Every finding on record at Edgewood Manor Health Care Center

Based on interview and record review, the facility failed to prevent abuse for one sampled resident (Resident #2) out of three sampled residents. On 5/1/26 Resident #3 threw coffee on Resident #2 while he/she was sitting in a chair watching television, resulting in first degree burns to Resident #2's chest. Resident #2 had redness and complained of pain and burning to his/her right upper chest and face area treated with first aid. The facility census was 69 residents. On 5/11/26, the Administrator and Director of Nursing (DON) were notified of past non-compliance which occurred on 5/4/26. All staff received education prior to working their next shift. The deficiency was corrected on 5/4/26. Review of the facility's Abuse and Neglect Policy dated 6/12/24 showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish, which could include staff-to-resident abuse and certain resident-to-resident altercations.-Abuse included beating, striking, wounding or injuring any resident or mistreating or maltreating a resident in a brutal or inhumane manner. 1. Review of Resident #2's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizoaffective Disorder, Bipolar Type (a chronic mental health condition blending schizophrenia symptoms (hallucinations (false sensory perceptions that occur in the absence of external stimuli, making the brain perceive sights, sounds, smells, tastes, or touches as real when they are not) /delusions (fixed false beliefs that persist despite evidence to the contrary and are disconnected from cultural or religious norms) with mood disorder episodes such as mania (excitement manifested by mental and physical hyperactivity, disorganization of behavior, and elevation of mood) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).-Bipolar Disorder (a mental health condition characterized by mood swinging from one extreme to another). -Generalized Anxiety Disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed).-Suicidal Ideations (occurs when someone thinks about or considered death or suicide).-Cognitive Communication Deficit (occurs when someone has trouble with one or more cognitive processes involved in communication). Review of Resident #2's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 2/5/26, showed the resident was cognitively intact. Review of Resident #3's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Post Traumatic Stress Disorder (PTSD-a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or traumatic event).-Schizoaffective Disorder, Bipolar Type.-Major Depressive Disorder, Recurrent (involves a depressed mood or loss of pleasure or interest in activities for long periods of time). -Restlessness (being unwilling or unable to stay still or to be quiet and calm, because you are worried or bored).-Agitation (a feeling of irritability, mental distress or severe restlessness).-Generalized Anxiety Disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed). Review of Resident #3's Quarterly MDS dated [DATE], showed the resident was cognitively impaired. Review of Resident #2's Physical Aggression Involving Head Sheet dated 5/1/26 at 2:42 P.M., showed:-The resident reported to the charge nurse that he/she was hit by Resident #3 and had hot coffee poured on him/her.-The resident had redness on his/her chest and face.-The resident had coffee splattered on his/her hoodie.-The resident complained of burning to the right side of the face and upper chest.-The resident complained of pain at a level of 5 out of 10. (pain scale where 10 is extreme pain) Review of Resident #2's Skin Check assessment dated [DATE] at 3:53 P.M., showed the resident had redness on his/her face and chest. Review of Resident #3's Skin Check assessment dated [DATE] at 3:20 P.M., showed the resident had an abrasion on the left side of his/her face on the left lower lip. Review of the Full Detailed Triage Call sheet dated 5/4/26 showed:-A resident to resident physical altercation occurred on 5/1/26 where Resident #2 was the victim and Resident #3 was the aggressor.-During a group movie and snack activity, Resident #3 approached Resident #2 while he/she was seated on the couch.-Resident #3 asked Resident #2 if he/she had a problem with him/her.-Resident #2 denied having a problem with Resident #3 and asked him/her to step away.-Resident #3 then threw coffee into Resident #2's face.-Resident #2 responded by striking Resident #3 in the face.-The residents were then both separated and Resident #3 was sent to the hospital for psychiatric evaluation. -Resident #3 later reported that he/she was having auditory hallucinations that instructed him/her to harm Resident #2. During an interview on 5/11/26 at 3:00 P.M., Resident #2 said:-He/She was attacked by Resident #3 while watching a movie on 5/1/26.-Resident #3 walked up to him/her and asked if he/she had a problem and he/she responded that there was no problem.-Resident #3 then threw hot coffee on his/her face and chest.-He/She defended himself/herself and stood up and hit Resident #3 in the face.-He/She had red burns on the face and chest, and his/her hoodie was soaked with coffee.-He/She had pain for about 3 or 4 days after the incident where the coffee burned his/her skin.-He/She was unsure why Resident #3 did not like him/her.-Resident #3 has never liked him/her for some reason. -He/She has had increased anxiety due to the incident and had to be placed on anxiety medication because of it.-He/She cried a lot since the accident because he/she was embarrassed by it.-He/She was starting to counsel the next week due to the incident. During an interview on 5/11/26 at 3:45 P.M., Resident #3 said:-He/She poured coffee on Resident #2 because he/she was talking bad about him/her.-Resident #2 slapped him/her after he/she poured the coffee on him/her. During an interview on 5/11/26 at 10:45 A.M., Administrator said:-Resident #2 was sitting on a couch watching a movie when Resident #3 stood up, walked over to, and poured a cup of coffee onto Resident #2. -Resident #2 responded by hitting Resident #3 in the face.-The investigation was completed and substantiated as abuse. During an interview on 5/11/26 at 3:30 P.M., Licensed Practical Nurse (LPN) A said:-Resident #3 poured coffee on Resident #2 and then Resident #2 hit Resident #3 in the face on 5/1/26.-The residents were immediately separated and evaluated after the incident occurred. -He/She evaluated Resident #2 after the incident. -Resident #3 was anxious after the incident and had to be given his/her as needed anti-anxiety medication. -Resident #3 complained of pain after the incident but refused pain medication.-Resident #3 had red marks on his/her face and chest.-Resident #3 was crying after the incident and was very upset. -Resident #2 was sent to the hospital after the incident for evaluation. During an interview on 5/11/26 at 5:00 P.M., Director of Nursing (DON) said:-He/She completed the investigation into the incident and concluded that it was substantiated as abuse.-He/She expected all residents in the facility to be free from abuse. 3001562

Based on observation, interview and record review, the facility failed to prevent abuse for one sampled resident (Resident #8) out of fourteen sampled residents. On 4/2/26, Resident #7 attacked Resident #8 while Resident #8 was in bed, resulting in superficial scratches on Resident #8's face, arm, abdomen and back. The facility census was 72 residents.Review of the facility's Abuse and Neglect Policy dated 6/12/24 showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which could include staff-to-resident abuse and certain resident-to-resident altercations. Purposely included beating, striking, wounding or injuring any resident or in any manner mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse also included, but was not limited to, hitting, slapping, punching, biting and kicking. 1.Review of Resident #7's Level One Nursing Facility Pre-admission Screening for Mental Illness dated 5/6/20 showed he/she had the following diagnosis: -Vascular dementia, (a disorder that damages brain tissue because of lack of blood flow). -Cerebral infarction (a medical emergency caused by a blockage in a blood vessel feeding the brain)-Hemiplegia (paralysis on one side of the body). -Hemiparesis (weakness on one side of the body). Review of Resident #7's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Cerebral infarction, (a stroke which occurs as a result of disrupted blood flow to the brain).-Unspecified dementia without behavioral disturbance, (a condition in which a person loses he ability to think, remember, learn, make decisions and solve problems).-Unspecified mood disorder, (a mental health disorder characterized by a disturbance in mood which is abnormally depressed or elated).-Schizoaffective disorder, (a mental health condition that includes features of both schizophrenia, (a serious mental illness that affects how a person thinks, feels, and behaves) and a mood disorder. Review of Resident #7's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 2/3/26, showed the resident was cognitively impaired. Review of Resident #8's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizoaffective disorder. -Mild neurocognitive disorder (the in-between stage between typical thinking skills and dementia).-Anxiety disorder (a mental disorder which involves more than occasional worry or fear).-Sequelae of cerebral infarction (effects of a stroke)-Cognitive communication deficit (a problem with communication due to disruption in cognitive processes). Review of Resident #8's Quarterly MDS dated [DATE], showed he/she was cognitively intact. Review of the Incident Report for Physical Aggression Involving Head for Resident #8 dated 4/3/26 showed: -Licensed Practical Nurse (LPN) B was alerted to the residents' room by staff members due to a physical altercation involving Resident #7.-Resident #8 was laying in his/her bed yelling, Call the police!.-Resident #8 stated he/she was sleeping, and Resident #7 woke him/her up and asked him/her if he/she would close the window for him/her because he/she was cold.-Then Resident #7 attacked him/her.-The residents were immediately separated in two separate locations in the facility.-Resident #8 was oriented to person, place, time and situation. -Resident #8's injuries at the time were located on the chest, abdomen, face, right wrist, right shoulder, right posterior forearm, right upper arm and right eye. Review of Resident #7's Progress Note dated 4/3/26 at 11:30 A.M. showed:-He/She was identified as the aggressor in prior resident to res ident altercation and was assessed by the Director of Nursing (DON) B.-He/She was alert and oriented to person, place and time.-He/She was calm, cooperative and appropriate during the interaction.-No visible injuries were noted, and vital signs were within normal limits.-He/She denied pain or discomfort.-He/She acknowledged involvement in the incident and offered an apology. Review of Resident #8's Progress Note Skin Check dated 4/3/26 at 3:13 A.M. showed:-He/She had multiple scratches to the face, shoulder, chest, abdomen, upper right arm and lower right arm. Review of Resident #8's Hospital Specialty Documentation dated 4/3/26 at 10:12 A.M. showed:-The resident was presenting status post assault.-Per Emergency Medical Staff (EMS) patient was assaulted while sleeping in bed at his/her living facility last evening (4/2/26).-Patient seemed confused on presentation and was a poor historian.-Staff were unable to gather further details of what transpired.-Patient complained of pain upon evaluation, however was unable to clearly vocalize where he/she felt severe pain.-Patient had abrasions to anterior right chest.-Patient reported being assaulted by another patient using fists. He/She endorsed when he/she believed he/she was hit he/she fell to the floor and hit his/her head.-Patient had eye laceration, right eye pain.-He/She had an approximately 2 centimeter (cm) very superficial laceration noted to the interior aspect of the right eyebrow. During an interview on 4/3/26 at 11:33 A.M., Resident #7 said:-He/She did not initially remember getting into a fight. -He/She was cold and wanted the window closed. -His/Her roommate, Resident #8, wanted the window open, because he/she was hot. -He/She was freezing. -He/She told Resident #8 he/she was going to beat his ass because he/she was fed up. If Resident #8 was hot, he/she should go outside.- I whooped his/her ass. -He/She was not trying to harm Resident #8 - just get his/her point across. -It wasn't a good idea to hit people. -He/She had not hit anyone else at this facility. -The police came and talked to him/her and asked him/her what was going on and he/she told them the same thing. -The police said not to have them come back out and he/she said fine. During an interview on 4/3/26 at 11:57 A.M., Resident #8 said:-This happened last night. -He/She didn't know what Resident #7's problem was. -Resident #7 was cold. -He/She had been in his/her bed asleep. -Resident #7 wanted the window closed. -Resident #7 said Hey, hey, hey!. -Resident #7 said he/she was going to beat his/her ass.-Resident #7 did not say why he/she was hitting him/her. -The nurses came in time to save his/her life. -He/She was lucky to be alive. -It was Resident #7 fingernails that cut him/her. -This is the first time he/she had a fight with Resident #7. -He/She was afraid of Resident #7 now. -He/She had never had a fight with any other residents.-He/She did not feel good about it. He/She felt bad. -He/She just wanted to go home. Review of Resident #8's Progress Note Skin Check dated 4/3/26 at 1:31 P.M. showed:-He/She had new skin issue which was an abrasion on his/her right outer forearm which was new.-He/She had a new skin issue located on his/her right eyelid which was an abrasion.-He/She had a new skin issue located on his/her right eyebrow which was an abrasion.-He/She had six scratches to his/her right arm. During an interview on 4/3/26 at 3:49 P.M., LPN B said:-Resident #7 said he/she was cold because the window was open. -Resident #8 was sleeping in his/her bed.-Resident #7 woke Resident #8 up and asked him/her if he/she could close the window because it was cold.-Resident #8 said he/she went to get out of the bed and as soon as he/she got up, Resident #7 attacked him/her, but did not say why. -When Resident #8 asked Resident #7 why he/she did it, Resident #7 just said, 'because' and that was all he/she would say. -Nobody witnessed this; the residents were in their room. -The two aides that were on the floor heard the commotion in the room and went in and separated the two residents. -These two residents had not argued before, to his/her knowledge. -This incident happened on the night shift. -He/She did the skin assessment on Resident #8. He/She had a scratch on the corner of his/her right eye and scratches on his/her abdomen, shoulder, chest and his right arm which looked like fingernail scratches.-Resident #8 insisted on going to the hospital. He/She thought Resident #8 wanted to get out of the facility because he/she kept saying, I just want to go home. -Typically, residents would not go out to the hospital for superficial scratches. During an interview on 4/16/26 at 1:28 P.M., CNAA said:-He/She was working the night of the altercation between Resident #7 and Resident #8.-The last time he/she saw the residents was during his/her rounds, but he/she could not recall what time that was.-He/She was not aware that Resident #7 did not like the room to be cold, although sometimes the resident did ask him/her for an extra blanket.-It should have been communicated to the staff that Resident #7 did not like the room to be cold.-There was a loud shout and that was when he/she went into the room.-He/she separated the residents. -It would be abuse if a resident hit another resident. Review of Resident #8's Psychosocial Post-Incident Impact Questionnaire dated 4/3/26 at 6:55 P.M. showed: -He/She was the victim in the incident.-He/She did not want to remain in the same room with Resident #7.-He/She was scared of Resident #7.-He/She was good now that his/her room had been changed.-He/She yelled for help. He/She did not do anything. -The staff helped him/her and the police came.-He/She felt safe but wanted Resident #7 told to leave him/her alone.-He/She was scared. He/She did not want any problems.-He/She had scratches on his/her arm and face. During an interview on 4/6/26 at 12:33 P.M., the DON said:-Resident #7 stayed cold; his/her brother brought him/her different clothes and blankets.-It could be 100 degrees and Resident #7 would say it was cold.-Resident #7 wanted to close the window on his/her own and did not call for help.-The incident was abuse. During an interview on 4/6/26 at 2:10 P.M., the Administrator said:-He/She did not think anything could have been done differently.-They could not have predicted Resident #7 would attack his/her roommate.-Resident #7 asked his/her roommate to close the window.-Residents had the right to sleep and not be hit.-It was abuse when a resident started beating another resident up. During an interview on 4/6/26 at 2:20 P.M., Physician A said:-Resident #8 was his/her patient.-Abuse was a case-by-case issue.-Just because a resident hit another resident, it may not be abuse.-He/She expected any of his/her patients not to be hit. 2972766, 2972909

Based on interview and record review, the facility failed to provide appropriate, necessary behavioral health services for one sampled resident (Resident #7) out of 14 sampled residents. On 04/2/26, facility staff failed to implement the resident's care plan for behavioral interventions related to environment. The facility census was 72 residents.Review of the facility's Behavioral Health Services Policy, revised 10/31/24, showed:-The purpose of the policy was to ensure all residents received necessary behavioral health services to assist them in reaching and maintain their highest level of mental and psychosocial functioning.-The facility staff were to ensure the residents were receiving necessary behavioral health care which were person-centered and reflect the resident's goals for care while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.-Behavioral health care and services were to be provided in an environment that was conducive to mental and psychosocial well-being. -The facility staff were to monitor the resident closely for expressions or indications of distress.-If the resident showed signs of distress, the staff were to evaluate if those changes in behavior were unavoidable.-The facility staff were to develop person-centered care for any concerns identified with the resident.-The facility staff were to have interventions that were person-centered, evidence-based, culturally competent, trauma-informed, and in accordance with professional standards of practice. 1.Review of Resident #7's Level One Nursing Facility Pre-admission Screening for Mental Illness dated 5/6/20 showed:-He/She had vascular dementia, (a disorder that damages brain tissue because of lack of blood flow), cerebral infarction, hemiplegia, (paralysis on one side of the body), hemiparesis, (weakness on one side of the body).-Plan of care for staff was to provide a safe environment for the resident and to be supervised for safety. Review of Resident #7's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Cerebral infarction, (a stroke which occurs as a result of disrupted blood flow to the brain).-Unspecified dementia without behavioral disturbance, (a condition in which a person loses he ability to think, remember, learn, make decisions and solve problems).-Unspecified mood disorder, (a mental health disorder characterized by a disturbance in mood which is abnormally depressed or elated).-Schizoaffective disorder, (a mental health condition that includes features of both schizophrenia, (a serious mental illness that affects how a person thinks, feels, and behaves) and a mood disorder.Review of Resident #7's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 2/3/26, showed the resident assessed as cognitively impaired. Review of Resident #7's Care Plan Report updated 2/12/26 showed:-The resident had the potential to be physically aggressive toward peers, related to poor impulse control.-Interventions included: two hour rounding with focus on ensuring he/she was dry, warm and repositioned; verifying he/she had sufficient blankets and appropriate nighttime clothing; monitoring for restlessness and agitation and redirection using calm verbal cues. Review of Resident #8's Quarterly MDS dated [DATE], showed he/she assessed as cognitively intact. Review of the Incident Report for Physical Aggression Involving Head for Resident #8 dated 4/3/26 showed: -Licensed Practical Nurse (LPN) B was alerted to the residents' room by staff members due to a physical altercation involving Resident #7.-Resident #8 was laying in his/her bed yelling, Call the police!.-Resident #8 stated he/she was sleeping, and Resident #7 woke him/her up and asked him/her if he/she would close the window for him/her because he/she was cold.-Resident #7 attacked him/her.-The residents were immediately separated into two separate locations in the facility.-Resident #8 was oriented to person, place, time and situation. -Resident #8's injuries at the time were located on the chest, abdomen, face, right wrist, right shoulder, right posterior forearm, right upper arm and right eye. Review of the undated facility Risk Management Incident Report showed:-The incident occurred in the late evening hours. - Emergency Medical Services (EMS) was activated at 11:46 P.M. and arrived at 11:57 P.M.-The incident was a resident-to-resident altercation.-Staff were alerted to a physical altercation occurring between roommates in their shared room. Upon arrival, Resident #8 was observed lying in bed, visibly upset, yelling, Call the police,-Resident #8 reported he/she had been asleep when his/her roommate, Resident #7, woke him/her and asked him/her to close the window because he/she was cold.-Resident #8 stated he/she attempted to get out of bed to assist when Resident #7 suddenly became physically aggressive and attacked him/her without further provocation.-Upon assessment, Resident #8 was noted to have multiple visible scratches to the face, chest, shoulder, abdomen, right upper arm and right lower arm. No additional injuries were observed at that time.-Resident #8 reported pain and requested a hospital evaluation.-Resident #8 requested police involvement and transport to the hospital.-Resident #7 stated he/she was cold, woke Resident #8 to close the window, and when Resident #8 got up, he/she (Resident #7) beat his/her (Resident #8) ass.-Root cause analysis showed the primary cause of the incident was placing a known aggressive resident (Resident #7) in a shared room.-Contributing factors were sleep disruption (trigger); environmental discomfort (temperature, window); poor impulse control (Resident #7); neurocognitive and psychiatric diagnoses (both residents); lack of protective intervention despite behavioral history.-System failure included: failure to evaluate roommate compatibility; lack of preventive intervention; inadequate behavioral risk management.-Gaps and weaknesses were: failure to remove aggressive resident from a shared room; documented roommate compatibility assessment; environmental triggers not managed; failure to implement higher level supervision prior to the incident; no escalation to psychiatric/PASSR reviews sooner.-The conclusion was the incident was a confirmed resident to resident assault resulting in injury and hospital transfer.-The root cause was failure to manage a resident with known aggressive behaviors within a shared room setting.-Systemic failures in behavioral management, supervision and roommate placement contributed to the event.-The facility identified the root cause as failure to appropriately manage a known aggressive resident within a shared living environment. During an interview on 4/3/26 at 11:33 A.M., Resident #7 said:-He/She did not initially remember getting into a fight. -He/She was cold and wanted the window closed. -His/Her roommate, Resident #8, wanted the window open, because he/she was hot. -He/She was freezing. -He/She told Resident #8 he/she was going to beat his ass because he/she was fed up. -If Resident #8 was hot, he/she should go outside.-He/She said, I whooped his/her ass. -He/She was not trying to harm Resident #8 it was just get his/her point across. -It wasn't a good idea to hit people. -He/She had not hit anyone else at this facility. -The police came and talked to him/her and asked him/her what was going on and he/she told them the same thing. -The police said not to have them come back out and he/she said fine. During an interview on 4/6/26 at 12:55 P.M., the Director of Nursing (DON) said:-There was a lack of preventive intervention with the two residents.-Resident #7 was triggered by environmental issues, like being cold.- Usually when a resident had begun to show signs of being aggressive, the resident was moved .-Resident #7 needed staff assistance with activities of daily living (ADLs) and Resident #8 did not, which is why they were roommates. The failure to Resident # 7 to a different or private room resulted from Resident #7's blindness and relationship to the room. -Neither resident used his/her call light for assistance, and it was dark. Luckily, the nurse was rounding and intervened right away.-If this had happened during the day, Resident #8 probably would have used his/her call light. In the dark, both residents were startled.-The residents could have been reminded to use their call lights if they had issues.-Certified Nurses Aide (CNA) A could have used due diligence when they put Resident #7 to bed and checked the window, it might have stopped the incident from happening. Since the staff were aware that Resident #7 had an issue with being cold, the CNAs could have been proactive on room comfort and closed the window.-Preventive intervention could be to make sure of the comfort of both residents while in the room. During an interview on 4/6/26 at 2:00 P.M., the Interim DON said:-One the resident to resident incident, (Resident #7 and Resident #8), the root cause was behavioral.-Resident #7's medical history indicated he/she had behaviors.-He/She thought Resident #7's behaviors were being managed, but the incident happened because it was nighttime.-Resident #7's eyesight could have been an issue.-The open window was close to Resident #8.-It would be normal for a resident to be startled if awakened in the dark.-Resident #7 should have used his/her call light instead of waking Resident #8 up.-Possibly Resident #7's cognitive issues might have caused him/her to react.-Residents were reminded to use their call lights.-Giving Resident #7 a private room could have prevented the incident knowing Resident #7 could be aggressive. During an interview on 4/6/26 at 2:10 P.M., the Administrator said:-Related to behavior management, it may have been an environmental factor.-Resident #8 liked the cold room and Resident #7 liked it warm, so they were not compatible.-The root cause of the incident was environmental factors.-The aides should have noted if residents were comfortable or not. During an interview on 4/16/26 at 1:28 P.M., CNA A said:-He/She was working the night of the altercation between Resident #7 and Resident #8.-The last time he/she saw the residents was during his/her rounds, but he/she could not recall what time that was.-He/She was not aware that Resident #7 did not like the room to be cold, although sometimes the resident did ask him/her for an extra blanket.-It should have been communicated to the staff that Resident #7 did not like the room to be cold.-Usually when he/she saw the residents, they were in bed.-There was a loud shout and that was when he/she went into the room.-When the staff did rounds, they would check and change the residents who needed it, and he/she would check every resident to make sure they were breathing.-It would probably be appropriate to check Resident #7's room to make sure it was not cold.-He/She did not know of a place where the residents' triggers could be checked.-He/She did receive computer education about abuse and resident rights; however, they did not enforce continued computer training and were just given a packet of papers to sign stating they understood abuse and resident rights. 2972766, 2972909

Based on interview and record review, the facility failed to notify the guardian/responsible party for one sampled resident (Resident #4) of 14 sampled residents. On 3/24/26 Resident #4 had a fall was transported and admitted to the hospital. The legal guardian was not notified until 3/25/26. The facility census was 72 residents.Review of the facility's Incidents and Accidents Policy dated 5/18/24 showed:-The resident's family or representative should be notified of the incident/accident and any orders obtained or if the resident was to be transported to the hospital. -Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, orders obtained and all follow-up interventions. 1. Review of Resident #4's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizoaffective disorder, bipolar type (a mental health condition marked by a mix of symptoms including schizophrenia and mood disorder symptoms).-Undifferentiated schizophrenia, (a mental health condition that affects how people think, feel and behave, and may result in a mix of seeing or hearing things not observed by others, disorganized thinking and behavior). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/1/26, showed he/she was cognitively intact. Review of the resident's Care Plan Report revised 4/30/24 showed:-He/She had impaired thought processes related to decision making due to diagnoses of schizophrenia and bipolar disorder.-He/She had a legal guardian.-Interventions included communication with the resident/family/caregivers regarding the resident's capabilities and needs. Review of the resident's Un-witnessed Fall Report showed:-He/She had a fall in the facility dining room on 3/24/26 while standing and attempting to purchase soda.-Pre-disposing factors are walking without assist, unsteady gait, joint pain and drowsiness.-He/She reported feeling dizzy before the fall and fell into his/her wheelchair.-His/Her jaw hit the wheelchair, and his/her chest hit the ground.-He/She was oriented to person, place, time and situation.-The nurse assessed the resident after the incident.-Vital signs and condition were monitored; wounds were identified, and initial care was provided.-A possible head injury was suspected.-The acting Director of Nursing (DON) and Nurse Practitioner were notified.-The resident was transferred to the hospital for further evaluation and treatment.-There was no documentation notifying the legal guardian.During an interview on 3/26/26 at 11:29 A.M. the resident's legal guardian said:-The facility had not notified him/her timely the resident was in the hospital. -The hospital was not notified that the resident had a legal guardian on admission. During an interview on 4/3/26 at 1:00 P.M., the resident said:-He/She was aware he/she went to the hospital due to a fall.-He/She did not know what the procedure was for notifying his/her legal guardian about things. During an interview on 4/3/26 at 1:30 P.M., Licensed Practical Nurse (LPN) A said:-He/She was the nurse when the resident's fall occurred.-He/She did not call the resident's legal guardian when it happened. -He/She called the legal guardian the following day. -There was so much going on, he/she forgot to make the call. -He/She did not document that he/she called the legal guardian the following day. -When he/she called the legal guardian he/she was upset that he/she did not call at the time of the fall. -The facility policy was that the legal guardian and the family were to be notified as soon as possible. -He/She forgot to do it. It was his/her fault. It was a mistake. During an interview on 4/6/26 at 2:26 P.M., the Director of Nursing (DON) said:-Nurses were educated to call the legal guardians regarding incidents.-The legal guardian should be notified as soon as possible and given details about what was going on with the residents.-The expectation was that the resident should be assessed, and then notification to the DON, administrator, physician and legal guardian. During an interview on 4/6/26 at 2:30 P.M., the Administrator said:-The expectation was that the legal guardian should be notified, along with the DON, the Administrator, and the physician if an event with a resident occurs.-The legal guardian should really be notified in the first thirty minutes after an incident.-If that was not possible, notification should occur as soon as possible and definitely before the staff left the building. 2965179

Based on observation, interview and record review, the facility failed to keep two sampled residents (Resident #1 and Resident #2) free from misappropriation and exploitation. On 3/31/25, Resident #1 gave the Social Worker Director (SSD) 400 dollars from his/her spend down Trust account to purchase a recliner chair, but no chair was purchase. On 11/20/25, Resident #2 gave Certified Nursing Assistant (CNA) A 1,000 dollars to pay his/her rent and later, around 11/24/25 Resident #2 gave his/her debit card to CNA A and Housekeeper (HK) B an additional 200 dollars to pay the electric bill and take a trip. On 11/26/25 Resident #2 gave Activity Assistant A 280 dollars to pay a car payment out of three sampled residents. The facility census was 80 residents. The Administrator was notified on 1/20/26 of Past Non-Compliance which occurred on 3/31/25, 11/20/25 and 11/24/25. An all-staff in-service on Abuse and Neglect and Resident's Rights, as well as a full audit of all resident funds was completed by 12/5/25. An audit was completed on all resident accounts prior to 12/9/25. All staff were educated on Resident Rights, Misappropriation including not accepting money or gifts from residents. All able-minded residents were educated on not offering staff or other residents' money or gifts. CNA A, HK B and the Activity Assistant were terminated on 12/8/25 and the SW was terminated on 12/9/25. The deficiencies were corrected by 12/9/25. Review of the facility policy for Code of Conduct revised 4/18/25 showed:-The purpose of the policy was to provide standards of conduct for all employees as well as setting ethical and legal standards for its employees.-Employees were not to accept or provide any benefits that could be viewed as a conflict between staff and residents.-Employees were to not to accept for offer gifts or benefits in exchange for any services. Review of the facility policy for Resident's Rights revised 9/21/25 showed:-The residents had the right to manage their financial affairs.-The facility was to establish and maintain a system that assured a full and complete separate accounting according to generally accepted accounting principles of each residents' personal funds entrusted to the facility on the resident's behalf. Review of the facility Abuse and Neglect Policy revised 6/12/24 showed:-The purpose of the policy was to protect residents from abuse, neglect, exploitation including misappropriation of personal property.-Misappropriation of property included--- Theft of money from resident bank accounts.--Unauthorized or coerced purchases from resident funds.--A resident who provides a gift to staff in order to receive ongoing care based on the staff's persuasion.--A resident who provides monetary assistance to staff, after staff has made the resident believe that staff was in financial crisis. 1. Review of Resident #1's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses:-Lewy Bodies (abnormal clumps of protein that form inside the brain nerve cells, disrupting their function and communication eventually leading to death).-Anxiety. Review of Resident #1's change of condition Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 12/5/25 showed he/she was moderately cognitively intact. Review of the resident's Nursing Care Plan dated 1/6/26 showed:-He/she was dependent on staff to meet his/her emotional, intellectual, physical and social needs.-The staff was to encourage his/her involvement in cognitive stimulation and social activities.-The staff was to allow the residents to make decisions and meet his/her physical and social needs.-The staff was to encourage the resident to make his/her own decisions.-The resident had the potential for anxiety, so staff was to ensure his/her needs were met in a timely manner in order to reduce his/her anxiety level and avoid any negative behaviors. Review of the Registered Nurse Investigation (RNI) dated 12/4/25 showed:-The incident involved a misappropriation of resident funds in the amount of 400 dollars.-On 12/4/25 the Administrator was notified that the resident was reporting to staff, hospice (end of life care) and visitors that the SSD stole his/her money as he/she gave the SSD 400 dollars for the recliner, and he/she never got the chair.-On 3/31/25 the Business Office Manager (BOM) gave 400 dollars of resident's spend-down funds to the SSD to purchase a recliner for the resident.-The SSD stated he/she ordered a recliner from his/her personal Amazon account but the resident didn't like the recliner and so he/she returned it.-The SSD stated there was an 80-86-dollar re-stocking fee which was deducted, but no refund documentation was found.-No recliner was ever delivered to the resident, and no funds were ever deposited back into the resident's Trust account.-Between 6/4/25 and 10/20/25, the Administrator and BOM attempted to obtain the recliner or a refund from the SSD via multiple emails and phone messages. but he/she did not respond to the calls or emails.-On 12/4/25 the Activity Director reported the resident was still expressing concerns, prompting the Administrator to begin an immediate investigation, notify police, and the guardian.-Based on the information available at the time of the investigation, the allegation of misappropriation of funds was substantiated at the facility level.-The SSD was terminated on 10/13/25.-The resident stated that the SSD had his/her money to purchase the recliner, but he/she never got the recliner, and the SSD took his/her money. Review of Resident #1's Request for Large Sums of Cash from Trust documentation dated 3/31/25 showed:-Resident #1 requested 400 dollars to be paid to him/her for a chair,-The resident gave a verbal signature, and it was signed by the SSD. Review of the resident's Trust Transaction List dated 3/31/25 showed a check number 3551 was issued from Resident's Trust Funds in the amount of 400 dollars. Review of an email from the SSD to the BOM dated 6/3/25 at 11:44 A.M., showed the SSD still needed to get the facility driver to go to a local furniture mart to pick up the chair. Review of an email from the BOM to the SSD dated 6/4/25 at 11:28 A.M., showed:-The BOM inquired about the status of the resident's recliner chair that the BOM was to have purchased for Resident #1 asking if the SSD was still purchasing the chair or was, he/she is returning the 400 dollars to the resident's Trust Account. Review of the local law enforcement report dated 12/5/25 at 2:33 P.M., showed:-The report was in regard to a Larceny attempt.-The SSD stole money from Resident #1. During an interview on 1/16/26 at 1:15 P.M., the BOM said:-He/she heard the original allegation regarding Resident #1 from the SSD.-The SSD said he/she needed money to purchase a chair for the resident.-After the BOM provided the money from the resident's trust account, the BOM checked with the SSD several times over the months about the chair.-The SSD had stated he/she ordered the chair from Amazon, and it was not of good quality, so he/she returned the chair and paid an 80-86 dollar restocking fee.-When the BOM checked later with the SSD, the SSD stated he/she had his/her brother, who was a facility transportation driver for a while, to go to a local furniture mart to get a chair.-The chair was never purchased.-The BOM felt uneasy about what was happening, so he/she sent another email to the SSD.-Right after he/she sent an email inquiring again about the chair, he/she found out the SSD had been terminated, and the money was to be returned to the resident's Trust account.-He/she reported the issue to the Administrator and the next thing he/she knew, the SSD was let go. Observation and interview on 1/16/26 at 2:55 P.M. Resident #1 said:-He/she was tearful, and his/her hands were shaking during the interview process.-The SSD took advantage of him/her.-He/she no longer wanted the chair, he/she just wanted his/her money back.-The SSD just took his/her money and never did what he/she was supposed to do.-The whole situation made him/her very angry and feeling taken advantage of. During an interview on 1/22/26 at 1:30 P.M., the SSD said:-He/she wanted to reschedule an interview when he/she could have his/her attorney present on the phone call as he/she had retained counsel and was suing the facility for wrongful termination.-When he/she was informed that his/her could not be on the call, he/she stated he/she would refrain from answering any questions. 2. Review of Resident #2's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses:-Chronic Obstructive Pulmonary Disease-(COPD)-Morbid Obesity (A body mass index (BMI) of 40 or greater with at least one serious obesity-related health condition). -Cirrhosis of the Liver (a condition where healthy liver tissue becomes permanently damaged and replaced by scar tissue, hindering its ability to function properly, often being caused by alcoholism or fatty liver disease). Review of Resident #2's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of Resident #2's Nursing Care Plan dated 12/1/25 showed:-He/she had a history of providing money willingly to facility staff.-The facility staff was to provide protective oversight for the resident.-The facility was to provide a financial safety review, education on boundaries for the staff and residents, and provide monitoring for high-risk financial behaviors.-Social Services was to provide ongoing support regarding interpersonal relationship expectations and vulnerability to manipulation.-The facility staff was to supervise access to his/her lockbox as applicable and ensure safe handling of valuables. Review of a text messages from Resident #3's cell phone, dated 9/26/25 at 4:50 P.M., showed: -Resident #3 sent a text message to Resident #2 stating, Activity Assistant A wants to borrow 280 dollars to pay his/her car insurance. He/she will pay you back, but I told him/her I can't go in your room, then I lied and said it was on a card. I don't know what to tell him/her. I'm between a rock and a hard place here. Review of the facility's RNI dated 11/27/25 showed:-The incident included a Misappropriation of Funds affecting Resident #2.-The Director of Nursing (DON) was notified that Resident #3 reported to HK A that he/she witnessed Resident #2 give money to HK B for CNA A. -Resident #3 went into Resident #2's lockbox for the resident and counted out 1000 dollars in cash on 11/20/25. -On 11/24/25, CNA A and HK B came and got Resident #2's bank card and took out an additional 100 dollars. -The Administrator questioned both employees involved, and both denied receiving money and that they both knew they should not take money from residents.-The local police were contacted, and officers came and interviewed all involved parties, confirming Resident #2 allegedly voluntarily provided the money to CNA A on 11/20/25 and 11/24/25.-At the resident's request, police counted the funds in the resident's lockbox and found 90 dollars.-While continuing the investigation on 12/1/25, Resident #2 reported to the BOM that he/she also gave Activity Assistant A 280 dollars on or around 9/26/25. -Resident #3 said he/she was in Resident #2's room and witnessed the transaction with Activity Assistant Aas well.-Activity Assistant A provided a statement denying he/she took any money from Resident #2.-The local police were also notified about the transaction.-Based on the interviews the facility felt there was a strong possibility that the alleged incidents indeed had taken place and all involved staff members were suspended and were ultimately terminated. Review of Resident #2's written statement dated 11/27/25 showed:-He/She gave money to CNA A because he/she was pending eviction without paying rent and utilities.-He/She tried to help as people because he/she didn't get out much and sometimes he/she felt like people didn't care about him/her unless he/she did things for them.-He/she had helped CNA A keep up with rent and the light bill paid.-On 11/20/25 he/she asked Resident #3 to open his/her lockbox so he/she could remove 1000 dollars in cash which Resident #3 then handed to HK B.-On 11/24/25, CNA A and HK B needed his/her debit card and Resident #3 repeated the PIN out loud.-CNA A and HK B took out 100 dollars and CNA A was also given 100 dollars for his/her trip to Oklahoma on that same day.-The resident confirmed he/she willingly told Resident #3 to open the lockbox and to give the staff members the debit card.-He/She had bought Resident #3 two hoodies for Christmas, and when Resident #3 asked for 200 dollars, he/she could not give it to the resident as he/she was helping CNA A with bills.-He/she knew that not everyone liked him/her so helping people makes them nicer to him/her.-When the police counted his/her lockbox, 90 dollars was found in the box and 10 dollars in a cup in his/her room. Note: Resident #2 was unable to be interviewed as he/she passed away on 12/4/25. Review of a written statement from Certified Medication Technician (CMT) A dated 11/27/25 showed:-Resident #2 stated that he/she gave CNA A 1,300 dollars to pay rent.-The resident stated he/she actually gave the money to HK B to give to CNA A.-Resident #2 stated he/she gave them the money because he/she didn't have anyone to love him/her.-The resident stated that he/she didn't want the CNA to get into trouble for taking the money, asking CMT A if CNA A would potentially get into trouble.-CMT A told Resident #2 that CNA A could get into trouble as staff were never to ask or accept money from residents.-The resident also stated he/she wanted to move out of the facility.-CMT A explained to the resident that he/she didn't have to move, he/she just needed to stop giving his/her money away. During an interview on 1/16/26 at 1:37 P.M., CMT A said: -Resident #2 liked to talk to him/her and seemed to be comfortable with his/her.-One day the resident shared that he/she had given CNA A money for rent.-The resident told him/her that there was a fear that CNA A would get into trouble for taking the money.-The resident told CMT A that he/she gave people money because he/she had been abused all his/her life, didn't have any friends, and he/she just wanted people to like him/her. -He/she tried to reassure the resident and encourage the resident to stop giving money away. During an interview on 1/16/26 at 2:10 P.M., HK A said:-Resident #3 came to him/her around 11/26/25 and said that Resident #2 was giving money to CNA A but when Resident #3 asked for money, Resident #2 told him/her that couldn't happen as Resident #2 was helping CNA A.-He/she immediately went to the DON to report the conversation. Review of Resident #3's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of Resident #3's written statement dated 11/27/25 showed: -Resident #3 reported that he/she had been upset because he/she was in a relationship with Resident #2, and didn't like how Resident #2 was giving money away.-He/she felt disrespected because Resident #2 had given CNA A money more than once to help him/her with bills.-On 11/20/25, Resident #2 asked him/her to unlock the lockbox so HK A could take 1000 dollars in cash.-On 11/24/25, Resident #2 told him/her to hand Resident #2's debit card to CNA A and HK B and Resident #3 said the PIN number out loud so the staff members could hear it.-Resident #3 gave CNA A and HK B took 100 dollars and then gave CNA A another 100 dollars to travel to Oklahoma. During an interview on 1/16/26 at 2:40 P.M. Resident #3 said:-He/she had witnessed Resident #2 take money out for CNA A on two separate occasions.-One of those occasions was for rent and the other for a car payment.-He/she was the one who took the 1000 dollars out of Resident #2's lockbox and gave it to HK B to give to CNA A.-He/she also gave Resident #2's debit card to CNA A and HK B employees so they could pay the car payment.-Both times Resident #2 was present and asked him/her to help as he/she was not ambulatory and was in bed at the time.-It bothered him/her as he/she knew it wasn't right.-He/she didn't tell anyone until 11/27/25. Review of the statement from Activity Assistant A dated 12/2/25 showed he/she stated that he/she never asked nor received any money from a resident for personal reasons. During an interview on 1/20/26 at 11:15 A.M., the DON said:-He/she was notified of all the incidents around the same time, between 11/27/25 and 12/3/25.-He/she had not been made aware of any large amounts of money given by Resident #2, nor was he/she aware the SW had been given 400 dollars to purchase a chair that the SW never purchased.-As soon as he/she was made aware he/she began to investigate.-All staff had been educated regarding resident rights and misappropriation upon hire as well as throughout the year.-Resident #2 had been previously educated on not loaning money to anyone on multiple occasions as the resident had a history of loaning money to other residents and potentially staff, although staff loans had never been proven. During an interview on 1/21/26 at 4:16 P.M. Activity Assistant A said:-He/she had been an employee for quite a while and knew better than to ask a resident for money.-He/she never asked Resident #2 for any money for any reason.-He/she had no idea what was going on and thought maybe Resident #3 was mad at him/her for some reason and that was why he/she was implicated in the incident.-He/she just got a phone call telling him/her that he/she was suspended pending an investigation as the residents involved said he/she had asked for and received 280 dollars from Resident #2.-The next thing he/she knew, the Administrator was calling him/her and telling him/her that he/she was fired.-He/she knew better than to take advantage of a resident by taking their money and would never do that. Review of an undated written statement from Licensed Practical Nurse (LPN) A showed he/she was standing at Resident #2's door and witnessed the resident stating he/she gave CNA A 1,000 dollars for rent. During an interview on 1/22/26 at 5:35 P.M. LPN A said: -He/she overheard Resident #2 speaking CMT A about having given CNA A 1,300 dollars for rent.-He/she was aware the resident sold items to residents and that he/she had a car business, but he/she had not heard of the resident giving away money until hearing the conversation with CMT A.-The resident expressed concern that CNA A could get into trouble, but it didn't stop him/her from giving away the money.-He/she was also present when the resident was interviewed by the police and admitted having given away money to staff on at least two separate occasions. Review of a written statement from HK B dated 11/28/26 showed:-He/she did not get any money from Resident #2.-All he/she knew was CNA A got money from a family member. **NOTE: HK B could not be reached by telephone. A certified letter was mailed on 1/22/26 to employee address the facility provided from the employee file. **NOTE: CNA A could not be reached by telephone. A certified letter was mailed on 1/22/26 to employee address the facility provided from the employee file. Review of the local law enforcement's report dated 11/27/25 at 11:14 P.M. showed:-Incident Synopsis: Officer took general information.- CNA A, Activity Assistant A, HK B, had stolen $1000 from the Resident #2.-On 11/27/25 at approximately 11:08 P.M., the officer responded regarding Larceny.-Resident #2 and the DON were interviewed.-The DON reported CNA A and HK B had taken money from Resident #2. -Resident #2 said he/she gave CNA A approximately $1,000.00 because he/she was receiving text messages from his/her landlord stating he/she would be evicted if he/she could not pay his/her rent by the 1st of December. HK A was given the money on 11/24/2025 by Resident #2. 3. During an interview on 1/20/26 at 11:30 A.M. the Administrator said:-All involved staff were trained in orientation and had further training through in services during staff meetings prior to the allegations of misappropriation on Abuse/Neglect/Misappropriation and about resident rights and inappropriate relationships between staff and residents including how it was not appropriate to provide residents with personal phone numbers. -They would not have expected this from any staff due to their education provided by the facility. -They would have expected any staff that had any idea someone was misappropriating a resident's money or exploiting a resident to immediately come forward and report to the DON or Administrator.-He/she felt these incidents were exploitation of the residents as both Resident #1 and Resident #2 were taken advantage of by the facility staff and the staff had all been educated against such behaviors. 4. Review of the Activity Assistant's Code of Conduct Education Sheet showed he/she received education on 6/7/22. Review of CNA A's Code of Conduct Education Sheet showed he/she received education on 9/24/24. Review of HK B's Code of Conduct Education Sheet showed he/she received education on 11/12/25. Review of the SW's Code of Conduct Education Sheet showed he/she received education on 8/27/24. Complaint #'s 2679576 and 2684961

