Every finding on record at Highland Rehabilitation & Health Care Center

Based on interview and record review, the facility failed to provide resident-specific behavioral health training to staff who are responsible for providing care to one sampled resident (Resident #1) out of ten sampled residents, with a known history of aggressive behaviors. The facility census was 119 residents.1. Review of Resident #1's admission Record Face Sheet dated 8/13/26 showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizoaffective disorder, (a mental health disorder that can cause unusual thoughts or perceptions along with significant changes in mood);-Psychotic disorder with delusions due to physiological condition, (a mental heath disorder involving impaired perception of reality and firmly held false beliefs);-Anxiety disorder, (a mental health disorder characterized by excessive fear, worry or nervousness);-Hostility, (anger, antagonism or opposition toward others);-Schizoaffective disorder, bipolar type, (a mental health disorder that can cause unusual thoughts and perceptions along with extreme highs and lows in mood);-Suicidal ideations, (thoughts about ending one's own life). Review of the resident's Care Plan Report dated 8/18/26 showed:-He/She had potential for behavioral problems due to his/her history of multiple mental health diagnoses;-He/She had delirium or an acute confusional episode;-On 7/19/26 he/she called the police stated a medication technician kidnapped him/her 20 years ago and there were a bunch of dead bodies in the basement;-On 8/13/26 he/she accused a staff member of telling him/her to touch him/herself;-He/She had assault charges pending against him/her;-On 8/13/26, 15-minute checks were initiated, and the Psychiatric Nurse Practitioner (PNP) was to review him/her medications.-On 8/18/26, he/she kicked a chair from under another resident's feet;-On 8/18/26, he/she had a verbal altercation with a peer;-Interventions included: facing the resident when speaking; reducing distractions; using simple, directive, consistent sentences; providing him/her with necessary cues, stop and return if agitated; reviewing chart to establish baseline level of functioning; care in pairs was initiated; he/she was given a private room; he/she was to be redirected to another table if another resident was sitting in his/her preferred seat; activities of his/her choosing were to be offered to him/her; a structural calendar would be made for him/her to be engaged in activities of his/her choosing; activities staff would provide 1:1 services daily during the week for 15-30 minutes; staff would continue to observe and report any further episodes of concerns and report pertinent changes; administration of medications per orders with monitoring for side effects and effectiveness; monitoring behavior episodes and attempt to determine underlying cause, persons involved and situations and document; anticipate and meet his/her needs.During an interview on 8/21/26 at 12:37 P.M., PNP said:-He/She had been seeing the resident weekly and although the resident told him/her he/she was having hallucinations/delusions at night, he/she refused to be specific regarding what those hallucinations/delusions were;-Because the resident was sleeping through the night and late into the mornings, he/she did not believe the resident was truly having those symptoms but rather using that as a means of manipulation;-He/She had been educating staff regarding ways to de-escalate the resident and felt the staff was doing that each time he/she escalated;-He/She felt the hardest part with this resident was that his/her triggers changed from day to day so it was impossible to predict what would set him/her off;-Most interventions attempted had failed as each time the staff did what the resident wanted or needed, the next time they tried the same interventions, they no longer worked.-He/She believed the resident's verbal altercations could eventually escalate to physical behavior which could put other residents and staff at risk.-He/She would not have recommended admission to the facility had he/she known the details of the resident's previous facility. During an interview on 8/24/26 at 11:25 A.M., Registered Nurse (RN) A said:-The staff do not have training specifically individualized to each resident's behaviors.-He/She was not usually on the floor with the resident.-He/She would get a text from other staff that the resident was having behaviors, what they tried to calm him/her, what worked and what did not.-He/She would assist the floor staff in any way he/she could.-The resident was there now, and they were doing the best they could with him/her. During an interview on 8/24/26 at 11:50 A.M., Licensed Practical Nurse (LPN) A said:-The resident was placed on 1:1 observation on 8/21/26 and remained on 1:1;-The staff have discussed redirection of the resident, but it would depend on his/her mood; -The resident's moods were not always the same;-His/Her verbal aggression had escalated in the past week;-The staff did not have any training specific to the resident or how to handle his/her behaviors;-It would be helpful to get some training specific to the resident's needs. During an interview on 8/24/26 at 12:40 P.M., Certified Nursing Assistant (CNA) A said:-He/She did not know the resident's triggers.-He/She did not have training specific to the resident's behavioral needs. During an interview on 8/24/26 at 1:05 P.M., Traveling RN, acting Director of Nursing (DON) said:-They have not had specialized training regarding this resident because his/her behaviors escalated so quickly;-His/Her aggression had only been going on for about a week;-There had not been any physical aggression by the resident yet;-They verbally tell the staff about redirection, but they do not have any formal training.-It would have been good to know more about the resident's behaviors before agreeing to admit him/her;-There should probably be a broad spectrum of training for the staff, which was hard to do with agency and revolving staff. During an interview on 8/24/26 at 1:45 P.M., the MDS Coordinator said:-The company has computer-based training with questions and videos about behaviors; -They constantly have education based on addressing resident behaviors;-The residents have care plans anyone could look at. During an interview on 8/24/26 at 3:00 P.M. the Administrator said:-The hospital did not give them accurate information regarding the resident's previous facility or informed them of his/her outstanding assault charge or they would not have taken him/her;-There was nothing in place to manage her behaviors initially because he/she had not been having them.-It was only recently that his/her behavior started escalating;-He/She thought the team responded appropriately to the resident's behaviors. During an interview on 8/24/26 at 2:45 P.M., the Social Worker said:-He/She was only involved with the resident's admission in a Zoom interview with the resident and the hospital Social Worker.-Prior to his/her admission, he/she was not made aware of the resident's diagnoses;-They received the resident's PASSR on the day the resident was admitted ;-They were not aware that the resident's previous facility would not take him/her back, nor were they aware he/she had outstanding assault charges until he/she was admitted ;-He/She did not know who made the decision to admit the resident and he/she did not think the resident was appropriate for this facility.-The staff do not have any training for individualized care of the resident that he/she was aware of. 3158019

Based on interview and record review, the facility failed to develop and implement an individualized plan of care to manage the known behavioral health needs of one sampled resident, (Resident #1), of nine sampled residents. The facility census was 119 residents.1. Review of Resident #1's admission Record Face Sheet dated 8/13/26 showed he/she was admitted to the facility on [DATE] with the following diagnoses:-Schizoaffective disorder, (a mental health disorder that can cause unusual thoughts or perceptions along with significant changes in mood);-Psychotic disorder with delusions due to physiological condition, (a mental health disorder involving impaired perception of reality and firmly held false beliefs);-Anxiety disorder, (a mental health disorder characterized by excessive fear, worry or nervousness);-Hostility, (anger, antagonism or opposition toward others);-Schizoaffective disorder, bipolar type, (a mental health disorder that can cause unusual thoughts and perceptions along with extreme highs and lows in mood);-Suicidal ideations, (thoughts about ending one's own life). Review of Resident #1's Quarterly Minimum Data set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 7/26/26, showed he/she was cognitively intact. Review of the resident's Care Plan Report dated 8/18/26 showed:-He/She had potential for behavioral problems due to his/her history of multiple mental health diagnoses.-He/She had delirium or an acute confusional episode;-On 7/19/26 he/she called the police and stated a medication technician kidnapped him/her 20 years ago and there were a bunch of dead bodies in the basement;-On 8/13/26 he/she accused a staff member of telling him/her to touch him/herself;-He/She had assault charges pending against him/her;-On 8/13/26, 15-minute checks were initiated, and the Psychiatric Nurse Practitioner (PNP) was to review his/her medications.-On 8/18/26, he/she kicked a chair from under another resident's feet;-On 8/18/26, he/she had a verbal altercation with a peer;-Interventions included: facing the resident when speaking; reducing distractions; using simple, directive, consistent sentences; providing him/her with necessary cues; stop and return if agitated; reviewing chart to establish baseline level of functioning; care in pairs was initiated; he/she was given a private room; he/she was to be redirected to another table if another resident was sitting in his/her preferred seat; activities of his/her choosing were to be offered to him/her; a structural calendar would be made for him/her to be engaged in activities of his/her choosing; activities staff would provide 1:1 services daily during the week for 15-30 minutes; staff would continue to observe and report any further episodes of concerns and report pertinent changes; administration of medications per orders with monitoring for side effects and effectiveness; monitoring behavior episodes and attempt to determine underlying cause, persons involved and situations and document; anticipate and meet his/her needs. Review of the resident's Progress Note dated 8/19/26 at 10:00 P.M. showed:-At approximately 9:00 P.M. staff heard voices coming from the common area;-Upon arrival, the nurse observed the resident and another resident engaged in a loud verbal altercation;-The nurse intervened and stepped between both residents;-Both residents were using aggressive language toward one another;-The nurse asked one resident to sit at another table;-Orders were received that the resident should be placed on 15-minute checks. Review of the resident's Progress Note dated 8/21/26 at 5:44 A.M. showed the resident remained on 15-minute checks. Review of the resident's Progress Note dated 8/21/26 at 9:23 A.M. showed:-He/She walked into the dining room and pulled a chair that another resident was using to elevated his/her legs away from him/her causing his/her legs to drop and stated, Move;-The resident was educated that this was inappropriate behavior and there were other seats he/she could sit in. Review of the resident's Progress Note dated 8/21/26 at 10:50 A.M. showed:-The resident experienced a change in condition.-The change in condition the resident was currently experiencing was the nurse reported verbal threats and allegations from the resident and refusing his/her medications. Review of the resident's Psychiatry Note dated 8/21/26 at 11:32 A.M. showed:-The resident had continually persisted with significant delusional/paranoid behavior and agitation/irritability/threatening behavior that continued to escalate despite multiple pharmacological/non-pharmacological interventions;-He/She had several aggressive/accusatory outbursts that have made other residents fearful.-Staff reported he/she was now refusing medications;-The resident's guardian recommended crushing the medications and if that did not work to send him/her to the hospital;-It was his/her professional opinion that the resident posed a significant safety risk to staff and residents at that time and hospitalization was necessary in order to deescalate and stabilize. During an interview on 8/20/26 at, the Maintenance Director said:-He/She brought five residents down to the first floor to visit the country store;-The residents got in line;-The resident and another resident began arguing over who should be before the other in the line order, and they began getting loud;-The resident was crowding the other resident;-The resident made a comment, but he/she did not hear it;-He/She told them if they did not stop, they would have to go back to their rooms.-At that point, they stopped and were quiet. During an interview on 8/21/26 at 3:00 P.M., the Assistant Director of Nursing (ADON), Director of Nursing (DON) and the Administrator said:-The facility had minimal information regarding the resident prior to admission;-The resident had been doing well at the inpatient psychiatric facility, and they believed the resident would continue to do well at this facility;-They did not contact the resident's previous facility to obtain addition information regarding the resident's previous behaviors prior to him/her admission to the facility;-They were aware the resident had a pending assault charge but were not aware of the circumstances and did not contact anyone to obtain additional information. During an interview on 8/24/26 at 1:15 P.M., Resident #2 said:-The resident screamed and cursed at staff after staff intervened regarding him/her taking another resident's belongings;-The resident called him/her a fat ass bitch and a stupid ass bitch and told him/her to stop looking at him/her;-Later, the resident went to the nurses' station and cursed and spit towards the staff;-The resident followed him/her and tried to instigate confrontations with him/her;-He/She moved away from the resident and asked staff to intervene if he/she followed him/her;-He/She was afraid of the resident when he/she was around because he/she did not know if the resident was all talk or would actually hit him/her. During an interview on 8/24/26 at 11:50 A.M., Licensed Practical Nurse (LPN) A said:-The resident was placed on 1:1 observation on 8/21/26 and remained on 1:1 observation;-Staff had discussed redirection, but the effectiveness of redirection depended on the resident's mood, which varied;-The resident's verbal aggression had escalated during the previous week;-The resident sometimes became upset when redirected and did not respond well to redirection;-The staff gave the resident space when possible;-Prior to the 1:1 observation, there was no specific plan for managing the resident's behaviors. During an interview on 8/24/26 at 1:05 P.M., the Traveling Director of Nursing (DON) said:-The resident's behaviors had escalated quickly.;-The resident's verbal aggression had been occurring for about a week;-At that point, there had not been physical aggression;-The resident initially appeared appropriate for the facility because there had been no significant negative behaviors until recently, but the facility might not have had the entire picture;-When the resident became verbally aggressive, staff attempted to redirect him/her, including asking if he/she wanted to move to another area or talk;-Staff had been verbally instructed regarding redirection, but here had been no resident specific training. During an interview on 8/24/26 at 1:45 P.M., the MDS Coordinator said:-He/She was the resident's MDS Coordinator;-He/She could not say whether there had been concerns regarding the resident's admission;-Care in pairs for the resident was implemented almost immediately,-Care plans were available to staff;-If the resident began escalating behavior, staff were to report it to the charge nurse and contact psychiatric services. During an interview on 8/24/26 at 2:45 P.M., the Social Worker said:-The interdisciplinary team (IDT) developed the resident's care plan interventions;-The resident had been on 15-minute checks prior to being placed on 1:1 observation;-Activities staff began meeting with the resident on 8/18/26, and planned to make a calendar the resident could follow with structured activities and individual attention;-One of the social services staff met with the resident daily;-The interventions were implemented recently and were not in place when the resident was admitted to the facility. During an interview on 8/24/26 at 3:00 P.M., the Administrator said:-There was nothing in place initially to manage the resident's behaviors because he/she had not been exhibiting behaviors;-The resident stayed primarily in his/her room;-The resident's behaviors began escalating within approximately the last week;-The facility responded to the resident's behaviors as they developed. 3158019

Based on interview and record review, the facility failed to ensure a safe and appropriate discharge for one sampled resident (Resident #1) out of three sampled residents when on 8/09/26 the resident was sent to the hospital Emergency Department (ED) with the intention of not taking the resident back after emergency care was provided and the resident had returned to baseline. The facility census was 121.At the time of exit the following policies were requested from the facility but were not received:-Transfer and Discharge;-Discharge Planning;-Safe Discharge;-Resident Rights. 1. Review of Resident #1's face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses:--Schizoaffective Disorder, Bipolar Type (a subtype of a very serious mental health condition called schizoaffective disorder. This mental illness is a combination of symptoms of schizophrenia and symptoms of a mood disorder).--Unspecified Mood Disorder (mood disturbances that do not meet the criteria for any specific mood disorder).--Borderline Personality Disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life).--Mild Intellectual Disabilities (previously known as mild mental retardation-refers to deficits in intellectual functions pertaining to abstract/theoretical thinking).--Dementia (a condition that affects memory, thinking and the ability to perform daily activities) with Agitation.--Post Traumatic Stress Disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it).--Suicidal Ideation (suicidal thoughts-occurs when you think about or consider death or suicide).--History of Suicidal Behavior (any action that could cause a person to die, such as taking a drug overdose or crashing into a car on purpose).--History of Traumatic Brain Injury (a brain injury that is caused by an outside force).--Epilepsy (a brain condition that causes recurring seizures). Review of the resident's care plan dated 05/9/26, showed:-The resident wished to discharge back to the community in a few months, if possible.-Staff was to evaluate the resident's motivation to return to the community.-The resident had impaired cognitive function or impaired thought processes.-The resident had a public administrator in place. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used by facility staff for care planning) dated 05/14/26, showed:-The resident was cognitively intact.-The resident had a serious mental illness. During an interview on 08/10/26 at 3:35 P.M. hospital Registered Nurse (RN) A said:-The resident was dumped at the hospital ED without a safe place to return to and the facility refused to accept the resident back.-On 08/9/26, the facility staff delivered an immediate discharge notice to the hospital ED staff.-The resident's legal guardian was unaware of the emergency discharge. Review of the Notice to Transfer/Discharge form dated 08/10/26 showed:-The resident had a representative. -The date of transfer/discharge was 08/10/26 and it was immediate.-The resident was discharged to a hospital and included the name and address of the hospital. -The reason for discharge/transfer was necessary for the welfare of the resident. -The needs of the resident could not be met at the facility. -The Administrator of the facility signed in the facility representative line and was dated 08/10/26. Review of the resident's progress note dated 08/10/26 at 10:00 P.M. showed:-The resident was transported to the hospital by Emergency Medical Services (EMS) after eloping from the facility.-The Administrator and Interim Director of Nursing (DON) went to the hospital to administer an immediate discharge notice to the resident in the ED.-The Administrator and DON gave the emergency room charge nurse a copy of the emergency discharge paperwork and left the hospital. During an interview on 08/12/26 at 4:15 P.M. Social Services A said:-The resident was issued an immediate discharge in the hospital ED.-He/She was not involved in the immediate discharge process.-The Administrator and the interim DON issued the immediate discharge notice.-He/She was unsure if the emergent discharge notice was given to the resident or hospital staff. -It was facility policy that residents could not be discharged to acute care settings, such as the hospital unless there was a documented reason.-He/She had no contact with the resident, Ombudsman, or the resident's guardian during the emergency discharge process. During an interview on 08/12/26 at 4:40 P.M. Social Services B said:-He/She was not involved in the emergency discharge of the resident.-The Interim DON and Administrator were the ones who issued the emergency discharge.-Prior to the emergency discharge being administered, he/she was working with the resident's guardian to try to get the resident transferred to another facility. During an interview on 08/12/26 at 7:15 P.M. Interim DON said:-The resident was issued an emergency discharge to the hospital. -The discharge notice was delivered to the ED by himself/herself and the Administrator.-The ED nurse was the person who was handed the emergency discharge paperwork. -He/She understood that a resident could not be discharged to a hospital setting unless there was a documented reason.-He/She expected that a resident be discharged to a safe environment and the facility policy be followed.-The facility felt that the emergency discharge to the hospital was in the best interest of the resident and other residents in the facility due to the resident's unsafe behaviors and history of elopements. During an interview on 08/12/26 at 7:30 P.M. Administrator said:-He/She delivered the resident's emergency discharge letter to the ED staff at the hospital with the interim DON. -The resident was not properly discharged per policy, and corrective action was put into place.-He/She knew that a resident could not be discharged to a hospital setting unless there was a documented reason. -He/She expected facility policy to be followed when residents were transferred or discharged from the facility. During an interview on 08/13/26 at 3:00 P.M. the guardian said:-He/She was the resident's guardian and was not notified of the immediate discharge until after the discharge was issued.-The facility did not give the resident a chance to appeal the immediate discharge.-He/She was not offered a chance to appeal the resident's discharge.-The resident was released from the hospital, and he/she was told by the hospital staff that the resident was discharged to a homeless shelter. -He/She was in the process of starting the appeal process on the resident's behalf. -He/She would have expected the facility to find the resident a safe place to be transferred to before issuing an immediate discharge. During an email interview on 08/13/26 at 3:00 P.M., Ombudsman said:-The facility did not give a proper discharge and/or discharge notice to the resident or the resident's guardian.-The facility listed the hospital as the place of discharge. 3154137

Based on interview and record review, the facility failed to implement safe discharge planning when on 8/10/26 the facility issued an emergency discharge notice to one sampled resident (Resident #1) with the intent of not taking the resident back after returning to baseline out of three sampled residents. The facility census was 121. At the time of exit the following policies were requested and were not received:-Transfer and Discharge;-Discharge Planning;-Safe Discharge;-Resident Rights. 1. Review of Resident #1's face sheet showed he/she admitted [DATE] with the following diagnoses:--Schizoaffective Disorder, Bipolar Type (a subtype of a very serious mental health condition called schizoaffective disorder. This mental illness is a combination of symptoms of schizophrenia and symptoms of a mood disorder).--Unspecified Mood Disorder (mood disturbances that do not meet the criteria for any specific mood disorder).--Borderline Personality Disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life).--Mild Intellectual Disabilities (previously known as mild mental retardation-refers to deficits in intellectual functions pertaining to abstract/theoretical thinking).--Dementia (a condition that affects memory, thinking and the ability to perform daily activities) with Agitation.--Post Traumatic Stress Disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it).--Suicidal Ideation (suicidal thoughts-occurs when you think about or consider death or suicide).--History of Suicidal Behavior (any action that could cause a person to die, such as taking a drug overdose or crashing into a car on purpose).--History of Traumatic Brain Injury (a brain injury that is caused by an outside force).--Epilepsy (a brain condition that causes recurring seizures). Review of the resident's care plan dated 05/09/26, showed:-The resident wished to discharge back to the community in a few months, if possible.-Staff was to evaluate the resident's motivation to return to the community.-The resident had impaired cognitive function or impaired thought processes.-The resident had a public administrator in place.-There were no discharge planning updates. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used by facility staff for care planning) dated 05/14/26, showed:-The resident was cognitively intact.-The resident had serious mental illness. During an interview on 08/10/26 at 3:35 P.M. hospital Registered Nurse (RN) A said:-The facility staff delivered an immediate discharge notice to the hospital Emergency Department (ED) staff while the resident was being evaluated.-He/She was the nurse who the facility staff gave the immediate discharge paperwork to.-The facility did not provide appropriate medical records to the hospital to ensure continuity of care. -The ED physician was not a continuing care provider and wanted to discharge the resident back to the facility, but the facility refused to accept the resident back. -The facility never contacted the resident when he/she was in the ED.-At the time that the notice was delivered to the ED staff, the resident was not aware that he/she was being discharged from the facility. -The resident was not admitted to the hospital. -The resident had a legal guardian from another county and was not his/her own person.-The resident's guardian was unaware of the emergency discharge when contacted by hospital staff about the immediate discharge being delivered to the resident in the ED. Review of the resident's progress note dated 08/10/26 but was referencing 08/9/26 at 7:10 P.M. showed:-The resident was transported to the hospital by Emergency Medical Services (EMS) after eloping from the facility.-The resident agreed to go to the ED to get checked due to walking outside in the heat.-The resident was transported via EMS to the hospital at around 10:00 P.M. on 08/9/26.-The Administrator and Interim Director of Nursing (DON) went to the hospital to administer an immediate discharge notice to the resident in the ED.-The Administrator and DON gave the ED charge nurse a copy of the emergency discharge paperwork and left the hospital.- A verbal report of current and historical behaviors was given to the hospital ED nurse. -No discharge summary, care plan or nursing notes were given to the hospital staff.-No personal belongings were given to the hospital staff.-None of the residents' medications were given to the hospital staff. Review of the resident's Notice to Transfer/Discharge form dated 08/10/26, showed:-The resident had a representative. -The date of transfer/discharge was 08/10/26 and it was immediate.-The resident was discharged to a hospital and included the name and address of the hospital. -The reason for discharge/transfer was necessary for the welfare of the resident. -The needs of the resident could not be met at the facility. -The Administrator of the facility signed in the facility representative line and was dated 08/10/26. Review of the resident's Electronic Medical Record (EMR) on 08/12/26 at 3:00 P.M., showed: -No discharge summary that included:--Recapitulation of stay.--Disposition of the resident.--Disposition of the resident's belongings.--Reconciliation of the resident's medication.--Discharge plan of care. During an interview on 08/12/26 at 4:15 P.M. Social Services A said:-He/She was responsible for ensuring that referrals were sent out to other facilities and finding placements for residents when planning to discharge or transfer residents out of the facility. -He/She sent out referrals attempting to get the resident placed in a different facility and the facility planned on giving the resident a 30-day discharge notice once placement was found. -The resident was issued an immediate discharge in the hospital ED.-He/She was not involved in the immediate discharge process.-The Administrator and the interim DON issued the immediate discharge notice.-He/She was unsure if the emergent discharge notice was given to the resident or hospital staff. -He/She was unsure if the resident was aware of the emergency discharge.-When a resident was properly discharged , the discharge process included a thorough discharge summary.-He/She was not sure if a discharge summary was completed and sent to the resident when discharged .-He/She was not sure if a recapitulation of stay had been completed. -He/She was not sure if the resident's medication was reconciled.-He/She does not believe that the resident left with his/her belongings. During an interview on 08/12/26 at 4:40 P.M. Social Services B said:-He/She was not involved in the emergency discharge of the resident.-The Interim DON and Administrator were the ones who issued the emergency discharge.-Prior to the emergency discharge being administered, he/she was working with the resident's guardian to try to get the resident transferred to another facility. -No facilities would accept the resident for placement and therefore a 30-day discharge was not given to the resident. During an interview on 08/12/26 at 4:45 P.M. MDS Coordinator A said:-The care plans were the responsibility of the MDS Coordinators, Social Services, and the DON at times.-Care plans should be updated quarterly, annually, when residents have a change of condition and when a resident is discharged from the facility. -He/She was not involved in the discharge of the resident and was not sure what steps were taken as far as ensuring that the resident was discharged with his/her medical records for further treatment. During an interview on 08/12/26 at 5:00 P.M. MDS Coordinator B said:-He/She was not involved in the discharge of the resident and was not sure what steps were taken as far as ensuring that the resident was discharged with his/her medical records for further treatment.-He/She did not complete a discharge plan of care on the resident prior to the resident being discharged from the facility.-He/She was not sure who was responsible for all of the required discharge paperwork when a resident was discharged from the facility. During an interview on 08/12/26 at 7:15 P.M. Interim DON said:-The resident was issued an emergency discharge to the hospital. -The discharge notice was delivered to the ED by himself/herself and the Administrator.-The ED nurse was the person who was handed the emergency discharge paperwork. -The discharge notice was not delivered to the resident him/herself.-The immediate discharge notice was not given to the resident or the resident's guardian prior to being delivered to the hospital ED staff. -The hospital staff called the facility in an attempt to have the resident returned back to the facility after hospital discharge. -The hospital staff spoke to him/her and the Administrator and was told that the resident was not allowed to come back to the facility. -He/She expected that the discharge policies and procedures be followed when discharging a resident with the intent of the resident not being able to return to the facility. -The hospital was not provided with all of the resident medical records upon discharge.-The hospital physician did not want to assume responsibility for the resident at the time of the immediate discharge.-The facility was aware at the time of the transfer to the hospital that they were not going to accept the resident back into the facility. -The facility felt that the emergency discharge to the hospital was in the best interest of the resident and other residents in the facility due to the resident's unsafe behaviors and elopements. During an interview on 08/12/26 at 7:30 P.M. Administrator said:-He/She delivered the residents emergency discharge letter to the ED staff at the hospital with the interim DON. -The resident was not properly discharged , and corrective action was put into place.-The hospital attempted to send the resident back to the facility, but the facility would not take the resident back.-He/She knew that the resident was not going to be accepted back into the facility once transferred to the hospital for evaluation. -He/She did not feel that it was in the best interest of the residents in the facility to allow the resident to return.-He/She had no contact with the resident or the hospital staff after the immediate discharge to ensure that the resident received continuity of care.-All of the resident medical records were not given to the resident or the hospital staff due to the immediate nature of the discharge.-No medical records have been emailed or faxed to the hospital for continuity of care of the resident. -He/She expected facility policy to be followed when residents were transferred or discharged from the facility. During an interview on 08/13/26 at 3:00 P.M. the resident's Guardian said:-The resident was discharged to the hospital ED after the resident eloped from the facility. -The hospital attempted to release the resident back to the facility, but the facility refused to accept the resident back. -The resident was sent back to the facility at one point during the process and had to wait in the lobby until he/she had the resident transferred to a different hospital.-The resident was not his/her own guardian.-He/She was the resident's guardian and was not notified of the immediate discharge until after the discharge was issued.-The resident was not aware of the immediate discharge until after the immediate discharge was delivered to the hospital staff. -The facility did not give the resident a chance to appeal the immediate discharge.-He/She was not offered a chance to appeal the resident's discharge.-He/She was in the process of starting the appeal process on the resident's behalf. -The resident had no alternate care provider and the hospital was not given medical records to ensure the continued safe treatment of the resident. -He/She would have expected the facility to find the resident a safe place to be transferred to before issuing an immediate discharge. During an email interview on 08/13/26 at 3:00 P.M., Ombudsman said:-The facility did not give a proper discharge and/or discharge notice to the resident or the resident's guardian.-The facility listed the hospital as the place of discharge.-He/She would have expected that the facility would take the resident back after the resident was discharged from the hospital.-He/She helped the guardian file an appeal.-The appeal hearing was set for 09/02/26. 3154137

