Every finding on record at Delmar Gardens on the Green

Based on interview and record review, the facility failed to obtain and document initial and weekly measurements of pressure ulcers (localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device) for one resident (Resident #4). The sample was 8. The census was 118.The Administrator was notified on 11/26/25 of the past non-compliance. The facility has changed their process on how they assess residents at risk for pressure ulcers, as well as their process to document measurements of wounds for residents at risk. Staff were in-serviced on the new process. The deficiency was corrected on 11/17/25. Review of the facility's Pressure Injury Prevent and Wound Documentation policy, dated October 2025, showed:-Purpose: To establish clear guidelines for the prevention, early identification, and management of pressure ulcers (also known as pressure injuries or bed sores) and all residents, thereby promoting skin integrity and improving quality of care; -Complete Braden Scale risk assessment on admission, quarterly, with Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), and with significant change of condition;-Nurse will conduct weekly skin assessments and document findings in the resident's medical chart. Review of the facility's Wound Documentation policy, dated October 2025, showed:-Purpose: To ensure consistent, accurate, and a timely documentation of wound assessment, treatment, and progress in accordance with best clinical practice, regulatory guidelines, and facility standards; -Goal of Assessment: --Provide uniform description;--Facilitate communication among staff;--Adequate monitoring of progress of deterioration;--Assess the entire person not just ulcer;--Assess for pain and implement interventions to relieve;-How to Assess/Document:--Initially assess the ulcer(s) for location, measurements, exudate (fluid that has seeped out of the tissue), and tissue type;--Initiate and complete the Causal Risk Analysis for Pressure Ulcers in the Electric Health Record (EHR) for each pressure ulcer upon initial finding and quarterly. Utilize the finding for development of the care plan;--Weekly reassessment should be done indicating the measurements and other descriptive characteristics consistent with the initial assessment in order to clearly communicate progress or decline;-If an ulcer/wound is assessed as unchanged at the second week assessment, the provider must be notified, and treatment plan reassessed. If an ulcer/wound is assessed as deteriorated, the provider must be notified and the treatment plan reassessed; -Documentation of initial and weekly assessment findings should be noted in the wound management section of the EHR. Review of Resident #4's hospital record, dated 9/24/25, showed:-Consult to wound/skin management;-Wound to scrotum: moisture-associated skin damage (MASD); -Sacral area: due to friction and MASD;-Left trochanter (hip) present on admission measured 4.0 by (x) 4.0 x 0.2 centimeters (cm). Review of the resident's medical record, showed:-Diagnoses included metabolic encephalopathy (neurological dysfunction) and dysphagia oropharyngeal phase (inability to swallow normally); -An admission progress note, dated 9/25/25, in which staff documented an open area to left hip measuring 3.2 x 2.6 cm, to right sacrum measuring 1.0 x 1.0 cm, and to coccyx measuring 3.0 x 0.6 cm;-No other measurements documented until the resident was discharged from the facility on 11/11/25 to the hospital. Review of the resident's electronic physician order sheet (ePOS) and Braden Scale observations, showed:-An order, dated 9/25/25, for weekly skin audits on Thursday between 3:00 P.M.-11:00 P.M.;-An order, dated 9/26/25, for complete Braden Scale observation on admission and weekly for four weeks, once a day, every seven days;-No skin assessments documented as completed on 10/23/25 or 10/30/25. Review of the resident's annual MDS, dated [DATE], showed:-At risk of developing pressure ulcers/injuries;-Has one or more unhealed pressure ulcers/injuries;-Has one unstageable pressure ulcer (slough (dead tissue) is present, the actual base and condition of the ulcer cannot be determined). Review of the resident's care plan, in use at the time of survey, showed:-Problem: An unstageable wound to left hip and MASD to sacrum/buttocks, had prior to admission;-Goal: Maintain/improve skin integrity next review;-Approach: Conduct a systematic skin inspection weekly, pay particular attention to the bony prominences; encourage turning and repositioning, provide supplants per physician's order. During an interview on 11/25/25 at 8:00 A.M., the Director of Nursing (DON) said she expects wounds to be documented and measured by facility nurses. It is her responsibility is to ensure the wounds are charted properly, measurements are accurate, and the resident's medical record is updated. The Wound Nurse failed to record or document measurements in EHR. During an interview on 11/25/25 at 12:42 P.M., the Administrator, Regional Nurse A, and DON said the facility failed to complete the resident's skin assessments. The resident was seen by nurse practitioner who specializes in geriatrics (senior population), but facility staff did not complete wound assessments weekly, and the admission audit was incomplete. The facility has a large presence of agency staff and they are not aware of the facility's policies, protocols, and procedures, which hinders facility staff. Regional Nurse A said each nurse's station has a binder with policies and procedures that agency staff can reference. The Administrator said that agency staff is to familiarize themselves with the binder and sign a form of comprehension of facility's policies and procedures. During an interview on 11/26/25 at 8:54 A.M., the DON, Administrator and Regional Nurse A said the Wound Nurse is newer to the role he/she has held the position for two months. The Wound Nurse had on the job training and was sent to train among the different sister facilities. Regional Nurse A said the Wound Nurse is not responsible for daily treatments to residents in the facility. The floor nurses are responsible for daily treatments. The Wound Nurse or designee should always measure residents' wounds, then place the measurements in the EHR. Regional Nurse A said occasionally, this is not documented in real time and there is a delay in entering the data. 2666564

Based on interview and record review, the facility failed to follow the physician's order when nursing staff on multiple occasions did not collect a physician ordered urine sample from a resident who had been admitted to the facility with a urinary tract infection (UTI) and who had a history of recurrent UTIs. The sample size was 3. The census was 111.Review of the facility's Following Physician Orders policy, effective date 6/29/25, showed:-Purpose: It is the policy of the community to ensure that all Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) and other healthcare professionals, follow physician orders in accordance with State, Federal regulations and their respective practice acts;-Procedure: -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the residents medical record; -If an order is questionable according to the seven rights of medication administration, a clarification order will be obtained; -All physician or other health care professionals verbal, telephone or written orders will be immediately entered in the electronic health record (EHR) by the nurse obtaining the order.Review of the facility's Resident's Rights document, no date, showed:-Dignity and Respect: -You have the right to expect we will: -Treat you as an individual and assist you in getting the most out of the programs and services we offer. Review of Resident #1's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 5/17/25, showed:-No cognitive impairment;-Wheelchair and Broda chair (specialized wheelchair);-Mechanical lift;-Diagnoses included: dementia, seizure disorder and Parkinson's disease (disorder of the central nervous system that affects movements, often including tremors).Review of the resident's significant change MDS, dated [DATE], showed moderate cognitive impairment.Review of the resident's care plan in use at the time of the investigation, showed:-Problem: Start date: 6/3/25. Infection. Antibiotic 6/2-6/7/25 due to urinary tract infection (UTI);-Goal: Resident will not experience complications from recent infection as evidenced by worsening symptoms;-Approach: Obtain diagnostic tests as indicated per medical doctor (MD) order;-No documentation related to prior history of UTI.Review of the resident's facility transfer paperwork, dated 5/6/25 and scanned into the EHR dated 5/12/25, showed:-History of UTI;-Lower urinary tract symptoms.Review of the resident's progress notes, showed:-5/11/15 at 12:31 P.M., MD in the facility today to meet with family. New orders received, obtain complete blood count (CBC, measures various components of blood), comprehensive metabolic panel (CMP, measures 14 different substances in blood to assess overall health and organ function), and urinalysis. Lab updated for pick up on 5/12/15. Family aware of lab work. Orders noted LPN B;-5/13/25 at 3:01 P.M., repeat UA with C&S (culture and sensitivity, lab test to attempt to grow bacteria, viruses, or fungi. and then test which medications will effectively work to stop the infection) on 5/18/25 due to recurrent UTIs. RN Director of Nursing (DON);-5/18/25 no documentation related to urine sample collected and/or picked up by the lab;-5/27/25 at 3:15 A.M., late entry for admission on [DATE], resident was admitted to hospice. Resident alert and oriented (A & O) times 1-2 (alert to person and place), intermittently confused with incoherent speech;-6/2/25 at 4:48 P.M., this writer was stopped by the resident's wife who had questions about an antibiotic for a possible UTI;-6/2/25 at 5:56 P.M., UA results have been pending since last week to determine if the resident has a possible UTI. Per his/her family the resident has had hallucinations and increased confusion with UTIs in the past. MD called in order for antibiotic three times a day (TID) for 5 days, obtained to treat suspected UTI. Order to obtain UA today still in place. Facility nurse called with verbal orders and read back.Review of the resident's physician order sheet in use at the time of the investigation, showed no documented urinalysis (UA, test that analyzes urine to detect and diagnosis a variety of medical conditions) orders.Review of the resident's 5/2025 medication administration record (MAR), showed documentation related to a physician ordered UA sample collection for suspected UTI per 5/11/25 or 5/18/25 due to recurrent UTIs or antibiotic.During an interview on 7/7/25 at 1:50 P.M., the resident's family member said the resident frequently had UTIs in the past. They could tell by his/her mood. After the resident had completed the antibiotics, he/she came to the facility. The MD wanted another UA to make sure the UTI was gone. The family member didn't have much confidence in the facility right now. The family member said every time he/she would ask about the urine sample and results, staff would say they were waiting on the results. He/She believed what the staff told him/her. But in fact, the urine sample was never collected. During an interview on 7/7/25 at 11:23 A.M., LPN A said he/she had worked with the resident since he/she had been admitted to the facility. He/She got report from the oncoming nurses and the 24-hour nursing report. Physician orders could be verbal, written, or come from pharmacy. LPN A looked through the resident's medical record for the UA order and result but said there wasn't an order for it. If the resident had orders, they should have been in the electronic system. He/She reviewed the resident's progress notes whenever he/she came in to work. He/She said the resident didn't have recurrent UTIs. After reviewing the resident's progress notes, LPN A said he/she didn't know about the physician orders to collect a urine sample for the resident. He/She said the orders from the progress note should have been put on the physician order sheet and it would trigger the nurse that something needed to be done. He/She said the nurse who received the UA order was supposed to collect the sample. That nurse should have documented and reported if he/she couldn't collect the sample, especially with the resident's behaviors. LPN A didn't know why it was thought the resident had frequent UTIs because he/she didn't see anything documented in the resident's medical record. He/She said if the information came from his/her family, that should have been documented in the resident's chart. LPN A said both of the UA orders fell off and were not done. He/She said the orders were lost in translation, either by paper or verbally. The UA should have been done the first week the resident got there. He/She expected the UA to have been collected. If the urine sample wasn't collected, a note should have been added so the other shifts would know to follow up. LPN A said physician orders should be followed. He/She said if the order was confusing, nursing should call for clarification.During an interview on 7/7/25 at 11:43 A.M., LPN B said physician orders should be followed. Physician orders noted in the resident's progress note should be followed and added to the physician order sheet. If an order was not clear, the nurse should call for clarification. If a nurse was unable to complete an order, that information should be documented and passed on to the next shift. He/She said there had to be extenuating circumstances for an order to not be completed. LPN B expected all physician orders to be followed.During an interview on 7/7/25 at 12:16 P.M., the DON said she knew who the resident was. She said the doctor gave nurses new orders over the phone, in writing, and in person. Those orders were added to the resident's physician order sheet. The nurse who received the order was responsible for carrying it out. If that nurse wasn't able to complete it, he/she was supposed to inform the oncoming nurse assigned to the resident. She expected all nursing staff to follow-up with the oncoming shift. She was aware of the physician order on 5/11/25. The resident was already on antibiotics when he/she admitted to the facility. The DON said the resident's family requested the UA because he/she had a UTI in the hospital and wanted to make sure the medicine was working. The MD gave the order for the UA. The DON said the family's request for the UA should have been documented. She asked the family for help collecting the urine sample. She said the resident was combative when his/her family was visiting, and they still couldn't collect the sample. She said all of that information should have been documented in the resident's record and she expected it to have been documented. She didn't notice the resident had any signs or symptoms of a UTI, but the family said the resident had become more combative. They thought the resident had a UTI. The DON expected nursing to follow all physician orders and facility policies. Nursing was supposed to review the 24-hour nursing report and pass on anything that needed follow-up. She expected the UA samples to have been collected before today. She expected staff to document actions taken related to any attempt at collecting the urine sample and/or any combative behavior that may have kept them from collecting the urine sample from the resident. She couldn't justify what happened and said she wasn't sure if the previous lab had picked up the sample or if the sample had ever been collected. She and corporate staff were responsible for locating lab results.During an interview on 7/7/25 at 2:45 P.M., the Administrator said she was only aware of one occasion of staff not collecting the resident's urine sample. Both the Administrator and DON expected nursing staff to have documented the urine sample wasn't collected, and any action steps taken during the process. The Administrator said nursing staff should have and were expected to communicate during the nursing report about any orders and/or tasks that need follow-up. The DON said if the physician was notified, the nurse should have documented that. Both the Administrator and DON expected documentation to be in the resident's record if the physician had been notified. The Administrator, DON, and Regional Nurse Consultant (RNC) expected nursing staff to follow the facility's policies.MO00255252

Based on interview and record review, the facility failed to conduct a thorough investigation after a facility nurse discovered a resident (Resident #1), who was confused, with a bruise on his/her chest, an abrasion above his/her right eye, a skin tear on his/her nose and an abrasion on his/her right elbow. The resident could not tell the nurse how he/she sustained the injuries. The sample was 3. The census was 105. Review of the facility's Injury of Unknown Source policy, revised May 2021, showed: -Indicators of physical abuse may include but are not limited to: -Bruises and/or hematomas; -Injuries of unknown source-no abuse/neglect suspected; -If a logical/reasonable explanation of the source of the injury cannot be determined, notify your local state agency within two hours of discovery; -Staff must provide a statement as to their knowledge or lack of knowledge of the injury; -The resident's physician must be notified; -The resident's representative must be notified; -A complete body assessment must be completed on the resident. Review of the facility's Post Fall Assessment policy, dated 7/1/15, revised July 2024, showed: -All falls are investigated to determine the reasons for the fall and to develop interventions to minimize or eliminate future falls; -The nurse on duty will complete a Post-Fall Assessment Event for each fall; -Physician and resident representative must be notified of all falls; -Neurological Assessment should be initiated with all falls: Initiate Neurological Assessment Form DGE 047A for falls with head injuries. Initiate Neurological Assessment Form DGE047B for unwitnessed falls without head involvement; -Nurses must assess the resident's condition following the fall and document every shift for 72 hours after a fall. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Cognitively intact; -Lower extremity impairment on one side; -Required substantial/maximum assistance with mobility and transfers; -Diagnoses included congestive heart failure, peripheral vascular disease (PVD, a progressive disorder that affects blood vessels outside the heart and brain, including arteries, veins, or lymphatic vessels), end stage renal disease, diabetes and absence of left leg above knee (amputated). Review of the resident's physical therapy discharge notes, dated 1/14/25, showed: -Bed mobility: Partial/moderate assistance; -Transfers: Substantial/moderate assistance; -Ambulation: Not applicable. Review of the resident's progress notes, showed: -On 1/21/25 at 9:04 P.M., (recorded as late entry on 1/23/25 at 5:07 P.M.) the nurse collected a urinalysis (UA) and placed it in the fridge in the soiled utility room for pick up. At 6:08 P.M. (recorded as late entry on 1/23/25 at 6:11 P.M.) the Director of Nursing (DON) noted the resident sustained a minor injury fall. The resident said he/she was sleeping and fell out of bed. The resident had an abrasion above his/her right eye, and an abrasion to the right elbow. The resident denied pain. Treatment and interventions were put in place. Physician and power of attorney (POA) were notified; -On 1/22/25 at 12:32 P.M., the nurse assessed the resident for wound care and noticed a red/purple area on the resident's chest which measured 0.5 centimeters (cm) x 3.5 cm, nose measured 3 cm x 1 cm, and above right eye measured 3 cm x 4 cm. There was also dried up blood on his/her right elbow which measured 1.9 cm by 0.1 cm. The nurse cleansed and applied xeroform (a sterile, non-adherent wound dressing) and foam dressing to the resident's elbow. The resident was confused and said he/she remembered rolling over, but did not remember falling or getting up. The resident's physician and family were notified; -On 1/23/25 at 2:28 A.M., the resident laid in bed with bed in lowest position, was able to make needs known, voiced no pain or discomfort, and skin was warm and dry to touch. The resident remained on observation for fall with skin tear to right elbow, bruising to right eye and nose, call light within reach. At 12:21 P.M., UA pending. At 5:07 P.M. the resident laid in bed. The bruise on his/her face and neck was going away. It was pink in color. The resident had some confusion, but it was better. Review of the resident's fall risk assessment, dated 1/23/25, showed: -History of falls; -Gait impaired; -Oriented to his/her own ability; -High risk for falls. Review of the resident's care plan, updated on 1/23/25, showed: -Problem: Cognitive loss/dementia. The resident scored 12 on BIMS upon admission. He/She had forgetfulness at times and needed reminders and cues; -Approach: Staff alerted the physician if this was a new observation, establish an environment of mutual trust and respect, excluded underlying related medical problem, and provided verbal and visual reminders; -Problem: Falls. The resident had a recent history of falls related to hallucinations; -Approach: Despite decreased safety and recommended assistance with mobility, the resident chose to remain as independent as possible and continued to self transfer. Staff were to provide frequent checks and offer to assist with toileting and transfers. Despite frequent reminders, the resident did not remember to use the call light and ask for assistance. Staff will attempt to anticipate his/her needs. Review of the resident's post fall assessment, dated 1/24/25, showed: -Unwitnessed fall occurred in the resident's room; -The resident said he/she was sleeping and fell out of the bed. Staff transferred him/her with the tent; -Neuro checks initiated and UA pending. Review of the resident's progress notes, showed: -On 1/24/25 at 1:51 P.M., the resident denied pain or discomfort. The resident's bruise on face was healing. Staff continued to monitor; -On 1/25/24 at 3:45 A.M., the resident remained on fall observation. No pain or discomfort. Bruising remained. Neuro checks and range of motion with in normal limits. At 3:06 P.M., urine culture reported to physician. New orders received for bactrim (used to treat a wide variety of bacterial infections) and acidophilus (used as a probiotic to promote the growth of good bacteria in your body) by mouth for five days. The resident's family was notified of UA results and new orders for antibiotics. Review of the resident's UA culture, dated 1/25/25, showed the sample was collected on 1/21/25 at 12:43 P.M. and positive for urinary tract infection (UTI). During an interview on 4/7/25 at 1:50 P.M., the Administrator said she heard the resident had a mark and staff did not know where it came from. The resident said he/she rolled out of bed. He/She said staff used a tent to get him/her back in bed. They assumed he/she was referring to the Hoyer lift. They are not sure who got him/her off the floor. He/She could not get off the floor without assistance. Whoever got the resident off the floor did not document the fall. The Administrator thought they did an investigation. She didn't think they in-serviced staff. During an interview on 4/7/25 at 2:04 P.M., the DON said they never established if the resident fell . The facility had all agency working on the day it happened. They called staff. No one answered their phone, or they did not remember the fall. She put in the fall investigation, because the resident said he/she fell . They did not do in-services, because none of the facility staff was working. The resident did have some confusion. They still use agency staff. They did not in-service agency staff, because the staff who worked that night were new. They usually use the same agency staff. They have agency staff review and sign off on our policies at the beginning of their shift. Review of the night shift staffing sheet for 1/22/25, showed two agency nurses, and six facility Certified Nursing Assistants (CNAs) were scheduled. During an interview on 4/7/25 at 3:14 P.M., agency CNA A said he/she has worked at the facility before. His/Her first shift was a year ago. He/She reviews the policy and procedures every now and again, but it is not mandatory to review it each shift. If he/she found a resident on the floor, he/she would get a nurse. During an interview on 4/7/25 at 3:20 P.M., agency Licensed Practical Nurse B said he/she has worked at the facility a few times. His/Her first shift was a few months ago. The facility has a policy book agency staff must sign before their first shift. If he/she found a resident on the floor, he/she would assess the resident. Then check their status, call paramedics, and call the doctor to see what he/she wants to do. He/She was sure something else should be done, but he/she could not remember everything. During an interview on 4/7/25 at 3:40 P.M., the DON said all the nurses were agency. The CNAs were facility staff. The resident's family member thought the resident hit the nightstand. The resident said he/she fell and as a precaution the DON documented a fall. She did not think it was an injury of unknown origin. She did not think they should have completed an investigation. She thinks they asked the questions they needed to ask. I think the post fall assessment covered us. MO00250795

Based on interview and record review, the facility failed to ensure professional standards of practice where met, when staff failed to transcribe one resident's new treatment order onto the electronic treatment administration record (eTAR), resulting in the new treatment order not being administered from 7/24/24 to 8/2/24 as ordered by the physician for one resident (Resident #8) resulting in the wound showing signs and symptoms of infection. The sample was 18. The census was 96 with 83 residents in certified beds. Review of the facility's Following Physician Orders Policy, dated June 29, 2021, showed: -Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses (Registered Nurse (RN)/Licensed Practical Nurse (LPN)/ Licensed Vocational Nurse (LVN)) and other healthcare professionals, follow physician orders in accordance with state, federal regulations, and their respective practice acts; -Procedure: -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record; -All physician or other health care professional's verbal, telephone or written orders will be immediately entered in the electronic health record (EHR) by the nurse obtaining the order. Review of the facility's Wound Care Protocol Policy, dated reviewed 7/23, showed: -How to assess/document: Initially assess the ulcer(s) for location, measurement, exudate (fluid that leaks out of blood vessels into nearby tissue), and tissue type; -Treatment should be determined based on the assessment; -Documentation of the initial and weekly assessment finding should be noted in the wound management section of the EHR. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 9/5/24, showed: -Cognitively intact; -No behaviors or refusal of care; -Diagnoses included: anemia (decrease in number of red blood cells), high blood pressure, diabetes, and muscular dystrophy (a genetic disease that cause progressive weakness and loss of muscle mass). Review of the care plan in use at the time of survey, showed: -Problem: currently has an alteration in skin integrity and required wound monitoring; -Goal: wound will not increase in size or exhibit signs of infection through next review; -Approach: Staff monitor the condition of skin during activities of daily living (ADL, self care) care. Nursing to complete weekly skin audits and document as required. All abnormal/new findings are reported to physician for treatment; -Wound treatment(s) to be completed per eTAR/physician order. Review of the resident's weekly skin audits, provided by the facility for June, July, and August 2024, showed: -On 6/1/24, open area noted on right ankle; -On 7/13/24, wounds to scrotum/ right ankle and right shin; -No other skin assessments were provided. Review of the progress notes dated 7/10/24 through 7/14/24, showed: -On 7/10/24 at 2:11 P.M., new wound noted to resident's scrotum (a pouch of skin containing the testicles) area, buttocks noted to be red. Wound on scrotum measures 0.6 centimeters (cm) X 1.0 cm. Peri area (area between legs and buttocks) was painful to touch due to wound being sore and buttocks being red and inflamed. Orders for Santyl (sterile enzymatic debriding ointment) and zinc (skin barrier) have been entered. Physician has been notified; -On 7/14/24 at 3:41 P.M., seen by the wound management team related to multiple wounds. Will continue to monitor wounds weekly for progress; -The note did not show the wound on the scrotum; -Staff did not document the treatment had changed or the resident refused the treatment; -Staff did not document why the treatment was not completed. Review of the wound management team notes, dated 7/18/24, showed: -Location: scrotum/posterior (back); -Type: Pressure ulcer/injury (any lesion caused by unrelieved pressure that results in damage to the underlying tissue): unstageable (depth obscured); -Wound bed description: no description was documented; -Measurements: no measurements were documented; -Exudate: moderate; -Peri-wound: erythema (redness of the skin), macerated (a softening and breaking down of the skin resulting from prolonged exposure to moisture) and scarring; -Color: sero-sanguineous (containing blood and serum); -Wound status: initial evaluation; -Treatment: cleanse with Normal Saline (NS) then apply Santyl and apply dry dressing, change daily and as needed. Review of the eTAR, dated 7/1/24 through 7/25/24, showed: -An order for Santyl apply to wound on scrotum, start date was 7/14/24 and discontinue date was 8/2/24; -Documentation showed: treatment was not completed on 7/15, 7/16, 7/17, 7/22, 7/23 and on 7/25; -There was no order for gentamicin and there was no order for weekly skin audits. Review of the progress notes, dated 7/24/24 through 7/30/24, showed: -On 7/24/24 at 12:47 P.M., resident was seen by the wound management team on 7/17/24 related to multiple wounds. New treatment order for gentamicin (antibiotic) and Santyl to the scrotum; -On 7/26/24 at 1:04 P.M., resident was seen by wound management team on 7/25/24 related to multiple wounds. Will continue the current treatments in place for all wounds. Will continue to monitor wounds weekly for progress; -There was no documentation showing the treatment was changed, or the resident refused the treatment and no documentation showing why the treatment was not completed. Review of the wound management team's notes, dated 7/25/24, showed: -Location: scrotum/posterior; -Type: Pressure ulcer/injury: unstageable (depth obscured); -Wound bed description: 25% granulation tissue (new connective tissue that forms in a wound during the healing process) and 75% necrotic tissue (dead or dying tissue); -Measurements: 3.1 cm length, X 6.3 cm width X 0.2 cm depth; -Peri-wound: erythema, macerated and scarring; -Exudate: moderate; -Color: sero-sanguineous; -Wound status: unchanged/stable; -Treatment: cleanse with NS then apply Santyl and apply dry dressing, change daily; -Wounds: scrotum/posterior-new on 7/18/24, stable, continue santyl and gentamicin. Review of the eTAR, dated 7/26/24 through 7/31/24, showed: -An order for Santyl apply to wound on scrotum, start date was 7/14/24 and discontinue date was 8/2/24; -There was no order for gentamicin. Review of the progress notes, dated 8/1/24 through 8/4/24, showed: -On 8/4/24 at 1:42 P.M., provider summary received for routine visit on 8/2/24. No new recommendations at this time, staff to continue to monitor and treat wound on left toe and continue monitoring and treatment of pressure ulcer to left medical side of left knee with tubi grip (elastic tubular support bandage) for added protection. No other concerns at this time; -The note did not show wound on scrotum. Review of the wound management team's notes, dated 8/1/24, showed, -Location scrotum/posterior; -Wound Bed Description: 0 % Granulation Tissue and 100 % Necrotic Tissue; -Measurements: 4.8 cm x 3.7 cm x unable to determine (UTD) depth; -Peri-wound: Erythema, Macerated and Scarring; -Exudate: Moderate; -Color: Sero-sanguineous; -Treatment: Cleanse with NS then apply Santyl and apply dry dressing; change daily and as needed; -Wound Status Improved - continue current treatment plan; -Wound: scrotum/posterior-new on 7/18/24, stable, continue santyl and gentamicin. Review of the eTAR dated 8/1/24 through 8/3/24, showed: -An order for: Santyl apply daily to wound on scrotum, start date was 7/14/2024 and discontinued on 8/02/2024; -An order for: Santyl, cleanse posterior scrotum with NS, mix Santyl and gentamicin, apply nickel thick and cover with a foam dressing, start date was 8/3/24; -An order for: gentamicin ointment 0.1 %; mix with Santyl and apply nickel thick to right ankle, right shin, and posterior scrotum, change daily, start date 8/3/24. Review of the progress notes, dated 8/4/24 through 8/15/24, showed: -On 8/15/24 at 5:10 P.M., resident was seen by wound doctor and was recommended to send to hospital for treatment. Contacted emergency medical service (EMS) for transport to the hospital. Review of the wound management team notes, dated 8/15/24, showed: -Location scrotum/ posterior; -Type: Pressure Ulcer/Injury: Unstageable (Depth Obscured); -Wound Bed Description: 100 % Granulation Tissue and UTD/ % Necrotic Tissue; -Measurements: 6.0 cm x 2.8 cm x UTD depth; -Exudate: Moderate; -Peri-wound: erythema, macerated and scarring; -Color: Sero-sanguineous; - Wound Status Deteriorated - See plan of care (POC); -Additional Notes: send out to hospital due to deteriorated wound with odor. Altered mental status (AMS). -Treatment: Cleanse with NS then apply Santyl; gentamicin; cover with foam dressing daily and as needed; -Wound: scrotum/posterior (new on 7/18/24): deteriorated, send out due to signs of infection. Review of the eTAR, dated 8/3/24 through 8/16/24, showed: -An order for: Santyl, cleanse posterior scrotum with NS, mix Santyl and gentamicin, apply nickel thick and cover with a foam dressing, start date was 8/3/24; -Documentation showed: On 8/7/24, not administered: day shift; on 8/10/24, not administered, resident unavailable, up in wheelchair doesn't want treatment completed at this time; on 8/13/24, not administered: previous shift; -An order for: gentamicin ointment 0.1 %; mix with Santyl and apply nickel thick to right ankle, right shin, and posterior scrotum, change daily ,start date 8/3/24; -Documentation showed: On 8/10/24, not administered, resident unavailable, up in wheelchair doesn't want treatment completed at this time; on 8/13/24, not administered: previous shift; During an interview on 10/2/24 at 9:00 A.M., the Wound Nurse said the floor nurse was responsible for completing the weekly skin audits and providing the treatments. She provided wound care for resident who required a wound vacuum (wound treatment that uses suction to help wounds heal). When the wound management team visited the facility, she rounded with the Nurse Practitioner (NP), then she would document some type of note in the EHR regarding the wounds. During an interview on 10/4/24 at 12:00 P.M., the Nurse Manager said skin audits were completed weekly on the resident's shower day, by the floor nurse. If the resident had a wound, it should be documented on the skin assessment and documented with treatment in place. If the wound was new, staff should assess the wound and document it, notify the physician and note any orders that were obtained or whatever the physician said to do and notify the resident/resident representative. If the nurse documented a new order in the progress notes she would expect for the order to also be noted on the physician order sheet and the eTAR. The Nurse Manager checked the eTAR for July 2024 and said she did not see an order for the gentamicin. She would expect for an order to be placed on the physician order sheet and on the eTAR. During an interview on 10/4/24 at 12:08 P.M., the NP said when she visited the facility, she assessed the wounds that were being treated unless the staff notified her the resident had a new wound or area of concern. If a resident needed new orders, the NP either wrote them down on a piece of paper or gave the nurse a verbal order. The nurse at the facility was responsible for entering the orders into the EHR. The NP said she likely gave an order for gentamicin and santyl because she preferred to use an antimicrobial agent (kills microorganisms or inhibits their growth) sometimes with the santyl. During an interview on 10/4/24 at 1:53 P.M., the Administrator said she would expect for staff to follow physician orders and for skin audits to be completed weekly.