Based on interview and record review, the facility failed to ensure laboratory services were provided when the physician ordered diagnostic testing that was not completed for three sampled residents (Resident #5, Resident #8, and Resident #10) out of 11 sampled residents. The facility census was 79 residents.Review of the facility's policy titled Diagnostic Testing Services Policy dated 6/26/24 showed:-The facility would provide the appropriate diagnostic services requires to maintain the overall health of its residents and in accordance with State and Federal guidelines.-The facility would maintain a schedule of diagnostic tests in accordance with the physician's orders.-Documentation of diagnostic tests, the results, and date/time Physician notification would be maintained in the resident's electronic health record.1. Review of Resident #8's admission Record showed he/she was admitted to the facility with the following diagnoses:-Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).-Vascular Demetia (a decline in cognitive function caused by reduced blood flow to the brain, often resulting from conditions like stroke, heart disease, or hardening of the arteries).Review of the resident's Order Summary Report dated October 2025 showed: -An order for a Complete Metabolic Panel (CMP- a blood test that measures 14 different substances to provide doctors with information about the body's chemical balance, including its metabolism, kidney function, liver function, and fluid balance) including glomerular filtration rate (GFR- a measure of kidney function that represents the volume of fluid your kidneys filter from your blood per minute).-An order for a Lipid Panel (a blood test that measures the different types of fats in your blood) with calculated low-density lipoprotein (LDL- a type of lipoprotein that transports cholesterol through the blood).-An order for a Glyco-HbA1c (a measurement of the percentage of red blood cells that have been coated with glucose, a sugar from the blood).-An order for a Thyroid Stimulating Hormone (TSH) blood test (measures the amount of TSH).-An order for a Complete Blood Count (CBC) without differential (a basic blood test that measures amounts and sizes of red blood cells (RBCs), hemoglobin, white blood cells (WBCs), and platelets).-An order for Vitamin D, 25-Hydroxy, (D3) LC/MS/MS (a lab test that measures levels of a metabolite of Vitamin D3, using a technique called Liquid Chromatography-Tandem Mass Spectrometry (a highly accurate and precise laboratory method used to separate, identify, and quantify substances in a sample).-All of the blood tests were to be drawn on 10/13/25.Review of the resident's Electronic Medical Record (EMR) on 10/31/25 showed no results from the resident's lab tests in his/her chart.2. Review of Resident #5's admission Record showed he/she was admitted to the facility with the following diagnoses:-Unilateral Pulmonary Emphysema (a rare condition where air spaces are abnormally enlarged in only one lung or lobe)-Quadriplegia, C1-C4 (the first four cervical (neck) vertebrae) Incomplete (an injury to the top of the spinal cord where some signals still pass through, allowing for some feeling and/or movements in the limbs and torso, though breathing may be severely impacted).-Other Cerebral Infarction Due to Occlusion of Stenosis of Small Artery (a stroke caused by the blockage or narrowing of a small blood vessel deep within the brain).Review of the resident's Order Summary Report dated October 2025 showed:-An order for a CMP including GFR.-An order for a Lipid Panel with calculated LDL.-An order for a Glyco-HbA1c.-An order for a TSH blood test.-An order for a CBC without differential.-An order for Vitamin D, 25-Hydroxy, (D3) LC/MS/MS.-All of the blood tests were to be drawn on 10/13/25.Review of the resident's EMR on 10/31/25 showed no results from the resident's lab tests in his/her chart.3. Review of Resident #10's admission Record showed he/she was admitted to the facility with a diagnosis of Paraplegia (paralysis of the legs and lower body), Unspecified.Review of the resident's Order Summary Report dated October 2025 showed: -An order for a CMP including GFR.-An order for a Lipid Panel with calculated LDL.-An order for a Glyco-HbA1c.-An order for a Iron, Total blood test (measures how well your blood's carrier proteins, specifically transferrin, can bind to a transport iron).-An order for a TSH blood test.-An order for a CBC without differential.-An order for Vitamin D, 25-Hydroxy, (D3) LC/MS/MS.-All blood tests were to be drawn on 10/20/25.Review of the resident's EMR on 10/31/25 showed no results from the resident's lab tests in his/her chart.4. During an interview on 10/31/25 at 10:42 A.M. the Assistant Director of Nursing (ADON) said:-He/She did not think that the facility had an active lab contract.-Sometimes the lab technicians would not come out to the facility to draw labs as ordered.-Sometimes the facility had to send residents to the hospital because labs could not be drawn immediately as needed.During an interview on 10/31/25 at 12:10 P.M. the ADON said:-Resident #8's labs were not collected by the lab technician.-The resident's labs still needed to be drawn.-All lab results could be found in the facility's EMR system.During an interview on 10/31/25 at 2:07 P.M. the Administrator and the ADON said:-They were aware that there was an issue with the current laboratory service that the facility used.-If the lab results were not found in Resident #5's, Resident #8's, and Resident #10's EMR then they were not completed.-Recently, a lab technician came into the building and did not complete all of the lab work that was ordered for the residents.During an interview on 10/31/25 at 2:20 P.M. the Regional Manager of the Laboratory Services that was used by the facility said:-He/She could not see orders in place for Resident #5, Resident #8, and Resident #10 to get lab work done.-He/She could not see any recent lab work completed/resulted for Resident #5, Resident #8, and Resident #10.-The lab orders were bi-directional which meant that the laboratory could see the orders placed by the facility within the facility's EMR system.-The facility's assigned dates for collections was every Tuesday and Thursday.-The lab technician had most recently been at the facility on 10/30/25.During an interview on 10/31/25 at 2:28 P.M. Licensed Practical Nurse (LPN) A said:-The nurses were responsible for putting in laboratory orders including blood work.-There was nothing specific that needed to be done by nursing staff besides putting the laboratory order in the facility's EMR system in order for a laboratory technician to come to the facility to draw blood.-The facility had an integrated system with the laboratory that the facility currently used which meant that the laboratory company could see orders within their system once the facility placed an order.-He/She had not experienced any issues with labs not being drawn as ordered.-Sometimes he/she would have to call lab to get the results of the test because it would not show the results correctly in the facility's EMR system.-He/She was unsure of why the resident's lab work was not completed.During an interview on 10/31/25 at 3:08 P.M. the Director of Nursing (DON) said:-The staff were doing everything he/she expected them to related to laboratory services.-The laboratory technicians don't come to the facility like they were supposed to.-He/She had been in touch with the laboratory services company that the facility used because of the known issues.-There was a lab book at the nurse's station.-The lab book also had all of the orders that needed to be completed when the laboratory technicians came to the building and were flagged.-He/She bets that Resident #5's, Resident #8's, and Resident #10's laboratory tests were not completed.-The EMR system that the facility used was integrated with the laboratory services system.-The facility recently ordered annual lab work to be completed for all residents.-A lab technician had come into the building and only completed a couple of orders before leaving the building.-The issue with the laboratory services was frustrating but he/she understood that the issue fell back on the facility to correct.During an interview on 11/3/25 at 12:20 P.M. Nurse Practitioner (NP) A said:-He/She would have expected all of the resident's laboratory orders to have been drawn when ordered.-There could be potential negative outcome related to not getting laboratory tests completed as ordered.-He/She was aware that the facility's company in general was having issues with the laboratory service that they currently used.-He/She would have expected the facility to be more vigilant in getting lab orders completed if it was a known issue.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #4) of ten sampled residents was free from misappropriation of property. Specifically, $845.00 in cash was stolen from the resident's dresser drawer. The facility census was 76 residents.The Administrator was notified on 8/14/25 of the past noncompliance which began on 7/30/25. The facility immediately completed education for staff on the Misappropriation of Resident Property policy. The facility planned to return the resident's money when he/she returned from the hospital. He/she would be assisted in making a bank account. The deficiency was corrected on 8/1/25.Review of the facility policy regarding Misappropriation of Resident Funds dated 6/12/24 showed:-Misappropriation of resident property included deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent and included: identity theft, theft of money from bank accounts, theft of money from a resident, unauthorized or coerced purchases on a resident's credit card, unauthorized or coerced purchases from a resident's funds, a resident who provided a gift to staff in order to receive ongoing care based on staff's persuasion, a resident who provided monetary assistance to staff after the staff made the resident believe that staff was in a financial crisis, misappropriation of a resident's property, or misappropriation of a resident's medication. 1 Review of Resident #4's admission Record face sheet showed he/she was admitted to the facility on [DATE].Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 6/20/25, showed he/she was cognitively intact. Review of the facility's Investigation dated 7/30/25 showed:-The incident was misappropriation of funds.-The persons involved were Resident #4 and a facility staff member.-The resident stated he/she had missing money. $845.00 was in the second drawer of his/her white dresser in a red Christmas stocking.-He/She stated he/she had the money out earlier in the day, then saw the in-house eye doctor, took a smoke break and returned to the room at 2:30 P.M.-He/She stated he/she looked for the money for a little while.-When questioned, he/she did not want to say how he/she got that much money as he/she did not leave the facility.-It was explained to him/her without that information, not a whole lot could be done.-He/She gave a statement stating he/she did not want a staff member to get in trouble and that was why he/she didn't want to give names.-He/She stated he/she was not real mad, but he/she did want to buy a wheelchair.-He/She stated a staff member got him/her money out of an automatic teller machine (ATM) for him/her as he/she was trying to save up for an electric wheelchair.-When asked why he/she didn't take the money to the bank and start an account, he/she stated he/she liked to keep his/her money to him/herself.-When asked if other staff knew about the money, he/she stated several staff knew about it.-The police were notified and reviewed the videos that showed a staff member unplug the 600-hall camera at 10:44 A.M.-No one was seen going into the room until 1:30 P.M.-The staff that was seen unplugging the camera was seen going in the resident's room and coming out with a bulging pocket with his/her hand in the pocket.-The staff person then picked up a box at the nurses' station and walked into the activity room.-The resident called his/her bank to ask for his/her statements so he/she could prove he/she really did have the money.-The staff member in the video was suspended until the investigation was completed.-The resident provided proof that the money was taken out of the ATM.-The suspected staff member was interviewed and when asked about unplugging the camera responded, I don't know what you are referring to. He/she made the same response when asked about the money.-The investigation concluded it was reasonable to believe this was not preventable and was not an ongoing problem that could have been foreseen due to prior history.Review of the facility videos of the hallway leading to the resident's room showed:-Activities Assistant A walking through the common area into a hallway, unplugging the security camera and moving a table in front of the plug.-He/She walked into the common area again and looked around.-He/She then walked down the hall and entered the resident's room.-He/She was not carrying anything when he/she went in.-He/She exited the resident's room with his/her hand in his/her pocket.-He/She walked to the nurses' station and picked up a box and carried it over the side with the pocket.-He/She left the area and entered the residents' dining room.-He/She entered the activities office followed by the Activities Director.During an interview on 8/14/25 at 12:09 P.M., Activities Assistant A said:-He/She was an aide at the facility.-He/She did not know anything about the money.-He/She went in the resident's room but did not take anything.-He/She talked to the resident, but that was all.-He/She went in resident rooms to pass out mail.-He/She was accused of something but did not know what it was.-He/She denied stealing anything.-He/She was suspended for tampering with the cameras.Review of Resident #3's admission Record face sheet showed he/she was admitted to the facility on [DATE].Review of the resident's quarterly MDS dated [DATE], showed he/she was cognitively intact. During an interview on 8/14/25 at 1:15 P.M., Resident #3 said:-He/She and Resident #4 were engaged.-Resident #4 once gave him/her $350.00 for a trip.-He/She was paying him/her back.-He/She was aware Resident #4 kept money in his/her room.During an interview on- 8/14/25 at 3:30 P.M., Resident #4 said:-He/She had $845.00 cash in a Christmas stocking in the dresser drawer.-He/She had the money because his/her wheelchair was too small for him/her, and he/she had found a new one on Marketplace. -He/She found that this wheelchair was also too small for him/her as well.-He/She did not give the money to the financial lady because he/she was under the assumption he/she could only get $100.00 of his /her money at a time.-He/She got up between 10:00 and 10:30 A.M. on 8/12/25 so he/she could go out to meet a friend.-He/She and his/her friend watched television until 11:30 A.M. at the facility and then went outside to smoke.-After that they watched television again until the 2:00 P.M. smoke break.-From there they went to his/her room.-He/She had his/her friend put $3.00 in his/her dresser drawer.-When the friend went to get the stocking where Resident #4 kept his/her money, they found the stocking was not there and the dresser drawer was open.-Certified Nursing Assistant (CNA) B knew about the money in the stocking.-Activities Assistant A knew about the money.-Housekeeper A knew about the money.-When the staff would come in the room, he/she would ask them to get his/her money if he/she needed it, since his/her dresser was clear across the room.-Activities Assistant A would get the stocking out and bring it to him/her, he/she would get his/her money out and then would put it back.-Other residents knew they could get small amounts of money from him/her if they needed small things like snacks.-He/She had been educated about not keeping large amounts of money, but he/she had trouble remembering.-He/She had not originally asked for a lock box but had one now.During an interview on 8/19/25 at 1:30 P.M. CNA B said:-He/She was aware of the resident's money; he kept it in a sock.-He/She saw the money, and it was $800-$900 because the resident was going to buy a power wheelchair.-The resident gave him/her his/her ATM card, and he/she got $400 for the resident.-A couple days later, the resident had him/her get another $400.-The resident had found a wheelchair on Marketplace.-The resident then found out he/she could not fit in the wheelchair, so then he/she just had the money in his/her room.-The resident had the money for possibly two weeks.-He/She did not know if the resident let his/her friend use his/her ATM card, but the friend was aware of the resident's money.-Sometimes the resident would give his/her friend a few dollars for cigarettes.-He/She did not know if anyone else knew about the money.-He/She did was not working when the money went missing.During an interview on 8/19/25 at 1:40 P.M., CNA C said:-He/She was aware of the missing money.-He/She was not aware the resident kept the money in a sock and never saw it.-When he/she found out about the missing money, he/she was offended because everyone on that hall was then a suspect.-He/She never saw or heard about the money until after it was gone.-The resident would buy pop and snacks for the other residents.-The resident would give him/her loose change and told him/her to put it in his/her top drawer.-He/She thought when he/she heard about the missing money that was what it was.During an interview on 8/19/25 at 1:55 P.M., Licensed Practical Nurse (LPN) A said he/she had not known about the resident's money.During an interview on 8/19/25 at 2:00 P.M., Graduate Practical Nurse (GPN) A said:-He/She was not aware the hall camera had been unplugged.-He/She was not aware that the resident kept a lot of money in his/her dresser.-He/She did not see Activities Aide A with a full pocket leaving the room.During an interview on 8/19/25 at 2:05 P.M., Housekeeper A said:-He/She was unaware the resident kept money in his/her drawer.-Activities Aide A did not say anything to him/her in the office.-During an interview on 8/18/25 at 2:15 P.M., Activities Director A said:-He/She was aware the resident's money had been stolen.-He/She did not see Activities Aide A take anything out of his/her pocket and he/she did not say anything.-He/She was not paying attention to Activities Aide A at the time.-He/She knew the resident kept money in his/her drawer, but did not know how much.-The resident would ask him to change $20.00 bills for #1.00 bills sometimes.-He/She did not notice anything suspicious.During an interview on 8/19/24 at 2:25 P.M., the Administrator said:-The resident had the money and kept it in a drawer.-The facility had a staff member who unplugged the surveillance camera and went in the resident's room.-The staff member came out of the room with a bulging pocket.-The residents had all been educated not to keep money in their rooms.-The resident did not have a lock box.-The resident had found an electric wheelchair he/she wished to buy and then found he/she was too big for the chair.-The resident had been making arrangements to get the chair and that was why he/she had the money, which was in his/her possession from 7/14/25 to 7/30/25 when it was stolen.-The resident had talked about being excited about getting the money for the wheelchair. He/she liked to brag about his/her money which could explain why the staff knew about it.-He/She was not sure how the Activities Aide knew the resident had the money.-The resident came to him/her when the money was missing.-Based on the videos, the money was in the stocking.-The missing money was not found during the investigation, and the facility would replace it.2576777

Based on observation, interview and record review, the facility failed to keep one sampled resident (Resident #2) out of 10 sampled residents from physical harm when on 8/9/25 Resident #1 and Resident #2 were involved in a physical altercation. Resident #1 attempted to pass Resident #2 in his/her wheelchair, words were exchanged and the residents struck at each other. Resident #1's ring caused a scratch to Resident #2's scalp. The facility census was 76 residents.The Administrator was notified on 8/14/25 of the past noncompliance which began on 8/9/25. The facility immediately completed education for staff on the Abuse and Neglect policy. The residents were instructed to eat in different dining rooms in the future, and to stay away from each other. The residents did not live near one another. The residents' care plans were updated. The deficiency was corrected on 8/10/25. Review of the facility's Abuse and Neglect Policy dated 6/12/24 showed:-Abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident to resident altercations.-Purposefully beating, striking, wounding or injuring any resident or in any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner.-Physical abuse also included, but was not limited to: hitting, slapping, punching, biting and kicking. 1. Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE] with a diagnosis of the absence of his/her right leg above knee. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning), dated 6/4/25, showed he/she was cognitively intact. Review of the resident's Care Plan Report dated 6/16/25 showed nothing documented for behaviors prior to this event. Review of the resident's Progress Notes dated 8/9/25 at 5:00 P.M. showed:-The resident was involved in a resident-to-resident altercation with Resident #2.-He/She admitted to initiating the incident, stating he/she became irritated with the other resident opened his/her mouth and struck him/her.-The resident was calm and cooperative with the staff after the event but declined physical assessment.-No visible injuries were noted; no change of condition observed.-No as needed medications or physical holds were necessary. Review of the resident's Progress notes dated 8/9/25 at 5:08 P.M. showed:-Licensed Practical Nurse (LPN) A was called to the dining room for a physical altercation.-When he/she arrived, he/she saw Resident #1 and Resident #2 had been separated from each other.-Both residents were assessed for injuries.-Resident #1 appeared calm and had no visible injuries or complaints of injury.-Resident #2 appeared upset and had a dime sized lump on the top of his/her head.-Both residents declined medical attention.-Resident #2 wanted to press charges, so the police were called, and the report was made.-Both residents would be monitored for any changes in behavior. Review of the resident's Incident Report dated 8/9/25 showed:-At approximately 4:21 P.M. on 8/9/25, Resident #1 self-reported a physical altercation with Resident #2.-Resident #1 stated he/she did not care for Resident #2, and he/she got on his/her nerves.-When asked what behavior was bothersome, Resident #1 stated that Resident #2 opened his/her mouth which irritated him/her to the point that he/she hit him/her.-Resident #1 admitted he/she was wrong but maintained he/she did not like Resident #2.-After striking Resident #2, Resident #1 mobilized his/her wheelchair to his/her room and requested to eat there.-Resident #1 was directed to eat in the front dining room, separate from Resident #2.-Resident #2 had been eating chicken when Resident #1 struck him/her, resulting in a scratch to the head due to Resident #1's ring.-Upon notification of the incident, staff separated the two residents to prevent further escalation.-Resident #1 was escorted to his/her room area and Resident #2 was relocated to the nurses' station near his/her hall.-Both residents were allowed time to calm and speak individually with nursing staff to share their accounts.-A skin assessment was completed on Resident #2 revealing a superficial scratch to the scalp; neuro checks were offered and declined, and pain was denied.-Resident #1 declined assessment.-No as needed (PRN) medications or physical holds were required.-Police were called per Resident #2's request. Review of Resident #2's admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Difficulty in walking.-Unsteadiness on feet.-Muscle weakness.-Slurred speech.-Cognitive communication deficit.-Unspecified intellectual disabilities. Review of the resident's quarterly MDS dated [DATE], showed he/she was cognitively intact. Review of the resident's Care Plan Report dated 12/23/24 showed he/she had a behavior of inserting him/herself in other peer or staff conversations. Interventions included assisting him/her in developing more appropriate methods of interacting; reinforcing why behavior was inappropriate and/or unacceptable; intervening as necessary to protect the rights and safety of others; approaching and speaking in a calm manner; diverting attention from the situation; removing from the situation and taking to an alternative location. Review of the resident's Progress Notes dated 8/9/25 at 4:53 P.M. showed:-Registered Nurse (RN) A stated at 4:25 P.M. he/she heard a noise of two men fighting in the dining room.-He/She had just walked by that area and there was no problem.-He/She had gotten about three feet from them and heard loud fighting.-There were two men in wheelchairs hitting each other and yelling.-The nurses tried to stop the fight, and they continued to hit each other.-The residents stopped fighting when they pulled their wheelchairs apart.-Resident #2 had a small gash on the top of his/her head which was bleeding slightly. Review of the resident's Progress Notes dated 8/9/25 at 5:22 P.M. showed:-At approximately 4:21 P.M. in the dining room, Resident #1 struck Resident #2 while he/she was eating.-Resident #1 admitted the incident stated Resident #2 opened his/her mouth which irritated him/her to the point of hitting him/her.-Resident #1 acknowledged his/her actions were wrong but stated he/she did not like Resident #2.-Resident #2 sustained a superficial scratch on the top of the head due to Resident #1's ring.-No pain reported.-The resident remained calm but requested police involvement.-No change of condition occurred with either resident. Review of the resident's Incident Report dated 8/9/25 showed:-He/She was oriented to place, time, person and situation.-There were no predisposing environmental factors.-He/She reported being struck on the head by Resident #1.-He/She sustained a scratch.-He/She declined neuro checks and denied pain.-He/She stated he/she was sitting at his/her table eating his/her chicken when Resident #1 hit him/her, and he/she did not know why.-The residents had been separated.-A skin assessment was completed and revealed a superficial scratch to the top of the head.-He/She was offered emotional support and allowed to speak with family members.-He/She was re-educated on maintaining personal boundaries and avoiding interactions with trigger residents. Review of the facility investigation dated 8/9/25 showed:-Resident #1 allegedly started the altercation.-RN A had just walked by the residents and did not see or hear anything out of order.-RN A got three feet behind them and heard loud fighting and yelling and tried to separate them.-The two residents were hitting each other with their fists.-Resident #2 was hit on the head by Resident #1's ring and it caused a gash.-Ice was applied after the wound was cleaned.-The wound was approximately 0.5 centimeters (cm) in size and was bleeding slightly.-Both residents said they did not like each other. Review of the Police Report dated 8/9/25 showed:-On 8/9/25 at approximately 5:36 P.M., Officer A responded to the facility regarding an assault.-Officer A spoke with staff members who stated Resident #1 and Resident #2 had gotten into a physical altercation.-Resident #2 stated Resident #1 rolled onto him/her with his/her wheelchair, and he/she yelled at him/her.-They then began to argue back and forth when Resident #2 stood up and was struck in the head.-Resident #1 stated they had been bickering back and forth for the last few days and that Resident #2 charged at him/her, so they began to wrestle with each other.-Officer A spoke with the Administrator over the phone and he/she said he/she would email over video footage of the altercation.-He/She spoke with Resident #2's family member who was there to find out what had happened.-He/She provided the family member with the police report number and advised him/her what he/she had been told.-Resident #2 had a swelled up bump on the top of his/her head and a scrape on top of it.-Multiple staff stated no staff were present in the dining room when the fight occurred. Review of facility video showed:-Resident #1 was visible watching television.-Resident #2 was visible sitting at a table with two other residents.-He/She left the area in his/her wheelchair, went to the trashcan, opened and closed it.-He/She backed up his/her wheelchair.-Resident #2 approached Resident #1; both were in wheelchairs.-RN A was visible walking past the two residents.-Resident #2 began backing his/her wheelchair up while Resident #1 was moving toward him/her.-Raised voices were audible.-Resident #2's movement was stopped by a cabinet he/she backed into.-Resident #1 began throwing fists at Resident #2; Resident #2 began hitting back.-While they were hitting, Resident #2 stood up, then sat back down.-RN A was visible attempting to stop the fighting.-Both residents stood up and RN A had instructed Resident #2 sit back down.-Both residents continued to shout, and Certified Nurse's Aide (CNA) A stepped between them.-Other staff had entered the area.-End of video. During an interview on 8/14/25 at 12:05 P.M., Resident #1 said:-Resident #2 was antagonizing him/her and was pushing against him/her.-He/She had this problem since he/she had been at the facility, but did not tell anyone.-The two of them had never had any fights before.-He/She had been sitting in the dining room and was getting ready to leave after lunch and Resident #2 deliberately blocked him/her from leaving.-Resident #2 had a defiant attitude, like he/she did not have the right to ask him/her to move.-He/She was trying to get away.-He/She wanted to get by Resident #2 and pushed his/her chair and he/she got up.-He/She pushed Resident #2 and hit him/her a couple times on his/her head and Resident #2 backed away.-Resident #2 attacked him/her first when he/she wanted to get by; if someone put his/her hands on him/her, he/she would protect him/herself.-He/She was attacked, but he/she bested Resident #2.-He/She did not have any animosity or intention of hitting Resident #2 or being around him/her.-He/She was defending him/herself and trying to protect his/her self-respect. -He did not have any injury and did not go to the hospital.-He/She tried to be an asset and not a liability at the facility and got along with people and obeyed the rules and regulations. He/she had not had any problems with any other residents at the facility.-There were staff present in the dining room.-He/She was not afraid of Resident #2 or anyone and felt safe in the facility. Observation of Resident #2's injury on 8/14/25 at 1:30 P.M. showed a small, closed cut, approximately 1/2 inch in length on the top of his/her head. During an interview on 8/14/25 at 1:30 P.M., Resident #2 said:-The altercation happened in the daytime.-Resident #1 was trying to get a paper towel and backed his/her wheelchair into him/her. -The paper towel dispenser was empty, and Resident #1 had a mean looking face.-He/She did not say anything at first, then we had a verbal exchange.-He/She told Resident #1 to get out of his/her face.-He/She told Resident #1, Hey, you better back off!-A nurse came and separated them.-He/She told Resident #1 he/she was going to call 911. The police came and he/she was going to press charges.-He/She was standing up for him/herself.-He/She was not afraid of Resident #1 or anybody and was fine with the two of them staying apart. During an interview on 8/14/25 at 2:00 P.M., RN A said:-He/She was walking down the hall and about 3 feet after he/she walked past the dining room he/she heard the two residents yelling at each other.-He/She turned around and saw Resident #1 was standing up with his/her wheelchair locked and Resident #2 was also standing up.-The residents were hitting each other, and he/she yelled at them to stop.-When they did not stop, he/she took Resident #1's wheelchair and pulled him/her back, while yelling for help at the same time.-Someone else pulled Resident #2 back but he/she did not know who.-Resident #1 said the two residents did not like each other and had never liked each other.-He/She had worked at the facility since 11/24 and has not known either of them to fight each other or other residents.-Resident #1 did not have any injuries and Resident #2 had a small cut on his/her head, which he/she cleaned.-At dinner, he/she told Resident #1 to move to the other dining room and that the two residents had to stay separated.-Resident #2 said he/she wanted to press charges, and the police came and talked to him/her. -After the residents were separated, they did calm down.-He/She was not aware of any triggers they had. Review of Resident #5's admission Record face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's quarterly MDS dated [DATE], showed he/she was cognitively intact. During an interview on 8/14/25 at 2:20 P.M., Resident #5 said: -He/She had been sitting at his/her own table in the dining room crocheting.-He/She heard a commotion.-Resident #1 had to go between two tables and in front of the TV to get to where he/she wanted to go.-In the past, he/she had never fought with anyone about it, and he/she thought it would be the same this time.-Resident #1 and Resident #2 did not like each other and had argued in the past.-Resident #2 was the town [NAME] and will tell if anyone was doing anything.-Resident #1 told Resident #2 to shut up and pointed at him/her.-Resident #2 told Resident #1, You shut up!-Resident #2 had been sitting and eating chicken.-Resident#1 rolled in and told Resident #2 to move so he/she could get to his/her spot.-There was not enough room between a table and Resident #2's wheelchair for him/her to get through.-Resident #2 told Resident#1 he/she was going to have to move.-Resident #2 backed up to get out of the way and said something.-The two residents were cursing at one another.-Resident #1 approached Resident #2 and they both stood up.-Then the two residents started fighting and Resident #1 hit Resident #2 on the head, and his/her ring cut him/her.-Resident #1 was in the wrong; Resident #2 could not go backward any further because there was a cabinet blocking him/her.-RN A was the first staff person there; he/she came running.-Then the other staff came running.-RN A told Resident #1 to stay in the other dining room and he/she did it. He/She thought he/she won the fight.-Resident #1 and Resident #2 had been cordial previously; he/she was stunned they were fighting. During an interview on 8/14/25 at 2:45 P.M., Physician A said:-He/She was aware of the altercation between the two residents.-Resident #1 had never previously had any kind of behaviors. -The resident had been his/her patient for at least ten years and had never been the kind of get upset.-The resident kept to him/herself and was not one to antagonize others.-It was absolutely not appropriate for one resident to strike another resident. During an interview on 8/14/25 at 2:55 P.M., LPN A said:-The two residents fight was broken up by the time he/she arrived.-He/She had been in the supply room getting supplies for another resident.-As far as he/she knew, the two residents had not had fights with each other or other residents.-Resident #1 kept to him/herself. Resident #2 had gotten into verbal incidents because he/she was nosey, but they were never physical.-Neither resident had previous behaviors. During an interview on 8/14/25 at 3:05 P.M., CNA A said:-He/She was at the nurses' station charting and a resident told him/her there was fighting.-When he/she came in the dining room, the two residents were yelling at each other.-Resident #2 was still standing and RN A was with them.-He/She stepped in the middle of the two residents and asked what was going on.-Resident #2 started yelling that Resident #1 had hit him/her.-She asked Resident #1 about it, and he/she said he/she did not like Resident #2, and he/she was talking, but not to him/her. Resident #1 rolled up to Resident #2 and hit him/her.-The two residents were separated.-He/She had never even seen the two residents exchange words before.-He/She had been trained to diffuse situations like this as possible or otherwise separate the residents involved. The nurse would tell them what to do next. Review of Resident #6's admission Record face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's quarterly MDS dated [DATE], showed he/she was cognitively intact. During an interview on 8/19/25 at 11:50 A.M., Resident #6 said:-Resident #1 was trying to get past Resident #2 in his/her wheelchair and the space was tight.-Resident #2 wheeled backward in his/her chair until he/she could not go back any further, due to a cabinet being in the way.-Resident #1 got frustrated.-The two residents exchanged hostile words. Resident #1 said, I'm just tired of you to Resident #2.-Then the two residents started slapping at each other. Resident #1 started slapping first.-The staff came and broke it up right away.-The two residents had never fought each other or other residents before to his/her knowledge.-Resident #1 would usually keep to him/herself.-He/She did not feel this was predictable.-He/She felt safe living at the facility. Review of Resident #7's admission Record face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's quarterly MDS dated [DATE], showed:-He/She was cognitively impaired. During an interview on 8/19/25 at 12:00 P.M., Resident #7 said:-The scuffle started around lunch time when Resident #1 tried to get past Resident #2 with his/her wheelchair.-The whole thing maybe lasted five minutes.-He/She called for a nurse, who came right away and broke up the altercation.-The staff pulled their wheelchairs apart and they each went their own way.-He/She had never seen either of them fight anyone before.-He/She felt safe living at the facility. During an interview on 8/19/25 at 2:25 P.M., the Administrator said:-RN A had just walked through the dining room at the time.-The incident happened near mealtime and there could have been bickering. If there was previous bickering between the two residents it was about small things and not brought to his/her attention.-Resident #1 was typically friendly with everyone, but a loner and stayed to him/herself.-Resident #2 would annoy everyone because he/she made it his/her business to know everything that happened in the building and talk about it.-Resident #1 ate all of his/her meals in the dining room.-It was not abnormal for the two residents to be in the dining room at the same time.-That day, Resident #1 got annoyed because he/she could not get his/her wheelchair through and decided to hit.-Resident #1 said he/she did it because he/she did not like Resident #2's mouth. He/She had never hit anyone before.-Neither resident had previous behaviors or physical altercations and lived on opposite ends of the hallway.-Resident #2 got a small abrasion on his/her head from Resident #1's ring.-They asked the residents not to eat in the same dining room.-The staff were where they were supposed to be and broke up the altercation immediately.-It was never appropriate for two residents to hit one another when they get frustrated.-He/She did not feel like the situation was abuse and did not feel like it was predictable. 25852852585315

Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, homelike environment by not sweeping and mopping the floors in the dining room, cleaning the carpet in the common area, cleaning resident rooms and bathrooms and ensuring urine odors were not present throughout the facility. The facility census was 79 residents. Review of the facility Housekeeping - Deep Cleaning Policy dated 6/29/23 showed: -Purpose was to ensure all rooms are clean. -Deep cleaning was to be completed as scheduled. -This includes complete pull-outs of furniture in rooms, wall cleaning, floor cleaning (scrubbing and waxing included), restrooms to be cleaned and disinfected, cob webs removed, beds and rails to be cleaned and free of bugs, sprinkler heads to be cleaned, light covers to be clean and free of bugs, over-bed light covers to be cleaned and free of bugs, sink clean, windows to be cleaned and ensure no spider webs, drapes and curtains to be cleaned (including privacy curtains), call lights to be clean and free from dust/dirt build-up, floors at closets and doorways are to be free from wax/dirt build up, etc. -All areas should be monitored on a daily basis and all resident living areas and non-living areas should be clean and odor free. -Daily cleaning: --Pick up all trash and put into trash can and empty. --Dust mop or sweep floor. --Submerse rag or sponge in with solution and clean surfaces beginning with touch areas on door and work clock or counter clock wise around the room. --Surfaces are to be cleaned including wall smudges, light and call light and side tables, head/foot board/side rails of bed and windows. --Clean the sink around the light fixtures and dispensers. --Clean inside and outside of the trash can. Let it air dry. Replace trash can liner. --Clean bathroom using the same cleanser/disinfectant wall smudges, lights, and call switches, and support rails. Use Honey Bowl to clean inside, outside toilet tank, seat and bowl. -Resident Room Deep Clean: --All resident rooms will be deep cleaned once monthly or more often if needed, as in the case of heavy care rooms. --All above-floor bathroom surfaces will be cleaned with a cleaner/disinfectant. --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 removable then the housekeeper will notify the maintenance department with a maintenance request form. --All furniture will be removed, cleaned behind, and upholstered furniture will be thoroughly cleaned. --Carpets will be inspected for cleaning determined by the supervisor. --Resident bed will be stripped with both frame and mattress cleaned with disinfectant cleaner. --Glass surface will be cleaned. --Necessary wall washing to remove smudges and spots will be done with disinfectant cleaner. Review of the facility job description for Environmental Services Director dated 2023 showed: -Position Purpose plans, organizes, supervises and directs all environmental service operations to ensure a clean, safe and orderly resident living environment. -The environmental services director was responsible for efficiently managing the facility's housekeeping operations and the environmental services staff. -The primary function of this position was to ensure nursing home resident enjoy a clean and orderly living environment. -Develops systems and programs for maximizing the effectiveness of the housekeeping functions. -Perform regular daily, weekly, and monthly environmental service inspections in order to ensure the facility is maintained in a safe and sanitary manner according to facility policy. -Maintains required records and reports as outlined in the policies and procedures of the environmental services department. -Consistently follows a written, current master cleaning plan for the entire facility. -Prepares and properly maintains required records, reports and evaluations. Review of the facility job description for Environmental Services Housekeeper dated 2023 showed: -Position purpose ensures the provision of a clean environment for residents and staff, providing high quality services and high standards of cleanliness, ensuring compliance with infection control procedures. -Carries out all cleaning duties as directed by the environmental services director according to required department policies and procedures. -Ensures that daily and deep cleaning schedules are adhered to. -Ensures all necessary documentation is completed daily. -Essential functions: --Dusts furniture, woodwork, equipment and dust-mops floors. --Polishes and cleans fixtures in rooms and bathrooms. --Wet-mops rooms, halls and other areas; shampoos rugs and furniture. --Cleans vents, fan fixates, top of windows, door frames and other high surfaces. --Gathers and disposes of trash and waste materials using specified bags and containers. --Performs terminal cleaning procedures of resident rooms and prepares rooms for new admissions. --Cleans and disinfects all fixtures, floors, mirrors, windows, doors, and walls of bathrooms. Review of undated Housekeeper Job Description showed: -The primary purpose of the position was to perform the day-to-day activities of the housekeeping department in accordance with current, federal, state and local standards, guidelines, and regulations governing the facility, and may be directed by the environmental services director and/or the administrator, to assure the facility was maintained in a clean, safe and comfortable manner. -Duties and Responsibilities: --Perform day-to-day housekeeping functions as assigned. --Clean and polish furnishings, fixtures, ledges, room heating or cooling units, etc. in resident rooms, recreational areas, etc. daily as instructed. --Clean, wash, sanitize, and/or polish bathroom fixtures, ensure water marks are removed. --Clean windows and mirrors in resident rooms, recreational areas, bathrooms, and entrance or exit ways. --Clean floors, to include sweeping, dusting, damp or wet mopping, stripping, waxing, buffing, disinfecting, etc. --Clean carpets, to include vacuuming, shampooing, deodorizing and disinfecting. --Clean walls and ceilings by washing, wiping, dusting, spot cleaning, disinfecting, deodorizing, etc. --Remove dirt, dust, grease, film, etc. from surfaces using proper cleaning or disinfecting solutions. --Clean hallways, stairways and elevators. --Ensure that work and cleaning schedules are followed as closely as practical. Review of Environmental Services Cleaning Procedures for Common Items dated 2022 showed: -Horizontal surfaces such as over bed tables, work counters, beds, mattresses, bedrails and call bells. --Cleaning on a regular basis. --When items are soiled. --Between residents and after discharge. --Clean spills up promptly. -Walls, blinds and curtains. --When visibly dusty or soiled. -Floors. --Clean on a regular basis. --When soiled. --Between residents and after discharge. --Damp mopping. -Carpets and upholstery. --Vacuum and shampoo according to cleaning schedule and as necessary. --Vacuum cleaners should be equipped with a HEPA filter. --Cloth chairs should be vacuumed on a regular basis. --Carpeting should be vacuumed on a regular basis. -Toilets. --Clean on a regular basis. --Clean when soiled. --Clean between resident and after discharge. 1. Review of the facility Housekeeping Daily Cleaning Assignment for 400/600 Hall dated 02/2013 showed: -7:00 A.M. Smoke residents. -7:15 A.M. to 9:00 A.M. Begin morning duties as follows: --Collect dirty laundry barrels from skilled nursing facility (SNF) and take to laundry. --Clean Activity room [ROOM NUMBER] (to also be cleaned at the end of shift). --Complete morning walk through of resident rooms on 400 hall. --Clean 600 shower room. --Clean 600 hall restroom. --Clean 601 employee break room, clean microwave daily and at the end of shift. --Complete morning walk through of resident rooms on 600 hall. --Clean front lobby area to include reception area, reception desk, time clock area and nurses station. --Clean lobby foyer to include the Assistant Director of Nursing (ADON) Office, clean game table after each meal. -9:00 A.M. to 9:15 A.M. Morning break. -9:15 A.M. to 11:30 A.M. Begin the daily total clean of the residents rooms. --When doing daily cleaning all residents' room is to be totally cleaned that would include dusting and sanitizing all areas on your assigned unit being sure that all this would include all toilets, sinks, mirrors being cleaned. --All over bed tables being cleaned and sanitized, all floors being thoroughly swept and mopped that would include under beds and items that are removable. -11:30 A.M. to 12:00 P.M. Lunch break. -12:30 P.M. to 1:30 P.M. Continue assigned duties. --Do scheduled deep clean. --Continue daily total cleaning of residents' rooms. -1:30 P.M. to 1:45 P.M. Afternoon break. -1:45 P.M. to 2:00 P.M. Smoke residents. -2:00 P.M. to 2:50 P.M. Continue daily assignments. --Finish assigned total cleans. --Complete rooms that are assigned as repeat cleans. --Tidy activity lounge, employee break room, public restroom and shower room. -2:50 P.M. to 3:00 P.M. End of shift. --Collect all wet floor signs. --Restock cart with paper and cleaning supplies. -Weekly assignments: --Thursday: Clean central supply and medical records located on 400 hall at the end of shift. --Friday: Clean employees break room refrigerator. --Saturday and Sunday: Collect all dirty laundry barrels to include rehab, sort and start laundry. --Do morning and afternoon trash run. --Clean dining rooms to include lobby game table after each meal. --Sweep and spot mop all common area floors to include all hallways and lobby areas. During an interview on 6/10/25 at 11:23 A.M. Family Member A said: -His/Her spouse was a resident in the facility. -He/She was satisfied with the overall care of his/her spouse. -His/Her only complaint was the cleanliness of the facility. -His/her spouse had several open areas to his/her arms and he/she smeared blood on the wall next to his/her bed. -The blood had not been cleaned from the wall and the resident's room was overall dirty with an odor of urine. -There were cigarette butts all over the ground of the courtyard from the smokers. -Corners of the resident's bathroom and walls do not get cleaned with visible build up. -The toilet in the resident's bathroom was filthy. Observation on 6/11/25 from 11:00 A.M. through 1:00 P.M. showed: -room [ROOM NUMBER] dust and debris on floors, bed frame and windowsill. -room [ROOM NUMBER] bathroom had no shower curtain, dirty towels on the floor and hanging from handrails. -room [ROOM NUMBER] toilet had grime around the base. -The Dining room floor was littered with food, debris, trash and spills from breakfast. -room [ROOM NUMBER] had a strong odor of urine, sticky floor, and dried blood on the wall. -Resident #5's bed was not made up with blood on the pillowcase. (Resident #5 was admitted to the hospital on [DATE] and not yet returned) -room [ROOM NUMBER] bathroom floor was brown with gray/black build up in the corners and strong urine odor. -room [ROOM NUMBER] floor was covered with dirt, trash and debris. -room [ROOM NUMBER] had urinals hanging from the trash can with cords hanging in and around the trash can. -room [ROOM NUMBER] windowsill was covered with dust. -room [ROOM NUMBER] bathroom was covered with black smudges and dark brown spots, grime at the base of the toilet, toilet bowl spotted with an unknown substance and a dark brown line, toilet seat soiled and urine in the toilet. -room [ROOM NUMBER] dirty floor and sink with trash and drinks spilled on both surfaces, and floor sticky. -room [ROOM NUMBER] toilet soiled with urine and feces. -400 hallway had dirt and debris build up in the corners and along base boards. -room [ROOM NUMBER] had cigarette butt on the floor. -500 hallway with dirt and debris in corners. -room [ROOM NUMBER] covered with black tire marks. -600 hallway with dirt, debris in corners and black build up in doorways. -room [ROOM NUMBER] trash all over the floor, old food on the floor, gnats flying around the resident and floor sticky. -room [ROOM NUMBER] floor was dirty and sticky, sink dirty. -room [ROOM NUMBER] bathroom was dirty with urine and feces around the toilet, empty toilet paper rolls on the floor, trash and soiled linens on the floor. -Front foyer carpet sticky and stained. -Entry from front foyer into dining room missing trim from carpet to flooring leaving groove filled with food and debris. -Milk on dining room floor. -The resident courtyard and smoking area was littered with cigarette butts in the grass and on the concrete walk ways. During an interview on 6/11/25 at 11:11 A.M. Licensed Practical Nurse (LPN) A said the housekeeper cleans per their normal routines. During an interview on 6/11/25 at 11:23 A.M. Certified Nursing Assistant (CNA) A said he/she felt housekeeping was doing what they can to clean in the facility. During an interview on 6/11/25 at 11:35 A.M. Certified Medication Technician (CMT) A said housekeeping tried to keep up. During an interview on 6/11/25 at 11:41 A.M. the Housekeeping Supervisor said: -He/She denied having a cleaning schedule in writing for the staff to utilize for daily and/or deep cleaning. -Staff are trained on procedures to clean rooms, lobbies and other areas. -About two months ago there was a reduction in the number of housekeepers. -The build up in the corners, along the baseboards and the doorways was a result of wax build up that was not cleaned up when the floors were waxed about three months ago. -There was no longer a floor technician position at the facility. -The dining room should be cleaned after every meal. -Ideally resident rooms were cleaned daily, unless they were short-staffed or ran out of time, then the trash should be emptied, and supplies replaced. -There were 48 resident rooms to be cleaned. -The housekeeping staff also help with residents smoke breaks. -The floor technician used to clean up the cigarette butts and empty ashtrays and disposals outside. -Staff was assigned halls to clean daily. -He/She monitored by observation if cleaning was getting done. -There was no delegation to clean the dining room, whoever gets to it first or was available, staff were encouraged to switch back and forth. -The dining room was cleaned in the evening by the dietary staff. -Activities was in the dining room on 6/11/25 and the dining room was not cleaned until just before lunch. -He/She presumed the housekeeper was on the 600 hall cleaning when he dining room was emptying. -He/She monitored/inspected throughout the facility maybe twice per week. -He/She was not sure when room [ROOM NUMBER] was cleaned and was unaware there was no shower curtain in the bathroom shower. -He/She reviewed the job description when onboarding housekeeping staff, but did not provide a copy for the staff member. During an interview on 6/11/25 at 12:25 P.M. the Housekeeper said: -He/She pulled the trash in the dining room, lobby, main entrance to the smoking area and the public bathroom. -Once he/she finished trash, then he/she would take the residents out to smoke. -When he/she cleaned resident bathrooms, he/she made sure there was toilet paper, paper towels, toilet cleaned and the floor was mopped. -He/She was not very consistent with his/her cleaning routine. -When cleaning the resident rooms, he/she cleans the mirror, sink, took out the trash, refilled the toilet paper, cleaned the toilet and mopped the floors. -He/She cleaned 55 resident rooms per day. -He/She cleaned 22 rooms prior to the interview on 6/11/25. -He/She was not able to clean all resident rooms daily. -He/She worked four to five days per week. -He/She cleaned the dining room after each meal and again before going home at the end of his/her shift. -He/She looks at the floor to know where to start cleaning rooms daily. -Deep cleaning of resident rooms is only done when a resident moves out. -Some rooms never get deep cleaned because the resident's clean the room themselves. -He/She said very rarely was someone assigned a hall to clean. -They are not able to keep up with the daily cleaning. -He/She felt the smoking breaks take up too much time at 45 minutes per smoke break. -He/She felt there needed to be someone to clean the dining room, like the floor technicians used to do. -He/She was not cleaning windowsills, baseboards or elevated surfaces as he/she was only supposed to do bathrooms. Review of Resident #10's admission Record showed the resident was admitted on [DATE] with diagnoses including muscle weakness and retention of urine. Review of Resident #10's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 5/22/25 showed the resident was cognitively intact. During an interview on 6/11/25 at 12:40 P.M. Resident #10 said: -He/She felt the facility cleanliness could be better on the main side, the skilled care side of the facility. -He/She did notice the main side and the dining room was sometimes filthy. Review of Resident #11's admission Record showed the resident was admitted on [DATE] with diagnoses including chronic pain syndrome and muscle weakness. Review of Resident #11's MDS dated [DATE] showed the resident was cognitively intact. During an interview on 6/11/25 at 12:43 P.M. Resident #11 said: -Housekeeping does not clean their rooms. -He/She can't even remember the housekeeper had cleaned his/her room. -His/her room has been dirty for as long as he/she could remember. Review of Resident #12's admission Record showed the resident was admitted [DATE] with diagnoses including tobacco use and type 2 diabetes mellitus with hyperglycemia. Review of Resident #12's MDS dated [DATE] showed the resident was cognitively intact. During an interview on 6/11/25 at 1:00 P.M. Resident #12 said: -Housekeeping does not come in his/her room regularly and clean. -He/She cannot remember the last time his/her room had been cleaned. During an interview on 6/11/25 at 1:26 P.M. the Administrator said: -There were no job descriptions available in the employee files for the housekeeping staff. -He/She agreed there was food, trash, debris, and spills on the dining room floor that should have been cleaned up. -He/She agreed the build up throughout the facility corners, baseboards and doorways should have been cleaned. -He/She acknowledged the cigarette butts in the courtyard should be cleaned. -He/She acknowledged the unsanitary conditions in resident rooms noted during the facility walk-through. -He/She said there was no longer a floor technician and housekeeping staff had been reduced. -He/She acknowledged the carpet needed cleaning. MO00255536

Based on interview and record review, the facility failed to ensure one resident was free from physical abuse when on 5/29/25 Resident #2 touched Resident #1 on his/her shoulder and struck Resident #1 on the buttocks twice, causing Resident #1 to feel violated and pain to his/her buttocks out of 12 sampled residents. The facility census was 79 residents. On 5/7/25 the Administrator was notified of the failure and immediately began an investigation, the residents were separated to ensure safety and law enforcement was contacted. Upon completion of the investigation it was determined the interaction was considered abuse. Training was completed immediately for 100% of all staff on abuse and neglect prior to being allowed to work and completed by 5/30/25. Supervision was increased and Resident #2 was set for alcohol rehabilitation. Review of the facility Abuse and Neglect Policy dated 6/12/24 showed: -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. -Physical Abuse is 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 it not limited to, hitting, slapping, punching, biting, and kicking. 1. Review of Resident #1's admission Record showed the resident was admitted on [DATE] with diagnoses including borderline intellectual functioning (a specific IQ margin between the formal diagnosis of intellectual disability (ID) and average intellectual function) and paranoid schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations). Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 5/10/25 showed the resident was cognitively intact. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnoses including alcohol abuse and adjustment disorder (a mental and behavioral disorder defined by a maladaptive response to a psychosocial stressor). Review of the resident's Quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the facility investigation dated 5/29/25 showed: -Alleged sexual conduct. -On 5/29/25 during the 9:00 P.M. smoke break, Resident #2 first touched Resident #1 on the shoulder and then slapped Resident #1 on the buttocks. -Resident #1 reminded Resident #2 there was a no touch policy in place. -As the residents returned inside the building Resident #2 again struck Resident #1 on the buttocks, but with greater force. -At that time Resident #1 reported the incident to the charge nurse. -Following the incident, the residents were separated and interview individually. -Resident #1 gave a verbal and written statement that were consistent. -Resident #2 was relocated to the opposite side of the building. -Physician, administration, and law enforcement were notified. -There was a determination of abuse and a report was filed with the state. Review of Police Report dated 5/29/25 showed: -Law enforcement was contacted at approximately 9:55 P.M. to investigate assault which a resident touched another resident inappropriately. -Resident #2 was using alcohol. -Resident #1 was interviewed and confirmed the allegations of being touched. -Resident #2 was interviewed and denied having contact with Resident #1. -Resident #2 said he/she was at the gas station drinking beer at the time of the alleged incident. -Video footage of the incident was obtained and confirmed Resident #2 was in the facility during the incident. During an interview on 6/5/25 at 2:43 P.M. Resident #2 said: -He/She did not recall being in contact with Resident #1. -He/She was sure he/she was intoxicated. -If he/she was out of character, it was because he/she was intoxicated. -He/She did not recall speaking with law enforcement about the incident. During an interview on 6/5/25 at 3:03 P.M. Resident #1 said: -On 5/29/25 at about 9:00 P.M. Resident #2 touched him/her on his/her shoulder, then hit him/her on the left butt cheek with an open hand as they were walking through the doorway to go smoke. -He/She reminded Resident #2 there was a no touch policy. -On the way back inside, Resident #2 was behind him/her again and hit him/her on the right butt cheek. -The second time Resident #2 hit him/her it was harder than the first time and hurt. -He/She became angry and upset when Resident #2 hit him/her the second time. -He/She went to the charge nurse immediately to report what happened. -He/She recalled smelling alcohol on Resident #2's breath and could tell by the look on Resident #2's face that he/she was drunk. -When Resident #2 hit him/her on the buttocks it triggered a memory for him/her when he/she was sexually assaulted in a previous facility. -He/She felt is was sexual due to it being inappropriate contact. -The second smack was the most upsetting and he/she felt violated. During an interview on 6/5/25 at 4:01 P.M. the Administrator said: -There had not been any disruptions with Resident #2 when he/she was intoxicated prior to the incident with Resident #1. -Resident #2 had a history of alcohol abuse and due to the incident, the resident had been scheduled for rehabilitation for alcohol. -The incident was considered abuse because of the way Resident #1 felt. MO00254995

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) was free from verbal and physical abuse by two staff members, Licensed Practical Nurse A and Certified Nursing Assistant (CNA) A. Multiple facility staff observed the interaction and did not intervene. LPN A and CNA A worked the entire shift after the abuse incident. The facility had 78 residents. The Administrator was notified on 3/20/25 at 1:13 P.M., of an Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 3/12/25. The facility started their investigation on 3/13/25 and suspended LPN A and CNA A and they were terminated on 3/14/25. The facility in-serviced staff before the start of their next shift. The IJ was corrected on 3/14/25. Review of the facility's policy titled Abuse and Neglect Policy, dated 6/12/24, showed: -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm. -This could include staff to resident abuse and certain resident to resident altercations. -Verbal abuse meant the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. -This included using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. -Examples included: --Harassing a resident. --Mocking. --Insulting ridiculing. --Yelling at a resident. -Physical abuse was 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 included, but was not limited to: --Handling a resident with any force than was reasonable for a resident's proper control, treatment or management. --Hitting. --Slapping. --Punching. --Biting. --Kicking. 1. Review of Resident #1's admission Record showed the resident admitted to the facility with the following diagnoses: -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Unspecified. -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats), Unspecified. -Mild Intellectual Disabilities. -Cognitive Communication Deficit. -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Recurrent, Mild. -Unspecified Intellectual Disability. Review of the Resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 3/10/25, showed: -The resident was cognitively intact. -The resident did not exhibit any behavioral symptoms during the seven day look back period. Review of the resident's care plan, dated 12/11/24, showed: -The resident was at risk for the following signs and symptoms related to his/her diagnoses of intellectual disability including difficulty communicating, difficulty in socializing with others, difficulty with problem solving or logical thinking, having problems remembering things, and the inability to connect actions with consequences with the following interventions: --Ensure his/her environment is safe. --Limit changes to his/her routine. --Provide him/her with diversional activities. --Provide positive reinforcement. --Use calm and gentle approaches with him/her. -The resident was at risk for the following signs and symptoms related to his/her diagnosis of bipolar disorder including displaying high or low emotions and an increase in the signs and symptoms of depression with the following interventions: --Be consistent. --Calmly direct him/her when he/she had inappropriate behaviors. --Staff were to not get into a power struggle with him/her. --Offer warm baths or soothing music to decrease restlessness. --Take care of any problems that were within the ability of the staff to address immediately. --Use a firm and calm approach with him/her. --Use short and clear explanations or directions with him/her. -The resident was at risk for the following signs and symptoms related to his/her diagnosis of Anxiety Disorder including cursing, hollering, and restlessness with the following interventions: --The staff were to be aware of their body stance and facial expressions when approaching the resident. --Do not argue with him/her or tell him/her that he/she was wrong when he/she was upset. --Do not get close with the resident and remember personal space. -On 5/12/24 the resident became upset with staff about being escorted back upstairs and hit a staff person, which caused a peer to intervene and pushed the resident. -The resident had a history of behavioral challenges that required protective oversight in a secure setting which included a Code [NAME] (a behavioral emergency and/or incident needing physical support and presence when an individual poses a threat to himself/herself or others) being called on the resident on 2/11/24 at 10:30 P.M. because the resident was demanding more snacks and was belligerent, yelled at staff, and made steps toward the nurse. Review of the resident's behavior note, dated 3/12/25 at 10:39 P.M., written by LPN A showed: -The resident had become very aggressive with staff due to the fact that there were no snacks during snack time. -The resident verbally assaulted LPN A and tried to attack LPN A. -The resident then turned to attack an employee who tried to diffuse the altercation. -The resident walked behind the nursing station and said, you think I won't slap you bitch. Observation of the undated video footage recorded of the incident showed: -The recording was one minute and 59 seconds long. -The footage took place at the nurse's station near Resident #1's hall. -LPN A and CNA B were sitting down in a chair in front of computers, CNA A was walking around near the nurse's station, Resident #1 is standing in front of the nurse's station speaking with LPN A, and Resident #2 is standing near the nurse's station. -Resident #1 can then be seen pointing his/her finger at LPN A and stated, anyway I want. -LPN A responded to Resident #1 by pointing his/her finger towards the resident's hall and said, get your ass down there. -Resident #1 responded to LPN A by slamming his/her hands down on the medication cart that was in front of him/her and said, get your ass gone somewhere. -Resident #1 then started to walk around the nurse's station and towards LPN A, LPN A called the resident's name, and another staff person also called out the resident's name. -CNA A then started to move towards Resident #1 by walking in front of the nurse's station. -A staff person can then be heard saying the resident's name and no, no, no, no, no, LPN A's name, no. -LPN A then got up from sitting in his/her seat. -CNA A continued to walk around the nurse's station and CNA B got up from his/her seat. -Resident #1 could then be seen getting close to LPN A and some muffled words were exchanged. -CNA C could be seen entering the frame in upper middle part of the frame. -CNA D could then be seen entering the frame at the bottom right corner. -CNA B was within arm's reach of Resident #1 and stood behind Resident #1. -CNA B then placed his/her hand between LPN A and Resident #1. -LPN A then pushed Resident #1 into CNA A in front of CNA B, CNA D, and Resident #2. -CNA C could still be seen walking towards the nurse's station. -CNA A then grabbed Resident #1 in a bear hug position from behind and started to take Resident #1 away from the nurse's station. -Resident #1 could be heard saying, get the fuck off me [derogatory term], get the fuck off. -CNA A continued to walk away from the nurse's station with the resident in the same hold position all while LPN A, CNA B, CNA C, and CNA D watched from behind the nurse's station. -Resident #2 remained in the same spot but could be seen watching the resident and CNA A. -Unintelligible words could be heard from the resident and other staff members. -CNA A then let go of Resident #1. -CNA A then started to walk backwards away from Resident #1 and a staff person could be heard saying, no. -Resident #1 then puts both of his/her fists in the air and stated, come on mother fucker, come on mother fucker, come on mother fucker, lets finish this and was stepping towards CNA A. -CNA A continued to walk backwards and away from the resident. -Once Resident #1 was within arm's reach of CNA A, CNA A reached his/her right hand up and swatted the resident's fists away from him/her. -Resident #1 then started swinging at CNA A with open hands. -CNA A responded by swinging his/her fists towards the resident, making contact with Resident #1's face. -CNA E could be seen entering the top left corner of the frame and was in direct sight of CNA A and Resident #1 when Resident #1 and CNA A were swinging at each other. CNA E was facing in the direction of Resident #1 and CNA A. -CNA A and Resident #1 naturally split apart from each other without staff intervention. -LPN A then walked towards Resident #1 and CNA A and could be heard saying something unintelligible, CNA B, CNA C, and CNA D all remained behind the nurse's station, and CNA E could be seen in the frame towards the altercation. -LPN A then walked back behind the nurse's station and LPN A, CNA A, CNA B, CNA C, and CNA D. -All staff present, LPN A, CNA A, CNA B, CNA C, and CNA D were looking toward -Resident #1 and Resident #2 then walk away from the nurse's station together and down the hall. Review of an Admin/RN Investigation, dated 3/13/25 at 11:55 A.M., showed: -The incident occurred on 3/12/25. -The type of incident was alleged abuse. -The persons involved were Resident #1, LPN A, and CNA A. -CNA B was a witness to the incident. -LPN A and CNA A were suspended with possible termination. -Staff had reported that the resident had hit a staff member, CNA A, on 3/12/25 at 10:30 P.M. -The staff member, CNA A, was okay, but the resident was being sent out to the hospital. -The Administrator had called to check in with CNA A around 6:30 A.M.-6:45 A.M. and CNA A reported to him/her that he/she was not hit by the resident. -Once the resident returned from the hospital, the Administrator interviewed the resident. -The resident stated the nurse was slamming the snack container down and I told him/her to stop, and he/she got mouthy with me, and I told him/her I would slap him/her, and he/she (the nurse) said ok you come over here. So, I did. Then the other guy/girl pulled me from behind and I told him to stop, and I said a bad word and he/she hit me. -The Administrator then reviewed the camera footage from the previous night. -The Administrator noted the following: --The resident walked up to the counter and asked for a snack. --CNA B stated there was none. --The resident said ok and started to walk off. --CNA B then told the resident he/she could look in the snack container. --The resident walked to the other end of the nurse's station and LPN A took the snack container and slammed it down. --LPN A asked the resident why did you come look, he/she told you there was none. --The resident stated don't slam things. --The resident started to walk off towards his/her hall when LPN A said take your ass on down there. --The resident returned to the nurse's station and said I'm not scared of you; I'll slap you and told LPN A to come out there to him/her. --LPN A then said no you come back here in which the resident did and got up close to LPN A. --CNA B got in-between the resident and LPN A. --CNA A then comes behind the resident and LPN A used his/her hand to push the resident backwards in the abdomen. --CNA A then attempted to move the resident away from LPN A. --The resident then turned on CNA A and doubled up both fists and stated to CNA A Finish what you started mother fucker and repeated it multiple times. --CNA was backing away then used his/her hands to push the resident's fists down. --The resident started to swing wildly at CNA A and CNA A did the same and smacked the resident. -The Administrator suspended LPN A and CNA A pending further investigation. -The investigation concluded that the resident had been physically abused by LPN A and CNA A. -LPN A and CNA A were terminated upon completion of the investigation on 3/14/25. During an interview on 3/20/25 at 8:45 A.M., the Administrator said: -He/She had received a call on 3/12/25 in which it was reported to him/her that Resident #1 had hit someone, and that Resident #1 was being sent out to the hospital. -The following morning, he/she had called CNA A to check-in with him/her and CNA A reported to him/her that he/she was never hit by Resident #1, that it was only a rumor that he/she had been hit. - When he/she spoke with Resident #1 about the incident, Resident #1 had said that he/she reached his/her limit and had cursed at staff. -Resident #1 denied hitting any staff person. -He/She then reviewed the camera footage from the previous night based off of the information he/she had received from Resident #1. -After reviewing the video, he/she immediately called the corporate office and suspended LPN A and CNA A. -None of the staff who were involved in the incident reported to him/her or the DON that Resident #1 had been hit by staff members. -Resident #1 had intellectual disabilities and mental health disorders but had never been in a physical altercation to his/her knowledge. -Resident #1 had a history of behaviors, mainly getting agitated, but would bang a wall or something similar, it never escalated much more than that. -Resident #1 had not received any injuries from the altercation. -He/She was unaware that CNA C and CNA D were also witnesses to the incident. Review of a witness statement, dated 3/13/25, completed by CNA B showed: -Resident #1 had come up to the desk asking for snacks. -He/She had let Resident #1 know that there weren't any snacks, but that Resident #1 could look in the snack bucket if Resident #1 wanted to, just so Resident #1 could see that he/she wasn't lying to Resident #1. -LPN A then grabbed the snack bucket and tossed it to the ground. -LPN A and Resident #1 then started going back and forth with each other. -LPN A and Resident #1 were arguing and then LPN A told Resident #1 to go to his/her room. -He/She assumed that that Resident #1 was too upset or angry to walk away. -Resident #1 then called out LPN A's name and threatened to call the police. -CNA A then came to try and de-escalate the situation. -CNA A was trying to get Resident #1 to go back to his/her room. -That was when things became physical. -He/She tried to step in and help prevent things from escalating but felt like he/she could not do much. During an interview on 3/20/25 at 10:10 A.M., CNA B said: -Resident #1 had come up to him/her and had asked for snacks. -He/She told Resident #1 that there were no snacks to give him/her. -He/She then told Resident #1 that Resident #1 could look in the snack box to show that there were no snacks available to hand out, for the purposes of closure. -LPN A then picked up the snack box and threw it to the ground. -This caused Resident #1 to become very upset. -Resident #1 and LPN A started arguing with each other and Resident #1 was calling the staff [derogatory name]. -CNA A had made physical contact with Resident #1 during the altercation. -Resident #1 had not hit CNA A. -LPN A had cursed at Resident #1 during the altercation. -He/She had not remembered that Resident #1 walked around the desk and could not say if LPN A pushed Resident #1. -Abuse had to do with anything that hurts a resident's feelings. -Verbal abuse had occurred during the altercation. -Physical abuse had not occurred during the altercation because there was no intention behind the contact that CNA A made with Resident #1. During an interview on 3/20/25 at 10:22 A.M., CNA A said: -He/She forgot what day and the time in which the incident occurred. -He/She had been sitting on his/her assigned hall and then heard yelling. -He/She left his/her hall to go look and see if everything was okay. -Once he/she arrived at the altercation, he/she tried to de-escalate the situation. -His/Her method of de-escalation was to take Resident #1 away from the situation. -He/She had touched Resident #1's shoulder, but that had agitated Resident #1 even more. -He/She had continued to try and move Resident #1 away from the situation and had let Resident #1 go after getting him/her away from the nurse's station. -Resident #1 then started to swing at him/her. -Resident #1 had never made contact with him/her when Resident #1 was swinging at him/her. -He/She was only trying to deflect Resident #1's swinging motions and had not realized that he/she had made contact with Resident #1. -He/She had remembered during the interview that LPN A had pushed Resident #1 during the altercation. -He/She was unsure if the push counted as abuse. -He/She was unsure if there was any camera footage of the altercation. -The whole situation could have been prevented. -When a resident is exhibiting a behavior, staff should not be hands-on and try to de-escalate the situation with words. During an interview on 3/20/25 at 11:21 A.M., Nurse Practitioner (NP) A said: -He/She was made aware of the altercation but was not called the night of the altercation. -The facility's Medical Director (MD) was called the night of the altercation. -He/She had reviewed the camera footage as well. -In the video you could see that a staff to resident altercation had occurred. -He/She would categorize the altercation as abuse. -LPN A and CNA A had showed a lack of self-control and should not have pushed or hit Resident #1. -The least amount of hands-on would have been the best way to approach the situation. -The staff should have tried to talk through things more calmly with Resident #1 and tried to change the topic or re-direct Resident #1 in a different way. -Resident #1 was known to get loud with other staff and/or residents but was not known to get physical with anyone. -When a resident looked like they were going to hit a staff person, the best way for staff to handle the situation would be to maintain distance between themselves and the resident. -If a resident did end up trying to hit a staff person, the staff should duck and move out of the way. -If staff were to get hit by a resident, then they just needed to continue to try to back away from the resident. -The staff 's response should never be to hit the resident back. During an interview on 3/20/25 at 11:35 A.M., Resident #1 said: -He/She got punched in the face. -He/She did not want to talk about the incident because it upset him/her too much. -He/She pointed to the areas where he/she was punched which were his/her left side of the chin and his/her right side of face in between the temple and eye. -He/She was tired of people asking if he/she was okay. -He/She was felt better knowing that LPN A and CNA A would not be caring for him/her again. During an interview on 3/20/25 at 11:47 A.M., CNA D said: -He/She had come in during the middle part of the incident. -He/She heard Resident #1 come around the nurse's station. -Everyone was just watching to see what Resident #1 would do. -Resident #1 then said, you think I won't slap you. -Then LPN A and Resident #1 got in each other's face. - He/She never saw LPN A push or put hands on Resident #1. -They both started cursing at each other, which prompted CNA A to grab Resident #1. -CNA A was attempting to remove Resident #1 away from the situation. -CNA A and Resident #1 were walking away from the nurse's station and Resident #1 just started swinging at CNA A. -CNA A was trying to block Resident #1's swings and denied seeing CNA A hit Resident #1. -He/She thought Resident #1 was the aggressor in this incident. -He/She did not think that any type of abuse had occurred during that situation. -He/She had texted the DON about Resident #1 hitting CNA A after the incident occurred. -Any unwanted touching counted as physical abuse; -They did not intervene because it all happened so fast, and they did not think it was abuse. During an interview on 3/20/25 at 12:19 P.M., the DON said: -He/She had received a text message from LPN A related to the incident during the shift. -He/She had to look through his/her phone to find the text message. -He/She then said that LPN A had called him/her at 12:25 A.M. and he/she then went to the local hospital to see Resident #1. -He/She had not responded to CNA D's text message, because he/she had already spoken to LPN A. During an interview on 3/20/25 at 12:52 P.M., LPN A said: -Resident #1 had come up to the nurse's station. -Resident #1 had asked for a snack. -Resident #1 was constantly coming up to the nurse's station and asking for snacks. -Resident #1 had directly asked CNA B, CNA B told Resident #1 that Resident #1 could look in the snack bucket to show that there were no snacks. -LPN A then grabbed the snack bucket and it slipped out of his/her hands. -Resident #1 responded to this by stating to LPN A Think your God? -Resident #1 had also called everyone derogatory names and said that he/she would slap LPN A. -He/She and Resident #1 were both standing and just looking at each other by that point. -He/She then thought he/she was going to get hit by Resident #1 and put his/her hands up and backed away from Resident #1 to get away from Resident #1. -CNA A then took Resident #1 away from the nurse's station. -CNA A thought Resident #1 was going to hit CNA A, so CNA A blocked Resident #1's swinging motions. -He/She thought Resident #1 had made contact with CNA A. -The incident was over after that. -No abuse occurred during the entirety of the altercation. -Physical abuse was when someone hit a resident. -Verbal abuse was when someone cursed at a resident. During an interview on 3/20/25 at 1:28 P.M. CNA C said: -He/She could not remember the time of the incident but thought that it happened about two hours after the shift had started. -He/She had been coming from the front and heard yelling. -Resident #1 had been asking for a snack. -LPN A had told Resident #1 no. -LPN A and Resident #1 started arguing. -Resident #1 said some rude things to LPN A. -LPN A then told Resident #1 to go to his/her room. -Resident #1 responded to this by telling LPN A that he/she would slap LPN A. -LPN A then told Resident #1 to do it. -Resident #1 then tried to smack LPN A and LPN A put his/her hands up. -CNA A then came around and grabbed Resident #1 from behind. -Resident #1 responded to this by cursing at CNA A and said that he/she would hit CNA A. -There was another resident that was watching and told Resident #1 to go back to his/her room. -CNA A then let Resident #1 go and that was when Resident #1 tried to hit CNA A. -CNA A had blocked all of the swings from Resident #1. -CNA A never made any contact with Resident #1 when Resident #1 was hitting CNA A. -He/She was aware that Resident #1 would become agitated when there were no snacks available. -LPN A and CNA A worked the remainder of the shift after the incident occurred. -He/She did not think that any abuse occurred during the altercation, so they did not intervene. -Physical abuse included hitting a resident. -Verbal abuse included being demeaning or disrespectful towards a resident. Review of Resident #2's quarterly MDS, dated [DATE], showed Resident #2 was cognitively intact. During an interview on 3/20/25 at 2:01 P.M. Resident #2 said: -Staff were sitting behind the counter. -Resident #1 had come up to the counter and had asked for a snack. -Resident #1 had bad hearing, so he/she thought that Resident #1 might not have heard the response. -The nurse then slammed the snack basket on the table. -Resident #1 responded to this by slamming his/her hands on the table. -Resident #1 then got into it with the staff. -He/She then told Resident #1 to come over to him/her to try and get Resident #1 out of the situation. -Resident #1 hesitated at this statement and then said, come on, put em up, what's wrong with you and put his/her fists up. -That was when Resident #1 was hit by a staff person. -He/She then told Resident #1 to come with him/her to get out of the situation and they walked away together. -Resident #1 was reactive to how any person approached him/her, meaning that if someone approached Resident #1 with aggression, then Resident #1 would respond with aggression. -He/She thought Resident #1 would have reacted calmly if the others around him/her had remained calm. -The staff instigated and initiated that type of response from Resident #1. Review of a witness statement dated 3/13/25 completed by Certified Medication Technician (CMT) A showed: -On 3/12/25 he/she had walked up to the front of the building and saw an ambulance pull up to the building. -He/She had asked a CNA about which resident was being sent out. -The CNA had stated that Resident #1 was being sent out because Resident #1 had been aggressive about getting a snack. -He/She was told that CNA A and Resident #1 had gotten into it and that Resident #1 was about to hit CNA A. -LPN A then interrupted the conversation and told the CNA that he/she did not have to explain anything to CMT A. -He/She then asked LPN A about what happened and LPN A responded to him/her stating that he/she was not going to explain anything to CMT A. -He/She then asked LPN A if Resident #1 was just being sent out because Resident #1 was upset over a snack. -LPN A again responded to him/her stating that he/she did not have to explain anything to CMT A. -He/She said okay and then went to clock out at 10:35 P.M. During an interview on 3/20/25 at 2:23 P.M., CMT A said: -A CNA had reported to him/her that Resident #1 was getting sent out for being agitated because there were no snacks. -He/She was questioning this because the staff could have grabbed Resident #1 a sandwich from the kitchen. -That was when LPN A came over and told the CNA that he/she did not have to explain anything and was very rude to CMT A. -He/She just felt like there was not something right with the whole situation. -There would never be any reason to hit a resident. -Physical abuse counted as putting hands on a resident with mal-intent. During an interview on 3/20/25 at 2:38 P.M. CNA E said: -He/She had been walking to the supply room at the time of the altercation. -He/She had only seen Resident #1 hit CNA A. -CNA A was only blocking the Resident #1's swings. -CNA A had not made contact with Resident #1 during the altercation. -He/She had not intervened and walked away from the altercation, because he/she thought abuse had not occurred. During an interview on 3/20/25 at 3:41 P.M. the DON said: -The altercation that occurred counted as abuse. -Staff should never hit a resident. -Staff should never curse at a resident. -The staff had not responded appropriately to the situation. -The hold that CNA A had on Resident #1 while walking Resident #1 away from the nurse's station was okay, but the force behind it was not okay. -LPN A and CNA A should have walked away from Resident #1 instead of pushing and hitting back at Resident #1. -The staff should have also tried to re-direct Resident #1 instead of egging Resident #1 on. -CNA C and CNA D were not supposed to be at the nurse's station at that time. -The staff had not handed out the snacks appropriately that night. -The snacks needed to be passed out to the resident's instead of the resident's coming up to the nurse's station and grabbing the snacks out of the basket. MO00251027

Based on observation, interview, and record review the facility failed to report abuse for one sampled resident (Resident #1). Facility staff Licensed Practical Nurse (LPN) A, Certified Nursing Assistant (CNA) A, CNA B, CNA C, CNA D, and CNA E all watched abuse and did not report. The facility census was 78 residents. On 3/20/25, the Administrator was notified of the past non-compliance which occurred on 3/12/25. Facility staff were educated on reporting abuse requirements. The deficiency was corrected on 3/14/25. Review of the facility's policy titled Abuse and Neglect Policy, dated 6/12/24, showed: -It was the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within the prescribed time frames. -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm. -New employees would be educated by the department manager, or designee, on issues related to abuse prohibition practices and abuse reporting requirements during initial orientation. -The facility would provide resident, families, and staff information on how and to whom they may report concerns, incidents, and grievances without fear of retribution. -Any owner, operator, employee, manager, agent, or contractor of the facility could report an allegation of abuse to the abuse agency hotline without fear of retaliation. -When suspicion of abuse or reports of abuse/neglect/exploitation occur, the following procedure would be initiated: --The licensed nurse would respond to the resident and protect him/her from further incident. --The licensed nurse would remove the accused employee from resident care areas. --The licensed nurse would notify the Administrator or designee. --The licensed nurse would notify the attending physician, resident's family/legal representative, and Medical Director. -Employees were trained through orientation and ongoing training on issues related to abuse prohibition practices, such as: --Reporting allegations without fear of reprisal. --The definition that constituted as abuse. -During orientation of new employees, the facility would cover at least the following topics: --Reporting of abuse and their obligations under law when receiving an allegation of abuse. 1. Review of Resident #1's admission Record showed the resident admitted to the facility with the following diagnoses: -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Unspecified. -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats), Unspecified. -Mild Intellectual Disabilities. -Cognitive Communication Deficit. -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Recurrent, Mild. -Unspecified Intellectual Disability. Review of the Resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 3/10/25, showed the resident was cognitively intact. Observation of the undated video footage recorded of the incident showed: -The recording was one minute and 59 seconds long. -The footage took place at the nurse's station near the resident's hall. -LPN A and CNA B were sitting down in a chair in front of computers, CNA A was walking around near the nurse's station, Resident #1 is standing in front of the nurse's station speaking with LPN A, and Resident #2 is standing near the nurse's station. -Resident #1 can then be seen pointing his/her finger at LPN A and stated, anyway I want. -LPN A responded to Resident #1 by pointing his/her finger towards the resident's hall and said, get your ass down there. -Resident #1 responded to LPN A by slamming his/her hands down on the medication cart that was in front of him/her and said, get your ass gone somewhere. -Resident #1 then started to walk around the nurse's station and towards LPN A, LPN A called the resident's name, and another staff person also called out the resident's name. -CNA A then started to move towards Resident #1 by walking in front of the nurse's station. -A staff person can then be heard saying the resident's name and no, no, no, no, no, LPN A's name, no. -LPN A then got up from sitting in his/her seat. -CNA A continued to walk around the nurse's station and CNA B got up from his/her seat. -Resident #1 could then be seen getting close to LPN A and some muffled words were exchanged. -CNA C could be seen entering the frame in upper middle part of the frame. -CNA D could then be seen entering the frame at the bottom right corner. -CNA B was within arm's reach of Resident #1 and stood behind Resident #1. -CNA B then placed his/her hand between LPN A and Resident #1. -LPN A then pushed Resident #1 into CNA A in front of CNA B, CNA D, and Resident #2. -CNA C could still be seen walking towards the nurse's station. -CNA A then grabbed Resident #1 in a bear hug position from behind and started to take Resident #1 away from the nurse's station. -Resident #1 could be heard saying, get the fuck off me [derogatory name], get the fuck off. -CNA A continued to walk with the resident in the same hold position all while LPN A, CNA B, CNA C, and CNA D watched from behind the nurse's station. -Resident #2 remained in the same spot, but could be seen watching the resident with CNA A. -Unintelligible words could be heard from the resident and other staff members. -CNA A then let go of Resident #1. -CNA A then started to walk backwards away from Resident #1 and a staff person could be heard saying, no. -Resident #1 then puts both of his/her fists in the air and stated, come on mother fucker, come on mother fucker, come on mother fucker, lets finish this and was stepping towards CNA A. -CNA A continued to walk backwards and away from the resident. -Once Resident #1 was within arm's reach of CNA A, CNA A reached his/her right hand up and swatted the resident's fists away from him/her. -Resident #1 then started swinging at CNA A with open hands. -CNA A responded by swinging his/her fists towards the resident, making contact with Resident #1's face. -CNA A and Resident #1 naturally split apart from each other without staff intervention. -CNA E could be seen entering the top left corner of the frame and was in direct sight of CNA A and Resident #1 when Resident #1 and CNA A were swinging at each other. -LPN A then walked towards Resident #1 and CNA A and could be heard saying something unintelligible, CNA B, CNA C, and CNA D all remained behind the nurse's station. -LPN A then walked back behind the nurse's station. -Resident #1 and Resident #2 then walk away from the nurse's station together and down the hall. Review of the text message that CNA D sent to the DON showed: -The text message had been sent on 3/12/25 at 10:03 P.M. -Resident #1 was hitting and threatening LPN A and CNA A. During an interview on 3/20/25 at 8:45 A.M., the Administrator said: -He/She had received a call on 3/12/25 in which it was reported to him/her that Resident #1 had hit someone, and that Resident #1 was being sent out to the hospital. -The following morning, he/she had called CNA A to check-in with him/her and CNA A reported to him/her that he/she was never hit by Resident #1, that it was only a rumor that he/she had been hit. -When he/she spoke with Resident #1 about the incident, Resident #1 had said that he/she reached his/her limit and had cursed at staff. -Resident #1 denied hitting any staff person. -He/She then reviewed the camera footage on 3/13/25 from the previous night based off of the information he/she had received from Resident #1. -None of the staff who were involved in the incident reported to him/her or the DON that Resident #1 had been hit by staff members. During an interview on 3/20/25 at 10:10 A.M., CNA B said: -He/She knew that he/she needed to report any abuse to the charge nurse. -He/She had not reported the altercation, because he/she did not think that abuse occurred. During an interview on 3/20/25 at 10:22 A.M., CNA A said: -He/She was only trying to deflect Resident #1's swinging motions and had not realized that he/she had made contact with Resident #1. -He/She had remembered during the interview that LPN A had pushed Resident #1 during the altercation. -He/She was unsure if the push counted as abuse. -He/She had worked the remainder of his/her shift that night. -He/She thought the nurse reported everything to management, so he/she did not have to report anything. During an interview on 3/20/25 at 11:21 A.M., Nurse Practitioner (NP) A said: -He/She had reviewed the camera footage. -In the video you could see that a staff to resident altercation had occurred. -He/She would categorize the altercation as abuse. -He/She expected all staff to follow the abuse and neglect reporting policy. During an interview on 3/20/25 at 11:47 A.M., CNA D said: -He/She did not think that any type of abuse had occurred during that situation. -He/She had texted the DON about Resident #1 hitting CNA A after the incident occurred. -He/She thought he/she had reported everything appropriately to the DON. -The staff could report anything suspicious or questionable to the DON and the DON usually would come up to the facility to look over things. During an interview on 3/20/25 at 12:19 P.M., the DON said: -He/She had received a text message from LPN A related to the incident during the shift. -He/She had to look through his/her phone to find the text message. -The incident was not reported correctly, no one told the DON or Administrator that CNA A had hit the resident, and no one reported LPN A shoved the resident. -The staff only reported the resident hit CNA A -He/She then said that LPN A had called him/her at 12:25 A.M. and he/she then went to the local hospital to see Resident #1. -He/She had not responded to CNA D's text message because he/she had already spoken to LPN A. During an interview on 3/20/25 at 12:52 P.M., LPN A said: -He/She had called the DON to report what happened. -No abuse occurred during the entirety of the altercation. -He/She thought he/she had reported everything appropriately. During an interview on 3/20/25 at 1:28 P.M., CNA C said: -He/She did not think that any abuse occurred during the altercation and did not report to anyone what had happened. -He/She felt that everyone responded and reported appropriately during the altercation. During an interview on 3/20/25 at 2:38 P.M. CNA E said: -He/She had been walking to the supply room at the time of the altercation. -He/She had only seen Resident #1 hit CNA A. -CNA A was only blocking the Resident #1's swings. -CNA A had not made contact with Resident #1 during the altercation. -He/She thought abuse had not occurred, so he/she did not report it. During an interview on 3/20/25 at 3:41 P.M. the DON said: -The altercation that occurred counted as abuse. -The staff had nor reported the altercation appropriately. -He/She expected staff to report any abuse to him/her or the Administrator immediately. -While the staff reported the altercation, the staff needed to provide him/her with more clarification. -What the staff reported to him/her was too vague and caused unnecessary confusion. -Once the camera footage was reviewed, the facility reported everything appropriately. -The altercation would have been handled differently if the staff had reported the abuse correctly. MO00251027

