Every finding on record at Hilltop at Blue River, The

Based on observation, interview and record review, the facility failed to prevent physical abuse for one sampled resident (Resident #1) out of four sampled residents. On 4/26/26 at approximately 11:00 A.M. Resident #2 who has a history of being physically aggressive to residents and staff, struck Resident #1 on the head with a chair resulting in a red and raised area on his/her head and a small scratch on the bridge of his/her nose which required first aid. The facility census was 143 residents.The Administrator was notified on 5/1/26 of Past Non-Compliance which occurred on 4/26/26. An all-staff in-service on Abuse and Neglect and Resident's Rights. Both residents were also set up for additional psychiatric services and therapy. The deficiency was corrected by 4/27/26. Review of the facility policy for Abuse and Neglect revised 8/2020 showed:-The purpose of the policy was to establish a program to prevent resident mistreatment and abuse.-The facility was committed to keeping all residents safe from abuse while in the facility including safe from resident-to-resident abuse.-The residents had the right to be free from abuse by others including other residents.-Physical abuse was the willful infliction of bodily injury causing injury. 1. Review of Resident #1's Facility admission Record showed he/she was admitted [DATE] with the following diagnoses:-Psychotic Disorder with Delusions (a type of serious mental illness (psychotic disorder) characterized by the presence of one or more fixed, false beliefs (delusions) that persist for at least one month).-Paranoid Schizophrenia (a chronic mental health condition characterized by intense, irrational suspicion and distrust of others (paranoia), accompanied by delusions and auditory hallucinations).-Anxiety Disorder (mental health conditions characterized by persistence, excessive fear or worry that interferes with daily life, functioning, and relationships).-Right Below the Knee Amputation. Review of Resident #1's Nursing Care Plan dated 2/10/26 showed:-The resident had been involved in a physical altercation months prior when he/she inserted himself/herself into an altercation between two other residents.-The facility staff was to give the resident as many choices in cares and activities as possible.-The staff was to encourage the resident to verbalize distress.-The staff was to respond to the resident with empathy and respect.-The resident was seeing behavioral health services in order to provide appropriate assessment and treatments. Review of Resident #1's quarterly Minimum Data Set-(MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 3/26/26 showed:-Was cognitively intact.-Had issues focusing his/her attention, was easily distracted, had disorganized thinking, had rambling talk with unclear thoughts and ideas, and irrelevant conversation.-Had delusions.-Rejected cares daily. Review of Resident #2's Facility admission Record showed he/she was admitted on [DATE] with the following diagnoses:-Chronic Pulmonary Edema (one-term, gradual buildup of fluid in the lung's air sacs (alveoli), usually caused by ongoing conditions like congestive heart failure or kidney disease).-Dementia ( a progressive decline in mental ability-including memory, thinking, and reasoning-severe enough to interfere with daily life).-Diabetes ( a chronic metabolic disease characterized by high blood glucose (sugar) levels, occurring when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it makes). Review of Resident #2's Nursing Care Plan dated 11/6/25 showed:-He/she had the potential to demonstrate physical behaviors as he/she had hit other residents and been verbally aggressive towards facility staff and other residents.-The staff was to analyze key times, places, circumstances, triggers and what de-escalates the resident's behaviors and document them.-The staff was to give the resident as many choices as possible about cares and activities.-When the resident became agitated, the staff was to intervene before he/she escalated by guiding him/her away from the source of distress, engage him/her calmly in conversation and if the resident's response was aggressive, staff was to walk calmly away and approach the resident later. Review of Resident #2's annual MDS dated [DATE] showed:-He/she had moderate cognitive impairment.-He/she showed physical behaviors such as hitting, kicking, scratching and/or grabbing one to three days were week during the look-back period.-He/she showed verbal behaviors such as swearing, threatening, screaming, and yelling one to three days per week during the look-back period. Review of the Facility Resident Altercation Investigation dated 4/26/26 at 11:00 A.M., showed:-While in the Dining Room Resident #2 approached Resident #1 about talking to the opposite sex and informed the opposite sex that he/she was married and was committing adultery.-Resident #2 stated Resident #1 did not appreciate this.-Resident #2 then proceeded to pick up a Dining Room chair and hit Resident #1 on the top of head with the chair.-Resident #1 stood up when Resident #2 picked up the chair and upon having been hit, both residents fell to the floor due to both residents primarily ambulating via wheelchair due to poor gait.-Staff promptly attended to the residents separating them and returning them to their respective areas for safety.-Resident #2 was temporarily placed on one-to-one staff observation during the investigation and until he/she showed stability.-The residents involved were interviewed as well as staff who were involved.-The resident's medications were reviewed with physicians.-The root cause analysis was completed.-Resident #1 refused to go to the hospital so was treated in house.-Resident #2 received same day hospital psychiatric evaluation and returned the same day without new orders.-An emergency care plan meeting was conducted with Resident #2's Durable Power of Attorney (DPOA). Review of Resident #1's Nursing Progress Note dated 4/26/26 at 12:11 P.M., showed:-He/she states he/she was in the Dining Room when he/she saw Resident #2 talking to a person of the opposite sex.-Resident #1 stated to Resident #2 that he/she shouldn't talk to people of the opposite sex in that way as it was considered adultery.--Resident #1 then said that Resident #2 went and got a dining room chair, dragged it to him/her and after they conversed, hit him/her on top of the head with the chair.-They then wrestled on the ground for a short time and staff separated them.-A skin assessment was completed, and the resident had a knot on the top of his/her head and a red spot on the bridge of his/her nose.-The resident did not want to go to the hospital saying he/she was okay. Review of Resident #2's Nursing Progress Notes dated 4/26/26 at 11:52 A.M., showed:-He/she got into an altercation with another resident.-Resident #2 stated that Resident #1 was yelling that he/she was cheating on his/her spouse and stated Resident #1 came up and pushed him/her down.-He/she stated that he/she was defending himself/herself, picked up a dining room chair and threatened to throw the chair at Resident #1.-The staff immediately separated the two residents.-The staff did a skin assessment and sent him/her out to the hospital for evaluation and treatment.-The resident showed no bumps, bruises or injuries. Review of Resident #1's Weekly Skin Check dated 4/26/26 at 12:30 P.M., showed:-He/she had a half-dollar sized knot on the top of his/her scalp.-He/she had redness across the bridge of his/her nose. -He/she showed a pain level of three on a scale of one-10 on his/her head.-He/she stated the pain was dull.-A cold compress was applied and the resident received two 500 milligrams (mgs) Tylenol (an analgesic medication used for minimal to moderate pain) by mouth at 12:30 P.M. Review of Resident #1's Medication Administration Record (MAR) dated 4/26/26 showed he/she received 500 mgs of Tylenol by mouth at 12:30 P.M. During an interview on 5/1/26 at 1:40 P.M., Certified Nursing Assistant/Central Supply CNA/CS A said:-He/she was standing outside CS door facing directly into the Dining Room at the coffee set up and in view of both tables. -Resident #1 and Resident #2's tables were next to each other. -He/she saw Resident #2 turn around and say something to Resident #1.-Neither resident appeared to be yelling at that point.-The next thing he/she knew Resident #1 turned around and both stood up from their wheelchairs.-When he/she saw the residents rise, he/she began getting closer and heard Resident #2 say, I'll hit you with this chair, however there was no chair in the resident's hands yet.