Based on observation, interview and record review, the facility failed to ensure all residents were treated in a manner to maintain dignity when staff left a resident exposed and visible from the hallway (Resident #10) and another resident in a hospital gown in the main dining room (Resident #21). In addition, staff failed to ensure two residents' (Resident #8 and #285) catheter bags (urine drainage bag) were not visible in the hallway from the residents' rooms. Staff also entered resident rooms without knocking (Resident #30 and #46). The sample size was 18. The census was 96 with 83 in certified beds. Review of the facility's undated Resident's Rights policy, showed: -Dignity and Respect: Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based. You have a right to expect that we will: -Treat you as an individual and assist you in getting the most out of the programs and services we offer; -Make sure your surroundings are safe, clean and comfortable; -Privacy and Confidentiality: Your right to privacy and confidentiality is as important to you as it is to any other person. You have the right to have other people respect your personal privacy as you receive care. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/9/24, showed: -Mild cognitive impairment; -Rejection of care occurred one to three out of seven days; -Dependent on staff for all personal care; -Diagnoses included stroke, diabetes, seizures, depression and respiratory failure. Review of the resident's care plan, revised 8/12/24, in use during the time of the investigation, showed: -Problem: Activities of Daily Living (ADL, self-care) functional status/rehabilitation potential; -Goal: The resident will participate in ADL activities promoting maximum independence through next review; -Approach: Assist with repositioning in bed and in wheelchair frequently. During an interview on 9/30/24 at approximately 11:29 A.M., the resident said he/she preferred his/her door shut. Observation on 10/4/24 at 8:26 A.M., showed the resident's door was open. The resident lay on his/her back in bed with his/her eyes closed. The resident was undressed and a towel covered his/her genitals. One resident passed the resident's room as the resident lay exposed. During an interview on 10/4/24 at 8:31 A.M., Certified Nursing Assistant (CNA) H said he/she was assigned to the resident. When shown the resident lay in bed with the door opened and exposed, CNA H said he/she provided care earlier that day and closed the door. CNA H did not leave the resident laying exposed. The resident's door should have been closed to maintain his/her dignity. The nurse was probably providing care to the resident. CNA H closed the resident's door. During an interview on 10/4/24 at 8:33 A.M., Licensed Practical Nurse (LPN) D, who was in the hallway during the time resident was exposed, said he/she did not leave the resident exposed. However, the resident's door should have been closed while he/she lay in bed exposed to maintain his/her dignity. 2. Review of the resident's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Clear speech; -Able to make self understood; -Able to understand others; -Moderate cognitive impairment; -Diagnosis included memory deficit, kidney disease, diabetes, and heart failure. Review of Resident's #21 care plan, revised 9/18/24, in use during the time of the investigation, showed the resident has a deficit in ADLs functioning and requires assistance related to weakness and cognitive deficit at times. Assist resident with ADLs as needed and requested. Observation in the main dining room on 9/30/24 at 12:36 P.M., showed the resident sat at the table wearing a hospital gown opened in the back, exposing his/her skin, pants, and shoes. During an interview, the resident said he/she preferred to wear a shirt to meals. Observation on 9/30/24 at 12:38 P.M., showed CNA P approached the resident while he/she was eating and said he/she would take the resident down the room to put a shirt on the resident. The CNA removed the resident from the dining room and returned at 12:47 P.M. The resident resumed eating his/her meal. During an interview on 10/2/24 at 9:51 A.M., LPN D said the resident should be dressed appropriately when eating in the dining room and the resident should not be removed while eating to be dressed. During an interview on 10/02/24 at 10:12 A.M., CNA F said residents should be dressed in clothes and not hospital gowns when eating in the dining room. A resident should not be removed from the dining room while they are eating so the hospital gown could be removed. When the resident returned their food could be cold and the resident may not continue to eat their meal. 3. Review of Resident #8's care plan, revised 8/30/24, in use during the time of the investigation, showed: -Problem: Indwelling catheter (a thin, hollow tube that is inserted into the bladder to drain urine and is left in place for a period of time). The resident has a catheter related to diagnosis of dysfunction of bladder; -Goal: The resident will have catheter care managed appropriately as evidenced by not exhibiting signs of infection through next review date; -Approach: Keep catheter system closed. Store collection bag inside a protective dignity pouch. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Required substantial assistance with staff for personal hygiene; -Diagnoses included renal disease, neurogenic bladder, multiple sclerosis, depression and anxiety. Observations on 9/30/24 at approximately 11:45 A.M. and 10/1/24 at 9:03 A.M., showed the resident lay in bed on his/her back. The resident's door was open and a catheter bag hung on the side of the bed, outside of a dignity bag and exposed to the hallway. Observation on 10/4/24 at 8:38 A.M., showed the resident sat in bed eating breakfast. The door was open and the catheter bag hung on the side of the bed, exposed and visible from the hallway. The resident said he/she could not cover the bag him/herself and wanted it covered and not visible from the hallway. During an interview on 10/4/24 at 8:40 A.M., CNA I said he/she was not assigned to the resident and did not leave the catheter bag exposed. However, the bag should be covered to maintain the resident's dignity. During an interview on 10/4/24 at 8:33 A.M., LPN D said catheter bags should be covered or the door should be shut to maintain a resident's dignity. 4. Review of the Resident #285 care plan, created 10/1/24, in use during the time of the investigation, showed the resident needed assistance with all ADLs. Review of the resident's face sheet, dated 10/1/24, showed diagnoses included kidney cancer, heart failure, and liver transplant. Observation on 10/2/24 at 7:45 A.M., showed the resident lay in bed, and the urinary catheter gravity bag attached to the bed frame, visible to persons passing by the room. During an interview on 10/2/24 9:51 A.M., LPN D said that the urinary catheter gravity bag should not be visible and should be placed in dignity bag or covered. During an interview on 10/2/24 at 10:12 A.M., CNA F said that a urinary catheter bag should be in a dignity bag, as to not embarrass the resident. 5. Review of Resident #30's annual MDS, dated [DATE], showed: -Cognitively intact; -Adequate hearing and vision; -Makes self understood and understands others; -No impairment to upper extremities; -No impairment to both lower extremities; -Dependent to lower body dressing and personal hygiene; -Diagnoses included anemia, heart diseases, high blood pressure, kidney disease, arthritis. Review of the resident's care plan, in use during the time of the investigation, showed: -Problem: The resident requires monitoring for continued bowel and bladder incontinence related to current incontinence, history of urinary tract infections (UTIs), and need for assistance with all toileting transfers and mobility; -Goal: The resident will remain clean, dry, and fee from odors; -Approach: Observe for signs and symptoms of infection, such as fever, hematuria (blood in urine), sedimentation (solid components in urine), mood or behavior changes. 6. Review of Resident #46's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Adequate hearing and vision; -Makes self understood and understands others; -No impairment to both upper and lower extremities. Review of the resident's care plan, in use during the time of the investigation, showed: -Problem: The resident is at risk for skin breakdown related to incontinent of bowel and bladder, history of pressure areas, diuretic use; -Goal: The resident's skin will remain intact; -Approach: Assist or encourage turning and repositioning frequently, keep clean and dry as possible, minimize skin exposure to moisture. Observation on 9/30/24 at 1:56 P.M., showed Resident #30's call light was on. He/She said he/she had pushed the call light at approximately ten minutes ago. At 2:00 P.M., CNA C entered the resident's room without knocking the door, turned off the call light and did not speak or ask the resident what he/she needed. The CNA then left the room. Resident #46 said CNA C was always in a hurry and enters the room without saying anything to both residents. He/She said the CNA slams the door at times. Resident #30 asked Resident #46 to turn on the call light again. At 2:26 P.M., CNA C and CNA F entered the room without knocking the door. Both CNAs assisted Resident #30. During an interview on 10/4/24 at 8:31 A.M., CNA H said staff were supposed to knock and announce themselves before entering a resident room. 7. During an interview on 10/4/24 at 1:52 P.M., the Administrator and Regional Nurse said they would expect all residents to be treated with dignity. Residents should not be exposed, catheter bags should be covered and staff should knock before entering a resident's room. 45083 Surveyor: [NAME], [NAME]

37681 42247 45083 Based on interview and record review, the facility failed to provide residents with a transfer notice when transferred to the hospital, for seven of seven residents investigated for hospital transfers (Residents #12, #45, #20, #43, #32, #81, and #8). The Census was 96 with 83 residents in certified beds. Review of the facility's undated Residents' Rights Policy, showed: -Admission, Transfer, Discharge: The residents have the right to due notice of the reasons for transfer or discharge if such occurrence takes place. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 9/13/24, showed: -Should a brief interview for mental status be conducted? No; -Both long-term and short-term memory loss; -Diagnoses included: heart failure, high blood pressure, obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), stroke, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), or hemiparesis (slight weakness in a leg, arm, or face); -Indwelling catheter (a thin, hollow tube that's inserted into the bladder to drain urine). Review of the resident's medical record, showed: -discharged to the hospital on 1/18/24; -Returned to the facility from the hospital on 1/25/24; -discharged to the hospital on 2/21/24; -No documentation transfer notices were given when the resident was sent to the hospital. 2. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included: urinary tract infection (UTI) in the past 30 days, high blood pressure and Parkinson's disease (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns). Review of the resident's medical record showed: -discharged to the hospital on 8/11/24; -Returned to the facility from the hospital on 8/14/24; -discharged to the hospital on 8/27/24; -Returned to the facility from the hospital on 9/1/24; -discharged to the hospital on 9/20/24; -Returned to the facility from the hospital on 9/23/24; -No documentation transfer notices were given when the resident was sent to the hospital. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included: heart failure, high blood pressure, anxiety, depression, acquired absence of the right leg above the knee. Review of the resident's medical record, showed: -discharged to the hospital on 3/24/24; -Returned to the facility from the hospital on 4/1/24; -No documentation transfer notice was given when the resident was sent to the hospital. 4. Review of Resident #43's quarterly MDS, dated [DATE], showed; -Moderately impaired cognition; -Diagnoses included heart failure, kidney failure, high blood pressure, and diabetes. Review of the resident's medical record, showed; -discharged to the hospital on 1/17/24; -Returned to the facility from the hospital on 1/26/24; -discharged to the hospital on 4/5/24; -Returned to the facility from the hospital on 4/8/24; -discharged to the hospital on 7/2/24; -Returned to the facility from the hospital on 7/19/24; -No documentation transfer notices were given when the resident was sent to the hospital. 5. Review of Resident #32's admission MDS, dated [DATE], showed; -Moderately impaired cognition; -Diagnoses included heart disease, kidney failure, high blood pressure, and dementia. Review of the resident's medical record, showed; -discharged to the hospital on 7/18/24; -Returned to the facility from the hospital on 7/20/24; -discharged to the hospital on 7/23/24; -Returned to the facility from the hospital on 7/30/24; -No documentation transfer notices were given when the resident was sent to the hospital. 6. Review of Resident #81's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included stroke, heart disease, high blood pressure, high cholesterol, and dementia. Review of the resident's medical record, showed: -discharged to the hospital on 7/3/24; -Returned to the facility from the hospital on 7/12/224; -Transferred to the hospital on 7/13/24; -Returned to the facility from the hospital on 7/14/224; -Transferred to the hospital on 7/15/24; -Returned to the facility from the hospital on 7/16/224; -Transferred to the hospital on 7/16/24; -No documentation transfer notices were given when the resident was sent to the hospital. 7. Review of Resident #8's medical record, showed: -Diagnoses included renal disease, multiple sclerosis (a chronic disease that affects the central nervous system), depression and anxiety; -discharged to the hospital on 6/23/24; -Returned to the facility from the hospital on 6/29/24; -discharged to the hospital on 8/15/24; -Returned to the facility from the hospital on 8/29/24; -No documentation transfer notices were given when the resident was sent to the hospital. 8. During an interview on 10/2/24 at 5:43 A.M., the Administrator said they had not issued any notices of transfer to residents upon their discharges to the hospital. They had identified this issue in Quality Assurance (QA) and would start issuing notices of transfers upon discharge with an anticipated return.

37681 42247 45083 Based on interview and record review, the facility failed to provide written notice to the resident, or their legal representative of the facility bed hold policy at the time of transfer to the hospital, for seven of seven investigated residents for hospital transfers (Residents #12, #45, #20, #43, #32, #81 and #8). The Census was 96 with 83 residents in certified beds. Review of the facility's undated Bed Hold Policy, showed: -Purpose: to notify the resident or representative of the Bed-Hold Policy in writing at the time of admission, upon discharge or revision and when transferred to a hospital or during therapeutic leave, as well as the intent of readmission according to state and federal regulations; -Procedure: The facility will inform and give a written copy of this policy to the resident and/or representative upon admission. The facility will also give a copy of this policy to the resident and representative if transferred to a hospital or during therapeutic leave. In addition, the facility will call the representative, if applicable, within 24 hours of the transfer or leave; -It is the policy of the facility to permit residents to return to the facility after they are hospitalized or placed on therapeutic leave. 1. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 9/13/24, showed: -Both long-term and short-term memory loss; -Diagnoses included: heart failure, high blood pressure, obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), stroke, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), or hemiparesis (slight weakness in a leg, arm, or face); -Indwelling catheter (a thin, hollow tube that's inserted into the bladder to drain urine). Review of the resident's medical record showed: -discharged to the hospital on 1/18/24; -Returned to the facility from the hospital on 1/25/24; -discharged to the hospital on 2/21/24; -No documentation the resident or the resident's representative received written notice of the facility's bed hold policy at the time of transfer. 2. Review of Resident #45's quarterly MDS, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included: urinary tract infection (UTI) in the past 30 days, high blood pressure and Parkinson's Disease. Review of the resident's medical record showed: -discharged to the hospital on 8/11/24; -Returned to the facility from the hospital on 8/14/24; -discharged to the hospital on 8/27/24; -Returned to the facility from the hospital on 9/1/24; -discharged to the hospital on 9/20/24; -Returned to the facility from the hospital on 9/23/24; -No documentation the resident or the resident's representative received written notice of the facility's bed hold policy at the time of transfer. 3. Review of Resident #20's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included: heart failure, high blood pressure, anxiety, depression, acquired absence of the right leg above the knee. Review of the resident's medical record showed: -discharged to the hospital on 3/24/24; -Returned to the facility from the hospital on 4/1/24; -No documentation the resident or the resident's representative received written notice of the facility's bed hold policy at the time of transfer. 4. Review of Resident #43's quarterly MDS, dated [DATE], showed; -Moderately impaired cognition; -Diagnoses included heart failure, kidney failure, high blood pressure, and diabetes. Review of the resident's medical record, showed; -discharged to the hospital on 1/17/24; -Returned to the facility from the hospital on 1/26/24; -discharged to the hospital on 4/5/24; -Returned to the facility from the hospital on 4/8/24; -discharged to the hospital on 7/2/24; -Returned to the facility from the hospital on 7/19/24; -No documentation the resident or the resident's representative received written notice of the facility's bed hold policy at the time of transfer. 5. Review of Resident #32's admission MDS, dated [DATE], showed; -Moderately impaired cognition; -Diagnoses included heart disease, kidney failure, high blood pressure, and dementia. Review of the resident's medical record, showed; -discharged to the hospital on 7/18/24; -Returned to the facility from the hospital on 7/20/24; -discharged to the hospital on 7/23/24; -Returned to the facility from the hospital on 7/30/24; -No documentation the resident or the resident's representative received written notice of the facility's bed hold policy at the time of transfer. 6. Review of Resident #81's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included stroke, heart disease, high blood pressure, high cholesterol, and dementia. Review of the resident's medical record showed: -discharged to the hospital on 7/3/24; -Returned to the facility from the hospital on 7/12/224; -Transferred to the hospital on 7/13/24; -Returned to the facility from the hospital on 7/14/224; -Transferred to the hospital on 7/15/24; -Returned to the facility from the hospital on 7/16/224; -Transferred to the hospital on 7/16/24; -No documentation the resident or the resident's representative received written notice of the facility's bed hold policy at the time of transfer. 7. Review of Resident #8's medical record, showed: -Diagnoses included renal disease, neurogenic bladder, multiple sclerosis, depression and anxiety; -Transferred to the hospital on 6/23/24; -Returned to the facility from the hospital on 6/29/24; -Transferred to the hospital on 8/15/24; -Returned to the facility from the hospital on 8/29/24; -No documentation the resident or the resident's representative received written notice of the facility's bed hold policy at the time of transfer. 8. During an interview on 10/3/24 at 12:00 P.M., Registered Nurse (RN) A said when a resident was sent to the hospital, he/she sent a copy of the Continuity of Care Document (CCD) and the bed hold policy with the resident. 9. During an interview on 10/2/24 at 5:43 A.M., the Administrator said they had not issued a copy of the facility's bed hold policy to residents upon their discharges to the hospital. They had identified this issue in Quality Assurance (QA) and would start issuing the bed hold policy upon discharge with an anticipated return.

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in a sufficient detail to enable accurate reconciliation. The facility failed to ensure accuracy and monitoring for controlled substances for one of four electronic narcotic counts reviewed. The census was 96 with 83 in certified beds. Review of the facility's Medication Administration policy, effective date January 2021, showed: -All inventoried drugs are to be counted by licensed/certified personnel at each shift change. Any discrepancy must be called to the attention of the Director of Nursing (DON). Review of the facility's electronic narcotic count system reviewed on 9/30/24 at 1:39 P.M., showed the electronic screen showed a count 120 tablets of tramadol (opioid) 50 milligrams (mg) and the card in the cart showed 114 tablets. During an interview on 9/30/24 at 1:39 P.M., the Certified Medication Technician (CMT) G said he/she mentioned to the DON that the count was not correct, and the count had been off since last Friday, 9/27/24. A count should be done at the beginning and end of each shift. During an interview on 10/2/24 at 10:12 A.M., Licensed Practical Nurse (LPN) D said narcotics should be counted at the beginning and end of each shift. If the count was not correct, staff should notify the supervisor on call. During an interview on 10/2/24 at 11:34 A.M., the interim DON said that she would expect the narcotic count to be correct during the exchange of keys at shift change. If the count was not correct, staff should notify nursing administration. The count should be corrected as soon as possible and not be allowed to be incorrect for days.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 30 opportunities observed, five errors occurred resulting in a 16.67% error rate (Residents #50, #74, #19 and #26). The census was 96 with 83 residents in certified beds. Review of the facility's Insulin Administration via Pen Devices policy, effective date 5/21, showed: -Purpose: To safely administer insulin via pen devices according to physician orders and the facility's Policy and Procedure recommendations; -Procedure: Prime the pen immediately before injection. Priming is dialing up two units of insulin and pressing the bottom on the pen to shoot some insulin into the air. You should see a drop of insulin at the end of the needle. More than one prime may be required for a new pen. Review of the facility's Following Physicians Orders, dated June 29, 2021, showed: -Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses and other Healthcare Professionals, follow physician's orders in accordance to State, Federal regulations and their respective practice acts; -Procedure: All physicians orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record. Review of the Humalog KwikPen, lispro solution, (a pre-filled, disposable pen that contains insulin lispro, a fast-acting insulin used to treat high blood sugar in people with diabetes) manufacture's instructions showed: -Prime before each injection; -Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensure that the pen is working correctly; -If you do not prime before each injection, you may give too much or too little insulin. Review of the Advair Diskus (prescription medicine used long term to treat chronic obstructive pulmonary disease (COPD)) manufacturer's highlights of prescribing information showed after inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis (fungal infection in the mouth). 1. Review of Resident #50's medical record, showed: -Diagnoses included diabetes, heart failure, kidney disease, and venous insufficiency (blood flow back to the heart is slowed); -An order, dated 3/2/24, showed Humalog KwikPen Insulin (insulin lispro) 100 units/milliliter (mL), 15 units subcutaneous (under the layers of the skin) three times a day before meals; -An order, dated 2/14/24, Humalog KwikPen Insulin (insulin lispro) 100 units/mL per sliding scale, before meals and at bedtime: -If blood sugar is less than 50, call physician; -If blood sugar is 50-150, give 0 units; -If blood sugar is 151-200, give 2 units; -If blood sugar is 201-250, give 4 units; -If blood sugar is 251-300, give 6 units; -If blood sugar is 301-350, give 8 units; -If blood sugar is 351-400, give 10 units; -If blood sugar is greater than 400, call physician. During a medication administration observation, on 10/1/24 at 7:10 A.M., the resident's blood sugar was 179. Registered Nurse (RN) A dialed the pen to 17 units/mL. He/she did not prime the pen. During an interview on 10/1/24 at 7:19 A.M., RN A said that he/she did not need to prime the pen because the pen was primed automatically when the pen was first accessed. During an interview on 10/2/24 at 9:51 A.M., Licensed Practical Nurse (LPN) D said insulin pens had to be primed to make sure the pen was working properly. During an interview on 10/2/24 at 11:35 A.M., the interim Director of Nursing (DON) said that insulin pens had to be primed before dialing up the dosage to be administered so the resident would get the right amount of insulin. 2. Review of Resident #74's medical record, showed: - Diagnosis included chronic obstructive pulmonary disease (permanent damage to the lung that makes it difficult to breath), lung cancer, anxiety, high blood pressure, and high cholesterol; - An order, dated 2/6/24, showed Advair Diskus 250-50 microgram (mcg)/dose, inhale twice a day. Rinse mouth after use; - An order, dated 4/14/24, showed insulin lispro 100 unit/mL, 5 units subcutaneous three times a day. During a medication administration observation, on 10/1/24 at 7:35 A.M. Certified Medication Technician (CMT) J, prepped the diskus and handed to the resident. After the resident inhaled the medication, he/she handed the diskus to CMT J. CMT J insluin lispro pen did not offer the resident a cup of water to rinse his/her mouth after inhaling the medication. During a medication administration on 10/2/24 at 7:35 A.M., LPN E dialed the pen to 5 units/mL. He/she did not prime the pen prior to administration. During an interview on 10/2/24 at 9:51 A.M., LPN D said staff should follow physician's orders as written. The resident was to swish with a liquid and spit into a cup. The rinsing with liquid removed leftover medication off the tongue. During an interview on 10/2/24 at 10:01 A.M., CMT G said a resident who used an Advair Diskus must rinse their mouth out. During an interview on 10/2/24 at 11:35 A.M., the interim DON said if a resident was ordered an Advair Diskus, staff should provide liquid to rinse out their mouth. 3. Review of Resident #19's medical record, showed: -Diagnosis included diabetes, anxiety, high blood pressure, and high cholesterol; -An order, dated 7/23/24, showed insulin lispro 100 units/mL, 10 units subcutaneous three times a day before meals; -An order, dated 7/23/24, insulin lispro 100 units/mL per sliding scale, before meals and at bedtime: -If blood sugar is less than 70, call physician; -If blood sugar is 151-200, give 2 units; -If blood sugar is 201-250, give 4 units; -If blood sugar is 251-300, give 6 units; -If blood sugar is 301-350, give 8 units; -If blood sugar is 351-400, give 10 units; -If blood sugar is greater than 400, give 12 units; -If blood sugar is greater than 401, call physician. During a medication administration observation, on 10/1/24 at 7:19 A.M., the resident's blood sugar was 307. RN A dialed the pen to 18 units/mL. He/she did not prime the pen prior to administration. During an interview on 10/1/24 at 7:19 A.M., RN A said he/she did not need to prime the pen because the pen was primed automatically when the pen was first accessed. 4. Review of Resident #26's medical record, showed: -Diagnosis included diabetes, high blood pressure, high cholesterol, and heart failure; -An order, dated 9/8/24, insulin lispro pen 100 units/mL, 22 units subcutaneous three times a day before meals; During a medication administration observation, on 10/2/24 at 7:14 A.M., LPN E dialed the pen to 22 units/mL. He/She did not prime the pen prior to administration. During an interview on 10/2/24 at 7:35 A.M., LPN E said that he/she did not need to prime the pen because the pen was primed automatically when the dial was turned. During an interview on 10/2/24 at 11:35 A.M., the interim Director of Nursing said insulin pens had to be primed before drawing up the dosage to be administered so the resident would receive the right amount of insulin.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. Problems were noted in one of three identified facility medication rooms and in one of four medication administration carts. The facility census was 96 with 83 residents in certified beds. Review of the facility's Storage of Drugs policy, updated 12/21, showed: -Drugs and medications are to be stored in the original container in which they were received. Refrigerator, freezer, and control room will be available in the pharmacy for medications requiring specific storage; -No discontinued, outdated, or deteriorated drugs or medications are stored in the facility over thirty (30) days. Review of the facility's Pharmacy Responsibility, dated 12/20, showed: Date opened stickers will be attached to all multi-dose vials and other medications with time-limited use. 1. Observation on 9/30/24 at 11:08 A.M. of the facility's 300 Division medication room, showed: -One 3 milliliter (mL) bottle of True Metrix Control Solution (a control solution used to check the accuracy of the glucometer machines that check resident's blood sugar) expired as of 12/31/23; -One 3 mL bottle of True Metrix Control Solution expired as of 1/31/24; -One 100 mL opened bottle of Levetiracetam (used to treat seizures associated with epilepsy, episodes of abnormal electrical activity in the brain) expires on 8/15/25, not dated; -One 16-ounce (oz) opened bottle of Robitussin (used to treat cough) with the expiration date blacked out and no date opened; -In the cabinet where medication was stored, there were opened bag of potato chips, a half empty bottle of soda, and a tied bag of food items. During an interview on 9/30/24 at 10:55 A.M., Registered Nurse (RN) A said it was the nurses' responsibility to remove expired medications from the medication rooms. Staff personal items should not be in the medication rooms. 2. Observation on 9/30/24 at 1:30 P.M., of the Division 100 Certified Medication Technician (CMT) cart, showed one bottle of Geri Tussin (used to treat cough) opened, with dry residue built up under the cap, with no date opened. During an interview on 9/30/24 at 1:30 P.M., CMT K said that the pharmacy came into the facility every week to check the carts. He/She was not aware when items were opened, they were to be dated. During an interview on 10/2/24 at 9:51 A.M. the Licensed Practical Nurse (LPN) D said medications were to be dated when opened and an expired medication to be removed from the medication cart or medication room. During an interview on 10/2/24 at 11:35 A.M., the interim Director of Nursing (DON) said the term time-limited use referred to the expiration date printed on a bottle or package. Medication should be dated when opened. If a bottle of medication had a build-up of residue near the cap it should be removed. It was the expectation that staff remove expired items from the medication carts. Staff and resident personal items should not be stored in the medication rooms.

