Every finding on record at Estates of Perryville, LLC, The

Based on observation, interview, and record review, the facility failed to implement a comprehensive care plan with specific interventions tailored to meet individual needs for two residents (Residents #4 and #13) out of 20 sampled residents. The facility census was 98.Review of the facility's policy titled, Care Plan and Care Plan Conference, dated 08/24/24, showed:- A care plan shall be used in developing the resident's daily care routine and will be available to the team for review to ensure the best person-centered care is provided to our residents; - A comprehensive care plan will be generated through collaboration with the interdisciplinary team, resident, and responsible party, to be completed by the 21st day of admission;- The care plan will reflect a problem, goal, and interventions to guide the interdisciplinary team to assist the resident in achieving the desired outcome for a specific problem. 1. Review of Resident #4's medical record showed:- admitted on [DATE];- Diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), bipolar (a mental disorder that causes unusual shifts in mood), major depressive disorder (MDD - a long-term loss of pleasure or interest in life), and asthma (condition making breathing more difficult);- History of self-harm/suicide attempts. Review of the resident's Care Plan, last revised 03/02/26, showed:- Did not address the history of self-harm/suicide attempts with specific goals and interventions;- Did not address dementia with specific goals and interventions;- Did not address bipolar with specific goals and interventions;- Did not address asthma with specific goals and interventions. During an interview on 03/10/26 at 3:10 P.M., Resident #4 said he/she had attempted suicide three times in the past. During an interview on 03/11/26 at 10:46 A.M., Certified Nurse Aide (CNA) B said he/she did not know about Resident #4's past or any interventions in place. During an interview on 03/11/26 at 10:35 A.M., Licensed Practical Nurse (LPN) A said he/she did not know about Resident #4's past. 2. Review of Resident #13's medical record showed:- admitted on [DATE];- Diagnosis of obstructive sleep apnea (condition causing difficulty breathing or periods of not breathing at times);- An order for continuous positive airway pressure (CPAP - medical equipment to assist with breathing) machine at bedtime. Review of the resident's Care Plan, revised 01/07/26, showed:- Did not address obstructive sleep apnea with use of a CPAP. During an interview on 03/11/26 at 6:05 P.M., the Director of Nursing (DON) and the Administrator said anything pertinent to a resident's care should be included in the care plan, and that the care plan should be revised as needed, but at least quarterly.

Based on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care, before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for 11 residents (Residents #2, #3, #4, #6, #8, #13, #30, #49, #59, #73, and #90) out of 20 sampled residents. The facility census was 98. Review of the facility's policy titled, Use of Psychotropic Drugs, reviewed 08/24/24, showed: - Residents who have not used antipsychotic (medication primarily used to manage psychosis (a mental disorder with a severe loss of contact with reality)) drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; - Residents who use antipsychotic drugs will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue use of these drugs; - With the physician as the leader, and in collaboration with a pharmacist and other members of the interdisciplinary team, each resident's drug regimen will be reviewed on a monthly basis, taking into consideration of the dose, duration of use, indications for use, presence of adverse consequences which indicate the dose should be reduced or discontinued, and non-pharmacological interventions (such as behavioral interventions); - Each resident will receive the lowest possible dose and for the shortest period of time necessary for treating his or her condition or to improve the target symptoms being monitored; - After initiating or increasing the dose of an antipsychotic drug, the behavioral symptoms will be reevaluated at least quarterly during the review to determine the effectiveness of the antipsychotic drug and the potential for reducing or discontinuing the dose based on target symptoms and any adverse effects or functional impairment; - If the antipsychotic drug is identified as probably causing or contributing to adverse consequences, risks and benefits will be considered in the decision-making process regarding the continuation, reduction or discontinuation of the antipsychotic drug; - Decisions and rationale will be documented in the medical record. 1. Review of Resident #2's medical record showed: - An admission date of 05/10/23; - Diagnoses of epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), major depressive disorder (a serious mental health condition characterized by at least two weeks of persistent, pervasive low mood, loss of interest, and low self-esteem), anxiety disorder (common, treatable mental health conditions characterized by excessive, persistent fear or worry that interferes with daily life), impulse disorder (mental health conditions characterized by an inability to resist urges, resulting in repetitive, harmful behaviors like gambling, stealing, or violence), and schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia (a chronic brain disorder with symptoms that can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation) symptoms such as hallucinations, delusions, and disorganized thinking, and a major mood disorder); - An order for Risperdal (an antipsychotic medication) 4 milligrams (mg) by mouth at bedtime for schizoaffective disorder, dated of 12/29/25; - An order for Zyprexa (an antipsychotic medication) 10 mg by mouth every morning and at bedtime for schizoaffective disorder, dated of 12/29/25; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the Risperdal and Zyprexa. 2. Review of Resident #3's medical record showed: - An admission date of 09/26/20; - Diagnoses of schizoaffective disorder, major depressive disorder, and generalized anxiety disorder; - An order for quetiapine (an antipsychotic medication) 50 mg by mouth three times a day for major depressive disorder, dated of 02/04/26; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the quetiapine. 3. Review of Resident #4's medical record showed: - An admission date of 02/19/26; - Diagnoses of major depressive disorder, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs); - An order for bupropion (an antidepressant medication) 12 hour extended release (ER) 200 mg by mouth in the morning for depression, dated 02/20/26; - An order for Zyprexa 5 mg 1.5 tablet by mouth at bedtime for bipolar disorder and agitation, dated 02/19/26; - An order for trazodone (an antidepressant medication) 100 mg by mouth at bedtime for depression, dated 02/19/26; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the bupropion, Zyprexa, and trazodone. 4. Review of Resident #6's medical record showed: - An admission date of 08/16/22; - Diagnoses of schizophrenia, generalized anxiety disorder, and Parkinson's disease (a movement disorder of the nervous system that worsens over time); - An order for haloperidol (an antipsychotic medication) 1 mg by mouth every eight hours as needed for generalized anxiety disorder, dated of 02/13/26; - An order for Zyprexa 15 mg by mouth at bedtime for schizophrenia, dated 03/08/26; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the haloperidol and Zyprexa. 5. Review of Resident #8's medical record showed: - An admission date of 04/04/25; - Diagnoses of attention deficit hyperactivity disorder (a common developmental disorder marked by persistent inattention, hyperactivity, and impulsivity that begins in childhood and can continue into adulthood), schizophrenia, narcissistic personality disorder (a mental health condition marked by an excessive sense of self-importance, a deep need for admiration, and a profound lack of empathy for others), autistic disorder (a condition related to brain development that affects how people see others and socialize with them), and bipolar type schizoaffective disorder; - An order for Zyprexa 5 mg by mouth two times a day for depression, dated of 03/10/26; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the Zyprexa. 6. Review of Resident #13's medical record showed: - An admission date of 11/03/25; - Diagnoses of schizophrenia, anxiety, and cerebral infarction (lack of blood flow to brain); - An order for Risperdal 1 mg by mouth one time a day related to schizophrenia and anxiety, dated 11/04/25; - An order for Keppra (an antiseizure medication also used as a mood stabilizer) 750 mg two tablets by mouth two times a day related to schizophrenia and cerebral infarction (stroke), dated 11/03/25; - An order for quetiapine 25 mg by mouth two times a day related to schizophrenia and anxiety, dated 11/03/25; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the Keppra and quetiapine. 7. Review of #30's Physician Order Sheet (POS) showed: - An admission date of 02/16/26; - Diagnoses of suicidal ideations, insomnia, and major depressive disorder, recurrent, severe, with psychotic symptoms; - An order for aripiprazole (an antipsychotic medication used to treat depression) 5 mg by mouth in the morning related to major depressive disorder, recurrent, severe with psychotic symptoms, dated 03/04/26; - An order for Remeron (an antidepressant medication) 15 mg by mouth in the evening for major depressive disorder, recurrent, moderate, dated 02/16/26; - An order for trazodone 50 mg 0.5 tab by mouth at bedtime for insomnia, dated 02/16/26; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the aripiprazole, Remeron, and trazodone. During an interview on 03/08/26 at 12:30 P.M., Resident #30 said he/she did not recall the staff explaining the risks and benefits of his/her medications to him/her. 8. Review of Resident #49's medical record showed: - An admission date of 12/14/23; - Diagnoses of traumatic brain injury (a disruption in brain function caused by a blow, jolt, or penetrating head injury), major depressive disorder, anxiety, migraines, post-traumatic stress disorder (PTSD – a psychological distress following a traumatic event), cerebral infarction, and falls; - An order for Zyprexa oral tablet 10 mg by mouth at bedtime for bipolar disorder, dated 02/06/24; - An order for amitriptyline (an antidepressant medication) 25 mg by mouth at bedtime related to major depressive disorder, dated 02/05/26; - An order for Lamictal (an antiseizure medication also used as a mood stabilizer) 100 mg by mouth one time a day related to impulsiveness and unspecified convulsions (define), dated 04/15/23; - An order for Zoloft 50 mg by mouth one time a day related to major depressive disorder, dated 11/07/25; - An order for divalproex (an antiseizure medication also used as a mood stabilizer) delayed release 500 mg two tablets by mouth twice a day for seizures and mood, dated 02/06/24; - An order for Keppra 750 mg by mouth two times a day related to convulsions, dated 11/01/23; - An order for gabapentin (an antiseizure medication) 600 mg by mouth three times a day related to diseases of the nervous system, dated 04/15/23; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the amitriptyline, Lamictal, Zoloft, divalproex, Keppra, and gabapentin. 9. Review of Resident # 59's medical record showed: - An admission date of 02/03/25; - Diagnoses of schizophrenia, mild intellectual disability, intermittent explosive disorder (define), bipolar disorder, anxiety, visual hallucinations, agitation and restlessness; - An order for Uzedy (an antipsychotic medication) 125 mg/0.35 milliliters (ml) 125 mg subcutaneously (injection under the skin) one time a day every 28 days related to schizophrenia, 08/13/25; - An order for olanzapine 20 mg by mouth one time a day related to schizophrenia, dated 01/17/25; - An order for paroxetine (an antidepressant medication) 40 mg by mouth one time a day related to bipolar disorder, dated 04/24/24; - An order for lorazepam (an antianxiety medication) 1 mg by mouth three times a day for anxiety, dated 10/06/25; - An order for valproic acid (an antiseizure medication also used as a mood stabilizer) 250 mg/5ml 5ml by mouth three times a day related to visual hallucinations, dated 04/24/24; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the Uzedy, olanzapine, paroxetine, lorazepam, and valproic acid. 10. Review of Resident #73's medical record showed: - An admission date of 11/05/25; - Diagnosis of depressive type schizoaffective disorder; - An order for haloperidol 10 mg by mouth three times a day for schizoaffective disorder, dated of 11/06/25; - An order for Invega (an antipsychotic medication) 234 mg/1.5 ml inject intramuscularly (an injection into the muscle) in the afternoon monthly on the 25th for schizoaffective disorder, dated 11/25/25; - An order for Invega extended release 9 mg by mouth in the morning for schizoaffective disorder, dated 11/06/25; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the haloperidol and Invega. 11. Review of Resident #90's medical record showed: - An admission date of 11/14/22; - Diagnoses of delusional disorder (a psychiatric condition characterized by a person having one or more fixed false beliefs), bipolar disorder, dementia, and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - An order for divalproex 125 milligram (mg) by mouth three times a day related to bipolar disorder, dated 01/03/23; An order for fluoxetine (an antidepressant medication) 20 mg by mouth one time a day related to bipolar disorder, dated 01/03/23; An order for olanzapine 5 mg by mouth one time a day related to bipolar disorder, dated 01/19/23; - No documentation of consents or education of risks and benefits were provided to the resident and/or their representative for the divalproex, fluoxetine, and olanzapine. During an interview on 03/11/26 at 1:30 P.M., Resident #90 said he/she did not remember anyone reviewing the risks and benefits of his/her medications with him/her. During an interview on 03/11/26 at 4:05 P.M., Licensed Practical Nurse (LPN) A said the nurse practitioner would review risks and benefits of a medication with a resident. He/She had never had a resident sign anything saying they understood the risks or benefits of a medication. During an interview on 03/11/26 at 4:25 P.M., LPN C said he/she told the residents the risks and benefits of their medication if they asked, but the doctor or nurse practitioner reviewed that with the resident before they prescribed a new medication. He/She never had residents sign anything stating they understood the risks or benefits of a medication. During an interview on 03/11/26 at 5:56 P.M., the Director of Nursing (DON) and the Administrator said they would expect residents and/or the resident representatives be informed of the risks and benefits of their medications and have informed consents for the psychotropic medications.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Residents #11 and #13) out of 20 sampled residents and for one resident (Resident #88) outside the sample. The facility census was 98. Review of the facility's policy titled, MDS Policy, reviewed 08/02/24, showed: - The Resident Assessment Instrument (RAI) Manual serves as the policy by which the facility follows the process of completing MDS assessments. Review of the RAI Manual, dated October 2025, showed: - J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services; - Code all high-risk drug class medications according to their pharmacological classification, not how they are being used; - Code any type of CPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized through a mask or other device continuously or via electronic cycling throughout the breathing cycle. 1.Review of Resident #11's medical record showed: - admitted on [DATE]; - Diagnosis of atrial fibrillation (a heart condition that causes an irregular heartbeat, increasing risks of blood clots); - An order for apixaban (an anticoagulant medication used to prevent and treat blood clots) 5 milligrams (mg) by mouth two times per day for atrial fibrillation; - No order for an antiplatelet (a class of medication used to prevent blood clots). Review of the resident's admission MDS, dated [DATE], showed: - No use of an anticoagulant; - Routine use of an antiplatelet. 2. Review of Resident #13's medical record showed: - admitted on [DATE]; - Diagnoses of obstructive sleep apnea (condition causing difficulty breathing or periods of not breathing at times); - An order for continuous positive airway pressure (CPAP - medical equipment to assist with breathing and a non-invasive mechanical ventilator) machine at bedtime, dated 11/04/25. Review of the residents quarterly MDS, dated [DATE], showed: - The resident did not require a non-invasive mechanical ventilator. 3. Review of Resident #88's medical record showed: - admitted on [DATE]; - No order for hospice. Review of the resident's annual MDS, dated [DATE], showed: - Resident received hospice. During an interview on 03/11/26 at 4:24 P.M., the MDS Coordinator said the MDS assessment should accurately reflect the resident's current condition at the time of the assessment. Resident #13 should have been coded for the non-invasive mechanical ventilation. Anticoagulants should have been coded on the MDS correctly for Resident #11, and Resident #88 was never on hospice. During an interview on 03/11/26 at 6:00 P.M., the Administrator and the Director of Nursing (DON) said they would expect the MDS to accurately reflect the resident's condition at the time of the assessment.

Based on observation, interview, and record review, the facility failed to follow physician orders when administering medications for five residents (Residents #4, #17, #30, #49, and #86) out of 12 residents. The facility census was 98.Review of the facility policy titled, Physician Orders, dated 08/24/24, showed: - Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Medication Technicians (CMT) are expected to review orders prior to administering medications and/or performing a treatment; - The RNs, LPNs, and CMTs are to follow the orders as written. 1. Review of Resident #4's medical record showed: - admitted on [DATE]; - Diagnosis of hypertension (high blood pressure); - An order for clonidine (a blood pressure medication) 0.1 milligrams (mg) by mouth four times a day for hypertension. Hold for a systolic blood pressure (SBP - the top number in a blood pressure reading, measuring the force against artery walls when the heart contracts) less than 120. Hold for a diastolic blood pressure (DBP - the bottom/lower number in a blood pressure reading, measuring pressure in the arteries while the heart relaxes between beats) lower than 80, dated 02/20/26. Review of the resident's Medication Administration Record (MAR), dated February 2026 - March 2026, showed: - For February 2026, the clonidine was not administered correctly according to the physician orders on 02/22/26 at 8:00 A.M. - 146/76 (administered), 02/22/26 at 12:00 P.M. - 142/72 (administered), 02/22/26 at 9:00 P.M. - 132/70 (administered), 02/28/26 at 8:00 A.M. - 100/74 (administered), and 02/28/26 at 12:00 P.M. - 100/74 (administered); - For March 2026, the clonidine was not administered correctly according to the physician orders on 03/03/26 at 9:00 P.M. - 126/76 (administered), 03/04/26 at 4:00 P.M. - 117/63 (administered), 03/06/26 at 12:00 P.M. - 112/68 (administered), 03/06/26 at 4:00 P.M. - 102/64 (administered), 03/07/26 at 12:00 P.M. - 96/56 (administered), and 03/09/26 at 9:00 P.M. - 133/81 (withheld); - A total of 11 doses the medication was administered incorrectly out of 72 doses. During an interview on 03/11/26 at 10:35 A.M., LPN A said if a resident's SBP or the DBP was inside the ordered parameters, then the medication should be given as ordered. If the SBP or the DBP was outside of the ordered parameters, then the medication should be withheld as ordered. If a resident's order did not have parameters and the staff had a blood pressure medication to administer with a questionable blood pressure, then staff would be expected to hold the medication and talk to the nurse to see if the medication still needed to be held or if the physician needed to be contacted for further instructions. 2. Review of Resident #17's medical record showed: - An admission date of 11/03/25; - Diagnoses of congestive heart failure (a chronic, progressive condition where the heart cannot pump blood efficiently, causing fluid buildup in the lungs and body) and essential hypertension (high blood pressure without a single known medical cause); - An order to monitor the blood pressure prior to the blood pressure medication administration. Hold if the SBP less than 90 or the DBP less than 60, dated 11/04/25; - An order for losartan (a blood pressure medication) 25 mg by mouth in the morning for hypertension, dated 11/04/25; - An order for metoprolol (a blood pressure medication) 25 mg 0.5 tablet by mouth two times a day for hypertension, dated 11/05/25. Review of the resident's MAR, dated December 2025 – March 2026, showed: - For December 2025, the losartan and metoprolol were not administered correctly according to the physician orders on 12/03/25 morning doses - 121/73 (withheld), 12/04/25 morning doses - 125/80 (withheld), 12/05/25 morning doses - 106/70 ; (withheld) 12/09/25 morning doses - 114/77 (withheld), 12/10/25 morning doses - 112/71 (withheld), 12/14/25 morning doses - 122/77 (withheld), 12/15/25 morning doses - 117/77 (withheld), 12/21/25 morning doses - 112/63 (withheld), and 12/25/25 morning doses - 94/69 (administered); - For January 2026, the losartan and metoprolol were not administered correctly according to the physician orders on 01/16/26 morning doses - 120/84 (withheld), 01/19/26 morning doses - 108/68 (withheld), 01/20/26 morning doses - 122/70 (withheld), 01/21/26 metoprolol morning dose - 121/89 (withheld), 01/23/26 morning doses - 123/81 (withheld), 01/26/26 morning doses - 94/60 (withheld), 01/27/26 morning doses - 135/93 (withheld), 01/28/26 morning doses - 113/69 (withheld), and 01/30/26 morning doses - 100/64 (withheld); - For February 2026, the losartan and metoprolol were administered incorrectly according to the physician orders on 02/01/26 morning doses - 115/60 (withheld), 02/04/26 morning doses - no blood pressure documented (withheld), and 02/26/26 metoprolol evening dose - 132/81(withheld); - For March 2026, the losartan and metoprolol were not administered correctly according to the physician orders on 03/01/26 morning doses – 116/92 (withheld) and the metoprolol evening dose – 116/93 (withheld), 03/05/26 metoprolol evening dose - 111/74 (withheld), and 03/11/26 morning doses - 134/83 (withheld); - A total of 45 doses the medications were administered incorrectly out of 302 doses. 3. Review of Resident #30's medical record showed: - admitted [DATE]; - Diagnosis of hypertension; - An order for lisinopril (a blood pressure medication) 20 mg by mouth in the morning, hold if SBP less than 90 or DBP less than 60, dated 02/04/25. Review of the resident's MAR, dated January 2026 - March 2026, showed: - For January 2026, the lisinopril was not administered correctly according to the physician orders on 01/02/26 - 121/72 (withheld), 01/05/26 - 115/68 (withheld), 01/08/26 - 132/85 (withheld), 01/09/26 - 96/68 (withheld), 01/12/26 - 120/77 (withheld), 01/14/26 - 135/93 (withheld), 01/16/26 - 114/70 (withheld), 01/18/26 - 136/89 (withheld), - 131/74 (withheld), 01/20/26 - 134/82 (withheld), 01/26/26 - 114/82 (withheld), 01/28/26 - 119/79 (withheld), and 01/30/26 for - 131/82 (withheld); - For February 2026, the lisinopril was not administered correctly according to the physician orders on 02/01/26 - 133/66 (withheld), 02/04/26 - 134/84 (withheld), 02/11/26 - 123/85 (withheld), 02/12/26 - 112/72 (withheld), 02/13/26 - 117/68 (withheld), 02/16/26 - 121/69 (withheld), 02/17/26 - 111/68 (withheld), 02/24/26 - 117/69 (withheld), and 02/26/26 - 123/69 (withheld); - For March 2026, the lisinopril was not administered correctly according to the physician orders on 03/03/26 - 115/75 (withheld), 03/04/26 - 120/75 (withheld), 03/05/26 - 131/76 (withheld), 03/09/26 - 117/75 (withheld), and 03/11/26 - 116/84 (withheld); - A total of 27 doses the medication was administered incorrectly out of 70 doses. 4. Review of Resident #49's medical record showed: - admitted on [DATE]; - Diagnosis of hypertension; - An order for propranolol (a blood pressure medication) 10 mg by mouth two times a day. Hold if SBP less than 90, DBP less than 60, or the heart rate is less than 60, dated 01/15/25 and discontinued 02/10/26; - An order for propranolol 10 mg by mouth one time a day, dated 02/06/26; - An order to monitor the blood pressure prior to the blood pressure medication administration. Hold the medication for a SBP less than 90 or a DBP is less than 60. Monitor the blood pressure three times a day for low blood pressure, dated 01/08/26. Review of the resident's MAR, dated December 2025 - March 2026, showed: - For January 2026, the propranolol was not administered correctly according to the physician orders on 01/24/26 at 9:00 A.M. - 90/60 (withheld), 01/25/26 at 9:00 A.M. - 98/60 (withheld), 01/26/26 at 9:00 A.M. - 99/62 (withheld), 01/27/26 at 9:00 A.M. - 101/71 (withheld), 01/30/26 at 6:00 P.M. - 96/70 (withheld), and 01/31/26 at 6:00 P.M. - 96/60 (withheld); - For February 2026, the propranolol was not administered correctly according to the physician orders on 02/01/26 at 9:00 A.M. - 98/61 (withheld), 02/04/26 at 6:00 P.M. - 89/65 (administered), 02/05/26 at 6:00 P.M. - 99/64 (withheld), 02/06/26 at 6:00 P.M. - 144/102 (withheld), 02/09/26 at 9:00 A.M. - 112/68 (withheld), 02/10/26 at 9:00 A.M. - 119/88 (withheld), 02/11/26 at 9:00 A.M. - 111/86 (withheld), 02/12/26 at 9:00 A.M. - 114/66 (withheld), 02/13/26 at 9:00 A.M. - 99/68 (withheld), 02/16/26 at 9:00 A.M. - 116/67 (withheld), 02/17/26 at 9:00 A.M. - 111/89 (withheld), 02/18/26 at 9:00 A.M. - 115/84 (withheld), and 02/22/26 at 9:00 A.M. - 100/66 (withheld); - For March 2026, the propranolol was not administered correctly according to the physician orders on 03/01/26 at 9:00 A.M. - 108/70 (withheld) and 03/02/26 at 9:00 A.M. - 111/75 (withheld); - A total of 21 doses the medication was administered incorrectly out of 202 doses. 5. Review of Resident #86's medical record showed: - An admission date of 12/02/22; - Diagnosis of essential hypertension; - An order to monitor the blood pressure prior to blood pressure medication administration, hold if SBP less than 90 or DBP less than 60, dated 03/12/25; - An order for atenolol 25 mg by mouth daily for essential hypertension, dated 08/27/24 and discontinued 12/15/25; - An order for atenolol 25 mg 0.5 tablet daily for essential hypertension, dated 12/16/25. Review of the resident's MAR, dated December 2025 – March 2026, showed: - For December 2025, the atenolol was not administered correctly according to the physician orders on 12/02/25 - 108/72 (withheld), 12/05/25 - 108/68 (withheld), 12/09/25 - 118/68 (withheld), 12/12/25 - 105/91 (withheld), 12/14/25 - 90/75 (withheld), 12/15/25 - 119/82 (withheld), 12/16/25 - 105/70 (withheld), 12/17/25 - 101/81(withheld), 12/19/25 - 127/81(withheld), and 12/30/25 - 98/76 (withheld); - For January 2026, the atenolol was not administered correctly according to the physician orders on 01/01/26 - 117/73 (withheld), 01/03/26 - 110/71 (withheld), 01/08/26 - 123/77 (withheld), 01/09/26 - 132/91 (withheld), 01/13/26 - 124/75 (withheld), 01/16/26 - 100/68 (withheld), 01/21/26 - 98/78 (withheld), 01/23/26 - 118/83 (withheld), 01/26/26 - 113/93 (withheld), and 01/30/26 - 137/77 (withheld); - For February 2026, the atenolol was not administered correctly according to the physician orders on 02/01/26 - 117/64 (withheld), 02/02/26 - 122/73 (withheld), 02/03/26 - 94/69 (withheld), 02/04/26 - 121/87 (withheld), 02/11/26 - 121/80 (withheld), 02/13/26 - 124/77 (withheld), 02/17/26 - 126/60 (withheld), and 02/27/26 - 117/68 (withheld); - For March 2026, the atenolol was not administered correctly according to the physician orders on 03/04/26 - 118/78 (withheld), 03/09/26 - 126/78 (withheld), and 03/10/26 - 130/76 (withheld); - A total of 31 doses the medication was administered incorrectly out of 100 doses. During an interview on 03/11/26 at 8:06 A.M., CMT D said blood pressure medications should not be given if the SBP was less than 135 or the DBP was less than 80. It also depended on how active the resident was or if they smoke. During an interview on 03/11/26 at 9:38 A.M., CMT E said the parameters for each resident was listed under the medication administration screen. He/She said the parameters for most residents was to hold if the SBP was under 90 or the DBP was under 60. During an interview on 03/11/26 at 9:45 A.M., LPN C said a medication should not be held without an order and if a CMT thought a blood pressure was too low, the CMT was to inform the nurse assigned, and they would contact the physician if needed. During an interview on 03/11/26 at 5:56 P.M., the Director of Nursing (DON) said blood pressure medications should be held when they were outside the parameters. The physician should be called before holding medications that did not have parameters ordered. During an interview on 03/11/26 at 5:56 P.M., the Administrator said she would expect physician orders to be followed.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 36 opportunities with two errors made, for an error rate of 5.56%, which affected two residents (Residents #17 and #86) out of six sampled residents. The facility census was 98.Review of the facility policy titled, Administering Medication Policy, dated 10/07/24, showed:- Medications will be administered in a safe and timely manner, and as prescribed (ordered by a qualified practitioner);- Medications must be administered in accordance with the orders, including any required time frame;- If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing the medication shall contact the resident's physician or if a Certified Medication Technician (CMT), the charge nurse to discuss the concerns;- Vital signs must be checked or verified to each resident prior to administering medication;- If a medication is withheld, refused or given at a time other than the scheduled time, the individual administering the medication will document the rationale. 1. Review of Resident #17's Physician Order Sheet (POS), dated 03/11/26, showed:- An order to monitor the blood pressure prior to blood pressure medication administration. Hold if systolic (the top number in a blood pressure reading, measuring the force against the artery walls when the heart contracts and beats) is less than 90 or diastolic (the bottom number in a blood pressure reading, measuring the pressure in arteries when the heart rests between beats) is less than 60, dated 11/04/25;- An order for losartan (a blood pressure medication) 25 milligrams (mg) by mouth in the morning for hypertension (high blood pressure), dated 11/04/25. Observation on 03/11/26 at 7:56 A.M. of the resident's medication administration showed:- CMT D took the resident's blood pressure with a reading of 134/83;- CMT D did not administer the losartan. During an interview on 03/11/26 at 7:56 A.M., CMT D said he/she did not give the resident's losartan because the resident's blood pressure was too low. 2. Review of Resident #86's POS, dated 03/10/26, showed:- An order to monitor the blood pressure prior to blood pressure medication administration. Hold if systolic is less than 90 or diastolic is less than 60, dated 03/12/25;- An order for atenolol (a blood pressure medication) 25 mg 0.5 tablet by mouth one time a day for hypertension, dated 12/16/25. Observation on 03/10/26 at 8:26 A.M. of the resident's medication administration showed:- CMT D took the resident's blood pressure with a reading of 130/76;- CMT D did not administer the atenolol. During an interview on 03/10/26 at 8:26 A.M. CMT D said he/she did not give the resident's atenolol because the resident's blood pressure was too low. During an interview on 03/11/26 at 8:06 A.M. CMT D said he/she would hold the blood pressure medication if the resident's systolic was less than 135 or diastolic was less than 80. He/She also considered if the resident was active or a smoker. During an interview on 03/11/26 at 5:56 P.M., the Director of Nursing (DON) said she would expect medication orders to be followed, and medications held only when they fall outside the parameters set by the physician. During an interview on 03/11/26 at 5:56 P.M., the Administrator said she would expect the facility's medication error rate to be less than five percent.

