Every finding on record at Eastview Manor Care Center

Based on interview and record review, the facility failed to protect one resident (Resident #1) from physical abuse when Certified Nurse Aide (CNA) A pushed into the resident's chest using his/her chest and then grabbed the resident by both arms and pushed the resident to a seated position in a chair and then used his/her hands to hold the resident in place until other staff intervened. Additionally, the facility failed to keep one resident (Resident #4) in the building free from verbal threats of abuse from Resident #1, when Resident #1 threatened to kill Resident #4 with a broken hanger. This affected two of six sampled residents, the facility census was 84.On 07/29/26 , the Administrator was notified of the past noncompliance incident which occurred on 07/25/26, An investigation immediately began and corrective actions were implemented to include: Staff education completed 07/25/26 including: Abuse and Neglect Policy, Reporting Abuse to the Administrator, Burn Out Recognition and Prevention. In addition, Resident #1 received additional therapy sessions and a medication review with medication adjustment. The noncompliance was corrected on 07/25/26. Review of the facility policy, Abuse and Neglect, dated June 2024, showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish;-Abuse can include staff to resident or certain resident to resident altercations;-Verbal abuse was defined as the use of oral, written or gestured language that included disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend or disability;-Examples of verbal abuse included but were not limited to harassment of a resident or staff member, mocking, insulting, yelling at a resident, threatening with or without the intent to intimidate;-Physical abuse could include, but was not limited to hitting, slapping, biting, or handling a resident with any more force than is reasonable for a resident's proper control, treatment or management;-Mental abuse could include but was not limited to humiliation, harassment, verbal or nonverbal conduct that had the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation;-Staff were trained upon hiring and had received ongoing training on issues related to abuse prevention practices such as how to assess, prevent and manage aggressive, violent and/or catastrophic reactions of residents in a way that would protect both residents and staff as well as how to recognize and deal with burnout, frustration and stress that may lead to inappropriate responses or abusive reactions to residents;-Residents who mistreat another resident would be removed from contact with the resident;-The accused resident's condition would be immediately evaluated to determine the most suitable therapy, care approach and placement considering his/her safety as well as the safety of the other residents and staff in the facility. Review of the facility policy titled, Behavioral Emergency, dated September 2025, showed:-The use of physical holds poses an inherent risk to the physical safety and the psychological wellbeing of residents and staff during crisis events;-Non-physical interventions, starting with de-escalation techniques were the first choice as an intervention;-The use of physical holds was seen as a safety intervention of last resort rather than a treatment intervention and its use should be a crisis event;-Steps for crisis intervention could include assessment by nursing staff and initiation of monitoring of the resident, assessment of the resident and continued needs to ensure placement at facility remains appropriate, physician/psychiatrist or designee notified to determine if the resident required additional hospitalization, licensed nurse would document the behavior in the medical record. Review of facility training, Nonviolent Crisis Intervention, by the Crisis Prevention Institute (CPI), dated 2023, showed that in response to a resident who was striking at staff, staff should block the strike and move to a place of safety and that holding was defined as a restrictive safety intervention necessary to restrict a person's range of movement to prevent the infliction of harm to self or others. 1.Review of Resident #1's Comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by facility staff) dated 07/05/26, showed:-The resident had no cognitive impairment;-He/She displayed no signs of delusions (misconceptions or beliefs that are firmly held, contrary to reality);-He/She had not had any physical behavioral symptoms directed toward others (hitting, scratching, grabbing);-He/She had not had any verbal behavioral symptoms directed towards others (threatening, screaming or cursing at others);-Diagnoses included: Psychotic disorder, schizophrenia and post-traumatic stress disorder (PTSD). Review of the resident's care plan, dated 06/24/26, showed:-He/She smoked and required supervision while smoking;-He/She had behaviors including aggression and breaking items;-He/She had a history of delusional thoughts and disorganized thinking, can be verbally aggressive, threatened to light things on fire and elopement from a facility;-He/She had a history of PTSD without any known triggers;-He/She had a history of behavioral challenges that required protective oversight in a secure setting, behaviors included threats of physical abuse, verbal abuse, refusal of care and harm to facility staff member;-He/She had schizophrenia and staff were to avoid arguing with the resident or getting defensive, staff were to respect personal space of the resident and notify the charge nurse on duty if the resident was observed with increased signs or symptoms of schizophrenia such as hallucinations, delusions, irritability, talking to himself/herself, anxiety and aggression;-He/She had the potential to be verbally aggressive related to mental illness and utilized cigarettes as a coping mechanism;-When he/she became agitated, staff were supposed to intervene before agitation escalated, guide resident away from source of distress, engage calmly in conversation, if his/her response was aggressive, staff were supposed to walk calmly away and approach later;-He/She was physically aggressive on 07/25/26 and received new medication orders, was offered an emergent therapy session, pain medication and to verbalize feelings and frustrations to staff at the time of the incident. Review of the facility abuse investigation, dated 07/26/26, showed:-It was reported to the facility administrator on 07/25/26, the resident had a physical and verbal altercation with staff members;-An investigation was done, and the facility determined the resident had been involved in a verbal and physical altercation with three staff members and no one had obtained any injuries;-As a result of the investigation, there was immediate abuse and neglect education provided to staff, increased visits from the social services designee was initiated for the resident to monitor for signs and symptoms of fearfulness, as well as a referral placed for therapy services and the three employees involved in the incident were suspended and ultimately terminated;-A witness statement written by Health Aid A (HA) the resident had complained that someone had come into his/her room overnight and stabbed him/her in the leg, that around lunch time the resident had a make shift weapon and attempted to attack another resident with the weapon, HA A and Certified Nurse Aid A (CNA) took the weapon and used CPI to put resident in a chair to calm him/her;-Witness statement written by CNA A that a resident reported to him/her that Resident #1 had a weapon and that he/she had stated that he/she was going to bite other residents, Resident #1 had been arguing with HA A and the nurse on duty, CNA A went to assist by walking the resident to his/her room, and before they were able to exit, the resident swung the makeshift weapon at a resident, HA A was able to remove the weapon, then CNA A assisted the resident to a chair, and later escorted the resident to his/her room;-Witness statement from Licensed Practical Nurse A (LPN), the charge nurse on the date of the incident, that the resident had been verbally aggressive, including derogatory name calling, towards him/her throughout the shift, that the resident had been cussing at staff and other residents, that the resident had been asked to return to his/her room as to not bother other residents, the resident refused, and continued to cuss at staff and residents, the resident then went after another resident with a weapon, HA A and CNA A blocked the strike, put him/her in a chair and released his/her arms, he/she was later escorted to his/her room by staff;-Interview with the resident that he/she was put in a chair by staff, that he/she did have a broken hanger in his/her hand and did threaten to harm anyone that touched him/her; During an interview on 07/29/26 at 2:40P.M., Resident #1 said that the broken hanger was not a weapon and HA A and CNA A pushed him/her into a chair and held him/her in the chair. During an interview on 07/29/26 at 2:00P.M., CNA A said:-The resident had a broken hanger and was yelling and screaming at Resident #4 and walking towards him/her aggressively while swinging the hanger;-He/She took both of the resident's arms and placed him/her into a chair that had been moved in to place by HA A;-He/She did not put his/her arms around the resident's waist or bump into the resident using his/her chest;-HA A was able to grab the hanger with his/her hand and then remove it from the resident's possession; -The resident was walked back to his/her room by HA A and CNA A;-He/She had completed all facility provided education including annual CPI training;-There was a new resident and their family that were witness to the incident and they expressed fear during and after incident. During an interview on 07/29/26 at 2:20P.M., LPN A said:-The resident had been harassing staff and other residents throughout the day to buy him/her cigarettes;-He/She texted the administrator to notify him/her of the resident's behavior;-After lunch, the resident stood near the fire door;- HA A asked the resident to move; -the resident then aggressively walked towards Resident #4 with the broken hanger and said he/she would kill him/her;-HA A removed the hanger from the resident;-HA A removed the hanger from the resident, grabbed the resident's right arm while CNA A grabbed the resident's left arm and pushed the resident into a chair with HA A and CNA A holding the resident's arms to the arms of the chair;-LPN A instructed staff to let go of the resident;-Staff escorted the resident to his/her room;-He/She did not report the incident to the administrator as he/she was too busy; -He/She received in-service training on CPI including an attestation to read and sign, he/she did not take any actual CPI classes and no additional training or help was offered despite the facility residents having increased mental health needs. During an interview on 07/29/26 at 2:55P.M., Resident #2 said: -CNA A bumped his/her chest into the resident's chest causing the resident to move backwards;-CNA A held the resident's hand and pushed the resident into a chair; -The resident was then taken to his/her room; -He/She was scared of Resident #1 During an interview on 07/29/2026 at 3:20P.M., Resident #4 said that Resident #1 had threatened to kill him/her this day with a broken hanger and that he/she feared the resident. During an interview on 07/29/2026 at 4:30P.M., HA A said:-The resident had a broken hanger in his/her hand and lunged toward Resident #4;- He/She thought Resident #1 would strike Resident #4; -He/She and CNA A placed the resident in a calm hold by placing the resident in a chair and holding his/her hands until calm; -The facility no longer used the calm approach, they have started using CPI, which was more about communication to and redirection of the resident, not to use physical touch;-Other residents were fearful of the resident and many filed grievances the day of this incident. During an interview on 07/29/26, at 4:40P.M., the Social Services Designee stated that there had been several grievances filed the day of the incident, that he/she had personally interviewed several residents regarding their safety at the facility and that he/she did not know what the plan was regarding Resident #1 going forward. During an interview on 07/29/2026 at 5:05P.M., the DON and Assistant Director of Nursing (ADON) said:-The facility does not use the calm method any longer, the CPI approach is what has been taught to facility staff, using physical touch and restraint as the last intervention during a behavioral crisis;-HA A and CNA A did not approach Resident #1 correctly as neither staff should have grabbed the resident;-Resident #1 had an emergent visit with a psychiatric practitioner, a medication adjustment/addition had been made, and the facility would monitor the resident for increased or additional behaviors until the medication had reached therapeutic levels. Intake 3117232

Based on observation, interview and record review the facility failed to ensure two residents were treated with dignity and respect when the facility allowed staff to speak to cognitively impaired residents with disrespectful tone. This affected two residents (Resident #4 and #5) out of six sampled residents. The facility census was 80.Review of facility's Promoting/Maintaining Resident Dignity policy, dated 09/21/25 showed:-All staff should treat residents with dignity and respect.-Staff should speak respectfully to residents. 1. Review of Resident #4's Quarterly minimum data set (MDS), A federally mandated assessment tool completed by staff, dated 04/12/26 showed:-Not Cognitively intact;-Diagnoses included: Traumatic brain injury, dementia, major depressive disorder, schizoaffective disorder, profound intellectual disabilities. Review of care plan dated 04/09/26 showed: -He/She had negative behaviors including being verbally aggressive with staff and peers when upset.-At risk for impaired nutrition.-Staff should speak in slow, calm manner.-The care plan did not say what interventions the staff should use to counteract the resident's negative behavior. Observation on 05/27/26 at 10:35 A.M. showed:-Resident was standing at the nurse's station counter near the entrance of the building.-Resident asked Certified Nurse Aide (CNA) A for a snack. -CNA A told resident in a disrespectful tone I already gave you a snack.-CNA A, in the same disrespectful tone said, Backup you know the drill.-Resident became visibly upset and sighed heavily while looking down at the floor and walked away.-The resident did not get the requested snack. During an interview on 05/27/26 at 10:40 A.M. the resident said:-Nursing staff are upset, rude, and short tempered often and speak harshly to me and others.-He/She was mad and sad that CNA A spoke disrespectfully to him/her. 2. Review of Resident #5's Quarterly MDS dated [DATE] showed:-Cognition impaired;-Dependent on staff for all ADL's (activity of daily living);-Diagnoses included: Autistic disorder, epilepsy, severe intellectual disabilities, intermittent explosive disorder, cerebral palsy. Review of the resident's care plan, dated 02/15/26., showed:-He/She had communication problems;-Used facial expressions, gestures and movement that do not match verbal communication;-He/She became nervous with hollering, and restlessness when upset. Observation on 05/27/26 at 12:30 P.M. showed: -Resident sat in a wheelchair at the dining room table and began to move backwards away from the table. CNA A was assisting another resident to the next table. -CNA A, in a loud voice with a disrespectful tone, said to the resident to stop moving!-Resident looked at CNA A and began hollering out at CNA A for stopping the resident from leaving the table. 3. During an interview on 05/27/26 at 04:10 P.M. CNA A said:-Resident's behaviors can be frustrating at times.- I was short tempered with the resident about the snack as I was frustrated.-If staff becomes upset with a resident, staff should walk away and tell charge nurse. 4. During an interview on 05/27/26 at 06:15 P.M. the ADON (assistant director of nursing) said:-She expected all staff to treat residents with dignity and respect.-She expected staff to walk away and not become rude or hateful to the residents.-If a resident is requesting a snack, staff should accommodate this need. 5. During an interview on 05/27/26 at 04:15 P.M. the Administrator said:-He expected all staff to always treat residents with dignity and respect.-If staff are unable to treat residents with dignity and respect they should walk away and find help from other staff.-Staff should not be limiting resident snacks. Intake 3022690 & 3021023

Based on observation, interview and record review, the facility failed to ensure that residents were allowed to exercise their right to make personal choices regarding their dietary preferences when facility staff limited residents to a maximum of two packets of each condiment per meal and depleted inventory of cold cereal, brown sugar and cottage cheese. This affected three out of the six sampled residents. The facility census was 80.Review of facilities policy titled Promoting/Maintaining Resident Dignity dated 09/21/25 showed the resident's personal choices will be considered when providing services to meet the resident's needs and preferences. Review of facility's policy titled Resident's Rights dated 09/21/25 showed residents had the right receive services with reasonable accommodations of individual preferences. Review of facility's Cost Accounting in Dietary Department policy dated 07/05/23 showed the facility was to have seven days of staples inventory on hand under normal operating procedures. 1. Review of Resident #1's Quarterly minimum data set, (MDS, a federally mandated assessment tool completed by facility staff) dated 03/12/26 showed:-Cognition not intact;-Supervision required for ADL's (activities of daily living);-Diagnosis included: Unspecified dementia, bipolar, PTSD (post-traumatic stress disorder), schizoaffective disorder. Review of the resident's care plan dated 04/23/21 showed staff should provide the resident opportunities to make simple choices in day-to-day life. During an interview on 05/27/26 at 12:30 P.M. the resident said:-Staff limited condiments to one or two packets each;-He/She filled out a menu at each meal for the next meal, requesting his/her condiments;-It doesn't matter what the number of condiments requested; staff only provided residents with two packets of each condiment and one packet of salad dressing;-Residents who do not request condiments on their menu are not asked if they would like condiments with the meal;-Residents who ask for butter are told butter is only provided with toast;-The facility ran out of cold cereal choices regularly. Review of the resident's 05/27/26 lunch menu showed he/she requested four packets of sugar, two packets of salt and pepper, and two packets of ranch salad dressing. Observation of the resident's lunch meal on 05/27/26 at 1:00 P.M. showed:-Resident received four sugar packets, one salt packet, one pepper packet, and one ranch dressing packet;-He/She asked the dining room staff for parmesan cheese for his/her spaghetti and was told staff did not have parmesan cheese, only cheddar was available;-He/She shook head back and forth and lowered his/her head in disappointment when no parmesan cheese was available for spaghetti. During a follow up interview on 05/27/26 at 1:45 P.M the resident said:-He/She was provided two sugar packets no matter how many glasses of tea he/she ordered; -He/She received four packets of sugar today which never happens;-He/She received butter for the biscuit today at lunch, and that never happens;-He/She was upset that parmesan cheese was not available to top his/her spaghetti;-He/She was angry and upset about receiving two sugar packets for three glasses of tea. 2. Review of Resident #2's Quarterly MDS dated : 03/12/26 showed:-Independent with ADL's;-Mild cognitive impairment;Diagnoses included: Schizophrenia, major depressive disorder, mild intellectual disabilities. Review of the resident's care plan, dated 10/26/23., showed:-He/She had nutritional problems;-Staff was to promote additional intake during meals;-Staff should provide the resident with opportunities to make simple choices. During an interview on 05/27/26 at 10:55 A.M., the resident said:-The facility ran out of cold cereal and brown sugar regularly;-Residents were limited to two condiment packets per meal;-He/She felt angry when there was no cold cereal for breakfast. Review of Resident's lunch menu on 05/27/26 showed resident requested two butter packets. Observation on 05/27/26 at 1:00 P.M showed he/she received one butter packet. 3. Review of Resident #3's Quarterly MDS dated , 03/12/26 showed:-He/She was independent with ADL's;-Cognition impaired;-Diagnoses included: Anxiety and depression. Review of the resident's care plan, dated 05/26/26 showed:-Staff was to provide resident opportunities to make simple choices with day-to-day life;-He/She was to have input in her decision making with all care and as much as possible. During an interview on 05/27/26 at 11:30 A.M. the resident said:-He/She was frustrated because the staff limited the resident to two packages of each condiment per meal;-I feel like I live in a concentration camp when I am limited on condiments.-He/She requested more ketchup for breakfast and was told by staff he/she could not have more as he/she was only allowed two packets. During an interview on 05/26/27 at 10:12 A.M. the dietary manager said:-The facility ran out of cold cereal often on Sunday's;-The food deliveries arrive on every Tuesday;-Cottage cheese was an alternate that the facility [NAME] out of occasionally.-Condiments were not supposed to be limited, if the resident orders five packets the resident was supposed to get five. During an interview on 05/27/26 the Administrator said:-Staff were not supposed to limit residents' condiments;-There was an ordering problem if the facility is out of cold cereal;-Residents who request extra sugar, butter, ketchup should be provided at meals. Intake 3021023

Based on interview and record review, the facility failed to protect one resident's right, (Resident #4), to be free from abuse when Resident #3 hit Resident #4 on the left side of his/her ear. This affected one of the four sampled residents, (Resident #4). The facility census was 84. On 2/6/26 the Administrator was notified of the past noncompliance that began on 02/02/26. The facility administration immediately conducted aninvestigation and corrective actions were implemented that included in-service for all staff regarding abuse prevention, incidents and accidents and behavioral monitoring. The noncompliance was corrected on 02/04/2026.Review of the facility's policy for Abuse and Neglect, revised 6/12/24 showed:It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other agencies in accordance with current state and federal regulations within prescribed time frames. Abuse is the willful infliction of injury.Physical abuse is purposefully beating, striking, wounding, or injuring any resident. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking.The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. The facility will identify, correct and intervene in situations in which abuse, neglect is more likely to occur. The facility will protect residents from harm during an investigation.The facility is committed to protecting the residents from abuse by anyone including other residents.Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices, such as dealing with aggressive residents. Sensitivity to resident rights and resident needs and what constitutes physical, sexual, verbal and mental abuse. The facility will identify and correct by providing interventions in which abuse is more likely to occur.The facility desires to prevent abuse, neglect, and theft by establishing a resident sensitive and resident secure environment. Assess the environment circumstances which may make abuse, neglect, or misappropriation of resident items more likely to occur. As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, completed by facility staff, dated 11/20/25 showed: Cognitive skills intact. No behaviors. Supervision or touch assistance with eating and transfers. Diagnoses included anxiety, depression, psychotic disorder and Schizophrenia. Review of the resident's care plan, initiated on 2/2/26 showed the resident was involved in a resident-on-resident altercation on 2/2/26 resulting in him/her being struck with a closed hand by another resident. The primary care physician, psychiatrist and guardian were notified. Medication and labs were ordered and reviewed. Already received counseling. Neuro checks were initiated per facility protocol. Skin checks completed and no new areas noted. Room moves completed. The residents no longer reside on the same hall. Review of Resident #4's progress notes, showed on 2/2/26 at 5:00 A.M. the resident was involved in an incident as the victim. The resident confirmed he/she felt safe and did not need to talk to anyone. The resident was able to name a staff member who he/she felt safe with to share any thoughts and feelings. The resident denied any aftereffects from the incident.During an interview on 2/6/26 at 8:34 A.M., the resident said he/she was at the nurse's desk waiting to put his/her Cheez its back in the snack room. Resident #3 had been banging his/her cup on the glass at the nurse's station and said he/she wanted a cup of ice. Resident #4 stood behind Resident #3 and when he/she turned around, asked Resident #4 if he/she was enjoying the show. Resident #4 replied, he/she did not care about his/her pathetic ass show Resident #3 went to hit Resident #4, and Certified Nurse Aide (CNA) A was in between them and when Resident #3 went to hit Resident #4, he/she had to reach around CNA A so instead of a full punch, Resident #3 hit Resident #4 on the left side of his/her face by his/her ear with a closed hand. Resident #3 then called Resident #4 a name and Resident #4 responded and said name calling did not hurt. Resident #4 turned and walked away. Resident #4 said he/she did not have any red marks or injuries, no pain and he/she felt safe in the facility but felt better since the room change. 2. Review of Resident #3's Annual MDS, dated [DATE] showed: Cognitive skills intact. No behaviors. Supervision or touch assistance with transfers. Diagnoses included depression, bipolar, and Schizophrenia. Review of the resident's care plan revised, 2/5/26 showed: -The resident was involved in a resident on resident on 2/2/26 where he/she made closed hand contact to another resident. Placed on protective oversight by staff. Primary Care Physician (PCP), Psych and Guardian notified. Medication and lab review completed. New one tome order received for Thorazine (used to treat mental health conditions), 50 milligrams (mg.) intramuscular (IM) injection via verbal order form the physician. New order received to continue the Thorazine 50 mg. IM every eight hours as needed for 14 days. Labs were drawn. Urinalysis with culture and sensitivity was obtained. Referral sent for psych counseling and consent obtained. Placed on Hot Rack charting twice weekly. Skin checks completed and no new areas noted. Room moves completed. Residents no longer reside on the same hall. - The resident is on antibiotic therapy related to a urinary tract infection. Administer antibiotic medication as ordered by the physician. Monitor/document side effects and effectiveness every shift. Report pertinent lab results to the physician. Review of the resident's Physician Order Sheet (POS) dated February 2026 showed an order with a start date of 2/4/26 for Macrobid oral capsule 100 mg., twice daily for five days for urinary tract infection (UTI). Observation and interview on 2/6/26 at 10:28 A.M., showed Resident #3 was in his/her room lying on the bed. Resident #3 declined to talk to the surveyor. CNA A was1:1 with the resident. CNA A said the resident had been placed on 1:1 since the morning of the incident. During an interview on 2/6/26 at 10:45 A.M., CNA A said Resident #3 had not had any further behaviors. The incident actually started about 1:30 A.M., when Resident #3 wanted to call a taxi to take him/her to St. Louis. Registered Nurse (RN) A informed Resident #3 not to get upset if no one answered because of the time of day. Resident #3 was upset because the numbers did not work. Resident #3 went back to his/her room then returned about 10 minutes later still mad. Resident #4 had come out of his/her room at that time to put his/her snacks back in the snack room. The next thing CNA knew, Resident #3 threw a punch at Resident #4 and connected with the left side of Resident #4's ear. Resident #4 did not fight back, just turned and walked away and went back to his/her room. During an interview on 2/6/26 at 1:21 P.M., Licensed Practical Nurse (LPN) A said he/she was not working when it happened. Resident #3 was placed on one on one after the incident. During an interview on 2/6/26 at 2:45 P.M., the Director of Nursing (DON) said RN A called at approximately 3:20 A.M. and informed her of the incident. The Administrator was already in the building and was aware of the situation. Resident #4 went to put his/her Cheez-its back in the snack room and when Resident #3 asked Resident #4 if he/she was liking the show, Resident #4 informed Resident #3 he/she was not interested in his/her pathetic ass show. CNA A intervened between the two residents, Resident #3 had to reach around CNA A, so it was not like a full-on hit. The staff were in-serviced over Crisis Prevention Intervention (CPI), resident behaviors, accidents/incidents and abuse/neglect. An in-service regarding abuse, intensive monitoring, behavioral emergencies and incidents and accidents was provided to all staff on 2/2/26 and 2/4/26. During an interview on 2/6/26 at 3:39 P.M., RN A said the incident between Resident #3 and Resident #4 occurred between 3:10 A.M. and 3:15 A.M., Resident #3 was upset because he/she thought the staff were lying to him/her. Resident #3 was waiting for a cab to leave and was upset. Resident #4 just happened to be in the wrong place at the wrong time. Resident #4 went to put his/her crackers back in the snack room. CNA A was between the two residents when Resident #3 took a swing at Resident #4. The punch caught Resident #4 on the left side of her head by his/her ear. The two residents were immediately separated. The DON, Administrator, physicians and guardians were notified. Resident #3 received an order for Thorazine (antipsychotic medication), and he/she was placed 1on 1 supervision. Typically, Resident #3 is more verbally aggressive and not physically aggressive. Residents have the right to not be hit by others and free from abuse. Intake 2731647

Based on interview and record review, the facility staff failed to follow facility policy and ensure the residents physician was verbally notified on 01/21/2026 of a resident fall with a head injury and on 1/24/2026 when staff found the resident unresponsive for about a minute and with seizure like activity for about 45 seconds before becoming responsive again. The staff notified the residents physician on 01/25/26 at 12P.M., approximately 16 hours after the change in condition occurred. The facility census was 82.Review of the facility policy titled Notification of Changes, dated 05/14/24, showed:- The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.- Circumstances requiring notification included accidents resulting in injury and accidents with the potential to require physician intervention.Review of the facility policy titled Incidents and Accidents, dated 5/18/24, showed:- Accidents refer to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.- The purpose of incident reporting can include assuring that appropriate and immediate interventions are implemented, and corrective actions are taken place to prevent recurrences and improve the management of resident care.- The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury.- Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders obtained or follow-up interventions.Review of the facility policy titled Notifying Clinicians, dated 06/26/24, showed:- The purpose of this policy is to ensure the Clinicians are properly notified of a Residents Change in Condition and overall, health and/or mental status;- The Clinician shall be notified of Changes in Conditions, Emergent Situations, Routine Diagnostics, and concerns of the resident's overall health status;- Examples: Falls, incidents, skin tears, out of range vital signs, abnormal labs, altered mental status, new wounds, changes in wounds, anything regarding a change in the resident's baseline or condition;- The nurse will implement 911 for immediate transfer for physician evaluation, when there is an accident involving the resident which results in an injury and has the potential for requiring physician intervention;- The nurse will initiate verbal communication with the clinician when a condition or incident arises with the resident which would warrant an immediate implementation of a change in plan of care to include physician advisement or initiation of physician orders to avoid a delay in treatment that may cause worsening in condition;- If you are unable to reach the physician, you shall notify nursing administration and they can assist in contacting a physician if/when needed;- Ensure that there is documentation of time, phone number dialed and to whom you spoke with when you reached out to the physician's office. Documenting if you reached anyone, or if the number of attempts made and if messages were left;- After-hours, the licensed nurse will notify the residents physician or the on-call physician for all changes is conditions, incidents or accidents, and emergency responses after-hours to ensure the physician is kept informed and to give guidance;- In the event the licensed nurse cannot reach the physician for guidance, the licensed nurse must call the Medical Director for guidance;- In the event the licensed nurse cannot reach the physician or the Medical Director, the licensed nurse must call the Director of Nursing for further guidance;- If the licensed nurse cannot get ahold of the physician in an event where the resident needs to be sent to the hospital via 911, the nurse will send the resident to the hospital and continue attempts to notify the physician of the situation.Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/15/25, showed:- Cognitively Intact;- Required the use of a wheelchair and supervision or physical assistance from nursing staff for toileting, bathing, and hygiene;- Required anticoagulant (medications that prevent or reduce blood clot formation) and antiplatelet (medications that reduce platelet clustering and inhibit blood clot formation in arteries) medications which increase the risk for bleeding;- Diagnoses include Heart Failure, Diabetes, and High Blood Pressure.Review of the resident's care plan, dated 01/21/26, directed staff to follow the facility fall protocol if a fall occurs. Review of progress notes for the month of January 2026 showed:- On 01/21/26 at 7:42 A.M., Registered Nurse (RN) A documented that on 01/21/26 at 1:45 A.M., He/She heard the resident call for help and found the resident lying on the floor with his/her head against the sink cabinet. RN A observed a moderate amount of bleeding from a four-centimeter laceration to the left side of the resident's head and cleaned the wound and applied two Steri-Strips (sterile, breathable, hypoallergenic adhesive tapes reinforced with polyester filaments, designed to securely close small, shallow wounds or surgical incisions). RN A found five other abrasions and a kiwi sized area on the resident and included that it had been important to state the resident had been on blood thinners, at that time. No documentation regarding notification to the physician about the resident's condition. - 01/21/26 at 7:58 A.M., showed RN A documented Skin is jaundice. Skin cold/clammy to touch. Skin is fragile, and described the skin issues the resident had received overnight. No documentation regarding notification to the physician about the resident's condition. - On 01/24/26 at 8:00 P.M., Licensed Practical Nurse (LPN) B documented the resident had become unresponsive for about a minute then had seizure like activity for about 45 seconds before becoming responsive again. LPN B wrote that the DON and Assistant Director of Nursing (ADON) had been notified and to monitor, and that the resident required three staff to transfer and was resting in bed. No documentation regarding notification to the physician about the resident's condition. - On 01/25/26 at 12:00 P.M., LPN A documented she notified the Nurse Practitioner (NP) to inform them that the resident had went unresponsive last evening with a 30-45 second period seizure type activity, had been jaundiced in color, and had swollen areas to his/her right hip and right abdomen. The physician gave an order to send the resident to a local emergency room for evaluation and treatment; - On 01/25/26 at 5:12 P.M., LPN A documented the resident had been admitted to the local hospital. During an interview on 01/28/26 at 10:10 A.M., RN A said:- On the night shift, on 01/21/26, he/she had heard someone calling for help and found Resident #2 on the floor with abrasions and a laceration to the head.- He/She did not call the physician but sent a text a message to the NP and Administrator the following around 5:23 A.M. - He/She would call the provider if an incident was emergent but at the time it was his/her understanding that he/she could notify them via text when it wasn't emergent. We have to notify the DON prior to sending someone out;- He/She did not feel it was warranted to send the resident out at that time. - When a resident falls as the nurse, she should assess the resident, treat or render first aid, and notify the provider and send out if the resident needs to be sent out. The facility has a chain of command to follow before sending the resident out.During an interview on 01/28/26 at 10:20 A.M., the Administrator said when a resident is injured or has a change in condition, they are to call the residents physician. During an interview on 01/28/26 at 12:13 P.M., the DON said the nurses should have notified Resident #2s physician provider as quickly as possible.- The nurses should notify the ADON, the DON, the Administrator, the guardians, and the regional administration in addition to the provider.- Nursing should document notification to the physician in the resident's medical record. During an interview on 01/28/26 at 1:04 P.M. LPN A said:- When a resident falls or has an incident, the nurse should assess the resident, get the resident's vital signs, fill out the risk management section in the electronic medical record, update the resident's care plan and initiate interventions if needed.- The nurse would also notify the resident's primary care provider, guardian if not their own person, DON, ADON, Administrator, and resident care coordinator.- On Sunday night, 01/24/26, a code blue was called for the resident, LPN A had been going off shift but responded and ran to the resident's room where the resident was having seizure like activity for about 30-45 seconds, then the resident responded he/she was okay.- On Monday, 01/25/26, the resident's hip and abdomen looked swollen, and his/her nursing judgement indicated the resident needed to be sent out to the emergency room.During an interview on 02/06/26 at 10:30 A.M., the Nurse Practitioner (NP) said: - The nurse should have notified her when Resident #2 fell and sustained injury and when the resident had changes in his/her condition. - She expected the facility nurses to notify her of any injuries, acute occurrences, or anything urgent that needs addressed right away.- Non-injury or routine issues can be a message, but with Resident #2 she would have expected the nurse to call her right away;During an interview on 02/09/26 at 12:35 P.M., the facility Medical Director said the nurse should have called the residents physician about the fall with injury and the resident should have been sent out to the hospital.During an interview on 02/09/26 at 1:52 P.M., LPN B said:- LPN A and LPN B had been called to the resident's room by therapy for seizure like activity. The resident wasn't totally unresponsive, but was responsive to painful stimuli;- The resident had no previous activity like that before;- The resident was acting fine afterwards that he/she just monitored the resident all night every 30 to 60 minutes. - - He/she should have notified the residents physician of the change in condition. During an interview on 02/10/26 at 12:04 P.M., the resident's primary physician said he/she or the FNP should have been called when the resident fell. Intake 2725241

Based on observation, interview and record review, the facility failed to ensure a sanitary and comfortable environment was maintained in the secured unit when staff did not maintain one of two-unit showers observed to have a slimy black-mold like substance, did not ensure showers/tubs were cleaned between residents, did not repair the ceiling is need of repair, and did not maintain an effective pest-control system. This affected three of four sampled residents (Resident #1, #2, #3) The facility census was 81. Review of the facility's undated admission Packet showed basic covered services for all residents includes housekeeping and maintenance services.Review of the facility's Safe and Homelike Environment policy, dated June 2024, showed:- In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment;- Environment refers to any environment in the facility that is frequented by the residents;- Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment;- Homelike environment is one that de-emphasizes the institutional character of the setting;- Sanitary includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored.Review of the facility's Housekeeping - Deep Cleaning policy, dated June 2023, showed:- Deep cleaning is to be completed as scheduled. This includes restrooms to be cleaned and disinfected, call lights to be clean and free from dust/build-up;- All areas should be monitored on a daily basis and all resident living areas and non-living areas should be clean and odor free;- Clean shower rooms inside the shower, around the shower, and the base boards in the room;- Carpets and upholstered furniture will be inspected and spot cleaned as needed;- Bathroom floors will be swept and mopped and any dirt, grime, or stains will be hand scrubbed with stiff brush or other equipment suitable for removing surface dirt from entire floor. If the stain is not removeable then housekeeper will notify maintenance department.Review of the facility's pest control company documents showed:- November 14, 2025 - Spoke with administrator and was asked to start coming back every other week for recent rodent escalation;- November 21, 2025 - Call back for rodent escalation. Placed two more bait stations outside. Helped maintenance place more glue traps and check in several areas where we found holes in wall and under vents that needed to be filled;- December 5, 2025. Rodent traps inspected and serviced.1. Review of Resident #1's, Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/24/25, showed:- Cognition mildly impaired;- Required supervision from nursing staff for showering, and hygiene;- Diagnosis of diabetes, dementia, chronic obstructive pulmonary disease (COPD - lung and airway diseases that restrict breathing), and schizophrenia.Review of the resident's care plan, dated 11/14/25, showed:- Post-Traumatic Stress Disorder, resident requires a safe environment free from actual or perceived judgement and physical or perceived danger;- The resident identified at risk of aggression, anxiety, and delusions related to schizophrenia diagnosis;- The nursing staff were directed to monitor and work with the resident to reduce his/her anxiety.During an interview on 12/30/25 at 8:51 A.M., the resident said:- His/Her room wasn't very clean, and staff only would sweep and mop every other day;- He/She has seen two mice running back and forth in his/her room that would get in under the radiator vent and go from one room to the other;- He/She wouldn't let the facility put down sticky traps in his/her room because he/she didn't want to hear mice dying and crying out;- He/She has seen mice all over the secured unit;- The staff do not clean the shower between residents and sometimes he/she gets in the shower and has to put a towel down because the shower floor was so slimy. The shower has black mold around the edges;- He/She has never seen the staff clean the showers. Observation on 12/30/25 at 8:52 A.M., showed Resident #1's room with a heat register on the floor, beneath the window, that ran wall to wall, with approximately a 1-to-1.5-inch gaps.2. Review of Resident #2's, Quarterly MDS, dated [DATE], showed:- Mildly impaired cognition;- The resident requires supervision from facility staff for showering and hygiene;- Diagnoses include Diabetes, Bipolar Disorder, and Schizophrenia.Review of the Resident's Care Plan, dated 10/20/25, showed:- The resident has a behavior trigger of not feeling safe in his/her environment;- The resident is at risk of anxiety, and delusions related to schizophrenia diagnosis;- The nursing staff are directed to monitor and work with the resident to reduce his/her anxiety.During an interview on 12/30/25 at 10:04 A.M., the Resident said: - He/She didn't like being at the facility because there is a mice problem and mice come out at night;- The mice run along the radiator from room to room; - He/she has sticky traps in his/her room, but the traps have not caught any mice;- The showers were awful, the staff do not keep the showers clean, and the showers had been like that since he/she arrived at the facility; - The shower floor is dirty and slimy.- The walls and the floors in the shower are dirty and this makes the resident feel dirty and unsafe;- He/She has seen dirty adult diapers piled on top of the trash can in the shower area for more than one day and had to pick up other residents' towels that were left lying on the shower floor;- Often there is hair in the tub or soap scum from other resident's in the tub which makes him/her feel gross like he/she has been taking a bath in someone else's filth. He/She does not like taking baths because of the poor shower conditions;3. Review of Resident #3's, Quarterly MDS, dated [DATE], showed:- Cognition is mildly intact; - The resident requires supervision from facility staff for showering and hygiene;- Diagnoses include Psychotic Disorder, Bipolar Disorder, and Schizophrenia.Review of the resident's care plan, dated 11/26/25, showed:- The resident has emotional distress triggers of overwhelming emotions, feelings, memories, sounds and images and likes to bathe every two to three days; - The resident had listed taking a bath as part of his/her safety plan for behaviors;- The nursing staff are directed to watch the resident's anxiety and act before the resident would lose control. During an interview on 12/30/25 at 8:43 A.M., the Resident said:- The facility needs to get rid of the mice;- He/She has seen three mice running across the heater in his/her room and all over his/her room;- He/She has notified facility staff about seeing mice in his/her room;- The mice have pooped everywhere;- He/She likes taking baths, but the bathtub is not clean, and she has to remove hair left in the tub by others who use it and that is gross; Observation of the unsupervised shower room on 12/30/25 at 9:04 A.M., showed:- Approximately 10 black fairly long curly hairs in the tub;- A metal chair, with rust on the seat, sitting next to the tub;- Several large dark, stained spots on the ceiling;- Peeling sheetrock hanging off the ceiling in a two-foot-long section with about 2 inches of the tape hanging down off the ceiling. Approximately 4 inch by 12 inch section of plaster/popcorn texture had fallen off the ceiling; - Three cracked and sagging sections of the plaster/popcorn ceiling;- The main shower area had a one-to-two-inch, dark, brownish black mold-like colored section around the base of the shower/wall surrounding the three sides. - [NAME] corrosion all over the shower head and a metal tube coming out of the shower wall;- An upholstered chair sitting in the shower that had cracked padding and exposed foam which had been soaked with water;- A rusty call light plate and rust stains down the wall to the top of the tile in the middle of the wall. During an interview on 12/30/25 at 10:18 A.M., Housekeeper A said:- The shower should be cleaned on Mondays, Tuesdays, Wednesdays, Thursdays, and Fridays by housekeeping staff. - He/she was not sure if the shower is cleaned between residents;- The aides are supposed to clean the shower between residents, but he/she was not sure if the aides do it;- He/She has seen mice in the facility and the facility had put down sticky traps;- He/She is unsure how to clean the mold like substance that is in the shower room;- He/She is unsure about the facility plan to fix the condition of the ceiling;- The tub and shower should be cleaned between residents, and the furnishings should be in good condition. During an interview on 12/30/25 at 10:28 A.M., Nursing Assistant (NA) A said:- The unsupervised shower room does not get cleaned between residents but it probably should; - Housekeeping staff clean the shower room, but he/she was unsure what days; - The shower rooms should be kept clean; - The cleaning supplies for the aides is locked up, and only housekeeping staff and the nurses have the key to get to the supplies; - The night shift staff are supposed to clean the shower room every night; - He/She has seen the condition of the ceiling and the spots on the floor in the unsupervised shower room and said, the shower rooms aren't great; - He/She has overheard a resident complain about the condition of the shower room being dirty;- He/She has seen mice run across the hallway from room to room before and had seen mouse droppings in the sinks and sometimes on the floor in resident rooms. Observation on 12/30/25 at 10:29 A.M., showed:- A clump of hair on the shower floor by the drain;- The ceiling had a number of large, dark water spots on the ceiling with a two foot by three-inch strip of sheet rock tape missing and a piece of the plaster/popcorn ceiling missing right outside the shower area. During an interview on 12/30/25 at 10:35 A.M., Registered Nurse (RN) A said the shower room should be maintained in good condition and clean for the residents.During an interview on 12/23/25 at 11:15 A.M., the Maintenance Supervisor said:- He didn't know the whole situation but towards the end of July the roof was being fixed, and the roofing company didn't put a tarp up and it rained and that's where the water damage in the shower room came from;- The roofing company doesn't want to pay to fix it, and corporate doesn't want to pay to fix it;- It's above my head now with who is going to fix it;- The shower rooms should be clean and maintained in good condition;- He thinks the black mold like substance around the edge of the shower floor is mildew and said it needs to be stripped and clean it up, but he has not gotten around to it yet; - He has been working with the exterminator, to get rid of the mice;- There was an infestation of mice in the Administrator's office and now they are gone but they come back in the winter time;- We have made improvements on the mice problem but it's an ongoing issue;- The exterminator comes out twice a month to work on getting rid of the mice problem. During an interview on 12/30/25 at 12:00 P.M., the Assistant Director of Nursing said:- The showers should be cleaned between residents and the nursing assistants/aides were responsible for the cleaning;- Housekeeping are to clean daily, and deep clean the shower rooms;- In July work was done on the roof and they couldn't communicate with the roofers due to language barriers, and had been fighting with the company since August regarding the ceiling condition and needed repairs;- The facility utilized pest control, and they had been coming twice a month; - The residents shouldn't not have to experience mice running on their beds or in their rooms;- She had seen a mouse on the unit every once in a while. During an interview on 12/30/25 at 12:07 P.M., Licensed Practical Nurse (LPN) A said:- When he/she was at work, the aides ask him/her to get the key for the closet where cleaning supplies are located so they can clean the shower;- The showers/shower rooms should be cleaned between residents and maintained in good condition.During an interview on 12/30/25 at 12:20 P.M., the Administrator said:- The shower should be clean for the residents and maintained in good condition;- The roofers are responsible to make the repairs to the ceiling. The corporate staff are fighting with the roofing company about repairs;- The exterminator has been coming to the facility every two weeks to check for holes, set up sticky traps and increased the bait traps outside the facility from six to eight. When holes are found they are filled with steel wool and caulking.Intakes 2686131, 2679844, 2696723, 2693065