Based on observation and interview, the facility failed to ensure the main kitchen floors, appliances and food storage areas were clean and free from debris. In addition, the facility failed to ensure outdated food was discarded. This affected all residents who ate at the facility. The census was 96 with 83 residents in certified beds. Review of the facility's undated Dining Services Clean-Sanitize-Disinfect policy, showed: -Policy: This facility will store, prepare, distribute and serve food under sanitary conditions to ensure proper cleanliness and food handling practices to prevent the outbreak of food-born illnesses is attained continuously; -Cleaning: The process of removing visible debris, dirt and dust and organize a space. Observation of the kitchen on [DATE] at 11:08 A.M., showed: -The floors throughout the entire kitchen contained white specs, dust, grease and water stains; -Two refrigerators in the preparation area were stained with debris on the doors of both refrigerators; -The prep table had several dirty dish rags on top. Several containers of various spices and sauces with debris and food spilled on the outside of the containers were on a shelf were under the prep table; -Visible rust, dirt and debris on the surface areas of the stove, oven, fryer and tilt skillet; -The dry storage area had several balled up napkins/paper towels on the floor; -Five boxes of cake mix sat on the shelf with a use by date of [DATE]. Observation of the kitchen on [DATE] at 8:16 A.M., showed: -The floors throughout the kitchen contained several white specs, balled up napkins/paper towels, grease and water; -The walk in freezer contained a bag of chicken on the floor; -The dry storage area contained four balled up napkins/paper towels on the floor, two bug traps under the shelving and five boxes of cake mix with a use by date of [DATE]; -The preparation area floor was wet with water and grease; -The two refrigerators contained white substances and dust on the doors of both refrigerators; -The shelf under the preparation table contained several bottles of sauces and seasoning with dust and spillage on the outside of the bottles and containers; -The stove, oven, fryer and tilt skillet contained rust, dirt, debris and grease on the surfaces. Observation of the kitchen on [DATE] at 6:03 A.M., showed: -The floors throughout the kitchen contained white specs, grease and dust; -The dry storage area contained five boxes of cake mix with a use by date of [DATE], two cups under the shelf on the floor and two bug traps on the floor; -The walk in freezer contained a smoked cigar on the floor; -The preparation area's table had several dish towels, papers, gloves and various other items on the table; -The two refrigerators contained white substances and dust on the doors of both refrigerators; -The shelf under the preparation table contained several bottles of sauces and seasoning with dust and spillage on the outside of the bottles and containers; -The stove, oven, fryer and tilt skillet contained rust, dirt, debris and grease on the surfaces. Observation of the kitchen on [DATE] at 10:42 A.M., showed: -The floors throughout the kitchen contained white specs, grease and dust; -The dry storage area contained two cups under the shelf on the floor and two bug traps on the floor; -The walk in freezer contained a smoked cigar on the floor; -The preparation area's table had several dish towels, papers, gloves and various other items on the table; -The two refrigerators contained white substances and dust on the doors of both refrigerators; -The shelf under the preparation table contained several bottles of sauces and seasoning with dust and spillage on the outside of the bottles and containers; -The stove, oven, fryer and tilt skillet contained rust, dirt, debris and grease on the surfaces. During an interview on [DATE] at 11:00 A.M., Dietary Aide (DA) O said all dietary staff were responsible for ensuring the kitchen was clean. They deep cleaned the kitchen daily. DA O said the floor contained dirt, grease and was not considered clean. The tilt skillet had a build up of food and the fryer contained years of build-up. He/she said the oven, stove and fryer were deep cleaned a month ago and now contained build up of grease, rust and debris. The stove and splatter guard were recently cleaned but now contained dirt, debris, grease and rust. The refrigerators were cleaned a couple of days ago but had dirt and debris on the doors. The kitchen was not considered clean. During an interview on [DATE] at 11:09 A.M., the Dietary Manager said the appliances were cleaned on Monday and the oven and stove was cleaned daily. The sauces and seasonings would be thrown away and not used. The cake mixes were discovered yesterday and thrown away. Staff were expected to clean after each meal service. They cleaned daily and deep cleaned monthly. The kitchen was short-staffed and the concern was ensuring the residents received hot food on time. She would expect the kitchen to be clean. During an interview on [DATE] at 1:52 P.M., the Administrator said she would expect the kitchen to be clean and expired foods to be discarded.

42247 Based on observation, interview and record review, the facility failed to follow acceptable infection control standards when staff failed to perform hand hygiene between glove changes and/or between residents for four residents observed. (Resident #50, #19, #26 and #74). In addition, staff left the catheter bag for one resident (Resident #12) on the floor without a protective barrier, and failed to wear appropriate personnel protective equipment (PPE) for residents who required Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs, bacteria or fungi resistant to multiple antimicrobials (an agent that kills microorganisms or stops their growth)); that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for one resident (Resident #61). The sample was 18. The census was 96 with 83 residents in certified beds. Review of the facility's Medication Administration Policy, dated January 2021, showed: -Procedure: Wash your hands before and after each different resident contact. An alcohol-based commercial wash may be substituted. Review of the facility's Catheter Care policy, revised 3/2021, showed: -Purpose: To keep indwelling catheter (a hollow tube that is inserted into the bladder to drain urine) free of discharge and/or crusting which can cause infections; -Procedure: -Catheter care should be given every shift and as needed; -Observation and Reporting: -Check tubing for positioning. Coil on bed; -Attach bag to bed frame only. Review of the facility's EBP policy, dated reviewed 8/24, showed: -Purpose: to reduce the spread of MDRO; - Types of MDROs include but not limited to: - Carbapenems-producing carbapenem-resistant Acinetobacter baumannii (CRAB, causes colonization and infection predominantly in hospitalized patients); -Residents with colonization of MDRO and/or with indwelling medical devices (urinary catheter) will be placed on Enhanced Barrier Precautions (EBP); -Signage will be placed outside of their rooms to alert staff that PPE is needed such as gowns and gloves; -PPE including gowns and gloves, will be available in an area accessible to use when high contact resident care activities are anticipated; -PPE should be worn with during high-contact resident care activities: -Bathing/showering; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: urinary catheter. Review of the magnet used for signage, showed: -EBP Steps: -Perform hand hygiene; -Wear gown; -Use gloves; -Dispose of gown and gloves in the room; -Repeat hand hygiene. 1. Review of Resident #50's medical record, showed diagnoses included diabetes, heart failure, kidney disease, and venous insufficiency (blood flow back to the heart is slowed). Review of the resident's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by the facility staff, dated 2/14/24, showed: -admitted [DATE]; -Clear speech; -Able to make self-understood; -Able to understand others; -Cognitively intact. During an observation on 10/1/24 at 7:10 A.M., showed Registered Nurse (RN) A prepared to check resident the resident's blood sugar and provide insulin. He/She entered the room, washed his/her hands in the resident's sink and put on gloves. He/She performed the blood sugar test, removed his/her gloves and documented in the computer. Without washing his/her hands, RN A put on another pair of gloves, and gathered insulins. Once the dosage was selected on the insulin pen, RN A removed his/her gloves and put on another pair of gloves. RN A administered the insulin, removed the gloves, and washed his/her hands. 2. Review of Resident #19's medical record, showed diagnoses included diabetes, high blood pressure, heart failure, kidney disease, and anxiety. Review of the resident's admission MDS, dated [DATE], showed: -admitted [DATE]; -Clear speech; -Able to make self-understood; -Able to understand others; -Cognitively intact. During an observation on 10/1/24 at 7:19 A.M., showed RN A prepared to check the resident's blood sugar and provide insulin. He/She put on gloves and gathered supplies from the cart. RN A removed gloves, washed his/her hands in the resident sink, and put on another pair of gloves. RN A performed the blood sugar test, removed his/her gloves and documented in the computer. Without washing his/her hands, RN A put on another pair of gloves. He/She administered insulin to the resident, removed the gloves, washed his/her hands. 3. Review of Resident #26's medical record, showed diagnoses included Parkinson's (disorder of the nervous system, causing triggers), diabetes, high blood pressure, high cholesterol, and anxiety. Review of the resident's admission MDS, dated [DATE], showed: -admitted [DATE]; -Clear speech; -Able to make self-understood; -Able to understand others; -Cognitively intact. Observation on 10/2/24 at 7:14 A.M., showed Licensed Practical Nurse (LPN) E set up the cart to perform blood sugar tests at the nurse's station. LPN E pushed the cart down the hall to resident the resident's room. LPN E removed the insulin pens from the drawer and put on a pair of gloves. He/She entered the resident's room and administered insulins. LPN E returned to the cart and removed the gloves. LPN E did not wash his/her hands and then documented in the computer. 4. Review of Resident #74's medical record, showed diagnosis included chronic obstructive pulmonary disease (permanent damage to the lung that makes it difficult to breath), lung cancer, anxiety, high blood pressure, and high cholesterol. Review of the resident's admission MDS, dated [DATE], showed: -admitted [DATE]; -Clear speech; -Able to make self-understood; -Able to understand others; -Mild cognitive impairment. Observation on 10/2/24 at 7:25 A.M., showed LPN E gathered supplies to perform a blood sugar test and put on gloves. He/She performed the blood sugar test for the resident. LPN E removed the gloves, and documented in the computer. LPN E then put on a pair of gloves and administered insulin to the resident and then removed the gloves. LPN E did not wash his/her hands prior to checking the resident's blood sugar or after insulin administration. During an interview on 10/2/24 at 9:51 A.M., LPN D said that hands should be washed prior to any resident interaction and when gloves are changed. A hand sanitizer can be used in place of handwashing. During an interview on 10/2/24 at 10:12 A.M., Certified Nursing Assistant (CNA) F said staff should wash their hands when they put on and take off gloves. 5. Review of Resident #61's care plan, revised 8/28/24, in use during the time of the investigation, showed no information regarding the use of a catheter or urine drainage bag (a container that collects urine that drains from a catheter). Review the resident's annual MDS, dated [DATE], showed: -Cognitively intact; -No behaviors; -Substantial/maximal assistance for toileting hygiene; -Indwelling catheter; -Diagnoses included heart failure, diabetes, and respiratory failure. Review of the resident's active physician's orders, viewed 10/1/24, showed: -An order dated 8/29/24, for Catheter Care, per shift; -An order dated 9/15/24, for Catheter output, every shift. Observation on 10/2/24 at 5:56 A.M. and 8:09 A.M., showed the resident lay in bed on his/her back. The resident's catheter bag lay on the floor on the right side of the bed. The tubing was also on the floor. At 8:10 A.M., the resident opened his/her eyes. He/She said staff provided catheter care and ensured the catheter bag was off the floor. During an interview on 10/4/24 at 8:31 A.M., CNA H said catheter bags should be in a privacy bag, off the floor. During an interview on 10/4/24 at 8:33 A.M., Nurse D said catheter bags should not be on the floor, due to infection control. 6. Review of Resident #12's quarterly MDS, dated [DATE], showed: -Should a brief interview for mental status be conducted? No; -Both long-term and short-term memory loss; -Diagnoses included: obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow); -Indwelling catheter. Review of the care plan, in use at the time of survey, showed: -Problem: Resident had a MDRO, CRAB that required the use of personal protective equipment during high contact activities; -Goal: will not exhibit complications to MDRO by the next review date; -Approach: is on EBP, staff must perform hand hygiene before and after providing care; -Problem: resident required an indwelling urinary catheter related to his history of malignant neoplasm of prostate (a cancerous tumor that forms in the prostate gland); -Goal: will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma through next review; -Approach: Monitor drainage. Record the amount, type, color, odor. Observe for leakage. Observation and interview on 10/2/24 at 6:25 A.M. showed PPE hanging on the resident's door and there an EBP magnet on the door frame. CNA L was in the resident's room wearing a face mask and gloves. He/She emptied 150 milliliters of urine from the resident's catheter. CNA L said nobody told him/her why there was PPE on the resident's door, maybe the resident had covid and the facility forgot to take the PPE off the door. CNA L did not wear a gown while providing care to the resident. Observation and interview on 10/2/24 at 10:25 A.M., showed the PPE remained hanging on the resident's door. The EBP magnet remained on the door frame. The resident lay flat in bed with no sheet covering the him/her. CNA M was in the resident's room wearing a mask and gloves. He/She did not wear a gown. CNA M said he/she had just finished cleaning the resident up. CNA M rolled the resident over and placed a pillow under the resident's knees and adjusted his/her catheter tubing. CNA M placed a new pillowcase on the pillow and placed it under the resident's head, then put the resident's protective boots on and covered the resident up. CNA M said he/she did not have to wear PPE while working with the resident. He/She wore the mask and gloves just because he/she had kids at home. When asked about the PPE on the door, CNA M said maybe he/she should have worn a gown because the resident had a catheter. During an interview on 10/3/24 at 12:00 P.M., RN A said, residents with indwelling catheters require EBP (gowns, gloves, and mask) while providing personal care for the residents. Staff knew which residents required EBP because there was PPE outside the door and a magnet on the door frame. During an interview on 10/4/24 at 12:28 P.M., the Nurse Manager said residents who had tested positive for CRABS and/or had an indwelling medical device required EBP. Staff knew which residents required EBP because there was PPE and a magnet on the door frame and through report. Agency and hospice staff were made aware when they came on board, or any staff could go to the nurse's station and ask the nurse. Staff should wear gown and gloves when they came in contact with a resident. They may need a mask if they could come in contact with splashes. PPE should be worn when staff empted a catheter, provided bed linen changes and when providing personal care. 7. During an interview on 10/4/24 at 1:53 P.M., the Administrator said she would expect for staff to follow the facility's policies and procedures for infection control. 49992

Based on interview and record review, the facility failed to ensure third party liability (TPL) forms were completed within 30 days for the final accounting for residents who expired. This affected three of three sampled residents who expired and had money in their accounts longer than 30 days (Residents #301, #302 and #300). The census was 96 with 83 in certified beds. The deficiency was changed to past non-compliance after an Informal Dispute Resolution conference where both parties agreed the deficient practice was corrected prior to the survey. Facility staff realized in mid-April, 2024 that some discharged residents still had funds in the resident trust account. The facility completed the proper documentation for those discharged residents and the remaining trust fund balances were refunded to the proper authority. The past-noncompliance was corrected on [DATE]. 1. Review of Resident #301's financial records, showed: -Expired on [DATE]; -Ending balance of $150.13; -TPL form sent on [DATE]. 2. Review of Resident #302's financial records, showed: -Expired on [DATE]; -Ending balance of $50.00; -TPL form sent on [DATE]. 3. Review of Resident #300's financial records, showed: -Expired on [DATE]; -Ending balance of $0.13; -TPL form sent on [DATE]. 4. During an interview on [DATE] at 11:16 A.M., the Business Office Manager (BOM) said the facility was supposed to send the TPL form within 30 days. The BOM said she started working at the facility in April and did not see many records where the funds were concurrent, some were lapsing. She said it was not acceptable to send the funds later than 30 days.

Based on interview and record review, the facility failed to position one resident safely (Resident #20) when staff turned the resident on the shower bed resulting in a fall, in which the resident was sent to the hospital and received 14 sutures. The sample was 18. The census was 96 with 83 residents in certified beds. The Administrator was notified on 10/4/24 at 3:00 P.M., of the past non-compliance, which occurred on 3/4/24. The facility provided training and in-servicing that began on 3/6/24 and ended on 3/18/24, for all staff regarding their policies on proper transfers and body mechanics. The past non-compliance was corrected on 3/18/24. Review of the facility's Transfer and Lift Policy (butterfly), dated reviewed 5/21, showed: -Purpose: To provide communication to staff about resident transfer abilities and to assure we take all precautions necessary to maintain the safe of our residents including acknowledgment that this facility has adopted a no lift policy for residents requiring a mechanical means of transfer; -Policy: Upon admission each resident will be assessed by the inter-disciplinary team on the capabilities of how the resident transfers; this will be re-assessed with changes in condition and at the quarterly care plan; -A butterfly magnet will be placed inside of the resident's room on the overhead light or door frame of resident's room indicating how the resident transfers. The butterfly will be coded to inform the staff of transfer ability. An additional red dot sticker will be placed on the magnets to indicate two people for all means of transfer and bed mobility; -The resident's transfer ability will be indicated in the resident's orders and included on the resident profile and care plan, as well as the butterfly; -All staff involved in the transfer of residents will be responsible for knowing how to identify transfer status of each resident. Review of Resident #20's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 7/14/24, showed: -Severe cognitive impairment; -Functional limitation in range of motion (ROM) in lower extremities (hip, knee, ankle, foot), impairment on both sides; -Shower/bathe self: dependent (helper does all the effort. Resident does none of the effort to complete the activity); -Roll left to right: dependent; -Tub/shower transfer: dependent; -Diagnoses included heart failure, high blood pressure, anxiety, depression, acquired absence of the right leg above the knee. Review of the care plan, in use at the time of survey, showed: -Problem: is at risk for falls related to his need for assistance with transfers, increased weakness, acquired absence (amputation) of right leg above knee, and psychotropic medication (drugs that affect the brain and nervous system to treat mental illnesses) use and bowel and bladder (B&B) incontinence, pacemaker, start date was 4/8/22; -Goal: Minimize the risk for falls and related injury thru next review; -Approach: On 3/04/24, Resident fell attempting to assist aide with transfer. Sent to hospital for evaluation. Sutures noted to forehead. Inservice and education completed on proper transfers. Will continue with plan of care (POC). -Problem: has a deficit in activities of daily living (ADL) functioning and impaired mobility related to increased weakness, history of repeated falls, decreased cognition, and acquired absence of right leg above knee; -Goal: will participate in ADL activities promoting maximum independence through next review; -Approach: Provide assistance with ADL's as needed or requested. Is dependent with ADLs; Transfer status: Hoyer (mechanical lift) assist x 2. Review of the progress notes, dated 3/4/24, showed: -At 4:25 P.M., the nurse went to resident's shower room to assist with fall from this resident. Upon entering the shower room, resident found lying face first on the floor, blood noted on the floor. The nurse asked the Certified Nurse Aide (CNA) what happened, CNA stated he/she had just finished giving the resident a shower. CNA attempted to place mechanical lift sling under the resident. CNA turned the resident onto his/her left side. The resident tried to hold onto the wall but fell out of the shower bed. The nurse called out to the resident. Resident was able to respond yes. The nurse asked the resident if he/she was hurting anywhere besides his/her head, resident responded no. Upon assessment resident noted to have laceration on left eyebrow, and skin tear to left wrist. Towel placed on the floor by resident's eyebrow to help with bleeding. Another nurse called 911 and printed all paperwork. Resident noted to be wheezing but still communicated with staff. Oxygen saturation was 83% (normal is 95% through 100%) no oxygen was applied because Emergency Medical Technicians (EMT) were at the facility to transport resident.; -At 10:44 P.M., resident returned to the facility by ambulance at 10:33 P.M., 14 stitches noted to left forehead above eyebrow, left hand bruised with skin tear, left leg has scabbing noted and left second toe bruised. During an interview on 10/3/24 at 11:31 A.M., Licensed Practical Nurse (LPN) N said the CNA was calling out for help. When he/she got to the shower room, the CNA and nurse were in the room. The resident was on the floor. There was so much blood on the floor, they were just trying to get him/her sent out (to the hospital). The CNA went to turn the resident and the resident fell out of the shower bed. Normally he/she would hold onto something when staff assisted him/her with turning. During an interview on 10/4/24 at 10:57 P.M., CNA C said two staff used the mechanical lift with a regular sling to transfer the resident onto the shower bed. After the resident was transferred, the other staff member left out of the shower room. CNA C provided the shower. Then, CNA C assisted the resident to roll over by giving the resident a little push and the resident rolled off the shower bed. CNA C called for the nurse. During an interview on 10/4/24 at approximately 12:00 P.M., the Nurse Manager said there should be two staff present when a resident was on a shower bed. The only bar in the shower room to grab onto is in the shower. It is not appropriate for staff to ask a resident to hold on to the wall. During an interview on 10/4/24 at 10:02 A.M., the Administrator said the resident did not fall during the transfer. The failure was the procedure was not followed. The CNA used the regular lift sling to transfer the resident in place of the shower sling which was mesh. The CNA was turning the resident when the resident fell . All nursing staff were educated on using the correct sling for showers and using two people for the shower bed and mechanical lift transfers. The agency binder has also been updated. MO00240083