Based on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures for four residents (Residents #7, #25, #57, and #73) out of 20 sampled residents. This deficient practice had the potential to affect all residents in the facility. The facility's census was 99. Review of the facility's policy titled, Food Temperature Control, dated February 2024, showed:- All potentially hazardous foods will be stored, prepared, held, and served at proper temperatures;- Food temperatures will be monitored, documented, and corrective action taken when necessary;- Temperature standards for hot food: greater than or equal to 140 degrees Fahrenheit ( F). Review of Resident Council Minutes dated 12/30/25, 01/27/26, and 02/24/26, showed:- No complaints regarding cold food;- Residents complained the food was overcooked, didn't like the menus, and meals were served late. During an interview on 03/08/26 at 10:14 A.M. Resident #73 said the food was not good and it was sometimes served cold. During an interview on 03/08/26 at 10:15 A.M., Resident #57 said the food was always undercooked and cold which would make him/her have to use the bathroom. During an interview on 03/08/26 at 10:53 A.M., Resident #7 said the food tasted dreadful and was always cold. During an interview on 03/08/26 at 11:11 A.M., Resident #25 said the food was often cold when it should be hot. Observation on 03/08/26 at 1:34 P.M. of the delivery of the hall trays to the D Hall from the kitchen showed:- The trays were delivered on an uncovered and unheated rolling cart;- Each plate was covered by an insulated plate cover. Observation on 03/10/26 at 1:15 PM of the delivery of the hall trays to the C Hall from the kitchen showed:- The trays were delivered on a closed and heated rolling cart;- Each plate was covered by an insulated plate cover. Observation on 03/11/26 at 9:05 A.M. of the breakfast meal test hall tray showed:- The meal tray removed from the heated rolling cart;- The meal tray was the last tray on the heated rolling cart;- The plate was covered with an insulated plate cover and the temperature of the food was:- Two poached eggs with a temperature of 94 F;- A bowl of oatmeal with a temperature of 110 F. During an interview on 03/11/26 at 3:14 P.M., the Dietary Manager said the residents had complained to her when she attended the February 2026 Resident Council meeting that the food was not hot enough. The complaints about the cold food were not documented on the February 2026 Resident Council meeting minutes. She did check the steam table temperatures and educated the staff on turning the steam table on at least an hour before putting food on it. The residents had complained the fries and tater tots were cold on the hall trays, but she didn't know what to do about that because those foods cooled off quickly. During an interview on 03/11/26 at 5:56 P.M., the Director of Nursing (DON) and the Administrator said they would expect food to be served at safe and appetizing temperatures.

Based on observation, interview, and record review, the facility failed to ensure and promote an environment which recognized each resident's rights for one (Resident #1) out of six sampled residents. Resident #1, who is responsible for his/her own decisions, was restricted from an independent leave of absence (LOA) from the facility. The facility's census was 88.Review of the facility policy titled, Resident Rights, dated 01/24/25, showed: - It is the policy of this facility to provide quality healthcare through communication, respect, and sensitivity between the residents and those who provide them care. Our facility strives to promote the exercise of rights for each resident, even if he/she is determined to be incompetent, should be able to assert these rights based on his or her degree of capability;- Residents have the right to make choices about his/her own life subject to the facility's rules, as long as those rules do not violate a regulatory requirement. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Diagnoses of cerebral infarction (blood flow to the brain is interrupted, leading to tissue damage), diabetes mellitus (a chronic metabolic disease characterized by high blood sugar levels), hypertension (high blood pressure), insomnia (difficulty going or staying asleep), and atherosclerotic heart disease (caused by plaque buildup in arterial walls);- Resident was his/her own responsible party.Review of the resident's Physician Order Sheet (POS), dated November 2025, showed:- Resident ok to have two alcoholic drinks weekly outside of the facility, dated 07/15/25;- Resident not to exit facility for a LOA at this time for 14 days, dated 10/30/25 with an end date 11/13/25. The order had no other clarification.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 08/22/25, showed:- No cognitive impairment;- Independent with activities of daily living (ADLs).Review of the resident's care plan, revised 09/02/25, did not address the resident's alcohol use or restriction on the LOA.Review of the resident's Nurse's Notes showed:- On 10/30/25, the Social Service Designee (SSD) and the Director of Nursing (DON) spoke with the resident about safety concerns when he/she was LOA from the facility. The resident became angry and threatened to burn the facility down and sign a death certificate for the physician who signed the no LOA order. Resident #1 was educated on the LOA policy. The physician felt the resident was not safe to go LOA and would re-evaluate in two weeks. The resident was instructed if he/she left the facility, then he/she would need to discharge from the facility against medical advice (AMA);- On 11/04/25, the SSD called to the lobby where the resident sat in a wheelchair and asked about leaving LOA. The resident was advised he/she had an order from the primary physician suspending his/her LOA due to unsafe behaviors and taking risks. Review of the resident's admission Packet, Leave of Absence (LOA) Procedures section of the admission packet, dated 08/04/25, showed:- It is the expectation of this facility that the resident will be free from the consumption of alcoholic beverages, non-prescribed medication, and/or illegal substances while they are their own responsibility and/or the responsibility of others. If any chemical consumption/intoxication is suspected at the time of the resident's return to the facility, we reserve the right to send the resident to the hospital for evaluation and testing, for the safety and wellbeing of the resident;- An individual residing at the facility has the opportunity to go out with friends and family. It is the intention of this facility to be aware of a resident's destination and approximate date and time of return. The facility is not responsible for the health, safety or welfare of any resident who is away from the facility with any person not directly employed by the facility;- If the resident returns under the influence of drugs or alcohol, the facility will call the attending physician and responsible party/guardian;- The document did not address LOA restrictions;- Signed by the resident on 08/04/25.During an interview on 11/06/25 at 10:15 A.M., Resident #1 said a physician gave an order restricting his/her ability to leave the facility on his/her own for two weeks due to being unsafe. Resident #1 said he/she is his/her own responsible party and had the right to leave when he/she wanted. The facility and the physician were infringing on his/her rights by not allowing him/her to leave and it made him/her mad.During an interview on 11/06/25 at 2:10 P.M., the SSD said Resident #1's physician sent an order for a two-week restriction on the resident's independent LOA because of returning to the facility intoxicated. The SSD said they had educated the resident on being safe when he/she went on LOA, but the facility kept hearing from community and staff members unsafe things Resident #1 was seen doing while LOA. The SSD said there had not been any involvement by law enforcement. The SSD said there has been no discussion with the resident regarding enacting a Power of Attorney, getting a guardian or discharging to a lower level of care. During an interview on 11/06/25 at 2:50 P.M., the Director of Operations said only the resident's independent LOA privilege had been restricted for two weeks. The resident showed poor insight and judgement. The resident is his/her own responsible party and generally would have the right to LOA, however, due to poor decisions the physician only prohibited the portion of the non-supervised LOA, or independent LOA. Complaint # 2656873