Based on interviews and record review, the facility failed to provide timely an appropriate discharge when staff failed to provide written notice of discharge that included the date and location the resident would be discharge to, statement of appeal rights and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman (advocates for the residents in nursing facilities). The facility's census was 85.Review of the facility's Resident Transfer/Discharge/Immediate Discharge, and Therapeutic Leave Policy, dated 4/28/25., showed:-Notice of discharge or transfer must notify the resident and the resident's representative of the reason for discharge in a writing and must notify a representative of the Office of the State Long-Term Care Ombudsman at least 30 days in advance of the discharge or as soon as possible. -If an emergency or immediate discharge copies shall be sent to the Ombudsman. The written notices shall include the reason for the transfer or discharge, the date of the discharge of transfer. The resident's right to appeal their discharge. The resident can remain in the facility while awaiting their appeal.1. Review of Resident #1's Face Sheet., showed the resident was admitted to current facility on 4/8/25 with a diagnosis of antisocial personality disorder, bipolar disorder, post-traumatic stress disorder, and suicidal ideation. Currently under the care of a public administrator.On 8/7/25 review of the resident's electronic medical record showed: On 7/31/25 the resident became physically violent with the facility staff and was unable to be calmed down, local police were called by the facility, and the resident was transported by EMS in hand cuffs to the local emergency room for evaluation. The resident was cleared by local ER for the resident to return to the facility, however the facility was not willing to accept the resident back due to continued behaviors. On 7/31/25 at 10:02 P.M. the resident's public administrator was notified by facility' Administrator, that the resident would not be allowed to return to the facility. A letter of immediate discharge notice was sent to the office of the Chief Public Administrator, not the current deputy public administrator for the resident, this document contained no signatures, or plan of care going forward, only that the resident was being discharged from the facility. The medical record showed no information that the Ombudsman was notified of immediate discharge from the facility.During an interview with hospital As RN A said facility Administrator A told him/her the resident could not return to the facility. The resident was being refused re-admission back to facility and now had no place to go.During an interview on 8/7/25 at 12:57 P.M the DON said the acting administrator, Administrator A made the final decision not to accept the resident back and it was the right decision because of the abuse the resident had caused to nursing staff. She was not the decision maker on who could be accepted, who was acceptable for the women's unit as that decision was made by corporate staff and the Administrator. During an interview on 8/7/25 at 4:05 P.M. Administrator B said: The resident's public administrator was notified on 7/31/25 by phone by Administrator A that the facility would not be accepting the resident back to the facility for the safety of the staff and other residents. Administrator B said she had forgotten the step of notifying the local Ombudsman regarding the immediate discharge of a resident. The local Ombudsman did call Administrator A after finding out about the immediate discharge from the local hospital staff. He/she believed it was in the best interest of the resident, the staff, and the other residents for the resident to be immediately discharged from the facility's secured behavioral unit, even though the resident still has no place to go and is being housed at the hospital until placement can be found for the resident. During an interview on 8/8/25 at 10:55 A.M the resident's current Deputy Chief Public Administrator said the resident is still at the hospital waiting for appropriate placement. She is unable to find placement for the resident.During an interview on 8/8/25 at 10:05 A.M. the hospital RN B said, the resident is at the hospital needing permanent placement.During an interview on 8/11/25 at 1:35 P.M, the hospital RN C said: The resident is still at the hospital needing permanent placement.During an interview on 8/11/25 at 1:20 P.M. Administrator A said the resident's public administrator was notified on 7/31/25 by phone.During an interview on 8/11/25 at 2:35 P.M. the resident said he/she believed that he/she would be going back to the facility after treatment at the hospital and that is where his/her personal belongings are at. He/she has friends at the facility and misses the other residents who live there. In regard to where he/she will live, he/she said he/she was uncertain about what the plans are for the future will and said he/she is very frustrated about this situation.Complaint #2579000 and #2580318

Based on interview and record review, the facility failed to allow one sampled resident to return to the facility when he/she did not meet criteria for hospitalization. Between 7/31/25 -8/1/2025 the resident was transported 5 times between 2 hospitals and the facility and on 8/1/25 was left stranded at the hospital with no clothes, money or personal belongings. The resident was without long-term care placement for approximately 9 days when he/she exhibited behaviors, requiring hospital staff to utilize restraints and admit the resident for psychiatric care. The facility census was 85. Review of the facility's Resident Transfer/Discharge/Immediate Discharge, and Therapeutic Leave Policy, dated 4/28/25., included: Residents who are sent emergently to the hospital are considered transfers because the residents return is generally expected. Residents who are sent to the emergency room must be permitted to return to the facility, unless the resident meets one of the criteria under which the facility can initiate discharge. The facility should work with the hospital to determine if the resident's condition and needs upon discharge from the hospital are within the facility's scope of care. 1. Review of Resident #1's Face Sheet., showed the resident was originally admitted from a sister facility on 3/26/25 and re-admitted on [DATE] with a diagnosis of antisocial personality disorder, bipolar disorder, post-traumatic stress disorder, and suicidal ideation. Currently under the care of a public administrator.Review of Resident #1's care plan initiated 5/1/2025 included the following diagnosis of antisocial personality disorder, bipolar disorder, major depressive disorder, nightmare disorder, seizures, post-traumatic stress disorder, suicidal ideations, unspecified convulsions, bipolar disorder, borderline personality disorder, unspecified intellectual disabilities.The care plan included the following directions for staff: Post-traumatic Stress Disorder (PTSD). PTSD affects the residents' symptoms and may flare up without any known trigger. Encourage the resident to express emotions in a safe environment. Allow resident the freedom to acknowledge their feelings and release any repressed emotions that may be exacerbating their distress. A safe environment should be free from actual or perceived judgement and physical or perceived danger.The resident is at risk for the following signs/symptoms r/t dx of Borderline Personality Disorder, chronic feeling of emptiness, explosive anger, extreme emotional swings, fear of abandonment. (Individuals with BPD are often terrified of being abandoned or left alone., impulsive, self-destructive behaviors).Review of the resident's electronic medical record showed:-The resident was admitted to the secured behavioral on 3/26/25. The clinical record showed the resident had behaviors of physical and verbal aggression towards others since the first week of admission to the facility.-On 3/30/25 at 7:45 P.M. the resident was found by staff attempting to harm self by choking self and had become physical with staff and spitting on others; a code green was called (an all-emergency staff response to the location of resident).-On 5/24/25 a code green was called for resident hitting, kicking and spitting at staff and was placed on 1:1 monitoring (when a staff person is assigned to watch the resident at all times) Police were called and resident became physically aggressive towards the police, and another code green was called.-On 6/15/25 the resident became physically and verbally aggressive with staff and required antipsychotic (medication used to control mood and behaviors) injection was administered to the resident in effort to control physical aggressive behavior and 1:1 monitoring continued.-On 6/21/25 the resident assaulted a nurse and attempted to hit others, code green called. Medications to calm the resident were administered by the nursing staff. 1:1 continued.-On 7/13/25 the resident requested to speak to a nurse and when nurse arrived the resident hit the nurse and attempted to hit other nursing staff. Medications to calm the resident were administered to the resident.-On 7/31/25 the resident hit a nurse aid in the face with a water pitcher, hit a nurse on the back of the head, spit in the face of nursing staff attempting to de-escalate the resident's behavior and was unsuccessful. The police were notified and arrived at the facility, placed the resident in handcuffs then EMS (Emergency Medical Services) ambulance arrived to the facility, and while the resident was cuffed took the resident to the local ER for psychiatric evaluation.Review of Hospital A emergency room records dated 7/31/25 showed the resident was threatening self-harm. Tele-health psychiatry (virtual face to face talking with a doctor) screened the resident and ER cleared the resident to return to the facility. Review of the facility documentation regarding Resident #1 showed on 7/31/25 the resident was sent to the emergency room at hospital A and was cleared to return to the facility. The ADON (assistant director of nursing) and facility staff went to hospital A to pick up the resident. The resident demanded to be taken to somewhere else because he/she was going to hurt his/herself if he/she could not get help. The ADON, van driver and two other staff members transported the resident to hospital B located 2 hours away from the facility because hospital B had inpatient psychiatric services. After arriving and being assessed by hospital B, the resident was again cleared by ER psychiatric care, and the resident was transferred back to the facility with another resident that was also returning to the secured unit. The documentation from the hospital B indicated the facility was willing to accept the resident back. Upon arrival to the facility, the resident was denied entry, and the transport company transported the resident back to hospital A where the resident was then transferred to hospital B again. On 7/31/25 at 10:02 P.M. the resident's public administrator was notified by the facility administrator, that the resident would not be allowed to return to the facility. A notice of immediate discharge was sent to the office of the Chief Public Administrator, not the current deputy administrator for the resident. The notice did not include an appropriate location for discharge and listed the location as hospital B. In an interview on 8/4/25 with RN A with Hospital B, said the facility administrator told him/her the resident could not return to the facility and was being refused re-admission back to the facility. Hospital A would not accept the resident again and had the resident brought back to Hospital B approximately 2 hours away from the facility and did with no place to go.During an interview on 8/4/25 at 4:29 P.M the ER Case Manager with Hospital B said the facility violated the resident's transfer and discharge rights when after midnight on Friday evening 8/1/23 the facility staff brought the resident to the ER claiming that the resident had suicidal ideation. When resident was discharged later Friday night, the facility refused to take the resident back. When the resident arrived at the facility, he/she was refused entry and sent back to Hospital B. The resident returned to Hospital B, with no need for medical care or further evaluation, no appropriate discharge location arranged by the facility. The resident had no personal belonging, and no home to go to. He/she contacted the public administrator and let him/her know the facility refused to accept the resident back. During an interview on 8/7/25 at 12:57 P.M the DON said the acting administrator made the final decision not to accept the resident back and it was the right decision because of the abuse the resident had caused the nursing staff. She was not the decision maker about who the facility would accept, and those decisions are made by corporate staff and the administrator. During an interview on 8/7/25 at 1:10 P.M the ADON said she was with the resident during the transport to Hospital B to be evaluated for psychiatric needs as the resident had stated he/she was going to hurt his/her-self and others. The ADON did not feel that the resident's needs could be met by the facility staff and that the resident was a danger to others. During an interview on 8/7/25 at 4:05 P.M. the Administrator B said the public administrator responsible for Resident #1 was notified on 7/31/25 by the Administrator A that the facility would not be accepting the resident back for the safety of the staff and other residents. She believed it was in the best interest of the resident, the staff, and the other residents for the resident to be immediately discharged from the facility's secured behavioral unit.During an interview on 8/8/25 at 10:55 A.M Deputy Chief Public Administrator said the resident is still at Hospital B waiting for Hospital B to find appropriate placement for the resident. She does not feel that long-term care setting is the appropriate place any longer. He/she has not been able to find placement for the resident. During an interview on 8/8/25 at 10:05 A.M. Hospital B's RN B said, as of 8/8/25 the resident has no need to be admitted to the hospital and remains at Hospital B in the emergency room pending permanent placement for the resident.During an interview on 8/11/25 at 1:35 P.M, the Hospital B's RN C said the resident became violent last night towards others and required restraints be applied to prevent the resident from hurting others. The resident was admitted to the hospital and currently is on 1 on 1 monitoring awaiting psychiatric evaluation.During an interview on 8/11/25 at 1:20 P.M. the Administrator A said on 7/31/25 she notified the public administrator by phone that an emergency discharge was issued for the resident, and the resident would not be allowed back to the facility for the health and safety of the residents and staff.During an interview on 8/11/25 at 1:50 P.M the DON from the sister facility said the resident could become aggressive with staff and would often get involved with other resident's drama or behaviors causing the resident to have behaviors. The sister facility thought the resident could use a change and though the facility would be a good fit for the resident.During an interview on 8/11/25 at 2:35 P.M. the resident said he/she believed that he/she would be going back to the facility after treatment at the hospital. His/her personal belongings are at the facility, and he/she has nothing. He/she had made friends at the facility and missed them and the other residents. He/she is uncertain about where she will live and what the plans for the future will be and said he/she was frustrated he/she was not able to return to his/her home.Complaint #2579000 and #2580318

Based on interview, observation, and record review, the facility failed to protect one resident (Resident #1) from physical abuse when another resident (Resident #2) grabbed Resident #1 by the back of the shirt and hair, causing Resident #1 to lose his/her balance and fall to the ground. Resident #2 then made closed hand contact with Resident #1's face. The facility's census was 81. Review of the facility policy titled, Abuse and Neglect Policy, dated 6/12/24, showed: -It is the policy of the this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies with current state and federal regulations within prescribed time frames; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. In includes verbal, sexual, physical and mental abuse including abuse facilitated or enabled through the use of technology; -Physical abuse is defined as purposefully beating, striking, wounding, or injuring any resident tor any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting and kicking; -Abuse Prevention and Intervention: Resident Assessment. As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches that would reduce the chances of mistreatment of these residents. Staff will continue to monitor the goals and approaches on a regular basis; Pattern Assessment. Review accident/incident reports, missing item reports, and safety committee reports to assess possible patterns or trends of suspicious bruising of residents, unexplained accidents, or other occurrences that may constitute abuse, neglect or theft. Based on an assessment of the reports, the Facility will further investigation and/or determine whether a change in Facility practices is warranted; 1. Review of Resident #1's medical record showed the resident has the diagnoses of schizophrenia (a chronic brain disorder that affects a person's ability to think, feel, and behave clearly), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), adjustment disorder with anxiety (a mental health condition where an individual experiences significant emotional or behavioral difficulty in response to a stressful life event or change), attention deficit hyperactive disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), traumatic subarachnoid hemorrhage (a condition where bleeding occurs in the subarachnoid space, the area between the brain and the surrounding membranes, due to head trauma), drug-induced Parkinsonism (a movement disorder that mimics Parkinson's disease and is caused by medications that interfere with dopamine transmission in the brain), psychosis (a mental disorder characterized by a disconnection from reality). Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff) dated 5/6/25, showed: -The resident had adequate hearing, clear speech, able to make self understood and understands others. -He/She scored 15 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). This score indicates no cognitive impairment. -The resident displayed behaviors including rejection of care. Review of the resident's comprehensive care plan dated 5/9/25 showed: - Interventions related to plans to discharge to the community, guardianship, anxiety, schizophrenia, behaviors/altercation with other resident (resident's separated, allowed to vent feelings, medications reviewed), elopement risk. 2. Review of Resident #2's medical record showed he/she has the diagnoses of anxiety disorder, schizophrenia, bipolar disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), history of traumatic brain injury, falls, borderline intellectual function (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), attention deficit hyperactive disorder, borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), impulse disorder (a behavioral condition that makes it difficult to control one's actions or reactions), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). Review of the resident's quarterly MDS dated [DATE] showed; -The resident had adequate hearing, clear speech, able to make self understood and understands others; -He/She scored 12 on the BIMS, indicating moderate cognitive impairment. The resident displays delusions, physical and verbal behaviors. Review of the resident's comprehensive care plan dated 5/9/25, showed: -Interventions related to guardianship, elopement risk, behaviors (intense anger, aggression, delusions), post-traumatic stress disorder (PTSD), behavior modification plan (remove self from situation, talk to staff member, request as needed medication, utilize coping skills, use distraction techniques, reduce expectation of situation, offer positive praise, working on skill building strategies to use on a daily basis to assist in learning to control negative behaviors, develop a structured environment, one on one counseling, dialectical behavior therapy (DBT, a form of talk therapy that helps an individual regulate emotions, foster healthy relationships, and tolerate distress)), altercation with another resident (residents separated, Resident #2 placed on one to one supervision, medication review), resident was a smoker, and decreased cognition. Review of Resident #2's progress notes showed: 5/9/25 The resident grabbed Resident #1's back the back of the shirt and hair because the Resident #1 was wearing Resident #2's shirt. Resident #1 lost his/her balance and fell to the floor. Resident #2 then made closed hand contact to the Resident #1's face. The residents were separated and Resident #2 was placed on one to one supervision. The residents were assessed. Resident #1 was found to have an abrasion to his/her neck. Resident #2 had an abrasion to right pinky finger; 5/14/25 The resident continues to be on one to one supervision for safety and oversite. Review of the facility investigation showed on 5/9/25 at 9:20 AM, both residents were sitting in the common sitting area of the dining room. Resident #2 stated to Resident #1 Hey, that's my shirt you have on. Resident #2 stated The laundry person delivered it to me. Resident #2 stated That's my shirt and I want it back now. Resident #1 stated You are such a bitch, you act just like my little nephews. Both residents then ambulated up the hall. Resident #2 grasped Resident #1's hair and shirt. Resident #1 lost his/her balance and slowly went down to the floor on his/her bottom. Resident #2 then made closed hand contact to Resident #1's face. The resident's were immediately separated. Resident #1 was accompanied by staff to his/her room to vent and verbalize frustrations. Resident #2 was placed on one to one supervision. Both residents were given PRN (as needed) medication. Skin assessments were completed on both residents. Resident #1 was found to have a small abrasion to his/her throat. Resident #2 was found to have an abrasion to the right pinky finger. Medication reviews were conducted for both residents with the physician and psychiatric nurse practitioner. Medications adjustments were made for both residents. Resident #1 returned the shirt to Resident #2. Laundry staff were educated on properly identifying resident's clothing. Observation of Resident #2 on 5/14/25 at 2:35 P.M. showed Resident #2 eating lunch in his/her room with the one to one supervision by a staff member. During an interview on 5/14/25 at 2:37 P.M., Resident #2 said: -He/She was doing well and felt safe at the facility; -He/She did not recall the incident with Resident #1. During an interview on 5/14/24 at 2:40 P.M., Resident #1 said: -He/She was doing well and felt safe at the facility; -He/She did not realize the shirt belonged to Resident #2, as it was is Resident #1's closet; -Resident #2 was angry a lot and causes problems on the unit. It can get scary sometimes because Resident#2 yells and throws things. During an interview on 5/14/25 at 4:15 P.M., the physician said: -He/She just deals with the resident's medical needs; -The facility has a psychiatric nurse practitioner and a whole psychiatric team that takes care of any of the psychiatric needs of the residents; -There is a strict separation between what the physician does and what the psychiatric team does; -He/She was last in the facility on 5/15/25 but Resident #2 was not on the list to be seen; -He/She has not been notified of any behaviors or incidents involving Resident #2. However, he/she does not expect to be notified of behaviors due to the separation between the psychiatric team and the physician; -He/She would expect normal protocol to be followed and if Resident #2 is having behavior and being more aggressive, the psychiatric team would be notified and to go from there. During an interview on 5/14/25 at 4:12 P.M., the Corporate Nurse Consultant said: -Resident #2 is constantly escalating and de-escalating. He/She will say I'm going to be good and will turn around and have an altercation; -There is a pattern of when Resident #2 comes off of one on one supervision, he/she will eventually have another altercation; -The resident should stay on one to one supervision. The facility is seeking alternate placement for the resident. During an interview on 5/21/25 at 1:37 P.M., the psychiatric nurse practitioner said: -He/She is very familiar with Resident #2; -Resident #2 is very difficult to treat due to the extent of his/her borderline personality disorder; -When Resident #2 does not get his/her way, he/she will have an outburst; -Resident #2 displays self-sabotaging behaviors. He/She will talk about going to a different facility, then the day before going to visit the facility, he/she will have another altercation. The new facility will then not accept Resident #2 due to behaviors; -When Resident #2 comes off of one to one supervision, he/she does well until he/she does not get his/her way. Then Resident #2 has explosive behaviors unless a staff member is right there to remind him/her to use coping and calming techniques; -Resident #2 should remain on one to one supervision for his/her safety, and the safety of the staff and other residents. During an interview on 5/14/25 at 2:59 P.M., the Administrator said: -He has received direction from corporate leadership to cut back on one on one supervision for Resident #2, to cut back on the cost of staff overtime; - Every time he backs off one on one supervision for Resident #2, the resident gets into a resident to resident altercation with another resident; -There is no plan at this time to remove Resident #2 from one to one supervision; -Resident #2 does well for a while and well be changed to 15 minute checks. Then something will trigger him/her, and then he/she will lash out; -The facility continues to work with the counselor and psychiatric nurse practitioner to support Resident #2 in learning coping skills. MO253985

Based on interview and record review, the facility failed to protect three residents (Resident #29, #30, and #33) from physical abuse when Resident #1 strangled and punched Resident #30 in the face to the extent hospitalization was required; strangled and punched Resident #33 in the face resulting in medical evaluation at the local hospital; and took Resident #29's walker away and shoved the resident in the face, causing a fall that required the resident to have an x-ray for a large abrasion sustained to his/her left knee. The facility census was 81. The Administrator was notified on 04/18/2024 at 5:05 PM of the past noncompliance Immediate Jeopardy (IJ) which began on 03/21/2025. The facility administration immediately separated and protected the residents from further abuse by Resident #1. Resident #1, #30, and #33 were sent to the hospital for medical assessment and treatment, staff updated each residents plan of care, and all residents were offered counseling from the mental health provider. When Resident #1 returned to the facility staff implemented one on one supervision. All staff were inserviced on the abuse and neglect policy and procedure, and behavioral emergency plans by 3/25/25. The noncompliance was corrected on 3/25/2025. Review of the facility's Abuse Policy, dated 6/12/24., showed: -The facility will develop and implement operational policies and procedures to screen and train employees for protection of residents and the prevention of abuse and mistreatment. - Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. - Physical Abuse is defined as purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. - Protection of Residents: Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation. The accused residents shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents. - The facility will identify, correct, and intervene in situations where abuse is likely to occur. - The facility will identify patterns, behaviors, and trends of behaviors that could result in harm to others. - The facility will protect all residents from harm. Review of the facility's Sufficient Staff Policy, dated 5/18/23, showed it was the policy of this facility to provide sufficient staff to assure resident safety and attain the resident's highest practicable, physical, mental, and psychosocial well being. 1. Review of Resident #1's Quarterly MDS (Minimum Data Set), a federally mandated assessment tool completed by facility staff, dated 12/10/24, showed: - Cognition intact; - Diagnoses included: bipolar schizophrenia (a mental health condition characterized by extreme mood swings, ranging from periods of elevated mood (mania or hypomania) to periods of depression), post traumatic disorder (a mental health condition that can develop after a person has experienced or witnessed a traumatic event), anxiety, depression, borderline personality disorder (a mental health condition characterized by significant challenges in regulating emotions, unstable relationships, a distorted self-image, and impulsive behaviors), and obesity; - Independent with ambulation and all mobility, if standing; - Behaviors of acting out and harming others. Review of the resident's care plan, dated 1/31/24, showed: - The resident had behavioral challenges that required protective oversight in a secured setting; - Expresses homicidal ideation towards others and had stated would like to see their blood on the floor; - History of destroying property, screaming, and acting violent towards people; - Required 24 hour nursing oversight to ensure self and others are safe; The care plan did not state how many nursing staff were needed. - One on one staff monitoring of resident as needed. Review of the resident's nursing progress notes for March 2025 showed: - 3/17/25 at 4:06 P.M., resident was removed from one on one monitoring per the approval of Regional Director of Operations. - 3/17/25 was placed on 15 min checks after the one on one monitoring was removed. - 3/18/25 at 11: 41 P.M., as needed Thorazine (antipsychotic medication) 50 milligrams (mg) given at the request of the resident for increased anxiety. - 3/20/25 at 2:14 P.M., Administrator and resident met to discuss how resident was doing, resident reported doing good and utilizing PRN (as needed) medications for anxiety and homicidal ideations. - 3/21/25 at 5:15 P.M., a Code [NAME] (emergency staff intervention for violent behaviors) was announced. Licensed Practical Nurse (LPN) C on the secured unit observed Resident #1 standing over Resident #30's bed strangling with left hand and punching Resident #30 in the face, with the right hand. Then Resident #1 proceeded to Resident #33's room and repeated the exact assault. Resident #33 was laying face down in the bed to protect his/her face from injury. Resident #1 then attempted to assault LPN C and that assault was interrupted by Resident #29 when attempting to get in the middle of Resident #1 and LPN C, Resident #1 took the walker from Resident #29 and threw it down the hall and then pushed Resident #29 by an opened hand to the face causing Resident # 29 to fall and sustain a baseball sized abrasion to the left knee. 2. Review of Resident #30's Quarterly MDS, dated [DATE], showed; - Cognition Intact; - Diagnoses: Bipolar disorder, post traumatic stress disorder, depression, and anxiety; - Ongoing mood and behavioral concerns towards others. - Independent with all mobility and ambulation. Review of the resident's care plan, dated 8/8/23, showed: - Resident is on behavior program: a 5 person assisted resident take down when resident poses a threat to self or others. - Resident had a long history of mental illness and has one on one monitoring when needed for the safety of self and others. Review of the resident's nursing progress notes, dated 3/21/25, showed: -At 5:05 P.M., LPN C heard screaming from Resident #30's room, discovered Resident #30 lying in bed and being strangled by Resident #1 by the use of the left hand and also punching Resident #30 in the face with the right hand. -Resident #30's statement to LPN C was that Resident #1 was asked to leave Resident #30's room and Resident #1 walked over shut the door to the room, climbed on top of Resident#30 and began choking and punching the resident in the face. -Resident #1 was removed from the room and Resident #30 was sent to local emergency room for evaluation. -Resident #30 was admitted to the hospital for monitoring of nasal fracture and neurological trauma. Review of the resident's hospital records, dated 3/21/25, showed Resident #30 was admitted to a local hospital for neurological evaluation, observation, and small nasal fracture. The resident returned to the facility on [DATE] with a small nasal fracture, soreness, and bruising. During an observation and interview on 3/23/25 at 3:10 P.M., Resident #30 said: -Resident #1 came into his/her room shortly after smoke break, jumped on top of him/her, choked and punched him/her in the face. It happened so fast, he/she couldn't get out from under Resident #1. -Observation showed a small bruise across the bridge of Resident #30's nose and bruising to the neck and left arm. -He/She was caught off guard because he/she thought Resident #1 was his/her friend. 3. Review of Resident #33's Re-Admission MDS, dated [DATE]., showed: - Cognition Intact; - Independent with mobility and ambulation; - Diagnoses: Borderline personality disorder, schizophrenia, depression, anxiety, and personally disorders, mood and behavioral disorders. Review of the resident's care plan, dated 2/2/25, showed: - The resident had hallucinations and aggressive behaviors at time towards others. - The resident was impulsive, will self harm and has destructive behaviors and will manipulate others. Review of the resident's nursing progress notes, dated 3/21/25, showed: - At 5:10 P.M., LPN C heard screaming from Resident #33's room, discovered Resident #33 lying in bed face down and being strangled by Resident #1 by use of the left hand, and also punching Resident #33 in the right side of the head with the right hand. - Resident #33's statement to LPN C was that Resident #1 came in and jumped on his/her back and started choking and punching him/her in the side of the face. -Resident #1 was removed from the room and Resident #33 was sent to local emergency room for evaluation. -The resident was not admitted to the hospital and had no injuries. Observation and interviews on the secured unit on 3/23/25 at 11:00 A.M., showed Resident #33, up and about on the secured unit with bruising to his/her left side of neck and face and some bruising noted to his/her left forearm. During an interview on 3/23/25 at 4:00 P.M., Resident #33 said it happened fast, he/she was laying on the bed on his/her stomach and Resident #1 jumped on his/her back and pushed on the back of his/her neck and punched his/her on the side of the face. Someone pulled Resident #1 off him/her. He/She was then taken to local hospital for evaluation on 3/21/25 and came back to the facility that night with no injuries. He/She feels safe now that Resident #1 was gone and would not have to worry about Resident #1 doing that again. 4. Review of Resident #29's Quarterly MDS, dated [DATE], showed: - Cognition intact; - Independent with ambulation and a four wheeled walker; - Diagnoses: Post traumatic stress disorder, anxiety, depression, diabetic, early onset dementia, history of falls. Review of the resident's care plan, undated, showed: - The resident required a secured unit and behavioral monitoring. -The resident must have a walker for ambulation and used a four wheeled walker. - The resident had braces to both lower legs to support limbs for ambulation and stability. - The resident had periods of yelling out and behaviors towards others at times. Review on the resident's nursing progress notes, dated 3/21/25, showed: - Resident heard the fighting going on in Resident #33's room with Resident #1 and with LPN C attempting to remove Resident #1 off Resident #33. - Resident #1 turned on LPN C and kicked LPN C in the knee and punched LPN C in the shoulder. Resident #29 attempted to get in between Resident #1 and LPN C when Resident #1 picked up Resident #29's walker threw it down the hall and then placed his/her hand on Resident #29's face and shoved there resident down causing Resident #29 to fall landing on his/her knees and causing a baseball sized abrasion to the left knee. - X-ray of knees were obtained, no injuries identified. Observation and interview on 3/31/25 at 4:05 P.M., showed Resident #29 with a baseball sized round abrasion to his/her left knee. The resident said it was tender and hurt a bit, but nothing was broke. He/She felt safe knowing Resident #1 won't be returning to the facility, because Resident #1 was known to have behaviors and could get mad easily, and that made here feel uneasy. 5. During an interview on 3/23/25 at 10:45 A.M. CNA C said: - He/She only works Friday through Sunday 7 A.M. to 7 P.M. - On 3/21/25 he/she was outside supervising residents who were smoking and did not witness the assaults. - On 3/21/25, prior to the incident, while outside with the residents, CNA C witnessed Resident #1 blowing smoke in the face of Resident #33, which was a new behavior, but he/she did not think anything about it at the time. - He/She and LPN C were the only staff on the unit at the time the assaults took place. During an interview on 3/23/25 at 11:30 A.M., LPN C said: - On 3/21/25 around 5:00 P.M. CNA C was the only CNA working and the Certified Medication Technician (CMT) had called in for the evening shift that day. - He/She went back to the secured unit to help CNA C. While down there LPN C was at the nurses desk making phone calls to look for an additional person to come in and help on the unit. - Resident #1 had just finished smoke break with CNA C and was at the nurses desk requesting LPN C get coffee creamer. - He/She was on the phone and CNA C had taken the next group of residents to smoke break. He/She hung up the phone and went to obtain the coffee creamer. There was no other staff on the secured unit during this time. When LPN C returned to the desk with the creamer, Resident #1 was not there. Then Resident #33 approached LPN C and said Resident #1 wants you to come down to Resident #30's room. - When approaching Resident #30's room he/she heard screaming and observed Resident #1 on top of Resident #30 holding him/her down by the neck with him/her left hand and punching the resident in the face with his/her right hand. LPN C pulled Resident #1 off of Resident #30 by grabbing a hold of his/her shirt and pulling backwards. -Resident #1 then left the room and headed for Resident #33's room. LPN C called the Director of Nursing (DON) on his/her cell phone because the walkie talkie was lost in the struggle with Resident #1. He/She asked the DON to call a Code [NAME] and that he/she needed help immediately in the unit. He/She went to Resident #33's room where Resident #1 was on top of Resident #33 strangling him/her by the neck with his/her left hand, and punching the resident in the side of the head with the other hand. -Resident #29 attempted to help and Resident #1 took the walker and pushed Resident #29 to the floor. -Multiple staff arrived to the unit to provide assistance. LPN D was placed with Resident #1 for one on one monitoring until police and ambulance arrived. -The DON also arrived to the unit to help. -He/She said the event happened very fast and was done in about 5 minutes. -Resident #1, #30, and #33 sent out to local hospital for evaluations. -He/She did not believe they had enough staff on the secured unit to provide a safe environment for the residents to be free from abuse. During an interview on 3/23/25 at 12:39 P.M., the DON said: - On the evening of 3/21/25 she worked later that day as there were two admissions that had came in that afternoon. - She received a frantic call from LPN C that said Get back here now and call a Code [NAME] (refers to behavioral emergency). - Upon arrival to the unit Resident #1 was sitting on the floor, screaming at LPN C You fat bitch, I am going beat up everyone. - A nurse was assigned to sit with Resident #1 until the resident left the facility via ambulance to the local hospital. - Skin assessments were completed on Resident #1, #30, #33, and #29 and Neuro checks on Resident #30, #33, and #29. - Resident #30 and #33 were transported to local hospital for evaluation. - Resident #30 was transferred to higher level hospital for neurology consult. - Resident #33 was returned without injury. - Resident #29 had portable X-ray of legs and no broken bones, but he/she did sustain a abrasion to left knee. During an interview on 4/2/25 at 1:30 P.M. LPN D said: - A code green was called over the paging system on 3/17/25 at 5:05 P.M. and he/she went to the unit. - He/She was working up front at station one. - He/She sat with Resident #1 until police and the ambulance took the resident. - There are resident's on the unit that are known to have behaviors and can become violent, including Resident #1. During an interview on 4/3/25 at 4:15 P.M. the Administrator said: - He became the administrator of the facility in January of this year. - He was aware of previous resident to resident abuse on the unit. - All resident's should be free from abuse. - The residents in this facility can be challenging and the staff work to try and meet those challenges. MO251511 MO251494

Based on observation, interview and record review the facility failed to ensure each resident and resident representative, if applicable, was involved in developing the care plan and making decisions about his or her care. This affected 3 out of 18 sampled residents (Resident #9, #47, and #59). The facility census was 81. Review of the Facility's Comprehensive Care Plan Policy, revised 10/31/2024, showed: The purpose of a care plan is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: A. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan. B. A registered nurse with responsibility for the resident. C. A nurse aide with responsibility for the resident. D. A member of the food and nutrition services staff. E. The resident and the resident's representative, to the extent practicable. F. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to: I. The RAI Coordinator II. Activities Director/Staff. III. Social services director/Social worker. IV. Licensed therapists V. Family members, surrogate or others desired by the resident. VI. Administration VII. Discharge Coordinator. VIII. Mental Health Professional. IX. Chaplain. X. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 1. Review of Resident #47's MDS, dated [DATE]., showed: -Cognition intact. -Diagnoses included: Anxiety disorder, Depression, Manic bipolar disease, Schizophrenia, Asthma or COPD. Review of the resident's care plan, dated 10/26/2024, showed: -Tendency to self-isolate self. - Provide with activities calendar. -No mention to include guardian in care plan meetings. Review of the resident's Face Sheet showed: - the resident had a guardian. Review of resident's record showed last care plan update was made on 10/26/24 with a target date of 12/28/24. During an interview on 04/03/25 at 8:39 A.M., the resident's guardian said he/she had not been invited to care plan meetings and would like to be included on conversations regarding the resident. He/she had concerns regarding communication from the facility. The resident's guardian stated he/she had never received updates regarding changes in a care plan and would like to be included. During an interview on 04/1/25 at 8:21 A.M., the resident said he/she had not been included in care plan updates or making decisions about care plans. 2. Review of Resident #59's Quarterly MDS, dated [DATE], showed: -Dependent in all activities of daily living. -Diagnoses: diabetes, stroke. Review of the resident's Care Plan, dated 07/11/2024, showed: -The resident was dependent upon staff for meeting all emotional, intellectual, physical and social needs. -Dependent on nursing staff for all ADLS. Record review of an undated care plan for Resident #59, located in the resident's medical record showed: - Ensure guardian's wishes are followed. -The guardian will assist in making decisions for the resident. Review of the electronic medical record showed the resident had a Durable Power of Attorney (DPOA). During an interview on 04/01/2025 at 5:20 P.M., the resident's DPOA said he/she has never been invited to a care planning meeting or been available to attend one in person. The resident's DPOA said he/she would like to be included on conversations over the phone regarding the resident and had not received phone calls from the facility. Communication with the facility was not working and they will not answer calls at the facility. The resident's guardian DPOA stated he/she had never received a written update to a care plan from the facility. During an interview on 4/02/2025 at 2:00 P.M., Social services said that the DPOA of Resident #59 does not answer phone calls. 3. Review of Resident #9's Quarterly Minimum Data Set (MDS), a Federally mandated assessment instrument completed by facility staff, dated 01/30/2025., showed: -Cognition Intact. -Diagnoses included: Migraines, Obsessive compulsive disorder, Bipolar disorder, Open wound of left lower quadrant, Diabetes, Insomnia, Traumatic brain injury, and Cerebral infarction. Review of the resident's care plan, dated 02/11/2025, showed: -Impaired decision making. -Guardian to be included in making decisions. During an interview on 04/1/25 at 8:30 A.M., the resident said his/her guardian had not been included in any care plan meetings or updates. 4. During an interview on 04/03/25 at 2:00 P.M., the Social Service Designee said has tried to include residents guardians in care plan meetings, but the guardians doesn't don't answer their phones. During an interview on 04/04/25 at 3:20 P.M., the Director of Nursing said guardians or resident representatives should be included in the care plan creation and revisions. During an interview on 04/04/25 at 3:30 P.M., the Administrator said guardians or resident representatives should be included in the care plan process.