Based on interview and record review, the facility failed to ensure one resident was free from verbal abuse and intimidation (Resident #1). On 8/19/23 between 3:30 P.M. and 4:30 P.M., during medication pass, Certified Medication Technician (CMT B) was observed by Certified Nurse Aide (CNA) C and Nurse A standing chest to chest with the resident, yelling/cursing at the resident, and/or throwing a towel at the resident. CMT B initially refused to leave the resident's room when Nurse A instructed him/her to do so and continued to yell and curse at the resident who was visibly upset. Furthermore, the facility failed to follow their policy, state and federal regulations when staff failed to ensure CMT B was removed from the building when he/she was seen by staff sitting in the resident smoking area and walking through the building unsupervised. The census was 103. Review of the facility's Freedom from Abuse, Neglect and Exploitation Policy, most recently revised in 9/2022, showed: -Resident Safety Position Statement: It is the policy to maintain a living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, or mental); -Providing a safe environment for the resident is one of the most basic and essential duties of the facility. Employees and volunteers have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents makes ethical and professional behavior essential; -Residents must not be subjected to abuse by anyone; -Abuse is defined as the willful infliction of intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse, and mental abuse; -Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, regardless of their ability to comprehend or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident; -Procedure for investigation; -The supervisor will do everything possible to protect the resident's welfare and safety from harm during the investigations; -An employee suspected of a violation of these safety policies, may be suspended pending investigation; -Administrator or designee on duty will assess the resident (including the size, location, etc. of any injury), and assure proper documentation of the date, time, and location of the reported or suspected incident. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/16/23, showed: -Moderately impaired cognition; -Rejection of care: Behavior not exhibited; -Diagnoses included Post Traumatic Stress Disorder (PTSD, a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances), anxiety disorder, and depression. Review of the resident's care plan, in use during the investigation, showed; -Problem: Cognitive Loss/Dementia, required monitoring for cognition due to impaired short term memory, decreased safety awareness/impaired decision making, disorganized thinking, and need for reorientation -Approach: Allow ample time to communicate needs. Always approach in a calm, non-threatening manner breaking tasks into small steps; -Problem: Psychotropic Drug (chemical substance that changes the function of the nervous system and results in alterations of perception, mood, cognition, and behavior) Use, at risk for adverse medication reactions related to taking psychotropic medication to assist in managing diagnosis of anxiety, PTSD and major depressive disorder; -Approach: Monitor resident's mood and response to medication; -No staff interventions to address the resident's PTSD, history of trauma, identification of potential triggers of re-traumatization and need for trauma informed care. Review of the facility's self-report, dated 8/19/23 at 6:00 P.M., showed: -CMT B entered the resident's room at approximately 3:50 P.M., on 8/19/23; -The resident became upset when the CMT educated the resident he/she was supposed to observe the resident taking his/her medications and wasn't supposed to leave medications unattended; -The resident threw the health shake in CMT B's face. While CMT B was attempting to clean up the mess, the resident attempted to strike at CMT B. CMT B caught the resident's hand to prevent being struck, exited the room and reported to the charge nurse; -The Administrator and Director of Nursing (DON) interviewed the resident, who reported it was simply a disagreement because he/she wanted to finish what he was doing and didn't feel he/she needed to be watched while taking medications; -When asked if he/she felt CMT B was threatening or abusive to him/her, he/she reported no. When asked if he/she felt safe, he/she reported yes. The resident did offer that he/she just does not like CMT B; -The Administrator called and notified the resident's family member of the situation. The resident's family member reported the resident was very combative with CMT B another time when he/she came to give him/her his/her medications. The resident's family member explained he/she attempted to redirect the resident's behavior and encouraged him/her to be kind to staff; -When asked, the family member felt maybe CMT B reminded the resident of someone he/she didn't like in the past. The facility suggested finding an alternative person to provide medications to the resident and the family member agreed; -CMT B was suspended pending investigation and the facility was in the process of interviewing three residents and employees on CMT B's assignment today. Review of the resident's medical record, showed: -Psychiatry note, dated 9/8/23 at 4:56 P.M.; -Past psychiatric history, excerpt from 7/17/2018, He/She is very impatient and cannot wait for anything. He/She goes from 0-100 in seconds. Has had problems since he/she came back from Vietnam. Family member reports he/she was not like this when he/she first met him/her before Vietnam. When he/she is angry, he/she yells, throws thing (threw a coffee cup today because there was another cup in the holder when they got to the car). Married for [AGE] years and he/she used to be more aggressive physically. He/She had hit a family member a couple times then, he/she would take a hammer and beat wood to get the anger out. He/she would sometimes punch the walls to avoid hitting others; -Military: Vietnam army combat-has suffered PTSD symptoms. Review of the Social Services notes, dated 8/19/23 through 8/24/23, showed; -No documentation regarding the incident between the resident and CMT B; -No documentation regarding a nurse's assessment following the incident between the resident and CMT B; -No documentation any support services were offered to the resident to assist in managing past trauma/abuse or coping skills. Review of the facility's investigation, dated 8/19/23, showed: -A typed, one page document, which included three staff interviews, each interview consisted of one sentence, in quotation marks, unsigned; -CNA C's statement showed, Quiet. No issues. Stayed to self and was busy working; -A typed resident interview, dated 8/19/23, and signed by the DON, which read, DON and Administrator interviewed the resident regarding incident with CMT B. Administrator conducted interview with this Registered Nurse (RN) (the DON) present. Administrator asked the resident if he/she felt safe, he/she reported yes. Administrator asked if he/she was threatened, hit, cussed at or felt abused in anyway, resident reported no, that it was a disagreement and I just don't like that guy, we had a scuffle. He/she didn't like being treated like a child and CT B wouldn't leave his/her pills. The Administrator asked what the resident meant by a scuffle, the resident reported he/she meant an argument. Administrator educated the resident if he/she felt anything was abusive, he would ensure the employee would not re-enter the building, and the facility would assist with pressing charges, and the employee would never have access to him/her again. The resident reported again, he/she was not abused. The administrator asked him/her if he/she was comfortable with CMT B providing care to him/her and he/she responded he/she would prefer he/she did not. Administrator assured the resident he would no longer receive care from CMT B. Administrator asked the resident if he/she would sign a statement saying he/she was not abused and he/she did not feel threatened and the resident agreed. No further concerns were noted; -A typed statement, signed by the resident, which read, Resident #1, was interviewed by the Administrator and DON on 8/19/23 at 4:30 P.M. CMT B and he/she had a simple misunderstanding this evening. He/She didn't feel there was abuse or neglect of any kind. He/She feels safe in at the facility; -Witness, signed by the DON, dated 8/19/23; -No interview with Nurse A, the nurse assigned to the resident's hall, who reported the incident to the DON, Review of CMT B's written statement, dated and signed, 8/19/23, showed upon taking the resident his/her medication, the resident said, What do you want? He/she let the resident know he/she had his/her dinner time medications. At that point, the resident took them from his/her hand and said, Get the fuck out! CMT B let the resident know he/she had to witness him/her take the medication. At that point the resident threw his/her health shake all over CMT B and the floor. The resident stood up and started walking towards him/her. CMT B told the resident he/she would leave and asked him/her to have a seat so he/she would not fall. The resident then decided to throw all of his/her medications at CMT B and started trying to stand face to face with him/her while his/her back was to the wall. At that point, Nurse A stepped in and asked him/her to leave. At which point, he/she called the Administrator to notify him/her and stepped out to the smoke area. He/She came in to continue passing medications to be told he/she was suspended. Review of the facility's Summary of Investigation, showed: -CMT B entered the resident's room at approximately 3:50 P.M., on 8/19/23. CMT B provided the resident with a health shake and medications. The resident became upset when CMT B educated him/her that he/she was supposed to observe the resident take his/her medications and wasn't supposed to leave medications unattended. The resident threw his/her health shake in CMT B's face. While CMT B attempted to clean up the subsequent mess, the resident attempted to strike at CMT B. CMT B caught the resident's hand to prevent being struck, left the room, and reported to the charge nurse; -The Administrator and DON interviewed the resident who reported that it was simply a disagreement because he wanted to finish what he/she was doing and didn't feel he/she needed to be watched while taking medications. When asked if he/she felt that CMT B was threatening or abusive to him/her, he/she reported no, when asked if he/she felt safe, he/she reported yes. The resident did offer he/she didn't like CMT B. The Administrator called and notified the resident's family member of the situation. The resident's family member reported the resident was very combative with CMT B another time when he/she came to give him/her his/her medications. The family member felt maybe CMT B reminded the resident of someone he/she didn't like in the past. The facility suggested finding an alternative person to provide the resident's medications and the family member agreed; -CMT B was suspended pending investigation and the facility interviewed three residents and employees on CMT B's assignment on 8/19/23. All resident and staff interviews indicated CMT B was professional when providing care. No concerns noted. Physician and family were notified with no concerns noted; -Disposition: The facility was unable to substantiate abuse or neglect involving this incident. They have ensured CMT B would not directly care for the resident moving forward as an intervention, to prevent further conflict; -Typed signature of the Administrator, dated 8/23/23. Review of the resident's electronic nurse's progress notes, dated 8/25/23, (Recorded as Late Entry on 8/26/23 1:50 A.M.), showed during dinner this resident had an episode in which he/she was very agitated. Aide explained prior situation occurred and the sighting of specific individual. When asked what was wrong this resident stated He/She was promised to never see this son of bitch again. This nurse allowed this resident to vent and share thoughts and emotions. After venting this resident stated he/she was ok and would let the nurse know if he/she needed further assistance or had any other issues. Later this nurse was approached by another nurse who stated this resident stated he/she was going to kill this individual and brandished a knife at the dinner table. Other nurse notified DON. Psychiatric evaluation recommend. Family member contacted. Dr contacted. Awaiting EMS arrival. Review of the resident's hospital records, dated 8/25/23 through 8/26/23, showed: -Resident presented to the Emergency Department (ED) with a chief complaint of aggressive behavior; -Psychological Evaluation: Patient states about a month ago, he/she was involved in a physical altercation with a caregiver after the caregiver attempted to give the patient pills. Patient states he/she was assured he/she would not see the caregiver again, however, last night, while eating, he/she saw the caregiver again. Patient states in the middle of the night, he/she was awoken by police, who asked the patient if he/she had intentions on hurting someone as they received a call from his/her room. Patient denies medical complaints apart from a posterior headache; -Medical Decision Making/Summary: Patient who presented for evaluation due to aggressive behaviors at the facility, has a history of dementia, but was able to provide a history. Review of the resident's Social Services Progress Note, dated 8/28/23 at 3:39 P.M., (Recorded as Late Entry on 8/30/23 3:57 P.M.), showed Social Worker followed up with resident in regards to a previous incident that took place. Resident states he/she was doing fine, no concerns voiced. Psychosocial well-being intact. Mood was pleasant at this time. Resident was smiling and making jokes. There were no social service concerns. Social Worker will continue to monitor and provide assistance as needed. Review of the resident's care plan, showed no documentation or interventions regarding the incident involving the resident and CMT B or the resident's psychiatric hospitalization . During an interview on 10/2/23 at 12:50 P.M., on 10/3/23 at 11:09 A.M., and on 10/5/23 at 2:40 P.M., the Administrator said there had been an incident which involved CMT B and the resident. The resident was in his/her room eating, and wanted to finish before he/she took his/her medications. The resident wanted the medications left with him/her and CMT B refused to leave the medications. The resident became upset and started yelling. CMT B tried to explain he/she was not being mean, it was his/her job to ensure medications were taken and not left with the resident. The resident became irate when CMT B wouldn't immediately leave the room. The resident threw his/her health shake at CMT B's face. The resident stood up and tried to hit CMT B. CMT B was told to leave the room by the resident, but he stayed in the room and attempted to clean up the spilled health shake. The Administrator said he was out of town and the DON came to the facility. The interviews were conducted on her phone while on he was on speaker. The DON and the Administrator had conversations and listened to the responses with the staff. CNA C was the real witness, and he/she didn't witness anything but an argument. CNA C heard cursing when he/she got to the door. CMT B was coming out of the door, and CNA C went to the charge nurse, but didn't witness anything. The resident said it was not abuse, he/she just got mad. His/Her family member said the resident had it out for CMT B. He/She had tried to give the resident medications in the past and the resident called CMT B a [NAME]. The family member said he/she had gotten on to the resident about the name calling and he/she thought this was over. CMT B was suspended, the facility did inservices on resident rights and abuse, and it was explained, if asked to leave, leave and get a witness. The resident had a skin assessment following the incident and there were no injuries. The resident and CMT B gave essentially the same stories. The one difference in the story was the blocking of the hand. The resident said CMT B grabbed his/her arm, and he/she lost his/her balance and he/she sat back down on the bed. The resident said CMT B never cussed at him/her, only tried to redirect him/her. The resident said he/she felt he/she was being treated like a child. The resident said he/she did not feel abused by CMT B and did not feel unsafe during the incident and following the incident. The resident said he/she couldn't stand CMT B and would get upset if he/she saw him/her. CMT B was removed from the hall assignment and did not pass the resident medications again. The resident had PTSD and became upset easily. Something triggered him/her when CMT B was giving him/her medications, and the resident threw his/her medications on the floor. Later, the resident saw CMT B in the dining room. CMT B was not near the resident and did not speak to the resident. But, the resident became triggered and lashed out, threatening CMT B harm and was sent out for a psychiatric evaluation. During an interview on 10/3/23 at 1:32 P.M. and on 10/4/23 at 11:40 A.M., the resident said he/she was watching television, and CMT B made a mess of everything. When CMT B was asked to leave, instead of leaving, he/she wanted to exaggerate the situation. The resident wanted CMT B to leave and he/she knew if he/she stayed in the resident's room, the resident would lose it. He/She did not try to hit CMT B, he/she just wanted him/her to go. Most people would shut up and back off, but CMT B did not. He/She told CMT B he/she didn't have to take it. The resident felt CMT B's behavior was abusive; he/she was pushing a button that was not there to push. The resident had rights, even though some people did not understand that. CMT B finally left, but afterward, the resident was still angry, like he/she didn't get to finish it. The facility did nothing, someone promised him/her he/she wouldn't see CMT B again. He/she said he/she saw CMT B in the dining room and he got mad again. During an interview on 10/6/23 at 3:14 P.M., the resident's family member said he/she was called the night of the incident, and he/she said that was the very first incident involving CMT B. He/She did not recall a conversation where the family member said he/she witnessed a previous interaction between the resident and CMT B. The resident was a Vietnam Veteran, and had some pretty tough things happen to him/her during the war. The war left a big impact on him/her. He/she had some violence in his/her childhood too. Staff had to understand the resident was not in his/her own environment and was used to living at home. The resident was extremely independent and wanted to do everything himself/herself. Generally, he/she was easy to get along with. He/she said he/she didn't realize how upset the resident was following the incident. He/she said sometimes the resident's memory was not good, but every time he/she told the story of what happened between him/her and CMT B, it was the same story, so it stuck in his/her head. It was the resident's understanding, CMT B had been terminated and he/she would not see CMT B again. He/she was unaware of the statement or content of the statement the resident signed following the incident. No one at the facility has ever asked him/her if there are triggering behaviors and what do if the resident becomes upset. During an interview on 10/4/23 at 12:44 P.M., CMT B said he/she went to give the resident his/her evening medications. When he/she entered the room, the resident was asleep. He/She called the resident's name and the resident didn't answer. He/she said, I've got your medicine. He/she said the resident's name again and the resident screamed at him/her and snatched the health shake out of his/her hand, then snatched the medications out of his/her hand. The resident told CMT B to, Get the fuck out of the room. The resident stood up and threw the health shake at CMT B's face. CMT B said it seemed like being supervised was the trigger. The resident had war experience with some type of PTSD. CMT B said both his/her and the and resident's voices were elevated, and he/she had his/her back to the wall. Nurse A walked into the resident's room and told CMT B he/she needed to get out there. Nurse A wanted to know what was going on, but CMT B said he/she wanted to talk to the Administrator. CMT B said he/she didn't know what brought this on. The resident's behaviors were probably from sundowning (a set of symptoms or dementia-related behaviors that may include difficulty sleeping, anxiety, agitation, hallucinations, pacing and disorientation, sometimes known as 'sundowning' but is not necessarily linked to the sun setting or limited to the end of the day). CMT B said he/she may have looked like someone in the resident's past which may have been a trigger. Since that incident, the resident had gone off when he/she saw CMT B. CMT B walked through the dining room and heard from other staff the resident wanted to stab him/her. There was some type of fixation because of the altercation. The resident was still triggered when he/she saw CMT B, just the sight of him/her was enough of a trigger. CMT B said someone said they thought they saw him/her with a butter knife. The resident was sent out for a mental evaluation, but CMT B wasn't worried about it. CMT B said he/she didn't know the resident's diagnoses, but it was getting worse and the older he/she got, he/she became more aggressive. During an interview on 10/6/23 at 11:30 A.M., CNA C said he/she heard a commotion, and the resident's door kept partially opening. Previously, he/she had seen the resident and he/she was sitting in his/her room, eating peacefully. Something was going on that wasn't right, like something was happening on the other side of the door. CNA C was the first staff to arrive on the scene and heard cussing and the door was bumping. He/She walked into the resident's room and there was chocolate shake everywhere, all over the floor. The resident was sitting on the bed, and he/she asked CMT B to come out of the room. CMT B, said no, and the resident wasn't going to keep talking to him/her like that. CMT B refused to leave the room. When he/she walked into the resident's room, he/she couldn't believe what he/she was seeing, and he/she ran to get Nurse A. CNA C didn't want to yell and shout and alarm the other residents, but it looked like an employee and a resident were about to go to blows. He/She did not try to put him/herself in the middle of the two, they were standing in the middle of the floor. CMT B was not up against the wall. He/She told Nurse A it was getting serious, he/she needed to see this. When they returned to the resident's room, the resident and CMT B were standing chest to chest cussing each other out. Nurse A asked CMT B to leave the room. CMT B started yelling This is how (he/she) is, This is how (he/she) does, This mother fucker was cussing him/her out and disrespecting him/her. When he/she handed a towel to CMT B to clean up the shake, CMT B threw the towel at the resident's foot and said, Fuck that, I don't care if (he/she) falls and busts (his/her) ass. CMT B got into a verbal altercation with Nurse A, who told CMT B he/she was messing up. He/She couldn't talk to the resident like that. Nurse A asked CMT B to leave the room several times. The resident was yelling for CMT B to get out of his/her room, but CMT B refused to leave the room. Afterwards, CNA C went back to the resident and said he/she was sorry that happened, but he/she needed to clean the floor. The resident said CMT B was a punk ass kid and was not going to shove pills in his/her face and watch him/her take those pills. The resident said he/she asked CMT B to come back or give him/her the medications. CMT B snatched his/her drink out of the resident's hand, and grabbed his/her wrist. When CNA C entered the room, the resident looked like he/she was pushed back on the bed and was trying to catch his/her balance on the bed. The resident was calm earlier, and even after that happened. It was all about your approach with him/her. He/She normally just sat and watched television. The resident had a table where he/she sat with buddies and they all got along. The incident happened around 4:00 P.M., and it didn't take long for the DON to get there. When the DON arrived, they were asked to write statements. The DON didn't understand why CMT B was still in the building. Nurse A had asked CMT B to leave the building, but he/she did not comply. CNA C thought CMT B left when the DON left, but he/she was still there, around 5:00 or 6:00 P.M. CMT B sat outside in the resident smoking area and smoked his/her vape pen. The resident smoking area was in a small courtyard, off of the resident's hall. CMT B had to come back into the building to leave. There was no one was watching CMT B to make sure he/she stayed in the courtyard. CMT B was unsupervised and went over to another hallway to talk to his/her family member to tell them what was going on. He/She had no training in PTSD, but he/she was a people person and knew how to talk to people. He/She knew how to deescalate a situation. The resident was told he/she had to sign paperwork and signed it. He/She said when CMT B grabbed his/her wrist, he/she knew they would evict him if he/she punched CMT B in his/her face. He/She was told to write a statement about exactly what he/she saw. Nurse A wrote a statement too. He/She placed the statement under the DON's door, but took a screen shot of it because Nurse A told him/her to make sure to take a picture of it. He/She said CMT B came back to work. The situation was being put under the rug instead of nipping it in the bud from the beginning. He/She thought something physical was going on before he/she entered the room. The resident kept talking about CMT B grabbing him/her by the wrist, and the resident looked like he/she was in the process of falling back on the bed when CNA C first entered the room. Whenever the resident saw CMT B, he/she got upset all over again. You can't be that upset with just words, he/she believed something happened to the resident. The resident was angry in a traumatizing way. After the incident, he/she heard the resident crying and the resident told him/her about the paperwork. The resident said this was a bunch of bull, they just made the resident sign it and did not give him/her a chance to read it. He/She signed it because he/she couldn't afford to get evicted. During an interview on 10/5/23 at 1:31 P.M., Nurse A said at approximately 4:30 or 5:00 P.M., CNA C said he/she witnessed an altercation between the resident and CMT B. There was a confrontation between the them. He/She walked into the room and the resident was screaming that CMT B had just pushed him/her down. CMT B put his/her hands on the resident and the resident was very upset. When he/she walked in the resident's room it looked like CMT B was getting ready to beat the resident's ass. Nurse A told CMT B to leave, but he/she stood there, face to face, chest to chest, with the resident. He/She told CMT B to leave again, but he/she refused to leave. Nurse A asked the resident what happened and he/she told him/her what happened. The resident said he/she didn't want the medicine then because he/she had food in his/her mouth, but CMT B said he/she needed to take the medication. CMT B had a towel in his/her hand and threw it in the resident's face. The resident told CMT B to get the fuck out of his/her room. CNA C tried to get CMT B out of the room. The resident was furious and screamed Get the fuck out of the room. He/She couldn't sleep after what he/she witnessed. He/She had never seen anyone get so mad at a resident. CMT B looked like he/she was going to fight. He/She grabbed CMT B and told him/her to get out of the room. CMT B said he/she was not going anywhere. CMT B said he/she was going to call the Administrator. Nurse A asked why CMT B was going to do that because Nurse A just saw CMT B physically and verbally abuse the resident, he/she needed to leave. CMT B called the Administrator. CMT B told the resident Fuck you and I hope you fall and bust your ass. The resident was hysterical. Nurse A called the DON, and said she needed to get up there right then, CMT B was into it with a resident. Afterwards the DON talked to him/her and CNA C, who were the only two witnesses. The DON said she knew Nurse A didn't see what happened and said to just write that on a paper. Nurse A reported the incident to the DON, wrote a statement and gave it to the Administer. Nurse A did not make a progress note because the DON said she would take care of everything. The DON said she would put in a skin assessment. The DON and Assistant DON were siblings and related to CMT B. Anyone else would have been fired. The DON did not make CMT B leave the premises; he/she stayed where the residents sat. The DON knew CMT B was still on the premises. He/She sat in the the smoking area, and other residents were present. CNA C reported to him/her that CMT B was still outside. The resident had behavior issues. You didn't debate or argue with the resident. They manipulated the situation, the resident believed what he/she signed was paperwork that said he/she would not have to work with CMT B again. The resident signed a paper he/she thought said this person abused him/her and he/she would never work around him/her again. A week later, he/she saw CMT B and got upset, like if you saw someone who abused you. He/she cried because he/she thought he/she wouldn't have to ever see him/her again. When he/she saw CMT B it triggered him/her and they sent him/her to the hospital. During an interview on 10/10/23 at 1:05 P.M., the DON said she received a call from Nurse A, who said there was a situation at the facility and he/she needed her. She told Nurse A she was in route, about five minutes away. Upon her arrival, CMT B was standing by the cart at the nurse's station, and she had him/her go to the conference room. She said she interviewed Nurse A and CMT B, told them to write statements and slide the statements under her door. She said the statements she documented in her investigation were all in regard to CMT B. She asked them if there were any issues prior to the incident. During an interview on 10/10/23 at 10:36 A.M., the Social Worker said she was familiar with the resident. The resident was alert and oriented x 2 (person and place) with some confusion. If the resident wasn't allowed to use his/her independence, it could trigger behaviors. He/She did not mean any harm. If not offered choices, that would be a trigger. When providing care, activities, anything and not given time to think about it could be a trigger. If he/she said not right now,it was just best to leave the situation and come back. She could come back in ten minutes and the resident was a whole different person. She was told a CMT tried to give the resident his/her medications, and he/she wanted them left with him/her. The CMT told the resident he/she had to watch him/her take them. The resident got upset and cursed him/her out. The CMT left and the nurse came to the resident's room. She said she didn't remember when the incident happened between the CMT and the resident. When the resident saw whomever tried to give him/her his medication, the resident became upset. She was not