Based on interview and record review, the facility failed to develop prevention, identify interventions, provide supervision and update the resident care after for one sampled resident (Resident #1) out of three sampled residents. On 07/09/26, 07/19/26 and 08/09/26 the resident exited through a stairway door by disabling the magnetic door lock when holding the door for 15 seconds. The resident then accessed the ground floor from the stairway, entered the front lobby, and left the facility through the front door. On 08/09/26 the facility staff lost sight of the resident who was later found by staff and police, walking on the shoulder of a major city highway. The facility census was 121. Review of the facility's Elopements policy dated 09/2025, showed:-It was the policy of the facility that all residents were afforded adequate supervision to provide the safest environment possible.-All residents would be assessed for behaviors or conditions that put them at risk for elopement.-All residents who were identified would have those issues addressed in their individual care plans.-All staff were responsible.-An elopement was characterized as any unplanned departure from a designed safe environment.-Residents who were at risk for elopement would be provided with at least one of the following safety precautions by the facility-Residents who were at risk for elopement would be identified and documented in the individual plan of care.-Should a resident attempt an elopement, a review of their individualized care plan would be triggered for possible changes in care practices or safety precautions for the resident. -Should an elopement occur, the facilities would determine the root cause of the elopement and review the facility systems policies and procedures and responses to elopements to identify areas or opportunities and improvement. 1. Review of Resident #1's Preadmission Screening and Resident Review (PASRR-a federal rule in the United States that checks if people with a serious mental illness or an intellectual disability are placed in the right care setting) dated 04/13/26, showed:-The resident eloped from two facilities within a month prior to admission.-The resident was court ordered to be in a locked down facility.-The resident had a guardian that was state appointed. -The resident had a history of being unhappy with guardianship and nursing facility placement.-The resident required a one on one and intense monitoring prior to admission. -It was recommended that the resident had continual 1:1 intense monitoring due to recent elopements and ongoing elopement risk. -The resident required 24 hour protective oversight. Review of the resident's face sheet showed he/she admitted [DATE] with the following diagnoses:--Schizoaffective Disorder, Bipolar Type (a subtype of a very serious mental health condition called schizoaffective disorder. This mental illness is a combination of symptoms of schizophrenia and symptoms of a mood disorder).--Unspecified Mood Disorder (mood disturbances that do not meet the criteria for any specific mood disorder).--Borderline Personality Disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life).--Mild Intellectual Disabilities (previously known as mild mental retardation-refers to deficits in intellectual functions pertaining to abstract/theoretical thinking).--Dementia (a condition that affects memory, thinking and the ability to perform daily activities) with Agitation.--Post Traumatic Stress Disorder (a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it).--Suicidal Ideation (suicidal thoughts-occurs when you think about or consider death or suicide).--History of Suicidal Behavior (any action that could cause a person to die, such as taking a drug overdose or crashing into a car on purpose).--History of Traumatic Brain Injury (a brain injury that is caused by an outside force).--Epilepsy (a brain condition that causes recurring seizures). Review of the resident's care plan dated 05/9/26, showed:-The resident wished to discharge back to the community in a few months, if possible.-Staff was to evaluate the resident's motivation to return to the community.-The resident had impaired cognitive function or impaired thought processes. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used by facility staff for care planning) dated 05/14/26, showed:-The resident was cognitively intact.-The resident had serious mental illness.-The resident had no behavior in wandering.-The resident had no risk of getting to a potentially dangerous place. -No risk for elopement or intense monitoring requirements was triggered, despite positive history for eloping and 1:1 being recommended on the resident's PASRR. Review of the resident's care plan dated 07/9/26, showed:-The resident left the facility through a stairwell exit door and out of the front entrance with staff following him/her.- 1:1 monitoring was initiated after the resident returned to the facility. Review of the resident's care plan dated 07/19/26, showed the resident left the facility through the stairwell exit door and out the front entrance with staff following. Review of the resident's care plan dated 07/19/26-08/09/26 showed no additional interventions were put in place to prevent continued elopement. Review of the resident's elopement assessment dated [DATE], showed:-The resident was at risk of elopement.-The resident did not have a history of elopement, exit seeking, or wandering. Review of the resident's psychiatric periodic evaluation note dated 08/04/26, showed:-The resident was seeking exit and required continued 1:1 monitoring. -The resident was upset about being on 1:1 monitoring and requested the provider to discontinue monitoring.-The order for 1:1 monitoring continued. Review of the facility staffing sheets from 08/05/26 through 08/09/26, showed:-On 08/05/26 during the night shift, there were no staff scheduled or assigned to be 1:1 with the resident.-On 08/06/26 during the evening shift, there were no staff scheduled or assigned to be 1:1 with the resident. -On 08/07/26 during the evening shift, there were no staff scheduled or assigned to be 1:1 with the resident. -On 08/08/26 during the evening shift, there were no staff scheduled or assigned to be 1:1 with the resident.-On 08/08/26 during the night shift, there were no staff scheduled or assigned to be 1:1 with the resident.-On 08/09/26 during the evening shift, there were no staff scheduled or assigned to be 1:1 with the resident. Review of the resident's care plan dated 08/09/26 showed the resident left the facility through stairway exit and out of the front door. Review of the resident's nursing note dated 08/09/26 at 8:00 P.M. showed:-The resident was upset about running out of cigarettes. -The resident called his/her ex-spouse at the nurses station and notified the ex-spouse that he/she was getting ready to escape. -Licensed Practical Nurse (LPN) A overheard the conversation between the resident and the ex-spouse. -The resident then slammed down the phone and ran towards the alarmed door on the unit. -LPN A witnessed the resident exit the door and leave the secure unit.-LPN A followed the resident outside, for about a block. -LPN A kept visual contact, until the resident was no longer visible. -LPN A called the police for assistance. -The police were unable to locate the resident. During an interview on 08/12/26 at 3:00 P.M. LPN A said:-He/She was the nurse that was on duty when the resident eloped. -The resident went to the nurse's station approximately 7:00 PM to smoke and got upset because he/she did not have any cigarettes at the time.-While at the nurse's station, the resident called his his/her ex-wife and told the ex-wife that he/she was going to break out of the facility.-While the resident was on the phone at the nurses station, the agency Certified Nurse Assistant (CNA) that was supposed to be sitting one-on-one with the resident, went to use the restroom.-As soon as the CNA walked away from the resident, the resident ran and shoved open the stairway door on the unit and ran down the stairs. -The door was locked but the resident knew how to make it open because he/she learned how to do so from previous elopements. -He/She ran after the resident but shortly lost sight of the resident down the street from the facility. -When he/she lost sight of the resident, he/she ran back to the facility, grabbed his/her car keys and attempted to find the resident by vehicle.-He/She was never able to find the resident and after about 30 minutes of looking, returned to the facility. -The Administrator found the resident about an hour later walking down the highway. -He/She believed the resident had been on 1:1 observation off and on for a couple weeks prior to this elopement. -He/She was not sure if staff who sat 1:1 with the resident documented the monitoring. -He/She did not attend any interdisciplinary team (IDT) meeting regarding the resident's elopements.-He/She was aware that the resident was an elopement risk and was aware that the resident eloped from the stairway door previously.-There was no staff guarding the stairways door when the resident eloped.-The resident's 1:1 CNA was in the restroom and not present when the resident eloped. -When a resident eloped, a new elopement assessment should be filled out for the resident and the care plan updated with new interventions. During an interview on 08/12/26 at 3:30 P.M CNA A said:-He/She worked the unit on the day that the resident eloped.-It was about 7:05 P.M., when the resident went to the nurse's desk to smoke and was upset and began to yell and scream with staff because he/she did not have any cigarettes left. -He/She went to the smoke deck to get away from the situation and that was when the door alarm on the unit sounded.-He/She attempted to run after the resident, but that resident was already gone.-LPN A ran after the resident and he/she remained on the unit to supervise the other residents. -LPN A was gone over an hour and never found the resident.-The resident was upset all day and escalating but would calm down when he/she got their way.-He/She was aware that the resident eloped in the past.-The CNA that was supposed to be sitting 1:1 with the resident was in the bathroom and he/she was on the smoke patio when the resident eloped. -He/She did not recall recent in servicing on elopement or interventions to help prevent the resident from eloping.-He/She knew that the resident eloped from the same door each time.-He/She was not instructed to guard the door that the resident eloped from when the resident was escalated.-He/She believed the resident was on 1:1 monitoring at the time that he/she eloped, but the CNA was not with the resident at the exact time of the elopement. -Staff who were sitting at 1:1 documented the observations every 30 minutes on a log during each shift. -When the aides were on duty 1:1, they were supposed to document the resident's activities, mood, behaviors, and if redirecting was required during that timeframe. -CNA's know if they were scheduled to be 1:1 with a resident because it's on their staffing sheet. During an interview on 8/21/26 at 1:00 P.M. CNA B said:-He/She was sitting one-on-one with the resident before the resident eloped.-At 7:00 P.M., the resident went up to the nurses station and found out that he/she did not have any cigarettes.-The resident was asking other residents if he/she could borrow a cigarette from them. -Another resident offered to give him/her a cigarette, but the LPN A refused to allow the transaction to happen.-The resident began to escalate at that time and went to the nurse's station to use the phone to call a friend.-When the resident was on the phone talking to a friend he/she asked LPN A if he/she could take a restroom break.-While he/she was in the restroom which is right behind the nurse's station he/she overheard the resident saying that they were going to escape. -He/She hurried up and left the restroom but by the time he/she got out of the restroom the alarm had already been sounded.-He/She was not sure that LPN A responded as quickly as what should have been done because there is a 15 to 30 second delay before the door will open.-He/She took off running down the stairs and jumped into his his/her car to drive around to try to find the resident.-After about 30 minutes and unable to find the resident he/she returned to the facility. -The police found the resident walking along the highway 45 minutes to an hour after the resident eloped.-He/She heard that LPN A said , I am not chasing anyone and wondered if there was a delay in reaction when the resident stated that he/she was going to escape. -There seemed to be a lot of tension between the resident and LPN A.-He/She felt the elopement could have been prevented if the resident was not being provoked to escalation and was being watched closer while he/she was in the restroom. During an interview on 08/12/26 at 4:15 P.M. Certified Medication Technician (CMT) A said:-He/She had been present when the resident eloped from the facility in the past. -He/She knew that the resident had a history of eloping through the stairway door.-The resident knew how to unlock the door and escape.-The resident knew to push the door a certain way, wait 15 seconds, and push it open again. -The resident eloped so many times from the facility that it was hard to keep track of. -He/She believed the resident was on 1:1 monitoring when eloping but could not remember for sure. -Staff were told if they heard the door alarm to go all the way down the steps and see if the resident attempted to elope again.-Staff were not instructed to guard the door. During an interview on 08/12/26 at 7:15 P.M. Interim Director of Nursing (DON) said:-He/She was not at the facility when the resident eloped but was contacted by staff. -Elopement risk assessments were expected to be completed on admission and be thorough and correct.-Elopement assessments were expected to be done each time a resident eloped from the facility and the care plans updated.-If a resident's PASRR and admission paperwork mentioned that the resident was an elopement risk, this should be triggered on the resident's admission MDS, care plan, and elopement assessment.-The MDS Coordinator was responsible for ensuring PASRR information was reflected on a resident's care plan upon admission. -The Social Worker was responsible for the monitoring of the care plan and ensuring that new interventions were added each time a resident eloped. -The charge nurse on duty when a resident was admitted was responsible for completing an accurate elopement assessment on a resident. During an interview on 08/12/26 at 4:35 P.M. Social Services A said:-It was the social workers' responsibility to update the care plans with new interventions as needed.-A resident's care plan should have been updated each time they eloped with new interventions each time. -He/She saw the resident was a risk for elopement on admission and completed the admission assessment on the resident.-The resident was not exit seeking admission.-He/She could not recall if the resident's PASRR was on site and considered when forming the initial care plan for the resident and the initial MDS for the resident. -The resident was on 1:1 monitoring for a month.-He/She was not sure if the 1:1 monitoring was continuous or off and on. -The staff who sat at 1:1 with the resident should have been filling out monitoring logs through their shifts. -He/She would have expected the elopement assessments to be completed by nursing staff and the resident be re assessed with each elopement.-He/She would have expected the elopement assessment to be accurate and reflect when a resident was high risk for elopement. During an interview on 08/12/26 at 5:00 P.M. MDS Coordinator B said:-The MDS coordinator's, Social Services, and sometimes DON, update the resident's care plans when they are informed about elopements.-Sometimes confusion was caused because so many staff members were responsible for the task of updating care plans. -New interventions were supposed to be added to a resident's care plan each time that they eloped or attempted to elope from the facility. -He/She was the one who updated the resident's care plan from the last elopement on 08/09/26.-He/She updated the resident's care plan from the 08/09/26 elopement today, 08/12/26. -Care plans should be updated immediately or at least within 24 hours of an incident occurring. -It was brought to his/her attention recently that some of the care plan, MDS, and other records did not match the resident's PASRR.-He/She started looking closer at the PASRR's to ensure that the residents' PASRR information was carried over to their MDS's and care plans. -He/She was responsible for admission MDS assessments.-If a resident had a history of elopement on their PASRR on admission, this information should have be reflected on the resident's admission MDS and care plan.-The staff member who was responsible for the resident's admission MDS was no longer employed at the facility and retired. -He/She was unsure if the previous staff member had the resident's PASRR when they created the resident's admission MDS. -It was expected that all of a resident's information from their PASRR be transferred to their admission MDS, if relevant.-It was expected that all of a resident's information from the PASRR be transferred to their care plan on admission, if relevant.-A resident having history of prior elopement would be relevant in the safe care planning and assessment of a resident. During an interview on 8/12/26 at 7:30 P.M. the Administrator said:-The resident eloped from the building by exiting the staircase door.-The resident ran down the staircase to the ground floor where he/she exited though the front door.-The staircase doorway on the unit was locked and alarmed but the resident knew how to manipulate the locking mechanism.-He/She was told that the resident was ablet to exit through the front door because it was open due to someone just exiting the building.-The resident was on 1:1 observation at the time that he/she eloped.-He/She was unable to provide documentation of the 1:1 observations and did not believe that the staff were documenting the 1:1 monitoring on logs.-He/She was not sure if it was the policy of the facility to document the 1:1 monitoring.-The facility did not have an intense monitoring or a 1:1 monitoring policy.-If a staff member was scheduled to be 1:1 with a resident, it was reflected on the staff sheets next to the staff member's name.-He/She was contacted by LPN A when the resident eloped. -He/She found the resident walking down the shoulder of the highway.-The resident was out of sight from staff for a period of approximately 30-45 minutes.-The resident had a guardian through the state.-He/She was aware that the resident had a history of elopements from the facility. -He/She expected if a resident had a history of elopement prior to admission, that the elopement risk would be triggered on the resident's admission MDS.-He/She expected elopement risk assessments to be completed thoroughly and accurately.-If a resident had a history of elopement prior to admission, the risk should have been transcribed to the admission elopement assessment risk.-A new elopement risk assessment was expected to be completed each time that a resident eloped or attempted to elope.-He/She expected care plans to be updated with new interventions each time a resident eloped or attempted to elope from the facility. -There were no staff guarding the door when the resident eloped.-The staff member who was 1:1 with the resident was taking a restroom break at the time the resident eloped. During an interview on 8/13/26 at 3:00 P.M. the resident's Guardian said:-The resident eloped from the facility on more than one occasion.-He/She was contacted when the resident eloped each time.-He/She expected a locked down unit to take steps to ensure that residents were not able to elope, especially from the same door multiple times.-The resident eloped from the door on the unit because the resident figured out how to demagnetize the door lock system.-Staff knew the resident had figured out how to manipulate the locked doors.-He/She would expect if a resident was able to elope through a locked door, that the door would be guarded and or constantly monitored by staff. 3152712

Based on interview and record review, the facility failed to develop and implemented an effective discharge planning process for two sampled residents (Resident #1 and Resident #2) out of 13 sampled residents. The facility census was 122 residents. On 7/17/26, the Administrator was notified of the past noncompliance which took place on 6/3/26 and 6/15/26. Discharge planning documentation discrepancies were discovered from the appeals. Education to address the problem was provided to facility staff, including the Administrator, the Director of Nursing (DON) and Social Services Director on 6/16/26 and problems with discharge planning were identified with Resident #1 and Resident #2. The deficiency was corrected on 6/16/26. Review of facility policy entitled Discharge Summary and Plan dated 8/25 showed:-The discharge plan would have included resident and family/caregiver education needs and would have initiated or maintained collaboration between the nursing facility had other post-acute providers to have supported the resident's transition to community living. 1.Review of Resident #1's admission Record showed the resident was admitted to the facility on [DATE]. Review of the resident's Quarterly [NAME] Data Set (MDS-a federally mandated assessment instrument completed by facility staff) dated 6/24/26 showed the resident was cognitively intact. Review of the Notice to Transfer/Discharge form dated 2/12/26 showed:-The resident was to be discharged from the facility on 3/15/26.-The resident was to be discharged to an extended stay hotel.-The resident could appeal the discharge. Review of the Discharge Appeals Hearing dated 6/3/26 showed:-That the facility failed to provide and document sufficient preparation and orientation to the resident that ensured a safe and orderly discharge to the community. -The resident had presumably met a level of care upon admission and that a community/hotel setting could not have been provided and there was no evidence that suggested that a discharge to the community is now appropriate and safe. During an interview on 7/17/26 at 11:00 A.M., the resident said:-He/She did not want to be discharged to a hotel.-He/She could not take care of himself/herself without help from others. -He/She appealed the discharge because he/she did not feel it was right there was no discussion with him/her about where he/she was going.-He/She was just told you are being discharged to the hotel. 2. Review of Resident #2's admission Record showed the resident was admitted to the facility on [DATE]. Review of the Quarterly MDS dated [DATE] showed the resident was moderately cognitively impaired. Review of the Notice to Transfer/Discharge form dated 2/12/26 showed:-The resident was to be discharged from the facility on 3/15/26.-The resident was to be discharged to an extended stay hotel.-The resident could appeal the discharge. Review of the Discharge Appeals Hearing dated 6/15/26 showed:-That the facility failed to provide and document sufficient preparation and orientation to the resident that ensured a safe and orderly discharge to the community. -The resident had presumably met a level of care upon admission and that a community/hotel setting could not have been provided and there was no evidence that suggested that a discharge to the community is now appropriate and safe. During an interview on 7/17/26 at 10:58 A.M., the resident said:-He/She did not want to be discharged to a hotel.-He/She was just told you are being discharged to the hotel. -He/She could not take care of himself/herself without help from others because he/she needed help with bathing, transfers, grooming, and dressing. -He/She appealed the discharge because he/she did not feel it was right that he/she needed help from staff at the facility and there was no discussion with him/her about where he/she was going to be discharged and where he/she would get assistance. 3. During an interview on 7/17/26 at 11:58 A.M., Social Services Director said:-He/She had been educated on discharge planning on 6/16/26.-Discharge planning should have started at admission. -When a resident was going to be discharged due to nonpayment he/she would send referrals out.-Once a facility accepts the residents then a 30-day notice could be issued with the new facility address on the form as the discharge location. -It was not appropriate to have a resident discharged to a hotel/motel or shelter. During an interview on 7/17/26 at 12:33 P.M., the Administrator said:-The facility did not have Social Services Director at the time of the 30 days notices were given. -He/She did the discharge planning and gave the 30-day discharge notices. -He/She did not know that a discharge to hotel was not an acceptable form of discharge.-He/She had been educated about discharge planning and that discharge to a hotel was not an appropriate discharge location or planning. 3062537

Based observation, interview and record review, the facility failed to prevent resident abuse when on 5/27/26 Resident #1 lunged at and grabbed Resident #2, the two residents wrestled to the floor hitting and scratching each other, out of three sampled residents. The facility census was 127 residents.The Administrator was notified on 6/4/26 of the past noncompliance which began on 5/27/26. The facility revised the resident smoking policy and the staff assignment sheets and completed education for licensed nurses and Certified Nursing Assistants (CNAs) regarding the revised resident smoking policy and assignment sheets. Education was completed with all staff on resident-to-resident abuse. The deficiency was corrected on 5/28/26. Review of the facility Abuse Prevention and Prohibition policy, dated March 2025 showed:-Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.-Instances of abuse of all residents, irrespective of any physical or mental condition, cause harm, pain, or mental anguish. 1. Review of Resident #1's admission record showed:-He/she was admitted to the facility on [DATE].-He/she had diagnoses of depression and anxiety. Review of Resident 1's care plan dated 5/22/26 showed-He/she had a history of assault (a violent physical or verbal attack).-Staff interventions included to intervene as necessary to protect the rights and safety of others, remove from the situation and report any incidents to police. Review of Resident #2's admission Record showed:-He/she was admitted to the facility on [DATE].-He/she had diagnoses of dementia (decline in mental ability that interferes with daily life), depression, psychosis (loss of contact with reality) and anxiety. Review of the Resident #2s' care plan dated 7/14/25 showed:-He/she had a mood problem including feeling down, feeling bad about himself/herself.-He/she had a history of displaying anger when antagonized by others; was verbally abusive, threatening and impulsive. Review of Resident #1's Health Status Note dated 5/27/26 showed:-At approximately 6:30 P.M. the Director of Nursing (DON) was called to the resident's living area.-The resident had a gash (a long, deep cut or wound), bleeding from his/her left eyebrow and left upper arm and would not allow assessment and cleansing of the areas.-He/she said he/she and another resident had a physical altercation and would not elaborate (explain with detail).-Resident #2 said he/she had punched the ohter resident three or four times in his/her face.-He/she was belligerent (hostile, aggressive, eager to fight or argue) toward staff and other residents.-Staff separated the residents and attempted to monitor the resident 1:1 (constant staff visual monitoring); the resident left the area.-Police and the resident's physician were notified. Review of the Resident#2's Health Status Note dated 5/27/26 showed:-The DON was called to the resident's living area for a physical altercation.-The resident said Resident #1 was calling him/her names and he/she told him/her to stop; Resident #1 jumped up and he/she then jumped up; he/she hit Resident #1 three or four times in his/her face.-Resident #2 had a scratch about 2 1/2 inches long on the center of his/her chest, a reddened area on his/her left chest, a small two centimeter (cm) scratch on the back of his/her left hand and a 5 cm (two inch) reddened area on the back of his/her back. Observation and interview with Resident #2 on 6/3/26 at 1:40 P.M. showed he/she had a scratch on his/her left wrist and two small red marks on his/her chest.-He/she said:-He/she and Resident #1 were in the resident smoking area with some other residents; he/she did not recall if any staff were present in the resident smoking area. -Resident #1 called him/her something he/she did not like.-He/she asked Resident #1 to not call him/her that, Resident #1 got up and then he/she got up.-Resident #1 lunged at him/her and grabbed him/her.-Resident #1 broke a necklace that he/she wore around his/her neck, scratched him/her and tried to hit him/her but he/she blocked Resident #2's punches.-He/she punched Resident #1 in the face three or four times.-Staff came and he/she left the smoking area with one of the staff.-A nurse stayed in the resident smoking area with Resident #1. Review of CNA A's Witness Statement dated 5/27/26 showed:-On 5/27/26 at 6:00 P.M. he/she was coming back up to the third floor.-He/she and DA A were entering the third floor off the elevator and saw two men fighting.-Resident #2 was standing over Resident #1 who was on the ground; as Resident #1 stood up, he/she was bleeding.-Resident #1 was on the ground and as he/she stood up, he/she was bleeding on the right side of his/her face and on his/her lower arm.-He/she and the nurse ran to break up the fight.-He/she then brought Resident #2 back inside with him/her while the nurse stayed outside trying to calm Resident #1 down. During an interview on 5/4/26 at 9:56 A.M. CNA A said:-On 5/27/26 he/she was working the evening shift on the third floor.-When he/she returned to the third floor and got out of the elevator with Dietary Aide (DA) A., he/she saw a fight with two residents in the smoking area.-At that time there were no staff in the smoking area.-He/she and the nurse went to the smoking area and broke up the fight.-He/she brought Resident #2 into the dining room from the smoke area and the nurse stayed on the smoking area with Resident #1. Review of DA A's Witness Statement dated 5/27/26 showed-DA A got off the elevator on 5/27/26 at 6:00 P.M.-Resident #2 was standing over and punching Resident #1. During an interview on 6/5/26 at 4:05 P.M. DA A said:-On 5/27/26 he/she was taking items to the third floor in preparation for the resident's evening meal.-There were no staff in the smoking area with a few residents.-As he/she and CNA A looked at the smoking area he/she saw a physical fight was going on with two residents. During an interview on 6/3/2/26 at 10:20 A.M. the Administrator said:-On 5/27/26 at around 6:30 P.M. Resident #1 and Resident #2 had a physical altercation.-His/her investigation showed that Resident #1 became aggressive toward Resident #2 and Resident #2 hit Resident #1 defending himself/herself.-Resident #1 had bleeding above his/her left eye but refused assessment and would not let staff clean him/her. Review of Resident #3's Comprehensive MDS dated [DATE] showed he/she was cognitively intact. Review of the facility Social Services Director (SSD) documentation of his/her interview with Resident #3, undated, showed:-Resident #3 said Resident #1 stood up and headed towards Resident #2.-Resident #1 then charged toward Resident #2 and grabbed Resident #2 by his/her throat.-Resident #2 then threw Resident #1 to the ground. During an interview on 6/3/26 at 2:40 P.M. Resident #3 said:-He/she saw what happened when Resident #1 and Resident #2 had a fight.-Resident #1 started the fight when he/she stood up and headed toward then charged toward and grabbed Resident 2 by his/her throat.-Resident #2 then threw Resident #1 to the ground.-A couple of other residents were nearby.-There were no staff in the smoking area at that time.-Staff separated Resident #1 and Resident #2. During an interview on 6/4/26 at 3:34 P.M. the DON said:-He/she was informed of the resident altercation on 5/27/26 right after it happened. -He/she immediately went to the Third floor.-The residents had been separated; Resident #2 was calm.-Resident #1 had blood on his/her face and would not let nurses assess him/her or clean the blood off his/her face, he/she was aggressive and threatening, refused 1:1 monitoring and left the facility and has not returned.-He/she expected staff to monitor residents during smoke breaks and whenever residents were out in the smoking area.-A new policy and assignment sheet was developed and put into place.-All staff had received training on the new policy by 5/28/26, that the third floor resident smoking area was to be unlocked for resident smoking breaks, assigned staff were to stay in the resident smoking area with residents until the all residents had gone back inside from the smoking area and staff were then to go back inside and lock the door the smoking area. 3025998