-CNA/CS A then began running towards the residents as Resident #1 eagled spread his/her arms and lunged at Resident #2.-At that point, Resident #2 picked up a dining room chair and hit Resident #1 on top of the head. During an interview on 5/1/26 at 1:55 P.M., Licensed Practical Nurse LPN A said:-By the time he/she got involved, the altercation was over as he/she came to the Dining Room after they paged the nurses overhead. -He/she performed the assessment on Resident #1 and noted a small, reddened bump on the top of the resident's head that dissipated as well as a small red mark on the bridge of the nose.-He/she believed the resident got one dose of Tylenol for some minor head pain. Observation and interview on 5/1/26 at 2:30 P.M., Resident #1 showed a small spot on the bridge of his/her nose which appeared to be completely healed and a small slightly raised area on the top of his/her head near middle/right with no redness noted.-The resident said:--He/she was in the dining room getting coffee and Resident #2 was talking to a staff member of the opposite sex.--As he/she rolled his/her wheelchair past Resident #2, he/she said, That's adultery because he/she was a Chistian and believed that's a sin.--He/she also said that when you sin, demons come to get you, and Jesus has to deliver you. --He/she shouldn't have said that though, because it made Resident #2 mad.--Resident #2 started yelling that he/she was going to hit him/her with a chair, so he/she lunged at him/her.--They both went to the ground, and were wrestling, when Resident #2 picked up the chair and hit him/her on the head with the chair. --Resident #2 also scratched his/her face and messed my face all up.--He/she didn't want it to happen again. --He/she sees these demons and angels and the demons sometimes make him/her say the wrong things to people. During an interview on 5/1/26 at 2:45 P.M., Resident #2 said:- It was just two patients fighting, that's all.- I don't have anything else to say about it.- It was self-defense because he/she was saying things to me that he/she had no business saying.- He/she was just staying away from him/her. Review of Resident #3's quarterly MDS dated [DATE] showed he/she was cognitively intact. During an interview on 5/1/26 at 3:15 P.M., Resident #3 said:-Resident #1 was always walking around saying crazy things to people and sticking his/her nose in where it didn't belong.-He/she doesn't know why they let people like Resident #1 in the facility as all they do is cause trouble.-Resident #1 says things just to make people mad.-He/she wants Resident #1 and anyone else like him/her out of the facility. During an interview on 5/1/26 at 4:00 P.M., the Director of Nursing (DON) and Administrator said:-The resident-to-resident abuse happened.-Resident #1 has schizophrenia and some delusions which caused him/her to talk continually saying some non-sensical things and other things that made sense.-Resident #1 also talked to things or people who weren't there which could make residents believe he/she was saying things to them that could be upsetting. During an interview on 5/6/26 at 3:45 P.M., Dietary Aide A said:-On 4/26/26 at around 11:00 A.M., he/she saw Resident #1 and Resident #2 exchanging words after Resident #1 got his/her coffee.-Once Resident #1 rolled his/her wheelchair over towards the tables after getting coffee and more words were exchanged, he/she heard Resident #2 say to Resident #1, I'm going to hit you with the chair.-Resident #2 then proceeded to pick up a dining room chair and hit Resident #1 on top of the head with it.-Both residents ended up on the floor and staff separated them and called for help. 2994390

Based on interview and record review, the facility failed to maintain the dignity of one sampled resident when on 12/19/25 Certified Medication Aide A forced Resident #2 to get out of bed against his/her will out of six sampled residents. The facility census was 143 residents. The Administrator was notified on 1/2/26 of the past noncompliance which began on 12/19/25. The facility immediately completed education for the violation of residents' rights and choices. The deficiency was corrected on 12/20/25. Review of the facility's policy entitled Resident Rights and revised on 8/20, showed:-Purpose: To promote and protect the rights of all residents at the facility.-Policy: All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility including those specified in this policy.- The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility will protect and promote the rights of the resident and provide equal access quality of care regardless of diagnosis, severity of condition or payment source.-Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights.The facility makes every effort to assist each resident in exercising his/her rights by providing the following services:-The facility's staff encourages residents to participate in planning their daily care routines including Activities of Daily Living (ADL)s.-Each resident is allowed to choose activities, schedules and health care that consistent with his/her interest, assessments and plans of care including sleeping, eating, exercise and bathing schedules health care scheduling, such as times of day for therapies and certain treatments. 1.Review of Resident #2's admission Face Sheet showed the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD-- a condition caused by damage to the airways or other parts of the lung. This damage leads to inflammation and other problems that block airflow and make it hard to breathe).-Spondylosis (age-related wear-and-tear (osteoarthritis) of the spine, involving degeneration of spinal discs, joints, and the development of bone spurs).-Anemia (a condition where there is a lack of enough healthy red blood cells (RBCs) or hemoglobin to carry adequate oxygen from the lungs to the body's tissues).-Hyperlipidemia (an excess of lipids or fats in your blood. This can increase your risk of heart attack and stroke).-Hemiplegia (paralysis or severe weakness affecting one side of the body, including the face, arm, and leg) affecting the left side. Review of resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 10/15/25 showed the resident was moderately cognitively impaired. Review of the resident's Progress Notes completed by the Social Services Designee (SSD) dated 12/19/25 showed:-The resident had informed Certified Medication Technician (CMT) A that he/she did not want to get out of bed.-CMT A made him/her feel somewhat uneasy and went overboard for no reason. -The resident did not want anything like this to happen again. During an interview on 12/29/25 at 9:04 A.M. Occupational Therapist Assistant (OTA) A said:-On 12/19/25, he/she attempted to work with the resident.-The resident said he/she did not want to do therapy that day.-He/she then witnessed CMT A who was working the roommate at first, tell the resident that he/she had to get up.-He/she then witnessed CMT A placed a pair of pants on the resident while he/she resisted. -Once the resident's pants were on, CMT A pulled the resident up from a supine (lying flat on your back with your face and torso pointing upward) position to a sitting position and placed the resident in a wheelchair.-The resident said he/she felt there was some excessive force used in getting him/her up. During an interview on 12/29/25 at 9:23 A.M. the resident said:-It was his/her exercise day, so the therapy person was in his/her room.-His/her leg was hurting on that day, and he/she did not want to do physical exercise because of the increased pain.-CMT A came in and said he/she needed to exercise.-CMT A put on his/her pants. -CMT A spoke very loudly to him/her and said he/she was going to get him/her out of bed.-The therapy person told CMT A that he/she did not have to get that rough with him/her.-CMT A grabbed him/her out of bed and placed him/her in a wheelchair even though he/she did not want to go. -The situation made him/her feel small. During a phone interview on 12/29/25 at 11:31 A.M. CMT A said:-The resident got combative and swung at him/her before he/she tried to administer his/her medication.-The resident was always annoyed in the mornings because the morning times were not good for the resident.-He/She was trying to protect himself/herself.-He/She grabbed the resident and placed the resident from the bed to the chair.-He/She was not forcing the resident to go to therapy.He/she needed the resident to be up in a chair, because the resident would choke if the resident didn't take the medications in a sitting position.-He/She assisted the resident in getting his/her pants on.-He/She was familiar with the facility's resident rights policy.-When the resident refused, he/she could have notified the charge nurse, but he/she did not notify the charge nurse that day. -The Director of Nursing (DON) sent him/her home after the incident. During an interview on 12/29/25 at 1:03 P.M. the SSD said:-OTA A approached him/her about a written grievance from the resident.-He/She spoke to the resident to ask him/her about what took place.-The resident said he/she was bothered by the incident because it had not happened before.- CMT A forced the resident to get out of the bed even when the resident said he/she did not want to get out bed. During an interview on 12/29/25 at 3:04 P.M. the Administrator said he/she would expect the staff to document the residents' refusal and honor the residents' choices even if the staff must remove themselves and have someone else come in to speak with the resident. Complaint 2697434

