/her. Nurse O tended to Resident #28's facial lacerations. The facility housed residents with mental illness. The resident with a broom didn't raise his/her awareness. None of the residents were placed on one to one watch. He/she wasn't aware of Resident #28's [DIAGNOSES REDACTED]. Nurse O said had he/she had known, Nurse O would have responded to the situation differently. The resident with a broom and those [DIAGNOSES REDACTED]. The charge nurses are expected to know the residents' diagnoses. During an interview on 11/2/11 at 9:50 A.M. Certified Medication Technician (CMT) CC said if he/she saw a resident with a broom in his/her hand, he/she would approach him/her. He/she said this was a psych facility, and precautionary measures are warranted. During an interview on 11/2/11 at 10:45 A.M. Resident #27 said Resident #28 swung the broom at him/her and Resident #26. The resident defended him/herself from being hit with the broom. He/she said Resident #28 was a bully. During an interview on 11/2/11 at 10:50 A.M. Resident #28 said he/she didn't remember the date that he/she grabbed the broom. He/she felt they were out to get him/her. The resident said he/she never swung the broom at them. Resident #26 "sucker" punched him/her. Resident #27 hit the broom out of his/her hand. He/she said Residents #26 and #27 attacked him/her for five to six minutes. His/her jaw and chin was busted. The staff separated them. He/she was sent to the hospital for stitches. When he/she returned to the facility, Resident #28 refused to go on the locked unit and was thrown on the floor by staff and sent to the hospital. During an interview on 11/2/11 at 9:56 A.M., the Restorative Aide AA, said it was not common to see a resident walk down the hall with a broom. He/she would have approached the resident and inquire about the broom in an attempt to obtain the broom from the resident. During an interview on 11/2/11 at 9:58 A.M., Restorative Aide BB said he/she would try to get the resident to give him/her the broom if he/she saw a resident with one. The resident had a potential to hurt someone or him/her self with the broom. During an interview on 11/2/11 at 10:15 A.M. the Director of Nursing (DON) said Nurse O told her that Resident #28 grabbed a broom and dust pan and swung it at Resident #26. Resident #27 saw Resident #28 swung the broom at Resident #26 and helped him/her against Resident #28. Review of the facility's investigation report, dated 10/15/11, showed: -The incident took place during the lunch meal; -Resident #28 grabbed a broom and dust pan from the dining room; -A Code Green was called. Resident #28 had swung the broom at Residents #26 and #27; -Resident #26 hit Resident #28 in the face and Resident #27 hit Resident #28 before the staff intervened; -Resident #28 was bleeding from his/her mouth and face. During an interview on 11/21/11 at 1:09 P.M. the Administrator said after the use of the CALM technique, the staff were expected to document the incident, get statements from the staff members and the registered nurse was to investigate the incident if a code was called or the CALM technique used. The staff handled each incident appropriately. The broom was usually kept behind a locked door. A resident with a broom in his/her hand should be approached by staff. The broom could be used as a potential weapon. 3. Review of the facility's undated guidelines for the CALM Techniques, showed: -The first five stages of crisis escalation are verbal. At each verbal stage the intervention is to return control to the client as soon as possible; -Physical intervention is only to be used as a last resort, when the client is physically acting out and when all other methods have failed. 4. Review of the facility's undated policy, on Behavioral Emergency, showed: -Any staff that responds to a Code Green where CALM techniques are used, all staff must fill out a Behavioral Emergency Review Sheet/Code Green Review. This will include writing about the events that lead up to the Code Green, if CALM techniques were properly used, and any concerns regarding the CALM techniques used. -Any resident who requires CALM techniques must have a complete skin assessment with vital signs monitored every fifteen minutes for the first hour, then every four hours for 72 hours unless changes in vital signs occur; then the Primary Care Physician is notified. MO 726 MO 750 MO 754

