Every finding on record at Grand River Health Care

Based on observation, interview and record review, the facility failed to protect one resident (Resident #1) from abuse on 01/05/26, when the Director of Nursing (DON) and the Administrator forced the resident to remove soiled clothing by physically restraining the resident's arms, hands, and ripping the soiled clothing off while the DON yelled curses and obscenities at the resident. As a result, the resident complained of arm pain and said they hurt me. Multiple, small, light-colored bruises were observed. The resident was transported to the emergency room for evaluation. The facility also failed to provide continued protection when the DON and Administrator were not immediately removed from the facility, per policy, and they continued to provide oversight for all residents until 01/06/26. The facility census was 31.The administrator was notified on 01/08/26 at 1:22 P.M. of an Immediate Jeopardy (IJ) which began on 01/05/26. The IJ was removed on 01/08/26 as confirmed by surveyor on-site. Review of the facility policy titled, Abuse Prohibition Protocol Manual, dated 11/28/16 showed: -It is the policy of the facility that each resident will be free from verbal, mental or physical abuse and corporal punishment; -Residents will be protected from abuse, neglect and harm while they are residing at the facility;-No abuse or harm of any type will be tolerated; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish; -Examples of physical abuse include: hitting, scratching, holding someone down, grabbing a resident by arms or legs;-All employees are mandated reporters; -All employees who have been alleged to commit abuse will be suspended immediately pending investigation. Review of Resident #1's Quarterly Minimum Data Set (MDS: a federally mandated assessment completed by facility staff) dated 09/23/25 showed:-He/She had cognitive loss; -He/She was able to make his/her needs and wants known; -He/She needed maximum assistance of staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself);-He/She was always incontinent of bowel and bladder; -He/She had verbal and physical behaviors (such as yelling, kicking, screaming, hitting) 4-6 days of a 7 day period; -Diagnoses included: Mood disorder (a mental health condition causing extreme, persistent emotional shifts such as sadness, elation and anger, that disrupt daily life), violent behaviors, diabetes, anxiety, depression, Parkinson's (a progressive brain and nerve disorder that effects movement, thought and body function), and dementia. Review of the resident's Comprehensive Care Plan dated 12/23/25 showed: -He/She exhibited verbal and physically abusive behavioral symptoms towards staff during cares, such as yelling, cursing, resisting care, hitting, kicking, pinching others; -The staff were supposed to avoid power struggles with the resident; -The staff were supposed to explain all procedures; -The staff were supposed to maintain a calm, slow, understandable approach with the resident; -When the resident becomes verbally abusive, STOP and try the task later; -Do not force the resident to do the task;-Allow the resident to have control over situations, if possible; -Allow the resident to make decisions.During an interview on 01/07/26 at 1:40 P.M., the Maintenance Director/Nurse Aide (NA) A said: -He went to assist Resident #1 to change a soiled brief and clothing on 01/05/26 at about 1:44 P.M.; -The resident did not want a female Certified Nurse Aide (CNA) Z in his/her room and yelled at CNA Z to get out; -CNA Z left the room and Maintenance Director/NA A started to assist the resident to roll to the side to get changed; -The DON walked into the room, told the resident he/she needed to get cleaned up; -The resident yelled at the DON to get out and leave him/her alone; -The Maintenance Director/NA A got the resident to agree to allow the DON to help him/her turn over in bed only; -The DON pulled on the resident; -The resident said it hurt and the DON told the resident he/she was fine and there was nothing wrong with him/her; -The resident was pulling and smacking at the DON, the DON let go of the resident's arms and the resident rolled to his/her back; -The Maintenance Director/ NA A applied a clean brief; -He/She noticed the resident's shorts were heavily soiled and asked the resident if the shorts could be changed; -The resident agreed to allow the Maintenance Director/ NA A to change them; -He/She told the resident he/she needed to check the laundry and would return; -The DON began grabbing and pulling on the resident's shorts; -The resident grabbed onto his/her shorts with one hand, began yelling for the DON to get out and leave him/her alone; -The resident began slapping at the DON with the other hand; -The Maintenance Director/NA A stepped away from the bedside; -The Administrator walked into the resident's room; -The DON told the Administrator/Certified Medication Technician(CMT)/Certified Nurse Assistant (NA) to grab the resident; -The Administrator grabbed the resident by the hand and the elbow and held his/her arm tightly; -The resident was kicking and screaming; -The resident kicked toward the DON's face; -The DON said kick me again motherfucker and see what happens; -The Maintenance Director/NA A told the Administrator and DON to stop and leave the resident alone, and he/she wanted nothing to do with it; -The Administrator told the Maintenance Director/ NA A to hold the resident's arms; -The Maintenance Director/NA A refused and he/she left the resident's room; -The Maintenance Director/NA A left the facility; -He/She was not sure who to report to, because normally he/she would report to the DON or Administrator, but it was them abusing the resident; -He/She was taking CNA classes and knew holding someone by the arm, cursing them and ripping their shorts off, when they do not want you to, was abuse; -He/She reported the event to the Social Service Director (SSD) the morning of 01/06/26 and the SSD told him/her call the abuse hotline to report it; -Resident #1 had some small bruises on his/her arms on 01/06/26 that he/she did not see during bathing the day before. During an interview on 01/09/26 at 10:53 A.M., the DON said:-She went to assist the Maintenance Director/NA A with the resident as she could hear the resident yelling in the next room; -She and the Maintenance Director/NA A got the resident changed into a clean brief; -She asked the resident to change his/her shorts and he/she said no; -The Administrator entered the room and went to the resident's left side; -She put her hands on the resident's shorts, and proceeded to attempt to pull them off, the resident had hold of his/her shorts with one hand and began hitting with the other hand; -The resident grabbed the Administrator's hand and kicked at the DON; -She would expect if the resident becomes combative, staff are to leave the resident and try again later; -She didn't leave the resident alone, because his/her shorts were heavily soiled; -The resident had a clean brief on; -The resident had daily behaviors of hitting, kicking, yelling; -She did not curse at the resident; -The resident cursed at her.During an interview on 01/10/26 at 10:50 A.M., the Administrator said:-She entered the resident's room on 01/05/26 as she could hear the resident yelling; -The resident was upset about his/her shorts being changed; -The resident said to leave him/her alone;-The resident had hold of his/her shorts; -The DON held the resident's shorts with one hand; -The resident had on a clean brief; -The resident was hitting and kicking; -She did not grab the resident's arm, but her hands were on the resident's arm; -She and the DON got the resident's shorts off, covered the resident up and left the room; -She was paying attention to the resident and not what the DON was doing to the resident's shorts:-She would expect staff to use appropriate approach; -There are approaches that work easier for the resident; -She would expect staff to leave the resident, if behaviors occurred, and get help; -She would do things differently from the very beginning and started the interaction differently; -When the resident became combative again she and the DON covered him/her up and left the room. During an interview on 01/07/26 at 2:31 P.M., the SSD said:-She heard the resident yelling and went to his/her room to investigate; -When she arrived in the hall outside the resident door, the Business Office Manager (BOM) was standing in the hallway; -She stayed outside the door as she could hear the DON's voice from the resident's room; -She heard the DON say kick me again motherfucker and see what happens; -The resident's room door opened, the Maintenance Director/NA A exited, and said he/she did not want any part of this; -She remained in the hall because the DON and the Administrator, who was her boss, were in the room and she did not think anything bad could be happening;-The next morning it was reported to her the resident wanted to call the police; -She asked the Maintenance Director/NA A what had occurred the day before; -He/She reported the Administrator held the resident down by the arm and the DON cursed at the resident and ripped off the resident's shorts; -She was not sure where to go since the allegations were against their bosses; -The SSD said when the MDS Coordinator (MDSC) came in on 01/06/26 she reported the incident to her because she knew the MDSC also had an Administrator license; -The MDSC instructed them to call the DHSS hotline;-She went to talk with the resident, he/she would not let her shake his/her hand, and reported his/her hand hurt, and he/she wanted to move closer to the nurses station for safety; -At the time of hire, three weeks ago, the SSD watched a video on abuse; -The video said to report to the Administrator, but did not tell her what to do if the Administrator was the perpetrator; -Multiple residents had complained of the Administrator being rude and hateful, but he/she was instructed by the Administrator not to file formal grievances. During an interview on 1/6/26 at 3:10 P.M., the BOM said:-She worked at the facility since September 2025; -On 01/05/26 she walked down the hall to find the Administrator, and could hear yelling from the resident's room; -She heard the DON yell the f word' but was unsure of anything else that was said as a staff member was in the hall talking; -The Maintenance Director/NA A exited Resident #1's room and said he/she wanted no part of this, and walked away; -On 01/06/26 a staff member asked her how to file a grievance against the Administrator, she was unsure, and told the staff member she would have to check; -When the MDSC came in to work, she asked her what needed to be done, and then the Maintenance Director/NA A entered and told the MDSC what had happened 01/05/26 with the resident; -She watched a video on abuse when she started; -The video said to report to the Administrator, but did not tell staff what to do if the alleged perpetrator was the Administrator; -She talked with the resident on 01/06/26 and he/she complained of arm pain; -The resident did not normally complain of arm pain, that the BOM was aware of. During an interview on 1/7/26 at 4:20 P.M., the Acting Administrator/MDSC said:-She was filling in for the MDSC as the facility did not have a current one; -She entered the facility on the morning of 01/06/26 and was approached by the SSD and BOM about the situation of the resident possibly being abused; -She notified the Director of Operations and began an investigation; -She called the DON and suspended her, and told the Administrator she was suspended when she came into the building; -The corporate reporting line was posted on the bulletin board, along with DHSS hotline number; -She was unsure why staff did not know about the phone numbers that were posted; -She would expect staff to report alleged abuse to the Administrator, if the Administrator was involved she would expect them to call the corporate line; -It was not appropriate for anyone to curse or hold the resident down; -The resident had a history of verbal and physical behaviors, but those lessen when he/she is approached correctly; -The Maintenance Director/NA A had a good rapport with the resident, and was in CNA classes.During an interview and observation on 01/07/26 at 1:25 P.M., the resident said:-His/Her arms hurt;-He/She would not allow his/her arm to be looked at. Review of the resident's right arm and hand x-ray dated 01/06/26 showed there were no fractures Observation on 01/07/26 at 2:13 P.M., showed:-Resident #1 had dime sized round light-yellow discoloration to inner left forearm, dime size light yellow discoloration on the hand below the thumb and a dime sized light yellow discoloration to inner left right forearm; -He/She said they hurt me here using his/her right hand to indicate his/her left arm. At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation.Intake 2709806Intake 2708966

Based on record review and interview, the facility failed to immediately report an allegation of abuse to the state survey agency. This effected one of four sampled residents (Resident #1). The facility census was 31.Review of the facility policy titled, Abuse Prohibition Protocol Manual, dated 11/28/2016 showed: -It is the policy of the facility that each resident will be free from verbal, mental or physical abuse and corporal punishment; -Residents will be protected from abuse, neglect and harm while they are residing at the facility;-No abuse or harm of any type will be tolerated; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish; -Examples of physical abuse include: hitting, scratching, holding someone down, grabbing a resident by arms or legs;-All employees are mandated reporters; -The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements; -All allegations of abuse, will be reported immediately, but no later than the following time frames: If abuse is alleged or the allegation results in serious bodily injury, the allegation must be reported within two hours after the allegation was made. If the allegation does not allege abuse or result in serious bodily injury, the report must be made within 24 hours. Review of Resident #1's Quarterly Minimum Data Set (MDS: a federally mandated assessment completed by facility staff) dated 9/23/25 showed:-He/She had cognitive loss; -He/She was able to make his/her needs and wants known; -He/She needed maximum assistance of staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself);-He/She had verbal and physical behaviors (such as yelling, kicking, screaming, hitting) 4-6 days of a 7 day period; -Diagnoses included: Mood disorder (a mental health condition causing extreme, persistent emotional shifts such as sadness, elation and anger, that disrupt daily life), violent behaviors, diabetes, anxiety, depression, Parkinson's (a progressive brain and nerve disorder that effects movement, thought and body function), and dementia. During an interview on 01/07/26 at 1:40 P.M., the Maintenance Director/Nurse Aide said: -He was assisting the resident with a brief change (01/05/26); -The Director of Nursing (DON) entered the room and told the resident he/she needed to get cleaned up; -The resident yelled at the DON to get out and leave him/her alone; -The Maintenance Director convinced the resident to allow the DON to help him/her turn over only; -The DON pulled on the resident; -The resident complained it hurt; -The DON told the resident he/she was fine and there was nothing wrong with him/her; -The resident began yelling and smacking at the DON; -The DON let go of the resident; -The Maintenance Director saw the resident's shorts were heavily soiled and got the resident to agree to be changed; -The DON began grabbing and pulling on the resident's shorts, the resident grabbed onto the shorts with one hand, and began yelling for the DON to leave him/her alone; -The resident began slapping at the DON with the other hand; -The Maintenance Director stepped away from the resident's bedside; -The Administrator entered the resident's room; -The DON told the Administrator to grab the resident; -The Administrator grabbed the resident by the hand and the elbow and held his/her arm tightly; -The resident was kicking and screaming; -The resident kicked toward the DON's face; -The DON said kick me again motherfucker and see what happens; -The Maintenance Director told the Administrator and DON to stop and leave the resident alone, and he wanted nothing to do with it; -The Administrator told the Maintenance Director to hold the resident's arms; -The Maintenance Director refused and he/she left the resident's room; -The Maintenance Director left the facility; -The Maintenance Director was not sure who to report to, because normally he/she would report to the DON or Administrator, but it was them abusing the resident; -The Maintenance Director was taking Certified Nurse Aide (CNA) classes and knew holding someone by the arm, cursing them, and ripping their shorts off, when they do not want you to, was abuse; -He reported the event to the Social Service Director (SSD) the morning of 01/06/26 and the SSD told him/her call the abuse hotline to report it; -The resident had some small bruises on his/her arms on 01/06/26 that he/she did not see during bathing the day before.During an interview on 01/07/26 at 2:31 P.M., the SSD said:-She heard the resident yelling and went to his/her room to investigate; -When she arrived in the hall outside the resident door, the Business Office Manager (BOM) was standing in the hallway; -She stayed outside the door as she could hear the DON's voice from the resident's room; -She heard the DON say kick me again motherfucker and see what happens; -The resident's room door opened, the Maintenance Director exited, and said he/she did not want any part of this; -She remained in the hall, because the DON and the Administrator, who was her boss, were in the room and she did not think anything bad could be happening;-The next morning it was reported to her the resident wanted to call the police; -She asked the Maintenance Director what had occurred the day before; -He/She reported the Administrator held the resident down by the arm and the DON cursed at the resident and ripped off the resident's shorts; -She was not sure where to go since the allegations were against their bosses; -When the MDS nurse came in on 01/06/26 she reported the incident to her, because she knew the MDS nurse also had an Administrator license; -The MDS nurse instructed them to call the DHSS hotline;-At the time of hire, three weeks ago, she watched a video on abuse; -The video said to report to the Administrator, but did not tell her what to do if the Administrator was the alleged perpetrator. During an interview on 01/06/26 at 3:10 P.M., the BOM said:-She worked at the facility since September 2025; -On 01/05/26 she walked down the hall to find the Administrator and could hear yelling from the resident's room; -She heard the DON yell the f word', but was unsure of anything else that was said as a staff member was in the hall talking; -The Maintenance Director exited Resident #1's room and said he/she wanted no part of this, and walked away; -On 01/06/26 a staff member asked her how to file a grievance against the Administrator, she was unsure, and told the staff member she would have to check; -When the MDS nurse came in to work, she asked her what needed to be done, and then the Maintenance Director entered and told the MDS nurse what had happened 01/05/26 with the resident; -She watched a video on abuse when she started; -The video said to report to the Administrator, but did not tell staff what to do if the alleged perpetrator was the Administrator. During an interview on 01/07/26 at 4:20 P.M., the Acting Administrator/MDS nurse said:-She entered the facility on the morning of 01/06/26 and was approached by the SSD and BOM about the situation of the resident possibly being abused; -She notified the Director of Operations and began an investigation; -She called the DON and suspended her, and told the Administrator she was suspended when she came into the building; -The corporate reporting line was posted on the bulletin board, along with DHSS hotline number; -She was unsure why staff did not know about the phone numbers that were posted; -She would expect staff to report alleged abuse to the Administrator, if the Administrator was involved she would expect them to call the corporate line.Intake 2709806Intake 2708966

Based on interview and record review, the facility failed to protect one residents (Resident #2) right to be free from physical abuse when Resident #1 hit Resident #2 on the arm on two separate occasions. The facility census was 28.Review of the facility Abuse Policy, undated, showed:- It is the policy of the facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property, and exploitation, corporal punishment, or involuntary seclusion;- The resident will be protected from abuse, neglect, and harm while they are residing at the facility;- Abuse is the willful infliction of injury, unreasonable restriction, threat or punishment with resulting physical harm or pain, or mental pain or deprivation by an individual; - Abuse is any intentional act that causes harm or potential harm to a resident. It can be physical, emotional, sexual, verbal, or financial. Abuse can occur as a single incident or a repeated pattern of behavior;- Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.1. Review of Resident #1's admission MDS (Minimum Data Set), a federally mandated assessment tool completed by facility staff, dated 8/31/25., showed:- Severe cognitive impairment;- Diagnoses included: psychotic disorder (disorder involving a disconnection with reality), obsessive compulsive disorder (a mental condition in which a person experiences persistent, intrusive thoughts that cause distress and performs repetitive physical or mental acts in order to prevent or counteract the thoughts and relieve the distress), and dementia;- Required substantial assistance from staff for activities of daily living (ADL's) to include showering, toileting, and transfers. Review of the resident's care plan, dated 11/10/25, showed:- The resident had the tendency to yell out or hit his/herself or others when he/she got frustrated or angry;- The resident resisted care related to behaviors toward self and others and the resident was often uncooperative with staff;- The resident had a care plan goal of no more than one episode of aggressive behavior per day toward self or others;- The resident required nursing staff to encourage the resident to voice feeling or redirection or to have alone time away from other residents and noisy environments. Review of the resident's nursing progress notes for the month of October 2025 showed:- On 10/24/25 at 8:47 A.M., Resident #1 witnessed in the hallway yelling. The resident usually is kind and affectionate with staff. This morning the resident seems agitated and irritable. The resident apologizes after yelling and can't fully control the impulse of yelling;- On 10/27/25 at 7:25 A.M., Resident #1 had hit Resident #2 in the dining hall. Resident #1 came to Resident #2's table and hit the resident in the left shoulder. The Administrator, the guardian, and the provider were notified.- No further charting noted related to this incident.Review of the resident's nursing progress notes for the month of November 2025 showed:- On 11/9/25 at 12:30 P.M., Resident #1 began to hit Resident #2 in the arm while in the dining hall. Staff tried to remove Resident #1 from the dining hall and he/she resisted by planting feet on the floor, hit self on the head repeatedly, flipped off staff and called staff names. Resident #1 continued to resist staff, began to flip off other residents and called them names until he/she calmed down and was put to bed. The Administrator, guardian, and provider were notified; - On 11/9/25 at 7:20 P.M., Resident #1 went to the dining room for supper and became agitated and began yelling and cursing at other residents. Resident #1 was brought to the dayroom where he/she continued to yell and curse but did not hit anyone;- No further charting noted related to this incident.2. Review of Resident #2's Quarterly MDS, dated [DATE], showed;- Mild cognitive impairment;- Diagnoses included: stroke, hypertension, and anxiety;- Required substantial assistance from staff for activities of daily living (ADL's) to include showering, toileting, and lower body dressing.Review of the resident's care plan, dated 10/21/25, showed:- The resident was at risk for fall related to generalized weakness;- At times the resident refuses or resisted personal cares and staff would maintain a pleasant friendly demeanor when approaching the resident.Review of the resident's nursing progress notes for the month of October 2025, showed:- On 10/27/25 at 7:25 A.M., Resident #2 said he/she was hit by Resident #1 in the left shoulder, in the dining room. Resident #2 was checked, denied pain, and no injury was noted. The Administrator, guardian and provider were notified;- On 10/27/25 at 11:20 A.M., Resident #2 said Resident #1 was next to him/her and bumped into his/her chair then tapped his/her arm;- No further charting noted related to this incident.Review of the resident's nursing progress notes for the month of November 2025, showed:- On 11/9/25 at 12:30 P.M., Resident #2 was eating lunch in the dining room when Resident #1 began hitting him/her on the arm. Staff removed Resident #1 from vicinity of Resident #2, assessed Resident #2, and notified the guardian and provider;- On 11/9/25 at 11:46 P.M., 72-hour observation for an incident with another resident. Resident #1 physically hit Resident #2. Resident #2 denied having any pain and was asked to stay separated from Resident #1. Resident #2 sleeping and not further incidences have occurred at this time;- No further charting noted related to this incident. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed:- Cognitively intact;- Diagnoses included: schizophrenia (condition that affects how people think, feel and behave and may result in a mix of hallucinations, delusions, and disorganized thinking and behavior), bipolar disorder (condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), and diabetes;- Required substantial assistance from staff for activities of daily living (ADL's) to include showering, toileting, and transfers.Review of the resident's care plan, dated 11/11/25, showed:- The resident was at risk for disturbed thought processes, impaired social interaction, and self-care deficit related to diagnosis;- Staff would use de-escalation techniques as needed and would reinforce appropriate social behavior;- Staff would encourage deep breathing exercises and reduce external stimuli as needed.Review of the facility's investigation of the incident, dated 10/27/25 at 8:57 A.M., showed:- Resident #2 reported he/she was in the dining room at his/her usual table, Resident #1 came over, and Resident #2 told him/her to get back to his/her table, then Resident #1 hit Resident #2 on left shoulder and went back to his/her table and called Resident #2 a son of a bitch;- Residents had been separated and skin assessments completed with no injuries noted;- Notifications to resident representatives and provider were made and witness statements taken from all available staff, residents involved and peers at the table;- Intervention would be Resident #1 would be taken to the dining room at a later time for meals and management would be in the dining room for meals.Review of the facility's investigation, dated 11/9/25 at 1:33 P.M., showed:- Resident #1 was in the dining room and started hitting Resident #2 and yelling and cursing at other residents in the dining room;- Resident and witness statements attached and no injury or distress noted; No injuries were identified.- Resident #1 was non-verbal and unable to give a statement;- Staff would redirect Resident #1 when upset and assist with activities to keep him/her occupied and Resident #1 would be monitored for behaviors.During an interview on 11/21/25 at 9:07 A.M., Resident #3 said:- He/She went to the dining room on 10/27/25 to visit and witnessed Resident #1 hit Resident #2 in the arm;- Resident #1 always gets mad and gets a little temper then gets happy.- He/She didn't remember the incident on 11/9/25;- He/She got hit by Resident #1 one time but didn't tell anyone;- Staff watches Resident #1 but here recently the staff leaves Resident #1 alone then the call lights are going off for staff to get him away from them;- He/She stays away from Resident #1 .During an interview on 11/21/25 at 9:15 A.M., Certified Nursing Assistant (CNA) A said:- He/She had seen Resident #1 yell at other residents and hit staff members;- Resident #1 needed time to cool off and separate from other residents when aggravated;- Resident #1 had threatened to hit him/her. It's important to know how to approach Resident #1;- Resident #1 would sit in the common area with staff and was checked on frequently;- Residents have the right to not get hit by other residents or anyone;- It is abuse for a resident to hit another resident.During an interview on 11/21/25 at 9:21 A.M., Registered Nurse (RN) A said:- He/She was at the facility when the incident on 11/9/25 occurred and had been told Resident #1 hit Resident #2 and both residents had been put on 15-minute checks and Resident #1 was one on one observation with staff;- Resident #1 was not always supervised and had good and bad days. He/She had seen Resident #1 strike out at others but believed it was more so to get attention and not hurt anyone;- Resident #1 had told him/her that he/she did not like Resident #2;- It was reported to him/her that the residents had been close in the dining room and Resident #1 started hitting Resident #2 in the arm;- Resident #1 had hit him/her once and would hit out at aides, at night, in bed;- A resident has the right not to be hit, and it could be abuse if a resident strikes another resident.During an interview on 11/21/25 at 9:31 A.M., Certified Medication Technician (CMT) A said:- Resident #1 and Resident #2 were having some sort of issue on 11/9/25 and Resident #2 would push Resident #1's chair and instigated it, then Resident #1 popped Resident #2's arm a few times in a row;- Staff separated the residents, let the nurse know, and Resident #1 was on 15 minute checks for awhile;- Staff have now started bringing Resident #1 to the dining room last and was now observed at all times;- A resident has the right to not be hit by anyone and it can be abuse if a resident hits another resident.During an interview on 11/21/25 at 9:40 A.M., Resident #2 said:- Resident #1 had hit him/her on the shoulder and called him/her names;- One other time, Resident #1 had kept coming over to the dining room table, so he/she told Resident #1 to go back to the other table. Then, Resident #1 flipped Resident #2 off, balled up his/her fist and put it in Resident #2's face shaking it and calling Resident #2 a son of a bitch. The only time Resident #1 touched him/her was a couple of weeks ago 0n 11/9/25);- The staff don't really watch Resident #1 but he/she just stays away from Resident #1. During an interview on 11/21/25 at 11:00 A.M., the Administrator said:- He/She believed Resident #2 antagonized Resident #1, Resident #1 didn't understand and to him/her Resident #2 was the bad person;- After the 10/27/25 incident the facility added managers to the dining room and Resident #1 would be brought in last;- After the 11/9/25 incident the facility added to Resident #1's care plan to redirect the resident and take him/her to a quiet place to lay down;- The facility had been working on improving Resident #2's instigating and better behaviors.Intake 2653050Intake 2664080