Based on record review and interview the facility failed to provide adequate supervision for one of three sampled residents. Resident #1 was assessed as needing 24-hour supervision for safety and had a history of making suicidal threats/ideations and aggression towards others and staff. The resident exited the facility's secured behavioral unit without staff knowledge and was gone for approximately 12 hours. Facility staff failed to implement the facility policy for rounding and making observations of residents. While away from the facility, the resident used a broken piece of glass and attempted suicide by inserting it into her skull. The facility census was 100.The administration was notified on 09/11/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred 09/06/25. Upon notification of the elopement on 09/06/25, the facility administration immediately started an investigation and notified the Department of Health and Senior Services of the elopement. The facility installed new window modifications to prevent residents from removing the glass and in-serviced all staff on the facility's policy and procedures for making rounds. The IJ was corrected on 09/06/25. Review of the facility's Rounding Policy, dated 02/24/24, showed:- All residents have the right to be cared for in a safe environment. Rounding will be ensured all resident needs are being addressed and proper supervision is occurring;- Rounds are completed every two hours unless directed by the charge nurse;- Rounds must be made at the beginning and ending of each shift ensuring physically walking into each room and physically seeing each resident;- To be proactive in our care, staff need to be rounding each hour, so the residents use the call lights less, you have less interruptions during your day and the residents are much happier. 1. Review of Resident #1's Level II Preadmission Screening and Resident Review (PASRR) (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 03/02/23, showed:- Requires 24-hour supervision for safety, fall risk;- History of physical behaviors;- Monitoring of behavioral symptoms;- Provision of behavioral support;- Assess and plan for the level of supervision required to prevent harm to self and others;- History of suicidal threats and ideations. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 04/24/24 showed:- Diagnoses of schizoaffective disorder (a chronic mental health condition combining symptoms of schizophrenia, such as hallucinations and delusions, with symptoms of a mood disorder, like bipolar disorder or depression), personality disorder (personality disorder is a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), impulse disorder (a mental health condition where a person cannot resist the urge to perform an act that is harmful to themselves or others), major depressive disorder (a mood disorder characterized by persistent feelings of sadness, hopelessness, or a loss of interest or pleasure in daily activities, lasting for at least two weeks), and anxiety (excessive fear, worry, and related behavioral disturbances that interfere with daily life);- Cognition intact;- Supervision of staff for activities of daily living;- Rejection of care and evaluation 4-6 days a week;- Ambulates independently. Review of the resident's Care Plan dated 01/21/24, showed:- Resident has a history of making suicidal threats and ideations related to depression;- History of refusals to eat, take medications, or be assessed;- History of verbal and physical aggression towards others and staff;- History of delusions. Review of the facility Self-Report form, dated 09/09/25 regarding Resident #1, showed: - On 09/06/25, police arrived at the building at approximately 8:30 A.M. responding to another resident situation. As Licensed Practical Nurse (LPN) A was walking the police to D Hall secured unit, he/she received a call about a person that was found on the outside of a local store. The officer's exact words he/she has been here (at the store) all night. LPN A asked the officer the name of the individual that had been found, and the officer responded with Resident #1's name. LPN A confirmed that he/she was a resident of facility. LPN A immediately checked Resident #1's room. LPN A contacted the Assistant Director of Nursing (ADON) that Resident #1 had exited the facility sometime the previous night. The ADON contacted the Administrator. Resident #1 had eloped from the facility. Staff initiated a head count on D-hall and the entire building which determined Resident #1 was missing and all other residents were accounted for. The ADON confirmed with the responding officer that Resident #1 arrived at a local liquor store via security camera footage at 3:24 A.M. on 09/06/25. The resident slept on the concrete in-front of the building. The store clerk arrived at 7:00 A.M. The store clerk went back outside at 8:00 A.M. to speak with the resident. The store clerk contacted local police who arrived at the liquor store at approximately 8:24 A.M. Resident #1 informed the police that he/she broke out of the facility to go for a walk and had been walking around the area for a while, before arriving at the liquor store. Emergency Medical Services arrived and transported the resident to the local emergency room. The resident had been missing for approximately 12 hours;- Review of the statements received from the night shift staff who worked during the incident, no one can account seeing the resident after the 8:00 P.M. smoke break. Staff wrote they completed rounds at different times, however, none of them opened the room door to lay eyes on Resident #1. Record review of the hospital report dated 09/06/25 showed:-This is a patient with self-inflicted head wound. He/she discovered a broken piece of glass and attempted suicide by inserting it into his/her skull. He/she continues to harbor suicidal thoughts, primarily due to his/her inability to communicate with family in another state. During a telephone interview on 09/11/25 at 11:15 A.M., Resident #1 said:- He/she left the facility because he/she heard one of the staff yelled at another resident and he/she no longer wanted to be there; - He/she did not know if his/her roommate was in the room when he/she left, but knew the staff would not be around because they all stay at the nurses station on their phones on night shift;- He/she used a rag to open the middle window of his/her room, slid it over and placed the window on his/her bed, busted through the screen and left the facility around 7:30 P.M., stating it was dark outside; - He/she did not have any injuries when crawling out of the window, used the rag because he/she is on blood thinners and did not want to bleed;- He/she just started walking through neighborhoods until he/she reached a gas station or something like that and sat down;- This is where he/she found a piece of glass and attempted to cut his/her head;- He/she said the next thing he/she knew the cops were there and he/she was bleeding from his/her head. Observation on 09/11/25 at 9:45 A.M. of Resident #1's room, showed three intact windows with approximately 4-inch metal plates screwed between each window to prevent the window glass from being raised higher than approximately 10 inches and unable to remove from frame. During an interview on 09/11/25 at 10:20 A.M. Certified Nurse Aide (CNA) B said he/she had seen the resident just a couple of hours prior to leaving his/her shift at 7:00 P.M., the resident was not eating that day due to not feeling well with a urinary tract infection. During an interview on 09/11/25 at 10:25 A.M., CNA C said the resident was his/her normal self on the 7 A.M. to 7 P.M., shift which was easily agitated by others but had not expressed suicidal threats or behaviors. He/she last saw the resident that day at 7:30 P.M., when he/she was leaving his/her shift. During an interview on 09/11/25 at 10:30 A.M., the Social Service Director said he/she had been on the secure unit most of the day noting Resident #1 was in a good mood, sitting in the dining room making the staff a list of all the local restaurants. During an interview on 09/11/25 at 10:35 A.M., the Maintenance Director said the day after the incident he/she installed the metal pieces with screws to each window to prevent the windows from rising enough for someone to crawl out of and or remove the glass from the frame. During an interview on 09/11/25 at 1:15 P.M., the Administrator said she would have expected the staff to perform hourly checks on each resident on the secure units per facility policy.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when another resident (Resident #2) open handed slapped the resident, in the face three times. Resident #2 said Resident #1 had behaviors that bothered him/her and hit Resident #1 repeatedly. Resident #1 sustained contusions, redness, and swelling to the right side of his/her face and was sent to the Emergency Department (ED) by ambulance. The facility census was 103.Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 04/08/24 showed:Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident must not be subject to abuse by anyone including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies, family, legal guardians, friends or other individuals:Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Review of Resident #1's medical record showed:The resident was own responsible party;Diagnoses of major depressive disorder (a mental disease characterized by persistent sadness), post traumatic stress disorder (PTSD - a mental health condition that can develop after experiencing or witnessing a traumatic event), Alzheimer's disease (a progressive disease causing loss of cognitive function), traumatic brain injury (TBI - a brain injury caused by physical force or a blow to the head that can affect a person's cognitive function), and paranoid schizophrenia (a mental disorder characterized by disruptions in thought, perception and behavior. Specifically marked by symptoms of paranoia, delusions and hallucinations). Review of the resident's Physician Order Sheet (POS), dated July 2025, showed:An order for Geodon (an antipsychotic medication - used to treat mental health conditions characterized by psychosis) 40 milligram (mg) two times daily, dated 06/05/24;An order for lorazepam (an antianxiety medication) 1 mg three times daily, dated 06/05/25;An order for risperidone (an antipsychotic medication) 2 mg two times daily, dated 12/18/23;An order for venlafexine (an antidepressant medication) 75 mg two times daily, dated 06/05/25.Review of the resident's Care Plan, dated 07/09/25, showed:Requires a supervised environment and supervision with all activities of daily living (ADL) care;Will become physically and verbally aggressive when not getting what he/she asks for and will scream when staff attempt to de-escalate;Psychiatry to follow up and prescribe/manage medications;Smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior;Has intellectual disabilities;Will ask others for money or cigarettes, including staff and other residents;The care plan did not address interventions to manage the resident's escalating behaviors. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 06/12/25, showed:Some cognitive inabilities; Behaviors of agitation and cursing when upset;Required supervision with all ADLs. Review of the resident's ED medical record, dated 07/06/25, showed:Was treated for assault;Had contusions to the face and right side of the head;Received a new order for Tylenol for pain as needed. Review of Resident #2's medical record showed:The resident had a guardian;Diagnoses of major depressive disorder, schizoaffective disorder bipolar type (a mental disorder characterized by both schizophrenia and a mood disorder - meaning a person may experience psychotic symptoms like hallucinations or delusions along with episodes or mania or depression), impulse disorder (a mental health condition that makes it difficult to control or resist urges which can cause harmful or socially unacceptable behaviors), and anxiety. Review of the resident's POS, dated July 2025, showed:An order for risperidone 4 mg daily at bedtime, dated 04/04/25;An order for Zyprexa (an antipsychotic medication) 10 mg twice daily, dated 04/04/25. Review of the resident's Care Plan, dated 07/04/25, showed:Has a history of racing thoughts, mood instability, agitation, impulse anger issues, paranoia and assaultive behaviors;Has a history of destroying things when getting upset;Has a history of striking other residents;Incarcerated a number of times due to aggressive behaviors;Intervention of staff to attempt to de-escalate the situation and give one-on-one visits and education on coping skills. Review of the resident's annual MDS, dated [DATE], showed:Has a history of disorganized thinking and illogical flow of ideas; Poor judgement and decision making;Delusional and aggressive when upset;Would destroy things when upset. Review of the facility's investigation for the incident on 07/06/25 showed:Resident #1 ran up to Licensed Practical Nurse (LPN) A and said he/she had been struck in the face multiple times by Resident #2. Resident #2 ran up and told LPN A Resident #1 had been asking for money and he/she had gotten tired of it and hit Resident #1;The incident was unwitnessed by any staff;Resident #1 had a red swollen face and was sent to the ED for an assessment. During an interview on 07/09/25 at 10:30 A.M., the Administrator said the incident between Resident #1 and Resident #2 happened on a weekend and the Director of Nursing (DON) made the report. She was unsure of the details or why there was no staff in the hallway to witness the incident. She would expect staff to have been in the hallway to respond. She had no further information on the incident. She did not know what needed to be done to protect Resident #1.During an interview on 07/09/25 at 11:00 A.M., Resident #1 said he/she was struck in the face by Resident #2, it hurt and was scary. It happened in the hallway at the end of the hall right outside Resident #2's room. After he/she told staff, they sent him/her to the ED. His/Her head really hurt all the time. Staff said to just stop bothering the other residents. The facility had not given him/her any new programs or new counseling.During an interview on 07/09/2025 at 11:30 A.M., Resident #2 said Resident #1 kept asking for money and so he/she hit Resident #1. Resident #2 said he/she would have asked for help but there was no staff around in the hallway. Resident #2 said the incident happened right outside his/her room in the hallway. Resident #2 refused to discuss the incident any further. During an interview on 07/09/25 at 1:30 P.M., the Hallway B Social Services Designee (SSD) said the B hallway was full of aggressive residents. He/She tried to monitor the residents but wasn't sure what was going on when he/she was not there. He/She talked with Resident #1 and educated on using his/her coping skills. The SSD said he/she hoped that would benefit Resident #1 and was not aware of any new programs or counseling for the resident. He/She was not aware there had been an incident with Resident #1 getting hurt and had no information regarding the incident. During an interview on 07/09/2025 at 1:40 P.M., the DON said the resident had behaviors, but the facility couldn't give into his/her requests, or he/she would only continue to do it all day. The facility did not incorporate any new programs, and they did not monitor the resident every 15 minute.During an interview on 07/16/2025 at 11:00 A.M., LPN B said he/she was in the office when Resident #1 ran in and said Resident #2 had struck him/her three times in the face. Resident #1's face appeared to be swelling and discolored. The physician was notified, and the resident was sent to the ED. LPN B did not witness the incident. LPN B said there was staff on the hallway, and they must have been attending to other residents.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from physical abuse when a staff member punched the resident in the face. Resident #1 was observed with escalating behaviors and pushed a staff member. Certified Nurse Aide (CNA) A approached the fighting resident and staff member and proceeded to punch Resident #1 with a closed fist, in the right eyesocket. This resulted in an injured eyelid and broken nose for Resident #1. The census was 101. The administration was notified on 06/10/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred 06/05/25. On 06/05/25, upon notification, the facility administration immediately started an investigation, notified the police department and the Department of Health and Senior Services of the physical abuse. The facility terminated employment of CNA A and in-serviced all staff on the facility's policy and procedures for abuse and neglect. The IJ was corrected on 06/05/25, Review of the facility's policy on Abuse, Neglect and Exploitation Policy, dated 04/08/24 showed: - Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The resident must not be subject to abuse by anyone including but not limited to: facility staff; other residents; consultants or volunteers; staff of other agencies; family; legal guardians; friends or other individuals. - Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain, or mental anguish. Review of Resident #1's face sheet showed: - The resident is his/her own responsible party; - The diagnoses included major depression disorder (a mental disease characterized by persistent sadness), Post Traumatic Stress Disorder (PTSD) (a life changing mental health disorder that can occur after a traumatic event causing significant impair to daily life), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), Alzheimer's (a progressive disease causing loss of cognitive function), and Paranoid Schizophrenia (a mental disorder characterized by disruptions in thought, perception, and behavior. Specifically marked by symptoms of paranoia, delusions and hallucinations.) Review of Resident #1's Active Order Summary (Physician's Orders) current as of 06/10/25 showed: - An order for behavior monitoring every shift started 05/10/24; (Documentation of behavior monitoring was not provided.) - An order for geodon (antipsychotic) 40 milligrams (mg) by mouth twice a day with meals for paranoid schizophrenia started on 06/06/25; - An order for lorazepam (anti-anxiety) injection solution 2 mg/milliliter (ml) every 8 hours as needed for agitation for 14 days started 06/05/25; - An order for lorazepam oral tablet 1 mg by mouth three times a day started 06/06/25; - An order for risperidone (antipsychotic) oral tablet 2 mg two times a day for schizophrenia started 12/18/23. Review of Resident #1's care plan dated 06/12/24 showed: - The resident requires a supervised environment and supervision with all activities of daily living (ADL) care; - The resident will become physically and verbally aggressive when not getting what he/she has asked for and will scream when staff attempt to de-escalate; - Psychiatry to follow up and prescribe/manage medications; -The resident smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior; - The resident has intellectual disabilities; - There were no documented interventions in place for helping to manage the resident's escalating behaviors. Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 03/12/25, showed: - The resident has some cognitive inabilities; - The resident requires supervision with all aspects of daily ADLs. Review of the facility's investigation dated 06/05/25 showed: - On 06/05/25 at approximately 6:00 A.M., Resident #1 approached Registered Nurse (RN) B and requested a cigarette and a soda; - RN B told the resident he/she would have to wait until the scheduled smoke time at 8:00 A.M.; - The resident was becoming agitated and the RN exited the office to avoid being in an enclosed office with the resident; - Certified Nurse Aides (CNAs) A, C, and D were in the hallway by the office and told the resident again he/she would have to wait until 8:00 A.M.; - The resident grabbed a hold of CNA C and appeared to be pushing the CNA down the hall; - CNA A approached the resident and CNA C, and struck the resident in the right eye causing bleeding; - An ambulance was called, and the resident was taken to the hospital; - The hospital noted a nasal fracture and blood in the resident's lower eye lid. During an interview on 06/10/25 at 11:50 A.M., RN B said he/she has received no formal training in mental health prior to working at the facility. He/she said the resident is triggered by wanting to smoke and becomes agitated when told no. The staff is aware of this trigger and behavior due to the resident doing it every day. He/she said nothing else was offered to the resident, due to he/she was taking report at that time. When the resident became agitated, he/she walked out of the office into the hallway. The resident grabbed CNA C and CNA A walked up and punched the resident in the right eye with a closed fist. The resident walked off and then said, is my eye bleeding. RN B said it is not safe to work at the facility. There is no recourse when a resident attacks or becomes agitated. During an interview on 06/10/25 at 12:10 P.M., CNA D said he/she was in the hallway, and heard RN B tell the resident that he/she would have to wait until 8:00 A.M. to smoke. The resident was very agitated, and they could not calm him/her down. CNA D said he/she was not looking at the resident when CNA A punched him/her. The resident walked off and asked if he/she was bleeding. He/she said they have rules and regulations, but no training in mental health prior to working. During an interview on 06/10/25 at 12:15 P.M., CNA C said the resident was agitated because RN B told him/her to wait to smoke until smoke break. The resident grabbed him/her and had both hands on his/her shirt collar. CNA A stepped in, drew back his/her closed fist. CNA C closed his/her eyes and felt CNA A punch the resident causing the resident to spin around and become disoriented. The resident released CNA C and walked away into the shower. The resident then returned saying is my eye bleeding. CNA C said there was no warning from CNA A. He/She just stepped in, punched Resident #1 and stepped back. They provide rules to read, but no training prior to starting work. During an interview on 06/10/2025 at 12:30 P.M., CNA A said on 06/05/25, at approximately 5:30 A.M., the resident walked out of his/her room with a cigarette. The residents are not supposed to have cigarettes in their room. CNA A told the resident it was not time to smoke. The resident became agitated and acted like he/she was going to throw a table at CNA A. CNA A said he/she told the resident that it was not time to smoke and that he/she (the resident) was aware of the rules. CNA A said the resident has been aggressive with staff before. CNA A told the resident to calm down and the resident walked away, upset. CNA A said the resident came back out and lunged at him/her again and was told again to stop by CNA A. The resident entered the nurse's office and told RN B that he/she wanted a cigarette and a soda. After being told no again, the resident seemed more agitated, and RN B came out of the office. The resident charged at CNA C and it appeared the resident was going to swing at CNA C. CNA A felt the resident was going to hit him/her due to the resident still being angry and he/she swung and hit the resident. CNA A said his/her hand was open. CNA A said it was self-defense. CNA A said he/she only hit the resident once and could have hit more, but did not. Most people would have hit more than once. CNA A said he/she did not hit the resident hard. After the hit, the resident went into the shower room and CNA A believes Resident #1 self-inflicted the injuries. The facility does not offer any training or guidance for this type of problem. CNA A said the staff are in danger with the residents who have these behaviors. During an interview on 06/10/25 at 1:30 P.M., Resident #1 said he/she had wanted a cigarette and was really upset. The resident said he/she would never hit a girl. The resident said he/she did not have his/her hands on CNA C. Someone did have hands on his/her shoulders and the resident said he/she was only trying to get loose. The resident said he/she did not realize CNA A had punched him/her in the eye, but only saw a flash of light. No one had ever hit him/her before. The resident said he/she had just wanted a cigarette, but after getting punched the staff provided the resident with a cigarette. During an interview on 06/10/25 at 1:45 P.M., local law enforcement (LE) said the resident did not want to press charges. He/she feels the staff at the facility know the residents have mental problems and they instigate them by denying them coffee or cigarettes. When the resident reacts and becomes aggressive, they want LE to come and take the resident away. During an interview on 06/10/25 at 11:00 A.M., the Director of Nurses (DON) said the resident has a history of demanding to smoke before the scheduled smoke breaks. If the resident is told no, he/she will react and become aggressive. She said staff reported that on 06/05/25, the resident came out of the room at approximately 5:45 A.M. The resident went to the nurses' office on B hallway. He/she wanted to smoke and have a soda. The day shift charge nurse, RN B told the resident no, he/she would have to wait until the designated smoke break. This upset the resident and caused more agitation. The nurse came out of the office into the hallway to avoid close contact with the resident. Three CNAs, A, C, and D were in the hallway, and they also told the resident he/she would have to wait. This continued to anger the resident. At this time, the resident grabbed onto CNA C by the shirt and was pushing CNA C down the hallway. CNA A then approached the resident and struck the resident in the right eye with a closed fist. She said the nurse did not offer to let a staff member take the resident to smoke. The staff did not attempt to de-escalate the resident with any other options. She said that this is a trigger for the resident and the staff is aware of this. If staff had tried to offer other options, it might have prevented the resident from being so agitated. She said the staff gets training and in-servicing on abuse and neglect. They are trained on de-escalation, but have no formalized mental health training in place. They are supposed to read a training manual prior to taking the floor. They are to sign a sheet that they have read the manual. The facility does not monitor and there is no way to ensure they have read the rules and policies provided in the manual. During an interview on 6/10/25 at 1:50 A.M., the Medical Director (MD) said CNA A would have had to hit the resident very hard to crack the resident's nose. The MD said there is an element of danger in working with these type of behaviors, but staff should never hit any resident. The staff cannot accommodate this resident every time the resident wants something or they would have to do it for all residents. MO255323, MO255327

Based on observation, record review and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one resident (Resident #1) with severe mental illness and behaviors, when Resident #1 displayed agitated behaviors and staff did not attempt to de-escalate. The census was 74. The facility did not provide a policy on behavioral health management. Review of Resident #1's face sheet showed: - The resident is his/her own responsible party; - The resident has diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), major depression disorder (a mental disease characterized by persistent sadness), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), Alzheimer's (a progressive disease causing loss of cognitive function). The facility did not provide a PASRR for Resident #1 Review of Resident #1's Active Order Summary (Physician's Orders) current as of 06/10/25 showed: - An order for behavior monitoring every shift started 05/10/24; No documentation of behavior monitoring completed by the facility was provided. - An order for geodon (antipsychotic) 40 milligrams (mg) by mouth twice a day with meals for paranoid schizophrenia started on 06/06/25; - An order for lorazepam (anti-anxiety) injection solution 2 mg/milliliter (ml) every 8 hours as needed for agitation for 14 days started 06/05/25; - An order for lorazepam oral tablet 1 mg by mouth three times a day started 06/06/25; - An order for risperidone (antipsychotic) oral tablet 2 mg two times a day for schizophrenia started 12/18/23. Review of Resident #1's care plan, dated 06/12/24, showed: - The resident requires a supervised environment and supervision with all ADL care; - The resident will become physically and verbally aggressive when not getting what is asked for and will scream when staff attempts to de-escalate; - The resident smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior; - The resident has intellectual disabilities; - There are no documented interventions in place for keeping resident from escalating behaviors; - The staff should attempt to accommodate the requests and needs in an effort to prevent escalation. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/12/25, showed: - The resident has some cognitive inabilities; - The resident requires supervision with all aspects of daily activities of life (ADL). During an interview on 06/10/25 at 11:00 A.M., the Director of Nurses (DON) said the resident has a history of demanding to smoke before the scheduled smoke breaks. If the resident is told no,he/she will react and become aggressive. She said the staff are aware of the resident's triggers and should attempt to keep him/her from escalating. There is no reason the staff staff on de-escalation but do not have any formal training on mental health disorders. She said staff reported that on 06/50/25, the resident came out of the room at approximately 5:45 A.M. The resident went to the nurses' office on B hallway. He/she wanted to smoke and have a soda. The day shift charge nurse, RN B told the resident no, he/she would have to wait until the designated smoke break. This upset the resident and caused more agitation. The nurse came out of the office into the hallway to avoid close contact with the resident. Three CNA ' s, A, C and D were in the hallway, and they also told the resident he/she would have to wait. This continued to anger the resident. At this time, the resident grabbed onto the CNA C by the shirt and was pushing the CNA C down the hallway. The CNA A then approached the resident and struck the resident in the right eye. She said the nurse did not offer to let a staff member take the resident to smoke. The staff did not attempt to de-escalate the resident with any other options. She said that this is a trigger for the resident and the staff is aware of this. If staff had tried to offer other options, it might have prevented the resident from being so agitated. She said the staff does get training and in-servicing on abuse and neglect. The four staff members involved are all agency staff. They are supposed to read a training manual prior to taking the floor. They are to sign a sheet that they have read the manual. The facility does not monitor and there is no way to ensure they have read the rules and policies provided in the manual. During an interview on 06/10/25 at 11:50 A.M., RN B said he/she has received no formal training prior to working at the facility. RN B said the resident is triggered by wanting to smoke and becomes agitated when told no. The resident will lash out at staff when angry. He/she said it is impossible to accommodate the resident every time he/she wants to smoke or have a soda. He/she said nothing else was offered, due to he/she was taking report at that time. When the resident became agitated, he/she walked out of the office into the hallway. RN B said it is not safe to work at the facility. There is no recourse when a resident attacks or becomes agitated. There is no need for mental health training as it allows for resident's to be taken down or restrained and this is a no touch facility. During an interview on 06/10/25 at 1:45 P.M., local law enforcement (LE) said the resident did not want to press charges. LE was not aware Resident #1 would be a special victim at first, and is now requesting information on the resident and referring this matter to the Prosecutor. LE said his/her people see so many problems which are the results of poor decisions by staff. Staff know the residents have mental problems, but continue to instigate them by denying them coffee or cigarettes. When the resident reacts and becomes aggressive, they want LE to come and take the resident away. During an interview on 06/10/25 at 1:50 A.M., the Medical Director (MD) said CNA A would have had to hit the resident very hard to crack the resident ' s nose. MD said there is an element of danger in working with these type of behaviors but staff should never hit any resident. The staff cannot accommodate Resident #1 every time the he/she wants something or they would have to do it for all residents. MO255323, MO255327

Based on interview and record review, the facility failed to have documenation of one resident with serious mental illness and intellectual disability diagnoses (Resident #1's) Level I preadmission screening/resident review (PASRR) assessment (used to identify individuals with mental illness or intellectual/developmental disabilities (IDD) completed before admission to the nursing facility or the more indepth Level II PASRR screening in the resident's record to ensure they were able to meet the resident's behavioral needs. The census was 74. The facility did not provide a policy related to PASRR screenings. Review of Resident #1's medical records showed: -The resident is his/her own responsible party; -The resident had diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), major depression disorder (a mental disease characterized by persistent sadness), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), Alzheimer's (a progressive disease causing loss of cognitive function) and Paranoid Schizophrenia (a mental disorder characterized by disruptions in thought, perception, and behavior; -No PASRR level I screen found; -No PASRR level II screen found. Review of Resident #1's care plan, dated 06/12/24, showed: - Level I/ Level II PASRR screening completed. Resident determined to have severe mental illness with diagnoses including PTSD and intellectual disabilities; - The following interventions were included: - Address, report, and implement plan to manage refusals/ noncompliance For example, Notify Provider/ Responsible Party of instances of noncompliance, ascertain immediate safety, and/or sending to acute setting for evaluation of mental deterioration; - Assess and plan for level of supervision required to prevent harm or self/ others; - Medication set and administration by staff and monitor compliance with prescription; - Monitor and plan for assaultive behaviors, as well as how to de-escalate and help regulate moods/behaviors; - Monitor for elopement or medication refusals, symptoms of rapid decline in mood, escalating aggressive or sexual behavior, confusion or bizarre thoughts; - Monitor therapeutic effects in managing mental health symptoms, including labs as ordered; - Provide a structured/ stable environment in order to maintain mood stability/ safety; - Provide for individual personal space and sensory support. The facility did not provide Resident #1's PASRR. During an interview on 06/17/25, a Central Office Medical Review Unit (COMRU) nurse stated a Level 2 screening had been completed on the resident in the past, however, the facility would be required by the Department of Mental Health to complete a replacement application since the Level 2 screening was greater than a year old, to ensure it accrately reflects the resident's current behavioral health needs. MO255323, MO255327

Based on interview and record review, the facility failed to identify, assess, and provide supportive interventions for one resident (Residents #1) with a diagnosis of post traumatic stress disorder ((PTSD) - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). The facility's census was 101. The facility did not provide a policy on trauma-informed care or behavioral health management. Review of Resident #1's face sheet showed: - The resident was his/her own responsible party; - The resident had diagnoses of PTSD, major depression disorder (a mental disease characterized by persistent sadness), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), and Alzheimer's (a progressive disease causing loss of cognitive function). Review of Resident #1's Active Order Summary (Physician's Orders) current as of 06/10/25 showed: - An order for behavior monitoring every shift started 05/10/24; - An order for geodon (antipsychotic) 40 milligrams (mg) by mouth twice a day with meals for paranoid schizophrenia started on 06/06/25; - An order for lorazepam (anti-anxiety) injection solution 2 mg/milliliter (ml) every 8 hours as needed for agitation for 14 days started 06/05/25; - An order for lorazepam oral tablet 1 mg by mouth three times a day started 06/06/25; - An order for risperidone (antipsychotic) oral tablet 2 mg two times a day for schizophrenia started 12/18/23. Review of Resident #1's care plan dated 06/12/24 showed: - The resident requires a supervised environment and supervision with all activities of daily living care; - The resident will become physically and verbally aggressive when not getting what is asked for and will scream when staff attempt to de-escalate; - The resident smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior; - The resident has intellectual disabilities; - The resident's PTSD is triggered if he/she does not get his medications on time. The interventions included following the directions given by staff and working on his/her coping skills. No further directions for staff on de-escalation (redirection or alternatives); - There were no documented interventions in place for helping resident to manage his/her escalating behaviors. Review of Resident #1's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 03/12/25, showed: - The resident has some cognitive inabilities; - The resident requires supervision with all aspects of daily activities of life (ADL). During an interview on 06/10/25 at 11:50 A.M., Registered Nurse (RN) B said he/she has received no formal training prior to working at the facility. He/she is agency staff. He/she said the resident is triggered by wanting to smoke and becomes agitated when told no. During an interview on 06/10/25 at 12:15 P.M., CNA C said the resident is triggered by wanting to smoke and being told no. He/she does it to try to get cigarettes. During an interview on 06/10/25 at 11:00 A.M., the Director of Nurses (DON) said the resident has a history of demanding to smoke before the scheduled smoke breaks. If the resident is told no, he/she will react and become aggressive. She said the staff are aware of the resident's triggers and should attempt to keep him/her from escalating. The DON said his/her PTSD can be triggered when he/she perceives his/her medications as being given late. She is unaware of what interventions are in place for that on the care plan. MO255323, MO255327

Based on interview and record review, the facility failed to provide staff with appropriate behavioral health training to develop competencies and skill sets in order to to provide services to ensure resident safety and attain the highest practicable physical, mental, and psychosocial well-being for one sampled resident (Resident #1) when staff failed to implement de-escalation interventions when Resident #1 began exhibiting increased behaviors. The facility census was 74. The facility did not provide a policy on behavioral health management. Review of Resident #1's face sheet showed: - The resident is his/her own responsible party; - The resident has diagnoses of post-traumatic stress disorder ((PTSD)-a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), major depression disorder (a mental disease characterized by persistent sadness), Traumatic Brain Injury (TBI) (a brain injury caused by a physical force or blow to the head affect the person's cognitive function), Alzheimer's (a progressive disease causing loss of cognitive function). Review of Resident #1's Active Order Summary (Physician's Orders) current as of 06/10/25 showed: - An order for behavior monitoring every shift started 05/10/24; No documentation of behavior monitoring completed by the facility was provided. - An order for geodon (antipsychotic) 40 milligrams (mg) by mouth twice a day with meals for paranoid schizophrenia started on 06/06/25; - An order for lorazepam (anti-anxiety) injection solution 2 mg/milliliter (ml) every 8 hours as needed for agitation for 14 days started 06/05/25; - An order for lorazepam oral tablet 1 mg by mouth three times a day started 06/06/25; - An order for risperidone (antipsychotic) oral tablet 2 mg two times a day for schizophrenia started 12/18/23. Review of Resident #1's care plan, dated 06/12/24, showed: - The resident requires a supervised environment and supervision with all ADL care; - The resident will become physically and verbally aggressive when not getting what is asked for and will scream when staff attempts to de-escalate; - The resident smokes and will yell when wanting to smoke if not allowed to do so, this is his/her repetitive behavior; - The resident has intellectual disabilities; - There are no documented interventions in place for keeping resident from escalating behaviors; - The staff should attempt to accommodate the requests and needs in an effort to prevent escalation. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/12/25, showed: - The resident has some cognitive inabilities; - The resident requires supervision with all aspects of daily activities of life (ADL). During an interview on 06/10/25 at 11:00 A.M., the Director of Nurses (DON) said the resident has a history of demanding to smoke before the scheduled smoke breaks. If the resident is told no, he/she will react and become aggressive. She said the staff are aware of the resident's triggers and should attempt to keep him/her from escalating. There is no reason the staff staff on de-escalation, but do not have any formal training on mental health disorders. She said staff reported that on 06/50/25, the resident came out of the room at approximately 5:45 A.M. The resident went to the nurses' office on B hallway. He/she wanted to smoke and have a soda. The day shift charge nurse, Registered Nurse (RN) B told the resident no, he/she would have to wait until the designated smoke break. This upset the resident and caused more agitation. The nurse came out of the office into the hallway to avoid close contact with the resident. Three Certified Nurse Aides (CNAs), A, C and D were in the hallway, and they also told the resident he/she would have to wait. This continued to anger the resident. At this time, the resident grabbed onto CNA C by the shirt and was pushing the CNA C down the hallway. CNA A then approached the resident and struck the resident in the right eye. She said the nurse did not offer to let a staff member take the resident to smoke. The staff did not attempt to de-escalate the resident with any other options. She said that this is a trigger for the resident and the staff is aware of this. If staff had tried to offer other options, it might have prevented the resident from being so agitated. She said the staff does get training and in-servicing on abuse and neglect. The four staff members involved are all agency staff. They are supposed to read a training manual prior to working the floor. They are to sign a sheet that they have read the manual. The facility does not monitor and there is no way to ensure they have read the rules and policies provided in the manual. During an interview on 06/10/25 at 11:50 A.M., RN B said he/she has received no formal training prior to working at the facility. RN B said the resident is triggered by wanting to smoke and becomes agitated when told no. The resident will lash out at staff when angry. He/she said it is impossible to accommodate the resident every time he/she wants to smoke or have a soda. He/she said nothing else was offered, due to he/she was taking report at that time. When the resident became agitated, he/she walked out of the office into the hallway. RN B said it is not safe to work at the facility. There is no recourse when a resident attacks or becomes agitated. There is no need for mental health training as it allows for resident's to be taken down or restrained and this is a no touch facility. During an interview on 06/10/2025 at 12:30 P.M., CNA A said on 06/05/25, at approximately 5:30 A.M., the resident walked out of his/her room with a cigarette. The residents are not supposed to have cigarettes in their room. CNA A told the resident it was not time to smoke. The resident became agitated and acted like he/she was going to throw a table at CNA A. CNA A said he/she told the resident that it was not time to smoke and that he/she (the resident) was aware of the rules. CNA A said the resident has been aggressive with staff before. CNA A told the resident to calm down and the resident walked away, upset. CNA A said the resident came back out and lunged at him/her again and was told again to stop by CNA A. The resident entered the nurse's office and told RN B that he/she wanted a cigarette and a soda. After being told no again, the resident seemed more agitated, and RN B came out of the office. The resident charged at CNA C and it appeared the resident was going to swing at CNA C. CNA A felt the resident was going to hit him/her due to the resident still being angry and he/she swung and hit the resident. CNA A said his/her hand was open. CNA A said it was self-defense. CNA A said he/she only hit the resident once and could have hit more, but did not. Most people would have hit more than once. CNA A said he/she did not hit the resident hard. After the hit, the resident went into the shower room and CNA A believes Resident #1 self-inflicted the injuries. The facility does not offer any training or guidance for this type of problem. CNA A said the staff are in danger with the residents who have these behaviors. During an interview on 06/10/25 at 1:45 P.M., local law enforcement (LE) said his/her people see so many problems at this facility which are the results of poor decisions by staff. Staff know the residents have mental problems, but continue to instigate them by denying them coffee or cigarettes. When the resident reacts and becomes aggressive, they want LE to come and take the resident away.