Based on interview and record review, the facility failed to notify Guardian A using the agreed upon protocol for one sampled resident (Resident #1) who had a change in condition out of 19 sampled residents. The facility census was 128 residents.1. Review of Resident #1's admission Record showed he/she admitted to the facility with a diagnosis of schizoaffective disorder (a mental health condition that includes features of both schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and a mood disorder), bipolar type (a mood disorder that can cause intense mood swings).NOTE: The admission Record showed the emergency after-hours phone number of Guardian A. Review of the resident's Behavior Note dated 5/4/26 at 5:51 A.M. completed by Licensed Practical Nurse (LPN) A showed:-The resident reported that another resident grabbed him/her by the arm and said that he/she would rape the resident.-Guardian A had been notified using the Guardian's office number.NOTE: Guardian A's office number was not the emergency after-hours phone number. Review of the resident's Health Status Note dated 5/5/26 at 1:30 P.M. showed:-Police were notified of the alleged incident.-The resident had talked to the police related to the alleged incident. During an interview on 5/21/26 at 11:34 A.M. Guardian A said:-He/She confirmed that the emergency after-hours line on the resident's admission record was the correct phone number.-He/She confirmed that the number that LPN A called was not the correct number.-The facility had signed a form related to the use of the emergency after-hours phone line back in 2025, so the facility was well aware of the correct protocol to use when notifying him/her of a change in condition after-hours. Review of the Public Administrator Emergency Call Information form on 5/21/26 at 11:40 A.M. showed:-The form had been completed on 5/28/25.-Normal business hours were considered Monday through Friday from 8:00 A.M. to 4:00 P.M.-The facility was to use the on-call (emergency) phone number for the following situations:--Significant change to ward's condition.--Ward's contact with law enforcement. During an interview on 5/22/26 at 9:30 A.M. LPN A said:-He called the number that was on the resident's face sheet.-He/She did not see that after-hours emergency phone number on the resident's face sheet.-He/She thought that he/she had followed facility protocol.-If he/she had not called the correct number, then it was a mistake.-Usually when he/she called Guardian A's office number, a message would indicate a different number be used if Guardian A was unable to pick up the phone call.-He/She could not remember if a different phone number had been provided when leaving a voicemail on Guardian A's office number. During an interview on 5/22/26 at 2:01 P.M. LPN B said:-The resident had a guardian.-If a resident had a guardian and was experiencing a change in condition, then it was the facility's responsibility to notify the guardian appropriately.-Guardian A's office phone number and emergency after-hours phone number could be found in the resident's chart.-If he/she needed to notify Guardian A after hours, then he/she did call the office number first, but if no one picked up, then he/she would also call the after-hours emergency line.-The correct number was also posted at the nurse's station.-Nursing staff had received education related to the use of the after-hours emergency line when notifying the resident's guardian.-There would be no reason for LPN A to have called the wrong number especially since LPN A was notifying Guardian A during the after-hours time frame. During an interview on 5/22/26 at 3:09 P.M. the Director of Nursing (DON) said:-He/She expected nursing staff to call the correct phone number to contact the resident's guardian. -If the resident's guardian needed to be notified of something after-hours, then he/she expected nursing staff to use the after-hours emergency phone number.-Nursing staff were not supposed to leave messages as part of a guardian's notification of change in condition.-The nursing staff were expected to speak with someone when notifying a guardian of a change in condition.-LPN A had not followed the facility's protocol to notify Guardian A of the resident's change in condition.-LPN A should have used the after-hours emergency phone number to contact Guardian A.-LPN A knew better because he/she had notified Guardian A correctly in the past. 3010522

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #4) was free from abuse when Resident #3 punched him/her multiple times resulting in Resident #3 fracturing his/her hand and Resident #4 scared and praying for a reason to live out of 19 residents sampled. The facility census was 127 residents.The facility staff was notified on 3/18/26 of Past Non-Compliance which occurred on 3/10/26. Facility investigation, safety measures to mitigate further occurrence, staff in-services and education was completed. The deficiencies was corrected 3/18/26. Review of the facility's Abuse, prohibition, and intervention policy, dated March 2025, showed:-Each resident had the right to be free from abuse.-The definition of abuse was the willful infliction of injury, with resulting physical harm, pain, or mental anguish. 1. Review of Resident 3's face sheet showed the resident admitted on [DATE] and some of his/her diagnoses included schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves), major depressive disorder (depressed mood most of the day and a loss of interest in normal activities and relationships), schizoaffective disorder (a mental health condition that includes features of both schizophrenia and a mood disorder), and anxiety disorder (psychiatric disorder that involve extreme fear, worry and nervousness). Review of the resident's care plan, dated 5/30/24, showed the resident had:-A history of behavior problems, pacing, and had an altercation with another resident.-Some diagnoses that included mood disorder (a mental health problem that affects a person's emotional state in which a person experiences long periods of extreme happiness, extreme sadness, or both), schizophrenia, schizophrenia, and personality disorder.-Had restlessness, agitation, aggressive behavior, and pacing. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 1/8/26, showed the following staff assessment of the resident:-No hearing impairment.-Vison was moderately impaired and corrected.-Had clear speech, usually understood others and others usually understood him/her.-Was cognitively intact.-Had mood indicators that indicated moderate depression.-Had hallucinations.-Had no negative behaviors-Ambulated independently.-Had no range of motion impairment in his/her arms or legs.-Was independent with all self-cares.-Some of his/her diagnoses included anxiety disorder, depression, psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), and schizophrenia. Review of Resident #3's skin assessment, dated 3/10/26 at 4:15 A.M., showed: -The resident's skin was warm and dry with skin color within normal range.-No skin issues were identified. 2. Review of Resident #4's face sheet showed the resident admitted on [DATE] and some of his/her diagnoses included schizophrenia and anxiety disorder. Review of the resident's care plan, dated 5/14/24, showed the resident had depression, anxiety, and schizophrenia. Review of the resident's quarterly MDS, dated [DATE], showed the following staff assessment of the resident:-Had clear speech.-Had no vision or hearing impairment.-Understood others and others understood him/her.-Cognitively intact.-Displayed mood symptoms that indicated moderate depression.-No negative behaviors.-Did not use any mobility devices.-Had no range of motion impairment in his/her legs or arms.-Was independent with almost all of his/her self-cares.-Some of his/her diagnoses included anxiety and schizophrenia. 3. Review of Resident #3's nurse's note and behavior note, dated 3/10/26 at 12:45 A.M., written by Registered Nurse (RN) A showed:-This resident went to use the bathroom. -He/She saw another resident in the bathroom. -The other resident was naked. -This resident physically attacked the other resident. -This resident said he/she beat up the naked resident he/she found in the bathroom. - Resident #3 hit the other resident with his/her fist a few times. -The sitter notified RN A immediately of the altercation. -RN A called the Administrator and left a voice message regarding the altercation.-RN A called the Director of Nursing (DON) and notified him/her. -The DON said he/she would call this resident's guardian, would call RN A back, and would let RN A know if this resident's guardian would authorize to transfer this resident to the hospital.-The DON called RN A back and instructed RN A to send this resident to the hospital emergency room.-This resident was transferred to the hospital emergency room. Review of Resident #4's nurse's note, dated 3/10/26 at 3:54 A.M., written by RN A showed:-Resident #4 went to the bathroom naked.-Another resident came to the bathroom while Resident #4 was in there. -The other resident attacked Resident #4 physically and hit Resident #4 with his/her fist a few times. -The sitter reported this attack to RN A.- RN A called the administrator and left a voice message.- RN A called the DON and notified him/her. -Resident #4 said that he/she was hit on the back of his/her head and back. -Resident #4 denied having any pain. -The nurse assessed Resident #4's skin and found no swelling, discoloration, bruising or drainage. Review of the facility's investigation, dated 3/10/26, showed:-Certified Nursing Assistant (CNA) A was the one-one (enhanced monitoring provided by staff) monitoring Resident #3.-Resident #3 went to the bathroom. -CNA A reported hearing noises and responded to the bathroom finding the door to the connected room side open and Resident #3 coming back into the bathroom from that side of room. -CNA A said Resident #3 said he/she beat Resident #4 up.-CNA A said he/she checked on Resident #4 and he/she reported to him/her that Resident #3 hit him/her. Review of Resident #4's Medication Administration Record (MAR), dated March 2026, showed the resident was not given pain medication on 3/10/26. Review of the resident's Electronic Medical Record (EMR) showed no pain assessments completed. During an interview on 3/17/26 at 11:39 A.M., Resident #4 said:-He/She had not had a problem with Resident #3 before.-He/She and Resident #3 were neighbors.-Resident #3 just came in and hit him/her.-Resident #3 hit him/her on his/her back and the back of his/her head maybe three or four times.-It hurt and it he/she was scared.-A staff member came and Resident #3 ran away.-After the incident, he/she prayed for a reason to live.-Resident #3 was gone, so he/she felt alright now. During an interview on 3/17/26 at 11:45 A.M., Resident #19 (quarterly MDS dated [DATE] showed he/she was moderately cognitively impaired) said:-He/She was in the room with Resident #4.-He/She saw Resident #3 throwing punches at Resident #4 in the back of his/her head.-A staff member came and stopped Resident #3. During an interview on 3/17/26 at 1:00 P.M., the Administrator said:-They gave Resident #3 an immediate discharge notice due to abuse of Resident #4 on 3/10/26.-Resident #3 was sent to the hospital and remains on the psychiatric unit. During an interview on 3/17/26 at 1:42 P.M., CNA A said:-He/She was assigned to do one-on-ones with Resident #3.-He/She was sitting in the hall outside Resident #3's room.-Resident #3 turned on his/her radio in his/her room.-Resident #3 walked in and out of his/her room mumbling to himself/herself.-He/She followed Resident #3 when he/she walked around in the hallways.-Resident #3 went into the bathroom in his/her room around 2:00 A.M.-Then he/she heard a bunch of ruffling around like someone was hitting something or someone.-Resident #3 and Resident #4 were next door neighbors and shared a bathroom between their rooms. -He/She saw Resident #4's bathroom door open and saw Resident #3 coming out and said he/she beat the mother fucker up. -Resident #3's hand looked swollen and he/she said it hurt.-Resident #4 said Resident #3 hit him/her on his/her back and head.-Resident #3's back was fire engine red with red marks up and down his/her back. During an interview on 3/18/26 at 7:54 P.M., Resident #3's guardian said:-The hospital staff told him/her the resident had a fractured right hand after the altercation.-The resident's fracture was from Resident #3 hitting Resident #4 or something else during the incident.-Resident #3 has a cast on his/her right hand. During an interview on 3/18/26 at 1:00 P.M., the DON and Administrator said:-RN A called the DON on 3/10/26 and said Resident #3 had gone through the adjoining bathroom and struck Resident #4 several times.-The DON told RN A to get Resident #3 sent out to the hospital due to abusing Resident #4.-The DON spoke with Resident #3's guardian and told him/her Resident #3 struck another resident and they needed to send him/her to the hospital.-The DON asked Resident #3's guardian to request a psychiatric hold at the hospital.-Resident #3 would not allow RN A to assess him/her before leaving to the hospital.-CNA A said Resident #3 was going to the bathroom and he/she did not think he/she needed to be within reach of the resident while he/she went to the bathroom. During an interview on 3/23/26 at 11:38 P.M., RN A said:-Resident #3 would explode without any warning.-Resident #3 was unpredictable and would just lose it.-Resident #3 was on one-on-ones (on 3/9/26 P.M. into 3/10/26 A.M.).-He/She did not think Resident #3 was displaying behaviors to indicate he/she was escalating that night.-CNA A sat at Resident #3's door because he/she would not allow anyone in his/her room.-He/She told the DON that the resident didn't want anyone in his/her room.-Resident #3 said he/she understood and agreed to supervision by staff but still would not let CNA A sit in his/her room.-CNA A was one-on-one with Resident #3 by sitting outside his/her doorway.-CNA A reported to RN A:--Resident #3 went to use to the bathroom that he/she shared with Resident #4.--CNA A did not follow Resident #3 to his/her bathroom. --Resident #4 was already in the bathroom and he/she was naked.--Resident #3 hit Resident #4 multiple times.-He/She asked Resident #3 why he/she hit Resident #4 and Resident #3 said he/she did not like it when other residents were naked.-He/She reported the incident to the Administrator and DON.-The DON instructed him/her to send the resident out to the hospital.-He/She was unable to fully assess Resident #3 for injury or pain before he/she left for the hospital because of Resident #3's lack of cooperation.-He/She assessed Resident #4 and found no injuries.-Resident #4 said Resident #3 hit him/her on his/her back and the back of his/her head. -After Resident #3 hit Resident #4, Resident #4 went straight to bed. During an interview on 3/25/26 at 12:11 P.M., the primary care physician for Residents #3 and #4 said:-The DON informed him/her of the altercation right after it happened.-He/She saw Resident #4 on 3/19/26 and the resident didn't say anything about the incident.-Resident #3 was still in the hospital.-He/She did not remember if either resident was injured.-It would have been best if Resident #3 did not share a bathroom with someone else.-This incident of Resident #3 attacking and punching Resident #4 was abuse. 2799433

Based on observation, record review and interview, the facility failed to ensure one sampled resident (Resident #6) out of seven sampled residents, was free from physical abuse. On 11/21/25, Resident #5 kicked and punched Resident #6 in the left jaw resulting in a fracture of the jaw. The facility census was 125 residents. Review of the facility Abuse, Prevention and Prohibition Policy dated 11/2025 showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. -Residents must not be subjected to abuse by anyone, including, but not limited to other residents. -The facility prohibited abuse of residents. -The resident must not be subjected to abuse by anyone. -Resident to resident abuse includes the term willful, which means that the individual's action was deliberate, regardless of whether the individual intended to inflict injury or harm. -Abuse meant the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Physical abuse includes, but it not limited to, hitting, slapping, punching, biting, and kicking. -Willful as defined in the definition of abuse, and means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 1. Review of Resident #5's admission Record showed the resident was admitted on [DATE] with the following diagnoses: schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems), anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety), restless, and agitation. Review of Resident 5#'s Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/16/25 showed the resident was severely cognitively impaired. Review of Resident #5's undated Care Plan showed: -On 5/30/24 the resident had a potential psychosocial well-being problem related to nursing home placement and psychiatric background. --When conflict arises, remove resident to a calm safe environment and allow to vent and share feelings. --On 9/10/24 assist the resident to develop more appropriate methods of coping and interacting. Review of Resident #6's admission Record showed the resident was admitted on [DATE] with the following diagnoses: schizoaffective disorder and anoxic brain damage (oxygen supply to the brain is interrupted, the functioning of the brain is disturbed immediately, and irreversible damage can quickly follow). Review of Resident #6's MDS dated [DATE] showed the resident was cognitively intact. Review of Resident #6's progress note dated 11/21/25 at 6:02 P.M. showed: -Resident # 6 was sent to the emergency room (ER) related to altercation with Resident #5. -Resident #6 was grabbing Certified Nursing Assistant (CNA) C's arm. Resident #5 did not like it. -Resident #5 told Resident #6 to move his/her arm. -Resident #6 did not move his/her arm, so Resident #5 kicked Resident #6, punched Resident #6 in the stomach then punched Resident #6 in the left side of the jaw. -Resident #6 fell to the ground, hit his/her head hard and his/her eyes rolled to the back of his/her head. Review of Resident #6's progress note dated 11/21/25 at 10:45 P.M. showed he/she returned to the facility with no new orders and the results of the x-ray showed fracture to coronoid process of the mandible (broken jaw). Review of the facility Resident Abuse Investigation Report dated 11/25/25 showed: -The Administrator received report from the second floor by CNA E of a resident to resident event with Resident #5 and Resident #6.-CNA C and Resident #5 were walking up the hall when Resident #6 approached and grabbed CNA C's arm.-Resident #5 asked Resident #6 to let go of CNA C's arm.-Resident #6 continued to hold CNA C's arm.-Resident #5 then grabbed Resident #6's hand and Resident #6 said let's fight.-Resident #5 kicked and punched Resident #6.-The investigation concluded as substantiated physical contact made between Resident #5 and Resident #6 related to a misinterpretation of thoughts between Resident #5 and Resident #6 that resulted in the physical contact.-Resident #6 was diagnosed with a small fracture to the left mandible. During an interview on 11/24/25 at 11:30 A.M., the Director of Nurses (DON) said: -Resident #5 was waking up the hall and Resident #6, who often grabs or reaches out to staff, grabbed CNA C.-Resident #5 told Resident #6 to let go. -Resident #6 asked if Resident #5 wanted to fight and they engaged in a physical altercation. -Resident #6 was struck by Resident #5 and hit the floor. -Resident #6 had a fracture to the jaw. Observation and interview on 11/24/25 at 3:27 P.M., showed Resident #6:-Was in his/her room in bed -He/She recalled having an x-ray done. -He/She complained of jaw pain on both sides, rated pain a 5 on a scale of 0-10 (0=no pain, 10=the worst pain ever). During an interview on 11/24/25 at 3:40 P.M., Resident #5 said: -He/She was on 1:1 because he/she assaulted someone. -He/She hit Resident #6 on the left side of the face. -Resident #6 came towards him/her, so he/she kicked Resident #6 and then hit Resident #6 with his/her right fist to Resident #6's left jaw. -Resident #6 fell to the floor and it was over at that time. During an interview on 11/26/25 at 12:51 P.M., CNA C said: -Resident #5 tried to remove Resident #6's hand from his/her wrist and Resident #6 got upset. -Resident #5 was cussing at Resident #6 when Resident #5 kicked, smacked, and then punched Resident #6. -After Resident #5 kicked and hit Resident #6, he/she just walked off and was quiet. -Resident #6 was laying on the ground for a while. During an interview on 11/26/25 at 12:35 P.M., CNA G said Resident #5 hit Resident #6 in the face with his/her fist. During an interview on 11/26/25 at 1:17 P.M, CNA E said: -He/She saw Resident #5 and CNA C walking when Resident #6 came up and grabbed CNA C. -Resident #5 tried to take Resident #6's hands off CNA C. -He/She saw Resident #6 go towards Resident #5, then Resident #5 kicked and punched Resident #6 causing Resident #6 to fall to the floor. During an interview on 11/26/25 at 1:52 P.M., Licensed Practical Nurse (LPN) B said: -He/She was sitting at the nursing station and looking on the computer. -Resident #5 was upset when Resident #6 grabbed CNA C. -Resident #5 tried to remove Resident #6's hand from CNA C, then Resident #5 kicked, hit, and punched Resident #6. During an interview on 11/25/25 at 2:50 P.M., the Nurse Practitioner (NP) said: -The incident between Resident #5 and Resident #6 was abuse by definition. -Resident #6 sustained a jaw fracture. During an interview on 12/2/25 at 1:47 P.M., the Assistant Director of Nursing (ADON) said the resident to resident incident between Resident #5 and Resident #6 was considered abuse. During an interview on 12/2/25 at 2:50 P.M., the DON said the incident with Resident #5 and Resident #6 was abuse. During an interview on 12/2/25 at 3:15 P.M., the Administrator said the incident with Resident #5 was abuse by definition. 2675696 and 2675687

Based on observation, record review and interview, the facility failed to provide adequate care and supervision to prevent accidents for one sampled resident (Resident #2) out of seven sampled residents, when on 11/12/25 CNA A failed to position the resident properly in the bed and then turned away from the resident which resulted in a fall from the bed onto the floor with bruising and abrasions. The facility had further failed to transfer the resident with a Hoyer lift (mechanical transfer) and two staff per policy. The facility census was 125 residents. Review of the facility Safe Lifting and Movement of Residents Policy, dated December 2024, showed: -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decision regarding the safe lifting and mobbing of residents. -Manual lifting of resident shall be eliminated when feasible. -Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. Review of the facility undated Skills Checklist showed two staff must always assist with Hoyer lift (mechanical lift) transfers. Review of the facility Senior Living Fall Policy, dated April 2025, showed: -The purpose of the fall program in senior living is to develop, implement, observe and evaluate an interdisciplinary approach and manage strategies and interventions that foster resident independence and quality of life. -The fall program promotes safety, prevention and education of both staff and resident. -The community shall ensure that the fall program is maintained to reduce the occurrence of falls, reduce risk of injury, and promote independence and safety. -A fall is defined as the unintentional coming to the rest on the ground, floor or other lower lever. -If a resident loses balance and would have otherwise fallen, if not for someone intervening, it is considered a fall. --This includes witnessed and unwitnessed falls. --The includes falls with or without injury. -Serious injury includes but is not limited to fracture, laceration requiring sutures, any fall related injury that requires an evaluation in the emergency room or admission to the hospital. 1. Review of the Resident #2's admission Record showed the resident was admitted on [DATE] with the following diagnoses: muscle weakness, need for assistance with personal care and history of falling. Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 11/14/25, showed the resident was severely cognitively impaired. Review of the resident's undated Care Plan showed: -The resident had impaired cognitive function related to vascular dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). --Staff were to reduce any distractions, turn off TV and ensure the resident understands, and provide with necessary cues. --Stop and return if agitated. -The resident was at risk for falls due to cognitive and functional disabilities. --Staff to ensure bolsters and/or scoop mattress was on the bed. --Monitor for safe positioning in the bed. --The resident needed assistance to turn and reposition frequently. -The resident needed assistance with self-care due to co-morbidities. --The resident was totally dependent on staff for mobility. --The resident required the assistance of one staff to turn and reposition in bed. --The resident required two person assist with Hoyer for transfers. -The resident was resistive to care at times. --Staff to give clear explanation of all care activities prior to and as they occur during each contact. --If the resident resists with activities of daily living (ADLs), reassure resident, leave and return 5-10 minutes later and try again. Review of the camera footage still frame (screenshot) provided by Family Member A, dated 11/17/25 at 9:53 P.M., showed Certified Nursing Assistant (CNA) A was operating the Hoyer lift independently and by him/herself to transfer the resident to bed. Review of camera footage provided by Family Member A, dated 11/17/25 at 10:02 P.M., showed: -CNA A bent over the resident's bed with the resident laying on his/her right side wearing a hospital gown and no protective boots on his/her feet/lower legs, facing away from CNA A. -CNA A was standing on the door side of the bed and the resident was positioned on the edge of the window side of the bed in close proximity of the wall. -The resident's head was hanging face down over the edge of the bolster on the window side of the bed. -The resident's right leg was slightly bent and hanging off the edge of the bed between the bolsters. -CNA A had his/her right hand on the posterior left hip while wiping the resident's buttocks. -As CNA A removed his/her hand from the resident's hip the resident's body tilted forward towards the window/wall. -CNA A was positioning what appeared to be a turn sheet on the bed, his/her hands were not on the resident when he/she turned away from the resident looking towards his/her left.-CNA's back was to the resident and CNA A shifted his/her whole body away from the resident. -The resident drew the left arm up towards his/her body, and he/she began rolling in a forward motion off the bed headfirst. -As the resident fell from the bed headfirst onto the floor CNA A attempted to reach for the resident but was too far away from the resident. -The resident's left hip and left leg made contact with the wall as the resident fell from the bed. -As the resident hit the floor headfirst, landing on his/her left side, his/her body contracted slightly inward twice before coming to rest on the floor with his/her back against the wall. -The resident was not combative or resistive to cares during this timeframe.-The resident audibly groaned on impact. -CNA A dropped the turn sheet, climbed onto the bed on his/her hands and knees, extending across the bed to view the resident on the opposite side of the bed on the floor. -CNA A walked to the foot of the bed and slide the foot of the bed away from the wall. -CNA A bent down and grabbed both of the resident's ankles. -CNA A then left the resident on the floor.-CNA A was heard asking, Can I get some help please? once he/she was out of the visible frame. Review of the camera footage still frame provided by Family Member A, dated 11/17/25 at 10:07 P.M., showed:-CNA A had positioned his/her arms under the resident shoulders and another (CNA F) had his/her hands around the resident's ankles to lift the resident back into bed. Review of the resident's Progress Note, dated 11/17/25 at 10:30 P.M., showed: -Witnessed non-injury fall occurred about 10:15 P.M. -CNA A reported assisting resident in bed, I was trying to the clean resident and he/she became resistant, therefore I lowered the resident down. -CNA A exited the room immediately. -No complaints of pain, bruising or swelling noted. -Vital signs obtained and notification to physician, family, and Director of Nursing (DON). Review of the resident's Progress Note, dated 11/17/25 at 10:45 P.M., showed he/she had bruising to right toes, right face, right knee, and right cheek. During an interview on 11/24/25 at 1:09 P.M., Family Member A said: -He/she had camera footage the resident had fallen off the right side of the bed next to the wall onto the floor resulting in bruising to his/her left brow, left hip and left arm.-The facility notified him/her at 10:25 P.M. on 11/17/25 the fall was non-injury and that the fall was witnessed by the staff when the staff lowered the resident to the floor. -During his/her visit to the facility on [DATE] the resident said ow, winced, and refused touch on the left side areas of the resident's arm.-He/she lifted the resident's sleeves and found the bruising. Review of undated photos provided by Family Member A showed the resident:-Had deep purplish-red bruising on the left lower arm from the elbow to the wrist that was red and blotchy in coloring with swelling to the left hand/wrist region.-Had a reddish-purple bruise at the corner of his/her left eyebrow with bluish bruising around the eye toward the temple. The resident's left eyelid/eyebrow was swollen in appearance from the eye lid to the cheekbone and a pinpoint purple bruise on the top of his/her earlobe-Had a dark red purplish colored bruising in a circular placement on the left jaw line over an older appearing brownish bruise to the left jaw line. During an interview on 11/24/25 at 2:15 P.M., CNA A said: -That day, 11/17/25, the resident fell while he/she was helping the resident in bed. -The resident was a Hoyer lift. -The nurse was supposed to watch from the door while he/she used the Hoyer to transfer the resident from the wheelchair to the bed. -He/She had been using the Hoyer without a second person because he/she can't get anyone to help him/her. -The facility Hoyer policy states there was supposed to be two people when using the lift. -All they need was for someone to watch, not necessarily assist with the transfer. -He/She put the resident in bed, pulled the Hoyer sling out from under him/her, then rolled him/her in the bed onto his/her right side towards the wall. -While he/she was cleaning the resident's buttocks, the resident kicked his/her leg and slid off the bed. -He/She was holding the resident's side when he/she was cleaning him/her and he/she helped keep the resident from hitting the floor. -He/She was holding the resident's upper side with his/her right hand on left shoulder while he/she was cleaning him/her with his/her left hand. -The resident's body fell off the bed and his/her head stayed on the bed. -He/She climbed into the bed and lowered the resident to the floor, then got the nurse. -The resident was in the fetal position on the floor, he/she was not sure if the resident hit his/her head on the wall. -He/She has been transferring the resident with a Hoyer by him/herself although he/she knew the resident was a two person assist for Hoyer transfer, and the facility policy was to make sure there were two people present. -The only mistake he/she made was not making sure he/she had someone to help with the transfer into bed before the fall. During an interview on 11/25/25 at 12:18 P.M., LPN A said: -The resident was a total care and transferred with a Hoyer with two people. -The resident was not combative but could be rigid during cares. -He/She has only had one instance when a CNA was transferring a resident alone with the Hoyer last week and he/she educated the CNA on the spot. -On 11/18/25 when he/she came in that morning the night nurse reported the resident had a noninjury fall and was lowered to the floor. -It was reported the resident was resistive and was lowered to the floor. -Later that day he/she spoke to the Family Member A who wanted X-rays done. -He/She denied noticing any injuries immediately. -Either later in the day or the day after he/she was informed it was a fall and the bruise was revealed. -When he/she observed the resident's injuries he/she did not feel that was from being lowered to the floor. -The mattress on the bed was a regular mattress with bolsters (to prevent rolling) and fall mats on both sides of the bed. -With the resident's size and mobility, he/she would typically not fall off the bed even with kicking leg out. -In order to fall off the bed he/she would have been positioned on the edge of the bed. -The resident should always be placed in the middle of the bed during cares. -His/Her bed should always be in a low position, maybe a foot off the floor. During an interview on 11/25/25 at 1:57 P.M., CNA A said: -The resident had a mattress with bolsters and fall mats on the floor next to the bed. -The resident was laying in the middle of the bed and he/she rolled the resident over to clean and change him/her. -He/She should have had a second person. -The resident had a bruise on his/her face prior to this fall. It was on his/her cheek but not recall which side. -Everybody uses the Hoyer by themselves and was told the resident was a one person assist. -The resident's family placed a camera in the resident's room, it was on ceiling over the bed. It would have been able to see the position of him/her and the resident on 11/17/25 and be verification the resident did not fall out of the bed. -He/She removed the sling, rolled the resident, the resident fell, he/she checked the resident and got help. During an interview on 11/25/25 at 2:50 P.M., Nurse Practitioner (NP) said: -He/She was notified on 11/17/25 of the discovery of bruising. -The resident had diagnoses that could lead to bruising. -On 11/19/25 he/she did an assessment on the resident. -He/She was told it was a non-injury witnessed fall and was not aware of the resident hitting his/her head. -The resident should have been aligned in the middle of the bed. -There was a camera in the resident room and he/she expected staff to report the incident accurately. -They did an Xray which was indicated no fractures.-The mattress on the resident's bed wings (bolsters) were to prevent the resident from slipping off the bed. -It was common sense to place the resident in center of the bed while providing cares. During an interview on 11/26/25 at 11:12 A.M., CNA H: -It takes two of staff to use the Hoyer. -It was the first or second of November he/she used the Hoyer without help and got wrote up for it. -In the handbook it states that it takes two people to use the Hoyer. During an interview on 11/25/25 at 11:37 A.M., CNA F said: -He/She was walking down the hall when the nurse flagged him/her for help. -He/She went into the room; CNA A was at the head of the bed with the resident on the floor. -They turned the resident over to get him/her up off the floor, the nurse and CNA A tried to lift the resident up. -Then he/she assisted the nurse and CNA A to lift the resident onto the bed. -The staff grabbed the resident's arms, legs, and body to lift him/her into bed. -The resident was just lying there and was twisted up on the floor when he/she walked in. -The resident was kind of groaning when they picked him/her up and put him/her to bed. -The resident transfers with the Hoyer. -He/she has used the Hoyer to transfer the resident with two staff. -There has been times when he/she has used the Hoyer alone due to not enough people and everybody was busy. -The last time he/she used the Hoyer alone was about a month ago. -He/she was not asked to assist with transferring him into bed on the evening of 11/17/25. -There is a policy for the Hoyer to have two people when using the Hoyer. During an interview on 11/25/25 at 12:51 P.M., CNA C said: -The resident required full assistance and staff had to turn him/her. -The resident should be placed in the middle of the bed as close to the top as possible on top of a sheet or chuck. -There was never a time he/she would place the resident at the edge on his/her side, always in the middle. -He/She would not be able to stop him/herself from falling if on the edge of the bed while on his/her side. During an interview on 11/25/25 at 1:52 P.M., LPN B said: -The resident was completely dependent on others and had no mobility outside of moving extremities. -The resident transferred with a Hoyer lift and the transfer required two people. -The resident was expected to be placed in the center of the bed between bolsters with bed low. -With the bolster and the limitation of mobility the resident wouldn't be able to push out of bed by him/herself. -The resident was not appropriate to leave alone, all you would have to do is turn for a second, because the resident cannot control his/her own weight. During an interview on 12/2/25 at 1:47 P.M., Assistant Director of Nursing ADON said: -On 11/17/25 there was an alleged fall. -Initially he/she wondered how the resident fell and was told he/she did not fall completely out of bed. -He/She had not seen the video. -He/She now thought CNA C turned to clean him/her, his/her boots were on, his/her legs slid off the bed, and CNA C tried to catch him/her. -There was supposed to be two staff when using the Hoyer for transfers. -He/She heard Family Member A say the resident was transferred with one person in the lift. -The facility just had re-education for Hoyer lifts after 11/12/25. -There should not have been anyone transferring with the Hoyer alone. -When picking up the resident off the floor, they should have used the Hoyer to move him/her from the floor back to the bed. -The resident should not have been moved from the floor without the lift or an assistive device. -The staff should not have lifted the resident by grabbing his/her legs and under arms. -While performing cares for dependent residents, they should be positioned in the middle of the bed to ensure the resident will not tip and fall over out of the bed. -Bolsters were on the bed and placed to prevent a resident from rolling out of bed. -He/She was told the bunny boots (protective footwear) were over the edge of the bed, his/her legs slid out of the bed and pulled him/her out of the bed. -When CNA C first told him/her about the fall he/she said it was the legs that pulled the resident from the bed. -At no time did CNA C report the resident falling and hitting his/her head. - CNA C reported the resident was assisted to the floor instead. -There was never a time when the Hoyer should be used alone. -A resident should never be placed on their right side at the edge of the bed with their head hanging over the bolster and right leg hanging off the bed. -Staff should not remove their hands from the resident in that position and be out of arms reach when positioned at the edge of the bed. During an interview on 12/2/25 at 2:50 P.M., the Director of Nursing (DON) said: -The staff should not have picked him/her up without a sheet, blanket or lift after the fall. -There have been some complaints about staff using the lift with only oner person. -He/She expected two people when using the Hoyer at all times. -The resident should be placed in the center of the bed while doing cares. -He/She expected CNA C to be honest about what happened to ensure the resident was assessed and treated appropriately. -There was a skills checklist for Hoyer lift use for staff to complete. -Knowing now the resident fell from the bed to the floor, the staff should have never moved him/her from the floor until the Hoyer was available and the ambulance arrived. -There should not have been only two staff attempting to lift the resident without a lift sheet/blanket or Hoyer. 2667054 and 2671947