Based on interview and record review, the facility failed to ensure one sampled resident's (Resident #3) representative/power of attorney was able to exercise his/her rights to make financial decisions on behalf of the resident out of four sampled residents. The facility census was 145 residents. Review of the facility Resident Rights Policy dated 8/2020 showed: -Promote and protect the rights of all residents at the facility. -All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in the policy. -The facility will ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. -State and federal laws guarantee certain basic rights to all residents of the facility including but not limited to: --Visit and be visited by others from outside the facility. --Use a telephone in privacy. --Treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident. Review of the facility undated Customer Service Program showed: -The average consumer (customer) makes decisions regarding the quality of care by how they feel about the care and the way they are treated. -The obvious customer is the resident or patient in the long-term-care facility. -A critical customer is the family member of the residents. -Residents and family members have a desire to trust the people who are in charge of caring for their loved one. -Establishing trust is critical to effective customer service. -When a customer trusts the caregiver, the customer is happy and spread a positive reputation into the community. -Respect for the individual is critical to customer service. -Working as a team necessitates respect for the individual as well as the team. Review of the undated facility admission Agreement showed: -The resident is a person who is being admitted to the facility. -Resident under this agreement also applies to the resident's agent/attorney-in-fact, representative, or any person signing this agreement. -Resident representative includes an individual chosen and authorized by the resident to act on behalf of the resident in order to support the resident indecision making, manage financial matters, or receive notifications. -The resident and/or resident representative agree to pay for accommodations and services by the facility. -By signing this agreement, resident representative agrees that he/she has access to the resident's income, assets and resources to pay for the resident's care at the facility. 1.Review of Resident #3's admission Record showed the resident was admitted on [DATE] with diagnoses including dementia, muscle wasting and atrophy. Review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/30/25 showed the resident was moderately cognitively impaired. Review of the resident's admission Agreement dated 10/30/25 showed the resident signed the agreement for admission. NOTE: There were no letters of incapacitation noted in the resident's chart. During an interview on 12/7/25 at 9:30 A.M. Family Member A said: -On 10/29/25 he/she met with Liaison A for the facility and selected the facility for short-term rehab for his/her family member.-The facility admission sheet listed him/her as power of attorney (POA) for financial and as an emergency contact #1. -Staff claimed there had been no family contact for three weeks and there was no POA on file. -On 11/3/25 he/she spoke to the Social Worker (SW) about rehabilitation. -Despite knowing he/she was the resident's POA, the facility caused or allowed the resident's social security direct deposit to be changed around 11/12/25 to an account under the facility's control. Review of the facility emails dated 11/21/25 through 11/28/25 showed: -Family Member A initiated contact with the SW on 11/21/25 at 2:46 P.M. to clarify POA status, medical records request and care planning for the resident. -On 11/21/25 an email alleged Liaison A was aware of the POA which was a key factor in selecting the facility. -On 11/25/25 Family Member A was sent a follow up email requesting information related to the resident's POA, updated for bed accommodations and equipment as well as home-care support needs. -On 11/26/25 the Social Services Director emailed Family Member A rejecting the completed POA paperwork and requested a new document be completed. -The Social Services Director responded to Family Member A that the resident would need to see a physician for an order for a hospital bed at home, would need 24-hour care and he/she was working on a primary care physician for the resident. -On 11/26/25 the Social Services Director sent a follow up email to Family Member A with medical information and referrals for the resident. Review of the POA document for the resident showed: -The POA was drafted on 5/27/25. -Family Member A was appointed Attorney-in-fact for financial and legal matters. Review of resident's hospital records dated 10/22/25 through 10/24/25 showed: -There was no family present during these assessments. -The resident was presumed to have dementia and a poor historian. -The resident could not recall the contact number for Family Member A, but did give a number for another family member. -Family Member A was not listed on the hospital documentation as an emergency contact or POA. Review of the resident's census billing showed: -The resident was admitted under managed care on 10/30/25 and billed appropriately. -The resident changed to Medicaid spending on 11/14/25. Review of the resident's Resident Fund Management Service showed the resident signed for his/her social security check to be directly deposited into a resident fund account on 11/5/25. Review of the resident's facility billing statement for 12/16/25 showed the resident's bill was paid in full for the month of December 2025. During an interview on 12/16/25 at 1:48 P.M. the resident said: -He/She was not sure how the decision was made for him/her to be admitted to the facility. -He/She did recall Family Member A having a conversation with someone about his/her transfer. During an interview on 12/16/25 at 2:11 P.M. the Social Services Director said: -When the resident first admitted they did not know much about him/her or the family. -They knew there was a new diagnosis of dementia. -The resident did have a son listed and he/she tried to contact that son without success. - Family Member B phone number was not valid when he/she tried to make contact. -He/She located a daughter in Colorado. -Two to three weeks into the resident's stay there was a care plan conference, and the resident decided to stay for long-term care. -At that time the facility made the appropriate arrangements with the resident's finances. -Family Member A first contacted the facility around mid-November. -The Social Services Designee (SSD) sent information to Family Member B about obtaining POA. During an interview on 12/16/25 at 2:22 P.M. the SSD said: -In the paperwork from the hospital, the resident had two family members listed, Family Member A and Family Member B and both phone numbers were disconnected. -The hospital was unable to make contact with the family and there was no POA paperwork. -He/She got the Business Office Manager (BOM) involved so if the resident wanted to stay, what that would look like. -He/She got a room phone for Family Member B to speak with the resident. -The resident was saying conflicting things while on the phone with Family Member B. - Family Member B let him/her know that he/she wanted to take care of the resident. -He/She told Family Member B the proper paperwork that would need to be filled out, otherwise, the resident was still his/her own person. -In the meantime, Family Member A showed up and had POA paperwork. -Family Member A wanted to take the resident home. -He/She asked about the home conditions. - Family Member A came to pick the resident up on 12/2/25 and the resident didn't want to leave. -The resident said he/she had no shoes, and they just wanted his/her money. -The Administrator met with the Family Member A. -When BOM went over everything the resident seemed to understand the obligation to pay for his/her stay. During an interview on 12/16/25 at 2:38 P.M. the BOM said: -When the resident was admitted he/she had adult children living out of state.