Based on observation, interview and record review, the facility failed to assess, document and report to other shifts, one expanded sample resident's pain (Resident #29). The facility also failed to identify, assess, monitor and measure wounds and failed to obtain a physician's orders [REDACTED].#3). The census was 142. 1. Review of Resident #29's quarterly social service notes, dated 7/29/11, showed the following: -Moderately impaired cognitive skills related to [DIAGNOSES REDACTED]. -Difficulty understanding and making self understood. Review of the resident's annual MDS, dated [DATE], showed the following: -Difficulty focusing; -Required staff supervision on and off unit; -Total dependence on staff with personal hygiene; -[DIAGNOSES REDACTED]. Review of the resident's care plan, dated 8/24/11, showed: -Impaired decision making related to poor insight and judgment confused, Alzheimer's and at risk for further cognitive deficit; -Observe for abnormal findings with mood, behavior, cognitive functions and gait; -Staff to notify physician of abnormal findings; -Weekly skin assessment, notify the physician of abnormal findings; -Monitor for any non-verbal expressive communication; -Assess for any acute medical changes that impact his/her baseline mobility and gait. Review of the resident's nurses notes, showed no documentation for 10/15/11. Review of the facility's investigation report, dated 10/18/11, showed: -10/15/11, day shift 7:00 A.M. to 3:00 P.M., Certified Nursing Assistant (CNA) DD informed Nurse V the resident complained of pain to his/her right and left sides. During an interview on 12/8/11 at 1:14 P.M., Nurse V said he/she didn't remember if he/she assessed the resident (on the dayshift of 10/15/11). If he/she assessed the resident, he/she would have documented in the nurses notes. Nurse V didn't receive in shift report the resident was in pain. He/she supposed if the resident was in pain it would be known by the resident's grimace, groaning and facial expression. Nurse V said he/she wasn't going to answer anything else and terminated the interview. Review of the Treatment Administration Record (TAR) showed, the only documented assessment by Nurse V was on 10/15/11. He/she documented the resident's skin was intact and there were no opened areas. Further review of the facility's investigation report, dated 10/18/11, showed: -10/15/11, evening shift 3:00 P.M. to 11:00 P.M. CNA M informed Nurse N the resident complained of pain. Nurse N conducted a physical assessment of the resident and no abnormal findings were found. Nurse N had Certified Medication Technician (CMT) P administer pain medication to the resident. During an interview on 12/8/11 at 9:53 A.M., CNA R said on 10/15/11, he/she informed Nurse N the resident complained of pain. During an interview on 12/7/11 at 3:20 P.M., CNA M said he/she worked the evening of 10/15/11, and reported to Nurse N that the resident was in pain when he/she tried to stand up. During an interview on 12/7/11 at 3:32 P.M., Nurse N said on 10/15/11, he/she was informed by a CNA that the resident was in pain. He/she assessed him/her and there were no abnormal findings. The resident didn't complain of pain. He/she had the CMT give the resident Tylenol for pain. During an interview on 11/1/11 at 2:55 P.M., CMT P said he/she was asked on the evening shift of 10/15/11, by Nurse N, to give the resident Tylenol for pain. The resident was unable to verbalize if he/she was in pain. During an interview on 12/7/11 at 1:25 P.M., CNA S said he/she was in the room on the evening shift of 10/15/11, with CNA M when the resident groaned upon moving. The resident denied he/she was in pain but groaned each time he/she moved. CNA M told Nurse N the resident was in pain. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -On 10/15/11 at 8:30 P.M. two tablets of Tylenol 650 milligrams (mg), pain level an 8. During an interview on 11/2/11 at 6:50 A.M., CNA Q said on the morning of 10/16/11, the resident told CNA Q that he/she hurt all over. CNA Q informed Nurse N the resident was in pain. CNA Q worked the night shift of 10/15/11 at 11:00 P.M. through 7:00 A.M. on 10/16/11. CNA Q said the resident told him/her that he/she was in pain and had fallen in the shower. CNA Q informed Nurse N of the resident's complaint of pain. Nurse N said the resident had complained of pain on the day shift. Further review of the resident's nurses notes, showed no documentation for the dayshift of 10/16/11. During an interview on 12/9/11 at 3:04 P.M., Nurse V refused to answer the questions regarding the resident's condition on the day shift of 10/15/11 and 10/16/11, both days he/she worked and was assigned to the resident. Nurse V refused to verbalize how a physical assessment of a resident would be conducted and when it would be warranted. He/she informed this surveyor if he/she wanted the questions answered then subpoena him/her. Further review of the resident's nurse's notes, showed: -10/16/11, evening shift, the resident guarded his/her left side, making noise as if in pain, area was painful to touch. No prior documentation of the resident's pain or assessment found in the nurse's notes. During an interview on 12/7/11 at 1:25 P.M., CNA S said on the evening shift of 10/16/11, the resident was still in pain. He/she groaned each time he/she would move but the resident verbally denied pain. During an interview on 12/7/11 at 3:20 P.M., CNA M on the evening shift of 10/16/11, CNA M reported to Nurse O that the resident was in pain. During an interview on 12/8/11 at 3:41 P.M., Nurse O said on the evening shift of 10/16/11, he/she was informed by a CNA that the resident was in pain. He/she assisted the resident in the bed. When the resident laid on his/her left side, he/she grimaced and groaned. Nurse O conducted a physical assessment of the resident. The