Based on interview and record review, the facility failed to ensure dignity was maintained for one sampled resident (Resident #1) when Certified Nurse's Aide (CNA) A told the resident to go in his/her brief during toileting assistance out of 14 sampled residents. The facility census was 133 residents.The Administrator was notified on 10/7/25 of the past noncompliance which began on 10/2/25. The facility immediately completed education for staff on the Abuse and Neglect policy, resident rights and dignity. The deficiency was corrected on 10/2/25. 1 Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses:-Generalized muscle weakness.-Morbid obesity.Review of the resident's Care Plan dated 10/2/25 showed:-The resident had the potential for behavioral symptoms and allegations over verbal abuse from staff member. -Interventions included: care in pairs, staff identify themselves and intentions before performing a task; speak slowly and distinctly for better understanding; monitor behavior episodes and attempt to determine underlying cause; consider location, time of day, persons involved and situations; document behavior and potential cause. During an interview on 10/7/25 at 11:00 A.M. Resident #1 said:-He/She came to the facility for rehab.-He/She was close to being able to walk but was not able to do so yet.-He/She did not know the CNA's name and had not seen him/her again.-Staff would assist him/her in using the bedpan.-The CNA said he/she did not like to do bed pans because it was too hard.-He/She asked the CNA to leave the room, and the CNA said it was his/her room, and he/she had to do his/her job.-It hurt his/her feelings when the CNA told him/her if he/she was not a baby to get up and walk, because he/she knew he/she could not walk.-It made him/her angry and it made him/her cry.-He/She felt safe staying at the facility.-The other staff were good and respectful, and he/she was getting good care.During an interview on 10/7/25 at 1:10 P.M. the Assistant Director of Nursing (ADON) A said:-He/She found out from the nurse what was said.-He/She went to the resident and asked him/her if he/she was ok with his/her CNA, and he/she said, No.-He/She asked the resident what was going on.-The resident told him/her what was said.-The resident said he/she wanted to use the bedpan, and CNA A told him/her he/she did not have help, so he/she could use his/her brief. He/She said, No, I'm not going in my brief. I'm not a baby.-CNA A said to the resident if he/she was not a baby, he/she could get up and walk to the bathroom.-He/She apologized to the resident and said he/she would take care of it and told him/her CNA A would not be in his/her room again.-The resident was there for therapy and stated if he/she could get up and walk, he/she would not be there.-He/She went directly to the administrator and told him/her what was said to the resident.-The administrator told him/her to go get CNA A and get him/her off the floor.-CNA A never denied anything and voiced that the resident was being rude to him/her.-It was inappropriate for CNA A to speak that way to the resident.-His/Her expectation was that staff would behavior professionally to the residents.-A lot of what was said did not have to be said.-He/She felt like this was a dignity issue for the resident.-It made the resident feel like a child, which was why he/she said he/she was not a baby.-He/She would never condone speaking like that to a resident.Review of CNA A's written statement dated 10/2/25 showed:-That morning (10/2/25) he/she answered the resident's call light and the resident said he/she needed to use the bedpan.-He/She asked the resident if he/she could go in his/her brief.-The resident made a big fuss and his/her comment and they went back and forth.-The resident yelled, I'm not a baby, so he/she told him/her then he/she should get up and walk.-The resident continued to go off and told him/her he/she didn't want him/her as his/her aide anymore.-He/She decided to continue his/her care with the resident but took CNA B in the room with him/her.-He/She decided to keep doing care while CNA B was in the room, and CNA B tried to calm the resident down.-The resident requested to speak with someone above him/her, so he/she told the resident, Gladly, after I finish my care. During an interview on 10/7/25 at 1:30 P.M. CNA A said:-Resident #1 had his/her call light on, so he/she went to answer it.-He/She asked the resident what he/she needed.-The resident asked to be placed on the bedpan.-He/She asked the resident why he/she did not use his/her brief, since the bedpan was hard to use.-The resident said he/she did not like to get urine on him/herself and he/she was not a baby.-He/She told the resident if he/she was not a baby, he/she could get us to go use the restroom.-This upset the resident more.-He/She probably should have handled it differently.-He/She was unaware the resident could not walk.-He/She explained to the resident that he/she would have to clean him/her up whether she used the bedpan or his/her brief.-The resident got upset about that and was snapping at him/her. -The resident said he/she did not like talking to him/her.-The resident was not respectful to him/her.-He/She told the resident to go ahead and use the bedpan and got him/her on it.-When the resident used the bedpan, he/she would never hit it and urine would get on the bed anyway, so using the brief would be more practical.-He/She took another employee in the room with her to keep things from escalating, but it escalated anyway.-He/She and the other employee stripped the bed. The resident was still snapping at him/her and telling he/she didn't want him/her as a CNA and didn't want him/her in the room. The other employee told the resident that wasn't nice.-Usually, people in that room are there for rehab.-He/She would let the ADON know if the resident was in a mood.-The resident was often rude, but he/she could work around it.-He/She had been educated on the use of a bedpan, but they have to strip the bed and changed the resident's gown every time they used it.-He/She had been previously educated on customer service.-This incident could have possible affected the resident's dignity. If the resident cried about it, it was probably after the fact.-After they got the resident cleaned up, she/she no longer went in the room, and then, two hours later, he/she got called to the office.-If he/she could do anything differently, he/she would have removed him/herself from the situation, kept his/her composure and went to get someone above him/her.-He/She would not tell the resident to toilet in his/her brief; he/she would get the bedpan, put the resident on it, clean everything up and go on about his/her day. During an interview on 10/7/25 at 1:50 P.M. ADON B said:- It would not be appropriate to tell a resident to go to the bathroom in their brief.-As a nurse she took a vow to take care of people. -Putting them on bedpan and cleaning up after them is part of a CNA's job.-The expectation would have done what the resident asked. -The resident is here to get stronger, so it is terrible that she was upset. Review of CNA B's written statement dated 10/2/25 showed:-CNA A asked him/her to pair with him/her in a room with a resident and when we went in there, the resident was already upset from what had previously happened. -The resident then refused to turn until speaking with the manager.-He/She told the resident to please let them finish their care, but then the resident was demanding his/her phone. He/she told the resident after they changed him/her, he/she would give him/her anything he/she needed, but we needed to get him/her off the bedpan.-The resident let them finish changing him/her and he/she told CNA A they could switch rooms so there would be no more conflict between them.-The resident was sometimes aggressive with his/her words, but only because of frustration.-CNA A changed and cleaned the resident after everything.-He/She wasn't there when CNA A said anything bad, but I could tell the he/she was agitated, as was the resident. During an interview on 10/7/25 at 2:30 P.M. CNA B said:-He/She was walking past the resident's room and CNA A came out of the room.-CNA A asked him/her if he/she could help finish changing the resident.-He/She could tell both the resident and CNA A were irritated.-At first, the resident did not want them to finish cleaning him/her up.-The resident said he/she wanted to speak to their boss.-He/She asked the resident to please let him/her finishing cleaning him/her up.-The resident and CNA A did not argue in front of him/her, but he/she was telling CNA A to get out.-He/She told CNA A he/she would take this resident's care for the rest of the shift.-The ADON talked to the resident and to CNA A and then CNA A got sent home.-It would never be appropriate at all to tell a resident it was too hard to help him/her use the bedpan and to use his/her brief instead.-This resident was usually really nice and not a bother at all, except for using the restroom.During an interview on 10/7 25 at 3:00 P.M. the DON said:-CNA A should have known better than to behave that way toward the resident.-The facility had education every month about appropriate staff behavior and CNA A had signed off on the education.-They do not say diapers; they call them briefs.-It was a dignity issue to ask someone to just pee in the diaper.-The whole interaction was wrong on CNA A's part.- If a care was in a staff person's scope, they should do it.-The lack of customer service was to the point that if one staff person felt this was ok, everyone needed to be educated.During an interview on 10/7/25 at 3:10 P.M. the Administrator said:-It was inappropriate for CNA A to speak to the resident disrespectfully. -It was not the best of customer service. -Her expectation was if a resident asked for help, the staff should meet the resident's needs, if it was not medically detrimental. 2633464

Based on interview and record review, the facility failed to provide adequate supervision of residents to prevent accidents. Facility staff failed to develop and implement interventions for one resident (Resident #8) who was at risk of elopement and who made statements regarding his/her intent to leave. The facility failed to ensure adequate supervision of residents during the smoke break, resulting in the resident not returning into the building at the end of the break. The resident climbed a fence and pushed him/herself off the ledge from the second floor smoke deck and broke his/her left tibia with a compound fracture which required immediate surgery and will require a second surgery. The facility census was 136. On 3/27/25 the Administrator and Director of Nursing (DON) were notified of past non-compliance Immediate Jeopardy (IJ) which occurred on 3/24/25. On 3/24/25 the facility administrator was notified of the incident and the investigation was started. The resident was sent to the hospital for evaluation and treatment. Staff were reeducated immediately. The IJ was corrected on 3/24/25. Review of the facility's Smoking Policy, dated December 2024, showed all residents will be supervised when they smoke. Review of the facility's Elopement Policy, dated December 2025 showed: -It is the policy of the facility that all residents are afforded adequate supervision to provide the safest environment. -All residents identified will have these issues addressed in their individual care plans. -All staff are responsible. -Wandering defined as aimless travel within the facility and enclosed courtyard areas. -Residents who are at risk for elopement shall be provided with at least one of the following safety precautions by the facility. --Door Alarms on facility exits. --A personal safety device that will alert facility staff when the resident had left the building without supervision. --Staff supervision. -Should a resident attempt an elopement, a review of their individualized care plan shall be triggered for possible changes in care practices of safety precautions for that resident. Review of Resident #8's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions and relate to others). -Bipolar disorder (a mental health condition causes extreme mood swings that include emotional highs, called mania and lows, known as depression). -Depression (a mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels that can significantly impact daily life). -Attention-deficit/hyperactivity disorder (ADHD - a mental health disorder that includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior). -Anxiety disorder (a mental health condition characterized by excessive, persistent, and often irrational worry, fear, and nervousness). -Stimulant: Methamphetamine (a highly addictive central nervous system stimulant), cocaine (highly addictive for the nervous system) and ecstasy (a drug that affects the brain's chemistry by releasing a high level of serotonin, which plays a role in regulating mood, energy level and appetite) abuse Review of the resident's Preadmission Screening and Resident Review Level II (PASRR - provides a comprehensive review of the resident's past and current behavioral health conditions and the services needed to ensure their health and safety) evaluation, dated 10/8/24, showed the following Psychiatric diagnoses: -Schizophrenia. -Bipolar disorder. -Anxiety disorder. -ADHD disorder. -Unspecified Psychosis not due to a substance or known physiological condition. -Cannabis use disorder. -Severe methamphetamine use disorder. -discharged from hospital to accepting facility, while in route, he/she escaped from the transportation vehicle and was homeless for a while. -He/she required ongoing assessment of mood, thought process and behaviors for early recognition of changes to promote early intervention and proactive modifications to plan of care. -A crisis plan should be developed to create clear steps for elopement precautions. -Guardians were concerned he/she needed higher level of care due to failed attempts at living independently in the community and inability to maintain medication/treatment compliance and substance use. -He/she does not want to admit to this facility, and it makes him/her upset. Review of the resident's Elopement Assessment, dated 10/15/24, showed: -cognitive impairment and independently mobile. -a history of elopement and desires to leave the facility. -had an active mental illness with changes in psychotropic medications in the past 90 days. -Based on the answers above the resident was an elopement risk. -Interventions: --Moved resident to a secure unit. --Picture in elopement book. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by staff and used for care planning), dated 1/20/25, showed he/she: -was cognitively intact. -had no behaviors or wandering. Review of the resident's Care Plan, dated 10/16/24 and revised on 10/25/24, showed: -he/she was a smoker and was to be supervised while smoking. -behavior problem care area revised on 2/4/25 due to resident exit seeking per charge nurse. --Monitor/record occurrence of target behavior symptoms (specify; pacing and wandering) and document per facility protocol. -Elopement risk/Wanderer revised on 2/4/25 due to exhibiting exit seeking behaviors. --He/she will not leave facility unattended through the review date. --Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and book. --Provide structured activities; toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. --Resident not allowed outside of community independently. Review of the resident's medical record for February 2025 showed no documentation of exit seeking behaviors as documented on the care plan. Review of the resident's Nurse Practitioner (NP) Encounter Note, dated 3/23/25 at 11:00 P.M., showed: -Resident was outside to smoke per facility smoke time. -After all residents completed smoking, the resident hid out and waited until everyone was coming back inside the building. -He/she had jumped outside the patio barrier wall which was about seven feet tall. -He/she stood on the top of the barrier wall then jumped down to the ground. -He/she lived on the second floor. -The NP was notified that he/she had multiple traumas on one of his/her legs (ankle, upper femur, and hand open visible broken bone). -Emergency Medical Services (EMS) was called and the resident was sent to the hospital for further surgery and treatment. Review of the facility's Resident Abuse Investigation Report, dated 3/24/25, showed: -This event took place during the 9:30 A.M. smoke break. -Resident #8 was on the 2nd floor patio on 3/24/25 when he/she eloped. -Injuries required medical attention. -Summary of interviews: --At the end of the smoke break all residents were directed into the building. --Resident #11 came outside towards the end of the smoke break and was the last resident known to be out on the patio smoking. --While outside Resident #8 darted out from the side of the building startling Resident #11. --Resident #8 told Resident #11 that he/she was going to jump the fence. --Resident #11 told Resident #8, you don't want to do that; you will hurt yourself. --Resident #8 took off running and jumped onto the fence. --While out smoking Resident #11 alerted staff the Resident #8 had jumped the fence. --Maintenance worker A alerted the management team of an event occurring in the front outside of the building. --Maintenance worker A reported that while he/she was going to his/her vehicle Certified Nurse Aide (CNA) C who was outside yelled out wait, wait, stop and was pointing up. --Maintenance worker A looked up and saw Resident #8 on the ledge of front of the building, dangling from the fence on the 2nd floor. --Resident #8 then jumped backwards onto the sidewalk of the parking lot. -The findings for this event: --There was no supervision of residents during the smoke break. --Resident #8 did not return into the building at the end of the break. --Resident #8 hid on the side of the building out of view as other residents returned into the building. --Once everyone was in the building Resident #8 jumped the fence from the 2nd floor attempting to elope, but was not successful. Review of the resident's Health Status Note, dated 3/24/25 at 12:54 P.M., showed: -Resident #8 went out for smoke break. -Residents came back in the building after smoke break was over. -Resident #8 hid out and waited for everyone to come back in. -Resident #11 had came out a little later due to ear drops. -Resident #11 stated that he/she seen Resident #8 come from the side and climb the fence and jump. -Resident #11 went looking for staff and finally found the Registered Nurse (RN) A and notified RN A. -RN A went out to the parking lot and saw Resident #8 surrounded by the Administrator, DON, Assistant Director's of Nursing (ADON), Maintenance Director, and Social Service. -Resident #8 had apparent fractures, NP, and family notified. -Will continue to assess. Review of the resident's hospital report, dated 3/24/25, showed: -Abrasions to the right and left palms. -Superficial abrasion to the left lateral lower extremity. -Left distal tibia (shinbone) fracture. -CT scan showed comminuted mildly displaced distal (lower part) tibia fracture extending into the tibia talar joint (connects the tibia to the ankle) with multiple small bone fragments in the joint space. -First surgery was on 3/25/25 and a second surgery will be needed to fix left [NAME] (a type of break that occurs at the bottom of the tibia and involves the weight bearing surface of the ankle joint) fracture. During an interview on 3/26/25 at 2:49 P.M., Licensed Practical Nurse (LPN) B said: -He/she had witnessed Resident #8 exit seeking while out on the smoke deck before this incident. -He/she charted the exit seeking behavior on Resident #8's care plan back on 2/4/25. -Resident #8 would walk along the fence on the second-floor smoke deck looking through the squares at the top of the fence down at the ground below. -Residents have designated smoking times and must always be supervised on the smoke deck. -Certified Nurse Assistant (CNA) A notified him/her of Resident #8 stating he/she was going to be the next person over the fence. -That is when he/she charted on Resident #8's care plan about Resident #8 exiting seeking. -The same day he/she seen Resident #8 looking through the openings at the top of the fence. During an interview on 3/27/25 at 11:18 A.M., CNA A said: -Staff are supposed to always be with the residents during the smoke break until the last resident is done smoking. -Staff are to walk around the smoke deck to ensure all residents are accounted for. -Resident #8 expressed to him/her that he/she was going to jump over the fence several times in the last month. -He/she reported this to his/her charge nurse, LPN B. -Resident #8 did not get any extra monitoring after notifying the charge nurse, LPN B. Review of Resident #11's annual MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 3/26/25 at 3:21 P.M., Resident #11 said: -He/she got out to 9:30 A.M. smoke break late. -When he/she arrived, there was no staff on the second-floor smoke deck monitoring residents. -He/she stayed on the smoke deck after all the other residents went back inside to finish smoking without supervision. -Resident #8 came up to him/her and said that he/she was going to jump over the fence. -He/she tried to talk Resident #8 out of going over the fence, telling Resident #8 he/she would get caught. -Resident #8 ran and jumped over the fence on the second-floor smoke deck anyway. -He/she was traumatized from Resident #8 jumping over the fence, because he/she was unsure if Resident #8 was dead or alive. -He/she ran into the facility to find RN A and tell RN A Resident #8 jumped over the fence. -No staff member was on the smoke deck at the time Resident #8 jumped over the fence. During an interview on 3/27/25 at 11:45 A.M., Certified Medication Technician (CMT) A said: -Resident #11 was the only resident on the smoke deck at the time of the incident. -He/she was passing medications while the residents were on smoke break. -He/she would have expected staff to always be with the residents on the smoke deck. During an interview on 3/27/25 at 12:40 P.M., LPN A said: -He/she was the charge nurse on shift when Resident #8 jumped over the fence on the second-floor smoke deck. -He/she saw the resident when they went out on a smoke break. -He/she thought agency CNA B would go out on the smoke deck and monitor the residents while they smoked, since agency CNA B was following him/her when he/she unlocked the door to the smoke deck. -He/she had not told CNA B to monitor the residents on smoke break. -He/she was unsure of the smoking policy. -He/she was doing a treatment on another resident in that resident's room at the time Resident #8 jumped over the fence. -Resident #11 came and found him/her and reported that Resident #8 had jumped over the fence to the ground below. -He/she should have made sure a staff member was out on the smoke deck. -That staff that are responsible for supervising residents during a smoke break is any staff on shift on the floor who were not assigned to the 1 to 1's as they had 2 staff sitting with 2 different residents that day. CMT was passing meds and another CNA were out of the building on an appointment with a resident. That left 2 CNAs and LPN A responsible for watching the residents. During an interview on 3/27/25 at 2:03 P.M., Agency CNA B said: -On 3/24/25 around 9:30 A.M., he/she decided to take his/her morning break and was not watching the residents on the smoke deck. -He/she watched LPN A pass out cigarettes to the residents who smoked, but he/she had not been told to watch the residents during the smoke break. -He/she saw the resident when they went out on a smoke break. -He/she had his/her back to the window overlooking the smoke deck by the door. -He/she did not know a resident had jumped until LPN A said they had. During an interview on 3/27/25 at 2:30 P.M., CNA C said: -He/she was on break in his/her car in the parking lot. -He/she saw Resident #8 on the ledge of the second-floor smoke deck. -He/she yelled at Maintenance worker A, because he/she was closer to the resident. -Resident #8 jumped before either of the staff could get to the resident. -Smoke deck doors are always to be locked unless residents are out smoking with supervision. During an interview on 3/27/25 at 2:47 P.M., Maintenance worker A said: -He/she went to get his/her lunch out of his/her car when he/she heard CNA C yelling wait. -He/she turned around and saw Resident #8 jump to the ground from the second-floor smoke deck. -Resident #8 started to walk away stating his/her mom and dad were waiting for him/her. -He/she knocked on the conference room window as the Administrator, DON, ADON and Social Services were in morning meeting. -Residents were to be supervised when smoking. During an interview on 3/27/25 at 3:00 P.M., the DON said: -He/she was finishing up morning meeting when Maintenance worker A knocked several times on the window to the conference room. -He/she and other staff went outside to see what was going on. -He/she went to Resident #8 who was sitting on the ground and assessed the resident for injuries. -Resident #8 had a deformity on the lower leg. -Resident #8 stated he/she wanted to go home. -EMS was called and the resident was sent to the hospital for evaluation and treatment. -Residents are to be supervised while out on the smoke decks. -On 3/24/25 he/she was not aware that no staff were supervising the resident on the smoke deck. -He/she expected staff to supervise residents out on the smoke deck. -He/she expected staff to chart in a resident's medical record if a resident expressed or was seen exit seeking. During an interview on 3/27/25 at 3:45 P.M., the Administrator said: -He/she was in morning meeting when Maintenance worker A knocked several times on the conference room window. -He/she went outside to see what he/she needed. -Resident #8 was sitting on the ground outside the front of the facility in the parking lot. -The resident was assessed and EMS was called to take the resident to the hospital for evaluation and treatment. -Supervision was always required for all residents during smoke breaks. -The resident hid away around the corner and then ran away. -He/She expected the resident to always be observed on the smoke deck by the staff assigned to that floor on shift. During an interview on 3/27/25 at 8:55 A.M., Resident #8 said: -He/she had planned on going over the fence on the second-floor smoke deck for a while. -He/she did not know how long he/she planned this. -He/she did not tell anyone including staff that he/she planned on going over the fence. -He/she has had one surgery and will be having another surgery on his/her broken leg. During an interview on 3/27/25 at 4:10 P.M., Resident #8's Family Member A said: -He/she was notified of the incident. -He/she wondered why the resident was left unsupervised. -Resident #8 was admitted to the facility because he/she always needed supervision and this was told to the facility. The facility should have done that so this would have not happened. MO00251597