Based on record review and interview, the facility failed to keep one resident (Resident #2) free from verbal and physical abuse when Nurse Aide (NA) A held resident's arms down and cussed at resident (Resident #2) and when Licensed Practical Nurse (LPN) A yelled at resident (Resident #2) and forced the resident to wear a bi-pap mask (A device that forces oxygenated air through mask that is suctioned against a person's face to provide respiratory support) against the resident's will . The facility census was 26. Review of facility policy, dated ,d+[DATE], showed: -It is the policy of the facility that at each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property, and exploitation, corporal punishment, or involuntary seclusion. The resident will be free from physical and chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. The resident will be protected from abuse, neglect, and harm while they are residing at the facility. -All employees who have been alleged to commit abuse will be suspended immediately pending investigation. -If allegation is substantiated there is a potential that the employee will be terminated, added to the Employee Disqualification List and not allowed to work in a nursing home, disciplined by their licensing agency, and charged with a crime. 1. Review of Resident #2's Significant change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed: -The resident was now on hospice care. Review of Resident #2's Quarterly MDS, dated [DATE], showed: -Cognition intact; -He/She had clear speech; -He/She was able to make self-understood and usually understood others; -He/She was dependent on a wheelchair; -He/She had impairment to both sides of his/her lower extremities range of motion; -He/She required set up or clean up assistance with eating and oral care; -Health conditions included shortness of breath, trouble breathing when exertion, sitting at rest, and lying flat; -He/She received oxygen therapy; -He/She did not use any restraints; -Diagnoses included:, Heart failure, hypertension (high blood pressure), schizophrenia (mental health condition that affects a person's thoughts, feelings, and behaviors), asthma (a respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), shortness of breath. Review of care plan, revised [DATE], showed: -He/She had an order for a Bi-level Positive Airway Pressure (Bi-Pap). The higher pressure helped with inhaling, while the lower pressure level helped with exhaling) during naps and at bedtime. He/She was on continuous oxygen. -Resident had been non-compliant with Bi-pap order; -Staff would assist resident with putting on his/her Bi-Pat every evening at bed time and encourage him/her to leave it on during the night; staff would check every one to two hours to make sure Bi-pap was on and working correctly; -Staff will remind and encourage resident to leave his/her oxygen on as ordered. Resident had been non-compliant at times and needs lot of reminding of orders; -Chronic non-compliance will be reported to ordering providers; -Oxygen saturations will be checked by nursing shiftily and documented on the Treatment Administration Records; -He/She would have advanced directives honored. He/She is a Do Not Resuscitate (DNR) as of [DATE]. He/She was placed on hospice on [DATE]. Review of physician's orders showed: -Order started [DATE], Bi-Pap: to wear at bedtime and naps. Settings: ,d+[DATE], 35%, rate 12; -Order started [DATE], Check oxygen saturations as needed and notify physician if lower than 90%; -Order started [DATE], oxygen therapy: ,d+[DATE] liters each nostril nasal cannula as need to keep oxygen saturation levels above 92%. Special instructions: As needed (PRN); -Order started [DATE], Continue home oxygen as directed and use Bi-Pap as directed. Special instructions: Continue home oxygen use as directed and use Bi-pap as directed; -Order started [DATE], code status DNR. Review of progress notes, dated [DATE]-[DATE], showed: -On [DATE] at 6:34 A.M., LPN A wrote oxygen saturations were checked every ,d+[DATE] minutes and were ,d+[DATE]%, at 3:00 A.M. resident saturations were at 75%. Resident's Bi-Pap was placed on and oxygen went up to 84% saturation. Breathing treatment was given. Resident kept saying he/she wanted to go to the hospital. Residents saturations dropped to ,d+[DATE]%. Resident became combative and not leaving Bi-pap on. Family Nurse Practitioner was contacted at 4:30 A.M. and new order was obtained to transfer to emergency room . At 5:35 A.M. ambulance was notified and EMS left with resident. Guardian notified by phone, fax sent to family nurse practitioner to notify of resident's transfer. -On [DATE] at 10:23 A.M., Registered Nurse (RN) A wrote call received from emergency room and transfer of resident was pending as soon as hospital bed was located for him/her; -On [DATE] at 4:50 P.M., RN A wrote resident was sent to hospital in Kansas City. Resident's guardian and family were made aware; -On [DATE], Facility received an email from resident's guardian regarding assessing resident for palliative care or hospice when discharged back to facility; -On [DATE] at 11:50 A.M., RN A wrote that resident was discharged from hospital; -On [DATE] at 2:55 P.M., RN A received report from RN at Kansas City hospital that resident had been hospitalized for acute chronic respiratory failure with hypoxia and hypercapnia. Resident continued to be noncompliant with bi-pap but did wear bi-pap 3.5 to 4 hours the previous night. -On [DATE] at 7:32 P.M., RN A wrote that the resident returned to facility. Review of facility investigation, dated [DATE] at 3:30 P.M., showed: -Notification: Facility was notified by Resident #2's guardian on [DATE] at 3:30 P.M. that Resident #2 told his/her family member that LPN A was condescending and told Resident #2 he/she would die if he/she was noncompliant with care and told NA B to hold Resident #2 down. -Witness Interview showed: -NA B informed facility that NA was frustrated at resident for not wearing his/her mask through the night, called Resident #2 stupid and to keep his/her fucking mask on and punched a pillow. NA B said LPN A was yelling and arguing with Resident #2 over compliance with mask and held Resident #2's right hand down to put his/her mask on face; -Interviews with alleged perpetrators showed: -LPN A said Resident #2 was having extremely low oxygen saturations, being combative, and noncompliant. NA A did have a heated episode according to coworker NA A and he/she removed him from the room but did not hear it and told NA A not to talk to residents rudely. Resident #2's oxygen was extremely alarmingly low and he/she called emergency medical services. He/She tried to get Resident #2's oxygen saturations up and Resident #2 was being combative, not in his/her right state of mind, so he/she did hold Resident #2's hand down just to get his/her mask repositioned. Resident #2 was not hurt at all and was not restrained. -NA A said: Resident #2's oxygen was low like down in the 30's. It was very emotional and intense. He/She got upset Resident #2 would not keep his/her mask on so he/she admitted that he/she called Resident #2 stupid and to keep his/her fucking mask on. He/She regretted it and realized it was wrong. The charge nurse, LPN A talked me through it and told me my behavior was unacceptable. Resident #2 was combative and ripped his/her mask off. LPN A was trying to talk us through it. He/She held down Resident #2's hands so the nurse, LPN A, could put Resident #2's mask on. It was a life or death situation and very intense. -Conclusion: Allegation was verified by eyewitness statement, confirming abuse and neglect by both perpetrators. NA A verbal abuse and LPN B physical abuse from using restraint. -Corrective Action: Facility immediately suspended perpetrators and following investigation terminated both LPN A and NA A. Psychosocial visits to victim upon return. Education to facility staff on abuse and neglect, restraints, and reporting abuse and neglect. -Facility interviewed five residents with BIMS over 12, all residents said they had no issues or bad experiences with either perpetrator. All denied abuse or neglect by a staff member. -Review of facility investigation, dated showed: -Twenty-three residents were interviewed regarding if they had experienced abuse or neglect from staff member, if they had been held down, constrained, or restricted by staff, and if there was anything they wanted to report or were too shy to report. -Statements were obtained from NA B on [DATE]; -Interview was conducted with Resident #2 on [DATE]; -Facility reported LPN A to professional Missouri licensing board; -Facility reported NA B to CNA Registry. Review of resident's medical chart, dated [DATE], showed Do Not resuscitate orders were signed by Resident #2's guardian on [DATE] and were also signed by two physicians. During an interview on [DATE] at 9:28 A.M., Resident #2 said: -He/She had staff at facility mistreat him/her when Licensed Practical Nurse (LPN) A, Nurse Aide (NA) A, and NA B came into his/her room and said they were going to give him/her a treatment; -LPN A came into his/her room and wanted to do a respiratory treatment; -He/She told LPN A that he/she would rather not do the respiratory treatment; -LPN A said he/she needed to do the treatment and started to get abrupt with him/her; -LPN A again said you need to do this treatment and started yelling and screaming at him/her that he/she would die over and over; -He/She said to LPN A that maybe LPN A could come back but LPN A proceeded with his/her respiratory treatment; -LPN A had the NA B hold me back and he/she pushed me down by the shoulders; -NA B continued to force me down; -It made him/her feel bad and upset; -He/She was not sure if it was NA A or NA B who held him/her down but it was a male staff who held his/her hands down; -He/She thinks LPN A cussed at him/her; -He/She had not seen LPN A back working at facility since that day; During an interview on [DATE] at 11:43 A.M., NA A said: -Situation with Resident #2 was stressful due to Resident #2 refusing to wear his/her bi-pay and his/her oxygen dropped to 35 and kept going down; -He/She held resident's arms down; -He/She said keep your fucking mask on and called the him/her stupid; -Resident #2 was swinging his/her arms; -NA B was holding resident's mask on his/her face per direction he/she received from LPN A; -Resident #2 did have his/her bi-pap on prior to that but when he/she took off his/her bi-pap his/her oxygen saturations kept dropping; -He/She was the only staff member that held Resident #2 down; -He/She received abuse and neglect training in monthly meaning; -Administration talked about restraints and how staff were not allowed to secure someone to wheelchair and we were supposed to allow residents to still be able to move; -He/She felt he/she had a good rapport with Resident #2; -He/She had not received any training on doing holds or restraints on residents. -There were other times he/she had held residents as he/she did not have option to leave residents soaked in their urine; -Residents could get very combative. During an interview on [DATE] at 11:56 A.M., NA B said: -Resident #2 was supposed to wear his/her bi-pap machine at night; -Resident #2's oxygen saturations went from 90's, to 50's, to the 40's; -LPN A held Resident #2's hand down and said you got to keep that thing on; -LPN A and NA A yelled at Resident #2; -NA A was on Resident #2's right side, and he/she was on Resident's left side; -NA A said 'Hey stupid, you need to put your fucking mask back on' and then punched the pillow beside resident #2's head; -Resident #2 said he/she was scared; -Resident #2's eyes got wide and resident said did he/she really just do that? He hit my pillow! and resident looked terrified; -Resident #2 wanted the ambulance; -LPN A said Resident #2 was not getting ambulance that Resident #2 had us; -It was normal for Resident #2 to take of his/her bi-pap machine; -He/She had to loosen up the bi-pap for him/her -The bi-pap did look tight around resident #2's head and ears; -LPN A told Resident #2 'you are going to keep that thing on, I don't care'; -LPN A held Resident #2's hand down; -When LPN A would leave room Resident #2 would put his/her bi-pap mask back on his/her face; -NA A came back into room to do Resident #2's vitals and Resident #2 did not like the idea of NA A being back in his/her room; -Resident #2 said he/she was going to tell and it was not right what LPN A was doing; -Facility talked about abuse and neglect all the time; -He/She was trained that he/she was not supposed to restrain anybody; -If resident was soiled, he/she would let them know they needed changed; -He/She knew some residents did not believe they were wet; -He/She spoke to Administrator and DON about what he/she observed; -He/She was aware that LPN A had been fired; During an interview on [DATE] at 1:46 P.M., LPN A said: -He/She was in and out of Resident #2's room on [DATE]; -Resident #2 would not leave his/her bi-pap on; -He/She notified the nurse practitioner who gave him/her an order to send resident out if resident's saturations got down to 75; -He/She got residents oxygen saturations back up to the 80's; -He/She ripped off bi-pap and his/her oxygen saturations got down to 38; -Resident #2 was combative; -He/She did take Resident #2's hand and held it and said to Resident #2 he/she needed to keep his/her bi-pap on; -He/She could not get saturations higher so he/she called 911; -He/She did not hold Resident #2 down; -He/She took Resident #2's hand because he/she was fighting; -When he/she held Resident #2's hand she pulled on his/her wrist lightly; -He/She laid Resident #2's wrist down and left the room; -He/She told staff to keep Resident #2's mask on; -He/She called 911 because resident would have died due to not getting oxygen saturations up higher; -At the beginning, Resident #2 did ask him/her to call 911, but he/she said she would call the doctor; -He/She called the nurse practitioner when resident's saturations were in the 70's and 80's; -He/She did not scream or yell at Resident #2; -He/She was told by NA B regarding NA A getting angry and saying to Resident #2 to keep that fucking bi-pap on; -He/She did talk to NA A and gave him a warning and he/she said he/she was sorry;; -It was normal for Resident #2 to not want to keep his/her bi-pap on; -It was routine for them to check resident #2 oxygen saturations throughout the night; -There was times resident's oxygen nasal cannulas kept his/her saturations up; -He/She would sometimes have staff lay resident down, reposition him/her, and pull him/her up in bed; -The protocols that were in place when resident not wanting to keep his/her bi-pap on were just to check residents saturations and if they got to low to call the nurse practitioner; -Resident #2 was a DNR; -It would have been Resident #2's right to have his/her bi-pap off; -He/She tried to encourage Resident #2 to have his/her bi-pap on because he/she did not Resident #2 to die; -Facility protocol was that no restraints were to be used on residents; During an interview on [DATE] at 2:22 P.M., RN A said: -Resident #2 was very non-compliant with wearing his/her bi-pap; -Agency nurses had issues with Resident #2 being non-complaint with wearing his/her bi-pap; -Facility protocol for resident #2 at night was to watch his/her oxygen saturations; -He/She was aware that LPN A had gotten an order to send Resident #2 out but nurse practitioner had said to try and not send Resident #2 out; -He/She would try to allow residents who were agitated or frustrated to calm down and or get a staff member that they liked to talk to them to support them in calming down; -All staff had been educated that they could not hold down a resident or force a resident; -He/She had not seen residents forced or provided unwanted cares; -LPN A called him/her when he/she was suspended; -LPN A indicated that it was out of desperation that he/she was trying to get Resident #2's oxygen saturations up; During an interview on [DATE] at 3:05 P.M., Business Office Manager (BOM) said: -He/She observed LPN A call residents name if he/she was referring to them but not directly to residents face; -Behaviors in facility were often instigated by staffs approach with resident. During an interview on [DATE] at 4:26 P.M., Director of Nursing (DON) said: -Resident #2's guardian notified facility with concerns when Resident #2 had told his/her family member that the LPN A was making him/her put his/her bi-pap on and tried to get the one of the nurse aides to hold him/her down and make Resident #2 wear the bi-pap; -Resident #2 said that LPN A kept screaming that he/she was going to die; -Resident #2's oxygen saturations were down to 30's so it was an intense situation; -LPN A had said during the facility interview that LPN A wasn't intending to hold Resident #2 down to harm him/her but was just trying to get his/her oxygen saturations up; -Resident #2 was a DNR at that time; -NA A said during facility interview that he/she did tell Resident #2 to put his/her mask on but said he/she did not hit the pillow; -LPN A had said he/she was not in the room when NA A cussed and hit pillow but as soon as NA B reported it to LPN A; -LPN A had talked to NA A and NA had said he/she was just worked about resident #2's safety; -LPN A said NA B did not hold Resident #2 down; -He/She expected residents to be free from physical and verbal abuse; -It was never okay for residents to be held down to provide cares; -Resident did have a right to refuse cares. During an interview on [DATE] at 4:48 P.M., Administrator said: -LPN A resigned prior to facility planned termination of his/her employment; -LPN A said during facility interview that he/she used a loud voice with resident #2; -LPN A did admit to holding hand of Resident #2 in an attempt to prevent Resident #2 from hitting NA A and pull off his/her mask; -NA A admitted to holding Resident #2 down, cussing, yelling, and using bad language indicating he/she was in a heated situation; -Facility did interview Resident #2, Resident #2's mother; -Resident #2 said he/she did not like the feeling of being restrained in any way; -He/She expected residents to be free from all abuse; -Abuse and neglect had been an issue since he/she started in his/her position in facility; -He/She implemented monthly education with employees; -He/She implemented doing pop in interviews (unannounced visits to the facility) with residents and had changed descriptions he/she used in those interviews to be more comprehensive for residents in facility such as asking residents if they had ever been held down by staff or ignored instead of asking if they had ever been abuse. MO251220.