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from abuse from another resident when staff failed to prevent Resident #2 from hitting Resident #1 which caused a hematoma (a collection of blood outside of the blood vessel) to the left side of the head. The facility also failed to ensure the resident was free from abuse from staff when staff removed Resident #1 from his/her room against their will, and rolled him/her onto a blanket and dragged the resident on the floor through the facility causing the resident to become anxious and require medication to calm down. The census was 120. On 02/25/25 at 3:30 P.M., the Administrator was notified of the immediate jeopardy (IJ) which began on 02/06/25. The IJ was removed on 02/27/25, as confirmed by surveyor onsite verification. Review of the facility's policy on Resident to Resident Altercations, updated 01/24/24, showed: -The staff member on the scene will immediately call a Code Gray on the walkie/talkie and/or overhead intercom; -Team members will attempt to separate residents and ensure the safety of all residents; -The team members will remain in the area of the disruption until further assistance arrives. Review of the facility's Abuse, Neglect and Exploitation Policy, dated 04/08/24, showed: -Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The resident must not be subject to abuse by anyone including but not limited to: facility staff; other residents; consultants or volunteers; staff of other agencies; family; legal guardians, friends or other individuals. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. 1. Review of Resident #1's face sheet showed: -Had a Public Administrator as a guardian; -Diagnoses of Schizoaffective Disorder-Bi Polar type (a mental health disorder involving depression, hallucinations and delusions with bouts of manic behavior), and heart failure. Review of Resident #1's annual Minimum Data Set ((MDS) a federally mandated assessment instrument completed by the facility staff), dated 01/29/25, showed: - The resident was cognitively intact; - The resident triggered for delirium (confused thinking, agitation and memory problems), cognitive loss, and falls. Review of Resident #1's Care Plan, dated 03/05/25, showed: - The resident required supervision with all activities of daily living (ADLs); - The resident had a history of aggression and throwing urine on others; - The resident had impaired cognitive thought processes; - The resident resided on a secured behavior unit until 02/06/25. Review of Resident #2's face sheet showed: - Diagnoses of Autistic Disorder (a lifelong disorder affecting how a person communicates, interacts with others and behaves), Schizophrenia (a mental health disease affecting how a person thinks including delusions, paranoia and hallucinations), and delusional disorder (a serious mental illness causing unshakeable false beliefs). Review of the resident's quarterly MDS dated , 02/06/25 showed the resident was cognitively intact and no behaviors listed. Review of Resident #2's care plan, updated 03/05/25, showed: - The resident becomes agitated if medications aren't on time; - The resident had delusions and hits staff and other residents without warning; - The resident had a history of frustration, agitation, impatience and striking others; - The resident resided on a secured behavior unit; - The resident was placed on 1:1 on 11/14/24. Review of the facility's investigation, dated 02/06/25, showed: - On 02/06/25, Resident #2 asked Certified Medication Technician (CMT) A for medications; - CMT A informed Resident #2 it was too early for the medications; - Resident #2 was on one on one with a designated staff member, Certified Nurse Aide (CNA) B, due to a history of aggressive behaviors; - The resident became agitated and started to walk down the hallway; - CMT A was afraid of Resident #2 and locked himself/herself in a clean linen closet; - CNA B and Licensed Practical Nurse (LPN) C, followed Resident #2 halfway down the hall and stopped two rooms away; - Resident #2 went to the end of the hallway and stared into Resident #1's room for a period of a few minutes; - CNA B and LPN C watched as Resident #2 raised his/her arms up and ran into the room of Resident #1 and hit Resident #1 in the head; - Resident #1 sustained a hematoma (damaged blood vessels surrounding the tissue). During an interview on 02/25/25 at 2:00 P.M., CMT A said Resident #2 becomes very agitated and angry when he/she is told it is not time for his/her medication administration. CMT A said Resident #2 became very threatening toward him/her (on 2/6/25), so he/she removed himself/herself from the situation by hiding in the closet. CMT A said he/she did not feel CNA B and LPN C would be able to handle Resident #2 if he/she escalated in behaviors, and that is why he/she hid. CMT A said he/she peeked out of the closet and saw Resident #2 enter Resident #1's room. CMT A heard Resident #1 yelling for help. LPN C and CNA B stood at least two room doors away and did not attempt to de-escalate Resident #2 or prevent Resident #2 from hitting Resident #1. During an interview on 02/25/25 at 3:15 P.M., LPN C said CNA B had been assigned to monitor Resident #2 in a one on one capacity due to the resident's history of aggressive behaviors toward other residents. Resident #2 asked CMT A for a medication and CMT A told the resident it was too early. Resident #2 became agitated. When Resident #2 started to walk down the hallway, he/she and CNA B followed. LPN C said they had watched Resident #2 standing at the doorway to Resident #1's room and they stood back down the hall to provide the resident space and not approach him/her. They were two rooms behind Resident #2 observing, when Resident #2 ran into Resident #1's room and hit Resident #1. LPN C said he/she and CNA B then ran toward Resident #1's room and stopped Resident #2 from hitting Resident #1 again. LPN C said when Resident #2 had become agitated the staff should have intervened to protect Resident #1. LPN C did not say why he/she did not intervene and attempt to de-escalate Resident #2 before he/she struck Resident #1. During an interview on 02/25/25 at 4:20 P.M., CNA B said he/she had been assigned to monitor Resident #2 one on one, due to the resident's history of hitting other residents in the head. Resident #2 was agitated due to not getting the medication he/she requested. Resident #2 started down B Hall while he/she and LPN C followed, but not too closely. He/she said they stood about two rooms away. CNA B said Resident #2 stood at the doorway of Resident #1's room for awhile then raised his/her arms and took off toward Resident #1 striking him in the head. CNA B said he/she and LPN C then ran toward Resident #1's room and heard him/her screaming. They intervened and stopped Resident #2 from striking the resident again. He/she felt CMT A was trying to stay away from Resident #1. CNA B did not say why he/she or LPN C did not attempt to stop Resident #2 from striking Resident #1 the first time. During an interview on 02/25/25 at 9:45 A.M., the Administrator (ADM) said he would expect all staff to protect the residents. He said staff are afraid of Resident #2 due to his/her size and strength. He expected the staff, CNA B and LPN C, to have stopped Resident #2 from hitting Resident #1. CNA B and LPN C should have called for assistance, but no Code Gray (in policy) that staff did not call for assistance when the resident became agitated knowing he had a history of attacking other residents 2. Review of the facility's investigation, dated 02/08/25, showed: - Resident #1 was removed from the B Hall after an incident involving Resident #2; - Resident #1 did not want to leave B Hall and went back to B Hall during the evening hours at approximately 10:00 P.M. to go to his/her old room; - Staff members LPN D and CNA E approached the resident and attempted to get Resident #1 redirected to his/her new hall; - Resident #1 sat in the floor and refused to get up; - Resident #1 continued to refuse to leave the B hall and laid in the floor while staff attempted to pull him/her to a standing position; - LPN D then placed a blanket on the floor and physically rolled Resident #1 onto the blanket; - LPN D and CNA E dragged the blanket and Resident #1 on the floor down B hall, through the lobby to his/her new room on A Hall at 11:30 P.M. Review of Resident #1's Medication Administration Record (MAR), dated February 2025, showed: - An order for Lorazepam (a drug used to treat anxiety) injection solution 2 milligram (mg) every 6 hours as needed for anxiety; - Lorazepam injection solution 2 mg given to Resident #1 on 02/07/2025 at 12:30 A.M. During an interview on 3/6/2025 at 10:20 A.M., CNA E said during the evening, Resident #1 came onto the B hall and said his/her room was there. The other staff members on the hallway told the resident that he/she needed to return to the A hall where the resident had been relocated to earlier that day. The resident sat on the floor and wanted to remain there. The charge nurse, LPN D, came to the B hall and told the resident he/she had to leave. CNA E said he/she requested multiple times to allow the resident to just remain on the floor and calm down and then redirect. LPN D got a blanket to put on the floor, rolled the resident onto the blanket and instructed CNA E to grab a corner and pull. LPN D drug the resident through the hallway to the A hallway. CNA E told LPN D this was not right. CNA E asked LPN D if he/she should write a statement and LPN D said no. During an interview on 3/6/2025 at 11:30 A.M., LPN D said on 02/06/25 when Resident #1 entered B hall the staff called him/her to come to the hall. Resident #1 was sitting in the hallway by the room that had previously been his/her room and wanted to go in. Staff, unknown to LPN D, were attempting to get the resident to stand up and the resident laid on the floor. LPN D said he/she tried to redirect. The staff said the resident had been attacked earlier and it was not safe to be there. LPN D said he/she attempted to reach the facility's Director of Nurses and on call staff and no one answered. He/she decided the resident needed to be moved to ensure his/her safety. He/she used the fireman blanket transfer (a blanket used to transfer people in emergency situations safely) to move the resident safely. The resident was pushed onto a blanket then rolled into the blanket. LPN D then had CNA E assist in dragging the blanket from Hall B, through the lobby to A hall. The resident was anxious and appeared nervous, but was not yelling or being aggressive at that time. Later in the shift Resident #1 became increasingly anxious and a Lorazepam injection solution 2 mg was administered on 02/07/2025 at approximately 12:30 A.M. LPN D felt it was the only way to ensure the resident was safe. During an interview on 02/25/25 at 9:45 A.M., the ADM said the two staff should not have treated the resident this way. He would have expected his other staff members to intervene with the physical abuse and did not understand why no staff stopped this from happening. COMPLAINT #MO249374 NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview and record review, the facility failed to provide staff with appropriate competencies and skill sets to provide nursing and related services to ensure resident safety and attain the highest practicable physical, mental, and psychosocial well-being for two sampled residents (Resident #1 and #2) when staff failed to implement interventions preventing Resident #2 from hitting Resident #1 and interventions preventing staff from physically moving Resident #1 against his/her will. The census was 120. On 02/25/25 at 3:30 P.M., the Administrator was notified of the immediate jeopardy (IJ) which began on 02/06/25. The IJ was removed on 02/27/25, as confirmed by surveyor onsite verification. The facility did not provide a policy regarding the unit staffing needs or specialized training needed to work on a locked behavior unit. The facility did not provide a documented mental health behavior training program for all staff including temporary agency staff working on the secured behavioral unit. 1. Review of Resident #1's Preadmission Screening and Resident Review (PASRR), dated 07/27/23, showed: - A 50 plus years of mental illness with no family support; - Impaired judgement and decision making; - A long history of psychiatric treatments; - Required a secured behavioral unit. Review of Resident #1's face sheet showed: - Had a Public Administrator as a guardian; - Diagnoses of Schizoaffective Disorder-Bi Polar type (a mental health disorder involving depression, hallucinations and delusions with bouts of manic behavior), and heart failure. Review of Resident #1's annual Minimum Data Set ((MDS) a federally mandated assessment instrument completed by the facility staff) dated, 01/29/25, showed: - The resident was cognitively intact; - The resident refused care and physically disrupts the environment on a daily basis; - The resident triggered for delirium (confused thinking, agitation and memory problems), cognitive loss, and falls. Review of Resident #1's Care Plan, dated 03/05/25, showed: - The resident required supervision with all activities of daily living (ADLs); - The resident had a history of aggression and throwing urine on others; - The resident had impaired cognitive thought processes; - The resident resided on a secured behavior unit until 02/06/25; - The resident may exhibit behaviors such as throwing himself/herself onto the floor when he/she does not get their way. Interventions included Social Services working with the resident one on one, staff redirecting resident when he/she is impatient and remind the resident of his/her coping skills when he/she is angry; - The resident has a history of elopement attempts from the locked unit. Interventions included staff will accompany the resident to and from destination if the resident needs to be off the locked unit, staff will notify the resident's psychiatric doctor and resident will be put on one on one monitoring or 15 minute checks to ensure safety; - The resident is resistive to care and treatments at time. Interventions included allowing resident time to make decisions and explaining processes slowly and leaving the situation and coming back 5-10 minutes later and approach again. Review of Resident #2's PASRR, dated 04/07/22, showed the resident meets requirements for short term nursing facility placement. The resident required: - A behavioral support plan; - A structured environment; - Crisis intervention services; - Discharge planning; - Medication therapy and monitoring; - ADL assistance. Review of Resident #2's face sheet showed: - Diagnoses of Autistic Disorder (a lifelong disorder affecting how a person communicates, interacts with others and behaves), Schizophrenia (a mental health disease affecting how a person thinks including delusions, paranoia and hallucinations), and delusional disorder (a serious mental illness causing unshakeable false beliefs). Review of Resident #2's annual MDS, dated [DATE], showed the resident: - Cognitively intact; - Exhibited hallucinations (the perception of the presence of something that is not actually there, involving one or more of the five senses, and delusions are fixed, false beliefs not shared by others that the resident holds even in the face of evidence to the contrary) and delusions (a fixed, false belief that the resident holds, even in the face of evidence to the contrary); - Exhibited physical behaviors (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) one to three day during the 7 day look back observation period; - Exhibited verbal behaviors (threatening others, screaming at others, cursing at others) one to three days during the 7 observation period; - The resident's behaviors put others at a significant risk and significantly disrupt the care environment. Review of Resident #2's care plan, updated 03/05/25, showed: - On 11/8/24 the resident had a resident to resident altercation and was placed on one on one monitoring. The care plan was updated on 12/10/24 to include the resident has delusions at times and will strike staff and other residents without warning. Interventions included remaining on one on one monitoring, informing the resident's physician of the behaviors and reminding the resident to use his/her coping skills; - The resident frequently becomes fixated on his/her medication administration and will follow CMTs around. The resident also has a history of hitting staff and staff equipment if he/she does not get his/her medications when he/she asks for them. Interventions included directing CMTs to give Resident #2 his/her medication first on his/her hall of residence and for the resident to seek assistance if he/she can't use his/her coping skills. Review of Resident #2's Care Plan for Behaviors, dated 11/14/24, showed: - The resident has a history of delusions with suspicious thoughts and impulsive behaviors which include medication non-compliance, poor hygiene, hitting head when distressed, consumption of non food items (i.e. paint chips), consumption of large quantities of food, rocking, strange postures, staring episodes, and startling easily per level II PASRR. - The resident also becomes distressed by loud noises, exhibits threatening behavior towards his/her father, fixation on particular items, abnormal thought process, and withdrawn; - Interventions included: - Administer medications as ordered; - Ascertain causes for symptoms; - Conduct intervention matching causes of symptoms, preferences include music therapy, orientation training, exercise and/or art cognitive activity; - Observe for effectiveness of medications; - Offer tea or [NAME] Aid as way to promote calmness; - Engage conversations with me about my musical preferences; - Refer resident to activities of choice, like watching TV; - Engage resident in conversations regarding baseball, or find a game on TV; - Offer resident his/her PAD. I enjoy playing games/using my PAD; - Staff will monitor for consumption of non-food items and report any abnormal findings to physician. Review of the facility's investigation, dated 02/06/25, showed: - On 02/06/25, Resident #2 asked Certified Medication Technician (CMT) A for medications; - CMT A informed Resident #2 it was too early for the medications; - Resident #2 was on one on one with a designated staff member, Certified Nurse Aide (CNA) B, due to a history of aggressive behaviors; - The resident became agitated and started to walk down the hallway; - CMT A was afraid of Resident #2 and locked himself/herself in a clean linen closet; - CNA B and Licensed Practical Nurse (LPN) C, followed Resident #2 halfway down the hall and stopped two rooms away; - Resident #2 went to the end of the hallway and stared into Resident #1's room for a few minutes; - CNA B and LPN C watched as Resident #2 raised his/her arms up and ran into Resident #1's room. Resident #2 ran into the room and hit Resident #1 on the left side of the head; - Resident #1 sustained a hematoma to the left side of the head (damaged blood vessels surrounding the tissue). During an interview on 02/25/25 at 2:00 P.M., CMT A said he/she is agency staff and had been with the facility as needed since July 2024. CMT A said that in the past he/she had received education and training on working with mental health residents. CMT A said on 02/06/25, Resident #2 asked for his/her medications too early. The CMT said he/she told Resident #2 it was not time for his/her medications yet. CMT A said getting his/her medications is a trigger for Resident #2 and he/she became very threatening toward the CMT after he/she told the resident he/she was unable to provide the medications. CMT A said he/she removed himself/herself from the situation by hiding in the closet. CMT A said he/she did not know if CNA B and LPN C would be able to handle Resident #2 if he/she escalated in behaviors, because Resident #2 is large and can be very aggressive. CMT A said he/she hid in hopes to de-escalate the resident by removing himself/herself from the situation quickly. CMT A said he/she peeked out of the closet and saw Resident #2 enter Resident #1's room. CMT A heard Resident #1 yelling for help. LPN C and CNA B stood at least two room doors away and did not attempt to stop Resident #2 from entering Resident #1's room. CMT A said the only intervention in place for Resident #2 was the one on one monitor, other than that he/she would attempt to redirect the resident. CMT A had never seen a care plan for a resident. During an interview on 02/25/25 at 3:15 P.M., LPN C said CNA B had been assigned to monitor Resident #2 in a one on one capacity due to the resident's history of aggressive behaviors toward other residents. Resident #2 asked CMT A for a medication and CMT A told the resident it was too early. Resident #2 became agitated. When Resident #2 started to walk down the hallway, he/she and CNA B followed. LPN C said they watched Resident #2 standing at the doorway to Resident #1's room and they stood back down the hall to provide the resident space and not approach him/her. LPN C said they were hoping if Resident #2 had some space he/she would de-escalate. LPN C did not know what interventions Resident #2 was care planned for. They were two rooms behind Resident #2 observing, when Resident #2 ran into Resident #1's room and hit Resident #1. LPN C said he/she and CNA B then ran toward Resident #1's room and stopped Resident #2 from hitting Resident #1 again. LPN C said when Resident #2 had become agitated the staff should have intervened to protect Resident #1 by attempting to redirect Resident #2 away from Resident #1's room. LPN C said he/she had received training on de-escalating a resident. LPN C did not say why he/she did not intervene and attempt to de-escalate Resident #2 before he/she struck Resident #1. LPN C said he/she did not try to engage Resident #2 in any conversation about his/her favorite things or other interventions from the resident's behavioral care plan. During an interview on 02/25/25 at 4:20 P.M., CNA B said he/she is an employee of the facility and not agency staff. CNA B said he/she had been assigned to monitor Resident #2 one on one, on 2/06/2025 due to the resident's history of hitting other residents in the head. Resident #2 was agitated due to not getting the medication he/she requested. Resident #2 started down B Hall while he/she and LPN C followed, but not too closely. He/she said they stood about two rooms away hoping Resident #2 would step back and away from Resident #1's room. CNA B said Resident #2 stood at the doorway of Resident #1's for awhile then raised his/her arms and took off toward Resident #1 striking him/her in the head. CNA B said he/she and LPN C then ran toward Resident #1's room and heard him/her screaming. They intervened and stopped Resident #2 from striking the resident again. He/she did not say why they were not closer to Resident #1. CNA B said he/she had received training on redirection and de-escalation, but did not use any verbal redirection with Resident #2. CNA B did not say why he/she or LPN C did not attempt to stop Resident #2 from striking Resident #1 the first time nor did he/she say why he/she did not attempt any of the interventions listed in the care plan. During an interview on 02/25/25 at 9:45 A.M., the Administrator (ADM) said facility staff receive training on de-escalation methods twice monthly. However, the facility currently has in house staffing issues and rely on agency staff. The ADM said he cannot force agency staff to participate in facility training. The ADM said they have invited the agency staff to all trainings, but they do not come. He said that he had called the agency to see if they could be made to attend and no one returned the call. He would expect all staff to protect the residents. The ADM said he expected the staff, CNA B and LPN C, to have stopped Resident #2 from hitting Resident #1. CNA B and LPN C are not agency staff and should have called for assistance if they felt they could not handle Resident #2. The ADM said on 02/06/25, Resident #2 was already being monitored one on one for previous aggressive behaviors. He was unsure what other interventions were in place for Resident #2. The ADM said they were doing the best they could, but staff seemed to be scared of Resident #2. The ADM said he was unsure how care plan information was shared with staff. 2. Review of the facility's investigation, dated 02/08/25, showed: - Resident #1 was removed from the B Hall after an incident involving Resident #2; - Resident #1 did not want to leave B Hall and went back to B Hall during the evening hours to go to his/her old room; - Staff members LPN D and CNA E approached the resident and attempted to get Resident #1 redirected to his/her new hall; - Resident #1 sat in the floor and refused to get up; - Resident #1 continued to refuse to leave the B hall and laid in the floor while staff attempted to pull him/her to a standing position; - LPN D then placed a blanket on the floor and physically rolled Resident #1 onto the blanket; - LPN D and CNA E dragged the blanket and Resident #1 on the floor down B hall, through the lobby to his/her new room on A Hall. During an interview on 3/6/2025 at 10:20 A.M., CNA E said he/she was an agency staff member. CNA E said prior to arriving at the facility, he/she had no idea he/she would be assigned to a behavior hall. CNA E said he/she did not know the names of any other staff. He/she received no training or policies on the Behavior Hall, a secured unit. During the evening, Resident #1 came onto the B hall and said his/her room was there. The other staff members on the hallway told the resident that he/she needed to return to the A hall where the resident had been relocated to earlier that day. The resident sat on the floor and wanted to remain there. The resident was not causing any problems or having any behaviors. The resident did refuse to go to his/her new room and was wanting to return to the old room he/she had been in prior to the relocation. The charge nurse, LPN D, came to the B hall and told the resident he/she had to leave. CNA E said he/she requested multiple times to allow the resident to just remain on the floor and calm down and then redirect. LPN D got a blanket to put on the floor, rolled the resident onto the blanket and instructed CNA E to grab a corner and pull. LPN D drug the resident through the hallway to the A hallway. During an interview on 3/6/2025 at 11:30 A.M., LPN D said he/she was agency staff brought in with no information regarding working a behavior unit. He/she was not given any policies or protocols, and did not have time to become familiar with residents prior to starting job duties. LPN D did not know Resident #1 had only been moved earlier that day and did not know the resident was at risk for elopement. On 02/06/2025 Resident #1 left his/her current hall and entered B hall. Staff from B hall called him/her to assist with Resident #1. Resident #1 was sitting in the hallway asking to go in his/her old room. Staff on B hall, unknown to LPN D, were attempting to get the resident to stand up and the resident laid in the floor. LPN D said he/she tried to redirect. The B hall staff said the resident had been attacked earlier by another resident who still was on B hall and it was not safe for Resident #1 to be there. LPN D said he/she attempted to reach the facility's Director of Nurses and on call staff and no one answered. He/she decided that the resident needed to be moved to ensure his/her's safety. He/she used the fireman blanket transfer (a blanket used to transfer people in emergency situations safely) to move the resident safely. The resident was rolled onto the blanket. LPN D then had CNA E assist in dragging the blanket from the unit on Hall B, through the lobby to A hall. The resident was anxious and appeared nervous, after being drug through the facility but was not yelling or being aggressive. LPN D felt it was the only way to ensure the resident was safe. During an interview on 02/25/25 at 9:45 A.M., the ADM said the facility currently has in house staffing issues and rely on agency staff. The facility has requested the agency staff to attend in-servicing but they have in the past refused. The two staff who put Resident #1 on a blanket and drug him/her through the facility were agency staff. The ADM did not know how their policies were communicated to agency staff. The ADM said in this situation, he would expect staff to attempt to redirect and if not possible to sit with the resident until they calm down. Complaint #MO249378 NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 115. Review of the facility's Handwashing policy, undated, showed: - Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures; - Wash hands and exposed portions of arms immediately before engaging in food preparation; - When to wash hands: after handling garbage or garbage cans, dirty trays or dishes, or anything soiled; as often as necessary during food preparation to remove soil/contamination, and to prevent cross contamination when changing tasks; any time a contaminated surface is touched; - Staff is educated on the importance of hand washing and retrained and reminded as necessary on the above guidelines; - To ensure safe and proper food handling during food preparation and service, the food code states that food items should not be handled with bare hands; - Handwashing per guidelines should occur between each task; - Gloves should be worn if handling food is necessary. Extra caution should be taken when multiple tasks are being completed; - Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines. The facility did not provide a policy regarding food storage. Observations on 12/01/24 at 7:15 P.M. of the kitchen showed: - Dirt, debris, and trash throughout the floor; - Pile of empty boxes near the kitchen door; - Two large round trash cans with no lids on them; - Black carbon buildup on stove top and oven; - Black carbon and debris buildup inside the convection oven; - Approximately two dozen live cockroaches inside the stove top oven; - Two missing knobs on front of the stove top; - Black carbon buildup on skillets, pots, pans, and cooking sheets; - A small cockroach crawling up the wall near the coffee maker; - Debris on countertops throughout the kitchen. Observation on 12/01/24 at 7:20 P.M. of the dry goods storage area showed: - A large dented can of solid packed apples on the can storage rack; - Dirt and debris throughout the floor. Observation on 12/01/24 at 7:22 P.M. of the refrigerator showed: - A tray containing small sealed cups of salad dressing, undated and unlabeled; - An unsealed bag of sandwiches. Observation on 12/03/24 at 11:50 A.M. of the kitchen showed: - Dietary Aide F in the kitchen without a hairnet; - Dirt, debris, and trash throughout the floor; - Debris on countertops throughout the kitchen; - Black carbon buildup on stove top and oven; - Black carbon and debris buildup inside the convection oven; - Two missing knobs on front of the stove top; - Black carbon buildup on skillets, pots, pans, and cooking sheets; - A pair of stained, torn oven mitts sitting on the counter near the oven with a live cockroach crawling on them; - An opened container of peanut butter with an expiration date of 11/27/24; - Two opened containers of jelly in a squeeze bottle that said refrigerate after opening stored on the lower cabinet behind the stove top oven. Observation on 12/03/24 at 11:52 A.M. of the dry goods storage area showed: - Dirt and debris throughout the floor; - Two dead cockroaches in the floor; - A large dented can of chocolate flavored syrup in the can storage rack; - Two five gallon containers of Sunburst Chemical sitting in the floor. Observation on 12/03/24 at 12:12 P.M. of the lunch meal service showed: - Dietary Aide H served trays to residents in the main dining room and did not sanitize in between serving residents; - Dietary Aide I touched multiple dirty surfaces, including pans, serving station, scoops and plastic wrap and then touched clean plates, including the center of the plates and residents' food while wearing the same soiled gloves; - Dietary Aide C touched multiple dirty surfaces including pans, serving station, scoops, plastic wrap, and a dirty trash can lid and then touched residents' food and the inside sections of divided plates while wearing the same soiled gloves; - A dead cockroach smashed in the lid of the water reservoir on the coffee maker that staff were using to serve residents coffee; - Dietary Aides F and G touched the ice scoop to the inside and rims of residents' personal cups, which residents had been using throughout the day; - Dietary Aides F and G put the ice scoop into the ice bucket to store between refilling residents' cups; - Dietary Aides F and G touched the drink pitchers to the rims of residents' personal cups, which residents had been using throughout the day when they were filling each resident's cup for the lunch meal; - Dietary Aides F and G did not wear gloves or sanitize their hands during the entire lunch meal service. During an interview on 12/05/24 at 2:36 P.M., the Dietary Manager (DM) said he/she would expect the kitchen to be free from pests. The facility has had an ongoing issue with cockroaches, but he/she knows there is a new company that is coming to spray for them. He/She doesn't know who the pest control company is, but knows they typically spray once a month. He/She would expect staff to wear hairnets in the kitchen and to sanitize their hands and change their gloves after touching something dirty and before touching food or assisting residents. He/She would expect all temperature logs to be completed per regulation. He/She would expect food requiring refrigeration to be stored in the refrigerator and all foods to be stored in appropriately-sealed containers or packages with dates and labels on them. He/She would expect the kitchen and equipment to be free from dirt, debris, and black carbon buildup. It is very challenging to get the buildup off the equipment. Dented cans are taken out of the can storage rack to be sent back to the food company. He/She would expect items past their best by date to be discarded and the dry goods storage area to be free from chemicals. During an interview on 12/05/24 at 2:52 P.M., Dietary Aide C said he/she should change gloves or sanitize hands when touching anything that's not food and when touching surfaces. Cockroaches have been an issue and they spray, but he/she guessed it's not working. During an interview on 12/05/24 at 2:59 P.M., Dietary Aide I said cockroaches have been an issue in the facility. He/She should change gloves between dirty to clean surfaces and he/she should wash his/her hands before putting on new gloves. He/She should wear a hairnet in the kitchen. During an interview on 12/06/24 at 11:36 A.M., Dietary Aide G said he/she has seen cockroaches in the facility and they have been an ongoing issue. He/She knows the facility has someone that comes to spray for them, but he/she still sees them. He/She should sanitize his/her hands every time he/she touches something unsanitary. He/She will wear gloves, but do not change them every time and the facility does not train them to sanitize between the residents. He/She should wear a hairnet when in the kitchen. The ice scoop and pitchers should not touch the resident's cups when staff serve drinks. During an interview on 12/05/24 at 3:45 P.M., the Maintenance Director said there is a book for pest control for employees to note issues with pests, and the company will look at it when they get to the facility to spray each month. The facility recently started using a different pest control company, who comes once a month unless they call for extra services. He/She did not have the pest control book because the pest control company took it with them when they came last Tuesday. The company sprayed and put out tamper-proof traps on their last visit. During an interview on 12/06/24 at 3:45 P.M., the Administrator and Director of Nursing (DON) said they would expect the facility to be free from pests. They would expect staff to change gloves or sanitize their hands between dirty to clean, to change dirty gloves before touching items, the residents, or resident food. They would expect hairnets to be worn in the kitchen, the kitchen and equipment to clean and free from carbon buildup, dirt and debris, refrigerated items to be stored in the refrigerator, food to stored in appropriately-sealed containers and dated and labeled, items past the best by date to be discarded, and the dry goods storage area to be free from chemicals.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during perineal (peri) care (cleaning the genital and anal areas of the body) for two residents (Resident #4 and #66) outside the sample. The facility failed to implement enhanced barrier precautions (EBP) during perineal and wound care for one resident (Resident #6) out of 23 sampled residents and failed in the prevention of communicable disease in regard to tuberculosis (TB-a communicable disease that affects the lungs and is characterized by fever, cough and difficulty breathing) screening/testing of two residents (Resident # 8 and #23) out of five sampled residents. The facility's census was 115. Review of the Centers for Medicare & Medicaid Services (CMS) memorandum QSO-24-08-NH, dated 03/20/24, showed: - CMS is issuing new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards; - EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status; - The new guidance related to EBP is being incorporated into F880 Infection Prevention and Control; - EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities; - EBP are used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; - EBP are indicated for residents with any of the following: Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO; - EBP should be used for any residents who meet the above criteria, wherever they reside in the facility; - For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line (a thin flexible tube that is inserted into a large vein to provide medications, fluids, and blood) urinary catheter (a flexible tube inserted into the bladder to drain urine), feeding tube, tracheostomy/ventilator (surgical opening in the neck used to provide airway for breathing) and wound care (any skin opening requiring a dressing). Review of the facility's Infection Control Policy, reviewed 10/24/24, showed: - Standard/Universal Precautions used to prevent contact with blood or other potentially infectious material, and will be utilized by facility personnel; - Hand hygiene refers to washing with soap or alcohol based hand rubs that do not require water; - Hands shall be washed with soap and water when visibly soiled with dirt, body fluids, blood or after direct or indirect contact with such, and before eating and after using restroom; - In absence of visible soiling of hands, alcohol based rubs are preferred for hand hygiene; - Wash hands after removing gloves; - Wear gloves when direct contact with blood, body fluids, mucus membranes, non-intact skin and other potentially infected material is anticipated; - Change gloves as necessary, during care of a resident to prevent cross-contamination from one body site to another; - Do not reuse gloves; - Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, before going to another resident, and wash hands or use alcohol based rub immediately to avoid transfer of micro oganisms to other residents or environment; - Do not wear gloves from one resident to another or walking down hallway; - Wear a mask and eye protection or face shield to protect eyes, nose and mouth during procedures and resident care activities that are likely to generate splashes or sprays; - Wear a gown to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions that may cause soiling; - Remove soiled gown as promptly as possible and perform hand hygiene prior to leaving room; - EBP not addressed in the Infection Control policy. Review of the facility's Peri-Care policy, reviewed 08/24/24, showed: - It is the practice of this facility to provide perineal care to all incontinent residents as needed and during routine bath time in order to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown; - Peri-care will be completed when a resident is incontinent, soiled, during routine bath time, and as needed; - The policy did not address hand hygiene or glove use during peri-care. Review of the facility's Handwashing policy, undated, showed: - Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures; - When to wash hands: to prevent cross contamination when changing tasks or any time a contaminated surface is touched; - Staff is educated on the importance of hand washing and retrained and reminded as necessary on the above guidelines; - Handwashing per guidelines should occur between each task; - Gloves should be removed when changing or walking away from specific tasks and hands should then be washed per guidelines. Review of the facility's document, Your Five Moments for Hand Hygiene, undated, showed: - The World Health Organization (WHO) recommends that medical professionals should clean their hands before touching a patient, before clean procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings. Review of the facility's TB Testing Policy, reviewed 08/25/24, showed: - In order to minimize the risk of resident acquiring, transmitting, or experiencing complications from tuberculosis, the facility will screen residents upon admission and annually; - Upon admission, each resident will have a two-step TB test administered and read per protocol; - Annually, each resident will be screened for TB, and the Director of Nursing (DON) and physician will be notified of any questions answered affirmative. 1. Observation on 12/05/24 at 12:50 P.M. of Resident #6's peri and wound care showed: - Certified Nursing Assistant (CNA) L and CNA M washed hands and gloved; - CNA L and CNA M removed the resident's wet brief and CNA L cleaned the front peri area wearing only gloves; - CNA M rolled resident to his/her left side, and held in place for CNA L to clean buttocks; - CNA L, with the same soiled gloves, cleaned the resident's buttocks with a clean wipe; - Licensed Practical Nurse (LPN) N washed hands, then cleaned wound on the resident's buttock and placed dressing, wearing only gloves; - LPN N removed gloves and sanitized hands before leaving room; - CNA L, CNA M, and LPN N did not wear a gown for the duration of peri care and wound care; - Resident #6 did not have an EBP sign on his/her door or EBP supplies available outside or near his/her door. During an interview on 12/05/24 at 2:35 P.M., LPN N said EBP should be used for wound precautions, to prevent spread of MRDOs. EBP should be worn when transferring and toileting residents with catheters, central lines, and tube feedings. Staff should wear gloves, gowns, and goggles/masks for wound care, depending on the wound. The facility has carts with the EBP supplies in different locations and EBP should have been worn during Resident #6's care. During an interview on 12/05/24 at 2:54 P.M., CNA L said EBP would include gowns and gloves and are kept in the clean supply or med supply room. CNA L said he/she should have worn EBP during Resident #6's care. During an interview on 12/05/24 at 2:54 P.M., CNA M said EBP would be worn if someone had something infectious, and the facility would let staff know. There was not anything in place like that for Resident #6 and, at that time, he/she was unaware of any resident in the facility placed on EBP. 2. Observation on 12/05/24 at 1:20 P.M. of Resident #4's peri care showed: - CNA O donned gloves without performing hand hygiene and moved the resident's bedside table; - CNA K brought in washcloths and a towel, put them on the sink, and donned gloves without performing hand hygiene; - CNA K and CNA O transferred the resident from wheelchair to bed via mechanical lift; - CNA K took the lift into the hall and attempted to spray it with an alcohol bottle zip tied to the lift, but said the bottle wasn't spraying very well, so he/she put the bottle back; - CNA K removed gloves, washed hands, donned gloves, obtained trash liners from his/her pocket and handed them to CNA O; - CNA O spread out two liners on the bed; - CNA K and CNA O removed the resident's soaked brief and pulled it out from under the resident as they both rolled the resident. CNA K put the wet brief into the trash liner that CNA O held open; - CNA K opened the nightstand drawer with the same soiled gloves and obtained a bottle of peri wash; - CNA K turned on the faucet at the sink with the same soiled gloves, wet the washcloth with water, sprayed peri wash onto the washcloth, and set the washcloth and peri wash bottle on the nightstand; - CNA K removed the lift pad from under the resident, put the lift pad and bed pad in the trash liner that CNA O held open; - CNA K wiped the resident's front peri area with the same washcloth folding it over with each use, then used a dry towel on the resident's peri area without changing gloves or performing hand hygiene; - CNA K and CNA O, with the same soiled gloves, rolled the resident side to side and both cleaned the resident's buttocks with a new washcloth sprayed with peri wash and dried with a new towel then disposed of washcloth and towel in trash liner on bed; - CNA K opened the nightstand drawer to obtain barrier cream, removed gloves, washed hands for approximately three seconds, while CNA O touched gloves in glove dispenser hanging on the wall, still wearing the same soiled gloves; - CNA O removed gloves, did not perform hand hygiene and, with bare hands, handed a new pair of gloves to CNA K to don; - CNA O retrieved new gloves for himself/herself from the glove dispenser on the wall and donned gloves; - CNA K applied barrier cream to the resident's buttocks, removed gloves, washed hands for approximately three seconds, and donned new gloves; - CNA K picked up the soiled bags from the bed, set them on the floor, then covered the resident with a blanket; - CNA K removed gloves, picked up trash bags from floor with bare hands, then set the bags back down on the floor, washed hands, and picked up the trash bags again; - CNA O removed gloves, washed hands and exited room; - CNA K put trash in soiled utility room and washed hands in the employee restroom by the nurses' station. During an interview on 12/05/24 at 1:50 P.M., CNA K said he/she would wash hands before care, in between, and if the resident is both wet and had a bowel movement, he/she would wash hands and change gloves before cleaning up the bowel movement, then wash hands before leaving the room. He/She would sanitize when out of the resident's room after care. He/She would try to not touch other things in the room with dirty hands. CNA O said he/she agreed with what CNA K said. 3. Observation on 12/05/24 at 1:57 P.M. of peri care for Resident #66 showed: - CNA K washed hands in the resident's room and donned gloves; - CNA O obtained clean gloves, put them in his/her pocket, washed his/her hands, then took gloves from pocket and donned them; - CNA K and CNA O transferred the resident from the wheelchair to the bed with a gait belt (a device used for assistance with transfers and walking); - CNA K removed the resident's pants and soaked brief as CNA O laid trash liners on the bed; - Without changing gloves or performing hand hygiene, CNA K laid a clean brief on the bed; - CNA O picked up the clean brief and set it on the wheelchair with same gloves used to hold bags open for CNA K to place the resident's soiled clothing and brief; - CNA K removed gloves, washed hands, sprayed washcloths with peri wash, handed a washcloth to CNA O, who wiped the resident's front peri area, folding the cloth with each wipe, and dried the resident with a clean towel; - CNA O assisted the resident to roll and, with the same washcloth and wearing the same soiled gloves, wiped bowel movement six times, folding the washcloth over each time, then disposed of the washcloth in the trash liner CNA K held; - Wearing the same soiled gloves and with a clean, dry towel, CNA O dried the resident's buttocks, picked up the clean brief from the resident's wheelchair, and put it on the resident while CNA K held the soiled bag; - CNA K and CNA O removed gloves. CNA K washed hands while CNA O did not; - The resident removed his/her socks, handed them to CNA O, who put the socks in the resident's wheelchair next to the bed. CNA O then covered the resident with a blanket; - CNA O did not wash hands prior to leaving the room. 4. Review of Resident #8's medical record showed: - admitted [DATE]; - First-step TB test given on 01/04/24, read on 01/08/24, one day late, with results of 0 millimeters (mm); - Second-step TB test given on 01/19/24, read on 01/22/24, results of 0 mm. During an interview on 12/05/24 at 4:26 P.M., the DON said the results of Resident #8's first step had been read a day late. 5. Review of Resident #23's medical record showed: - admitted [DATE]; - A TB screening, dated 08/12/24, indicated further instructions needed due to resident had prolonged cough; - No documentation of further instruction requested or orders for further testing. During an interview on 12/05/24 at 4:21 P.M., the DON said she would expect at minimum for a resident that did not have a passing annual screening to at least have a chest X-ray, but this occurred before her time. During an interview on 12/06/24 at 3:45 P.M., the Administrator and DON said they would expect staff to change gloves or sanitize their hands between dirty to clean and to change dirty gloves before touching items or the residents. They would expect staff to use EBP when a resident has wounds, tracheostomies (a surgical procedure that creates an opening in the windpipe and inserts a tube to provide an airway), peg tubes (a thin, flexible tube inserted through the skin of the abdomen directly into the stomach used for food, fluids, or medication), or communicable diseases. The EBP PPE is to be stored somewhere close to resident rooms or the nurse's station where staff can easily access it. They would expect TB tests to be read per regulation and residents with a positive TB screening to have the physician notified and a chest X-ray completed. 46555