Based on observations, interviews, and facility document and policy review, the facility failed to ensure food was prepared, stored, and served in accordance with professional standards for food safety as evidenced by the following: 1. Staff were not wearing beard guards to cover facial hair when in food preparation areas; 2. Food items, including sausage patties and chocolate chips, were not stored in closed containers; 3. Open food items, including preboiled eggs, diced pineapple, honey, and sausage gravy, were not dated; and 4. Residents' personal food items stored by the facility were not labeled with a resident's name and date and were not discarded when indicated. These failures had the potential to affect all 129 residents receiving meals from the dietary department at the time of the survey. Findings included: 1. An undated facility policy titled, Hair Restraints indicated, 1. Staff shall wear hair restraints in all food production, dishwashing, and when serving food from steam or cold table areas. 2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing areas. An observation on 02/07/2025 at 8:34 AM revealed the Building Engineer entered the kitchen without using hair restraints to cover their long hair and long facial hair. While in the kitchen, the Building Engineer entered the food preparation area where there was an uncovered pot of oatmeal and an uncovered pan of scrambled eggs. During an interview on 02/07/2025 at 8:59 AM, the Building Engineer stated staff were expected to cover their hair and facial hair anytime they entered the kitchen. The Building Engineer stated he/she forgot to cover his hair when he/she entered the kitchen on the morning of 02/07/2025. The Dietary Manager (DM) was interviewed on 02/07/2025 at 8:45 AM. The DM stated he/she expected staff to wear hair restraints to cover hair on their head and their face. 2. During a concurrent observation and interview on 02/03/2025 at 9:10 AM with Dietary Aide (DA) #32, an open box of frozen sausage patties, approximately three-fourths full, was observed in the freezer. The box was not closed, and the contents were open to air. DA #32 stated the box of sausage patties should have been closed. During a concurrent observation of the dry storage area and an interview on 02/03/2025 at 9:37 AM with the Dietary Manager (DM), a 25-pound box of chocolate chips was not closed, which exposed the contents to the air. The DM stated the box should have been closed. 3. An undated facility policy titled, Food Storage (Dry, Refrigerated and Frozen) indicated, 1. General storage guidelines to be followed: a. All food items will be labeled. The label must include the name of the food and the date by which it shall be sold, consumed, or discarded. During a concurrent observation of the walk-in refrigerator and an interview on 02/03/2025 at 9:15 AM with Dietary Aide (DA) #32 and the Dietary Manager (DM), eight boiled eggs wrapped in plastic wrap and a plastic container of diced pineapple were stored without a date to indicate when the items were prepared, opened, or when they should be discarded. The DM and DA #32 stated that each food item should be labeled with the date of storage. During a concurrent observation of the dry storage area and an interview on 02/03/2025 at 9:20 AM with the Dietary Manager (DM), an open package of peppered sausage gravy mix and five open bottles of honey were observed without a date to indicate when the items were opened or when they should be discarded. The DM stated the items should have been labeled with the dates they were opened. During an interview on 02/07/2025 at 9:12 AM, the Interim Director of Nursing (IDON) stated dietary staff were expected to date and label all foods with a label to record the date the food was made or opened prior to storing the food. 52219 4. A facility policy titled, Foods Brought by Family/Visitors, reviewed 01/2017, revealed, 5. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name and dated. The policy also indicated, 6. The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, foul odor, past due package expiration dates). A concurrent interview and observation on 02/07/2025 at 8:29 AM of the fourth-floor dining room refrigerator revealed a pizza box not labeled with a name or date. Staff who were present did not know who the pizza belonged to. Certified Nursing Assistant (CNA) #17 said the pizza should have been labeled with the name of who it belonged to. During an interview on 02/07/2025 at 9:25 AM, Resident #98 stated they ordered the pizza on the evening of 02/06/2025. An observation of the refrigerator in the fourth-floor dining room on 02/07/2025 at 1:42 PM revealed a sandwich consisting of what appeared to be two pieces of bread and a jelly-like substance. The sandwich was inside a plastic bag labeled with a date of 01/03/2025 but no name to indicate who it belonged to. A small plastic container with a white substance inside was also observed inside the refrigerator without a label identifying what it was, when it was prepared, opened, or placed in the refrigerator, or who it belonged to. During an interview on 02/07/2025 at 1:48 PM, Assistant Director of Nursing (ADON) #42 stated that whoever placed items in the refrigerator was supposed to label the items with a name and date. ADON #42 stated he/she thought housekeeping was responsible for maintaining the items in the refrigerator but was not sure.

Based on observation, interview, record review, facility document and policy review, and review of the Centers for Disease Control and Prevention (CDC) enhanced barrier precaution (EBP) signage, the facility failed to provide care in accordance with infection control standards for 2 (Resident #336 and Resident #103) of 9 residents reviewed for the infection control task. Specifically, the facility failed to ensure staff implemented enhanced barrier precautions (EBP), including appropriate hand hygiene and personal protective equipment (PPE) use, when providing care to Resident #336 and Resident #103. In addition, the facility failed to ensure Resident #336's indwelling urinary catheter drainage bag and tubing were not on the floor. Findings included: An undated facility policy titled, Infection Prevention and Control Manual - Enhanced Barrier Precautions revealed, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (such as residents that have wounds or indwelling medical devices). This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring a MDRO and may [sic] residents colonized with a MDRO are asymptomatic or not presently known to be colonized. Enhanced Barrier Precautions expand the use of gown and gloves beyond the anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. The policy specified EBP was recommended for, 2) A wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO. Indwelling medical devices include central venous catheters, urinary catheters, feeding tubes, tracheostomies/ventilators. The policy further specified, High-contact resident care activities where a gown and gloves should be used include: -Transferring residents from one position to another and -Caring for or using an indwelling medical device. 1. An observation on 02/03/2025 at 10:26 AM revealed Resident #103's and Resident #336's room (shared room) had a CDC sign posted on the door that indicated the residents required EBP. The undated CDC signage indicated, ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin openings requiring a dressing. A facility policy titled, Catheter Care, Urinary, dated 12/2024, revealed the section titled Infection Control specified, b. Be sure the catheter tubing and drainage bag are kept off the floor. An Admission Record revealed the facility originally admitted Resident #336 on 01/09/2025 and readmitted Resident #336 on 01/28/2025. According to the Admission Record, Resident #336 had a medical history that included diagnoses of gastrostomy status (presence of a surgically created opening in the stomach) and acute kidney failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2025, revealed Resident #336 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #336 utilized a feeding tube while a resident at the facility and received 51 percent (%) or more of their total calories through parenteral or tube feeding. Resident #336's care plan included a focus area, initiated 01/09/2025, that indicated the resident required a feeding tube related to dysphagia (difficulty swallowing). Resident #336's care plan did not address the need for EBP. A Nursing Admission/Readmission Data Collection, dated 01/28/2025, revealed Resident #336 was readmitted to the facility with an indwelling urinary catheter. Resident #336's Order Summary Report contained an order dated 01/27/2025 for a urinary catheter. The Order Summary Report also contained orders dated 02/05/2025 addressing enteral feedings (by way of feeding tube). During a concurrent observation and interview on 02/03/2025 at 10:30 AM, Resident #336 was in a low bed, with the resident's catheter drainage bag and tubing lying on the right side of the bed on the floor. Certified Nursing Assistant (CNA) #14 entered the resident's room wearing a mask and gloves but no gown. CNA #14 pulled the catheter drainage bag and tubing off the floor and emptied the catheter bag. Without washing hands or changing gloves, CNA #14 verified the positioning of Resident #336's catheter by lifting the resident's bedding and touching the resident. During an interview on 02/03/2025 at 10:36 AM, CNA #14 confirmed he/she did not wear a gown when emptying Resident #336's catheter bag and said he/she missed the sign that was posted regarding EBP. An observation on 02/03/2025 at 10:47 AM revealed Resident #336's catheter tubing was on the floor. During an interview on 02/03/2025 at 10:48 AM, CNA #14 confirmed Resident #36's catheter tubing was on the floor and stated catheter tubing was not supposed to be on the floor. An observation on 02/05/2025 at 11:20 AM revealed Registered Nurse (RN) #25 was providing care to Resident #336. RN #25 was not wearing a gown while utilizing the resident's feeding tube. During an interview on 02/05/2024 at 11:50 AM, RN #25 stated she should have worn a gown while providing care to Resident #336 but he/she did not. During an interview on 02/07/2025 at 2:17 PM, Assistant Director of Nursing (ADON) #41 stated that when a resident required EBP, staff should wash their hands before entering and when leaving the resident's room and should wear a gown and gloves when providing resident care. ADON #41 further stated that when performing catheter care, staff should wash their hands before initiating the care and after finishing, prior to touching the resident. During an interview with the Interim Director of Nursing (IDON) and the Administrator on 02/07/2025 at 3:22 PM, the IDON stated for a resident that required EBP, staff should perform hand hygiene prior to entering the room to provide care and when leaving the room. The IDON further stated that after providing catheter care, staff should wash their hands and change gloves before touching the resident. 2. An Admission Record revealed the facility originally admitted Resident #103 on 11/20/2023 and readmitted Resident #103 on 01/09/2025. According to the Admission Record, Resident #103 had a medical history that included diagnoses of dysphagia (difficulty swallowing) and gastrostomy status (presence of a surgically created opening in the stomach). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/2024, revealed Resident #103 had a short-term memory problem but was independent with cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). The MDS indicated Resident #336 utilized a feeding tube while a resident at the facility and received 51 percent (%) or more of their total calories through parenteral or tube feeding. Resident #103's care plan included a focus area, initiated 07/31/2024, that indicated the resident required EBP due to the presence of a feeding tube. Resident #103's Order Summary Report contained orders dated 01/09/2025 addressing enteral feedings (by way of feeding tube). The Order Summary Report also included an order dated 01/09/2025 for EBP. During an observation on 02/04/2025 at 2:05 PM, the Admissions Coordinator (AC) entered Resident #103's room without performing hand hygiene. Without donning a gown or gloves, the AC assisted Resident #103 by placing the resident's leg back into the bed and repositioning the resident. In addition, the AC assisted the resident by rearranging the resident's pillows and repositioning a pillow under the resident's head. The AC then left the room without performing hand hygiene. During an interview on 02/04/2025 at 2:08 PM, the AC stated he/she should have performed hand hygiene before entering Resident #103's room and should have washed his/her hands after assisting the resident. The AC further stated she guessed he/she should have also worn a gown while assisting Resident #103. During an interview on 02/07/2025 at 2:17 PM, Assistant Director of Nursing (ADON) #41 stated that when a resident required EBP, staff should wash their hands before entering and when leaving the resident's room and should wear a gown and gloves when providing resident care. During an interview with the Interim Director of Nursing (IDON) and the Administrator on 02/07/2025 at 3:22 PM, the IDON stated for a resident that required EBP, staff should perform hand hygiene prior to entering the room to provide care and when leaving the room.

Based on observation, interview, record review, and facility policy review, the facility failed to provide a privacy cover for a urinary catheter drainage bag for 1 (Resident #63) of 1 resident reviewed for dignity. Findings included: A facility policy titled, Resident Rights Policy, dated 12/2024, indicated, Each resident residing in this community has the right and will be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the community without interference, coercion, discrimination, or reprisal. The policy also indicated, Resident rights include but are not limited to: Privacy and confidentiality. 1. On 02/07/2025 at 2:34 PM, the Administrator stated the facility did not have a policy that addressed protecting the resident's dignity with the use of a privacy cover for a catheter drainage bag. An Admission Record indicated the facility admitted Resident #63 on 09/01/2024. According to the Admission Record, the resident had a medical history that included diagnoses of vascular dementia and obstructive and reflux uropathy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 12/06/2024, revealed Resident #63 had moderate impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident had an indwelling urinary catheter. Resident #63's care plan included a focus area revised 10/03/2024, that indicated the resident had a suprapubic catheter related to obstructive neuropathy. Interventions directed staff to provide catheter care every shift and as needed (initiated 07/10/2023). Resident #63's Order Summary Report, with active orders as of 02/07/2025, contained an order dated 01/09/2025 for the use of a suprapubic urinary catheter every 24 hours as needed for blockage or dislodgement. Observations on 02/03/2025 from 11:30 AM until 1:18 PM, revealed Resident #63 was seated in a wheelchair in the dining area. The observation revealed the resident's catheter drainage bag contained approximately 100 cubic centimeters (cc) of yellow urine. The observation revealed the catheter drainage bag with urine was not contained in a privacy cover. The resident's catheter drainage bag with urine was visible to staff, residents, and visitors. During an interview on 02/05/2025 at 3:12 PM, Licensed Practical Nurse (LPN) #20 stated that he/she was the assigned nurse for Resident #63 on Monday (02/03/2025) and he/she forgot to put a privacy cover over the resident's catheter drainage bag. LPN #20 stated that there was no privacy cover over the catheter drainage bag when the resident was sitting out in the common area. LPN #20 stated that the nurse was responsible for ensuring that the catheter drainage bag was covered. The Interim Director of Nursing (IDON) was interviewed on 02/07/2025 at 9:24 AM. The IDON stated that when staff provided catheter care, the catheter drainage bag should be placed in a privacy cover. The IDON stated that the catheter drainage bag should be kept covered for the dignity of the resident and that nobody needed to know that the resident had a catheter. The IDON stated that all staff should monitor to ensure the catheter drainage bag was kept in a privacy bag. During an interview on 02/07/2025 at 9:50 AM, the Administrator stated the charge nurse and unit coordinator should monitor to ensure resident catheter drainage bags were kept in a privacy cover when the resident was in a community area. The Administrator stated the resident's assigned Certified Nurses Aide (CNA) should make sure the privacy cover was in place to provide the resident with dignity.

Based on observation, interview, record review, and facility document review, the facility failed to ensure resident room floors and equipment were cleaned and maintained for 1 (Resident #103) of 4 residents reviewed for environmental concerns. Specifically, the facility failed to ensure tube feeding formula was cleaned off the resident's tube feeding pump, pole, and floor. Findings included: 1. An Admission Record revealed the facility originally admitted Resident #103 on 11/20/2023 and readmitted Resident #103 on 01/09/2025. According to the Admission Record, Resident #103 had a medical history that included diagnoses of dysphagia (difficulty swallowing) and gastrostomy status (presence of a surgically created opening in the stomach). An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/2024, revealed Resident #103 had a short-term memory problem but was independent with cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS). The MDS indicated Resident #336 utilized a feeding tube while a resident at the facility and received 51 percent (%) or more of their total calories through parenteral or tube feeding. Resident #103's care plan included a focus area, initiated 11/21/2023, that indicated the resident required tube feeding. Resident #103's Order Summary Report contained orders dated 01/09/2025 addressing enteral feedings (by way of feeding tube). An observation on 02/03/2025 at 10:43 AM revealed Resident #103's feeding tube pump had multiple dried splatters in the same color (beige) as their tube feeding formula. The four feet of the metal feeding tube pole also had beige-colored splatters on them, and the floor beneath the feeding tube pole had beige splatters. An observation on 02/04/2025 at 2:13 PM revealed Resident #103's feeding tube pump had splatters on the sides and underneath in the same color (beige) as the resident's tube feeding formula. An observation on 02/07/2025 at 9:33 AM revealed tube feeding formula was on the floor under Resident #103's tube feeding pump and pole. An undated facility document titled, Housekeeper 4 {4} Daily Job Routine revealed, 7:30 [AM] Do morning walk-through of your area addressing spills. The document indicated housekeepers completed a 7 Step Room Cleaning that included 3. Spot Clean Vertical Surfaces and 7. Mop Floor. The document directed housekeeping staff to clean specific rooms using the 7 step method daily, including Resident #103's room. During an interview on 02/07/2025 at 9:37 AM, Registered Nurse (RN) #26 acknowledged the tube feeding formula on the resident's tube feeding pump and floor and stated housekeeping needed to clean it. During an interview with the Interim Director of Nursing (IDON) and the Administrator on 02/07/2025 at 3:22 PM, the IDON stated tube feeding formula spills should be cleaned by the nurses and Certified Nurses Aides (CNA), or any staff member that saw the spills; however, the IDON said housekeeping staff should not clean the tube feeding pump when it was in use.

Based on observation, record review, facility document and policy review, and interview, the facility failed to ensure facility staff honored a resident's right to be free from a physical restraint that was not required to treat the resident's medical symptoms for 1 (Resident #386) of 3 residents reviewed for abuse. Specifically, a facility staff member picked up and carried Resident #386 off the smoking patio and back into the facility, thereby restricting the resident's freedom of movement when the resident attempted to grab another resident's cigarette. Findings included: The facility policy titled, Restraint Policy, dated 12/2024, indicated, Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. The policy also specified, Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life sustaining treatment, and no other less restrictive interventions are feasible. The Director of Nursing Services has the authority to order the use of emergency restraints. The Attending Physician must be notified of such use and the reason for the order. The State Operations Manual - Appendix PP definitions at F604 defined a physical restraint as, any manual method, physical, or mechanical device, equipment, or material that meets all of the following criteria: - is attached or adjacent to the resident's body; - cannot be removed easily by the resident; and - restricts the resident's freedom of movement or normal access to his/her body. The definitions at F604 also indicated, Manual method means to hold or limit a resident's voluntary movement by using body contact as a method of physical restraint. 1. An Admission Record revealed the facility admitted Resident #386 on 01/30/2025. According to the Admission Record, the resident had a medical history that included diagnoses of Huntington's disease (a progressive inherited neurodegenerative disorder that affects the brain, causing uncontrolled movements, cognitive decline, and psychiatric symptoms), gastrostomy status, and anxiety disorder. An annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/30/2025, indicated it was in progress. A Nursing Admission/Readmission Data Collection tool, dated 01/30/2025, revealed Resident #386 had the ability to express ideas and wants, had the ability to understand verbal content, did not use a mobility device, and did not require assistance to transfer, walk in room, walk in corridor, or walk on the unit. According to the tool, the resident's current weight was 77.4 pounds and the resident's level of consciousness was alert and oriented to person, place and time. The tool indicated the resident did not use restraints, had adequate hearing and vision, and did not exhibit any verbal or physical behaviors in the last 14 days or have a history of harming self or others. Resident #386's Care Plan included a focus area initiated 01/30/2025 that indicated the resident was a smoker. Interventions directed staff to keep smoking materials secured and to encourage smoking per facility protocol (initiated 01/30/2025). An Initial Report dated 01/31/2025 indicated the facility admitted Resident #386 to the facility on [DATE] and informed the resident about the smoking policy. The report indicated a skin assessment completed on 01/30/2025 noted bruises and scratches to the resident's arms, but that the resident reported to the Administrator that the bruises resulted from being manhandled by staff on 01/31/2025. The report indicated the resident had displayed agitation when the resident went behind the nurse's station to get a cigarette and required staff redirection. The report indicated that the resident then went to the smoking patio and tried to take a lit cigarette from another resident, and a certified medication technician (CMT) wrapped their arms around the resident to keep the resident from harming another resident or harming self. The report revealed that the resident tried to get on the elevator but was redirected. The report indicated the CMT provided the facility with a written statement and was suspended pending the outcome of the investigation. On 02/03/2025 at 12:06 PM, Resident #386 was observed ambulating independently on the second floor secure unit, with an unidentified staff member providing one-to-one monitoring. During an interview at this time, Resident #386 stated that at another facility (prior to admission to this facility), a staff member had manhandled them, causing bruises and scratches on both arms. During the interview, Resident #386 showed their arms to the surveyor, but no bruises were visible. Resident #386 then stated the incident occurred at the current facility over the weekend. The surveyor asked Resident #386 to clarify which weekend and what day of the weekend this occurred. Resident #386 stated, The weekend. The surveyor asked Resident #386 what time the incident occurred, and Resident #386 stated, In the morning. Resident #386 further stated that they were new to the facility, and staff on the third floor grabbed the resident's arms and threw the resident on the bed. Resident #386 stated they did not know the names of the staff. The resident stated this incident occurred on the third floor and after it occurred, the resident was moved to the second floor. The resident also stated that they reported the incident to the nurse on the second floor and then told the Administrator, who said the incident would be investigated. During an interview on 02/04/2025 at 3:11 PM, Licensed Practical Nurse (LPN) #1 stated Resident #386 was moved to the second floor on 02/01/2025 around 10:30 AM, before lunch and before the 11:30 AM smoke break. LPN #1 stated that after the 11:30 AM smoke break, Resident #386 asked him/her to get a sandwich the resident had left on the third floor, and when LPN #1 returned with the sandwich, the resident stuck their wrists out and told LPN #1 that staff on the third floor grabbed the resident and threw them on the bed. LPN #1 stated that the resident's wrists were both red and had old bruising but did not have the color of fresh bruising. The resident reported to LPN #1 that they were aggressive with third floor staff and that third-floor staff were aggressive to them. LPN #1 stated he/she then called the Administrator to notify him/her of the resident's allegation. He/She stated the ADM instructed him/her to write a statement and place Resident #386 on one-to-one monitoring. During a telephone interview on 02/05/2025 at 9:37 AM, CMT #5 stated he/she worked the 6:45 AM - 2:45 PM shift on 02/01/2025 and met Resident #386 for the first time that day. CMT #5 stated that during the shift, Resident #386 asked LPN #2 for a cigarette. The nurse gave the resident a cigarette, and the resident went to the smoking patio and smoked it. After the resident completed the cigarette, the resident tried to take Resident #64's cigarette. Resident #64 tried to keep the cigarette from Resident #386, but the resident stood over Resident #64 and continued to try and take it. CMT #5 stated when the resident would not stop trying to take Resident #64's cigarette, the only other option was to pick the resident up and bring the resident inside. CMT #5 stated he/she did not see any physical contact between the residents, but when Resident #386 would not stop trying to take Resident #64's cigarette, CMT #5 opened the patio door, grabbed Resident #386 by the waist from behind, picked the resident up, and put the resident back inside. CMT #5 stated Resident #386 was a small-framed resident and when he/she picked the resident up, he/she carried the resident inside about five feet and put the resident down on their feet. CMT #5 stated he/she blocked the patio door because the resident kept trying to go back outside. CMT #5 stated he/she received a phone call from the Administrator around 1:30 PM and was told to write a statement, clock out, and go home. The CMT denied that he/she threw the resident in bed or grabbed the resident by the wrists. During a telephone interview on 02/05/2025 at 10:30 AM, Certified Nursing Assistant (CNA) #4 stated on 02/01/2025, an incident occurred around 9:30 AM when staff tried to get Resident #386 to calm down. CNA #4 stated he/she was at the nurse's desk charting when Resident #386 tried to go out to smoke and tried to take a cigarette from Resident #64. CNA #4 stated staff went outside, and CMT #5 grabbed Resident #386 around the waist, picked the resident up, and carried the resident back inside while the resident snatched, grabbed, punched, and swung their hands at staff. CNA #4 stated that once the resident was back inside, they calmed down, then CMT #5 and CNA #4 walked with the resident to the resident's room, but on the way to the resident's room, the resident turned around to go back toward the door, so CMT #5 picked the resident up from behind by the waist again, carried the resident to the resident's room, and sat the resident on the bed. CMT #5 asked the resident to calm down and to come out of the room once they calmed down, and staff then left the room. CNA #4 stated staff were trained not to put their hands on residents. CNA #4 stated that when CMT #5 carried the resident inside from the smoking patio, the distance was a few feet, and the second time CMT #5 picked the resident up to take them to the room, the distance was the width of one resident's room. During a follow-up telephone interview on 02/07/2025 at 10:35 AM, CNA #4 stated that if a resident became combative, it would be best to walk away and go get the nurse but not to pick up the resident. During an interview on 02/05/2025 at 3:46 PM, LPN #2 stated that on 02/01/2025 around 9:30 AM, Resident #386 came to the nurse's desk and asked for a cigarette. He/She gave the resident a cigarette, and the resident went to the third-floor smoking patio to smoke. LPN #2 stated that when the resident came back into the third-floor dining room, the resident asked for cigarettes to smoke again. LPN #2 stated he/she told the resident to wait until the next smoke break, and Resident #386 came around the nurse's desk and took the cigarette box. LPN #2 stated he/she was able to retrieve the cigarette box, but then Resident #386 went back to the smoking patio and physically tried to take a lit cigarette from Resident #64. LPN #2 stated that CMT #5 went onto the smoking patio and told the resident not to take the cigarette from Resident #64. LPN #2 stated he/she went onto the smoking patio to help, held the door open, and witnessed CMT #5 put his/her hands around Resident #386's waist from behind and walk the resident back inside. During an interview on 02/06/2025 at 8:46 AM, the Interim Director of Nursing (IDON) stated he/she looked through the facility's investigation on 02/03/2025, and he/she did not believe CMT #5's intention was to abuse or harm the resident but felt the CMT was trying to deescalate the situation. The IDON indicated the CMT could have stood between the residents, grabbed another staff member to help redirect, or offered food or medicine and try to get to the root cause of why the resident was so upset. During an interview on 02/06/2025 at 10:03 AM, the Administrator stated during his/her investigation, he/she spoke with CMT #5, who stated that Resident #386 tried to take a cigarette from Resident #64 during a smoke break on the third-floor patio and would not stop when asked by Resident #64 and by staff to stop. The Administrator stated that CMT #5 reported he/she then lifted the resident up by the waist and brought the resident back inside but denied that he/ threw the resident on the bed. The Administrator stated CMT #5 said he/she just picked Resident #386 up by the waist and brought them back inside for redirection, to keep them from taking the cigarette from Resident #64, and to prevent anything from happening to Resident #64. The Administrator stated that during his/her investigation, it was determined that CMT #5 did not intend to abuse or harm Resident #386, but that when he/she picked Resident #386 up, he/she violated the resident's right to move independently and the right not to be physically redirected to a different space. The ADM stated CMT #5's response to the resident was a poor method of redirection. During a telephone interview on 02/07/2025 at 10:46 AM, CMT #6 stated that he/she worked the 7:00 AM to 3:00 PM shift on the third floor on 02/01/2025. He/She did not witness the incident involving Resident #386 and Resident #64 but stated he/she witnessed Resident #386 cursing and yelling when CMT #5 walked the resident to their room. CMT #6 stated that when CMT #5 walked Resident #386 to their room, CMT #5 held the resident by the shoulders as they walked. CMT #6 denied witnessing CMT #5 pick the resident up. CMT #6 stated that if he/she witnessed a staff member pick up a resident, he/she would report this to the Director of Nursing, the Administrator, or the nurse. CMT #6 indicated that staff were not trained to pick up a resident or put hands on them. CMT #6 also stated, If they [residents] are able to walk and you pick them up, now they can't walk. That's a restraint and we can't put them in a restraint, period. They would not be walking on their own. During a follow-up interview on 02/07/2025 at 11:39 AM, the IDON read the facility's Restraint Policy and stated he/she agreed with the definition of a restraint as recorded in the policy. The IDON stated that a restraint would be anything hindering a resident's ability to move about freely. He/She stated in an emergency, the nurse would need to alert the DON, and the DON could give the authority for restraint use, and the attending physician would have to be notified and would need to sign orders within 48 hours of the emergency. The IDON stated that in his/her opinion, when CMT #5 picked Resident #386 up, that was a poor choice but did not meet the definition of a restraint because the resident was let go and their arms and legs remained free. When asked if the IDON agreed that Resident #386 could ambulate independently prior to being picked up by staff but could not do so while being carried by CMT #5, he/she stated that the resident could not ambulate when they were picked up by staff, but that this was a poor choice, not a restraint. The IDON stated staff were expected to use other means to intervene like moving other residents away from an aggressive resident or attempting to corral the aggressive resident elsewhere, trying to talk to the aggressive resident to diffuse the situation, or trying to get the focus of the aggressive resident on staff rather than on everybody else. The IDON stated the expectation would be for staff to deescalate the situation by staying calm, making eye contact with the aggressive resident, and talking with the resident in a calm voice, while other staff moved other residents away from the situation to avoid any harm. During a follow-up interview on 02/07/2025 at 12:33 PM, the Administrator read the definition of a restraint per the facility policy and stated that he/she agreed with the definition. The Administrator stated that if a resident could not remove a device applied by staff or anything that restricted the resident's physical ability to move, that would be considered a restraint and would require an assessment, documentation in the medical record, and a physician's order prior to its use. The Administrator stated CMT #5 used poor judgement and that he/she did not agree with the way CMT #5 handled the situation, as the resident had the right to move on their own and not be redirected to a different place. The Administrator stated that CMT #5 should have used better techniques to deescalate the situation, like telling Resident #386 the goals and why the resident should calm down. The Administrator stated that he/she would expect CMT #5 to avoid putting his/her hands on a resident and to redirect the resident with verbal cues and guide the resident in a safe direction. MO00248912