- Family Member B was the only one that they were able to contact. -The resident said he/she could handle his/her own care. -Around 11/19/25 Family Member A showed up with paperwork for POA. -The hospital papers did not list any POA. -Prior to the Family Member A coming in, the resident wanted to stay long term. -He/She set up the payee status for the resident for his/her stay. -When Family Member A came in, he/she went through all the paperwork from the hospital.-The family agreed for the resident to stay. - Family Member A was supposed to be changing the direct deposit from social security. During an interview on 12/16/25 at 3:40 P.M. the Director of Nursing said: -He/She was not aware of the POA at the resident's admission. -He/She was aware Social Services was trying to contact family without success. During an interview on 12/16/25 at 3:49 P.M. Liaison A said: -He/She was at the hospital and met with two family members in the hallway. -He/She spoke with Case Manager at the hospital in reference to the resident's admission at the facility. -He/She received referrals from the hospital Case Manager for skilled to long-term-care (LTC) and visits with the patient to assess for admission. He/she worked for the facility as a liaison. -The nurses were getting the resident up in the bathroom and the family was in the hallway. -The family asked why he/she was there to visit, and he/she introduced him/herself as from the facility. -The family advised one of them was the POA. -It was discussed the resident would need LTC and couldn't be home alone. -He/She verified who the family members were and the POA at discharge and the information was sent to the facility. -His/Her whole job was to help the resident transition to the facility for rehab. -It was on the hospital to ensure all information was sent with the resident, even though he/she had spoken to the family. During an interview on 12/18/25 at 11:33 A.M. Family Member A said: -He/She was in the hospital when the doctor suggested rehab. -Liaison A from the facility was already in the hospital and came up to talk with the family. -Liaison A was walking the halls and going in and out of rooms. -Liaison A was going through the [NAME] about the facility. -The first thing Liaison A talked about was the resident's insurance. -Liaison A ensured rehab could be provided and gave them a pamphlet. -Liaison A said they would pick the resident up and they wouldn't have to pay anything. -Liaison A spoke in detail about how they enabled the resident with the whole person. -They made sure he/she had a cell phone at home, Liaison A told them to not allow the resident to have a phone so they could focus on his/her rehab. -Liaison A then said they don't want the family up there so they could focus on his/her rehab, because they enable the resident. -Liaison A said there would be 20 days of rehab then they should pick her up for 60 days and then bring the resident back for another 20 days. -Liaison A told them he/she was getting the POA paperwork from the hospital and their contact information. -Liaison A said he/she would make sure all the paperwork was in place when the resident got to the facility. -Liaison A focused on no contact with the resident while the resident was in rehab so he/she could focus on rehab. -It was strange the facility said the resident was abandoned and got into his/her money right away. -The only reason they did not go in there was because they were instructed not to while the resident was in rehab. -It caught their attention when a letter from social security was sent that the change had went through. -Family Member B was panicking trying to move the resident out of state. -The first contact with anyone at the facility was with SSD was 2-3 days after the resident was admitted . 2686218, 2685806

Based on observation, interview and record review, the facility staff failed to ensure one sampled resident (Resident #4) was free of abuse when on 9/8/25, Certified Nursing Assistant (CNA) A pushed Resident #4 to the ground and was dragged backwards by his/her pants out of the doorway. No injuries were reported. Ten residents were sampled. The facility census of 146 resident.On 9/17/25, the Administrator were notified of the past noncompliance for an incident of alleged physical abuse that occurred on 9/8/25. The facility administration was notified on 9/8/25 of the allegation of abuse between an employee, CNA A, and Resident #4. The facility investigation of the allegation of employee to resident physical abuse/dignity began on 9/8/25 after Resident #4 had notified by Director of Nursing (DON) of the incident. In-services were provided to the staff who were potentially involved and to all facility staff related to abuse, neglect and immediate reporting any allegation of abuse to the administrator and/or DON. Secure Care Training provided for those staff members assigned to secured locked unit. The facility had also increased the required in-service of abuse and neglect and schedule specialty training on De-escalation and Care giver burn out by community mental health partner. The deficiency was corrected on 9/9/25.Review of the facility's undated Abuse & Neglect Prevention policy showed: -Each resident has the right to be free from mistreatment, neglect and abuse.-This facility was committed to protecting residents from abuse by anyone including, but not limited to, facility staff.-Employees were trained through orientation and ongoing training on issues related to abuse prohibition practices, such as dealing with aggressive residents. 1. Review of Resident #4's admission Record showed the resident admitted to the facility on [DATE] with following diagnoses:-Dementia with mild psychotic disturbance (is a term used to describe a group of symptoms affecting memory, thinking and social abilities).-Bipolar Disorder (is a mental illness that causes clear shifts in a person's mood, energy)-Mild intellectual disability (are slower in all areas of conceptual development and social and daily living skills) -Anxiety disorder (involve more than occasional worry or fear).Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 5/6/25, showed he/she:-Was cognitive intact. -Able to make his/her needs known and usually understand others. Review of the resident's Care Plan revised on 9/8/25 showed:-The resident alleged abuse on 9/8/25, he/she had a history of manipulative behavior of staff to get his/her way. --Refer to psychological services as needed. --Skin assessment, pain assessment, psychosocial assessment and mental health consult referral for alleged abuse. Review of the resident's Physical Aggression Assessment Incident report dated 9/8/25 at 4:26 A.M., showed: -The DON was made aware of the alleged incident on 9/8/25 at approximately 10:48 A.M., by Resident #4.-The resident said he/she had fallen due to a staff member pushing him/her down. -Resident #4 said CNA A pushed him/her down. Review of the resident's Mood/Behavior Progress Noted dated 9/8/25 at 10:09 A.M., showed:-The resident was cussing and yelling at the CNA A due to his/her diet. -The resident then came out of his/her room with his/her tablet blasting music. -The resident was asked to turn his/ her music down due to residents sleeping. -CNA A went to get assistance, and when he/she returned the resident was noted behind the nurse's desk and threw the phone when his/her call was not answered. -Staff was unable to redirect resident. -The resident at that time attempted to leave the unit, when CNA A had attempted to redirect the resident, he/she bitten CNA A and then sat on the ground choosing to not move. -The resident was given some time to calm down and then after a while another CNA A and a nurse was able to assist resident up off the floor. -Writer went to speak with resident related to his/her behaviors, resident stated that the CNA A had pushed him/her to the ground, and he/she was not able to get up. Review of the resident's Social Services Note dated 9/8/25 at 1:02 P.M. showed:-The resident was seen for follow-up psychosocial session by the Social Services Director (SSD) shortly after lunch.-During the session the resident reported that an overnight CNA A had pushed him/her down.