resident groaned when his/her left side areas were palpated. Nurse O didn't remember if the resident received any pain medication. Nurse O became sidetracked. A physical assessment would be warranted if the resident complained of pain. The nurse would palpate for pain, conduct range of motion and document the findings in the nurse's notes. The nurse would verbalize to the next shift's nurse his/her findings of the residents. Review of the resident's MAR, dated 10/2011, showed the resident received pain medication as follows: -On 10/16/11 at 6:00 P.M. two tablets of Tylenol 650 mg, pain level a 7. Further review of the resident's nurse's notes, showed: -10/17/11, no time documented, the resident complained of pain to his/her left elbow. The physician was called; -10/17/11 at 5:00 P.M., the resident complained of left flank pain, had a small bruise on his/her left side of the abdomen. Also, had large bruise with small scab on his/her left elbow. The physician requested an x-ray of the resident's left elbow. The results of the x-ray of the left elbow showed a [MEDICAL CONDITION] with modest displacement. The physician notified of results and received new orders to send the resident to the hospital. During an interview on 11/2/11 at 8:30 A.M., Nurse T said on 10/17/11, he/she saw the resident walking to the dining room. Nurse T noted a long red area on the resident's left forearm. The area was scabbed over and measured 4? to 6 centimeters (cm) by 0.2 cm. He/she was told by Nurse N that the resident complained of pain over the weekend after he/she had received a shower. He/she was also told by the CMT that the resident had complained of pain in his/her side. During an interview on 11/2/11 at 7:40 A.M., Nurse U said the resident was unable to verbalize his/her pain. He/she assessed pain by facial cues and physical assessment with palpation. For witnessed falls, the nurse would conduct an assessment of the resident before moving him/her. For unwitnessed falls, the nurse would conduct an assessment of the resident before moving him/her. Nursing would get an x-ray when pain was indicated. The resident's physician and responsible party were to be notified. The resident would then be monitored for 72 hours with documentation. During an interview on 11/2/11 at 10:00 A.M., the Assistant Director of Nursing (ADON) said the resident received a shower by a newly hired CNA. CNA FF was hired on 9/26/11 and terminated on 10/20/11. CNA FF left the resident alone in the shower room. The resident did not complain of any pain. Staff should never leave a resident alone in the shower room. During an interview on 11/2/11 at 10:15 A.M., the Director of Nursing (DON) said staff was expected to obtain all the supplies needed for a shower before entering the shower room. Staff was not to leave the resident alone in the shower room. The DON and the ADON found out on 10/17/11 that the resident had fallen on the evening of 10/14/11. During an interview on 11/2/11 at 7:55 A.M., Resident #29 said he/she didn't remember falling. Review of the resident's emergency room records, dated 10/18/11 at 2:41 A.M., showed: -Fractured rib and left ulna; -Fall; -Pneumonia (an inflammation of the lungs caused by infection). During an interview on 12/27/11 at 2:43 P.M. Physician W said when he/she was notified of the resident's pain, that's when he ordered an x-ray of the resident's left arm. Upon receiving the results of the x-ray, he requested that the resident be sent to the hospital. The resident's fractured ribs could cause atelectasis (a complete or partial collapse of a lung). That's why the resident was on [MEDICATION NAME] (antibiotic) 500 mg three times a day for 10 days. 2. Review of Resident #3's readmission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/2/11, showed the following: -Alert and oriented; -Required supervision from staff for all activities of daily living; -No skin issues. Review of the resident's physician's orders [REDACTED]. -[DIAGNOSES REDACTED]. -An order dated 11/8/11, for Santyl ointment (a medication that removes necrotic tissue from wounds) topically with nickel thickness to right great toe, cover with a 2 X 2 dressing and secure with tape daily; -An order dated 11/8/11, for the resident to wear a post-op shoe (a shoe designed to protect the foot following a injury or surgery) on the right foot; -An order dated as far back as 11/1/11, for staff to do weekly skin assessments; -No other treatment orders for the open area on the lateral aspect of the right foot. Review of the resident's care plan dated 11/8/11, showed staff identified the resident as having a surgical wound with a diabetic ulcer to the right great toe and provided the following interventions: -Weekly skin assessments to be done by licensed nursing staff and abnormal findings documented and reported to the physician; -Obtain measurements of the wound weekly and follow-up with the wound clinic; -Have the resident wear his/her diabetic shoes while up. Review of the resident's treatment administration record (TAR), dated 11/1/11 through 11/30/11, showed the following: -An order dated 