Based on observation, interviews, and record reviews, the facility failed to assure one resident (Resident #1) was free from misappropriation of his/her property when the resident's narcotic medications were found missing from the facility. The facility census was 26. Review of facility's abuse policy, dated ,d+[DATE], showed: -It is the policy of the facility that at each resident will be free from abuse. Abuse can include misappropriation of resident property -All employees who have been alleged to commit abuse will be suspended immediately pending investigation. -If allegation is substantiated there is a potential that the employee will be terminated, added to the Employee Disqualification List and not allowed to work in a nursing home, disciplined by their licensing agency, and charged with a crime. Review of facility policy, Scheduled II-V Medications, undated, showed: -Schedule II-V medications may be kept in medication cart lock box, refrigerator, boxes, or double lock box maintained in medication room. -Scheduled medications will have disposition records that are in a binder on medication cart or area instructed by Director of Nursing (DON). -Scheduled medications that are as needed (PRN) must be kept in medication cart locked box. -Additional cards may be kept in the medication room locked box or in the medication locked box in nurse medication cart. Dispositions records will be kept with the schedule II medication disposition records. -When a Schedule II, III, IV, V car is emptied, the CMT will place the card with the disposition record in the designated area for the DON or licensed designee to collect. -When new or refill schedule II, III, IV, or V cards arrive from the pharmacy, the disposition record is filled out, the card is counted and placed in the locked box in the medication cart. -All schedule II, III, IV, and V medications must be counted (comparing number of pills to disposition record) at every change of shift by two CMT, or one CMT and one licensed nursing staff. Both personnel must sign verification of correct count for Schedule II, III, IV, and V. -If at any time the count is incorrect, CMT must notify licensed nursing staff, who will call DON or designee for instruction. -All scheduled II medications will be administered by the nurse or authorized CMT. Review of facility policy, destruction of medications, undated, showed: -Two licensed nurses or one licensed nurse and facility pharmacist will destroy all medications, except controlled substances which will require DON supervision. -Documentation of medication destruction will include: -date; -Name of medication; -RX number; -amount of medication to be destroyed; -method of destruction; -signature of nurses and/or pharmacist; -Scheduled II-IV medication will be destroyed as stated above with the following exceptions: -the controlled medication count sheet will include the following information: -signature of nurses and/or pharmacist destroying the medication -amount destroyed -date destroyed -The following method of destroying medications will be utilized: -Medications to be destroyed including pills, capsules, liquids, creams, etc will be placed in a sealable container such as a plastic bag. -An unpalatable substance such as kitty litter or used coffee grounds will be added to the plastic bag of medications. -Before sealing plastic bag approximately one cup of fluid (i.e. water, liquid detergent, etc ) will be added to the plastic bag of medications. -The plastic bag will then be sealed and placed in the trash. 1. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed: -Cognition severely impaired; -He/She had limited range of motion to both lower extremities; -He/She was dependent on a wheelchair; -He/She required partial to moderate assistance with toileting, upper body dressing, rolling left and right, sit to stand transfers, and toilet transfers; -He/She required substantial to maximal assistance for chair to bed transfers, lying to sitting transfers, and bathing; -He/She was on scheduled pain medication regimen; -He/She was taking an opioid; -Diagnoses included: vascular dementia (cognitive decline caused by damage to the blood vessels in the brain), major depressive disorder (persistently depressed mood), pain, and anxiety. Review of Medication Administration log, dated [DATE]-[DATE], showed: -Document header, Nurses MAR flow sheet, showed: As needed pain medication. -Order date [DATE], Hydro/Apap tablet; 7XXX,d+[DATE]; amount to administer: 1 tablet; oral three times a day, every 4 hours as needed for pain, for pain unspecified not to exceed 3 GM Apap/24 hours. -On [DATE], Resident received medication at 8:00 A.M., 12:00 P.M., and 8:00 P.M.; -On [DATE], Resident received medication at 8:00 A.M., 12:00 P.M., and 8:00 P.M.; -On [DATE], Resident received medication at 8:00 A.M., 12:00 P.M., and 8:00 P.M.; -On [DATE], Resident received medication at 8:00 A.M., and 12:00 P.M. -Document header, Medications Flow sheet, showed: Routinely scheduled medication. -Order started [DATE], hydrocodone-acetaminophen - Schedule II tablet; 7XXX,d+[DATE]mg;, amount to administer: 1 tab TID PO; oral TID, pain in left hip; -On [DATE], Resident received medication between 8:00 A.M.-10:00 A.M., 11:00 A.M.-2:00 P.M., and 3:,d+[DATE]:00 P.M.; -CMT A signed he/she administered medication all three administration times; -On [DATE], Resident received medication between 8:00 A.M.-10:00 A.M., 11:00 A.M.-2:00 P.M., and 3:,d+[DATE]:00 P.M.; -CMT A signed he/she administered medication between 11:00 A.M.-2:00 P.M.; -On [DATE], Resident received medication between 8:00 A.M.-10:00 A.M., 11:00 A.M.-2:00 P.M., and 3:,d+[DATE]:00 P.M.; -CMT A signed he/she administered medication between 8:00 A.M.-10:00 A.M. and 11:00 A.M.-2:00 P.M.; -On [DATE], Resident received medication between 8:00 A.M.-10:00 A.M., 11:00 A.M.-2:00 P.M., and 3:,d+[DATE]:00 P.M.; -CMT A signed he/she administered medication at all three administration times. Review of care plan, revised [DATE], showed the resident had constant chronic back pain. Physician's orders, dated [DATE], showed the order started [DATE], Hydrocodone-acetaminophen -schedule II tablet; 7XXX,d+[DATE]mg, 1 tab three times a day by mouth. Observation of medication room on [DATE] at 2:58 P.M., showed: -There were two bubble packs for resident #1 of hydrocodone-acetaminophen 7XXX,d+[DATE]mg in medication cart, 1 card had 20 remaining, the other card had 60 count. -Controlled drug count sheet matched the number of pills found in medication cart; -Controlled drug box inside the medication cart was not locked. Review of pharmacy facility delivery receipts, [DATE]-[DATE], showed: -On [DATE], 60 quantity, hydrocodone-acetaminophen 7XXX,d+[DATE] mg tablets, were delivered to the facility; -On [DATE], 60 quantity, hydrocodone-acetaminophen 7XXX,d+[DATE] mg tablets, were delivered to the facility; -On [DATE], 60 quantity, hydrocodone-acetaminophen 7XXX,d+[DATE] mg tablets, were delivered to the facility. 2. Review of facility investigation, dated [DATE], showed: -Facility became aware of incident on [DATE] at 3:00 P.M.; -RN A reported that on [DATE] she returned to work from having two days off and noted a missing pack of Resident #1's hydrocodone-acetaminophen as he/she had previously had two bubble packs of the hydrocodone-acetaminophen when he/she had worked on [DATE]. He/She had inquired with CMT A what had happened to them and CMT A reported that DON and Administrator had destroyed medications due to state survey agency being in building and facility having too many controlled drugs and an inhaler. RN A shrugged off the information but later heard a conflicting story on [DATE] when CMT A had said that he/she had destroyed the controlled drugs so he/she reported information to facility administration. DON and Administrator informed RN A that they had not destroyed any medications. -Steps taken included: -Suspended CMT A; -Obtained written statements; -Searched for medication destruction and controlled medication sheet for Resident #1 but were unable to locate either documentation; -Notified pharmacy -Educated all nurses on narcotics; -Review of written statements showed: -On [DATE], Administrator wrote: On [DATE], RN A reported an incident to him/her, DON, and Quality Assurance Nurse regarding a missing narcotic medication (Hydrocodone-Acetaminophen) for Resident #1. RN A had questioned CMT about the missing medication to which CMT said Administrator and DON were cleaning out the med room since state was in building trying to destroy all expired or non-labeled medications, they must have gotten rid of it. The DON and he/she clarified that this statement was false and that neither of us had cleaned out the medication room. RN A expressed concerns that CMT A might be involved with theft, citing his/her strong desire to pass narcotics at the start of his/her shift, although RN A did not have sufficient evidence to formally accuse CMT A of stealing. As a result of incident, CMT A will be terminated from his/her role as CMT, but will be allowed to maintain his/her position as a CNA without medication administration privileges. -On [DATE], RN A wrote: On Friday February 28, 2025 while getting a narcotic out I noted that resident #1 only had one full card of hydrocodone-acetaminophen and one partial card. When he/she had worked on Tuesday, February 25 there was one partial card and two full 60 count cards of hydrocodone-acetaminophen. CMT A said that Administrator and DON had been in the medication room going through the medication cart and cleaning and that they had taken a card of hydrocodone-acetaminophen because facility had too much and it looked back with state agency in the facility. He/She inquired with CMT A what Administrator and DON did with the card and CMT A said he/she did not know. The sign out sheet for the hydrocodone-acetaminophen was also missing from the narcotic count book. He/She intended to speak with the DON about the medication, but was not able to until [DATE]. He/She did know for a fact that there were two sixty count cards of hydrocodone-acetaminophen in the medication cart because hospice nurse A and him/her had counted the controlled medications for hospice patients on [DATE] and he/she had discussed the controlled drug count for Resident #1 yesterday on [DATE]. Hospice nurse showed me his/her computer that showed the partial count plus 120 more. -On [DATE], Business Office Manager (BOM) wrote: CMT had told him/her he/she had taken a controlled drug home when he/she went to pick CMT A up for work. He/She said he/she had told RN A that he/she had taken it home and he/she would bring the medication back in the morning. CMT A said he/she had left medication on the dryer. BOM offered for CMT A to go back and pick up the medication and CMT A said no that RN A would not say anything or write him/her up for it; -On [DATE], CMT A wrote: On February 25, 2025 state notified him/her that he/she had an abundance of extra medications on his/her medication cart. He/She put extra eye drops, nasal sprays, inhalers on the counter to be destroyed. RN A asked him/her about medications being destroyed and he/she said that we had a lot from his/her cart. The only narcotics he/she seen to be destroyed was morphine and RN A was doing correctly so with another nurse. He/She did not normally pop out the narcotics but he/she did get into their cart. He/She accident took home another resident's bromoimide drops. He/She did say that RN A probably wouldn't write him/her up for it. -Undated, DON wrote, CMT A came to him/her and Administrator and informed them that state made him/her and RN A destroy several medications which included an inhaler, morphine, and a medication that belonged to Resident #1 but he/she could not remember the name of the medication. He/She spoke to RN A on [DATE] and informed hi/her that it was weird that CMT A told RN A that DON and Administrator had gotten rid of a card of hydrocodone-acetaminophen for Resident #1. He/She took RN A to administrator and Corporate Quality Assurance nurse to repeat what he/she had said. With guidance from Corporate Quality Assurance nurse, CMT would no longer do medications in facility, a soft file had been started, nurses were in-service and medication sheet is unavailable as he/she, RN A looked for the controlled drug sheet and medication and were unable to locate either items. -On [DATE], Hospice Nurse A wrote: He/She served as hospice case manager for Resident #1 and had conversation with RN A. RN A had asked him/her if he/she had destroyed any of Resident #1's medications. He/She responded no. RN A stated he/she did not feel Resident #1's controlled drug count was correct. RN A stated that CMT A had told RN A that he/she, DON, and a state agency representative was in medication room discussing Resident #1's medications and that had stated Resident #1 had too many hydrocodone-acetaminophen and that Resident #1 did not need that many. I told RN A that conversation never took place and that he/she had not destroyed any of Resident #1's medications. According to his/her charting of Resident #1's medications he/she had 135 tabs of hydrocodone-acetaminophen 7XXX,d+[DATE] on [DATE] and 55 tablets of hydrocodone-acetaminophen 7XXX,d+[DATE] mg on [DATE]. -Corrective Actions showed: -CMT A suspended -Pharmacy and Hospice were notified and medications were replaced; -CMT A would no longer be allowed to work as CMT, only as a CNA; -Only licensed nurses were allowed to pass controlled drugs; -Licensed nurses must count controlled drugs between shifts. Neither nurse shall leave facility if there was miscount, missing narcotics, or undocumented destruction until the DON was informed and approved. -Controlled drug destruction required direct approval from the DON. -Plan of oversight included: Education to nurses regarding corrective action; -DON to audit narcotics weekly for any unreported missing narcotics; -Systemic changes included: Change in facility policy that revoked CMT privileges to pass controlled medications. -Conclusion of investigation showed: Inconclusive. Facility could not confirm or disprove due to lack of sufficient evidence. No direct observation of CMT stealing narcotics as charge nurse did not witness theft and BOM did not observe the narcotics in CMT's possession. It was verified that controlled drug was missing from Resident #1's supply. It remained inconclusive whether it was misplaced, destroyed, discarded, or stolen. -Inservice was completed on [DATE] with three facility nurses regarding passing of controlled medications; During an interview on [DATE] at 1:46 P.M., Licensed Practical Nurse (LPN) A said: -Two nurses counted narcotics together; -If a medication was discontinued the facility had a jug of drug buster and two nurses fill out a form and both nurses have to sign, destroy, and put it in the drug buster stuff; -He/She knew Resident #1's narcotic medication count was off; -He/She was informed that there had been two cards but they were just using the one card; -One of the nurses reported to him/her that one of the cards was missing; -Evidently someone took the whole controlled dug page out of the controlled medication book and everything; -RN A or RN B had to be the nurse that told him/her that Resident #1's medication card was missing; -He/She worked night shift from 6:00 P.M.-6:30 A.M.; -He/She had never had any issues with missing medication bubble packs; -CMT A had access to the narcotics; -This was a new policy that they allowed CMT's access to narcotics when they hired CMT A; -CMT was allowed to go into both medication carts; -The nurses cart had the narcotics in it; -Resident #1 received Hydrocodone-Acetaminophen scheduled for his/her pain; -CMT A was always asking charge nurse if he/she could give Resident #1 and Resident #4 pain medication; -Resident #4 was on same medication as Resident #1; -Resident #4 was on morphine which we had not been giving to him/her because the hydrocodone-acetaminophen seemed to hold his/her pain; -There was time he/she had to give Resident #4 the morphine and it was always when CMT A had passed his/her hydrocodone-acetaminophen; -There was one time Resident #1 was crying he/she had so much pain. During an interview on [DATE] at 2:22 P.M., Registered Nurse (RN) A: -He/She normally counted narcotics of hospice residents when the hospice nurse was in the building; -He/She had counted narcotics with the hospice nurse on [DATE]; -On ,d+[DATE] he/she counted two bubble packs of 60 count pills of hydrocodone-apap for Resident #1; -The hospice nurse had logged his/her counts with me on his/her computer; -When he/she returned to work on ,d+[DATE] Resident #1 only had one bubble pack of 60 plus a partial card of hydrocodone-apap; -He/She asked CMT A what had happened to Resident #1's bubble pack of hydrocodone; -CMT A said that the Administrator and DON had been in the medication room going through stuff and took the extra card of hydrocodone-acetaminophen for Resident #1 out because it had looked bad having that much hydrocodone-acetaminophen on hand for one resident; -From that point on he/she never got an opportunity to tell the DON about it until he/she remembered on [DATE]; -DON immediately took him/her to Administrators office and he/she relayed the information she had with the Administrator, Corporate Nurse, and the DON; -DON reported to him/her that CMT A had reported that he/she and CMT A had wasted Resident #1's drugs; -There had been no reason to waste Resident #1's medications; -We were unable to locate Resident #1's hydrocodone-acetaminophen controlled drug count sheet the missing bubble pack; -Facility had a box that the completed controlled drug count sheets went into when they had been completed, the box was checked and the missing narcotic sheet was not located; -CMT A did pass controlled drugs for the nurses; -The controlled drugs were maintained in the nurses medication cart; -The nurse would have to unlock the cart for CMT A; -When CMT A needed a controlled drug for a resident he/she would ask for it; -He/She would pop the medication for CMT A and give it to him/her to administer; -He/She learned that he/she should not have been popping the medication for CMT A and he/she should have popped his/her own medications for residents; -The controlled drug counts were completed with the oncoming nurse; -He/She did not know if CMT A had completed the controlled drug counts with staff; -The controlled drugs were always maintained in the nurses cart; -CMT A was the only CMT the facility had employed; -He/She had notified interim DON his/her concerns with CMT A having access to the nurses cart and a long write up was received back from the facility corporate nurse notifying us that CMT A could pass narcotics; -He/She had identified concerns regarding CMT A with controlled drug passes but did not have any solid proof because the residents in the facility had a routine with their medications; -In the mornings, CMT A would always want Resident #1 and Resident #4's controlled medications of Hydrocodone-Acetaminophen; -One day CMT A asked him/her for Resident #1 and Resident #4's medications at breakfast. The aids then had came to me and said Resident #4's was in a lot of pain; -He/She felt this was unusual as Resident #4's pain was usually managed by his/her hydrocodone/acetaminophen; -When He/She went into Resident #4's room to assess Resident #4', he/she found that Resident #4 was crying; -He/She had to administer Resident #4's morphine for the pain; -He/She had charted that he/she had administered the morphine to Resident #4's for break through pain rated 10 out of 10 on the pain scale; -Sometimes he/she had to crush Resident #4's medication in pudding because Resident #4 could not take his/her medication in a whole pill form; -Another instance, a day aide came up and asked if he/she could give Resident #3's his/her medications because they were getting ready to change him/her and the day aide thought it would help him/her. CMT A already had Resident #3's medication cup ready in medication cart, but when he/she looked in his/her medication cup Resident #3's did not have his/her Ativan in the cup and there was no Ativan in the medication cart. CMT A had popped pills in advance and had them already in a pill cup in the medication cart; -Resident #1 is fairly agreeable resident but at times he/she would become hateful on days CMT A passed Resident #1's medications. He/She had wondered if Resident #1 had been experiencing pain; -CMT A was in medication room helping straighten Medication Administration Records (MARS) during this past month and the MDS Coordinator was working to pass medications that evening; -CMT A was not in facility working to pass medications that shift but he/she asked him/her three times if he/she wanted him/her to go and pass Resident #4's pain medication. On the third time of CMT A asking about Resident #4's pain medication, he/she went to ask and assess Resident #4's pain. Resident #4 said he/she was fine and was not having any pain. CMT A became upset with me. During an interview on [DATE] at 3:05 P.M., Business Office Manager (BOM) said: -He/She transported CMT A to and from work; -He/She dropped CMT A off from work on [DATE] and he/she had a back pack he/she carried with him/her; -He/She picked up CMT A on morning of [DATE] and when he/she backed out of CMT A's driveway, CMT A said he/she had forgotten medication. He/She asked CMT A if he/she needed to go back into get the medication and CMT A said no it was just a pill in a cup; -He/She observed CMT A open his/her backpack and pulled medicine out of his/her bag. Inside his/her bag he/she had long oval pills that were loosely laying in his/her bag; -He/She had also observed some pill bottles and CMT A did indicate he/she took Xanax and Tramadol; -The next day CMT A did bring a pill in a white paper cup up to the Business Office Manager's office and said resident no longer took the medication; -CMT A did not mention any eye drops to him/her, he/she was not aware of any eye drops; -He/She had observed concerns regarding CMT A's behavior at work; -He/She had observed CMT standing at medication cart acting loopy and dozing off and did not appear functional; -He/She had residents ask him/her what was wrong with CMT A and why CMT A would fall asleep or was falling over while trying to write; -He/She reported his/her concerns to the Director of Nursing (DON) and encouraged DON to send CMT A home from work; -DON did not send CMT A home from work; -CMT A would yell at residents; -CMT A would drop medications on the floor and pre-set his/her medications; -CMT A would set up medications for LPN A because LPN A could not see; -CMT A would put medications in baggies or cups; -LPN A would have to use a magnifying glass or flashlight to be able to see; -LPN A used to stay in facility because he/she had quit driving cause he/she could not see; During an interview on [DATE] at 3:39 P.M., Certified Medication Technician (CMT) A said: -RN A asked him/her why there were multiple items in the medication box that were missing; -He/She told RN A that he/she did not touch anything; -He/She told RN A that he/she had extra inhalers, eye drops in his/her medication cart and he/she had put them on the counter to be destroyed; -The medications he/she put on the counter were not narcotics; -We had multiple doses of medications on the medication cart; -He/She did not know what medications RN A was concerned about; -He/She had passed medications to all residents in facility; -He/She had passed narcotic medications to residents that were on his/her hall; -He/She knew residents ( Resident #3) received Ativan, Resident #4 received hydrocodone-acetaminophen at breakfast and lunch, and Resident #1 received narcotic at 8, noon and 8 P.M.; -He/She sometimes completed narcotic counts with the nurse; -He/She never had an issue with narcotic count being wrong; -He/She never passed the liquid narcotics, only the pill narcotics; -He/She was not allowed to destroy medications; -He/She had put meds in the destroy box and wrote on a piece of paper to destroy; -Due to narcotics being in the nurses cart he/she would sometimes have the nurse pop the narcotic and he/she would administer the medication; -He/She would sometimes get into the nurses medication cart to pass medications if the nurse was running late; -If he/she was getting into the nurses medication cart then it was to do count because he/she touched the medications; -He/She would set up medications for the night nurse, LPN A; -LPN A had a hard time reading and he/she felt it was safer for the resident cause he/she could not see; -He/She would leave medications for nurse to destroy cause legally he/she could not destroy them; -He/She accidentally took home medications; -He/She took home eye drops, it was bromide eye drops; -He/She had placed the eye drops in his/her pocket by accident while he/she had administered them to resident; -He/She had never taken pills home; -He/She did not know where the allegation that he/she took medications from facility came from; -The facility suspended him/her and he/she had not worked since the suspension During an interview on [DATE] at 4:26 P.M., DON said: -CMT A mentioned to him/her that when the state survey team had been in the building they had said there had been too many narcotics on hand and too many being used at one time; -He/She passed the information on to Administrator and Corporate Nurse; -RN A came up to him/her and said CMT A had told her something that had been really odd to him/her that Administrator and myself had taken Resident #1's hydrocodone-acetaminophen and put them up until after state survey team left the building; -He/She made RN A go into Administrator's office and repeat information he/she had shared with the Administrator and Corporate Nurse; -When he/she questioned CMT A, CMT A said he/she had never said that; -BOM reported that CMT A had said he/she had taken medication while he/she had transported CMT A to work which was also reported to Administrator; -Administrator and myself started an investigation; -CMT A was suspended; -State agency was notified of investigation; -They had interviewed all individuals who had access to medications at time the medications went missing including day shift nurses, CMT A, BOM, and the hospice nurse; -CMT A had access to the controlled medications and did pass controlled medications; -He/She did not have any concerns regarding CMT A passing medications; -He/She had not had any concerns reported to him/her regarding CMT's behavior other than some would say he/she was tired; -He/She had never been able to catch her tired or extra sleepy; -No staff had reported to him/her that residents had more pain when CMT A would pass medications; -He/She expected that staff would pass pills immediately and pre-setting medications was unacceptable; -He/She was aware that staff had been pre-setting medications prior to his/her start date with facility and that it had been addressed through a facility in-service; -He/She was aware that CMT A stayed late to assist LPN A with passing medications; -It was difficult for LPN A to see little words on the MARs; -Resident #1's controlled medication count sheet was lost and unable to be located for the missing bubble pack of hydrocodone; -He/She expected residents to be free from misappropriation of their property; -The facility replaced Resident #1's missing medications with the pharmacy. During an interview on [DATE] at 4:48 P.M., the Administrator said: -CMT A went through a period of working an excessive amount of hours of the facility; -CMT A had been sent home two times for being drowsy; -CMT A did not show signs of being intoxicated; -BOM had reported that CMT A had been drowsy when the BOM had been working the floor with CMT A toward the end of January; -He/She had not received any concerns from residents regarding CMT A's behavior; -He/She expected residents to be free from misappropriation of their personal property; -Facility implemented interventions of suspending CMT A, implemented policy that only nurses are allowed to pass controlled drugs, a strict counting policy is in place and nurses may not leave their shift until the controlled drug count is accurate or DON has approved staff to leave, and destruction of medications only was to occur with oversight of DON or under his/her instruction. MO251028

Based on interview and record review, the facility failed to report to the state survey agency and law enforcement, misappropriation of resident property (missing narcotics), when the facility became aware on 3/11/25 that one resident (Resident #1) had one bubble pack card of a narcotic medication, hydrocodone-acetaminophen 7.5-325mg (a controlled drug used to relieve severe pain) missing. The facility census was 26. Review of facility abuse and neglect policy, dated 11/2017, showed: -The facility will ensure that any reasonable suspicion of crimes committed against a resident of the facility will be reported to the appropriate Law Enforcement Agency as established by section 6703(b)(3) of the Patient Protection and Affordable Care Act of 2010. When there is reasonable suspicion that a crime had occurred, then in addition to reporting the allegation of abuse to the state survey agency, the incident must be reported to the local law enforcement. -All reports of suspected crime must be reported immediately reported to local law enforcement to be investigated. The facility will fully cooperate with local law enforcement. 1. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/14/25, showed: -Cognition severely impaired; -He/She had limited range of motion to both lower extremities; -He/She was dependent on a wheelchair; -He/She required partial to moderate assistance with toileting, upper body dressing, rolling left and right, sit to stand transfers, and toilet transfers; -He/She required substantial to maximal assistance for chair to bed transfers, lying to sitting transfers, and bathing; -He/She was on scheduled pain medication regimen; -He/She was taking an opioid; -Diagnoses included: vascular dementia (cognitive decline caused by damage to the blood vessels in the brain), major depressive disorder (persistently depressed mood), pain, and anxiety. Review of care plan, revised 3/7/25, showed the resident had constant chronic back pain. Review of facility investigation, dated 3/11/25, showed: -Facility became aware of one bubble pack of 30 missing narcotics for resident #1 when Registered Nurse (RN) A reported on 3/11/25 that when she returned to work on 2/28/25 there was one package of narcotics that were missing from when he/she had previously worked on 2/25/25. RN A reported that Certified Medication Technician (CMT) A said to him/her that with state in building for survey the Director of Nursing (DON) and Administrator destroyed medications because they had too much narcotics. RN A reported he/she shrugged off the comment until 3/11/25 when he/she heard a conflicting story that CMT A had reported that he/she had destroyed the narcotics. DON and Administrator reported to RN A that they had not destroyed any medications. -Facility steps in their investigation included notifying the state survey agency, gathering statements, suspending alleged perpetrator, informing pharmacy and paying for replacement medications, and education to their nurses; -Law enforcement was not contacted. Physician's orders, dated 3/25/25, showed the order started 1/20/25, Hydrocodone-acetaminophen -schedule II tablet; 7.5-325mg, 1 tab three times a day by mouth. During an interview on 3/25/25 at 1:15 P.M., Administrator said: -He/She did not contact law enforcement regarding the missing medications; -He/She felt like the narcotics had been missing for too long when it had been reported to him/her. During an interview on 3/25/25 at 4:26 P.M., Director of Nursing (DON) said: -He/She did not know if Administrator had contacted law enforcement regarding missing narcotics; -Administrator was the facility investigator. During an interview on 3/25/25 at 4:48 P.M., Administrator said: -The resident's missing narcotics should have been reported to local law enforcement. -He/She expected resident's to be free from misappropriation of their personal property. MO251028

Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a record of the dishwasher chemical tests, label and date all foods, dispose of expired foods, properly store glasses and cups, failed to ensure kitchen was clean and in good repair, and failed to ensure walk-in cooler was in good repair. The facility census was 27. A policy regarding dietary services and food storage was requested but not provided. 1. Continuous observation of the kitchen on [DATE] beginning at 9:44 A.M. showed: - Expired 8 oz. Always Save baking cocoa best by date was [DATE]; - Expired10 lb. Clabber Girl baking powder best by date was ,d+[DATE]; -No open date labeled on 1 gallon Kikkoman soy sauce; -.49 oz. Supreme Tradition parsley flakes with no open or best by date; -11 lb. Gold Medal chocolate fudge icing with no open date; -Three boxes of Hyvee 5.85 oz. chocolate pudding with best by date of [DATE] and no received date; -Three boxes of Hyvee 5.85 oz. chocolate pudding with best by date of [DATE] and no received date; -Two unbranded, opened packages of tortilla chips with no open date; -No open date on a bag of tater tots in the walk-in freezer; -No received date on a bag of fried rice in the walk-in freezer; -No open date on a bag of frozen corn in the walk-in freezer. Observation on [DATE] at 9:06 A.M. showed: -Expired 18 oz. Sysco Imperial paprika open date was [DATE] with no best by date; -Expired Sysco Imperial 18 oz. light chili powder open date was [DATE] with a best by date of [DATE]; - 14 oz. Sysco Imperial ground cumin best by date was [DATE] with no open date. During an interview on [DATE] at 3:53 P.M., Dietary Aid A said: -Opened food should be labeled with date opened; -Seasonings should not be discarded until they are gone. During an interview on [DATE] at 8:32 A.M., the Dietary Manager said opened food packages should be labeled with the date opened. During an interview on [DATE] at 10:14 A.M., the Dietician said: -He/She expects opened food to be labeled with the date opened; -He/She expects all food items to be dated with a received date; -If a product is unopened, the item should be discarded a year past the best-by date. During an interview on [DATE] at 4:15 P.M., the Administrator said: -He/She expects food items to be labeled with opened date; -He/She expects food items to be discarded after best by date. 2. Observation on [DATE] at 9:06 A.M. showed cups stored upright and uncovered on beverage cart. Observation on [DATE] at 8:17 A.M. showed: -Coffee mugs were stored upright and uncovered on a tray in front of the microwave; -Cups on beverage cart under cooler were stored upright and uncovered. During an interview on [DATE] at 3:53 P.M., Dietary Aid A said cups and glasses should be stored face down. During an interview on [DATE] at 8:32 A.M., the Dietary Manager said cups and glasses should be stored face down. During an interview on [DATE] at 10:14 A.M., the Dietician said he/she expects cups and glasses to be stored inverted. During an interview on [DATE] at 4:15 P.M., the Administrator said he/she expects glasses and cups to be stored in a downward facing position. 3. Review of the Waste Disposal policy, dated ,d+[DATE], showed trash cans should be covered when not in use. Observation on [DATE] at 9:06 A.M. showed garbage can next to dishwasher was not covered while not in use. During an interview on [DATE] at 3:53 P.M., Dietary Aid A said the garbage can should be covered when not in use. During an interview on [DATE] at 8:32 A.M., the Dietary Manager said garbage cans should have a lid on them when not in use. During an interview on [DATE] at 10:14 A.M., the Dietician said garbage can should have a lid on it when not in use. During an interview on [DATE] at 4:15 P.M., the Administrator said he/she expects the kitchen garbage to be covered when not in use. 4. Review of the Dish Machine Temperature policy, dated ,d+[DATE], showed: -Chemically sanitized machines should be checked daily with a test strip; -Logs are to be kept on file for three months. Observation on [DATE] at 9:44 A.M. showed no dishwasher chemical test log. During an interview on [DATE] at 3:53 P.M., Dietary Aid A said there should be a log for the dishwasher chemical tests. During an interview on [DATE] at 8:32 A.M., the Dietary Manager said there should be a log for the dishwasher chemical tests. During an interview on [DATE] at 10:14 A.M., the Dietician said he/she expects there to be a log for the dishwasher chemical tests. During an interview on [DATE] at 4:15 P.M., the Administrator said he/she expects there be a log for the dishwasher chemical tests. 5. A policy regarding kitchen cleaning and maintenance was requested but not provided. Observation on [DATE] at 9:06 A.M. showed: -Vent outside of kitchen office was caked with dust; -Dirty floor with white stains on the floor under the three-bay sink; -Dirty and dusty floor under the dishwasher station. Continuous observation on [DATE] starting at 8:17 A.M. showed: -Wall next to the three-bay sink had been spackled but not painted; -Paint on the ceiling next to a vent was peeling in a 3x5 inch area; -Floor next to the ice machine has white stains, brown buildup, crumbs and debris on the floor. -Dark brown spatter on the ceiling in front of the ice machine near sprinkler; -Dirty and dusty ceiling around vent outside the pantry door; -Dirty and dusty vent next to sprinkler outside the kitchen office door. During an interview on [DATE] at 3:53 P.M., Dietary Aid A said: -Floors around equipment should be clean and free of debris; -Kitchen ceiling and vents should be clean and free of dust. During an interview on [DATE] at 8:32 A.M., the Dietary Manager said: -Floors around equipment should be clean and free of debris. -Kitchen ceiling should be clean, and vents should be clean and free of dust. During an interview on [DATE] at 10:14 A.M., the Dietician said: -Floors around equipment should be clean and free of debris; -He/She expects kitchen ceiling and vents be clean and free of dust. During an interview on [DATE] at 4:15 P.M., the Administrator said: -He/She expects the floors around kitchen equipment to be clean and free of debris. -He/She expects the kitchen ceiling and vents to be clean and free of dust. 6. A policy regarding maintenance of walk-in coolers was requested but not provided. Continuous observation on [DATE] starting at 8:17 A.M. showed: -Water was dripping from walk-in cooler ceiling; -The walk-in cooler floor was wet with a wet towel inside the doorway on the floor. During an interview on [DATE] at 3:53 P.M., Dietary Aid A said: -The walk-in cooler floor should not be wet and have a wet towel on the floor; -The ceiling of the walk-in cooler is leaking. During an interview on [DATE] at 8:32 A.M., the Dietary Manager said the walk-in cooler floor should not be wet and should not have a wet towel on the floor. During an interview on [DATE] at 10:14 A.M., the Dietician said the walk-in refrigerator floor should not be wet and should not have a wet towel on the floor. During an interview on [DATE] at 4:15 P.M., the Administrator said the walk-in refrigerator floor should not be wet and have a wet towel on the floor.