Based on observation, interview and record review, the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff failed to ensure they provided perineal care at least every two hours for three residents (Resident #56, #8, and #59), The facility census was 81. The facility did not provide the requested policy on ADLs. Review of the facility policy Perineal Care, dated 06/29/23, showed: -Ensure residents' perineal area is kept clean to prevent skin breakdown, odor, and infection; -Perineal care is very important to maintaining the comfort of residents; -More frequent care is required for residents who are incontinent and for those who have an indwelling catheter. 1. Review of Resident #56's care plan dated 02/27/24, showed: -ADL self-care deficit related to stroke; -Used a wheelchair; -Required assistance of two staff for ADLs. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/20/25, showed: -Moderate cognitive impairment; -Upper and lower body impairment on one side of the body; -Dependent on staff for toileting; -Diagnoses included: Stroke, diabetes, and depression. During an observation beginning on 03/31/25 at 07:32 A.M. - 10:13 A.M., showed: -07:32 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:50 A.M., the resident sat at the table in the dining room in his/her wheelchair; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -10:13 A.M., the resident sat at the table in the dining room in his/her wheelchair; -During this time frame the facility staff had not offered to toilet the resident. During an observation beginning on 3/31/25 at 10:59 A.M. - 1:25 P.M. showed: -10:59 A.M., the resident sat in his/her wheelchair at the table with his/her eyes closed; -11:03 A.M., the resident sat in his/her wheelchair at the table. The Assistant Director of Nursing (ADON) walked by the resident and did not provide incontinent care for the resident; -11:17 A.M., the resident sat in his/her wheelchair at the table. Nurses Aide (NA) J and Certified Nurses Aide (CNA) H walked by the resident and did not provide incontinent care for the resident; -11:25 A.M., CNA H walked by the resident in his/her wheelchair at the table and CNA H did not offer to provide incontinent care for the resident; -12:26 P.M., lunch was delivered and the resident still sat in his/her wheelchair at the table with his/her eyes closed; -12:46 P.M., available staff did not offered to reposition or toilet the resident; - 01:01 P.M., the resident finished his/her lunch and sat in his/her wheelchair at the table. Available nursing staff failed to provided incontinent care for the resident; -01:25 P.M., the resident sat at the table in his/her wheelchair. No staff had toileted the resident. - 1:30 P.M., the resident was incontinent of urine with a urine puddle under the wheelchair and strong urine odor on the resident. During an observation beginning on 04/01/25 at 07:20 A.M. until 9:30 A.M., showed: -07:20 A.M., the resident sat at the table in the dining room in his/her wheelchair; -07:39 A.M., the resident sat at the table in the dining room in his/her wheelchair; -07:24 A.M., NA J and CNA H walked by the resident and did not toilet the resident; -08:15 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available staff did not offer to toilet the resident; -08:30 A.M., the resident sat in his/her wheelchair at the table; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair. During an observation starting on 4/1/25 at 9:45 A.M - 10:45 A.M., showed: -09:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available staff did not offer to toilet the resident; -10:00 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available staff did not offer to toilet the resident; -10:22 A.M., NA J and CNA H walked by the resident setting at the table and did not toilet the resident; -10:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. During an interview on 04/02/25 at 1:10 P.M., NA J said: -He/She tried to toilet the resident at least every two hours; -Several residents are incontinent and things get busy sometimes and he/she does not have time to toilet and change the residents. -Incontinent residents should be toileted at least every two hours including this resident. During an interview on 04/02/25 at 1:30 P.M., CNA H said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -The resident had been setting in his/her wheel since breakfast; -He/She had not provided incontinent care or repositioned since breakfast; -The resident should be provided incontinent care and repositioned at least every two hours; -The facility needed more staff; -He/She did not provide incontinent care and reposition the resident every two hours, because there was not enough staff. During an interview on 04/02/25 at 1:42 P.M., the Assistant Director of Nursing (ADON) said: -He/She expected the resident to have incontinent care every two hours or as needed; -He/She was not aware the resident had not been toileted for over two hours; -Incontinent residents should be toileted at least every two hours. 2. Review Resident #8's care plan, dated 03/18/24, showed: -ADL care deficit related to weakness; -Assist of two staff with transfers and ADLS; -History or pressure injury to buttock; -Uses a urinary catheter; -Incontinent of bowel; -Clean perineal area after each incontinent episode. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Dependent with ADLs; -Frequently incontinent of bowel and bladder; -Diagnoses included cancer, depression, and schizophrenia (a chronic mental disorder characterized by a breakdown in thought processes and a disconnection from reality). During an observation beginning on 03/31/25 at 07:32 A.M.-10:59 A.M., showed: -07:32 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:50 A.M., the resident sat at the table in the dining room in his/her wheelchair; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -10:13 A.M., the resident sat at the table in the dining room in his/her wheelchair. No facility staff around to toilet the resident. -10:59 A.M. the resident sat in his/her wheelchair at the table with his/her eyes closed. During an observation on 3/31/25 starting at 11:03 A.M.-1:25 P.M., showed: -11:03 A.M., the resident sat in his/her wheelchair at the table. The ADON walked by the resident and did not provide incontinent care for the resident; -11:05 A.M., the hospice nurse took the resident to his/her room; -11:07 A.M., the hospice nurse spoke with the resident in his/her room, but did not change or toilet the resident; -11:12 A.M., the hospice nurse took the resident back to the dining room; -11:17 A.M., the resident sat in his/her wheelchair at the table. NA J and CNA H walked by the resident and did not provide incontinent care for the resident; -11:25 A.M., CNA H walked by the resident in his/her wheelchair at the table and CNA H did not offer to provide incontinent care for the resident; -12:26 P.M., Lunch was delivered and the resident continued to sit in his/her wheelchair at the table; -12:46 P.M., Available staff did not offer to reposition or toilet the resident; - 01:01 P.M., The resident finished his/her lunch and sat in his/her wheelchair at the table. No staff were around to provide incontinent care for the resident; -01:25 P.M., the resident sat at the table in his/her wheelchair. Available nursing staff did not toilet the resident. During an observation beginning on 04/01/25 at 07:20 A.M. until 10:45 A.M., showed: -07:20 A.M., the resident sat at the table in the dining room in his/her wheelchair; -07:39 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:15 A.M., the resident sat at the table in the dining room in his/her wheelchair. Nursing staff did not offer to toilet the resident; -08:30 A.M., the resident sat in his/her wheelchair at the table; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -09:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. Nursing staff did not offer to toilet the resident; -10:00 A.M., the resident sat at the table in the dining room in his/her wheelchair. Nursing staff did not offer to toilet the resident; -10:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. Nursing staff did not offer toilet the resident and the resident had a strong urine odor. During an interview on 04/02/25 at 1:30 P.M., CNA H said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -The resident should be provided incontinent care and repositioned at least every two hours; -He/She did not provide incontinent care and reposition the resident every two hours, because there was not enough staff. 3. Review of Resident 59's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff with ADLs; -Always incontinent of bowel and bladder; -Diagnoses included, stroke and depression. Review of the resident's care plan, dated 01/14/25, showed: -Limited physical mobility; -Total dependence on staff with ADLs; -Incontinent of bladder; -Clean perineal area after each incontinent episode. Observation beginning on 03/31/25 at 07:32 A.M. until 10:59 A.M., showed: -07:32 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:50 A.M., the resident sat at the table in the dining room in his/her wheelchair; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -10:13 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available facility staff had not offered to toilet the resident; 10:59 A.M. the resident sat in his/her wheelchair at the table, with his/her eyes closed; Observation on 3/31/25 at 11:03 A.M through 1:25 P.M., showed: -11:03 A.M., the resident sat in his/her wheelchair at the table. The ADON walked by the resident and did not provide incontinent care for the resident; -11:17 A.M., the resident sat in his/her wheelchair at the table. NA J and CNA H walked by the resident and did not provide incontinent care for the resident; -11:25 A.M., CNA H walked by the resident in his/her wheelchair at the table and CNA H did not offer to provide incontinent care for the resident; -12:26 P.M., Lunch was delivered and the resident continued to sit in his/her wheelchair at the table with his/her eyes closed; -12:46 P.M., available staff did not offer to reposition or toilet the resident; - 01:01 P.M., The resident finished his/her lunch and sat in his/her wheelchair at the table. Available facility staff did not provided incontinent care for the resident; -01:25 P.M., The resident sat at the table in his/her wheelchair. Available nursing staff did not offer to reposition or toilet the residents. The resident had a strong urine odor. Observation beginning on 04/01/25 at 07:20 A.M.- 10:45 A.M., showed: -07:39 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:15 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available nursing staff never offered to toilet the resident; -08:30 A.M., the resident sat in his/her wheelchair at the table; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -09:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. Staff never offered to toilet the resident; -10:00 A.M., the resident sat at the table in the dining room in his/her wheelchair. Staff never offered to toilet the resident; -10:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. Staff never offered to toilet the resident. -There was a strong smell of urine. During an interview on 04/02/25 at 1:10 P.M., NA J said: -The resident was nonverbal; -He/She liked to toilet in the shower room; -He/She tried to toilet the resident at least every two hours; -The resident should have been toileted at least every two hours, but there was not enough staff. During an interview on 04/02/25 at 1:30 P.M., CNA H said: -The resident was dependent on staff for transfers; -The resident was incontinent; -The resident should be provided incontinent care and repositioned at least every two hours; -He/She did not provide incontinent care and reposition the resident every two hours, because there was not enough staff. 52043 4. During an interview on 04/02/25 at 1:48 P.M., Licensed Practical Nurse (LPN) D said: -The CNAs usually toilet the residents; -He/she expected the residents to have incontinent care every two hours or as needed; -Incontinent residents should be toileted at least every two hours. During an interview on 04/03/25 at 04:11 P.M., the Director of Nursing (DON) said: -He/she expected residents to have incontinence care every two hours or as needed; -He/she was not aware the incontinent residents had not been toileted for over two hours; -Over four hours was too long to wait to change incontinent residents; -He/she expected incontinent residents be provided peri care and changed at least every two hours. During an interview on 04/03/24 at 04:15 P.M., the Administrator said: -He/she expected residents to have incontinence care every two hours or as needed; -He/she was not aware incontinent residents had not been toileted for over two hours; -Over four hours was too long to wait to change incontinent residents; -He/she expected incontinent residents be provided perineal care and changed at least every two hours.

Based on observation, interview, and record review, facility staff failed to maintain resident dignity by assisting Resident #43 with removal of unwanted facial hair, failed to provide privacy during personal care for two residents (Residents #43 and #56), and failed to fully dress Resident #47 and cover exposed skin while in the dining room. This affected three out of the 18 sampled residents. The facility census was 81. Review of the facility's Resident Rights Policy, dated 12/27/23, showed: - Residents shall be treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. - All persons, other than the attending physician, facility personnel necessary for any treatment or personal care, or the Missouri Department of Health and Senior Services, as appropriate, shall be excluded from observing resident during any time of examination, treatment, or care. 1. Review of Resident #43's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 03/26/25, showed the resident: - Was cognitively intact. - Required partial to moderate assistance and verbal cues. - Had diagnoses including heart failure, schizophrenia, and asthma. Review of the resident's Care plan, revised on 10/25/24, showed: - The resident had an activities of daily living (ADL) self-care deficit related to impaired balance. -Required some assistance and encouragement with cares. -The resident did not want to shave arm pits or face. The resident stated he/she preferred to have hair on face tweezed and not shaved. Observation on 03/31/25 at 10:07 A.M., showed: - The resident lay in bed in his/her room with an incontinence brief on; - The resident had a sheet available, but was unable to pull the sheet up on his/her own; - The bathroom door was blocked open with walker. The bathroom was adjoined to the next room; - The window curtains were open and the privacy curtain was pulled back enough to expose the lower half the resident's body. The resident's roommate was also in the room, in bed, in direct view of the exposed resident; - The windows looked out to the roadway; - The resident had substantial hair growth of 1.5 inches inches on chin. During an interview on 03/31/25 at 10:07 A.M., the resident said: - He/She had no privacy. - The staff do not always knock before entering their room. - The resident did not want to be shaved and has asked staff to use tweezers, but the staff has not located tweezers and used them to remove the resident's chin hair. -It did not make him/her feel good to have his/her facial hair not removed. Observation on 04/01/25 at 7:58 A.M., showed: - The resident standing by sink in a brief in his/her room with the door open. - Staff assisted the resident with oral care in view of the public. - The window curtains were open. - The hair growth remained on the resident's chin. During an interview on 04/01/25 at 11:30 A.M., the resident said: - Privacy was not respected at all during oral care and grooming. - The staff don't pull the curtains when they change him/her. - He/She had to ask most of the staff to pull the curtains and some staff leave the door open too. During an interview on 04/03/25 at 8:05 A.M., CNA F said: - Nursing staff are to knock, ask permission, pull privacy curtain, close the door, and begin the process of providing cares. - Nursing staff should ask in the shower if resident wants to be shaved, it's put in the care plan if the residents don't. On a day-to-day basis nursing staff will check and ask. - Nursing staff do not have tweezers if residents don't want to be shaved, but staff will get scissors to trim or use an electric razor to trim. Staff just never have used tweezers. During an interview on 04/03/25 at 11:32 A.M., the Assistant Director of Nursing (ADON) said: - She expected staff to knock, announce their name and preferably announce their department, ask permission, wait for a response, and ask resident what help was needed. - She expected staff to always pull privacy curtains, window curtains, and shut the door. During an interview on 04/03/25 at 3:30 P.M., the Director of Nursing (DON) said: - She would expect staff to pull privacy curtain, shut room door, and close window curtains. - If a resident didn't want to be shaved a certain way, and preferred to have tweezers used, the resident could. 46706 2. Review of Resident #56's annual MDS, dated [DATE], showed: -Moderate cognitive impairment; -Upper and lower body impairment on one side of the body; -Dependent on staff for toileting; -Diagnoses included: Stroke, diabetes, and depression. Review of the resident's care plan dated 02/27/25, showed: -ADL self-care deficit related to stroke; -Used a wheelchair; -Required assistance of two staff for ADLs; Observation on 04/01/25 at 09:49 A.M., showed: -The resident asleep, in a wheelchair, seated at a table in the dining room; -The resident was not wearing pants; -The resident's bare legs were exposed thigh down to his/her feet, because the resident's blanket was not pulled up; -NA J walked past the resident and did not cover up the resident's exposed areas. Other staff walked by and other residents were seated in the dining room. -The ADON walked by the resident and did cover up the resident's exposed legs During an interview on 04/01/25 at 10:04 A.M., NA J said: -Being uncovered in the dining room is not dignified; -He/She did not notice the resident was exposed from the upper thigh down; -The resident should not be exposed in the dining room; -Any staff passing by should offer to cover the resident up. During an interview on 04/01/25 at 10:18 A.M., the ADON said: -Being uncovered in the dining room is not dignified; -He/She did not notice the resident was exposed from the upper thigh down; -The resident should not be exposed in the dining room; -Any staff passing by should offer to cover the resident up. Observation on 04/01/25 at 12:16 P.M., showed: -CNA H and NA J entered the resident's room; -The resident's roommate lay in bed facing the resident's side of the room; -The window curtain and privacy curtain were open. The windows looked out to the courtyard; -CNA H and NA J removed the resident's brief; -The resident was exposed from the perineal area down; -CNA H and NA J provided perineal care to the resident; -The staff did not close the window curtain before providing perineal care to the resident; -The staff did not close the privacy curtain before providing perineal care to the resident. During an interview on 04/01/25 at 01:09 P.M., CNA H said: -The window curtain and the privacy curtain should be closed before providing cares and just forgot to close the curtain; -The resident being exposed from the waist down when both curtains were not closed was not dignified. During an interview on 04/01/25 at 01:10 P.M., NA J said: -The window curtain and the privacy curtain should be closed before providing cares; -He/she had forgot to close the curtain; -The resident should have privacy when cares are provided; -The resident was exposed to the resident in the next bed; -The resident being exposed from the waist down when both curtains were not closed was not dignified. Observation on 04/01/25 at 3:19 P.M., showed window curtain and privacy curtain open as CNA F, CNA A, and NA I provided peri-care to the resident. During an interview on 04/03/25 at 8:05 A.M., CNA F said nursing staff are to knock, ask permission, pull privacy curtain, close the door, and begin the process of providing cares. During an interview on 04/03/25 at 11:32 A.M., the Assistant Director of Nursing (ADON) said: - She expected staff to knock, announce their name and preferably announce their department, ask permission, wait for a response, and ask resident what help was needed. - She expected staff to always pull privacy curtains, window curtains, and shut the door. During an interview on 04/03/25 at 3:30 P.M., the Director of Nursing (DON) said: - She would expect staff to pull privacy curtain, shut room door, and close window curtains. - If a resident didn't want to be shaved a certain way, and preferred to have tweezers used, the resident could. 52044 3. Review of Resident #47's Quarterly MDS, dated [DATE]., showed: -Cognition intact. -Diagnoses included: Anxiety disorder, Depression, Manic bipolar disease, and Schizophrenia. Review of the resident's care plan, dated 10/26/2024, showed: -The resident was dependent upon nursing staff to anticipate and meet all needs. -The resident required one person to assist with personal hygiene and grooming. -The resident had behaviors and was non-complaint with grooming and hygiene. Observation on 03/31/25 at 08:20 A.M., showed the resident in the dining room with heavily soiled clothing and food stains down the front of his/her shirt and hair dirty and matted. Observation on 04/01/25 at 08:21 A.M., showed the resident in the dining room wearing the same clothing as 3/31/25. The clothing had stains down the front. The resident's hair was greasy, dirty, and matted. Observation on 04/03/25 at 08:30 A.M., showed the resident in the dining room wearing the same clothing as 3/31/25 and 4/1/25. The clothing had heavy stains and his/her hair was unkempt. During an interview on 04/03/25 at 09:00 A.M., the resident said he/she was afraid to take a shower because his/her clothing would be stolen so he/she would not shower. The resident voiced concerns of having one outfit left to wear and that he/she was afraid if clothing was changed his/her clothes would not get returned and it was his/her favorite piece of clothing and the only clothing left. The resident said he/she wanted to shower, but he/she can't so he/she felt angry. Observation on 04/03/25 at 09:05 A.M., showed: -No clothes were found in the resident's closet. During an interview on 04/02/25 at 02:00 P.M., the Social Services Designee said residents should be dressed in clean clothing. During an interview on 04/03/25 at 09:00 A.M., the Housekeeping Supervisor said residents clothing should be clean. During an interview on 04/03/25 at 10:30 A.M., CNA H said he/she helps give showers and they put clean clothing on residents following showers. During an interview with the DON and Administrator on 04/04/25 at 3:30 P.M., they said residents should be in clean clothing.

Based on interview and record review, the facility failed to ensure four nurse aides currently working and providing direct resident care met the minimum qualifications, which included satisfactory participation in a state-approved nurse aide training and competency evaluation program within four months of hire. The facility census was 81. Review of the facility's policy titled, Nurse Aide (NA) Qualifications and Training Requirements, revised May, 2019, showed: - Nurse Aides must undergo a state-approved training program; - In keeping with the Omnibus Budget Reconciliation Act of 1987 (OBRA), our facility will only employ those nurse aides who meet the requirements set forth in the federal and state statutes concerning the staffing of long-term care facilities; - Our facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, or otherwise, unless: that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or that individual has been deemed competent as provided in 483.150 (a) and (b) of the Requirements of Participation; - Nursing aides failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services. Review of facility employee list showed the following four Nurse Aides were actively working, not enrolled in a state approved nurse aide training, or had not completed a competency evaluation within four months of hire: - Nurse Aide E was hired on 3/17/24; - Nurse Aide B was hired on 10/22/24; - Nurse Aide C was hired on 9/13/24; - Nurse Aide F was hired on 12/11/24. During an interview on 3/28/25 at 2:30 P.M., the Administrator said the nurse aides who had been employed since March of 2024 through December 2024 should be enrolled in Certified Nurse Aide (CNA) classes within four months of their hire date.

Based on observation, interview and record review the facility failed to provide sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident: when there was minimal oversight by nursing staff on the secured unit resulting in resident to resident abuse, when one resident (Resident #1) physically assaulted three residents (Resident #30, #33, and #29); the facility failed to ensure the facility had enough staff to provide perineal care at least every two hours to dependent residents who were unable to carry out activities of daily living (ADLs) for three residents (Resident #56, #8, and #59); and when the facility failed to have enough staff to maintain the dining room in a clean and sanitary manner, as well as provide adequate housekeeping and laundry services to meet the needs of the facility and residents. This affected seven of 18 sampled residents. The facility census was 81. Review of the facility's Sufficient Staff Policy, dated 5/18/23, showed it was the policy of this facility to provide sufficient staff to assure resident safety and attain the resident's highest practicable, physical, mental, and psychosocial well being. Review of the facility assessment, dated 02/03/25, showed: -Overall staffing needs: o Registered Nurses (RNs) providing direct care, 0; o Licensed Practical Nurses (LPNs) providing direct care, 3; o RNs available to provide direct care, includes Director of Nursing (DON) and RNs with administrative duties, 1 o LPNs available to provide direct care, i.e., LPNs with administrative duties, 1; o Nurse Aides, Certified Nurses Aides (CNAs), Certified Medication Technicians (CMTs), 12; -Resident acuity affecting Nurse Aides (NAs): o 27 residents provided assistance with dressing; o 49 residents provided assistance with bathing; o 16 residents provided assistance with transfers; o 18 residents provided assistance with toileting; o 18 residents provided assistance with mobility; o Seven residents provided assistance with splints/braces; o 52 residents provide assistance with behavioral symptoms. Review of the facility staffing schedules, dated 03/31/25 through 04/03/25, showed: -03/31/25 Station 1- 07:00 A.M., to 07:00 P.M.: o LPN 1; o CMT 1; o CNAs 2; o Shower Aide 1; o 1:1 staff 1; -07:00 P.M., to 7:00 A.M.: o LPN 1; o CMT 1; o CNAs 3; o 1:1 staff 1; -Station 2 (behavior unit) 7:00 A.M., to 7:00 P.M.: o CMT 1; o CNAs 1; o 1:1 staff 1; -07:00 P.M., to 7:00 A.M.: o LPN 1; o CMT 1 until 10:00 P.M.; o CNAs 2; -03/31/15 from 07:00 A.M., to 07:00 P.M.: o LPN 1; o CMT 1; o CNAs 2; o Shower Aide 1; o 1:1 staff 1; -07:00 P.M., to 07:00 A.M.: o LPN 1; o CMT 1; o CNAs 3; o 1:1 staff 1; -Station 2, 07:00 A.M., to 07:00 P.M.: o CMT 1; o CNAs 1; o 1:1 staff 1; -07:00 P.M., to 07:00 A.M.: o LPN 1; o CMT 1 until 10:00 P.M.; o CNAs 2; -04/01/25 from 07:00 A.M., to 07:00 P.M., station 1: o LPN 1; o CMT 1; o CNAs 2; o Shower Aide 1; o 1:1 staff 1; -07:00 P.M., to 07:00 A.M.,: o LPN 1; o CMT 1; o CNAs 3; o 1:1 staff 1; -Station 2, 7:00 A.M., to 07:00 P.M.,: o CMT 1; o CNAs 1; o 1:1 staff 1; -07:00 P.M., to 07:00 A.M.,: o LPN 1; o CMT 1 until 10:00 P.M.; o CNAs 2; -04/02/25 from 07:00 A.M., to 07:00 P.M., station one: o LPN 1; o CMT 1; o CNAs 2; o Shower Aide 1; o 1:1 staff 1; -07:00 P.M., to 07:00 A.M.,: o LPN 1; o CMT 1; o CNAs 3; o 1:1 staff 1; -Station 2 (behavior unit) 07:00 A.M., to 7:00 P.M.,: o CMT 1; o CNAs 1; o 1:1 staff 1; -07:00 P.M., to 07:00 A.M.,: o LPN 1; o CMT 1 until 10:00 P.M.; o CNAs 2; 04/04/25 from 07:00 A.M., to 07:00 P.M., station one: o LPN 1; o CMT 1; o CNAs 2; o Shower Aide 1; o 1:1 staff 1; -07:00 P.M., to 07:00 A.M.,: o LPN 1; o CMT 1; o CNAs 3; o 1:1 staff 1; -Station 2 (behavior unit) 07:00 A.M., to 7:00 P.M.,: o CMT 1; o CNAs 1; o 1:1 staff 1; -07:00 P.M., to 07:00 A.M.,: o LPN 1; o CMT 1 until 10:00 P.M.; o CNAs 2. Review of the nursing staffing sheets for the women's secured unit showed: - Monday 3/17/25: CMT C working 6 A.M.- 6 P.M., CNA E 6 A.M.- 2 P.M., CNA-C 7 A.M.-7 P.M. -- no one assigned to one on one duties and there was one resident who required 1:1 monitoring. - Wednesday 3/19/25: LPN D was the only nurse to cover the building. - Thursday 3/20/25: LPN C was the only nurse to cover the building. NA E (non certified nursing assistant) 7 A.M.-7 P.M. - Friday 3/21/25: LPN C, one CNA C, and no one was assigned to one on one duties when one resident was assigned a 1:1 person to monitor. - Saturday 3/22/25: RN A was the only nurse to cover the building, no nurse assigned to the unit, CNA C was the only CNA for the secured unit, and no one was assigned to one on one duties when there was one resident who was to be on on 1:1 monitoring. - Sunday 3/23/25: RN A was the only nurse to cover the building, no nurse assigned to the unit. CNA C was the only CNA for the secure unit and no one was assigned to 1:1 duties when one resident required 1:1 monitoring. - Wednesday 3/26/25: LPN D was the only nurse to cover the building, CMT C, and CNA D where the only staff assigned to the secured unit. 1. Review of Resident #1's Quarterly MDS (Minimum Data Set), a mandatory assessment completed by facility staff, dated 12/10/24, showed: - Cognition intact; - Diagnoses included: Bipolar schizophrenia, Post traumatic disorder, Anxiety, Depression, Borderline personality disorder, and Obesity; - Independent with ambulation and all mobility, if standing; - At risk for elopement, required a secured unit; - Behaviors of acting out and harming others. Review of care plan, dated 1/31/24, showed: - The resident had behavioral challenges that required protective oversight in a secured setting; - Expresses homicidal ideation towards others and has stated would like to see their blood on the floor; - History of destroying property, screaming, and acting violent towards people; - Required 24 hour nursing oversight to ensure self and others are safe; The care plan did not state how many nursing staff are needed to ensure this. - One on one staff monitoring of resident as needed. Review of the resident's nursing progress notes, dated 3/21/25 at 5:15 P.M., showed staff documented a Code [NAME] (emergency staff intervention for violent behaviors) was announced. LPN C on the secured unit observed Resident #1 standing over Resident #30's bed strangling Resident #30 with left hand and punching Resident #30 in the face with the right hand. Then Resident #1 proceeded to Resident #33's room and repeated the exact assault on Resident #33. Resident #33 was laying face down in the bed to protect his/her from injury. Resident #1 then attempted to assault LPN C and that assault was interrupted by Resident #29 when attempting to get in the middle of Resident #1 and LPN C. Resident #1 took the walker from Resident #29 and threw it down the hall and then pushed Resident #29 by an opened hand to the face causing Resident # 29 to fall and sustain a baseball sized abrasion to the left knee. 2. Review of Resident #30's Quarterly MDS, dated [DATE], showed; - Cognition Intact; - Diagnoses: Bipolar disorder, post traumatic stress disorder, depression, and anxiety; - Ongoing mood and behavioral concerns towards others. - Independent with all mobility and ambulation. Review of the resident's care plan, dated 8/8/23, showed: -The resident was on behavior program, a 5 person assisted resident take down when resident poses a threat to self or others. -The resident had a long history of mental illness and had one on one monitoring when needed for the safety of self and others. -The resident needed encouragement to participate in life activities. -The resident required a secured living environment for concerns related to elopement. Review of the resident's nursing progress notes, dated 3/21/25, showed: -At 5:05 P.M., LPN C heard screaming from Resident #30's room, discovered resident #30 lying in bed being strangled by Resident #1 by his/her left hand and also punching Resident #30 in the face with the right hand. -Resident #30's statement to LPN C was that Resident #1 was asked to leave Resident #30's room and Resident #1 walked over shut the door to the room, climbed on top of Resident #30 and began choking and punching Resident #30 in the face. -Resident #1 was removed from the room and Resident #30 was sent to local emergency room for evaluation. - The resident was admitted to the hospital for monitoring of nasal fracture and neurological trauma. 3. Review of Resident #33's Re-Admission MDS, dated [DATE], showed: - Cognition Intact; - Independent with mobility and ambulation; - Diagnoses: Borderline personality disorder, schizophrenia, depression, anxiety, mood and behavioral disorders and personality disorders. Review of the resident's care plan, dated 2/2/25, showed: -The resident had hallucinations and aggressive behaviors at time towards others. -The resident was impulsive, would self harm, and had destructive behaviors, and will manipulate others. -The resident was at risk for elopement and required a secured unit and monitoring. Review of the resident's nursing progress notes, dated 3/21/25, showed at 5:10 P.M. LPN C heard screaming from Resident #33's room, discovered Resident #33 lying in bed face down and being strangled by Resident #1 by use of the left hand and also punching Resident #33 in the right side of the head with the right hand. 4. Review of Resident #29's Quarterly MDS, dated [DATE]., showed: - Cognition intact; - Independent with ambulation and a four wheeled walker; - Diagnoses: Post traumatic stress disorder, anxiety, depression, diabetic, early onset dementia, and history of falls; - Behaviors once in every 3 days during look back period of the MDS assessment. Review of the resident's care plan, undated, showed the resident required a secured unit and behavioral monitoring. Review of the resident's nursing progress notes, dated 3/21/25, showed the resident heard the fighting going on in Resident #33's room with Resident #1 and with LPN C attempting to remove Resident #1 off Resident #33. Resident #1 turned on LPN C and kicked LPN C in the knee and punched LPN C in the shoulder. Resident #29 attempted to get in between Resident #1 and LPN C when Resident #1 picked up Resident #29's walker threw it down the hall, and then placed hand on Resident #29's face and shoved Resident #29 down causing Resident #29 to fall landing on knees and causing a baseball sized abrasion to the left knee. 5. During an interview on 3/23/25 at 10:45 A.M., CNA C said: - He/She only works Friday through Sunday 7 A.M. to 7 P.M. - On 3/21/25 he/she supervising residents smoking and no one was on the halls watching residents. - He/She and LPN C were the only ones on the unit at that time. He/She was often the only CNA watching the hall. During an interview on 3/23/25 at 11:30 A.M., LPN C said: - On 3/21/25 around 5 P.M. CNA C was the only CNA working and the CMT had called in for the evening shift. - He/She went back to the women's unit to help CNA C. While down there LPN C was at the nurses desk making phone calls to look for an additional person to come in and help on the unit. - Resident #1 had just finished smoke break with CNA C and was at the nurses desk requesting LPN C to get coffee creamer. - LPN C was on the phone and CNA C had taken the next group of smokers to their smoke break. LPN C hung up the phone and went to obtain the coffee creamer from the dining room area supply room. There was no other staff on the secured unit during this time. When LPN C returned to the desk with the creamer, Resident #1 was not there. Then Resident #33 approached LPN C and said Resident #1 wants you to come down to Resident #30's room. - When approaching Resident #30's room he/she heard screaming and observed Resident #1 on top of Resident #30 holding him/her down by the neck with his/her left hand and punching the resident in the face with his/her right hand. LPN C pulled Resident #1 off Resident #30 by grabbing a hold of the shirt and pulling backwards. -Resident #1 then left the room and headed for Resident #33's room. LPN C called the Director of Nursing (DON) and asked the DON to call a Code [NAME] and that LPN C needed help immediately in the unit. LPN C went to Resident #33's room where Resident #1 was on top of Resident #33 strangling him/her by the neck with his/her left hand and punching the resident in the side of the head with the other hand. -Resident #29 attempted to help and Resident #1 took the walker and pushed Resident #29 to the floor. -Multiple staff arrived to the unit to provide assistance. LPN D was placed with Resident #1 for one on one monitoring until police and ambulance arrived. - LPN C said the event happened very fast and was done in about 5 minutes. - He/She did not believe they had enough staff on the secured unit. During an interview on 4/2/25 at 1:30 P.M., LPN D said: - A code green was called over the paging system and he/she went to the unit just after 5 P. M. on 3/21/25. - He/She was working up front at station one. - He/She was the resident care coordinator for the women's unit. - He/She was often pulled off the unit to fill in at station one and up front when needed. - He/She sat with Resident #1 until police and the ambulance took the resident. - There are resident's on the unit that are known to have behaviors and can become violent. - He/She did not have any answers regarding if staffing was sufficient on the women's unit. - He/She said he/she was the only person on the secured unit and the only CNA working was outside smoking the residents. During an interview on 4/2/25 at 2:30 P.M., the SSD (Social Service Designee) said: - His office was on the women's unit. - He had already left for the day and was not at the facility when the assaults occurred. - He felt that during 8 A.M. to 5 P.M. there was enough staff in and out of the unit to keep watch on the unit. - He was unable to verify how many staff were scheduled to work on the secured unit that evening. During an interview on 3/23/25 at 12:39 P.M., the DON said there was not enough nursing staff on the women's unit and felt that a nurse should be down there at all times. During an interview on 4/3/25 at 4:15 P.M., the Administrator said: - He was aware of previous resident to resident abuse concerns on the women's unit. - Staffing, especially nurses, had been challenging for the facility. - Staffing for the women's unit and the amount of staffing needed for the unit to reduce resident abuse was continually being evaluated. - He felt that staffing at the time of the resident to resident abuse was sufficient. 6. Observation and interview on 3/31/25 at 8:45 A.M., showed: - Women gathering in the unit dining room awaiting breakfast meal. - CMT C passing medications on the women's unit and telling the resident's to stay in their rooms for their morning blood glucose finger stick. - CNA D assigned to the unit was not visible on the unit hallways. - CNA I assigned to one on one supervision of a resident sitting in the resident's room, and NA E assigned to one on one supervision with another resident, sitting in a chair outside the resident's room. - The only occasional staff observation of the resident hallways or the dining room was from CMT C who was passing meds on the different hallways of the secured unit, and residents walked up and down halls. - Resident #29 said he/she never had to wait in his/her room for a finger stick. He/She was not sure where everyone was and that this was not the normal process for finger sticks. - The Resident Care Coordinator for the unit was working in the main dining room up front passing breakfast trays, leaving just CMT C on the halls of the unit to monitor. During an interview on 3/31/25 at 12:45 P.M., CNA D said that it was normal for staff to leave the unit to help in other areas of the building. Observation on 3/31/25 at 2:45 P.M., showed no changes to the staffing on the secured unit from the morning observation. Residents continually walked up and down the hallway and in and out of each other's rooms, with staff walking in and out of the secured unit. Record review for the staffing sheet on 4/1/25 showed 1 CMT and 1 CNA, with no nurse scheduled for the day shift. During an interview on 4/1/25 at 10:05 A.M., CMT C said he/she could not adequately monitor the secured unit when passing meds in and out of resident rooms. Observation on 4/1/25 at 1:10 P.M., showed: - No nurse designated for the secured unit. - CMT C passed resident medications. - No CNA was visible on the secured unit. - There was 1 staff member, CMT C, on the hall to observe all resident movement and activity on the secured unit. Observation on 4/2/25 at 9:11 A.M., showed CMT C outside the dining room passing medications. There were residents gathering and walking in groups on the unit and no CNA was seen. The business office person was in office on the unit with the door closed. During an interview on 4/2/25 at 1:20 P.M., the transportation person said he/she was often in and out of the unit, most days, transporting residents to appointments, but does not monitor the residents on the unit. Observation on 4/2/25 at 1:30 P.M., showed: - No nurse designated for the secured unit. - The business office manager helping watch the hall during a fire alarm system check. - No CNA was visible on the secured unit. - The CMT was not visible during this time during the fire alarm system check. - Transportation was assisting with door monitoring during the fire alarm system check. - There was no scheduled nursing staff visible on the secured unit during the fire drill. - During this time, fire doors and exit doors remained unlocked. During an interview on 4/2/25 at 1:35 P.M. the business office manager said, she has an office on the unit, can be available when needed like watching the fire doors, but keeps her office door shut at all times and does not monitor the residents activity on the unit. 7. Observation on 3/31/25 at 7:30 A.M., showed upon entry into the facility a strong, pungent (a foul, sharp smell that is very unpleasant) urine smell in the lobby, main dining room, and central hallway leading back to the secured unit. The dining room floor was sticky. Residents #56, #8, and #59 were soiled with urine on the floor under them as they sat waiting for breakfast in the dining room . Staff were observed in the main dining room feeding residents, passing medications, and at the nurses station. Observation on 04/03/25 09:45 A.M.-10:45 A.M showed two residents sat in the common areas with urine pooled under them. Strong urine odors in the building. Two residents sat for a period of greater than 1 hour with urine puddle under them on the floor without available nursing staff assisting the residents to be cleaned or repositioned. Scheduled staff from the secured unit came out to assist station 1 dining room with dining room clean up and removal of residents from the dining room leaving residents on the secured unit with one CMT on the behavioral unit. Resident #47 had a dirty beard and was covered in debris, his/her shirt and pants were covered in multiple stains, dirt, and the resident had a foul odor. Resident #59 sat in the dining room after morning meal with visible dried food on clothes, mouth, hands, legs, floor and lap blanket, with available staff walking by without assisting the resident. Observation and interview on 4/3/25 at 11:15 A.M., showed the receptionist monitoring the residents in the main dining room. The receptionist said it was not his/her normal job duties, but the facility could use more staff in the building to help assist the residents in the dining room. During an interview on 04/03/25 at 1:10 P.M., NA J said the nursing staff allowed Resident #59 to feed him/herself a pureed diet with his/her own hands, and that is why he/she looked they way he/she did. 8. During an interview on 04/03/25 at 11:48 A.M., Housekeeper A said: -There are only two housekeepers during the day. One housekeeper on the locked unit and one housekeeper on the hall; -The dining rooms are cleaned daily and spot cleaning is done after each meal; -The floors on the halls are cleaned daily and as needed; -He/She said the dining room and halls smell like urine, because there are a lot of incontinent residents; -He/She said the halls and dining room should not have a strong smell of urine; -The floors in the dining room and in the halls should be free from dirt and debris. -The housekeeping supervisor is new and is trying to hire more housekeeping staff to take care of the building cleaning needs. During observation and interview on 04/03/25 at 12:12 P.M., Laundry Aide A said: -He/She was aware resident clothes had not been passed out to the residents, due to staffing issues. -He/She was starting to pass out laundry on the hall as he/she could; -He/She was behind because the night shift laundry staff quit; -He/She was trying to come in at night and train new staff; -He/She will be glad when there is more help. 9. Review of Resident #56's care plan, dated 02/27/24, showed: -ADL self-care deficit related to stroke. -Uses a wheelchair. -Assistance of two staff for ADLs. Review of the resident's Annual MDS, dated [DATE], showed: -Moderate cognitive impairment. -Upper and lower body impairment on one side of the body. -Dependent on staff for toileting. -Diagnoses included stroke, diabetes, and depression. Observation beginning on 03/31/25 at 7:32 A.M. until 10:13 A.M., showed: -Available facility staff coming and going from the dining room and did not reposition or toilet the resident during these times. -07:32 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -08:50 A.M., the resident sat at the table in the dining room in his/her wheelchair; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -10:13 A.M., the resident sat at the table in the dining room in his/her wheelchair. Facility nursing staff did not offer to toilet the resident. Observation on 3/31/25 at 10:59 A.M through 1:25 P.M., showed nursing staff were available and did not address the needs of the resident: -10:59 A.M. the resident sat in his/her wheelchair at the table with his/her eyes closed; -11:03 A.M., the resident sat in his/her wheelchair at the table. The Assistant Director of Nursing (ADON) walked by the resident and did not provide incontinent care for the resident; -11:17 A.M., the resident sat in his/her wheelchair at the table. NA J and CNA H walked by the resident and did not provide incontinent care for the resident; -11:25 A.M., CNA H walked by the resident in his/her wheelchair at the table and CNA H did not offer to provide incontinent care for the resident; -12:26 P.M., Lunch was delivered and the resident still sat in his/her wheelchair at the table with his/her eyes closed; -12:46 P.M., NA J and CNA H walked by the resident and did not offer to reposition or toilet the resident; - 01:01 P.M., the resident finished his/her lunch and sat in his/her wheelchair at the table. No staff provided incontinent care for the resident; - 01:12 P.M., the resident smelled strongly of urine; - 01:18 P.M., NA J and CNA H walked by the resident and did not offer to reposition or toilet the resident; -01:25 P.M., the resident sat at the table in his/her wheelchair. No staff offered to toilet the resident. Continuous observation beginning on 04/01/25 at 07:20 A.M. 10:45 A.M.,showed: -07:20 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available staff did not reposition the resident; -07:39 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available staff did not reposition the resident; -07:24 A.M., NA J and CNA H walked by the resident and did not toilet the resident; -08:15 A.M., the resident sat at the table in the dining room in his/her wheelchair. No staff offered to toilet the resident; -08:30 A.M., the resident sat in his/her wheelchair at the table; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair; -09:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. No staff offered to toilet the resident; -10:00 A.M., the resident sat at the table in the dining room in his/her wheelchair. No staff offered to toilet the resident; -10:22 A.M., NA J and CNA H walked by the resident setting at the table and did not toilet the resident; -10:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. No staff offered to toilet the resident. -10:45 A.M., a strong smell of urine odor from the resident, staff walking around the resident, the staff had not offered to change the resident's position or toilet the resident. During an interview on 04/02/25 at 1:10 P.M., NA J said: -He/She tried to toilet the resident at least every two hours. He/She was aware it had been several hours since the resident had been changed, but he/she had been busy. -Several residents are incontinent and things get busy sometimes and he/she does not have time to toilet or provide incontinent care. -There are not enough staff somedays. He/She was busy and some things do not get. -Incontinent residents should be toileted at least every two hours. During an interview on 04/02/25 at 1:30 P.M., CNA H said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -The resident had been setting in his/her wheelchair since breakfast; -He/She had not provided incontinent care or repositioned since breakfast, because they were too busy caring for other residents on 4/1 and 4/2. -The resident should be provided incontinent care and repositioned at least every two hours; -It would be nice if there were more staff to help; -He/She did not provide incontinent care and reposition the resident every two hours. During an interview on 04/02/25 at 1:42 P.M., the ADON said: -She expected the resident to have incontinent care every two hours or as needed; -She was not aware the resident had not been toileted for over two hours; -She comes in early and stays late to help with cares; -There was not enough staff to keep up with the residents cares. -Incontinent residents should be toileted at least every two hours. 10. Review Resident #8's care plan, dated 03/18/24, showed: -ADL care deficit related to weakness; -Assist of two staff with transfers and ADLs; -History or pressure injury to buttock; -Had a urinary catheter; -Incontinent of bowel; -Clean perineal area after each incontinent episode. Review of the resident's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Dependent with ADLs; -Frequently incontinent of bowel and bladder; -Diagnoses included cancer, depression, and schizophrenia (a chronic mental disorder characterized by a breakdown in thought processes and a disconnection from reality). A continuous observation beginning on 03/31/25 at 07:32 A.M. until 01:25 P.M., showed: -07:32 A.M., the resident sat at the table in the dining room in his/her wheelchair nursing staff passed by taking care of other residents; -08:30 A.M., the resident sat at the table in the dining room in his/her wheelchair nursing staff passed by taking care of other residents; -08:50 A.M., the resident sat at the table in the dining room in his/her wheelchair nursing staff passed by taking care of other residents; -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair, nursing staff passed by taking care of other residents; -10:13 A.M., the resident sat at the table in the dining room in his/her wheelchair. Facility staff had not offered to toilet the resident; -10:59 A.M. the resident sat in his/her wheelchair at the table, with his/her eyes closed. Nursing staff passed by taking care of other residents; -11:03 A.M., the resident sat in his/her wheelchair at the table. The ADON walked by the resident and did not provide incontinent care for the resident; -11:05 A.M., the hospice nurse took the resident to his/her room; -11:07 A.M., the hospice nurse spoke with the resident in his/her room, but did not change or toilet the resident; -11:12 A.M., the hospice nurse took the resident back to the dining room; -11:17 A.M., the resident sat in his/her wheelchair at the table. NA J and CNA H walked by the resident and did not provide incontinent care for the resident; -11:25 A.M., CNA H walked by the resident in his/her wheelchair at the table and CNA H did not offer to provide incontinent care for the resident; -12:26 P.M., lunch was delivered, and the resident still sat in his/her wheelchair at the table; -12:46 P.M., available nursing staff did not offer to reposition or toilet the resident; - 01:01 P.M., the resident finished his/her lunch and sat in his/her wheelchair at the table. No staff provided incontinent care for the resident. Nursing staff passed by taking care of other residents; -01:25 P.M., the resident sat at the table in his/her wheelchair. No staff had toileted the resident. Nursing staff passed by taking care of other residents, the resident had a strong urine odor. Continuous observation beginning on 04/01/25 at 07:20 A.M. until 10:45 A.M., showed: -07:20 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available nursing staff did not offer to assist the resident; -07:39 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available nursing staff did not offer to assist the resident; -08:15 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available nursing staff did not offer to assist the resident; -08:30 A.M., the resident sat in his/her wheelchair at the table. -09:30 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available nursing staff did not offer to assist the resident; -09:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available nursing staff did not offer to assist the resident; -10:00 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available nursing staff did not offer to assist the resident; -10:45 A.M., the resident sat at the table in the dining room in his/her wheelchair. Available nursing staff did not offer to assist the resident, the resident had a strong urine odor. During an interview on 04/02/25 at 1:30 P.M., CNA H said: -The resident was dependent on staff for transfers and toileting; -The resident was incontinent; -The resident should be provided incontinent care and repositioned at least every two hours; -He/She did not provide incontinent care and reposition the resident, because he/she said there was not enough nursing staff to help toilet and change residents every 2 hours. 11. Review of the Resident 59's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff with ADLs; -Always incontinent of bowel and bladder; -Diagnoses included stroke, and depression. Review of the resident's care plan, dated

Based on interview and record review, the facility failed to conduct pre-employment screenings per facility policy. The facility failed to check the certified nurse aide (CNA) registry prior to employment to ensure all newly hired employees did not have a Federal Indicator (marker given to individuals who have committed abuse/neglect), and the facility was unable to show they had completed a criminal background check (CBC) or employee disqualification list (EDL) check prior to employment. This affected 7 out of 7 sampled employees hired since March 2024. The facility census was 81. Review of the facility's hiring policy, undated, showed all applicants, employees, volunteers and vendors will have a pre-employment screening completed and will include a Criminal Background Check (CBC), Employee Disqualification Check (EDL), Certified Nursing Assistant (CNA) Registry, Family Care Safety Registry (FCSR), and verification of licensure. Review of randomly selected new employee hire records for March 2024 through March 2025., showed the facility did not have documentation available to show CBC/EDL, CNA, and FCSR screenings had been completed for staff #1, #2, #3, #4, #5, #6, #7. Observation and interview with the Business Office Manager on 4/2/25 at 1:15 P.M., showed when she was provided with a name of an employee who had been hired during the date range, she spent several minutes for each one and was not able to produce all the files requested for review. The Business Office manager said she was unable to locate the requested documentation and the information must be somewhere else in storage. There was no employee records collected from storage or provided. During an interview on 4/3/25 at 4:25 P.M., the Administrator said all verifications through the registries should be completed prior to the new employees start date and documentation of screenings should be available upon request.