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program. This had the potential to affect all residents in the facility. The facility's census was 115. Review of the facility's policy, Pest Control, dated 08/24/24, showed: - This facility will ensure the facility remains clean and free from pests; - Daily cleaning of facility will be maintained; - Monthly contracted pest control company will treat inside and outside of facility; - Entry points to facility will be kept in good repair; - Residents will be provided bags for their snacks they keep in their rooms. Observation of the kitchen on 12/01/24 at 7:17 P.M. showed: - Approximately two dozen live cockroaches in the oven that scattered when the oven door was opened; - A live cockroach crawling up the wall near the coffee maker. Observation of the kitchen on 12/03/24 at 11:50 P.M. showed: - A live cockroach on a pair of oven mitts lying on a shelf next to the oven; - Multiple live cockroaches inside the oven; - A dead cockroach in the floor to the right of the oven. Observation of the dry goods storage room on 12/03/24 at 11:53 A.M. showed a dead cockroach in front of the walk-in refrigerator. Observation of the main dining room serving area on 12/03/24 at 12:12 P.M. showed: - A dead cockroach smashed between the lid and top of the water reservoir area on the coffee maker the staff were using to serve residents coffee; - Multiple mouse droppings throughout the serving counter cabinets and drawers; - A dead insect in the steam table well. Observation of the nursing office on locked portion of B hall on 12/05/2024 at 11:55 A.M. showed a small cockroach crawling on the floor out from under the desk. During an interview on 12/05/24 at 2:36 P.M., the Dietary Manager (DM) said he/she would expect the kitchen to be free from pests. They have had an on going issue with cockroaches. He/She doesn't know who the pest control company is, but knows they typically spray once a month. During an interview on 12/05/24 at 2:52 P.M., Dietary Aide C said cockroaches have been an ongoing issue. He/she knows someone comes to spray for them, but he/she guesses it has not been working. During an interview on 12/05/24 at 2:59 P.M., Dietary Aide I said cockroaches have been an issue in the facility. During an interview on 12/06/24 at 11:36 A.M., Dietary Aide G said he/she has seen cockroaches in the facility and they have been an ongoing issue. He/she knows the facility has someone that comes to spray for them, but he/she still sees them. During an interview on 12/05/24 at 3:45 P.M., the Maintenance Director said there is a book for pest control for employees to note issues with pests, and the company will look at it when they get to the facility to spray each month. The facility recently started using a different pest control company, who comes once a month unless they call for extra services. He/she did not have the pest control book because the pest control company took it with them when they came last Tuesday. The company sprayed and put out tamper-proof traps on their last visit. During an interview on 12/06/24 at 3:45 P.M., the Administrator said he/she would expect the facility to be free from pests.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This had the potential to affect all residents. The facility's census was 115. Review of the facility's policy, Maintenance Repair Policy, dated 08/24/24, showed: - All team members are orientated to the Maintenance Work Order log located at each nurses' station; - Any team member can complete the Maintenance Work Order; - Maintenance personnel shall address routine maintenance work orders throughout the day, within 24 hours, or the next business day; - Emergency work orders shall be addressed upon notification; - In the event a work order has not been addressed within the timeframe specified, any team member will contact the Maintenance Director; - A log of these work orders shall be retained by the Maintenance Director; - In the event the Maintenance Director is unavailable, all concerns should be directed to the Administrator. Observations on 12/01/24 at 1:30 P.M. of the main entrance common area showed an overwhelming urine odor. Observation on 12/01/24 at 4:55 P.M. showed numerous brown stains on ceiling tiles on C hall near the nurses station and fire doors. Observations on 12/01/24 at 5:00 P.M. of the D hall common area showed: - A missing ceiling tile with exposed wires by the exit to the men's unit; - Eight missing ceiling tiles over the nurse's station showing exposed wires and duct work; - Large brown stains on the remaining ceiling tiles over the nurse's station; - Dirt and debris in the large vented tiles in the corner of the ceiling opposite of the door to the men's unit; - [NAME] stains and chipped tiles throughout the common area ceiling in unit D. During an interview on 12/01/24 at 4:53 P.M., Resident #30 said he/she has lived here three years and the owner won't fix the leaking roof. Staff have to put buckets in the hall to catch the water. During an interview on 12/01/24 at 5:15 P.M., Resident #8 said it bothered him/her that there were missing ceiling tiles and exposed wires in the common area of unit D. During an interview on 12/02/24 at 3:27 P.M., the Maintenance Director said the facility will be getting a new roof hopefully before the end of this week. He/she had not replaced the tiles yet because he/she wanted to wait until the new roof is installed. During an interview on 12/06/24 at 3:45 P.M., the Administrator said they are in the process of getting a new roof and they planned to replace the ceiling tiles once the new roof is installed. Complaint #MO00245882