Based on interview, record review, and facility document and policy review, the facility failed to thoroughly investigate 1 of 3 entity self-reported incidents reviewed. Specifically, the facility failed to thoroughly investigate an incident involving a missing resident (Resident #96). Findings included: A facility policy titled, Abuse, Prevention and Prohibition Policy, revised 10/2022, revealed the section titled Investigation, included, The facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. The policy further revealed, Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on. If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated. The policy revealed the facility was to Complete the investigation summary of statements and summary of investigation within five business days. 1. Resident #96's Admission Record indicated the facility admitted the resident on 03/25/2024. According to the Admission Record, the resident had a medical history that included diagnoses of orthopedic aftercare following surgical amputation, assistance with personal care, muscle weakness, abnormalities of gait and mobility, alcohol abuse, and psychoactive substance abuse. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/2024, revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS further indicated the resident used a manual wheelchair for locomotion independently. The MDS revealed the resident was independent with eating, oral hygiene, and toileting hygiene. The MDS revealed the resident required supervision or touching assistance with showering/bathing and personal hygiene and required setup or clean-up assistance with upper and lower body dressing. Resident #96's care plan included a focus area initiated 01/12/2025, that indicated the resident had a current diagnosis of a substance use disorder related to alcoholism and had been leaving the facility, drinking, and returning inebriated. Interventions (initiated 01/12/2025) directed staff to allow one-on-one time to discuss behaviors and reasons for use of alcohol in a non-judgmental way; to ask the resident if they have ingested medications or drugs that were not prescribed to them; to assess and support respiratory and cardiovascular function; to assess mental status and determine if there was a change from the resident's baseline; and to assess the resident for the following symptoms and report as they present: stumbling, nodding off mid-conversation, incoherent speech, slurred speech, rambling, sleepy, erratic behavior, hyperactive, threatening, hostile, bloodshot eyes, pinpoint pupils, pale face sweaty unruly appearance, fumbling, nervous, jerky movements, and eating candy or sweets. A sign-out sheet used by Resident #96 to leave the facility on 01/24/2025 revealed the resident placed their initials on the sheet and identified a date of 1-26. The sheet revealed the resident had marked the Time Out to be 10:40 AM. The sheet revealed that the resident did not fill out the Time Planned to Return and marked the Visit Location to be the library. During an interview on 02/04/2025 at 12:40 PM, the Administrator stated Resident #96 had signed out at 10:40 AM on 01/24/2025 to go to the Downtown Library and had not returned. He/She stated the resident had dated the sign-out sheet for 01/26/2025; however, the date was 01/24/2025. Resident #96's Progress Notes, revealed a Health Status Note, dated 01/25/2025 at 11:35 PM, that indicated Resident #96 had left the facility the day before and still had not returned. The note revealed the Administrator and unit manager were notified and had asked staff to look for the resident throughout the facility. The note revealed that when Resident #96 was not found, the Administrator notified the police, who came to the facility to ask questions, obtained a Face Sheet, and called the local hospital. The note revealed the police notified the Administrator the resident had been discharged from the hospital around 11:30 PM (the evening prior). The note revealed the police left an emergency number with instructions to call and have the resident's name removed from the missing persons list if they arrived back at the facility. The note revealed Resident #96's Nurse Practitioner (NP) was notified and asked to be notified if the resident returned to the facility. Resident #96's Progress Notes revealed a Health Status Note dated 01/28/2025 at 7:53 PM, that indicated Resident #96 had returned to the facility with another person. The note revealed the person that accompanied Resident #96 back to the facility stated they found the resident wandering around 39th and Main [street] and Resident #96 asked for a ride back to the facility. The note revealed this person pushed Resident #96 in the wheelchair from 39th street to the facility. The note revealed Resident #96 was alert, not in distress, and had no complaints of pain or discomfort. The note revealed the resident's clothes were visibly soiled, so staff assisted to get the resident toileted, changed, and offered them snacks and fluids. The note revealed the resident had no recollection of being gone for four days. The note revealed Resident #96's physician and NP were notified of the resident's safe return. During an interview on 02/05/2025 at 1:30 PM regarding investigative efforts into the event involving Resident #96, the Administrator stated, There are no other interviews written anywhere, or additional information. He/She stated, Every incident that is called into the State [Survey Agency] has an initial investigation and then we have to send in our final five-day investigation for each one as well. He/She stated, All the information for that incident is in the folder I gave to you. A folder containing a copy of the investigation completed for Resident #96 included an initial report submitted to the State Survey Agency (SSA); the sign-out sheet filled out by Resident #96 prior to the leave of absence; timelines to show the dates and times phone calls were placed to the police, local hospitals, detention centers, and jails; and the in-service sign-in sheets for the education provided on the sign-out process for residents given to the staff following Resident #96's departure from the facility. No interviews from staff or residents were present in the folder presented as the investigation, and a follow-up five-day final report was not completed or submitted to the SSA for this incident. During an interview on 02/07/2025 at 10:17 AM, the Administrator stated, In hindsight, I should have interviewed everyone. We are learning, and no one has ever said anything about that [interviewing everyone] before. He/She also stated, Any incidents that we send into the State [Survey Agency] should have an initial investigation and a final five-day investigation sent in for each. MO00248567

Based on interview and record review, the facility failed to ensure Level I Preadmission Screening and Resident Reviews (PASRRs) were completed when 2 (Resident #45 and Resident #23) of 4 residents reviewed for PASRR requirements were diagnosed with new mental disorders. Findings included: During an interview on 02/07/2025 at 1:53 PM, the Administrator stated the facility did not have a policy that addressed the completion of PASSRs. 1. Resident #45's Admission Record indicated the facility admitted the resident on 01/13/2017. According to the Admission Record, the resident had a medical history that included diagnoses of paranoid schizophrenia. The Admission Record indicated an additional diagnosis of recurrent major depressive disorder was added on 06/24/2024. Resident #45's Level One Nursing Facility Pre-Admission Screening for Mental Illness/Mental Retardation or Related Condition, dated 01/12/2017, indicated the resident was diagnosed with a major mental disorder, specifically schizophrenia, paranoia type. The screening indicated the resident did not have any serious problems with their level of functioning in the six months prior to the screening and had not received intensive psychiatric treatment in the prior two years. According to the results of the screening, the resident did not require a PASRR Level II evaluation. Resident #45's care plan included a focus area, initiated 04/27/2018 and revised 04/22/2024, that indicated the resident had behaviors related to a diagnosis of schizophrenia. The care plan also included a focus area, initiated 08/29/2022 and revised 04/22/2024, that indicated the resident was at risk for depression due to history of voicing feeling depressed. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. According to the MDS, at the time of the assessment, Resident #45 had active diagnoses that included depression and schizophrenia. Resident #45's medical record revealed no documented evidence a new PASRR was completed when Resident #45 was diagnosed with major depressive disorder. During an interview on 02/07/2025 at 1:53 PM, the Administrator and Interim Director of Nursing (IDON) stated Resident #45's PASRR should have been updated. 46258 2. An Admission Record revealed the facility admitted Resident #23 on 06/25/2021. According to the Admission Record, the resident had a medical history that included diagnoses of major depressive disorder (onset 02/01/2023) and psychotic disorder with delusions (onset 3/15/2023). Resident #23's Level One Nursing Facility Pre-Admission Screening for Mental Illness/Mental Retardations or Related Condition, dated 01/04/2013, indicated Resident #23 had not been diagnosed with a major mental disorder. A Psychiatric Periodic Evaluation, dated 06/14/2022, indicated Resident #23 was evaluated for follow-up for medication management for potential psychiatric conditions. The evaluation indicated the resident was diagnosed with major depressive disorder. A Psychiatric Periodic Evaluation, dated 03/28/2023, indicated Resident #23 had a Chief Complaint of Depression. The evaluation indicated the resident was diagnosed with major depressive disorder and delusional thoughts. Resident #23's Care Plan Report included a focus area, initiated 03/27/2023, that indicated the resident had symptoms of depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score 12, which indicated the resident had moderately impaired cognition. According to the MDS, at the time of the assessment, the resident had active diagnoses that included psychotic disorder and depression. Resident #23's medical record revealed no documented evidence the facility completed a new PASRR after the resident was diagnosed with major depressive disorder or psychotic disorder. During an interview on 02/07/2025 at 1:53 PM, the Administrator and Interim Director of Nursing (IDON) stated Resident #23's PASRR was not updated when Resident #23 received new major mental illness diagnoses.

Based on observation, interview, and record review, the facility failed to ensure that one sampled resident (Resident# 1) remained accident free when the resident reported pain and sustained bruising on both of his/her upper arms and forearms due to staff not following the resident care plan instruction to transfer with a Hoyer lift (mechanical lift) out of seven sampled residents. The facility census was 125 residents. Record review of the facility's undated skills checklists, which were provided as the facility's transfer policy, showed: -There were skills checklists for sit-to-stand lift; one person transfer; two person transfer to bed; two person transfer to chair; and Hoyer lift. -The first item on all of the checklists was to check the computer system for appropriate lift/transfer technique. -The rest of the checklists described how to use a sit-to-stand lift/Hoyer lift or how to complete transfers with gait belts. -The transfer checklists said to not pull up on the resident's shoulders and to not let the resident put his/her arms around the staff member. 1. Record review of the Resident # 1's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Multiple Sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability). -Major Depressive Disorder, Recurrent, Moderate (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Dependence on a Wheelchair. Record review of the resident's Nursing Admission/Readmission Data Collection dated 7/24/22 showed: -The resident was admitted for respite care (temporary care providing relief for the usual caregiver). -The resident was totally dependent on staff for transfers. -The resident used a wheelchair. Record review of the resident's baseline care plan dated 7/24/22 showed that the resident required Mechanical Aid (HOYER lift) for all transfers. Record review of the resident's weekly and PRN (as needed) skin check dated 8/2/22 showed the resident had bruising on of his/her forearms. Record review of the resident's Discharge Minimum Data Set (MDS -a federally mandated assessment instrument completed by facility staff for care planning) dated 8/3/22 showed: -The resident had a BIMs (brief interview for mental status) of 15, indicating the resident was cognitively intact. -The resident needed extensive assistance during transfers, which meant the resident was involved in the activity and staff provided weight-bearing support. Record review of the facility's undated investigation showed: -On 8/2/22, Unit Manager A notified the Administrator that he/she had received a report from the physician that the physician was shown bruising to both of the resident's forearms. -The resident reported the bruising was caused by staff grabbing him/her. -Interviews and statements from staff members who worked the evening shifts on 7/30/22 and 7/31/22 showed that Agency Certified Nurses Aide (CNA) B said the resident used a sit-to-stand lift on 7/30/22 but the resident did not want to use the sit-to-stand lift on 7/31/22. -Agency CNA D said he/she transferred the resident with a sit to stand life on 7/31/22 with another agency staff member. -The resident said staff was not using the lift. -A progress note by the physician showed the resident showed the physician bruising on both of his/her arms and said it was from being grabbed by staff. -The physician's physical exam showed small circular/oval bruises noted on both upper extremities with no joint swelling, redness, skin breakdown or decreased range of motion and resident denied bruising elsewhere. -The investigation found that the resident changed preference in how he/she wanted to transfer and the staff members were unsure of how to meet the resident's needs. -The findings of the investigation indicated the need for transfer education and training as an appropriate intervention and transfer training was immediately initiated upon the notification of the allegation made by the resident. Observation and interview on 8/2/22 at 2:07 P.M., the resident said: -He/she was supposed to use the sit-to-stand lift. -Two Agency CNAs got on either side of him/her, grabbed his/her arms and pushed/pulled him/her everywhere to transfer. -He/she thought this happened on Saturday. -His/her legs were messed up and wouldn't work properly because of the way the CNAs transferred him/her. -Neither of the CNAs used the gait belt or any other piece of equipment to transfer him/her. -The CNAs only used his/her arms. -He/she told them to stop and that they were hurting him/her but they didn't stop. -This happened on the evening shift. -He/she did not remember one of the CNA's names. -The CNA the resident did name was unable to identified. -He/she had multiple small round/oval discolorations on his/her forearms, along with two small round discolorations on the inside his/her right upper arm. -The discolorations of his/her skin ranged in color from dark blue to yellow. -He/she had on a long-sleeved shirt with the arms of the shirt pushed up slightly above his/her elbows. During an interview on 8/3/22 at 9:58 A.M., the Administrator said: -He/she talked with Agency CNA B, who worked with the resident over the weekend on the evening shift. -Agency CNA B said the resident didn't want to use the sit-to-stand and asked Agency CNA B to get someone to help. -Agency CNA B said the resident had an anxiety attack and had muscle spasms. -CNA A helped him/her with the transfer. During an interview on 8/3/22 at 12:11 P.M., Certified Medication Technician (CMT) A said: -He/she worked on the fourth floor on Saturday and Sunday evening. -He/she only saw the resident one time when he/she peeked through the door on Sunday because he/she needed a CNA to help with another resident. -The resident was supposed to use a Hoyer lift. -He/She thought the CNAs were using a lift but he/she didn't remember if it was a sit-to-stand lift or a Hoyer lift. During an interview on 8/3/22 at 12:19 P.M., Agency CNA B said: -He/she did work on the fourth floor on both Saturday and Sunday. -He/she did care for the resident on both days. -On Saturday, the resident wanted to use the sit-to-stand lift. --The resident said he/she was in respite care and he/she usually used the sit-to-stand lift. --He/she worked with another agency staff but he/she didn't know his/her name on Saturday. --He/she and the other agency staff used the sit-to-stand lift and the resident started to slip. --He/she told the resident it wasn't safe to use the sit-to-stand lift and sat him/her down on the bed and changed his/her brief. -He/she worked on Sunday with CNA A. -The resident said he/she needed help and CNA A said the resident used the sit-to-stand lift. -The resident started crying and said he/she didn't feel safe in the sit-to-stand lift. -He/she told the resident that he/she wanted to use the sit-to-stand lift the day before. -The resident said he/she was having spasms in his/her legs. -The resident wanted CNA A to stand in front of him/her and he/she put his/her arms around CNA A's neck. -CNA A then helped the resident to his/her wheelchair and then from the wheelchair to the commode. -CNA A transferred him/her back to the wheelchair in the same manner he/she got the resident onto the commode. -The only objection or complaint the resident had was that he/she did not want to use the sit-to-stand lift on Sunday because his/her legs were hurting really badly. -There was no flow sheet or report to get information about the residents. -He/she did not have any information on how to find out about residents' Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) information. -He/she asked about a charting system and was told there was no system. -A gait belt was not used to transfer the resident. During an interview on 8/3/22 at 12:44 P.M., the resident's responsible party said: -The resident had not spoken with him/her about the incident yet. -He/she noticed the bruising on the resident's arms. -The bruising was not normal for the resident. During an interview on 8/3/22 at 2:21 P.M., the physician said: -The resident showed him/her the bruising on the resident's arms. -The resident said staff grabbed him/her. -He/she would expect CNAs to know how residents are supposed to transfer. -If CNAs need specific equipment, including gait belts, to transfer a resident, he/she would expect the CNAs to use the specific equipment, including gait belts, to do the transfer. During an interview on 8/3/22 at 2:27 P.M., CNA A said: -CNAs got information on how to transfer a resident from the nurse or from the resident. -He/she was called in to help with the resident's transfer on Sunday evening. -The resident used the Hoyer lift for transfers. -The resident was not comfortable using the sit-to-stand lift. -CNA B was in the room with him/her. -He/she put his/her arms under the resident's armpits and around his/her back. -The resident held onto him/her, a gait belt was not used. -That was how he/she transferred the resident onto the toilet and then back into his/her wheelchair. During an interview on 8/3/22 at 2:49 P.M., Registered Nurse (RN) A said: -He/she worked on the fourth floor on Sunday evening. -The CNAs typically got a report from the nurse or use care cards to know how to transfer residents. -He/she did not know where the CNAs kept that information as he/she had never had to look it up. -He/she only helped with transfers when someone asked him/her to help. During an interview on 8/3/22 at 2:56 P.M., the resident said he/she felt that he/she was disrespected when the staff wouldn't listen to him/her about the transfers. During an interview on 8/4/22 at 3:09 P.M., MDS Coordinator said: -The residents' care plans had information about how they should transfer the resident. -Transfer information was also available in the electronic record where CNAs charted. -It would not be appropriate to transfer with a CNA's arms under a resident's armpits and around the resident and the resident holding onto the CNA. -CNAs should know how a resident transferred and if the resident requested a different way of transferring, the CNA should go to the nurse. -The nurse should verify how the resident is supposed to transfer and tell the CNA what has to be used for the transfer. During an interview on 8/4/22 at 3:09 P.M., the Administrator said: -Agency CNAs have a communication sheet that should show how to transfer residents. -Agency CNAs had access to the electronic record to see how residents transfer. -The Staffing Coordinator or Payroll Clerk gave agency CNAs information about where to find information on residents. -He/she fully expected agency staff to know how to find information before they got to the facility for their first shift. During an interview on 8/4/22 at 3:41 P.M., the Director of Nursing (DON) said: -One of the requirements for agency staff to work at the facility was to have knowledge of the computer system they use for the electronic record. -Agency staff should have a login to the computer system and he/she would always ask if they had access or if they needed a password reset. -The Staffing Coordinator or Payroll set up information with the agency company they use the most so that staff that come from that company have the minimum information they need before they get to the facility. -It would not be appropriate to transfer with a CNA's arms under a resident's armpits and around the resident and the resident holding onto the CNA. -It would not be appropriate to transfer a resident in a different way than is in the resident's record. -If a resident wanted to use a sit-to-stand lift but was supposed to use a Hoyer lift, the CNA should go to the charge nurse to make sure he/she used the correct transfer method. -If the resident's record said the resident was supposed to transfer using a Hoyer lift, the resident should transfer using a Hoyer lift. During an interview on 8/4/22 at 3:58 P.M., the Payroll Director said: -There was an orientation book at each of the nurse's stations for agency staff. -The charge nurse should try to go over it with agency staff. -The charge nurse knew the book was there. -The only thing the facility did before agency staff work there for the first time was to make sure the agency staff could time in and time out. -He/she and the staffing coordinator would also set up the computer system login if the agency staff did not have access yet. -He/she and the staff coordinator called agency staff to let them know where the agency staff could find the schedule so the agency staff knew where the agency staff were working. -That was all he/she and the staff coordinator did for agency staff. During an interview on 8/8/22 at 2:51 P.M., Agency CNA D said: -He/she helped CNA B during a sit-to-stand transfer with the resident by standing close and ensuring the resident did not fall on 7/31/22. -The resident said he/she was in pain because he/she hadn't had his/her medications yet. -There were no issues with the sit-to-stand transfer. -Agency staff did not have a way to see how residents were supposed to transfer. During an interview on 8/8/22 at 4:05 P.M., Unit Manager A said: -He/she did a head to toe skin assessment on the resident on 8/2/22. -The resident had bruises on his/her forearms. -He/she did not see any bruises on the resident's upper arms. -The resident told him/her that he/she got the bruises from staff transferring him/her without using a lift. -The resident said the staff used his/her arms to transfer him/her. MO00204954

Based on observation, interview and record review, the facility failed to keep one resident (Resident #1) free from physical abuse when the resident was found with his/her mouth bleeding and a red area on his/her face after a staffing agency Certified Medication Technician (CMT) A exited the resident's room stating the resident hit and spit on him/her and he/she was done with the resident out of three sampled residents. The facility census was 101 residents. Record review of the facility abuse and neglect policy revised 11/18 showed: -Each resident has the right to be free from abuse from anyone including facility staff; -The facility strictly prohibits abuse from any individual including facility staff; -Each staff member is educated regarding abuse and neglect upon hire and at least annually; -The owner, licensee, Administrator, employee or agent of the facility will not abuse any resident; -Resident behaviors would be monitored for changes in behaviors that could trigger abuse by staff, and -The facility would immediately remove any alleged perpetrator from further contact with any residents. 1. Record review of Resident #1's undated Admission Record showed he/she was admitted on [DATE] with the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION]-(a severe mental disorder in which thought and emotions are so impaired that contact is lost with reality); -Restlessness and agitation; -Mood disorder-(a mental disorder characterized by the elevation and lowering of a person's mood); -[MEDICAL CONDITION]-(a progressive mental disorder that causes degeneration of the brain causing severe dementia); -Impulsive disorder-(a mental disorder causing a failure to resist temptation) and -Delusional disorder-(a mental disorder which causes delusions but no hallucinations). Record review of the resident's care plan dated 8/31/17 showed: -The resident resisted care from facility staff; -The resident displayed verbal and physical aggression when frustrated; -The facility staff was to administer the resident's mediation as ordered and monitor the medication for side effects; -The facility staff was to leave the resident alone if he/she was agitated, waiting until he/she settled his/her behaviors; -The facility staff was to monitor the resident's behaviors and attempt to determine the cause; -The facility staff was to protect the safety of the resident and other residents, and -The facility staff was to explain procedures to the resident prior to start and allow the resident to adjust to change. Record review of the resident's quarterly Minimum Data Set -(MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 4/15/19 showed the resident: -Was not cognitively intact; -Had experienced delusions; -Did not show any refusal of cares; -Had verbal behaviors such as screaming, cursing or hollering one to three days over a seven day period, and -Required maximum assistance of one staff member for bathing, dressing, transferring, hygiene, and toileting Record review of the resident's nurse's notes dated 6/10/19 at 9:42 P.M., showed: -The resident was found sitting in his/her room with blood coming from his/her mouth; -The resident had redness on the left side of his/her cheek; -The resident said that a staff member hit him/her, and -The Director of Nursing (DON), physician and family notified. Record review of the facility Incident Summary dated 6/10/19 at 6:45 P.M., showed: - The DON was notified by Licensed Practical Nurse (LPN) A that Resident #1's mouth was bleeding; -Certified Nursing Assistant (CNA) A and CNA B had notified LPN A of the resident's bleeding mouth and that the left side of the resident's face was red; -LPN A immediately went to assess the resident and the resident kept repeating, he/she hit me; -The resident was unable to state who hit him/her; -CNA A and CNA B reported that while caring for another resident, they had heard Resident #1 screaming in his/her room; -While walking towards the resident's room, both CNA's witnessed Certified Medication Technician (CMT) A coming from the resident's room stating, Y'all can deal with him/her. I'm done. He/she hit me and spit on me and I'm done with him/her; -The CNA A and CNA B entered Resident #1's room and witnessed the resident crying, with blood coming from his/her mouth and redness to the left side of his/her face; -The CNA A and CNA B immediately reported the injury to LPN A; -The resident refused to allow a skin assessment to be completed stating, :Don't touch me. Leave me alone; -The resident also refused to allow the staff to place an ice pack on his/her mouth or face; -CMT A was immediately sent home and the staffing agency was notified CMT A would not be able to return to the facility to work; -The physician and family were notified; -Neurological checks (an assessment completed by nursing staff where the resident's sensory and motor functions are assessed) were initiated and were within normal limits; and -The physician stated he/she would examine the resident on 6/11/19. Record review of the Abuse Investigation Employee Questionnaire completed by CNA A on 6/10/19 at 6:45 P.M., showed: -He/she worked the evening shift on 6/10/19; -He/she was assisting another resident and heard Resident #1 screaming from the resident's room; -He/she walked out into the hallway towards Resident #1's room and saw CMT A walking down the hallway stating that he/she could no longer take care of Resident #1 as the resident had just spit in CMT A's face; -CNA A and CNA B then went to Resident #1's room and the door was shut; -CNA A and CNA B witnessed Resident #1 hollering and crying with blood coming out of his/her mouth and a scratch on his/her right cheek; -CNA A and CNA B were asking the resident questions and the resident said, They are hitting me in my face; -The resident would not allow anyone to touch him/her, and -CNA A and CNA B ran to go tell the charge nurse what happened. Record review of the Abuse Investigation Employee Questionnaire completed by CNA B on 6/10/19 at 6:45 P.M., showed: -He/she worked the evening shift on 6/10/19; -He/she heard screaming coming from an unknown room; -As he/she walked down the hall he/she witnessed CMT A walking down the hall saying, Y'all can deal with Resident #1, he/she spit on me and everything.; -He/she and CNA A went down to Resident #1's room and the resident was crying hard, his/her mouth was bleeding and his/her face was red; -The resident stated that he/she was hit in the face and that was the last time someone was going to hit him/her in the face, and -CNA B and CNA A then went to get the charge nurse. Record review of the facility Abuse Investigation Non-employee Questionnaire dated 6/11/19 and completed by DON A showed: -Resident #1 stated, He/she hit me; -The resident was unable to state or describe who was involved, and -The resident continued to repeat, He/she hit me. During an interview on 6/11/19 at 10:00 [NAME]M., Nurse Practitioner (NP) A said: -He/she had seen Resident #1 one time and was scheduled to see him/her again for a psychiatric assessment; -The resident had been unable to answer most questions during the assessment; -The resident had a history of [REDACTED]. -The resident's behaviors appeared to be worse after 3:00 P.M., each day, and -NP A was considering changing the time that some of the resident's psychiatric medications to see if that might improve the resident's behaviors. During an interview on 6/11/19 at 10:45 P.M., CNA A said: -He/she was caring for Resident #1 on 6/10/19; -CMT A was assisting the CNA's with getting the residents ready for bed; -He/she was with CNA B assisting another resident when he/she heard someone screaming down the hall; -As he/she was walking down the hall to see who was screaming, he/she saw CMT A coming out of Resident #1's room; -CMT A was stating that he/she could no longer assist Resident #1 as the resident had spit on him/her and asked him/her and CNA B to care for the resident; -He/she approached Resident #1's room and the door was closed; -He/she entered the resident's room and found the resident sitting in his/her wheelchair near the door; -The resident was crying hard and had blood coming from his/her mouth; -The left side of the resident's face was red and there was a scratch under the resident's left eye; -Resident #1 kept repeating, They hit me. They won't do this to me again!; -He/she attempted to calm the resident down; -The resident refused to allow him/her to touch him/her, and -He/she went and reported the incident to LPN [NAME] During an interview on 6/11/19 at 11:50 [NAME]M., CNA B said: -At around 7:30 P.M., on 6/10/19, he/she was assisting CNA A with getting residents ready for bed; -While assisting another resident, he/she heard screaming coming from down the hall; -The scream sounded muted but as CNA B got closer to Resident #1's room, the door opened, the screaming got louder and CMT A came out of the room closing the door behind him/her; -As CMT A left Resident #1's room, he/she stated that he/she could no longer deal with the resident that the resident had spit and hit him/her; -He/she entered Resident #1's room and the resident was crying; -As he/she tried to comfort the resident, the resident flinched and would not allow being touched; -The resident then stated that it was the last time that he/she was going to allow anyone to hit him/her; -The resident had blood coming from his/her lip and the left side of his/her face was red with a scratch below his/her left eye; -The resident also appeared to have redness above his/her right eyebrow; -He/she immediately reported the incident to LPN A, and -The resident finally allowed him/her to help him/her get ready for bed about 45 minutes after the incident. During an interview on 6/11/19 at 12:55 P.M., CMT A said: -The same thing happened on 6/10/19 that happened every night that he/she took care of the resident; -Resident #1 fought with him/her every time he/she took care of the resident; -When the resident fought with him/her, he/she would just leave the resident alone; -On 6/10/19 at around 7:00 P.M., to 7:15 P.M., he/she was assisting with getting the resident ready for bed; -Resident #1 had been fine and allowed him/her to get him/her undressed; -As he/she was attempting to get the resident's gown on, the resident began to fight and spit on him/her; -He/she then left the resident alone, closing the door as the resident's shirt was not on; -He/she the went to get another staff member to assist the resident; -Using another person to assist instead of trying to care for the resident alone did no good as the resident still fought with the staff; -Prior to caring for Resident #1, he/she never saw any marks on the resident's face or any blood on his/her mouth; -He/she never struck Resident #1 in the mouth, face or head, and -Why would he/she strike the resident when the resident is so small? Observation on 6/11/19 at 1:30 P.M., showed: -Resident #1 was sitting in his/her wheelchair near the dining room; -There was a one inch long red scratch on the resident's face just below his/her left eye, and -The resident's lips appeared to be slightly swollen but no cut was visible. During an interview on 6/11/19 at 1:30 P.M., Resident #1 said: -I got hit in the face last night, and -When asked if he/she felt safe in the facility the resident stated, I feel a lot of things. During an interview on 6/11/19 at 3:00 P.M., LPN A said: -He/she was the charge nurse caring for Resident #1 on the evening of 6/10/19; -The resident had no marks on his/her face or any bleeding in his/her mouth prior to the incident; -CNA A and CNA B came to him/her stating that the resident had been heard screaming and had blood coming from his/her mouth and the left side of the resident's face was red with a scratch below his/her left eye; -The incident had occurred while CMT A was caring for the resident; -Upon assessment, the resident appeared visibly shaken stating he/she had been hit; -He/she sent CMT A home, called DON A, the physician and the family. Record review of all sampled facility staff showed: -All employees had abuse and neglect training upon hire and prior to being allowed to care for residents at the facility, and -All employees had signed an abuse and neglect policy, indicating their understanding of the policy, prior to being employed in the facility. During an interview on 6/11/19 at 3:30 P.M., Administrator and DON said: -They acknowledged that the facility had a responsibility to keep the residents free from abuse; -CMT A refused to interview or make statement for the facility investigation; -The staffing agency was contacted and advised CMT A was no longer allowed to work in the building; and -They substantiated their investigation. MO 029