-When asked if he/she knew the staff member's name, the resident did not know but gave a description of CNA A. -The resident appeared visibly upset and angry. -He/She was emotionally distressed and expressed feeing unsafe as result of the alleged incident. During an interview on 9/16/25 at 10:00 A.M. the resident said: -He/She had an x-ray of his/her left knee yesterday with no results yet and had a brace on his/her left knee. -He/She said he/she does not feel safe at the facility. -Facility staff were rude and disrespectful to him/her and will not assist him/her as needed. During an interview on 9/16/25 at 2:00 P.M., the resident said:-Last week a staff member pushed him/her down and was rude to him/her. -Police were called and he/she was pressing charges against the staff member/employee. -He/She had not seen the staff member at the facility since last week. Review of the resident's facility investigation dated 9/8/25 and completed by DON showed:-On 9/8/25 at 10:45 A.M., writer was informed by Resident #4 that CNA A, who was assigned on the night shift, had pushed him/her causing the resident to fall to the ground. -Action taken to include: --Suspension of CNA A pending facility investigation. --The resident was provided psychosocial support. --Licensed nursing staff conducted comprehensive skin inspection of the resident, and all resident assigned hall. --Conducted pain assessment for resident with no abnormal findings. --Appropriate staff interview and written statements obtained. -Local Police Authorities called on 9/9/25. -Primary Care provider and Public Administrator were contacted. and SSD had conducted trauma informed assessment.-Notification of Administrator completed and education to all staff on Abuse and Neglect.-A thorough investigation into the alleged incident of potential staff to resident physical abuse and the facility had determined the claim of abuse to be substantiated. -The information collected indicated that CNA A did show physical action towards the resident. The resident did not have any injuries, and he/she felt safe in the facility with his/her current caregivers. -The final assessment suggests that these actions occurred due to inability to safely de-escalate the resident behavior or incident. -The facility implemented the following proactive measure to prevent similar incidents for occurring in the future to include: --Care plan revised. --Psychosocial support provided trauma assessment completed. --Referral to Mental Health Care Center for counseling--Staff received Secure neighborhood training. --The facility has a scheduled all staff in-services, with focus of de-escalation, care giver burnout. Review of the witness statement dated 9/8/25 CNA A, who worked the 300 hallways from 10:30 P.M., to 6:30 A.M., showed: -The resident did not like it here at the facility. So, he/she kept walking by CNA A, heading toward the exit door and saying if someone walks in, I'll sneak out behind them. I'll watch someone put the code in, then leave. -CNA A wanted to clarify, that he/she was only staff member on the secure unit with 12-14 residents. -CNA A had exited the secure unit to talk with the nurse that was nearby, to inform him/her of what was happening.-The nurse told him/her whatever you do just don't let the resident leave. -CNA A came back on the unit and the resident was going behind the nursing desk trying to grab the phone. -CNA A let the resident make the call and he/she got mad because the person he/she was calling did not answer the phone, and then the resident had thrown the phone. -CNA A had took the phone back and put it back on the desk. -The resident then walked back by the door.-CNA A told the resident to go watch TV or go to his/her room, but he/she kept refusing.-CNA A then placed his/her hand on the resident's back and told him/her to go away from the exit and the resident then bites CNA A and then plopped himself/herself on the ground. Resident said, I am going tell them you pushed me. -The resident stayed on the floor the whole time, screaming and scooting around saying he/she was going to report CNA A. -CNA A even tried to help him/her up, but he/she kept putting his/her weight down and was stiffening up his/her body. -CNA A had grabbed the back of the resident's pants and pulled him/her back in the unit. -The resident sat on the floor until Registered Nurse (RN) A and another aide came to unit and assisted in picking up the resident off the ground. -The resident stayed standing by the door the whole time, after staff left the unit. -The resident continued exit seeking until around 6:00 A.M., trying to escape. Review of a typed interview by facility staff with CNA A dated 9/8/25 showed:-Resident #4 had been up all night and was making noise, CNA A stated that the resident was not listening. -CNA A stated the approximately 4:26 A.M., CNA A was attempting to go out of the unit and the resident was standing behind him/her attempting to get the code, because the resident stated he/she was leaving. -CNA A said he/she asked the resident to step back and to go back to the unit.-CNA A stated that when the resident stepped back and turn around, the resident sat down on the floor and refused to get up. -CNA A had attempted to assist the resident up by back of his/her pants. -While attempting to help the resident up, the resident bite CNA A and refused to allow him/her to help the resident. -CNA A said he/she had gone get the nurse and another CNA assist him/her off the floor. -CNA A said that he/she never pushed or hit Resident #4. During an interview on 9/17/25 at 10:05 A.M., CNA A said:-He/She had only worked on that unit 2-3 times as a CNA.-He/She was aware he/she needed to be more patient with secure unit residents due to behaviors and dementia. -He/She had behavioral training upon hire and at other facilities he/she had worked at. -On 9/8/25 around 1:30 -2:00 A.M., the resident came out of his/her room and went to dining area on the unit with a tablet playing music and games.-He/She had asked the resident several times to turn down volume due other residents sleeping and it was 2:00 A.M -After about 30 minutes the resident asked for snack but he/she could only offer applesauce or a banana due to the resident's new diet change. -The resident became upset because he/she could not have the snack he/she wanted. -The resident left area and came back to area with a backpack, he/she said was leaving.-The resident was cussing calling all the staff the b name. -The resident said he/she should not be on this unit and he/she was not like the other residents on the locked unit. -The resident then went up to the double doors knocking and trying open the door. -He/She tried redirect the resident by telling him/her to set down and step away from the doors. -The resident kept saying I want out of here over and over. -The resident had become more defensive with him/her and would not listen. He/She was unable to redirect the resident. -The resident was able to open the double doors and went to another door keypad trying to get out of the unit.-The resident said he/she would stand there until someone comes through then leave. -He/She asked the resident again to go back to his/her room and he/she refused. -He/She had then placed code in and left the unit to go get the nurse for help. -He/She had left the resident standing by the coded door, he/she could not find the assigned nurse.-He/She saw another nurse who told him/her, whatever you do, do not let the resident leave the unit. -He/She returned to the unit. -The resident was by the double doors and he/she had placed his/her hand on the resident's shoulder to guide him/her away from the door.-He/She then pulled the resident's walker back as the resident stepped back. The resident plopped down onto the floor. -The resident would not get up and was yelling I'll tell everyone that pushed me .-He/She then asked the resident if he/she needed help getting up and the resident refused. -He/She tried again to assist the resident up from the floor, but the resident refused.-He/She grabbed the back of the resident's pants and pulled /slid the resident backwards out of the doorway and then shut the door. -The resident kept sliding around on the floor back and forth and would not get up. -He/She then recorded the resident on his/her phone since he/she was the only staff person on the unit, the resident was sliding around for about 15-25 minutes and yelling. -He/She went back behind the nursing station to complete his/her work, the resident sat on the floor while sliding himself/herself back forth on the living/dining area floor. -Another unknown CNA came onto the unit and saw the resident sitting on the floor.-He/She was still behind nursing station at that time. -The unknown CNA left the unit to get another nurse to help the resident. -They attempted to get the resident up as the resident was fighting them but finally got up in chair. The resident sat in the chair the rest of the shift. -He/She did not lay hands on the resident or if hit the resident.