Based on observation, interview, and record review, the facility failed to consistently provide a program of meaningful activities in accordance with the resident's preferences for six residents (Resident #59, #47, #48, #78, #43, and #29) of 18 residents. The facility census was 81. The facility Therapeutic Activities policy and scheduled activity calendar was requested and neither were provided. 1. Review of Resident's #59's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/24/24, showed the activity section of the MDS was not completed. Review of Resident #59's Quarterly MDS, dated [DATE], showed: -Cognition severely impaired. -Dependent in all activities of daily living (ADLs). -Diagnoses of Diabetes Mellitus and stroke. Review of the resident's care plan, dated 07/11/2024, showed: -Limited physical mobility. -Unable to communicate needs. -Encourage resident to become engaged in facility life through group activities, meals in dining rooms, and therapeutic groups if applicable to needs. Review of the resident's medical record from February 2025- April 2025 showed no documentation of activities. During an interview on 04/01/2025 at 5:20 P.M., the resident's guardian said he/she has not aware any activities in the facility, and was unsure what activities the resident would like currently, maybe music. The resident was unable to communicate likes or interests. The resident only gets up in their chair and is then left in their chair quite often over 2 hours without changing positions. The resident's activity is the chair to bed, but no therapeutic or meaningful activities are provided. Observation on 04/01/2025 at 3:00 P.M., showed the resident sat up in a chair in the dining room sleeping. No activities were observed. 2. Review of Resident #47's Quarterly MDS, dated [DATE], showed: -Cognition intact. -Diagnoses: Schizophrenia, aphasia, and Bipolar disease. Review of the resident's care plan, dated 12/20/23., showed: -Ensure the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed, and Compatible with individual needs and abilities, and age appropriate, dated 12/20/23. -Invite the resident to scheduled activities, dated 12/20/23. -Modify daily schedule, treatment plan PRN (as needed) to accommodate activity participation as requested by the resident, dated 12/20/23. -Provide activities calendar. Review of the resident's medical record from February 2025 -April 2025 showed no documentation of activities. During an interview on 04/01/2025 at 8:21 A.M., the resident said he/she was not included in any activities and he/she had nothing to do. During an observation on 04/01/25 from 8:00 A.M. to 10:15 A.M., the resident was observed sitting in a dining room area with no activities provided to the resident. During an observation on 4/1/25 from 10:30 A.M.-11:30 A.M., the resident was observed sitting in dining room chair with no activities being provided to the resident. During an observation on 4/1/25 from 11:35 A.M- 1:00 P.M., the resident was observed sitting in a dining room chair with no activities being provided to the resident. During an observation on 04/02/25 from 8:00 A.M. to 11:17 A.M., the resident was observed sitting in a dining room area with no activity provided to the resident. During an observation on 4/2/25 12:00 P.M. -1:00 P.M., the resident sat in a dining room chair and ate lunch. During an observation on 4/2/25 from 1:00 P.M.-2:00 P.M., the resident sat in a dining room chair with no activities being provided to the resident During an observation on 04/03/25 from 8:00 A.M. to 11:25 A.M., the resident sat in a dining room area eating a meal in a chair with no activities provided to the resident. During an observation on 4/3/25 from 1:00 P.M.-3:15 P.M., the resident sat in a dining room chair with no activities being provided to the resident. 3. Review of Resident #48's Admission MDS, dated [DATE], showed: -Cognition intact -Required supervision in self-care. -Diagnoses: Schizophrenia and Diabetes. -Activities are important to resident. -Enjoys books, the news and newspapers, and magazines. -Enjoys music, animals, pets. -Enjoys participating with groups of people. -Likes to go outside and get fresh air. -Important to participate in religious services or practices. Review of the resident's care plan, dated 02/17/2025, showed: -No activities were included in care plan. Record review of the resident's February 2025 Activity Documentation showed: -Participated in playing ring toss for 60 minutes on 2/04/25. -Participated in basketball for 60 minutes on 2/05/25. -Provided new television for room. During an observation of a care plan meeting (with the consent of Resident #48) on 04/02/25 at 2:00 P.M., the resident said he/she was not engaged in any activities. The last activities were weeks ago. The resident said they thought him/her wandering the halls was escalating, but he/she was just trying to walk for exercise. He/She can't go outside without supervision and there was not enough staff to supervise him/her and staff think he/she could cause problems playing basketball, weight lifting, or going outside. He/She requested to lift weights, but was told by the Assistant Director of Nursing (ADON) that he/she can't without occupational therapy (OT) being present and OT was not ordered. The resident said he/she wanted to play PlayStation, but had no one to play against in the games he/she liked to play. Staff are too busy to play and other residents are not able to play anywhere near his/her level. The resident's public administrator said the resident needs for activities were music, listening, talking, walking, daily showers and to use senses 5-4-3-2-1 plan during a care plan meeting. The public administrator told the resident that means identifying 5 things you can see, 4 things you can touch, 3 things you can hear, 2 things you can smell, and 1 thing you can taste in order to minimize his/her stress level. The Public Administrator and the ADON told the resident he/she could have daily showers as part of his/her activities going forward. Observation on 4/01/25 at 09:00 A.M., showed the resident sleeping in bed with no activities provided. Observation on 4/01/25 at 1:00 P.M., showed the resident ate lunch in dining room area with no activities provided. Observation on 4/01/25 at 4:00 P.M., showed the resident laid in bed and said there was nothing to do. Observation on 4/02/25 11:00 A.M., showed the resident was sleeping. There was no activities taking place in the facility. Observation on 4/02/25 at 12:30 P.M., showed the resident ate lunch in dining room area. During an interview on 4/02/25 at 1:00 P.M., the resident said: -There was nothing to do at the facility. - He/she wanted to play basketball, but there was no one to go outside and play with him/her. Observation on 4/02/25 at 4:00 P.M., showed the resident lay in bed. There was ball toss activities taking place in the dining room. Record review for Resident #48 on 04/03/25 at 2:00 P.M., showed activities were not updated on the care plan per meeting on 4/2/25. 4. Review of Resident's #78's Annual MDS, dated [DATE], did not address activity interests. Review of the resident's Quarterly MDS, dated [DATE], showed: -Cognition Intact. -Diabetes Mellitus. -Dependent of nursing staff for mobility and ADLs. Review of the resident's care plan, dated 02/25/2025, showed: -Self care deficit. -There was no information regarding resident activities. During an interview on 03/31/2025 at 10:31 A.M., the resident said the facility did not have any activities. The resident said before he/she was admitted to facility, he/she had a hobby of making miniature statues related to the Lord of the Rings and he/she can't do anything now, There are no crafts, coloring, cards, or games offered. The resident said he/she lays in bed watching television or gets up to eat meals. He/She had requested crafts of some kind to work on, because he/she wasn't mentally challenged, he/she was bored. 5. Review of Resident #29's Annual MDS, dated [DATE]., showed - The resident enjoyed activities and daily activities were in important to him/her. - Enjoyed group activities, reading, books, pets, inside and outdoor activities. Review of the resident's Quarterly MDS, dated [DATE], showed: - Cognition intact; - Independent with ambulation and a four wheeled walker; - Diagnoses: Post traumatic stress disorder, anxiety, depression, diabetic, early onset dementia, and a history of falls; - Behaviors once every 3 days during look back period of the MDS assessment. Review of care plan, undated, showed: - The resident required a secured unit and behavioral monitoring. - The resident must have a walker for ambulation and uses a four wheeled walker. - The resident had braces to both lower legs to support limbs for ambulation and stability. - The resident had periods of yelling out and behaviors towards others at times. -Encourage resident to attend and participate in activities. Resident enjoys socialization. Review of the activity calendars from February 1, 2025 through April 3, 25 showed no documented scheduled activities with the resident other than scheduled/supervised smoke breaks. Review of activity calendars for November and December of 2024 showed the resident enjoyed group activities and music. Observation on 3/31/25 at 10:30 A.M., showed the resident went to the scheduled smoke break. Observation on 4/1/25 at 1:30 P.M., the resident gathered to go outside with group for smoke break. Observation on 4/2/25 at 9:15 A.M., showed the resident went to the scheduled smoke break. Observation on 4/3/25 at 9:30 A.M., showed the resident went to the scheduled smoke break. Observation from 3/31/25 through 4/3/25, showed there were no scheduled or planned activities in the secured unit. Observation and interview on 4/2/25 at 1:15 P.M., showed the activity assistant handing out resident money to the residents on the unit for daily banking. The activity assistant said there was no one in charge of activities at this time and he/she was doing the best he/she can with little to no experience in activities. He/She was trying to focus activities mostly in the main part of the building. During an interview on 4/3/25 at 10:05 A.M., the resident said he/she was bored and there have not been any activities on the unit for weeks. There was no one in charge of activities any more. He/She enjoys group activities and being around people. During an interview on 4/3/25 at 1:45 P.M., the activity assistant said that he/she did not have time to do activities in the unit, as he/she was the only person in activities and was not sure what activities the resident liked, other than smoking. 6. Review of Resident #43's Comprehensive Admission MDS, dated [DATE], showed: - All daily preferences marked as very important. - All activity preferences marked as very important. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], showed: - Cognitively intact. - Required partial/moderate assistance and verbal cues. - Diagnoses included: Heart Failure, Schizophrenia, and Asthma. Review of the resident's care plan, revised on 10/25/24, showed: - The resident had an ADL self-care deficit related to impaired balance. - The resident required some assistance and encouragement with cares. - No information listed in care plan regarding activity preferences. Observation on 03/31/25 at 10:07 A.M., showed the resident in bed, in room, not doing activities. Observation on 04/01/25 at 11:26 A.M., showed the resident in bed, in room, not doing activities. Observation on 04/02/25 at 10:22 A.M., showed the resident in bed, in room, not doing activities. During an interview on 04/01/25 at 11:26 A.M., the resident said: - He/She did not participate in activities, because he/she did not like to play bingo just for a little piece of candy. - They never asked him/her what he/she would like to do for activities. 7. Observation on 04/02/25 at 2:00 P.M., showed for hire positions were posted on the bulletin board in the facility for an Activities Director. During an interview on 04/02/25 at 09:00 A.M., the Activities Assistant said activities is short staffed currently and plans to be fully active as soon as hiring is completed for the department. During an interview on 04/04/25 at 3:20 P.M., the Director of Nursing said she expected a variety of activities to be offered to all residents. During an interview on 04/04/25 at 3:30 P.M., the Administrator said he expected a variety of activities to be offered to all residents. 52043 52044

Based on interview and record review, the facility failed to follow infection control policy and procedures when the facility did not complete initial TB skin test procedures (Tuberculosis Testing-A skin test to check for active Tuberculosis- a serious bacterial respiratory infection that is highly transmissible) on newly hired employees, failed to read the TB skin test, and failed to document the results in the employee record or facility TB test book. This affected eight newly hired employees from March of 2024 through March of 2025. The facility census was 81. Review of the facility's Tuberculosis Testing policy, dated 4/28/23, showed: upon hire, a new employee will receive a 2 step TB skin test to ensure any possible TB infection can be proactively managed to prevent further spread. If a new hire has had a positive reaction to a TB skin test in the past a chest x-ray will be obtained. All TB skin test and chest X-rays will be kept on file in the employee record. Review of Employee TB Records showed: - Current employee Certified Nurse Assistant (CNA) K: hire date 7/24/24, no documentation to support initial TB skin test was completed. - Current employee Certified Medication Technician (CMT) D: hire date 13/20/24, no documentation to support initial TB skin test was completed. - Previous CNA L: hire date 9/5/24, no documentation to support initial TB skin test was completed. - Previous Hall Monitor: hire date 4/19/24, no documentation to support initial TB skin test was completed. - Previous CNA M: hire date 6/6/24, no documentation to support initial TB skin test was completed. - Current employee CNA L: hire date 12/3/24, no documentation to support initial TB skin test was completed. - Current employee Nursing Assistant (NA) D: hire date 11/19/24, no documentation to support initial TB skin test was completed. - Previous Activity Director: hire date 1/14/25, no documentation to support initial TB skin test was completed. During a Interview on 4/2/25 at 1:10 P.M., the Business Office Manager said nursing completed the TB skin testing and documentation. During a Interview on 4/2/25 at 3:10 P.M., the Director of Nursing (DON) said all new employees must have the initial TB skin test given and read prior working and a follow up with a second TB skin test 1-2 weeks later and documented. The TB skin tests are completed and read by Licensed Practical Nurse (LPN) C. The tests are documented and recorded in a TB documentation book. During a interview on 4/3/25 at 4:20 P.M., the Administrator said all new employees should have a TB skin test completed and documented and the DON oversees TB skin testing.

Based on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for three residents (Resident #38, #43, and #50). This affected three of 18 sampled residents. The facility census was 81. Review of the facility's Comprehensive Care Plan Policy, dated 10/31/24, showed: - The facility will develop and implement a comprehensive person-centered care plan for each resident. - The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. - The care plan will describe, at a minimum, the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility's Oxygen Administration policy, dated 05/18/24, showed: - The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as: Type of oxygen delivery system, when to administer, Equipment setting for the prescribed flow rates, Monitoring of the SpO2 (oxygen saturation) levels and/or vital signs as ordered, Monitoring for complications associated with the use of oxygen. Review of the facility's Noninvasive Ventilation - CPAP/BiPAP/AVAPS/Trilogy policy, dated 05/14/24, showed: - The facility will obtain an order for the use of a CPAP/BiPAP/AVAPS/Trilogy device and settings from the practitioner. - The CPAP/BiPAP/AVAPS/Trilogy device must be set up and maintained by the facility's medical equipment vendor (Skilled Medical Solutions comes quarterly per Administrator). - Document the use of the machine, resident's tolerance, any skin, respiratory or other changes and response. - Follow the manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine. Only the supplier may service the machine. -The policy did not include any guidance related to care planning the devices. 1. Review of Resident #38's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 02/25/25, showed: - Was cognitively intact. - Required non-invasive mechanical ventilator. - Required substantial assistance with most cares. - Diagnoses included: heart failure, Diabetes Mellitus, and Asthma. Review of the resident's care plan, revised on 10/26/24, showed: - Resident had Activities of Daily Living (ADL) self-care performance deficit. - Required 1-2 assist with all cares. Review of the resident's Medication Administration Record (MAR), dated 04/02/25, showed no provider orders for oxygen, BIPAP, or the corresponding cares and settings for each. Observation on 03/31/25 at 9:49 A.M., showed: - The resident in his/her room with BIPAP and oxygen in use. Observation on 04/02/25 at 11:06 A.M., showed: - an oxygen concentrator in the resident's room with tubing dated 03/31/25 and flow rate set at 1.5 liters. The resident returned to room and applied his/her nasal cannula. - a BIPAP machine was near the resident's recliner plugged in with mask/hose connected for use as needed. During an interview on 04/02/25 at 11:06 A.M., the resident said: -No one has wiped down or cleaned their BIPAP mask since they received it 3 months ago. -He/She got the BIPAP about 3 months ago. Review of the resident's care plan showed no information listed regarding oxygen or bilevel positive airway pressure (BIPAP) use. 2. Review of Resident #43's Quarterly MDS, dated [DATE], showed: - Cognitively intact. - Required partial/moderate assistance and verbal cues. - No information regarding oxygen use. - Diagnoses included: Heart Failure, Schizophrenia, and Asthma. Review of the resident's care plan, revised on 10/25/24, showed: - The resident had an ADL self-care deficit related to impaired balance. - Required some assistance and encouragement with cares. Observation on 03/31/25 at 10:07 A.M., showed: - The resident in his/her room with an oxygen concentrator on and running at 3 liters. - Oxygen tubing dated 03/26/25. - Substantial hair growth on the resident's chin. - Concentrator set and running at 3 liters. During an interview on 03/31/25 at 10:07 A.M., the resident said: - He/She went without my oxygen machine for a long time when I first got here. - Doesn't want facial hair to be shaved and had asked staff to use tweezers, but they won't. - He/She gets one shower a week and that's it, would like at least two. Observation on 04/01/25 at 7:58 A.M., showed the resident in his/her room with oxygen concentrator on and in use. Observation of on 04/02/25 at 10:22 A.M., showed the resident in his/her room with oxygen concentrator on and in use. Further review of the resident's care plan showed no information listed regarding oxygen use or that he/she wanted his/her facial hair tweezed. 46706 3. Review of Resident 50's quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Supervision with ADLs; -Diagnoses included, viral hepatitis (can lead to acute or chronic infections, potentially causing serious liver damage), stroke, and respiratory failure. Review of the resident's care plan, dated 01/28/25, showed: -Assistance with ADLs; -The resident had a behavior problem; -The resident had a communication problem related to aphasia (a neurological disorder that affects the ability to communicate and understand language); Review of the resident's POS dated, April 2025 showed a diagnosis of viral hepatitis C. Review of the National Institute for Communicable Diseases website shows Hepatitis C is spread by blood to blood contact. Prevention strategies include practicing safe sex, avoid sharing needles, toothbrushes, razors or nail scissors. Treatment can include combination therapies with direct acting antivirals. Review of the resident's care plan showed it did not address the resident's diagnosis of viral hepatitis. During an interview on 04/02/25 at 1:10 P.M., CNA H said: -He/She was not aware of any residents that had viral hepatitis; -All nursing staff should be aware that a resident had viral hepatitis; -If a resident has viral hepatitis, it should be in their care plan; -No residents that he/she knew of had viral hepatitis in their care plan; -He/She does not updated the care plans; -The nurses updated the care plans. During an interview on 04/02/25 at 1:30 P.M., NA J said: -He/She was not aware of any residents that had viral hepatitis; -All nursing staff should be aware that a resident has viral hepatitis; -He/She does not updated the care plans; -The nurses updated the care plans. -Hepatitis was something that should be care planned. During an interview on 04/02/25 at 1:48 P.M., LPN D said: -He/She was aware the resident had viral hepatitis C; -He/She would expect a diagnosis of viral hepatitis C to be included in the resident's care plan; -When diagnoses are included in the resident's care plan it aids in their care; -The DON updates the care plans. During an interview on 04/03/25 at 04:11 P.M., the DON said: -She would expect a diagnosis of viral hepatitis to be included in the resident's care plan; -She expects the SSD to update the care plan; -The staff look in the care plan to guide them in taking care of the resident. During an interview on 04/03/24 at 04:15 P.M., the Administrator said: -He expected Resident #50's care plan to include viral hepatic; -He expected the staff to be able to know if a resident had hepatitis; -He expected the SSD to ensure the care plans were updated and compressive to each resident. During an interview on 04/02/25 at 2:05 P.M., the Social Services Director (SSD) said: -He is responsible for ensuring the resident care plans were updated and resident specific; -Resident care plans should resident specific. During an interview on 04/03/25 at 8:05 A.M., Certified Nursing Assistant (CNA) F said: - He/She asks the residents in the shower room if they want to be shaved. Some don't want to be shaved, and it's put in the care plan if they don't. - He/She doesn't have tweezers, if residents do not want shaved, he/she would get scissors or electric razor to trim the facial hair. During an interview on 04/03/25 at 11:32 A.M., the Assistant Director of Nursing (ADON) said: - Since the change in MDS Coordinator the nurses are responsible for updating care plans. - Nurses know baseline care plans, but have had no training for updating care plans and we requested people to come in and train. - She communicates with staff as much as possible verbally, face to face, who is on oxygen and what cares to provide. - Oxygen use should be care planned. During an interview on 04/03/25 at 3:30 P.M., the DON said: - Oxygen use and bipap use should be care planned. - If a resident didn't want to be shaved a certain way, and preferred to have tweezers used, the care plan should reflect that. - Oxygen use and resident's preferences should be care planned.

Based on observation, interview and record review, the facility failed to obtain a physician order and care plan for hospice services for one sampled resident (Resident #8). The facility census was 81 residents. Review of the facility's Comprehensive Care Plan Policy, dated 10/31/24, showed: - The facility will develop and implement a comprehensive person-centered care plan for each resident. - The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. - The care plan will describe, at a minimum, the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of the Resident#8's Quarterly (MDS), a federally mandated assessment tool completed by facility staff, dated 01/31/25, showed: -Moderate cognitive impairment; -Dependent with Activities of Daily Living (ADLs); -Frequently incontinent of bowel and bladder; -Diagnoses included: Cancer, depression and schizophrenia (a chronic mental disorder characterized by a breakdown in thought processes and a disconnection from reality); -The MDS did not address hospice care. Review of Resident #8's care plan, dated 03/18/24., showed: -ADL care deficit related to weakness; -Assist of two staff with transfers and ADLs; -Incontinent of bowel. Review of the resident's Physician's Order Sheet (POS), dated April 2025, did not show an order for hospice. Review of the resident's March 2025 nurse's notes showed: -03/19/25 at 03:32 A.M., the resident was admitted to hospice yesterday; -03/19/25 at 08:36 P.M., the resident had started services with hospice this week; -03/28/25 at 11:29 P.M., the resident continued hospice services. Review of the resident's care plan showed it did not address the resident's hospice care. Observation and interview on 03/31/25 at 11:03 A.M., showed: -The resident sat in his/her wheelchair at the table in the dining room; -Hospice nurse A took the resident to his/her room; -The hospice nurse said the resident was admitted to hospice a few weeks ago. During an interview on 04/02/25 at 1:10 P.M., Certified Nurse Aide H said: -The resident was on hospice; -The resident had been on hospice for a while; -Hospice gave the resident showers on certain days of the week; -He/She did not know what days hospice gave the resident showers; -He/She was not sure what else hospice did for the resident; -He/She found out the resident was on hospice from the charge nurse; -If the resident was on hospice, it should be care planned; -He/She did not know if it was on the care plan. During an interview on 04/02/25 at 1:30 P.M., Nurses Aide (NA) J said: -The resident had been on hospice for a while now; -He/She was not sure besides showers what hospice provided for the resident; -He/She said hospice should be in the resident's care plan; -He/she did not know if hospice was care planned for the resident. During an interview on 04/02/25 at 1:48 P.M., Licensed Practical Nurse (LPN) D said: -He/She was aware the resident was on hospice; -He/She would expect hospice to be included in the resident's care plan; -He/She said there should be a physician's order admitting the resident to hospice. During an interview on 04/03/25 at 04:11 P.M., the Director of Nursing said: -She expected Resident #8 to have an order to admit to hospice; -She expected Resident #8's care plan to include hospice care; -The charge nurses are responsible for ensuring the care plans are updated. During an interview on 04/03/24 at 04:15 P.M., the Administrator said: -He expected Resident #8 to have an order to admit to hospice; -He expected Resident #8's care plan to include hospice care; -He expected changes to a resident's care be added to the care plan.

Based on interview and record review, the facility failed to provide supervision to prevent an accident for one resident (Resident #1), when on [DATE] staff transferred the resident into a transport wheelchair (a wheelchair designed for short-term use) and left the resident unsupervised. Approximately ten minutes later, the resident was found face down on the floor in a pool of blood with his/her bottom sitting on his/her feet and forehead against the floor. The resident was sent to the hospital, sustained bleeding in his/her brain and was placed on end of life care on [DATE]. The resident passed away while at the hospital on [DATE]. In addition, the facility failed to keep resident's safe when, on [DATE], the Housekeeping Supervisor (HS) used toilet bowl cleaner to clean a stain on the floor of the beauty shop, causing a chemical reaction, resulting a smoky haze in the facility and setting off the fire alarm. The facility census was 84. The Administrator was notified on [DATE] at 6:55 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Review of the facility's undated Fall Prevention Program policy showed: -Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere. -The facility utilizes a standardized risk assessment for determining a resident's fall risk. The assessment categorizes the residents according to low, moderate or high risk. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. -Upon admission, the nurse will complete the resident's fall risk assessment along with the admission assessment to determine the resident's level of fall risk. -The nurse will refer to the facility high risk or low/moderate risk protocols when determining primary interventions. -When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. -When any resident experiences a fall the facility will: a. assess the resident b. complete a post-fall assessment c. complete an incident report d. notify the physician and family e. review the resident's care plan and update as indicated f. document all assessments and actions g. obtain witness statements in the case of injury. Review of the facility's Fall Risk Protocol dated 2022, showed: Low/Moderate: -Fall Risk Assessment score of ,d+[DATE]. -Implement universal environmental interventions: A clear pathway to the bathroom and bedroom doors; Bed is locked and lowered to a level that allows the resident's feet be flat on the floor when the resident is sitting on the side of the bed; Call light and frequently used items are within reach; Adequate lighting; Wheelchairs and assistive devices are in good repair; -Implement routine rounding schedule. -Monitor for changes in resident's condition, gait, ability to rise/sit, and balance. -Encourage residents to wear shoes or slippers with non-slip soles when ambulating. -Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating. -Complete a Fall Risk Assessment every 90 days and as indicated when the resident's condition changes. High Risk: -Fall risk assessment score of ,d+[DATE], or recent change in functional status, or dizziness/postural hypotention (low blood pressure) or experiences a fall in the facility. -Implement interventions from the Low/Moderate Fall Risk Assessment. -Place resident on the Fall Prevention Program. Indicate fall risk on care plan. Place Fall Prevention Indicator on the name plate to the resident's room. Place Fall Prevention Indicator on resident's wheelchair. -Provide interventions that address unique risk factors: medications, phsychological, cognitive status, recent change in functional status, or root causes of recent falls. -Consider additional interventions as directed by the resident's assessment: Assistive devices, increased frequency of rounds, sitter/one on one observation, medication regimen review, low bed, alternate call system access, scheduled ambulation or toileting assistance, family/caregiver or resident education, therapy services referral. Review of the owner's manual for the Drive Fly-Lite Transport Chair showed: -The transport chair should not be operated without the assistance of an attendant. -Before entering or leaving the chair, engage the dual wheel locks against the tires on both rear wheels. -Do not move forward on the seat while leaning forward in the chair. Leaning out of the transport chair without proper assistance could cause tipping. 1. Review of Resident #1's Annual Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated [DATE], showed: -Diagnoses of bradycardia (excessively low heart rate), osteoarthritis (a chronic degenerative joint disease that causes cartilage in the joints to break down over time), repeated falls, weakness and anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). -Scored a 4 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). A score of 4 indicates severely impaired cognitive abilities. -No impairment to arms or legs and uses a manual wheelchair for ambulation. -Required partial to extensive assistance with activities of daily living, including bathing, toileting, dressing and personal hygiene. -Occasionally incontinent of bowel and bladder. -Had two or more falls since admission to the facility. -Had falls prior to admission to the facility and two or more falls at the facility since admission. Review of the resident's comprehensive care plan, dated [DATE], showed: -He/she was a high fall risk. -Interventions in place include anticipating the resident's needs, make sure call light is within reach and encourage the resident to use it, encourage the resident to participate in physical activities, make sure the resident is wearing appropriate footwear, follow facility fall protocol, review information from previous falls and determine cause and remove cause if possible, and educate family and care givers of fall risks and interventions. Review of the resident's progress note, dated [DATE], showed the resident tested positive for COVID (a respiratory infection). He/she was displaying increased weakness, not eating as much, and requiring increased assistance with care. Review of the resident's the progress note, dated [DATE], showed fall assist was called to resident's room. Upon entering the room, resident noted to be laying prone (face down) on the floor. Assistant Director of Nursing (ADON) and Wound Nurse (WN) rolled resident and noticed blood. The resident was assessed for injuries. The resident was noted to be bleeding from forehead, left hand, and bilateral elbows. The resident's vitals were taken. WN called Emergency Medical Services (EMS) for resident to be sent to the local hospital for evaluation and treatment. Director of Nursing (DON), Administrator, Primary Care Physician (PCP) notified of fall. Review of the resident's medical record from the local hospital, dated [DATE] at 8:10 A.M., showed: -The resident was seen in the emergency roiagnom on [DATE] after falling forward from his/her wheelchair at the facility, and hitting his/her head. He/she sustained a large laceration to the left side of the forehead and skin tears to both arms. Computed Technology (CT) scan showed the resident sustained a head injury that resulted in bleeding in the front and back of the brain. The resident was unresponsive and admitted to the hospital to receive end of life care. Review of the resident's undated medical record from the local hospital showed: -The resident died at the hospital on [DATE] at 11:34 P.M.; -The preliminary cause of death was traumatic subarachnoid hemorrhage resulting from a fall from non-moving wheelchair. Review of the resident's facility electronic medical record showed: -[DATE] at 6:45 P.M., Fall Risk Assessment, showed the resident is a high risk for falls. -There were no other Fall Risk Assessments found in the resident's medical record. Observation of the resident's wheelchair on [DATE] at 10:15 A.M., showed the wheelchair was a Drive Fly-Lite Transport Chair. During an interview on [DATE] at 11:53 A.M., Nurse Aide (NA) A said: -He/she was aware Resident #1 was a fall risk. He/she was unsure what fall prevention interventions should have been in place for the resident, only that the resident was to have two staff members to provide care. NA A was not sure where to find what interventions needed to be in place. -Since testing positive for COVID earlier in the month, the resident needed more help with care, like increased incontinence and needing more help with eating and drinking. The resident seemed weaker. -On [DATE], around breakfast time, NA A and Certified Nurse Aide (CNA) A went into Resident #1's room to provide care. The resident was found to have wet the bed and needed his/her clothing and bed linens changed. NA A and CNA A transferred the resident to the wheelchair and stripped the linens from the bed. NA A and CNA A then left the room, leaving the resident sitting in the wheelchair next to the bed. NA A went to get clean linens and was unsure what CNA A was doing after they left the room. -Approximately ten minutes later, NA A heard a commotion in the hall and saw staff running toward the resident's room. A staff member told him/her the resident had fallen, but NA A did not enter the resident's room again that day. During an interview on [DATE] at 11:34 A.M., CNA A said: -CNA A was aware the resident was a fall risk. He/she did not know what interventions the resident should have in place. CNA A said the interventions could be found on the care plan. -CNA A would try to make sure the resident's bed was in the lowest position and have a fall mat on the floor next to the bed. The resident had a chair and bed alarm at one time, but he/she kept taking it off, so the staff quit using it. - On [DATE], CNA A and another staff member entered the resident's room shortly after breakfast to provide care. CNA A thinks the other staff member may have been Licensed Practical Nurse (LPN) C. The resident had urinated in the bed and needed his/her clothing and bed linens changed. CNA A and the other staff member transferred the resident to the wheelchair and stripped the bed. CNA A left the room to get supplies and to let housekeeping know the bed needed to be cleaned. The other staff member also left the room, but CNA A was not sure what that staff member went to do. -While in the hall, CNA A saw other staff members running towards the resident's room and someone told him/her the resident was on the floor. CNA A reentered the resident's room and observed the resident on the floor. He/she was laying on his/her side on the floor, one arm under him/her and one arm beside him/her. His/her legs were bent to the side. The WN and LPN C were in the room and picked the resident up off the floor and placed him/her back in the wheelchair. The resident had scrapes on his/her left hand and a cut to the forehead. The WN instructed CNA A to hold a bandage to the resident's forehead. The WN and LPN C left the room to call EMS and get the paperwork ready. The ADON took over holding the bandage to the resident's forehead and stayed in the room with the resident until EMS arrived and CNA A left the room. During an interview on [DATE] at 3:45 P.M., the WN said: -Two staff members went into the resident's room to check on him/her and to provide care around 7:45 and 8:00 A.M. The staff found the bed was wet. He/She is unsure of who the two staff members were but thinks it may have been CNA A and NA A. He/She instructed the staff to get the resident up, put clean linens on the bed and clean the resident up. He/She then left the room to assist another resident. While in the other resident's room, the ADON informed him/her Resident #1 was on the floor. -He/She returned to the resident's room. The resident was on the floor, with his/her head on the floor and knees under him/her. He/she was between the bed and the wall. The WN observed blood on the resident's left hand from a skin tear. There were linens on the floor near the resident's head. When staff moved the linens, he/she noted additional blood on the floor. He/She and the ADON made the decision to move the resident from the floor to the wheelchair. After the resident was transferred to the wheelchair, he/she and the ADON assessed the resident. He/she was found to have two skin tears to the left hand, one skin tear to the left elbow and one skin tear to the right hand. He/she was also noted to have a laceration to the left side of the forehead. The WN conducted vitals on the resident. -The WN then left the room to call EMS and get the paperwork ready for the resident's transfer. During an interview on [DATE] at 4:45 P.M., CNA B said: -He/She entered the resident's room after he/she was told of the resident's fall. The resident was already in the wheelchair. CNA B observed the resident had an injury to the forehead and some skin tears to his/her arms. He/she sat with the resident to help keep him/her calm while the ADON and WN assessed the resident. After the assessment, the ADON and CNA B left the room. The WN and CNA A were still in the room with the resident. During an interview on [DATE] at 4:49 P.M., LPN C said: -LPN C was not working the day the resident fell . -The resident tested positive for COVID on [DATE]. After testing positive, he/she became weaker and needed more assistance with cares. During an interview on [DATE] at 6:14 P.M., the ADON said: -He/she believed the resident was a fall risk. He/she is unsure what exact interventions the resident should have had in place. He/She believes the interventions in place should have included proper footwear, bed in lowest position, and a fall mat by bed. -He/she did not witness the fall on [DATE]. The resident's roommate yelled out the door of their room that the resident had fallen. He/She instructed CNA B to go get the WN, who was also the charge nurse that day. This was about 7:40 A.M. The WN and ADON entered the resident's room. The resident was on the floor, face down, with his/her head on the floor. The resident was squirming on the floor, and the ADON noted blood on the resident's right arm. The resident was between the bed and wall. His/her arms were under him/her. The resident's head was on a pile of folded bed linens. The linen had no blood on them when the ADON and WN moved the resident. The ADON did not believe at that time the resident had a head wound. When the resident was rolled to rest on his/her back, the ADON noted the resident had skin tears to both arms and also had an injury to his/her forehead. The ADON and WN decided to transfer the resident to the wheelchair so they may better assess the injuries. Either CNA A or CNA B stayed in the room with the resident while the ADON and WN went to the desk to call EMS and get the paperwork together. -As the resident was weak from COVID, the ADON believes the resident should not have been left alone in the wheelchair. During on interview on [DATE] at 10:40 A.M., Emergency Medical Technician (EMT) A said: -EMS was called to the facility the morning of [DATE] for a resident who had fallen out of a wheelchair and hit his/her head. -When EMS arrived at the resident's room, the resident was in the bed. -The resident had lacerations to both forearms and left hand. He/she also had a laceration to the forehead. -Facility staff in the room where unable to tell EMS when the resident fell . -EMS transferred the resident to the stretcher and transported him/her to the local hospital. During an interview on [DATE] at 5:35 P.M., the DON, said: -He/she believes that Resident #1 was a high fall risk. -It is his/her expectation that at least one staff member remain with the resident while he/she was up in the wheelchair, due to the resident's decline in condition. During an interview on [DATE] at 5:30 P.M., the Administrator said: -He/she believed that Resident #1 was a fall risk due to his/her recent decline. -He/she expects that a staff member should have stayed with the resident when he/she was up in the transport wheelchair, as the resident was COVID positive and in a weakened state. 2. Review of the Material Safety Data Sheet (MSDS), [DATE], for the cleaner showed: -The cleaning product's name is Acid Bowl Clean. -It's recommended use is as a clinging toilet bowl cleaner. -It has the hazards of skin corrosion, serious eye damage/irritation, and is corrosive to metal. -Users should not breathe fumes/gas/vapors/spray of the product. Users must wash face, hands and any exposed skin after handling. Users should wear protective gloves/protective clothing/eye protection/face protection when using the product. -If inhaled, remove the person to fresh air and keep at rest in a position comfortable for breathing. Immediately call a poison control center or doctor/physician. -The cleaner is incompatible with Acids, Bases, Oxidizing Agents, and uncontrolled contact with water. Observation of the facility on [DATE] at 11:45 A.M., showed: -The fire alarm sounded. -A white, smoke-like haze was in hallways and dining room. This was accompanied with a strong chemical smell. -The DON said the Housekeeping Supervisor (HS) was using a chemical to clean a stain on the floor of the beauty shop and it started to smoke. They were opening the windows and doors to the facility to help air out the smoke. During an interview on [DATE], at 3:22 P.M., the HS said: -He/she has been the HS since February 2024. -He/she was cleaning the floor today in the beauty shop. He/she put a fresh mop head on the mop and ran it under water. He/she then squeezed the water out with the mop wringer. He/she then put some of the acid toilet bowl cleaner on a spot on the floor, mopped it up and then put some more of the cleaner on the spot and used a paper towel to wipe it up. Then it began to smoke. -He/She did not think anything else was on the floor. The HS said he/she did not mix it with anything, only the water on the mop -He/she had used this cleaner in the same way many times and it had never reacted this way. -He/she worked in housekeeping before becoming a supervisor. -The facility has had the cleaner as long as the HS has worked at the facility. He/she has not received education on safe chemical usage. The old housekeeping supervisor trained him/her before he/she took over. No one had instructed the HS to use the cleaner on the floor. During an interview on [DATE] at 5:35 P.M., the DON, said: - He/she had told the HS not to use toilet bowl cleaner on surfaces other than the toilet. -Residents were present in the dining room and hallways when the smoke was observed. -It is his/her expectation that all chemicals in the facility be used appropriately and safely. During an interview on [DATE] at 5:30 P.M., the Administrator said: -It is his/her expectation that all chemicals be used safely and appropriately within the facility. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO243716, MO243656, MO243662, MO243797