Based on observation, interview and record review, facility staff failed to provide appropriate interventions and protective oversite of residents after finding Resident #1, who resided on the locked dementia unit, in bed, under the covers, and nude from the waist down with another resident. The sample size was four residents. The facility's census was 113 residents. 1. Record review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. -Muscle weakness; -Retrograde amnesia (a loss of memory-access to events that occurred, or information that was learned, before an injury or the onset of a disease); -Depression; -Hypertension (HTN- high blood pressure); -Gastro-esophageal reflux. Record review of the resident's Daily Skilled Nurses Notes, dated 2/24/15, showed staff documented the resident displayed socially inappropriate behaviors (no specific behaviors were documented). Record review of the resident's behavior progress note, dated 2/24/15, showed staff documented: -The resident was a new admission from a psychiatric unit; -He/she had the potential to demonstrate sexually inappropriate behaviors; -He/she made inappropriate sexual gestures toward staff. Record review of the resident's care plan, dated 2/24/15 and revised 2/27/15, showed: -The resident had the potential to demonstrate physical self-satisfying sexual behaviors; -Facility staff were advised to monitor and record the occurrence of target behavior (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff or others, inappropriate sexual comments to staff and others) and document per facility protocol. Record review of the resident's Behavior Summary Report, dated 11/1/15 and 11/5/15-11/19/15, showed staff did not document the resident displayed any sexually inappropriate behavior. Record review of the resident's behavior progress note, dated 11/19/15 at 11:23 P.M., showed staff documented: -Staff found the resident in the bed of Resident #2 at 9:15 P.M.; -Resident #1 and Resident #2 were under the covers and nude from the waist down; -Facility staff called Resident #1 by his/her name, and the resident responded that the name was not his/her name, and he/she did not know anyone by that name; -Facility staff advised the residents that they would need to put their clothing back on; -Both residents complied and allowed staff to assist with getting dressed; -All appropriate contacts were made, 15 minute checks were started, and Resident #1 was moved to a room on the other side of the unit. Record review of Resident #1's 15 minute observation log, dated 11/19/15, showed: -15 minute checks were documented as started at 10:45 P.M.; -15 minute checks were stopped at 6:15 A.M. on 11/20/15. During an interview on 11/20/15 at 9:35 A.M., the Director of Nursing (DON) and Social Services Director (SSD) said: -Both resident's lived on the fourth floor locked unit; -Based on the facility's investigation of the incident that occurred on 11/19/15, Resident #1 entered Resident #2's room; -The SSD reported that Resident #2 was newer to the facility, and Resident #2 told the SSD that Resident #1 was telling him/her about the facility when they were in bed; -Resident #2 also informed the SSD that Resident #1 talked about sex, and Resident #2 did not agree to have sex; -Both laid in bed talking, before facility staff entered Resident #2's room; -Both residents were now under constant supervision, not one-to-one monitoring, and facility staff were to just keep an eye on them; -Once the two residents were awake, the DON did not see the need to have facility staff continue the 15 minute checks since both residents come and go on the unit as they please. Record review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/20/15, showed staff assessed the resident as: -Cognitively impaired; -Displayed physical behaviors towards others within the past one to three days; -Did not exhibit wandering behaviors; -Required minimal assistance with activities of daily living (ADL's - dressing, grooming, bathing, eating, and toileting). Record review of Resident #1's updated care plan, dated 11/20/15, showed: -The resident had a behavior problem related to his/her [DIAGNOSES REDACTED].>-He/she displayed inappropriate sexual conduct with another resident; -He/she was found in another resident's bed partially clothed; -Facility staff were advised to notify appropriate individuals if found again in another resident's bed; -Staff were instructed to redirect and chart any attempted sexual conduct, inappropriate touching, or if attempting to enter other residents' rooms; -Staff were instructed to intervene as necessary to protect the rights and safety of others; -The care plan gave no further direction to staff regarding how they were to observe the resident or other interventions that were to be put in place to ensure the safety of other residents. Record review of the resident's Health Status Progress Note, dated 11/20/15 at 12:48 P.M., showed staff documented: -The DON instructed staff to discontinue the resident's 15 minute checks; -Facility staff were instructed to keep him/her under close observation until further notice. Record review of the resident's 15 minute observation log, dated 11/20/15, showed: -15 minute checks were started back up at 2:15 P.M. by oncoming facility staff; -Facility staff did not complete the resident's 15 minute observation log during the day shift on 11/20/15. During an interview on 11/20/15 at 10:19 A.M., Certified Nursing Assistant (CNA) A said: -He/she has never witnessed any incidents in which the resident was sexually inappropriate; -He/she was unaware of any one-to-one monitoring for the resident; -He/she was responsible for keeping an eye on the resident just like all other residents. During an interview on 11/20/15 at 10:25 A.M., the resident said: -He/she was a head full of clouds these days, and he/she did not remember being in the other residents room the night before; -He/she asked if the resident was okay and what happened; -He/she reported he/she was doing so/so, but would be able to do a lot better if he/she was able to continue to look at the state surveyor smile throughout the day. During an interview on 11/20/15 at 10:30 A.M., Certified Medication Technician (CMT) A said: -He/she witnessed the resident being sexually inappropriate with other facility staff; -He/she reported the incident to his/her charge nurse after redirecting him/her; -He/she was unaware of any ongoing one-on-one monitoring or ongoing checks for the resident by facility staff. During an interview on 11/20/15 at 10:40 A.M., the facility's Assistant Director of Nursing (ADON) said: -There were occasions reported to him/her that the resident was sexually inappropriate with facility staff; -The resident was seen by the psychiatrist in the past and was scheduled to see the psychiatrist again today (11/20/15); -Staff usually just redirected the resident, and they reported incidents to the charge nurse on duty and were supposed to document them; -The resident had a care plan for the behavior, and to his/her knowledge, the resident never acted on any of his/her comments or touched any staff or other residents. During an interview on 11/201/15 at 10:46 A.M., CNA B said: -The resident flirted with staff; -To his/her knowledge the resident did not touch anyone; -CNA B said to his/her knowledge the resident was still on 15 minutes checks. During an interview on 11/20/15 at 11:11 A.M., Resident #3 said: -He/she has been at the facility about four weeks; -There was only one resident that he/she felt was inappropriate, and that was Resident #1; -Resident #1 was always blowing kisses and calling people baby; -A few days ago the staff had to break Resident #1 and another resident up from hugging. During an interview on 11/20/15 at 12:48 P.M., Licensed Practical Nurse (LPN) A said: -He/she entered the room of Resident #2 on the fourth floor to provide a knee treatment; -Upon entering he/she observed Resident #1 and Resident #2 in bed under the covers; -Resident #1 wheeled himself/herself into Resident #2's room; -He/she assisted Resident #1 back into his/her wheelchair when he/she discovered that both residents were disrobed from the waist down; -He/she called for a CNA to assist with getting Resident #1 dressed and back to his/her room while he/she assisted Resident #2; -He/she decided to bring both residents to the main dining room while calls were made; -He/she has never known Resident #1 to do anything like this or touch another resident; -Resident #1 required multiple redirections during his/her shift on a routine basis due to making sexually inappropriate comments; -A lot of Resident #1's conversation became inappropriate and sexual in nature on a routine basis, and facility staff were advised to redirect him/her; -There have been times when newer dietary staff delivered meal trays, and the resident would say something inappropriate to them, and he/she advised them to redirect him/her. During an interview on 11/20/15 at 1:00 P.M., CMT B said: -On 11/19/15, he/she gave Resident #1 and Resident #2 their night medication, both resident's conversed in the dining room, and Resident #1 decided to go smoke a cigarette after his/her medication; -He/she went on break and upon returning was advised of the incident; -In the past he/she had to redirect Resident #1 because the resident's conversations with facility staff were very sexually driven; -He/she usually just reminded the resident that he/she was married and his/her spouse would not like for him/her to speak to others in that way. Observation on 11/20/15 at 1:18 P.M., showed: -The resident conversed with a family member; -Facility staff were in the area and tended to all residents in the area. During an interview on 11/20/15 at 1:18 P.M., Resident #2 said: -He/she thinks someone came into his/her room last night; -He/she is not sure if it was a man or a woman, but they only left him/her a couple of clothing items; -There was someone who came into his/her room yesterday, and he/she told him/her to turn right back around and get out; -He/she doesn't remember anyone being in his/her bed the previous night or anyone being in his/her bed naked from the waist down. Observation on 11/20/15 at 1:45 P.M., of Resident #1 showed: -He/she was at the nurse's station with family; -The ADON entered the fourth floor and spoke to his/her family about the incident. During an interview on 11/20/15 at 1:45 P.M., CNA B said all CNA's are responsible for doing checks on the resident and documenting in the computer. During an interview on 11/20/15 at 1:53 P.M., CNA C said: -He/she was on his/her lunch break when the incident took place; -Staff informed him/her of what took place; -He/she has had to redirect Resident #1 in the past due to him/her being sexually inappropriate with facility staff; -The resident wanted staff to be his/her boyfriend/girlfriend; -He/she continued to redirect the resident. During an interview on 11/20/15 at 5:25 P.M., CNA D said: -He/she returned from his/her lunch break and was charting when other staff informed him/her of the incident; -Both residents were confused about what happened when he/she saw them; -Resident #1 was always inappropriate with facility staff, and he/she had to redirect him/her as soon as he/she stepped onto the unit; -As soon as he/she sees the resident, the resident starts making comments; -CNA D was advised to redirect the resident or change the topic of conversation; -He/she had just been able to access the facility's computer system to complete his/her own documentation; -Prior to having access, he/she relied on other nurses he/she shadowed to complete his/her documentation. During an interview on 11/20/15 at 6:00 P.M., the facility Administrator, DON, ADON, and SSD said: -No one was specifically assigned to sit with Resident #1; -He/she was never truly out of site, and the administrative staff continued to check the facility's video monitors throughout the day; -Also, Resident #1 had family at the facility throughout the day, so he/she in a sense had one-to-one monitoring throughout the day; -Facility staff were aware that the facility was responsible for one-to-one monitoring and could not rely on family to step-in in that capacity, and video files would not be placed into the resident's progress notes or other documentation; -Facility staff were in the process of sending a staff member to do one-to-one monitoring with the resident at 7:00 P.M.; -Due to the resident's right to privacy, facility staff did not think it was necessary to provide continued 15 minute checks and one-to-one monitoring when the resident's family visited. During an interview on 11/20/15 at 5:00 P.M., 6:00 P.M. and 7:00 P.M., policies related to resident behaviors and the requirements of staff regarding the documentation of resident behaviors was requested from the facility staff. As of 12/1/15, no policies had been received. During an interview on 11/20/15 at 6:45 P.M., the MDS Coordinator said: -The facility did not have any other behavior tracking for the resident; -The facility had a system update and no documentation was available prior to the first of November 2015. During an interview on 11/24/15 at 9:39 A.M., the resident's physician (Physician A) said: -Staff notified him/her of the incident that took place with Resident #1 and the other resident; -He/she advised staff to keep the residents separated and to complete 15 minute checks; -The plan was to continue the 15 minute checks for a couple of days; -This was to ensure the resident did not continue to display this type of behavior, and to allow time for the resident to be seen by his/her psychiatrist; -He/she was under the impression that the resident was sent out for a psychiatric evaluation on 11/20/15. Complaint MO 463 Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. A visit was completed on 11/20/15. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at this time. The facility implemented one-on-one staffing for 72 hours for Resident #1, 15 minute checks for 72 hours for Resident #2, inservice and training for all staff, and auditing of the resident population to ensure there were no other residents that needed a care plan to address inappropriate sexual behaviors. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. The severity of the deficiency was lowered to a D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on staff interview and record review, the facility failed to ensure one resident (Resident #4) of four sampled residents was free from physical abuse and to immediately protect residents from the potential of further abuse. Two facility contract staff witnessed Resident #4 being physically abused on 5/30/15 by a Certified Nurse's Assistant (CNA). The two contract staff failed to report their observation of abuse immediately to administrative staff and/or the charge nurse and the CNA continued to work until administrative staff was notified on 6/1/15. This had the potential to affect all residents in the building who were cared for by the CNA. The facility census was 114 residents. Record review of the facility's undated policy and procedure for Prevention and Prohibition of Abuse, showed in part: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. -Facility staff shall be trained on the abuse prohibition program during orientation and ongoing during educational sessions. The facility will utilize the Training Program: Keeping Nursing Facility Resident Safe (by AHCA) . including in the pre/post testing for competency. Additional inservices shall include: --How staff should report their knowledge related to allegations without fear of reprisal; --What constitutes abuse, neglect and misappropriation of resident property and facility programs that are designed for detection and prevention. -Protection: The facility will immediately remove any alleged perpetrator from any further contact with any resident. --Employee allegations: When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcome of the facility investigation, prosecution or disciplinary action against the employee. The Administrator and/or the Director of Nursing (DON) will relay this suspension. -Reporting/Response: The facility employee or agent who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the Facility Administrator and/or the DON. --Any employee who knows or has reason to believe that abuse or neglect occurred and does not immediately report will face possible termination. Record review of the undated Healthcare Services Group, Inc. (a company contracted by the facility to provide dietary services for residents) Employee Handbook, Patient/Resident Abuse/Neglect, page 17 showed: -If you see abuse or neglect you must report it: Any employee who has actual knowledge of the abuse or neglect of a patient/resident shall immediately submit a complaint to the employee's supervisor (or if the employee's supervisor is not immediately available to the Administrator or Nursing Supervisor). 1. Record review of the contract company's inservice sign-up sheet on Reporting/Response to Abuse or Neglect showed: - Nine employees were inserviced on 2/20/15; - Two employees were inserviced on 2/23/15; - One employee was inserviced on 2/24/15; - One employee was inserviced at an unknown date; and - Dietary Aide (DA) A and DA B were not listed on the inservices. Record review of CNA A's employee file, showed CNA A was disciplined on 3/25/15 for cursing on 2/19/15. Record review of the facility's Inservice Education Signature Sheet dated 5/26/15, showed employees attended an inservice regarding the facility's sexual harassment policy, abuse, facility security and wellness program. The inservice included: The facility employee or agent who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator and the Director of Nursing. The signatures of CNA A, DA A and DA B were on the signature sheet as having attended. Record review of Resident #4's care plan dated 4/19/13, showed he/she had impaired cognitive function or impaired thought processes related to short-term memory loss, long-term memory loss, and dementia. He/she was usually understood and he/she understands, but was forgetful. Staff was instructed to: - Identify yourself at each interaction; - Face the resident when speaking and make eye contact; - Reduce any distractions such as the television and radio; and - Provide the resident with necessary cues, and stop and return if agitated. Record review of the resident's care plan dated 4/19/13, showed he/she had a communication problem related to a hearing deficit. Staff need to look at him/her when talking and talk in a loud voice. Staff was instructed to encourage the resident to continue stating thoughts even if he/she is having difficulty. Record review of the resident's care plan dated 4/19/13, showed he/she had an Activities of Daily Living (ADL; how a person self-performs grooming, eating, toileting, walking, etc.) self-care performance deficit related to muscle weakness and [MEDICAL CONDITIONS], and required the use of a Hoyer lift (a device designed to transfer people) for transfers and toileting. The resident also: - Was dependent on staff to keep him/her clean and dry;- Required extensive assistance with bed mobility, dressing and personal hygiene; - Was totally dependent on staff for bathing; - Was mobile via an electric wheelchair with safety belts that he/she used to get around on and off the unit. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, dated 6/2/15, showed: - Had long-term and short-term memory problems; - Had moderately impaired decision making ability; - Displayed disorganized thinking, delusions and wandering behaviors; - Had [DIAGNOSES REDACTED]. - Required extensive assistance on one staff member with wheelchair mobility; - Required extensive assistance of two staff members with bed mobility and toileting; and - Was dependent upon staff for transfers and bathing. Attempts to interview the resident on 6/8/15 were unsuccessful, due to the resident's communication difficulties. Record review of CNA A's Time Detail information dated 5/30/15, showed he/she worked from 6:39 A.M. to 7:05 P.M. and from 7:57 P.M. to 10:46 P.M. Record review of the daily facility staffing schedule dated 5/30/15, showed CNA A worked the fourth floor on the day shift where Resident #4 resided, and worked on the second floor during the evening shift. Record review of a facility handwritten statement dated 6/1/15 by DA A, showed on 5/30/15 DA A and DA B were on the elevator. When the elevator door opened on the fourth floor, he/she witnessed CNA A hitting Resident #4 on the hand and then pushing the resident's electric wheelchair into the elevator wall. Record review of an undated facility handwritten statement by CNA A regarding his/her interactions with Resident #4 on 5/30/15, showed he/she stated he/she was not around Resident #4 at no time when this happened, was not on elevator at all. During a telephone interview on 6/9/15 at 1:50 P.M., DA A said: - He/she and DA B were on the elevator on 5/30/15, and as the elevator door was opening on the fourth floor, he/she saw CNA A swatting Resident #4's hand. - He/she could hear the sound of skin slapping against skin. - CNA A moved the electric wheelchair control and the resident's foot went into the door frame. - The resident said Ahh ahh and looked so sad. - He/she reported this to the Dietary Manager (DM) on Monday 6/1/15. - Then the DM went to the Administrator and the DON to report the incident. - He/she did not report the incident until Monday morning as there was no administrative staff in the building over the weekend. During a telephone interview on 6/9/15 at 2:11 P.M., DA B said: - He/she and DA A were going up on the elevator and the elevator stopped at the floor and the elevator doors opened. - CNA A was moving the controller on Resident #4's electric wheelchair and the resident was trying to place his/her hand on the controller. - CNA A started tapping the resident's hand several times and said No don't do that. - This was when the wheelchair and the resident's foot hit the door frame. During an interview on 6/10/15 at 2:45 P.M., DA B said: - The incident occurred after lunch on 5/30/15. - He/she did not report the incident involving Resident #4 on 5/30/15 as DA A had reported it. - He/she did not attend an abuse and neglect inservice on 5/26/15. - He/she remembered attending the 5/26/15 inservice after being shown his/her signature on the inservice attendance sheet. - He/she thought they had five days to report abuse and neglect. - He/she received abuse and neglect information in the new-hire packet. - He/she had not viewed a video regarding abuse and neglect. - He/she did have the ability to call his/her supervisor when the supervisor was not in the building. Record review of CNA A's Time Detail information dated 5/31/15, showed he/she worked from 6:43 A.M. to 1:05 P.M., and from 1:31 P.M. until 2:31 P.M. Record review of the daily facility staffing schedule dated 5/31/15, showed CNA A worked on the third floor on the day shift. Record review of CNA A's Time Detail information dated 6/1/15, showed he/she worked from 6:39 A.M. to 1:00 P.M. and from 1:30 P.M. to 2:40 P.M. Record review of the daily facility staffing schedule dated 6/1/15, showed CNA A worked the fourth floor on the day shift. During an interview on 6/11/15, at 11:14 A.M., Licensed Practical Nurse (LPN) A said: - He/she was a charge nurse for the fourth floor. - He/she worked on 6/1/15. - CNA A worked that day. CNA A came in at about 8:00 A.M. because he/she was called in due to a call in. - CNA A worked the full shift on 6/1/15 he/she believed. During an interview on 6/8/15 at 8:40 A.M., the Administrator said: - He/she was notified of the incident on Monday morning (6/1/15) after DA A came in on his/her day off to report what he/she had observed on 5/30/15. - DA A was upset while relaying what he/she witnessed. - The facility immediately began to investigate. - The employee was suspended on Monday 6/1/15. - The employee has not worked since Monday 6/1/15. - It was determined by the facility management that the incident had occurred and the employee was terminated. During an interview on 6/10/15 at 1:40 P.M., the DM said: - He/she had been at the facility since September 2014. - New dietary staff employees received information about resident rights, the employee hand book and watch a video regarding abuse during orientation. - The company he/she worked for provided new dietary staff with their employee hand book and dietary staff watch a video regarding abuse that the facility provided. - He/she did not believe DA A and DA B watched the resident abuse video. - He/she last provided an inservice regarding how to report abuse to his/her staff in February of 2015. - He/she stated the facility Administrator had an all staff mandatory inservice regarding abuse/neglect a few weeks ago that he/she believed DA A and DA B attended. - The inservice included information on abuse/neglect and when and who to report it to. - He/she tells his/her staff if it hurts their heart they need to report it. - Most of the time dietary staff report it to him/her. His/her staff have his/her cell number. - DA A reported the incident regarding Resident #4 to him/her on Monday morning at approximately 7:30 A.M. He/she immediately called DA B to ask about the incident and then informed the DON. - The staff should have called him/her or told any supervisor in the building on Saturday what happened to Resident #4. - He/she believes that two of his/her new staff, which includes DA A, have not seen the facility Abuse video. During an interview on 6/11/15 at 11:45 A.M., the fourth floor Unit Manager said: -CNA A worked the 6/1/15 day shift, but was taken off the floor as soon as the Administrator and DON were informed of the abuse allegations that afternoon. -CNA A was scheduled to work the evening shift as well. During an interview on 6/11/15 at 11:47 A.M., the DON said: -The DM brought DA A to his/her office in the afternoon because DA A came in on his/her day off. Before DA A told him/her the information, he/she immediately got the Administrator and Social Services Director so he/she would only have to tell the story one time. During an interview on 6/12/15 at 8:01 A.M., CNA A said: - He/she worked the fourth floor on 5/30/15 during the day shift. - He/she was responsible for resident rooms 411-418. - The Activities department was gathering residents for an activity downstairs. - He/she saw Resident #4, hit his/her foot into the wall in his/her electric wheelchair. - He/she then put his/her body between the wall and Resident #4. - He/she said Back up, back up and the resident finally backed up the wheelchair. - The activities person was then able to guide the resident onto the elevator. - He/she asked the activities person if he/she had the resident, and the activities person replied Yeah I have him/her. - He/she stated the incident occurred around 10:30 A.M. or 11:00 A.M. on 5/30/15. - He/she denied placing a hand on the resident. - During orientation he/she received information regarding abuse and neglect in a packet. - He/she worked the third floor (his/her regular floor) on 5/31/15. - He/she was called the evening of 5/31/15 and asked to work on 6/1/15. - He/she agreed to come in and was suppose to work on the third floor. - When he/she got to the facility, he/she was reassigned to work on the fourth floor as another employee had called in and couldn't work his/her scheduled shift. - He/she was working a double shift on 6/1/15. - At approximately 4:00 P.M., the Administrator pulled him/her from the floor and suspended him/her. - He/she loves his/her residents and would never hurt them. - He/she denied slapping the resident's hand. Record review of an undated form entitled Employee Corrective Action Form, showed the facility Administrator investigated an allegation of resident abuse/neglect which occurred on 5/30/15 by CNA A. Upon completion of the investigation, the facility Administrator found actual abuse did happen. CNA A was terminated and was not eligible for rehire. During a telephone interview on 6/11/15 at 12:24 P.M., the DM said: -He/she came in at 7:30 A.M. on Monday 6/1/15. Later that day DA A came in on his/her day off and told him/her about what he/she saw on 5/30/15. He/she immediately took DA A to the DON's office to tell what he/she saw. The DON immediately got the Administrator and the Social Services Director. -He/she took DA A immediately to the DON to report the abuse. During an interview on 6/11/15 at 12:45 P.M., the District Manager of Dietary Services said: - He/she oversees the dietary services at the facility. - His/her company is responsible for completing the background checks, screenings, and hiring process. The personnel files are kept at the employed facility. - His/her company provides abuse/neglect training that was basically printed material. It includes types of abuse and the response staff should make to witnessing abuse. - The employee was to respond immediately without delay to intervene and then report to the DON and Administrator, not their immediate supervisor. - Additionally, dietary staff attend the facility all staff inservices that includes abuse and neglect information. During an interview on 6/10/15 at 2:10 P.M., the Administrator said: - He/she conducted an all-staff inservice on 5/26/15. The inservice included employees and contract staff. It included information regarding the abuse policy and that reporting needed to be to the Administrator and/or the DON. A police colonel also discussed the criminal aspect of committing abuse. The inservice included all staff including dietary, therapy, and housekeeping. - He/she expected staff to immediately call the Administrator, DON or Social Services Director. - He/she told them to report immediately and not to wait. - If their immediate supervisor was not in the building, staff should tell another supervisor or charge nurse. If it was during the day, staff can tell any manager. Their numbers were at the nursing stations and the front desk. - He/she was called by the nursing staff all the time. - All dietary staff have the DM cell number as well. - His/her dietary, housekeeping, laundry, activity, and therapy staff were all contract staff. During an interview on 6/18/15 at 3:30 P.M., LPN A said: - No one had reported any type of abuse to him/her on 6/1/15. - CNA A worked the floor. - LPN A did not recall the time CNA A left the floor. - If abuse was reported to him/her, he/she would immediately call the Administrator and the DON, and he/she had their telephone numbers. - The telephone numbers of the Administrator and the Director of Nursing were posted at the nurses' station. - He/she had received abuse and neglect training. - He/she just completed the online learning regarding abuse and neglect. - The facility provided information regarding abuse and neglect at least on a monthly basis. Record review of a typewritten note from the Administrator dated 6/18/15, showed: - CNA A was pulled from the floor at 3:10 P.M. - The report of abuse was reported to the Administrator at 3:08 P.M. During an interview on 6/19/15 at 9:50 A.M., LPN C said: - No one had reported any type of abuse to him/her on 5/30/15. - If abuse was reported to him/her, he/she would immediately call the Administrator and the Director of Nursing. - He/she had the Administrator's and the Director of Nursing's telephone numbers, and they were also posted at the nurses' station. Record review on 6/19/15 at 1:37 P.M. of a handwritten statement from the Dietary Manager dated 6/18/15 showed: - On Monday, June 1, 2015, DA A came in around 3:05 P.M. on his/her off day. - DA A told the DM he/she had seen a CNA slapping a resident's hand on Saturday and didn't feel it was right. - DA A stated DA B had witnessed this. - DM informed DA A they had to report this and took DA A to the DON's office. - When DA A started telling the DON what he/she had witnessed, the DON said Wait a minute and the DON, DM and DA A went into the administrator's office and DA A told what he/she had witnessed. - The Administrator told the DM to call DA B and get him/her in the building for a statement. Complaint #MO 177