Based on observation, interview and record review, the facility failed to provide adequate supervision when one cognitively impaired resident (Resident #1), who resided on a locked unit, gained access to an unlocked bathing room and was later found unresponsive, submerged in water in the bathtub by staff approximately 45 minutes after the last time staff noted his/her whereabouts. The resident had no signs of life after being removed from the water. Staff did not assist Resident #1 with bathing as directed on the care plan. Thirty three residents reside on the locked unit and the facility total census was 93. The administrator was notified on [DATE] at 4:35 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE] as confirmed by surveyor onsite verification. Record review of the Criteria for the Secured Unit dated [DATE] showed: - Residents on the unit will have one or more of the following; mental illness, confusion, elopement risk, danger to self or others, behaviors, combative with staff or others, suicidal ideations, anxiety and requires less stimulation, requires a closer supervision regarding safety. Record review of the facility's Showers/Bathing Policy, dated [DATE], showed: - Showers/Baths will be offered at a frequency of at least two times per week, unless otherwise requested; - If a resident has a specific preference related to bathing/showering this will be identified and staff will assist as needed; - Staff will assist with bathing/showering as needed to ensure residents remain clean and odor free; - Residents who are independent with bathing/showering will be monitored for compliance; - Residents that resist bathing/showering will be added to their comprehensive care plan; - The policy did not address how resident preferences will be made known to staff; - The policy did not address how resident abilities will be made known to staff; - The policy did not address the process for assessing a resident's ability to shower/bathe; - The policy did not address how independent residents will be monitored for compliance or frequency. Record review of the facility's investigation dated [DATE] showed: - On [DATE], the Administrator (ADM) was notified Resident #1 had been found unresponsive in a bathtub full of water on B hall; - The staff immediately called 911; - CPR (cardiopulmonary resuscitation - an emergency life-saving procedure) was not initiated due to the resident being a do not resuscitate (DNR); - Staff interviews showed the resident was last seen at approximately 4:00 P.M.; - At approximately 4:45 P.M. the staff could not locate the resident and started a search; - The resident was found in the shower room in the bathtub, the water was running and the resident was fully submerged, naked and unresponsive. Observation on [DATE] at 12:45 P.M. of the B Hall, showed the bathroom door unlocked. The bathroom contained a commode, a shower stall and a bathtub approximately 60 inches long, 30 inches wide and 14 inches high. 1. Record review of Resident #1's Level 1 Pre-Admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care, which consists of two potential levels of assessment), dated [DATE], showed: - Met the federal definition of serious mental illness, but did not require specialized services; - Diagnoses of Major Depressive Disorder (a mental disease characterized by low mood, low self-esteem and loss of interest), Personality Disorder (a mental disorder of rigid thinking and unhealthy thoughts); Major Neurocognitive Disorder (a new term for dementia); Generalized Anxiety Disorder; and long history of suicidal thoughts; - Qualified for a Level 2 screening (more in depth assessment of the PASRR). Review of Resident #1's Level 2 PASRR screening, dated [DATE], showed: - Assessed needs included maximum assistance with activities of daily living (ADLs), especially bathing; - Referral notes included poor judgment and poor insight; - The resident required physical assist of staff for bathing. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated [DATE], showed: - Admission to the facility on [DATE]; - Severe cognition impairment; - A need for physical assistance with bathing/showering; - Diagnoses of anxiety, depression, Parkinson's Disease (a chronic degenerative disorder of the central nervous system), and Traumatic Brain Injury (TBI - a brain injury caused by an outside force). Review of Resident #1's care plan, last revised on [DATE], showed: - An increased risk for falls; - An ADL self-care performance deficit related to Parkinson's diagnosis. Staff will assist with bathing, shaving, dressing and incontinent care as needed; - Impaired cognitive function and thought process. During an interview on [DATE] at 1:30 P.M., Certified Medication Technician (CMT) A said on [DATE], just before 5:00 PM, he/she was on A hall. Staff from B hall yelled for help and he/she responded. When CMT A entered the shower room on B hall, he/she saw Resident #1 naked and submerged in water in the bathtub with the water still warm and running. Certified Nurse Aide (CNA) F came into the room and attempted to hold Resident #1's head above the water until they could determine the code status. CNA B said he/she is usually assigned to work the B hall secured unit. CNA B said most of the residents on the unit are mobile and able to come and go to the shower room as they please, to use the bathroom or to take a shower. CNA B said he/she observed Resident #1 working out earlier in the afternoon and noted nothing out of the ordinary with his/her behaviors. CNA B said he/she did not know Resident #1 had gone into the shower room. When the resident was discovered, CNA B did not go into the shower room, but stayed on the hall. During an interview on [DATE] at 1:45 P.M., CMT C said the resident had been exercising on [DATE] at 1:30 P.M. He/she was not aware the resident was in the shower room until staffed yelled for help. During an interview on [DATE] at 10:45 A.M., CNA E said he/she had seen the resident at 4:00 P.M. with no shirt on. CNA E said shortly after seeing Resident #1, he/she took residents outside to smoke. When CNA E came back in the building, Licensed Practical Nurse (LPN) D asked him/her to assist in locating Resident #1. After searching the hall and the rooms, he/she looked in the shower room and saw the resident in the tub. The water was still running and the resident was fully submerged, naked and on his/her side. CNA E said he/she was unaware if the resident required supervision with bathing. During an interview on [DATE] at 6:00 P.M., LPN D said he/she was alerted to the shower room by CNA E. LPN D said after entering the shower room, he/she observed the resident laying in the bathtub, naked and submerged in water on his/her side, knees bent. LPN D said he/she was not aware the resident had entered the shower room unattended. The LPN had worked with the resident often and had no idea he/she was cognitively impaired. The LPN said in his/her opinion the resident did not appear cognitively impaired and was not aware of the diagnoses in the MDS and care plan. LPN D said the resident normally showered not bathed, but could not say how he/she confirmed the resident took a shower. LPN D said he/she has never looked at a resident's PASRR. LPN D said he/she and the other charge nurses get most of their historical information on residents from the discharge paperwork in the admission packet. During an interview on [DATE] at 2:45 P.M., the resident's physician (PHY) said he/she had not been made aware of the resident's passing. The PHY said the resident required supervision and should never have been allowed to shower or bathe alone. During an interview at 12:30 P.M., the ADM said the bathroom on the secured hall is always unlocked. They do not want to lock the shower door as residents use the toilet frequently and would be constantly asking staff for a key. The residents on B hall are residents with behaviors, but are physically able to shower without supervision based on the resident's physical ability. The ADM did not know what specific assessment was completed to determine physical ability or the criteria that would make a resident independent to shower/bathe unsupervised. The ADM said the resident was physically able to shower alone based on what she knew of him/her. The ADM said the residents who are deemed physically capable of showering are allowed to do so independently with no supervision. A shower list is kept and the staff try to document when the resident has showered. The ADM said none of the staff were aware or had ever seen evidence of a resident taking a tub bath. A resident could have entered the shower room without the staff knowing. The ADM said staff were unaware the resident wanted to use the bathtub instead of the shower. The ADM said on [DATE], the staff were not aware the resident had gone into the shower room. The ADM said since Resident #1 was able to shower unsupervised staff cannot say if he/she had taken a tub bath previously. The ADM said the staff do keep shower sheets when the residents shower, but could not explain the process as to how staff find out if a resident had showered. The ADM said she did not know what the resident's PASRR said, he/she had never looked at it. The ADM said the PASRR information should be part of the care plan. During a telephone interview on [DATE] at 1:30 P.M., the detective said the preliminary autopsy results indicated Resident #1 drowned. MO216036, 216266 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).

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) remained free from physical abuse when Licensed Practical Nurse (LPN) A used physical force to obtain a lighter from Resident #1. The LPN dove onto the resident's bed, hitting the resident in the neck, resulting in both the resident and LPN falling to the floor. The facility also staff failed to follow the facility's policy on Abuse, Neglect, Exploitation, which addressed resident behaviors. The facility census was 86. The Administrator was notified on 5/5/2022 at 1:30 PM of an Immediate Jeopardy (IJ), which began on 5/1/2022. The IJ was removed on 5/6/2022, as confirmed by surveyor onsite verification. Record review of the facility Abuse, Neglect, Exploitation policy dated 4/15/2019, showed: - Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including caretaker, of goods and or services that are necessary to attain or maintain, physical, mental and psychosocial well-being; - The facility will train staff on appropriate interventions to deal with aggressive and /or catastrophic reactions by residents; - Observe resident behavior and their reaction to other residents, roommates and or tablemates. Place residents in accommodations and environments that keep them calm; - Provide instruction to staff on care needs of residents. Supervise staff to identify inappropriate behaviors such as using derogatory language, rough handling; - Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, utilize facility's abuse/neglect assessment and develop care needs according to findings. Record review of the facility in-service records showed: - In-service provided to staff regarding Behavioral Training performed on 3/23/2022; - In-service provided to staff regarding Health Insurance Portability and Accountability Act (HIPAA), and Abuse/Neglect/Misappropriation performed on 4/22/2022; - LPN A attended the inservices. Record review of a facility training, titled Crisis Prevention Institute (CPI's) (a non-violent crisis intervention training that equips staff with proven strategies for safely defusing anxious, hostile, or violent behavior or the earliest possible stage) Top 10 De-Escalating Tips, given to all staff on 4/22/2022 and 5/3/2022, showed: - Be empathetic and nonjudgmental; - Respect personal space; - Use nonthreatening nonverbal; - Avoid overreacting; - Focus on feelings; - Ignore challenging questions; - Set limits; - Choose wisely on what you insist upon; - Allow silence for reflection; - Allow time for decisions. Record review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 4/20/22 showed: - Admission to facility on 4/8/2022; - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Cognition intact; - Thoughts of being better off dead and/or of hurting self in some way 12-14 days, nearly every day; - Requires supervision of one staff member for exiting secure unit; - Requires limited assistance of one staff for bathing, hygiene, and transfer; - Current smoker; - Receives antipsychotic, antidepressant and antianxiety medications seven days a week on a routine basis; - No guardian. Record review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Resident may see psychiatry as needed. Record review of Pre-Admission Screening/Resident Review (PASRR) dated 2/2/2022, showed: - Has serious mental illness as defined by PASRR; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Below average intellectual functioning; - Needs psychiatric rehabilitative services of lesser intensity which can be provided by the nursing facility; - No secured placement needed. Review of Resident #1's temporary care plan (initial care plan for new admissions during the assessment period) dated 4/8/2022 showed no behaviors or interventions for behaviors addressed. Record review of Resident #1's progress notes showed: - On 4/20/2022, two staff members observed the resident with a lighter in the smoking area, when approached by the two staff members the resident refused to give the lighter up. Education was provided on the facility policy regarding having lighters on their person, lighters should be locked up at the nurse's station, and staff must supervise. Resident gave lighter to staff, Administrator advised; - No documentation of any behaviors related to using a lighter in the building or using a lighter inappropriately; - No documentation of any instances where the resident was smoking unsupervised or in a nonsmoking area; - No documentation indicating an incident reported on 5/1/2022. Review of Resident #1's medical record showed: - No social services notes regarding behaviors, counseling, assessments or concerns. Record review of the facility self-report dated 5/2/2022, showed: - It was reported Resident #1 choked LPN A leaving red marks and scratches on LPN A's neck and arm; - The incident was witnessed by Certified Nurse Aide (CNA) C and Certified Medication Technician (CMT) B; - The local police department was called into the facility, the police did not take any statements and left the facility; - The police returned to the facility and informed LPN A, Resident #1 called and reported he/she had jumped on the resident; - The facility started an investigation, witness statements are being gathered and LPN A has been placed on administrative leave pending the outcome of the investigation. During an interview on 5/3/2022 at 11:50 A.M., LPN A said on 5/1/2022, CMT B observed Resident #1 with a lighter and contacted LPN A by phone. LPN A said he/she did not witness the resident at that time and did not know if he/she was actively using the lighter. CMT B followed the resident into the building and on in to his/her room. CMT B reported to LPN A the resident put the lighter in a fast food bag. LPN A said on arrival to the resident's room, the resident was sitting on the bed, agitated and arguing with two staff members, CMT B and CNA C. CMT B was on the cell phone with the Assistant Director of Nursing (ADON). The CMT said the ADON instructed staff to get the lighter by any means necessary. LPN A noticed the fast food bag beside the resident on the far side of the bed. He/she then reached across the resident to retrieve the bag, the resident grabbed him/her by the right forearm causing both to fall on the floor sideways. The resident then got on top of him/her and started choking him/her. LPN A said the ADON instructed the staff over the phone to call the police and press charges for assault on the nurse. Once the police arrived, and spoke to other witnesses they came back and arrested LPN A and removed him/her from the facility, and he/she has not returned to the facility pending the investigation. LPN A said she did not contact the resident's physician since she was taken to jail. LPN A said he/she did not know what the care planned interventions were for Resident #1. He/she is unaware of the resident care plan interventions for behavioral outburst. He/she did not try any additional interventions other than removing the lighter. The LPN receives training from the facility on de-escalating tips and abuse/neglect periodically. LPN A denied pulling the resident off of the bed to the floor. During an interview on 5/3/2022 at 12:05 P.M., CNA C said on the night of 5/1/2022, CMT B told him/her to follow him/her to Resident #1's room. When arriving to the room, Resident #1 placed a lighter into a fast food bag and set it on the bed next to him/her. CMT B kept arguing with the resident over the lighter, that he/she could not have a lighter in the facility. CMT B then called the ADON and was instructed to get the lighter since it was no longer in his/her possession. When LPN A arrived to the room he/she reached across the front of the resident and attempted to grab the fast food bag. During an interview on 5/3/2022 at 9:20 A.M., Resident #1 said a couple of days ago he/she came in from outside with a lighter. The resident said he/she had the lighter since admission. A staff person, unknown to him/her, started saying he/she could not have the lighter. The staff person followed Resident #1 to his/her room and argued with him/her about it. Resident #1 said he/she got upset and put the lighter in the empty fast food bag he/she had in the room from dinner, so they could not take it away. The resident said a nurse came in the room and dove on him/her, pulling the resident to the floor from the bed. Resident #1 said the nurse used his/her arm under his/her neck causing him/her and the nurse to fall off the bed into the floor. They fought over the fast food bag and it tore. The resident said by that time lots of people were in the room and he/she guessed somebody took the lighter away. Resident #1 said he/she did fight with the nurse and may have tried to hurt him/her because staff had Resident #1 down and someone was holding his/her legs. The resident said he/she did not know residents could not have a lighter. Resident #1 said he/she is almost [AGE] years old and does not deserve to be treated this way. During an interview on 5/4/2022 at 4:00 P.M., CNA D said he/she had been in the resident's room assisting another resident. He/she saw LPN A enter the room in an effort to retrieve a lighter from a bag on the resident's bed. The resident did not have the lighter out. Upon approaching the resident, LPN A swung his/her forearm in a chopping motion and hit the resident in the neck causing the resident and the LPN A to fall to the floor. CNA D said the resident then put his/her hands on LPN A's neck trying to defend himself/herself. At that point, CNA D went to the resident and wrapped his/her arms around the resident in an effort to protect the him/her. CNA D said I have never seen anything like it before. During an interview on 5/9/2022 at 9:00 A.M., CNA E said he/she and CNA D were in the resident's room. LPN A came into the room looking for a lighter. The resident did not have the lighter in his/her hand. The lighter was in a bag on the bed. LPN A used his/her forearm in a forward swing and hit the resident in the neck. The resident and LPN A both fell to the floor. He/she then saw the resident put his/her hands on LPN A. CNA D went to the resident and helped the resident to safety. During an interview on 5/4/2022 at 6:30 P.M., the Law Enforcement Officer ([NAME]) said there was one trip made to the facility. Upon arrival on 5/1/2022 the staff accused the resident of attacking a nurse. Upon further investigation, two witnesses, CNA D and CNA E, told the [NAME] the resident was in his/her room sitting on the bed with a lighter in a paper bag on the bed beside him/her. Then LPN A came into the room and in a chopping motion hit the resident with his/her arm across the resident's neck causing them to both fall to the floor. It was then the resident put his/her hands on the LPN A in an effort to defend himself/herself. CNA D went to assist the resident and held onto him/her in a protective position and requested LPN A to leave the resident alone. The [NAME] said the LPN A was arrested and charges are pending. The [NAME] said there was no question in his/her mind the resident had been abused by the LPN A. During an interview on 5/3/2022 at 12:25 P.M., the ADON said he/she would not speculate on what happened on the evening of 5/1/22 between staff and Resident #1, as he/she only heard the incident through the phone. The ADON said she would expect staff to remove the lighter from the resident regardless of the situation, no matter what it took, for the well-being of others on the unit. The ADON said he/she will continue to instruct staff to remove a lighter from a resident by any means necessary without waiver. He/She said the staff did not report the resident was trying to actively light anything or threatening to do so. The ADON said he/she did not feel the resident is really mentally ill. The ADON said the resident is manipulative, if the resident was really mentally ill he/she would or should have a guardian in which he/she does not. I'm not sure these statements help anything. He/she instructed staff to press charges against Resident #1 for assault due to the resident refusing to get help and is a danger to himself and others. After the incident, the ADON said she was unsure if the staff notified the physician and or psychiatrist, she thought a fax was sent, but was unable to produce any documentation. The ADON did not know if the incident was documented since LPN A was taken to jail before he/she could. The ADON said it was LPN A's responsibility to document any post incident information. During an interview on 5/3/2022 at 12:50 A.M., the Social Services Director (SSD) said he/she was not the one who admitted the resident to the facility, the previous SSD that was here at the time should have done the admission paperwork and assessments. The SSD is unable to locate any admission paperwork. The SSD said the resident never signed an admission agreement for care nor a facility smoking policy. The SSD said he/she did speak with the resident after an incident with another resident on the locked behavioral unit and he/she appeared to be maladaptive to the surroundings. The staff are trained to attempt several de-escalating interventions for behavioral outburst, the staff are never to become physical and/or reach into the resident's personal space while upset and or agitated. Staff are not to argue and be the cause of distress for a resident. The SSD said the facility's population is primarily mentally ill with behaviors or dementia residents with behaviors. During an interview on 5/3/2022 at 1:30 P.M., Corporate Staff (CS) said staff should never use physical aggression with the residents although staff are to retrieve items such as lighters from the residents regardless of the means to do so as a safety measure for the building. During an interview on 5/4/2022 at 1:20 P.M., the Psychiatric Family Nurse Practitioner (FNP) said he/she was not notified of Resident #1's admission to the facility, nor had the Psychiatrist seen the resident. The FNP said the nurse/staff should not have become physically aggressive with a mentally ill resident over a facility policy. The staff should have attempted to de-escalate the situation from the beginning and he/she would expect to be notified of resident's admission to the facility due to mental health concerns. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to 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 #'s MO 0607 & MO 0625

Based on observation and interview, the facility failed to keep the environment as free of accident hazards as possible by not securing all rooms of the behavioral unit (a secured, locked unit housing psychiatric residents). This practice affected 31 residents residing on the behavioral unit. The facility census was 76. The Administrator was notified on 3/16/2022 at 1:45 PM of an Immediate Jeopardy (IJ), which began on 3/15/2022. As confirmed by surveyor's onsite verification, the IJ was removed on 3/16/2022. The facility did not provide policies or procedures for resident safety, safety training for contractors or safety training for staff members during remodeling. 1. Observation on 3/16/2022 at 10:50 A.M. showed: - The 200 hall designated as a locked behavioral unit; - Residents ambulating at will throughout the unit; - Room 205 with the door open; - Two metal box cutters with blades exposed and a metal flathead screwdriver laying on the top of a nightstand, which could be seen from the hallway and entryway of the room; - Inside the room, three 2-foot solid wood poles used for paint scrapers, a metal paint scraper, a steel wood brush, one six-inch paintbrush frame, and multiple cans of paint; - No staff in the room; - No warning signs or directional signs for staff posted on the door or outside the room. Record review showed all 31 residents on the behavioral unit had at least one mental illness diagnosis and exhibited behaviors. Thirteen of the 31 residents on the behavioral unit had a history of physically aggressive behaviors and one resident with a diagnosis of self-harm. During an interview on 3/16/2022 at 11:00 A.M., the Maintenance Director (MD) said a contractor had been hired to paint and remodel areas of the behavioral unit. The contractor was on site on 3/15/2022 for an unknown amount of time. The MD said he had not been on the unit since the contractor had left. The MD said they did not offer the contractor any training or in-servicing on the dangers of leaving equipment out for this type of population. The MD said having any equipment in an unsecured room put residents and staff in danger. During an interview on 3/16/2022 at 10:55 A.M., the Administrator said the equipment in room 205 should never have been left out, nor should the room have been left unattended by staff members. The Administrator said equipment left in the open placed both residents and staff in danger because several residents currently residing on the unit have histories of self-harm or physically aggressive behaviors. The Administrator said the contractor had been working on 3/15/2022, but was not there today. She did not know how long the door had been open. During an interview on 3/16/2022 at 12:25 P.M., Resident #3 said he/she had seen inside room 205 from the hallway and that the door was open. Resident #3 said he/she was aware of the box cutters and had been anxious since seeing the blades as they could have been used as a weapon. During an interview on 3/16/2022 at 12:25 P.M., Resident #4 said he/she had seen the door open on room 205 and saw box cutters lying on the nightstand table. During an interview on 3/16/2022, Certified Nurse Aide (CNA) A said the door to room 205 had been open while the contractor was working in the facility the day prior. CNA A did not know if the contractor locked up after he/she was done the day prior. CNA A said he/she noticed again today that the door was open, but did not see the contractor. CNA A said when he/she had glanced in the room, only paint cans could be seen. During an interview on 3/16/2022 at 12:35 P.M., Resident #5 said he/she looked in room 205 while the door was open and noticed paint supplies and a cutting knife beside the door on a table. The resident said the cutters could be used to hurt someone. During an interview on 3/16/2022 at 12:40 P.M., Residents #6 and #7 said they noticed the door to room 205 open today. When they looked in, they saw all kinds of tools, including cutting tools in the room on a table. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level K. 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 E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO 4