Based on observation, interview and record review the facility failed to educate staff on how to de-escalate one sampled resident (Resident #1) with known intellectual and mental health needs per facility policy and the resident's care plan. This effected one out of three sampled residents. The facility census was 78 residents. Review of the facility's policy titled Behavioral Emergency Policy, dated 6/26/24, showed: -The purpose of the policy was to provide safe treatment and humane care to the resident in a behavioral crisis, to outline steps to correctly care for the resident in a behavioral crisis, and to ensure that the resident was not being coerced, punished, or disciplined for staff convenience. -Non-physical interventions were the first choice as an intervention unless safety issues demanded immediate physical intervention. -Care would be guided by resident's plan of care and based on the strategies taught by the Crisis Prevention Institute non-violent crisis intervention, or the current company guidance, and would help to respond to difficult behaviors in the safest and most effective way possible. Review of the facility's policy titled Behavioral Health Services Policy, dated 10/31/24, showed: -All staff, including contracted staff and volunteers, should receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. -Education should be based on the role of the staff member and resident needs identified through the facility assessment. -Facility staff would implement person-centered care approaches designed to meet the individual goals and needs of each resident, which included non-pharmacological interventions. -Examples of individualized, non-pharmacological interventions to help meet behavioral needs of all ages may include, but were not limited to: --Ensuring adequate hydration and nutrition. --Exercise. --Individualizing sleep and dining routines. --Supporting the resident through meaningful activities. --Providing support with skills related to verbal de-escalation, coping skills, and stress management. 1. Review of staff training records showed CNA A and CNA C completed training related to tips for challenging behaviors. Records showed LPN A, LPN B, and LPN D did not have documentation of training related to challenging behaviors. Record review during the abbreviated survey showed no staff in-services regarding the resident's behavioral history and direct staff training on behavioral intervention (resident triggers, redirection and intervention) occurred after the incident. Review of Resident #1's admission Record showed the resident admitted to the facility with the following diagnoses: -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Unspecified. -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats), Unspecified. -Mild Intellectual Disabilities. -Cognitive Communication Deficit. -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Recurrent, Mild. -Unspecified Intellectual Disability. Review of the Resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 3/10/25, showed: -The resident was cognitively intact. -The resident did not exhibit any behavioral symptoms during the seven day look back period. Review of the resident's care plan, dated 12/11/24, showed: -The resident was at risk for the following signs and symptoms related to his/her diagnoses of intellectual disability including difficulty communicating, difficulty in socializing with others, difficulty with problem solving or logical thinking, having problems remembering things, and the inability to connect actions with consequences with the following interventions: --Ensure his/her environment is safe. --Limit changes to his/her routine. --Provide him/her with diversional activities. --Provide positive reinforcement. --Use calm and gentle approaches with him/her. -The resident was at risk for the following signs and symptoms related to his/her diagnosis of bipolar disorder including displaying high or low emotions and an increase in the signs and symptoms of depression with the following interventions: --Be consistent. --Calmly direct him/her when he/she had inappropriate behaviors. --Staff were to not get into a power struggle with him/her. --Offer warm baths or soothing music to decrease restlessness. --Take care of any problems that were within the ability of the staff to address immediately. --Use a firm and calm approach with him/her. --Use short and clear explanations or directions with him/her. -The resident was at risk for the following signs and symptoms related to his/her diagnosis of Anxiety Disorder including cursing, hollering, and restlessness with the following interventions: --The staff were to be aware of their body stance and facial expressions when approaching the resident. --Do not argue with him/her or tell him/her that he/she was wrong when he/she was upset. --Do not get close with the resident and remember personal space. -On 5/12/24 the resident became upset with staff about being escorted back upstairs and hit a staff person, which caused a peer to intervene and pushed the resident. -The resident had a history of behavioral challenges that required protective oversight in a secure setting which included a Code [NAME] (a behavioral emergency and/or incident needing physical support and presence when an individual poses a threat to himself/herself or others) being called on the resident on 2/11/24 at 10:30 P.M. because the resident was demanding more snacks and was belligerent, yelled at staff, and made steps toward the nurse. Review of the resident's behavior note, dated 3/12/25 at 10:39 P.M., written by LPN A showed: -The resident had become very aggressive with staff due to the fact that there were no snacks during snack time. -The resident verbally assaulted LPN A and tried to attack LPN A. -The resident then turned to attack an employee who tried to diffuse the altercation. -The resident walked behind the nursing station and said, you think I won't slap you bitch. -LPN A called 911 and EMS was sent out for change in orientation. Review of an Incident Report titled Physical Aggression not Involving Head, dated 3/13/25 at 12:00 A.M., completed by LPN A showed: -He/She had copied the resident's behavior note from 3/12/25 at 10:39 P.M. into the nursing description. -The resident was unable to give a description of the incident. -The immediate action that was taken was to call 911/EMS. -The resident was not sent to the hospital. -The resident was oriented to person, place, time, and situation. -The resident did not have any injuries. -The resident had predisposing physiological factors which included agitation and anxiety. Observation of the video footage recorded of the incident, dated 3/13/25 at 12:17 A.M., showed: -The recording was one minute and 59 seconds long. -The footage took place at the nurse's station near the resident's hall. -LPN A and CNA B were sitting down in a chair in front of computers, CNA A was walking around near the nurse's station, Resident #1 is standing in front of the nurse's station speaking with LPN A, and Resident #2 is standing near the nurse's station. -Resident #1 can then be seen pointing his/her finger at LPN A and stated, anyway I want. -LPN A responded to Resident #1 by pointing his/her finger towards the resident's hall and said, get your ass down there. -Resident #1 responded to LPN A by slamming his/her hands down on the medication cart that was in front of him/her and said, get your ass gone somewhere. -Resident #1 then started to walk around the nurse's station and towards LPN A, LPN A called the resident's name, and another staff person also called out the resident's name. -CNA A then started to move towards Resident #1 by walking in front of the nurse's station. -A staff person can then be heard saying the resident's name and no, no, no, no, no, LPN A's name, no. -LPN A then got up from sitting in his/her seat. -CNA A continued to walk around the nurse's station and CNA B got up from his/her seat. -Resident #1 could then be seen getting close to LPN A and some muffled words were exchanged. -CNA C could be seen entering the frame in upper middle part of the frame. -CNA D could then be seen entering the frame at the bottom right corner. -CNA B was within arm's reach of Resident #1 and stood behind Resident #1. -CNA B then placed his/her hand between LPN A and Resident #1. -LPN A then pushed Resident #1 into CNA A in front of CNA B, CNA D, and Resident #2. -CNA C could still be seen walking towards the nurse's station. -CNA A then grabbed Resident #1 in a bear hug position from behind and started to take Resident #1 away from the nurse's station. -Resident #1 could be heard saying, get the fuck off me nigger, get the fuck off. -CNA A continued to walk with the resident in the same hold position all while LPN A, CNA B, CNA C, and CNA D watched from behind the nurse's station. -Resident #2 remained in the same spot, but could be seen watching the resident with CNA A. -Unintelligible words could be heard from the resident and other staff members. -CNA A then let go of Resident #1, but it could not be directly seen due to a column being in the way. -CNA A then started to walk backwards away from Resident #1 and a staff person could be heard saying, no. -Resident #1 then puts both of his/her fists in the air and stated, come on motherfucker, come on motherfucker, come on motherfucker, lets finish this and was stepping towards CNA A. -CNA A continued to walk backwards and away from the resident. -Once Resident #1 was within arm's reach of CNA A, CNA A reached his/her right hand up and swatted the resident's fists away from him/her. -Resident #1 then started swinging at CNA A with open hands. -CNA A responded by swinging his/her fists towards the resident, making contact with Resident #1's face. -CNA E could be seen entering the top left corner of the frame and was in direct sight of CNA A and Resident #1 when Resident #1 and CNA A were swinging at each other. -CNA A and Resident #1 naturally split apart from each other without staff intervention. -LPN A then walked towards Resident #1 and CNA A and could be heard saying something unintelligible, CNA B, CNA C, and CNA D all remained behind the nurse's station. -LPN A then walked back behind the nurse's station. -Resident #1 and Resident #2 then walk away from the nurse's station together and down the hall. Review of Resident #1's Daily Behavior Symptoms and Cognitive Performance assessment, dated 3/13/25 at 5:58 A.M., showed: -Resident #1 had exhibited physical behavioral symptoms during the shift which included hitting. -Resident #1 had exhibited verbal behavioral symptoms during the shift which included threatening others, screaming at others, and cursing at others. -Resident #1 had exhibited verbal/vocal symptoms like screaming or disruptive sounds during the shift. -Resident #1's behaviors had significantly disrupted care or the living environment. -The intervention that was used for Resident #1's behaviors was redirection/removed from situation/ensured resident safety. NOTE: All other Daily Behavior Symptoms and Cognitive Performance assessments showed no behavioral symptoms were exhibited prior to the incident in the month of March 2025. During an interview on 3/20/25 at 8:45 A.M., the Administrator said: -He/She had received a call on 3/12/25 in which it was reported to him/her that Resident #1 had hit someone, and that Resident #1 was being sent out to the hospital. -The following morning, he/she had called CNA A to check-in with him/her and CNA A reported to him/her that he/she was never hit by Resident #1, that it was only a rumor that he/she had been hit. - When he/she spoke with Resident #1 about the incident, Resident #1 had said that he/she reached his/her limit and had cursed at staff. -Resident #1 denied hitting any staff person. -He/She then reviewed the camera footage from the previous night based off of the information he/she had received from Resident #1. -Resident #1 had intellectual disabilities and mental health disorders but had never been in a physical altercation to his/her knowledge. -Resident #1 had a history of behaviors, mainly getting agitated, but would bang a wall or something similar, it never escalated much more than that. During an interview on 3/20/25 at 10:10 A.M., CNA B said: -Resident #1 would get agitated about smoke breaks at times, but Resident #1 was not normally agitated when he/she worked with Resident #1. -He/She had only worked at the facility for a month, so he/she was not sure about Resident #1's behavioral history or what to do when there was a behavior for this resident. During an interview on 3/20/25 at 10:22 A.M., CNA A said: -He/She had used his/her own knowledge on how to de-escalate the situation, because he/she had never been trained. -Resident #1 was never agitated and was usually respectful towards staff and other residents. During an interview on 3/20/25 at 11:21 A.M., Nurse Practitioner (NP) A said: -LPN A and CNA A had showed a lack of self-control and should not have pushed or hit Resident #1. -The least amount of hands-on would have been the best way to approach the situation. -The staff should have tried to talk through things more calmly with Resident #1 and tried to change the topic or re-direct Resident #1 in a different way. -Resident #1 was known to get loud with other staff and/or residents but was not known to get physical with anyone. -When a resident looked like they were going to hit a staff person, the best way for staff to handle the situation would be to maintain distance between themselves and the resident. -The staff's response should never be to hit the resident back. During an interview on 3/20/25 at 11:35 A.M., Resident #1 said: -He/She got punched in the face. -He/She did not want to talk about the incident because it upset him/her too much. -He/She pointed to the areas where he/she was punched which were his/her left side of the chin and his/her right side of face in between the temple and eye. During an interview on 3/20/25 at 11:47 A.M., CNA D said: -He/She thought Resident #1 was the aggressor in this incident. -Resident #1 would constantly come up to the nurse's station and asks for snacks. -Resident #1 was already aware that there were no snacks available at the time of the altercation. -The resident was not normally physically aggressive. -Resident #1 usually needed a lot of re-direction related to snacks during the night shift. -He/She was unable to say what re-direction worked best for the resident because he/she was not the one that normally did it. During an interview on 3/20/25 at 12:52 P.M., LPN A said: -Resident #1 was constantly coming up to the nurse's station and asking for snacks. -Resident #1 was not normally aggressive. -Resident #1 had never been in that type of altercation before with staff or other residents to his/her knowledge. During an interview on 3/20/25 at 1:28 P.M., CNA C said: - Resident #1 had a known behavior of getting frustrated and agitated when snacks were not available to him/her. -LPN A had told management before about snacks being an issue on night shift. -The facility would not have snacks to give the residents on a consistent basis. -He/She felt everyone had responded appropriately during the altercation. He/She received CALM training but did not know how to re-direct resident. During an interview on 3/20/25 at 2:01 P.M. Resident #2 said: -Resident #1 was reactive to how any person approached him/her, meaning that if someone approached Resident #1 with aggression, then Resident #1 would respond with aggression. -He/She thought Resident #1 would have reacted calmly if the others around him/her had remained calm. -The staff instigated and initiated that type of response from Resident #1. NOTE: Review of Resident #2's quarterly MDS, dated [DATE], showed Resident #2 was cognitively intact. During an interview on 3/20/25 at 2:23 P.M., CMT A said: -A CNA had reported to him/her that Resident #1 was getting sent out for being agitated because there were no snacks. -He/She was questioning this because the staff could have grabbed Resident #1 a sandwich from the kitchen. -He/She just felt like there was not something right with the whole situation. -Resident #1 was not normally physically aggressive. -Resident #1 could get angry, but it all came down to how someone approached Resident #1. -If staff had approached Resident #1 in a calm manner, then Resident #1 would have responded in calm manner. -The staff had not responded to the altercation appropriately and should have walked away from the resident if they felt like Resident #1 was going to be physically aggressive. He/She said that if you got a snack for the resident then he/she would be satisfied, she did receive training related to resident behaviors and de-escalation. During an interview on 3/20/25 at 2:38 P.M., CNA E said: -Resident #1 was not normally aggressive. -If a person was sweet with Resident #1, then Resident #1 would be sweet in response. -He/She had never experienced any physical aggression from Resident #1. During an interview on 3/20/25 at 3:41 P.M., the DON said: -The staff had not responded appropriately to the situation. -The staff had turned the situation into a pissing contest. -The hold that CNA A had on Resident #1 while walking Resident #1 away from the nurse's station was okay, but the force behind it was not okay. -LPN A and CNA A should have walked away from Resident #1 instead of pushing and hitting back at Resident #1. -The staff should have also tried to re-direct Resident #1 instead of egging Resident #1 on. -The staff had not handed out the snacks appropriately that night. -The snacks needed to be passed out to the resident's instead of the resident's coming up to the nurse's station and grabbing the snacks out of the basket. -If the snacks had been passed out correctly then the situation could have been avoided and just that the staff were making the situation worse instead of better by egging on his/her behavior when the resident tried to walk away. -Resident #1 had a known behavior of yelling at times. -If a resident had a known behavior, then it did not need to be documented at each occurrence. -Resident #1 was very motivated by food. -Resident #1 could get fixated on things and repeat the same question(s) over and over, but he/she did not think that those counted as behaviors. -Resident #1 would not be at the facility if Resident #1 had the capability of making appropriate decisions and felt that the staff instigated that response from Resident #1. During an interview on 3/21/25 at 8:39 P.M., CNA D said: -Resident #1 was always going up to the nurse's station to request a snack. -The staff would have to re-direct Resident #1 away from the nurse's station if there was not a snack that could be provided to Resident #1. -He/She would not consider consistently coming to the nurse's station to ask for a snack a behavior. -Resident #1 is at the facility for a reason, but he/she was aware of his surroundings and knows what he/she is doing. -He/She had told the DON that snacks were getting passed out too early in the evening and that there would not be snacks available for night shift. -When a resident was exhibiting a behavior, the staff should approach the resident calmly and talk with them. -Staff should never taunt a resident who was exhibiting a behavior or egg them on in any way. -LPN A was the one who usually re-directed Resident #1 away from the nurse's station. -Most resident behaviors occurred in front of the nurse's stations because there were cameras at the nurse's station. -If a resident was exhibiting a behavior or something questionable was going on, the staff could always call the DON, and the DON would come up to the facility to check-in. During an interview on 3/21/25 at 9:03 A.M., LPN A said: -He/She was unsure about Resident #1's behavioral history. -The CNAs interacted with Resident #1 more often and they would be the ones to provide the redirection. -Resident #1 could be grumpy at times, but nothing usually more than that. -He/She would consider Resident #1 coming to the nurse's station constantly asking about snacks a behavior. -He/She did not have to chart that type of behavior. -Resident #1's Behavior Symptoms and Cognitive Performance assessments were correct. -CNAs needed to report behaviors to him/her or he/she would not know that the resident was exhibiting a behavior and would not chart it. -When Resident #1 would come up to the nurse's station to ask for a snack, the only re-direction he/she would provide to Resident #1 was just telling him/her that there were no snacks available. -He/She had not received any behavioral training from the facility. During an interview on 3/21/25 at 9:40 A.M., CNA A said: -Resident #1 did not normally have any issues on night shift unless there were no snacks. -He/She was unsure of Resident #1's behavioral history. -He/She had received behavioral training from the facility. -He/She was unsure if Resident #1 constantly coming to the nurse's station for snacks counted as a behavior. -He/She was unsure of what the staff normally did to re-direct Resident #1 away from the nurse's station when Resident #1 would come up and ask for snacks. -He/She was unsure of how to re-direct the resident in general, just knew that in order to de-escalate the situation that the resident needed to get away from the nurse's station all together. During an interview on 3/24/25 at 10:37 A.M., CNA B said he/she would not consider Resident #1 going to the nurse's station constantly and asking for snacks a behavior. MO00251027

Based on observation, interview and record review, the facility failed to follow Federal, State and Local Laws to ensure the facility van was licensed legally and proper maintenance was performed to ensure a safe and legal transport for all residents. This failure has the potential to affect all residents in need of transport to and from the facility. The facility census was 77 residents. 1. Review of the facility van service invoice dated [DATE] showed the facility van had brakes serviced and six new tires. Review of facility monthly credit card approval sheet dated [DATE] through [DATE] showed gas for the van on: -[DATE] for $30.75. -[DATE] for $89.27. -[DATE] for $75.03. -[DATE] for $78.62. -[DATE] for $74.74. -[DATE] for $83.20. -[DATE] for $63.26. Review of email dated [DATE] at 4:28 P.M. showed: -Email initiated by the Administrator to four corporate care management members, including the Director of Finance (DOF) and the Regional Nurse Consultant (RNC). -Our van has expired tags by four years. My understanding from my staff is it was never transferred when the facility was purchased. Please let me know what I could do at my end. Review of email dated [DATE] at 11:25 A.M. through 11:27 A.M. showed: - DOF asked , Any update? -Regional Maintenance Director responded, I searched for it yesterday with no luck. Review of email dated [DATE] at 11:09 A.M. showed -DOF responded to previous email, We will have to apply for lost title. Can you please send us all the information you have on the vehicle. -Several team members names were attached to the email. Review of emails dated [DATE] at 1:06 P.M. showed: -Administrator replied to prior email he/she began filling out the title application and was waiting for the vehicle identification number (VIN). -DOF asked the Administrator to send the filled out form for a quick review. Review of email dated [DATE] at 1:13 P.M. showed the Administrator responded to DOF with attachment for the title, I filled out everything I knew. Review of invoice dated [DATE] showed the van had two new tires put on the front. Review of invoice dated [DATE] showed the van had the air conditioner recharged. Review of email dated [DATE] showed the administrator sent, Do we know anything on our van title so it can be licensed? to DOF. Review of Resident #2's Face Sheet showed the resident was admitted on [DATE], with diagnoses including dependence on renal dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood), hemiplegia and hemiparesis (paralysis/weakness affecting one side of the body) following a stroke. Review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed the resident was mildly cognitively impaired. During an interview on [DATE] at 5:01 A.M. the resident said he/she was transported in the facility van to dialysis three days per week, on Monday, Wednesday and Friday. During an interview on [DATE] at 8:21 P.M. Van Driver A said: -The facility van has not been licensed for four years. -The facility van has not been inspected. -There was no title for the facility van. -He/She was not sure if the van had insurance. -He/She was told by corporate legal department that if he/she was stopped while driving the van they would take care of it. -The lift on the facility van has not been inspected and is supposed to be inspected every six months. -He/She has told the Administrator the lift needed to be inspected several times. -His/Her main concern was he/she felt the lift was dangerous. During an interview on [DATE] at 2:00 P.M. the Administrator said: -He/She did not have any documentation for the facility van. -There was insurance on the facility van, but was unable to provide proof of insurance at that time. -The facility was using the facility van to transport residents, and there was a transport occurring at the time of the interview. -The facility van had not been legal for operation since he/she started about a year ago. -He/She has sent things to corporate to obtain a title for the facility van, but has never heard anything about the process. During an interview on [DATE] at 2:28 P.M. the RNC said: -They had been working to get a title for the facility van. -The facility van was inherited from the previous company in 2020 with the building. -As far as he/she knew the corporate legal department was working to get the van legal. During an interview on [DATE] at 2:32 P.M. the Corporate Legal Representative said: -The facility van was not licensed because of issues from the previous owner. -There has never been a title turned over from the previous owner, therefore they will need to file for a lost title. -He/She was aware it was an ongoing issue and the license was expired on the facility van. -He/She was not sure how long the facility van license had been expired. -His/Her solution was to purchase a new van for the facility. -He/She said any relevant documents related to the van would be sent for review. During an interview on [DATE] at 3:10 P.M. the Maintenance Director said: -He/She did not know when the last time the van was legal or had any kind of maintenance. -He/She was not responsible for the van and thought the driver was the person who took care of van maintenance. -The van is in use almost daily transporting residents to and from the facility. During an observation on [DATE] at 3:56 P.M. showed: -The facility van parked in the facility parking lot. -Missouri license plate labeled disabled with placard, September and orange 2021 sticker/tab mounted to the front of the van. -Missouri safety inspection dated [DATE]. -Missouri license plate labeled disabled with placard, September and year tab here space with no sticker/tab mounted to the back of the van. During an interview on [DATE] at 4:07 P.M. Van Driver B said: -He/She had no idea when the last time the facility van had been serviced. -The lift in the van tilts towards the back of the van when there was a heavy person on the lift. -He/She had no idea when the last time the lift was serviced or inspected. -Maintenance documentation located in the van was from 2023 for services related to the air conditioner for [DATE], [DATE], and [DATE]. -No legal documents located in the van for title, licensing, inspection or insurance. -He/She has been telling the administration the van needs to be legal and it put him/her at risk with his/her commercial driver's license (CDL- allows a tested and approved driver to operate certain types of motor vehicles including 18-[NAME] trucks, tour buses, school buses, tanker vehicles and vehicles transporting hazardous materials). -He/She was concerned about the engine and service lights that are illuminated on the dash. During an interview on [DATE] at 5:27 P.M. the Administrator said: -He/She did not know when the last time the lift was serviced or inspected, but had not been since he/she started about a year ago. -He/She did not know how often the lift should be serviced or inspected, but most are yearly. -He/She was not aware of any concerns related to the lift. -He/She did not know when the last time the facility van was inspected or serviced for safety and functionality. MO00249465

Based on interview and record review, the facility failed to ensure the safety when on 6/19/24 Agency Certified Nursing Assistant (CNA) E transferred one sampled resident (Residnet #17) identified as a fall risk, by himself/herself that caused a fall which resulted in a closed right sided tibial fracture (a tibial fracture occurs along the length of the bone, below the knee and above the ankle), and failed to complete a fall investigation for the fall, out of 19 sampled residents. The facility census was 74 residents. Review of the facility policy titled Safe Resident Handling Transfers Policy, revised 5/14/24, showed: -All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. -While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. -Staff members were expected to maintain compliance with safe handling/transfer practices. -The staff was to use gait belts with residents that could not independently ambulate or transfer for the purpose of safety. -Two staff members must be utilized when transferring residents with a mechanical lift. -Resident lifting and transferring would be performed according to the resident's individual plan of care. Review of the facility policy titled Incidents and Accidents Policy, revised 5/18/24, showed: -Incident/accident reports are part of the facility's performance improvement process. -Falls require an incident/accident report. -The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. -Documentation should include the date, time, nature of the incident, location, initial findings. Immediate interventions, notifications and orders obtained or follow up interventions. -If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnesses it and submit that documentation to the Director of Nursing and/or administrator. Review of the facility policy titled Fall Prevention Program, revised 6/26/24, 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. -The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. -The nurse will refer to the facility's high risk or low/moderate risk protocols when determining primary intervention. -When a resident experiences a fall, the facility will: Assess the resident, complete a post fall assessment, complete an incident report, notify physician and family, review the resident's care plan, and update as indicated, document all assessments and actions, and obtain witness statements in the cases of injury. 1. Review of Resident #17's Face Sheet with an initial admitted [DATE], showed the resident was admitted to the facility with the following diagnoses: -Morbid obesity (A disorder that involves having too much body fat, which increases the risk of health problems). -Dysfunction of lower extremities. -Muscle wasting and atrophy (Muscle atrophy is the wasting or thinning of muscle mass. It can be caused by disuse of your muscles or neurogenic conditions), multiple sites. -Difficulty in walking. -Primary osteoarthritis (Osteoarthritis occurs when the flexible, protective tissue at the ends of bones, called cartilage, wears down), right hip. Review of the resident's admission Minimum Data Set (MDS-A federally mandated assessment tool required to be completed by facility staff for care planning), dated 4/11/24, showed the resident: -Was cognitively intact. -Was in a wheelchair. -Could not walk. -Required substantial/maximal assistance to stand. -Required full assistance from chair/bed to chair transfers. -Did not have any ability to complete a chair/bed to chair transfer and the helper had to do all the effort to transfer from chair/bed to chair. -Had no history of falls. Review of the resident's Care Plan, revised 4/23/24, showed the resident: -Was a fall risk (FRAPSS risk for falls related to deconditioning, gait/balance problems). -No documentation on how the resident transferred from surface to surface. -Was unaware of safety needs. -Would be evaluated by physical therapy and treated as ordered. Review of the resident's Occupational Therapy Evaluation and Plan of Treatment note obtained from the therapy department, dated 6/10/24, showed: -Resident required a sit to stand lift (An assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, using electrical or hydraulic power) for functional transfers, shower chair, or power wheelchair. -Resident was dependent on a sit to stand lift for shower transfers. -Resident was dependent on a sit to stand lift for toilet transfers. -Resident was unsteady when standing. -Resident could not stand without support for ten seconds. -Resident had fears about falling. Review of the resident's nursing progress note, dated 6/19/24, showed: -The resident had a fall due to transferring from the shower chair to the toilet. -His/Her right knee gave out and he/she was guided to the floor. -The resident complained of pain (to his/her right knee). -The Physician was notified and an X-ray was ordered. Review of the facility's fall investigation, dated 6/19/24, showed: -The resident was lying on his/her back on the ground stating his/her right knee hurt. -He/She was getting out of the shower and transferring to the toilet when his/her knee gave out and he/she was guided to the floor by the (unidentified) CNA. -No injuries observed at the time of the incident. -No injuries observed post incident. -A section on the report was check marked that a statement was given by staff on 6/21/24. --No documentation which staff were interviewed/provided a statement and no documentation the resident was interviewed. -Note: No witness/staff statement was completed at the time of the fall in the investigation. -Note: No root cause analysis was completed at the time of the fall. Review of the resident's nursing progress note, dated 6/20/24 at 1:51 P.M., showed: -The resident complained of continued and increased pain post fall on 6/19/24. The resident rated his/her pain an eight out of 10 (10 being the worst pain). -Mobile x-ray negative. -The resident request transfer to the hospital for assessment and treatment. -The Physician was notified. Review of the resident's Hospital history and physical notes, dated 6/20/24, showed: -Computerized Tomography scan, (CT scan, is a type of imaging that uses X-ray techniques to create detailed images of the body) showed a mildly displaced and impacted fracture involving the medial (toward the middle of the body) tibial plateau (the tibial plateau is the flat top part of your tibia bone. The tibia (shin bone) goes from your knee to your ankle), extending into the tibial spines. -Additional mildly displaced fracture along the far lateral aspect (toward the outside of the body) of the lateral tibial plateau. -Probable nondisplaced fracture involving the fibular head (The fibula is a long bone in the lower extremity that is positioned on the lateral side of the tibia). -Resident was admitted to the medical surgical unit for treatment. During an interview on 9/23/24 at 11:56 A.M., the resident said: -He/She had a fall on 6/19/24 that resulted in a broken leg. -He/She informed Agency CNA E that it took two people or a sit to stand lift to transfer him/her before Agency CNA E attempted to transfer the resident by himself/herself without the lift. -Agency CNA E responded, No, it will be okay and attempted to transfer resident by himself/herself. -Agency CNA E was an agency staff and he/she had not seen Agency CNA E since the fall. -After his/her shower, Agency CNA E rolled the resident up to the grab bar in the shower chair and asked the resident to grab the bar and stand up. -The shower chair was unlocked, and it rolled from underneath the resident and he/she fell on the floor. -He/she fell hard and knew something was broke. His/Her pain after the fall was a 20, on a 0-10 pain scale. -He continued to have severe pain and requested to be sent to the hospital for evaluation on 6/20/24. During an interview on 9/25/24 at 11:03 A.M., the Occupational Therapy Assistant (OTA) said: -He/She was the therapy manager for the facility. -At the time of the resident's fall, his/her transfer order recommendations were to use a sit to stand lift with two persons assist. -If an event happened that required new or additional therapy recommendations, those new or additional recommendations would have been made verbally during the next scheduled morning staff meeting with the department heads after an event took place. -He/She did not have documentation when the recommendation was communicated with the facility staff. -Transfer orders were communicated with staff in the morning staff meetings. -Therapy orders were not entered into the resident's electronic charting by the therapy department. -At the time of the residents fall, the resident should have always had at least 2 staff members assisting with transfers. During an interview on 9/25/24 at 11:45 A.M., CNA D said: -Prior to the fall, he/she transferred the resident with a hoyer lift and minimum 2 person assist at all times. -Prior to the fall, he/she believed the resident's transfer orders were a sit to stand lift, but the facility did not have one available to use for the resident due to residents' weight, so the staff used a hoyer to transfer him/her instead. -There should have never been only one person attempting to transfer the resident solely. During an interview on 9/25/24 at 12:00 P.M., Agency Licensed Practical Nurse (LPN) D said: -He/She worked with the resident prior to the fall but could not recall how the resident transferred at that time. -He/She was unaware of the resident's transfer order prior to the residents fall in June. During an interview on 9/25/24 at 1:22 P.M., the Director of Nursing (DON) said: -The resident's transfer orders were in the electronic medical record. -Prior to the resident falling, the residents transfer order was either a standby with two persons assist or a sit to stand with two persons assist. During a phone interview on 9/26/24 at 11:54 A.M., Agency CNA E said: -He/She was giving the resident a shower on the day that he/she fell . -He/She wheeled the resident in the shower chair up to the transfer bar near the toilet and asked the resident to stand up to transfer the resident to his/her wheelchair. -The resident's knee gave out on him/her and he/she lowered the resident to the floor. -He/She was the only staff member in the shower house at the time of the transfer. -He/She was unaware of the resident's transfer orders, but always transferred him/her by himself/herself with a gait belt (A gait belt or transfer belt is a device put on a patient who has mobility issues, by a caregiver prior to that caregiver moving the patient). -He/She was not educated by facility staff on the resident's transfer orders. During an interview on 9/26/24 at 12:00 P.M., the MDS Coordinator said: -A residents transfer orders should have been on the resident's care plan. -He/She did not recall therapy department communicating a transfer technique for the resident prior to the resident's fall. -He/She could not locate the transfer technique on the resident's care plan prior to his/her fall. -Prior to the residents fall, the resident had a transfer order for a sit to stand and two CNA's should have been assisting with the resident transfers. During an interview on 9/27/24 at 11:58 A.M., the DON and the Regional Director of Operations (RDO), said: -The therapy department was in charge of determining how a resident should be transferred and it should be noted in the initial assessment in the electronic medical record. -He/She did not recall therapy department communicating a transfer technique for the resident prior to the resident's fall. -The resident's care plan should have transfer orders within them. -Staff members have access to care plans and transfer orders. -Staff members were educated on where to find a resident's transfer orders, including agency staff members. -The DON and the Administrator were in charge of completing fall investigations. -It would be expected that a fall investigation be completed with: witness statements, root cause analysis, new interventions to prevent future falls, and factors involving the fall. -Prior to fall, the staff were using a sit to stand to transfer the resident. -On the day of the fall, the resident should have had two people assisting with the transfer. -He/She (DON) was unaware that there was one staff member with the resident when he/she fell . During a phone interview on 9/27/24 at 1:42 P.M., Physician A said: -He/She was aware that the resident had a fall in the shower. -He/She was unsure of how the resident was supposed to be transferred at the time of the fall. -He/She did not recall the resident requiring a hoyer lift transfer prior to the fall. -He/She was unaware if the resident should have been a one person, or a two person transfer at the time of the fall, but with the resident's morbid obesity and extreme weight, he/she would not want to transfer the resident alone.