-He/She had raised his/her hand in the air and turned back around, but that was when the resident bit his/her hand. -The facility had placed him/her on suspension during the facility investigation and then on 9/16/25 he/she received a call that he/she was fired. -He/She was aware he/she should not be recording the resident but he/she was afraid of the allegation the resident was making and that's why he/she started recording since resident was yelling he/she pushed me down, -The resident kept changing story from he/she hit the resident to he/she had pushed him/her down. -He/She does not remember the assigned nurse entering the unit during the shift until after incident happened. Review of an email statement dated 9/8/25 at 6:20 P.M. showed: -Licensed Practical Nurse (LPN) A was the assigned nurse for the shift on 9/8/25. -He/She was made aware of the resident's behaviors that took place on that date listed. -He/She was unaware of any resident falls that took place during the behavior incident on 9/8/25 or after. During an interview 9/16/25 at 2:13 P.M., LPN A said:-He/She had just been on the unit about 30 minutes before incident and all residents were quiet and asleep.-He/She heard yelling and screaming so he/she went onto the unit to find the resident agitated, saying something about a snack.-Resident said someone pushed him/her but would not go in detail of what happen. -The resident denied any falls or that he/she had been hit by the staff member. -He/She did not see any signs or symptoms that abuse had happened. Review of the handwritten statement dated 9/8/25 by Registered Nurse (RN) A, showed: -The writer was asked by CNA A to assist a resident who was on the floor in 300 hallway. -As he/she was walking to 300 hall, he/she heard a loud shouting, they won't let me leave, they are mean to me, get me out. -After he/she unlocked the door, he/she observed the resident sitting on the floor with his/her walker in front of him/her yelling.-He/She had explained who he/she was to the resident and attempted to assess for injuries and the resident stated he/she was not hurt. -The resident was extremely agitated in the hall and as he/she was leaving the unit the resident began yelling they pushed me.NOTE: Attempted to contact the RN and no answer, left several messages. Review of the facility undated video footage on 9/16/25 at 10:00 A.M. showed:-The video start time of 4:25 A.M. and copy of video footage was located on the DON's phone. - CNA A and the resident were seen by the double doors on the locked memory care unit, with one door open.-At 4:27 A.M. and 31 seconds, CNA A had place both hands on the resident as the resident went down to the ground. The video was difficult to determine what happened, but it appeared CNA A pushed the resident to the ground.-CNA A then walked away from the resident, as the resident sat on the ground.-CNA A had walked back into doorway area and bent down and grabbed the back of the resident's pants and pulled the resident backwards out of the doorway. -Did not provide video footage prior to incident or afterward when other staff entered the unit. During an interview on 9/17/25 at 11:39 A.M., the resident Public Administrator (PA, court ordered legal Guardian) said: -The facility did notify him/her of the incident on 9/8/25 between employee and the resident.-He/She was also notified after the local law enforcement had interviewed the resident.During interview on 9/17/25 at 12:25 P.M., Administrator said: -On 9/8/25 was brought to his/her attention by the DON of alleged abuse incident. -He/She had reviewed the video footage with DON on 9/8/25, that morning and incident. -The video appeared to show CNA A lay hands on or touching the resident who then landed on the ground. CNA A then dragged the resident backwards by his/her pants out of the doorway and left the resident on the ground, -The DON interviewed the resident and obtained witness statements from resident and staff members including the Alleged Perpetrator statement. -The facility has put in place to increase in-services related to abuse and de-escalation, and behaviors management. -The facility had arranged for all staff training scheduled on 9/25/25 related to de-escalation and staff burn out. -Staffing the unit was one CNA normally standard for the facility, the 300 hallway was normally a quite unit during the night shift. Night licensed nurse assigned floats from 400 and 300 hallway and makes nursing rounds at least every two hours. -He/She would expect nursing staff, once notified of resident's behaviors or incident, to intervene and assess the resident and try to redirect the resident by offering another distraction.-He/She would expect CNA A to have notified licensed nursing staff by phone any change in the resident's behavior that he/she could not redirect. During an interview on 9/17/25 at 12:30 P.M., the DON said:-He/She was made aware of the incident on 9/8/25 by the resident and then notified the resident Public Administrator, Physician and Administrator. -The nursing staff completed full skin assessment of the resident and obtain resident statement of what happen. -The facility staff provided psycho-social support and completed trauma informed assessment by SSD.-He/She had obtained statement from CNA A and then called state hotline to report the alleged abuse on 9/8/25. Earlier that next morning of 9/9/24 law enforcement notified and came to investigate. -Law enforcement was notified early morning on 9/9/25, after the facility had determined potential abuse occurred before they called. -CNA A was suspended on 9/8/25 until further investigation.-The secure unit staff were aware they should let the resident call DON as comfort person for the resident any time. -He/She would expect if the CNA was having behavioral situation, he/she was not able to redirect the resident or an out-of-control resident, he/she would expect staff to use the phone to contact nursing for assistance. -He/She would expect the CNA assigned not to leave the unit until relief staff arrive. -He/She would expect the licensed nursing staff should assess the resident once informed of the resident behaviors and sat down on the ground and when staff were unable to redirect the resident. -Licensed Nurse were to round every two hours on the 300 hallway and Certified Medication Technician (CMT) and Nurse provide medication for the resident on that unit. -CNA A had also worked as a CMT on 600 hallways.-He/She had interviewed staff and residents from 600 hallway, and no reports of CNA A being disrespectful or rude to other resident and had not seen any questionable interaction with residents.Complaint # 2611135 and 2612342

Based on interview and record review, the facility failed to have sufficient staff on the weekends to provide care and services for residents and for one sampled resident (Resident #10) out of 29 sampled residents. The facility census was 140 residents. Review of the facility's policy, Staffing, Scheduling, and Posting, dated 06/2020 showed: -Staffing an adequate number of nursing service personnel, scheduling would have been done as needed to met the residents' needs and would have accounted for the number, acuity and diagnoses of the facility resident populations. -The facility would have submitted to the Centers for Medicare and Medicaid Services (CMS - a federal agency that administers programs along with other health related initiatives) complete and accurate direct care staffing information based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. -The Director of Nursing (DON) or designee was responsible for validating the accuracy of data on such staffing and census forms. 1A. Review of the CMS Payroll Based Journal (PBJ) for the period of January 1, 2024 through March 31, 2024 showed the report was triggered for excessively low weekend staffing. 