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) remained free from physical abuse when staff failed to respond appropriately to the resident's behavior. The staff (CNA A) failed to be in control of their own behavior and struck, pushed and pinched the resident. The facility census was 80. The Administration was notified on December 17, 2021, of an Immediate Jeopardy (IJ) of Past Non-compliance which began on December 15, 2021. On December 15, 2021, the administrator identified CNA A had physically and verbally abused Resident #1. Upon discovery, CNA A was escorted off the premises, staff contacted the police, conducted an investigation, and notified appropriate parties. The employee was arrested upon his/her return to facility premises. Facility staff created new policies and procedures related to agency staffing records, reviewed their abuse and neglect policies and inserviced staff on abuse and neglect. The IJ was removed on December 16, 2021. Record review of Resident #1's physicians' order sheet (POS), dated December 1, 2021, through December 31, 2021, showed: - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Resident entered into hospice care with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Admission Minimum Data Set (MDS), dated [DATE], showed: - Resident was unable to complete the assessment for a Brief Interview for Mental Status (BIMS); - Resident needs extensive assist of two persons for bed mobility, personal hygiene and bathing, transferring; - Resident is always incontinent of bowel and bladder. Record review of the resident's plan of care (POC), updated October, 21, 2021, showed: - Resident resists care and orders care givers out of the room; - Resident has an activities of daily living (ADL) self-care performance deficit. Record review of the facility's self report, showed on December 15, 2021, at 6:30 A.M., Certified Nurses Aide (CNA) C and CNA B reported to Registered Nurse (RN) D, that CNA A was abusive to Resident #1 during care. CNA B and CNA C were doing bed checks and came in to assist CNA A in changing the resident. Before entering Resident #1's room, CNA A informed CNA B and CNA C that the resident was abusive and hateful. CNA A entered the room eating a bag of chips. While CNA B removed the resident's blankets to change the brief, the resident grabbed the bag of chips out of CNA A's hand. CNA A forcefully grabbed the resident's hand and threw it back at him/her. CNA A whispered die in the resident's face. While providing care, the resident was rolled to his/her side towards CNA B, the resident tried to hit the CNA. CNA A then hit the resident twice in the left shoulder. CNA C entered the room. As the resident was rolled back, he/she hit CNA B in the face and CNA A palmed (pushed the resident's face with the palm of hand) and then 'flipped him/her off'. CNA A pulled on the resident's right arm to roll him/her and CNA A put his/her elbows on the resident's right side/hip applying pressure. Once the resident had been changed, CNA A pushed the resident onto his/her back. CNA A had been escorted out of the facility and will not be working any shifts. The physician and guardian were notified. At the time of this report, the resident refused to be interviewed. During an interview, via telephone on 12/16/21 at 7:15 P.M. to confirm his/her written statement, CNA B said he/she forgot to add in the statement that prior to CNA C entering the room, CNA A pinched Resident #1's nipple and the resident placed his/her hand over his/her breast to protect it. CNA B said on the morning of 12/15/21, he/she and CNA C went to assist CNA A with Resident #1. CNA A and CNA B entered the resident's room and CNA A was eating a bag of chips. CNA B said the resident grabbed the chips out of CNA A's hands. CNA A threw the resident's hand back at his/her (resident's) person and whispered die in the resident's face. While providing care, the resident was rolled to his/her side towards CNA B, the resident tried to hit the CNA. CNA A then hit the resident twice in the left shoulder. CNA C entered the room. As the resident was rolled back, he/she did hit CNA B in the face and CNA A pushed the resident's face with the palm of his/her hand, then 'flipped him/her off'. CNA A pulled on the resident's right arm to roll him/her and CNA A put his/her elbows on the resident's right side/hip applying pressure. Once the resident had been changed, CNA A pushed the resident onto his/her back. During an interview via telephone on 12/21/21 at 11:50 A.M., CNA A said he/she didn't know what was going on the morning of 12/15/21. CNA A said he/she was told by an aide to come to the nurses' desk, then the nurse asked CNA A to write a statement regarding an accusation of abusing Resident #1 during care. CNA A said he/she didn't abuse anybody and had no idea what they were talking about. CNA A said the statement he/she wrote said he/she (CNA A) had seen Resident #1 hit one of the other aides. CNA A said after writing the statement, the nurse marched CNA A out the door and said his/her services were no longer needed. During an interview via telephone on 12/16/21 at 7:15 P.M., CNA C said he/she came in a little after CNA B and CNA A went in Resident #1's room. CNA C did not see CNA A hit the resident on the shoulder or pinch the resident's nipple. CNA C said he/she did see CNA A push the resident's face down with his/her palm, pull on the resident's arms and press his/her elbows into the resident's hip. During an interview on 12/16/21 at 9:30 A.M., the Administrator said the facility had no complaints regarding CNA A prior to the incident. CNA A worked for a contracted staffing agency, (Agency A), as many of the CNAs do currently. The Administrator said RN D followed appropriate policy and procedures after being informed CNA A had abused Resident #1. Complaint #MO 632

Based on interview and record review, the facility failed to assess, monitor, and ensure a resident (Resident #1) with a surgical incision received treatment and services to promote healing and prevent infection; failed to ensure the resident attended follow up appointments for post-surgical dressing changes or contact the physician for incision care orders; failed to obtain the resident's laboratory (lab) tests as ordered by the physician. These deficient practices resulted in Resident #1 developing an infection and re-injury, requiring a prolonged hospital stay and antibiotic therapy. The facility also failed to provide appropriate care and treatment necessary to prevent the occurrence of constipation (a condition with a difficulty of emptying the bowels) and follow the bowel protocol for one resident (Resident #49) and failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's census was 81. The administrator was notified on 11/18/21 at 11:30 AM of an Immediate Jeopardy (IJ) which began on 10/8/21. The IJ was removed on 11/18/21, as confirmed by surveyor onsite verification. 1. The facility did not provide a policy regarding the care and monitoring of surgical incisions. Record review of the facility's policy titled Medical Appointments and Transportation policy, dated 10/09/18, showed: - The Nursing and or Designee will be responsible for the scheduling of medical appointments for those not scheduled by a resident and/or their responsible party/family; - Nursing and or Designee will arrange transportation to/from medical appointment; - When appointments and transportation are scheduled they will be documented in the designated appointment book; - Nursing and or Designee every Friday places updated transportation schedule at nurse station for upcoming week. Nursing Department communicates upcoming appointments to residents on their assigned halls; - The facility staff will make every effort to get a resident to all of their scheduled medical appointments, however, if an appointment is missed due to transportation issues, inclement weather, and or other reasons beyond the facility's control, the staff will reschedule the appointment at the earliest available date. Record review of the facility's policy titled Laboratory Services Policy, undated, showed: - The facility will provide or obtain laboratory services to meet the needs of the residents; - The facility is responsible for the quality and timeliness of the services; - The nurse/designee will review physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - A copy will be placed in the resident's record with the name and address of the testing laboratory. Record review of Resident #1's Hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] - status post [MEDICAL RECORD OR PHYSICIAN ORDER] - Knee does not appear infected; - Dressing change today with PICO (a negative pressure wound therapy used to draw out excess fluid from surgical incision) dressing. Record review of the resident's Hospital Discharge instructions, dated 10/8/21, showed: - Surgical site: right knee, PICO dressing to stay on until follow up with physician, keep dry and intact; - Follow up appointment with physician on Monday (10/11/21) at 10:30 A.M.; - Have primary care physician round on resident in one week. Draw lab: complete blood count (CBC), comprehensive metabolic panel (CMP), and magnesium (MAG) before visit. Record review of the resident's interim care plan, effective date 9/17/21, showed: - Resident admitted to the facility on [DATE]; - Resident readmitted to the facility on [DATE]; - No updates to the care plan to include the resident's right knee surgical incision; - No interventions on the care plan to assess, monitor, or care for the resident's incision. Record review of the resident's comprehensive care plan, dated 11/15/21, showed the care plan was completed after the resident was readmitted to the hospital on 11/11/21. Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - readmitted to the facility on [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - An order on 10/08/21 to keep PICO dressing on, dry, and intact until appointment with physician; - No orders for lab tests. Record review of the resident's September, October, and November 2021 Treatment Administration Record (TAR) showed no documentation of incision monitoring or care. Record review of the resident's September, October, and November 2021 progress notes, showed: - On 10/08/21 at 10:16 A.M., the resident returned to the facility with PICO drain on right knee incision site. Follow up with the physician on 10/11/21 at 10:30 A.M.; - On 10/19/21, NP visit note, resident status post [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation of lab tests performed or reviewed; - On 11/9/21 at 9:47 A.M., the resident has PICO dressing on from right total knee repair, PICO pump was laying on the resident's night stand, this nurse asked how long has it been off and the resident stated it had been a few days. The nurse called the physician's office and waiting to hear back; - No documentation of assessments, monitoring, or care of the resident's surgical incision; - No documentation of reasons why the resident did not attend post-surgical follow up appointments or any communication with the physician for incision care orders; - No documentation of reason lab tests not obtained as ordered. Record review of the physician's office log notes, showed: - No show for appointment on 10/11/21 at 10:30 A.M.; - The facility's receptionist on 10/21/21 called to cancel the resident's appointment on 10/22/21 due to the resident being in quarantine. The physician's office requested to make a telehealth visit and was transferred to the social worker and did not get an answer; - The facility's receptionist called on 11/3/21 and an appointment was scheduled for 11/11/21. Record review of the resident's Hospital History and Physical, dated 11/11/21, showed: - admitted to the hospital on 11/11/21; - Chief complaint of right knee infection with wound dehiscence (a surgical complication where the incision reopens); - The resident was seen by a physician today. The resident's knee was scabbed over and had wires sticking out of it and had surrounding swelling and [CONDITION(S)] (redness); - The resident reports that there had been no changes to his/her bandages (while in the nursing home); - Wound care specialist consulted and debrided (removed) all the eschar (dead skin tissue). Record review of the resident's Hospital Consultant Note, dated 11/11/21, showed: - The resident is post ORIF of the right patella over six weeks ago and had multiple cancellations of his/her clinic visits; - The resident arrived at the clinic today with the same dressing on and sutures were not removed; - There was [CONDITION(S)] around the knee; - There was wound dehiscence with hardware exposed; - The area of dehiscence was approximately one centimeter with hardware exposed which was 18 gauge wire; - The fracture had lost reduction (alignment) as well; - The resident admitted to the hospital for wound care and IV antibiotics as did appear to have [CONDITION(S)] (skin infection) and wound dehiscence; - Would like wound to heal before doing hardware removal and then have to determine possible ORIF versus patellectomy (removal of the knee cap). Record review of the resident's Hospital Progress Notes, dated 11/15/21, showed: - Infected patellar hardware; - Evaluation for long-term acute care as the patient will need 2-3 weeks of IV antibiotics on top of need for skin culture and wound healing prior to orthopedic evaluation for hardware removal. Record review of the resident's November 2021 progress notes, showed: - On 11/15/21 at 2:37 P.M., the hospital called and informed the facility that the resident was being transferred to a critical care hospital for long term intravenous (IV) therapy; Record review of the resident's Hospital Discharge Summary/Transfer Report, dated 11/16/21, showed: - The resident had underwent ORIF on 9/30/21; - The resident discharged to the nursing facility; - The resident had poor wound care and follow up with noncompliance; - The resident was not seen by orthopedic until 11/11/21; - The resident was noted to have no bandage changes and eschar formation which was debrided; - Presumed [CONDITION(S)] (bone infection) and bone exposure underneath; - The resident agreed to transfer to an acute long-term care facility with IV antibiotic therapy; - Will follow up with orthopedic and decide on when eschar and skin has healed over in the next ten days to two weeks; - Considerations for repeat surgery and potential hardware removal versus complete patella removal will be decided at a later date. During an interview on 11/17/21 at 3:50 P.M., Licensed Practical Nurse (LPN) A said he/she was the resident's re-admission nurse on 10/08/21. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A note was left for the receptionist to schedule transportation to the appointment. Until, recently, he/she was not aware the resident did not go the appointment. LPN A assessed the resident's incision on re-admission by pulling back the dressing on the resident's right knee. The incision was intact with sutures. This was the only time he/she assessed the resident's incision because the resident had no orders to do so. If any assessments, monitoring, or dressing changes had been completed, he/she would have documented in the resident's progress notes. He/she did not know why the resident's lab tests were not completed and unsure why orders were not on the resident's POS. The lab test orders should have been entered into the computer. The Minimum Data Set (MDS: a federally mandated assessment instrument required to be completed by facility staff) nurse is responsible for developing and updating a resident's care plan. During an interview on 11/18/21 at 8:45 A.M., Receptionist B said he/she was not made aware of the resident's appointment on 10/11/21 until 10/14/21. The physician's office was called and the appointment rescheduled for 10/22/21. This appointment was canceled due to the resident being on quarantine. Since it was unknown how long the resident would be on quarantine, the appointment was not rescheduled. He/she asked a facility staff member if a telehealth visit was an option, but was told no due to being a privacy issue. When the resident was done with quarantine, the appointment was rescheduled for 11/11/21. He/she said each week the nursing stations are provided a calendar with resident appointments for the week and rely on nursing staff to notify him/her of any resident appointments not scheduled by him/her. During an interview on 11/18/21 at 9:50 A.M., Certified Nurse Aide (CNA) C said sometime last week, part of the resident's RLE dressing was lying on the bedside table. The resident said he/she had not seen the surgeon since returning from the hospital. CNA C checked the appointment calendars and did not see any appointments scheduled for the resident. The nurse was notified. On 11/11/21, CNA C assisted the resident to a physician appointment. The physician said the resident's knee looked infected and had parts of the hardware sticking out. The physician said the resident's dressing had not been changed since discharge from the hospital. The resident was admitted to the hospital from the physician's office. During an interview on 11/18/21 at 11:00 A.M., LPN D said he/she had not assessed, monitored, or changed the dressing on the resident's RLE incision. He/she did not contact the physician for any incision care orders. Any care or monitoring would have been documented in the resident's progress notes. The physician's office called on 11/11/21 and said the resident had missed several appointments and was being direct admitted to the hospital. LPN D said prior to the phone call he/she was not aware of the missed appointments. The facility has a weekly log of appointments. Nursing staff are responsible for notifying the receptionist of any new resident appointments so transportation can be arranged. The nurse that received orders for lab testing is responsible for entering into the computer. The computer gives a reminder when lab test due. LPN D did not know who updated resident care plans. During a telephone interview on 11/18/21 at 2:00 P.M., LPN E said he/she had not assessed, monitored, or changed the resident's RLE dressing because the resident had an order not to remove the dressing. Any care would have been documented in the resident's progress notes. He/she was not aware of the resident missing any appointments nor did he/she call the physician's office for orders. The nurse who received a new physician appointment should notify the scheduler. During a telephone interview on 11/19/21 at 11:25 A.M., Registered Nurse (RN) F said the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she did not remove or change the resident's dressing. Any care performed would have been documented in the resident's progress notes. Care plans are developed and updated by the MDS staff not the nurses. The nurse who received lab testing orders is responsible for entering the order into the computer. During an interview on 11/18/21 at 2:45 P.M., the Director of Nursing (DON) said she expects nurses to ensure residents attend physician appointments and follow up with physicians for orders. Nurses are responsible for communicating with the receptionist to schedule transportation to appointments. She expects nurses to assess and monitor a resident's surgical incision site at least daily. Nurses are expected to document any assessments, monitoring, care, or communication with physician's office. Nurses are expected to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses should pass on in report any resident changes and update care plan within 24 hours. She expects care plans to be completed in a timely manner. During an interview on 11/18/21 at 4:00 P.M., the Administrator said she expects staff to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses should contact the physician for care orders. Staff are expected to make sure resident's attend appointments. During a telephone interview on 11/22/21 at 8:33 A.M., the Physician said the resident had on ORIF of right knee on 9/30/21. During the resident's stay in the hospital, a PICO dressing was placed. He/she likes to follow up with the resident in the office within 7 days of the dressing being placed. At the appointment, he/she would have removed the dressing and determined if a new PICO dressing would be placed or another type of dressing. The resident missed several appointments. When the resident arrived at his/her office on 11/11/21, the original dressing was still on the resident's right knee. The resident's incision was infected, open with wires sticking out, and the sutures had not been removed. The sutures should have been removed 14 days after placement. The facility staff did not contact him/her for any care orders. The resident will be on IV antibiotics for a couple of weeks and will need additional surgery as a result of the facility not monitoring, providing care, and ensuring the resident attended appointment. 2. Record review of the facility's policy titled Bowel policy, updated March 2018, showed: - Each resident will be assessed for 72 hours for bowel and bladder voiding patterns on admission, quarterly and with a significant change in elimination patterns with evaluation for feasibility in retraining for bowel and/or bladder control; - The licensed nurse will gather information from the chart, the resident's family/representative, staff members, from resident observations, and from review of the 72 hour voiding patterns; - The information will be used to complete the bowel and bladder assessment; - The residents plan of care will be developed to address the issue, goals, and appropriate interventions. Record review of Resident #49's POS, dated October 2021, showed: - diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - No documentation the resident received the medication for the 31 days. Record review of the resident's bowel movement (BM) records, dated 9/21 - 11/21, showed: - No documentation of BMs from 9/1/21 - 9/30/21 (30 days); - No documentation of BMs from 10/1/21 - 10/8/21, 10/11/21 - 10/14/21 (four days), 10/21/21 - 10/23/21 (three days); - No documentation of BMs from 11/6/21 - 11/16/21 (11 days). Record review of the resident's hospital medical record showed: - The resident admitted to the hospital on 11/19/21 - 11/29/21; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Received three rounds of [MEDICATION(S)] (a [MEDICATION(S)]) to treat the fecal impaction while in the hospital. Record review of the resident's POS, dated November 2021, showed: - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/8/21 at 2:16 P.M., Registered Nurse (RN) F said the resident BMs are recorded on the BM forms in the BM book. Staff should record whether a resident had a BM, if so, the size, or if they had no BM each shift. The nurses should check the BM book but he/she isn't sure if it's being done. During an interview on 12/8/21 at 2:40 P.M., Certified Nurse Assistant (CNA) P said there is a resident BM book the CNAs document the residents' BMs in. If a resident hasn't had a BM in two days, they are to let the certified medication technician (CMT) know. If a resident hasn't had a BM in three days, again, the CNA's are to let the CMT know. He/she works the memory care unit where Resident #49 resides quite often, and he/she is unaware of the resident not having BM's documented and being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 12/9/21 at 11:57 A.M., the Administrator said she would expect the staff to monitor and record the residents' BMs. The CNAs and nurses are responsible for the BM monitoring and documentation. She would expect the resident's physician to be notified if a resident hadn't had a BM in a couple of days, depending on the resident's signs and symptoms. 3. Record review of Resident #334's medical record showed: - admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - The annual MDS, dated [DATE], showed BIMS score to be not evaluated; - Extensive assistance for mobility, dressing, eating and toileting; - Totally dependent on one staff for transfers, personal hygiene and bathing; - Frequently incontinent of bowel and bladder. Observation on 11/30/21 at 10:37 A.M., showed the resident's head has crusty growths and scabs over the top and down the resident's forehead. One bandaid placed so that the adhesive is on part of the scabbed area. During an interview on 11/30/21 at 10:37 A.M., the resident said the staff do not clean his/her head everyday. During an interview on 11/30/21 at 4:00 P.M., RN F said the resident has [CONDITION(S)] (a condition marked by thickening of the outer layer of the skin) and sometimes it breaks open. He/she has it pretty much all over his/her head, I don't think we have any orders to do anything, let me double check. While checking, the nurse said the doctor saw the resident last month and commented on what it was but did not give any specific orders. No one asked for any. Observations showed: - On 12/1/21 at 9:33 A.M., on 12/2/21 at 9:20 A.M., and on 12/7/21 at 9:40 A.M., the resident's head crusty growths and scabs over the top and down the resident's forehead. One bandaid placed so that the adhesive is on the scabbed area; - On 12/8/21 at 8:56 A.M., the resident sat with head of bed up. The resident's head crusty growths and scabs over the top and down the resident's forehead. One bandaid placed so that the adhesive is on the scabbed area. During an interview and observation on 12/8/21 at 8:56 A.M., the Director of Nursing (DON) said she was unaware of the band aid being in place that long. She said that is not acceptable, she is working on getting a wound care nurse for the facility and she will make sure it is addressed. NOTE: At the time of the 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).