Based on interview and record review, the facility failed to designate one or more individuals with the required primary professional training as an Infection Preventionist (IP) for the facility's Infection Prevention control program. The facility census was 74 residents. The certifications were requested for all employees who were certified in the IP program and were not received at the time of exit. 1. Review of the Centers for Disease Control (CDC) online IP course showed: -The Minimum Data Set (a federally mandated assessment tool completed by facility staff for care planning) Coordinator had completed 15 of the 26 modules for the CDC IP course. -He/She worked 15 hours a week as the IP. During an interview on 9/27/24 at 9:32 A.M. the MDS Coordinator said: -He/She had started the IP course a couple of years ago. -He/She had not finished the IP course. -He/She was not certified in the IP program. -He/She worked 15 hours a week as the IP. During an interview on 9/27/24 at 12:00 P.M. the Director of Nursing (DON) said: -He/She had completed the IP program training and had the certification. -The Administrator had also completed the IP program training and had the certification. -The MDS Coordinator had not completed the IP program training and was not certified.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility failed to properly screen and follow their policies for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for eight out of nine new employees sampled for TB screening. This practice had the potential to affect all residents, employees, and visitors to the facility. The facility failed to ensure staff practiced Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities example residents with wounds or indwelling medical devices) for one sampled resident (Resident #49) who had a colostomy (a surgical opening into the large intestine), for one sampled resident (Resident #28) who had a supra pubic catheter (a surgically created connection between the bladder and the skin to drain urine from the bladder in individuals with an obstruction of normal urinary flow), and one sampled resident (Resident #20) who had a pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin), failed to ensure staff was educated on EBP, failed to ensure staff were cleansing their hands during a medication pass, and failed to ensure a nebulizer mask ( liquid medicine delivered as a mist that was inhaled through a mouthpiece or mask) was kept in a sanitary condition for one sampled resident (Resident #41) out of 19 sampled residents. The facility census was 74 residents with a licensed capacity for 91 residents at the time of the survey. 1. Observation on 9/23/24 between 9:24 A.M. and 10:10 A.M. during the initial facility Life Safety Code (LSC) kitchen inspection with the Dietary Manager (DM) showed there was a three-sink area, an ice machine, a low-heat chemical dish-washing machine, and a hand-washing sink. During an interview on 9/23/24 at 2:07 P.M. the Administrator said the following: -They had only been working at this facility for about six months and they had not had the chance to go through the whole disaster manual yet. -They could not say if there was a copy of their disaster manual at the nurses' desks. Review of the undated binder from their East Nurse Station entitled Edgewood Manor Disasters Book showed it was full of their residents' admission face sheets only. Observation on 9/24/24 between 3:10 P.M. and 3:45 P.M. during the facility LSC walk-through inspection with the Maintenance Supervisor (MS) showed the following: -The building was equipped with a full fire sprinkler system and had its incoming water supplied by the local water company. -There was a piped fire sprinkler riser room (A dedicated space for fire protection equipment) which served the whole facility's system. -There were housekeeping closets and water heaters throughout the six resident room hallways. -There were at least 54 resident rooms with private or shared bathrooms and sinks. -There was a laundry area with two commercial grade clothes washers. -There were two Shower Rooms, two gender specific public restrooms, and a Beauty Shop with a sink. Review of the facility's binder entitled Edgewood Manor Disaster Manual, last reviewed 2/27/23 and provided by the Administrator, under the heading, Legionnaire - Water Management Program, was a 35-page policy and procedure which showed the following: -The answers to the 2-page Worksheet to Identify Buildings at Increased Risk for Legionella Growth and Spread showed the building was a healthcare facility that housed people primarily older than 65-years overnight and therefore needed a water management program. -The Water Management Facility Documentation Form listed a previous Administrator and Maintenance Supervisor. -The page with the heading Water System Diagram had a written explanation of the water flow throughout the facility, but no schematic, diagram, or flowchart of the facility's water system that indicated areas of risk with the potential likelihood and risk level for each. -There was no facility-specific risk management plan assessment that considered all elements of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed CDC toolkit assessment. -There were sampling results on the water analyzed 8/16/24, but no documentation of any site logbook being maintained with any cleanings, sanitizings, descalings, and/or inspections mentioned. During an interview on 9/26/24 at 12:53 P.M. the MS said the following: -He/She took samples of the facility's water and sent them off to a lab for testing. -He/She was somewhat familiar with the federal requirements. -He/She educated themselves on them by reading their policy and asking the lab questions about it. During an interview on 9/26/24 at 2:46 P.M. the Administrator said the following: -Their MS was responsible for implementing the Legionella program. -He/She believed they were aware of some of the basic requirements. -They had not had a chance to look at all of their policy, however. 22727 2. Review of the facility's policy titled Tuberculosis Testing dated 6/29/23 showed new employees would receive a two-step Tuberculin Skin Test (TST-used to screen for TB). Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A was hired on 7/16/24. -Employee B was hired on 6/25/24. -Employee C was hired on 5/29/24. -Employee D was hired on 8/27/24. -Employee E was hired on 6/25/24. -Employee G was hired on 4/17/24. -Employee H was hired on 8/6/24. -Employee J was hired on 7/2/24. Review of the above employees' employee files showed employees A, B, C, D, E, G, H, and J did not have any TSTs completed. During an interview on 9/24/24 at 3:46 P.M., the Human Resources Director said: -He/She started working at the facility at the end of July 2024. -He/She asked the Director of Nursing (DON) to make sure the employee TSTs were completed. During an interview on 9/25/24 at 1:19 P.M., the Administrator said: -They were supposed to be doing TSTs on new employees when they were in orientation at another facility owned by the same company. -He/She thought it was being done there but it was not. -The TSTs should have been done prior to hire. During an interview on 9/27/24 at 11:57 A.M., with the DON present, the Regional Director of Operations (RDO) said: -The TSTs were supposed to be administered on the employee's first day of orientation at another facility, which was their human resources hub. -The TSTs were supposed to be read 48 hours after administration at this facility where the DON was supposed to print the form, read the TST and sign the form. -The TST had to be read before the employee worked on the floor. -The second-step of the TSTs were to be given at the facility they were working at within 21 days of the first TST being read. -The second-step TST was the responsibility of the DON. -They just got a Human Resources Director for this facility in July 2024, so the responsibility of TB screening will shift to the Human Resources Director. 37576 3. Review of the facility's policy, Infection Prevention and Control Program, dated 5/7/24 showed: -The designated Infection Preventionist was responsible for oversight of the program and served as a consultant to out staff on infectious diseases, implementing isolation precautions, staff and resident exposures, surveillance, and investigations of exposures of infectious diseases. -See Infection Preventionist Policy. -All staff were responsible for following all policies and procedures related to the program. -A system of surveillance was to have been utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards. -The Infection Preventionist serves as the leader in surveillance activities, maintained documentation of incidents, findings, and any corrective actions made by the facility and reported surveillance finding to the facility's Quality Assessment and Assurance Committee. -All staff should have assumed that all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. -Hand hygiene was to have been performed in accordance with the facility's established hand hygiene procedures. -All staff was to have used personal protective equipment (PPE) according to established facility policy governing the use of PPE. See PPE policy. -Licensed staff was to have adhered to safe injection and medication administration practices, as described in relevant facility policies. -All staff would have received training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. -All staff was to have demonstrated competence in relevant infection control practices. -Direct care staff was to have demonstrated competence in resident care procedures established by our facility. -The facility would have conducted an annual review of the infection prevention and control program, including policies and procedures based upon the facility assessment which included any facility and community risk. -Following the review, the infection and prevention control program would have been updated as necessary. The facility did not have a policy for Infection Preventionist. The facility did not have a policy for EBP. The facility did not have a hand washing policy. Review of Resident #28's Admission Record showed he/she was admitted with the following diagnoses: -Neuromuscular Dysfunction of the Bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Retention of urine (a condition in which urine cannot empty from the bladder). Review of the resident's Physicians Order Summary (POS) dated September 2024 showed: -Supra Pubic Catheter 20 FR (French scale -a unit of measurement used to size catheters) with a 30 cubic centimeter (cc-a measure of volume in the metric system) balloon (a flexible part of the catheter tip that is inflatable to hold the catheter in the bladder). -Cleanse urostomy (Urinary diversion - a surgically created opening in the abdominal wall through which urine passes) site with wound cleanser twice a day (BID) and as needed (prn); cover with abdominal pad dressing (ABD pad an extra thick primary or secondary dressing used for wounds) two times a day for Prophylaxis (action taken to prevent disease, especially by specified means or against a specified disease). Observation on 9/23/24 at 1:18 P.M., of the resident's room showed: -No posted signage on the door or near the door for EBP precautions. -No isolation cart outside the room for the required Personal Protective equipment (PPE-gowns, gloves, face masks, goggles or face shields) for staff to wear while doing resident cares. Observation on 9/24/24 at 1:15 P.M., of the resident's Suprapubic catheter care and Perineal care (care to the area between the anus and the exterior genitalia) showed: -Certified Nursing Assistants (CNA)'s J, CNA M and Licensed Practical Nurse (LPN) A did not put on the EBP PPE before entering the resident's room. -CNA J and CNA M did not change gloves after the perineal care before changing the resident's bed linen. -CNA J, CNA M and LPN A did not wear the EBP PPE when doing cares for the resident. -No posted signage on the door or near the door for EBP precautions. -No isolation cart outside the room for the required PPE. During an interview on 9/27/24 at 8:50 A.M., CNA H said: -He/She washed his/her hands and put on gloves when entering a resident's room to do any cares. -He/She removed gloves and washed or sanitized his/her hands before putting on clean gloves if he/she touched other items during cares. -He/She removed gloves and washed or sanitized his/her hands and put on clean gloves when going from a dirty body part to a clean body part. -He/She removed gloves and washed his/her hands when finished with resident cares. During an interview on 9/27/24 at 9:13 A.M., CNA J said: -Should wash hands and put on gloves when entering a resident's room to do any cares. -Should change gloves wash or sanitize hands when going from a dirty body part to a clean body part during perineal care. -Should change gloves wash or sanitize hands if he/she touched other items in room during perineal cares. -Should wash or sanitize hands between any glove changes. -He/She did not know what EBP was thought it was an ointment to place on a resident's buttock. -He/She had not received any education pertaining to EBP. -Did not know he/she was supposed to be wearing PPE when caring for any resident with a catheter, colostomy, or tube feeding. -There were no signs showing to wear PPE on resident doors who had catheters, colostomies, or tube feedings. -There were no isolation carts with PPE outside of residents rooms who would require EBP. -Had not worn any type of PPE for residents who may need EBP except for gloves when doing cares. During an interview on 9/27/24 at 9:30 A.M., LPN A said: -He/She thought EBP was an ointment. -Had not received any education on EBP. --When informed what EBP was LPN A said he/she had received education in July 2024 on the online training program when he/she started at the facility. -Would know which residents would need EBP/PPE by looking at the resident's care plan. -EBP/PPE was required if the resident had any type of tubes going into the body. -The facility did not put signs for EBP/PPE on the resident's doors who required it. -The facility did not keep carts with EBP/ PPE in them outside of the resident rooms. -If a resident required the use of EBP/ PPE he/she went to central supply to get the needed items. -He/She did wear PPE while doing Resident #28's Supra pubic catheter care this morning. During an interview on 9/27/24 at 9:40 A.M., the resident said: -LPN A did change his/her Supra pubic catheter dressing this morning. -LPN A did not wear a gown or mask during the cares. 4. Review of Resident #20's Admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnosis: -Morbid (severe) obesity (a disorder involving excessive body fat that increases the risk of health problems). Review of the resident's POS dated September 2024 showed: -Abrasion to left posterior thigh: Cleanse with normal saline or wound cleanser. Pat dry. Apply Xeroform (a medicated) dressing to wound bed and cover with border gauze dressing every day shift and as needed for soiled/dislodged. 9/12/2024. -Eucerin cream (a brand name of dry skin cream) apply to bilateral lower extremities and shin area every shift for dryness and monitor for signs and symptoms of infection or open area. 8/23/2024. -Weekly skin assessments every day shift every Thursday. 3/28/2024. Observation on 9/23/24 at 11:55 A.M. of the resident's room showed: -No posted signage on the door or near the door for EBP precautions. -No isolation cart outside the room for the required PPE for staff to wear while doing resident wound care. During an interview on 9/23/24 at 11:57 A.M., the resident said: -Had pressure sores on his/her buttocks that wound care saw. -Had a scabbed area on his/her left shin. Observation on 9/26/24 at 10:05 A.M. of the resident's perineal care by CNA G and LPN B showed: -CNA G touched the resident's motorized chair then removed the resident's brief without changing gloves or sanitizing his/her hands and putting on new gloves. -CNA G cleaned the resident's buttock then perineal area without changing gloves or sanitizing his/her hands and putting on new gloves. -CNA G removed gloves and put on new gloves without sanitizing his/her hands. -LPN B removed gloves and sanitized his/her hands, he/she picked up some paper towels that were on the floor and placed in trash, he/she did not wash or sanitize his/her hands. -LPN B left the room to get a larger gown for the resident. -LPN B washed his/her hands on re-entering the room. During an interview on 9/26/24 at 10:30 A.M., CNA G said: -He/She should have changed his/her gloves during perineal cares between dirty and clean areas and if gloves become dirty. -Should have washed his/her hands between glove changes. -Should have washed his/her hands after removing gloves at end of resident cares. Observation on 9/26/24 at 10:34 A.M. of the resident's wound care by LPN B showed: -He/She sanitized his/her hands and put on gloves. -He/She cleansed the small wound on the left posterior (back) thigh and placed the Xeroform on the wound. -He/She did not wash or sanitize his/her hands, he/she changed gloves and placed a bordered gauze dressing over the area. -He/She did not wash or sanitize his/her hands, he/she changed gloves and cleaned the resident's left shin as ordered. -He/She did not wash or sanitize his/her hands, he/she changed gloves and placed barrier cream on the back of the resident's right thigh reddened area. -He/She removed the gloves, did not wash his/her hands then took the trash to the dirty utility room. During an interview on 9/26/24 at 10:45 A.M., LPN B said: -He/She would ask the resident about his/her pain level before starting wound cares. -NOTE: LPN B was needed and the interview was abruptly ended with no other questions or answers asked and answered. 39469 5. Review of Resident #49's face sheet showed he/she had the following diagnoses: -Colostomy. -Malignant neoplasm of the colon (a cancer of the colon). Review of the resident's Care Plan dated 7/24/24 showed: -He/She had a colostomy due to malignant neoplasm of the colon. -NOTE: the Care Plan did not address EBP. Review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 8/4/24 showed: -He/She was cognitively intact. -He/She had a colostomy. -He/She had malignant neoplasm of the colon. -The MDS did not address EBP. Review of the resident's POS dated September 2024 showed the following order: -Change the colostomy bag and wafer (the pouching system around the stoma (the opening of the colostomy), use water to clean around the site, pat dry. Cut the wafer to fit the stoma. Change every three days on the night shift and as needed, dated 9/22/24. -There was no order for EBP. Observation on 9/23/24 at 10:47 A.M. showed: -There was no sign for EBP on the resident's door. -There was no isolation cart for PPE. During an interview on 9/25/24 CNA B said: -He/She did stoma cares for the resident. -During cares he/she would wear gloves and a mask. -He/She would not have worn a gown. -There were no masks in the resident's room. -Every resident's room had a box of gloves. During an interview on 9/25/24 at 7:58 A.M. CNA C said: -When he/she did stoma care on the resident he/she would have worn gloves, no mask, no gown. Observation on 9/25/24 at 10:11 A.M. of stoma care showed: -CNA C changed the resident's colostomy bag wearing only gloves. During an interview on 9/26/24 LPN A said: -During colostomy care staff should have worn gloves, a gown, and a face shield. -Supplies were available in central supply. During an interview on 9/26/24 at 11:16 A.M. the Assistant Director of Nursing (ADON) said: -He/She was unsure if the resident should have been on EBP. -He/She used a gown for his/her own protection. -The staff should have been trained on EBP. 6. Review of Resident 41's face sheet showed he/she had the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe).) -Malignant Neoplasm of Bronchus and lung (a cancer that begins in the lungs and often spreads). -Tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea(windpipe) from outside the neck). Review of the resident's care plan dated 6/4/24 showed: -He/She had a tracheostomy and performed own cares. -It did not show he/she had nebulizer treatments. -It did not show he/she was able to administer own breathing treatments. Review of the resident's Discharge Summary MDS dated [DATE] showed: -He/She had Cardiorespiratory conditions (heart and lungs). -He/She had COPD. -He/She had cancer. -No breathing problems was checked. -He/She was receiving tracheotomy cares. Review of the resident's POS dated September 2024 showed the following orders: -Change nebulizer/oxygen tubing every Sunday on night shift, dated 9/19/24. -Oxygen at two liters per nasal cannula (a device that delivers extra oxygen through a tube into your nose) as needed, dated 9/19/24. -Albuterol Sulfate Inhalation Nebulization solution (medication used to prevent and treat wheezing,difficulty breathing,caused by lung diseases) 1.25 milligrams(mg)/3 milliliters (ml) one vial inhale orally via nebulizer every six hours as needed for wheezing, dated 9/22/24. Observation on 9/23/24 at 10:05 A.M. showed: -He/She had a tracheostomy. -His/Her nebulizer mask was on the dirty floor, not in a bag. -There was no date on the tubing. During an interview on 9/23/24 at 10:05 A.M. the resident said: -He/She had a tracheostomy for four years and took care of it himself/herself. -He/She did not think the staff had ever changed out the tubing. -The staff had not provided a bag for the nebulizer. -The staff was supposed to have provided a humidifier for the oxygen. -He/She had asked the nurse several times and still did not have a humidifier. -He/She had not seen the staff ever clean the nebulizer mask. Observation on 9/24/24 at 8:00 A.M. showed: -The nebulizer mask and tubing sitting on a dirty (greasy) plastic cart, not in a bag. During an interview on 9/25/24 at 7:56 A.M. Certified Mediation Technician (CMT) C said: -The resident was able to do his/her own nebulizer treatments. -The tubing for the nebulizer should have been changed out weekly by the night shift CNA's. -The nebulizer mask should have been changed out weekly by the night shift CNA's. -The oxygen tubing, nebulizer mask and tubing should have been in a bag with the date it was changed written on it. -The tubing and mask should not have been on the floor. -Anyone could change the nebulizer mask and tubing. -He/She had seen the tubing and nebulizer on the floor. -He/She did not change the tubing or the nebulizer mask, Observation on 9/25/24 at 8:50 A.M. showed: -LPN B looked into the resident's room and saw the nebulizer mask on the floor. -He/She did not change out the tubing or the nebulizer mask. During an interview on 9/25/24 at 8:50 A.M. LPN B said: -Oxygen tubing or tubing for the nebulizer should have been changed out weekly by the night shift CNA's. -The nebulizer mask and tubing should have been in a bag with the date it was changed out written on it. -Anyone who went in the room should have seen the tubing and mask on the floor and changed it out. Observation on 9/25/24 at 9:00 A.M. showed: -The nebulizer mask and tubing sitting on a dirty (greasy) plastic cart, not in a bag. 7. Observation on 9/25/24 at 7:46 A.M. with CMT C showed: -He/She did not cleanse his/her hands before delivering a resident's medications to him/her. -When the CMT came out of the resident's room he/she reached into the trash and pulled out a piece of paper with his/her bare hands. -He/She did not cleanse his/her hands before continuing medication pass. -He/She went into a different resident's room to deliver medications. -He/She did not cleanse his/her hands when he/she came out of the room and continued medication pass. During an interview on 9/25/24 at 8:00 A.M. CMT C said: -Staff should cleanse their hands before starting medication pass, after the medication pass, and after administering medications to each resident. -He/She should not have reached into the trash without washing his/her hands after. -The DON had provided education on hand washing. During an interview on 9/25/24 at 8:50 A.M. LPN B said: -The Administrator and DON had provided education on hand washing. -Staff should wash their hands before and after medication pass. -Staff should wash their hands after delivering medications to each resident. -The CMT should have washed his/her hands after reaching into the trash. 8. During an interview on 9/27/24 at 9:32 A.M. the Infection Preventionist/LPN said: -Handwashing should have been done before and after doing cares with a resident. -Staff was expected to wash their hands after passing medications after every third resident. -The CMT should have washed his/her hands after reaching into the trash bag. -Residents who had a catheter, feeding tube, or tracheostomy should have had EBP. -There should have been a sign on the door to alert staff EBP was to be used with that resident. -There should have been an isolation bag with PPE hanging on that door. -He/She should have provided education to the staff regarding EBP, he/she had not done this. -He/She had no documentation of infection control training that had been provided to the staff, such as monitoring hand washing. -He/She had not provided any education to staff regarding hand washing. -Oxygen tubing and equipment such as a nebulizer mask should have been changed out on Sundays. -The oxygen equipment should have been changed out by a CNA on Sunday night with a date on the bag that it had been changed. -Even if the resident self-administered nebulizer treatments the staff was responsible for changing it out. -He/She was responsible for ensuring Infection policies were followed by the staff. During an interview on 9/27/24 at 12:00 P.M. the DON, RDO, and Administrator said: -During a medication pass staff should have cleansed their hands before and after the medication pass, and after administering medications to each resident. -The CMT should have washed his/her hands after reaching into the trash. -Anyone with a manmade opening to the body should have been on EBP. -This would have included; catheters, feeding tubes, colostomy, and wounds. -There should have been a sign on the resident's door alerting staff to use EBP with that resident. -There should have been an isolation cart so that staff would have had access to PPE. -EBP should have been documented in the resident's care plan. -They were expected to have worn a gown, gloves, and a mask while providing cares for the resident. -No education had been provided to the staff regarding EBP. -The DON was responsible for ensuring staff was using EBP and had been educated on it. -Oxygen tubing/nebulizer equipment should have been stored in a clean plastic bag even if the resident was self-administering. -Oxygen tubing/nebulizer equipment should not have been on the floor. -The CNA's were responsible for changing the tubing out weekly on the night shift. -The oxygen tubing should have been stored in a clean bag with the date it was changed out written on it.

Based on observation and interview the facility failed to keep the walk-in refrigerator, and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to safeguard against foreign material possibly getting into food and/or beverages; failed to keep trash dumpsters lidded; failed to consistently measure and document hot food temperatures at the oven and/or stove, or steam table to ensure they were suitably cooked, and cooked longer if needed, to lessen the chance of bacterial contamination; failed to maintain plastic and/or rubber cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs; failed to store foodstuffs within acceptable temperature parameters; and failed to ensure the proper labeling, refrigeration, and/or disposal of foodstuffs to preserve their freshness, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 74 residents with a licensed capacity for 91 residents at the time of the survey. 1. Observation on 9/23/24 between 9:24 A.M. and 10:10 A.M. during the initial kitchen inspection with the Dietary Manager (DM) showed the following: -The ice machine in the kitchenette off the kitchen proper had a non-sealing gasket on its lid. -The manual can opener had paper debris on the blade. -A red handled spatula in the top utensil drawer that had chips on and around its blade and crumbs in the bottom of its drawer and the middle drawer. -Four of five 50 ounce (oz.) cans of cream of chicken soup on a baker's rack in the Dry Storage (DS) were dented on their sides and/or upper rims and a 6 pound (lb.) 14 oz. large can of black beans on the can dispenser rack was heavily dented on its side -One open 1 gallon (gal.) jug of 13 jugs of soy sauce on a bottom shelf of a rack in the southwest corner of the DS was approximately (app.) 3/5 full and its label read to Refrigerate after Opening for Quality. -The green, beige, white, and red cutting boards by the east window were excessively scored to the point of plastic flaking off. -There were 15 undated jars of 16 oz. grated parmesan cheese in the walk-in refrigerator with plastic trash and a lettuce leaf on the floor, and an undated 4 oz. vanilla ice cream cup and paper trash on the floor of the walk-in freezer. -There were no visible thermometers in the Serving Room refrigerator or either of the walk-ins. Observation on 9/23/24 at 11:48 A.M. during the initial facility Life Safety Code (LSC) outdoor perimeter inspection with the Maintenance Supervisor (MS) showed the north lid of the west dumpster was flipped backward completely. Observation on 9/24/24 at 12:01 P.M. during a follow-up outer perimeter LSC inspection showed the north lid of the west dumpster was flipped backward completely. Observation on 9/24/24 between 12:26 P.M. and 12:43 P.M. showed the following: -There was a red handled spatula in the top utensil drawer that had chips on and around its blade and crumbs in the bottom of its drawer and the middle drawer. -Two remaining 50 oz. cans of cream of chicken soup on the baker's rack in the DS were dented on their sides and/or upper rims and a 6 lb. 14 oz large can of black beans on the dispenser rack was heavily dented on its side. -One open 1 gal. jug of 13 jugs of soy sauce app. 3/5 full on a bottom shelf in the southwest corner of the DS read Refrigerate after Opening for Quality on its label. -The green, beige, white, and red cutting boards by a window were excessively scored. -There were 15 16 oz. undated jars of grated parmesan cheese in the walk-in refrigerator with a lettuce leaf on a bottom shelf and butter pod on the floor. -There was no thermometer in the Serving Room fridge or either of the walk-ins. -The food temperature log sheet for 9/2/24 in a binder by the walk-in refrigerator had temperatures recorded for breakfast and lunch, but none for dinner, and no further days filled out. Observation on 9/25/24 at 9:45 A.M. during another follow-up outer perimeter LSC inspection showed the south lid of the west dumpster was flipped backward completely. During an interview on 9/26/24 at 1:44 P.M. the new DM said the following: -The cooks were responsible for cleaning the walk-in floors. -He/She would expect if a foodstuff read store at a certain temperature on its label that it would be. -Damaged foodstuffs were separated out, they contact the food vendor for a credit, and then they are thrown out. -Damaged food preparation items were brought to their attention by the dietary staff and replaced. -He/She would expect food to be free of foreign substances. -Food temperatures should be taken and recorded when they were done cooking, when they were served, and if a resident complained about it. -Refrigerators and freezers should have extra thermometers inside. -After each meal or meal clean-up the leftover garbage was thrown away, bagged up, and taken outside to the dumpsters.

Based on observation, interview, and record review, the facility failed to ensure medication carts were locked when staff was not in sight of the cart, failed to ensure medication carts were clean and did not contain other non medical objects, failed to ensure the medication refrigerator's temperature was within temperature range by not checking it daily, failed to ensure nursing staff was counting narcotics at the beginning and end of each shift for three sampled residents, (Resident #61, #42, and #325) out of 19 sampled residents. The facility census was 74 residents. Review of the facility's policy, Medication Storage Policy, dated 5/18/24 showed: -All drugs and biologicals would have been stored in locked compartments under proper temperature controls. -During a medication pass, medications must be under the direct observation of the person administering medications or locked. -Any discrepancies which could not been resolved must have been reported immediately as follows: -Notify the Director of Nursing (DON), charge nurse, or designee and the pharmacy. -Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted. -Staff may not leave the area until discrepancies were resolved or reported as unresolved discrepancies. -All medications requiring refrigeration were to have been stored in refrigerators located in the medication rooms. -Temperatures were to have been maintained within 36 to 46 degrees Fahrenheit (F). -Charts were to have been kept on each refrigerator and temperature levels were to have been recorded daily by the charge nurse or other designee. -In the event that a refrigerator was malfunctioning, the person discovering the malfunction must promptly report such finding to the Maintenance Department for emergency repair. Review of the facility's policy, Controlled Substance Administration and Accountability Policy, dated 5/14/24 showed: -The facility would have safeguards in place in order to prevent loss, diversion or accidental exposure. -The charge nurse or other designee was to have conducted a daily audit of the required documentation of controlled substances. -Areas without an automated dispensing systems utilize a substantially constructed storage unit with two locks and a paper system for for 24 hour recording of controlled substance use. -The amount on hand was to have been checked against the amount used daily from the documentation records. -For areas without an automated dispensing system, two licensed nurses account for all controlled substances and access keys at the end of each shift. -Any discrepancy in the count of controlled substances or disposition of the narcotic keys was to have been resolved by the end of the shift during which it was discovered. -Staff may not leave the area until discrepancies were resolved. 1. Observation on 9/25/24 at 7:03 A.M. of the 100/200/300 hall Nurses' medication cart with Licensed Practical Nurse (LPN) B showed: -There was a container of bleach wipes and a bottle of isopropyl alcohol (rubbing alcohol used in cleaning) in the locked narcotic box with the residents' prescribed medications. -There was a pair of used toe nail clippers, a lighter, a box cutter, a computer mouse, and a stapler in a drawer with the residents' prescribed medications. During an interview on 9/25/24 at 7:03 A.M. LPN B said: -There should not have been any other items in with the residents' prescribed medications. -The person who had used the cart was responsible for ensuring it was clean and there were no items that didn't belong in the medication cart. 2. Observation on 9/25/24 at 7:26 A.M. of the Certified Medication Technician's (CMT) medication cart for 100/200/300/ halls with CMT C showed: -The drawers had a brown colored debris in with the residents' prescribed medications. -There was one loose red oblong pill in a drawer with the residents' prescribed medications. During an interview on 9/25/24 at 7:26 A.M. CMT C said: -There should not have been loose pills in the medication cart drawers. -The person who had used the cart was responsible for ensuring it was clean and there were no items that didn't belong in the medication cart. 3. Observation on 9/25/24 at 7:26 A.M. showed: -The night shift nurse (LPN C) left without counting the narcotics in the locked medication drawer with the day shift CMT (CMT C) for the CMT medication cart for the 100/200/300 halls. During an interview on 9/25/24 at 7:26 A.M. CMT C said: -The night shift nurse should have counted the narcotics with him/her before leaving. -There were many blanks where there should have been two signatures verifying the count was correct. -The person coming on shift counts with the off going staff and both of them should have signed at the same time they had counted. -If there was a blank space the DON should have been notified. -He/She had not notified the DON but should have when there were not two signatures. -He/She would count without the second person to count with him/her. During an interview on 9/25/24 at 7:30 A.M. LPN B said: -He/she had told the night shift nurse (LPN C) not to leave before counting with the day shift CMT. -The narcotic count should have been signed by two nurses at the beginning and end of each shift. -The oncoming nurse should have counted with the off going nurse. -There should not have been any blanks. -The DON should have been notified. -He/she knew there were many blanks but had not said anything to the DON. During an interview on 9/25/24 at 7:30 A.M. LPN C declined to be interviewed. Observation on 9/26/24 at 8:20 A.M. showed the night shift nurse (LPN C) left without counting with the day shift CMT. During an interview on 9/26/24 at 8:20 A.M. LPN B said he/she had told the night shift nurse not to leave before counting with the day shift CMT. During an interview on 9/26/24 at 8:20 A.M. LPN C declined to be interviewed. 4. Observation on 9/25/24 at 7:47 A.M. of the medication pass with CMT C showed: -He/She went into a resident's room to administer medications. -He/She left the medication cart unlocked for three minutes while in the resident's room. -The cart was facing outward. -One resident walked by the unlocked cart within two feet of it. Observation on 9/25/24 at 7:51 A.M. of the medication pass with CMT C showed: -He/She went into a resident's room to administer medications. -He/She left the medication cart unlocked for two minutes while in the resident's room. -The cart was facing outward. -One resident walked by the unlocked cart within two feet of it. Observation on 9/25/24 at 7:55 A.M. of the medication pass with CMT C showed: -He/She went into a resident's room to administer medications. -He/She left the medication cart unlocked for two minutes while in the resident's room. -The cart was facing outward. -One resident walked by the unlocked cart within two feet of it. During an interview on 9/25/24 at 7:55 A.M. CMT C said if staff were not in front of the medication cart it should have been locked he/she had forgotten to lock the cart. During an interview on 9/25/24 at 8:30 A.M. LPN B said staff should never leave the medication cart unlocked if they were not directly in front of it. 5. Observation on 9/25/24 at 8:00 A.M. of the September 2024 medication refrigerator log for 100/200/300 hall with LPN B showed: -Out of 24 shifts, 11 shifts showed the temperature was blank, indicating it was not checked. -On 9/14/24 showed there was no thermometer. -There was no documentation from 9/14/24 to 9/23/24. -On 9/24/24 the temperature was recorded at 25.0 degrees Fahrenheit ( F) (below freezing) and the refrigerator's temperature was reset. --There was no documentation the temperature was rechecked. --There was no documentation the maintenance department was notified. -There were more than 10 insulin pens in the medication refrigerator, directions on the box said to keep insulin between 36 to 46 degrees F do not freeze. -One vial of Tuberculin (TB -a bacteria, a skin test for TB injected into the skin) was in the refrigerator, directions said TB was to be stored at 35 to 46 degrees F. -There was no documentation the pharmacy had been notified about the medications that had been at a temperature that was out of range. During an interview on 9/25/24 at 8:10 A.M. LPN B said: -The night shift nurse was responsible for checking the temperature in the medication refrigerator. -There should not have been any days missed. -If the temperature was out of range the nurse should have told the charge nurse. -He/She did not know what to do if the medications had been frozen. -The DON was ultimately responsible for ensuring medications were stored at the correct temperature. 6. Review of Resident #61's Individual Patient Narcotic Record with LPN B showed: -The resident had a Physician's order for Hydrocodone/Tylenol (pain medication) 5/325 milligram (mg) one or two tablets by mouth to be given every six hours as needed. -On 9/22/24 the count was 60. -From 9/22/24 to 9/25/24 10 times two tablets were given for a total of 20 tablets. -The remaining amount documented was 42 tablets (verified by surveyor and LPN B). -60 tablets minus the 20 given should have equaled 40. 7. Review of Resident #42's Individual Patient Narcotic Record with LPN B showed: -The resident had a Physician's order for Lorazepam (used to treat anxiety) 0.5 mg tablet one tablet by mouth every four hours as needed. -On 9/17/24 the count was 15. -On 9/17/24 the medication was given twice. -The remaining amount was 11 (verified by surveyor and LPN B). -The count was corrected by staff to have been 11. -15 minus 2 should have equaled 13. 8. Review of Resident #325's Individual Patient Narcotic Record with LPN B showed: -The resident had a Physician's order for Tramadol Hydrochloride (medication for moderate to severe pain) 50 mg tablet to be given every six hours as needed. -The resident had a second order for Tramadol Hydrochloride 50 mg tablet to be given every six hours. -On 9/20/24 at 12:00 A.M. the record showed the resident received one as needed pill from the nurse and one as needed pill from the CMT. -On 9/25/24 at 6:00 A.M. the nurse gave the resident one scheduled pill and one as needed pill. -LPN B did not know why this had happened. -The DON should have been notified, he/she had not reported anything to the DON. 9. Review of the CMT Narcotic Count sheet dated July 2024 showed: -7/1/24 to 7/8/24 (two shifts per day with two signatures per shift) out of 32 opportunities there were 23 times there were missing signatures. -There were 11 out of 16 shifts with no card count at the end of the shift. -Started with 11 cards, four were added, two were subtracted should have equaled 13, facility showed 11. -7/9/24 to 7/26/26 the narcotic count sheet was missing. -7/27/24 to 7/31/24 out of 20 opportunities there were 11 times there were missing signatures. -There were 7 out of 10 shifts with no card count at the end of the shift. Review of the CMT Narcotic Count sheet dated August 2024 showed: -8/1/24 to 8/30/24 (two shifts per day with two signatures per shift) out of 120 opportunities 55 times there were missing signatures. -There was no documentation for 8/31/24. -There were 23 out of 60 shifts with no card count at the end of the shift. -Started with 11 cards, 12 were added, eight were subtracted should have equaled 15, facility showed 9. Review of the CMT Narcotic Count sheet dated September 2024 showed: -9/1/24 to 9/25/24 (two shifts per day with two signatures per shift) out of 96 opportunities 60 times there were missing signatures. -There were 26 out of 48 shifts with no card count at the end of the shift. 10. Review of the Nurses' Narcotic Count sheet dated July 2024 showed: -7/1/24 to 7/31/24 (two shifts per day with two signatures per shift) out of 124 opportunities 15 times there were missing signatures. -There were 29 out of 62 shifts with no card count at the end of the shift. Review of the Nurses' Narcotic Count sheet dated August 2024 showed: -8/1/24 to 8/31/24 (two shifts per day with two signatures per shift) out of 124 opportunities 12 times there were missing signatures. -There were 14 out of 62 shifts with no card count at the end of the shift. -Started with 15 cards, four were added, 10 were subtracted should have equaled nine, facility showed 10. Review of the Nurses' Narcotic Count sheet dated September 2024 showed: -9/1/24 to 9/25/24 (two shifts per day with two signatures per shift) out of 98 opportunities 16 times there were missing signatures. -There were 13 out of 48 shifts with no card count at the end of the shift. -On 9/25/24 the night shift nurse had pre signed the Narcotic count sheet before the day shift nurse arrived at the facility. 11. During an interview on 9/27/24 at 12:00 P.M. the DON said: -Staff were to keep the medication carts locked if they were not directly in front of it. -Two nursing staff were expected to count the narcotics at the beginning and end of each shift. -The on coming nurse and the off going nurse would count at the same time ensuring the count was correct. -There should not have been any blank spaces, or he/she should have been notified. -The DON and Assistant DON have done audits weekly on the narcotic count sheets. -There should not have been an non medical objects in the medication cart. -The staff member who had used the cart was responsible for ensuring the cart was clean without other objects in it. -Pharmacy also did cart audits. -The night shift charge nurse was responsible for ensuring that the medication refrigerator was within range, every night shift. -If the medication refrigerator was out of range it was expected staff notified the maintenance department so it could be adjusted and the medication did not freeze. -If the medications were out of range then the Pharmacy should have been notified and they would have directed them what to do. -The acceptable temperature range for the medication refrigerator was 36 to 42 degrees F. -The temperature should have been rechecked if it had been adjusted and documented on the temperature log sheet. -The DON, Charge Nurse, and CMT did weekly audits of the temperature on the medication refrigerator.

Based on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment including, but not limited to, unbroken furniture and/or window treatments, clean and comfortable sleeping conditions, and a physical layout of the facility that maximized people with disabilities' independence, met The Americans with Disabilities Act (ADA) requirements, and did not pose a safety risk and/or tripping hazards. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in at least four locations throughout the building. This facility had a census of 74 residents with a licensed capacity of 91 residents at the time of the survey. 1. Observation on 9/24/24 at 11:48 A.M. during the initial facility walk-through inspection showed the plumbing clean out (the access point for a sewer line and is considered a means to access the sewer line for cleaning and unclogging) in the middle of the 300 Hall by resident room [ROOM NUMBER] was missing its cover which allowed for an approximately (app.) 1/2 inch (in.) deep, 9 in. diameter drop in the floor that someone could catch their foot or walker on. Observation on 9/24/24 between 3:10 P.M. and 3:45 P.M. during a follow-up facility walk-through inspection with the Maintenance Supervisor (MS) showed the 100, 200, and 300 Halls' resident rooms had their numerals in both Arabic and Braille next to their doors. During an interview on 9/24/24 at 3:33 P.M. the MS said that he/she was going to change out the room numbers on the 400, 500, and 600 Halls because those resident rooms only had regular numbers and no Braille. Observation on 9/25/24 between 10:31 A.M. and 1:01 P.M. during another facility follow-up walk-through inspection with the MS showed the following: -The 400, 500, and 600 Halls' resident rooms had regular numbers next to their doors. -In resident room [ROOM NUMBER] there was a four-drawer chest with the front of the 2nd drawer from the top lying inside the drawer itself, and some slats in the window blinds missing. -In resident room [ROOM NUMBER] bed #2 had several long rips in the mattress top. -In resident room [ROOM NUMBER] the inside hinged edge of the bathroom door was cracked and broken towards the bottom to the point of showing that it was a hollow-core door. During an interview on 9/25/24 at 1:04 P.M. the Environmental Services Supervisor (EVS) said the following: -If any Housekeepers, nursing staff, or anyone noticed a damaged mattress they reported it to him/her and they would order a new one. -They had replaced a couple about a month or so ago. -It was the same process for damaged furniture or window blinds, but the MS is included on those too. During an interview on 9/26/24 at 12:53 P.M. the MS said the following: -He/She would order new blinds when reported. -The EVS or Administrator would do the mattresses and furniture. During an interview on 9/26/24 at 2:46 P.M. the Administrator said the following: -The facility should be free from any tripping hazards. -The EVS, or the MS could order any furniture, mattresses, or blinds when needed, they just had to wait for their corporate office to approve it.

Based on interview and record review, the facility failed to provide appropriate treatment and services for one sampled resident (Resident #2) who had refused his/her psychoactive medications on a consistent basis and was experiencing a change in his/her mental status. On 12/20/23 Resident #2 struck Resident #3 on top of his/her head with his/her fist causing Resident #3 to complain of a headache, a knot on top of his/her head, neck pain and was transfer to the emergency room for treatment out of four sampled residents. The facility census was 62 residents. Review of the facility Behavioral Emergency Policy dated 1/5/23 showed: -Purpose: --To provide safe treat and humane care to the resident in a behavioral crisis, to outline steps to follow to correctly care the resident in a behavioral crisis, to ensure that the resident is not being coerced, punished or disciplined for staff convenience. -Procedure: --It is the policy of Reliant Care Management to provide a safe environment and provide humane care to all residents. Review of the facility Abuse and Neglect Policy dated 1/5/23 showed: -Purpose: --To outline procedures for reporting and investigating complaints of abuse and to define terms of types of abuse. --To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. -Physical abuse: --Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. --Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. -Policy: --Mistreatment, neglect, or abuse of resident is prohibited by this facility. --This includes physical abuse. --This facility is committed to protecting our resident 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. 1. Review of Resident #2's Admission Record showed the resident was admitted on [DATE] with the diagnoses of Paranoid Schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations) and Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). Review of Resident #2's Preadmission Screening and Resident Review (PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 9/21/22 showed the resident: Please define diagnoses below -Psychiatric Diagnoses: --Schizoaffective Disorder (a mental condition that causes loss of contact with reality and mood problems). --Psychotic Disorder (a mental disorder in which there is a severe loss of contact with reality). --Bipolar Disorder Type I Manic Episode (mood disorders characterized usually by alternating episodes of depression and mania). --Personality Disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems). --Antisocial Personality Disorder (a condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society). --Borderline Personality Disorder (BPD-a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior). -Had no family supports or outside contacts. -Had a chronic mental illness and would have difficulty working with the public due to paranoia. -Had a history of paranoid ideation/delusions, recurrent homelessness, and believed he/she had been another person of fame in which his/her identity has been stolen repeatedly. -Had a history of non-compliance with medications. -Had several in-patient psychiatric admissions in multiple mental health facilities. -Had a history of becoming agitated with severe verbal and physical aggression directed at staff members at prior placements. -Although was able to communicate needs, rambled and lost train of thought several times throughout the assessment. -Symptoms include paranoid/grandiose delusions, fixed in nature. -Had a history of psychomotor agitation with verbal and physical aggression toward prior caregivers in structure settings. -History of auditory and visual hallucinations, irritable mood, repeated episodes of homelessness, non-compliance with psychotropic medications. -Required 24 hour per day nursing supervision and oversight due to chronic serious mental illness associated with impaired judgement and insight. -Required ongoing evaluation of mood, thought process, behaviors to identify signs of increased anxiety, agitation, confusion which may precipitate aggression toward other due to past history. Review of Resident #2's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/2/23 showed the resident: -Was cognitively intact. -Rejected care (such as taking medications) determined to be consistent with resident values, preferences or goals, one to three days per week. -Had diagnoses of stroke, seizures, anxiety and schizophrenia. Review of Resident #2's Physician Orders dated 12/20/23 showed: -Behaviors: monitor for behaviors every shift. -Divalproex 250 milligram (mg) give one tablet orally two times a day related to paranoid schizophrenia. -Divalproex 500 mg give one tablet orally two times a day related to paranoid schizophrenia. -Levetiracetam 1000 mg give one tablet orally verbally two times a day related to other seizures. -Olanzapine 20 mg give one tablet by mouth at bedtime related to paranoid schizophrenia, give with 5 mg tablet for total of 25 mg. -Olanzapine 5 mg give one tablet by mouth at bedtime related to paranoid schizophrenia, give with 20 mg tablet for a total of 25 mg. Review of Resident #2's Medication Administration Record dated 12/1/23 to 12/31/23 showed: -Divalproex 500 mg was refused 35 out of 38 attempts. -Divalproex 250 mg was refused 35 out of 38 attempts. -Levetiracetam 1000 mg was refused 35 out of 38 attempts. Review of Resident #2's undated Care Plan showed he/she: -Required protective oversight. -Was at risk for manifestations of behaviors related to his/her mental illness (paranoid schizophrenia) that may create disturbances that affect others. -Would not experience episodes of inappropriate behaviors that can affect others. -Was encouraged when disturbing others to go to a more private area to voice concerns/feelings to assist in decreasing episodes of disturbing others. Review of Resident #2's Progress Notes dated 12/18/23 showed he/she: -Refused morning medications. -Called 911 regarding two employees have apparently been signing bank documents on his/her account for years to the amount of 100 million dollars and that he/she was the New York police. Local law enforcement found this to be unsubstantiated. -Was yelling in the morning at peers, accusing them of stealing from him/her and saying he/she was a billionaire and was a famous person. -He/she had to be separated on multiple occasions from Resident #3. Review of Resident #2's Physician Progress Note dated 12/19/23 showed he/she: -Was seen by the physician. -Had refused medications and behaviors. -Was sent to the emergency roiagnom on [DATE] after a seizure. -On 12/6/23 was noted to have had a 21 pound weight loss. -On 12/18/23 the provider was notified of the resident calling 911 with grandiose allegations, refusing medications on a regular basis and requesting urinalysis due to mental status changes and current behavior. -History of present illness: Was sent to the emergency room for seizure, been refusing all of his/her meds, behaviors area also worsening and he/she had been aggressive towards other patient, at least verbally. -The physician tried to encourage the resident to take his/her medications. -The resident stated he/she did not need any medications. -Had a lot of forced speech during the encounter. -The physician questioned the resident's decision making capacity. Review of Resident #3's Admission Record showed he/she was admitted on [DATE] with the diagnoses of muscle weakness and anxiety disorder. Review of Resident #3's Annual MDS dated [DATE] showed the resident was cognitively intact. Review of Resident #2's Progress Note date 12/20/23 showed the resident: -Walked up to another resident and hit the resident on top of the head. -Stated the other resident owed him/her 50 million dollars and that he/she was going to get it some how even if it meant beating him/her up. -Sent to the emergency room for evaluation and treatment. Review of Resident #2's Investigation Report dated 12/20/23 showed he/she: -Was his/her own responsible party. -Had been refusing medications for the past two weeks. -Psychiatry and medical physician were notified. -Staff noted the resident has been delusional in the he/she believed that he/she was robbed of 50 million dollars, so far as to call the local police department to make a report. -Resident #2 approached Resident #3 and struck Resident #3 on the head, unprovoked. -Transferred and admitted to the hospital. -Plan to initiate guardianship for the resident. During an interview on 12/26/23 at 2:22 P.M. the MDS Coordinator said: -Resident #2 was sent for a psychological admission at the hospital for medication refusal, non-compliance and increased behaviors after Resident #2 assaulted Resident #3. -He/she did not know why Resident #2 was not sent out prior to the assault of Resident #3 because Resident #2 had increased behaviors and had called 911 on 12/18/23. -He/she believed the assault could have been prevented if Resident #2 had been sent out sooner. -The resident had been refusing medications since September and because he/she was his/her own person there was little that could be done about it. -He/she told the Director of Nursing (DON) and the Administrator about Resident #2's increasing behaviors. -The assault by Resident #2 was abuse. During an interview on 12/26/23 at 2:00 P.M. the Regional Nurse Consultant said: -All staff and the physician were aware of Resident #2 refusing his/her medications. -Due to the resident being his/her own person there was not much that could be done about the resident refusing medications. -Because the resident was having a psychotic break, he/she would not define the resident altercation as abuse. -The facility was responsible to ensure the safety of the residents. -He/she was working on the floor with the resident as a Certified Medication Technician (CMT) and had no formal training on Resident #2's behaviors. During an interview on 12/26/23 at 3:13 P.M. the Regional MDS Coordinator said: -It would have been appropriate to send Resident #2 to the hospital for a psychiatric evaluation prior to the assault due to a change in the resident's behaviors two days prior and it may have prevented the abuse. -He/she was unable to specify any measures within the facility to protect Resident #2 and others during a psychotic episode such as the abusive behavior. During an interview on 12/26/23 at 3:45 P.M. the Administrator said: -When Resident #2 called law enforcement on 12/18/23 it was indicative Resident #2 had a significant change in increased behaviors. -He/she expected the staff to review Resident #2's care plan and possibly complete a significant change on the MDS. -He/she expected the care plan to be updated. -He/she was unaware the resident was upset and there had been verbal altercations between Resident #2 and Resident #3 prior to the abuse 12/20/023. -He/she said Resident #2 had been delusional in the past, just not to that extreme. -He/she did not see what could have been done to prevent the assault due to Resident #2 being his/her own person and being non-compliant with medications. -With mental health residents, the only predictable thing was that the residents were unpredictable. -When asked how the facility staff was to ensure the safety of the residents, he/she said by taking reasonable steps according to the resident's care plan. -He/she was unable to clarify any steps specific for Resident #2's care plan. -The facility was responsible for ensuring protective oversight for all residents in the facility. During an interview on 1/10/24 at 3:44 P.M. the Nurse Practitioner said: -Resident #2 has a long history of non-compliance in which he/she becomes more delusional and aggressive over the course of time. -He/she expects the staff to inform him/her each time the resident refused medications in an effort to create a plan and place interventions to ensure the safety of the resident and others. -By the time the resident has refused his/her medications for a few months it is too late and the resident will have had grandiose delusions and aggression. -The facility did not inform him/her each time the resident had refused his/her medications. -He/she was told the staff did not feel it was necessary to notify hi/her due to the resident not having a guardian, therefore non-compliance was a right and nothing could be done. -He/she does not feel there was prompt notification. -He/she was aware Resident #2 contacted law enforcement, but was not aware Resident #2 targeted Resident #3 in the past. -If he/she was aware of Resident #2 targeting another resident there may have been more preventative measures implemented to ensure the safety of both residents. -The resident contacting law enforcement on 12/18/23 with grandiose delusions was a significant indicator of the resident having a significant change in his/her mental status. -Resident #2 has not been physically aggressive with residents or other patients, but has been resistive to cares and hyperfocused on others in the past. -Resident #2 should have had a guardian. MO00229028, MO00229029