Based on observation, interview, and record review, the facility staff failed to provide adequate mealtime monitoring and provide adequate assistance to clear the resident's airway such as administering an effective Heimlich Maneuver (an emergency technique for preventing suffocation when a person's airway (windpipe) becomes blocked by a piece of food or other object) after the resident was found to be choking and/or aspirating on his/her food on [DATE] during the noon meal, and follow the facility's policy to contact 911 to request emergency assistance during a choking and/or aspiration incident for one sampled resident (Resident #1) with a history of swallowing problems and choking during mealtime. The resident expired during the noon meal on [DATE]. The facility census was 113 residents. Record review of the facility's undated policy titled "Heimlich Maneuver" included the following instructions for the staff: -The purpose of the Heimlich maneuver is used as a response to choking emergencies, and may restore airway potency and prevent anoxia (absence of oxygen) by removing the airway obstruction; -The description of the Heimlich maneuver is a technique which involves sudden compression of the lungs to provide air pressure within the trachea (windpipe) and eject the object from the throat; -The following are symptoms of choking: Inability to speak, inability to breath, cyanosis (bluish discoloring of skin and mucous membranes resulting from inadequate oxygenation of the blood), and unconsciousness; -The three situations in which the Heimlich maneuver may be needed are when the resident is standing or sitting, when the resident is lying down, and when the victim is yourself; -Staff should use the following procedure to carry out the Heimlich maneuver if the resident is standing or sitting: --Positioning yourself behind the victim; --Wrapping your arms around the victim's waist; --Make a fist with one of your hands and place it thumb side in above the resident's navel and below the sternum; --Have the resident bend forward slightly, if possible to allow gravity to assist your efforts; --Grasp your fist with your other hand press upward and inward with four quick thrusts; --Repeat several times, if necessary, until the object is ejected; --Assist in the resident's transfer to the hospital if necessary; and --Record in the medical record all pertinent information. -Staff should use the following procedures for the Heimlich maneuver if the resident is lying down: --Place the resident face up; --Kneel astride the resident so that your shoulders are directly over the resident's abdomen; --If the resident is too large to straddle, kneel close to the resident's side with your knees parallel to the resident's hips; --Place one of your hands directly over your other hand; --Place the heel of the bottom hand on the resident's abdomen above the navel and below the sternum; --Press upward and inward with four quick thrusts; --Repeat several times, if necessary, until the object is ejected; --Assist in the resident's transfer to the hospital, if necessary; --Record in the medical record all pertinent information. -The policy did not show that the Heimlich maneuver was to be initiated or stopped based on a resident's life sustaining code status; and -The policy did not state when emergency personal (911) should be contacted for a choking victim. Record review of the American Heart Association's (AHA) "Instructions for Foreign-Body Airway Obstruction (FBAO-Choking)" dated 2010, included the following: -The AHA changed the procedure name from Heimlich maneuver to abdominal thrusts for FBAO in 2010; -FBAO is an uncommon, but preventable, cause of death; -Most reported cases of FBAO occur in adults while they are eating; -The choking event is therefore commonly witnessed, and the rescuer usually intervenes while the victim is still responsive; -Treatment is usually successful, and survival rates can exceed 95%; -Because recognition of FBAO is the key to successful outcome, it is important to distinguish this emergency condition from fainting, heart attack, seizure, or other conditions that may cause sudden respiratory distress, cyanosis, or loss of consciousness; -Foreign bodies may cause either mild or severe airway obstruction; -The rescuer should intervene if the choking victim shows signs of severe airway obstruction; -These include signs of poor air exchange and increased breathing difficulty, such as a silent cough, cyanosis, or inability to speak or breathe; -The victim may clutch the neck, demonstrating the universal choking sign; -When FBAO produces signs of severe airway obstruction, rescuers must act quickly to relieve the obstruction; -If mild obstruction is present and the victim is coughing forcefully, do not interfere with the patient's spontaneous coughing and breathing efforts; -Attempt to relieve the obstruction only if signs of severe obstruction develop: The cough becomes silent, respiratory difficulty increases or the victim becomes unresponsive; -Activate the EMS system (call 911) quickly if the patient is having difficulty breathing; -If more than one rescuer is present, one rescuer should phone 911 while the other rescuer attends to the choking victim; -Although chest thrusts, back slaps, and abdominal thrusts are feasible and effective for relieving severe FBAO in conscious (responsive) adults; for simplicity in training it is recommended that abdominal thrusts be applied in rapid sequence until the obstruction is relieved; -If abdominal thrusts are not effective, the rescuer may consider chest thrusts; -Chest thrusts should be used for obese patients if the rescuer is unable to encircle the victim's abdomen; -If the adult victim with FBAO becomes unresponsive, the rescuer should carefully support the patient to the ground, immediately activate (or send someone to activate) EMS, and then begin CPR; -The healthcare provider should carefully lower the victim to the ground, send someone to activate the emergency response system and begin CPR (without a pulse check); -After two minutes, if someone has not already done so, the healthcare provider should activate the emergency response system; -Each time the airway is opened during CPR, the rescuer should look for an object in the victim's mouth and if found, and remove it; -Simply looking into the mouth should not significantly increase the time needed to attempt the ventilation's and proceed to the 30 chest compressions; -No studies have evaluated the routine use of the finger sweep to clear an airway in the absence of visible airway obstruction. The recommendation to use the finger sweep in past guidelines was based on anecdotal reports that suggested that it was helpful for relieving an airway obstruction; however, case reports have also documented harm to the victim in using the finger sweep; -The instructions did not show that the procedure should be initiated or stopped based on a resident's code status; -The EMS should be activated immediately when the conscious or unconscious victim was having breathing difficulty. Record review of the facility's policy titled "Advance Directives for Residents" dated [DATE], included the following information: -Do Not Resuscitate (DNR) indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative have directed that no cardiopulmonary resuscitation (CPR) or other life saving methods be used. -The policy did not show that a medical emergency situations not related to the resident's physiological medical condition was included in an DNR request. 1. Record review of Resident #1's Admission Face sheet dated [DATE] showed the resident was admitted with the following Diagnoses: [REDACTED]. -Alzheimer's disease (a disease marked by the loss of cognitive ability); -Depression; -[DIAGNOSES REDACTED] (sudden attacks of pain in areas of the Trigeminal nerve of the face; the cheeks, jaw, teeth, gums, and lips); -[DIAGNOSES REDACTED](an irregular heart rhythm that increases the risk of strokes, heart failure, and blood clots); -Overweight; -Hypertension (high blood pressure); and -Esophageal reflux (a condition where the esophagus (the tube that carries food to the stomach) does not close properly and allows the stomach contents to leak back into the tube and irritate it, causing heartburn and acid indigestion). Record review of the resident's "Outside the Hospital, Do Not Resuscitate (DNR)" Order dated [DATE], signed by the resident's physician's, showed the following for the resident: -Authorization for emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation from himself/herself in the event that he/she suffered cardiac or respiratory arrest; -Cardiac arrest means his/her heart stops beating and respiratory arrest means that he/she stopped breathing; -He/she understood that this decision will not prevent him/her from obtaining other emergency medical care and medical interventions; -He/she gave permission for this DNR order to be given to outside the hospital care providers that included paramedics, doctors, nurses, or other health care personnel as necessary to implement this order; -The DNR showed that other emergency medical care should be received; -The DNR did not show that respiratory arrest indicated breathing was stopped due to a Foreign Body Airway Obstruction (FBAO). Record review of the resident's Refusal to Follow Prescribed Diet form dated [DATE], and signed by the resident's legal guardian, showed the following information: -The resident was aware that his/her physician had ordered a mechanical soft diet (food that is softened or chopped so that a resident can't chew or swallow can eat); -The mechanical soft diet was ordered for his/her medical condition of difficulty swallowing; -The resident received counseling regarding the refusal of the diet by the Licensed Practical Nurse (LPN); -He/she understood the goal of following the mechanical soft diet was to prevent choking and aspiration; -He/she understood that if he/she did not follow the mechanical soft diet, that the consequences of choking, aspiration, aspiration pneumonia, and possibly death could occur; -He/she understood that it was his/her right not to follow the diet in whole or in part; -He/she understood that by refusing to follow the mechanical soft diet, he/she absolved his/her physician, the facility, and it's employees and dietary consultant from any responsibility for any deterioration in my health, including death that may result by my refusal to follow this therapeutic and/or mechanically altered diet as ordered by the physician; -He/she understood that his/her physician, facility staff and/or Dietician would periodically discuss compliance with the therapeutic diet; -He/she understood that at any time, he/she may change his/her mind and decide to follow his/her mechanical soft diet, and it was his/her responsibility to let the facility staff know this choice. Record review of the resident's Speech Therapy initial evaluation dated [DATE], showed the resident would require skilled services that included focus on speech and swallowing due to a severe decline in cognitive function and orientation, memory deficit, and being unable to judge safety issues without verbal cuing. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff) dated [DATE], showed staff assessed the resident: -Had clear speech; -Had moderate difficulty with hearing; -Was able to make himself/herself understood by others both verbal and non-verbal expressions; -Was usually able to understand the verbal content of others; -Had mild cognitively impaired deficit; -Was oriented to person, place, time, and year; -Had negative physical and verbal behaviors towards others approximately every three days; -Had impaired vision; -Weight was 173 pounds and height was 68 inches; -Was independent with bed mobility, transfers, ambulation in room and on the unit, and required supervision when ambulating off the unit; -Required set up and supervision for meals and with dressing; -Had required set up and supervision with personal hygiene; -Had not triggered for a swallowing disorder which included the loss of food from the mouth when eating, holding food in the mouth after a meal, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain when swallowing; -Had not required therapy services; -Participated with staff and his/her guardian with the assessment. Record review of the resident's quarterly MDS dated [DATE], showed staff assessed the resident: -Had clear speech; -Had moderate difficulty with hearing; -Was usually able to make himself/herself understood by others both verbal and non-verbal expressions; -Was usually able to understand the verbal content of others; -Had severely impaired cognitive deficits; -Was oriented to person and place only; -Had negative physical and verbal behaviors towards others approximately every three days; -Was independent with bed mobility, transfers, ambulation in his/her room and on the unit, and very limited time being off unit with no staff assistance required; -Required set up and supervision for meals; -Required set up and was independent with dressing; -Required one person assist and supervision with personal hygiene; -Had not triggered for swallowing disorder which included the loss of food from the mouth when eating, holding food in the mouth after a meal, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain when swallowing; -Had not required therapy services; -Participated with staff and the guardian with his/her assessment. Record review of the resident's Interdisciplinary Care Plan dated [DATE], showed the resident: -Had chewing and swallowing problems; -Was to be served his/her diet as ordered by the resident's physician and offer alternatives; -Had been told of his/her risk of choking and/or death by not following the physician ordered mechanical soft diet; -Would require staff assistance as needed with meals to include providing cuing and supervision, and to make a restorative referral as needed. Record review of the resident's Care Plan dated [DATE], included the following focus, goals, and nursing interventions for the resident: -He/she had impaired cognitive function due to Alzheimer's, dementia, and mood disorder; -He/she would require staff assistance to maintain his/her current level of cognitive function, to communicate basic needs, and maintain a current level of decision making ability; -The staff would monitor, document, and report to the resident's physician any changes in cognitive function, decision making ability, memory, recall and general awareness, difficulty expressing self, understanding others, level of consciousness, and mental status; -He/she had deficits with activities of daily living (ADL's - how a person self-performs eating, grooming, dressing, toileting, etc.) with a goal of maintaining his/her current level of function; -He/she would require supervision and set up during meals and was capable of feeding himself/herself; -The care plan did not show the emergency procedure to follow for a resident with a potential for choking/aspiration, and that he/she had signed a wavier for refusing a physician ordered mechanical soft diet. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's Nurse's Notes dated [DATE], showed the following occurred during the evening shift: -The resident was eating in the dining room when the charge nurse observed the resident choking; -The resident was cyanotic (a bluish discoloration of the skin and membranes resulting from inadequate oxygenation of the blood) and lethargic; -The charge nurse requested the Certified Nurses Aide (CNA) lower the resident to the floor onto his/her right side; -The charge nurse then removed the large amount of visible food from the resident's mouth; -The resident had begun to cough up the remaining food; -The resident was assessed and vital signs (blood pressure, heart rate, temperature and respirations) were taken; -The resident was returned to sit in his/her chair and he/she requested to continue to eat; -The resident's physician was notified of the events, did not order any new treatment, but reinforced that staff should continue to monitor the resident during mealtimes; -The choking event information was reported to the next charge nurse on the night shift during report time; -The resident was monitored by staff for the remainder of the shift. Record review of the nursing staff 24 hour report sheet dated [DATE] for the evening shift (3:00 P.M. to 11:00 P.M.) and the night shift (11:00 P.M. to 7:00 A.M.), showed no documentation of the choking event recorded on the report sheet by the evening charge nurse or the night charge nurse. Record review of the resident's Nurse's Notes dated [DATE], showed the following information for the resident's activity during the day shift: -The charge nurse had seen that the resident was not in the dining room during the lunch meal; -The charge nurse had left the dining room after the meal trays were passed to the other residents, leaving four CNAs and one Certified Medication Technician (CMT) in the dining room; -The charge nurse found the resident in his/her room, sitting on his/her bed and covered with stool (bowel movement); -The charge nurse cleaned the resident and changed his/her clothing and the resident ambulated without assistance to the dining room for the lunch meal; -The charge nurse and one CNA had remained in the resident's room to complete the cleaning of the resident's room that included the bed, floor, and the bathroom; -While in the process of cleaning the room, CNA A came from the dining room requesting the charge nurse to come to the dining room to assess the resident, stating the resident "didn't look right;" -The charge nurse found the resident sitting at the independent feeding table with CNA B and CNA C at the resident's table; -The resident was cyanotic, with his/her head down and his/her mouth full of chicken; -The charge nurse instructed the CNA's to move the resident from his/her chair into a small alleyway outside the dining room; -The charge nurse attempted to clear the resident's airway and performed the Heimlich maneuver in the hallway; -The charge nurse was unable to clear the resident's airway at this time, and had the three CNA's and himself/herself move the resident into an empty resident room across from the dining room, and continued to try to clear the resident's airway; -The charge nurse checked the apical pulse (the heart rate when measured with a stethoscope placed over the heart) and found no pulse was present; -The charge nurse had not started CPR or called the paramedic (911) because the resident had a DNR order; -During the report to the resident's physician, after the resident had expired, he/she was informed for the first time of the resident having a choking episode on Friday evening at the supper meal. During telephone interviews on [DATE] at 1:35 P.M. and 3:25 P.M., the facility Administrator said: -The resident expired during the lunch meal; -The resident choked on a mechanical soft chicken while feeding himself/herself; -The staff assisted the resident; -He/she was not sure what kind of assistance the staff had given the resident when he/she was choking; -The staff had removed the resident from the dining room and placed him/her in the hallway; -The resident did not have a pulse and had a DNR order; and -The staff involved were LPN A and CNA A. During an interview on [DATE] at 8:20 A.M., LPN A said: -The lunch meal served to the residents on [DATE] was boneless chicken fried thigh, mixed vegetables, mash potatoes, and desert; -The resident was on a regular diet, double portions, and fed himself/herself; -The resident ambulated independently with a walker; -The resident's care plan required that he/she needed set up for meals and monitoring during meal times; -He/she had seen that the resident had not come to the dining room and often arrived later than the other residents during meal times; -He/she went to locate the resident and found the resident in his room; -The resident had on an incontinent brief and a white undershirt, and was covered with stool "all over himself/herself," the bed and the bathroom; -The resident often exhibited this behavior and would be combative and resist assistance from the staff; -The resident's daughter called during this time and inquired about the resident; -He/she had cleaned up the resident, changed his/her clothes, and the resident ambulated to the dining room; -He/she and a CNA stayed in the resident's room to clean the resident's room and bathroom; -Approximately ten minutes later, CNA A came to the resident's room and requested that he/she check on the resident and stated, "he/she doesn't look right;" -He/she had found the resident sitting at the dining table, the resident's head was leaning down, his/her face was cyanotic coloring, and his/her mouth was full of chicken; -CNA A and B were trying to remove the chicken pieces with their fingers, and CNA C was also with the resident at this time; -He/she had not checked the resident's pulse, had not called 911, and had not attempted the Heimlich maneuver with the resident sitting up in the chair; -He/she instructed CNA A and CNA B to move the resident to the small alleyway between the dining room and the hallway; -He/she had went to the nurses station to obtain a glove and checked the resident's record to verify the resident's code status, and found he/she was a DNR; -CNA A and CNA B held the resident up from off the floor in a sitting position and he/she got behind the resident sitting on the floor, straddling the resident's back (the position for the Heimlich was to be straddled across the resident's lower abdomen or pelvic area or to the side of an obese person) and started the Heimlich maneuver, with no results of removing the obstruction; -He/she had not heard any breath sounds from the resident and the resident had no chest movement; -He/she had not checked the resident's pulse at that time; -The resident had become incontinent of urine; -He/she had performed the Heimlich maneuver three or four more times without success in removing the obstruction; -He/she had CNA A obtain his/her stethoscope and blood pressure cuff from two different areas on the unit; -He/she and CNA A, B, and C put the resident on a mattress in the main hallway and pulled the resident into an empty resident room across from the alleyway and main dining room; -The resident was a large person and the transfer had taken about five minutes; -He/she and CNA A and B continued to try and clear the resident's mouth of the food obstruction: -He/she had listened for the resident's apical pulse (the heart rate when measured with a stethoscope placed over the heart) and had not heard a heart beat; -CNA B asked whether to perform CPR at this time, and he/she said that the resident had a DNR order and not to call 911; -He/she called the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) and received no answer; -He/she notified the Administrator and the resident's physician about the resident's situation and death; -During the conversation, the resident's physician informed him/her that the resident had a choking episode on Friday evening during the supper meal; -He/she then called the resident's guardian and was given further instructions about who to contact. -The facility had not given inservices on this specific type of situation in the last year; -The facility had a monthly nursing meeting for the licenses nurses to ask questions, bring up concerns, discuss responsibilities of being a charge nurse, and working as a team. During an interview on [DATE] at 9:10 A.M., CNA A said: -The staff was to monitor the resident at mealtimes, because he/she had often fallen asleep during the meal with food in his mouth; -During the lunch meal on [DATE], he/she was assisting other residents with their meal; -The resident was seated at the far end of the dining room in the alcove, and the resident's back was to him/her; -He/she had not observed the resident eating before he/she heard the other residents arguing at the resident's table; -He/she was called to the resident's table by the other two residents at the table who were arguing: -He/she went to investigate the argument and saw the resident was vomiting like, head down "trying to spit stuff up;" -Food was leaking from his/her mouth and he/she tried to get the chicken out of the resident's mouth; -Because the resident was a DNR, he/she did not know if he/she should do the Heimlich before the charge nurse assessed the resident; -He/she went to get the LPN charge nurse who was in the resident's room; -He/she, LPN A and CNA B tried to get the resident to respond; -The resident was gasping for air; -He/she was not instructed to call 911; -He/she and CNA B were instructed to move the resident to the floor in the alleyway, and placed the resident on his/her side; -He checked the resident's radial pulse (checking for a pulse in the wrist) and felt a faint pulse; -The LPN charge nurse had gone to the nurse's desk to get gloves and when he/she returned, he/she got on the floor behind the resident while CNA B and himself/herself raised the resident up to a sitting position; -The resident was a large person; -The resident appeared to gasp for breaths; -LPN charge nurse told him/her that the resident had a DNR order; -The LPN charge nurse instructed him/her to obtain the blood pressure cuff and his/her stethoscope from two different places on the unit, and he/she also decided to get the mattress off an empty bed to put in hallway to move the resident; -During this time, the staff kept trying to remove the chicken and assist the resident even though the resident had a DNR order; -After they moved the resident into the empty room, the resident made a few gasping sounds and stopped breathing; -The charge nurse checked the resident's apical pulse and said the resident did not have a heart beat; -The charge nurse said the resident had a DNR order and not to do CPR. During an interview on [DATE] at 9:17 A.M., CNA C said: -The resident was late for the meal on [DATE]; -The resident feeds himself/herself, often comes to meals late, and had fallen asleep at mealtimes; -He/she observed the back of the resident's from his/her side two times, while he/she had assisted feeding other residents; -The resident had his/her back to him/her; -The first time he/she looked at the resident, he/she was eating; -The second time he/she looked at the resident was after he/she had looked at another resident sitting at the table behind the resident's table, checking on another resident who had fallen asleep, and he/she saw the resident had his/her head down; -He/she saw two other CNA's at the resident's table, found the resident with food "crammed" in his/her mouth, and CNA B trying to remove the food from out of the resident's mouth; -The resident was cyanotic around his/her eyes and lips; -CNA A left to locate the charge nurse; -He/she and CNA B tried to remove the chicken; -The resident appeared to be gasping; -When the charge nurse arrived at the resident's table, he/she assessed the resident and determined he/she had choked; -The charge nurse had not attempted the Heimlich maneuver with the resident sitting in the chair; -The charge nurse had not checked the resident's pulse and had not instructed anyone to call 911; -CNA A and CNA B moved the resident to the alleyway; -The charge nurse had tried to do the Heimlich maneuver "even though the resident was a "DNR;" -CNA A, CNA B, the charge nurse, and himself/herself transferred the resident onto a mattress in the main hallway; -The resident was a really heavy person; -The charge nurse checked the resident's heart rate and blood pressure while the resident was on the mattress and before he/she was moved into the private room; -The charge nurse kept trying to get the food out, even though the resident was a DNR; -When the resident was moved into the private room, he/she was told not to do CPR because the resident had a DNR order; -He/she had not heard the charge nurse instruct the staff to call 911 during the event; -The charge nurse repeatedly tried to help the resident even though the resident was a DNR. During an interview on [DATE] at 9:25 A.M., CNA B said: -He/she had been instructed to monitor the resident during mealtimes, and would watch the resident to make sure he/she did not choke on his food; -He/she had not known the resident had choking issues before [DATE], but had been told by other staff that the resident had fallen asleep at meal time with food in his/her mouth; -During lunchtime on [DATE], the resident ambulated to the dining room later than other residents; -He/she was sitting at the table next to the resident, but the resident's back was to him/her; -He/she was assisting with feeding other residents; -The resident was sitting at a table in the alcove off from the main dining area; -He/she heard other residents arguing at the resident's table about the grossness of the resident with the food coming out of his/her mouth, and went to the table to resolve the issue; -The resident was awake, trying to cough food out of his/her mouth; -The resident was cyanotic around his/her mouth; -He/she and CNA A also tried to get the chicken out because the resident's mouth was full of chicken; -CNA A went to obtain the charge nurse in another room; -The charge nurse assessed the resident, said he/she was choking, and instructed CNA A and CNA B to move the resident out of the chair on to the floor and lay the resident on to his/her side; -The charge nurse had not checked the resident's pulse at this time; -The charge nurse did not instruct staff to call 911; -He/she and CNA A moved the resident to the floor in the alleyway; -The resident was gasping for air, he/she and CNA A set the resident upright and continued to try and remove the food; -The charge nurse went to obtain gloves from the nurse's station; -The charge nurse returned to the resident and instructed staff that the resident had a DNR order; -The charge nurse sat on the floor behind the resident and tried two or three times to do the Heimlich maneuver; -The resident was gasping for breath and the charge nurse removed food from the resident's mouth; -The resident became unresponsive; -He/she and CNA A moved the resident on to the mattress; -He/she checked the resident's carotid pulse, felt a faint pulse, and told the charge nurse he/she felt a pulse; -CNA A went to obtain the nurse's blood pressure cuff and his/her stethoscope after the staff moved the resident onto the mattress in the main hallway; -The staff moved the resident into an empty room on the mattress; -The charge nurse checked the resident's apical heart rate and informed the CNA's the resident did not have a heart rate, and not to start CPR because the resident had a DNR order; -The resident gasped a few more times and then stopped; -Facility had not done a hands on in-service the past year for using the Heimlich maneuver, CPR, or emergency situations. During an interview on [DATE] at 4:00 P.M., LPN A said: -During mealtimes, the CNA's and the charge nurse would pass trays to the residents in the dining room; -On [DATE] at lunchtime there were four CNA's, one CMT, and himself/herself in the dining room; -The charge nurse should stay in the dining room to monitor the safety of the residents, to be sure that all the residents are at the dining room, to observe things that the CNA's would not see, observe issues with weight, assist with feeding the residents, and observe residents who were having a swallowing issues; -During the lunch meal on [DATE], he/she had gone to the resident's room and cleaned up the resident; -The resident ambulated to the dining room; -He/she had another CNA come to the resident's room to assist him/her; -About ten minutes later, CNA A requested him/her to come to the resident's table; -CNA B and CNA C were with the resident but not sure if they had tried to get the food out of the resident's mouth; -He/she found the resident with his/her head down and his/her entire face cyanotic; -The resident was lim