Based on observations, interviews, and record review the facility failed to ensure staff cared for residents in a dignified and professional manner when they ignored a resident's request for medical help and were seen vaping (inhaling aerosol vapor containing tobacco, through a battery operated device) while in the resident's room (Resident #11), provided care for two residents (Resident #15, #22) in a public common area in view of others, served room meal trays to residents on Styrofoam and with plastic utensils for meals and additionally failed to serve all residents who sat at the same dining room table before serving other tables. This affected five of the 12 sampled residents. The facility census was 27. The facility did not provide a residents rights policy. Review of the facility's undated Professionalism policy showed: - Staff are to respect resident requests, if concerned about a request ask the charge nurse first; - Do not tell residents what to do, if staff have suggestions, inform the charge nurse; - Treat residents how you would want to be treated; Review of the facility's Resident Smoking policy, undated, showed smoking restrictions shall be strictly enforced in all nonsmoking areas; 1. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/2/24, showed: - Severely impaired cognitive skills; - Total assist for all Activities of Daily Living; Mobility, Transfers and Hygiene - Diagnosis: Anemia, hypertension (high blood pressure), diabetes (chronic disease when body can't produce insulin), seizure disorder, schizophrenia (mental disorder with a disruption in thought processes), PTSD (mental health condition from witnessing a traumatic event); Review of the facility's self report complaint, dated 1/24/25 showed: - the resident filed a grievance regarding staff rudeness and vaping in the resident's room; Review of facility's investigation report, dated, 1/29/25, showed: - The resident has a Brief Interview for Mental Status (BIMS) score of 12 which indicates a moderate cognitive impairment; - The resident was mentally distraught and had triggers that caused him/her to get upset fast; - The resident said in his/her statement that NA (C) made me cry, gave me a dirty look, and was vaping in his/her room; - NA (C) said in his/her statement that the resident requested that he/she look at his/her urine and staff member refused and then redirected resident back to their bed. NA (C) then went back to the nurse's station and asked LPN (A) if they needed to look at the urine and they were told no; - NA (C) was suspended and written up for unprofessional behavior and vaping in the building; During a phone interview on 2/25/25 at 1:50 P.M., NA (C) said: - He/she answered resident's call light and helped them to the bathroom. Resident asked them to look at the urine but he/she refused and told the resident to flush the toilet and then had to re-direct resident out of the hall and to their bed since it was late at night; - The next day NA (C) was informed by MDS/CP Coordinator that resident was on a new medication that causes them to pace and that's why the resident was wandering to the hallway; - NA (C) admitted that they had their vaping pen in their hand at the time of cares in the resident's room; During an interview on 2/26/25 at 8:30 A.M., the Resident said: - NA(C) was rude and in his /her opinion, yelled at him/her and that NA C was also vaping in the room; - He/she felt hurt that NA (C) would be mean towards him/her and didn't like the staff member vaping in the his/her room; During an interview on 2/26/25 at 9:00 A.M., The Administrator said: - NA (C) was suspended due to vaping in the building and in the resident's room and additionally for unprofessional behavior; - NA (C) can sometimes be gruff with his/her tone; - She provided face to face training with all CNAs and in-service training on 1/30/25 for professional standards; - NA (C) should have spoken to the charge nurse about looking at the urine and attempt to alleviate the resident's anxiousness about the urine color. 31102 2. Review of Resident #15's Quarterly MDS, dated [DATE], showed:- Cognitive skills moderately impaired; - Independent with eating and transfers; - Diagnoses included: Diabetes mellitus, depression, high blood pressure, schizophrenia ( a serious mental illness that affects how a person thinks, feels, and behaves) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's POS, dated 1/25/25 - 2/25/25, showed: - Start date: 3/5/24 - Check and record blood sugar daily; - Start date: 7/22/24 - Humulin R (short acting) insulin per sliding scale. The order did not indicate how often it was to be administered; - Start date: 6/19/24 - Trelegy Ellipta 100-62.5 - 5-25 micrograms (mcg.), inhale one puff daily and rinse mouth after use for COPD. Review of the resident's Nurse medication administration record (MAR) dated February 2025, showed: - Check and record blood sugar daily; - Trelegy Ellipta 100-62.5 - 5-25 mcg., inhale one puff daily and rinse mouth after use for COPD. Observation in the day room, on 2/25/25 at 4:58 P.M., showed; - The resident sat in a chair in the day room with five other residents present; - At 5:00 P.M., Registered Nurse (RN) A obtained the resident's blood sugar while he/she sat in the day room; - At 5:03 P.M., the resident pulled up his/her shirt and exposed his/her abdomen and RN A administered the insulin in the resident's abdomen. Observation in the day room on, 2/26/25 at 6:48 A.M., showed: - The resident sat in the day room at the table with other residents in the day room; - CMT A gave the resident his/her Trelegy Ellipta inhaler and instructed the resident to blow out, place the inhaler in his/her mouth and inhale; - CMT A had the resident rinse his/her mouth with water afterwards and spit into a cup. During an interview on 2/26/25 at 11:17 A.M., CMT A said staff should not administer inhalers in the day room and should do it in the resident's room. 3. Review of Resident #22's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Independent with eating dressing, personal hygiene and transfers; - Diagnoses included psychotic disorder ( a mental illness that causes a person to lose touch with reality), COPD and diabetes mellitus. Review of the resident's POS, dated 1/25/25 - 2/25/25 showed an order dated 8/27/23 for Novolog (fast acting) Flexpen insulin per sliding scale three times a day for diabetes mellitus. Review of the Nurse MAR, dated February 2025. showed the Novolog insulin per sliding scale was not addressed on the MAR. Observation in the day room, on 2/25/25 at 5:06 P.M., showed;- The resident sat at the table in the day room; - At 5:11 P.M., RN A obtained the resident's blood sugar; - At 5:12 P.M., the resident pulled up his shirt and exposed his/her abdomen and RN A administered the insulin in the resident's abdomen. During a interview on 3/6/25 at 1:48 P.M., RN A said nursing staff should not obtain blood sugars, administer insulin or inhalers in the day room, it should be administered in private area. During an interview on 2/27/25 at 4:15 P.M., the DON said;- Staff should not obtain blood sugars, or administer insulin and inhalers in the day room; - It should be done privately. 51166 4. Review of Resident #9's Admission MDS assessment, dated 2/16/25, showed: -Resident is cognitively intact; -Independent with walking and eating; -Requires set up and clean up assistance with meals; -Diagnoses included: Depression, lung disease and, high blood pressure. Review of Resident #2's Quarterly MDS, dated [DATE], showed: -Resident is cognitively intact; -Requires walker or wheelchair; -Independent with eating and wheeling; -Diagnoses included: heart disease, kidney disease, diabetes, dementia, anxiety, and depression. Observation on 2/24/25 at 11:37 A.M., showed Residents meal trays were passed to several tables before serving all residents at the same table. During resident council meeting on 2/25/25 at 9:15 A.M., Resident #9 said: -Residents should be treated equally; -He/She did not understand why they were usually served last; -The food was cold when they were served last. During the resident council meeting on 2/25/25 at 9:15 A.M., Resident #2 said: -Residents sit in the same places in the dining room for every meal; -Residents at the same table were not served at the same time; -Diabetic residents were served first because they receive their insulin shots. During an interview on 2/26/25 at 3:06 P.M., RN B said Residents sitting at the same table should not be served their meal at the same time because the diabetic residents needed to be served first and the diabetic residents don't sit together at the same table. During an interview on 2/27/25 at 4:15 P.M., the DON said Residents that sit at the same table should be served meals at the same time. 5. Observation on 2/26/25 at 11:26 A.M. showed staff served residents lunch on Styrofoam (disposable) plates with plastic utensils. During an interview on 2/26/25 11:26 A.M., [NAME] A said Styrofoam plates and cups and plastic utensils are used for the residents that eat in their room because the dishes and silverware do not get returned to the kitchen. During an interview on 2/26/25 at 3:53 P.M., Dietary Aid A said: -Residents should be served on regular dishware and utensils rather than disposable plates and plastic utensils; -Residents have thrown dishes away in the past; -It is faster and easier to use disposable plates and plastic utensils. During an interview on 2/27/25 at 10:14 A.M., the Dietician said staff should serve residents meals on regular dishware instead of disposable plates. During on interview on 2/27/25 at 4:15 P.M., the Administrator said the resident meals should be served on regular dinnerware, rather than disposable plates. MO00248511

Based on observation, interview, and record review, the facility failed to promote an environment respectful of the rights of each resident to make choices about significant aspects of their lives when staff did not respond to shower preferences for two of the 12 sampled residents, (Resident #2 and Resident #3) and when staff failed to assist Resident #3 to shave per his/her preference. The facility census was 27. The facility did not provide a policy regarding showers or shaving. 1. Review of Resident #3's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/20/24 showed:- Cognitive skills intact; - Independent with showers, dressing, personal hygiene and transfers; - Always continent of bowel and bladder; - Diagnoses included anxiety and schizophrenia ( a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, revised 1/28/25 showed: - The resident preferred to take showers at night. He/she did not want other residents interrupting him/her; - The staff would ensure the resident had privacy and would not be disturbed during showers and self care. Observation and interview on 2/24/25 showed: - The resident said he/she was normally clean shaven; - It bothered him/her to have long facial hairs on his/her face and it made him/her feel unkempt. During an interview on 2/26/25 at 11:43 A.M., Certified Medication Technician (CMT) A said: - The resident is very specific about who he/she allows to shave him/her; - CMT A has never seen the resident clean shaven, but normally the beard is clean, short and tidy. During an interview on 2/27/25, at 4:15 P.M., the Director of Nursing (DON) and the Administrator said: - The DON said the aides will ask the residents if they want to be shaved; - The Administrator said the shift aides are primarily responsible to ask residents and they are to shave residents if the residents ask. Some residents are particular with which staff member they will let shave them. 51166 2. Review of Resident #2's Quarterly MDS, dated [DATE], showed: -Resident is cognitively intact; -Requires walker or wheelchair; -Requires supervision or touching assistance for showers; -Diagnoses included: heart disease, kidney disease, diabetes, dementia, anxiety, and depression During an interview on 2/24/25 at 10:30 A.M., Resident #2 said: -When the shower room is too cold, he/she can't shower because it is painful; -He/She hasn't showered in over a week and had been trying to get a shower today; -He/She smells and doesn't want to see other people because he/she stinks; -It is humiliating to not have a shower; -He/She did not eat in the dining room on 2/24/25 because it would gross people out. During an interview on 2/25/25 at 4:47 P.M., Resident #2 said he/she did not get his/her requested shower today. During an interview on 2/26/25 at 3:10 P.M., CMT A said residents should be able to receive a shower any day they want. During an interview on 2/27/25 at 4:15 P.M., the DON said residents should be able to receive a shower whenever they want, even daily.

Based on interview and record review the facility staff failed to ensure residents (Resident #1, #4, #6, #15) had timely access to their personal funds on the weekend. This affected four of the 12 sampled residents. The facility census was 27. Review of facility policy Guidelines for Maintaining the Resident Trust Fund Account, revised, 8/20/19, showed: - The resident and/or legal representative, upon request will have reasonable access to the resident's personal funds during normal business office hours; - If funds are requested for weekend use, funds should be requested during normal business hours on Friday or if outside normal business/banking hours, facility staff may contact a member of facility management for access; 1. Review of Resident #1's Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/2/24, showed: - Cognition Intact-(understands and makes all needs known) - Diagnosis: hypertension (high blood pressure), diabetes (chronic disease when body can't produce insulin), Parkinson's disease (progressive neurological disorder; . During an interview on 2/24/25 at 10:13 A.M., the resident said the facility holds money for him/her but he/she is unable to get money on Saturdays. He/she has to request money during the week or he/she can't get it on the weekends; 2. Review of Resident #4's Quarterly MDS, dated [DATE], showed diagnoses of hypertension (high blood pressure), anxiety disorder, schizophrenia (chronic mental illness that disrupts thought processes); During an interview on 2/24/25 at 1:37 P.M., resident said he/she can not get money on the weekends; 3. Review of Resident #6's Quarterly MDS, dated [DATE], showed: - Cognition Intact; - Diagnosis: hypertension (high blood pressure), hyperlipidemia (high cholesterol), dementia (decline in cognitive abilities), anxiety disorder, depression, schizophrenia (chronic mental illness that disrupts thought processes); During an interview on 2/24/25 at 2:10 P.M, resident said he/she gets frustrated sometimes that he/she can's get his/her personal funds on Saturdays; 4. Review of Resident #15's Quarterly MDS, dated [DATE], showed: - Cognition Intact: - Diagnosis: hypertension (high blood pressure), diabetes (chronic disease when body can't produce insulin), depression, schizophrenia (chronic mental illness that disrupts thought processes); During an interview on 1:21 P.M., resident said he/she cannot get money on the weekends but he/she would like to have access to his/her money on the weekends so he/she does not have to worry about forgetting about it during the week; During a group interview on 2/25/25 at 9:15 A.M., with nine residents, five of the nine residents said they cannot access their money on the weekends and they have to request it during the week if they want their funds; During an interview on 2/25/25 at 2:04 P.M., The BOM (Business office Manager) said: - The petty cash is kept in a safe in a closet and she and the Administrator are the only ones who have access to the safe; - Residents cannot get funds on the weekends because there is no one available at the facility to access the funds, residents need to request funds Monday through Friday; During an interview on 2/27/25 at 4:15 P.M., The Administrator said staff ask the residents on Fridays if they need funds for the weekend but residents should be able to get their money on weekends.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain comfortable temperatures in the shower room, fill, sand, and paint drywall patches, maintain facility furniture in good repair, ensure all call lights were functional, flooring was clean and in good repair and replace wallpaper as needed. This affected all residents in the facility. The facility census was 27. A policy regarding Maintenance and Upkeep of Facility was requested but provided. Review of the Maintenance Work Log at the nurses' station showed: - A binder containing repair requests entered in by staff for the maintenance department to complete; - Entry: room [ROOM NUMBER] hole in wall needs filled, marked down as fixed; - Entry: Shower room drain won't go down (not fixed) 2/18/25; Observation on 2/24/25 showed: - 10:17 AM room [ROOM NUMBER] misaligned coat cabinet near door misaligned will not shut properly, door needs repainting in several places front and back. Call light string in bathroom is cut and only two inches long and unreachable from the floor. Large gouging behind chair on wall; - 10:42 A.M. room [ROOM NUMBER] has peeling paint on back of door; - 10:56 AM room [ROOM NUMBER] floors are very sticky, paint coming off the walls, drawers are misaligned (one drawer opens two drawers due to alignment), floor laminate coming up at entrance to room; Observation on 2/25/25 showed: - 8:55 A.M. room [ROOM NUMBER] bathroom door has wood peeling off toward the bottom and paint is chipped; - 11:02 A.M. Residents eating meals on Styrofoam containers and cups; Observation on 2/26/25 showed: - 8:08 A.M. room [ROOM NUMBER] wallpaper coming apart from wall, surface damage to front and back of door; - room [ROOM NUMBER] Bathroom door has damage needs painting, cabinet laminate is coming off of wood in several locations on dresser drawer; - room [ROOM NUMBER] paint coming off of walls severely in several areas; - 100 Hallway, outside room [ROOM NUMBER] wall has missing paint; - room [ROOM NUMBER] has large missing paint spots, broken laminate at corner entrance of door, wall molding at bottom of wall near back of room and on side of room is coming away from wall; - room [ROOM NUMBER] light cord string broken off for wall light, about six inches in length; - room [ROOM NUMBER] no call light string attached to call light in bathroom; - room [ROOM NUMBER] large patch needs painting on back wall near left side of heater; - 200 Hallway missing chunk of paint out of wall; - Liquid stains on wall outside room [ROOM NUMBER]; - room [ROOM NUMBER] rust stains on tiles along entire back wall floor; - room [ROOM NUMBER] bathroom door missing paint; - TV lounge at nurses' station corner wall entering lounge has damage to wall, missing some plaster and paint, has plastic coming off at the base of wall; - room [ROOM NUMBER] broken wooden board in front of sink basin; - 9:05 A.M. chairs next to salon door have peeling and cracked vinyl seats; - 2:41 P.M. chair outside shower room has vinyl cracking with multiple cracks; - 5:55 P.M. ceiling vent near thermostat coated with dust; During an observation on 2/26/25 at 7:30 A.M. of the shower room showed the room temperature measured at 68 degrees Fahrenheit (taken with infrared thermometer). During an observation on 2/27/25 at 8:49 A.M. the shower room showed the room temperature measured at 65.7 degrees Fahrenheit (taken with infrared thermometer). During an interview on 2/25/25 at 9:15 A.M., members of the resident council said: - One resident said the shower is dirty; - Five of five residents said the shower room is too cold. When the local area got to be zero degrees outside the shower room was unbearable; - Two of five residents said the cold shower room makes their arthritis hurt - Four of five residents said they have missed showers due to the cold temperatures; - During an interview on 2/26/25 at 9:00 A.M., HSK (A) said housekeeping deep cleans every day which includes washing the walls if there are stains, removing black marks on doors and cleaning windows; During an interview on 2/26/25 at 10:45 A.M., Maintenance Supervisor said: - He is trying to catch up on all the work required at the facility, currently working on room [ROOM NUMBER], patched a hole in the room, next step is to get painted and there are a couple of spot on the ceiling that need work; - Not sure if anyone in the facility inspects the rooms, he just repairs them whenever someone tells him there's a requirement; - Has a book at the nurses station which staff can enter in work requests; - There is a small heater in the shower room that can be turned on for 15 minutes at a time when it is operated manually inside the shower; During an interview on 2/26/25 at 11:52 A.M., CMT (A) said: - He/she is only aware of one resident who has turned down showers due to it being too cold in the shower room during the recent cold spell in the area. - Interventions are to make sure the heater in the room was turned on prior to a resident taking a shower first thing in the morning. The heater will stay on for 15 minutes and then has to be re-energized again by staff. No temperatures are taken before residents take a shower and he/she does not know of any required temperatures for the showers; During an interview on 2/27/25 at 4:15 P.M., Administrator said: - The temperature should be no less than 68 degrees (F) in the shower room; - Vinyl on chairs should not be torn or cracked; - Floors in resident rooms should not have large rust stains or be coming up from the base; - Laminate should not be coming off of furniture; - All furniture drawers should operate properly; - Walls and doors should be painted after sustaining damage over time.

Based on observation, interview and record review, the facility failed to ensure staff developed and updated a care plan consistent with resident's specific conditions and needs which affected two of the 12 sampled residents, (Resident #11, #26). The facility census was 27. A policy regarding care plans was requested but not provided. 1. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/2/24, showed: - Cognition severely impaired; - Total assist of all Activities of Daily Living; Mobility, Transfers and Hygiene - Diagnosis: Anemia, hypertension (high blood pressure), diabetes, seizure disorder, schizophrenia (mental disorder with a disruption in thought processes), Post Traumatic Stress Disorder (PTSD) (mental health condition from witnessing a traumatic event); Review of the resident's care plan revised, 2/12/2025, showed: - Resident diagnosed with PTSD. - No identified triggers are listed and no interventions for staff to avoid or address when behaviors occur; Review of Behavioral Triggers document, undated, shows: - A behavioral trigger is any stimulus, situation, or action that prompts or initiates a specific behavior, often leading to an emotional response; - Resident #11 lists police, trains, rope, suicide, and loud noises as triggers; Observation on 2/25/25 in the dining room showed: - 6:00 P.M. Resident is eating in the dining room near the side wall; - 6:05 P.M. Paramedics enter from the other side of the dining room and start talking with the Administrator. Resident stopped eating and immediately went to the ground and started screaming when he/she saw the paramedics enter the room; - Nursing staff and the Administrator try to calm resident and do a health assessment on him/her; - 6:06 P.M. Paramedics leave the dining room and resident is still shaking and upset on the ground; - 6:23 P.M. Four police officers arrive at the facility and are speaking to the Administrator. The resident is now calmed down and still sitting in the dining room eating; - 6:27 P.M. Resident got visibly upset when a police officer entered the dining room and he/she screams Oh my god! That's right. My mom got raped with a knife. Resident is screaming and staff run over to him/her to calm them and then walked resident out of the dining room; -6:30 P.M. The facility did not remove the resident from the area were police and EMS were present, causing the resident to show extreme verbal behaviors. During an interview on 2/26/25 at 8:35 A.M., Resident #11 said: - He/she was very upset last night. The people in uniforms really upset him/her and he/she didn't know what to do; - Loud noises also make him/her upset though they realize that the noise may not be that loud to others but it is to them; During an interview on 2/26/25 at 2:35 P.M., RN (B) said: - No one at the facility has a diagnosis of PTSD; - If someone did have PTSD their triggers would be listed in the 802 Matrix (a list of serious conditions and controlled medications identified for each resident); - Could not recall having any specific training for PTSD; During an interview on 2/26/25 at 3:05 P.M., MDS-Care Plan Coordinator said: - PTSD should be documented in the resident's care plan along with identified triggers; - Interviews with the resident and the guardian are conducted to identify triggers for each resident and this occurs within the first two weeks of admission to the facility and is an ongoing process; - Resident #11 does not meet the definition of PTSD according to their psychological provider; - Resident #11 will normally be cooperative when police are present and immediately calm down if upset; During an interview on 2/27/25 at 4:00 P.M., the Administrator said PTSD and the resident's known triggers should be documented in the care plan for each resident; 31102 2. Review of Resident #26's Physician Order Sheet (POS) dated, 1/25/25 - 2/25/25 showed: - Start date: 2/16/25 - Bactrim DS 800-160 milligrams (mgs.) daily on Mondays, Wednesdays, and Fridays for systemic involvement of connective tissue (a term for a group of autoimmune diseases that cause inflammation of connective tissues throughout the body); - Start date: 2/11/25 - Code status: full code. Review of the resident's electronic chart showed: - admitted : 2/11/25; - The baseline care plan did not address the resident's code status. Review of the resident's Admission MDS, dated [DATE], showed: - Short term and long term memory problems; - Required set up and clean up for eating, oral care and personal hygiene; - Diagnoses included high blood pressure, anxiety and diabetes mellitus. Review of the resident's care plan, revised 2/25/25, showed the plan did not address the use of antibiotics. During an interview on 2/25/25 at 3:08 P.M., the MDS/Care Plan Coordinator said: - The baseline care plans are completed by the charge nurse (CN) and within 14 days, he/she tried to have an actual care plan completed; - He/she reviewed the baseline care plan and it did not indicate what the resident's code status should be; - He/she would expect the code status to be on the baseline care plan so everyone would know the resident's code status; - If a resident was on an antibiotic prophylactically (to prevent disease or infection, or to guard against), then it should be care planned. During an interview on 2/27/25 at 4:15 P.M., the DON said the baseline care plan should address the resident's code status and if a resident was taking an antibiotic prophylactically, then it should be care planned. During a telephone interview on 3/6/25 at 1:48 P.M., Registered Nurse (RN) A said he/she would expect to see a resident's code status and use of antibiotics on the care plan.

Based on observation, interview, and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to have medications available for two of the 12 sampled residents, (Resident #6, #15) and failed to clarify a sliding scale insulin order for Resident #15. The facility census was 27. The facility did not provide a policy for ordering medications. 1. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/15/24, showed: - Cognitive skills moderately impaired; - Independent with eating and transfers; - Diagnoses included diabetes mellitus, depression, high blood pressure, Schizophrenia ( a serious mental illness that affects how a person thinks, feels, and behaves) and Chronic Obstructive Pulmonary Disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's Physician Order Sheet (POS) dated 1/25/25 - 2/25/25 showed: - Start date: 3/1/24 - Myrbetriq tablet, extended release, 25 milligram (mg.) daily for overactive bladder; - Start date: 10/19/24 - Jardiance tablet 25 mg., one tab daily for Schizophrenia; - Start date: 7/22/24 - Humulin R regular (short acting) insulin per sliding scale. Does not indicate how often it is to be administered. Review of the resident's Medication Administration Record (MAR), dated February 2025, showed: - Jardiance tablet 25 mg., one tab daily for Schizophrenia. On 2/26/25 Certified Medication Technician (CMT) A initialed in the box and circled it; - Myrbetriq tablet, extended release, 25 mg. daily for overactive bladder. On 2/26/25 CMT A initialed in the box and circled it; - On the Nurse's medication notes, CMT A documented the resident was out of the Jardiance and the Myrbetriq and the Charge Nurse (CN) was notified; - Humulin R regular insulin per sliding scale. Does not indicate how often it is to be administered. 2. Review of Resident #6's Quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Independent with eating and transfers; - Diagnoses included Congestive Heart Failure (CHF, an accumulation of fluid in the lungs and other areas of the body), dementia (inability to think), anxiety, depression, bipolar (a mental illness that involves extreme mood swings, or shifts in energy, thinking and behavior) and Schizophrenia. Review of the resident's POS, dated 1/26/25 - 2/26/25, showed: - Start date: 11/10/22 - Eliquis 5 mg. twice daily for atrial fibrillation ( A-fib, a condition where the upper chambers of the heart (atria) beat irregularly and rapidly). Review of the resident's MAR, dated February, 2025 showed: - Eliquis 5 mg. twice daily for atrial fibrillation (A-fib.); - On 2/26/25 CMT A initialed in the box and circled it; - On the Nurse's medication notes, CMT A documented the resident was out of the Eliquis and the CN was notified. During an interview on 2/26/25 at 11:17 A.M., CMT A said: - The residents should have their medications available but the local pharmacy only fills certain medications, like Jardiance, Myrbetriq and Eliquis (blood thinner), for 14 days; - The facility is in the process of switching pharmacies; - On the MAR if he/she initialed the box and circled it, either the resident had refused the medication or it was not available. Staff should fill out an entry on the back of the MAR to indicate why the medication was not administered. During a telephone interview on 3/6/25 at 1:48 P.M., Registered Nurse (RN) A said the order for the sliding scale insulin should indicate how often it was to be administered. During an interview on 2/27/25 at 4:15 P.M., the Director of Nursing (DON) and the Administrator said: - The DON was just made aware that the pharmacy only filled Eliquis, Myrbetriq and Jardiance for 14 days and the residents have been running out of them; - The Administrator said they are going to be switching pharmacies; - The DON said there should be an order to indicate how often sliding scale insulin should be administered.

Based on observation, interview, and record review, the facility failed to ensure the residents had fresh water at bedside that was easily accessible to the residents. This affected three of the 12 sampled residents, (Resident #15, #22 and #26). The facility census was 27. Review of the facility's undated policy titled, Hydration, showed staff were directed to do the following: - Each resident is supplied with sufficient fluid intake to maintain proper hydration; - Fresh water is distributed each shift, pitchers and glasses are within reach of the resident and residents who are unable to pour and drink independently will be given assistance by the staff. 1. Review of Resident #15's care plan, revised 11/30/24 showed;- The resident had a diagnosis of constipation; - Will follow diet as ordered by the primary care physician; - Will maintain adequate hydration daily. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/15/24, showed: - Cognitive skills moderately impaired; - Independent with eating and transfers; - Diagnoses included diabetes mellitus, depression, high blood pressure, schizophrenia ( a serious mental illness that affects how a person thinks, feels, and behaves) and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's Physician Order Sheet (POS), dated 1/25/25 - 2/25/25 showed no diet order. Observation and interview with the resident on 2/24/25 at 1:28 P.M., showed; - The resident's water pitcher was almost empty and did not have any ice in it; - The staff do not always pass fresh ice water to him/her; - He/she feels like the staff forget about him/her; - He/she would like to have fresh ice water. 2. Review of Resident #22's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Independent with eating dressing, personal hygiene and transfers; - Diagnoses included psychotic disorder ( a mental illness that causes a person to lose touch with reality), COPD and diabetes mellitus. Review of the resident's POS, dated 1/25/25 - 2/25/25, showed an order dated 11/22/24 to start Level 7 diet (easy to chew diet that consists of soft and tender foods), reduced concentrated sweets. Review of the resident's care plan, revised 1/28/25, showed;- The resident was on a therapeutic diet related to diabetes mellitus; - The resident had difficulty chewing some foods and needed a mechanical soft diet. Observation and resident interview on 2/24/25 at 1:39 P.M., showed; - The resident's water pitcher was half full and did not have any ice in it;- The staff bring a clean cup with ice in it around 3:30 A.M., but by the time he/she woke up, it was melted; - If he/she wanted fresh ice water, then he/she would have to get up and get him/herself; - It would be nice if the staff would pass fresh ice water each shift. 3. Review of Resident #26's Admission MDS, dated [DATE], showed: - Short term and long term memory problems; - Lower extremity impaired on one side; - Required supervision or touch assistance with transfers; - Required set up and clean up for eating, oral care and personal hygiene; - Diagnoses included high blood pressure, anxiety and diabetes mellitus. Review of the resident's care plan, revised 2/24/25, showed the resident was on a low sodium, low cholesterol, low fat diet. Review of the resident's POS dated 1/25/25 - 2/25/25, showed an order with a start date of 2/20/25 for a low fat, low cholesterol, low sodium, diet. Observation and interview on 2/24/25 at 10:12 A.M., showed: - The resident's was almost empty and did not have any ice in it; - The resident said the staff do not always pass fresh ice water and he/she would like to have it each shift. During an interview on 2/26/25 at 11:17 A.M., Certified Medication Technician (CMT) A said: - The night shift passes fresh ice water; - He/she was not for sure when the day shift passed fresh ice water. During an interview on 2/26/25 at 10:27 A.M., Registered Nurse (RN) B said: - The day shift did not actually pass fresh ice water; - If a resident asked for fresh ice water, the staff would get it for them. During an interview on 2/27/25 at 8:54 A.M., Nurse Aide (NA) B said the staff were supposed to pass fresh ice water every shift. During an interview on 2/27/25 at 4:15 P.M., the Director of Nursing (DON) said the staff should pass fresh ice water on each shift. During an interview on 3/6/25 at 1:48 P.M., RN A said: - The day shift do not pass fresh ice water often enough; - The night shift passes fresh ice water, but it's hit or miss on the day shift; - He/she thought it was supposed to be passed three times a day; - They have several residents who will ask for fresh ice water during the day.