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #3) remained free from abuse. On 12/20/23 Resident #2 struck Resident #3 on top of his/her head with his/her fist causing Resident #3 to complain of a headache, a knot on top of his/her head, neck pain and was sent out to the emergency room (ER) for treatment out of four sampled residents. The facility census was 62 residents. Review of the facility Abuse and Neglect Policy dated 1/5/23 showed: -Purpose: --To outline procedures for reporting and investigating complaints of abuse and to define terms of types of abuse. --To establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed. -Physical abuse: --Purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. --Physical abuse also includes, but is not limited to, hitting, slapping, punching, biting, and kicking. -Policy: --Mistreatment, neglect, or abuse of resident is prohibited by this facility. --This includes physical abuse. --This facility is committed to protecting our resident 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. 1. Review of Resident #2's Admission Record showed the resident was admitted on [DATE] with the diagnoses of Paranoid Schizophrenia (a form of schizophrenia [a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others] characterized by persistent preoccupation with illogical, absurd, and changeable delusions, usually of a persecutory, grandiose, or jealous nature, accompanied by related hallucinations) and Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). Review of Resident #2's Preadmission Screening and Resident Review (PASRR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 9/21/22 showed the resident: -Psychiatric Diagnoses: --Psychotic Disorder (a mental disorder in which there is a severe loss of contact with reality). --Bipolar Disorder Type I Manic Episode (mood disorders characterized usually by alternating episodes of depression and mania). --Personality Disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems). --Antisocial Personality Disorder (a condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society). --Borderline Personality Disorder (BPD-a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior). -Had a history of paranoid ideation/delusions, recurrent homelessness, belief she has been another person of fame in which her identity has been stolen repeatedly. -Had a history of becoming agitated with severe verbal and physical aggression directed at staff members at prior placements. -History of auditory and visual hallucinations, irritable mood, repeated episodes of homelessness, non-compliance with psychotropic medications. -Required 24 hour per day nursing supervision and oversight due to chronic serious mental illness associated with impaired judgement and insight. -Required ongoing evaluation of mood, thought process, behaviors to identify signs of increased anxiety, agitation, confusion which may precipitate aggression toward other due to past history. Review of Resident #2's Annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 12/2/23 showed the resident: -Was cognitively intact. -Rejected care (such as taking medications) determined to be consistent with resident values, preferences or goals, one to three days per week. -Had diagnoses of stroke, seizures, anxiety and schizophrenia. Review of Resident #2's undated Care Plan showed he/she: -Would be in the lowest restrictive environment while maintaining protective oversight. -Was at risk for manifestations of behaviors related to his/her mental illness (paranoid schizophrenia) that may create disturbances that affect others. -Would not experience episodes of inappropriate behaviors that can affect others. -If the resident is disturbing others, encourage him/her to go to a more private area to voice concerns/feelings to assist in decreasing episodes of disturbing others. Review of Resident #2's Progress Notes dated 12/18/23 showed he/she: -Refused his/her morning medications. -Behaviors were observed and documented. -The facility called 911 regarding two employees who have apparently been signing bank documents on his/her account for years to the amount of 100 million dollars and that he/she is the New York police. Local law enforcement found this to be unsubstantiated. -Was yelling in the morning at peers, accusing them of stealing from him/her and saying he/she was a billionaire and was a famous person. -Resident #2 had to be separated on multiple occasions from Resident #3. Review of Resident #3's Admission Record showed he/she was admitted on [DATE] with the diagnoses of muscle weakness and anxiety disorder. Review of Resident #3's Annual MDS dated [DATE] showed the resident was cognitively intact. Review of Resident #3's Progress Note dated 12/20/23 showed he/she: -Was sitting outside on the smoke porch when another resident walked up and hit him/her on top of the head. -Complained of dizziness, headache, neck pain, and ringing in his/her ears. -Was sent to the emergency room for evaluation and treatment. -Had a small raised area on the top of his/her head. Review of Resident #2's Progress Note date 12/20/23 showed he/she: -Walked up to Resident #3 and hit him/her on top of the head. -He/she said Resident #3 owed him/her 50 million dollars and that he/she was going to get it some how even if it meant beating Resident #3 up. -He/she was sent to the emergency room for evaluation and treatment. Review of Resident #3's Progress Note dated 12/25/23 showed he/she: -Was seen by the physician. -Was assaulted by Resident #2 and complained of headache, dizziness with neck pain. -Initially refused to go to emergency room , but did go for evaluation. -Was still having some neck pain. -When the other resident struck him/her from behind it caused his/her head to go forward causing pain. -He/she saw stars. Review of Resident #2's Investigation Report dated 12/20/23 showed: -Resident #2 approached Resident #3 and struck him/her on the head, unprovoked. -Resident #2 had been delusional, he/she believed he/she was robbed of 50 million dollars, and called the local police department to make a report. During an interview on 12/26/23 at 1:38 P.M., Resident #3 said: -Prior to the incident Resident #2 was out smoking and had become confrontational with him/her. Staff had to intervene -A couple of days later Resident #2 came up behind him/her and hit him/her on the top of the head one time. -He/she was sent to the hospital for evaluation. -He/she had a knot on top of his/her head and a headache. -He/she had requested Resident #2 be kept away from him/her. During an interview on 12/26/23 at 2:22 P.M., the MDS Coordinator said: -He/she did not know why Resident #2 was not sent out for psychiatric evaluation for his/her increased behaviors prior to assaulting Resident #3. -The assault might have been prevented if Resident #2 had been sent out sooner for his/her increased behaviors. -Resident #2's assault on Resident #3 was abuse. During an interview on 12/26/23 at 2:00 P.M., the Regional Nurse Consultant said: -Resident #2 had a psychotic break, and his/her assault of Resident #3 was not abuse. -The facility was responsible to ensure the safety of the residents. During an interview on 12/26/23 at 3:13 P.M., the Regional MDS Coordinator said: -It would have been appropriate to send Resident #2 to the hospital for a psychiatric evaluation prior to the assault of Resident #3 due to a change in the resident's behaviors two days prior. -For an incident to be defined as abuse there must be intent. -He/she did not believe Resident #2 had intent to harm Resident #3. During an interview on 12/26/23 at 3:45 P.M. the Administrator said: -The facility was responsible for ensuring protective oversight for all residents in the facility. -Resident #2 assault of Resident #3 was abuse. During an interview on 1/10/24 at 3:44 P.M. the Nurse Practitioner said the incident with Resident #3 was consistent with the definition of abuse. MO00229028, MO00229029

Based on interview and record review, the facility failed to provide supervision to prevent an elopement from a locked behavioral unit for one sampled resident (Resident #1), who was identified at risk on the facility elopement risk assessment and on his/her care plan. On 11/14/22 about 5:30 P.M. the resident broke a window in room [ROOM NUMBER] and said he/she wanted out. The resident was moved down the hall to room [ROOM NUMBER]. The Administrator sat on the hall to provide monitoring for the resident behavior and placed his/her chair in front of room [ROOM NUMBER] until the Administrator provided report to Hall Monitor A on resident behaviors at 7:00 P.M. There was no instruction to monitor room [ROOM NUMBER] with the broken window to Hall Monitor A. The resident was unable to be located at 7:05 P.M. The resident was found about 8:48 P.M. three miles away by local law enforcement. Six sampled resident were selected for review. The facility census was 61 residents. The Administrator was notified on 11/15/22 at 4:47 P.M. of an Immediate Jeopardy (IJ) which began on 11/14/22. The IJ was removed on 11/16/22, as confirmed by surveyor onsite verification. Record review of the facility elopement policy, dated 1/19/22, showed: -An elopement was defined as any time a resident was missing from the facility or there was a possibility a resident had left the facility without adequate supervision and their whereabouts were unknown. -The first person aware of an elopement would call a Code White (elopement) to the area of believed elopement. -The facility staff were to first search for the missing resident by going room to room, including closets, bathrooms, and work areas were to be searched. The Administrator would call or designate calls to the guardian, local police department, emergency call list and coordinate the search. 1. Record review of Resident #1's PASSR (Preadmission Screening for Mental Illness or Mental Retardation or Related Condition) date 8/12/19 showed he/she: -Had a history of agitated, tangential, screaming, and delusional talking. -Had history of writing illegible content. -Presented disorganized and with flight of ideas. -Had history of inpatient psychiatric treatment, secured behavioral unit and 15 minute checks by staff. -Refused medications, refused activities, was seclusive and suspicious of others. -Had not made good decisions. -Had a history of aggression and risky behaviors. Disorganized behavior and thought process. Poor Insight and judgment. -Was unable to negotiate a path to safety independently and need supervision of staff. -Had a poor understanding of his/her situation, guardianship, and placement. He/she was at risk for elopement and plan to prevent was needed including counseling and support. Record review of the resident's facesheet showed he/she admitted to the facility on [DATE] with the following diagnosis: -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Schizoaffective Disorder (a mental condition that causes loss of contact with reality and mood problems). -Hallucinogen Abuse with Hallucinogen induced Psychotic Disorder with Hallucinations -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Vascular Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Mild Cognitive Impairment. Record review of the resident's elopement assessment, dated 4/13/22, showed: -He/she was an elopement risk. -He/she had attempted elopement while at the facility. -He/she had a history of or attempting to leave the facility without informing facility staff. -He/she had verbally expressed a desire to go home, packed belongings to home or stayed near an exit door. Record review of the resident's care plan, dated 4/13/22, showed: -The Problem: --He/she was identified as an elopement risk. --He/she had eloped form the facility before on 4/13/22 and had a history of elopement from a prior facility. --He/she had verbal expression of wanting to leave the facility. -The Desired Outcome: He/she would be monitored closely, remain safe and would not elope through review. -Interventions: --His/her photo was placed in an elopement book. --He/she had face checks and intensive monitoring per facility protocol initiated 4/13/22. --He/she would be assessed for elopement risk on readmissions and quarterly. Record review of the resident's progress notes, dated 11/4/22, showed: -He/she was an elopement risk. -He/she had attempted elopement while at the facility. -He/she had a history of or attempting to leave the facility without informing facility staff. -He/she had verbally expressed a desire to go home, packed belongings to home or stayed near an exit door. -He/she had a wandering behavior likely to affect the privacy of others. -Facility staff were notified of the resident elopement risk. -The resident location was frequently monitored. -Exit alarms were utilized. -Check in/check out log was utilized. -Facility staff were notified of the resident wandering risk. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 11/4/22, showed he/she was cognitively intact. Record review of the resident's progress note, dated 11/14/22, showed: -He/she had broken his/her bedroom window at approximately 5:45 P.M. -The window had a large hole approximately measuring 18 inches in diameter. -He/she appeared confused and stated he/she wanted to leave. -He/she said he/she missed his/her mom. -Environmental Services picked up the broken glass and Maintenance applied a barrier to maintain the bedroom temperatures. -The resident was moved to another room. -The Administrator remained on the unit until 7:00 P.M., when Hall Monitor A reported for his/her shift and was provided report of the resident's earlier incident. -Hall Monitor A went to place his/her belongings in the common area and then went to do face checks on the residents on the unit. -At 7:05 P.M., Hall Monitor A called the Administrator and said he/she could not find the resident. -At 7:18 P.M., the Administrator returned to the unit and searched all rooms. -The resident's prior room was observed with the window mesh out and stepped on. -The Administrator checked outside at the back of the building and noticed the resident's footprint by the window at approximately 7:18 P.M. -At 7:36 P.M., local police and the resident guardian was contacted. -At 8:40 P.M., the resident was located by the police and emergency services personal approximately three miles from the facility at a local grocery store. -The resident had left wearing a black shirt, black pants, white socks, tennis shoes and a black coat. Record review of www.Wunderground.com showed on 11/14/22 the temperature range in Raytown Missouri was between 35-41 degrees Fahrenheit, with light rain and snow. During an interview on 11/14/22 at 9:20 PM., the Administrator said: -The resident had eloped. -At 5:30 P.M. the resident was on the locked behavioral unit and begun to have a behavior. The resident shattered the glass to his/her window in his/her room. There was one staff person on the unit, the Environmental Services Director (EVS) Director, after the day shift had left at 4 P.M. The Administrator, the DON, and maintenance responded afterward. The Maintenance Director placed cardboard and duct tape over the widow after EVS cleaned up the glass. The resident was moved to another room with a roommate. Assessment was completed on the resident and no injury was found, the resident said he/she had just wanted to get out, he/she was being kept at the facility and he/she wanted to go somewhere. It was unknown what the resident shattered the window with. -The Administrator remained on the unit sitting in the hallway until 7 P.M. when Hall Monitor A came on shift to relieve him/her. -He/she provided report to Hall Monitor A about the day and the resident behaviors. -About 7:05 P.M. Hall Monitor A reported he/she could not find the resident when doing checks. -He/she was back in the building by 7:10 P.M. -Hall Monitor A was asked if he/she checked all rooms, room checks were immediately initiated. -The resident's roommate was interviewed who said he/she thought the resident had went out for a smoke. -About 7:18 P.M. he/she went outside to check and noticed the mesh had been cut or ripped on the resident window for the old room. On the ground was a footprint. Inside the cardboard was pulled back. -At 8:48 P.M. the resident was found by the Police Department approximately 3 miles away at a local store. Emergency Medical Services (EMS) had already been called, when administration staff showed up. No facility staff was able to do assessment. EMS were going to transport the resident to the hospital. There was no known visible injury. The resident was wearing black sweat pants, white socks, gray hoodie, coat, hat, and sneakers. The resident said he/she was homeless and was going to the city union mission. During an interview on 11/15/22 at 9:45 A.M., the EVS Director said: -He/she was assigned to work the locked unit as relief about 5 P.M. -He/she heard a crash and went to one room first and then to the resident room and saw the shades were pulled up and broken, and the glass was on the resident's bed and floor. -He/she checked the resident's hands and there was no blood, cuts, or scratches. -He/she was unsure of what the resident broke the glass with, he/she suspected it was the resident's hands. -The resident was not agitated any more than usual and described the resident as usually pretty high strung. -The resident had said he/she had to get out of here, and needed to see family, maybe it was a brother. -Before the resident had broken the window, the resident was in his/her room with the door closed, and quite often went into his/her room with the door closed. -The resident said nothing else other than he/she had to get out of here. -The resident does talk a lot and rambled and liked to write things down. The rambling had not always made sense. -The maintenance man had come in and covered the window with cardboard, tape and heavy plastic. The screen was still in tact. -The administrator relived him/her after the incident. During an interview on 11/15/22 at 1:33 P.M., the DON said: -He/she had assessed the resident after the resident had broken the window. -The resident had no injury. -He/she was unaware of how or with what the resident had broken the window. -The resident was at baseline saying erratic off the wall things and was delusional. -The resident was a little more vocally loud than usual. -He/she had administered a PRN (as needed) medication for the resident after the resident had broken the window. During an interview on 11/15/22 at 12:21 P.M., the Administrator said: -After the resident broke the window in his/her room, the resident was moved to another room. -He/she remained on the hallway of the unit and placed a chair by the room with the broken window and closed the door to the room. -He/she sat in the chair. -The resident was moved across the hallway, placed with a roommate and was pretty quiet. -About 6:00 P.M., the resident had taken a smoke break with other residents on the smoke deck. -The resident had eaten supper in the dining room area after smoke break and then went back to his/her new room. -He/she gave report to Hall Monitor A at 7:00 P.M. about the resident's behaviors earlier in the day. -He/she reported the resident had a room change. -The resident's prior room door was shut, the broken window was covered with cardboard and duct tape. -He/she had not instructed Hall Monitor A that no resident should go into the room or to watch the door to the room. -He/she had not placed the resident on a one to one staff person observation. -He/she had expected Hall Monitor A to remain on the unit at all time unless the residents were on the smoke deck. -He/she left shortly after 7:00 P.M. and about 7:05 P.M., Hall Monitor A called and could not find the resident. -He/she returned to the unit and searched the room with Hall Monitor A. -He/she opened the resident's prior room door and noticed the mesh in the broken was torn and the cardboard was removed. -He/she went outside to the back of the building and noticed a footprint. -He/she had not asked Hall Monitor A where or what Hall Monitor A was doing during the time after he/she left the building. -The resident was not placed on one to one assistance, because the resident showed no agitation and was at his/her behavior baseline. -He/she had placed the resident with a roommate the resident liked. -He/she could have provided more detailed instructions for Hall Monitor A. During an interview on 11/15/22 at 1:15 P.M., Resident #6 said: -Resident #1 was his/her roommate for only a few minutes. -He/she did not know where Resident #1 had went other than to smoke. During an interview on 11/15/22 at 5:20 P.M., Hall Monitor A said: -He/she clocked in at 6:53 P.M. -The Administrator gave him/her report. -The Administrator had said the resident had broken the glass to the window and was moved to another room with a roommate. -The Administrator said to make sure the resident was doing alright. -He/she was not told to do extra monitoring, just to make sure the resident was ok. -The Administrator left and he/she was on the unit by him/herself. -He/she went to put his/her stuff away in the staff bathroom in the locked area of the common room on the unit. -He/she was off the main hall of the unit for about one minute. -He/she then began his/her face checks for all residents. -He/she had not seen the resident on the hall after checking all the rooms. -He/she called the Administrator about 7:04 P.M. -He/she checked the resident's prior room which had a piece of cardboard and tape that was pulled and folded back from the window. -He/she had not received in report he/she needed to monitor the room with the broken window. During an interview on 11/17/22 at 2:25 P.M., the Administrator and the DON said: -The resident's access to the window could have been prevented, by ensuring the resident had no access to the room and the window was fixed or sealed. -The resident did not want the facility staff to know he/she was going to leave, when he/she left the resident was calm and not agitated. -The resident was almost too calm. -If the resident had been out of baseline or agitated facility staff would have been instructed to provide one on one staff observation or assistance with the resident. During an interview on 11/17/22 at 3:52 P.M., the Maintenance Director said: -He/she had first placed tape and cardboard over the resident broken window per the administrator instruction because the stores were closed. -He/she should have placed a piece of sheet rock on the window, after the resident eloped he/she placed a plastic and a whiteboard over the broken window. During an interview on 11/15/22 at 9:00 A.M., the resident's Psychiatric Physician said: -The resident was one of the higher functioning residents and had some ability to reason. -The resident's mental stability had been stable with no recent changes for any acute things. -He/she was aware of the resident elopement. -His/her recommendations for behavioral intervention dealing with a resident with no reasoning skills included: talk with resident, deescalate, if continued to be upset have someone stay with the resident on 1-1 until calm and deescalate. Give space, PRN (as needed) if necessary. During an interview on 11/15/22 at 9:30 A.M., the resident's legal guardian designee said: -The Administrator had notified the guardian, and sent a picture and text of the window that was shattered. It was not provided how the window was broken or that there was any injury to the resident. -The resident had a history of elopement from prior placements and once from this facility. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO00209903

Based on observation, interview and record review, the facility failed to ensure safe smoking practices were followed and to provide protective oversight for one sampled resident (Resident #1) who required direct supervision while smoking, was at risk of smoking in his/her room and required oxygen, which resulted in a burn to his/her face. This deficient practice affected 1 out of 8 sampled residents. The census was 64 residents. The Administrator was notified on 1/6/22 at 1:30 P.M. of an Immediate Jeopardy (IJ) which began on 1/4/22. The IJ was removed on 1/8/22, as confirmed by surveyor onsite verification. Record review of the Facility Smoking Safety Regulations policy dated 7/9/21 showed the facility would provide direct supervision for smoking classified as not responsible. Record Review of the facility Smoking Contraband policy dated 7/9/21 showed: -Contraband were any items used as smoking materials, cigarettes, lighters, matches, other smoking devises, tobacco, pipes, cigars or other illegal substances. Resident will be assessed for independent smoking upon admission/readmission, quarterly and as needed. The resident must be approved per legal guardian and by the interdisciplinary care plan team to smoke unsupervised. This is determined by assessment of the resident history and current plan of care. -Resident will not be allowed to carry or keep any smoking contraband on their person or in their possession on the unit or in their rooms. -Unused personal smoking contraband must be turned back into the facility staff and signed back in when the resident returns to the unit. Record review of Resident #1's Admission Face sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of [CONDITION(S)] ([CONDITION(S)] - a disease process that decreases the ability of the lungs to perform ventilation.) Record review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 11/29/21, showed he/she: -Was cognitively intact. -Needed supervision with setup assistance with bathing, dressing,and transferring. -Used a wheelchair to mobilize. -Did not indicate he/she smoked cigarettes. -Required oxygen upon admission for shortness of breath. Record review of resident's Physician Order Sheet (POS) dated 12/13/21 showed the resident had a Physician's order for as needed Oxygen (O2) at an oxygen flow rate of two liters per minute (LPM means the patient will have two liters (2L) of oxygen flowing into their nostrils over a period of one minute) per nasal cannula (NC, a small, flexible tube that contains two open prongs delivers oxygen) for shortness of breath. Record review of the resident's Smoking assessment dated [DATE] at 4:04 A.M., showed: -The resident required supervision while smoking in designated smoking area at facility assigned smoking times. -The resident had a vision issue noted. -Did not identify if the resident had been screened as able to keep smoking materials in his/her room. -No documentation of the resident history of smoking with oxygen on and if he/she had smoked in his/her room. Record review of the resident's Smoking Care Plan revised on 12/17/21, showed: -The resident smoked cigarettes. -The resident goal included he/she would not smoke without supervision through the review date of 3/20/22 and the resident would not suffer any injury from unsafe smoking practices through the review date of 3/20/22. -Interventions included, but were not limited to: --Facility nursing staff and social worker were to instruct the resident about smoking risk and hazards and about smoking cessations aids that are available. --Facility nursing staff and social worker were to instruct the resident about the facility policy on smoking related to the locations, times and safety concerns. --Facility staff were to notify the charge nurse immediately if it they had suspected the resident had violated the facility Smoking policy. -No documentation of any history of smoking with oxygen on or smoking in his/her room. Record review of the resident's nursing Hot Rack Notes by Licensed Practical Nurse (LPN) B dated 1/1/22 at 12:42 P.M., showed: -Certified Nurse Aide (CNA) D reported to LPN B and to his/her supervisor the resident had been in his/her room smoking with his/her oxygen on. -LPN B immediately went to talk to the resident, discussed the importance of why he/she should not smoke in his/her room and why he/she should not smoke with his/her oxygen on. -The resident said he/she was sorry and said he/she won't do it again. -LPN B was on the hallway 10 minutes prior to this incident occurring. -LPN B would continue to monitor the resident. Record review of the resident's notes dated 1/1/22 to 1/3/22 showed: -No documentation nursing completed a head to toe assessment of the resident for any [CONDITION(S)] marks or observed the resident's clothes or linens for burn holes. -No documentation related to a resident interview about smoking material items in his/her room or if he/she had been smoking in his/her room. -No documentation the nurse notified the resident's physician of the resident's smoking incident. Record review of the resident's Nursing Alert Note dated as a late enter note on 1/4/22 at 1:19 P.M., showed: -The resident had redness noted on the tip of his/her nose and around his/her nostrils. -The resident reports that it was nothing and he/she denied any discomfort. -The resident used O2 continuously via NC and it was on at that time. -The Director of Nursing (DON) had questioned the resident if he/she had been smoking with his/her O2 on and the resident denied smoking with O2 on. -The area on the resident's nose was cleansed. The area was not open or draining at that time. -Nursing staff would continue to monitor. Record review of the resident's Nurse Practitioner (NP) Progress Note dated 1/4/22, showed no documentation related to the assessment of the resident's nose or review of the smoking incident with the resident. Record review of the resident's medical record dated 1/4/22, showed no documentation the facility staff completed further investigation into the suspected possibility of the resident smoking in the resident room. Observation on 1/5/22 at 12:29 P.M. showed: -The resident was on the phone and had O2 per nasal cannula in place running at flow rate of 4 liter per minute. -The resident's nose had large amount of reddish-brown discoloration on the tip and around and inside his/her nares. -There was a pen point scabbed area on his/her left check by his/her nose. During an interview and observation on 1/5/22 at 12:31 P.M. the resident said: -He/she had been smoking in his/her room with O2 in place and he/she caught on fire a few days ago. -When asked if he/she notified the facility staff, the resident said they know. -He/she had put the fire out and did not say anything to staff about the fire, he/she said they know. -Closer look of the resident nose inside his/her nares showed charred/scabbed over area, he/she had red drainage dripping from his/her nose and the tip of the nose had a reddish-brown charred looking color. -The resident said facility nursing staff had not came to clean or assess his/her nose at that time. -He/she had complaint of congestion in his/her nasal area. -The resident had several soiled rags with red drainage and soiled Kleenex on the table and floor in his/her room. During an interview on 1/5/22 at 12:30 PM. the DON said: -He/she was the acting charge nurse on the 400 hallway. -The resident had a history rubbing his/her nose. -He/she thought the resident's nose could have been irritated from the resident's nasal cannula or could be from the resident smoking with his/her nasal cannula in place. -The resident had denied smoking with his/her oxygen on. -Plan was for the resident to be seen by the wound doctor and his/her physician was aware. During an interview on 1/5/22 at 12:50 P.M. with DON said: -He/she was not aware the resident had burnt his/her nose while smoking in his/her room with oxygen on. -The resident had denied any pain and denied smoking with oxygen on in room on 1/4/22. -He/she had noticed some redness of the resident's nose on 1/4/22 and documented it in a nursing note. -The resident should not be keeping any smoking material in his/her room. -He/she had heard the resident may have tried to smoke in his/her room at the hospital, but did not have any documentation to support that. -He/she did not complete an incident report for an unknown injury to the resident's nose at that time. During observation and interview on 1/5/22 at 1:35 P.M., the resident said: -The smoking accident happened at this facility in his/her room on the 600 hallway and the Administrator was aware. -The resident said he/she had just thrown away his/her burnt nasal cannula in the trash earlier in the morning. -The resident's trash can had already been emptied and taken to the dumpster. -The resident said he/she had put the fire out by himself/herself. -He/she knew it was dumb and not safe to smoke in the room and with oxygen on. -The resident had not signed a facility Resident Smoking Agreement or reviewed the facility's smoking guidelines while at this facility. -He/she had verified he/she had been smoking at this facility in his/her room while on the 300 hallway and while on the 600 hallway. Record review of resident's facility Administration/Registered Nurse (RN) Investigation dated 1/5/22 at 2:55 P.M., showed: -Date of the Incident was on 1/3/22. -Investigation notes: Small scabbed and red area noted on tip of nose and round nares, cleansed the area and had no open area noted at that time. -The resident denied any injury or discomfort. -The resident recently returned from hospital. -Resident denied smoking while wearing O2 via NC and verbalized understanding of the smoking education from this RN on dangers of smoking while using O2. -Per Administrator the resident had admitted to smoking in his/her bathroom while at this facility. -On 1/5/22, the resident admitted the red area on his/her nose was from smoking while on O2 and causing a small fire burning his/her nose 1-2 days ago. -The resident denied any further respiratory distress and no pain or discomfort. -Conclusion: The resident was in possession of cigarettes and a lighter upon returning from the hospital, or after signing self out of the facility as he/she was his/her own responsible party. -The resident had lit a cigarette in the bathroom in his/her room and caused flames from O2 which had caused the tip of his/her nose to be burnt. -Plan: the resident had been moved to a locked unit where there was increased supervision. -The resident belongings were searched with permission and all cigarettes and lighters were removed. -The resident care plan updated to include these safety measures. -The resident verbalized understanding of education given related to dangers of smoking in the facility and most importantly smoking at all with oxygen on. Record review of the resident's Nursing Note Alert by DON showed a late entry on 1/5/22 at 1:22 P.M. had been created on 1/5/22 at 1:43 P.M. showed: -The resident was interviewed in relation to worsening skin of nares. -The resident had admitted to this RN that he/she had been smoking with his/her O2 on and got a burn. -His/her nasal cannula was intact and the resident reports that current cannula was not what was in use when the incident occurred. -Notified the NP of this report and of worsening of the resident's skin in this area. Order given for [MEDICATION(S)] cream 1% BID to affected area. During an interview on 1/5/22 at 2:08 P.M., Resident #8 said: -Resident #1 had been smoking in their shared room. -He/she had the privacy curtain pulled so, he/she could not see Resident #1 smoking, but could smell the smoke. -He/she was not aware if he/she had oxygen on. -He/she was not aware about a fire or if Resident #1 had been burnt. -Record review of the resident MDS dated [DATE] showed he/she was able to make his/her needs known and able to comprehend and understand others. During an interview on 1/5/22 at 2:00 P.M. CNA B said: -The facility staff had smelled smoke from the resident's bathroom on 1/1/22. -Administration made the decision to move the resident to the 400 hall, a secure unit, for closure monitoring. During an interview on 1/5/22 at 4:12 P.M., LPN B said: -On 1/1/22 CNA D smelled smoking in the resident's room. -The resident was not smoking when the LPN B had entered the resident room. -The resident was had his/her O2 in place per NC. -LPN B reeducated the resident on the hazards of smoking in his/her room and with having oxygen in room. -The resident did admit to smoking in his/her room to the LPN B. -LPN B did not inspect the resident room or look for any smoking materials. -The resident had history of becoming combative and aggressive when confronted. -The resident had history of trying to smoke with his/her oxygen on while outside in smoking areas. -The facility staff had redirected the resident about smoking with oxygen on several times. -LPN B said this was not the first time the resident had smoked in his/her room. -LPN B had reeducated the resident several times about the importance of not smoking in his/her room and not smoking with O2 in place. -He/she was not sure if it had been documented in the resident nursing note before or if the facility completed an incident report about smoking in unassigned areas. -The resident was his/her own person and able to go out of the facility to buy items. He/she brings them back to the facility including smoking items. -He/she had notified the Administrator of the smoking incident on 1/1/22. -LPN did not notified the resident's physician about the resident alleged smoking in his/her room. During an interview on 1/5/22 at 5:10 P.M., CNA A said: -On 1/1/22 the resident was not seen smoking in his/her room, facility staff only smelled the smoke in the resident's bathroom. -When he/she was off work, it was reported the resident had been smoking again in his/her room and the facility had removed the resident's smoking materials from his/her room. During an interview on 1/5/22 at 2:05 P.M., Social Services Worker (SSW) said: -It had been reported to the Administrator on 1/3/22 and the Administrator had talked to the resident about smoking his/her room. -The Administrator had searched the resident room with his/her permission and removed the resident's lighter and cigarettes from the resident's room. During an interview on 1/5/22 at 2:15 P.M. Administrator said: -He/she was notified on Monday 1/3/22 of alleged smoking in the resident room over the weekend. -The facility did a room change for the resident to a secure unit for closer monitoring on 1/4/22. -The facility had started an investigation, but unsure of the date of when the investigation had been started. -Administrator obtained the resident smoking materials from his/her room. -Not sure if the resident physician had been notified or if the resident had any injury's. -Facility staff had smelled smoke in the resident room. -No facility staff had observed the resident smoking in his/her room. During an interview on 1/5/22 at 5:15 P.M., DON and Administrator said: -The Administrator said he/she followed up with the resident on 1/3/22 related to incident on 1/1/22. -The facility did not report to the resident's physician the alleged smoking in his/her room. -Administrator said no facility staff had seen the resident smoking in his/her room, facility staff only reported smelling the smoke. -The resident's roommate on the 600 hallway had told CNA D that Resident #1 had been smoking in his/her room. -On 1/4/22 the facility Administrator reported they had put in place a plan for the resident safety: --The facility had changed the resident room to the more secure unit to be able to monitor more closely. --The facility had removed any smoking materials from the resident's room. --The resident had agreed to a room search and to be searched when he/she returned to the facility for any smoking items. -DON first noticed the redness on the resident nose on 1/4/22, which had been reported by CNA E. -The resident denied any injury and when asked, he/she had denied smoking in his/her room with oxygen on. -On the afternoon of 1/5/22 the DON reassessed the resident and agreed the resident had a worsening change of condition to his/her nasal area. The nasal area look more like burn now. -DON and administrator were not aware if the resident had signed or completed a smoking agreement. -The resident had been in or out of the hospital a lot and he/she was his/her own responsible party. -The resident's Smoking Assessment had been completed on 1/5/22. -Administration were not aware the resident had been admitted to smoking on the 300 hallway also. -Did not have any additional reports from facility staff of the resident smoking in his/her room. During an interview on 1/5/22 at 5:55 P.M., NP said: -He/she was not aware the resident had been smoking in his/her room. -He/she saw the resident on 1/4/22 and had seen the resident had slight redness to his/her face. -He/she did not document that finding in his/her progress note initially. -The facility did not mention the alleged smoking incident to the NP. -He/she would expected the facility nursing staff to had notified NP or the physician group, of any changes in the resident condition and of any alleged smoking accident immediately. -He/she would expect the facility staff and the resident to follow the facility's smoking policy related to the smoking safety monitoring of the residents. Record review of the resident's POS dated 1/5/22 at 6:28 P.M., showed the resident had a telephone order that was ok to send the resident to Emergency Department (ER) for evaluation and treatment if appropriate related to burn on nares. Record review of the resident's Discharge Summary dated 1/5/22 at 6:45 P.M. showed a late Entry Note that the resident had been sent to the ER for evaluation and treatment as needed. The resident was taken by emergency medical services (EMS). Record review of the resident's Nursing Alert note dated 1/6/22 at 10:37 A.M. showed it was reported [CONDITION(S)] on nares to be less than 1% burn, per the nurse. Record review of the resident's Physician order sheet dated 1/6/22 at 9:34 A.M., showed a phone order by the NP for [MEDICATION(S)] Cream 1% two times a day for [CONDITION(S)] on the resident nares until 1/20/22. Record review of the resident's hospital discharge instruction dated 1/6/22 at 1:19 P.M. showed: -The resident had been seen for [CONDITION(S)] to the nares. -He/she was smoking a cigarette with his/her oxygen on and burnt his/her nose and nostril. No charring in throat or further up his/her nose. -Treatment included monitoring the resident and antibiotic ointment to the burn area. -He/she required a follow-up physician visit for burn to his/her nares. During an interview on 1/6/22 at 2:16 P.M., Physician A said: -He/she was not aware and did not see notes that his/her office had been contacted about the resident's alleged smoking in his/her room or about smoking with oxygen in place. -He/She would expect the facility to notify the physician practice of the smoking incident and the alleged burn to the resident's nose immediately. -He/she would expect smoking safety intervention to be initiated for the resident to include but not limited to: --Education on the facility's smoking safety protocols and the risk of the use oxygen and smoking. --Checking for smoking items in the resident's room. --Monitoring the resident more often for smoking safety and compliance. -Physician A reviewed the resident medical record did not find a resident smoking agreement, he/she would expect the facility to have all residents who smoke to review and sign a smoking agreement for their rights and responsibility as smokers. -Most facility residents were not allowed to have smoking material in their rooms, he/she was not sure about this facility policy on smoking materials. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). Complaint# MO 058

Based on interview and record review, the facility failed to keep three sampled residents (Residents #39, #21, and #9), free from verbal abuse from a facility employee when Resident #39 had felt bad' about him/herself, Resident #21 had felt worthless about him/herself and had thrown up and Resident #9 felt bad about him/herself after the verbal abuse from facility staff out of three sampled residents. The facility census was 48 residents. Record review of the facility's Abuse Policy dated 5/2019 showed: -The facility policy was to prohibit resident abuse where there was cause to believe a resident' mental health or welfare had been adversely affected by the abuse caused by another person. -Verbal was the use of oral, written or gestured language that included disparaging or derogatory terms within the resident's hearing distance. -The definition of abuse meant to inappropriately treat or exploit a resident including humiliation, harassment, threats, deprivation or intimidation. -All residents were to be immediately protected from abuse. -Allegations involving facility staff would necessitate suspension without pay pending the investigation and termination if the allegations were substantiated. 1. Record review of Resident #39's Facility Face Sheet showed he/she was admitted on [DATE] with the following Diagnoses: [REDACTED]. -Weakness. -History of shortness of breath. Record review of the resident's Nursing Care Plan initiated on 8/8/19 showed: -The resident had issues with mobility and required assistance with turning and repositioning. -He/she had periods of incontinence and required assistance with elimination needs and incontinence care. -The resident's linens were to be kept clean and dry. -The facility staff was to assist with positioning, dressing, bathing and transfers. -He/she was to be checked for incontinence every two hours and as needed during the night. -The facility staff was to provide absorbent products as needed for dignity. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 2/4/20 showed he/she: -Was cognitively intact. -Had no negative behaviors. -Required supervision to total dependence of one to two facility staff for bed mobility, transfers, daily hygiene, bathing, toileting and dressing. -Was incontinent of both bowel and bladder at times. During an interview on 3/13/20 at 2:15 P.M., the resident said: -When he/she turned his/her call light on, two Certified Nurses Aide's (CNA) came into his/her room early the morning of 3/13/20. -He/she asked to be changed as his/her brief was wet. -CNA G told the resident that he/she and CNA H could not change him/her for an hour because that was when they would do rounds. -CNA H did not say anything. -When the CNA's came back to his/her room an hour later to change his/her brief, CNA G asked the resident to help by rolling over so they could change him/her. -The resident stated that he/she could not help a lot but would try. -At that time, CNA G said, You need to move your white fat ass and help us! -CNA H said nothing but just continued to help CNA G to roll the resident over to his/her side. -The resident also felt that CNA G was very rough with him/her when turning him/her but said he/she was not injured. -The resident felt bad about himself/herself after the interaction with CNA G. 2. Record review of Resident #21's Facility Face Sheet showed he/she was admitted on [DATE] with a [DIAGNOSES REDACTED]. Record review of the resident's Nursing Care Plan initiated 8/1/19 showed: -The resident had issues with elimination, requiring assistance with toileting. -The facility staff was to check the resident for incontinence every two hours and as needed during the night. -The facility staff was to provide absorbent products as needed for dignity. -The resident had issues with mobility and performing daily needed self-care. -He/she needed to be frequently checked for proper positioning, ensuring that he/she was comfortable due to the resident's inability to adequately use his/her extremities. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -Had no negative behaviors. -Required supervision to total dependence of one to two facility staff for bed mobility, transfers, daily hygiene, bathing, toileting and dressing. -Was incontinent of both bowel and bladder at times. During an interview on 3/13/20 at 2:45 P.M., the resident said: -Two CNA's came into his/her room early the morning of 3/13/20 to reposition him/her. -CNA G jerked on him/her to get him/her turned and called the resident a white MF'er. -The resident said that it made him/her feel worthless to be treated that way. -He asked the Activity Coordinator (AC) to sit with him/her at breakfast because he/she was afraid CNA G might come back and he/she was afraid of CNA G. -CNA H said nothing while in his/her room. 3. Record review of Resident #9's Facility Face Sheet showed he/she was admitted on [DATE] with a [DIAGNOSES REDACTED].>-[MEDICAL CONDITION] (a condition marked by impaired muscle coordination and [DIAGNOSES REDACTED] of the limbs). -[MEDICAL CONDITION]. Record review of the resident's Nursing Care Plan initiated on 9/16/20 showed: -The resident was to be observed for any [MEDICAL CONDITION] activity throughout all shifts. -The facility staff was to keep the resident safe. -The facility staff was the check the resident for incontinence every two hours and as needed during the night. -The facility staff was to provide absorbent products as needed for dignity. -The resident had issues with mobility and performing daily needed self-care. -The facility staff was to provide absorbent products as needed for dignity. -The resident had issues with mobility and performing daily needed self-care. -He/she needed to be frequently checked for proper positioning, ensuring that he/she was comfortable due to the resident's inability to adequately use his/her extremities. During an interview on 3/16/20 at 1:20 P.M., the resident said: -CNA G and CNA H pulled him/her up in bed and tossed him/her on the mechanical lift sling. -CNA G was very rude and said not to tell anyone. -CNA H did not say anything but seemed to be doing what CNA G said to do. -CNA H was very quiet. 4. During an interview on 3/13/20 at 10:00 A.M., the Director of Nursing (DON) said: -CNA A came to the DON stating that Resident #39 wanted to speak with him/her and was upset. -The DON went to see the resident who reported that CNA G, a night shift CNA had been verbally abusive to him/her earlier in the morning of 3/13/20. -Around the same time, the AC was helping to pass breakfast trays when Resident #21 told the AC that he/she was afraid to be alone, asking the AC to stay with him/her as CNA G had been mean to him/her earlier in the morning of 8/13/20 and he/she did not want to be alone. -As the DON and Administrator began interviewing other residents, they found Resident #9 had a similar experience with the same CNA earlier in the morning of 3/13/20. During an interview on 3/13/20 at 11:00 A.M., the Administrator said: -Resident #39 told him/her, CNA G came in to answer my call light and when I told CNA G I was wet, CNA G told me I had to wait an hour until their rounds before he/she would change me. Then when the CNA G came back in early this morning, he/she called me a fat ass for not helping enough to turn myself. -Resident #39 described CNA G to the Administrator. -Resident #39 stated CNA G was rough when turning him/her, but he/she was not injured. -When the Administrator interviewed Resident #21, he/she stated that he/she had issues with CNA G being mean to him/her, it made him/her feel bad about himself/herself and it made him/her throw up. Attempts were made to contact CNA G by phone at 11:15 A.M., 11:45 A.M., 1:00 P.M., and 2:30 P.M. on 3/13/20 with messages left each time with no return call. Attempts were made to contact CNA H by phone at 11:20 A.M., 11:50 A.M., 1:15 P.M., and 2:45 P.M., on 3/13/20 with messages left each time and no return call. During an interview on 3/16/20 at 10:00 A.M., the Administrator said: -He/she had terminated CNA G. -He/she felt that CNA G was intimidating CNA H and that CNA G was the abusive employee. During an interview on 3/16/20 at 1:30 P.M., the AC said: -He/she took food into Resident #21. -Resident #21 asked him/her if he/she would stay with him/her. -Resident #21 said CNA G had been mean to him/her, and did not want to be alone and felt scared. -The AC stayed with the resident until he/she felt safe and then he/she went and reported the issue to the DON. During an interview on 3/16/20 at 2:00 P.M., CNA A said: -On 3/13/20 when he/she was coming into work and CNA G was clocking out, CNA G confronted CNA A. -CNA G said to CNA A, I should start working the dayshift so I can show you [***] es how it's done! -CNA A stated to CNA G the comment greatly offended him/her and it was inappropriate. -CNA G replied to CNA A he/she did not mean to offend CNA A, he/she just talked like that because he/she was ghetto. During an interview on 3/16/20 at 2:30 P.M., the Administrator and DON said they understood they had responsibility for keeping the residents free from all types of abuse at all times. Attempts were made to contact CNA G by phone on 3/16/20 at 9:00 A.M., 10:30 A.M., 12:30 P.M., and 1:45 P.M., with messages left each time and no return call. Attempts were made to contact CNA H by phone on 3/16/20 at 9:05 A.M., 10:35 A.M., 12:35 P.M., and 12:40 P.M., and 1:55 P.M., P.M., on 3/16/20 with messages left each time and one return call. When CNA H returned the telephone call on 3/16/20 at 12:35 P.M., he/she left a message stating he/she did not know why anyone needed to speak with him/her. He/she was called back at 12:40 P.M., on 3/16/20 and a message was left for him/her informing him/her that he/she was a witness to three separate incidents and he/she was needed to give his/her recount of the incidents. No return calls were received from CNA H. Record review of the Facility Investigation date 3/18/20 showed: -CNA G and CNA H were both notified on 3/13/20 that they were suspended pending investigation. -All three sampled residents were assessed by the nursing staff on the morning of 3/13/20 and none showed any physical injuries. -All three sampled residents' physicians were notified on the morning of 3/13/20. -The facility made the determination after the conclusion of their investigation, CNA G would be terminated and CNA H would be reinstated as all sampled residents described CNA G as being the abusive staff member. -All three sampled residents showed their Nursing Care Plans were being followed as written. -The facility determined that the incidents could not have been prevented as CNA G had been educated regarding Abuse and Neglect and Resident Rights facility policies upon hire. -The Administrator notified the CNA Registry regarding the abuse allegations towards CNA G. -CNA H was re-educated by the DON regarding the Abuse and Neglect policy. A certified letter was sent to CNA G on 3/18/20. As of 3/24/20, no return call had been received by CNA G. MO 876