Based on interview and record review, the facility failed to follow the facility's policies to notify the physician and obtain physician orders when pressure ulcers were found, continue to conduct and document assessments of the wounds, and notify the physician of accurate descriptions and deterioration of the wounds for one resident (Residents #1) who developed a large unstageable pressure ulcer. Additionally, the facility failed to notify the physician and obtain orders for an open area over the bony prominence of one resident's (Resident #2) coccyx and conduct and document assessments of the resident's wound per policy. The facility census was 84. The Administrator was notified on 10/25/24 at 5:54 P.M. of an Immediate Jeopardy (IJ) which began on 10/02/24. The IJ was removed on 10/31/24 as confirmed by surveyor onsite verification. Review of the facility's undated Wound Treatment Management Policy showed: -The purpose of the policy is to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse. 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. -Review of the facility's undated Documentation of Wound Treatments Policy showed: -The purpose of this policy is that the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. 1. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: a. Type of wound and location. b. State of wound or degree of skin loss. c. Measurements d. Description of wound characteristics. 3. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift. Review of the facility's undated Special Wound Investigation policy showed: -The purpose of this policy is to ensure there is a process in place for a thorough investigation to be conducted in the event when there is an identified deterioration or progression in the stage of a pressure ulcer or the identification of a new pressure ulcer that may be determined as avoidable or unavoidable. 1. Upon notification of any deterioration of an existing pressure ulcer or the identification of a new pressure ulcer, the Director of Nursing will complete a Special Wound Investigation including completion of the Facility Acquired Investigation Tool and/or the Pressure Ulcer Letter of Unavoidability and immediately notify the Regional Director, Premier Nurse Consultant and primary care physician. This investigation will be completed within 24 hours. 2. The Special Wound Investigation will consist of any pertinent information describing the deterioration of the wound or change in staging of the pressure ulcer including the identification of unavoidable risk factors that have increased the resident's susceptibility to develop wound deterioration.; 3. After reviewing the Special Wound Investigation, the Director of Nursing will analyze the date and initiate a Pressure Ulcer Letter of Unavoidability if indicated after consultation with the primary care physician. The Director will notify the guardian, physician and family members. 4. An immediate review of the regulatory requirement and identification of any deficient practices will be determined. An immediate action plan shall be put into place including physician notification, wound care documentation, care plan documentation, and completion of the wound assessment sheet. 5. Weekly (or more frequent) wound assessment will be completed by nurses providing wound care and reviewed by the Director of Nursing. 6. The interventions put in place for the pressure ulcer will be monitored daily by the Director of Nursing/designee. 1. Review of Resident #1's Annual Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 9/22/24, showed: -Diagnoses of bradycardia (excessively low heart rate), osteoarthritis (a chronic degenerative joint disease that causes cartilage in the joints to break down over time), repeated falls, weakness and anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). -Scored a 4 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). A score of 4 indicates severely impaired cognitive abilities. -Had no impairment to arms or legs and used a manual wheelchair for ambulation. -Required partial to extensive assistance with activities of daily living, including bathing, toileting, dressing and personal hygiene. -Occasionally incontinent of bowel and bladder. -Was not at risk and did not have any unhealed pressure ulcers/injuries. Review of the resident's comprehensive care plan, dated 3/18/24, showed no problems or interventions related to skin integrity. Review of the resident's medical record showed no Braden scale assessment (an assessment to determine the risk to develop pressure ulcers) in the resident's medical record. Review of the resident's facility Skin Check, dated 9/26/24, showed the resident had no skin issues. Review of the resident's shower sheet, dated 10/2/24, showed: -During a shower, the resident was noted to have two small blisters, approximately the size of a pencil eraser, at the top of his/her buttocks. Licensed Practical Nurse (LPN) A documented he/she notified the Wound Nurse (WN), Director of Nursing (DON), primary care provider (PCP) and Administrator of the new skin area. LPN A also documented he/she applied a silicone bandage to the area above the resident's buttocks. Review of the resident's electronic medical record (EMR) from 10/2/24 through 10/10/24, showed: - No documentation of the physician being notified of the blisters found on the resident on 10/2/24. -No wound assessments. Review of Resident #1's physician orders dated October 2024 showed no orders for wound treatments for the blisters found on 10/2/24. During an interview on 10/24/24 at 9:46 A.M., LPN A said: -On 10/2/24, he/she noted two small blisters, approximately the size of a pencil eraser at the top of Resident #1's buttocks. The two blisters were not open at that time. The skin surrounding the blisters was red. -LPN A notified the WN of the blisters and asked what treatment LPN A should do for the blisters. The WN instructed him/her to do what ever treatment was being done for another resident. He/she asked the WN for clarification, as the other resident has had multiple different skin treatments. The WN instructed him/her to do whatever he/she felt was the best for the treatment of the wound. -He/She applied a silicone pad over the blistered area for protection. -He/She then notified the DON and Administrator of the blistered areas. -He/She did not notify the physician of the wound or get orders, because he/she began to care for other residents and it slipped his/her mind. Review of the resident's facility October 2024 Skin Checks showed: -10/9/24: The resident had no skin issues. -10/15/24: New laceration to forehead, resulting from a fall. No other skin issues noted. During an interview on 10/22/24 at 11:34 A.M., Certified Nursing Assistant (CNA) A said: -He/she was first aware the resident had a wound on his/her coccyx on 10/11/24. -The wound was approximately the size of a golf ball. CNA A was unsure if the wound had an odor. -He/She did not notify anyone of the wound. Further review of the resident's medical record from 10/11/24 - 10/15/24, showed no documentation or assessments of the wound on the resident's coccyx. Review of the resident's medical records from a local hospital, dated 10/15/24, showed: -The resident was sent to the hospital after experiencing a fall at the facility. -Upon being admitted to the hospital, Hospital Registered Nurse (HRN) A found a large, unstageable wound on the resident's coccyx. The wound had foul smelling drainage. During an interview on 10/25/24 at 9:14 A.M., HRN A said: -Upon admission to the hospital, HRN A removed a bandage from the area above the resident's buttocks. The bandage was approximately four inches by four inches and was curling up on itself and not covering the wound. The wound had a strong, foul odor and had a large amount of yellow drainage. The wound was approximately the size of a baseball with multiple black areas. During an interview on 10/22/24 at 11:53 A.M., Nursing Assistant (NA) A, said: -NA A first noted the area above the resident's buttocks on 10/15/24 when the he/she and CNA A got the resident up to change his/her linens. -He/She was unsure of how large the wound was. It had black areas and smelled of rotting meat. -He/She did not notify the charge nurse of the wound, as shortly after noting the area, the resident fell and was sent out to the hospital. During an interview on 10/22/24 at 3:45 P.M., the WN said: -He/She was notified of Resident #1's wound above his/her buttocks on 10/11/24. -LPN C told the WN, he/she had notified the Primary Care Provider (PCP) of the wound. He/She is unsure if the PCP gave LPN C any treatment orders. -He/She observed the wound on 10/11/24. It was about the size of a golf ball and had no odor or drainage. There was a black area at the top of the wound, about the size of a nickel. -He/She has had no formal education or training regarding wounds. He/She does rounds with the wound team that comes to the facility and takes pictures of the wounds. -He/She did not take pictures of the resident's wounds as he/she was in too much pain. The WN put a patch on the wound and laid the resident back down. -On 10/11/24, the WN did not document the wound assessment. He/She was more concerned with keeping the resident comfortable. -The charge nurse is responsible for notifying the DON, Administrator, and PCP of any new wounds. If the WN is not working, the charge nurse should call him/her to inform him/her of the any new wounds. -He/she does not recall LPN A informing him/her of Resident#1's wound. He/she is unsure who instructed LPN A to apply the silicone patch to the resident's wound. During an interview on 10/23/24 at 4:49 P.M., LPN C said: -He/she was the charge nurse on 10/11/24. He/she assisted staff in transferring the resident to his/her bed from the recliner. -The resident had been incontinent and he/she assisted staff in changing the resident's brief and gown. -He/She noted the wound to the resident's bottom. -He/She spoke to the PCP's nurse about the resident's wound. He/she doesn't recall how he/she described the wound. The PCP or nurse did not give treatment orders regarding the wound, but the PCP would see the resident on rounds on 10/15/24. -He/She put a dry dressing to the wound. It had some slough (tissue coming off of the wound) and a dark area, possibly on the left buttock. The wound was slightly bigger than a quarter. He/She did not notice any odor or drainage from the wound. -If a resident has any wounds or skin issues, the WN and PCP are to be notified. -He/She thought he/she notified the WN. During an interview on 10/22/24 at 4:49 P.M., CNA B said: -He/she was first aware of Resident #1's wound on 10/14/24 when CNA B gave the resident a shower. -The wound was approximately the size of a grapefruit, black with red around the edges and smelled strongly of rotting flesh. -CNA B did not notify anyone of the wound, as he/she thought the charge nurse was already aware. During an interview on 10/24/24 at 11:44 A.M., the resident's PCP said: -He/she was not notified of the resident's wound until 10/11/24, when LPN C notified the PCP's nurse. -The PCP intended on seeing the resident when he/she was in the facility for rounds on 10/15/24, but the resident was sent to the hospital that day. - The PCP did not give any treatment orders for the wound. He planned to assess it himself on rounds on 10/15/24. -The PCP said LPN C said the resident had an open area on his/her coccyx, but did not provide further detail. During an interview on 10/22/24 at 4:45 P.M., the Assistant Director of Nursing (ADON)/Interim DON said: -He/she was notified of Resident #1's wound on 10/15/24. -The wound was oval shaped, approximately the size of a computer mouse. The middle of the wound was black with an approximately one centimeter red edge around the wound. The wound had a very foul odor of rotting meat that the ADON noticed upon entering Resident #1's room. -The ADON said he/she and the WN were trying to get the resident sent out to the hospital due to a fall with a head injury. The ADON became aware of the wound when he/she went into the resident's room to assess him/her after the fall. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Diagnoses of cellulitis of the right lower leg (a common and potentially serious bacterial skin infection), diabetes mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), lymphedema (swelling, most often in an arm or leg, caused by a lymphatic system blockage), heart failure, bipolar disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Scored a 15 on the BIMS exam. A score of 15 indicates no cognitive impairment. -Was dependent on staff for all activities of daily living, including bathing, dressing, toileting, and personal hygiene. - The resident was at risk for the development of pressure ulcers; - The resident did not have any pressure ulcers. Review of the resident's comprehensive care plan, dated 6/17/24, showed: -The resident had limited physical mobility and prefers to sleep in his/her recliner. He/she will frequently refuse showers and other care. -The resident was at risk for development of pressure ulcers. Apply treatments as ordered, follow facility wound care policy, staff to do weekly treatment documentation and assessment. Review of the resident's Braden Risk Assessment, dated 9/14/24, showed the resident to be a high risk for skin breakdown. Review of the resident's physician orders showed: -6/24/24: Wound Care Plus to evaluate and treat. -9/17/24: Buttocks-cleanse with foam cleanser and pat dry. Apply triad (a zinc-oxide based cream used for wound care) every shift and evening soilage, and leave open to air. Continue pressure reduction with moisture prevention protocol. One time a day for wound care. -There was no documentation in the resident's record as to why this treatment was ordered. Review of the resident's weekly skin checks showed: -9/26/24: The resident's skin is warm and dry, turgor was within normal limits. The resident has a rash on right and left inguinal (groin) regions. -10/3/24: The resident's skin is warm and dry, turgor was within normal limits. The resident has a rash on right and left inguinal regions. -10/10/24: The resident's skin is warm and dry, turgor was within normal limits. The resident has a rash on right and left inguinal regions. -10/17/24: The resident's skin is warm and dry, turgor was within normal limits. The resident has a rash on right and left inguinal regions. Review of the resident's Monthly Nurses Note, dated 10/16/24 completed by LPN D, showed no ulcers or other skin issues were noted. Observation on 10/22/24 at 10:15 A.M., showed the resident had a crack that had peeling skin about the size of a nickel at the top of his/her buttocks over his/her coccyx, and then a cracked crease on the right buttock. During an interview on 10/22/24 at 10:45 A.M., CNA B said: -He/she was not aware Resident #2 had open areas on his/her bottom. -He/she knew the staff were to put cream on resident's bottom, and he/she did apply the cream after the resident's shower. However, CNA B did not pull the resident's skin folds apart or look closely at his/her bottom to see if there was an open area. He/she thought the cream was for preventative measures. During an interview on 10/22/24 at 10:50 A.M., the resident said: -He/she has had the area on his/her bottom for a few weeks. -The area was really sore. Staff put some type of cream on it. He/she was unsure what type of cream it was. During an interview on 10/24/24 at 9:46 A.M., LPN A said: -He/she was aware the resident had an open area on his/her bottom when he/she worked on 10/16/24. He/she was not aware the resident had a second open area in a crease on his/her buttock. -He/she told the WN on 10/16/24 of the open area on the resident's coccyx. -He/she did not notify the physician of the open area because he/she thought it was the WN's duty to notify the physician of new areas and get treatment orders. During an interview on 10/23/24 at 4:49 P.M., LPN C said: -He/she knew Resident #2 had redness to his/her bottom. He/she did not know that he/she had an open area on his/her bottom. -Resident #2 had an order for Nystatin as needed (a medication used to treat fungal infections). -LPN C was unsure if the WN was aware of the open area. During an interview on 10/22/24 at 4:45 P.M., the ADON/Interim DON said: -He/she did not know the resident had an open area. -He/she would expect the WN to do a full body assessment, staging, pictures, what treatments are put in place. At least follow up on orders to ensure they were done. The WN is the nurse who does rounds with the wound care provider. -He/she expected the charge nurse or WN to notify the DON, Administrator, and PCP of any new or worsening wounds. During an interview on 10/23/24 at 5:33 P.M., the WN said Resident #2 does not have any open areas that he/she is aware of. 3. During an interview on 10/24/24 at 5:30 P.M., the Administrator said: -He/she did not know either Resident #1 or Resident #2 had wounds. -It is his/her expectation the WN or charge nurse notify the DON, Administrator and physician of any new wounds. -It is also his/her expectation that the WN assess the wound, take measurements, and get physician orders for treatment to the wound. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO243716, MO243656, MO243662, MO243797

Based on observation, interview, and record review, the facility failed to provide appropriate education and ensure staff were competent to provide care and protection to residents with mental and behavioral health diagnoses, when Resident #1, who resided on the secured special care unit, had multiple physical altercations with other residents, causing physical injury and emotional distress to other residents. Additionally, Resident #6 engaged in self-harming behaviors, causing lacerations to his/her forearms and upper legs. Staff were unaware of non-pharmacological interventions, individual care plan interventions, and were unable to provide appropriate protection, as no education was provided to them prior to assignment on the special care unit for behavioral health. The facility failed to ensure a process was in place to ensure employees had the knowledge and training necessary to support individuals with a history of trauma and behavioral health diagnoses. The facility census was 87. The Director of Nursing was notified on September 13, 2024 at 3:47 P.M. of an Immediate Jeopardy (IJ) which began on September 3, 2024. The IJ was removed on September 17, 2024, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect Policy, dated 9/17/24, showed: -Guidelines: Training: New employees will be educated by the department manager, or designee, on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. Annual education and training will be provided to all existing employees. Front line supervisors will provide education as situations arise. Review of the facility's Behavioral Emergency Policy, dated 9/17/24, showed: -Interventions: Non-Physical and Proactive: It is the policy of the facility to provide a safe environment and provide humane care to all residents. Non-physical interventions are the first choice as an intervention unless safety issues demand immediate physical intervention. The facility's approved early intervention crisis prevention techniques will be used to de-escalate conflict when possible. Care will be guided by resident's plan of care and based on the strategies taught by Crisis Prevention Institute non-violent crisis intervention, or the current facility guidance, and will help to respond to difficult behaviors in the safest and most effective way possible. The facility shall maintain continuous efforts to reduce the use of physical holds and the administration of medication which poses traumatic effects associated with their application by prominently reflecting such efforts in strategic initiatives and performance improvement processes. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment conducted by staff), dated 4/11/24, showed: -The resident admitted to the facility on [DATE] with diagnoses including: -chronic Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, accompanied by intense emotional and physical reactions), -Borderline Intellect (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), -chronic pain, -Bipolar Disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), -Generalized Anxiety Disorder (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), -Attention Deficit Hyperactive Disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness), -Binge Eating Disorder (an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems), -Borderline Personality Disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), and -Disruptive Mood Dysregulation Disorder (a mental disorder characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of peers); -Resident has adequate hearing, clear speech, and is able to make self understood and understand others; -Score of 15 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients), indicating no cognitive impairment; -Has physical, verbal and other behaviors (including pacing, throwing things, and yelling/screaming). Review of Resident #1's Level II screening, dated 9/5/2023 showed: -He/she can be supported in a nursing facility with the following interventions: Behavioral Support System and Plan, Structured Environment, Medication Therapy, Activities of Daily Living Program, Crisis Intervention Services, and Personal Support Network. Review of Resident #1's Comprehensive Care Plan, most recently dated 5/17/24 showed: -He/she has a long history of mental illness with behaviors and history of being discharged from previous facility for physical behaviors and property damage. He/she requires behavior modification programs as needed, long term psychiatric management and counseling as needed, non-pharmaceutical interventions and one to one interventions as needed, pharmaceutical interventions as needed; -He/she has a history of behavioral challenges that require protective oversight in a secure setting per the resident's Level II screening. Staff should implement plans to change inappropriate behavior as needed. The resident needs daily living skills training, develop personal support network, drug therapy as needed, implement activities of daily living program as needed, provisions of a structured environment, and structured socialization; -He/she has a history of PTSD. The resident is triggered by loud noises, if people are touchy/feely, crowds, yelling. He/she has bad coping skills and agreed to try coloring as a coping skill. Engage the resident in coloring, crafts, journaling, puzzles, groups, listening to music, talking, going to quiet places and resting. Practice sensory interaction in a moment of crisis to ground self to the present, such as describe a happy place and focus on that. Relaxation techniques such as deep breathing, meditation, progressive muscle relaxation, guided imagery. Seek professional help from a counselor or psychologist; -The resident is triggered by the smell of men's cologne and families fighting in a movie; -The resident has a safety plan. His/her warning signs are making a fist, grinding teeth, deep tone in voice. He/she can be distracted and comforted by socializing with friends. Steps to keeping the resident's environment safe include stay away from negativity, walking away, talking to staff and venting. Review of the resident's medical record showed: -On 9/3/24, while at the nurses' station, Resident #3 told Resident #1 you fake all your seizures. Resident #1 became upset and hit Resident #3 in the back of the head with a closed fist. Neither resident had injuries. Resident #1 was placed on one-to-one supervision at this time; -On 9/9/24, while on one-to-one supervision, Resident #1 walked into the dining room for dinner and saw Resident #5 sitting at a table. Resident #1 said I can't eat with that bitch pushed through the staff member providing supervision and hit Resident #5 with closed hands. Neither resident was injured; -On 9/11/12, while on one-to-one supervision, Resident #1 attempted to break up an altercation in the hall between Resident #4 and Resident #5. Resident #5 began calling Resident #1 names. Resident #1 became upset and hit Resident #5 in the face. Resident #5 received a scratch to the face. 2. Review of Resident #6's Annual MDS, dated [DATE], showed: -diagnoses of Bipolar Disorder, PTSD, polysubstance abuse, major depressive disorder, ADHD, generalized anxiety disorder, adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior), borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships). -adequate hearing and clear speech and is able to make self understood and understand others. -Scored 15 on the BIMS, indicating no cognitive impairment. -Has displayed other behavioral symptoms, such as self-harm and yelling. Review of the resident's Level II screening, dated 6/11/15, showed: -He/she can be supported in a nursing facility with the following interventions: secured unit, art/music/recreation therapy, psychological testing and evaluation, individual counseling/psychotherapy, group counseling, grief/loss/adjustment counseling, medication education/counseling, and a 12-step substance abuse program. -Review of the resident's medical record showed he/she did not have orders for or was involved in individual counseling, group counseling, grief/loss/adjustment counseling, medication education/counseling or a 12-step substance abuse program. Review of the resident's comprehensive care plan, dated 7/25/24: -The resident has a long history of mental illness and frequent psychiatric hospital admissions. Behavior modification programs as needed. Long-term psychiatric management and counseling if needed; -At the time of the Level II screening, the resident is deemed to be safe for admission to a skilled facility. The resident has interventions for daily living skills training, drug therapy, implement activities of daily living programs as needed and a structured environment; -The resident has a history of behavioral challenges that require protective oversight in a secure setting. Staff should implement plans to change inappropriate behavior as needed. Staff should use non-pharmaceutical interventions and one to one interventions as needed; -The resident's safety plan includes: Warning signs are silence, reclusive, paranoia, difficulty concentrating, sleep depravation, muscle tension. His/her past crisis moments include past hospitalization due to self-harm, being suicidal and eating disorder. The ways to distract or comfort the resident is left blank on the care plan. The ways to make the resident's environment safer was left blank. Observation of Resident #6 on 9/12/24 showed: -He/she had one white bandage on each of his/her forearms; -He/she said it was from self-harming behaviors, by scratching/cutting him/herself with the clip from a cap from a writing pen; -He/she lifted his/her short legs and scratches and scarring were observed to both upper legs; -He/she then presented a small bag, saying that he/she had multiple pieces of pen caps, of which he/she intended to continue self-harming behaviors; -Resident #6 stated he/she needs help to stop these behaviors, and he/she has informed facility staff he/she is needing this help. The facility staff are not doing anything to help. Review of staffing records for September 01-11, 2024 showed: -Certified Medication Technician (CMT) A worked on the secure unit on 9/1/24, 9/2/24, 9/3/24, 9/5/24, 9/6/24, 9/9/24 and 9/10/24. Review of CMT A's employee file showed: -No documentation CMT A received education of providing care for resident's with mental and behavioral health diagnoses, including non pharmacological interventions, individual care plan interventions and providing appropriate protection of residents. Review of staffing records for September 01-11, 2024 showed: -Hall Monitor (HM) A worked at the facility on 9/2/24, 9/3/24, 9/4/24, 9/5/24, 9/8/24, and 9/10/24. Review of HM A's employee file showed: -No documentation HM A received education of providing care for resident's with mental and behavioral health diagnoses, including non pharmacological interventions, individual care plan interventions, and providing appropriate protection of residents. During an interview on 9/12/24 Certified Nurse Aide A said he/she had worked for the facility for four months. He/she did not receive any education on working with residents on the special care unit, providing 1:1 support, or care of individuals with mental health and behavioral diagnoses. During an interview on 9/12/24, Laundry Aide A said: -He/she had received some training in de-escalation years ago. -He/she had not received any training from the facility on working with residents with mental or behavioral health diagnoses, working on the secure unit, or responding to a behavioral emergency. -He/she is on the secure unit frequently picking up and delivering laundry. During an interview on 9/12/24, Housekeeper A said: -He/she had not received any training from the facility on working with residents with mental or behavioral health diagnoses, working on the secure unit, or responding to a behavioral emergency. -He/she is on the secure unit frequently to perform housekeeping tasks. During an interview on 9/13/24 at 10:49 A.M., the Staffing Coordinator/Receptionist said: -He/she had never received training from the facility on working with residents with mental or behavioral health diagnoses, working on the secure unit, or responding to a behavioral emergency. During an interview on 9/12/24 the Director of Nursing (DON) said: -There is not enough staff and it is not safe for staff to work on the secured care unit without training. -If staff are working on the floor on the secure unit or up front, they work with another staff member for three days. If the staff do one to one supervision, a supervisor will ask if the staff member feels comfortable doing the one to one supervision. -The facility used to train staff using the CALM training (de-escalation techniques), but no longer uses this training. The DON and the Dietary Manager were certified to teach the CALM training but their certification has lapsed. The facility is supposed to start using a new training for working with residents with behavioral health diagnoses, but he/she is not sure when this is starting. He/she is unsure when the certification lapsed, but it has been several months. -The sign in sheet for a training/in-service should be copied and kept in the employee HR file. -Crisis Prevention Institute training had not been started. The DON and dietary manager have not been trained or certified in this program. The Corporate Trainer assigned to their community is certified to train CPI, however had not been to the facility to train employees. The Corporate Trainer is also the current administrator of a facility in this corporation and had not had time to get to this facility During an interview on 9/19/24 at 10:38 A.M., the Administrator said: -It is his/her expectation staff receive appropriate training when working with residents who have mental and behavioral health diagnoses. He/she expects staff to be trained on crisis intervention/de-escalation techniques, however, no one in the facility is certified to train staff on these techniques. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO241916, MO241881, MO241860, MO241820, MO241633, MO241504

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to address the behavioral health needs of two residents (Resident #1 and #6) to attain the highest practicable mental and psychosocial well-being. This is evidenced by Resident #1, who requires behavioral health support needs and has a history of physically abusive behaviors, abusing two residents (Residents #3 and #5) on the secure care community, as a result of the facility failure to assess and implement appropriate interventions to address their behavioral health needs. Additionally, Resident #6 displayed self-harming behaviors and the facility failed to assess behavioral support needs and implement appropriate interventions to address the self-harming behaviors and ensure their safety. The facility also failed to ensure one resident (Resident #6) received care planned support and supervision during medication administration by failing to crush the residents medications and checking the resident's mouth to ensure they were swallowed. The facility census was 87. The Director of Nursing was notified on September 13, 2024 at 3:47 P.M. of an Immediate Jeopardy (IJ) which began on September 3, 2024. The IJ was removed on September 17, 2024, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect policy, dated 9/17/2024, showed: -It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timelines. -Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment, which can include staff to resident abuse and certain resident to resident altercations. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. -Physical abuse is the purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. -Guidelines: The facility will develop and operationalize policies and procedures for screening and training employees, protection or residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Training: New employees will be educated by the department manager, or designee, on issues related to abuse prohibition, practices and abuse reporting requirements during initial orientation. Annual education and training will be provided to all existing employees. Front line supervisors will provide education as situations arise. Prevention: The facility will provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution, and will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Identification: The facility will identify events, occurrences, patterns and trends that may constitute mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property as defined above. -This facility is committed to protecting our residents from abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices, such as dealing with aggressive residents. During orientation of new employees, the facility will cover at least the following topics: How to assess, prevent and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff. -As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the changes of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. -Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreat another resident will be removed form contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. Review of the facility's Behavioral Emergency Policy, dated 9/17/24, showed: -The purpose of this policy is to provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care for the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished, or disciplined for staff convenience. -1. Background: While some of the individuals we serve have high rates of violence toward themselves and others, there is recognition that many of the individuals we serve also had a high incidence of exposure to sexual, physical, and emotional abuse. Consequently, we recognize that any emergency interventions have the potential for (re)traumatizing such individuals. Further, we recognize that despite best intentions, decisions concerning the use of physical holds and the administration of medication are necessarily made under less-than-ideal circumstances (i.e. emergencies), and involve the urgent weighing of significant risks versus the benefits of physical safety. Therefore, such emergency interventions such as the use of physical holds and the administration of medication are to be avoided as possible. -3. Non-Physical and Proactive: It is the policy to provide a safe environment and provide humane care to all residents. Non-physical interventions are the first choice as an intervention unless safety issues demand immediate physical intervention. The facility's approved early intervention crisis prevention techniques will be used to de-escalate conflict when possible. Care will be guided by resident's plan of care and based on the strategies taught by non-violent crisis intervention or current company guidance, and will help to respond to difficult behaviors in the safest and most effective way possible. Proactive management for our residents is the best plan. All staff should recognize when the resident has become or can become a danger to themselves or someone else. De-escalation techniques should be utilized as first resort. -Steps for Crisis Intervention: Should the extreme behaviors such as suicidal, homicidal, self-mutilation, elopement, or resident to resident altercations which did not respond to the non-violent crisis intervention, the following steps will occur: A. The licensed nursing staff and/or nursing administration will assess the resident who is displaying signs of crisis, ensuring that safety of resident and others is the priority. Monitoring of resident will be initiated, if appropriate. B. The Facility's Administrative Team will assess the see if the resident's needs can continue to be met safely or whether the resident continues to be appropriate for placement at the facility. C. The facility will notify the Physician and/or Psychiatrist of the behavioral emergency. Should the resident require additional hospitalization ,coordination of care will occur with the Physician and/or Psychiatrist with receiving hospital to ensure transfer of patient specifics. D. If the resident is unable to be redirected or is personally requesting a PRN (as needed) medication for mood stabilization, the resident will be given a PRN per physician's orders. If the resident receives a by mouth or injection mood stabilizing medication, the licensed nurse will document the administration and effectiveness. E. The Licensed Nurse will document the behavioral emergency in the medical chart. G. The Interdisciplinary Team will ensure the care plan is updated if appropriate. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment conducted by staff), dated 4/11/24, showed: -The resident was admitted to the facility on [DATE] with diagnoses of: -chronic Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, accompanied by intense emotional and physical reactions), -Borderline Intellect (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), -chronic pain, -Bipolar Disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), -Generalized Anxiety Disorder (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), -Attention Deficit Hyperactive Disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness), -Binge Eating Disorder (an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems), -Borderline Personality Disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), and -Disruptive Mood Dysregulation Disorder (a mental disorder characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of peers); -Resident has adequate hearing, clear speech, and is able to make self understood and understand others; -Score of 15 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients), indicating no cognitive impairment; -Has physical, verbal and other behaviors (including pacing, throwing things, and yelling/screaming). Review of Resident #1's Level II screening, dated 9/5/2023 showed: -He/she can be supported in a nursing facility with the following interventions: Behavioral Support System and Plan, Structured Environment, Medication Therapy, Activities of Daily Living Program, Crisis Intervention Services, and Personal Support Network. Review of Resident #1's Comprehensive Care Plan, most recently dated 5/17/24 showed: -He/she has a long history of mental illness with behaviors and history of being discharged from previous facility for physical behaviors and property damage. He/she requires behavior modification programs as needed, long-term psychiatric management and counseling as needed, non-pharmaceutical interventions and one to one interventions as needed, pharmaceutical interventions as needed; -He/she has a history of behavioral challenges that require protective oversight in a secure setting per the resident's Level II screening. Staff should implement plans to change inappropriate behavior as needed. The resident needs daily living skills training, develop personal support network, drug therapy as needed, implement activities of daily living program as needed, provisions of a structured environment, and structured socialization; -He/she has a history of PTSD. The resident is triggered by loud noises, if people are touchy/feely, crowds, yelling. He/she has bad coping skills and agreed to try coloring as a coping skill. Engage the resident in coloring, crafts, journaling, puzzles, groups, listening to music, talking, going to quiet places and resting. Practice sensory interaction in a moment of crisis to ground self to the present, such as describe a happy place and focus on that. Relaxation techniques such as deep breathing, meditation, progressive muscle relaxation, guided imagery. Seek professional help from a counselor or psychologist; -The resident is triggered by the smell of men's cologne and families fighting in a movie; -The resident has a safety plan. His/her warning signs are making a fist, grinding teeth, deep tone in voice. He/she can be distracted and comforted by socializing with friends. Steps to keeping the resident's environment safe include stay away from negativity, walking away, talking to staff and venting. Review of the resident's medical record showed: -No counseling, group or individual.interventions from the resident's Level II evaluation had been put in place to support the resident and minimize continuing behaviors. -On 9/3/24, while at the nurses' station, Resident #3 told Resident #1 you fake all your seizures. Resident #1 became upset and hit Resident #3 in the back of the head with a closed fist. Neither resident had injuries. Resident #1 was placed on one-to-one supervision at this time; -On 9/9/24, while on one-to-one supervision, Resident #1 walked into the dining room for dinner and saw Resident #5 sitting at a table. Resident #1 said I can't eat with that bitch pushed through the staff member providing supervision and hit Resident #5 with closed hands. Neither resident was injured; -On 9/11/12, while on one-to-one supervision, Resident #1 attempted to break up an altercation in the hall between Resident #4 and Resident #5. Resident #5 began calling Resident #1 names. Resident #1 became upset and hit Resident #5 in the face. Resident #5 received a scratch to the face. 2. Review of Resident #6's annual MDS, dated [DATE], showed: -The resident has the diagnoses of Bipolar Disorder, PTSD, polysubstance abuse, major depressive disorder, ADHD, generalized anxiety disorder, adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior), borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships); -Has adequate hearing and clear speech and is able to make self understood and understand others; -Scored 15 on the BIMS, indicating no cognitive impairment; -Has displayed other behavioral symptoms, such as self-harm and yelling. Review of the resident's Level II screening, dated 6/11/15, showed: -He/she can be supported in a nursing facility with the following interventions: secured unit, art/music/recreation therapy, psychological testing and evaluation, individual counseling/psychotherapy, group counseling, grief/loss/adjustment counseling, medication education/counseling, and a 12 step substance abuse program; -Review of the resident's medical record showed that he/she did not have orders for nor was involved in individual counseling, group counseling, grief/loss/adjustment counseling, medication education/counseling, or a 12-step substance abuse program. -He/She had a history of self-harming behaviors. Review of the resident's comprehensive care plan, dated 7/25/24: -The resident has a long history of mental illness and frequent psychiatric hospital admissions. Behavior modification programs as needed. Long term psychiatric management and counseling if needed; -At the time of the Level II screening, the resident is deemed to be safe for admission to a skilled facility. The resident has interventions for daily living skills training, drug therapy, implement activities of daily living programs as needed and a structured environment; -The resident has a history of behavioral challenges that require protective oversight in a secure setting. Staff should implement plans to change inappropriate behavior as needed. Staff should use non-pharmaceutical interventions and one to one interventions as needed; The care plan did not include specific interventions for staff to use related to non-pharmalogical interventios, plans to change behaviors, or criteria for using one to one interventions. -The resident's safety plan includes: Warning signs are silence, reclusive, paranoia, difficulty concentrating, sleep depravation, muscle tension. His/her past crisis moments include past hospitalization due to self-harm, being suicidal and eating disorder. The ways to distract or comfort the resident was left blank. The ways to make the resident's environment safer was left blank on the care plan. -Interventions including group and individual counseling, from the resident's Level II evaluation, were not put in place to support the resident and aid in decreasing continuing behaviors. -The care plan did not address the resident's needs related to self-harming behaviors or interventions for the staff to utilize in addressing the resident's self-harming behaviors. Observation of Resident #6 on 9/12/24 showed: -He/she had one white bandage on each of his/her forearms; -He/she said it was from self-harming behaviors, by scratching/cutting him/herself with the clip from a cap from a writing pen; -He/she lifted his/her short's legs and scratches and scarring were observed to both upper legs; -He/she then presented a small bag, saying that he/she had multiple pieces of pen caps, of which he/she intended to continue self-harming behaviors. During an interview 9/12/24 at 10:50 A.M., Resident #6 said he/she needs help to stop these behaviors, and he/she has informed the facility staff he/she needs this help. The facility staff are not doing anything to help him/her. During an interview on 9/12/24, Licensed Practical Nurse (LPN A) said: -He/she was aware the resident has self-harming behaviors; -LPN A showed a clip from a pen cap that Resident #6 had given him/her; -Resident #6's injuries were noted the weekend of September 6, 2024; -LPN A said, in regards to interventions staff put into place to address the resident's behavior, Resident #6 is scheduled to be seen by a wound care provider on 9/13/24. No other interventions have been put in place. During an interview on 9/17/24 at 1:05 P.M., the Social Services person said: -He/she does not schedule the residents to be seen by the psychiatrist. The nurse does that. -He/she has scheduled residents for counseling at the local mental health services, but Resident #1 or #6 have not been scheduled for counseling. He/she has not been asked to schedule those residents. During an interview on 9/17/24, the Director of Nursing (DON) said: -He/she was aware Resident #6 has self-harming behaviors; -He/she expects staff monitor the resident for self-harming/abusive behaviors, document the behaviors, and notify the physician and psychiatrist of the behaviors; -He/she is aware Resident #1 has physically aggressive/abusive behaviors toward other residents. The facility has sent the resident to the hospital for evaluation, but the hospital did not admit the resident and sent him/her back to the facility. The resident has been on one-to-one supervision since a resident to resident altercation on 9/3/24. He/she has had two additional resident to resident altercations since being placed on one to one supervision; -It is his/her expectations that residents are safe in the facility. During an interview on 9/19/24, at 10:38 A.M., the Administrator said: -He/she was aware Resident #6 had self-harming behaviors; -It is his/her expectation the staff monitor the resident's safety and notify the DON, Administrator, and physician of the behaviors. Staff should also put interventions in place to assist the resident in de-escalation before beginning the self-harming behaviors; -He/she was aware Resident #1 has had physically aggressive behaviors toward other residents; -It is his/her expectation that all residents are safe in the facility and each resident receives the appropriate care. Staff should practice de-escalation techniques to prevent resident to resident altercations. 3. Review of the facility's Medication Administration Policy, dated 7/30/24 showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. It is the policy of this facility to ensure the safe and effective administration of all medications by utilizing best practice guidelines. -General Medication Administration Process: O. Administer medication as ordered in accordance with manufacturer specifications. 1. Provide appropriate amount of food and fluid. 2. Shake well to mix suspensions. 3. Crush medications as ordered. Do not crush medications with do not crush instruction. 4. Observe resident consumption of medication. Review of Resident #6's Annual Minimum Data Set (MDS, a federally mandated assessment conducted by staff), dated 8/9/24, showed: -The resident had diagnoses of Bipolar Disorder, Post Traumatic Stress Disorder, polysubstance abuse, major depressive disorder, ADHD, generalized anxiety disorder, adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions and changes in behavior), borderline personality disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships). -Has adequate hearing and clear speech and is able to make self understood and understand others. -Scored 15 on the BIMS, indicating no cognitive impairment. -Displayed other behavioral symptoms, such as self-harm and yelling. Review of the resident's comprehensive care plan, dated 7/25/24: -The resident has a long history of mental illness and frequent psychiatric hospital admissions. Behavior modification programs as needed. Long term psychiatric management and counseling if needed. -The resident has a potential for behavior problems related to bipolar disorder, post traumatic stress disorder, and anxiety disorder. Administer medications as ordered and observe for side effects and effectiveness. Review of the resident's physician orders dated September 12, 2024 showed: -Order to check mouth after giving medication to observe for cheeking meds. -Order to crush medications as needed. -Order for hydroxyzine HCl (a medication used to treat anxiety, nausea, vomiting, allergies, skin rash, hives, and itching. Also known as Atarax) oral tablet 50 milligrams (mg) every eight hours as needed for itching related to bipolar disorder. Review of the resident's electronic medical chart showed: -On 9/5/24 at 5:25 P.M., staff were called to Resident #6's room. The resident reported to staff Certified Medication Technician (CMT) A does not crush the resident's medication and he/she cheeks the medication and saves them. Review of facility staffing dated 9/1/24 to 9/11/24 showed: -CMT A worked on the secure unit as the CMT on 9/1/24, 9/2/24, 9/3/24, and 9/5/24. CMT A worked from 7:00 P.M. to 7:00 A.M. Review of the facility's investigation on 9/13/23 showed: -CMT A confirmed he/she had not crushed the medication before administering it to Resident #6. During an interview on 9/12/24 at 1:42 P.M., Resident #6 said: -CMT A never crushed the resident's medication or checked to make sure the resident swallowed the medication. During an interview on 9/16/24, the DON said: -It is his/her expectation that staff follow physician orders and standards of practice, including crushing the medications of residents on the secure unit and always checking to make sure the residents are not cheeking the medication. During an interview on 9/19/24 at 10:38 A.M., the Administrator said: -It is his/her expectation staff crush medications that can be crushed and check to make sure residents have swallowed the medication. -Staff should always follow physician orders and not administer more medication than ordered. Review of CMT A's employee file showed: -He/she was hired by the facility on 11/7/23 as a CMT. -He/she participated in a Medication Pass Audit on 3/26/24 at 3:15 P.M. During the audit, he/she observed the resident to ensure the medication was swallowed. -On 7/30/24, CMT A received education on medication administration, and signed verifying he/she received the education. The education included: All medications that can be crushed are to be crushed. If they can not be crushed, those medications are to be administered first, then a drink, then crushed medications are to be given in pudding or applesauce and a drink after administration. All residents' mouths are to be checked after administration. This is not an option. If there are not crush pouches, there are alternate ways to crush medication. It is never an option on the secure unit to not crush medication. -CMT A's employment was terminated on 9/6/24 due to gross negligence in performance of job duties and serious violation of safety rules, related to medication administration. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO241916, MO241881, MO241860, MO241820, MO241633, MO241504