Based on observation, interview, and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made five medication errors out of 26 opportunities for error which resulted in a medication error rate of 19.23%, which affected four of the 12 sampled residents, ( Resident #2, #22, #15 and #9). The facility census was 27. Review of the facility's undated policy titled, Medication, Administration Guidelines, showed staff were directed to do the following: - It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; - Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident; - The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the information. Review of the facility's undated policy titled, Instillation of eye medication, showed staff were directed to do the following: - Tilt resident's head backward, draw down lower lid. Have resident look up; - To prevent dropper tip from touching eye or lids, nurse should support hand on resident's forehead or bridge of nose; - Introduce drop on center of lower lid; - Instruct resident to close eye; - Gently press tissue against the inner corner of the eye close to the nose for one minute. 1. Review of Resident #2's Physician Order sheet (POS) dated 1/25/25 - 2/25/25., showed: - Start date:1/22/25 - Cyclosporine 0.05% one drop in both eyes twice daily for dry eyes. Review of the resident's medication administration record (MAR), dated February, 2025, showed to apply Cyclosporine 0.05%, one drop in both eyes twice daily for dry eyes. Observation on 2/25/25 at 9:36 A.M., showed: - Certified Medication Technician (CMT) A instilled two drops in the left eye and applied lacrimal pressure for six seconds; - CMT A instilled one drop in the right eye and applied lacrimal pressure for five seconds. 2. Review of Resident #9's POS, dated 1/26/25 - 2/26/25 showed: - Start date: 2/24/25 - Brimonidine 0.2% eye drops, one drop in both eyes twice daily for blindness in both eyes. Review of the resident's MAR (Medication Administration Record), dated February, 2025 showed: - Brimonidine 0.2% eye drops, one drop in both eyes twice daily for blindness in both eyes. Observation on 2/26/25 at 6:54 A.M., showed:- CMT A instilled one drop in the resident's right eye and CMT A applied lacrimal pressure for 19 seconds; - CMT A instilled one drop in the resident's left eye and CMT A applied lacrimal pressure for 20 seconds. During an interview on 2/26/25 at 11:17 A.M., CMT A said: - If the physician's order said for one drop, then he/she should have administered one drop; - He/she thought lacrimal pressure should be applied for 30 seconds up to one minute. During an interview on 2/27/25 at 4:15 P.M., the Director of Nursing (DON) said: - Staff should apply lacrimal pressure for one minute; - Staff should only administer one drop if that's what the physician ordered. 3. The facility did not provide a policy for how soon a resident should have a meal after receiving Novolog (fast-acting) insulin. Review of the website, https://novologpro.com for Novolog insulin showed:-Eat a meal within five to tem minutes after using Novolog, a fast-acting insulin, to avoid low blood sugar. Review of Resident #22's POS, dated 1/25/25 - 2/25/25, showed: - Start date: 8/27/23 - Novolog Flexpen insulin per sliding scale three times a day for diabetes mellitus; - For blood sugar of 163, give four units of Novolog insulin (150-199- give four units). Review of the resident's MAR, dated February 2025, showed: - It did not have Novolog insulin on the MAR. Observation on 2/25/25 at 5:11 P.M., showed: - Registered Nurse (RN) A obtained the resident's blood sugar, which was 163; - At 5:12 P.M., RN A administered four units of insulin; - At 5:42 P.M., the resident sat in the dining room and received his/her dinner and started eating. During an interview on 3/6/25 at 1:48 P.M., RN A said residents should have a meal within 15 minutes of receiving a fast-acting insulin. 4. Review of the resident's Medication Administration Record (MAR), dated February 2025, showed: - Jardiance tablet 25 mg., one tab daily for Schizophrenia. On 2/26/25 Certified Medication Technician (CMT) A initialed in the box and circled it; - Myrbetriq tablet, extended release, 25 mg. daily for overactive bladder. On 2/26/25 CMT A initialed in the box and circled it; - On the Nurse's medication notes, CMT A documented the resident was out of the Jardiance and the Myrbetriq and the Charge Nurse (CN) was notified. During an interview on 2/26/25 at 11:17 A.M., CMT A said: - The residents should have their medications available but the local pharmacy only fills certain medications, like Jardiance, Myrbetriq and Eliquis (blood thinner), for 14 days; - The facility is in the process of switching pharmacies; - On the MAR if he/she initialed the box and circled it, either the resident had refused the medication or it was not available. Staff should fill out an entry on the back of the MAR to indicate why the medication was not administered. During an interview on 2/27/25 at 4:15 P.M., the Director of Nursing (DON) and the Administrator said: - The DON was just made aware that the pharmacy only filled Eliquis, Myrbetriq and Jardiance for 14 days and the residents have been running out of them; - The Administrator said they are going to be switching pharmacies.

Based on observation and interview, the facility staff failed to ensure they provided a reasonable accommodation of needs when they made residents, some with potential gait instabilities, from entering a dark restroom connected to their room and having to cross the whole restroom to flip the light switch to get the light to illuminate. This affected 11 of 30 rooms. The faciltiy census was 27. 1. Observation on 2/5/25 stating at 2:36 P.M., showed the the restrooms between rooms 201/203, 202/204, 205/207, 206/208, 209, and 210/212 had a shared restroom. Both sides had a light switch. The light switch was located just inside the restroom on the interior wall on both sides. To get to the other light switch the resident would need to pass by the sink, toilet, and get to the other wall with the light switch. If the light was on, both light switches could turn off the light, but if the light were off, only one switch could turn on the light. If the light switch on the side of the resident did not turn on the light, they would need to traverse through the restroom to get to the other side to turn on the light. During an interview on 2/5/25 at 2:36 P.M., Resident #480 said the only one light switch would turn on the light. At night one would need to pass to the other side of the restroom to turn on the light. He/she wished they would fix it. During an interview on 2/25/25 at 2:30 P.M., the Maintenance Supervisor said the lights had been wired that only one light switch would turn on the light in the shared restrooms on the 200 hall. He was not sure why they were wired that way.

Based on observation, interview, and record review, the facility failed to discard expired medications, and biologicals stored within the medication room and the medication cart, failed to date an opened vial of Influenza vaccine, and failed to ensure resident's cigarettes and personal money was not stored in the medication cart. This had the potential to affect all residents within the facility. The facility census was 27. Review of the facility's undated policy titled, Medication Administration Guidelines, showed: - It is the purpose of this facility that residents receive their medications on a timely basis and in accordance with established policies; - Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident; - The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container, verifying it with the physician's orders. giving the individual dose to the proper resident, and promptly recording the information; - The same person preparing the doses for administration must administer the medications; - Medications may not be prepared in advance and must be administered within one hour of preparation. Review of the facility's undated policy titled, Labeling Drugs and Medications, showed: - All drugs and biologicals must be properly labeled and legible at all times; - Medications in containers having no labels must be destroyed in accordance with the facility procedures governing the destruction of medications. 1. Observation and interview on 2/25/25 at 8:20 A.M., of the medication room showed: - Two opened 10 milliliters (ml.) bottles of Sterile Water, expired 12/1/24; - Two unopened 10 ml. bottles of Sterile Water, expired 12/1/24; - Resident #10 had an opened bottle of Lorazepam (used to treat anxiety) and did not have a date when it was opened; - Resident #22 had a Symbicort inhaler (used to treat chronic obstructive pulmonary disease, (COPD), an obstruction of air flow that interferes with normal breathing), dated 9/25/23; - A can of house stock burn relief, expired 3/6/24; - A medication cup with five ml. of powder in it, and did not have a date or labeled; - A packaged of tactical electrolyte drink mix, expired 12/24; - An opened vial of tuberculin (TB) purified protein derivative (Mantoux), dated 12/10/25. The label on the box said to discard 30 days after opening; - Registered Nurse (RN) A said everything should be dated when opened; - An opened vial of Influenza vaccine, did not have a date when it was opened; - Inside the medication refrigerator there was a yellow and brown dried substance inside the door. The freezer had an excess of ice; - An opened chocolate health shake in the medication refrigerator did not have an expiration date on it. RN A said there had been a recall on it and it should not be in the medication refrigerator; - Resident #79 had an opened bottle of Constulose (used for constipation), expired 2/1/25; - An unopened house stock bottle of Aspirin (used to treat mild pain), expired 8/24; - A Suprep bowel prep kit, expired 5/31/21; - A black box with a pair of hearing aides in them. RN A said he/she was not for sure they belonged to. 2. Observation and interview on 2/25/25 at 9:10 A.M., of the Nurse's medication cart showed: - In the locked box, Resident #8 had an envelope in a zip lock bag and it had $1.01 in it. A piece of paper said there should be $1.42; - A loose dime in the top drawer of the medication cart; - Two paper medication cups stacked on each other had Resident #21's name on the bottom cup and it had 0.72 in it; - Resident #10 had an open envelope and unknown staff wrote $20.00 to order from a local fast food restaurant, the list is inside the envelope of what the resident wants, on the outside of the envelope. There was only 0.11 in the envelope. RN A said the list is long gone; - Resident #11 had an open envelope and the note inside was dated 9/20/24 at 6:00 P.M., used $4.50, remained $11.50. The envelope contained $11.50; - Resident #5 had an open envelope and had $10.00 in it; - Resident #79 had an opened bottle of Morphine Sulfate, (MS, used to treat moderate to severe pain), and did not have a date when it was opened; - In the locked drawer of the medication cart, there was a plastic cup with 1 ml. of clear liquid in the dropper, and a syringe with a little less than 1 ml. of pink liquid in it. A yellow sticky note said, 2/23/25, RN A, just in case you're going to need this. Resident #79 - 1 ml. of Ativan, 1 ml. of MS. It was signed by RN B. That should not have been left in the cart, it should have been destroyed; - There were four different zip lock bags with cigarettes in them and no names on the bags. There was loose tobacco in the drawer of the medication cart. During an interview on 2/25/25 at 9:31 A.M., RN A said: - The expired medications should not be used, they should be destroyed; - Vials should be dated when opened; - Ativan and MS should be dated when opened. Everything should be dated when opened; - Should not have health shakes in the medication refrigerator; - There should not be any money or cigarettes in the medication cart; - The hearing aide should have a resident's name on them; - He/she thought the pharmacy consultant checked the medication room and cart for expired medications; - The nurses try to check for expired medications; - He/she was not for sure who was responsible to clean and defrost the medication refrigerator and freezer. During an interview on 2/26/25 at 6:47 A.M., RN B said he/she should not have left the eye dropper and the syringe with medication in the plastic cup. It should have been discarded. During an interview on 2/27/25 at 4:15 P.M., the Director of Nursing said:- There should not be any expired medication in the medication room or the medication cart, they should be destroyed; - All medications should be dated when opened; - Staff should not have left a syringe and an eye dropper with medication in them, it should have been destroyed; - There should not be any food in the medication refrigerator; - Staff should not store residents' money or cigarettes in the medication cart; - She will start checking the medication room and medication carts monthly for expired medications; - She will be responsible to clean the medication refrigerator and defrost the freezer; - Residents hearing aides should not be left in the medication room.

Based on observation, interview, and record review the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for seven random sampled, newly hired employees, and failed to use proper handwashing in between tasks, and failed to use enhanced barrier precautions during wound care for resident #79, which affected one of twelve sampled residents. The facility census was 27. Review of the facility's undated Tuberculosis (TB) Control policy showed: -Initial examination: Provide a tuberculin skin test to all employees during pre-employment procedures. -If the initial skin-test result is 0-9mm, a second test should be given at least one week and no more than three weeks after the first test. Review of the facility's policy titled, Enhanced Barrier Precautions to Infection Guidance, showed: - To prevent broader transmission of multidrug-resistance organisms (MDRO) and to help protect residents with chronic wounds and indwelling devices; - Enhanced Barrier Precautions (EBP) should be implemented for the period of their stay or until wounds have resolved or indwelling medical devices have been removed; - Who requires EBP: residents with a wound, regardless of their MDRO status; - When to use EBP: Use EBP when providing high - contact resident care activities such as those listed below: transferring residents from one position to another; providing hygiene; changing briefs or assisting with toileting; performing wound care; - Conduct proper hand hygiene before starting care; gloved and donning and doffing of gown are required when conducting high-contact resident care activities that are listed above. Gloves and gown should be removed and discarded after each resident care encounter. Attempt to arrange cares to be grouped together to assist in reducing consumption of supplies where practical; - Residents that are placed on EBP should have personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), in close proximity outside the door and a trash can in resident's room for disposal prior to leaving the room; - Multi-resident medical equipment must be sanitized between resident uses. 1. Observation on 2/27/25 of newly hired employees records., showed: -The facility did not maintain records for new employee TB tests: -Housekeeping Aid B, hire date 6/13/24- TB skin test process was not completed; -CNA B, hire date 7/17/23-TB skin test process was not completed; -Activities Director B, hire date 11/16/23-TB skin test process was not completed; -Maintenance B, hire date 1/8/24 -TB skin test process was not completed; -Transportation Aid A, hire date 9/24/24 -TB skin test process was not completed; -Laundry Aid A, hire date 1/18/25 -TB skin test process was not completed; -LPN B, hire date 2/25/25 -TB skin test process was not completed; During an interview on 2/27/25 at 1:56 P.M., the BOM (Business Office Manager) said the facility policy is to test new employees for TB with a two-step process; During an interview on 2/27/25 at 4:15 P.M., the DON (director of nursing) said TB two-step testing for pre-employment screening should be performed and recorded for prospective employees. During an interview on 2/27/25 at 4:15 P.M., the Administrator said TB two-step testing for pre-employment screening should be performed and recorded for prospective employees. 50980 2. Observation on 2/25/25 at 8:47 A.M., showed Housekeeper (HSK) A cleaned room [ROOM NUMBER] with gloves on while using disinfectant cloth/towel on high contact surfaces and used a mop to clean the floors. HSK then went to room [ROOM NUMBER] with the same gloves on and started to clean that room without changing gloves or performing hand washing; Observation on 2/25/25 at 9:01 A.M., showed the Maintenance Supervisor came from another room and entered room [ROOM NUMBER] to perform work without washing hands. Observation on 2/26/25 7:36 A.M., showed CNA A passing room trays to resident rooms without washing hands between each rooms. CNA A returned from a resident's room after delivering the meal tray and picked up the next food container and drinks and delivered them to a different room without washing hands; During an interview on 2/26/25 at 9:15 A.M, CMT A said Hygiene precautions for Enhanced Barrier Protection (EBP) are to wash hands, apply gloves and then gown prior to entering a resident room. Before leaving room take gown and gloves off and put in biohazard container and then wash hands, then exit room. During cares in the room if your hands get soiled remove the gloves, wash your hands and put on a new pair of gloves; During an interview on 2/26/25 at 10:29 A.M., HSK B said: - He/she has been here for eight months and in the kitchen before moving to housekeeping; - The routine for going into rooms is to put gloves on first, check the trash, grab cleaner, spray around the room and put on a new pair of gloves if they get soiled. He/she doesn't use hand sanitizer each time he/she changes gloves because it dries out their hands; - Training has consisted of one on ones with the Supervisor initially but no follow-on training. There is no scheduled training but when there are issues to address training occurs; 31102 3. Review of Resident #79's Quarterly MDS,(Minimum Data Set), a mandatory assessment completed by facility staff, dated 12/13/24, showed: - Cognitive skills severely impaired; - Lower extremities impaired on both sides; - Required partial to moderate assistance with oral care, personal hygiene and transfers; - Required substantial to maximum assistance with toilet use; - Frequently incontinent of urine; - Occasionally incontinent of bowel; - Diagnoses included psychotic disorder ( a mental illness that causes a person to lose touch with reality), diabetes mellitus and schizophrenia ( a serious mental illness that affects how a person thinks, feels, and behaves). Review of the resident's care plan, revised 1/28/25 showed;- The resident was frequently incontinent of urine. One to two staff assistance with toileting every two hours during waking hours; checked and changed by staff every two hours during the night; - The resident was at risk for pressure ulcers (an area of localized damage to skin and underlying tissue caused by pressure, shear, friction and/or a combination of these), related to limited mobility and need for assistance with transfer and activities of daily living (ADLs); - The resident has a documented wound on the buttock region and was referred to wound care consultants and treatment order received; - The care plan did not address the use of EBP. Review of the resident's Physician Order Sheet (POS), dated 1/26/25 - 2/26/25, showed:- Start of order date: 2/4/25: Apply collagen powder (a supplement that provides the body with collagen, a protein that plays a vital role in various bodily functions), mixed with any barrier cream (used to protect and moisturize the skin) directly to buttocks wound daily and as needed, do not apply a dressing. Review of the resident's Medication Administration Record (MAR), dated February, 2025, directed staff to mix collagen powder with any barrier cream and apply to affected area daily and as needed. Do not apply a dressing. Observation on 2/25/25 at 3:45 P.M., showed: - An isolation medical supply cart beside the resident's door; - Nurse Aide (NA) A and Certified Medication Technician (CMT) A used the mechanical lift and transferred the resident from the Broda chair (reclining geri chair) to the bed and provided incontinent care; - Registered Nurse (RN) A entered the room and provided wound care to the resident's inner gluteal (buttocks) cleft; - NA A, CMT A and RN A used gloves but did not follow the EBP guidelines. During an interview on 2/26/25 at 11;17 A.M., CMT A said since the resident had a wound, he/she should have used the EBP during the peri care and assisting with the wound care. During a telephone interview on 3/6/24 at 1:48 P.M., RN A said he/she should have used EBP during the wound treatment. During an interview on 2/27/25 at 4:15 P.M., the DON said staff should have used EBP during the incontinent care and during the wound treatment.

Based on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to date weekly oxygen tubing, allowed oxygen tubing to lay on the floor (Resident #17, #22, #79, #129), and additionally failed to refill humidifiers daily with distilled water (Resident #17, #22) resulting in possible exposure to bacteria and discomfort during oxygen usage. This affected four of 12 sampled residents. The facility census was 27. Review of the facility's Cleaning (Sanitizing) Guidelines - Oxygen Equipment policy, undated, showed; - Humidifiers - standards include changing humidified water, rinsing the humidifier and replacing humidifier water; - Humidifiers are to be dated, initialed, and replaced every seven days; - Tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and marked with date and initials; - All concentrator outside surfaces are to be cleaned weekly by nursing personnel, and marked with date and initials; - Humidifiers must be emptied and refilled every 24 hours with distilled water; 1. Review of Resident #129's Face Sheet, undated, showed: - Diagnoses: fracture right hip joint, GERD (acid reflux), ventricular arrhythmia (abnormal heart rhythm), neck fracture of right femur (leg); Review of resident's care plan, dated 2/14/2025, showed no entry for oxygen care; Review of resident's physician orders, dated 2/24/25, showed no orders for oxygen; Review of resident progress note dated 2/24/25 at 12:00 P.M., showed: - Staff called to resident's room because resident complained that he/she couldn't breathe. SPO2 (oxygen saturation, percentage of oxygen in the blood) was 82% on 3 liters per minute. Resident was in obvious respiratory distress with respirations of 28. - Call placed to provider who gave order to send resident to ER for evaluation and treatment. 911 called; Observation of the resident's room on 2/24/25 at 10:56 A.M. showed several coils of oxygen tubing hooked up to the oxygen humidifier lying on the ground with no date of when last changed taped to the tubing; 31102 2. Review of Resident #22's Quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Independent with eating dressing, personal hygiene and transfers; - Diagnoses included psychotic disorder ( a mental illness that causes a person to lose touch with reality), chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing), and diabetes mellitus. Review of the resident's POS, dated 1/25/25 - 2/25/25, showed; - Start date: 9/27/23 - O2 at 2L/NC (Liters per Nasal Cannula) with ambulation, none required at rest for acute respiratory failure with hypoxia (lack of oxygen to the tissues); - Start date: 8/13/23 - Ipratropium-albuterol solution for nebulization 0.5 mg. -3 mg./3 ml four times a day for shortness of air. Review of the resident's care plan, revised 1/28/25, showed: - The resident had a diagnosis of COPD and required oxygen during the day; - Had nebulizer treatments as ordered. Review of the resident's MAR, dated February, 2025, showed: - O2 at 2L/NC with ambulation, none required at rest for acute respiratory failure with hypoxia; - Ipratropium-albuterol solution for nebulization 0.5 mg. -3 mg./3 ml four times a day for shortness of air. Observation and interview on 2/24/25 at 10:30 A.M., showed: - The resident said he/she used his/her oxygen frequently; - The resident's oxygen tubing was lying on the floor and was dated 2/13/25; - The front of the O2 concentrator had dried white debris spilled down the front; - The nebulizer machine was sat directly on the floor; - The nebulizer tubing was not dated; - The humidified water bottle was almost empty and was not dated. Observation on 2/27/25 at 8:34 A.M., showed;- The O2 concentrator had dried white debris spilled down the front of it; - The nebulizer machine remained directly on the floor and the tubing was not dated; - The oxygen tubing was dated but the bag it was lying directly on the floor. During an interview on 2/26/25 at 11:17 A.M., Certified Medication Technician (CMT) A said: - The oxygen tubing should not be on the floor, it should be in a bag and dated; - The oxygen tubing is supposed to be changed out on Wednesdays on the night shift; - There should be distilled water in humidified water bottle; - The oxygen concentrators should be clean; - The nebulizer machine should not be on the floor and the tubing should be dated and in a bag. 51166 3. Review of Resident #17's Quarterly MDS, dated [DATE], showed: -Cognitive skills intact; -Diagnoses include: heart failure, and high blood pressure. Review of Resident's physician's orders showed: -Start date 1/31/25 - Ipratropium-albuterol solution for nebulization 0.5 mg. -3 mg./3 ml every six hours, as needed, for acute congestive heart failure; -Start date 2/17/25 - O2 therapy: 1-2L each nostril NC, as needed, to keep oxygen levels above 92%. Observation of the resident's room on 2/24/25 at 1:15 P.M. showed: -Undated oxygen tubing on the floor; -Humidifier bottle had 1/4 inch of water; -Resident was short of breath. 4. Review of Resident #79's Quarterly MDS, dated [DATE] showed: -Moderately impaired cognition; -Active diagnoses include: diabetes, and manic depression. Observation of the resident's room on 2/24/25 at 2:36 P.M. showed: -Nebulizer tubing was was undated; -Undated oxygen tubing was on the floor. During an interview on 2/27/25 at 8:54 A.M., Nurse Aide (NA) B said: - The oxygen and nebulizer tubing should not be on the floor. It should be dated and in a bag; - The oxygen and nebulizer tubing should be changed out on Wednesdays on the night shift; - The nebulizer machine should not be on the floor; The oxygen concentrator should be clean; - There should be water in the humidified water bottle; - He/she thought the nurses were supposed to check it. During an interview on 2/27/25 at 4:15 P.M., the Director of Nursing (DON) said: - The oxygen concentrators should be clean; - There should be water in the humidified water bottle; - The nebulizer machine should not be on the floor and the tubing should be dated; - The oxygen tubing should not be on the floor and it should be dated. During a telephone interview on 3/6/25 at 1:48 P.M., RN A said: - The oxygen and nebulizer tubing should be dated and should not be on the floor; - The tubing should be changed weekly on Wednesdays on the night shift; - The humidified water bottle should have water in it; - The nebulizer machine should not be on the floor.