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards by not maintaining water temperatures between 105 degrees Fahrenheit (F) to 120 degrees F in occupied resident room sinks and community bathhouses, which put the residents at increased risk [MEDICAL CONDITION] by scalding; failed to respond to reports of out of range/fluctuating water temperatures and investigate the causes; and failed to have a policy in place for maintaining safe water temperatures. This had the potential to affect the residents residing on the 100, 500 and 600 halls. The facility also failed to transfer one sampled resident (Resident #36) out of 12 sampled residents in a safe manner. The facility census was 46. Record review of the Burn Foundation website, www.burnfoundation.org, showed the following: -Hot Water Causes Third [MEDICAL CONDITION](full [MEDICAL CONDITION] go through the skin and affect deeper tissue resulting in white or blackened, charred skin) . -- .in 1 second at 156 degrees F; -- .in 2 seconds at 149 degrees F; -- .in 5 seconds at 140 degrees F; -- .in 15 seconds at 133 degrees F. 1. Record review of the Hot Water Temps facility log completed by the Maintenance Director dated 9/2018, 10/2018, 11/2018, 12/2018 and 1/2019 showed: -For the dates of 9/5/18, 9/15/18, 9/20/18, 9/26/18, 10/4/18, 10/9/18, 10/17/18, 10/23/18, 10/30/18, 11/6/18, 11/14/18, 11/20/18, 11/19/18, 12/5/18, 12/13/18, 12/20/18, 12/28/18, 1/2/19, 1/10/19, and 1/16/19: --Two rooms on each hall (100, 200, 300, 400, 500 and 600 halls) had water temperature checks and were documented to be in a safe range between 105 degrees F to 120 degrees F; --There was no documentation that showed the community bathhouses had water temperature checks. Observation on 1/27/19 at 10:43 A.M., showed the following water temperatures taken by the surveyor: -In room [ROOM NUMBER], the sink temperature measured 126.5 degrees F; -In room [ROOM NUMBER], the sink temperature measured 126.2 degrees F. Observation on 1/27/19 at 11:07 A.M., showed the following water temperatures taken by the surveyor: -In room [ROOM NUMBER], the sink temperature measured 130.0 degrees F; -In room [ROOM NUMBER], the sink temperature measured 127.9 degrees F; -In room [ROOM NUMBER], the sink temperature measured 129.4 degrees F; -In room [ROOM NUMBER], the sink temperature measured 126.6 degrees F. Observation on 1/27/19 at 11:10 A.M., showed the following water temperatures taken by the surveyor: -In room [ROOM NUMBER], the sink temperature measured 123.4 degrees F; -In room [ROOM NUMBER], the sink temperature measured 124.6 degrees F; -In room [ROOM NUMBER], the sink temperature measured 123.0 degrees F; -In room [ROOM NUMBER], the sink temperature measured 123.6 degrees F. During an interview on 1/27/19 at 11:05 A.M., Certified Nurses Assistant (CNA) B said: -The water temperatures in the sinks on the 100 hall did get hot at times, but then the temperature would go down; -He/she had noticed the water temperature was hot a few times, but that was not normal. During an interview on 1/27/19 at 11:06 A.M., Licensed Practical Nurse (LPN) D said: -He/she had not noticed any hot water issues where water can be too hot; -The resident in room [ROOM NUMBER] was cognitively impaired and could use his/her sink independently; -He/she was not aware if water temperatures were monitored. During an interview on 1/27/19 at 11:24 A.M., the Maintenance Director said: -He/she checked the water temperatures on the halls weekly; -He/she checked the temperatures in the resident room sinks; -He/she checked the resident room the furthest away from the hot water heater and both sides of the hallway closest to the hot water heater on all of the halls. Observation on 1/27/19 at 12:28 P.M., showed the water temperatures taken by the surveyor in room [ROOM NUMBER] was 135.5 degrees F at the sink. During an interview on 1/27/19 at 12:29 P.M., Resident #47 said when he/she washed his/her hands, the hot water tap at first feels warm and then it gets hotter and he/she adds cold water to the hot. Observation on 1/27/19 at 12:40 P.M., the water temperatures were: -room [ROOM NUMBER], the sink was 122.9 degrees F; -room [ROOM NUMBER], sink was 120.3 degrees F and -The 100/300 hall community bath house sink was 143.1 degrees F. During an interview on 1/27/19 at 12:46 P.M., Certified Medication Technician (CMT) A said: -He/she had not noticed hot water temperatures on the 500 hall; -None of the residents had complained of hot water temperatures on the hall; -He/she was unaware of any hot water issues at the facility and -He/she would report any hot water issues to the Maintenance Director or the charge nurse. During an interview on 1/27/19 at 12:48 P.M., LPN E said: -He/she had not noticed hot water temperatures on the 500 hall; -None of the residents had said there were issues of hot water temperatures on the hall; -He/she was unaware of any hot water issues at the facility and -He/she would report any hot water issues to the Maintenance Director. Observation on 1/27/19 starting at 12:49 P.M. showed the following water temperatures taken by the surveyor: -In room [ROOM NUMBER], the sink was 124.4 degrees F; -In room [ROOM NUMBER], the sink was 123.3 degrees F; -In room [ROOM NUMBER], the sink was 124.7 degrees F and -In room [ROOM NUMBER], the sink was 124.2 degrees F. During an interview on 1/27/19 at 12:51 P.M. LPN D said: -Residents from the 100 & 300 halls take showers in the community shower/bath house and -He/she has not received complaints of the water being too hot. During an interview on 1/27/19 at 12:58 P.M., the Director of Nursing (DON) said the facility did not have a written policy on how often to check water temperatures. Observation on 1/27/19 at 1:16 P.M. showed: -The Maintenance Director and surveyor completed rounds for water temperatures throughout the building; -The water temperatures were taken by the Maintenance Director and by the surveyor; -The water temperatures were as follows as taken by the Maintenance Director: --In room [ROOM NUMBER], the sink was 123.6 degrees F and the shower was 122.5 degrees F; --In room [ROOM NUMBER], the sink was 124.5 degrees F and the shower was 124.5 degrees F; --In the bathhouse on 500 hall: the sink was 106 F to 118 F and the temperature kept fluctuating; the shower was 122.3 degrees F; --In room [ROOM NUMBER], the sink was 123.2 degrees F; --In room [ROOM NUMBER], the sink was 124.3 degrees F; --In room [ROOM NUMBER], the sink was 123.5 degrees F; --In room [ROOM NUMBER], the sink was 123.4 degrees F; --In the bathhouse on 600 hall: the sink was 129.4 F and the shower was 130.8 F; --In room [ROOM NUMBER], the sink was 140.2 degrees F; --In room [ROOM NUMBER], the sink was 138.6 degrees F; --In room [ROOM NUMBER], the sink was 138.7 degrees F; --In room [ROOM NUMBER], the sink was 136.7 degrees F; --In room [ROOM NUMBER], the sink was 135.2 degrees F and -During the above observations, the water temperatures would fluctuate from hot to cold. During an interview on 1/27/19 at 1:16 P.M., while taking the above temperatures, the Maintenance Director said: -He/she would check the water temperatures on the halls weekly and sometimes more than weekly; -The facility had re-circulator water pumps; -The facility had chemical dispensers and this could change the water temperatures and make the temperatures jump up; -He/she had battled the water heaters since he/she had been employed here; -He/she had been here for about three months; -He/she had brought the issues up in the Interdisciplinary Team Meeting (IDT) meetings in the morning to the Administrator, the DON, and the Assistant Director of Nursing (ADON); -During the daily IDT meetings, he/she had stated the water temperatures were too hot and too cold and he/she was having trouble maintaining the water temperatures; -He/she expressed the water temperature issues all of the time but nothing was done by administration; -The water temperatures should be maintained between 105 degrees F and 120 degrees F; -The water temperatures could cause injury to a resident by scalding the resident; -He/she had taken temperatures during the last three months and had temperatures on the halls at 138 degrees F; -He/she would adjust the water heater then write on the temperature log the temperature when he/she got the temperature in a safe range; -He/she did not write down high or low water temperatures on the weekly log or what he/she did to try to correct the water temperatures and -He/she made adjustments all of the time because he/she could not maintain a safe water temperature on the halls. During an interview on 1/27/19 at 1:22 P.M. CMT A said: -He/she normally used hand sanitizer rather than washing his/her hands at resident sinks; -He/she had never noticed the residents' water was too hot unless it was turned on full blast on 600 hall; -He/she always added cold water to the hot and -If he/she noticed the water scalding hot he/she would report it to the Maintenance Director. Observation on 1/27/19 at 2:11 P.M. showed the following water temperatures taken by the surveyor: -In room [ROOM NUMBER], the sink was 134 degrees F; -In room [ROOM NUMBER], the sink was 132.8 degrees F; -In room [ROOM NUMBER], the sink was 131 degrees F and -In room [ROOM NUMBER], the sink was 132 F. During an interview on 1/27/19 at 1:31 P.M. CNA C said: -He/she worked as needed, usually 16 hours per week; -No resident had ever complained to him/her about water temperatures and -If he/she noticed the water was so hot he/she couldn't stand it he/she would report it to the Maintenance Director. During an interview on 1/29/19 at 11:29 A.M. CNA A said if a resident complained about hot water, he/she would tell the charge nurse. During an interview on 1/31/19 at 8:57 A.M. LPN A said: -CNAs should let the charge nurse know of any complaints about water temperatures and -He/she has not received notification of the water being too hot. During an interview on 1/27/19 at 2:15 P.M., the DON said: -He/she had been told by the Maintenance Director about water temperature issues; -During the IDT team morning meeting, the Maintenance Director said the water temperatures were too high on the 600 hall; -The Maintenance Director took care of the hot water temperature issues; -He/she did not really pay attention to the water temperature issues because the Maintenance Director was handling it; -He/she would pay more attention to care issues during the meetings and -The Maintenance Director stated he/she was doing micro adjustments to the water temperatures to fine tune them. During an interview on 1/27/19 at 3:08 P.M. the ADON said: -On a daily basis during the IDT meeting, the Maintenance Director would talk about needing to adjust the water temperatures; -The Maintenance Director had trouble maintaining temperatures in range on different halls in the facility; -The Maintenance Director had found the water temperatures out of range and had to adjust them; -The Maintenance Director would bring the issue up about the water temperatures two to three times per week. During an interview on 1/28/19 at 11:08 A.M., the Regional Director of Operations said: -Monitoring was expected weekly by the Maintenance Director and all staff should watch for hot water temperatures; -He/she expected the staff to report discrepancies in temperatures to the Administrator; -The Maintenance Director should be checking temperatures in bath houses also; -He/she expected the Maintenance Director to log the correct high temperatures on the log, bring it to the attention of the Administrator, and try to correct the hot water issue; -If brought to the attention of the Administrator, he/she should have acted upon the issues. During an interview on 2/1/19 at 8:29 A.M., the Administrator said: -Issues were brought to his/her attention daily in the IDT meeting; -The hot water heater had recently been replaced on the 400 hall; -The Maintenance Director had only brought cold water temperatures to his/her attention in the IDT meetings; -He/she had reviewed the water temperature logs and no water temperatures were out of range; -The Maintenance Director should have been documenting the actual temperatures on the logs, not the corrected temperatures. 2. Record review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Muscle weakness. Record review of the resident's Care Plan dated 11/6/18 showed he/she required transfers to be completed with a sit-to-stand lift (a mechanical lift used to assist residents when they were unable to transition from a sitting position to a standing position on their own). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by the facility staff for care planning) dated 1/9/19 showed he/she: -Was moderately cognitively impaired; -Needed the extensive assistance of two staff members with the sit-to-stand lift for transfers. Observation on 1/29/19 at 10:15 A.M., showed: -CNA D and CNA E transferred the resident from his/her wheelchair to the toilet; -The resident was placed in the sit-to-stand lift; -The belt buckle and Velcro were not properly secured around the resident; -The belt was under the resident's arm pits, which made the resident's shoulders go upward during the transfer; -The resident hung from the straps that were under his/her shoulders; -The clasp of the belt buckle was broken; -The Velcro did not attach due to wear; -The transfer was completed for the resident; -A second sit-to-stand sling in good repair was in the resident's room. During an interview on 1/29/19 at 11:00 A.M.: -CNA D said the resident's lift belt had been broken for at least one year; -CNA E said the resident's lift belt had been broken since he/she started at the facility about three months ago; -If a lift belt was broken it should be reported to the charge nurse or Maintenance Director; -CNA D and CNA E had not reported the lift belt was broken to the charge nurse or Maintenance Director. During an interview on 1/31/19 at 1:01 P.M., LPN A said: -He/she was not aware of the sit-to-stand lift being in poor repair; -He/she expected the CNAs to bring this to nurses' attention if the lift belts were in bad repair; -He/she expected the CNAs not to perform a transfer with buckles and straps in poor repair; -The CNAs should not complete a transfer with a broken lift belt; -This could cause damage to the resident's shoulders. During an interview on 1/31/19 at 1:42 P.M., LPN B said: -He/she was not aware of the sit-to-stand lift being in poor repair; -The CNAs had not reported any issues, but should report equipment in poor repair to the charge nurse; -He/she expected the CNAs to not continue a transfer with a resident when the lift belt was broken. During an interview on 2/1/19 at 11:00 A.M., the DON said: -If a lift was in poor repair, he/she expected the staff not to use the lift on the resident; -He/she expected the staff to take the sit-to-stand lift out of service and add it to the maintenance log; -He/she expected the staff to obtain another lift belt and not use one in poor repair that would not buckle; -The staff should not have used the bad sling and held the resident up by his/her arms. NOTE: At the time of the survey, the violation was determined to be at an imminent danger Immediate Jeopardy K level. 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. During the onsite visit, the facility began immediately training the staff on the hot water notification process, had a company come to the facility to reset and repair/replace the hot water tanks, implemented an on-going water temperature monitoring system to ensure safe temperatures of the water by the Maintenance Director, which included notification of any out of range temperatures to the facility's Regional Manager. A 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 E level.

Based on observation, interview, and record review, the facility staff failed to ensure one sampled resident (Resident #2) was free of any significant medication errors including omission of medications, which contributed to sub-therapeutic lab values, which in turn contributed to the resident having a [MEDICAL CONDITION] and a subsequent hospitalization where he/she had two additional [MEDICAL CONDITION]; and to ensure that a resident received his/her scheduled insulin as ordered by his/her physician for one sampled resident (Resident #3) out of 12 sampled residents. The facility census was 54 residents. Record review of the facility's policy titled Administering Medications with a revision date of 2/1/11 showed: -The purpose was to ensure medications would be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director; -The Director of Nursing (DON) services is responsible for the supervision and direction of all personnel with medication administration duties and functions; -The person preparing/administering the medication should contact the resident's attending physician or the facility's medical director for further instructions for any medication order that seemed to be unrelated to the resident's current [DIAGNOSES REDACTED]. -The individual administering the medication shall initial the resident's Medication Administration Record (MAR) on the appropriate line and date for that specific day before administering the next resident's medications; -If it is discovered the person administering medications has forgotten to initial in the appropriate space the supervisor shall notify that person, ask if the medication/treatment has been performed; -If the response indicates the medication/treatment was administered the staff member shall return to the facility and initial the MAR; -If the medication was not administered the missed dose/medication error protocol shall be followed; -Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that particular drug; -The resident's continuous need and use of as needed medications should be evaluated by the interdisciplinary care planning team, pharmacist and the attending physician on a monthly basis; -An explanatory note on the reverse side of the MAR must be entered when medications are withheld, refused, or given other than at the scheduled time; and -The DON and attending physician should be notified when three consecutive doses of a medication are refused or withheld. 1. Record review of Resident #2's lab results showed he/she had [MEDICATION NAME] Acid ([MEDICATION NAME] an anti-[MEDICAL CONDITION] medication with a normal range for males being 50-100 ug/ml (Microgram per milliliter)) sub-therapeutic (below normal) levels: -On 5/16/16 his/her [MEDICATION NAME] level was sub-therapeutic at 48; -On 5/27/16 his/her [MEDICATION NAME] level was sub-therapeutic at 36; -On 6/6/16 his/her [MEDICATION NAME] level was sub-therapeutic at 43; and -On 6/27/16 his/her [MEDICATION NAME] level was sub-therapeutic at 40; - The staff documented on the lab result sheet that they sent the lab results by fax to the resident's physician and there was no documentation by the resident's physician of any response to the fax or of any new orders given. Record review of the resident's MAR dated July 2016 showed he/she: -Had a [DIAGNOSES REDACTED]. -Had an order for [REDACTED].M. ante meridiem, meaning before noon) and once in the afternoon P.M. post meridiem, meaning after noon) for [MEDICAL CONDITION] disorder; -Had an order for [REDACTED].M., and once in the afternoon P.M.); -Did not receive the [MEDICATION NAME] 1000 mg and the [MEDICATION NAME] 1000 mg afternoon doses on 7/1/16 or have any documentation explaining why the medication was not given; -Did not receive the [MEDICATION NAME] 1000 mg and the [MEDICATION NAME] 1000 mg afternoon doses on 7/4/16 or have any documentation explaining of why the medication was not given. Record review of the resident's [MEDICATION NAME] lab results dated 7/5/16 showed he/she: -Had a sub-therapeutic level of 37; and -Had a hand-written note on the lab results to change the [MEDICATION NAME] to 250 mg take three tablets (750 mg) three times a day (once in the morning , once at noon, and once in the afternoon ). Record review of the resident's MAR dated July 2016 showed he/she: -Did not receive the [MEDICATION NAME] 750 mg at noon on 7/5/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 7/5/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 7/7/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 7/7/16; -Did not receive the [MEDICATION NAME] 750 mg at noon on 7/9/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 7/9/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 7/9/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 7/10/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 7/10/16; -Did not receive the [MEDICATION NAME] 750 mg in the morning on 7/12/16; -Did not receive the [MEDICATION NAME] 1000 mg in the morning on 7/12/16; -Did not receive the [MEDICATION NAME] 750 mg at noon on 7/12/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 7/12/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 7/12/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 7/15/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 7/15/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 7/19/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 7/19/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 7/20/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 7/20/16; -Did not receive the [MEDICATION NAME] 750 mg in the morning on 7/21/16; -Did not receive the [MEDICATION NAME] 1000 mg in the morning on 7/21/16; -Did not receive the [MEDICATION NAME] 750 mg at noon on 7/21/16; -Did not receive the [MEDICATION NAME] 750 mg at noon on 7/26/16; -Did not have any documented explanations of why the [MEDICATION NAME] and [MEDICATION NAME] were not given for any of the missed doses on the back of the MAR; and -Did not have any documentation noting the physician had been notified of the missed doses of [MEDICATION NAME] and [MEDICATION NAME]. Record review of the resident's [MEDICATION NAME] lab results dated 7/27/16 showed he/she had a sub-therapeutic level of 47. The staff documented on the lab result sheet that they sent the lab results by fax to the resident's physician and there was no documentation by the resident's physician of any response to the fax or of any new orders given. Record review of the resident's telephone orders dated 7/27/16 showed he/she did not have any new physician's orders [REDACTED]. Record review of the resident's nurse's notes showed he/she: -Did not have any nurse's notes written on 7/27/16; and -Did not have any documentation noting the physician had been notified of the multiple missed doses of [MEDICATION NAME] and [MEDICATION NAME]. -The staff documented on the lab result sheet that they sent the lab results by fax to the resident's physician and there was no documentation by the resident's physician of any response to the fax or of any new orders given. Record review of the resident's [MEDICAL CONDITION] care plan dated 8/11/16 showed he/she: -Had a potential for injury or adverse effects related to [MEDICAL CONDITION] disorder as evidenced by the need of routine anticonvulsant medication use to manage the [MEDICAL CONDITION]; -Would have oversight from staff to ensure he/she had no injury or adverse effects related to the [MEDICAL CONDITION] disorder; -Would have documentation of any episode of [MEDICAL CONDITION] activity that would include the duration; -Would be observed for any adverse effects related to the medications; -Would have [MEDICAL CONDITION] medications provided as ordered; and -Would have labs reviewed and sub-therapeutic levels reported promptly. Record review of the resident's MAR dated August 2016 showed he/she: -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 8/1/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 8/1/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 8/4/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 8/4/16; -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 8/9/16; -Did not receive the [MEDICATION NAME] 1000 mg in the afternoon on 8/9/16; -Did not receive the [MEDICATION NAME] 750 mg at noon on 8/15/16; and -Did not have any documented explanations of why the [MEDICATION NAME] and [MEDICATION NAME] were not given for any of the missed doses on the back of the MAR; and -Did not have any documentation noting the physician had been notified of the missed doses of [MEDICATION NAME] and [MEDICATION NAME]. Record review of the resident's [MEDICATION NAME] lab results dated 8/22/16 showed he/she: -Had a sub-therapeutic level of 15; -Had a hand-written note on the lab results sheet that the physician had been notified via fax and text at 5:05 P.M.; and -Hand a hand-written note on the lab results sheet that the physician had responded by text to continue the current dose at 5:15 P.M. Record review of the resident's telephone orders dated 8/22/16 showed he/she did not have any new physician's orders [REDACTED]. Record review of the resident's nurse's notes showed he/she did not have any nurse's notes written on 8/22/16. Record review of the resident's MAR dated August 2016 showed he/she: -Did not receive the [MEDICATION NAME] 750 mg at noon on 8/29/16; -Did not receive the [MEDICATION NAME] 750 mg at noon on 8/30/16; and -Did not have any documented explanations of why the [MEDICATION NAME] was not given for any of the missed doses on the back of the MAR; and -Did not have any documentation noting the physician had been notified of the missed doses of [MEDICATION NAME]. Record review of the resident's nurse's notes dated 8/30/16 at 7:30 P.M., showed the resident: -Was not acting right; -Was not able to speak when attempting to do so; -Was not making eye contact; and -Physician A was notified and gave an order to send the resident to the emergency room (ER) for evaluation. Record review of the resident's hospital records dated 8/30/16 showed he/she: -Was brought to the ER at 8:31 P.M.; -Had a sub-therapeutic [MEDICATION NAME] level of 33 in the ER; -Had two witnessed episodes of gaze deviation and muscle twitching (symptoms of a [MEDICAL CONDITION]) each [MEDICATION NAME] 30 seconds; -Was given [MEDICATION NAME] ([MEDICATION NAME] a sedative used following [MEDICAL CONDITION] activity) 1 mg in the ER at 9:00 P.M. for his/her [MEDICAL CONDITION]; -Was given [MEDICATION NAME] 1000 mg at 11:00 P.M. for his/her [MEDICAL CONDITION]; and -Had no further [MEDICAL CONDITION] activity in the ER; and -Was admitted to the hospital with [REDACTED]. Record review of the resident's MAR dated August 2016 showed the staff initialed the boxes that they gave the resident his/her afternoon dose of [MEDICATION NAME] on 8/31/16. (the resident had been sent and admitted to the hospital on [DATE]). Record review of the resident's nurse's notes dated 9/9/16 at 6:25 P.M., showed the resident returned to the facility at that time. Record review of the resident's MAR dated September 2016 showed he/she: -Had an order for [REDACTED].M., 2:00 P.M., and at bedtime); and -Had an order for [REDACTED]. Record review of the resident's lab results dated 9/12/16 showed he/she: -Had a sub-therapeutic [MEDICATION NAME] level of 36; -Had a sub-therapeutic [MEDICATION NAME] level of less than 3; and -Had no new physician's orders [REDACTED]. -The staff documented on the lab result sheet that the resident's physician was notified by fax and by text and the resident's physician texted the staff a reply of no new orders. Record review of the resident's telephone orders dated 9/12/16 showed he/she had a physicians order to draw the [MEDICATION NAME] and [MEDICATION NAME] levels monthly. Record review of the resident's MAR dated September 2016 showed he/she: -Did not receive the [MEDICATION NAME] 750 mg in the afternoon on 9/12/16; and -Did not have a documented explanation of why the medication was not given. Record review of the resident's telephone orders dated 9/13/16 showed he/she had a physician's orders [REDACTED]. Record review of the resident's MAR dated September 2016 showed he/she: -Did not receive the [MEDICATION NAME] 750 mg at 2:00 P.M. on 9/13/16; and -Did not have a documented explanation of why the medication was not given. During an interview on 9/15/16 at 4:00 A.M., Licensed Practical Nurse (LPN) E said: -He/she started the 6:00 A.M. medication pass around 5:00 A.M. because there were quite a few residents who had medications; -A blank on the MAR meant someone forgot to sign the MAR; -If initials were circled it meant that the medication was not given; and -There should be something on the back of the resident's MAR saying why the medication was not given. During observation of the medication pass on 9/15/16 from 5:00 A.M. to 7:00 A.M., the resident: -Was seen in the lobby of the facility at 5:30 A.M.; -Was sitting in his/her wheelchair; -Was awake with his/her eyes open; and -Did not receive any medication from LPN E. Record review of the resident's MAR dated September 2016 showed he/she: -Did not receive the [MEDICATION NAME] 750 mg at 6:00 A.M. on 9/15/16; -Did not have a documented explanation of why the medication was not given; and -Did not have any documentation noting the resident's physician had been notified of not receiving the scheduled [MEDICATION NAME]. During an interview on 9/15/16 at 7:00 A.M., LPN E said all the residents who had 6:00 A.M. medications had received them. During an interview on 9/16/16 at 4:00 P.M. Certified Medication Technician (CMT) B said: -If there was a blank area on the MAR it meant the medication was not signed out which also meant the medication was not given; -If there were initials that were circled it meant the medication was not given; and -If a medication was not given there should be something documented on the back of the resident's MAR explaining why it wasn't given. During an interview on 9/19/16 at 10:00 A.M., CMT A said: -If the MAR has a blank it meant the medication was not signed out which meant it wasn't given; -If the initials were circled it meant the medication was not given; and -If a medication is not given there should be an explanation on the back of the resident's MAR as to why it wasn't given. During an interview on 9/19/16 at 10:30 A.M., Pharmacist A said: -The facility receives medication on demand meaning when the medication is re-ordered it is sent; -The resident had a 15 day supply of [MEDICATION NAME] tablets delivered to the facility on [DATE], 8/9/16, and 8/20/16; -The resident had a 30 day supply of [MEDICATION NAME] tablets delivered to the facility on [DATE], 7/20/16, and 8/20/16; -The resident had a 10 day supply of [MEDICATION NAME] solution delivered to the facility on [DATE]; -The resident had a 23 day supply of [MEDICATION NAME] solution delivered to the facility on [DATE]; -As a pharmacist there were two reasons he/she could think of why a lab value would be sub-therapeutic: --The resident was not metabolizing and/or absorbing the medication; and --The medication was not being given to the resident. During an interview on 9/19/16 at 11:25 A.M., Physician A said: -He/she had no explanation as to why the [MEDICATION NAME] levels were sub-therapeutic; -He/she honestly thought the resident was not receiving his/her medications and that was why he/she did not increase the dose of the [MEDICATION NAME] and the [MEDICATION NAME]; -The resident ended up having a [MEDICAL CONDITION] at the facility, was sent to the ER and had two more [MEDICAL CONDITION] while in the ER; -The resident did not have any more [MEDICAL CONDITION] while in the hospital and was getting the medications; -The resident was not metabolizing and absorbing the medications or he/she is not getting the medications; -He/she didn't think the resident was getting the medications at the facility; and -He/she had not been notified of the resident missing multiple doses of the [MEDICATION NAME] and [MEDICATION NAME]. During an interview on 9/19/16 at 2:30 P.M., the resident said he/she: -Didn't know if he/she was getting all the medications he/she was supposed to get; and -Knew he/she was getting medications at all times during the day, but didn't know what he/she was getting each time. During an interview on 9/20/16 at 11:10 A.M., LPN D said: -All medications should be given as ordered; -Blank areas on the MAR meant it wasn't signed out/done so it wasn't given; -Circled initials meant medications were not given; -If a medication was not given there should be a reason documented on the back of the resident's MAR explaining why it wasn't given; and -The resident's physician should be notified when three doses have been missed or not given. MO 733 2. Record review of Resident #3's face sheet showed he/she was admitted to the facility on [DATE]; and had the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] diabetic (damage to the nerves resulting in sensory loss in the extremities); Record review of the resident's physician's orders [REDACTED]. -He/she had a physician's orders [REDACTED]. -He/she had a physician's orders [REDACTED].M. and P.M. were listed). Record review of the residents [DATE]/1/16 through 6/30/16 showed: -On 6/2/16 his/her 8:00 P.M. blood sugar was recorded as 283, facility staff did not document administering the resident his/her [MEDICATION NAME], or his/her refusal of his/her [MEDICATION NAME]; and -On 6/26/16 his/her 8:00 P.M. blood sugar was recorded as 201, facility staff did not document administering the resident his/her [MEDICATION NAME], or his/her refusal of his/her [MEDICATION NAME]. Record review of the resident's POS dated 7/1/16 through 7/31/16 showed: -He/she had a physician's orders [REDACTED]. -He/she had a physician's orders [REDACTED]. -He/she had a physician's orders [REDACTED]. Record review of the residents MAR dated 7/1/16 through 7/31/16 showed: -On 7/3/16 his/her 8:00 P.M. blood sugar was recorded as 217, facility staff did not document administering the resident his/her [MEDICATION NAME], or his/her refusal of his/her [MEDICATION NAME]; -On 7/15/16 he/she refused to have his/her blood sugar checked at 8:00 P.M., facility staff documented administering the resident his/her [MEDICATION NAME]; -On 7/24/16 his/her 8:00 A.M. blood sugar was recorded as 445, facility staff did not document administering the resident his/her [MEDICATION NAME], his/her refusal of his/her [MEDICATION NAME], and did not document notifying his/her physician that his/her blood sugar was above 400; -On 7/26/16 his/her 8:00 P.M. blood sugar was recorded as 338, facility staff did not document administering the resident his/her [MEDICATION NAME], or his/her refusal of his/her [MEDICATION NAME]; and -On 7/27/16 his/her 8:00 P.M. blood sugar was recorded as 328, facility staff did not document administering the resident his/her [MEDICATION NAME], or his/her refusal of his/her [MEDICATION NAME]. Record review of the resident's POS dated 8/1/16 through 8/31/16 showed: -He/she had a physician's orders [REDACTED]. -He/she had a physician's orders [REDACTED].M. and P.M. listed). Record review of the residents MAR dated 8/1/16 through 8/31/16 showed: -On 8/7/16 his/her 8:00 P.M. blood sugar was recorded as 165, facility staff did not document administering the resident his/her [MEDICATION NAME], or his/her refusal of his/her [MEDICATION NAME]; and -On 8/10/16 he/she refused to have his/her blood sugar checked at 8:00 P.M., facility staff documented administering the resident his/her [MEDICATION NAME]. During an interview on 9/19/16 LPN C said: -A blank space on the MAR could indicate multiple things; -Usually it's that a treatment or medication was not given, or either the nursing staff forgot to complete the documentation; and -It is his/her expectation that physician's orders [REDACTED]. 3. During an interview on 9/20/16 at 3:10 P.M. the DON said: -If the MAR had a blank slot it meant the medication was not signed for and therefore was not given as ordered; -If the initials were circled it meant the medication was not given; -He/she expected all medications that were not given to have a reason why they were not given documented on the back of the MAR; -He/she expected the resident's physician to be notified if medications were not given; -He/she expected all medications to be given as ordered; -He/she expected that the resident's MAR documentation to be accurate and complete. -He/she expected to have the staff ask for clarification or explanation from the resident's physician if medication orders did not seem appropriate for the condition of the resident; -He/she expected staff to have a conversation with the resident's physician if lab values were sub-therapeutic and dosages were not changed; -He/she expected staff to notify him/her of any concerns with medication dosages and lab values that were sub-therapeutic; and -There should have been more documentation regarding conversations that had taken place regarding sub-therapeutic lab values and no changes in the medication dosages. MO 733