Based on interview and record review, the facility failed to complete a thorough investigation, and failed to maintain documentation that a thorough investigation was conducted for an allegation of verbal abuse of a resident (Resident #1) and a staff member (Certified Medication Technician (CMT) B). Staff reported witnessing CMT B cursing/yelling and making intimidating statements while standing chest to chest with Resident #1. The facility census was 103. Review of the facility's Freedom from Abuse, Neglect and Exploitation Policy, most recently revised in 9/2022, showed: -Resident Safety Position Statement: It is the policy to maintain a living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, or mental); -Providing a safe environment for the resident is one of the most basic and essential duties of the facility. Employees and volunteers have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents makes ethical and professional behavior essential; -Residents must not be subjected to abuse by anyone; -Abuse is defined as the willful infliction of intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse, and mental abuse; -Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, regardless of their ability to comprehend or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident; -Reporting suspected, observed or reported violation of the resident safety policy shall be reported immediately, not later than two hours after the allegation is made; -The supervisor on duty shall immediately report any alleged violations of this resident safety policy to the Administrator/Designee or Director of Nursing (DON)/Designee; -Procedure for investigation included: -Administrator or designee on duty will assess the resident, and assure proper documentation of the date, time and location of the reported or suspected incident; -The Administrator or designee and/or supervisor on duty will interview the resident as well as any nursing, housekeeping, laundry, dietary, activity, social services staff or others who may have knowledge of the occurrence or who may have been in the vicinity at the time of the incident. The Administrator or designee on duty will prepare a written summary of each interview; -The Administrator or designee will be the custodian of all documents generated during the course of the investigation. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/16/23, showed: -Moderately impaired cognition; -Rejection of care: Behavior not exhibited; -Diagnoses included Post Traumatic Stress Disorder (PTSD, a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances), anxiety disorder, and depression. Review of the resident's care plan, in use during the investigation, showed; -Problem: Cognitive Loss/Dementia, required monitoring for cognition due to impaired short term memory, decreased safety awareness/impaired decision making, disorganized thinking, and need for reorientation -Approach: Allow ample time to communicate needs. Always approach in a calm, non-threatening manner breaking tasks into small steps; -Problem: Psychotropic Drug (chemical substance that changes the function of the nervous system and results in alterations of perception, mood, cognition, and behavior) Use, at risk for adverse medication reactions related to taking psychotropic medication to assist in managing diagnosis of anxiety, PTSD and major depressive disorder; -Approach: Monitor resident's mood and response to medication; -No staff interventions to address the resident's PTSD, history of trauma, identification of potential triggers of re-traumatization and need for trauma informed care. Review of the facility's self-report, dated 8/19/23 at 6:00 P.M., included: -CMT B entered the resident's room at approximately 3:50 P.M., on 8/19/23; -The resident became upset when the CMT educated the resident he/she was supposed to observe the resident taking his/her medications and wasn't supposed to leave medications unattended; -The resident threw the health shake in CMT B's face. While CMT B was attempting to clean up the mess, the resident attempted to strike at CMT B. CMT B caught the resident's hand to prevent being struck, exited the room and reported to the charge nurse; -The Administrator and DON interviewed the resident, who reported it was simply a disagreement because he/she wanted to finish what he was doing and didn't feel he/she needed to be watched while taking medications; -When asked if he/she felt CMT B was threatening or abusive to him/her, he/she reported no. When asked if he/she felt safe, he/she reported yes. The resident did offer that he/she just does not like CMT B; -The Administrator called and notified the resident's family member of the situation. The resident's family member reported the resident was very combative with CMT B another time when he/she came to give him/her his/her medications. The resident's family member explained he/she attempted to redirect the resident's behavior and encouraged him/her to be kind to staff; -When asked, the family member said he/she didn't feel the need to report the incident to facility staff, and felt maybe CMT B reminded the resident of someone he/she didn't like in the past. The facility suggested finding an alternative person to provide medications to the resident and the family member agreed; -CMT B was suspended pending investigation and the facility was in the process of interviewing three residents and employees on CMT B's assignment today. Review of the facility's investigation, dated 8/19/23, showed: -A typed, one page document, which included three staff interviews, each interview consisted of one sentence, in quotation marks, unsigned; -CNA E's statement showed, Saw on hall. Quiet. Appeared calm and to (himself/herself); -CMT D's statement showed, Always polite and kind. Never seen a problem with (him/her); -CNA C's statement showed, Quiet. No issues. Stayed to self and was busy working; -A typed resident interview, dated 8/19/23, and signed by the DON, which read, DON and Administrator interviewed the resident regarding incident with CMT B. Administrator conducted interview with this Registered Nurse (RN) (the DON) present. Administrator asked the resident if he/she felt safe, he/she reported yes. Administrator asked if he/she was threatened, hit, cussed at or felt abused in anyway, resident reported no, that it was a disagreement and I just don't like that guy, we had a scuffle. (He/she) didn't like being treated like a child and CT B wouldn't leave (his/her) pills. The Administrator asked what the resident meant by a scuffle, the resident reported he/she meant an argument. Administrator educated the resident if he/she felt anything was abusive, he would ensure the employee would not re-enter the building, and the facility would assist with pressing charges, and the employee would never have access to him/her again. The resident reported again, he/she was not abused. The administrator asked him/her if he/she was comfortable with CMT B providing care to him/her and he/she responded he/she would prefer he/she did not. Administrator assured the resident he would no longer receive care from CMT B. Administrator asked the resident if he/she would sign a statement saying he/she was not abused and he/she did not feel threatened and the resident agreed. No further concerns were noted; -A typed statement, signed by the resident, showed Resident #1, was interviewed by the Administrator and DON on 8/19/23 at 4:30 P.M. CMT B and he/she had a simple misunderstanding this evening. He/She didn't feel there was abuse or neglect of any kind. He/She felt safe in at the facility; -Witness, signed by the DON, dated 8/19/23; -No interview with Nurse A, the nurse assigned to the resident's hall, who reported the incident to the DON. During an interview on 10/5/23 at 11:58 A.M., CNA E said he/she did not remember an incident with the resident. During an interview on 10/5/23 at 1:23 P.M., CNA D said he/she was never asked to write a statement. He/She was not assigned to the resident's hall. He/She told the DON he/she wasn't down that hall or near the resident's room. During an interview on 10/6/23 at 11:30 A.M., CNA C said he/she submitted a handwritten statement explaining what he/she saw. He/She said the statement provided in the facility's investigation was not his/her statement. Review of CMT B's written statement, dated and signed 8/19/23, showed upon taking the resident his/her medication, the resident said, What do you want? He/she let the resident know he/she had his/her dinner time medications. At that point, the resident took them from his/her hand and said, Get the fuck out! CMT B let the resident know he/she had to witness him/her take the medication. At that point the resident threw his/her health shake all over CMT B and the floor. The resident stood up and started walking towards him/her. CMT B told the resident he/she would leave and asked him/her to have a seat so he/she would not fall. The resident then decided to throw all of his/her medications at CMT B and started trying to stand face to face with him/her while his/her back was to the wall. At that point, Nurse A stepped in and asked him/her to leave. At which point, he/she called the Administrator to notify him/her and stepped out to the smoke area. He/She came in to continue passing medications to be told he/she was suspended. Review of the facility's Summary of Investigation, showed: -CMT B entered the resident's resident room at approximately 3:50 P.M. on 8/19/23. CMT B provided the resident with a health shake and medications. The resident became upset when CMT B educated him/her that he/she was supposed to observe the resident take his/her medications and wasn't supposed to leave medications unattended. The resident threw his/her health shake in CMT B's face. While CMT B attempted to clean up the subsequent mess, the resident attempted to strike at CMT B. CMT B caught the resident's hand to prevent being struck, left the room, and reported to the charge nurse; -The Administrator and DON interviewed the resident who reported that it was simply a disagreement because he wanted to finish what he/she was doing and didn't feel he/she needed to be watched while taking medications. When asked if he/she felt that CMT B was threatening or abusive to him/her, he/she reported no, when asked if he/she felt safe, he/she reported yes; -The Administrator called and notified the resident's family member of the situation. The resident's family member reported the resident was very combative with CMT B another time when he/she came to give him/her his/her medications. The family member felt maybe CMT B reminded the resident of someone he/she didn't like in the past. The facility suggested finding an alternative person to provide the resident's medications and the family member agreed; -CMT B was suspended pending investigation and the facility interviewed three residents and employees on CMT B's assignment on 8/19/23. All resident and staff interviews indicated CMT B was professional when providing care. No concerns noted. Physician and family were notified with no concerns noted; -Disposition: The facility was unable to substantiate abuse or neglect involving this incident. They have ensured CMT B would not directly care for the resident moving forward as an intervention, to prevent further conflict; -Typed signature of the Administrator, dated 8/23/23. Review of the resident's electronic medical record, social service's notes, dated 8/19/23 through 8/24/23, showed; -No documentation regarding the incident between the resident and CMT B; -No documentation regarding a nurse's assessment following the incident between the resident and CMT B. Review of the resident's hospital records, dated 8/25/23 through 8/26/23, showed: -Resident presented to the Emergency Department (ED) with a chief complaint of aggressive behavior; -Psychological Evaluation: Patient states about a month ago, he/she was involved in a physical altercation with a caregiver after the caregiver attempted to give the patient pills; -Medical Decision Making/Summary: Patient who presented for evaluation due to aggressive behaviors at the facility, has a history of dementia, but was able to provide a history. During an interview on 10/2/23 at 12:50 P.M., on 10/3/23 at 11:09 A.M., and on 10/5/23 at 2:40 P.M., the Administrator said there had been an incident which involved CMT B and the resident. The resident was in his/her room eating, and wanted to finish before he/she took his/her medications. The resident wanted the medications left with him/her and CMT B refused to leave the medications. The resident became upset and started yelling. CMT B tried to explain he/she was not being mean, it was his/her job to ensure medications were taken and not left with the resident. The resident became irate when CMT B wouldn't immediately leave the room. The resident threw his/her health shake at CMT B's face. The resident stood up and tried to hit CMT B. CMT B was told to leave the room by the resident, but he stayed in the room and attempted to clean up the spilled health shake. The Administrator said he was out of town and the DON came to the facility. The interviews were conducted on her phone while he was on speaker. The DON and the Administrator had conversations and listened to the responses with the staff. CNA C was the real witness, and he/she didn't witness anything but an argument. CNA C heard cursing when he/she got to the door. CMT B was coming out of the door, and CNA C went to the charge nurse, but didn't witness anything. The resident said it was not abuse, he/she just got mad. His/Her family member said the resident had it out for CMT B. He/She had tried to give the resident medications in the past and the resident called CMT B a [NAME]. The family member said he/she had gotten on to the resident about the name calling and he/she thought this was over. CMT B was suspended, the facility did inservices on resident rights and abuse, and it was explained, if asked to leave, leave and get a witness. The resident had a skin assessment following the incident and there were no injuries. The resident and CMT B gave essentially the same stories. The one difference in the story was the blocking of the hand. The resident said CMT B grabbed his/her arm, and he/she lost his/her balance and he/she sat back down on the bed. The resident said CMT B never cussed at him/her, only tried to redirect him/her. The resident said he/she felt he/she was being treated like a child. The resident said he/she did not feel abused by CMT B and did not feel unsafe during the incident and following the incident. The resident said he/she couldn't stand CMT B and would get upset if he/she saw him/her. CMT B was removed from the hall assignment and did not pass the resident medications again. The resident had PTSD and became upset easily. Something triggered him/her when CMT B was giving him/her medications, and the resident threw his/her medications on the floor. During an interview on 10/3/23 at 1:32 P.M. and on 10/4/23 at 11:40 A.M., the resident said he/she was watching television, and CMT B made a mess of everything. When CMT B was asked to leave, instead of leaving, he/she wanted to exaggerate the situation. The resident wanted CMT B to leave and he/she knew if he/she stayed in the resident's room, the resident would lose it. He/She did not try to hit CMT B, he/she just wanted him/her to go. Most people would shut up and back off, but CMT B did not. He/She told CMT B he/she didn't have to take it. The resident felt CMT B's behavior was abusive; he/she was pushing a button that was not there to push. The resident had rights, even though some people did not understand that. CMT B finally left, but afterward, the resident was still angry, like he/she didn't get to finish it. The facility did nothing, someone promised him/her he/she wouldn't see CMT B again. He/she said he/she later saw CMT B in the dining room and he got mad again. During an interview on 10/6/23 at 3:14 p.m., the resident's family member said he/she was called the night of the incident, and he/she said that was the very first incident he/she was aware of involving CMT B. The family member did not recall a conversation where he/she said he/she witnessed a previous interaction between the resident and CMT B. The resident was a Vietnam Veteran, and had some pretty tough things happen to him/her during the war. The resident was extremely independent and wanted to do everything himself/herself. Generally, he/she was easy to get along with. He/She didn't realize how upset the resident was following the incident. He/she said sometimes the resident's memory was not good, but every time he/she told the story of what happened between him/her and CMT B, it was the same story, so it stuck in his/her head. During an interview on 10/4/23 at 12:44 P.M., CMT B said he/she went to give the resident his/her evening medications. When he/she entered the room, the resident was asleep. He/She called the resident's name and the resident didn't answer. He/she said, I've got your medicine. He/she said the resident's name again and the resident screamed at him/her and snatched the health shake out of his/her hand, then snatched the medications out of his/her hand. The resident told CMT B to, Get the fuck out of the room. The resident stood up and threw the health shake at CMT B's face. CMT B said it seemed like being supervised was the trigger. The resident had war experience with some type of PTSD. Both CMT B's and the resident's voices were elevated, and he/she had his/her back to the wall. Nurse A walked into the resident's room and told CMT B he/she needed to get out there. Nurse A wanted to know what was going on, but CMT B said he/she wanted to talk to the Administrator. CMT B said he/she didn't know what brought this on. During an interview on 10/6/23 at 11:30 A.M., CNA C said he/she heard a commotion, and the resident's door kept partially opening. Previously, he/she had seen the resident and he/she was sitting in his/her room, eating peacefully. He/She walked into the resident's room and there was chocolate shake everywhere, all over the floor. The resident was sitting on the bed, and he/she asked CMT B to come out of the room. CMT B said no, and the resident wasn't going to keep talking to him/her like that. CMT B refused to leave the room. CNA C couldn't believe what he/she was seeing, and he/she ran to get Nurse A. It looked like an employee and a resident were about to go to blows. CNA C told Nurse A it was getting serious and Nurse A needed to see this. When they returned to the resident's room, the resident and CMT B were standing chest to chest cussing each other out. Nurse A asked CMT B to leave the room. CMT B started yelling This is how (he/she) is, This is how (he/she) does, This mother fucker was cussing (him/her) out and disrespecting (him/her). When he/she handed a towel to CMT B to clean up the shake, CMT B threw the towel at the resident's foot and said, Fuck that, I don't care if (he/she) falls and busts (his/her) ass. CNA C went back to the resident and said he/she was sorry that happened, but he/she needed to clean the floor. The resident said CMT B was a punk ass kid and was not going to shove pills in his/her face and watch him/her take those pills. The resident said he/she asked CMT B to come back or give him/her the medications. CMT B snatched his/her drink out of the resident's hand, and grabbed his/her wrist. The incident happened around 4:00 P.M., and it didn't take long for the DON to get there. When the DON arrived, they were asked to write statements. He/She was told to write a statement about exactly what he/she saw. Nurse A wrote a statement too. He/She placed the statement under the DON's door, but took a screen shot of it because Nurse A told him/her to make sure to take a picture of it. During an interview on 10/5/23 at 1:31 P.M., Nurse A said at approximately 4:30 or 5:00 P.M., CNA C said he/she witnessed an altercation between the resident and CMT B. There was a confrontation between them. He/She walked into the room and the resident was screaming that CMT B had just pushed him/her down. CMT B put his/her hands on the resident and was very upset. When he/she walked in the resident's room it looked like CMT B was getting ready to beat the resident's ass. Nurse A told CMT B to leave, but he/she stood there, face to face, chest to chest, with the resident. He/She told CMT B to leave again, but he/she refused to leave. CMT B had a towel in his/her hand and threw it in the resident's face. CNA C tried to get CMT B out of the room. The resident was furious and screamed Get the fuck out of the room. CMT B looked like he/she was going to fight. He/She grabbed CMT B and told him/her to get out of the room. CMT B said he/she was not going anywhere. CMT B said he/she was going to call the Administrator. Nurse A asked why CMT B was going to do that because Nurse A just saw CMT B physically and verbally abuse the resident, CMT B needed to leave. CMT B told the resident Fuck you and I hope you fall and bust your ass. The resident was hysterical. Nurse A called the DON, and said she needed to get up there right then, CMT B was into it with a resident. Afterwards the DON talked to him/her and CNA C, who were the only two witnesses. The DON said she knew Nurse A didn't see what happened and said to just write that on a paper. Nurse A reported the incident to the DON, wrote a statement and gave it to the Administrator. Nurse A did not make a progress note because the DON said she would take care of everything. The DON said she would put in a skin assessment. The DON and Assistant DON were siblings and related to CMT B. Anyone else would have been fired. During an interview on 10/10/23 at 1:05 P.M., the DON said she received a call from Nurse A, who said there was a situation at the facility and he/she needed her. She told Nurse A she was in route, about five minutes away. Upon her arrival, CMT B was standing by the cart at the nurse's station, and she had him/her go to the conference room. She interviewed Nurse A and CMT B, told them to write statements and slide the statements under her door. She said the statements she documented in her investigation were all in regard to CMT B. She asked them if there were any issues prior to the incident. During an interview on 10/10/23 at 1:10 P.M., and on 10/11/23 at 2:33 P.M., the Administrator said they completed three staff interviews, asked staff how did everything go that day and no one noted CMT B's behavior was unprofessional. The witnesses provided a descriptive statement of CMT B prior to the incident. CNA A did not see anything, he/she only heard the raised voices, cursing each other out. CNA A said he/she didn't know who it was, he/she just heard voices. The resident said he/she and CMT B got into a scuffle. The resident told CMT B to get the fuck out of the room and tried to hit CMT B. The resident said CMT B might have grabbed him/her. The resident already said it was not abuse. When asked for a statement, it was not presented to make him/her feel like something was going to happen if he/she said it was abuse. The resident apologized for his/her behavior and was adamant it was not an abusive situation. The administrator said if felt like his integrity was being questioned. They held the CMT to a higher standard, spoke with residents and staff on his/her assignment and no one alleged abuse or neglect. The CMT was trying to do the right thing. There was a line between resident rights and watching medication administration. CMT B was trying to redirect, make sure the pills were removed, the shake was cleaned up and follow the request to leave the room. No one said CMT cursed. They all dealt with difficult residents and you had to raise your voice to be heard. The expectation was to assess the resident's safety. Within 15 minutes of the DON's arrival, it was determined CMT B was not a threat to resident safety. In that case, there was not abuse. MO00223214

Based upon interview and record review, the facility failed to ensure residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice, when the facility failed to identify, assess and provide supportive interventions for (Resident #1) who had a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event/either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). Staff failed to identify the resident's past history of trauma, triggers which could cause re-traumatization and use approaches that were culturally competent and/or are trauma informed. After the resident was verbally abused by a staff member, the facility failed to implement individualized, person centered interventions and/or supportive services. The facility failed to ensure the resident's understanding of a form the resident was asked to sign. This resulted in the resident having increased agitation, necessitating psychiatric hospitalization , upon seeing the staff member in the facility six days later. The facility also failed to educate direct care staff on how best to approach the resident to avoid increased agitation. The facility census was 103. Review of the facility's Trauma Informed Care and Behavioral Health Management policy, revised 9/2022, showed: -Purpose: It is the philosophy of the facility, to treat all residents with love, care and understanding. We believe all behaviors have meanings and is often a way of communication of a need. To assist in the early identification of residents' past traumatic events/behaviors and to develop and implement interventions to manage or de-escalate those behaviors; -Definitions: -Behavioral Health, a state of mental/emotional being and/or choices and actions that affect wellness; -Posttraumatic Stress Disorder (PTSD), a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event and may result in repeated, involuntary memories, distressing dreams or flashbacks of the traumatic event; -Re-traumatization, occurrence of traumatic stress reactions and symptoms after exposure to multiple events; -Trauma, an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being; -Trauma-Informed, recognition that people often have many different types of trauma in their lives and recognition that those with a history of trauma need support and understanding from those around. Trauma survivors can be re-traumatized by well-meaning caregivers and community service providers; -Trauma-informed care, is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma; -Procedure: -Within seventy two hours of admission, a review of the admission medical record will be completed by the social worker and the resident will be asked, If they have experienced any trauma in their life that continues to upset them today? If the answer is yes, resident will be asked if there are certain triggers that may cause re-traumatization. The question should be reviewed with significant changes; -Care plans will be communicated to all direct caregivers to avoid triggers for residents and promote their mental and psychological wellbeing; -Residents admitted with a diagnosis of history of trauma or PTSD will receive care and services to address the problem/illness; -Resident and/or resident representative are active participants in identifying triggers for behaviors and developing coping interventions. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/16/23, showed: -Moderate cognitive impairment; -Rejection of care: Behavior not exhibited; -Diagnoses included PTSD, anxiety disorder, and depression. Review of the Social Services Quarterly Review Assessment, dated 3/14/23, showed; -Trauma Screening, In your life, have you ever had a traumatic event that upsets you today? Box checked, No; -No additional trauma screening assessments. Review of the resident's care plan, in use during the investigation, showed; -Problem: Cognitive Loss/Dementia, requires monitoring for cognition due to impaired short term memory, decreased safety awareness/impaired decision making, disorganized thinking, and need for reorientation; -Approach: Allow ample time to communicate needs. Always approach in a calm, non-threatening manner breaking tasks into small steps; -Problem: Psychotropic Drug Use (changes the function of the nervous system and results in alterations of perception, mood, cognition, and behavior), at risk for adverse medication reactions related to taking psychotropic medication to assist in managing diagnoses of anxiety, PTSD and major depressive disorder; -Approach: Monitor resident's mood and response to medication; -No staff interventions to address the resident's PTSD, history of trauma or need for trauma informed care. Review of the resident's medical record, showed: -Psychiatry note, dated 9/8/23 at 4:56 P.M.; -Past psychiatric history, excerpt from 7/17/2018, He/She is very impatient and cannot wait for anything. He/She goes from 0-100 in seconds Has had problems since he/she came back from Vietnam. Spouse reports he/she was not like this when he/she first met him/her before Vietnam. When he/she is angry, he/she yells, throws things (threw a coffee cup today because there was another cup in the holder when the got to the car). Married for [AGE] years and he/she used to be more aggressive physically, he/she hit a family member a couple times then, he/she would take a hammer and beat wood to get the anger out. He/she would sometimes punch the walls to avoid hitting others; -Military: Vietnam army combat-has suffered PTSD symptoms. Review of the facility's self-report, dated 8/19/23 at 6:00 p.m., showed: -Certified Medication Technician (CMT) B entered Resident #1's room at approximately 3:50 P.M. on 8/19/23. The resident became upset when the CMT educated him/her that CMT B was supposed to observe him/her taking his/her medications and wasn't supposed to leave medications unattended. The resident threw his/her health shake (nutrition supplement) in CMT B's face. While CMT B was attempting to clean up the mess, the resident attempted to strike at CMT B. CMT B caught the resident's hand to prevent being struck, exited the room and reported to the charge nurse. The facility Administrator and Director of Nursing (DON) interviewed the resident, who reported it was simply a disagreement because he/she wanted to finish what he/she was doing and didn't feel he/she needed to be watched while taking medications. When asked if he/she felt that CMT B was threatening or abusive to him/her, the resident reported no. When asked if he/she felt safe, he/she reported yes. The resident did offer that he/she just does not like CMT B. The Administrator called and notified the resident's family member of the situation. The family member felt maybe CMT B reminded the resident of someone he/she didn't like in the past. The facility suggested finding an alternative person to provide medications to the resident and the family member agreed. CMT B was suspended pending investigation and the facility was in the process of interviewing three residents and employees on CMT B's assignment today. Review of the facility's investigation, dated 8/19/23, showed: -A typed statement, signed by the resident, which read, Resident #1, was interviewed by the Administrator and DON on 8/19/23 at 4:30 P.M. CMT B and he/she had a simple misunderstanding this evening; -He/She didn't feel there was abuse or neglect of any kind. He/She feels safe in at the facility; -Witness, signed by the DON, dated 8/19/23. Review of the resident's electronic medical record, Social Services notes, dated 8/19/23 through 8/24/23, showed; -No documentation regarding the incident between the resident and CMT B; -No documentation regarding a nurse's assessment following the incident between the resident and CMT B; -No documentation of any supportive services were offered to the resident to assist in managing past trauma/abuse or coping skills. Review of the resident's electronic nurse's progress notes, dated 8/25/23, (Recorded as Late Entry on 8/26/23 1:50 AM), showed during dinner this resident had an episode in which he/she was very agitated. Aide explained prior situation occurred and the sighting of specific individual. When asked what was wrong, this resident said he/she was promised to never see this son of bitch again. This nurse allowed this resident to vent and share thoughts and emotions. After venting this resident said he/she was ok and would let the nurse know if he/she needed further assistance or had any other issues. Later this nurse was approached by another nurse who stated this resident stated he/she was going to kill this individual (CMT B) and brandished a knife at the dinner table. Other nurse notified DON. Psychiatric evaluation recommended. Family member contacted. Doctor contacted. Awaiting emergency medical services (EMS) arrival. Review of the resident's care plan, in use during the investigation, showed no documentation related to the incident with CMT B or the resident being sent to the hospital after seeing CMT B in the dining room. Review of the resident's hospital records, dated 8/25/23 through 8/26/23, showed: -Resident presented to the Emergency Department (ED) with a chief complaint of aggressive behavior; -Psychological Evaluation: Patient states about a month ago, he/she was involved in a physical altercation with a caregiver after the caregiver attempted to give the patient pills. Patient states he/she was assured he/she would not see the caregiver again, however, last night, while eating, he/she saw the caregiver again. Patient states in the middle of the night, he/she was awoken by police, who asked the patient if he/she had intentions on hurting someone as they received a call from his/her room. Patient denies medical complaints apart from a posterior headache; -Medical Decision Making/Summary: Patient who presented for evaluation due to aggressive behaviors at the facility, has a history of dementia, but was able to provide a history. Review of the resident's electronic Social Services Progress Note, dated 8/28/23 at 3:39 P.M., (Recorded as Late Entry on 8/30/23 3:57 PM), showed Social Worker followed up with resident in regards to a previous incident that took place. Resident stated he/she was doing fine, no concerns voiced. Psychosocial well-being intact. Mood was pleasant at that time. Resident is smiling and making jokes. There are no social service concerns. Social Worker will continue to monitor and provide assistance as needed. During interviews on 10/2/23 at 12:50 P.M., on 10/3/23 at 11:09 A.M., and on 10/5/23 at 2:40 P.M., the Administrator said there had been an incident, which involved CMT B and the resident. The resident was in his/her room eating, and wanted to finish before he/she took his/her medications. The resident wanted the medications left with him/her and CMT B refused to leave the medications. The resident became upset and started yelling. CMT B tried to explain he/she was not being mean, it was his/her job to ensure medications were taken and not left with the resident. The resident threw his/her health shake at CMT B's face. The resident said he/she couldn't stand CMT B and got upset if he/she saw him/her. CMT B was not assigned to the resident anymore. The resident had PTSD and became upset easily. Something triggered him/her when CMT B was giving his/her medications, and the resident threw his/her medications on the floor. The resident became irate when CMT B wouldn't immediately leave the room, but CMT B was trying to pick up the pills and explained he/she could not leave the pills on the floor. CMT B was removed from the hall assignment and did not pass the resident medications again. The resident signed a statement that said there was no abuse. It was explained to him/her, if he/she felt abused by CMT B, the police would be called and CMT B would be terminated. The resident said no, it was not abuse. The signed statement by the resident was explained and the resident knew what he/she was signing. Later, the resident saw CMT B in the dining room. CMT B was not near the resident or spoke to him/her, but the resident became triggered and lashed out. The resident threatened CMT B harm and was sent out for a psychiatric evaluation. During an interview on 10/3/23 at 1:32 P.M. and on 10/4/23 at 11:40 A.M., the resident said he/she was watching television, and CMT B made a mess of everything. When he/she was asked to leave, instead of leaving, CMT B wanted to exaggerate the situation. He/She wanted CMT B to leave. The resident knew if CMT B stayed in the room, he/she would lose it. The resident said he/she did not try to hit CMT B, but just wanted him/her to go. Most people would shut up and back off, but CMT B did not. The resident told CMT B he/she didn't have to take it. He/she felt CMT B's behavior was abusive. CMT B pushed a button that was not there to push. The resident had rights, even though some people did not understand that. CMT B finally left, but afterward, he/she was still angry, like he/she didn't get to finish it. The facility did nothing. Someone promised the resident he/she wouldn't see CMT B again. When he/she saw CMT B in the dining room, he/she got mad again. During an interview on 10/6/23 at 3:14 P.M., the resident's family member said he/she didn't realize how upset the resident was following the incident. Sometimes the resident's memory was not good, but every time he/she told the story of what happened between him/her and CMT B, it was the same story, so it was stuck in the resident's head. It was the resident's understanding CMT B had been terminated and he/she would not see CMT B again. The resident was a Vietnam Veteran, and had some pretty tough things happen to him/her during the war. Because of those experiences, the resident was a casualty of war. He/She saw people blown up in front of him/her and he/she had to pick up their flesh. The war left a big impact on him/her. The resident had some violence in his/her childhood too. A parent of the resident tried to stab the other parent, and his/her grandparents raised him/her. The resident had a lot of trauma in his/her past. The resident was a good person, but suffered from those experiences. Staff had to understand the resident was not in his/her own environment. He/She was used to living at home. He/she was extremely independent and wanted to do everything himself/herself. Generally, the resident was easy to get along with. The resident had the gift of being able to read people like a book. If he/she detected something about someone, his/her alerts went up. He/She was called the night of the incident, and he/she said that was the very first incident involving CMT B and did not recall a conversation where the family member said he/she witnessed a previous interaction between the resident and CMT B. He/She was unaware of the statement or content of the statement the resident signed following the incident. No one at the facility had ever asked him/her if there were triggering behaviors and what do if the resident became upset. No staff have talked to him/her about the resident's PTSD. During the care plan meetings, they basically would say the resident was friendly and had pleasant behaviors. During an interview on 10/4/23 at 12:44 P.M., CMT B said he/she went to give the resident his/her evening medications. When he/she entered the room, the resident was asleep. He/She called the resident's name and the resident didn't answer. He/She said, I've got your medicine. He/She said the resident's name again and the resident screamed at CMT B. Then the resident snatched the health shake out of his/her hand, then snatched the medications out of his/her hand. The resident told him/her to, Get the fuck out of the room. The resident stood up and threw the health shake at CMT B's face. CMT B said it seemed like being supervised was the trigger. The resident had war experience with some type of PTSD. The resident sundown's (a set of symptoms or dementia-related behaviors that may include difficulty sleeping, anxiety, agitation, hallucinations, pacing and disorientation, sometimes known as 'sundowning' but is not necessarily linked to the sun setting or limited to the end of the day) bad. He/she was not the only person this had happened to. He/She knew the resident had border line almost assaulted staff and it didn't get charted. The resident was still triggered when he/she saw CMT B. Just the sight of him/her was enough of a trigger. CMT B didn't know what brought this on. CMT B said the resident's behaviors were probably from sundowning. CMT B said he had not had any in-services or training on how to care for the resident. Everyone just said don't go all the way in the room. Since that incident, the resident has gone off when he/she saw CMT B. He/She had tattoos, which might have been a trigger, he/she didn't know. CMT B said he/she may have looked like someone in the resident's past which may have been a trigger. CMT B walked through the dining room and heard from other staff the resident wanted to stab him/her. There was some type of fixation because of the altercation. CMT B said someone said they thought they saw the resident with a butter knife. The resident was sent out for a mental evaluation, but CMT B wasn't worried about it. CMT B said he/she didn't know the resident's diagnoses, but it was getting worse. The older he/she got, he/she became more aggressive. During an interview on 10/5/23 at 1:31 P.M., Nurse A said at approximately 4:30 or 5:00 P.M., CNA C told him/her he/she witnessed an altercation between the resident and CMT B, there was a confrontation between the two. He/She walked into the room and the resident was screaming he/she just pushed him/her down. CMT B put his/her hands on him/her, he/she was very upset. Nurse A told CMT B to leave, but he/she stood there, face to face, chest to chest, with the resident. He/she told CMT B to leave, but he/she refused to leave. The resident had behavior issues, you didn't debate or argue with the resident. The resident signed a paper he/she thought said CMT B abused him/her and he/she would never work around the resident again. The resident cried because he/she thought he/she wouldn't have to ever see CMT B again. A week later, he/she saw CMT B and got upset. The resident was so upset and was crying when he/she saw CMT B. It triggered the resident and he/she was so upset. They sent him/her to the hospital. During an interview on 10/6/23 at 11:30 A.M., CNA C said he/she heard a commotion coming out of the resident's room. He/She was the one who arrived on the scene and heard cussing and the door was bumping. When he/she opened the door and saw what was going on, it looked like the resident and CMT B were going to have a brawl. There was chocolate milk shake everywhere, all over the floor. The resident was sitting on the bed, and he/she asked CMT B to come out of the room. CMT B, said no and the resident was not going to keep talking to him/her like that, and refused to leave the room. The resident was calm earlier, and even after that happened. It was all about your approach with him/her. The resident just normally sat and watched television. CMT B had been back since that incident. The resident was told he/she had to sign paperwork and signed it. He/She said when CMT B grabbed his/her wrist, he/she knew they would evict him if he/she punched CMT B in his/her face. After the incident, he/she heard the resident crying and he/she told CNA about the paperwork, and said it was a bunch of bull. They just made him/her sign it and did not give him/her a chance to read it. He/She signed it because he/she couldn't afford to get evicted. The resident was in the dining room and saw CMT B and he/she got really shaky. The resident said they let CMT B be there to antagonize the resident. The resident lived there and that was his/her home. During an interview on 10/10/23 at 10:36 A.M., the Social Worker said she had been at the facility since November of last year. She said she recently took over the previous social workers assignments. She said she was familiar with the resident. The resident was alert and oriented x2 (person and place) with some confusion. The resident used a walker to ambulate, ate in dining room, and was very independent. He/She liked to be told before starting something, otherwise he/she became anxious. Some days, he/she did not want to be bothered, those days he/she could become very verbally aggressive. His/Her family member visited every day or every other day and attended appointments. He/She socialized well with other residents. The resident had been in the service, she thought his/her behaviors were from being in the service. The resident was independent and was in control, now having been brought to the facility, this was a big issue, the loss of control. When walking into his/her room, telling him to do something, he/she would become anxious. You needed to explain what was expected, it's mainly the approach. Not allowing him/her to use his/her independence could trigger behaviors. The resident did not mean any harm. If not offered choices, that would be a trigger. When providing care, activities or anything, if the resident was not given time to think about it, that could be a trigger. If he/she said not right now, it was just best to leave the situation and come back. The Social Worker could come back in ten minutes and the resident was a whole different person. The family member just informed the Social Worker the resident was top sergeant in the military, and he was the one making the commands. The family member felt since the resident was the one giving the commands, it was hard to receive commands because the resident had always been in charge. She was pretty sure they had conversations about the resident, but nothing particularly stood out to the Social Worker. The resident just liked things his/her way. The facility had Trauma informed care assessments. Staff asked questions about past history, abuse and if the resident served in the military. Staff completed an assessment, which should be in the medical record. She said she was told a CMT tried to give the resident his/her medications, and the resident wanted them left with him/her. The CMT told the resident he/she would have to watch him/her take them and the resident got upset and cursed out the CMT. She said she didn't remember when the incident happened between a CMT and the resident. The resident later saw the CMT and became upset. She was not working that week, but when she returned, she did a psycho social well-being visit. He/she was pleasant and did not recall the incident. The resident's care plan should be specific to his/her care and approaches. During an interview on 10/5/23 at 11:58 a.m., CNA E said there were a lot of veterans who lived at the facility. The training he/she had received on dealing with residents with behaviors was if you can't do anything to calm the resident down, then tell the nurse. During an interview on 10/5/23 at 1:23 P.M., CMT D said there were quite a few veterans on his/her hall, maybe four or five. One of the residents lost a leg because he/she said a bomb went off by him/her. CMT D did not really talk about the past because PTSD was real. CMT D was afraid he/she may say something that might trigger them. Sometimes when you opened a door too quickly, the veteran residents would jump, and say it was from a bad experience. He/she said he/she has not received training on how to deal with war veterans. During an interview on 10/10/23 at 1:10 P.M., the Administrator said the resident said he/she and CMT B got into a scuffle. The resident preferred CMT B not provide his/her care. His/Her family member suspected CMT B reminded him/her of someone. The resident hated CMT B. After an incident in the dining room, the resident said he/she didn't like CMT B being there and he/she didn't think CMT B should work there. The Administrator said he went through the resident's favorite care givers and told him/her one of his/her favorite caregivers was someone who was previously accused of abuse. If the Administrator fired everyone who was accused of abuse, everyone would be fired. No one had been able to express what the triggers were for the resident. The resident said he/she just did not like CMT B. He/She was just like this according to his/her family member, he/she had always been like this. Approximately half of the residents are veterans. Trauma informed care is documented in the medical record. If staff identify a need to have a trauma informed care assessment it would be a multi-disciplinary approach. The Administrator didn't know a whole lot about the resident's history. He didn't know if he/she had been involved in combat. He was not aware of any childhood trauma or abuse. They try to get a social history. Looking at his/her diagnosis of PTSD, they should have gone more in depth and asked more questions in regard to the PTSD. Based upon the resident's admission documentation/hospital referral, there was not a diagnosis for PTSD. The Trauma Informed care screening was negative. The resident had neurological and cognition disorder diagnoses, so staff would not have seen a need for the trauma informed care plan. MO00223214