1B. Review of the Daily Staffing Sheets for January 2024 showed the following shortages for weekend staffing: -1/6/24 - Day shift short two Certified Nursing Assistants (CNA)s. -Evening shift short four CNAs. -1/7/24 -Evening shift short three CNAs. -Night shift short one CNA. -1/13/24 - Evening shift short three CNAs. -1/20/24 -No documentation. -1/21/24 -No documentation. -1/27/24 -Evening shift short three CNAs. -Night shift short one CNA. -1/28/24 -Day shift short two CNAs. -Evening shift short one CNA. -Night shift short one CNA. 1C. Review of the Daily Staffing Sheets for February 2024 showed the following shortages for weekend staffing: -2/3/24 - Day shift short two CNAs. -Evening shift after 8:00 P.M. short eight CNAs. -Night shift short one CNA. -2/4/24 -Evening shift after 8:00 P.M. short three CNAs. -Night shift short one CNA. -2/10/24 Day shift short two CNAs. -Evening shift short four CNAs. -Night shift short one CNA. -2/11/24 Day shift short one CNA. -Evening shift after 7:00 P.M. short four CNAs. -Night shift short one CNA. -2/17/24 Day shift short three CNAs. -Evening shift after 7:00 P.M. short seven CNAs. -Night shift short two CNAs. -2/18/24 Day shift short three CNAs. -Evening shift after 7:00 P.M. short seven CNAs. -Night shift short two CNAs. -2/24/24 Day shift short four CNAs. -Evening shift after 7:00 P.M. short seven CNAs. -Night shift short one CNA. -2/25/24 Day shift short one Certified Medication Technician (CMT) and three CNAs. -Evening shift short five CNAs. -Night shift short one CNA. 1D. Review of the Daily Staffing Sheets for March 2024 showed the following shortages for weekend staffing: -3/2/24 Day shift short two CNAs. -Evening shift short five CNAs. -Night shift short two CNAs. -3/3/24 Day shift short one CNA. -Evening shift short five CNAs. -Night shift short three CNAs. -3/9/24 Day shift short two CNAs. -Evening shift short three CNAs. -Night shift short three CNAs. -3/10/24 Day shift short one CNA. -Evening shift short one CMT and two CNAs. -Night shift short two CNAs. -3/16/24 Day shift short two CNAs. -Evening shift short three CNAs. -Night shift short two CNAs. -3/17/24 Day shift short two CNAs. -Evenings short five CNAs. -Night shift short one Nurse and two CNAs. -3/23/24 Day shift short two CNAs. -Evening shift after 7:00 P.M. short one Nurse and five CNAs. -3/24/24 Day shift short three CNAs. -Evening shift short five CNAs. -Night shift short one CNAs. 3/30/24 Day shift short one CNA. -Evening shift short two CNAs. -Night shift short four CNAs. -3/31/24 Day shift short six CNAs. -Evening shift short seven CNAs. -Night shift short one CNA. 2A. Review of the CMS PBJ for the period of April 1, 2024 through June 30, 2024 showed the report was triggered for excessively low weekend staffing. 2B. Review of the Daily Staffing Sheets for April 2024 showed the following shortages for weekend staffing: -4/6/24 Day shift short four CNAs. -Evening shift short four CNAs. -Night shift short one CNA. -4/7/24 Day shift short five CNAs. -Evening shift short four CNAs. -4/13/24 Day shift short two CNAs. -Evening shift short seven CNAs. -Night shift short two CNAs. -4/14/24 Day shift short four CNAs. -Evening shift after 8:00 P.M. short six CNAs. -Night shift short one CNA. -4/20/24 Evening shift short four CNAs. -4/21/24 Day shift short two CNAs. -Evening shift after 7:00 P.M. short three CNAs. -4/27/24 Evening shift short three CNAs. -Night shift short one CNA. -4/28/24 Day shift short two CNAs. -Evening shift short three CNAs. 2C. Review of the Daily Staffing Sheets for May, 2024 showed the following shortages for weekend staffing: -5/4/24 Day shift short one CNA. -Evening shift after 7:00 P.M. short four CNAs. -5/5/24 Evening shift after 8:00 P.M. short six CNAs. -5/11/24 Day shift short two CNAs. -Evening shift after 7:00 P.M. short one nurse, after 8:00 P.M. short one CMT and six CNAs. -5/12/24 Day shift short two CNAs. -Evening shift after 7:00 P.M. short one Nurse, one CMT and six CNAs. -5/18/24 Evening shift after 7:00 P.M. short six CNAs. -5/19/24 Evening shift after 7:30 P.M. short four CNAs. -Night shift short two CNAs. 5/25/24 Day shift after 12:00 P.M. short two CNAs. -Evening shift short four CNAs. -Night shift short two CNAs. 5/26/24 Day shift short three CNAs. -Evening shift short five CNAs. -Night shift short one CNA. 2D. Review of the Daily Staffing Sheets for June, 2024 showed the following shortages for weekend staffing: -6/1/24 Day shift short three CNAs. -Evening shift short five CNAs. -Night shift short two CNAs. -6/2/24 Day shift short two CNAs. -Evening shift short five CNAs. -6/8/24 Day shift short three CNAs. -Evening shift after 7:00 P.M. short five CNAs. -Night shift short one CNA. -6/9/24 Day shift short five CNAs. -Evening shift short six CNAs. -Night shift short two CNAs. -6/15/24 Evening shift after 6:30 P.M. short five CNAs. -Night shift short two CNAs. -6/16/24 Day shift short one CNA. -Evening shift after 7:00 P.M. short one Nurse, after 8:00 P.M. short seven CNAs. -6/22/24 Day shift short four CNAs. -Evening shift after 7:00 P.M. short four CNAs. -6/23/24 Day shift short five CNAs. -Evening shift short five CNAs. -Night shift short two CNAs. -6/29/24 Day shift short one CNA. -Evening shift short four CNAs. -6/30/24 Day shift after 12:30 P.M. short three CNAs. -Evening shift short three CNAs. -Night shift short two CNAs. 3. During an interview on 3/14/25 at 8:58 A.M. the Staffing Coordinator said: -The was not always enough staff to have the quota needed for staffing the floors. -They try to ask people to come in to work extra or to work a double. -Sometimes the managers would work on the floors. -He/She did not have any documentation if the managers helped out on the floors. -They were always advertising for more help. -He/She was always to staff the nursing units with the following amount of staff: -Day shift four Nurses, four CMTs, and 13 CNAs. -Evening shift three or four Nurses, four CMTs, and 13 CNAs. -Night shift three Nurses, and eight CNAs, no CMTs. -The Staffing Coordinator would tell the DON if they needed more staff. 4. Review of Resident #10's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Traumatic Brain Injury (a brain dysfunction caused by a violent blow to the head). -Lack of coordination. -Heart Failure (a condition in which the heart does not pump blood effectively). -Muscle Weakness. -Need for assistance with personal cares. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE] showed: -He/She was cognitively intact. -Staff were to use the mechanical lift to transfer him/her from bed to wheelchair. Review of the resident's Care Plan dated 2/19/25 showed: -He/She had a self care deficit. -He/She required the Mechanical Aid Hoyer (a mechanical device that would safely transfer a person from one place to another) lift for transfers. A minimum of two staff members must complete transfers. During an interview on 3/14/25 at 10:00 A.M. the resident said: -Many times there was not enough staff on the weekends to do cares. -He/She needed help to get out of bed with a hoyer lift and two staff. -Many times on the weekend staff does not get him/her out of bed until 2 P.M. and she likes to get up to eat breakfast. -If there was not enough staff meals were served late. 5. During an interview on 3/14/25 at 10:20 A.M. CNA F said: -The facility was short staffed almost every weekend. -Some of the resident's cares were not done when they should have been like moving them out of bed especially if it took two staff members like using a hoyer lift. -The facility has asked him/her to work extra about five times a month. -He/She has picked up extra shifts when he/she was able to but sometimes they were still short staffed. During an interview on 3/14/25 at 10:30 A.M. CNA A said: -Many times on the weekends they were short staffed. -He/She was not always able to get cares done when they were short staffed. -Sometimes the residents did not get a bath when they were scheduled to. -They try to offer a bath on a different day. -Evening weekend staff was short staffed maybe twice a month. -Night shift was short staffed more than twice a month. During an interview on 3/14/25 at 11:10 A.M. Registered Nurse (RN) A said: -On the weekends they were short staffed at least once a month. -Evening weekends were short every other weekend. -When they were short residents cares were delayed such as assistance with feeding and a few times baths were skipped. -He/She was asked to work extra every week. During an interview on 3/14/25 at 2:25 P.M. the Director of Nursing (DON) said: -He/She was not aware there was not enough staff according to the PBJ. -The payroll sheets were sent to CMS by someone in the Corporate Office. -He/she did not monitor the PBJ reports. -If they were triggered for low staff that was something the Administrator should have taken care of. -If there was not enough staff on the Daily Staffing sheets then the Staffing Coordinator would notify him/her. -If they were notified that there was not sufficient staff the Managers would help out on the floors. -There was no documentation if Manager helped out with Nursing tasks. -If they were short staffed the facility offered incentives, posted open shifts, and were continuously hiring more staff. -He/She had not been notified by the nursing staff that resident cares were not done because they did not have enough staff.