Based on interview and record review, the facility staff failed to identify, assess and thoroughly document the skin condition and treatments for one sampled closed record (Resident #17) prior to discharge. He/she was admitted to the hospital with [REDACTED]. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) pressure sore (also called decubitus ulcers are injuries to skin and underlying tissue resulting from prolonged pressure on the skin) to his/her right hip with moisture associated skin damage to his/her gluteal folds and perineum out of eight sampled residents. The facility census was 56 residents. Record review of the Clinical Practice Guidelines, Number 15, treatment of [REDACTED]. -Assess the pressure ulcer initially for location, stage, size, tracts, exudate (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury), necrotic tissue (death of tissue in response to disease or injury), and presence or absence of granulation (formation of new tissue, usually pink to red in color) tissue and [MEDICATION NAME] (healing by the growth of epithelium over a denuded surface). -To monitor progress or deterioration, the examiner must accurately measure the length, width, and depth of the ulcer; -Reassess pressure ulcers at least weekly; -Indicators of a deteriorating pressure ulcer include increases in exudate and wound [MEDICAL CONDITION], loss of granulation tissue, and a purulent discharge; -A clean pressure ulcer should show evidence of some healing within two to four weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary. Record review of the facility's policy titled, Wound and Skin Care Policy and Protocol revised 2/1/12, showed it's purpose was to prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions; to promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown, and to promote healing for pressure ulcers in a cost efficient and timely manner. The procedure directed staff to do the following: -The purpose of the assessment is to collect enough information to evaluate the resident's general condition, characterize a pressure ulcer, and identify related causes and complications; -A Braden Scale should be completed for all residents upon admission, readmission, when a significant change of condition occurs, and with each Minimum Data Set (MDS; a Federally mandated assessment tool required to be completed by facility staff for care planning) assessment; -Identified risk factors should be discussed in Resident Assessment Protocol (RAP) documentation and addressed in the resident's care plan to assure appropriate interventions to manage the risk are implemented; -Residents with a Braden score (a tool used for predicting pressure sore risk) of 12 or less should be considered to be at high risk for pressure ulcer development; -Residents should be examined thoroughly at least weekly by a licensed nurse on a Weekly Skin Assessment form; -Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc ., should be assessed and documented weekly by the Wound Nurse, or designee, on the Wound Evaluation Flow Sheet; -Documentation should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissue, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; -The PUSH Tool 3.0 and Pressure Ulcer Healing Chart should be completed in conjunction with these weekly wound assessments; -Any risk factors identified by the Braden Scale, MDS, or other assessment should be reviewed and addressed as determined appropriate through the RAI process, including the resident's care plan. -A nutrition consultation should be completed for residents who are at-risk for malnutrition; -Pressure reduction surfaces should be provided on beds and chairs for at-risk residents, unless intolerance or lack of needs is noted and documented; -For resident's who have pressure ulcers, treatment choices are generally not stage-specific; -The goals of dressing an ulcer are to keep the ulcer bed moist and the surrounding skin dry, protect the ulcer from contamination, and promote healing; -Nursing staff should keep the attending physician aware of the progress of all ulcers, especially those in higher-risk residents, those that do not heal as anticipated and those that develop complications; -The Wound Nurse, or designee, should maintain and update a list of residents who have been identified to be at high risk, and an assessment and documentation schedule; -Residents with wounds should be reviewed during weekly Risk Management Committee meetings for progress, interventions, and care plan revision as appropriate; -The Risk Management Committee should also monitor to assure the facility's policies and protocols are followed; and -At the direction of the facility Quality Assurance Committee, a Weekly Wound Report should be completed by the Director of Nursing (DON), or designee, on a weekly basis for review and monitoring by the Quality Assurance Committee to assure the objectives of this Policy and Protocols are being followed. Record review of the Facility's Weekly Skin Assessment Policy and Procedure revision on 2/1/11, showed: -The Licensed Nurses shall perform a weekly skin assessment, in addition to the inspection performed by the nurse's aide staff; -Any area of impairment identified during skin assessment, including incontinent care and activities of daily living (ADL) with the assistance of nurses aid staff, should be reported to the licensed nurse for initiation of interventions; -The nurse shall document results of the skin assessment on the pharmacy Treatment Administration Record (TAR) or weekly Skin Inspection report. 1. Record review of Resident #17's Face Sheet showed he/she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. diff-bacteria that can cause swelling and irritation of the large intestine and is infectious-it is characterized by diarrhea and abdominal pain), pain, [MEDICAL CONDITIONS], high blood pressure, diabetes, [MEDICAL CONDITION] (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), difficulty walking, [MEDICAL CONDITION] and obesity. Record review of the resident's Pressure Sore Risk assessment dated [DATE], showed he/she: -Had no impairment to sensory perception and was able to respond meaningfully to pressure related discomfort; - Had most skin often; -Was chair fast and his/her ability to walk was severely limited or non-existent; -Was slightly limited in his/her ability to change body position -Was able to make frequent though slight changes in position independently; -Had adequate nutrition and ate over half of most of his/her meals; -Had no apparent problem with friction and shear-he/she was able to move in bed and in chair independently and had sufficient muscle strength to lift up completely during movement. He/she maintained good position in bed/chair at all times and -Scored a total of 17 on the pressure risk tool (a score of 9 or less was considered high risk and a score of 15 to 18 was considered mild risk). Record review of the resident's Care Plan dated 8/4/15, showed he/she: -Had visual impairment and had the potential for self-care deficits and needed set up and oversight with care tasks. It showed: -He/she needed set up and oversight with baths/showers to promote safety and well-being. -He/she was independent with bed mobility, and self-transferred without assistance. Staff was to cue him/her and to provide oversight. -He/she toileted himself/herself as desired and staff was to encourage him/her to use the grab bars for support with transfers. -He/she completed his/her own grooming and hygiene, dressing and staff was to provide assistance as needed. -He/she used a wheelchair for mobility and could self-propel the wheelchair and occasionally ambulated. Staff was to provide oversight of safety as needed. -There was no care plan regarding the resident's risk for skin integrity problems and there were no interventions for preventing skin breakdown (pressure relief cushion/mattress, ointments) documented in his/her care plan. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was alert, oriented and cognitively intact; -Was independent with bed mobility, transferring, toileting, dressing and hygiene; -Needed limited assistance with mobility; -Was continent of bowel and occasionally incontinent of bladder; -Was at risk for pressure ulcers but had no unhealed pressure ulcers, venous ulcers (also known as stasis ulcer, is the most common of lower extremity ulcers caused by poor blood circulation) or arterial ulcers (also known as ischemic ulcers are mostly located on the lateral surface of the ankle or the distal digits and are caused by poor blood supply to the area); -Had no other ulcers, wounds or skin problems and -Received a pressure relieving device for his/her bed and chair, and received ointments/medications (other than to his/her feet) for preventive care. Record review of the resident's TAR dated 10/1/15-10/31/15, showed a physician's orders [REDACTED]. The TAR showed the nursing staff followed the treatment orders from 10/1/15 to 10/6/15 when treatment concluded. Record review of the resident's Weekly Skin Assessments showed: - On 10/2/15, his/her skin was warm, dry with fair turgor (a sign used to assess fluid loss/dehydration). The resident's skin was intact and the body diagram showed no areas of concern (it was blank); and -On 10/9/15, his/her skin was warm, dry with fair skin turgor. His/her skin was intact and the body diagram showed no areas of concern (it was blank). Record review of the resident's Nursing Notes dated 10/1/15-10/31/15, showed: -The resident was being treated for [REDACTED]. diff and [MEDICAL CONDITION]; -On 10/12/15, nursing staff found a small open area on the resident's left lower back. The measurements were 0.1 centimeters (cm) x 0.2 cm x 0.1 cm. The nurse documented there was a new order for triple antibiotic ointment (TAO) to the area and to cover it with a band-aid. The nurse also documented the resident had a reddened perineum area and there was a new order for [MEDICATION NAME] ointment (a moisture barrier ointment used to prevent/heal skin irritations) to be applied on every shift and as needed to the area. There were no additional notes showing the progress of the resident's wound or wound healing. Record review of the resident's TAR dated 10/1/15-10/31/15, showed a physician's orders [REDACTED]. Change daily and as needed with soiling (the original order date was not identified). The TAR showed nursing staff started the treatment on 10/12/15 and continued treatments daily except on 10/13/15 and 10/17/15 (areas were left blank) and 10/20/15 (there was no documentation showing why the treatments were not completed). The TAR showed the area as healed on 10/22/15. Record review of the resident's Care Plan showed the most recent update, dated 10/13/15, did not show a care plan for his/her skin/wounds. It did not show if he/she had developed a wound to his/her lower back and there were no interventions regarding an skin care treatment interventions or preventive interventions implemented to prevent further deterioration of the resident's wound or surrounding skin. There were no further updates to the resident's care plan. Record review of the resident's Weekly Skin Assessments showed: -On 10/16/15, his/her skin was warm and dry with fair turgor. It showed the facility used a pressure reduction mattress and wheelchair cushion for the resident. The nurse documented the resident's skin was not intact. There was no additional documentation describing the skin that was not intact, the type of skin issue (pressure sore, skin tear, abrasion) the size or location of the problem area, or what if any treatment was applied. The body diagram did not show where the non-intact skin area was located (it was blank). -On 10/23/15, the resident's skin was warm, dry and had fair skin turgor. Staff was using a pressure reduction mattress and wheelchair for the resident. The nurse documented the resident's skin was not intact. There was no additional documentation describing the non-intact skin (to include the type, size, location) or any treatments applied. The body diagram was left blank. - On 10/30/15, the resident's skin was warm, dry and had fair turgor. The nurse documented the resident's skin was intact. There was no additional documentation on the assessment and the body diagram was left blank. - On 11/6/15, the resident was in the hospital (no skin assessment was completed). - On 11/13/15, the resident's skin was warm, dry and had good skin turgor. The resident's skin was intact and the nurse documented there were no skin issues. The body diagram showed there was a red area on the front of the resident's left shin. Record review of the resident's Nursing Notes showed: -On 11/1/15-11/16/15, nursing staff documented no skin concerns (open areas, skin tears, redness or abrasions); the resident had no skin treatments ordered. He/she was still being treated with antibiotics for [MEDICAL CONDITION]; -On 11/4/15-11/10/15, the resident was an inpatient in the hospital geri-psych unit for an acute mental health issue (he/she returned on 11/10/15); -On 11/10/15 and 11/11/15, the notes did not show if the resident had any skin issues or was receiving any skin treatments; and -There were no nursing notes from 11/16/15-11/24/15, and no note showing nursing staff identified any skin issues or wounds on the resident. Record review of the resident's Pressure Sore Risk assessment dated [DATE], showed he/she: -Had no impairment to sensory perception and was able to respond meaningfully to pressure related discomfort; -Was rarely moist-his/her skin was usually dry; -Was chair fast and his/her ability to walk was severely limited or non-existent; -Was able to make frequent changes in position without assistance; -Had inadequate nutrition; -Had no apparent problem with friction and shear-he/she was able to move in bed and in his/her chair independently and had sufficient muscle strength to lift up completely during movement. He/she maintained good position in bed/chair at all times; and -Had a total risk score of 19 (a score of 9 or less was considered high risk and a score of 15 to 18 was considered mild risk). Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Weekly Skin Assessments showed on 11/20/15, the nurse documented the resident refused the skin assessment. Record review of the resident's Skin Monitoring Certified Nursing Assistant (CNA) Shower Review dated 11/20/15, showed the resident refused his/her shower on 11/20/15. Record review of the resident's Medical Record showed there was no wound care report or documentation showing the nursing staff had completed a formal assessment of the resident's lower back wound that included the type of wound, location, measurements, description of the skin affected and surrounding skin, treatment ordered and preventive measures to prevent further deterioration. Record review of the resident's TAR dated 11/1/15-11/30/15, showed a physician's orders [REDACTED]. Nursing documentation showed nursing staff followed the physician's orders [REDACTED]. They did not document any treatment was applied from 11/24/15 to 11/27/15 (four days) and then treatment was resumed on 11/28/15 and 11/29/15. There was no documentation showing why the nursing staff did not complete the treatment for [REDACTED]. Record review of the resident's Nursing Notes dated 11/24/15, showed the resident's physician saw the resident and had new orders. The note did not identify what the new orders were for and did not identify any skin issues (to include a wound the resident was receiving treatment for [REDACTED]. The nurse did not document a description of the resident's wound to his/her left back at the waist nor progress of the wound since treatment orders were initiated. There was no documentation showing why the treatment was not completed from 11/24/15 to 11/27/15. Record review of the resident's Physician's Note dated 11/24/15, showed the resident was complaining of recurring [MEDICAL CONDITION] (excessive fluid in the tissues) and a burning sensation in his/her feet. The physician reviewed the resident's physiological health and noted no cough (his/her lungs were noted to be clear), shortness of breath nausea, vomiting constipation or diarrhea. His/her extremities revealed mild to moderate [MEDICAL CONDITION]. The physician did not document any skin concerns or wounds found on (or reported about) the resident. The physician was to continue current medication, treat the resident's [MEDICAL CONDITION] and burning sensation, and continue to monitor his/her response to current treatments. Record review of the resident's Skin Monitoring Comprehensive CNA Shower Review dated 11/25/15 showed the resident had a rash and a sore. The body diagram showed the rash was located at the front of the resident's right leg at the fold where the leg and groin meet. Documentation showed cream was applied there. The sore was shown on the diagram to be located on the back of the resident at the right lower back/waist area. This section was signed by the CNA. The section where the nurse assessment was to document treatment orders was left blank, but was signed by the nurse on 11/25/15. Record review of the resident's Nursing Notes showed there were no nursing notes documented from 11/25/15-11/30/15. Record review of the resident's Weekly Skin Assessments showed on 11/27/15, the nurse documented the resident's skin was warm, dry and had good skin turgor. The nurse did not document if the resident's skin was intact (area was left blank). The nurse documented the resident had [MEDICAL CONDITION] in his/her bilateral lower extremities (legs). The body diagram was left blank. Record review of the resident's Nursing Notes dated 11/30/15, showed at or around 3:15 A.M., the resident turned on his/her call light and when the nurse arrived he/she saw the resident halfway out of his/her bed, attempting to transfer to his/her wheelchair. The nurse reminded the resident that he/she could not stand and noted the resident had a wet, non-productive cough. The resident's roommate said that the resident had been coughing all night. The resident requested to be sent to the hospital. The resident's physician and daughter were notified and the resident was sent out at or around 2245 (10:45 P.M.) Record review of the resident's Hospital Admission History and Physical dated 11/30/15 showed: -On 11/30/15 at 4:08 A.M., the resident was admitted to the hospital. -On 11/3015 at 8:26 A.M. the physician examined the resident and noted the resident was brought in to the hospital emergency room from the facility with a fever (temperature of 101.2) audible ronchi (rattling lung sounds) and high frequency respirations. It was reported the resident had been treated for [REDACTED]. He/she had a chest x-ray which showed healthcare associated pneumonia and was started on antibiotics. The physician documented the resident could not stand and was primarily wheelchair bound and the resident also reported having loose stools. -Upon physical examination of the resident the physician noted the resident's skin was warm and dry but noted there were two Stage II decubitus ulcers to his/her right gluteal cleft (the groove between the buttocks that runs from just below the sacrum (base of the spine) to the perineum and on the upper outer quadrant of his/her right buttock. He/she also noted [MEDICAL CONDITION] in his/her legs. -The resident was admitted to the hospital in the intensive care unit for further evaluation and management of [MEDICAL CONDITION] due to right lower lobe pneumonia and possible [DIAGNOSES REDACTED]. and a wound consult would be obtained. Record review of the resident's hospital Wound Progress Note dated 11/30/15 at 5:34 P.M., showed: -The resident's skin assessment showed the resident had a Stage II to the right hip, the wound was 6 cm x 3 cm and was pink with a small amount of serous (thin and water-like fluid) drainage. There was no surrounding [DIAGNOSES REDACTED] (redness), induration (signs of infection) or fluctuance (indication of bacteria). The resident also had moisture associated skin damage to his/her gluteal folds and perineum, a red rash to his/her pannus (excess skin below the abdomen) and under both breasts. -The nurse documented the resident's moisture associated skin damage was from frequent stools (pictures accompanied written documentation). Record review of the resident's Hospital Discharge Summary dated 12/8/15, showed: -The resident was admitted on [DATE] at 4:08 A.M. with [MEDICAL CONDITION] (which was resolved) and other active problems to include a Stage II decubitus ulcers. -The resident had slow but continued clinical improvement regarding his/her infections and [MEDICAL CONDITION] concerns. He/she was stabilized and was discharged to another nursing facility on 12/8/15. During an interview on 12/18/15 at 1:05 P.M., CNA A said: -He/she worked with the resident while he/she lived at the facility and the resident was a very large sized person; -The resident was heavy care and needed a lift to transfer him/her at times and had to assist him/her with incontinence care, bathing and dressing; and -He/she did not remember the resident having any skin issues or wounds before he/she left the facility to go to the hospital. During an interview on 12/18/15 at 1:10 P.M., CNA B said: -He/she was familiar with the resident while he/she was a resident at the facility; and -The resident was heavy care and was assisted with toileting, bathing and dressing, but he/she did not notice any pressure sores or hear that the resident had any skin issues on his/her bottom. During a telephone interview on 12/21/15 at 11:00 A.M., the Wound Care Nurse said: -He/she was not aware of the resident having any pressure sores, wounds or skin issues prior to being admitted to the hospital (on 11/30/15); -He/she was not treating the resident's skin for anything prior to his/her hospitalization and he/she was not being seen by the wound care consultants; -At 11:41 A.M., the Wound Care nurse called and said he/she reviewed the resident's medical records and there was no indication that the resident had any skin issues, wounds or pressure sores on his/her buttocks, but there was documentation that the nursing staff had been providing treatment to an area on the resident's back; -He/she did not see any documentation in the resident's medical record showing the wound on the resident's back had been assessed and did not find any wound measurements or description of the wound, surrounding skin or weekly monitoring of the wound; -He/she said he/she did not assess the wound and was not providing any treatment to it; -He/she was not able to say what type of wound it was due to a lack of documentation; and -He/she only saw the treatment order for the wound to his/her back that was dated 11/19/15. During an interview on 12/21/15 at 1:29 P.M., Licensed Practical Nurse (LPN) A said: -He/she was one of the nurses that worked with the resident and documented notes regarding the resident and was one of the nurses that were treating the wound on the resident's back; -The resident was very obese and initially had what looked like a yeast infection and the resident would pick at it and scratch it; -The location was on the resident's left lower back between his/her bra strap and his/her waist; -The wound was superficial, on the surface of the resident's skin and was not a pressure sore, so they did not measure it and would not have requested the wound care nurse or wound care team to assess it; -They notified the resident's physician and obtained a physician's orders [REDACTED]. -The resident could have rubbed the area because the wound was located where the resident would lean against his/her wheelchair; -After they began treating the area, if they noticed the treatment was not working or the area worsened, they would initiate the wound nurse and wound care team to assess the area; -Weekly skin assessments were completed by the evening shift nurses, and any skin concerns were supposed to be documented on those weekly sheets; -The CNA's completed the shower sheets where they also were supposed to document any/all issues with the resident's skin when they completed the resident's showers; -He/she thought they had healed the wound on the resident's back before the resident went into the hospital and did not remember the resident having any pressure ulcers on his/her bottom or any additional skin issues; -The resident was alert and oriented and would let them know if he/she noticed any skin issues or had any concerns about his/her skin or any other problem he/she may have been having, so the nurse could address it; -If the CNAs saw any skin concerns when they were assisting with cares, they were supposed to notify the nurses so that the resident's skin could be assessed and treatment could be obtained and provided if necessary; and -He/she was not informed by any of the nursing staff that there were any concerns with the resident's skin or that there were any pressure ulcers or wounds noted on the resident's skin before he/she was sent to the hospital. During a telephone interview on 12/21/15 at 2:24 P.M., CNA C said: -He/she worked with the resident and was responsible for providing care and assistance to the resident while he/she was a resident at the facility; -The resident was incontinent and they had to provide incontinence care to him/her and give his/her showers; -The resident was supposed to receive showers on Monday, Wednesday and Friday, but usually only accepted a shower on Wednesdays; -When they assisted the resident with a shower, they usually had to dry the resident off while he/she stood up in order to get him/her completely dry because he/she was obese; -He/she documented any skin issues on the resident's shower sheets and documented the location on the body diagram each time he/she gave the resident a shower; -He/she did not remember if he/she worked with the resident the week that he/she was sent to the hospital, but he/she did not remember seeing any pressure sores on the resident's buttocks when he/she gave the resident a shower (on 11/25/15); -The resident had a scratch on his/her lower back that the nurses were putting ointment on, but he/she did not see a pressure sore on the resident; -Whenever they saw any open areas or skin issues during cares or when giving the shower, they were supposed to notify the charge nurse and if it was seen during the shower, they were supposed to document it on the shower sheet; -The resident was alert and oriented and would come get the CNA when he/she needed to go to the bathroom; and -If something was concerning the resident, he/she would let them know and the resident did not have any complaints about his/her skin that he/she was aware of. During an interview on 12/22/15 at 12:20 P.M., the Director of Nursing (DON) said: -Whenever the CNA's provide care for a resident, they should be looking to see if there is anything that was not normal for the resident that would be concerning and report it immediately to the charge nurse; -If the CNAs were giving a bath/shower and noticed a skin area they should document it on the bath/shower sheet and report it to the charge nurse so an assessment could be completed; -The charge nurses should complete the weekly assessments of the resident's skin and document any and all skin areas (concerns) on the resident and get treatment orders or notify the wound care nurse (if there is a wound) so they can assess the resident's skin also; -He/she would expect any skin tears, wounds or pressure sores to be documented (description and measurements); -He/she was not employed at the facility at the time the resident was in the facility, but he/she would have expected any skin areas the resident had prior to leaving the facility to have been documented; -It was possible that the resident may have acquired the pressure sore and maceration while at the hospital, before they were able to assess him/her (while waiting in the emergency room ); -They did not have any documentation from the hospital concerning the hospital's assessment of the resident; and -They did not have any documentation showing communication with the hospital nursing staff regarding the resident's care while he/she was in the hospital. Complaint #MO 727

Based on observation, interview and record review, the facility failed provide pain interventions for one sampled resident (Resident #2) with cognitive impairments who expressed pain when being provided with wound care; to consistently and appropriately assess pain and document the resident's pain intensity level for one sampled resident (Resident #2); to properly assess the residents pain and before and after administering as needed (PRN) pain medication for one sampled resident (Resident #11); to develop a comprehensive care plan for pain management that was individualized for one sampled resident (Resident #2); and to follow the facility policy and procedure for assessment and documentation of pain and pain medication administration for two sampled residents who had pain and received PRN pain medications (Resident #2 and #11) out of 12 sampled residents. The facility census was 53 residents. Record review of the facility's policy titled, "Pain Medications" revised 2/1/12, showed it's purpose was to provide guidelines for assessing the resident's level of pain prior to administering non-narcotic or narcotic [MEDICATION NAME]. The procedure stated following: -A resident's experience of pain is highly individual and subjective. Pain is whatever the resident says it is; -Intense pain can result from even minor procedures or surgery; -Be familiar with the physiologic and behavioral signs of pain, and visible physiologic and/or behavioral signs of pain do not always accompany the experience of pain; -Residents may be reluctant to report pain due to the belief that pain is a normal part of the aging process or because of a reluctance to "bother" busy staff members; -Acute pain assessment consists of gathering both subjective and objective data; -Assessment tools included pain assessment tools, as indicated per facility protocol, the 5-point (or 10-point) Pain Intensity Scale with word modifiers, the FACES Pain Rating Scale (for non-verbal or cognitively impaired residents or residents who do not speak English); and/or the Pain Assessment form and Pain Flow Sheet; -Obtain the following subjective information from the resident: --Location: Ask the resident to point to the site(s) of pain; --Pain Intensity: Provide the resident with a 5-point (or 10-point) Pain Intensity Scale and ask the resident to choose the best description of his/her pain experience. Use the FACES Pain Rating Scale with residents who are cognitively impaired, non-verbal, or who do not speak English; --Pain Quality: Encourage the resident to use adjectives to describe the quality of pain (sharp, piercing, dull, aching, shooting, burning, intense, agonizing, unbearable, etc); --Onset and Duration: Ask the resident about the time of onset and periods of relief (if any); --Aggravating factors: Ask the resident if there are circumstances or activities that make the pain worse; --Alleviating factors: Ask the resident if there are circumstances or activities that help reduce the pain; --Accompanying symptoms: Ask the resident if there are accompanying symptoms such as nausea, vomiting, and sensitivity to light and sounds. -Obtain objective information through assessment of behavioral responses to (acute) pain such as the following: --Facial wrinkling/grimacing; --Tightly closed or widely opened and blinking eyes; --Crying or moaning; --Aggression, hitting, or biting; --Increase in body movements; --Guarding; --Decreased interaction; --Need for more rest, and/or --Irritability/mental confusion; -Obtain objective information through assessment of physiologic responses to (acute) pain such as the following: --Evidence of depression, anxiety, fear or hopelessness; --Effect of pain on activities of daily living; and/or --The condition of the site of pain, if appropriate. -Evaluate the effectiveness of non-pharmacological interventions (e.g., repositioning, warm or cold compresses, etc.); -The following information should be recorded in the resident's medical record as appropriate: --Subjective and objective evidence of pain; --Condition of the pain site, if appropriate; --The drug name, dose, time, date, and route of administration; --The name and title of the individual assessing the resident for pain and administering the medication; and --Any adverse reaction experienced by the resident. Record review of the facility's policy titled, "Wound and Skin Care Policy and Protocol" revised 2/1/12, showed: -Resident's should be assessed for pain, related to the pressure ulcer or its treatment per policy; -Manage pain by eliminating or controlling the source when possible (wound coverings, support surfaces, repositioning); -Try to prevent or relieve pain associated with or made worse during dressing changes and debridement; -[MEDICATION NAME] may be given routinely before dressing changes and as needed after dressing changes or debridement; and -Staff should assess and care plan pain management (such as providing [MEDICATION NAME] 30-45 minutes prior to pressing change) when appropriate. 1. Record review of Resident #2's Face sheet showed he/she was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION] (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable); -Abnormality of gait; -Altered mental state; -Anxiety state; -[MEDICAL CONDITION] (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception); and -Intellectual disability. Record review of the resident's comprehensive care plan reviewed on 5/28/13, showed: -The staff did not update the resident's care plan to reflect he/she was experiencing pain related to pressure ulcers, did not include a section in the resident's care plan that addressed pain or how staff should assess the resident's pain, and did not state how to assess the resident's pain or to use the FACES Pain Rating Scale. Staff documented in the resident's care plan under the behaviors section on 1/7/14, that [MEDICATION NAME] (a medication used to treat severe pain) had been added to the resident's medication regimen to manage his/her pain. Record review of the resident's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument required to be completed by facility staff for care planning) dated 11/17/13, showed he/she: -Was able to answer three out of 15 items asked on the Brief Interview for Mental Status (BIMS), where three represents severely cognitively impaired; -Required extensive assistance with one person physical assist with bed mobility, transfers, walking, locomotion, dressing, toilet use, personal hygiene, and bathing; -Used a wheelchair; -Was frequently incontinent of urine and occasionally incontinent of bowel; -Had [MEDICAL CONDITION], dementia, depression, and [MEDICAL CONDITION] (a [MEDICAL CONDITION] marked by severely impaired thinking, emotions, and behaviors); -Had no pain; -Was at risk for developing pressure ulcers and currently had no pressure sores; and -Had a pressure reducing device in his/her bed and wheelchair. Record review of the resident's "Pain Evaluation" form dated 11/17/13, showed: -Staff did not complete the resident's quarterly pain assessment to include completing the Pain Advanced Dementia Scale (PainAD); -Staff did not document any information related to the resident's pain and concluded that the resident had no pain, intervention was not necessary, and to re-assess quarterly or with the onset of pain; and -Staff did not complete a "Pain Evaluation" to appropriately assess and treat the resident's pain when the resident had acquired pressure ulcers which had caused the resident pain. Record review of the front side of the resident's MAR (an area for staff to document their initials and times for administration of medication) dated December 2013, showed: -A physician's order for Tylenol (a medication used to treat mild pain and fever) 325 milligrams (mg), take two tablets (650 mg) orally every six hours PRN for pain, and it was administered on 12/16/13 at 6:00 A.M., 12/24/13, 12/28/13, 12/29/13, and 12/30/13 at 7:30 A.M.; -A physician's order to conduct a pain assessment (0-10; zero meaning no pain and ten meaning very severe horrible pain) for each shift (7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M., and 11:00 P.M. to 7:00 A.M.). --For 7:00 A.M. to 3:00 P.M., out of 31 opportunities, staff documented 27 results for that month, leaving three blank areas for pain intensity results. Staff documented the resident's pain level at zero in December for that shift except on 12/29/13, where staff had documented a question mark (?) for the pain rating result; --For 3:00 P.M. to 11:00 P.M., out of 31 opportunities, staff documented ten results for that month, leaving 21 blank areas for pain intensity results. Staff documented the resident's pain level at zero in December for that shift except on 12/29/13, where staff had documented a question mark (?) for the pain rating result; -- For 11:00 P.M. to 7:00 A.M., out of 31 opportunities, staff documented 21 results for that month leaving ten blank areas for pain intensity results. Staff documented the resident's pain level at zero consistently in December for that shift; and --The MAR indicated [REDACTED]. Record review of the reverse side of the resident's MAR (an area for staff to document the time, date, name of the medication, reason for administering the medication, an assessment of the medications effectiveness) dated December 2013, showed: -On 12/28/13, Tylenol 650 mg was given orally for "preventive pain (for bottom area)," and the result was effective. At 6:30 P.M., Tylenol 650 mg was given orally for "preventive pain (for bottom area)" and the result was effective. -On 12/29/13 at 8:00 A.M., Tylenol 650 mg was given orally for "bottom discomfort" and the result was effective. At 5:00 P.M., Tylenol 650 mg was given orally for "bottom discomfort" and the result was effective. -Staff did not document any information related to administration of PRN Tylenol on 12/16/13, 12/24/13, and 12/30/13. Record review of the resident's PRN Pain Medication MAR indicated [REDACTED] -Before giving PRN pain medication, please utilize non-pharmacological methods using the key below: --Offer reassurance, reposition, offer/provide water or a snack, change room temperature and/or put more clothing on the resident, toileting needs addressed, and other-document on back of MAR. -Staff was instructed to conduct a pain assessment (0-10) prior to PRN medication administration; -On 12/28/13, staff did not document attempting non-medication interventions prior to administration of Tylenol PRN. At 9:15 A.M., and 6:30 P.M., staff documented a question mark (?) in the area for staff to rate the resident's pain on a zero to ten scale. -On 12/29/13 at 9:15 A.M., and 6:30 P.M., staff documented attempting all interventions listed. At 8:00 A.M. and 5:00 P.M., staff documented a question mark (?) in the area for staff to rate the resident's pain on a zero to ten scale. -A follow-up evaluation was conducted for medication administered on 12/28/13 and 12/29/13. -Staff did not document any information related to administration of Tylenol on 12/16/13, 12/24/13, and 12/30/13. -The MAR indicated [REDACTED]. Record review of the resident's correlating nurse's notes for December 2013 showed: -On 12/13/13 at 2:50 P.M., staff documented the resident had been crying/yelling and singing for most of this shift, and when asked why the resident stated, "I don't know." The resident said he/she was not in pain. -On 12/16/13 at 9:55 A.M., staff documented the resident had been yelling/crying uncontrollably at the top of his/her lungs. Drinks and food were offered, but nothing worked. The resident denied pain. -On 12/22/13, staff documented the resident was up in common area yelling repetitive sounds and was able to be redirected for a few minutes, then resumed yelling with increased volume. The resident was send to the emergency room for an elevated temperature later that day; -On 12/23/13, At 2:30 P.M., staff documented the resident had been sobbing, yelling, and crying all day long. He/she was offered food, drink, and reassurance, but nothing made the behaviors subside. At 9:00 P.M., staff documented the resident was crying/screaming until approximately 8:30 P.M. and was inconsolable. The resident denied pain and said "I don't know" when asked what was bothering him/her. -On 12/24/13 at 1:50 P.M., staff documented the resident had been crying/chanting/yelling throughout the day. The resident stated nothing hurts and "I'm all right." At 8:00 P.M., staff documented the resident was yelling and screaming almost continually. The resident denied pain. -On 12/28/13 at 9:00 A.M., dressing was changed to buttocks wounds. --From 11:00 P.M. to 7:00 A.M., staff documented finding several open areas (five to six) on his/her coccyx (tailbone). These areas were bleeding and one of the areas had puss and feces on it. The resident was very lethargic and alert only to his/her name. The writer stated there was Duoderm (a flexible dressing that adheres to skin) on one area and it was very loose, scrunched-up, and splattered with blood and feces. As the Duoderm was being pulled off, off came a small bit of skin. The areas were cleaned with sterile water and patted dry then dressed. When checked about two and a half hours later, the resident's wounds seemed to be drying out and there was little drainage. -On 12/28/13 at 5:50 P.M., staff documented the resident was "yelling out" and unable to redirect and denied pain or discomfort. -On 12/29/13 at 9:15 A.M., staff documented the resident was yelling out continuously and was unable to redirect. The resident denied pain or discomfort. From 11:00 P.M. to 7:00 A.M., staff documented the resident had slept the whole night. The resident was lethargic alert to his/her name with a moan. -On 12/30/13, staff documented the resident had been yelling and singing very loudly. The resident denied pain and fluids were offered. -On 12/31/13 at 12:00 A.M., staff documented the resident had been screaming since the start of the shift and quieted at approximately 11:30 P.M. A late entry was documented by staff on 12/31/13 for 12/30/13, which stated the resident had been yelling/crying/sobbing whether he/she was up in his/her wheelchair or down in bed eating or drinking. When asked what was wrong, the resident said, "I'm all right." Record review of the resident's Physician's Order Sheet (POS) dated January 2013, showed: -A physician's order for Tylenol 325 mg, take two tablets (650 mg) orally every six hours PRN for pain; -Conduct a pain assessment (0-10) and rate pain each shift; -On 1/7/14, a physician's order for [MEDICATION NAME] 0.3 milliliters (ml) sublingual (sl) two times daily for pain; -The POS did not state to assess the resident's pain using the FACES Pain Rating Scale; and -No physician's order to use a topical treatment for [REDACTED]. Observations on 1/6/14 at 7:30 A.M. showed: -The resident was laying in his/her bed covered, yelling out and loudly moaning which could be heard from the main nurse's station and the resident's room was near the end of the hall. During an interview on 1/6/14 at 7:40 A.M., Licensed Practical Nurse (LPN) B said: -The resident had no complaints of pain; -The resident was able to voice his/her needs; -Staff was not able to figure out why the resident yelled out frequently and the resident had been in the facility for many years; and -He/she did not know why the resident shouted out and screamed. Observations on 1/7/14 at 11:22 A.M. showed: -The resident in his/her bed turned toward his/her left side and yelling loudly, and had been yelling out loudly since approximately 10:35 A.M. Record review of the resident's "physician progress notes [REDACTED]. -The resident had developed wounds on his/her coccyx (above the buttocks) and left ischium (forms the lower and back part of the hip bone) and had been more agitated in the past week; -The skin exam found wounds over coccyx and left ischium, both wounds had slough (live tissue separating from dead tissue); -The assessment showed sacral and left ischium decubitus ulcers; and -[MEDICATION NAME] would be given to manage the residents pain. Observations of the resident's wound treatment on 1/8/14 at 11:05 A.M., showed: -LPN A performed wound care for the resident; -The resident had one wound on his/her coccyx. The wound bed covered with yellow slough and the edges around the wound were bright pink; -The resident had a second wound on his/her right buttock. The wound bed was covered with yellow slough, and the edges around the wound were bright pink; -The resident was yelling out loudly during wound care; -Staff repeatedly asked the resident if he/she was having pain; -The resident acknowledged that he/she was experiencing pain when staff was cleaning the resident's wounds; -Staff did not ask the resident if he/she would like to have something for his/her pain; -Staff continued the wound care to the resident, did not stop care to give the resident his/her pain medication, and did not premedicate the area of the wound prior to completing his/her treatment. Record review of the resident's nurse's notes dated 1/8/14 and not timed, showed the staff did not document that the resident experienced pain during wound care, and the staff did not document that they offered the resident his/her PRN pain medication to manage his/her pain during the wound care. During an interview on 1/8/14 at 2:20 P.M., Certified Nurse's Aide (CNA) A said: -While assisting with incontinence care, the resident had some pain due to the wounds on his/her bottom last week; and -He/she had reported this to the charge nurse. During an interview on 1/8/14 at 2:30 P.M., the MDS Coordinator said: -The Pain Evaluation forms should be filled out even if the resident was denying pain; and -Nursing staff should add any new interventions to the resident's care plan. Record review of the resident's physician's telephone order dated 1/8/14, showed a physician's order to transfer him/her to a geriatric psychiatric facility. During an interview on 1/9/14 at 8:35 A.M., LPN A said: -The resident did not verbalize pain on a scale; -Rating the resident's pain using a zero to ten scale would not be appropriate for the resident; -He/she would know the resident was in pain by facial expressions and grimacing; -The FACES Pain Scale should be used for assessing the resident's pain; -Non-medication interventions should be documented in the resident's record prior to giving a resident PRN pain medication. During an interview on 1/9/14 at 10:30 A.M., the Director of Nursing (DON) said: -The resident was resistive to laying down and acquired his/her wounds by scooting his/her bottom back and forth on the wheelchair due to agitation; -The resident could let staff know if he/she was in pain; -He/she was unaware the resident experienced pain due to the wounds present on his/her coccyx and bottom, and did not know the resident had received PRN Tylenol for bottom pain; -The physician had ordered scheduled [MEDICATION NAME] for the resident since his/her physician thought that the resident could not communicate his/her pain; and -Non-medication interventions should be documented in the resident's record prior to giving a resident PRN pain medication. Record review of the resident's hospital "Physical Therapy Daily Treatment Form" dated 1/10/14, showed: -The resident had pressure ulcers and also exhibited behavioral signs of pain; -A PainAD evaluation was conducted and the resident scored a six out of ten; -The resident had repeated trouble calling out, loud moaning/groaning, and crying; -The resident had facial grimacing; and -The resident's body language was tense, distressed, and fidgeting. 2. Record review of Resident #11's Face sheet showed he/she was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. -Muscle weakness. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was able to answer 15 out of 15 items asked on the BIMS; -Required only supervision with bed mobility, transfers, walking, locomotion, dressing, eating, and bathing; -Had depression and [MEDICAL CONDITION]; -Was on a scheduled pain medication regimen, received PRN pain medication, did not receive any non-pharmacological interventions for pain; and -Had occasional pain and rated his/her pain at a six out of ten. Record review of the resident's "Pain Evaluation" dated 9/13/13, showed: -The resident had occasional leg pain and was on a PRN medication to treat his/her pain; -Instructions for staff to refer to the resident's care plan for necessary pain management interventions; and -Staff did not document completing a quarterly "Pain Evaluation" which was due in December 2013. Record review of the resident's comprehensive care plan reviewed on 9/13/13, showed he/she had the potential for discomfort related to conditions [MEDICAL CONDITION] as evidenced by routine and PRN medication use, and staff was instructed to: -Encourage the resident to report episodes of breakthrough pain; -Assist with positioning for comfort as needed or requested; -Provide PRN medication for complaints of pain; -Document response to all PRN medication administered; -Observe him/her for nonverbal signs of pain such as grimacing and increased facial movements; -Observe his/her ability to rest at night, assess for pain as needed; and -Notify the physician of any episodes of pain not relieved with current regimen. Record review of the resident's MAR indicated [REDACTED] -A physician's order for [MEDICATION NAME]/[MEDICATION NAME] (APAP-a narcotic and non-narcotic medication used to treat pain) 5/325 mg orally every six hours PRN for pain; -A physician's order to conduct a pain assessment using a pain scale of 0-10 and to rate the resident's pain every shift; -Staff documented the resident had received PRN [MEDICATION NAME]/APAP on a daily basis 40 times out of a potential 124 times in December 2013; -Staff documented the resident's level of pain from 7:00 A.M. to 3:00 P.M. was zero 31 out of 31 opportunities; -Staff documented the resident's level of pain from 3:00 P.M. to 11:00 P.M. was zero 12 out of 31 opportunities, and was not documented 19 times; -Staff documented the resident's level of pain from 11:00 P.M. to 7:00 A.M. was zero 21 out of 31 opportunities, and was not documented ten times. Record review of the reverse side of the resident's MAR indicated [REDACTED] -The resident complained of leg pain; -Staff did not consistently document conducting a pain scale evaluation prior to administering PRN [MEDICATION NAME], and did not consistently document the result of the medication with a follow-up pain scale; -Staff did not consistently document attempting non-medication interventions prior to administering PRN [MEDICATION NAME]; -Staff documented the resident received PRN [MEDICATION NAME] 14 times on the back of the MAR, which did not correspond to the front of the resident's MAR. Record review of the resident's corresponding nurse's notes for December 2013, showed staff did not document consistently attempting non-medication interventions prior to administering PRN [MEDICATION NAME], and did not consistently assess his/her pain using a zero to ten scale before and after administering PRN [MEDICATION NAME]. During an interview on 1/8/14 at 2:30 P.M., the MDS Coordinator said: -Documentation for administering PRN narcotics should include a pain scale evaluation before and after administration, as well as attempting non-medication interventions prior to administering the medication. The documentation should be present on the resident's MAR. During an interview on 1/9/14 at 8:35 A.M., LPN A said: -He/she was unaware of the resident complaining of pain, and the resident usually complained of indigestion; -If the resident required PRN [MEDICATION NAME] daily, he/she would try to obtain an order to administer the medication on a scheduled basis and not PRN; -He/she would try non-medication interventions such as giving the resident a leg rub or repositioning if the resident complained of pain. During an interview on 1/9/14 at 10:30 A.M., the DON said: -The resident would always ask for PRN [MEDICATION NAME] in the evening; -She would like to see this medication on a scheduled basis rather than PRN; -Staff should rate pain for the resident before and after administering the medication as well as document any non-medication interventions in the resident's record.

This deficiency is uncorrected. For previous examples, refer to the Statement of Deficiencies dated 1/9/14. Based on observation, interview, and record review, the facility staff failed to report a change in the condition of the skin surrounding one sampled resident's (Resident #3) PEG tube ([DEVICE]-percutaneous endoscopic gastrostomy tube- a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) site to his/her physician or seek changes in the resident's treatment orders, out of eight sampled residents. The facility census was 54 residents. Record review of the facility's Wound and Skin Care Policy and Procedure revised 2/1/12, showed: -One of the purposes of the policy was to promote a systemic approach and monitoring process for the care of residents with existing wounds and for those who were at risk for skin breakdown; -Findings of the weekly skin assessment should be documented by the licensed nurse on a Weekly Skin Assessment form; -Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, on the Wound Evaluation Flow Sheet; -Residents with wounds should be reviewed during the weekly Risk Management Committee Meetings for progress, interventions, and care plan revision, as appropriate. 1. Record review of Resident #3's Face Sheet showed the resident: -Was admitted to the facility on [DATE]; -Had a gastrostomy tube ([DEVICE]-surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube). Record review of the resident's quarterly Minimum Data Set (MDS- a federal mandated assessment tool required to be completed by staff for care planning) dated 12/31/13, showed the resident: -Was unable to speak; -Was able to understand others; -Did not have any long-term or short-term memory problems; -Had modified independence cognitively when making decisions; -Was totally dependent upon two to three staff members for his/her Activities of Daily Living (ADLs) needs; -[DIAGNOSES REDACTED]. -Had a feeding tube ([DEVICE]). Record review of the resident's feeding care plan last reviewed 12/31/13, showed the following: -Required a tube feeding per [DEVICE] to maintain nutrition and hydration; -The resident will have hydration needs met while experiencing no adverse effects or complications related to the use of the [DEVICE] for feeding through the next review; -The staff were instructed to provide local treatment to the resident's [DEVICE] site as ordered by the resident's physician; -The care plan did not instruct the staff on how to clean the resident's [DEVICE] site, how often to clean the resident's [DEVICE] site, and did not instruct the staff to notify the resident's physician of any skin or other problems with the resident's [DEVICE] site. Record review of the resident's physician's orders [REDACTED]. This order was dated 12/28/13. Record review of the resident's Treatment Administration Record (TAR) dated 2/1/14 through 2/28/14, showed: -The staff was to change the resident's [DEVICE] dressing each shift, and as needed for soiling. This order was dated 12/28/13; -Documentation showed staff had signed the resident's TAR indicating the resident's [DEVICE] site care had been completed on each shift ("7-3", "3-11" and "11-7") on 2/27/14 and 2/28/14; -There was no documentation showing the resident's dressing was changed on an "as needed" basis. Record review of the resident's Nurse's Notes dated 2/24/14 through 3/5/14, showed no documentation related to the condition of the resident's [DEVICE] site, i.e., the presence of any redness or drainage from the site. Record review of the resident's Weekly Skin Assessments dated 2/25/14 through 3/6/14 showed only one assessment had been completed. There was no documentation showing the resident did not have a PEG tube nor was the condition of the skin at that [DEVICE] site recorded. Record review of the resident's Tube Feeding form dated 2/27/14 through 3/6/14, showed the appearance of the [DEVICE] site was documented as "red." Once (2/27/14 on the "7-3" shift) it was described as "dry red." There was no documentation showing the resident's physician had been notified. Record review of the resident's POS dated 3/1/14 through 3/31/14, showed the resident was to have his/her [DEVICE] dressing changed every shift, and as needed, for soiling. Record review of the resident's POS dated 3/1/14 through 3/31/14, showed the resident had orders which included the following: Change [DEVICE] dressing each shift, and as needed for soiling. This order was dated 12/28/13. Record review of the resident's TAR dated 3/1/14 through 3/31/14, showed there was no documentation related to the care of the resident's [DEVICE] site. Observation and interview on 3/6/14 showed: -At 8:29 A.M., RN Z raised the resident's gown and checked his/her [DEVICE] site. The dressing had a moderate amount of dried as well as moist brown drainage present. There was redness of the resident's skin in the area covered by the [DEVICE] flange (a projecting rim, collar, or ring used to give additional strength or stiffness or support to an area); -He/she used gauze and soap and water to clean around the [DEVICE] site. RN Z said there were no specific orders on how he/she was to provide the site care, so that was what he/she knew to do; --Stringy, mucousy brown drainage was removed from around the [DEVICE] site. Once clean, the skin under the flange of the [DEVICE] was bright red and shiny. RN Z said he/she first thought the [DEVICE] site might be leaking a little, then said it might be infected, i.e., he/she wasn't sure. He/she was not sure if anyone had notified the resident's physician about the redness or drainage, but he/she would. Record review of the resident's Nurse's Notes dated 3/6/14, showed the facility staff notified the resident's physician of the condition of the resident's [DEVICE] site, i.e., redness and drainage. This had been done at the request of the surveyor. New orders were received. Record review of the resident's Telephone Orders (TOs) dated 3/6/14, showed the staff was to clean the [DEVICE] site with wound cleanser and then apply [MEDICATION NAME] cream (a topical, antibacterial cream; often used to treat burns) to the site twice a day for 14 days. During an interview on 3/16/14 at 1:52 P.M., RN Z said: -He/she looked in the resident's medical record and found no documentation showing the resident's physician had been notified of the redness or drainage at the [DEVICE] site. He/she said such information was usually found in the Nurse's Notes; -The facility had a new sheet they were using to record a resident's tube feeding, and this form had a column for the condition of the [DEVICE] site. He/she acknowledged the documentation showed the site was red, and said there was no documentation showing anyone had been notified about it, i.e., neither the Wound Nurse nor the resident's physician; -He/she expected there to have been documentation about the [DEVICE] site skin on the resident's Weekly Skin Assessment, but the assessment that had been due on 3/4/14 had not been completed. He/she verbalized the previous assessments had not included the condition of the resident's [DEVICE] site or the condition of the skin surrounding it; -He/she thought the Wound Nurse should be informed about the change in the resident's skin, but he/she wasn't sure; -He/she had read the in-service information provided after the facility had been surveyed and signed that he/she had completed this. He/she said there were no demonstrations of any processes reviewed nor had he/she performed any return demonstration related to any of the processes reviewed. He/she said no one had yet watched him/her (audited) performing cares. During an interview on 3/16/14 at 3:28 P.M., the Director of Nursing (DON) said: -He/she expected the staff to report changes in a resident's condition to his/her primary care physician, and that included changes in a [DEVICE] site; -He/she had noticed the resident's Weekly Skin Assessment that had been scheduled for 3/4/14 had not been documented, and he/she had reminded the staff that it needed to be completed; -He/she expected the [DEVICE] site to be identified on the Weekly Skin Assessment forms and that a notation would be made about the condition of the site; -If there were skin issues, he/she expected the staff to share that information with the Wound Nurse; -He/she had been unaware Resident #3's skin had become reddened or that there was drainage coming from his/her [DEVICE] site. He/she said the resident had such issues in the past, i.e., it comes and goes; -There was a place on the new tube feeding form for staff to document the condition of the [DEVICE] site. He/she acknowledged there was documentation showing the site was "red," but there was no documentation on the resident's forms showing the resident's physician had been notified. He/she said this should be found in the resident's Nurse's Notes and/or there should be new orders, if the physician had been called; -Staff had been provided in-service materials related to wound/skin care after the facility's annual survey (in January, 2014).