Based on interview and record review, the facility failed maintain documentation that staff had notified residents and/or responsible parties in a timely manner when a resident's account was within the $200 Social Security (SSI) limit ($5,301.85) or when the resident's account was over the SSI limit ($5,301.85) per their policy. This affected two of six residents reviewed who received Medicaid benefits (Residents #3 and #35). The census was 100 with 83 in certified beds. Review of the facility's Policy on Protection of Resident Funds, dated 1/20/22, included: -The facility must establish and maintain a system that assures a full, complete and separate accounting system for each resident's personal funds entrusted to the facility on the resident's behalf; -The individual financial record must be available to the resident or his/her legal representative through quarterly statement and upon request; -The facility must notify each resident that receives Medicaid benefits before the amount in the trust account reaches the Medicaid allowable resource limit for one person. If the amount in the account, in addition to the other non-exempt resources, reaches the resource limit for one person, the resident may lose eligibility for Medicaid. This letter must be sent out when a Medicaid resident's total resources reaches $5301.85. Review of the Resident Trust Fund Procedures, dated 1/20/22, showed Medicaid benefit letters not addressed. 1. Review of Resident #3's financial record, showed the following: -Medicaid recipient; -A note, dated 6/8/22, showed the Business Office Manager (BOM) spoke to the resident's Responsible Party (RP) regarding the resident being over resource limit; -A note, dated 2/22/23, showed the BOM sent a letter to the RP regarding resident being over the resource limit; -On 4/3/23, the resident had a resident trust fund balance of $6,835.16; -No documentation the resident or the RP had received notification letters the resident was over the resource limit. 2. Review of Resident #35's financial record, showed the following; -Medicaid recipient; -A note, dated 6/8/22, showed the BOM spoke with the resident's RP regarding the resident being over the resource limit; -A note, dated 2/22/23, showed the BOM mailed letter to RP regarding resident being over asset limit; -On 4/3/23, the resident had a resident trust fund balance of $7,496.84; -No documentation the resident or the RP had received notification letters the resident was over the resource limit. 3. During an interview on 4/3/23 at 2:37 P.M., the BOM said when residents are over the resource limit, he will notify the RP first with a call and then will send a letter. he sends phone calls at first and then will send a letter. He does not keep a copy of the resource limit notification letters. 4. During an interview on 4/5/23 at 5:23 P.M., the Administrator said he expected staff to notify residents of being at/over asset limit and document notification. He would not expect staff to retain a copy of that notification. -

44950 Based on observation, interview and record review, the facility failed to ensure staff followed infection control prevention practices for two sample residents when one staff member adjusted a resident's oxygen tubing after he/she removed a soiled sheet from under a resident (Resident #15) and when another staff member placed a clean brief under a resident after he/she removed the old one with the same gloves (Resident #59). In addition, the facility failed to implement facility policies and procedures to ensure all employees who work 10 or more hours per week were screened appropriately for tuberculosis (TB), in accordance with the Division of Community and Public Health. The facility failed to ensure the two-step purified protein derivative (PPD) was completed for seven of 10 employee files reviewed. The sample was 25. The census was 100 with 83 in certified beds. Review of the facility's Tuberculosis Control Policy, Employee and Resident, dated January 2018, showed: Procedure: For employee protection, personal protective equipment is available for all staff through adherence to Standard Precautions/Body Substance Precautions; For Employees: -All new employees will be screened on hire by using the Two Step Mantoux skin test unless they have a documented previous significant reaction; -Complete Employee Tuberculosis Screening Form (DGETBI EMP) to document administration of the TB test; -The first test will be read in 48-72 hours (10 millimeters (mm) of induration or greater). If the first test results are 0-9 mm of induration, a second test will be given in one week and no more than three weeks after the first test; -The second test will be read in 48-72 hours after administration. If a significant reaction occurs after the skin test(s) the employee will be referred to his/her private physician or the Health Department for evaluation and treatment. 1. Review of Resident #15's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/28/22, showed: -Severe cognitive impairment; -Total dependence with bed mobility, transfers, dressing, toilet use, and personal hygiene; -Always incontinent of bowel; -Diagnoses included neurogenic bladder (the bladder does not empty properly due to a neurological condition), diabetes, quadriplegia (paralysis of all four limbs) and multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness, impairment of speech and muscular coordination, blurred vision and severe fatigue). Observation on 4/4/23 at 8:35 A.M., showed Licensed Practical Nurse (LPN) N and Registered Nurse (RN) Q enter the resident's room to provide wound care. The resident was rolled to his/her right side and RN Q observed the resident would need perineal care before wound care. RN Q left the room and returned with Certified Nursing Assistant (CNA) R. CNA R removed the resident's brief. He/she changed gloves but did not wash his/her hands. CNA R wiped the resident from front to back and tucked a clean sheet under the resident. CNA R applied Calmoseptine (a wetness barrier) to the resident's buttock area with the same gloves. CNA R changed one glove without washing his/her hands and rolled the resident to his/her side. CNA R wiped feces from the resident then removed his/her gloves, wiped his/her forehead, and then donned new gloves. He/she did not wash his/her hands. RN Q removed the soiled sheet from under the resident and placed into a trash bag. RN Q did not change his/her gloves before he/she assisted CNA R to pull the resident up in bed and fix the residents oxygen tubing by the resident's nose with the same gloves. 2. Review of Resident #59's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Extensive assistance with bed mobility and dressing; -Total dependence with toilet use and personal hygiene; -Always incontinent of bowel and bladder; -Diagnoses included heart failure, diabetes, hemiplegia (paralysis on one side of the body), seizure disorder, anxiety, and Chronic Obstructive Pulmonary Disease (COPD, lung disease) Observation on 3/31/23 at 9:45 A.M., showed the resident lay in bed. NAT (Nurse Assistant in Training) J and RN A entered the room to provide resident care. NAT J donned gloves, unfastened the resident's brief and wiped across the pubic area and under the resident's genital area. RN A and NAT J rolled the resident to his/her right side. NAT J pulled out the old brief, and tucked a clean brief and rolled the resident to his/her back wearing the same gloves. Nurse A and NAT J finished with care. NAT J removed his/her gloves and left the room. During a interview on 4/5/22 at 12:30 P.M., CNA I said nursing staff should change gloves between dirty and clean. The resident should be cleaned, the old brief removed, and then the staff should remove gloves, wash hands, and apply new gloves before putting the clean brief on the resident. During an interview on 4/5/22 at 12:40 P.M., RN A said nursing staff should change gloves when going from dirty to clean. NAT J should have removed his/her gloves and washed his/her hands before a new brief was placed on the resident. During an interview on 4/5/22 at 1:00 P.M. the Director of Clinical services said she would expect clinical staff to change gloves between dirty to clean. The staff should have removed their gloves and washed their hands. Staff should wash their hands and not use dirty gloves. 3. Review of employee files on 4/3/23, showed: -Employee V date of hire 10/26/22: First PPD administered 3/29/23, read as negative on 4/1/23. No documentation for second PPD; -Employee W date of hire 3/27/23: No PPD documentation; -Employee X date of hire 10/18/22: No PPD documentation; -Employee Y date of hire 1/18/23: First PPD administered 1/18/23, read as negative on 1/11/23. No documentation for second PPD; -Employee Z date of hire 11/14/22: First PPD administered 1/14/22, read as negative on 1/16/22. No documentation for second PPD; -Employee AA date of hire 11/9/22: No PPD documentation; -Employee BB date of hire 5/27/20: First PPD 8/30/22, read as negative 9/2/22. No documentation for second PPD. During an interview on 4/04/23 10:53 A.M. the Administrator said there was no additional employee PPD information. He would expect staff to follow their policy. He would expect first and second PPD administration upon hire and be reviewed annually. During an interview on 4/5/22 at 1:00 P.M. the Director of Clinical services said she would expect PPD administration to be done upon hire.

Based on observation, interview and record review, the facility failed to ensure residents have the right to make choices about aspects of their life in the facility that are significant to the resident, when the facility's staff failed to put one resident back to bed. The resident waited over an hour for assistance back to bed after he/she requested it (Resident #69). The sample was 25. The census was 100 with 83 in certified beds. Review of the Resident Rights handbook (found in the facility's admission packet) included: -Your right to be treated with dignity and respect is the foundation on which all other resident rights and responsibilities are based. You have the Right to expect that we will: -Treat you as an individual and assist you in getting the most out of the programs and services we offer; -Make sure your surroundings are safe, clean, and comfortable; -Provide safeguards against any kind of harsh or abusive treatment; -Freedom of Choice: -Your right to freedom of choice in the medical decision you make and the goals you pursue is guaranteed to you as a resident of this community and a citizen or resident of the United States. You may exercise this right free from interference, coercion, discrimination, or reprisal; -If, for any reason, you are unable to make your own decision, or if you later lose the ability to do so, you still retain the right to act in your own best interest. Review of Resident #69's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 3/7/23, showed: -Cognitively intact; -Extensive assistance with bed mobility, transfers, dressing and toilet use; -Limited assistance with personal hygiene; -Diagnoses included: high blood pressure, diabetes, end stage renal disease (ESRD), dementia, depression and Alzheimer's. Review of the resident's care plan, last reviewed 7/20/22, showed: -Problem: Resident has a strong identification with past roles and life status related to his/her recent move to facility and misses his/her prior independence; -Goal: Resident will continue to express feelings of connection with prior lifestyle; -Approach: Allow resident to express feelings, allow resident to make decisions, to set realistic goals, and to participate in self-care. Observations and interviews on 3/30/23, showed: -At 2:20 P.M., the resident sat in a wheelchair outside of his/her room by the doorway. The resident said he/she was upset because right after lunch he/she told staff he/she was ready to be put to bed. The staff said they would be right back and no one had come back. The resident said he/she had sat for a while and was uncomfortable. Licensed Practical Nurse (LPN) G was informed of the resident's request to be put back to bed. LPN G said he/she would find a certified nursing assistant (CNA) to assist the resident. LPN G said the resident normally wanted to go back to bed after lunch; -At 2:39 P.M., the resident remained in his/her wheelchair just inside his/her room and said he/she wanted to go to bed. He/She hurt, it's awful. He/she propelled his/her wheelchair into the hall and said maybe staff would see him/her and come down to help; -At at 2:40 P.M., Registered Nurse (RN) A told a CNA B the resident had asked to lay down. CNA B said ok, and went to a different hall; -At 2:43 P.M., the resident began to moan and rock, and said it hurts and said this happens a lot. Staff do not care that he/she wanted to go to bed, they do what they want. He/She wished they would just help him/her when he/she requested it; -At 2:52 P.M., showed the nurses at the nurses' station gave report to the oncoming shift. CNA B was not observed at the nurses' station; -At 3:00 P.M., the resident propelled up the hall, towards the nurses station; -At 3:07 P.M. CNA B exited the break room and said he/she was now off duty and leaving; -At 3:09 P.M., the Corporate Administrator was informed of the resident's request; -At 3:11 P.M., staff propelled the resident to his/her room and said they needed to get a Hoyer lift (mechanical lift) and noted there was not a Hoyer pad under the resident; -At 3:13 P.M., staff brought a Hoyer lift to room and left it outside the door to the resident's room; -At 3:14 P.M., CNA B, CNA E, and Nurse C entered the room. Staff assisted the resident to sit forward and put a Hoyer pad under him/her. Staff said the Hoyer pad is not the right one. Nurse C left the room to get a different one; -At 3:24 P.M., Nurse C, CNA F and CNA D entered the room and CNA E left the room. Staff pulled out the other Hoyer pad from under the resident and put the new one behind him/her; -At 3:28 P.M., staff used the Hoyer lift and assisted the resident to bed. During an interview of 4/5/23 at 12:35 P.M., CNA I said the resident had the right to make choices about when he/she went to bed or got up. The resident should not have to wait more than an hour to lay down. During an interview on 4/5/23 at 12:45 P.M., RN A said the resident had the right to choose when to get up or when to go to bed. A resident should not have to wait an hour after they asked to go to bed or to get up. During an interview on 4/5/23 at 1:00 P.M., the Administrator said the residents have the right to make choices about their daily life, such as when to get up and when to go to bed. The request should be accommodated as soon as possible, but no longer than an hour. Anything over an hour would be unacceptable.

Based on interview and record review, the facility failed to keep one resident (Resident #1) free from physical abuse. On 2/23/22, at approximately 9:00 P.M., two agency staff members, Certified Medication Technician (CMT) I and Nurse F held the resident's upper extremities and attempted to pry the resident's hand open, in an effort to take back an antibiotic medication. The resident was upset, yelled out, and sustained bruises. The census was 93. The administrator was notified on 3/10/22 at 4:00 P.M. of an immediate jeopardy (IJ) which began on 2/23/22. The IJ was removed on 3/11/22 as confirmed by surveyor at onsite verification. Review of the facility's Freedom From Abuse, Neglect and Exploitation policy, dated 6/2021, showed the following: -Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking; -Mistreatment-means inappropriate treatment or exploitation of a resident; -Application/Prevention: The policy regarding resident safety has applications in the manner in which prospective employees are screened, new employees are oriented, how on-going education is provided for all employees, the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -New employee and volunteer orientation; 1. Each new employee and volunteer shall be orientated to facility resident safety policies and procedures regarding the prevention, reporting, and investigation process associated with resident safety; 2. Each new employee and volunteer shall be informed that violation of this resident safety policy will not be tolerated and may be grounds for immediate termination or dismissal; 3. Each new employee and volunteer will be informed of their responsibility to immediately, without fear of any reprisal, report any violations or alleged violations. Failure to do so will result in disciplinary action; -Ongoing education: At new employee education and at least annually, in-service programs shall be presented which encompass: Identifying, intervening and reporting situations in which abuse, neglect, exploitation, mistreatment, use of resident photographs or recordings are likely to occur, or where there are occurrences of unexplained injuries or misappropriation of resident's property. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/4/22, showed: -Cognitively intact; -Adequate hearing and vision; -Able to understand others and be understood; -No behaviors noted; -No rejection of care including taking medications; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's weekly skin assessment, dated 2/22/22 at 1:14 A.M., showed the resident had reddened areas to his/her right lower extremities. No documentation of reddened areas, rashes, skin tears or bruises on any other part of the resident's body. Review of the resident's progress notes, showed the following: -On 2/23/22 at 11:49 P.M., the resident was given medication by the CMT and said he/she was not ready to take it. The CMT asked to take it back and the resident refused so the CMT called the nurse who approached the resident with a calm voice. He/she refused to give it to the nurse and began to scream and tried to hit the nurse with his/her water cup and swung his/her left arm and hit the table, and now had a bruise on his/her left wrist. The nurse told the CMT to let the resident calm down and passed on to the night nurse that the resident was upset; -On 2/24/22 at 2:03 A.M., the resident informed the nurse he/she was in a physical altercation with the CMT on the 3-11 (evening) shift at approximately 9:00 P.M. The resident reported it at 11:30 P.M. The nurse noted bruising to bilateral wrists and informed the resident, he/she would have to call the DON and report the incident. The police then arrived as the nurse was on the phone. The nurse asked the resident if he/she called the police and he/she stated, Yes. The nurse left a message with the DON and called the other temporary DON who told him/her to call the administrator. After he/she called the administrator, he/she went back into the resident's room and it appeared as if another bruise was forming on the right wrist. At 3:21 A.M., the Assistant Director of Nursing (ADON) assessed the resident. The resident reported the CMT came to give the resident his/her bedtime pills. The resident requested the CMT bring back the antibiotic at a later time due to his/her stomach being upset. The resident said the CMT spoke to him/her in a threatening manner and told him/her to take the pills or give them back. At this time, the CMT grabbed his/her hands and was squeezing/holding them tightly trying to take the medication back. The resident yelled out, You're hurting me! At this point the nurse entered the room. The nurse held one arm while the CMT held the other arm. Then the nurse told the CMT the resident was not going to give the medication back and to just leave. The resident said as the nurse and CMT were leaving his/her room, he/she called them names. The resident then stated he/she knew he/she should not have said this and regretted it, but was so angry. He/she did not want to hurt them and just wanted them to leave him/her alone. The ADON asked the resident if he/she swung at or hit the staff and the resident stated, No. The ADON completed a full body assessment. The resident's left knuckles were noted with light purple discoloration, 2 centimeters (cm) by 8 cm. Left medial (in the middle) forearm with purple area, 1.5 cm by 1 cm. Left proximal (closer to the center of the body) forearm with light purple area 1 cm by 1 cm. Right distal (away from the body) forearm with dark purple/maroon area 2.5 cm by 2.2 cm. Right upper arm near shoulder with purple area 1.2 cm by 1.0 cm. Resident complained of tenderness to areas but no pain; -At 2/25/22 at 2:02 A.M., the resident with bruising to bilateral forearms and also what appears to be bruising to left knuckles. Bruising remains purple/brown in color. Bruising to left forearm is larger in size than the previous night. Review of the resident's care plan, dated 2/24/22, showed the following: -Problem: Behavioral symptoms; -Approach: Avoid over-stimulation due to my Asperger's diagnosis. Convey an attitude of acceptance toward the resident. Needs to be asked to do something, not told. Take your time with the resident. Does not like it when people are rushing. Review of the facility's self -report, dated 2/24/22, showed the following: -At approximately 12:15 A.M., the administrator received a call from the facility to inform her the police were on the premises as a response from Resident #1 calling the police to report abuse. The resident alleged he/she was attacked by the evening shift CMT I; -The incident occurred somewhere between 8:00 P.M. and 9:00 P.M. The resident refused to take his/her medication and wanted to take it later but would not allow the CMT to remove the medication from the room. The CMT then called for assistance from the evening shift nurse and the resident continued to refused to give either of them the cup of medication; -Nurse F, an agency staff member, reported he/she tried to explain the situation and the resident continued to hold on to the medication and would not let them remove it from the room. The nurse said the resident attempted to hit him/her and the CMT, swinging at him/her with his/her water pitcher and struck his/her hand on the bedside table. Nurse F denied he/she laid hands on the resident and did not witness the CMT have any physical contact with the resident. The resident yelled at them and called them names and told them to get out of his/her room. At this point, they left the room to allow the resident to calm down; -Nurse O measured the bruising to the wrist area at approximately 1 cm by 1 cm on the right wrist and 1.1 cm by 1.2 cm on the left wrist as well as 0.7 cm by 0.3 cm; -The prior administrator spoke to the resident who vehemently denied he/she struck out at the staff members or hit his/her hand on the bedside table. He/she reported the nurse and CMT in question held his/her wrists as they attempted to retrieve the antibiotic and he/she refused to give it to them. The bruising patterns near the wrist could appear to be that of a hand print or fingerprints. During an interview on 3/3/22 at 10:35 A.M., the resident said the incident occurred around 9:00 P.M. He/she had never seen the CMT before. The CMT was trying to give him/her an antibiotic, but he/she did not want to take it because he/she had taken one three hours prior, and it would make him/her sick. The CMT told him/her to throw it away or give it back to him/her. The resident asked if the CMT could bring it back later and he/she said, No, take it now or not at all. He/she realized the only way to be able to take the antibiotic at 11:00 P.M., was to keep it. The resident took the antibiotic out of the cup to save for later and the CMT started to attack him/her. He/she grabbed the resident's wrists and held his/her hands together very tightly to try and grab the pill back. The resident told him/her to stop and it was hurting him/her. The resident started yelling, Stop you're hurting me! The nurse came into the room a few minutes later. He/she found out what was going on and began to help the CMT try and get the pill. The CMT had his/her right hand and wrist and was yanking on his/her hand and the nurse had his/her left hand. He/she was yelling at them to stop. It was hurting so bad. They finally gave up. The nurse said we are not going to get that pill from him/her. The CMT said, I was going to give that pill back to you. Just give it to me, but I knew he/she was lying. The resident was hurting and angry so he/she called them names, but he/she did not swing at or hit them. The table might have been pushed over when the nurse and CMT were struggling with him/her. The resident did tell other staff members the CMT and nurse assaulted him/her. He/she felt angry there was no protection for him/her that night. Review of an emailed statement from CMT I, dated 3/1/22, showed at approximately 8:45 P.M., he/she entered the resident's room with his/her medication. After he/she handed the resident his/her medication, he/she noticed the resident take a green pill out of the medication cup, which was his/her antibiotic. The CMT asked him/her what he/she was doing, and he/she said he/she just took the pill at 6:00 P.M., and if he/she took it now, he/she would be on the toilet all night. The CMT told the resident he/she could not leave the pill with him/her but could bring it back when he/she was ready or at his/her next scheduled time, and the resident refused. The CMT tried to obtain the medication cup but the resident balled it up in his/her hand. The CMT went and got the nurse and also asked Certified Nurse's Aide (CNA) K who was on duty to come in as a witness. The nurse came in and the resident became hostile and aggressive and began trying to attack them. He/she tried to hit the nurse with his/her drinking cup. The nurse told the CMT to hold the resident's arm, and the nurse tried to get the pill. The resident began screaming and yelling. Finally the nurse said to just let the resident keep the pill and they left the room. During an interview on 3/7/22 at 9:00 A.M., CMT I said the night of the incident was his/her first night working at the facility. He/she was not sure of the exact time when he/she entered the resident's room. He/she handed the resident his/her medication. The resident asked him/her for a tissue and when he/she turned to get the tissue, he/she saw the resident remove a pill from the cup. He/she looked in the cup and observed the resident had removed his/her antibiotic and asked him/her what he/she was doing. The resident said he/she already took the antibiotic at 6:00 P.M., and if he/she took it again so soon, it would give him/her diarrhea. The resident swallowed his/her other pills and put the antibiotic back in a paper cup. The CMT told him/her, he/she could not leave the medication and reached for the cup. The resident balled the cup up in his/her hand, yanked it away and yelled he/she was not going to give it to the CMT. The CMT immediately went out into the hallway and yelled for the nurse. The nurse came in and tried to get the pill. He/she grabbed the resident's hand and tried to pry his/her fingers open. The resident got angry and tried to whack the nurse. The resident picked up his/her water cup to hit the nurse. The nurse moved the water cup out of the way. He/she told the CMT to hold the resident's arms but the CMT was uncomfortable with this and went out and got CNA K as a witness. When they came back in the room, the nurse told the CMT to hold one of the resident's arms and he/she held the other one, but the CMT let him/her go because the resident was swinging his/her arms. The resident was screaming and tussling. He/she did what the nurse told him/her to do. He/she never put his/her hands on the resident prior to the nurse being in the room. CNA K said maybe he/she could try and get it, but the resident would not give it to him/her either. The CMT did not want to leave the medication with the resident because another resident might come in and take it. The nurse finally said they were not going to get the medication and they left the room. Review of Nurse F's written statement, dated 2/23/22, showed the CMT called him/her to come to the resident's room around 9:15 P.M. to 9:30 P.M. He/she tried to get the medication back by explaining they could not leave it in the room. The resident called them some names that were inappropriate. The nurse did not know what kind of medication the resident had, but he/she wanted to take it later because he/she had already taken some at 6:00 P.M. The resident attempted to hit the nurse and swung his/her water pitcher and hit his/her left arm while trying to hit the nurse and CMT. During interviews on 3/4/22 at 11:45 A.M. and on 3/7/22 at 11:10 A.M., Nurse F said CMT I came out of the resident's room and yelled for him/her to come there. The CMT said the resident would not take his/her medication and would not give it back. When the nurse entered the room, the resident was very upset. He/she could not say what happened to the resident prior to his/her entering the room. The nurse told the CMT he/she would try and get the medication from the resident. The resident was so angry. The nurse asked the resident if he/she could have the medication and the resident refused to give it to him/her. The resident said the CMT tried to take his/her medication from him/her. He/she was not ready to take the medication yet because he/she just took it earlier, but the resident did not want the CMT to take it. The resident was attempting to stand and was unsteady, and the nurse was afraid the resident was going to fall. There was so much going on. The resident was so upset when they first came in the room. He/she swung his/her hand but hit the bedside table and threw the water pitcher at them. The nurse moved the table out of the way so the resident would not harm him/herself. The nurse went out and got CNA K to see if he/she could get the resident to calm down. CNA K offered to try and get the medication, but CMT I would not allow the CNA to help. The nurse did not remember who grabbed the resident. They did try to get the pill out of his/her hand by pulling the resident's fingers. They finally gave up when he/she realized they were not going to get the medication from the resident. He/she never worked with this CMT before. He/she never had a problem with the resident taking medication before. Review of CNA K's undated written statement, showed on the night of the incident, the CMT went into the resident's room to give him/her medications. A few minutes after, he/she heard the resident screaming. After the nurse called the CNA into the room, the resident explained they were trying to take his/her medication. The CMT explained the resident told him/her, he/she had taken his/her medication at 6:00 P.M. and he/she was not going to take the additional medication. The CMT said he/she tried to take it back and would bring them back to the resident later. The resident said they were not going to bring the medication back and were grabbing his/her arms, but the CNA did not see them grabbing him/her while he/she was in the room. During an interview on 3/7/21 at 9:35 A.M., CNA K said he/she was at the desk that night after dinner. CMT I went in the resident's room first and he/she heard the resident start yelling, Help! Get away from me! Then Nurse F went in and the screaming started again. The nurse came out and got the CNA to try and help calm the resident down. When he/she entered the room, the resident was very upset and crying. He/she said the CMT and nurse grabbed his/her arms and tried to take his/her medication away from him/her. The nurse told the CNA, he/she had told the resident if he/she gave them the medication they would bring it back but the resident said the CMT told him/her, he/she would not bring the medication back, so he/she was not going to give it back to them. The nurse said the resident tried to bite them when they reached for the medication and he/she called them inappropriate names. The nurse and the CMT finally gave up and left the room. He/she did not see them hold the resident's arms or wrists while he/she was in the room. CNA K stayed in the room after they left. The resident told the CNA, he/she had never been treated that way before. They had assaulted him/her. They grabbed his/her arms and tried to take his/her medication away from him/her. The CNA did not look for any marks on the resident's arms or hands that night. He/she had never seen the resident act this way or be this upset. Staff should not try to force medication out of a resident's hand. He/she did not go in the room when he/she heard the resident screaming because the nurse already went in there. He/she did not report it to anyone because he/she thought the nurse was going to report it. Review of a written, undated statement by CNA J, showed the CMT went into the resident's room and tried to take away the resident's antibiotic. The resident refused to give it to him/her so the CMT went and got the nurse. The nurse went in and both the nurse and CMT were yelling at the resident. The resident screamed, Stop hurting me! He/she also yelled at them to get out of his/her room. The nurse told CNA J, he/she did not touch the resident, but when the CNA went in to check on the resident, he/she showed the CNA the bruises on his/her wrists from where the CMT and nurse held him/her down to get the pill. The nurse also got mad at CNA J for mentioning getting another nurse to witness what was going on. He/she told the CNA, he/she was the nurse and did not need him/her telling the other nurse anything. He/she said the resident called them names because of how angry he/she was. During an interview on 3/7/22 at 9:45 A.M., CNA J said he/she was working at the desk, on the resident's hall the night of the incident between 8:00 P.M. and 9:00 P.M. CMT I went into the resident's room and he/she heard the resident yelling and screaming, Get off me, you are hurting me! Nurse F went into the room and the resident started screaming again. He/she did not know if he/she could go in the room because Nurse F was already in there. The resident sounded fearful and like he/she was in pain. CNA J asked the other CNA if they should do something and he/she told him/her, the nurse was already in the room. He/she probably should have gone and told a nurse from another floor, but he/she did not know what to do. The resident did not usually get agitated or scream at people, so this was concerning. He/she believed something was going on in the room. He/she asked Nurse F afterwards if he/she should get another nurse as a witness and the nurse got angry with him/her and said he/she was the nurse. CNA J went into the room around 10:00 P.M., and the resident was still upset. He/she said CMT I and Nurse F restrained him/her by holding his/her arms and tried to take his/her medication away. He/she had red marks on his/her arms and wrists. The resident genuinely sounded scared. The CNA had seen staff leave medication with the resident in the past and did not know why they had to fight with him/her over it this time. The resident told him/her, he/she might call the police and report the incident. The CNA did not report the incident at the time because he/she already tried to get the nurse to report it and was going to talk to administration in the morning. He/she did tell someone at the front desk the police might be coming, as he/she was leaving at 11:00 P.M. During an interview on 3/8/22 at 3:10 P.M., Nurse O said he/she arrived at the facility around 10:00 P.M. on 2/23/22. Nurse F said the resident refused to take his/her medication and refused to give it back. He/she called them names when they tried to get him/her to give it back. He/she made it sound like it was the resident's issue. Around 11:00 P.M., Nurse O went in to check on the resident. The resident was very upset and told him/her, the CMT and nurse had attacked him/her. Nurse F had grabbed one arm and CMT I grabbed the other and they tried to take his/her medication away. Nurse O told the resident he/she would have to report the incident and went to call the DON. As he/she was calling, he/she saw the police walking down the hallway. He/she set the police up with the resident and called the DON. The DON told him/her to call the former administrator and report it to her. The former administrator told him/her to start an investigation and document the resident's injuries. Nurse F was still in the building filling out paperwork and talked to the police. CMT I was already gone for the night. After the police left, he/she went in to assess the resident. There were two small bruises on his/her right wrist and a bigger bruise on his/her left wrist. The bruise on his/her left wrist got bigger and darker during the night. During the shift change report, Nurse F said the resident did not have any bruising. Nurse O had never had a problem with the resident or seen him/her that upset before. All they had to do was take the medication and bring it back. The CMT told the resident, he/she was not going to bring the medication back. They should not have tried to force the medication from his/her hands. They should have taken it and brought it back. No one said anything to him/her about the resident saying he/she was assaulted. Staff should have reported it to the nurse or the DON. During an interview on 3/8/22 at 9:45 A.M., the ADON said she interviewed the resident on the morning of 2/24/22. She did a full assessment on the resident and noted bruising on both wrists and discolorations on the knuckles of both hands. The resident said CMT I came in the night before to give his/her evening medications and the resident had asked if he/she could take the antibiotic back because he/she had recently taken the previous dose. The CMT told the resident to take them all or he/she would take them all back, and the resident would not get any of them. The CMT spoke to the resident in a threatening manner, grabbed his/her hands and squeezed them roughly trying to get the pill cup out of his/her hand. The resident started yelling, You are hurting me! Nurse F came in and held one arm, and the CMT held the other arm, and they tried to get the pill back. The nurse finally told them to leave; that they were not going to get the pill back. The resident denied swinging at them but did say he/she called them names. The resident had never had a problem like this before. The ADON would have expected the CMT to take the medication and bring it back later. They had until 11:15 P.M., to administer the medication. It was absolutely not okay to try and force the resident to give up the medication. If staff heard the resident yelling, they should have gone in and assessed the situation and made sure the resident was safe. They should have reported it to the nurse manager or administrator. During an interview on 3/4/22 at 10:30 A.M., the DON said she would expect staff to take the medication back and bring it back to the resident later. The medication could have been given as late as 11:15 P.M. Staff should have documented it in the resident's progress notes. All allegations of abuse should immediately be reported to the nursing manager or DON. During an interview on 3/16/22 at 3:15 P.M., the administrator said she would have expected the staff who heard the resident yelling to have intervened immediately to keep him/her safe. Note: At the time of the investigation/abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on 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. Note: 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 be taken to address Class I violation(s). MO 612 MO 668