Based on interview and record review, the facility failed to protect the resident's right to be free from abuse when Resident #12 threatened harm to Resident #9. The facility census was 27. Review of the facility's undated Abuse Prohibition Protocol Policy, showed: - It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion - Additionally, residents will be protected from abuse, neglect and harm while they are residing at the facility; - No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection; - The objective of the abuse policy is to comply with the seven step approach to abuse and neglect detection and prevention. The abuse policy will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance and performance Improvement (QAPI) program; - Overview of the seven components: reporting and response; screening; training; prevention; identification; investigation; and protection. 1. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/8/25., showed: - 12/9/16 - admitted ; - Cognitive skills moderately impaired; - Rejected cares daily; - Wandering occurred daily; - Independent with transfers, dressing, personal hygiene and toilet use; - Diagnoses included schizophrenia ( a serious mental illness that affects how a person thinks, feels, and behaves) and psychotic disorder ( a mental illness that causes a person to lose touch with reality). Review of the resident's care plan, revised 2/10/25 showed: - The resident had delusions (something that is believed to be true or real but that is actually false or unreal) related to schizophrenia. Do not confront, argue against, or deny resident's thoughts. Maintain a calm environment and approach to the resident. Refocus resident when he/she changes the subject in middle of conversation. Reinforce and focus on reality. Use clear, concise terms. Set limits and expectations for resident's behavior; - 2/26/25 - The resident has verbal behavioral symptoms directed toward others (threatening others, screaming at others and cursing at others). Administer medications and monitor and record effectiveness. Report adverse side effects. Report to provider if resident tries to cheek his/her medications. Allow distance in seating other residents around resident. Assess whether the behavior endangers resident or others. Intervene as necessary. Avoid over-stimulation (noise, crowding, other physically aggressive residents). Avoid power struggles with resident. Convey an attitude of acceptance towards the resident. Divert resident's behavior by removing him form other residents and providing 1:1 counsel. If resident has delusions/hallucinations, do not try to reason with or confront resident. Offer reassurance. Ignore resident's verbal abuse. Maintain a calm, slow, understandable and environment approach to the resident. Provide 1:1 session with resident, and one monitoring if he/she is being threatening to other residents , or verbally abusive. Proved consistency in approaching the resident: set boundaries for personal space, do not allow him/her to talk to a single staff member behind a closed door. Proved private, comfortable environment for care. Refocus conversation when resident becomes verbally abuse. Set expectations and limits for resident. When resident becomes verbally abusive, move to a quiet, calm environment. Review of the nursing progress notes, showed: - 2/25/25 at 5:15 P.M. - Behavior: This nurse with State surveyor in hall checking blood sugars and insulin, Resident #9 stopped to talk. Resident #9 reported being in the dining room and turned the television on. Resident #12 went and turned the television off. Resident #9 turned the television back on and Resident #12 told Resident #9 the next time he/she catches Resident alone, he/she is going to hurt Resident #9; - 2/25/25 at 9:34 P.M. - Resident had a 1:1 ordered, confirmed night shift 1:1 with staff member and with charge nurse (CN) checking in hourly. Resident refused to get on ambulance at 6:15 P.M. as Emergency Medical Services (EMS) was called to transport for immediate medication evaluation due to a report from another resident that Resident #12 threatened to hurt him/her and flipped him/her off. Police were called but informed Administrator that they did not have authority to detain Resident #12 at this point due to no crime being committed. Police recommended calling guardian and getting a court order. Guardian was called. Guardian said they were not sure what to do and that the Police should have detained Resident #12 for his/her comments, or or made to got to a psych inpatient. Administrator informed the Guardian the staff could not force Resident #12 to go. The Guardian will work on a court order in the morning. Resident #12 pointed a butter knife in the Administrator's direction and said, This is threatening. I would have used this if I threatened anyone. I am not threatening you right now either, just showing you an example. Resident #12 is certain that a particular resident told on him/her which is a completely different resident. Resident #12 said all he/she said to the him/her was that He/she needs help, and he/she isn't a doctor. Resident #12 then stated to the business office manager (BOM) that he/she will threaten him/her, and he/she will deserve what is coming for him/her. This was gathered in a statement. Resident #12 then walked back to his/her room with the BOM (who was Resident #12's current 1:1) and Certified Medication Technician (CMT) stated Resident #12 stated he/she wanted to kill him/herself and take down the entire joint with him/her too. When the Administrator asked him/her about both statements, he/she denied saying anything and that he/she did not have a plan to hurt him/herself. - Administrator called Police again to update them on Resident #12's comments and actions. The Sergeant said Resident #12 still was not committing a crime even though the Administrator stressed her worry that Resident #12 needs psych evaluation and that there is a resident who is scared of Resident #12. Administrator placed Resident #12 1:1 overnight to ensure safety of other residents. The Police said to call them if Resident #12 advanced to the victim's room or becomes combative. Review of the facility's initial reporting form, dated 2/25/25 showed: - Resident #9 went to the Administrator, Director of Nursing (DON) and BOM at 5:30 P.M., and said he/she was afraid because Resident #12 threatened him/her for turning on the television in the dining room. He/she said Resident #12 turned the television off and he/she turned it back on and Resident #12 turned it off again and said, Do that again, I am going to hurt you, flipped him/her off and said, up yours. Resident #9 is scared of Resident #12 because he/she is mean. Resident #9 said it happened earlier today and he/she did not tell anyone because he/she did not want to tattle on Resident #12 and he/she was threatened often at his/her last facility. Review of the fax sent from the Public Administrator's (PA) office, dated 2/26/25 at 4:50 P.M. showed the PA office filed a petition with the court to have Resident #12 transported by the Sheriff's department to a psych hospital. 2. Review of Resident #9's medical records showed an admitted [DATE]. Review of the resident's Admission MDS, dated [DATE], showed: - Cognitive skills intact; - Independent with dressing, toilet use and transfers; - Diagnoses included high blood pressure, depression, schizophrenia and chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). Review of the resident's care plan, revised 2/20/25 showed;- The resident has a diagnosis of paranoid schizophrenia. Staff will allow the resident to vent any concerns regarding his/her diagnoses and reassure him/her that he/she is in a safe environment; - The resident has exhibited change in usual behavior as evidenced by anxiety at times (increased restlessness, fidgety, lack of initiative/involvement. Evaluate whether the behavior is attributed to organic causes or other risk factors. Review of the resident's progress notes, recorded as a late entry on 8/26/25 at 8:57 A.M., showed: - The resident went to the Administrator's office with the DON, and BOM. He/she said he/she was sorry to bother them but that Resident #12 had threatened him/her. Resident #9 had turned the television on in the dining room, and Resident #12 turned it off and told him/her, Do that again and I will hurt you.Resident #12 them flipped Resident #9 off and said, up yours while walking away from him/her. Resident #9 said Resident #12 is very mean person and made him/her feel very scared. Resident #9 said it happened earlier in the day and he/she did not tell anyone because he/she did not want to tattle. The Administrator reassured the resident that it is not tattling and wanted the resident to feel at home. - At 10:00 P.M., the Administrator spoke with Resident #9 in his/her room and asked him/her how he/she was feeling. Resident #9 said,Better now, Resident #12 scared him/her. The resident was reassured a staff member was watching #12 and he/she was safe. During an interview on 3/6/25 at 1:48 P.M., Registered Nurse (RN) A said: - Resident #12 was currently out of the facility; - He/she makes a lot of hateful comments to other residents but did not do it in front of the staff; - Some of the residents are afraid of him/her. During an interview on 3/6/25 at 2:00 P.M., the Administrator said: - The facility obtained the court order to send Resident #12 to a psych hospital; - Since he/she has been there, they have refused all of his/her medications; - The hospital is wanting to send him/her back but they have not done anything with him/her, he/she is the same as when they were transferred out; - The facility had sent out referrals to try and find different placement for him/her, but have not heard anything back yet. MO250171

Based on interview and record review, the facility failed to ensure one resident, (Resident #1) was free from verbal and physical abuse when Certified Nursing Assistant (CNA) A grabbed the resident's arm, jerking him/her back into the wheelchair, while yelling and cursing at the resident. The facility census was 27. Review of the facility's Abuse Prohibition policy, dated November 2017, showed: -It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties; -Any owner, licensee, administrator, licensed nurse, employee or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat or neglect a resident. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 11/12/24 showed: -He/She has the diagnoses of mood disorder due to known physiological condition (a mental health condition characterized by persistent and pervasive change in a person's emotional state), violent behaviors, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), Diabetes Mellitus type 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), heart failure, generalized anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities); - The resident has minimal difficulty hearing, unclear speech, usually makes self understood and usually understands others; -He/She refused to participate in a Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients). He/She does have short and long term memory problems; -He/She displays verbal behaviors, physical behaviors, and rejection of care almost daily; -He/She requires moderate to substantial assistance with Activities of Daily Living (ADL's), including dressing, bathing, toileting and personal hygiene. Review of the Resident's comprehensive care plan, dated 11/12/24, showed the following interventions: -He/She has impaired decision making due to cognitive loss; -He/She has difficulty making self understood due to impaired cognition and unclear speech. Staff are to approach him/her calmly and allow him/her time to speak. Observe the resident for signs of distress, including guarding, restlessness and increased breathing; -He/She prefers low-noise environments and solitary activities. Maintain a calm, slow approach with the resident. -He/She has socially inappropriate/disruptive behavioral symptoms as evidenced by fluctuations in mood, and non-compliance with taking medications. Allow resident to have control over situations, if possible. Avoid over-stimulation. Assess if the resident' behavior is dangerous to self, other residents and/or staff. Review of the resident's progress note, dated 12/8/24 at 11:40 A.M., said: -Staff heard the resident yelling from his/her room. Nurses Aide (NA) A went into the room to see why the resident was yelling. The resident was observed on the fall mat and had been incontinent of urine. The resident was yelling and combative with staff as they assisted him/her up from the floor. The resident agreed to allow NA A to assist him/her to the restroom. While in the restroom, the resident became angry and combative, as the resident thought the NA was going to close the restroom door. The resident began to yell that he/she wanted out of the restroom. The NA got out of the resident's way and the resident began making his/her way to the nurses' station. Once at the nurses' station, the resident tried to go behind the desk, saying he/she wanted to use the phone. Staff advised the resident that he/she could use the phone in the resident phone room. The resident stated the phone in the phone room did not work and he/she wanted to use the one at the nurses' station. Staff attempted to pull the resident's wheelchair back from the nurses' station. At this time, two laundry staff members, Laundry Aide A and Laundry Aide B, heard commotion by the nurses station. The resident was having behaviors, yelling, and trying to strike staff. Laundry Aide A said that CNA A, grabbed the resident's arm and said You're not going to fucking hit me! and pulled him/her around. CNA A was kicking at the resident's wheelchair. Activity Director was called and he/she came to the nurses' station, took the resident to a quiet area, and asked him/her what happened. He/She said the aides were hurting him/her by not letting him/her use the phone and one, CNA A, pinched his/her arm and kicked him/her. The Activity Director noticed a red mark on the resident's inner elbow. The Administrator was called and spoke to resident and Activity Director about the incident. During an interview on 12/16/24 at 12:23 P.M., Resident #1 said: -He/She had fallen on the mat next to the bed and yelled for staff to come help him/her. NA A and CNA A came into the room and helped him/her back up into the wheelchair. NA A then assisted him/her to the restroom. NA A went to leave the restroom and the resident became upset because he/she thought NA A was going to close the restroom door. He/She left the restroom and went down to the nurses's station to use the phone to call his/her sister. CNA A and NA A followed him/her to the nurses' station and told him/her to use the phone in the resident phone room. That phone does not work and he/she wanted to use the phone at the nurses' station. CNA A began yelling and cursing at the resident. The resident became upset at CNA A for yelling at him/her and attempted to hit CNA A. CNA A grabbed the resident by the right arm and jerked him/her around in the wheelchair while cursing at him/her. CNA A was also kicking at the wheelchair, trying to get the resident to back up from the nurses' station. The resident felt scared when CNA A grabbed his/her arm, jerked him/her around and cursed at him/her. During an interview on 12/16/24 at 1:10 P.M., Laundry Aide A said: -He/She heard yelling at the nurses station and Laundry Aides A and B went to the desk to see what was going on. Resident #1 was trying to get behind the desk. He/She was yelling that he/she wanted to use the phone. CNA A and NA A were attempting to keep the resident from going behind the desk. The resident was swinging his/her arm at CNA A. CNA A was yelling and cursing at the resident and kicking at his/her wheelchair, trying to get the resident to back up. CNA A then grabbed the resident by the right arm and jerked him/her back in the wheelchair. The Activity Director came to the desk at this time, took the resident to the front of the building to calm down and calm the Administrator. During an interview on 12/16/24 at 1:15 P.M., the Activity Director said: -Laundry Aides A and B witnessed CNA A yelling at Resident #1, grab his/her right arm and jerk him/her back in the wheelchair. The Laundry Aides called the Activity Director on his/her cell phone and told him/her to come to the nurses desk. The Activity Director heard yelling as he/she came down the hall towards the nurses desk. When he/she got to the desk, he/she witnessed the resident yelling at CNA A and NA A. The Activity Director accompanied the resident to the front of the building to calm down and to call the Administrator. The Activity Director noted a red mark to the inside of the resident's right arm. The Administrator told the Activity Director to instruct CNA A to leave the facility and the Administrator was on the way to the facility. The Activity Director told CNA A to leave the facility. CNA A became upset, began yelling at the Activity Director and refusing to leave. The Activity Director informed CNA A he/she would have to call law enforcement if he/she did not leave the facility. At this time, CNA A left. During an interview on 12/16/24 at 2:00 P.M., the Administrator said: -It is his/her expectation that staff treat residents with respect. -Residents have the right to be free from abuse. -It is his/her expectation that the staff should have allowed the resident to use the phone at the nurses desk and notify the charge nurse that the resident was agitated. MO246288

Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from abuse when a staff member forcibly used the resident's own hand to hit himself/herself in the face multiple times. This affected one of four sampled residents (Resident #1). The facility census was 28. Review of the facility provided, Abuse Prohibition Policy dated March 2012 showed: -It is the purpose of this facility to prohibit mistreatment, neglect abuse of resident and misappropriation of resident property. -Abuse is defined as the willful infliction of injury,unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. -All employees of this facility are mandated reporters. -All allegations of abuse, neglect,exploitation, mistreatment, injuries of unknown sources, will be reported immediately. Review of the resident's Quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 11/12/24 showed: -Brief Interview of Mental Status (BIMS) of 99, indicated the resident had severe cognitive deficits; -Understands others and able to make self understood. -Physical behaviors such as hitting, kicking, spitting or scratching, occurred 4-6 days of the 7 day assessment period; -Verbal behaviors such as screaming, yelling or cursing,occurred daily of the 7 day assessment period; -Rejection of cares such as refusal of medications, bathing, assistance to toilet, occurred 4-6 days of the 7 day assessment period; -Need for moderate assistance from staff for Activities of Daily Living (ADL's: activities done in a day to care for oneself such as bathing, using the toilet, transfers and mobility); -Limited mobility of both upper and lower limbs; -Diagnoses of: Mood Disorder (a mental disorder that causes a person to feel sad, empty, anxious and cranky.) Violent behavior (any action that threatens or harms others, or destroys property) Generalized Anxiety (constant worry that is uncontrollable) Parkinson's Disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain) and pain. Review of the resident's care plan dated 8/12/24 showed: -The resident had socially inappropriate and disruptive behaviors: allow the resident to have control over situations if possible; convey an attitude of acceptance toward the resident; maintain a calm, slow, understandable approach to the resident; -The resident has impaired decision making ability due to dementia: calm the resident if signs of distress develop; respect the resident's rights to make decisions. Review of the facility investigation dated 11/27/24 at 1:00 P.M. showed: -On 11/25/24 in the afternoon the resident locked himself/herself in the activity room; -Housekeeping Aide A tried tied to remove the resident from the room when the resident began hitting/kicking/yelling; -Housekeeping Aide A walked away and got assistance from the Director of Nursing (DON); -The resident continued to yell/hit/kick; -The DON grabbed the resident's arm and would not let go; -The resident hit the DON; -The DON then grabbed the resident's arm and began hitting the resident in the face with the resident's own hand, and was yelling in the resident's face; -Evaluation of the resident showed he/she did not feel safe around the alleged perpetrator (AP); -Notification was made to the physician and the guardian. Review of the Resident's progress notes showed: November 25, 2024 at 2:00 P.M. -The resident locked himself/herself in the activity room; -Activity staff unlocked the door and the resident began screaming, kicking and hitting; -The DON intervened and the resident continued to kick, hit and scream; -The Social Service Director (SSD) de-escalated the situation and the resident was taken to his/her room; November 27,2024 at 2:00 P.M. -A complete skin assessment was completed; -The resident had no bruises or abrasions to the right side of his/her face; -The physician and guardian were notified; -At 3:56 P.M. law enforcement was notified. During an interview and observation on 12/5/24 at 1:32 P.M. Resident #1 said: -The DON was mad and yelling in his/her face; -The DON hurt his/her right cheek, when he/she used his/her hand to smack his/her own face; -The resident demonstrated his/her hand smacking his/her right cheek, with an open palm; -He/She was not scared now and felt safe since the DON was gone; -He/She was afraid of the DON. During an interview on 12/5/24 at 2:07 P.M. Housekeeping Aide A said: -He/She was cleaning and attempted to open the Activity Room door but something was blocking it; -He/She went through the connecting room and found Resident #1 was backed up against the door in his/her wheelchair; -Resident #1 was yelling, kicking and hitting at the DON who was standing in front of the resident; -The DON grabbed Resident #1's right arm and said to stop. The resident pulled his/her arm away from the DON and hit the DON in the face, knocking off the DON's glasses and scratching his/her face; -The DON grabbed the resident's arm again and began using the resident's hand to smack the resident on the right side of his/her own face; -He/She left the room and got the SSD to come help, leaving the resident in the room alone with the DON; -The SSD got the resident to calm down and they all left the activity room; -He/She reported the incident the next to day to his/her supervisor. During an interview on 12/5/24 at 2:27 P.M. the SSD said: -He/She heard yelling, so he/she went to investigate; -He/She tried to get into the Activity Room and the door was blocked; -He/She entered through the connecting door and saw Resident #1 sitting in his/her wheelchair, yelling at the DON, and the DON was yelling at the resident; -He/She told the DON to stop; -He/She bent down to the resident's level and explained to the resident to focus on him/her; -He/She got the resident to stop yelling and then removed him/her from the Activity Room to the SSD office. During an interview on 12/5/24 at 2:50 P.M. the Administrator said: -The Housekeeping Aide had come to her office on November 27th to discuss something and while there reported the incident with Resident #1 and the DON; -He/She educated the staff immediately on what Abuse and Neglect was and to report immediately; -Once he/she found out about the incident an investigation was started, the DON was placed on leave and 1:1 education was initiated; -When he/she interviewed Resident #1 they said they were afraid of the DON and that the DON hit them in the face. MO245813 MO245823

Based on interview and record review, the facility failed to ensure one resident was free from physical restraints and to follow their policy regarding restraints (a device used to restrict a resident's movement) when a gait belt (a cloth belt used placed around a resident to transfer the resident) was wrapped around a resident and his/her wheelchair to allegedly keep him/her from sliding down and out of his/her wheelchair. The resident was observed to have slid down the wheelchair with the gait belt around his/her chest and arm pits. This affected one resident (Resident #1). The facility census was 29. The Administrator was notified on 3/12/22 of an Immediate Jeopardy (IJ) which began on 3/12/22. The IJ was removed on 3/14/22 as confirmed by surveyor onsite verification. Review of the facility policy, dated March 2015, regarding restraints showed: - Staff shall use restraints for the safety and well-being of the resident. - Restraints should only be used after staff tried other alternatives. - Restraints should never be used for staff convenience. - A resident must be able to remove the restraint. - Prior to placing a resident in restraints, staff must perform a pre-restraint assessment. - Staff must notify the Director of Nursing (DON) and the resident's physician prior to applying restraints. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/29/21, showed: - Mild cognitive impairment; - Independent of staff assistance for transfers, eating, toileting, and hygiene; - Diagnoses included diabetes, Parkinson's disease (a disease of the nerves), anxiety, and schizophrenia (a serious mental illness that affects how a resident thinks, feels, and behaves). Review of the resident's care plan, dated 2/27/22, showed the resident was dependent upon staff for all cares. During an interview on 3/12/22 at 4:40 P.M., Registered Nurse (RN) A and Licensed Practical Nurse (LPN) A said: - They had no issues with residents today. - All wheelchair bound residents stayed upright and positioned well in their wheelchairs without difficulty. -They did not put the resident in a wheelchair with a gait belt around the resident and the wheelchair. During an interview on 3/12/22 at 4:50 P.M., Certified Nurse Assistant (CNA) C said: - He/she worked 6:00 A.M. to 6:00 P.M. - He/she had no issues with residents sliding down and out out of their wheelchairs. - He/she did not see a resident in a wheelchair with a gait belt around the resident and the wheelchair. During an interview on 3/12/22 at 4:57 P.M., CNA A said: - He/she worked the 6:00 A.M. to 2:00 P.M. shift on 3/12/22. - The resident kept sliding down and out of his/her wheelchair. - RN A and LPN A tied the resident in his/her wheelchair by wrapping a gait belt around him/her to keep him/her from sliding down and out of his/her wheelchair. - The resident was very out of it mentally. - He/she asked RN A for help transferring the resident back to bed. - Around lunch, the resident slid down the wheelchair with the gait belt around his/her chest and wheelchair and the gait belt pulled tightly under the resident's arms when they were transferring the resident. - No injuries noted to the resident. - He/she asked Housekeeper (HK) A, who was also a CNA to help him/her get the resident into bed. During an interview on 3/12/22 at 5:00 P.M., HK A said: - HK A identified the resident as Resident #1. - HK A said the gait belt was under the resident's arms and attached to the wheelchair and RN A & LPN A applied the gait belt. During an interview on 3/12/22 at 5:25 P.M., the Environmental Services Supervisor (ESS) said: - CNA A and Housekeeper (HK) A called him/her to ask what to do about a situation. - He/she was not at the facility on 3/12/22. - CNA A and HK A told him/her that RN A and LPN A restrained the resident to his/her wheelchair with a gait belt. - The resident was sliding out of his/her wheelchair and choking. - He/she told staff they needed to call the DHSS. During an interview on 3/12/22 at 5:40 P.M., HK A said: - He/she worked the 8:30 A.M. to 2:30 P.M. shift. - He/she was also a CNA. - CNA A asked him/her to assist putting the resident back to bed. - He/she did not see who restrained the resident with a gait belt to his/her wheelchair. - The resident was slipping down in his/her wheelchair. - HK A and CNA A practically lifted the resident into bed. - HK A said the resident was limp. - HK A said the gait belt was around the resident's arms pits and attached to the wheelchair. Observation on 3/12/22 at 5:50 P.M., of the resident showed: - A purple bruise on the resident's right forearm approximately 3 inches by 1 1/2 inches. - A purple bruise on the resident's left elbow approximately 3 inches by 1/2 inch. During an interview on 3/12/22 at 6:25 P.M., RN A said: - He/she would never restrain a resident with a gait belt to a wheelchair. - The resident did keep slipping in his/her wheelchair and he/she did not put any interventions in place to stop the resident from slipping. - CNA A was angry with him/her because RN A was going to write up CNA A for yelling. - RN A said she did not restrain the resident with a gait belt - Staff had not requested a physical therapy evaluation to prevent the resident from slipping in his/her wheelchair. Review of the facility's investigation of the incident, dated begun on 3/12/22 and completed on 3/13/22, showed: - The incident was reported to the Administrator (ADM) on 3/12/22 at 5:00 P.M. by the surveyor. - The alleged offenders were RN A and LPN A. - The resident was Resident #1. - Resident #1 was cognitively impaired. Review of the statement, dated 3/12/22 at 7:00 P.M., by LPN A showed: - Resident #1 slid out of his/her chair multiple times on 3/12/22. - Two unnamed CNAs helped pull the resident back in her chair. - One unnamed CNA began yelling and cussing at LPN A and RN A. - RN A was going to write up the CNA for conduct. - At no time did LPN A restrain the resident. Review of the statement, dated 3/12/22 at 7:10 P.M., by RN A showed: - The resident kept sliding in his/her wheelchair. - Multiple times CNAs pulled the resident up in the wheelchair. - CNA A asked for help putting the resident to bed. - CNA A and another CNA pulled the resident up in the wheelchair. - About 20 minutes later, Certified Medication Technician (CMT) A asked CNA A if he/she needed help; - CNA A said, I fucking needed help 20 minutes ago not now. - RN A was going to write up CNA A for his/her behavior. - RN A stated at no time throughout the day was a gait belt put on the resident to use as a restraint. Review of the statement, dated 2/12/22 at 7:14 P.M., by CNA C showed: - The resident was sliding down in the wheelchair. - CNA C frequently pulled up the resident in the wheelchair. - At no time did CNA C see a restraint on the resident. Review of the statement, dated 3/13/22 no time given, by House Keeper (HK) A showed: - Was also a CNA. - HK A started work on 3/12/22 before 9:00 A.M. - The resident kept sliding in the wheelchair. - HK A assisted staff with pulling up the resident in the wheelchair. - HK A helped staff put the resident back to bed. - Unnamed staff informed HK A that the resident had a gait belt wrapped around the resident and the wheelchair. Review of the statement, dated 3/13/22 at 8:25 A.M., by HK B showed: - On 3/12/22 HK B noticed the resident was restrained with a gait belt wrapped around the resident and the wheelchair. - An unnamed CNA told HK B that the resident was choked by the restraint. - HK B did not see the resident choked. - HK B saw the resident strapped to the wheelchair by a gait belt. Review of the statement, dated 3/13/22 at 9:35 A.M., by RN B showed: - Around 8:30 A.M. Resident #1 was slipping down in the wheelchair. - RN B helped other staff pull up the resident. - RN A put a gait belt around the resident and the wheelchair to prevent the resident slipping. Review of the statement, dated 3/13/22 at 9:50 A.M., by CNA A showed: - Resident #1 kept sliding down in the wheelchair. - Around 9:00 A.M. RN A and LPN A wrapped a gait belt around the resident and the wheelchair. - CNA A felt very uncomfortable with the fact that the resident was wrapped up in a gait belt attached to the wheelchair. - RN B was at the desk. - Around 12:00 P.M., CNA A brought the resident from the dining room. - CNA A walked by the office and asked RN A and LPN A for help putting the resident back to bed. - RN A and LPN A told CNA A to wait until the other CNA got back from lunch. - The resident slipped so far in the wheelchair that the residents bottom was on the wheelchair's foot pedals. - HK A helped CNA A remove the gait belt. - The gait belt had slid up to the resident's breasts. - The resident could have been seriously hurt. Review of the summary of the incident, dated 3/13/22 no time given, by the ADM showed: - He/she interviewed Resident #1's roommate, Resident #5. - Resident #5 did not see any unusual occupancies on 3/12/22. - CNA A and RN B noticed Resident #1 restrained with a gait belt to the wheelchair, - Staff acted with resident safety in mind. - Staff were in-serviced on reporting abuse and neglect and proper use of restraints. During an interview on 3/15/22 at 8:00 A.M., RN B said: - He/she had only worked in the facility about a month. - He/she came in on 3/12/22 in the morning for a short time. - He/she saw Resident #1 restrained with a gait belt to the wheelchair. - He/she did not see who applied the gait belt. During an interview on 3/15/22 at 8:30 A.M., the Administrator (ADM) said: - Staff should not keep a resident in a wheelchair with a gait belt. - Staff should notify a resident's physician when the resident was slipping out of the wheelchair. - RN A and LPN A denied the incident. - CNA A did not work well with RN A and LPN A. During an interview on 3/17/22 at 12:37 P.M. the resident's physician said: - Staff should have call him/her when the resident kept slipping in the wheelchair. - Staff should never restrain a resident without a physician's order. - Staff should not attach a gait belt to a resident to keep the resident in a wheelchair. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO198350