Based on interview and record review, the facility failed to ensure two residents (Resident #12 and #33) out of 20 sampled residents received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility's census was 81. Record review of the facility's undated policy titled, Pain Management Policy, showed: - The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being; - Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status; - Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: loss of function, decline in activity level, resisting care, striking out, increased restlessness, facial expressions, change in behavior, depressed mood, loss of appetite, sleeping poorly, sighing, groaning, crying, and breathing heavily; - Reassess residents with pain regularly based on the facility's established intervals; - If re-assessment findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated. 1. Record review of Resident #12's medical record showed: - admitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . - The quarterly Minimum Data Set (MDS: a federally mandated assessment completed by the facility), dated 6/6/21, showed the brief interview for mental status (BIMS: a test used to get a quick snapshot of how well the resident is functioning cognitively), score to be 14 out of 15 which indicated the resident to be cognitively intact. Record review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - An order, dated 2/23/21, to assess pain four times a day; - An order, dated 4/28/21, for [MEDICATION(S)] (a medication used to treat severe pain) 20 milligram (mg), scheduled every six hours for pain. Record review of the resident's comprehensive care plan, last updated 9/29/21, showed: - Problem: I have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] - Goal: My pain will be maintained at an acceptable level for me; - Approaches: Administer my ordered pain medication as needed, monitor for effectiveness, ask me frequently if I am having pain, offer alternative pain interventions as needed- music, relaxation techniques, deep breathing, etc. Record review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - Dated 10/1/21 - 10/31/21 showed oxycodone 20 mg not administered 17 out of 124 opportunities without a reason documented. Four out of 124 opportunities to assess pain missed without a reason documented; - Dated 11/1/21 - 11/30/21 showed oxycodone 20 mg not administered 18 out of 120 opportunities without a reason documented. One of 120 opportunities to assess pain missed without a reason documented; - Dated 12/1/21 - 12/1/21 showed oxycodone 20 mg not administered 2 out of 4 opportunities without a reason documented. Three of four opportunities to assess pain missed without a reason documented. During an interview on 11/30/21 at 8:45 A.M., the resident said he/she has been a resident about seven months and has not seen a doctor, only a nurse practitioner (NP). The resident feels he/she needs more pain medication, that is why he/she agreed to palliative care (PC: an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex illnesses). The resident said he/she has pain in all joints due to DM [CONDITION(S)] (a disease of the nerves causing tingling, burning or loss of sensation). He/she has taken [MEDICATION(S)] (pain medication) for years and the doctor has never increased his/her dose. During an interview on 11/30/21 at 10:05 A.M., the resident stated his/her pain is not controlled and they refuse to change or increase his/her pain medication. He/she agreed to PC so that they could get his/her pain under control but they haven't changed anything. He/she just feels like giving up and going on hospice (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) if they can't get the pain under control. During an interview on 12/1/21 at 4:14 P.M., Licensed Practical Nurse (LPN) M said the resident is on PC but he/she does not know the date the resident was admitted and did not make a note. LPN M was there that day and they told the resident to call if anything changes, his/her Primary Care Provider would manage his/her pain medications. They made no changes. During an interview on 12/2/21 at 10:04 A.M., the LPN with the PC agency said they do not replace a current physician, the nurse practitioner (NP) sees the resident and makes recommendations for pain management. The NP has seen Resident #12 one time and did not recommend any changes to the current order. The resident is supposed to be seen again 12/15/21 but they can move the appointment sooner. The LPN will talk to the NP when he/she returns to the office. During an interview on 12/7/21 at 9:41 A.M., the resident stated he/she went to the hospital this weekend because his/her blood pressure went up and oxygen saturation was below 90%. The resident stated he/she has tried to reach palliative care for his/her pain management and has not heard back. His/her pain is not under control and the resident wants someone to help him/her, it is getting worse. 2. Record review of Resident #33's medical record showed: - Original admitted [DATE] with readmitted [DATE]; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual MDS dated [DATE] showed: - The BIMS score of 9 out of 15, moderate cognitively intact; - Section J 0100 showed the resident on a scheduled pain regimen, not received prn medications, and not received non-medication interventions; - Section J 0200 showed the resident should be interviewed for pain assessment; - Section J 0300 showed yes for pain presence; - Section J 0400 frequent pain; - Section J 0500 pain makes it hard to sleep at night; - Section J 0600 rated pain as 6 out of 10; - Section J 0700 showed should the staff assessment for pain be conducted and the answer was no. Record review of the resident's MAR, dated 9/1/21 through 9/30/21, showed the resident received acetaminophen 650 mg on 9/4/21 at 8:38 P.M. for pain rated 5. Record review of the resident's quarterly MDS dated [DATE] showed: - The BIMS score of 10 out of 15, moderate cognitively intact; - Section J 0100 showed the resident not on a scheduled pain regimen, not received prn medications, and not received non-medication interventions - Section J 0200 showed the resident should be interviewed for pain assessment; - Section J 0300 showed no for pain presence; - Section J 0400 through Section J 0700 no documentation. Record review of the resident's MAR, dated 10/1/21 through 10/31/21, showed the resident received prn acetaminophen 650 mg: - On 10/16/21, at 12:21 A.M. for pain rated 8 and at 4:33 P.M. for pain rated 8; - On 10/17/21 at 2:41 P.M. for pain rated 8; - On 10/18/21 at 8:16 A.M. for pain rated 8; - On 10/24/21 at 7:15 P.M. for pain rated 8; - On 10/28/21 at 4:26 A.M. for pain rated 4; - On 10/31/21 at 5:13 A.M. for pain rated 5 and at 11:50 P.M. for pain rated 3. Record review of the resident's MAR, dated 11/1/21 through 11/30/21, showed the resident received acetaminophen 650 mg on 11/2/21 at 8:57 A.M. for pain rated 2. Record review of the resident's November and December 2021 POS's showed: - An order, dated 11/12/21, to assess and monitor resident for pain four times daily with medication pass; - An order, dated 11/12/21 for acetaminophen (mild pain medication) 650 mg every four hours as needed (prn) for fever or pain; - An order, dated 11/12/21, for [MEDICATION(S)] (anticonvulsant and nerve pain medication) 300 mg three times daily for [CONDITION(S)] (a disease of the nerves causing tingling, burning or loss of sensation, chronic pain); - An order, dated 11/13/21, for [MEDICATION(S)] (to treat moderate to moderately severe pain) 5-325 mg every six hours prn for pain. Record review of the resident's Treatment Administration Record (TAR), dated 11/1/21 through 11/30/21, showed: - An order, dated 11/12/21, to assess and monitor resident for pain four times daily with medication pass at 9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M. starting on 11/12/21 at 5:00 P.M., - The resident not assessed for pain on 11/12/21 at 5:00 P.M. or 9:00 P.M., 11/13/21 at 5:00 P.M., 11/16/21 at 9:00 P.M., and 11/23/21 at 5:00 P.M. Five opportunities missed; - On 11/13/21 at 9:00 A.M. resident rated pain 3 (on a scale from 0-10, with 0 being no pain and 10 being the worst pain) and at 12:00 P.M. resident rated pain 9, no prn pain medication given; - On 11/15/21 at 12:00 P.M. resident rated pain 2, acetaminophen 650 mg given at 4:20 P.M.; - On 11/16/21 at 5:00 P.M. resident rated pain 3, no prn pain medication given; - On 11/17/21 at 12:00 P.M. resident rated pain 4 and at 5:00 P.M. resident rated pain 1, no prn pain medication given; - On 11/18/21 at 9:00 A.M. resident rated pain 2, at 12:00 P.M. resident rated pain 5, no prn pain medication given; - On 11/21/21 at 9:00 A.M. resident rated pain 9, at 12:00 P.M. resident rated pain 9, and at 9:00 P.M. resident rated pain 9, no prn pain medication given; - On 11/22/21 at 9:00 A.M. resident rated pain 3, at 12:00 P.M. resident rated pain 2. At 4:27 P.M., resident rated pain 8, acetaminophen 650 mg given; - On 11/23/21 at 12:00 P.M. resident rated pain 5, no prn medication given; - On 11/24/21 at 9:00 A.M. resident rated pain 2 and at 5:00 P.M. resident rated pain 4, [MEDICATION(S)] 5-325 mg given at 8:28 P.M.; - On 11/27/21 at 9:00 A.M. resident rated pain 4, at 12:00 P.M. resident rated pain 4, and at 5:00 P.M. resident rated pain 5, prn [MEDICATION(S)] 5-325 mg given at 6:12 P.M.; - On 11/28/21 at 9:00 A.M. resident rated pain 2, at 12:00 P.M. resident rated pain 3, no prn pain medication given; - On 11/29/21 at 9:00 A.M. resident rated pain 8, at 12:00 P.M. resident rated pain 1, no prn medication given. Record review of the resident's comprehensive care plan last updated 11/30/21, showed the care plan did not address pain and interventions. During an interview on 11/30/21 at 9:45 A.M., the resident said he/she has to beg for pain medicine. During an interview on 12/08/21 at 10:55 A.M., the resident said his/her pain is about medium. The resident broke his/her leg and it hurts sometimes. The resident fell on e night going to the bathroom. The resident doesn't always get pain medicine because no one ever comes in room. Resident #33 said, You can't ask for pain medicine if you don't see anybody. During an interview on 12/9/21 at 11:57 A.M., the Administrator, Director of Nursing, and Director of Operations said they would expect pain assessments to be completed as ordered. They would expect the comprehensive care plan to include each area of concern. The MDS nurse is responsible for completing the care plans.

Based on observation, interview and record review, the facility staff failed to ensure the resident environment remained as free from accident hazards as possible and failed to provide protective oversight and supervision for one resident (Resident #1) out of seven sampled residents with a [DIAGNOSES REDACTED]. Resident #1 exited the locked memory care unit without staff knowledge when the facility staff failed to respond appropriately to door alarms. Staff found the resident outside the facility at the bottom of a four foot sinkhole, with the resident's wheelchair on top of him/her. The resident was last seen approximately four hours prior to being found. The sinkhole developed on the facility property in July 2017 and was located 22 feet from the rear exit of the facility. The resident sustained [REDACTED]. The facility census was 85. 1. Record review of the facility's policy for Elopement Identification and Management, dated 9/1/16, showed: -It is the policy of this facility to ensure that each resident receives adequate supervision and assist services to prevent elopements and that all personnel will report and investigate all reports of missing residents. -It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse or their immediate supervisor, as soon as practical. -If a resident is missing from the facility at any time, staff are to do a thorough search of the building and premises. -When a resident is not located in the facility, the charge nurse should call Code Green event alert immediately and notify the Administrator and Director of Nursing (DON). -Staff are to report any malfunctioning door alarm immediately to any supervisor and immediate measures will be implemented. If a door alarm is not functioning, a staff member will be placed to have continuous visual observation to ensure confused residents do not exit the premises without an escort. Record review showed the facility did not have a policy and/or procedure regarding staff response to activated door alarms. Record review of Resident #1's admission paperwork showed the resident entered the facility on 8/9/17 from another skilled facility due to the need for a secured locked unit. The resident had multiple medical [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Record review of Resident #1's Elopement Risk Assessment form dated 8/9/17, showed staff assessed the resident at no or low risk for elopement. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/16/17, showed staff assessed the resident as: - Cognitively impaired; - Did not wander; - Locomotion per wheelchair. Record review of the resident's care plan, dated 8/16/17, showed: - The resident resided on a locked unit for safety; - Staff to accompany when off unit for supervision for safety; - Staff will redirect if attempts to go off unit. Record review of the resident's behavior charting showed: - On 9/25/17 the resident attempted to get out of the doors while a staff member stood in front of the locked doors. The resident continued to attempt to leave the locked unit with staff preventing the resident from leaving by standing in front of the doors. Later, the resident left through the locked doors and another staff member from C hall brought the resident back to the unit. Record review of the facility's Incident Investigation Form, completed by the facility administrator on 10/10/17, showed on 10/9/17 the resident exited off D wing and made it outside in his/her wheelchair. The resident fell in a sinkhole by exiting the facility through the E wing exit door. When staff started to look for the resident they noted the E wing door ajar where the resident exited the facility. The staff followed out the E wing door and noted orange caution fencing down. They proceeded to that location and found the resident in a sinkhole. The staff called 911 and the resident was removed from the hole. The resident was transferred to the hospital for evaluation and treatment. Record review of a police report, dated 10/9/17, showed police were dispatched to the facility at 10:30 P.M. regarding a resident who fell in a hole behind the building. Upon arrival police were directed to the rear of the building and found the resident in a hole with a wheelchair on top of him/her. The police officer and a paramedic got into the hole and removed the wheelchair from the resident. They assisted the resident to his/her feet and then out of the hole with the assistance of the fire department. Licensed Practical Nurse (LPN) F told the police officer that the resident had been missing since 6:00 P.M. and that he/she belongs on the Alzheimer's unit. LPN F said the resident somehow got out of the unit and out of the building. Certified Nurses Aide (CNA) K told the police officer he/she was in charge of the D wing unit and the resident was trying to get out of the doors around 5:00 P.M. When CNA K went to give the resident a bath and put her to bed at 10:00 P.M. he/she could not find the resident. CNA K said he/she had worked at the facility for three days and did not know all the procedures. LPN F said it took them five minutes to locate the resident. The police report showed the hole 3-4 feet deep and 3 feet wide. The officer saw wheel marks across the grass that headed to the hole. There was orange fencing up in the area but the officer could not tell if the hole had fencing around it. Record review of the emergency room records, dated 10/9/17, of a computerized tomography (a test used to provide detailed diagnostic information) (CT) scan of the resident's lumbar spine showed a compression fracture of the first lumbar vertebrae (lower portion of spinal vertebrae) (L1). During a telephone interview on 10/10/17 at 9:07 A.M., the Director of Nursing (DON) said around 8:00 P.M. on 10/9/17, the memory care unit aide, CNA K, went to get the resident for his/her shower. The CNA couldn't find the resident and attempted to call the charge nurse, but the charge nurse did not answer. Around 10:00 P.M., a charge nurse came on the hall and the CNA said he/she could not find the resident. They started looking for the resident and saw that the E hall door, which leads to the outside was open. They found the resident nearby, in his/her wheelchair, in a sinkhole. The resident was taken to the hospital and had a fractured L1 vertebra in his/her lower back. Observation on 10/10/17 at 1:50 P.M., of the facility layout showed D wing designated as the memory care unit with 16 residents. The unit had three designated exit doors: -An exit at the end of D wing opened directly outside with a delayed egress; -An exit opened with a key coded mechanism onto an unoccupied storage/maintenance area designated as E wing, had an exit that opened directly outside; -A key coded mechanism exit that opened onto the C wing. The location of these exit doors provided no line of sight to the D wing. Observation on 10/10/17 at 1:50 P.M., showed the only memory care unit staff person stood outside the memory care unit doors, attempting to re-direct a resident away from the door while the alarm sounded, which left 15 residents on the unit unsupervised. The audible alarm on the exit at the end of the D wing was in the off position. During an interview on 10/10/17 at 2:10 P.M., the Assistant Maintenance Staff (AMS) said they had been having problems with the door locks disengaging due to being misaligned. The AMS said this had been a problem for a while now. The AMS said the nursing staff have keys to the audible alarms, but they keep turning them off due to the noise. The audible alarm on the E wing exit door had been completely removed. During an interview on 10/10/17 at 2:15 P.M., LPN J said on 10/9/17 at 10:10 P.M., he/she entered the D wing. CNA K informed the LPN that the resident was missing and they began searching for the resident. LPN J said he/she last saw the resident at 6:15 P.M. in the dining room on D wing. LPN J went from D wing to the E wing and found the E wing exit door open to the outside. LPN J stepped outside, looked around and called the resident's name. LPN J then ran back to D wing and paged for two additional charge nurses to help. The three of them got flashlights and went back to the E wing and out the exit door. LPN L went over to the big hole in the yard and said there was a wheelchair in the hole and that the resident was in there too. LPN J said the resident had been missing for four hours. LPN J said the resident and other residents are constantly attempting to leave the locked D wing. LPN J said typically there is only one CNA assigned to the D wing and a nurse goes back and forth to pass medication. LPN J said it is not safe for residents to have only one CNA on the unit, because that is not enough supervision. The LPN said when an alarm sounds he/she would expect the staff to drop what they were doing, check on the residents and page overhead if a resident is missing.' During an interview on 10/10/17 at 3:40 P.M., CNA K said 10/9/17 was her third day on the job and he/she was still learning about the residents. CNA K said at 5:00 P.M. he/she started getting things ready for supper, there were residents that wanted drinks, some residents still needed changed and Resident #1 wanted a shower. CNA K told the resident to wait until after supper for a shower. The CNA recalled seeing the resident rolling up and down the hall talking about how he/she can't ever get any help. CNA K said he/she was the only staff person assigned to the unit for 16 residents. The CNA said the unit door alarms sounded off and on all evening during her shift, and he/she turned them off several times due to them going off so much. CNA K said she did not look for residents when the door alarm sounded, because she assumed if any resident left the unit someone from the other halls would return them. At 8:00 P.M., CNA K went to the resident's room to help the resident with a shower. The resident was not in his/her room, the bathroom, or any other rooms on the unit. CNA K attempted to call the charge nurses on the other halls, but no one answered his/her call. CNA K said it never occurred to him/her that the resident would get out of the building. CNA K did not continue to look for the resident until he/she completed all of his/her work around 9:30 P.M. when the charge nurse entered the unit. CNA K had never been instructed on what to do when the door alarms sounded, because he/she had not received orientation. During an interview on 10/11/17 at 11:15 A.M., the DON said the resident had not been assessed as an elopement risk upon admission by nursing staff although the assessment was updated after the elopement on 10/9/17 identifying the resident at high risk. The DON further stated the admission criteria for placement on the secure memory care unit was partially determined by diagnosis, but was unsure of the facility policy. The DON said she would expect the staff to respond to door alarms and make sure all residents are accounted for. Observation on 10/11/17 at 11:25 A.M., showed CNA G responded to a door alarm by turning it off. The CNA said he/she had been instructed to turn off the alarms if they were sounding. The CNA said the family members do not like the noise. During an interview on 10/11/17 at 1:00 P.M., the Administrator said she was aware of the resident's exit seeking behaviors prior to admission to this facility and would have expected the nursing staff to have identified the resident as an elopement risk. The Administrator was not aware the alarms had been turned off on the D wing, but was aware the E wing alarms did not work. The Administrator said she would like to have two CNA's on the D-wing unit because one staff person is not adequate to care for the residents. The Administrator said she has been trying to get more staff and had let corporate know. 2. Observation on 10/10/17 at 2:00 P.M., showed a five foot diameter sinkhole, filled with hay, located 22 feet outside the E wing and D wing exits. During an interview on 10/10/17 at 2:30 P.M., the Maintenance Director (MD) said the sinkhole opened suddenly in July 2017. It opened to approximately five feet in diameter and four feet deep. In July 2017 he/she contacted the city about repairs. The city told him/her to remove the fence paneling around the hole and they (the city) would come and fix it. The MD said as of this moment, the city has never come back and filled the hole. The MD said he/she filled the hole with hay and put safety fencing around it after they got Resident #1 out. During a telephone interview on 10/11/17 at 9:15 A.M., City Employee (CE) A said the MD contacted the city on 7/13/17 to report a large sinkhole had opened on their property. CE A said he/she visited the property on 7/17/17 and saw the hole, which was approximately six feet in diameter and four feet deep. CE A said he/she informed the MD, according to city policy, the first step is to have an easement drawn up between the facility and the city. CE A said the facility would need to contact the city office to get that set up. That was the last contact the city had with the facility. During a telephone interview on 10/11/17 at 9:23 A.M., the Administrator said she was unaware of what an easement was or that one was needed prior to the city fixing the sinkhole. The Administrator said she was going to contact private contractors today and see if they could hire one to come and fix the hole. At 3:00 P.M., the Administrator said they had hired a private contractor who was going to fill in the hole on 10/12/17. In a telephone interview on 10/11/17 at 9:30 A.M., the Facility Operator (FO) said he/she was aware of the situation. The FO said the sinkhole in the yard is a tremendous liability. The FO said he/she had been told by the MD the city told them to take the fencing down around the hole, then let them (city) know and they would come out and fix it. The FO said they did those things and the city never came. The FO said he/she was unaware of the need of an easement, but would grant one as soon as possible if it would get the hole fixed. Review of the Missouri Department of Natural Resources (DNR), Missouri Geological Survey pamphlet, entitled Geologic Hazards in Missouri, and website showed: - Development in areas prone to sinkhole formation can be very dangerous; - Sinkholes may start as a small hole in the ground that slowly grows to full size or may form in a sudden catastrophic collapse that occurs with no warning. Collapsed sinkholes generally are steep sided and very unstable; - Activities near sinkholes should be undertaken with great caution; - Once a sinkhole has developed, the landowner should erect a barrier at a safe distance to prevent access to the sinkhole. As the perimeter of the sinkhole erodes, the diameter likely will increase. Complaint MO 9 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observations, record review and interviews completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. During the onsite visit, the facility had ensured the residents on the secured wing were monitored by two staff members. The sinkhole had been secured with fencing and filled in with hay. An audible alarm was added to the E-wing exit door to increase staff notification of door activity. The door alarms will be checked by the charge nurse or designee every shift. If a door alarm sounds, staff will report to that door immediately. If no residents are seen in the vicinity, staff are to perform a head count prior to silencing the alarm. If a resident is missing staff will immediately page overhead for assistance. The facility began in-servicing all staff on the elopement policy, accounting for each resident, and door alarms. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the severity level was lowered to a 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.

Based on observation, interview and record review the facility failed to provide appropriate interventions to ensure the safety of all residents after a resident-to-resident altercation occurred between two (Resident's #1 and #2) of three sampled residents that shared a room on the locked dementia unit. The facility census was 71. Record review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility's staff, dated 8/7/15, showed: - [DIAGNOSES REDACTED]. - Verbal and physical behaviors, rejects care, and delusions. Record review of the care plan dated 10/28/15 showed Resident #1 had paranoid behaviors, takes others belongings, has delusional ideations with behavioral disturbances, overly protective, anxious, and difficult to calm down. The resident is to be placed on one on one care after episodes of aggression and will be sent to the hospital to be medically and psychologically cleared. Record review of the resident's Psychiatric Service Sheets showed on 9/1/15, due to increased behaviors staff called and new orders for Risperdal 0.5 milligrams (mg) three times per day (TID) received. Record review of Resident #1's nurse's notes dated April 2015 through October 2015 showed Resident #1 displayed on-going aggressive behaviors that included agitation, verbal outburst at both residents and staff, annoying other residents, taking items that belonged to other residents, and kicked and yelled at staff. Record review of the facility's investigation for resident to resident altercations, dated 11/10/15, showed: - Certified Nurse Aide (CNA) A said on 11/8/15 he/she found Resident #1 standing over Resident #2's bed, both residents had fingers inter-locked; - CNA A re-directed Resident #1 away from Resident #2; - Resident #1 cursed and yelled as he/she was guided away from Resident #2; - CNA A noted injuries to Resident #2 and reported to charge nurse; - Resident #2 had extensive bruising and swelling to the face, head, and hands; - Resident #2 sent to the emergency room at 8:00 P.M. and returned to facility at midnight with [DIAGNOSES REDACTED]. (Resident #2 returned to the same room he/she shared with Resident #1.); - On 11/9/15 at 3:13 P.M. (nearly 24 hours after incident) Resident #1 sent to ER for evaluation and returned to facility; - On 11/10/15, Resident #1 moved to different room. (48 hours after the incident occurred). - No documentation of additional interventions or modifications to ensure all resident's safety including one-on-one supervision by staff as specified in the resident's plan of care. Record review of Resident #2's annual MDS dated [DATE] showed [DIAGNOSES REDACTED]. Resident required total assistance with all activities of daily living. Observation on 11/11/15 at 10:30 A.M., showed Resident #2 sat in a wheelchair and had extensive bruising to his/her nose, eyes, forehead and left cheek. The right eye area and right side of the nose had long scratch-looking areas. The left side of the resident's head/scalp had multiple lacerations and redness. The right index finger and hand had blue bruising and the left hand had faint green bruising. The resident had garbled speech and could not answer any questions. Observation on 11/11/15 at 10:40 A.M., showed Resident #1 sat in a wheelchair while staff assessed his/her hands. The resident's hands had bruising of various shades. The resident became agitated (cursed and yelled) while staff assessed his/her hands. During an interview on 11/11/15 at 12:49 P.M., CNA A said on 11/8/15 around 4:00 P.M., he/she found Resident #1 standing over Resident #2's bed. CNA A said Resident #1 had inter-locked his/her fingers with Resident #2's fingers. Resident #1 was saying, Come on, the cops are coming. We have got to get out of here. CNA A asked Resident #1 to go with him/her and the resident said, Get the hell out of here. CNA A assisted Resident #1 to a wheelchair and out into the hall. Resident #1 attempted to use the wheelchair to run over another resident and CNA A had to re-direct the resident. CNA A said he/she went to assist Resident #2 and found bruising to his/her face. Nurse Aide (NA) B notified Licensed Practical Nurse (LPN) C. During an interview on 11/11/15 at 2:44 P.M., LPN C said NA B notified him/her of the incident. LPN C noted bruising to Resident #2's face, head and hands. The resident was sent to the ER and came back with [DIAGNOSES REDACTED]. LPN C said an assessment was done on Resident #1 and he/she did not have any bruising at that time. Resident #1 is continually aggressive and requires as need medications to deal with the aggression. During an interview on 11/11/15 at 3:00 P.M., the Administrator said she was made aware of the altercation the next day (11/9/15) and she started the investigation. Her investigation showed a resident to resident altercation occurred. She said she was unaware of Resident #1's previous behaviors of hitting other residents. She said the facility should have called the physician and sent the resident for an evaluation much sooner. She said that might have prevented this incident. She said the staff should have moved Resident #1 to another room immediately. Record review of the facility's Abuse, Neglect, and Exploitation Policy, undated showed: - Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, families, or other individuals; - Report allegations of abuse to the Administrator; - Physical abuse includes, but not limited to hitting, slapping, pinching, and kicking; - Train staff in appropriate interventions to deal with aggressive reactions by residents; - Assess, monitor, and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict; - When suspicion of abuse it must be communicated to the facility's Administrator to initiate an investigation; - Temporary (less than 24 hours) separation from other residents if resident's behavior poses a threat of abuse or violence; - Temporary or permanent room or roommate change; - Contact the State Agency to report the alleged abuse; - Monitor and document the resident's condition. Complaint MO# 7