Based on interview and record review, the facility failed to ensure all staff, including agency staff, were aware of procedures on how to report abuse when one resident (Resident #1) was physically abused. On 2/23/22 at approximately 9:00 P.M., two agency staff members, Certified Medication Technician (CMT) I and Nurse F, held the resident's upper extremities and attempted to pry the resident's hand open, in an effort to take back an antibiotic medication. The resident was upset, yelled out and sustained bruises. Two additional, certified nurse's aides, employed by the facility, heard the resident yelling but did not immediately intervene. Staff did not immediately report the incident to management or the regulatory agency, so that an investigation and protective measures could be put into place. The census was 93. The administrator was notified on 3/10/22 at 4:00 P.M. of an immediate jeopardy (IJ) which began on 2/23/22. The IJ was removed on 3/11/22 as confirmed by surveyor onsite verification. Review of the facility's Freedom From Abuse, Neglect and Exploitation policy, dated 6/2021, showed the following: -Immediately-CMS believes reporting immediately means not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities in accordance with state law through established procedures; -Mistreatment-means inappropriate treatment or exploitation of a resident; -Application/Prevention: The policy regarding resident safety has applications in the manner in which prospective employees are screened, new employees are oriented, how on-going education is provided for all employees, the care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -New employee and volunteer orientation; 1. Each new employee and volunteer shall be orientated to facility resident safety policies and procedures regarding the prevention, reporting, and investigation process associated with resident safety; 2. Each new employee and volunteer shall be informed that violation of this resident safety policy will not be tolerated and may be grounds for immediate termination or dismissal; 3. Each new employee and volunteer will be informed of their responsibility to immediately, without fear of any reprisal, report any violations or alleged violations. Failure to do so will result in disciplinary action; -Ongoing education provided for facility staff: At new employee education and at least annually, in service programs shall be presented which encompass: Identifying, intervening and reporting situations in which abuse, neglect, exploitation, mistreatment, use of resident photographs or recordings are likely to occur, or where there are occurrences of unexplained injuries or misappropriation of resident's property; -The facility procedure for nursing home staff to report their knowledge of suspected violations of the resident safety policy without fear of reprisal; -Contractors and consultants: The administrator will be responsible for sending the community's policy on the residents Rights, Abuse, Neglect and Exploitation and Unauthorized Photographs and/or Audio/Visual Recordings of Residents to all contractors (agency staff) and consultants associated with their facility along with an acknowledgement agreement. The acknowledgement will be signed by the company's human resource or administrative representative confirming all said contractual or consulting staff have been properly informed and/or in-serviced on these policies in accordance with state and federal regulations and the standards set forth prior to providing care for residents and at least annually thereafter; -Reporting suspected violations: 1. Any suspected, observed or reported violation of the resident safety policy shall be reported immediately to the supervisor and the administrator per facility policy without fear of reprisal; 2. The supervisor on duty shall immediately report any alleged violations of this resident safety policy to the administrator/designee or DON/designee; 3. The administrator or designee will be responsible to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to other officials in accordance with state law including to the state survey and certification agency. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/4/22, showed: -Cognitively intact; -Adequate hearing and vision; -Able to understand others and be understood; -No behaviors noted; -No rejection of care including taking medications; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes, showed the following: -On 2/23/22 at 11:49 P.M., the resident was given medication by CMT I, agency staff, around 9 P.M. and he/she said he/she was not ready to take the medication. The CMT asked the resident to give the medication back and the resident refused, so the CMT called Nurse F, agency staff, who approached the resident with a calm voice and asked for the medication. He/she refused to give it to the nurse and began to scream and tried to hit the nurse with his/her water cup and swung his/her left arm and hit the table, and now has a bruise on his/her left wrist. The nurse told the CMT to let the resident calm down and gave a report of the incident to Nurse O, oncoming night (11 P.M. - 7 A.M. shift) nurse, that the resident was upset. (Nurse F did not notify administrative staff of the incident); -On 2/24/22 at 2:03 A.M., the resident informed Nurse O, at 11:30 P.M., that he/she was in a physical altercation with the CMT I on the 3-11 (evening) shift at approximately 9:00 P.M. The nurse noted bruising to bilateral wrists and informed the resident he/she would have to call the Director of Nursing (DON) and report the incident. The police arrived as the nurse was on the phone. The nurse asked the resident if he/she called the police and he/she stated, Yes. The nurse left a message with the DON and called the other temporary DON, who told him/her to call the administrator. After he/she called the administrator, at approximately 12:30 A.M., he/she went back into the resident's room and observation showed another bruise was forming on the right wrist. Review of the facility's self -report, dated 2/24/22, showed the following: -At approximately 12:15 A.M., the administrator received a call from the facility to inform her the police were on the premises as a response from Resident #1. The resident alleged he/she was attacked by CMT I, on the evening shift; -The incident occurred somewhere between 8:00 and 9:00 P.M. The resident refused to take his/her medication and wanted to take it later but would not allow CMT I to remove the popped medication from the room. The CMT then called for assistance from the evening shift nurse and the resident continued to refuse; -Nurse F, an agency staff member, reported he/she tried to explain the situation and the resident continued to hold on to the medication and would not let them remove it from the room. Nurse F said the resident attempted to hit him/her and the CMT, swinging at him/her with his/her water pitcher and struck his/her hand on the bedside table. Nurse F denied he/she laid hands on the resident and did not witness the CMT have any physical contact with the resident. The resident yelled at them and called them names and told them to get out of his/her room. At this point, they left the room to allow the resident to calm down; -At 12:45 A.M., Nurse O measured the bruising to the wrist area at approximately 1 cm by 1 cm on the right wrist, and 1.1 cm by 1.2 cm on the left wrist, as well as 0.7 cm by 0.3 cm; -The former administrator spoke to the resident who vehemently denied he/she struck out at the staff members or hit his/her hand on the bedside table. He/she reported the nurse and CMT in question held his/her wrists as they attempted to retrieve the antibiotic and he/she refused to give it to them. The bruising patterns near the wrist could appear to be that of a hand print or fingerprints. On 2/24/22 at 3:21 P.M., the Assistant Director of Nursing (ADON) assessed the resident. The resident reported CMT I came to give the resident his/her bedtime pills. The resident requested the CMT bring back the antibiotic at a later time due to his/her stomach being upset. The CMT spoke to him/her in a threatening manner and told him/her to take the pills or give them back. At this time, the CMT grabbed his/her hands and was squeezing/holding them tightly trying to take the medication back. The resident yelled out, You're hurting me! At this point the nurse entered the room. The nurse held one arm while the CMT held the other arm. Then the nurse told the CMT the resident was not going to give the medication back and to just leave. The ADON asked if he/she swung at or hit them and the resident stated, No. The ADON completed a full body assessment. His/her left knuckles were noted with light purple discoloration, 2 centimeters (cm) by 8 cm. Left medial (in the middle) forearm with purple area, 1.5 cm by 1 cm. Left proximal (toward the center of the body) forearm with light purple area 1 cm by 1 cm. Right distal (away from the center of the body) forearm with dark purple/maroon area 2.5 cm by 2.2 cm. Right upper arm near shoulder with purple area 1.2 cm by 1.0 cm. Resident complained of tenderness to areas but no pain; -At 2/25/22 at 2:02 A.M., the resident with bruising to bilateral forearms and also what appears to be bruising to left knuckles. Bruising remains purple/brown in color. Bruising to left forearm is larger in size than the previous night. During an interview on 3/3/22 at 10:35 A.M., the resident said the incident occurred around 9:00 P.M. He/she had never seen CMT I before. The CMT was trying to give him/her an antibiotic. He/she takes the antibiotic at 1:00 P.M., 6:00 P.M., and 11:00 P.M. and he/she did not want to take his/her antibiotic because he/she had taken one three hours prior and it would make him/her sick. The CMT told him/her to throw it away or give it back to him/her. The resident asked if the CMT could bring it back later, and he/she said no, take it now or not at all. He/she realized the only way to be able to take the antibiotic at 11:00 P.M., was to keep it. The resident took the antibiotic out of the cup to save for later, and the CMT started to attack him/her. He/she grabbed the resident's wrists and held his/her hands together very tightly to try and grab the pill back. The resident told him/her to stop and it was hurting him/her. The resident started yelling, Stop you're hurting me! Nurse F came into the room about five minutes later. He/she found out what was going on and began to help the CMT try to get the pill, which hurt the resident's hands. The CMT had the resident's right hand and wrist and was yanking on his/her hand. The nurse had his/her left hand. The resident said he/she was yelling at them to stop. It was hurting so bad. They finally gave up. The nurse said we are not going to get that pill from him/her. The CMT said I was going to give that pill back to you, just give it to me but the resident said he/she knew the CMT was lying. The resident said he/she was hurting and he/she was angry, so he/she called them names, but he/she did not swing at or hit them. The table might have been pushed over when the nurse and CMT were struggling with him/her. The resident did tell another staff member the CMT and nurse assaulted him/her. He/she felt angry there was no protection for him/her that night. Review of an emailed statement dated 3/1/22 , showed CMT I said at approximately 8:45 P.M. he/she entered the resident's room with his/her medication. After he/she handed the resident his/her medication, he/she noticed the resident take a green pill out of the medication cup, which was his/her antibiotic. The CMT asked him/her what he/she was doing and he/she said he/she just took the pill at 6:00 P.M., and if he/she took it now, he/she would be on the toilet all night. The CMT told the resident he/she could not leave the pill with him/her but could bring it back when he/she was ready or at his/her next scheduled time, and the resident refused. The CMT tried to obtain the medication cup, but the resident balled it up in his/her hand. The CMT went and told the nurse and also asked Certified Nurse's Aide (CNA) K that was on duty to come in as a witness. Nurse F came in and the resident became hostile and aggressive and began trying to attack the staff. The resident tried to hit the nurse with his/her drinking cup. The nurse told the CMT to hold his/her arm, and he/she tried to get the pill. The resident began screaming and yelling. Finally the nurse said to just let him/her keep the pill, so they left the room. During an interview on 3/7/22 at 9:00 A.M., CMT I said the night of the incident was his/her first night working at the facility. He/she had some issues with other residents prior to getting to this resident because they wanted him/her to leave their medications with them and he/she would not do it and he/she had reported this to a nurse. He/she was not sure of the exact time when he/she entered the resident's room. He/she handed the resident his/her medication in a medication cup. The resident asked him/her for a tissue and when he/she turned to get the tissue, he/she saw the resident remove a pill from the cup. He/she looked in the cup and observed the resident had removed his/her antibiotic and asked him/her what he/she was doing. The resident said he/she took the antibiotic at 6:00 P.M., and if he/she took it again so soon it would give him/her diarrhea. The resident took his/her other pills and put the antibiotic back in a paper cup. The CMT told him/her, he/she could not leave the medication and reached for the cup. The resident balled the cup up in his/her hand, yanked it away and yelled he/she was not going to give it to him/her. The CMT went out into the hallway and yelled for the nurse. Nurse F came in and tried to get the pill. He/she grabbed the resident's hand and tried to pry his/her fingers open. The resident got angry and tried to whack the nurse. The resident picked up his/her water cup to hit the nurse. The nurse moved the water cup out of the way. He/she told the CMT to hold the resident's arms but the CMT was uncomfortable with this and went out and got Certified Nursing Assistant (CNA) K as a witness. When they came back in the room, the nurse told the CMT to hold one of the resident's arms and he/she held the other one, but the CMT let him/her go because the resident was swinging his/her arms. The resident was screaming and tussling. He/she only did what the nurse told him/her to do. He/she never put his/her hands on the resident prior to the nurse being in the room. CNA K said maybe he/she could try and get it, but the resident would not give it to him/her either. The CMT did not want to leave the medication with the resident because another resident might come in and take it. The nurse finally said they were not going to get the medication and they left the room. He/she had not been in-serviced on the abuse/neglect policies by the facility or at the agency prior to starting work. He/she asked the nurse to write up the incident because the resident was making allegations. He/she thought the nurse was going to report it to the oncoming nurse. Review of Nurse F's written statement, dated 2/23/22, showed CMT I called him/her to come to the resident's room around 9:15 P.M. to 9:30 P.M. He/she tried to get the medication back by explaining they could not leave it in the room. The resident called them some names that were inappropriate. The nurse did not know what kind of medication the resident had, but he/she wanted to take it later because he/she had already taken some at 6:00 P.M. The resident attempted to hit the nurse, swung his/her water pitcher and hit his/her left arm while trying to hit the nurse and CMT. During interviews on 3/4/22 at 11:45 A.M. and on 3/7/22 at 11:10 A.M., Nurse F said CMT I came out of the resident's room and yelled for him/her to come there. He/she said the resident would not take his/her medication and would not give it back. When the nurse entered the room, the resident was very upset. He/she could not say what happened to the resident prior to his/her entering the room. The nurse told the CMT he/she would try and get the medication from the resident. The resident was so angry. He/she asked the resident if he/she could have the medication and the resident refused to give it to him/her. The resident said the CMT tried to take his/her medication from him/her. The resident was not ready to take the medication yet and did not want the CMT to take it. The resident was attempting to stand and was unsteady and the nurse was afraid the resident was going to fall. There was so much going on. The resident was so upset when they first came in the room. He/she swung his/her hand but hit the bedside table and threw the water pitcher at them. The nurse moved the table out of the way so the resident would not harm him/herself. He/she went out and got CNA K to see if he/she could get the resident to calm down. CNA K offered to try and get the medication but CMT I would not allow him/her to take it from the resident. The nurse did not remember who grabbed the resident. They did try to get the pill out of his/her hand by pulling the resident's fingers. They finally gave up when the nurse realized they were not going to get the medication from the resident. He/she never worked with this CMT before. He/she never had a problem with the resident taking medication before. He/she did not report the incident because the resident did not say he/she was abused. He/she reported the incident to the oncoming nurse, Nurse O. He/she stayed at the facility until 1:00 A.M., the next morning to talk to the police and fill out a statement. He/she had not been in-serviced on the abuse/neglect policies and procedures by the agency or the facility. During an interview on 3/7/21 at 9:35 A.M., CNA K said he/she was at the desk that night after dinner. CMT I went in the resident's room first and he/she heard the resident start yelling, Help. Get away from me! Then Nurse F went in and the screaming started again. The nurse came out and got the CNA to try and help calm the resident down. When he/she entered the room, the resident was very upset and crying. He/she said the CMT and nurse grabbed his/her arms and tried to take his/her medication away from him/her. The nurse told the CNA, he/she had told the resident if he/she gave them the medication they would bring it back but the resident said the CMT told him/her, he/she would not bring the medication back so he/she was not going to give it back to them. The nurse said the resident tried to bite them when they reached for the medication and he/she called them inappropriate names. The nurse and the CMT finally gave up and left the room. He/she did not see them hold the resident's arms or wrists while he/she was in the room. CNA K stayed in the room after they left. The resident told the CNA, he/she had never been treated that way before. They had assaulted him/her. They grabbed his/her arms and tried to take his/her medication away from him/her. The CNA did not look for any marks on the resident's arms or hands that night. He/she had never seen the resident act this way or be this upset. Staff should not try to force medication out of a resident's hand. He/she did not report it to anyone because he/she thought the nurse was going to report it. During an interview on 3/7/22 at 9:45 A.M., CNA J said he/she was working at the desk, on the resident's hall the night of the incident between 8:00 P.M. and 9:00 P.M. CMT I went into the resident's room and he/she heard the resident yelling and screaming, Get off me, you are hurting me! Nurse F went into the room and the resident started screaming again. He/she did not know if he/she could go in the room because Nurse F was already in there. The resident sounded fearful and like he/she was in pain. CNA J asked the other CNA if they should do something and he/she told him/her, the nurse was already in the room. He/she probably should have gone and told a nurse from another floor, but did not know what to do. The resident did not usually get agitated or scream at people, so this was concerning. CNA J believed something was going on in the room. He/she asked Nurse F afterwards if he/she should get another nurse as a witness, and the nurse got angry with him/her and said he/she was the nurse. CNA J went into the room around 10:00 P.M., and the resident was still upset. He/she said CMT I and Nurse F restrained him/her by holding his/her arms and tried to take his/her medication away. He/she had red marks on his/her arms and wrists. The resident genuinely sounded scared. The CNA had seen staff leave medication with the resident in the past and did not know why they had to fight with him/her over it this time. The resident told him/her, he/she might call the police and report the incident. The CNA did not report the incident at the time because he/she already tried to get the nurse to report it and was going to talk to administration in the morning. He/she did tell someone at the front desk the police might be coming, as he/she was leaving at 11:00 P.M. Review of the facility's undated contract with Nurse F and CMT I's agency on 3/9/22, showed the following: -The agency is a software company that provides a technology platform for healthcare facilities and self-employed or independent contractor health care providers (professional providers) to find one another for the purposes of engaging in a business to business arrangement whereby the two may contract for services needed by the healthcare client; -Professional providers are independent contractors operating as self-employed individuals who use the agency's platforms and services to offer and provide healthcare services to clients; -The client acknowledges and agrees the agency does not and will not provide professional providers with any tools of the trade or other materials in order for the professional provider to perform the work on a shift; -The client is solely responsible for management of patient care and of the professional provider's provision of healthcare services during a shift with the client; -Professional providers are required to upload to the platforms current copies of the certifications, documents and/or records, and/or otherwise consent to the following actions: Specialty specific testing. The agency is not responsible for the selection of content to be included in any testing or assessment of a professional provider, whether for professional competency or otherwise; -Agency is not responsible for ensuring the accuracy, currency or completeness of any documentation or information that a professional provider uploads to the platform or otherwise provides to the agency. During an interview on 3/9/22 at 10:30 A.M., the regional vice president of the staffing agency said they utilize computerized competency assessments which are submitted online by potential employees. There are generalized abuse/neglect categories in these assessments, but these are not required. It is up to the facility to provide specific training on their policies and procedures. The agency does not provided mandated, specific abuse and neglect training for their employees. During an interview on 3/8/22 at 9:50 A.M., the ADON said full time staff are in-serviced on abuse/neglect at orientation and annually. This is usually done by an educator but they do not have one right now, so it is bouncing around between herself and the DON and there is no procedure for ensuring staff receive the training. Agency staff are given information about the policies when they show up to work, but they do not sign off on anything. There is not a designated person who goes over the policies with them. It is usually the person at the desk is supposed to give them the policies. The ADON could see how this system could be a problem. During an interview on 3/11/22 at 3:55 P.M., the corporate nurse said they keep policies and procedures on abuse/neglect in binders at the front desk and nurse's stations and there is always information available for agency staff, although they do not require documentation of signatures showing staff received or read the policies and procedures. During an interview on 3/16/22 at 3:20 P.M., the administrator said she would have expected staff to report to the charge nurse or DON if there was an allegation of abuse. Abuse is supposed to be reported within two hours. She did not know the agency was not training their staff on abuse/neglect. All staff should be knowledgeable of the abuse/neglect policies before working. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on 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. Note: 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 be taken to address Class I violation(s). MO 612 MO 668

Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #6), admitted on [DATE], for a respite stay (a planned short term stay). On 6/1/21 at 6:40 P.M., the resident was observed pushing on, opening and sounding an alarm on a delayed egress emergency exit door (to open the door, 15 seconds of pressure is required on the door handle/bar. Once opened, an alarm sounds alerting staff). After the resident was redirected away from the delayed egress emergency exit door, facility staff failed to follow their Elopement, Residents at Risk policy by failing to apply a department alert bracelet on the resident (an electronic device most often worn on the wrist or ankle that sets off an alarm on two of the 12 facility exit doors equipped only with the department bracelet alarm system. The other 10 exit doors had the delayed egress system only), update the resident's care plan, and document the incident on the facility 24 hour report. On 6/7/21 at approximately 4:30 P.M., police notified the facility a passerby contacted them and reported the resident was in front of a restaurant located 0.7 miles from the facility. The restaurant was located down and across a busy road. Facility staff were unaware the resident had left the facility. Prior to 6/7/21, the facility had identified four residents as being at risk for elopement/wandering, all of whom were sampled and wore department alert bracelets. Resident #6 was not identified as one of those residents at risk to elope/wander until after he/she was returned to the facility by police on the evening of 6/7/21. The census was 95. The administrator was notified on 6/11/21 at 2:30 P.M., of an immediate jeopardy (IJ) which began on 6/7/21. The IJ was removed on 6/9/21 as confirmed by surveyor onsite verification. Review of the facility Elopement, Residents at Risk policy, revised on 2013, showed: Purpose: -To prevent accidents, falls or injuries related to unsafe wandering or elopement. Wandering is defined as random or repetitive locomotion or movement that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or may be non-goal-directed or aimless. Unsafe wandering may occur when the resident enters an area that is physically hazardous or that contains potential safety hazards. Elopement occurs when a resident leaves the premises without authorization and/or any supervision to do so; Procedure: -Prior to admission, residents at risk will be assessed for a history of wandering, impaired cognition to place and the physical ability to leave the building. This information will be noted on the admission inquiry sheet; -On the day of admission, the charge nurse will assess the resident for elopement potential (History of wandering, impaired cognition to place, and mobility status.) This information will be documented in the resident's record on the Elopement Risk Assessment Form; -Residents identified as being an elopement risk will receive a department alert bracelet. A notation will be made on the resident's certified nursing assistant (CNA) assignment sheet to inform the care givers of the elopement risk. Social Services will also perform a BIMS (Brief Interview for Mental Status, an assessment that uses a score from 00 - 15 to determine a resident's cognitive status) or other baseline cognitive screening on any resident who is identified as being an elopement risk. The resident's name and photo will be placed at the front desk and/or nursing stations; -The risk of elopement will be indicated on the resident's Care Plan along with the interventions in place to minimize risk factors and promote safety. The risk of elopement will be re-evaluated quarterly or more often if behavior indicates the necessity -If a resident develops unsafe wandering behavior after admission to the facility the charge nurse will initiate risk precautions, document the resident's behavior and communicate the resident's identified behavior on the 24 hour report. The Care Plan will be updated appropriately, and the departure alert bracelet will be placed on the resident; -Residents with repeated attempts to leave the premises unsafely or without adequate supervision will be reported to the DON/Designee. The DON/Designee will contact the attending physician or resident's designee, and/or interdisciplinary team members for other interventions to minimize risk factors and review other options/alternatives for safety; -The facility designee will randomly test the door departure alarms and departure alert bracelets in use every week. Results of the tests will be documented; -Designated nursing staff will perform daily checks on departure alert bracelets to ensure that the bracelet is in place and functioning properly. Results will be documented on the medication administration record (MAR) or treatment administration record (TAR); -Facility staff will be inserviced on the Elopement Policy during orientation, at annual inservices and as necessary. Review of Resident #6's pre-admission medical history, faxed to the facility on [DATE] at 11:47 A.M., and used by the facility to determine if the resident qualified for admission and/or the resident's medical needs required post-admission, showed: -Planned admission: 5/31/21 with a discharge on 6/8/21; Medical Records dated 3/24/21: -Patient's spouse is here today, reports worsening short term memory, resident doesn't come back to normal self like he/she used to. Trialed other medications for dementia that causes hallucinations. Dementia is rapidly progressing; -Medications include: [MEDICATION(S)] (can be used to treat Alzheimer's disease, to improve mental function) for memory and [MEDICATION(S)] (antidepressant) for mood; -Patient's spouse feels the patient's short term memory is becoming worse and has worsened since COVID; -Dizziness, [CONDITION(S)], unsteady when walking and dementia/debility; -Patient has stopped driving and has home health aide several times a week; Screening Results 3/24/21: -Dressing, grooming, bathing: Needs some help from another person; -Transferring: Needs somebody to be there for guidance, but can move in and out of bed or chair; -Walking: Walks without help of any kind; -Behavior: Needs and receives regular staff intervention in the form of redirection because the person has episodes of disorientation, hallucinates, wanders, is withdrawn or exhibits similar behaviors. Person may be resistive, but responds to redirection; -Communication: Sometimes understood; -Cognitive skill for daily decision making: Severely impaired, never/rarely made decisions; -Short term memory recall: Memory problem; Medical Records dated 3/29/21: -Patient lives at home and requires substantial assistance in activities of daily living (ADL) in order to reside safely in the home; -Dependent for: Using telephone, driving, shopping, preparing meals, housework, laundry, taking medication and managing finances; Medical Records dated 4/21/21: -Problem/Diagnoses list that included: Dementia, dizziness, unsteady when walking, and debility; -Diagnoses with chronic (long [MEDICATION(S)]) disabling illness/condition: Dementia; -Medical condition considered stable; -Patient reports his/her main problems is his/her poor memory, confusion and frustration as he/she cannot figure out how to do things, cannot use TV remote. He/she sees bats when he/she sees leaves and his/her watch cracking when he/she is looking at the watch. During a telephone interview on 6/10/21 at 8:25 A.M., the resident's spouse said the facility called him/her prior to the resident's admission. The facility asked if the resident had a history of wandering at home and he/she said no. The resident went somewhere else for a respite stay a few months ago and did not wander there. He/she did inform the facility the resident was confused and could walk independently. The facility did not tell him/her about department alert bracelets. Had they asked, he/she would have had no problem with the resident wearing one since the resident is confused and can walk independently. During a telephone interview on 6/10/21 at 12:36 P.M., the resident's physician (the physician that provides care while the resident is at home) said she had been seeing the resident for quite some time prior to his/her respite admission to the facility. She was very familiar with the resident's history. The resident has a diagnosis of dementia that is getting worse and a history of hallucinations. The resident's cognition is rapidly deteriorating. If the facility had a locked unit for dementia residents, the resident would have been a candidate. If they had department alert bracelets, the resident would have been a candidate for that as well. Her primary concern about the resident being outside unsupervised would be getting lost and not being able to find his/her way back. She would think the facility would have tested the resident's cognition on day one, whether with a BIMS or some other type of cognitive testing. Review of the resident's Elopement Risk Assessment, with a completed date of 5/31/21 at 12:50 P.M., showed: Cognitive Patterns: -Modified independence - some difficulty in new situations only Mobility: -Walk in room and locomotion on unit: Independent - no help or staff oversight at any time; -Has the resident exhibited any of the following behaviors? Responses included: Elopement attempts or elopement successes in the past: None of the above was checked; -Has the resident exhibited or experienced any of the following?: Recent move to facility was checked; -Does resident have any of the following conditions: Dementia was checked, depression was not checked; Interventions: -Indicate measures taken: The only item checked was activities. Door alarm band (department alert bracelet) was not checked; Evaluation: -Based on assessment, does resident present an elopement risk?: No; Plan of Care: -Indicate care plan action taken: Initiate plan of care was checked. Review of the resident's medical record from 5/31/21 until 6/7/21, showed no completed BIMS. Review of the resident's admission physician's order sheet, showed: -5/31/21: [MEDICATION(S)] 15 milligrams (mg) daily; -5/31/21: [MEDICATION(S)] 75 mg daily; -5/31/21: Monitor daily for any other symptoms outside of the resident's normal baseline. Symptoms to be monitored included: Acute mental status changes and exacerbation of chronic conditions. Review of the resident's undated admission care plan, showed: -6/1/21 Daily Antidepressants: Monitor resident's mood and response to medication. Monitor for effectiveness of the medication; -6/1/21 Falls: Ask resident if assistance for toileting is needed. Keep frequently used items with in reach. Keep routines and care givers the same as much as possible. Observe for unsteady gait or weakness. Place call light in reach and assess the residents ability to use call light; -6/1/21 ADL Functional/Rehabilitation Potential: Respite stay from 5/31/21 to 6/8/21. Normally lives at home with spouse. Needs assistance with medication administration. Independent for activities of daily living (ADLs) except bathing for which supervision is required. May not remember everyone's names. Independent for transfers and toileting. Review of the resident's progress note's, showed: -5/31/21 at 12:52 P.M.: Resident admitted for respite stay through 6/8/21. Lives at home with spouse who provided daily care for the resident. Resident in pleasant mood and able to answer questions mostly appropriately. Has history of dementia. Walks with walker. Offered resident to go to the dining room for meals, but he/she requested to stay in his/her room. Spouse states resident does not always comprehend and is very structured due to time spent in the military. Resident can fool you by hiding his/her dementia; -6/1/21 at 8:55 A.M. (an entry by Nurse D): Monitoring related to new admit status. Resident in room sitting on side of bed watching TV, alert and oriented x 4 (person, place, time and situation) with this assessment. Up ad lib (independently) using wheeled walker in room without difficulty. Appears to be adjusting to new environment without difficulty; -6/1/21 at 6:40 P.M. and documented by Nurse B: Resident went out the door at the end of the hallway (the resident's room was at the end of the hall next to that door). Still adjusting to his/her surroundings. Confused as to where he/she is. He/she was looking for his/her dogs. Resident at the nurse's station so he/she can be monitored. Reminded him/her that his/her spouse will pick him/her up on Monday. Nurse B did not document if he/she placed a department alert bracelet on the resident, updated the care plan or notified the resident's physician, DON, Assistant Director of Nurses (ADON) or a Nurse Manager on duty; -6/2/21 at 4:04 P.M. (first entry since 6/1/21 at 6:40 P.M. and entered by Nurse D): Continue monitoring related to new admit status. Alert and oriented x 4. No attempts at exiting doors this A.M.; -6/3/21 at 8:19 P.M.: Resident prefers to eat in his/her room. No changes at this time; -6/7/21 at 6:49 P.M. (the first entry since 6/3/21 at 8:19 P.M. and entered by Nurse B): Resident returned to facility and was placed in administrator's office. Wander guard (department alert bracelet) was placed on resident's right ankle. Body audit was done. All skin was intact. Resident was placed at nurse's station so he/she could be monitored. 15 minute checks are being done. Physician notified of elopement. No further orders at this time; -6/8/21 at 8:57 A.M.: Resident will be picked up between 10:30 A.M. and 11:00 A.M. this morning to be discharged from our facility ending his/her respite. Review of a facility self-report sent to the Department of Health and Senior Services, dated 6/7/21 at 6:03 P.M. and completed by the facility administrator, showed the resident was admitted on [DATE], for respite care. An elopement assessment was done upon admission and he/she was not noted to be an elopement risk. Spouse stated the resident does not try to elope and has not exhibited that behavior. Received a call at approximately 4:50 P.M., from police that they had the resident at a local restaurant. The resident was returned to the facility by the police at 5:00 P.M. Police noted they had received a call at approximately 4:30 P.M., noting that a man (the resident) was at the restaurant's property pulling flowers out of a flower bed. Body assessment was completed with no injuries noted. Resident's spouse and physician notified. Review of the resident's care plan, showed the following problem was added on 6/8/21: 6/7/21 Wandering/Elopement Risk: At risk for unsafe wandering/elopement due to dementia. History of elopement. Will wander in safe boundaries throughout facility without causing self harm. Check for proper functioning and placement of wander guard daily on the night shift. Notify family and physician if elopement occurs. Monitor resident when wondering throughout the facility and redirect the resident if he/she enters unsafe boundaries. During an interview on 6/8/21 at 8:40 A.M., the resident sat fully dressed in a recliner in his/her room wearing a wrist watch on his/her wrist and a department alert bracelet on his/her right ankle. He/she was alert, friendly and spoke with clear speech. He/she did not know the name of where he/she was staying, or the current month/day/year. When asked what time it was, he/she stared at the wall, but there was no clock on the wall. The surveyor pointed to the resident's wrist watch that showed 9:30 A.M. The resident looked at the wrist watch and said it was 10:15. The resident correctly said the nearby community where he/she lived with his/her spouse. He/she said he/she had a dog, but could not recall the dog's name for a minute before correctly saying the name of his/her dog. The resident said he/she was up and dressed today because he/she was going to work. The resident was asked if he/she remembered leaving yesterday and where he/she went. He/she said he/she left through the big glass doors in the big gymnasium. He/she recalled talking to the police when he/she left, but said that was the day before yesterday. Someone said he/she was wrecking their flowers. He/she was with his/her spouse and his/her brother at the time. The police came and asked them questions and gave him/her a ride here. During a telephone interview on 6/10/21 at 8:25 A.M., the resident's spouse said the resident's brother passed away about [AGE] years ago. When the police contacted him/her on 6/7/21, they stated the resident had told them he/she was with his/her brother and his/her brother-in-law. The resident's brother-in-law had also passed away. The resident has hallucinations sometimes. He/she will see tree leaves and believe they are bats. He/she also looked at his/her watch and thought it was breaking apart as he/she looked at it. He/she is reclusive, and suffers from [CONDITION(S)]. He/she was not informed the resident opened the emergency exit door on 6/1/21, until he/she called the facility for an update on the resident on 6/4/21. During an interview on 6/8/21 at 8:50 A.M., CNA C said he/she had taken care of the resident for the past week. The resident was independent for ADLs, calm and watched TV. The only thing he/she has had to do for the resident is get him/her coffee. Yesterday around 9:30 A.M. or 10:00 A.M., the resident left his/her room and walked up and down the hall where his/her room is located. That was the first time he/she had seen the resident leave his/her room. He/she heard the resident left the facility yesterday, but did not know the resident had opened the delayed egress emergency exit door next to his/her room on 6/1/2. He/she did not know the resident had a department alert bracelet on now. Review of the resident's BIMS assessment, completed by the Social Service Director on 6/8/21 at 8:39 A.M., showed a score of 05. A score of 00 - 07 indicates severe cognitive impairment. During an interview on 6/8/21 at 9:10 A.M., the administrator said the facility was still investigating the resident's elopement that occurred on 6/7/21. On 6/7/21, Restorative Aide (RT) A was the last staff member to see the resident around 2:30 P.M. on 6/7/21. They believed the resident walked out the front lobby door by the main dining room, and directly in front of the receptionist desk between 2:45 P.M. and 3:00 P.M. The front lobby door is used by the general public to enter and exit. It opens automatically when a person approaches. It is equipped with a department alert bracelet alarm system only. Staff contacted the resident's spouse prior to admission and he/she said the resident had no history of wandering. The resident was assessed for elopement risk upon admission and was found not to be at risk to wander so the resident was not wearing a department alert bracelet. On 6/7/21 around 4:30 P.M., someone from the community called the police about a person pulling flowers up from a flower bed. The resident gave the police his/her wallet and the police were able to contact the resident's spouse who informed them the resident was staying at the facility. The police brought the resident back to the facility. The resident was assessed when he/she returned and had no injuries. A department alert bracelet was applied to the resident's ankle as well. During an interview on 6/8/21 at 12:10 P.M., Nurse D said he/she was familiar with the resident. The resident needs cues for direction, but can dress toilet and independently. For the most part the resident stays in his/her room watching TV. His/her orientation fluctuates. On his/her second day there, he/she was alert and oriented x 4. Today he/she is alert and oriented x 2. It was reported to him/her the resident tried to get out of the delayed egress emergency exit door on his/her second day there, but he/she was not sure if the resident set the door alarm off or not. Yesterday at 10:00 A.M., the resident came to the nurse's station to tell him/her a little lady kept going past his/her room. Around 1:00 P.M., he/she saw the resident in the hall and he/she was directed back to his/her room by RT A. During an interview on 6/8/21 at 2:50 P.M., CNA E said the resident pretty much does everything for him/herself. He/she walks steady with no assistive devices. He/she is a little confused. The last time he/she spoke to the resident, prior to 6/7/21, he/she was talking to people who were not there. He/she had never seen the resident out of his/her room. He/she liked to watch TV and drink coffee. He/she did not know the resident opened the exit door on 6/1/21. During an interview on 6/8/21 at 3:40 P.M., CNA F said he/she worked yesterday on the evening shift which starts at 3:00 P.M. He/she had not been assigned to the resident since his/her admission. He/she did not see the resident at all yesterday. He/she had seen the resident wander the halls prior to yesterday. He/she would walk, then sit down, get up and walk again. He/she did not know the resident opened the delayed egress emergency exit door on 6/1/21, and felt that should have been something he/she should have known. During an interview on 6/8/21 at 4:30 P.M., the corporate nurse and administrator said they reviewed the resident's medical record after the resident was returned to the facility by the police on 6/7/21. That was when they read, for the first time, the progress note documented by Nurse B on 6/1/21 at 6:40 P.M., regarding the resident opening the delayed egress emergency exit door. They spoke to Nurse B after reading the progress note. Nurse B told them the resident did open the delayed egress emergency exit door, but he/she did not think the resident was exit seeking, and would not have walked out of the facility. Based on their interview with Nurse B, they did not think there would have been a reason on 6/1/21, to have reassessed the resident and apply a department alert bracelet. They did review the Elopement, Residents at Risk policy with Nurse B at that time. The facility keeps spare department alert bracelets at each nurse's station. During an interview on 6/8/21 at 4:40 P.M., CNA G said he/she had taken care of the resident for a couple of hours last Saturday. He/she went into the resident's room to speak to the resident. The resident did have some confusion. The resident asked him/her what is this place he/she was at? He/she was unaware the resident opened the delayed egress emergency exit door on 6/1/21. During an interview on 6/8/21 at 4:47 P.M., CNA H said he/she works evening shifts, worked on the evening of 6/1/21 and 6/7/21, and was assigned to care for the resident both days. Usually, the resident mostly stayed in his/her room and never hardly ever came out. The resident is able to walk independently. One day he/she entered the resident's room and the resident had the bed table on it's side. His/her hand was closed and making twisting movements like he/she was holding a screwdriver. The resident said he/she was fixing the bed table. On 6/1/21, he/she was in the hall and saw the resident pushing on the delayed egress emergency door located just outside the resident's room. By the time he/she got to the resident, the door had opened and the alarm sounded. Nurse B was not with him/her at that time. The resident was not able to exit the facility. He/she asked the resident where he/she was going and the resident stated to get his/her dogs. The resident was easy to redirect away from the door. Nurse B came down the hall after the door alarm sounded. They both escorted the resident to the nurse's station. He/she thought the resident should have been moved to a room farther away from the delayed egress emergency exit door since it was right outside the resident's room at the end of the hall, but did not discuss that with Nurse B. On 6/7/21, he/she arrived to work at 3:00 P.M. and did not see the resident until the resident was brought back to the facility by the police. During an interview on 6/9/21 at 3:00 P.M., RT A said he/she had taken care of the resident a couple of times prior to 6/7/21. He/she really did not know too much about the resident's cognition because he/she pretty much took care of himself/herself. He/she was unaware the resident opened the delayed egress emergency exit door on 6/1/21. On 6/7/21, he/she saw the resident at the nurse's station between 2:30 P.M. and 3:00 P.M., somewhere in that time range. The resident inquired something about his/her spouse and RT A told him/her your spouse is not here right now and he/she said ok. Someone said the resident wanted to go to the dining room and he/she directed the resident by pointing down the hall in the direction of the dining room/front lobby. There was an activity in progress and he/she thought the resident was going to go to the activity. That was the last time he/she saw the resident on 6/7/21. During an interview on 6/9/21 at 2:32 P.M., Nurse B said he/she thinks he/she was inserviced to the facility Elopement, Residents at Risk policy during his/her initial orientation. On 6/1/21, he/she responded to the resident opening the delayed egress emergency exit door. The resident was looking for his/her dogs. He/she did not follow the facility policy, because he/she did not think the resident was going to leave the building even if he/she and CNA H had not been there. He/she was 100% certain the resident would not have left the building on 6/1/21, because he/she was just looking for his/her dogs. Upon the resident's return to the facility on [DATE], the resident said he/she had dropped his/her spouse and a friend off and needed to pick them up. During an interview on 6/9/21 at 9:20 A.M., the ADON said the social service director completed the resident's BIMS on 6/8/21, the day of his/her discharge. The resident scored a 05. Typically the BIMS assessments are completed on day seven post-admission to coincide with the admission Minimum Data Set (a federally mandated assessment completed by facility staff). The BIMS can be completed earlier than day seven. Had the BIMS been completed for the resident on day one or day two, a score of 05 would have prompted her to look closer for cognitive problems. During an interview on 6/14/21 at 12:47 P.M., the social service director said she is responsible for completing residents BIMS. She was not aware of the resident opening the emergency delayed egress exit door on 6/1/21. No one asked her to complete a BIMS on the resident prior to 6/8/21. During an interview on 6/9/21 at 1:20 P.M., the DON said the facility contacted the resident's spouse who said the resident did not wander. She was not aware the facility was not completing the BIMS assessment upon admission. The BIMS is used to help facility staff determine what a resident is able to do or not cognitively. Had they completed a BIMS on admission and the resident scored a 05, she would have had staff place a department alert bracelet on the resident that day. She was not aware the resident opened the delayed egress emergency exit door on 6/1/21. Nurse B did not contact her or document that information on the 24 hour report form. She reviews the 24 hour report form every morning. Had she been made aware she would have instructed Nurse B to put a department alert bracelet on the resident on 6/1/21. Anytime a resident sets off an alarm, she wants staff to document it. If it is a new behavior for the resident staff should report it to her. During a telephone interview on 6/11/21 at 8:20 A.M., the facility medical director said he spoke to the facility regarding the elopement. The facility said based on the spouse's statement the resident had no previous wandering and the elopement risk assessment completed upon admission, he agreed with the facility as far as the resident not needing a BIMS assessment and a department alert bracelet upon admission even with a diagnosis of dementia and the ability to walk independently. On 6/1/21, when the resident opened the delayed egress emergency exit door, that should have prompted the facility to complete a new assessment including a BIMS along with a psychological assessment to determine other potential factors such as depression. The results of that assessment may or may not have warranted the placement of a department alert bracelet, but the assessment should have been completed to make that determination. Nurse B should have notified management on 6/1/21, when that occurred. Regarding the BIMS completed on 6/8/21, with a score of 05, he said he was familiar with the BIMS scoring and knew a 05 indicated severe cognitive impairment. Note: At the time of the investigation/ abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on 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. Note: 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 be taken to address Class I violation(s). MO 386

Based on interview and record review, the facility failed to document a description of a pressure ulcer on the coccyx (tail bone area) on the date it was first identified and begin a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident #3). The census was 90. Review of the facility Wound Care Protocol, revised on 8/2018, showed: Goals of Assessment: -Provide uniform description; -Facilitate communications among staff; -Adequate monitoring of progress or deterioration; -Assess the entire person, not just the ulcer; -Assess for pain and implement interventions to relieve; How to Assess/Document: -Initially assess the ulcer(s) for location, stage, [MEDICATION(S)] tract, undermining, tunneling, exudate (drainage), necrotic tissue, the presence or absence of granulation (pink or red tissue with shiny, moist, granular appearance) and epithelialization (new skin growing in superficial ulcer. It can be light pink and shiny, even in persons with darkly pigmented skin.); -Documentation of the initial and weekly assessment findings should be noted in the wound management section of the electronic medical record or on the Weekly Wound Assessment Form; Other Considerations: -Identify pre-existing signs (such as purple or very dark area that is surrounded by profound redness, [CONDITION(S)] (swelling), or induration (an area of hardness in the skin), suggesting that deep tissue injury has already occurred and additional deep tissue loss may occur. Review of Resident #3's Admission Observation form, dated 2/6/21 at 3:40 P.M., showed: Skin: -Skin temperature: Warm; -Skin moisture: Dry; -Skin color: Normal color; -Petechiae present (small red or purple spots): No; -Skin turgor (the elasticity of the skin, used to determine dehydration or fluid loss in the body): Normal; -Alterations in skin: No; -Comments: 5 centimeter (cm) scab on right knee - healing, 3 cm scab on left knee - healing. Review of the resident's Braden Scale (an assessment tool used to determine a residents risk for developing pressure ulcers), dated 2/6/21 at 4:17 P.M., showed a score of 17. A score of 15-18 is considered at risk. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/9/12, showed: -admitted [DATE]; -admitted from an acute hospital; -Hearing/vision adequate; -Speech clarity - distinct intelligible words; -Ability to express ideas and wants: Understood; -Ability to understand verbal content: Understands; -Brief Interview for Mental Status (cognitive assessment) score of 15, indicating cognition is intact; -Hallucinations and delusions: Not indicated; -Physical, verbal or other behavioral symptoms: Not indicated; -Does not reject care; -Extensive assistance of one person required for bed mobility, transfers, walk in room, dressing, toilet use, personal hygiene and bathing; -Eating, how resident eats and drinks: Independent, setup help only; -Mobility devices: Walker and wheelchair; -Always continent of urine; -Occasionally incontinent of bowel; -Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Risk of pressure ulcers: Yes; -Unhealed pressure ulcers: No; -Special treatments and programs: Oxygen therapy. Review of the resident's care plan dated 2/24/21, showed: Goal: -Skin will remain intact with no signs and symptoms of breakdown through next review; Problem: -At risk for developing pressure ulcers related to immobility. Open area on coccyx and left and right buttock; Interventions 2/16/21: -Assess skin for any redness, bruises, and open areas and report to nurse; -Barrier cream (skin protectant) as ordered; -Encourage and monitor nutritional and fluid intake; -Pressure reducing/relieving devices to bed and/or chair; -Provide a Braden Scale; -Report red or open areas to physician for treatment; -Skin checks during activity of daily living care and on shower days. Shower sheet report to be turned into the nurse with any areas of concern noted. Nurse to assess and report to physician if needed; Interventions 2/24/21: -Position in side lying position when in bed; -Tends to be non-compliant with turning to assist with pressure reduction despite continued education; -Instruct/remind to shift weight frequently when up in wheelchair and in bed; -Keep off affected area if possible; -Monitor effectiveness of treatment and notify physician if order needs changed; -Treatment to be completed as ordered; -Weekly body audits by nursing. Review of Nurse Practitioner A's progress note, dated 2/18/21 at 8:30 A.M., showed: Objective: -Skin: Open pressure ulcer to coccyx; Assessment/Plan: -New wound to coccyx, [MEDICATION(S)] (an ointment used to protect skin from wetness, urine, or stools) every shift; -The progress note did not show a description of the pressure ulcer (stage, appearance, measurement, etc.). Review of the resident's treatment administration record (TAR), dated 2/6/21 thru 3/6/21, showed: 2/18/21 through 2/20/21: Coccyx/sacrum: Calmeseptine ointment every shift. Staff initialed the treatment was administered was as ordered. Review of the resident's TAR and medical record, showed no description of the pressure ulcer on the coccyx from 2/18/21 thru 2/19/21. Review of the resident's Bath Skin Report forms (skin checks as defined on the care plan), showed: -No report forms from 2/7/21 thru 2/18/21; -2/19/21: The anatomical form on the bath sheet had the buttocks circled and cream applied documented. Review of the facility Wound Management Detail Report, showed: Coccyx: -Date/time observed: 2/20/21; -Measurement: 1.0 cm by 1.0 cm by unable to determine; -Exudate amount: Light; -Exudate type: seropurulent (yellow or tan, cloudy and thick); -Stage: Unstageable (known but not stageable due to coverage of wound bed by slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and/or eschar (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder that surrounding skin)); -Tissue type: Slough; -Percent of wound covered by slough tissue: 100%; -Surrounding skin: [CONDITION(S)] (redness); Right Buttock: -Date/time observed: 2/20/21; -Measurement: 4.0 cm by 3.0 cm by unable to determine; -Exudate amount: Light; -Exudate color and consistency: Seropurulent; -Percent of wound covered by granulation tissue: 75%; -Percent of wound covered by slough tissue: 25%; -Stage: Not listed; -Surrounding skin: [CONDITION(S)]; Left Buttock: -Date and time observed: 2/20/21; -Measurement: 4.0 cm by 3.0 cm by unable to determine; -Exudate amount: Light; -Exudate color and consistency: Seropurulent; -Tissue type: Slough; -Percent of wound covered by granulation tissue: 75%; -Percent of wound covered by slough tissue: 25%; -Surrounding skin: [CONDITION(S)]. Review of the resident's TAR, dated 2/6/21 thru 3/6/21, showed: 2/20/21 thru 2/22/21: -Coccyx: 1.0 cm by 1.0 cm; -Left Buttock: 4.0 cm by 3.0 cm; -Right buttock: 4.0 cm by 3.0 cm; -Santyl (an enzymatic debridement ointment) and dry dressing daily. Review of the resident's medical record, showed a wound care company began to assess and treat the resident's pressure ulcers on the coccyx, left and right buttock, and left heel on a weekly basis on 3/2/21. Review of the resident's Bath Skin Report forms, showed: -No report forms from 2/19/21 thru 3/10/21; -3/11/21: The anatomical figure had the buttocks circled and said his/her bottom is hurting, very sore documented; -No forms completed after 3/11/21. Review of the wound care company report, dated 3/19/21, showed: Right Hip (the pressure ulcer is identified on the facility Wound Management Detail Report, dated 3/19/21, as the left hip): -Type: Pressure Ulcer/Injury; -Stage Unstageable; -Wound bed description: 80% granulation and 20% necrotic (slough or eschar); -Measurement: 1.0 cm by 0.6 cm by unable to determine; -Exudate: Small; -Color: Sero-sanguineous (contains both blood and the liquid part of serum); -Plan: Cleanse with normal saline (water/sodium solution), apply Santyl and cover with dry dressing daily and as necessary. Review of the resident's TAR, dated 3/19/21 thru 3/22/21, showed no treatment order for the unstageable pressure ulcer for the right or left hip. Review of the resident's nurse's note's, showed: -3/22/21 at 1:20 P.M.: 911 notified and resident sent to hospital; -3/22/21 at 1:30 P.M.: Resident's representative notified of change in condition and transfer to hospital (the resident did not return to the facility). During a telephone interview on 4/15/21 at 1:30 P.M., the administrator said residents receive two to three showers a week. Certified Nursing Assistants are supposed to complete a bath skin report each time. They could not find any more bath skin reports other than those dated 2/19/21 and 3/11/21. During a telephone interview on 11/27/21 at 2:10 P.M., the Corporate Regional Nurse said they could not find documentation describing the area on the resident's coccyx on 2/18/21. She expects staff to document a description in the progress notes or on the TAR when a pressure ulcer or wound is first identified. They could not find any documentation on the TAR regarding the right/left hip after it was identified on 3/19/21. There is no documentation to show the treatment was completed on 3/20/21 or 3/21/21, prior to being sent to the hospital on 3/22/21. MO 256