Based on observation, interview and record review, the facility failed to protect two residents (Resident #3 and Resident #5) that reside on the secure unit from abuse by Resident #1. Residents #3 and #5 were hit in the head by Resident #1. Resident #2 said residents feel they have to walk on eggshells on the unit, because they do not know when Resident #1, will become upset and lash out verbally or physically. Resident #2 stated he/she feels staff are unable to protect others from Resident #1. Resident #3 said he/she does not feel safe in the facility due to Resident #1's verbal and physical abuse to him/her and the other residents. Resident #4 said he/she does not feel safe because the other residents on the secure unit have too many behaviors and do whatever they want on the unit. Resident #5 said he/she does not feel safe as he/she has gotten beaten up, had multiple physical altercations with Resident #1, and is scared of Resident #1. Resident #5 said Resident #1 has hit him/her in the face and also slammed his/her head on the ground. The facility census was 87. The Director of Nursing was notified on September 13, 2024 at 3:47 P.M. of an Immediate Jeopardy (IJ) which began on September 3, 2024. The IJ was removed on September 17, 2024, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect policy, dated 9/17/2024, showed: -It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timelines. -Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment, which can include staff to resident abuse and certain resident to resident altercations. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. -Physical abuse is the purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. -Guidelines: The facility will develop and operationalize policies and procedures for screening and training employees, protection or residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure the the facility is doing all that is within its control to prevent occurrences. Training: New employees will be educated by the department manager, or designee, on issues related to abuse prohibition, practices and abuse reporting requirements during initial orientation. Annual education and training will be provided to all existing employees. Front line supervisors will provide education as situations arise. Prevention: The facility will provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution, and will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Identification: The facility will identify events, occurrences, patterns and trends that may constitute mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property as defined above. -This facility is committed to protecting our residents from abuse by anyone including but not limited to facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices, such as dealing with aggressive residents. During orientation of new employees, the facility will cover at least the following topics: How to assess, prevent and manage aggressive, violent, and/or catastrophic reactions of residents in a way that protects both residents and staff. -As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the changes of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis. -Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreat another resident will be removed form contact with the resident during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement considering his or her safety, as well as the safety of other residents and employees in the facility. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment conducted by staff), dated 4/11/24, showed: -The resident admitted to the facility on [DATE]. -Diagnoses of chronic Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, accompanied by intense emotional and physical reactions), Borderline Intellect (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), chronic pain, Bipolar Disorder (a mental health condition characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function), Generalized Anxiety Disorder (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), Attention Deficit Hyperactive Disorder (a chronic condition including attention difficulty, hyperactivity, and impulsiveness), Binge Eating Disorder (an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems), Borderline Personality Disorder (a personality disorder characterized by severe mood swings, impulsive behavior, and difficulty forming stable personal relationships), and Disruptive Mood Dysregulation Disorder (a mental disorder characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of peers). -Has adequate hearing, clear speech, and is able to make self understood and understand others. -A score of 15 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients), indicating no cognitive impairment. -Has physical, verbal and other behaviors (including pacing, throwing things, and yelling/screaming). Review of Resident #1's Level II screening, dated 9/5/2023, showed: -Diagnoses of chronic PTSD, Borderline Intellect, chronic pain, Bipolar Disorder, Generalized Anxiety Disorder, Attention Deficit Hyperactive Disorder, Binge Eating Disorder, Borderline Personality Disorder, and Disruptive Mood Dysregulation Disorder. -He/she can be supported in a nursing facility with the following interventions: Behavioral Support System and Plan, Structured Environment, Medication Therapy, Activities of Daily Living Program, Crisis Intervention Services, and Personal Support Network. Review of Resident #1's Comprehensive Care Plan, dated 5/17/24 showed: -He/she has a long history of mental illness with behaviors and history of being discharged from previous facility for physical behaviors and property damage. -Interventions of behavior modification plan as needed, calming techniques as needed, one on one intervention as needed, pharmaceutical interventions as needed, implement plans to change inappropriate behavior, encourage relaxation techniques (deep breathing, meditation, guided imagery), set the resident up with a counselor or psychologist as needed. Review of the resident's medical record showed: -On 9/3/24, while at the nurses' station, Resident #3 told Resident #1 you fake all your seizures. Resident #1 became upset and hit Resident #3 in the back of the head with a closed fist. Neither resident had injuries. Resident #1 was placed on one-to-one supervision; -On 9/9/24, while on one-to-one supervision, Resident #1 walked into the dining room for dinner and saw Resident #5 sitting at a table. Resident #1 said I can't eat with that bitch pushed through the staff member providing him/her direct one-on-one supervision and hit Resident #5 with closed hands. Neither resident was injured; -On 9/11/12, while on one-to-one supervision, Resident #1 attempted to break up an altercation in the hall between Resident #4 and Resident #5. Resident #5 began calling Resident #1 names. Resident #1 became upset and hit Resident #5 in the face. Resident #5 received a scratch to the face. During an interview on 9/12/24 with Certified Nurses Assistant (CNA) A said: -He/she is the staff providing one-to-one supervision to Resident #1; -He/she had not received formal training but the charge nurse told him/her to be within an arms distance of Resident #1 and keep the resident out of trouble; -He/she is not aware of interventions on Resident #1's care plan to assist the resident in de-escalation and to redirect the resident from engaging in behaviors. During an interview on 9/12/24, Licensed Practical Nurse (LPN) A said Resident #1 is usually triggered by believing other residents are talking about him/her or when the other residents comment about Resident #1's seizures. During an interview on 9/12/24, Resident #2 said he/she and the other residents feel they have to walk on eggshells on the unit, because they do not know when Resident #1, will become upset and lash out verbally or physically. He/she does not feel safe at the facility because Resident #1 has hurt him/her and other residents and staff are unable to protect others from Resident #1. During an interview on 9/12/24, Resident #3 said he/she does not feel safe in the facility due to Resident #1's verbal and physical abuse to him/her and the other residents. During an interview on 9/12/24, Resident #4 said he/she does not feel safe because the other residents on the secure unit have too many behaviors. The staff are always busy with residents and residents do whatever they want on the unit. During an interview on 9/12/24, Resident #5 said he/she does not feel safe as he/she has gotten beaten up by Resident #1 and is scared of Resident #1. Resident #5 said he/she has had multiple physical altercations with Resident #1, where Resident #1 has hit him/her in the face and also slammed his/her head on the ground. During an interview on 9/12/24 at 1:42 P.M., the Director of Nursing (DON) said: -Resident #1 has been on one to one direct supervision since he/she hit Resident #3 on 9/3/24; -It is his/her expectation that when a resident has a physical behavior directed toward another resident, the staff should separate the residents and notify the charge nurse. The charge nurse should assess the involved residents for injuries and safety. The charge nurse should inform the DON and the Administrator, residents' responsible parties, and the residents' physician. The resident who is the aggressor should be sent to the hospital for a psychiatry assessment and possible treatment; -It is his/her expectation that if a resident is having repeated physical behaviors directed toward other residents, the resident should be assessed to determine if the resident's needs could be met in the facility or possibly find other placement for the resident. During an interview on 9/19/24 at 10:36 A.M., the Administrator said: -It is his/her expectation that residents are safe in the facility; -When a resident has physical behaviors directed toward other residents, the residents should be immediately separated and assessed for injury and safety; -The resident who is the aggressor should immediately be placed on one to one supervision. The physician should be notified, as should the resident's responsible parties. The resident who is the aggressor should be sent to the hospital for evaluation. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation. MO241916, MO241881, MO241860, MO241820, MO241633, MO241504

Based on interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice when staff failed to recognize, monitor or treat a resident with a diagnoses of Diabetes Mellitus Type II, failed to draw ordered laboratory tests on admission, failed to thoroughly assess a change of condition and to request any direction from the Primary Care Physician for one resident (Resident #1) of 4 sampled residents. Additionally, the facility failed to schedule an ordered orthopedic follow up appointment for one resident (Resident #4) who had broken his/her right ankle on [DATE]. The resident did not see a physician for the fracture until he/she had an appointment with his/her podiatrist on [DATE]. Since that time the resident became dependent on staff for all Activities of Daily Living (ADL)'s, incontinent of bowel and bladder, developed a wound, and had a significant weight loss. Facility census was 88. The administrator was notified on [DATE] at 4:52 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor on-site. Review of the facility policy for Admission Process, dated [DATE], included the Registered Nurse (RN) will need to complete a chart audit within 24 hours of admission. - The 24 Hour RN Chart Audit includes, but is not limited to: admitting diagnosis, primary diagnosis, all diagnosis on physician order sheet, RN note (to include: Chart audit completed by RN and chart reviewed) baseline labs ordered, and orders checked from facility physician order sheet to discharge orders from previous placement. Review of the facility policy for Blood Glucose Monitoring and Insulin Administration, dated [DATE], showed: -The blood sugar monitoring/accucheck orders will be obtained from the physician including the recommended time and frequency of the monitoring. -If the resident's blood sugar is over 400, the physician will be notified by the charge nurse and orders will be followed. 1. Review of Resident #1's Face sheet showed: -admitted [DATE]; -Diagnosis of: -DM Type II (DM Type II: a disease where the pancreas doesn't produce enough insulin to control the amount of glucose, or sugar, in the blood causing hyperglycemia (high blood sugar). Hyperglycemia can cause vomiting, excessive hunger and thirst, rapid heartbeat, vision problems and other symptoms, including coma and death); -Anxiety; -Chronic Obstructive Pulmonary Disease (COPD: a disease that blocks airflow into the lungs and causes difficulty breathing); -Cellulitis (an infection of the skin cells); -Alzheimer's (a disease of the brain that effects, memory, sensory ability, and thought process). Review of the Discharge Information from the previous hospital stay, dated [DATE], showed: -Diagnosis of: -DM Type II, long term insulin use; -Cellulitis; -Urinary Tract Infection (UTI); -Pressure Ulceration; -Blood Glucose of 130 (a lab that shows the concentration of sugar in the blood. Normal range is ,d+[DATE] per record); -Medications: -Trimethoprim-sulfamethoxazole (an antibiotic used to treat infections. Also known as Bactrim DS) 160 milligrams (mg) /800 mg. 1 tablet by mouth every 12 hours. -Acetaminophen (Tylenol) 650 mg every 4 hours as needed for pain. Review of the Physician Order Sheet (POS) for [DATE] showed: -Trimethoprim-sulfamethoxazole 160 mg/800 mg. 1 tablet by mouth twice a day. -Acetaminophen (Tylenol) 650 mg every 4 hours as needed for pain. -Regular diet, mechanical soft (chopped meat and vegetables) texture, with regular liquids. -Glycosolated Hemoglobin (HgbA1c: a laboratory test that shows the amount of sugar in the blood) every 6 months. -Complete Blood Count (CBC: a blood test used to evaluate your overall health) yearly. -Comprehensive Metabolic Panel (CMP: a blood test that provides important information about your body's chemical balance and metabolism) yearly. Review of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE] showed: -Diagnosis of DM; -Brief Interview of Mental Status of 10 (indicating some cognitive impairment). -No noted behaviors; -Extensive assistance with Activities of Daily Living (activities related to personal care, such as: bathing, combing hair, brushing teeth, shaving, toileting); -Received no insulin; -No physician visits or new orders. Review of the Admission Care Plan, dated [DATE], showed: -He/she had DM. -He/she will have no complications related to DM through the next review date. -Diabetes medication as ordered by the physician. -Monitor and document for side effects. Review of the resident's medical record, dated [DATE] through [DATE], showed: - Resident #1 admitted to the facility at 11:46 P.M. - No documentation the attending physician notified of the resident's admission. - No documentation the resident's ordered Glycosolated Hemoglobin lab work was obtained. - No documentation the resident's ordered CBC was obtained. - No documentation the resident's ordered CMP was obtained. - No documentation of any lab work requested or completed. - No documentation of any accuchecks or monitoring of the blood sugar. - No documentation staff addressed the resident's diabetes or monitoring of the diabetes. Review of the Progress Notes, dated [DATE] at 9:33 A.M., by the Director of Nursing (DON) showed: -Resident was found with fixed stare and shallow breaths. -Unable to obtain blood pressure or oxygen saturation. -His/her hands are cold and discolored. -911 was called. -He/she was sent to area hospital by ambulance. Review of the hospitalization Records from the local hospital, dated [DATE] at 10:04 A.M., showed: -Resident arrived to the Emergency Department (ED), unresponsive to all stimuli (such as sound, touch and pain). -He/she was being oxygenated with a bag/valve mask (mask covering the mouth and nose, operated by a healthcare professional, used to force oxygen into the lungs of a person who is not breathing on their own). -He/she quickly lost pulses (the heart is no longer beating) and Cardiopulmonary Resuscitation (CPR) was started. -Resident #1 passed away at 11:32 A.M. -Clinical Impression: -Cardiac Arrest. -Respiratory Failure. -Diabetic Ketoacidosis (DKA: a serious complication of diabetes that can be life-threatening with the most common cause of death being infection or cardiovascular-related events such as circulatory collapse (the heart stops beating and blood flow to the body ceases). Review of the local Hospital laboratory results, dated [DATE] at 10:06 A.M., showed: -Blood glucose level of 785 milligrams/deciliter (normal range noted as 70 mg/dl-100 mg/dl). During an interview on [DATE] at 12:17 A.M., Licensed Practical Nurse (LPN) A said: -When a resident admits to the facility, discharge orders are reviewed by the admitting nurse, from the previous placement, assessments are completed, and the physician is notified of admission. -Primary Care Physician (PCP) A or the Nurse Practitioner will see residents once a week after admission. -Baseline (first set) of blood tests and urine tests (referred to as lab tests) would be obtained. -Results of lab tests are usually received in 24 hours after obtained. -PCP A uses their own laboratory and those resident lab tests are only obtained on Monday and Wednesday. -If a resident admitted to the facility on a Thursday, lab would not be drawn until the following Monday. -If the new admission had DM and was a resident of PCP A his/her labs would not be drawn until the following lab day, depending on their admission day. -For residents with DM, PCP A waits for labs to determine course of care. -He/she did not admit Resident #1. During an interview on [DATE] at 5:25 P.M., LPN C said: -He/she was the nurse that admitted the resident. -He/she was not aware Resident #1 was diabetic. -He/she was not informed from the transferring hospital that Resident #1 was diabetic. -When a resident admits to the facility after office hours for the physician, orders and information are faxed to the physician's office and then addressed by the physician the next business day. -He/she faxed all hospital discharge information to the physician's office. During an interview on [DATE] at 12:51 P.M., the Medical Director said: -He/she does not provide care for Resident #1. -Not all people with DM need medications; those patients should have monthly labs and treatment is driven from the results. -If a resident is unable to tell him/her their medication regimen for DM, he/she would order glucose monitoring and HgbA1c. -He/she would expect the admitting nurse to recognize a diagnosis of DM with no treatment and address it with him/her. -He/she would expect labs to be drawn as ordered on admission. During an interview on [DATE] at 2:10 P.M., the LPN Resident Care Coordinator (RCC) said: -Management Nurses (the DON or RCC) are responsible for reviewing hospital paperwork prior to an admission. The RCC reviews Unit 2 admissions and the DON reviews Unit 1 admissions. -Once a resident is admitted , the PCP must be contacted for orders such as medications, labs, diet, etc. -He/she was not aware Resident #1 was diabetic as Resident #1 was admitted on Unit 1. -He/she would expect the admitting nurse to know the diagnosis and call the PCP for orders to address the diagnosis. During an interview on [DATE] at 4:07 P.M., the DON said: -He/she was unaware Resident #1 was diabetic until printing paperwork while sending resident to the hospital. During an interview on [DATE] at 3:07 P.M., the Administrator said: -Management Nurses are responsible for completing an audit of admission and completing the audit checklist. -The audit for Resident #1 was missing. -He/she would expect the admitting nurse to review admission paperwork sent to the facility and address any diagnosis or medication that needed to be addressed. -He/she would expect the auditor of the admission to notice the diabetes diagnosis and no treatment. -He/she would expect the auditor to notify the PCP of the diagnosis. During an interview on [DATE] at 3:42 P. M., Resident #1's PCP said: -He/she was not aware of the extensive medical history for Resident #1. -He/she would have provided treatment for diabetes based on Resident #1's admission labs. -He/she would expect the facility to obtain the ordered labs and notify him/her of the results. -In his/her professional opinion, if the facility had obtained the lab orders and results, the outcome may not have been death. 2. The facility did not provide a policy for scheduling follow up appointments. Review of Resident #4's quarterly MDS, dated [DATE], showed: - He/she had a BIMS score of 15, indicating no cognitive deficit. - Diagnoses included: chronic obstructive pulmonary disease (COPD, a disease of the lungs making it difficult for the resident to breathe), heart failure and osteoporosis, (a disease in which the bones become fragile). - He/she was able to transfer, use the toilet, reposition in bed, and propel his/her wheelchair him/herself. - He/she required the assistance of one staff to get dressed and use the toilet. - He/she was occasionally incontinent of bladder and always continent of bowel. - He/she had no skin damage or wounds. - He/she weighed 255 pounds. Review of the resident's nurses' note, dated [DATE] at 5:54 P.M., showed the resident returned from the Emergency Department (ED) and had a broken right ankle after he/she fell in the facility. Resident #4 received a new order to be non-weight bearing and contact the orthopedic group for follow up. Review of the resident's [DATE] physicians' order sheet (POS) showed an order, dated [DATE], that Resident #4 was to be non-weight bearing and to follow up with the orthopedic specialist. Review of the resident's record did not show documentation that the facility staff contacted the orthopedic specialist to schedule a follow up appointment. Review of the resident's nurses' note, dated [DATE] at 10:37 P.M., showed LPN C documented the resident continued to be non-weight bearing on his/her right foot due to his/her right ankle was broken. The resident required the assistance of two staff to transfer to and from his/her chair and bathroom. Review of the resident's nurses' note, dated [DATE], showed LPN A documented two staff assisted Resident #4 to transfer. Review of the resident's a nurses' note, dated [DATE], showed LPN A documented the resident was non-compliant with non-weight bearing. The facility staff transferred the resident using the mechanical lift. He/she had a nonproductive cough. Review of the ADL care plan, dated [DATE], showed: - He/she had an ADL self-care performance deficit due to his/her right broken ankle. - He/she required the use of the mechanical lift for transfers and required assistance with his/her ADLs. - He/she will maintain or improve his/her level of function. Review of the resident's nurses' note, dated [DATE], showed Resident #4 was incontinent of bladder and bowel. He/she had an open area to his/her coccyx (the bony area at the very low back) and he/she had fragile skin on his/her buttocks. Review of the resident's pressure ulcer care plan, dated [DATE], showed the resident had a pressure ulcer to his/her coccyx area due to immobility. - The facility staff were to administer medications and treatments as ordered by the physician. Review of Resident #4's significant change MDS, dated [DATE], showed: - BIMS score of 14, indicating no cognitive deficit. - He/she required the assistance of two staff to reposition in bed, use the toilet, get dressed, transfer, and to provide personal hygiene. - He/she required the assistance of one staff member to push his/her wheelchair. - He/she was incontinent of bowel and bladder. - He/she had moisture associated skin damage (MASD). - He/she weighed 230 pounds. Review of the resident's nurses' note, dated [DATE], showed LPN A documented Resident #4 was encouraged to get out of bed and eat the evening meal due to recent weight loss. Review of the resident's nurses' note, dated [DATE], showed LPN D documented Resident #4 received an order for health shakes three times daily for weight loss. Review of the resident's dietary notes, dated [DATE], showed Registered Dietician (RD) A documented the resident was sent to the hospital on [DATE], diagnosed with a urinary tract infection (UTI) and returned to the facility the same day. The resident had not been eating well recently but was drinking his/her fluids. The recent weight loss was most likely related to his/her UTI. RD A did not address the resident's fractured ankle. Review of his/her weights showed Resident #4's weight on [DATE] was 247 pounds, on [DATE] his/her weight was 230 pounds. His/her weight decreased 17 pounds and 6.9% in 19 days. During an interview on [DATE] at 2:15 P.M., Resident #4 said: - He/she had a wrap and splint on his/her right ankle from [DATE] to [DATE]. - The facility staff did not remove it or check his/her skin. - He/she used to be able to take him/herself to the bathroom and transfer him/herself. - Now he/she had to depend on the staff to help him/her to the bathroom and transfer. - He/she was sad that he/she was no longer able to do the things for him/herself that he/she was able to do before he/she broke his/her ankle. - He/she felt like if he/she had an orthopedic appointment soon after he/she broke his/her ankle, he/she might have had some of his/her independence back. During an interview on [DATE] at 11:52 A.M., CNA D said: - Resident #4 fell a few weeks ago and broke his/her right ankle. - He/she was sent back from the ED with two plastic pieces that fit to his/her foot and ankle and went part way up his/her leg. The plastic pieces were wrapped with an ace wrap. - He/she was unaware if staff removed the splint. During an interview on [DATE] at 1:23 P.M., LPN D said: - The Transportation Driver (TD) A was supposed to set up the orthopedic follow up appointment for Resident #4. - He/she wrote Resident #4's information on a paper and placed the paper in the Social Service Director's (SSD) box to alert TD A to set up an orthopedic appointment for a follow up. - SSD and TD A share an office and sometimes the SSD would help with scheduling appointments. - Resident #4 returned from the ED on [DATE] with two plastic stabilizers and his/her ankle wrapped in an ace bandage. - He/she did not take the splint off, but loosened the ace bandage and slid his/her fingers under the splint to assess the resident's pedal (foot and ankle) pulses and check the resident's skin. - He/she thought the resident had a follow up appointment scheduled, but it had to be canceled because another transportation driver quit. - He/she was unsure of the follow up appointment was to see the orthopedic specialist or podiatry. - The resident developed his/her wound and became incontinent of bowel and bladder after he/she broke his/her ankle. - The splint remained on the resident from [DATE] until he/she followed up with the podiatrist on [DATE] and the resident had a cam boot (special immobilizing boot) placed on him/her. - He/she should have followed up with TD A about the date the orthopedic follow up was scheduled for. During an interview and observation on [DATE] at 12:50 P.M., SSD said: - TD A was supposed to schedule all of the resident appointments. - He/she reviewed the transportation schedule and did not find an appointment scheduled for the resident to follow up with an orthopedic specialist. During an interview on [DATE] at 12:58 P.M., TD A said: - He/she made all of the appointments, because he/she is the driver. - He/she did not set up an orthopedic appointment for Resident #4, because he/she did not know the resident had an order. - The residents often told him/her they needed an appointment set up. - Resident #4 did not tell him/her that he/she needed an orthopedic appointment. - The nurses were supposed to either hand him/her a copy of the order for an appointment or place it in the SSD box outside of the office so that he/she could schedule the appointment. - LPN D did not tell him/her the resident had an order to have an appointment set up to follow up with an orthopedic specialist. During an interview on [DATE] at 12:30 P.M., Podiatry Nurse (PN) A said: - Resident #4 presented to the podiatry appointment still wearing the same plastic splint on his/her right ankle that was placed on him/her in the ED on [DATE]. - The resident's skin appeared very dry and pale. - The facility did not set up an orthopedic follow up appointment that the ED physician ordered on [DATE]. During an interview on [DATE] at 2:00 P.M. the DON said: - He/she expected LPN D to make a copy of the order given to TD A so that Resident #4's follow up appointment could have been scheduled. - He/she expected the appointment to be scheduled right away. - He/she expected the nurses to assess the resident's right leg. During an interview on [DATE] at 12:08 P.M., Family Member A said: - He/she expected the facility staff to schedule Resident #4's appointment to follow up with an orthopedic specialist as quickly as possible. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation. MO207598 MO208626

Based on record review and interview, the facility failed to assess, contact the physician, and treat timely one sampled resident (Resident #64) when he/she voiced complaints of being in pain from constipation and reported seeing blood when trying to have a bowel movement. The facility census was 83. 1. Review of Resident #64's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 3/18/21, included the following: - Date admitted [DATE]; - Cognitively intact; - Independent with toilet use; - Constipation section was not completed. Review of the resident's care plan, dated 4/4/21, did not show any information regarding a history of constipation. Review of the resident's May 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - Check for fecal impaction and remove as needed, order date 2/16/21; - There were no orders for treating constipation. Review of the resident's medical records showed the following: - Nurses' note, dated 5/5/21 by Licensed Practical Nurse (LPN) C, showed the resident returned to the facility from the hospital at 8:15 P.M. after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] - There was no other note regarding the resident being constipated or that the resident was sent to the hospital; - The resident's last bowel movement before 5/5/21 was on 5/3/21 (2 bowel movements were documented as medium). Review of the hospital records, dated 5/5/21, included the following: - Reason for visit- urinary retention and unable to void bowel; - Diagnosis- constipation; - Fleet enema was performed; - History present illness: Patient presents to the emergency department with a chief complaint of pain. The patient has not had a bowel movement for about a week. Today he/she found it difficult to urinate. He/she strained at the stool and sometimes had a little bit of blood. He/she is on [MEDICATION(S)] (blood thinner). It hurts in his/her lower abdomen and in his/her back; - Reports having diarrhea last week. He/she took two doses of [MEDICATION(S)] (used to treat diarrhea) at that time. No bowel movement since, reports very little amount coming out that is solid after sitting on toilet for a long time. Unable to fully void out bladder for over 24 hours. Noting blood when wiping and dripping into stool. Straining a lot. Has history of hemorrhoids; -Gastrointestinal: Positive for abdominal pain, anal bleeding, constipation and rectal pain. Negative for diarrhea, nausea and vomiting; - Rectal exam done with nurse present. There is a large amount of stool. Was able to disimpact a fairly large piece of stool that appeared tannish-brown without evidence of blood; - Patient responded well to a fleets enema with good results and now feels better; - Abdomen x-ray findings- Nonobstructive bowel gas pattern. Increased volume of formed fecal matter in the [MEDICATION(S)] and left colon. No evidence of sub diaphragmatic free air. Stable appearance of surgical clips in right abdomen. No suspicious calcifications, organomegaly or focal osseous abnormality. Impression: No evidence of mechanical bowel obstruction or free aid, probably component of constipation, stable postoperative changes without additional acute process. During an interview on 5/6/21 at 8:07 A.M., the resident said he/she: - Was really constipated yesterday; - Told nursing staff yesterday morning but LPN A did not feel comfortable giving an enema so the facility sent him/her out to the hospital; - Asked for Magnesium [MEDICATION(S)] (used to treat constipation) yesterday morning but LPN A was so busy he/she could not get the order for it; - Also asked LPN A to use a straight catheter (is a soft, thin tube used to pass urine from the body) because he/she could not urinate, but LPN A did not; - Went out to the hospital around 4:30 P.M. on 5/5/21; - He/she was up all night the night before (5/4/21) because he/she could not have a bowel movement. He/she was on and off the toilet an hour and a half at a time. He/she was bleeding. LPN B, the night nurse, knew about it. He/she was not sure if LPN B called the doctor; - He/she believed the constipation was caused from taking a medication twice the previous week to treat diarrhea; - He/she had not had a bowel movement since last week, but he/she did not tell anyone. Staff found out about it two nights ago. Staff chart on his/her bowel movements but they do not ask him/her, they chart whatever they want; - Typically he/she had two to three bowel movements per day. During an interview on 5/11/21 at 8:28 A.M., Transportation Staff said: - That morning (that the resident went to the hospital) he/she heard the resident was light headed, but he/she she got light headed occasionally. That afternoon, the resident was doubled over at the dining room table, and staff said he/she needed to be taken out, so he/she took him/her to the hospital. During an interview on 5/11/21 at 9:29 A.M., LPN A said he/she: - Believed it was unsafe to do an enema (used to clear the bowels) because the resident said it was right there and his/her fear was it would cause a bowel rupture; - Assessed the resident and told the Director of Nursing (DON) he/she felt unsafe about giving an enema because he/she did not want to cause bowel rupture; - The resident had requested the Magnesium [MEDICATION(S)] that morning. She was going to request an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . That was the first day he/she had heard about the resident being constipated. He/she heard it from the resident. He/she sent the resident out around 4:00 P.M. During an interview on 5/11/21 at 9:35 A.M., Certified Nurse Aide (CNA) B said bowel movements were charted on all residents daily each shift. During an interview on 5/11/21 at 9:36 A.M., LPN A said: - If a resident went three days without a bowel movement, the electronic health record would populate a notification for the nurse; - The resident did not have a history of constipation; - The resident had diarrhea a couple days last week and got a one time order for [MEDICATION(S)]; - The resident was on narcotic medications which can cause constipation; - He/she told the resident to get up and walk to help with the process but he/she wanted to lay in bed. The resident did complain that he/she could not urinate but did not say anything about wanting to use a straight catheter. He/she encouraged the resident to bare down and try to pee, this was around lunch time on 5/5/21. At approximately 4:00 P.M., he/she called the physician because that was when he/she had the time, that day was really hectic. During an interview on 5/11/21 at 11:25 A.M., LPN A said: - He/she would usually contact a physician within 30 minutes to 1 hour when a resident complained of constipation. He/she was in the process of contacting the physician, but he/she had more than one fall occur; - The resident complained of constipation at approximately 8:30 A.M. He/she talked to the DON about his/her concerns at 3:15 P.M., then contacted the physician at approximately 4:00 P.M. He/she thought he/she documented the incident, but it did not save. Typically a note was entered as a transfer to hospital note. During an interview on 05/11/21 at 3:12 P.M., LPN B said: - The resident mentioned being constipated to the aide and he/she went and assessed the resident; - There were no interventions for constipation that he/she was aware of; - He/she monitored the resident and asked another nurse what to do about it, he/she thought it was LPN A. The resident fell asleep and that was the end of it; - He/she was not sure if it was documented, it was busy. He/she would normally make a note about the resident complaining of constipation; - The resident had mentioned bleeding, but it was nothing major because it was nothing he/she had seen, he/she noted hemorrhoids when he/she talked to the resident. He/she did not call the physician and did not remember what time it was when the resident was complaining, but it was late at night on 5/4/21 or early in the morning on 5/5/21; - The resident did not ask for any medications; - He/she did not remember who the aide was who told him/her that the resident was complaining of constipation. During an interview on 5/12/21 at 4:34 P.M., the DON said: - LPN A called her in the afternoon and told her they were going to send the resident to the hospital. The resident was crying and unable to have a bowel movement, they had called the physician and got permission to send him/her out; - She had not heard prior to that about the resident being constipated; - Normally they would try to take care of it in house by giving Magnesium [MEDICATION(S)] or get an order from physician but she was told the resident was in tears and hurt and the resident requested to be sent out; - If a resident is in pain due to being unable to have a bowel movement, she would expect the physician to be called immediately or she has sent residents out and got the order later. The resident's care came first; - She would expect the nurse to take immediate action. Review of the Medical Director's expectations regarding a resident complaining of constipation, dated 5/21/21, showed the following: - Her expectation of nursing staff was when a resident complained of constipation and rectal bleeding to assess the resident at the time of the complaint, do an examination with vital signs and examination of the abdomen and the rectum. If there were clear signs of bleeding, the physician should have been notified at that time. If there were any significant concerns with the examination or vital signs, then the physician should have been contacted. If there was no evidence of bleeding and if examination was stable, the physician should have been sent a fax notification for their review the next day. If there were no abnormal findings on examination and the patient had a PRN (as needed) order for constipation, then it should have been administered. If they did not have a PRN order for constipation then again this should have been requested by fax. The night nurse should have addressed this rather than just passing it on to the day nurse. During a telephone interview on 5/25/21 at 10:30 A.M., Physician A (the resident's primary physician) said: - Usually a resident has a PRN for stool softener or a medication to treat constipation, he/she would expect that to be given and to be contacted within 24 hours. If the resident was complaining of pain and doubled over, then he/she should have been contacted immediately and the resident should have been sent out immediately; - If a person was constipated for an extended period of time it could cause the abdomen to be distended and could cause a lot of discomfort. Also, a person can become impacted due to being constipated for an extended period of time. MO 8

Based on observations, interview and record review, the facility failed to identify, assess and document, accurately and timely, a sacral pressure ulcer (PU), when the ulcer was first identified as a Stage 3 PU (Stage 3 is a full thickness tissue loss. Subcutaneous (the tissue between the fat layer just under the skin and over the top of the muscles) fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining (when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through subcutaneous tissue or muscle)and failed to follow physician's orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 82. Review of Pressure Ulcer Policy, dated 4/6/2017, showed: -The purpose of this policy is to provice a description of pressure ulcers and give protocols for providing care and treatment to the Resident with a pressure ulcer. -Upon admission, weekly and as needed (PRN) the resident will have a skin assessment completed by licensed nursing personnel or designee; -Once it is determined the resident has a skin integrity issue or is at a potential of having skin integrity concerns, they will be placed on a turn and reposition schedule: documented on the Certified Nurse Aide (CNA) Activities of Daily Living (ADL) sheets, or turn and repositioning sheets. 1. Review of Resident #7's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/21, showed: - Brief Interview of Mental Status (BIMS) of 2. This indicates severe cognitive deficit; - Extensive assistance from staff for eating, toilet use, hygiene, bed mobility and dressing; - Dependent on staff for locomotion on and off unit; - Incontinent of bowel and bladder; - At risk for the development of PU; - No pressure ulcers; - Weight 145 pounds; - No use of pressure relieving devices for bed or chair; - No turning and repositioning program. Review of the residents medical record from 1/11/21 through 3/16/21 showed no skin assessments or documentation of the resident's skin, care plan for the PU's or interventions to prevent PU's, and turn/reposition program. Review of the resident's Wound Assessment Reports completed by the Wound Nurse, dated 3/16/2021, showed: - Sacral (the triangular area just above the tail bone) wound identified on 3/15/21; - 50% of wound bed is covered with slough (dead tissue that needs to be removed from the wound for healing to take place varying from wet, yellow stringy to dry, hard crusts); - Identified at Stage 3; - Measured 3.5 centimeters (cm) long by 4 cm wide by 0.1 cm depth; - Small amount of serous drainage (the mostly clear or slightly yellow thin plasma drainage that is just a bit thicker than water); - Surrounding skin is normal; - No odor noted; - The physician was notified. Order to cleanse wound with wound cleanser (solutions used to remove contaminants, foreign debris and drainage from the wound surface), apply pixie dust (medicated prescription powder used to treat wounds), cover with [MEDICATION(S)] (moisturizing cream for dry skin) cream and allevyn (soft sponge covering) dressing daily and as needed; - Current weight 131 pounds; - Right heel wound identified on 2/24/01; - Identified as blister; - Measured 2 cm in length, 1.5 cm in width and 0.1 cm in depth; - Small amount serous drainage; - Order to cleanse wound with wound cleanser, apply pixie dust, cover with [MEDICATION(S)] cream and cover with boarder gauze (gauze dressing with adhesive at edges) daily and as needed. Review of the resident's Nurse Practitioner progress Notes, dated 3/17/21, showed: - Wound wrapped on lower extremity; - No documentation of the Stage 3 PU to the sacral area or the wound to the right heel. Review of the resident's Wound Assessment Reports completed by the Wound Nurse, dated 3/30/2021, showed: - Sacral Wound: - Stage 3; - Measured 5.5 cm length by 6.7 cm width by 0.1 cm depth; - 75% slough; - 25% eschar (dead tissue that is typically tan, brown or black); - Surrounding skin is normal; - Area is declining; - Foul smell; - Small amount of drainage; - Family and physician aware; - Current weight 131 pounds. -Right heel wound: - Area declining; - No measurements noted; - No descriptions noted. Review of the quarterly MDS, dated [DATE], showed: - Brief Interview of Mental Status (BIMS) of 2; - Extensive assistance from staff for eating, toilet use, hygiene, bed mobility and dressing; - Dependent on staff for locomotion on and off unit; - Incontinent of bowel and bladder; - Two unstageable pressure ulcerations (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar (dead tissue). - Weight 130 lbs; - Pressure relieving devices for bed; - Turning and repositioning program. Review of the April 2021 Physician's order sheet showed: - Cleanse wound with wound cleanser, apply pixie dust, cover with [MEDICATION(S)] cream and cover with dressing daily, dated 4/28/21. - No physician's order for wound to be packed. Observation on 5/3/21 at 2:51 P.M., showed: - The resident was incontinent of urine. Perineal care provided by CNA B and Nurse Aide (NA) A; - The dressing on the sacral wound was attached to the skin on one side of the wound, most of the wound was exposed with no dressing; - The dressing was saturated with dark yellow brown drainage; - CNA B removed dressing with soiled gloves from perineal care; - Registered Nurse (RN) A completed the following wound care with directions given from Resident Care Coordinator (RCC) B/Wound Nurse: -RN A and RCC B/Wound Care nurse entered the resident's room with a medicine cup filled with a white cream, swabs, wound cleanser and gauze; -RN A measured the wound at 9 cm length by 8.7 cm width, and 2 cm depth at 9 o'clock, 3.5 cm depth and at 5 o'clock, and 3 cm depth at 12 o'clock; -He/she sprayed the wound with wound cleanser, and used a gauze sponge to wipe the wound cleanser off the wound, then applied the white cream to area with a swab; -He/she then packed dry gauze into the wound using the same swab that was used to apply the white cream; -Without washing hands and changing gloves, he/she then used the same white cream on the ankle wound using his/her soiled gloved finger; -He/she then covered sacral wound with Allevyn dressing (a soft sponge dressing used to absorb drainage) and covered the ankle wound with gauze and tape. -Pixie dust was not applied to the sacral or heel wound as ordered. - There was a regular mattress on bed. During interview on 5/3/21 at 2:51 P.M., RN A said: - The cream he/she was applying from the medicine cup was [MEDICATION(S)] cream; - He/she asked the RCC/wound nurse to assist with wound care as he/she does not usually do wound treatments. Review of the resident's Individual Care plan, dated 5/5/21, showed: -Resident has pressure ulcer on his/her coccyx and potential for pressure ulcer development due to disease process and immobility; - Desired outcome is for Resident's pressure ulcer to show signs of healing and no infection; - Approaches include: -The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with (SPECIFY: 2 people, lifter, slider); -Administer treatment as ordered and monitor for effectiveness; -Assess, record, monitor wound healing (SPECIFY FREQUENCY). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing process. Report improvements and declines to the MD; -Avoid positioning resident on (SPECIFICY location); -Educate resident/family/caregiver as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility; good nutrition and frequent repositioning. Review of the resident's care plan for Pressure Ulcers showed no specific time for assessing and recording the wound, no specific methods of repositioning and did not address the wound to the right heel. Review of the resident's Wound Assessment Reports completed by the Wound Nurse, dated 5/5/21, showed: - Sacral Wound: - Unstageable; - Measured 8.1 cm length by 8.39 cm width and 2.8 cm deep; - Tunneling (tunneling is the channels which extend from the wound, into or through tissue or muscle.) noted at 2.8 cm at 10 0' clock (from top of head to feet for clock method); -Undermining (tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge) of 2.8 cm over 100% of the wound; - 80% slough; - 20% eschar; - Heavy amount of purulent drainage (drainage that contains or consists of pus); - Moderate Odor; - Surrounding skin with 3 cm [CONDITION(S)] (redness caused by injury or irritation) and warmth; - Right heel wound: - Pressure area unstagable; - Measures 1.51 cm length by 1.23 cm width and 0.2 cm depth; - 100% slough; - Light drainage; - Documentation from Nurse Practitioner states non healing related to end of life and malnutrition. During an interview on 5/6/21 at 10:14 A.M., CNA F said: - Skin assessment should be completed with baths; - If there is a change in the resident's skin, the charge nurse should be notified. During an interview on 5/6/21 at 2:44 P.M., CNA E said: - The resident should be turned every every 2 hours; - The staff try to keep him/her off of his/her back. During an interview on 5/3/21 2:50 P.M., RCC B/Wound Nurse said: - Skin assessments should be done with baths; - The Charge Nurse should be notified of any new areas; - Treatments are completed by the wound nurse daily; - The Charge Nurse will complete if RCC/wound nurse is not in the facility; - Measurements should be obtained weekly; - The resident is on Hospice; - There are no orders for packing the sacral wound.