11/8/11, for Santyl ointment topically, with nickel thickness to right great toe, cover with a 2 X 2 dressing and secure with tape daily; -11/3/11 skin assessment; no open areas; -11/7/11 skin assessment; skin warm to the touch, resident noted to have a [MEDICAL CONDITION] on the right great toe measuring 2.2 centimeters (cm) by 3.0 cm with dark brown eschar (dead or dying tissue) and pink edges; -11/10/11 skin assessment; no open areas; -11/17/11 skin assessment; no open areas; -11/24/11 skin assessment; no open areas. Review of the resident's TAR, dated 12/1/11 through 12/31/11, showed the following: -12/9/11 skin assessment; no open areas; -12/15/11 skin assessment; skin warm to the touch, resident's right great toe is beefy red in the center with white edges and eschar. Area has a slight odor with drainage measuring 0.5 cm by 1.3 cm; -12/16/11 skin assessment skin; warm and dry to the touch. Treatment to the right great toe done, bandage was intact with no drainage. Observation on 12/14/11 at 1:30 P.M., showed the resident fully dressed with white crew socks on both feet, laying in bed watching television. The right crew sock had a blood soaked area measuring approximately 2 inches by 3 inches on the lateral aspect of the right foot. Observation on 12/15/11 at 7:40 A.M., showed the resident ambulated in his/her room wearing white crew socks with a blood soaked area measuring approximately 2 inches by 3 inches on the lateral aspect of the right foot. Observation on 12/15/11 at 7:40 A.M., at 9:50 A.M., and at 12:30 P.M., showed the resident ambulated down the hallway wearing regular shoes. Observation on 12/19/11 at 6:20 A.M., showed the resident fully dressed with white crew socks on both feet, laying in bed watching television. The right crew sock had a blood soaked area measuring approximately 3 inches by 4 inches on the lateral aspect of the right foot. Observation on 12/19/11 at 7:55 A.M., and at 12:30 P.M., showed the resident sat in the main dinning room, waiting for his/her meal, wearing regular shoes. Review of the resident's nurse's notes, dated 12/14/11 through 12/19/11, showed no documentation regarding assessment, monitoring or description of lateral aspect of the right foot. Observation on 12/20/11 at 8:30 A.M., showed the resident ambulated in his/her bedroom wearing regular shoes. Nurse I entered the room and asked the resident to return to bed so he/she could change the dressing to the resident's right foot. When the resident removed his/her shoes a blood soaked area, measuring approximately 1 inch by 2 inches on the lateral aspect of the right foot, could be seen on his/her sock. The nurse removed the sock from the resident's right foot which revealed an open area measuring approximately 2 cm long and 1.5 cm wide. Black eschar covered the bed of the wound, on the lateral aspect of the resident's right foot. The lower edge of the wound had an area that measured approximately 2 cm long by 0.25 cm wide where the black eschar had separated from the edge of the wound. Nurse I said the area was bleeding and that he/she was not aware of the open area on the side of the foot. During an interview on 12/21/11 at 9:00 A.M., Certified Nurse Aide (CNA) J said he/she noticed the blood soaked sock on the residents right foot on 12/15/11, and immediately notified Nurse I. During an interview on 12/21/11 at 9:15 A.M., Nurse I said he/she never noticed the wound to the resident right lateral foot prior to 12/20/11. He/She had done daily dressing changes to the resident's right great toe, on 12/14/11 and 12/15/11, and did not notice the wound because the resident's socks had already been removed and staff had positioned the lateral aspect of the resident's right foot on the mattress and the wound could not be seen. The CNAs do weekly skin assessments during resident showers and none of them had informed him/her of any new open areas. He/She conducts weekly skin assessments. Staff only document pressure ulcers on the weekly skin assessments. Review of the resident's face sheet, showed Physician K as the resident's primary physician. During an interview on 12/21/11 at 9:30 A.M., a staff member said Physician K's office was not in the immediate area and his/her partner, Physician L followed the resident at the facility. During an interview on 12/21/11 at 12:00 P.M., Physician L said he/she was not aware of the wound, on the lateral aspect of the resident's right foot. He/She would expect the facility to call him/her about any new wounds to the resident's feet. The facility may have called Physician K and informed him/her. During an interview on 12/21/11 at 2:00 P.M., the Director of Nurses (DON), said she expected the nursing staff to assess, monitor and notify the resident's physician regarding any new open areas. She expected the nursing staff to notify the physician with the assessment of the open areas and document, the notification of the physician, in the resident's chart. Nursing staff need further training in the documentation of open wounds. Nursing staff should complete a 100% body assessment and identify all wounds weekly. MO 726