Based on interview and record review, the facility failed to ensure staff notified one resident's physician when the resident had a change in condition. This affected one resident (Resident #1). The facility census was 29. Review of the undated facility policy on notification of a change in condition showed: - The purpose of the policy was to observe, record, and report any condition change to the resident's physician so that proper treatment could be implemented. - After a change in resident physical or mental condition staff should ask the resident if in pain. - Observe for change in personality. - Observe for weakness. - Observe for incontinence. - Observe for gait, posture, or balance disorder. - Take a set of vital signs (temperature, pulse, respirations, blood pressure, and oxygen saturation). - Notify the resident's physician. - Notify the resident's responsible party. - Monitor the resident's condition frequently. 1. Review of Resident #1's care plan showed: - Dated 3/24/16, showed a diagnosis of schizophrenia and staff should monitor for gait changes and notify his/her physician if any changes occur. - Dated 2/27/22, showed the resident was dependent upon staff for all cares. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/29/21, showed: - Mild cognitive impairment; - Independent of staff assistance for transfers, eating, toileting, and hygiene; - Diagnoses included diabetes, Parkinson's disease (a disease of the nerves), anxiety, and schizophrenia (a serious mental illness that affects how a resident thinks, feels, and behaves). Review of the resident's nurses notes, dated 3/8/22 at 9:07 P.M., by Registered Nurse (RN) D showed: - Called Family Member (FM) A for notification of change in condition. - The resident normally recognized RN D, but did not recognize him/her. - The resident's speech was slurred and did not seem to understand when staff spoke to the resident. - The resident required a mechanical lift (Hoyer) for transfers. - The resident had decline in mental status. - The resident was unwilling or unable to stand. - The resident was incontinent of bowel and bladder. - FM A was concerned about the resident's decline. -No documentaion the physician was notified of the change in condition. Review of the resident's nurse's notes, dated 3/9/22 at 5:10 A.M., by RN D showed: - Resident tried to get out of bed and nearly fell out of bed. - Resident had difficulty swallowing medications and fluids. -No documentation of the physician being notified. Review of the resident's nurse's notes, dated 3/11/22 at 1:21 P.M., by Licensed Practical Nurse (LPN) B showed: - The resident was up in a wheelchair. - The resident continued to slide down in wheelchair. - Resident incontinent of bowel and bladder. - Resident unable to bear weight. -No documentation of the physician being notified. Review of the resident's nurse's notes, dated 3/12/22 at 4:29 P.M. by LPN A, showed: - Resident frequently sliding down in wheelchair. - LPN A stated did not think this was a behavior. -No documentation of the resident's physical status, no documentation of the resident vomiting or diarrhea. Review of the resident's nurse's notes, dated 3/12/22 at 4:29 P.M. by RN A, showed public administrator (PA) A called regarding the resident's condition. Review of the resident's nurses notes, dated 3/13/22 at 12:39 A.M. by RN D, showed: - Staff from the previous shift reported that the resident vomited after lunch. - Staff offered the resident a clear liquid diet and he/she did eat jello. - At bedtime snack time offered the resident tea, but he/she refused. - The resident did not recognize RN D. - No documentaion of the resident's physician being notified of the resident refusing to eat and not recognizing RN D. Review of the resident's nurse's notes, dated 3/13/22 at 02:45 A.M. by RN D, showed: - Resident vomited large amount of yellow fluid. - After vomiting the resident continued spitting out yellow fluid out of mouth. - Vital signs blood sugar 131 (less than 140 normal), temperature 97, pulse 73 (normal 60-100), respirations 21 (normal 16-20), saO2 91%. - Placed the resident on 2 liters O2. Review of the resident's nurse's notes, dated 3/13/22 at 3:00 A.M. by RN D, showed: - Resident projectile vomiting; - Attempted to notify DOC A with no answer. - Notified NP A. - NP A gave order to send to the ER. - Notified PA A who ordered that the resident be sent to the ER 30 miles away. Review of the resident's ER notes, dated 3/13/22 at 7:56 A.M. by Physician B, showed the resident had: - Brain mass; - Colorectal mass with moderate fecal retention; - Hospice consult. Review of the resident's nurse's notes, dated 3/13/22 at 9:20 A.M. by RN C, showed: - Report called from the ER. - Reporting nurse said the resident had colorectal cancer with metastasis to the brain. During an interview on 3/16/22 at 9:55 A.M., Family Member (FM) A said: - He/she felt the resident had been declining over the last month. - Four weeks ago the resident was walking, self-toileting, talking. - When FM A called the resident, the resident normally spoke at length. - Two weeks ago the resident would ask FM A about the family. - On 3/7/22, staff sent the resident to the local ER. - The local ER did labs, a chest X-ray, and administered IV fluids. - After 3/7/22 FM A asked the resident questions and the resident could not respond. - On 3/9/22 FM A called and was told the resident was having behaviors of sliding out of wheelchair. - On 3/12/22 FM A called and LPN A put the phone to the resident's ear. - The resident did not recognize FM A. - FM A asked LPN A if he/she called Physician A regarding the resident's change in condition. - The resident had a massive decline over the last month. - FM A talked to staff regarding possible stroke symptoms on 3/12/22. During an interview on 3/16/22 at 10:50 A.M., the Social Services Designee (SSD) said: - The resident had a rapid decline. - PA A requested the resident be sent to another ER due to felt received poor treatment in the local ER. During an interview on 3/16/22 at 11:45 A.M., PA A said: - Staff did notify him/her regarding the resident's decline in condition. - PA A called and spoke with RN A on 3/12/22 in the afternoon, - PA A told RN A if the resident declined, do not send the resident to the local ER. - Staff did not notify PA A when the resident stopped walking. - Staff did not notify PA A when the resident the resident had a mental status decline. - Staff should have notified PA A when the resident had a change in condition. During an interview on 3/16/232 at 12:50 P.M., LPN B said: - According to policy when a resident had a change in condition, he/she should notify the resident's physician, the Director of Nursing, and the resident's responsible party. - The resident went from walking and talking to frequent falls, no longer talking, not walking, and not eating. - The resident went to the localER on [DATE] and returned with a diagnosis of dehydration. - He/she should have notified the resident's physician regarding change in condition after the resident returned from the ER but thought the ER covered the issues. During an interview on 3/16/22 at 12:50 P.M., Certified Medicine Technician (CMT) B said: - He/she noticed a slow decline in the resident over the last year. - The resident had an increase in falls. - He/she mentioned to charge nurse that the resident was declining. - The charge nurse felt the resident had behaviors. During an interview on 3/16/22 at 1:30 P.M. Certified Nurse Assistant (CNA) A said: - He/she felt the resident was declining for the last month. - He/she had reported to RN A and LPN A that the resident was declining and reported this on a daily basis to the charge nurse that the resident was declining, because the resident used to self toilet, the resident no longer stood, the resident fed herself and could no longer do that. - RN A and LPN A told CNA A that the resident was not declining, but had behaviors. - The resident kept sliding in his/her wheelchair and RN A and LPN A used a gait belt to keep the resident in his/her wheelchair. During an interview on 3/16/22 at 2:00 P.M. the Environmental Services Supervisor (ESS) said: - He/she also worked as a CNA. - He/she noticed a the resident was declining. - He/she reported the decline to the charge nurse whenever he/she worked two to three times a week for a month. The resident used to walk, self-toilet, and feed herself and could no longer do any of these things. During an interview on 3/16/22 at 2:05 P.M., CNA D and CNA E said: - They noticed the resident was declining over the last one to two months. - The resident no longer could walk and had to use a wheelchair. - They told several charge nurses, but were told behaviors by RN A and LPN A whenever they worked. - RN A tried to get the resident to walk. - The resident could no longer get up with a gait belt. - Therapy assessed the resident on 3/7/22 and said the resident should be transferred with a mechanical lift. - A week or two ago the resident stopped eating without assistance. - The resident went from walking to bed bound. - They assumed the resident had a stroke. - The resident seemed to be in pain and reported the issue to RN A and LPN A and they did not do anything. During an interview on 3/16/22 at 3:05 P.M., the Administrator (ADM) said: - The facility did not have a Director of Nursing (DON) presently. - RN A was the DON, but resigned and was only working weekends. - Staff must notify a resident's physician and PA when the resident had a change in condition. During an interview on 3/17/22 at 12:37 P.M., Physician A said: - The resident was seen in the local ER due to decline on 3/7/22. - TheER on ly did a chest X-ray and blood work. - The ER diagnosed the resident with dehydration and sent the resident back to the facility. - He/she felt the facility should have notified him/her after the ER visit that the resident was continuing to decline. - Staff did not notify him/her of the resident's gradual decline. - Staff should have notified him/her of the resident's gradual decline. - The resident had a brain tumor due to a colorectal mass. - If staff reported the resident's decline sooner and the ER did a complete work up the resident could have been diagnosed sooner. - The resident could have been placed on hospice sooner. - The resident would have received hospice comfort sooner. During an interview on 3/17/22 at 1:15 P.M., RN A said: - He/she had not worked at the facility for two weeks. - The resident was slipping out of his/her wheelchair on 3/12/22. - The resident was seen in the local ER. - The ER diagnosed the resident with dehydration and sent the resident back to the facility on [DATE]. - He/she thought the resident was having behaviors of slipping out of wheelchair. - The resident used to walk and never slipped in wheelchair. During an interview on 3/17/22 at 1:33 P.M., LPN A said: - Only worked every other weekend. - Every time he/she worked the resident seemed to decline a little. - The resident was seen in the ER with a diagnosis of dehydration on 3/7/22. - The resident went from walking to using a wheelchair. MO198500

Based on observation, interview, and record review, facility staff failed to provide twenty-four hour (24) protective oversight and supervision when one resident (Resident #1), who was assessed and identified to be at risk for elopement, left the facility without staff knowledge. The resident was last seen by staff at 3:50 P.M. on 10/14/17 and was discovered missing at 4:50 P.M. on 10/14/17. Staff found the west hall exit door unlatched and the door alarms were not activated. Staff failed to ensure that all exit door alarms were on and functioning. Staff failed to follow their policy for Missing Resident Drills. The facility census was 41. Review of the facility's policy for Resident Elopement Risk Procedures, dated 4/06, showed: -It is the purpose of this facility to provide 24 hour protective oversight and maintain the quality of life for each resident; -The admission screening process should thoroughly evaluate the potential resident's wandering or hiding risk. This information should be gathered from the family, physician, social worker, friends, hospital staff, other facility staff, general observation, and information on the screening tool; -If during admission screening, a potential resident is classified as an elopement risk, arrangements should be made for the resident to be placed on the Special Care Unit; -If a resident is admitted with no previous elopement potential, but verbalizes or attempts to leave the facility, the following criteria should be followed: evaluate the resident to see if they meet the criteria for the Special Care Unit, which is a locked unit; the Director of Nursing (DON) must notify the resident's physician as soon as possible; the Social Services Director (SSD) will notify the resident's family for assistance and information; address the potential in a care plan and implement the interventions listed; place the resident in a room that is in the line of sight of the nurse's station; instruct one Certified Nurse Aide (CNA) to be in charge of the resident. That CNA must observe them at all times, but especially during meal time, medication administration time, scheduled activity of daily living (ADL), every time the door alarm sounds, and as indicated by the care plan. Review of the facility policy for Code White Protocol (missing resident), dated 4/06, showed: -It is the purpose of this facility to ensure that resident safety and security are maintained. Identification of residents at risk for wandering or elopement is imperative; -Every resident will be assessed using the wander and/or elopement assessment form upon admission, readmission, annually, and with significant change; -A nurse will complete the assessment. Once completed, and the determination has been made, if or if not the resident is at risk, the Care Plan Coordinator will review and will then incorporate the information with the Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, the Resident Assessment Protocol (RAPS) and the care plan; -If the resident has been determined to be at risk, the resident will be placed on the At Risk protocol and will be added to the Code White Program.; -Each resident at risk will be given a number for identification purposes and will have the resident identification record completed to include a current picture. A listing of the residents at risk with the resident identification record will be kept at each nursing station and in the front office; -If the resident is placed on the Code White Program, the resident will be observed carefully for increased fatigue, pacing, anxiety, listlessness, verbalization of discontent, or desire to leave. Interventions will include charge nurse rounds at least every four hours. Social Services will increase the frequency of one-on-one visits and make appropriate interventions. The Activity Director will encourage group interaction and make one-on-one visits. CNA's will be responsible for encouraging toileting, ADL's and nutrition/hydration on their two-hour rounds; -The charge nurse will assign visual location observation to a staff member; -If, at any time, the resident is not located on rounds, the staff member must page over the intercom, Code White and the resident's identifying number. At that time, all staff members are to immediately make an assessment of their work area, closets, bathrooms, and outside of exterior doorways. Review of the facility policy for High Risk Protocol, dated 4/06, showed: -If the resident has left the building and/or property, the charge nurse immediately will follow the Elopement protocol; -A point of reference and reminder: All door alarms are to be activated at all times, without exception. Review of the facility policy for Elopement Protocol, dated 4/06, showed: -The purpose of the elopement guidelines is to: Identify residents at risk for elopement; protect residents that are not capable of protecting themselves; provide the techniques and equipment to minimize safety risks; -Door alarms are tested at least once a month. The results of the test are recorded; -Testing of the system includes not only the alarms' function, but also the staff's appropriate response to the alarms; -Only the administrator may authorize disabling the alarm system, and is responsible for the method of monitoring for residents' safety and resetting the alarms; -All new employees are in-serviced on elopement guidelines during orientation; -All employees will be in-serviced on elopement procedures annually; -The charge nurse is responsible for coordinating a building search followed by an immediate search of the facility grounds if a resident is discovered missing or an elopement is evident; -The charge nurse will take the following steps: search the facility in teams; if non-nursing personnel are present, they initiate a search outside the building, otherwise nursing will initiate the search; charge nurse is to remain in the facility coordinating the search; prepare to provide a picture and description of the resident, including clothing, height, weight, hair and eye color; Administrator and DON are to be notified within 20 minutes of the discovery; Administrator or designee calls in the off-duty department heads or staff as needed to assist with the search; narrow the time frame in which the resident was last noted in the facility; assign staff member to complete a search of places in the community frequented by the resident; call 911 for law enforcement assistance to aide in the search; notify family/responsible party and physician within two hours of discovery; when found, assess for injuries and document. Make sure a plan has been developed to ensure protective oversight; the care plan is to be revised to include further preventive interventions to prevent re-occurrence; in-service staff of the plan of care that will be implemented within 48 hours of incident and address all personnel involved in the direct care of the resident, and alerting non-nursing staff of precautions and elopement guidelines. Review of the Missing Resident Drill, dated 4/06, showed: -The drill should be completed annually. 1. Review of Resident #1's hospital psychiatric evaluation, dated 4/18/17, showed: -History of bipolar disorder; -admitted on a 96 hour hold after he/she was found by the police roaming the streets. Review of the resident's face sheet showed: -He/she was admitted [DATE]; -Had [DIAGNOSES REDACTED]. -Responsible party listed as a family member. Review of the Wander Data Collection Tool (a tool used to assess if a resident is at risk for wandering/elopement), dated 6/13/17, showed: -Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? - Marked yes; -Does the wandering place the resident at significant risk of getting to a potentially dangerous place? - Marked Yes; -Is the resident cognitively impaired with poor decision-making skills?- Marked Yes; -Does the resident ambulate independently, with or without the use assistive devices?- Marked Yes; -Does the resident verbally express the desire to go home or pack belongings to leave? - marked Yes; -Is this a new behavior or has there been changes in their functional status?-Marked Yes; -Interventions of exit and stairwell alarms, secured unit, frequent monitoring, utilization of check in/out log, exercises, personalization of room with familiar objects and photos, photo on wander list; staff aware of resident's wander list and behavior logs; -Summary of findings: Resident walks halls, stands by doors wanting to leave facility. Review of the care plan for psychosocial well-being, dated 9/5/17, showed: -Problem: The resident is at risk for elopement due to cognitive impairment and is not aware of hazards and potential injury to self outside of the facility and may wander; -Goal: The resident will remain in a safe environment and will not be outside of the facility without assistance; -Approaches: All facility employees will be educated on elopement procedures during orientation and annually; if elopement occurs, the facility policy will be followed; the facility will conduct elopement drills at least monthly and more often as necessary; the facility will contact the primary care physician (PCP) and responsible party if redirection is unsuccessful; the resident will be redirected when he/she attempts to leave the facility; the resident will be identified as being at risk for elopement and his/her information and picture will be placed in the elopement book; the resident will have someone with them when outside of the facility. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 9/19/17, showed staff assessed the resident as: -Moderately impaired cognitive skills for daily decision-making, difficulty making decisions; -[DIAGNOSES REDACTED]. -No history of wandering; -Independent with ambulation. Review of the resident's nurses notes, dated 10/14/17 at 6:46 P.M., showed Licensed Practical Nurse (LPN) A documented: -At 3:50 P.M., the resident returned from smoke break with a staff member. At 4:45 P.M., noted the door at the end of the west hall was open approximately two inches, the alarm was not sounding. The door was closed and staff performed an internal search of the building, not finding the resident. One staff member went to the ball field near the facility where there was an activity in progress and checked the crowd; however, the resident was not there. Local police were notified of elopement at 5:15 P.M. and arrived at facility to begin a search at 5:20 P.M. One staff member walked the outside of the facility grounds, but did not find the resident. SSD, Administrator, guardian, and department managers notified and began arriving and began looking for the resident. During an interview on 10/15/17 at 8:50 A.M., LPN A said: -The resident had not returned to the facility; -The resident was last seen by facility staff on 10/14/17 at 3:50 P.M.; -The ambulance was at the facility to transport another resident to the hospital on [DATE] at 2:00 P.M.; -He/she did not accompany the paramedics to the west hall exit door when they left the facility; -At 4:45 P.M., he/she began administering pre-supper insulin when he/she noticed the west hall door was open and the alarm was not sounding; -He/she shut the door and activated the alarm; -He/she instructed all staff to do a resident search and found that Resident #1 was not in the facility; -Two staff members went outside, one searched around the facility and one went to the ball field near the facility and did not find the resident; -He/she notified the administrator and called 911; -He/she called the SSD and the SSD instructed him/her to call the resident's guardian; -He/she was not aware the resident had a guardian, the resident's face sheet did not list the guardian as the responsible party; -He/she did not notify the responsible party on the face sheet; -The west hall door will not automatically close, the door sticks and the door has to be physically shut; -The alarms will not activate if the door is not closed; -The door has two alarms, one connected to the fire panel and cannot be silenced at the door and the other one that can be shut off; -Both alarms should be on and activated when the door is opened if the code is not put in to silence the alarms first; -Another nurse told him/her that the door had not functioned properly for months; -He/she started working at the facility on 8/31/17 and was not informed that the door had to be physically shut for the alarms to be activated; -He/she did not receive training on the facility elopement policy or was shown where the elopement book was located; -He/she gave the police a description of the resident, but there was no picture available. Observation on 10/15/17 at 8:50 A.M., showed: -The west hall door alarm connected to the fire panel with a green light indicating the alarm was on; -An additional alarm placed on the door above the alarm for the fire panel with a slide button in the off position; -When opened, the west hall door did not close completely to make a connection with the alarms on the door; -There was a one inch gap between the door and the door jamb; -Once the door was opened, the alarm connected to the fire panel was activated then silenced with a code. During an interview on 10/15/17 at 9:15 A.M., the Administrator said: -The resident had not been located yet; -The police issued an Endangered Persons Alert; -The west hall door has two alarms, one connected to the fire panel and one that was purchased at a local store for added security; -If the door does not completely close, the alarms will not activate; -The west hall door will not automatically shut, it has to be physically shut; -The west hall door has not been fully functional since August 2017; -A local company was contacted in August to fix the door, but had not been to the facility yet. Observation on 10/15/17 at 9:30 A.M., showed: -The north hall exit door alarm connected to the fire panel functioning; -The secondary alarm turned off. During an interview on 10/15/17 at 9:30 A.M., CNA A said: -The secondary alarm should be turned on; -The secondary alarm is for added security; -The ambulance was at the facility on 10/14/17 at 2:00 P.M. and took another resident to the hospital; -He/she last saw the resident at 2:00 P.M. on 10/14/17; -He/she did not see any staff go with the paramedics when they exited out the west door; -A staff member should let non-staff members out the west door; -Only staff know the code to the exit doors. During an interview on 10/15/17 at 10:10 A.M., Certified Medication Technician (CMT) A said: -He/she left the facility at 2:00 P.M.; -He/she saw the resident sitting by the front door when he/she left the facility; -He/she saw the ambulance sitting in the parking lot by the west hall exit door; -He/she had not been in-serviced on the facility's policy for elopement; -He/she just keeps a close eye on the residents; -The resident frequently said that he/she wanted to leave the facility. During an interview on 10/15/17 at 10:50 A.M., the Maintenance Director said: -The west hall exit door will not shut automatically; -He/she contacted a local contractor to fix the door over a month ago; -No one had been to the facility to check the door; -He/she checks the alarms on all exit doors weekly; -Staff shut off the secondary alarm to the west hall door several times a week; -He/she has told the staff that the secondary alarm should be on at all times. During an interview on 10/16/17 at 3:52 P.M., a local contractor said: -He/she was contacted by the Maintenance Director on 8/11/17 about the west hall exit door not functioning properly; -He/she had not been to the facility to check the door; -No one had contacted him/her since 8/11/17. During an interview on 10/15/17 at 11:30 A.M., Housekeeper A said: -He/she worked on 10/14/17 and left the facility at 2:00 P.M.; -He/she last saw the resident on the south hall right before he/she left the facility; -He/she did not see the ambulance or the paramedics in the facility; -He/she was told the west hall exit door would not shut automatically about a month ago. During an interview on 10/15/17 at 11:35 A.M., Housekeeper B said: -His/her first day of employment was 10/14/17; -He/she did not know what the resident looked like; -He/she had not received any training on the facility's elopement policy; -He/she did not know where the elopement book was. During an interview on 10/15/17 at 1:00 P.M., Resident #1's roommate said: -The resident had been his/her roommate for a couple of weeks; -He/she does not spend a lot of time in his/her room; -The resident told him/her that he/she did not want to be in the facility; -The resident walks in the halls a lot. During an interview on 10/15/17 at 1:10 P.M., Dietary Cook A said: -He/she worked on 10/14/17 and last saw Resident #1 during the noon meal; -He/she did not know that the west hall door did not close automatically. During an interview on 10/15/17 at 2:50 P.M., CMT B said: -He/she worked on 10/14/17 and started his/her shift at 2:00 P.M.; -He/she did not see an ambulance in the parking lot; -He/she took the resident out to smoke at 3:50 P.M. and brought the resident back into the facility; -At 4:45 P.M., LPN A announced that the staff needed to do a resident check; -He/she went outside the facility to look for the resident; -He/she did not see the resident; -The resident would stand or sit at the exit doors; -He/she had seen the resident peck at the door alarms trying to figure out the code; -He/she had not been in-serviced on the elopement policy or participated in any elopement drills. During an interview on 10/16/17 at 11:45 A.M., Paramedic A said: -He/she responded to an emergency call from the facility for on 10/14/17 at 2:00 P.M.; -He/she pushed the button on the outside of the west hall entrance door and entered the facility; -Usually a staff member has to enter a code to deactivate the west hall exit door alarm when leaving; -He/she was not accompanied by a staff member when exiting the facility from the west hall exit door; -He/she pushed the west hall exit door open without having to put a code in to deactivate the alarm; -Three staff members were at the nurses station when he/she exited the facility with another resident; -He/she does not remember if the west hall exit door shut. During an interview on 10/16/17 at 1:50 P.M., Nurse Assistant (NA) A said: -He/she worked on 10/14/17 from 6:00 A.M. to 6:00 P.M.; -He/she last saw Resident #1 between 2:30 P.M. and 3:00 P.M. on 10/14/17; -The resident was pacing up and down the halls; -He/she was unsure what time LPN A notified him/her and CNA A to do a head count of all residents in the building; -The resident was not in the facility; -He/she received training on elopement and code white upon hire; -He/she had not been instructed to do any further interventions; -He/she had not received any additional training on elopement procedures Review of the police report dated, 10/16/17, showed: -On 10/14/17, at approximately 5:17 P.M., Officer A responded to the facility regarding a missing person, later identified as Resident #1. Upon arrival he/she made contact with an employee who stated the resident left the facility through a door that did not latch around 4:00 P.M. The employee stated they had searched the facility several times and could not locate the resident. The employee stated the resident was wearing a pink sweat shirt and dark blue sweat pants. The officer left the facility and began looking for the resident in the area, but was unsuccessful. The officer later made contact with the resident's guardian who wanted to report the resident missing. On 10/15/17 , at approximately 12:30 P.M., an officer went to the resident's home to see if the resident had made it to his/her old residence. The resident was located at the residence. The resident was taken back to the facility and released to facility staff. During an interview on 10/18/17 at 6:40 P.M., Officer A said: -Dispatch received a call from the facility at 5:12 P.M. of a missing person; -He/she arrived at the facility at 5:17 P.M.; -The facility staff gave a description of the resident; -He/she was familiar with the resident when he/she lived in the community; -He/she began a search for the resident, but was unable to locate him/her; -An endangered silver alert was issued on 10/14/17; -On 10/15/17, officers went to the resident's home in the community; -The resident was at his/her prior residence; -The officers returned the resident to the facility around 1:00 P.M. During an interview on 10/15/17 at 1:30 P.M., LPN A said: -The resident was brought back by the local police department at 1:25 P.M.; -He/she was found in a family member's house. During an interview on 10/15/17 at 1:45 P.M., the resident said: -He/she had been watching the west hall exit door for several hours on 10/14/17; -The door was propped open; -He/she had a house in town and did not want to be at the facility; -He/she walked a long way down the railroad tracks; -It was raining and storming; -His/her clothes and shoes were soaked; -He/she went to his/her house where his/her family member lives. During an interview on 10/15/17 at 2:50 P.M., the Administrator said: -He had been employed at the facility since June 2017; -He had not conducted any elopement drills. During an interview on 10/16/17 at 2:00 P.M., CNA B and CNA C said: -They had both been employed at the facility for one month; -They had not received any training on the facility's elopement policy, code white or door alarms. During an interview on 10/16/17 at 2:10 P.M., Housekeeper C said: -He/she had not received any additional training on the facility elopement policy, code white or door alarms since the resident eloped. During an interview on 10/16/17 at 3:40 P.M., Public Administrator A said: -He/she was designated the resident's guardian on 8/31/17; -The resident expressed a desire to return to his/her home in the area; -The resident could not return home due to a court order to be on a secured locked behavior health unit. During an interview on 10/16/17 at 3:45 P.M., Physician A said: -Staff did not notify him/her when the resident eloped from the facility on 10/14/17; -Staff notified him/her when the resident returned to the facility on [DATE]; -He/she expected to be notified when any resident eloped from the facility at the time of elopement. During an interview on 10/16/17 at 5:00 P.M., the Administrator said: -He was not aware that elopement/code white drills should be done; -In-services on the code white policy, elopement policy and monitoring of door alarms should have been done on 10/14/17 and continued until all staff had been in-serviced; -He should have followed up on the repair of the west hall exit door; -Staff should have accompanied the paramedics to the west hall door; -Staff should have notified the physician when the resident could not be found on 10/14/17. During an interview on 10/16/17 at 5:00 P.M., the Quality Assurance Nurse said: -In-services on the code white policy, elopement policy and monitoring of door alarms should have been done on 10/14/17 and continued until all staff had been in-serviced. MO 329 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, record review, and interview 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, Resident #1 was returned to the facility by the local police department on 10/15/17. Resident #1 was placed on one on one monitoring immediately upon his/her return on 10/15/17 and continued until 10/17/17 at 12:00 P.M., when fifteen-minute checks were initiated and will continue until he/she can be assessed by his/her psychiatrist. Based upon this assessment, psychiatrist recommendations will be implemented to ensure his/her safety. A new west hall exit door alarm was ordered on [DATE] and installed on 10/16/17. At the same time, the door was adjusted so the alarm will sound if the door does not close securely. The alarm will continue sounding, until it is manually turned off with a key by the staff. A designated staff member will be assigned to make rounds of the facility and document on a log at least every four hours until the new door is installed to ensure the exit door alarms remain engaged. Thereafter, the door alarms will be tested at least once a month, per policy. Staff in-servicing was initiated on the morning of 10/15/17, and will continue until all staff have been in-serviced. Content of the staff in-service included Code White Guidelines, checking exit doors and alarms, Elopement Risk Book, identifying residents who exhibit exit-seeking behaviors, Missing Resident policy and protocol and Code White drills. All exit doors are equipped with a keypad for which a staff member must enter a code to exit the building. Only staff know the code and must physically assist any person who exits the building. A contractor was at the facility on 10/17/17 to measure and provide a bid for a new door, at which time the door will be ordered. Installation of the door will occur after it is constructed and delivered, which is expected to take approximately two to three weeks. 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 be taken to address a Class I violation