Based on record review and interview, the facility failed to ensure the availability of a Cardiopulmonary Resuscitation (CPR) certified staff member on every shift. This had the potential to affect all residents who specified CPR in their advance directive. Staff also failed to follow facility policy to notify 911 upon finding a resident with no pulse or respirations. The facility census was 72. Review of the facility's undated policy and procedure for Emergency Procedures / Medical Emergencies C.P.R. certified staff, showed: - The staff will determine unresponsiveness of the resident. The staff will verbally call for help. - In the event that the resident is found to be nonresponsive without respirations or pulse, the charge nurse will not leave the resident until qualified personnel, emergency medical service (EMS) arrives, their condition significantly improves or the resident expires. - The Registered Nurse (RN) or Licensed Practical Nurse (LPN) will assess the resident for breathing and pulse. If no active exchange of air or no carotid pulse is detected, the nurse will then direct staff as to whether the resident is a full code or the code status. - If the resident is determined a full code, then the nurse will direct a staff member to call 911 with the resident's name and condition. - The resident's attending physician is to be notified and all attending physician orders [REDACTED]. - The Administrator and Director of Nursing (DON) will be notified. 1. Review of Resident #28's medical record showed: - The resident was admitted on [DATE]; - The resident's code status was Full Code (wanted CPR). Review of the resident's nurse's notes, dated [DATE], at 6:00 A.M., showed Licensed Practical Nurse (LPN) C documented the resident was found at 5:55 A.M. with no pulse or respirations and was unresponsive. Extremely cold, pale and stiff. Obtained mask, started CPR for 20 to 25 minutes, two breaths to 30 compressions. No change in status, contacted management, administration, and DON and was advised to continue CPR. Contacted by physician and he/she said staff 'can stop CPR at 6:40 A.M ' During an interview on [DATE], at 10:50 A.M., the DON said: - She thought LPN C was CPR certified. - All copies of the CPR cards for staff were kept in the business office manager's office in the staff files. - She did not know how many staff were CPR certified, she made the schedule for the nursing staff to work and did not know if she scheduled a certified staff on each shift. During an interview on [DATE], at 11:00 A.M., the business office manager (BOM) said: - The dietary manager was an Emergency Medical Technician but had let that expire. The facility plan was to have the dietary manager get his/her CPR teaching certificate and then train the rest of the staff, but that had not happened because they could not find a class for him/her to attend. - He/she did not think anyone in the building was currently certified to perform CPR. During an interview on [DATE], at 5:25 P.M., LPN C said: - He/she worked the 11:00 P.M. to 7:00 A.M. shift. - He/she was CPR certified, but could not find his/her card or anyway to show it had not expired. He/she did not know if it had expired. - During report on [DATE], staff said the resident had issues on the previous shift with dizziness. - A Certified Medication Technician (CMT) worked the unit and LPN C went back and forth between the two stations. - He/she assessed the resident earlier on his/her shift and the vital signs were normal. The resident looked pale and felt cold but his/her window was open. LPN C closed the window. - The CMT saw the resident in his/her room drinking water at 2:00 A.M - At 3:00 A.M., the CMT told LPN C he/she went in the resident's room and the resident was sleeping. - At 5:00 A.M., the CMT called LPN C and told him/her the resident was dead. LPN C went back to the unit and the resident was cold and had rigor mortis (stiffening of the limbs). - LPN C called the DON who said the resident was a Full Code and he/she needed to inform a corporate person and start CPR. - After LPN C called the corporate person and retrieved a non-rebreather mask, he/she began CPR for ,[DATE] minutes, two breaths every thirty compressions. - At 6:00 A.M., the corporate physician called and said to stop CPR. - At no time did he/she or any other facility staff call 911. Record review of staff CPR certifications on file showed six staff members who were CPR certified. Review of the nursing schedule showed fifteen shifts in January and four shifts up to [DATE] were not covered by CPR certified staff. Seven additional shifts in February were covered by LPN C, who could not produce proof of his/her certification. Review of an undated resident code status list showed 49 residents chose Full Code status. During an interview on [DATE], at 11:00 A.M., the BOM said: - He/she had not asked for a copy of CPR certifications since he/she took over the position in 2014. - He/she could not show proof of any CPR certified staff in the building. - He/she thought Registered Nurse A was still CPR certified but he/she had his/her billfold stolen and did not have a way to prove it was still current. Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level, L. An onsite visit was completed on February 12, 2016. Based on observation, record review, and interviews completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. On [DATE], the facility began in-services of all licensed staff to assure they were certified in CPR and began reviewing staff schedules to assure each shift was covered by CPR certified staff. Licensed staff was in-serviced on assessment and notification of 911 upon discovery of a resident without pulse or respiration. Facility office staff have begun to keep on file, all current CPR certified staff. Each licensed staff will become certified prior to reporting for duty. Over the next several weeks, the facility will assess staff performance and resident treatment through reviews, observations, re-education, and analysis through the Quality Assurance process. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to a F 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 violations.

Based on interviews and record review, the facility failed to follow their policy to investigate and report allegations of physical abuse when resident to resident altercations occurred on the behavioral unit, which affected two of 15 sampled residents, (Resident #10 and #13), and two additional residents, (Resident #16 and #17). This had the potential to affect the 36 residents on the unit. The facility census was 72. Review of the facility's undated abuse, neglect, and grievance procedure policy showed, in part: - Purpose: to outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, to ensure immediate reporting of all abuse allegations to the Administrator or the Director of Nursing (DON), and outside persons or agencies. To ensure investigation and assessment of all residents involved was completed. - It is also the policy of this facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. - Investigation: the facility will investigate all incidents including incidents of unknown origin or source and have procedures to protect residents from harm during the investigation. - Orientation and training of employees: during orientation of new employees, the facility will cover at least the following topics: sensitivity to resident rights and resident needs, staff obligations to prevent and report abuse, neglect, and theft. - Internal reporting requirements and identification of all allegations: employees are required immediately to report any occurrences of potential mistreatment including: alleged violations, mistreatment, neglect, abuse, and injuries of unknown source and misappropriation of resident property they observe, hear about, or suspect to a supervisor or the Administrator. - Anonymous reports will also be thoroughly investigated. - Upon learning of the report, the Administrator shall initiate an incident investigation. - The facility will notify the Department of Public Health/Department of Heath and Human Services within 24 hours of the complaint. - Upon completion of the investigation the findings will be reported within five working days by the Administrator. - The investigation will include assessment of all residents and involved residents in the facility, interventions will include: nursing staff separating alleged perpetrator and alleged victim, including moving the residents to separate halls, physician involvement, intensive monitoring of 15 minute face checks of the alleged perpetrator and alleged victim. 1. Review of Resident #13's care plan, dated, 11/5/15, showed: - [AGE] years or more age difference between him/her and his/her roommate; - Goal: maintain compatibility for the next three months; - Approaches: monitor for any signs/symptoms of increased depression or anxiety related to age difference, monitor for any need for room change, and address as needed, monitor for any signs/symptoms of incompatibility. Review of the resident's nurse's notes, dated, 1/11/16, showed: - 11:30 P.M., the resident was praying loudly. - The roommate (Resident #10) asked him/her to stop. - The resident ignored resident #10. - Resident #10 went to turn the TV off. - The resident got up and tapped Resident #10's arm and said, Please don't, which caused Resident #10 to begin smacking the resident. - The resident responded by smacking Resident #10 back. - The resident's TV was removed from his/her room. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated, 1/20/16, showed: - Cognitive skills for daily decision making moderately impaired; - Independent with bed mobility, transfers, ambulation in his/her room, and hallways; - Minimal assistance of one staff for dressing, toilet use, and personal hygiene; - Had seven antipsychotic medications in the last seven days; - Had seven antidepressant medications in the last seven days; - [DIAGNOSES REDACTED]. During an interview on 2/12/16, at 8:40 A.M., Licensed Practical Nurse (LPN) C said: - He/she was the charge nurse on 1/11/16 when Resident #13 and Resident #10 had the altercation and staff removed Resident #13's TV from his/her room. - He/she documented a resident's behavior in the nurse's notes and the nurse's report book. - He/she did not contact the director of nursing (DON) about the resident to resident altercation. - If staff removed Resident #13's personal items (Bible, blanket or TV), it would make his/her behavior worse. During an telephone interview on 2/17/16, Certified Medication Technician (CMT) A said: - He/she had only had the CALM (behavior management approach) training related to the resident's behaviors. - If a resident had a behavior, he/she would have the resident use their coping skills, if that didn't improve the resident's behavior, he/she would notify the charge nurse. - He/she informed the charge nurse and he/she agreed the TV needed to be removed. - The only behavior the resident had on nights, and he/she wouldn't really call it a behavior, but the resident would walk up and down the halls. He/she did not bother any of the residents or go in their rooms. 2. Review of Resident #13's nurse's notes, dated, 1/13/16, at 3:15 P.M., showed: - The resident was in his/her room. - Resident #17 came into the room to talk to Resident #10. - Resident #13 was walking back and forth in his/her room. - Resident #17 hit Resident #13 and told him/her to stop walking. - No redness noted on Resident #13's arm. During an interview on 2/11/16, at 11:30 A.M., Registered Nurse (RN) A said: - On 1/13/16, Resident #13 was walking back and forth in his/her room. - Resident #17 was in the room with Resident #10 playing a game. - RN A heard another resident say Resident #17 hit Resident #13. - Resident #17 admitted he/she had hit Resident #13 on his/her arm. - Resident #13 said it did not hurt. - RN A removed Resident #17 from the room and he/she lost a smoke break. - RN A monitored the Resident #13's arm for redness and pain. During an interview on 2/12/16, at 9:25 A.M., RN A said: - He/she notified the DON when a resident had any behaviors or when any resident to resident altercations occurred. - The DON would instruct him/her if the corporation should be contacted. - If he/she did not document it in the nurse's notes about the DON being contacted, he/she should have. During an interview on 2/16/16, at 3:12 P.M., the DON said: - She was unaware of any altercations between residents. - When an altercation occurred, staff should notify the charge nurse and/or call the DON and Administrator. - The staff are taught CALM training and that is it. - If there are any changes in the resident's condition, behaviors, resident to resident altercations, pretty much anything, she could come in or the Administrator. - The behaviors should be documented in the nurse's notes, including what the staff had tried, and the outcome. - During an investigation of alleged abuse, she would interview the residents, staff on duty and see what is going on. - She was responsible to complete the investigation, if she was made aware of the allegation. - The Administrator or whoever finds the abuse, should notify the state agencies. 3. Review of Resident's #10's last psychiatric consult dated 4/24/15, showed: - Staff reported occasional outbursts. - Resident admitted having a couple of fits. - Sleeps pretty well. - Auditory hallucinations that tell resident to hurt his/herself. - Resident admits feeling sad about not talking to his/her mother. - Recommendations included: have a co-captain he/she trusts, as resident is attention seeking with staff. Reward resident for appropriate behaviors. Monitor mood, behaviors, and side effects of medications. Call 911 if unsafe. Review of the November 2015, resident council minutes showed the resident requested a room change as he/she was not getting along with his/her roommate. Review of Resident #10's quarterly MDS dated [DATE] showed: - Cognitively intact. - [DIAGNOSES REDACTED]. - [DIAGNOSES REDACTED].) - No behaviors. - Feels down, depressed, hopeless at times. - Lower limb mobility impaired (amputation of left leg below knee). - Uses wheel-chair for mobility. Review of the residents care plan updated on 12/10/15, showed: - Problem: Resident has psychiatric disorders, mild intellect disability and a history of self harming and attention seeking behavior. - Goal: Resident will have no significant increase in behaviors/hallucinations of delusions for the next three months. Goal continued as resident has had occasional outbursts and self harm attempts. - Approaches: Administer medications as ordered, redirect when having inappropriate behaviors, encourage resident to use coping skills such as quiet time in room, reading, writing in journal, coloring etc. when upset. Increase supervision or monitoring as indicated for behaviors or safety. Monitor for any factual causes for anxiety and assist to resolve if able. Psych teleconference as scheduled. Monitor for any significant changes in mood/behaviors and notify physician as indicated. Review of the resident's nurse's notes dated 1/11/16, showed: - Resident in room reading but was unable to read with roommate praying out loud. - Resident asked roommate to pray to self. - Resident started to turn off roommate's TV. - Roommate placed hand on his/her arm which caused resident to smack out. - Both residents smacked each other. - Residents separated, resident continued to cry and scream loudly. - Staff talked and educated resident on how he/she should have handled the situation. During an interview on 2/10/16, at 9:30 A.M., the resident said: - He/she and his/her roommate do not always get along. - They usually just yell at each other but they did have a physical fight over the TV and noise. - He/she lost a smoke break and they took the roommate's TV because he/she does not smoke. - He/she asked to be moved to another room several months ago because they do not get along very well. - Staff did not allow him/her to move to a different room. During an interview on 2/12/16, at 1:50 P.M., the Social Service Director (SSD) said: - She teaches staff if an incident happens on the unit to chart the incident and to notify the guardian if she is not in the building. - The charge nurses are to notify the DON who in turn notifies her of any incidents. - She was not aware Resident #10 and #13 had a physical altercation a few weeks ago. - She did not remember being told about any resident to resident physical altercations. During an interview on 2/16/16, at 7:45 A.M., the Administrator said: - Resident #10 and Resident #13 had been roommates since Resident #10 was admitted in March of 2015. - She was not aware of any conflict between the two residents. - She had not read the November resident council minutes that showed Resident #10 asked to be moved since he/she and the roommate did not get along. - If she had been made aware of the physical altercation, she would have moved the residents to different rooms. During an interview on 2/16/16, at 11:30 A.M., the Life Enhancement Director said, she follows-up on any concern with the residents not only in resident council monthly but also weekdays. She writes out the minutes of the resident council and the daily concerns and gives copies to the department heads, the director of nursing and the administrator. The department heads discuss behaviors as part of the morning staff meetings but she was not aware Resident #10 and #13 got into a physical altercation a few weeks ago. During an interview on 2/16/16, at 2:10 P.M., the Administrator and DON said they did not receive copies of resident council minutes. They keep no documentation to show staff followed-up about residents' concerns such as room change requests or when residents stated they did not get along with their roommates. 4 During an interview on 2/10/16, at 9:30 A.M., Resident #10 said: - Another resident, Resident #16 bullied him/her all the time. - Resident #16 threatened him/her often, called him/her names and threatened to beat him/her up. - Resident #16 hit him/her in the eye for no reason. - Resident #16 walked into the dining room, hit him/her in the eye and walked out without saying a word. - He/she had a black eye from the incident and it felt like his/her nose was broken. - Staff took away two smoke breaks from Resident #16 for hitting him/her. Review of Resident #16's quarterly MDS dated [DATE], showed: - Cognitively intact; - No behaviors; - Independent with cares; - [DIAGNOSES REDACTED].>- Takes antipsychotic medication daily. Review of the resident's nurse's notes dated 11/2/15, at 5:50 P.M., showed: - LPN D heard a resident cry out from the dining room. - Upon entering the dining room Resident #10 informed him/her another resident walked into the dining room and punched him/her in the right eye. - Resident #10's right eye was red but not swollen. Review of the resident's nurse's notes dated 11/2/15, at 9:45 P.M., LPN C charted resident's eye still red but not swollen. During an interview on 2/22/16, at 2:40 P.M., LPN D said: - A couple of months ago as he/she worked at the desk on the unit he/she heard a resident scream from the dining room. - As he/she approached the dining room Resident #16 walked down the hallway from the dining room. - Resident #10 wheeled his/her wheelchair out of the dining room. - Resident #10 told him/her Resident#16 walked right up to him/her without saying a word and punched him/her in the eye. - Resident #10's eye was red but not swollen. - He/she talked to the Resident #16 who said he/she did not like Resident #10. - He/she interviewed a witness who confirmed Resident #16 walked up to and hit Resident#10 in the eye with his/her fist. - He/she charted the incident in the nurse's notes and completed an incident report for the DON. - He/she did not remember if he/she notified the DON by phone or just completed the incident report since the residents was not hurt. During an interview on 2/16/16, at 11:30 A.M., the Life Enhancement Director said: - She once witnessed another resident (Resident #16) bullying some of the residents a few weeks ago. - She reported the incident to the charge nurse. - She had been told of other incidents but it was hearsay. - The bullying incidents she had been told about and saw had to do with Resident #16. During an interview with 2/10/16, at 9:40 A.M., the SSD said: - She documented a call made to Resident #10's guardian about the incident on 11/3/15 when another resident hit the resident in the eye. - The resident sustained [REDACTED]. During an interview on 2/10/16, at 2:10 P.M., the Administrator said: - She was unaware of any altercation between Resident #10 and Resident #16 resulting in Resident #10 being hit in the eye. - Staff should have reported the incident to her or the DON. 5. Review of Resident #10's nurses' notes initialed by RN A and dated 1/10/16 showed another resident grabbed the resident leaving a red mark on his/her chest. The red mark disappeared after 10 minutes. During an interview on 2/10/16, at 9:30 A.M., Resident #10 said certain residents often pick on him/her, he/she gets hit, made fun of and bullied often. He/she has no teeth, one leg and is too heavy. During an interview on 2/11/16, at 11:30 A.M., RN. A said: - He/she did not remember the incident between Resident #10 and another resident that caused a red mark on his/her chest. - He/she did not remember the name of the other resident. - He/she probably did an incident report which would contain the name of the other resident. During an interview on 2/10/16, at 2:10 P.M., the Administrator said: - She was unaware of any altercation between Resident #10 and an unidentified resident resulting in the resident having a red mark on his/her chest. - She could not investigate incidents staff did not communicate to her. - The charge nurses are to notify her or the DON on all resident to resident altercations. - The DON would have told her if staff had documentation of a resident to resident altercation. 6. Review of Resident #10's nurse's notes on 2/5/16 at 2:45 P.M., showed: - RN A documented Resident #10 came to the nurses desk and said he/she was suicidal. - He/she asked the resident if he/she had plans and said he/she had already tired. - Resident had a sheered area with scant amount of blood on his/her inner wrist. - Resident said he/she used a pencil eraser to try and cut his/her wrist. - RN A cleaned the wrist and applied a dressing. - RN A wrote he/she notified management and placed the resident on one-on-one observation. - Staff removed all pencils from the residents room. - Resident had smoking privileges and phone call privilege removed. - Resident stated he/she was sorry and would not try again. Observation on 2/8/16 at 7:10 A.M., and 2/9/16 at 12:50 P.M., showed resident with a bandage on his/her left wrist. During an interview on 2/10/16, at 9:30 A.M., Resident #10 said: - Certain residents pick on him/her, he/she gets hit, made fun of and bullied often. - He/she has no teeth, one leg and was too heavy. - Other residents make him/her mad and in turn he/she feels bad about his/herself. - When he/she is upset he/she does things to him/her self. - He/she tried to cut his/her wrist after Resident#16 upset him/her by calling him/her fat, ugly and a cripple. - RN A cleaned and wrapped his/her wrist. - RN A called the administrator who threatened to send him/her to another facility if he/she continued to try to hurt his/her self. During an interview on 2/16/16, at 10:50 A.M., RN A said: - He/she cleaned and wrapped the resident's wrist after he/she used an eraser to cause a skin sheer because the resident picked at the area. - There was no treatment in the treatment book for the resident's wrist. He/she did not know why the resident tried to cut his/her wrist other than for attention. - The resident often seeks attention from the nursing staff. During an interview on 2/1/16, at 2:40 P.M., the administrator said she was aware of the resident using an eraser to try to cut his/her wrist, but did not know if staff conducted an investigation on why he/she tried to cut his/her wrist. During an interview on 2/10/16, at 4:45 and 2/16/16, at 11:05 A.M., the DON said: - She did not know if staff informed the resident's physician or psychiatrist about any of the resident to resident altercations or the attempted cutting of his/her wrist. - She made notes for the physician prior to his/her visits but did not keep a copy. - She made rounds with the physician, but he/she did not have any notes about who or what issues the physician addressed with the residents. - She did not remember if they discussed the resident's attempt to cut his/her wrist since it was just a mark made by a pencil eraser. Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level, K. A monitoring visit was completed on February 12, 2015. Based on observation, record review, and interviews, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. On 2/12/2016, the facility began re-education of all staff regarding protection of residents, recognizing sign/symptoms of abuse, and the facility policy regarding abuse. All staff was to be educated on what procedures to follow if they suspected abuse or neglect. Procedures included immediate interventions to protect each resident, reporting to charge staff, implementing monitoring protocols to prevent re-occurrence, notification or the Administrator, Director of Nursing, responsible party and physician, investigation of the cause/source of any behaviors, completion of Incident Reports, forwarding any reports through the chain of command, and implementing corrective actions based on the results of a thorough investigation. Over the next several weeks, the facility will assess staff performance and resident treatment through reviews, observations, re-education, and analysis through the Quality Assurance process. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a E 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 violations.

Based on interview and record review, facility staff failed to protect two of 15 sampled residents (Resident #10 and #13), and two additional residents (Resident #16 and #17), from physical abuse when resident to resident altercations occurred on the behavioral unit. Additionally, staff did not implement measures to protect one sampled resident (Resident #10) who tried to harm him/herself after being bullied by another resident (Resident #16). This had the potential to affect all 36 residents on the unit. The facility census was 72. Review of the facility's undated abuse, neglect, and grievance procedure policy showed, in part: - Purpose: to outline procedures for reporting and investigating complaints of abuse, neglect, and misuse of funds/property, to ensure immediate reporting of all abuse allegations to the Administrator or the Director of Nursing (DON) and outside persons or agencies; - It is the policy of this facility that every resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion; - This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, or other residents; - Internal reporting requirements and identification of all allegations: employees are required immediately to report any occurrences of potential mistreatment including; alleged violations, mistreatment, neglect, abuse, and injuries of unknown source and misappropriation of resident property they observe, hear about or suspect to a supervisor or the administrator; - Supervisors shall immediately inform the Administrator or designee of all reports of potential mistreatment; - The facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreat another resident will be removed from contact with the resident during the course of the investigation; - Any such employee who has reasonable cause to believe that a resident has been subjected to physical abuse, sexual abuse, misuse of funds/property, class I neglect, class II neglect, or verbal abuse while under the care of the facility shall immediately make a verbal or written complaint; - The staff will report any and all allegations to the Administrator and the DON; - The Administrator and/or DON will begin an investigation on all allegations on abuse/neglect immediately; - The allegations will be reported as soon as possible within 24 hours to the abuse hotline/agencies by the Administrator; - Upon completion of the investigation the findings will be reported within five working days by the Administrator; - The investigation will include assessment of all residents and involved residents in the facility, interventions will include: nursing staff separating alleged perpetrator and alleged victim, including moving the residents to separate halls, physician involvement, intensive monitoring of 15 minute face checks of the alleged perpetrator and alleged victim. 1. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/27/16, showed staff assessed the resident as: - Cognitively intact; - Did not have any behaviors; - Independent with Activities of Daily Living (ADL's); - [DIAGNOSES REDACTED].>- Took antipsychotic medication daily. Review of the resident's nurse's notes, dated 11/2/15, at 5:50 P.M., showed: - Licensed Practical Nurse (LPN) D heard a resident cry out from the dining room. - Upon entering the dining room, Resident #10 informed him/her another resident walked into the dining room and punched him/her in the right eye. - Resident #10's right eye was red but not swollen. Review of the resident's nurse's notes, signed by LPN C and dated 11/2/15, at 9:45 P.M., showed he/she documented the resident's eye was still red but not swollen. During an interview on 2/22/16, at 2:40 P.M., LPN D said: - A couple of months ago as he/she worked at the desk on the unit, he/she heard a resident scream from the dining room. - Resident #16 walked down the hallway from the dining room. - Resident #10 wheeled his/her wheelchair out of the dining room. - Resident #10 told him/her Resident#16 walked right up to him/her without saying a word and punched him/her in the eye. - Resident #10's eye was red but not swollen. - He/she talked to Resident #16 who said he/she did not like Resident #10. - He/she interviewed a witness who confirmed Resident #16 walked up to and hit Resident #10 in the eye with his/her fist. - He/she charted the incident in the nurses notes and completed an incident report for the DON. - He/she did not remember if he/she notified the DON by phone or just completed the incident report since the resident was not hurt. During the group interview on 2/8/16, at 2:40 P.M., the residents said some of the other residents, such as Resident #16, bully other residents and staff do nothing to protect the weaker residents. Resident #16 picks on other residents and even hit Resident #10 in the eye. During an interview on 2/10/16, at 9:30 A.M., Resident #10 said: - Resident #16 bullied him/her all the time. - Resident #16 threatened him/her often, called him/her names and threatened to beat him/her up. - Resident #16 hit him/her in the eye for no reason in November. - Resident #16 walked into the dining room, hit him/her in the eye and walked out without saying a word. - He/she had a black eye from the incident and it felt like his/her nose was broken. - Staff took away two smoke breaks from Resident #16 for hitting him/her. During an interview on 2/16/16, at 11:30 A.M., the Life Enhancement Director said: - She once witnessed Resident #16 bullying some of the residents during group several weeks ago. - Resident #16 called other residents names and made threatening comments. - She reported the incident to the charge nurse. - She had been told of other incidents but it was hearsay. - The bullying incidents she had been told about and saw had to do with Resident #16. During an interview on 2/10/16, at 9:40 A.M., the Social Services Director (SSD) said: - She documented a call made to Resident #10's guardian about the incident on 11/3/15 when another resident hit Resident #10 in the eye. - The resident sustained [REDACTED]. During an interview on 2/11/16, at 11:30 A.M., Registered Nurse (RN) A said: - He/she was aware Resident #16 hit Resident #10 in the eye. - He/she was told about the incident when he/she first started to work at the facility in November. - He/she might have received the information in report. During an interview on 2/10/16, at 2:10 P.M., the Administrator said: - She was unaware of any altercation between Resident #10 and Resident #16 resulting in Resident #10 being hit in the eye. - Staff should have reported the incident to her or the DON. 2. Review of Resident #10's care plan, updated on 12/10/15, showed: - Problem: Resident has psychiatric disorders, mild intellect disability and a history of self harming and attention seeking behavior; - Goal: Resident will have no significant increase in behaviors/hallucinations of delusions for the next three months. Goal continued as resident has had occasional outbursts and self harm attempts; - Approaches: Administer medications as ordered, redirect when having inappropriate behaviors, encourage resident to use coping skills such as quiet time in room, reading, writing in journal, coloring, etc. when upset. Increase supervision or monitoring as indicated for behaviors or safety. Monitor for any factual causes for anxiety and assist to resolve if able. Psych teleconference as scheduled. Monitor for any significant changes in mood/behaviors and notify physician as indicated. Review of Resident #10's nurse's notes, dated 2/5/16, at 2:45 P.M., showed: - RN A documented Resident #10 came to the nurses desk and said he/she was suicidal. - He/she asked the resident if he/she had a plan and the resident said he/she had already tried. - The resident had a sheered area with scant amount of blood on his/her inner wrist. - The resident said he/she used a pencil eraser to try and cut his/her wrist. - RN A cleaned the wrist and applied a dressing. - RN A wrote he/she notified management and placed the resident on one-on-one observation. - Staff removed all pencils from the residents room. - The resident had smoking privileges and phone call privileges removed. - The resident stated he/she was sorry and would not try again. Observation on 2/8/16, at 7:10 A.M. and 2/9/16, at 12:50 P.M., showed the resident with a bandage on his/her left wrist. During an interview on 2/10/16 at 9:30 A.M., the resident said: - Certain residents pick on him/her, he/she gets hit, made fun of and bullied often. - He/she is bullied because he/she has no teeth, one leg and was too heavy. - Other residents make him/her mad and in turn he/she feels bad about himself/herself. - When he/she is upset he/she does things to himself/herself. - He/she tried to cut his/her wrist with a pencil eraser after Resident #16 upset him/her by calling him/her fat, ugly and a cripple. - RN A cleaned and wrapped his/her wrist. - RN A called the Administrator, who threatened to send him/her to another facility if he/she continued to try to hurt his/her self. During an interview on 2/10/16, at 4:04 P.M., the SSD said she had no knowledge of residents being bullied by other residents. During an interview on 2/10/16, at 4:45 P.M., the DON said he/she had not been told some residents bully other residents. He/she made notes for the doctor when they visit. The physician was on the unit early yesterday morning. He/she did not remember if he/she discussed Resident #10's attempt to cut his/her wrist with the physician. Probably not, since he/she was not injured. During an interview on 2/11/16, at 2:40 P.M., the Administrator said she was aware of the resident using an eraser to try to cut his/her wrist but did not know if staff conducted an investigation on why he/she tried to cut his/her wrist. During an interview on 2/12/16, at 9:30 A.M., Physician A's nurse said they did not have any records on the residents. They went by the information provided by the facility. He/she would have the physician call. The physician did not return the surveyor's phone calls. During an interview on 2/16/16, at 10:50 A.M., RN A said: - He/she cleaned and wrapped the resident's wrist after he/she used an eraser to cause a skin sheer because the resident picked at the area. - There was no treatment in the treatment book for the resident's wrist. - He/she did not know why the resident tried to cut his/her wrist other than for attention. - The resident often seeks attention from the nursing staff. - He/she had no knowledge other residents bullied him/her. During an interview on 2/10/16, at 4:45 P.M. and 2/16/16, at 11:05 A.M., the DON said: - She did not know if staff informed the resident's physician or psychiatrist about any of the resident to resident altercations or that Resident #10 attempted to cut his/her wrist. - She would expect staff to notify her about incidents and concerns so she could notify the physician or direct staff to do so. - She made notes for the physician prior to his/her visits but did not keep a copy. - She made rounds with the physician, but he/she did not have any notes about who or what issues the physician addressed with the residents. - She did not remember if they discussed the resident's attempt to cut his/her wrist since it was just a mark made by a pencil eraser. - She did not remember if she received an incident report when the resident tried to cut his/her wrist. During an interview on 2/16/16, at 3:12 P.M., the DON said staff had not made him/her aware prior to the survey that residents bullied other residents. 3. Review of Resident #13's inventory sheet, dated 11/21/14, showed the resident's personal belongings included: - Two Bibles; - TV/flatscreen. Review of Resident #13's social service's notes, dated 5/30/15, showed: - The resident is alert and oriented to person, place and time; - He/she is able to make his/her needs known; - He/she is his/her own responsible party, but refused to sign any forms. Review of Resident #13's care plan, dated 11/5/15, showed: - [AGE] years or more age difference between him/her and his/her roommate; - Goal: maintain compatibility for the next three months; - Approaches: monitor for any signs/symptoms of increased depression or anxiety related to age difference, monitor for any need for room change, and address as needed, monitor for any signs/symptoms of incompatibility. Review of Resident #13's undated Certified Nurse Aide (CNA) care plan, showed: - The resident did not have a legal guardian; - Low (few) behaviors; - The resident was non-compliant with care. Review of the November 2015 resident council minutes showed Resident #10 (Resident #13's roommate) requested a room change as he/she did not get along with his/her roommate. Review of Resident #10's quarterly MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact; - [DIAGNOSES REDACTED]. - No behaviors; - Felt down, depressed, and hopeless at times; - Lower limb mobility impaired (amputation of left leg below knee); - Used a wheelchair for mobility. Review of the Resident #13's nurse's notes, dated 1/11/16, showed: - At 11:30 P.M., the resident was praying loudly. - The roommate (Resident #10) asked him/her to stop. - Resident #13 ignored Resident #10. - Resident #10 went to turn the TV off. - Resident #13 got up and tapped Resident #10's arm and said, Please don't, which caused Resident #10 to begin smacking the resident. - The resident responded by smacking Resident #10 back. - Staff removed Resident #13's TV from the room. Review of Resident #10's nurse's notes, signed by LPN C and dated 1/11/16, showed: - Resident in room reading but was unable to read with roommate praying out loud. - Resident asked roommate to pray to self. - Resident started to turn off roommate's TV. - Roommate placed hand on his/her arm which caused resident to smack out. - Both residents smacked each other. - Residents separated, resident continued to cry and scream loudly. - Staff talked and educated resident on how he/she should have handled the situation. Review of Resident #13's quarterly MDS, dated [DATE], showed: - Moderately impaired cognitive skills for daily decision-making; - Independent with bed mobility, transfers, ambulation in his/her room and hallways; - Minimal assistance of one staff for dressing, toilet use and personal hygiene; - Received antipsychotic medications daily during the last seven days; - Received antidepressant medications daily during the last seven days; - [DIAGNOSES REDACTED]. During an interview on 2/10/16 at 9:30 A.M., Resident #10 said: - He/she and his/her roommate do not always get along. - They usually just yell at each other but they did have a physical fight over the TV and noise. - He/she lost a smoke break and they took the roommate's TV because he/she does not smoke. - He/she asked to be moved to another room several months ago because they do not get along very well. - Staff did not allow him/her to move to a different room. During an interview on 2/11/16, at 6:15 P.M., the SSD said: - Resident #13 did not have any outbursts or hit. - The nurse should let him/her know if the resident had any altercations with other residents. During an interview on 2/12/16, at 8:40 A.M., LPN C said: - He/she was the charge nurse on 1/11/16 when Resident #13 and Resident #10 had the altercation and staff removed Resident #13's TV from his/her room. - He/she was not on the unit when the altercation occurred. - He/she documented the resident's behavior in the nurse's notes and the nurse's report book. - He/she did not contact the DON about the resident to resident altercation. - If staff removed Resident #13's personal items (Bible, blanket or TV), it would make his/her behavior worse. - He/she did not remove either resident from the room. During an interview on 2/12/16, at 1:50 P.M., the SSD said: - She taught staff if an incident happens on the unit, to chart the incident and notify the guardian if the SSD is not in the building. - The charge nurses are to notify the DON who in turn notifies the SSD of any incidents. - She was not aware Resident #10 and Resident #13 had a physical altercation a few weeks ago. - She did not remember being told about any resident to resident physical altercations. During an interview on 2/16/16, at 7:45 A.M., the Administrator said: - Resident #10 and Resident #13 have been roommates since Resident #10 was admitted in March of 2015. - She was not aware of any conflict between the two residents. - She had not read the November resident council minutes prior to the survey that showed Resident #10 asked to be moved since the resident and the roommate did not get along. - If she had been made aware of the physical altercation, she would have moved the residents to different rooms. During an interview on 2/16/16, at 11:30 A.M., the Life Enhancement Director said she was responsible for the activities for the entire building. She started in November 2015. She follows-up on concerns with the residents, not only in resident council monthly, but also weekdays. She writes out the minutes of the resident council and the daily concerns and gives copies to the department heads, the director of nursing, and the administrator. The department heads discuss behaviors as part of the morning staff meetings, but she was not aware Resident #10 and #13 got into a physical altercation a few weeks ago. During a telephone interview on 2/17/16, at 2:05 P.M., Certified Medication Technician (CMT) A said: - He/she had only had the CALM training (behavior management approach) related to the resident's behaviors. - If a resident had a behavior, he/she would have the resident use their coping skills, if that didn't improve the resident's behavior, he/she would notify the charge nurse. - The CNA's and CMT's used to be able to take away smoke breaks from residents if they had a behavior, but now only the charge nurse is allowed to remove privileges. - He/she discussed the incident with the charge nurse and he/she agreed the TV needed to be removed. During an interview on 2/16/16, at 2:10 P.M., the Administrator and DON said they did not receive copies of resident council minutes. They keep no documentation to show staff followed-up on residents' concerns such as room change requests or when residents stated they did not get along with their roommates. They were not aware Resident #10 requested a roommate change in November. During an interview on 2/22/16, at 3:40 P.M., CNA G said: - As he/she came out of the smoke room on 1/11/16, CMT A yelled at him/her to come help. - Resident #10 was hysterical. - He/she interviewed Resident #13 who said Resident #10 asked him/her to stop praying out loud. - Resident #10 tried to turn off Resident #13's TV. - Resident #13 said he/she touched Resident #10 on the face to make him/her stop. - He/she had Resident #13 demonstrate where he/she touched the resident and placed a hand on his/her cheek. - Resident #13 said Resident #10 started hitting him/her and he/she hit back. - They called LPN C who told him/her and CMT A to remove the resident's TV from the room. - Neither resident was removed from the room. - CNA G didn't see any injuries on either resident. 4. Review of Resident #13's nurse's notes, signed by RN A and dated 1/13/16 at 3:15 P.M., showed: - The resident was in his/her room. - Resident #17 came into the room to talk to Resident #10. - Resident #13 was walking back and forth in his/her room. - Resident #17 hit Resident #13 and told him/her to stop walking. - No redness noted on Resident #13's arm. During an interview on 2/11/16, at 11:30 A.M., RN A said: - On 1/13/16, Resident #13 was walking back and forth in his/her room. - Resident #17 was in the room with Resident #10 playing a game. - RN A heard another resident say Resident #17 hit Resident #13. - Resident #17 admitted he/she hit Resident #13 on his/her arm. - Resident #13 said it did not hurt. - RN A removed Resident #17 from the room and he/she lost a smoke break. - RN A monitored Resident #13's arm for redness and pain. During an interview on 2/12/16, at 9:25 A.M., RN A said: - He/she notified the DON when a resident had any behaviors or when any resident to resident altercations occurred, - The DON would instruct him/her if the corporation should be contacted. - He/she should have documented in the nurses notes that he/she contacted the DON. During an interview on 2/16/16, at 3:12 P.M., the DON said: - She was unaware of any altercations between any of the residents. - When an altercation occurred, staff should notify the charge nurse and/or call the DON and Administrator. - The staff are taught CALM training. - They are not trained on any other techniques. - If there are any changes in the residents' conditions, behaviors, resident to resident altercations, pretty much anything, she or the Administrator could come in to the facility. - The behaviors should be documented in the nurse's notes, including what interventions the staff tried and the outcome. - During an investigation of alleged abuse, she would interview the residents, staff on duty and see what is going on. - She was responsible for completing the investigation once she was made aware of the allegation. - The Administrator or whoever finds the abuse, should notify the state agencies. 5. During an interview on 2/10/16, at 9:30 A.M., Resident #10 said certain residents often pick on him/her, he/she gets hit, made fun of and bullied often. He/she is bullied because he/she has no teeth, one leg and is too heavy. Review of Resident #10's nurses notes, initialed by RN A and dated 1/10/16, showed another resident grabbed the resident leaving a red mark on his/her chest. The red mark disappeared after 10 minutes. During an interview on 2/11/16, at 11:30 A.M., RN A said: - He/she did not remember the incident between Resident #10 and another resident that caused a red mark on his/her chest. - He/she did not remember the name of the other resident. - He/she probably did an incident report which would contain the name of the other resident. During an interview on 2/10/16 at 2:05 P.M., the surveyor asked the DON for a copy of the incident report. The DON did not provide a copy of the incident report for the surveyor. During an interview on 2/10/16, at 2:10 P.M., the Administrator said: - She was unaware of any altercation between Resident #10 and an unidentified resident resulting in the resident having a red mark on his/her chest. - She could not investigate incidents staff did not communicate to her. - The charge nurses are to notify her or the DON on all resident to resident altercations. - The DON would have told her if staff had documentation of a resident to resident altercation. 6. During an interview on 2/16/16, at 3:15 P.M., RN A said: - If they have resident to resident altercations on the unit they try to separate the residents into different rooms. - He/she would call the DON, administrator, or cooperate management if they have physical altercations between residents. - If a resident was actually hurt, he/she would send them to ER. - If the area was red, staff would observe and put residents on five minute checks. During an interview on 2/16/16, at 3:23 P.M., CMT D said: - When residents have verbal or physical altercations, such as when residents push and shove each other, staff tell them to separate. - Staff try to re-direct the residents and have them use their coping skills, such as deep breathing, and tell them to think pleasant thoughts, and get into their happy place. - He/she would report altercations between residents to the charge nurse. During an interview on 2/11/16, at 11:15 A.M., CMT E said: - Staff monitor the residents as the residents often have issues with each other. - The residents also have other types of issues related to their mental disorders. - Staff can kind of tell by the way residents are acting if there is going to be an issue or behaviors. - Staff report the problems to the charge nurse. - The charge nurse reports to the DON. - The charge nurse and/or the DON normally talk to the residents about their issues or behaviors. - In training, the trainer told them to separate the residents, talk one-on-one with them, and to let each resident decide what is going to help them cope with the situation. Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level, K. A monitoring visit was completed on February 12, 2015. Based on observation, record review, and interviews, completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. On 2/12/2016, the facility began re-education of all staff regarding protection of residents, recognizing sign/symptoms of abuse, and the facility policy regarding abuse. All staff was to be educated on what procedures to follow if they suspected abuse or neglect. Procedures included immediate interventions to protect each resident, reporting to charge staff, implementing monitoring protocols to prevent re-occurrence, notification or the Administrator, Director of Nursing, responsible party and physician, investigation of the cause/source of any behaviors, completion of Incident Reports, forwarding any reports through the chain of command, and implementing corrective actions based on the results of a thorough investigation. Over the next several weeks, the facility will assess staff performance and resident treatment through reviews, observations, re-education, and analysis through the Quality Assurance process. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a E 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 violations.