Based on record review and interviews the facility failed to follow their suicide precaution policy when they failed to notify the resident's medical physician to obtain additional services as deemed necessary; failed to notify the resident's mental health physician at the time of the incident; failed to transfer resident's who attempted or planned harm to self to a mental health facility for further evaluation; failed to establish a written care plan that included interventions taken to manage suicide/self-harm risk; failed to engage the resident in meaningful activities during his/her safety watch time period, and failed to document in the medical record related to the resident's sense of psychosocial well-being during the time the facility placed the resident on safety watch. This affected one of 10 sampled residents, Resident #8. The facility census was 43. Review of the facility's undated guide to suicide assessment included the following: - Any perceived need for suicide assessment should be directed to the charge nurse. - Self assessment (e.g. Beck Suicide Scale): Like risk factors, self-rating scale information is used to alert staff to intent, deceit and estimates of probability. - Determine Sad Persons risk factors such as depression, sickness, rational thought loss and lack of social support. - Other factors included [DIAGNOSES REDACTED]. -Available means/weapons. -Command hallucinations. Review of the facility's undated suicide precautions policy showed: - OBJECTIVE: Identify residents at risk for suicide and provide a safe environment while seeking further treatment and services to manage the underlying problem. - NOTE: The immediate goal is prevention of suicide; the long range goal is prevention of maladaptation of mental illness and providing services for the resident to establish alternative, effective coping mechanism. All threats or reference to suicide are to be taken seriously and reported to the resident's attending physician and, if applicable, the resident's guardian and/or family, for further referral or intervention. PRECAUTIONS: - A resident that attempts suicide is to be transferred to a mental health facility for further evaluation as soon as transfer can be arranged. Between the time of the attempt and until transfer, the resident is to be under constant observation. A resident determined to be a suicide risk shall have suicide precautions in place until further evaluations for treatment and mental health services. The suicide precautions are an interim measure until further evaluation and treatment can be implemented. PRECAUTIONS (continue): -Identify the seriousness of the intent when resident makes attempts, threats and suicidal comments or gives any indications that suicide is being considered. -Notify the physician of the threats and, if appropriate, orders obtained for additional services. Services might include a mental health evaluation by a mental health expert, initiation of a suicide precaution care plan, or transfer to a mental health facility. - Notify guardian/family and advise of further care planning and physician orders. - Initiate precautions such as removing all harmful objects from environment and closely observe the resident (initially one-on-one observation until transfer is deemed necessary, or 15 minute checks with frequent interactions while awake and, eventually, hourly checks until determined safe). - Continue close observations of resident's whereabouts. - Continue to engage resident in activities of interest such as exercise, reading, television and music and socialization opportunities with family, friends and staff. - Evaluate resident's condition frequently at first and then at least daily until no longer considered a risk. Make notes in the medical record related to the resident's sense of psychosocial well-being. Documentation it to be done as assessed by the nurse and as further evaluated by social services. - Establish a written care plan that includes interventions taken to manage the risk. --Administer medication as ordered and monitor side effects and advise guardian/family of effects and side effects of medication. --Continue to develop a rapport with the resident that establishes a supporting, trusting relationship. Encourage the resident to talk about his/her current situation, identify aspects that can be changed and ways of changing them; including obtaining support and help. --Observe for change in mood, such as calmness or [MEDICATION NAME], as prelude to suicide decision. 1. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally-mandated assessment completed by facility staff, dated 4/18/16, showed staff assessed the resident as follows: - Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact for decision making). - Independent with care. - No behaviors, no depression and no [MEDICAL CONDITION] - medications: [REDACTED]. Review of the resident's April 2016 physician order [REDACTED]. that affects how a person thinks, feels, and behaves). During an interview on 8/23/16 at 9:45 A.M., the resident said a few months ago he/she had been very upset; he/she had chest pains earlier in the day and was sent back to the facility from ER. When he/she returned the Administrator had gotten all over him/her for lying, telling him/her no one would ever believe him/her if he/she really got sick. He/she really had chest pains but no one at the facility believed him/her. The lecture from the Administrator greatly upset him/her to the point he/she just did not care what happened. He/she wrapped his/her call light cord around his/her neck. He/she was not thinking straight, he/she just did not care anymore about his/herself. Staff came in and removed the cord, removed all of his/her clothing except his/her underwear and put him/her in a hospital gown and cut the strings, he/she had to wear one gown forward and one backwards. He/she had to go to the day room couch to be watched until they removed everything out of his/her room except for a mattress, chair and bedside table and then he/she had to stay in his/her room unless staff escorted him/her to the shower. He/she was supposed to be in the room for a day or so but the Administrator made him/her stay in his/her room unless escorted out to the shower room for multiple days. Having to stay in his/her room increased his/her depression and made him/her feel like he/she was being punished. He/she had been placed in a room for several days for behaviors in the past. He/she tried to be good, but sometimes it seemed like his/her medications just made him/her do and say strange things. He/she liked to be social and normally went to all of the activities and visited with other residents daily in the dining room. Being stuck in his/her room in a hospital gown was awful and nothing less than punishment for his/her impulsive behavior. Review of the nurses' notes showed: - 4/27/16 at 4:00 P.M., facility received call from the resident's guardian. The resident started having chest pains and a drop in blood pressure during a stress test and had been sent to the ER. -- 5:30 P.M., resident returned from ER to the facility. - 4/28/16 at 10:15 P.M., staff answered the resident's call light; the call light was wrapped around the resident's neck. Took three staff to hold resident so cord could be removed from around his/her neck. Resident's neck contained red marks. Staff removed resident's clothing except for underwear and placed resident into a gown with the strings cut off. Resident placed in dayroom for 24 hour observation. During an interview on 8/24/16 at 1:40 P.M., and 8/25/16 at 2:05 P.M., the Administrator said she was working the floor when the resident wrapped the call light cord around his/her neck. She documented the event in the nurses' notes and placed the resident in more comfortable clothing. The resident was placed on the dayroom sofa for staff monitoring, while staff made the room safe by removing hazardous items from the resident's room. She placed the resident on 15 minute checks as part of the suicide watch. She did not send the resident out for evaluation. It was her professional judgement to keep the resident on 15 minute watch in house instead of sending him/her to the hospital. During an interview on 8/25/16, at 8:45 A.M., the social service designee said: - The Administrator was working the floor when the resident had the cord around his/her neck. - The Administrator setup the in room monitoring and removing the items from the resident's room. - When she came to work the next day the resident was on 15 minute checks; wore a hospital gown and was in his/her room on a mattress. - Staff served the resident's breakfast to him/her on paper products in his/her room. -Staff should call the physician when a resident has bad behaviors or attempts to harm his/her self. - She did not see any physician order [REDACTED].>- The charge nurse is to call the guardian if in hour monitoring and she was to call the guardian if the resident was sent out of the hospital and on to the mental health hospital. - Staff should follow the suicide policy which is a corporate policy. - The physician not the Administrator makes the decision if in-house seclusion (in room monitoring) should be started. - She had no special training on how to handle suicide or self harm behavioral issues. - All physician orders [REDACTED]. - She felt that this so called 72 hour watch was done as a punishment at times, but at other times it deemed necessary to keep the resident safe. - The facility had no monitoring tool or assessment tool to determine if in room isolation was deemed necessary. During an interview on 8/30/16, at 9:20 A.M., the medical director said: - He was the resident's physician as well as the facility's medical director. - He was unaware of any issue when the resident put a call light cord around his/her neck. - The facility should have notified him and the resident's mental health physician at the time of the incident. - The facility should have obtained orders on how to handle the resident related to the cord around the neck issue. - The facility should have followed their suicide guidelines (policy). - The facility should have formal guidelines for in house/room monitoring; on when it was appropriate to be used; and how it was to be conducted. - He was unaware the facility placed resident's in their room for monitors with only a mattress or bed, table and chair. - A five day in room monitoring seemed extreme. During an interview on 8/25/16, at 8:41 A.M., the resident's guardian, Public Administrator A said: - The facility notifies him/her when the resident has behaviors and they put his/her on watch. - He/she was told the facility had the resident on suicide watch, but not sure if it was in April. - He/she did not know what the facility's suicide watch consisted of nor did she know who long the suicide watch lasted. - The Administrator or social service designee discussed with her when the resident has issues. They discuss if the resident should be sent on for evaluation at a mental health hospital but they felt it was just the resident protocol for attention seeking and decided not to send him/her out. - The facility is the expert on mental health issues and knows what is best for the resident. - The resident likes to go to the hospital. He/she thought the resident looked at the hospital as a vacation. - He/she expected the facility to keep the resident safe and to know how to best treat his/her behaviors. Review of the facility's 15 minute check form dated 4/28/16, showed resident in living room (TV area across from nurses' station) from 10:15 P.M., until midnight. The form showed the reason for the 15 minute checks was suicide watch Review of the facility's 15 minute check form dated 4/28/16, showed from midnight to 5:45 A.M., on the 29th the resident was located in the living room. The formed showed the reason for the 15 minute checks as suicide watch. Review of the facility's 15 minute check form dated 4/29/16 from 6:00 A.M. until 7:45 A.M., showed resident sleeping in the phone room. (Adjacent to the nurses' station) Review of the facility's 15 minute check form dated 4/29/16, showed from 8:15 A.M. until 5:45 A.M. on 4/30/16, resident in resident's room except for 15 minutes spent in social service office and meals spent in the dining room. The formed showed the reason for the 15 minute checks was suicide watch. During an interview on 8/25/16, at 8:35 A.M., Social Worker A said he supervised Social Worker B, he had known the resident for a long time. Mental health residents are difficult to manage since they are smart enough to work the system. The resident cries out for attention, sometimes residents like this resident who seek attention will actually harm his/herself unintentionally while trying to get the attention they seek. The facility really needs to keep an eye on the resident when he/she is in the state of mind to try to harm self for attention and obtain guidance from the resident's medical physician or mental health physician. Review of the resident's psychological services session dated 4/29/16 showed Therapist A said staff reported the resident put a call light cord around his/her neck last night. Regarding this, resident described the incident as an impulsive action and that he/she did not want to die. Resident depression on a scale of 1-10, rated as a8, prior to this the resident's depression score was a 3 to 4. During a phone interview on 8/25/16, at 10:15 A.M., Social Worker B said, he visited with the resident on 4/29/16, a few hours after the cord around the neck incident. It was his regular day to visit residents at the facility. The resident was in his/her room on a mattress, in a hospital gown when he went to visit with the resident. His position is one of a sympathetic ear for the resident. The facility did not ask his opinion of the resident's mental health or mood. He/she was not qualified to say if the way the facility treated the resident after the cord incident was appropriate. Staff must make sure residents are safe and it was up to the resident's primary physician to say if their actions were appropriate for this specific resident. Review of the facility's 15 minute check form dated 4/30/16, showed from 6:00 A.M. until 5:45 A.M. on May 1st resident in resident room, shower or bathroom; except between 10:15 A.M., and 11:30 A.M., some one wrote food for location and eating for what resident was doing. Staff marked the resident was on bed, in chair, in door way standing or laying down in the section doing what?. The form showed the reason for the 15 minute checks was suicide watch. Review of the nurses' notes dated 4/30/16 (no time noted) showed resident remains in room with mattress on floor. Comes to dining hall for meals, eats on paper products. During an interview on 8/24/16, at 2:42 P.M., Charge Nurse B said: - He/she worked the week-end of 4/30/16, was told in report the resident had put a call light cord around his/her neck resulting in red marks around his/her neck. - The resident was in his/her room on a mattress, dressed in a hospital gown. The room also contained a bed side table and chair. - The curtains had been removed from the windows. - The resident's meals were served in the resident's room on paper products. - Nursing staff were responsible for the 15 minute checks and they were to make sure he/she was safe, breathing and were to document where he/she was in the room and what he/she was doing on the monitoring form. - The resident's corridor door remained open. The resident was not allowed to come out of the room. - The facility usually sends residents out to the hospital for a mental health evaluation if they attempt to harm self or others. - He/she had never seen a policy on what should happen and why, when a resident tried to harm his/herself. - He/she was unaware of any assessment form related to suicide of self harm. - He/she would have sent the resident out for an evaluation if he/she felt the resident was a harm to self. - He/she did not know why the resident had been placed on 15 minute checks and in room monitoring if the Administrator had not thought the resident was a threat to his/her self. - The resident is attention seeking. Record review showed no 15 minute monitoring form was found for May 1st., which was for the time period beginning at 6 A.M. on May 1st until 5:45 A.M. on May 2nd. During an interview on 8/24/16, at 5:08 P.M., Charge Nurse A said: - If residents happen to make a statement or attempt to hurt themselves the Administrator places them on watch (monitoring). - The resident's room will be modified to consist of a mattress on the floor, a chair and a table. - Dietary staff brings their food to their room on paper plates with plastic silverware. - There is nothing in the residents room that they could use to harm his/herself. - Last time Resident #8 was on watch, he/she was told in report the resident was allowed to get dressed and go to the dining room with his/her one-on-one staff. The Administrator come to work later and let him/her know that was not allowed and the resident was sent back to his/her room and placed back into the hospital type gown. - Resident #8 is attention seeking. He/she has multiple issues and the 72 to 96 hours behavior monitoring usually deescalates the behaviors. - He/she was not working the night the resident wrapped the call light cord around his/her neck. He/she did not see the marks on the resident's neck. - There was no assessment form to determine the need for intensive behavior monitoring. - He/she was informed the decisions for behavior monitoring was made by the Administrator. - He/she had never seen a physician's orders [REDACTED]. - Staff document very little while the resident is in intensive monitoring other than the person responsible to document on the 15 minute checks form. That staff member writes down where the resident is located (bed, chair, bathroom) and what they are doing (sleeping, standing, sitting, etc.). - The 15 minutes checks are usually done by one of the certified nurse aides (CNAs) assigned to do them. He/she had the CNAs walk by and look in but were not to engage in conversation with the resident, so it was not a reward to be placed on watch. - Nursing is not involved in any decisions related to the behavior monitoring conducted in the resident's room. - He/she was unaware if administrative staff contacted the resident's mental health physician before or during the resident being placed into his/her modified room. During an interview on 8/24/16, at 3:05 P.M., Charge Nurse C said, if a resident threatens to harm self or if they say they want to die they are put on suicide watch. He/she worked part of the week-end in April when the resident was on in room watch/monitoring. The Administrator determines who is put on the watch and when they go off the suicide watch. Usually the watch is for 72 hours but that is determined by the Administrator. If the resident does not have a roommate they remove everything from the room except for a bed, chair and small table. Sometimes it is just a mattress on the floor for a bed and other times the frame and mattress is left. He/she could not remember if the resident was placed in a hospital type gown or not. Sometimes that happened and other times not. He/she was aware of at least four residents who had been on suicide/behavior watch at one time or another but did not remember the dates. During an interview on 8/26/16, at 4:10 P.M., the housekeeping supervisor said when a resident is placed on suicide/behaviors monitoring staff remove everything from the resident's room except a bed or mattress, a table, a chair, trash can and a blanket. If the resident has a roommate they move the resident into a room at the end of 300 hall, with only the same items. Her staff were allowed to clean and room daily. Suicide/behavior monitoring has happened a few times, but not often. When Resident #8 was on monitoring one time they only had a mattress on the floor and another time the complete bed was left in the room. She could not remember if they removed the curtains in this resident's room or not; they had been instructed at one time or another to remove curtains. What they leave in the room all depends on what they are instructed by the Administrator to do. During an interview on 8/25/16, at 3:05 P.M., the dietary manager said when residents are placed on suicide/behavior monitoring her staff sometimes takes meals to the room on paper products and other times they come to the dining room with their staff escort. They served the resident on paper products. He/she had not seen the resident in the dining room in hospital gowns but he/she did not work evenings or week-ends. Review of the 15 minutes checks showed the resident remained on 15 minute checks on May 2nd and May 3rd until 5 P.M. The form said the purpose of the 15 minute checks was for suicide risk. Review of the resident's chart showed no nurses' notes between 5/1/16, and 5/14/16. During an interview on 8/25/16, at 1:40 P.M., the Administrator said they were unable to locate any nurses' notes on the resident for the time period 5/1/16 until 5/14/16. Review of the resident's current care plan last reviewed on 6/22/16, showed: - PROBLEM: 4/10/13, Resident self-mutilation at times by pinching and/or hitting self. - GOAL: Resident will seek out staff members if the feeling of harming self emerges though the review date in 90 days (Goal date 10/13/16). -APPROACH: Resident would like staff to encourage him/her to talk about his/her feelings he/she is having before the behaviors of self-mutilation occurs to establish trust. Resident would like staff to observe his/her behaviors frequently through routine activities. Resident would like staff to report any bruising he/she has to the nurse. No new approaches started since 4/10/2013. - PROBLEM: Resident comes to staff several times with medical problems due to attention seeking behaviors. - GOAL: Resident will have no more than three attention seeking behaviors in a week thought eh nest review of 10/13/16. - APPROACH (started 4/10/13): Staff to encourage resident to participate in activities to provide socialization. Staff to re-direct resident's attention seeking behavior in a calm manner to decrease agitation and to validate resident's feelings. Staff are to provide one-on-one sessions as needed to build a trusting relationship. No new approached started since 4/10/13. The care plan contained no information related to the resident's attempted suicide or self-harm related to the cord wrapped around the resident's neck in April 2016 nor did the care plan mention in house/room extensive monitoring done in April/May of 2016. During an interview on 8/25/16 at 9:50 A.M., the care plan coordinator said: - He/she started at the facility in May. - He/she was unaware of the residents attempt to do self-harm. - He/she knew nothing about in room monitoring. - A new care plan should have been written related to the resident attempt at self-harm. - A care plan should have been written for in house/room monitoring. - The residents care plan should have been updated related to the resident's behavior and there should have been a suicide prevention care plan. - Anyone reading the care plan should be able to know the resident's current needs. During an interview on 8/25/16, at 10:20 A.M., the Administrator said: - They called their in house/room monitoring a 72 hour watch. - Professional nursing opinion deems if the watch is needed longer than 72 hours. - They had no formal written documentation of how they determined monitoring is needed or if extended monitoring is needed. - The nurses should have notes related to the resident's behavior and some type of an assessment documented. - If resident have a plan for self-harm, staff are to call the physician to see if the resident needs to be sent out to the hospital or if the 72 hour watch is sufficient. - If a resident is sent to the local hospital they do a video chat with a mental health specialist from a mental health hospital. The person on the other end of the video chat determines if the residents needs to be sent on and if a bed is available. - They notify the guardian if the resident is to be sent out or if they are sending the resident back to the facility from the local hospital. - Staff would notify the resident's mental health physician if we thought a [MEDICAL CONDITION] medication was part of the issue. - Residents who would need 72 hour monitoring would be residents who had a plan to harm self and the hospital sent them back to us. - When that happens staff write a new care plan (significant change) related to the behavior. - During the 72 hour watch, staff remove everything from the resident's room (or a different room if they have a roommate) that could be harmful. Beds would not be harmful but TV and radios might be and are not left in the resident's room. Clothing without strings would be ok, but no shoes. Most residents would be allowed to go to the dining room for meals but it would just depend on the situation. - If on 15 minute checks, residents can come out of their rooms and walk around, can go to the TV room and to activities. - We determine if a resident can come off 72 hour watch by his/her actions and behaviors. - Staff are to call the primary physician when a 72 hour watch is needed. - If residents have a behavior such as an angry outburst staff will place them on a 15 minute watch. - They have conducted 72 hour watches on a few residents when deemed necessary. - Staff do not document our plans or interactions while a residents is on 72 hour watch other than the information on the 15 minute check list. - She would expect nurses to document what is going on with the residents while they are on the 72 hour watch in the nurses' notes. - Probably should have physician orders [REDACTED]. - They do not obtain physician orders [REDACTED]. - She had no prior mental health training other than what was received working at the facility. - Staff received CALM (Crisis, Aggression, Limitation and Management training program is an approach to aggression management) but no other training related to working with mental health residents. Record review of a session dated 5/15/16, from the Mental Health Physician showed: - Resident attempted suicide three weeks ago. - Resident stated he/she heard voices that tell me people don't care about you. - Resident stated I did something stupid, I tried to commit suicide three weeks ago. - Resident said, the Administrator had talked to him/her and called him/her a liar and would not listen to him/her which made the resident feel like a pea-on so he/she went to his/her room and took a cord and wrapped it around his/her neck. The Administrator made him/her feel this small (and he/she holds fingers up and shows small amount). - Resident stated he/she was not going to let the Administrator get to him/her anymore. - Resident reports depression now. - Physician increased the residents Trazadone (an antidepressant) from 100 milligrams (mg.) to 150 mg. and increased the resident's 25-100 mg. [MEDICATION NAME] (medication that helps to decrease tremors) from three times daily to four times daily and changed the resident's [MEDICATION NAME] (an antipsychotic used to treat a number of mental illnesses, including depression) 10 mg twice daily to [MEDICATION NAME] 30 mg at night time. -Physician marked the resident's thought content as hopeless and worthless and marked mood as depressed with impaired abstract thinking and judgement. During an interview on 8/24/16 at 2:20 P.M. CMT A said: - He/she was recently hired in April; - He/she saw Resident #8 dressed in two hospital gowns, in a room sitting on a mattress; - The mattress, blanket and pillow were the only things in the room; - Other staff said the resident was on suicide watch; During an interview on 8/24/16 at 8:10 A.M., the Director of Nurses said: - He/she had no input on resident behaviors and suicide watch; - Decisions on residents placed on suicide watch, and how long they remain on the watch, are made by the Administrator; - Residents who go on suicide watch are not always transferred to the emergency room for evaluation, and he/she does not know if the family and physician are notified by the Administrator. During an interview on 8/24/16 at 2:55 P.M. Certified Medication Technician (CMT) B said: - Some resident threats of suicide are sent out for psychiatric evaluation and some are not, but he/she did not know how it was decided; - Residents who threaten suicide are put on a 72 hour watch in a room with only a mattress, pillow, and blanket; - Meals are brought to the room on Styrofoam plates with plastic utensils; - Residents are placed on one on one observation or 15 minute checks, depending on the severity of the behaviors; - Residents #5, #8, and #9 have been on 72 hour watch; - One resident (Resident #8 ) was placed in two hospital gowns and not allowed to wear regular clothes. During an interview on 8/24/16 at 3:15 P.M. the Activity Director said: - When residents are on suicide watch, they cannot leave the room, except for showers; - Meals are served in the room on Styrofoam plates and plastic utensils; - Suicide watches last at least 48 hours and are decided by the facility Administrator; - Residents threatening suicide are not always sent to the emergency room and he/she is unsure if the physician and family are notified; - Residents are monitored every 15 minutes during the watch.