Based on observation, record review, and interviews, the facility failed to assure they followed their policy when one of 13 sampled residents (Resident #5) began to exhibit an unplanned weight loss and the registered dietician (RD) recommended adding high protein snacks and a high protein liquid supplement. In November, 2015, the RD documented the resident's weight loss to be beneficial, but that the resident lost the weight too quickly. The resident was transferred to the local hospital for blood [MEDICAL CONDITION] due to a [DIAGNOSES REDACTED]. Staff also failed to assure they monitored the resident's daily meal intake, snack intake and failed to implement and document the resident's supplement intake. The resident's usual body weight was 287 pounds upon admission to the facility in May, 2015, and he/she lost a total of 80 pounds since admission and an 18% weight loss in six months (August, 2015 through February, 2016). The facility census was 72. Review of the corporate undated weight loss policy showed: - If a resident meets the parameters of a 5% weight loss in 30 days, a 7.5% weight loss in three months or a 10% weight loss in six months staff are required to notify the physician and the dietician should consulted. - The physician and registered dietician's (RD) recommendations should be charted and followed. - Residents with concerns of weight loss will be weighed at least weekly. - Snack intake will be charted and reviewed. - Resident will be offered alternate snacks as needed. - If resident refuses his/her meal or a portion of his/her meal, alternate foods will be offered to ensure that adequate intake is provided. - The WHIP (weigh, hydration, incontinence and pressure) committee will meet weekly and discuss the resident's dietary intakes of both meals and snacks and what interventions are needed to increase the resident's nutritional intake. - Labs will be reviewed and sent to the physician and RD. - The care plan coordinator will address weight concerns in the resident's care plan. - Follow up from the weekly WHIP meetings will be followed up on during the monthly Quality Assurance (QA) meetings. - Other interventions including psychiatric evaluations may be appropriate. 1. Review of Resident #5's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/1/15, showed: - Slightly impaired decision making skills; - Weight loss unknown; - Weight 282 pounds; - [DIAGNOSES REDACTED].) - Staff did not mark [MEDICAL CONDITION] as one of the resident's medical diagnoses. Review of the physician examination notes, dated 8/12/15, showed: - Obese; - Continues to have weight loss over past few months without medical intervention; - Resident's appetite is poor. Review of the resident's quarterly nutrition assessment, dated 8/19/15, showed RD A documented: - Resident weighed 253 pounds; - Beneficial weight loss of 4% over last 30 days and an over all loss of 11% in 90 days; - Resident had a 28 pound weight loss in last six weeks; - Weight loss significant but appropriate; - No labs to assess; - Appetite reported good. Review of the resident's physician examination report, dated 9/8/15, showed: - No information related to resident's continued weight loss. - Resident eating and drinking well. Review of the resident's physician examination report, dated 10/7/015, showed: - Resident has abnormal lab results, but reviewing resident's lab trends, are within normal for the resident. - No medical concerns at this time. - Good appetite. Review of a physician's telephone order, dated 10/14/15, showed the physician wrote for staff to administer an appetite stimulant Periavlin 4 milligrams (mg) twice daily. Review of the resident's medical records showed the record did not contain a copy of the resident's Medication Administration Record [REDACTED] During an interview on 2/10/16, at 1:30 P.M., Certified Medication Technician (CMT) C, who also worked with the facility's medical records, said he/she continued to look for the October and November medication administration records for the resident. During an interview on 2/10/16, at 2:05 P.M., the Director of Nursing (DON) said: - She did not know the medication periavlin. - Staff may have misspelled the name of the medication on the phone order. - The physician put the resident on a appetite stimulant for a month last fall. - The resident continued to lose weight so the appetite stimulant was discontinued. - She had staff trying to locate the resident's medical records related to the appetite stimulate. - The missing records must be in overflow. Review of the resident's dietary progress notes, dated 11/17/15, showed: - Resident weight 220; - Resident continues to have significant weight loss (65 pounds in list six months); - Weight loss is beneficial but too fast; - Appetite is reported good; - [MEDICATION NAME] level low at 2.7, (a decreased blood [MEDICATION NAME] may occur when the body does not get or absorb enough nutrients); - Recommend to draw labs due to weight loss being to rapid; - Recommend to start 30 mg Prostat (liquid protein) twice daily for six weeks and recheck labs; - Goal is to stabilize weight, then gradual weigh loss. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/24/15, showed: - Slightly impaired decision making skills; - Set up for meals only; - On planned weight loss; - Weight 212. Review of the physician order [REDACTED]. Review of the resident's physician summaries for visits in October, November showed the physician did not address: - The resident's continued weight loss; - The resident's abnormal labs; - The RD's recommendation for liquid protein. Review of the resident's nursing notes showed staff did not document they contacted the resident's physician regarding the RD's recommendation for lab work to be drawn or to begin administering a liquid protein supplement to the resident for six weeks. Staff documented they sent the resident to the hospital for blood [MEDICAL CONDITION] due to [MEDICAL CONDITION] on 12/11/15 and 12/17/15. Review of the physicians visit summary dated 12/17/16, showed staff sent the resident to the emergency room over the weekend due to a hemoglobin level of 7.0 grams per deciliter (normal range is 12.0 to 15.5 grams per deciliter), however resident did not receive any blood products and was sent back to the facility. Resident reports that he/she feels fatigued more so than usual. Appetite fair. Review of the physician visit summary, dated 1/13/16, showed: - Resident reported he/she did not feel well. - Staff reported resident reported daily that he/she did not feel good and spends a great deal of time in bed. - Lab tests reviewed with facility staff. - No new recommendations. Review of the resident's hospital records, dated 1/16/16, showed: - Resident hospitalized for [REDACTED]. spreads into the bloodstream). - Resident stated he/she has an 80 pound unintentional weight loss over the past year. - [MEDICATION NAME] level abnormal at 2.3. - Hemoglobin abnormal at 7.2 grams per deciliter. - On 1/18/16, the resident received one unit of packed red blood cells due to a hemoglobin of 6.0. Review of the resident's January 2016 weight showed staff documented the resident's weight as 205 pounds (a 80 pound weight loss since admission on May of 2015). Review of the resident's January POS showed no order for liquid protein and no house supplement. Review of the resident's quarterly nutrition assessment completed by RD A, dated 2/2/16, showed: - Resident's weight 205 pounds; - Continue previous recommendation for protein supplement due to low visceral protein (visceral protein status is a measure of all other proteins (organs, viscera, serum, blood cells, white blood cells) labs; - [MEDICATION NAME] level very low at 2.3; - Resident continues weight loss of 8% over 90 days and 23% in last six months. Weight loss is significant. - Recommendation to give house supplement 120 cubic centimeters (cc) three times daily to help with protein levels and and weight loss. Review of the resident's February POS showed: - Mechanical soft diet (may have regular per resident consent form); - New order for a house supplement three time daily added on 2/9/16; - No order for liquid protein supplement; - No order for an appetite stimulate. Review of the resident's nurses notes for the last four months showed staff did not document any information regarding: - Significant weight loss. - Any abnormal labs. - Any indication of added protein supplement or house supplement. Review of the resident's care plan, dated with onset of 6/2/15, and updated on 2/9/16, showed: - Resident's goal to have adequate nutrition and hydration; - Resident will maintain weight within five pounds of present weight of 282 pounds and maintain adequate nutrition and hydration for the next three months; - Regular diet; - 11/24/15, goal not met weight now 212 pounds; - Monitor meal and fluid percentages; - Encourage adequate fluid intake; - Monitor monthly weights; - Report any refusals to eat and offer substitutes as indicated; - Monitor labs as ordered; - Consult registered dietitian; - Encourage resident to get up for all meals. - 2/9/16: house supplement three time daily. During an interview on 2/8/16 at 10:22 A.M., the resident said: - He/she now was very weak and had trouble walking with his/her walker to the dining room for meals. - When he/she felt too weak, he/she did not even get up and try to walk to the dining room. - He/she forgot to fill out his/her breakfast menu and staff did not allow him/her to have his/her favorite breakfast: biscuits and gravy. - Staff gave him/her cold oatmeal and one glass of cranberry juice. - He/she asked if he/she could have biscuits and gravy but staff told him/her he/she knew the rules. - He/she slept a lot because he/she did not feel well. - After he/she came back from the hospital, he/she was ill but staff would not allow him/her a room tray. - If he/she did not go to the dining room, he/she could have nothing to eat. - The facility had a rule that residents could only eat in the dining room. - He/she seemed to be weaker and weaker each day. - He/she asked the physician if he/she could have therapy because he/she was weak, but the physician said no because the reason he/she had trouble walking was because he/she was fat. - He/she got upset when the physician called him/her fat and did not eat for a while. - Sometimes he/she was just too weak to go to the dining room. - He/she had been given several units of blood because he/she was always anemic. During an interview on 2/8/16, at 1:55 P.M., Registered Nurse A said the unit had a rule that the resident's could not have food other than water in their rooms. The unit residents had to eat all of their meals and snacks in the dining room. Review of the resident's current POS, showed a new order, dated 2/9/16, for house supplement three times daily. Observation on 2/9/16, at 8:30 A.M., showed the resident asleep in his/her room while staff served breakfast in the dining room. During an interview on 2/9/16, at 1:16 P.M., the resident said he/she missed breakfast and snack time this morning. Staff never offer residents anything to eat other than at meal time or snack time and then only when it is eaten in the dining room. Observation of the unit two dining room and interview on 2/9/16, at 12:45 P.M., showed the resident ate and drank 80% of the food served. The resident received a eight ounce bowl of ham and beans, a half cup serving of green beans, a half cup serving of small potatoes pieces, a two and one-half inch square of peach cake, a cup of a hot beverage, and a glass of an orange colored drink. Staff did not give the resident a glass of house supplement. He/she said the orange drink was sugar free kool-ade. He/she did not care for the potatoes or cake. The potatoes did not have any seasoning on them. He/she enjoyed the ham and beans. It was strange to serve green beans with ham and beans but he/she ate them. This was one of the best meals he/she had been served in a long time. He/she actually got full. During an interview on 2/9/16, at 12:55 P.M., Registered Nurse (RN) A said he/she did not believe residents were allowed to have second helping of foods. He/she was sure they were not allowed anything more to drink because he/she asked the administrator about the limitation of fluids and and was told they did not want the resident to flush their meds. During an interview on 2/9/16, at 4:50 P.M., the administrator said: - They addressed issues like weight loss in their quality assurance meeting and she was not allowed to provide that information to the surveyors. - She did not know why there was any concern about the resident's weight loss since the resident's weight loss was beneficial. - The resident was too heavy and needed to lose weight. - They did not have an order for [REDACTED].>- He/she did not know of anything, diet wise, they did differently for this resident than any other resident. - The resident was on a regular diet by choice. Observation on 2/9/16, during the evening meal showed staff did not provide the resident with any type of supplement with his/her meal. Observation on 2/10/16, at 9:00 A.M., showed the resident asleep. Staff were in the processing of taking the breakfast food carts back to the kitchen. During interviews on 2/8/16, at 10:22 A.M., the resident said: - He/she had lost a lot of weight. - He/she used to weight over 350 pounds when he/she was first admitted to a locked unit. - The physician called him/her fat which upset him/her. - At first it was nice to lose weight without trying. - He/she now was very weak and had trouble walking with his/her walker to the dining room for meals. - When he/she felt too weak, he/she did not even get up and try to walk to the dining room. - He/she slept a lot because he/she did not feel well. - After he/she came back from the hospital, he/she was ill but staff would not allow him/her a room tray. - If he/she did not go to the dining room, he/she could have nothing to eat. - The facility had a rule that residents could only eat in the dining room. - He/she seemed to be weaker and weaker each day. - He/she had been given several units of blood because he/she was always anemic. - Staff gave him/her a sugar free cookie and a sugar free drink for snacks since he/she was diabetic. - His/her blood sugar levels had not been high for several months. - He/she normally ate all the food staff served him/her. - Sometimes after he/she had eaten all of the food served he/she was still hungry. - Staff did not allow residents to have second servings of anything. - Staff limited fluids at meals and snack time. - Residents could drink water from the sink if they were really thirsty. - His/her clothing just fell off, he/she had lost so much weight. - He/she folded his/her top around his/her midsection in half to demonstrate how loose his/her clothing had become. - He/she worried there was some awful medical reason that caused him/her to lose the weight so fast. - He/she did not want to complain about the lack of food or his/her weight loss because if he/she complained he/she would lose his/her smoking privilege. - Having a chew (chewing tobacco) was the only enjoyable thing he/she had left in life. - He/she felt like crying most of the time. Observation and interview on 2/10/16, at 1:58 P.M., showed the resident sat on his/he bed, then stood up. He/she appeared unsteady and used his/her walker to walk down the hallway toward the smoke room. He/she said he/she could not be late or he/she would lose his/her smoke time privilege. He/she did not smoke but chewed. His/her clothing hung loosely from his/her body. During an interview on 2/10/16, at 1:50 P.M., the resident said: - He/she now was very weak and had trouble walking with his/her walker to the dining room for meals. - When he/she felt too weak, he/she did not even get up and try to walk to the dining room. - He/she forgot to fill out his/her breakfast menu and staff did not allow him/her to have his/her favorite breakfast: biscuits and gravy. - Staff gave him/her cold oatmeal and one glass of cranberry juice. - He/she asked if he/she could have biscuits and gravy but staff told him/her he/she knew the rules. - He/she slept a lot because he/she did not feel well. - After he/she came back from the hospital, he/she was ill but staff would not allow him/her a room tray. - If he/she did not go to the dinning room, he/she could have nothing to eat. - The facility had a rule that residents could only eat in the dinning room. - He/she seemed to be weaker and weaker each day. - He/she asked the physician if he/she could have therapy because he/she was weak, but the physician said no because the reason he/she had trouble walking was because he/she as fat. - He/she got upset when the doctor called him/her fat and did not eat for a while. - Sometimes he/she was just too weak to go to the dinning room. - He/she had been given several units of blood because he/she was always anemic. During an interview on 2/10/16, at 4:00 P.M., the social service director said the physician knew about Resident #5's weight loss. He/she said it was a good thing. During an interview on 2/10/16, at 4:05 P.M., the MDS coordinator said: - The resident's weight loss was not planned. - She was told the resident's weight loss was beneficial since the resident was obese. During an interview on 2/10/16, at 4:45 P.M., the DON said: - She made notes about resident's medical issues for the physician. - She did not remember if, and when, she last discussed the resident's weight loss with the physician before yesterday. - She was sure the last time they spoke about the resident's weight lose that it was a good thing for him/her to lose weight since he/she was obese. - The physician ordered a house supplement three times a day for the resident early yesterday morning. - The administrator made notes about resident's weight and dietary concerns for the RD. Observation on 2/10/16, during the evening meals showed staff did not provide the resident with any type of supplement with his/her meal. During an interview on 2/11/16, at 3:10 P.M., Certified Medication Technician (CMT) G said he/she charted meals intake daily. He/she had not noticed Resident #5 was not on the forms. During an interview on 2/11/16, at 3:15 P.M., RN A said staff charted dietary intake and supplements on the meal consumption forms after each meal. He/she did not know anywhere else staff would document if they gave or the resident consumed a supplement. During an interview on 2/11/16, at 7:35 P.M., RN A said: - The resident normally did not get up for breakfast. - He/she did not know if staff gave the resident a house supplement, but had not seen such. - He/she assumed dietary sent house supplement to residents on their meal trays. - He/she did not think the resident received an extra protein supplement. - Staff documented meal and supplement intake of the meal consumption sheets. - Staff must have forgotten to add the resident's name to the meal consumption sheets. - They had no documentation to prove the resident received any meals or supplements for the last month. Review of the facility's January and February 2016, meal consumption forms showed staff did not document any meals or meal supplements for the resident for the last month. During an interview on 2/11/16, at 6:45 A.M., and on 2/12/16, at 4:00 P.M., the dietary manager said: - If dietary received a note on the resident's meal sheet for a supplement, they would put one on the tray. - He did not have a list of residents who received house supplements. - He had been told during his/her training this week that he needed to obtain a list of residents who received special diet orders from the DON. - He did not know until this week's training that dietary needed to provide alternate foods and/or food choices to the residents. - Dietary staff did not pre-pour dietary supplements into glasses for residents on station two (the unit) like they did for the residents on station one. - They sent cartons of the supplements to the unit along with empty glasses so unit staff could pour the supplement for the residents who had orders for house supplements. - He did not think dietary had a list of residents on the unit who received house supplements. - Someone from the unit normally told them how many cartons of supplement to send on the unit food cart daily. During an interview on 2/12/16, at 9:30 A.M., Physician A's nurse said they did not have any records on the residents. They went by the information provided by the facility. He/she would have the physician call. The physician did not return the surveyor's phone calls. During an interview on 2/23/16, at 11:21 A.M., Registered Dietitian (RD) A said: - The resident was on a regular diet by choice. - The resident had beneficial weight loss at first. - Staff told her the resident wanted to lose weight. - He/she did not know the resident normally slept in and did not eat breakfast. - Staff told him/her the resident had a good appetite. - The resident lost too much weight too fast. - Upon his/her recommendation, the physician placed the resident on an appetite stimulant a few months ago which slowed down the weight loss. - He/she did not know why the physician or facility stopped giving the resident the appetite stimulation after only one month. - The resident had chronic urinary tract infections and was hospitalized in December but before then, and even now, he/she continued to have low protein and [MEDICATION NAME] levels. - He/she suggested to facility staff they provide high protein snacks to the resident several times daily and continue on the liquid protein. - He/she did not know if staff provided the extra snacks or protein for the resident. - He/she provided a written copy of his/her recommendations to the administrator.

Based on observation, interview and record review, the facility failed to assure staff obtained treatment orders in a timely manner for two of four sampled residents (Residents #3 and #1) with a change in condition. Resident #3 sustained a fractured leg and Resident #1 was hospitalized with pneumonia. The facility also failed to assure staff assessed three of six sampled residents (Residents #1, #2 and #4) with changes in skin condition and contacted the physician for treatment or treatment changes in a timely manner. The facility census was 47. 1. Review of the facility policy entitled "Condition Change of the Resident" dated 2006 showed: - The purpose of the policy was to (ensure staff) observed, recorded and reported any condition change to the attending physician so proper treatment would be implemented. - Staff were directed to assess the resident and compare the resident's current condition to his/her prior level of function. Staff were to notify the resident's attending physician of the resident's condition. - Assessment included inquiring if the resident had pain, noting swelling or discoloration, noting weakness and gait, posture or balance change. 2. Review of Resident # 3's care plan, dated 2/28/13, showed: - The resident was at risk for falls. Interventions included two (staff) assist with transfers. - The resident had chronic cognitive loss and limited ability to communicate needs. Interventions included monitor for any personal or safety needs. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/22/13, showed: - Rarely, never understood others. - Moderately impaired cognitive skills for daily decision making. - [DIAGNOSES REDACTED]. - Required extensive assistance of two + staff for bed mobility and transfers. - Did not walk in room or hall. During an interview on 8/1/13, at 2:15 P.M., Certified Nurse Aide (CNA) A said: - He/she cared for the resident on the day shift on 6/29/13. - Staff had already gotten the resident up when he/she began caring for the resident on 6/29/13. - After lunch we transferred the resident to bed using a gait belt (sturdy belt applied around the resident's waist - used to give staff a handle when assisting the resident to transfer and walk). - The resident kept saying "My knee hurts!" - As we went to lay him/her down, the resident "let out a war whoop." - He/she pulled up the resident's pants' leg and noted a little swelling, and very little redness. - He/she reported the resident's complaints of knee pain to Registered Nurse (RN) A . During an interview on 8/2/13, at 10:15 A.M., RN A said: - At about 9:00 A.M. on 6/29/13, he/she helped staff transfer the resident from the wheelchair to the toilet, using a gait belt to assist the resident to stand. The resident had no complaints at that time. - Later on 6/29/13, staff reported to him/her that the resident would not straighten his/her left knee. The resident did not cry out with pain or complain of pain. - He/she looked at the resident's knee and noted the resident was guarding it. The knee was maybe a little swollen, but no redness. - The resident could not remember what caused the knee pain. - He/she reported to the night nurse who came on at 7:00 P.M. that he/she needed to keep an eye out for the resident's complaints related to the left knee. Review of Nurses' Notes, dated 6/29/13, showed RN A documented at 2:00 P.M. the resident complained of left knee pain on movement. There was no redness, no warmth, no open area and no injury noted with the left knee. Staff gave the resident prn (as needed) Tylenol. RN A did not document any vital signs taken on 6/19/13. During an interview on 8/1/13, at 2:15 P.M., CNA A said: - On 6/30/13, he/she assisted other staff to transfer the resident to bed from his/her wheelchair. - He/she asked if staff should use a mechanical lift to transfer the resident. RN A told him/her he/she did not need to use mechanical lift to transfer resident. - They used a gait belt an assisted the resident to stand. The resident did not bear weight on the left leg. - The resident did not want him/her to touch the leg to pull his/her pants down. - He/she told RN A the resident complained of pain, could not bear weight and the knee felt hot to touch. - RN A said yes the resident's knee looked worse and said he/she would fax the physician. During an interview on 8/2/13, at 10:15 A.M., RN A said: - On 6/30/13, the resident seemed unchanged until the evening when staff noted redness and some increased swelling. - He/she gave the resident Tylenol and that seemed to help. - The resident did not complain of pain when staff got him/her up. - The CNAs reported the resident would not bear weight. - He/she thought possibly the resident had developed [MEDICAL CONDITION] (inflammation of the tissues) with the left knee. - He/she thought standing the resident for a gait belt transfer was okay. - He/she didn't remember if he/she took vital signs but would have charted them if he/she had. - He/she prepared a fax to send to the physician on 7/1/13. He/she did not feel there was enough of change in the resident's condition to call the physician. Review of Nurses' Notes, dated 6/30/13, at 10:35 A.M., showed RN A documented the resident complained of left knee pain with movement. The left knee was swollen, with no redness, warmth or injury noted. RN A made a fax to send to the resident's physician in the A.M. RN A did not document any vital signs taken on 6/30/13. Review of Nurses' Notes, dated 6/30/13, at 2:30 P.M., showed RN A documented the resident complained of left knee pain. The knee was swollen, red and warm to touch. The resident refused to bear any weight to the left leg. Staff gave prn Tylenol. Review of Nurses' Notes, dated 7/1/13, at 2:30 A.M., showed the resident complained of left knee pain. The knee was red, swollen, and warm to touch. The resident refused to move the knee and it was tender to touch. Staff gave the resident prn Tylenol. Review of Nurses' Notes, dated 7/1/13, at 1:30 P.M., showed staff documented the resident complained of left knee pain. The resident guarded movement to the left leg. The left knee was swollen, red and warm. Fax sent that A.M. to PCP (primary care provider). No return fax at this time. Review of the fax sent to the resident's physician (Physician A) on 7/1/13, showed: - The resident complained of left knee pain with movement or touch. - The left knee was swollen, red, and warm to touch. - The resident refused to bear weight on the left side. - Staff had given the resident Tylenol with no relief of pain. Review of the response to the fax on 7/1/13, written by Family Nurse Practitioner (FNP/associated with Physician A) showed the order for an x-ray of the left knee and blood tests today and fax results. Review of Nurses' Notes, dated 7/1/13, at 3:15 P.M., showed staff sent the resident to the hospital for an x-ray and returned. Then staff sent the resident to the hospital for evaluation and treatment. Review of the hospital history and physical, dated 7/1/13, showed: - Left lower extremity (leg) pain and swelling. - Resident unable to relate cause of left leg pain due to dementia. - X-ray showed distal femoral (lower thigh bone) spiral fracture (break is produced by a twisting of the bone). Review of the hospital discharge summary, dated 7/5/13 ,showed the hospital admitted the resident with a spiral [MEDICAL CONDITION] femur. The resident had a surgical repair of the fracture. Discharge [DIAGNOSES REDACTED]. acute blood loss [MEDICAL CONDITION]. During interview on 8/1/13, at 2:45 P.M., the director of nursing (DON) said: - Staff first noted the resident had minor swelling and pain with movement of the left knee on 6/29/13. - On 6/30/13, staff noted pain with movement and swelling. - Staff did not notify her until 7/1/13, and told her the resident would not bear weight and complained of pain with the left knee. - Staff should have called her regarding the change in the resident's condition - they usually do, so we can formulate a plan. - Also staff know there was an on-call physician they could contact on the weekend. During an interview on 8/1/13, at 4:50 P.M., Physician A's office nurse, Licensed Practical Nurse (LPN) B said Physician A expected staff to call him/her regarding a resident's sudden change in condition such as pain, swelling and being unable to bear weight. 3. Review of Resident #1's MDS, dated [DATE], showed: - Severely impaired cognitive skills for daily decision making. - [DIAGNOSES REDACTED]. Review of the care plan, dated 6/14/13, showed: - The resident had advanced dementia, was disoriented to time and place and had periods of increased confusion, restless and periods of agitation. - The plan directed staff to notify the physician as needed for evaluation if the resident had signs of increased confusion, behavior problems, skin breakdown, changes in mental status or if pain management was ineffective. - The plan did not direct staff to notify the physician for other changes in condition such as fever or a decrease in oxygen saturations. Review of Mayo Clinic.com, showed oxygen saturation is a measure of oxygen carried in the blood. Normal range is 95 - 100%, below 90% is considered low. Review of Nurses' Notes, dated 7/20/13, at 5:45 P.M. showed staff noted the resident started coughing after eating a hot dog. He/she coughed up a large amount of clear phlegm with small amounts of hot dog. Staff monitored the resident's vital signs (within normal limits), lung sounds (clear but diminished) and oxygen saturation (94%). Review of a fax to the resident's physician (Physician A) on 7/21/13, showed: - Staff reported the resident choked on a hot dog at supper on 7/20/13. Vital signs were Temperature 98.4?, pulse 84 (beats per minute), respirations 20 (breaths per minute) and blood pressure 120/86. - On 7/21/13, staff began a trial of pureed diet for three days. The resident ate 100% at breakfast and at lunch with no problems. Review of a fax to Physician A on 7/24/13, showed: - Staff had noted the resident coughed after drinking liquids and asked if it was okay to have a speech evaluation (gives information regarding swallowing problems that could result in aspiration or food/fluids entering the resident's lungs whcih can cause pneumonia). - The physician gave the order for a speech evaluation. Review of Nurses' Notes showed: - From 7/24/13, through 7/26/13, showed no information regarding the speech evaluation. - On 7/26/13, at 2:20 A.M., staff documented the resident was warm to touch, cheeks were flushed and his/her temperature was 102?. Staff administered Tylenol. - On 7/26/13, at 2:40 A.M., staff documented blood pressure (B/P) was 110/55, pulse 110, respirations 20 and oxygen saturation was 87% on room air. Staff administered oxygen and the resident oxygen saturation increased to 90%. - At 3:20 A.M., the resident's temperature was 99.8?, pulse 100 and respirations 20. - At 4:45 A.M., the resident's temperature was 98.3 ?, pulse 94 and oxygen saturation 93% on oxygen. - At 7:00 A.M., Licensed Practical Nurse (LPN) A documented the resident's color was grey and he/she was unresponsive to verbal and tactile (touch) stimuli. Oxygen saturation was 77% on room air. Staff replaced the resident's oxygen and the oxygen saturation increased to 95%. The resident's temperature was 97.7?, pulse 88, respirations 20 and B/P 88/50. - At 7:15 A.M., LPN A sent a fax to Physician A's office. During an interview on 8/1/13, at 1:45 P.M., LPN A said he/she sent a fax to Physician A informing him/her of the decrease in the resident's responsiveness and oxygen saturations and waited for the physician to respond. Review of Nurses' Notes on 7/26/13, showed: - At 8:45 A.M., LPN A documented the resident's temperature was 98.2?, pulse 84, respirations 18, B/P 94/50, Oxygen saturation was 95% on room air. Staff fed the resident and he/she ate 100%. - At 9:00 A.M., LPN A called Physician A's office and noted the nurse was to return their call. During an interview on 8/1/13, at 1:45 P.M., LPN A said he/she called the physician's office at 9:00 A.M. and asked for the physician to call him/her back. He/she said because the resident oxygen saturation level was up at that time he/she felt it was appropriate to wait for the physician to call back. LPN A said he/she monitored the resident's color and oxygen saturations from 9:00 A.M. until 12:00 P.M. and both remained good. He/she did not document those oxygen saturations or try to contact the physician during that time. Review of Nurses' Notes on 7/26/13, showed: - At 12:15 P.M., while in the dining room eating, the resident began coughing. His/her oxygen saturation was 88% on room air. Staff returned the resident to his/her room and administered oxygen. His/her oxygen saturation increased to 92%. LPN A documented the resident's lung sounds as having inspiratory (on breathing in) crackles (abnormal lung sound) and expiratory (on breathing out) rales (abnormal lung sound) throughout. - At 12:45 P.M., LPN A sent a fax to Physician A. During an interview on 8/1/13, at 1:45 P.M., LPN A said he/she again faxed Physician A and then called the physician's office. Office staff said they had given the fax to the physician. Review of a fax, dated 7/26/13, at 12:47 P.M., showed LPN A reported the following to Physician A: - While at lunch, the resident started coughing. - Oxygen saturation 88% on room air, pulse 80, respirations 20, B/P 130/58, temperature 98.2?. - Lungs noted with inspiratory crackles and expiratory rales throughout. Taken to room and placed on oxygen. - Oxygen saturation increased to 92%. - Please advise. During an interview on 8/1/13, at 1:45 P.M., LPN A said he/she called back to the physician's office a second time and then got the order from the physician to send the resident to the emergency room . Review of Nurses' Notes on 7/26/13, showed: - At 1:15 P.M., LPN A documented fax received, spoke with (resident's) family who agreed to send to the emergency room . - At 1:45 P.M., LPN A documented he she gave report to the emergency room nurse. - No documentation of when or how resident left for the emergency room . Review of the 7/26/13, emergency department report showed: - The resident arrived at 2:14 P.M. with a chief complaint of shortness of breath and difficulty breathing. - The clinical impression was pneumonia with hypoxemia (decreased oxygen in the blood) and [MEDICAL CONDITION] exacerbation (worsening). Review of the response (at 4:13 P.M.) by Physician A, written on the fax sent on 7/26/13, at 12:47 P.M., showed the note, "You did send (him/her) to ER right? That is what I had been told." During interviews on 8/1/13, at 2:45 P.M., and 8/2/13, at 1:55 P.M., the DON said: - Usually when staff needed to contact Physician A during the week, they called the office and also sent a fax. - If it was not an acute problem, she felt just faxing the physician was sufficient. - If it needed direct attention, staff were to call the office and give the information to the physician's nurse. - Physician A usually did not look at faxes until noon and again at the end of the day. - She thought LPN A's attempts to contact the physician were appropriate. - She would have preferred the physician call back sooner, but did not feel this was a situation where the resident needed to go to the emergency department sooner. - By 12:00 P.M. she told LPN A to call every five minutes if you have to - We had to get the resident to the hospital. During an interview on 8/1/13, at 4:50 P.M., Physician A's office nurse LPN B said staff were in the physician's office by 7:30 A.M. on weekdays, but if there was no immediate response to a fax, facility staff should call the physician's office. When the resident became unresponsive with a decrease in oxygen saturations, staff should have called the physician's office and said this was an emergency and office staff would have obtained a physician's order to send the resident to the hospital. 4. During an interview on 8/2/13, at 1:56 P.M., the DON said: - The facility did not have a written policy related to skin assessment. - Aides assessed each resident's skin with bathing/showers usually twice per week and completed a Skin Assessment sheet with any abnormal areas marked. - The charge nurse reviewed the Skin Assessment sheets and assessed those areas then contacted the physician for treatment if indicated or used the facility protocol and notified the physician they had initiated the protocol. - Also nurses completed a weekly skin assessment for residents who scored 15 or below on the Braden Scale (tells degree of risk for pressure ulcers). 5. Review of Resident #1's Braden Scale, dated 6/4/13, showed the score of 17. A score of 15- 17 indicated mild risk for pressure ulcers. Review of the MDS, dated [DATE], showed: - Severely impaired cognitive skills for daily decision making. - [DIAGNOSES REDACTED]. Review of the care plan, dated 6/14/13, showed: - The resident was at risk for skin breakdown related to mobility limitations, potential for friction and shear, and incontinence of bowel and bladder at times. - Directions to staff to monitor for skin irritations or breakdown and notify the charge nurse. The charge nurse was to notify the physician as needed for treatment orders. Review of the Skin Assessment sheet, dated 7/25/13, showed staff circled the anterior (front) genital area on the body drawing and wrote "bleeding" by that area. LPN A signed the Shower Sheet. During interviews on 8/1/13, at 1:45 P.M., and 8/5/13, at 9:55 A.M., LPN A said staff reported a small bleeding area on the back of the resident's scrotum on 7/25/13. He/she assessed the area as excoriation due to the resident sitting up in his wheelchair for long periods and being incontinent. Staff applied [MEDICATION NAME] (moisture barrier used to help heal skin irritation due to incontinence of urine or feces) to the area. He/she did not see/document any other abnormal skin areas. He/she said he/she would have documented any assessment of the resident's skin on the treatment administration record. Review of Nurses' Notes, dated 7/26/13, (no specific time given) showed staff transferred the resident to the emergency room for treatment of [REDACTED]. Review of hospital Nurses' Notes, dated 7/26/13, at 10:30 P.M., showed staff noted a raw open area encompassing the head of the penis and foreskin area. Resident's scrotum was raw with an open area - unable to measure. Resident also had an open area to coccyx and "slit in crack." Review of the hospital Physician's Progress Note, dated 7/27/13, showed the physician noted the resident had a very red and excoriated and red genital region as well as open wounds on his/her buttocks.The wounds required different treatments. He/she ordered [MEDICATION NAME] (an antifungal) cream to the red, yeast - appearing areas on the resident's penis and scrotum and a triple antibiotic ointment to the necrotic (tissue death) appearing areas between the glans (end) and the shaft of the penis. The physician noted the resident might need surgical debridement if the area was truly necrotic. The physician ordered a thick barrier (moisture barrier) cream to the open wounds inside the gluteal (buttock) folds. During an interview on 8/2/13, at 1:55 P.M., with the DON and the administrator, the administrator said: - The resident scored 17 on his Braden Scale and as a result was not on the schedule for weekly skin assessments by the nurses. - Staff should have noted the redness, and black discoloration with the penis with peri care. - Nurses should have documented scrotal redness and bleeding reported on the Skin Assessment sheet. They also should have assessed the area and noted the open areas inside the gluteal folds. - They had not found further documentation of these skin conditions at the time of exit. - The administrator said this "fell through the cracks." During an interview on 8/1/13, at 4:50 P.M., Physician A's office nurse LPN B said Physician A expected staff to assess resident's skin condition and report abnormalities such as this resident had to the physician for treatment. 6. Review of Resident #2's MDS, dated [DATE], showed: - Brief Interview for Mental Status (BIMS) score of 14 indicated the resident was cognitively intact. - Did not walk, required extensive assistance of two + staff for bed mobility. - Urinary catheter (sterile tube inserted into the bladder to drain urine) in place. - Always continent of bowel. Review of the care plan, dated 3/8/13, showed the resident had diabetic ulcers with both heels. The care plan directed staff included monitor for any further skin breakdown and the charge nurse to notify the physician as needed for treatment orders. Review of Physician's orders, dated 3/9/13, showed the order [MEDICATION NAME] ointment to groin/peri area every shift for excoriation. Review of Skin Assessment sheets showed: - On 7/5/13, staff documented redness with the groin/peri area (on the body drawing) both front and back. LPN A initialed the sheet indicating he/she was informed of this. - On 7/9/13, staff documented redness with the front of the groin/peri area. Review of Nurses' Notes, dated 7/3/13, through 7/21/13, showed no documentation of assessment of the redness with groin/peri area. Review of Nurses' Notes, dated 7/22/13, at 2:00 P.M., showed the following entry. Resident's buttocks red, raw with several small open areas noted on buttocks and scrotum. Had resident lay down this A.M. and P.M. Resident states buttocks feels very sore. Review of Skin Assessment sheets showed: - On 7/23/13, staff documented redness with the front and back of the groin/peri area. - On 7/26/13, staff documented "open" on the buttocks. - On 7/30/13, staff documented redness with the groin/peri area both in the front and the back. Staff also wrote "blood around buttocks." LPN A initialed the shower sheet indicating he/she was informed of this. During an interview on 8/5/13, at 9:55 A.M., LPN A said she knew the resident's skin condition had changed (on 7/30/13) and that he/she now had a few small open areas, LPN A thought was due to excoriation and the fact that the resident sat for long periods. He/she said he/she would have documented and assessment of this in the treatment administration record. He/she felt the [MEDICATION NAME] was the appropriate treatment. Observation and interview on 8/1/13, at 10:35 A.M. with the DON, showed the resident's buttocks and back of his scrotum was red with small open areas. Staff applied [MEDICATION NAME] to the areas. The resident complained of pain and soreness with the area. Observation and interview on 8/2/13, at 10:15 A.M., showed generalized redness with the resident's buttocks, scrotum and posterior thighs, with two small pea-sized open areas on the right posterior thigh. The area was covered with a white cream. The resident said the area was very tender and hurts. He said he did not like to lie down and did not like to lie on his side. During an interview on 8/2/13, at 1:30 P.M., RN A (charge nurse on the resident's hall that day) said the resident's buttocks have been red for a "couple of months" and more red the last one or two weeks. This was the first time he/she had seen the resident's skin look that bad. He/she was not aware if the resident's physician (Physician A) knew about this because staff did not accompany the physician on rounds. During interviews on 8/2/13, at 1:55 P.M. and 2:10 P.M., the DON said: - Physician A's Family Nurse Practitioner saw the resident on 7/3/13, but his bottom was not red then. - The problem was the redness improved and then worsened because the resident did not want to lie down. - She did not know the resident's skin was that red with open areas. - Charge nurses should have documented the skin condition weekly and contacted the physician for a change of treatment if no improvement. - If there was no improvement in a resident's skin condition after seven days of treatment, she expected staff to contact the physician for a different treatment. - She was not able to show that staff had done that. During an interview on 8/1/13, at 4:50 P.M., Physician A's office nurse LPN B said Physician A expected staff to report to him/her whenever a treatment for [REDACTED]. Staff should contact the physician for a treatment change. 7. Review of Resident #4's Care Plan, dated 11/20/12, showed: - Resident at risk for skin breakdown related to some mobility limitation and occasional urinary incontinence. - Directions to staff to monitor for any skin irritations or breakdown and notify charge nurse. - Charge nurse to assess any reported skin irritations or breakdown and notify physician as indicated for treatment order. - On 4/19/13, staff documented open superficial ulcer on coccyx, length 3 centimeters (cm) by 0.4 cm. Directed to staff to monitor for adequate healing and notify physician if not progressively healing. Review of the MDS, dated [DATE], showed: - Severely impaired cognitive skills for daily decision making. - [DIAGNOSES REDACTED]. - Required extensive assistance of staff for bed mobility and transfers. - Frequently incontinent of urine, occasionally incontinent of bowel. - At risk for pressure ulcers. - Currently had one Stage III (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle is not) pressure ulcer. Review of the Care Plan update on 5/9/13, stating area on coccyx started as excoriation and was now a Stage III pressure ulcer, measuring 2 cm by 1.4 cm by 0.1 cm. Review of the current Physician's Order Sheet on 8/1/13, at 11:35 A.M., showed the order dated 6/12/13, to cleanse the area to the coccyx with normal saline or wound cleanser, pat dry, apply silver alginate rope (type of pressure ulcer treatment promotes healing and prevents infection), cover with dry dressing and change every three days and prn. Review of the most recent wound assessment by RN B, the facility wound nurse on 7/26/13, showed the wound measured 1.2 cm by 1 cm by 0.1 cm. The wound bed was pink with scattered yellow slough (tissue that adheres to the base of an ulcer). Observation on 8/1/13, at 10:28 A.M., showed a quarter sized pressure ulcer over the coccyx with yellow slough in the base. There were quarter sized red, raw areas on each side of the pressure ulcer. CNA C applied [MEDICATION NAME] to the red areas on each side of the pressure ulcer and said the nurse would have to apply the dressing to the ulcer site. Observation on 8/1/13, at 2:20 P.M., showed LPN A washed the coccyx area wound and the area around it with normal saline. The two quarter sized areas on each side of the pressure ulcer were deep red, bleeding and very tender to touch. The resident said "Ouch, stop that!" as LPN A cleansed and dried the area. LPN A applied the treatment to the pressure ulcer as ordered. During an interview on 8/1/13, at 2:28 P.M., LPN A said he/she did not know what caused the red, tender areas on each side of the pressure ulcer. He/she said the facility wound nurse assessed and measured the wound every week, but was not available at this time. When this surveyor asked if the adhesive on each side of the wound dressing might be the cause, LPN A said he/she would apply a larger dressing to avoid the adhesive being in contact with the raw, bleeding areas. Review of Physician's orders on 8/2/13, at 11:35 A.M., showed an order written [REDACTED]. There was no order for treatment of [REDACTED]. During interviews on 8/2/13, at 11:45 A.M. and 2:10 P.M., the DON said LPN A should have documented an assessment of the pressure ulcer and surrounding area on 8/1/13, and should have documented notifying the physician of the reddened areas around the pressure ulcer. She could not find any documentation of the assessment. During an interview on 8/5/13, at 12:25 P.M., LPN A said he/she did not contact the physician about the red, raw areas to each side of the pressure ulcer. The nurse practitioner who worked with the resident's physician saw the resident's pressure ulcer the week before and called in the new order for [MEDICATION NAME] on 8/1/13. She didn't know if the nurse practitioner was aware of the red areas to the side of the pressure ulcer. Any assessment he/she documented would be in the treatment administration record. During an interview on 8/5/13, at 1:00 P.M., the administrator said she would fax any nursing assessment of the resident's wound since the 7/26/13 wound nurse assessment to this surveyor. As of this time, the administrator had not provided documentation of the skin condition changes to the area around the resident's pressure ulcer. MO