Based on observation, interview and record review, the facility failed to use the liquid to maintain the nutritive value of pureed carrots and pureed chicken for residents who received pureed diets. This deficient practice potentially affected residents who received pureed diets. The facility also failed to ensure the temperature of carrots and ham was maintained throughout the meal service for residents who consumed food out of the kitchen. The facility census was 140 residents. Review of the facility's Therapeutic Diet policy and procedure dated 12/2020, showed the purpose was to ensure that the facility provided therapeutic diets to residents that meet nutritional guidelines and physician orders. It showed: -The Nutrition Service Manager was responsible for ensuring the correct type and amount of food is purchased to meet the needs of residents receiving therapeutic diets. -The Nutrition Services Manager was responsible for ensuring each food item is pureed and served separately for a pureed diet per the menu and recipe. Review of the facility Food Temperatures policy and procedure dated 12/2020, showed the purpose was to provide the nutrition services department with guidelines for food preparation and service temperatures. The policy showed: -When measuring food temperature .take the temperature of each pan of product before serving. -The acceptable serving temperatures for vegetables, and pureed foods showed at or above 135 degrees Fahrenheit. -If temperatures are not at acceptable levels and cannot be corrected at the time of the meal service, an appropriate substitution should be implemented. Review of the facility recipe for completing pureed vegetables and meats, showed the facility could use vegetable broth or vegetable paste mixed with water to add to the pureed vegetable. It showed before chicken broth or paste mixed with water prior to adding to the puree for beef, chicken or pork puree. 1. Observation on 3/12/25 at 10:21 A.M., showed: -Cook A was prepping the lunch menu food items. -On the steam table were pureed food items (chicken, carrots, and mashed potatoes).The steam table was turned on and there was steam coming from the cells on the table indicating it was in working order. -Cook A took the ham out of the oven and regular food items, that had already been prepared. -Cook A was chopping ham for the mechanical (ground meat) diets. When he/she was done, he/she placed the food items on the steam table. -At 11:03 A.M., [NAME] A had placed ham slices, cooked carrots, mashed potatoes, mechanical ham, gravy, pureed chicken, pureed carrots, cream of chicken soup with chicken chunks, and chili on the steam table. [NAME] A placed serving utensils in all food items and then took out baked potatoes from the oven and placed them on steam table . -At 11:15 A.M. [NAME] A began serving plates, to include pureed diets, from the steam table without taking the temperatures of the food items prior to serving. -At 12:10 P.M., showed all meals were served. The test tray showed the temperatures of the following food items: pureed carrots 140 degrees Fahrenheit, pureed chicken 139 degrees Fahrenheit, mashed potatoes 138 degrees Fahrenheit, Chili 139 degrees Fahrenheit, baked potato 135 degrees Fahrenheit, chicken soup 130 degrees Fahrenheit, carrots 111 degrees Fahrenheit and ham slices 104 degrees Fahrenheit. -The test of the pureed carrots and pureed chicken showed the texture was that of mashed potatoes, but the taste was bland and without flavor or seasoning. During an interview on 3/12/25 at 12:10 P.M., the Dietary Manager said: -The temperatures of the carrots and ham were below the acceptable serving temperature of 120 degrees Fahrenheit. -Either he/she or the [NAME] usually take the temperatures of the food right before serving. -He/She didn't know if they were taken today before the service, or why the temperatures were not taken before the service started. -At 12:20 P.M. the Dietary Manager tasted the pureed carrots and chicken and said the puree tasted bland and without any seasoning. -He/She said they did not usually taste the pureed foods, but they should taste like the food item being served and should have some seasoning or butter to add to the flavor. -They should add broth, chicken base or milk as the liquid for making the puree. During an observation and interview on 3/12/25 at 12:21 P.M., with [NAME] A and the Dietary Manager showed [NAME] A tasted the pureed carrots and chicken and said: -The pureed carrots and chicken had no seasoning and was not good. -He/She used water as the liquid to add to the puree and was not aware that he/she should have used chicken base, broth or milk. -He/She had not looked at the recipe. -The Dietary Manager said they can add honey, butter, broth to season the puree and should not use water. He/She said they have chicken paste they could have added to the puree to thin and add flavor to it.

Based on observation, interview and record review, the facility failed to ensure kitchen was kept clean and kitchen devices were free from caked on grease, soil and food debris. This deficient practice potentially affected all residents who ate out of the kitchen. The facility census was 140 residents. 1. Observation on 3/12/25 at 10:21 A.M., showed: -The dishwasher had yellowish, dried on food debris on outside of washer. -The tray containing covered bowls of dry cereal on the prep table in front of the oven showed spilled cereal debris on and around the tray and floor. -The toaster on top of the prep table had dried food debris and grease on the outside of the toaster. The mechanical parts inside the toaster had food debris that was caked on the roller mechanism. -The convection oven had baked on grease and debris on the knobs, panel front and sides of the oven and there was dark brown and black, thick, greasy debris on the top of the oven and backsplash. -The well cookers (two) showed the outside of the right cooker was soiled with dried food debris. -The floor throughout the kitchen showed soil and food debris and stains that were over time. During an interview on 3/12/25 at 10:42 A.M., [NAME] A said: -They clean the wells daily and they use them for cooking eggs. -At this time he/she looked at the pots and said they needed to be wiped down. -They had a cleaning schedule, but the dietary staff were supposed to clean after every meal and cleaning consisted of making sure everything-countertops, shelves, and cooking equipment, were all wiped down and cleaned off before they start the next meal. -The final cleaning occurred after the last meal of the day. -Cook A used a wet scrubber to scrub the wells and then wiped them down. During an interview on 3/12/25 at 12:31 P.M., the Dietary Manager: -Looked at the tray with food debris and said the dietary staff should have cleaned this off after breakfast. -The cook and dietary staff were supposed to wipe everything (all kitchen equipment and countertops) down after each meal. -The cook was responsible for cleaning the stove and they should do a deep cleaning at least weekly. -The cook or dietary staff should wipe down the toaster after each use, but they had not taken the toaster roller apart to clean it thoroughly and that should be done at least weekly. -The floors were dirty and they were waiting for the cleaning team to come in to clean the floors. He/ She said the dietary staff sweep and mop at the end of the day, but the floors needed a deep cleaning and they were just waiting for the vendor to come in.

Based on interview and record review, the facility failed to ensure a facility transfer/discharge notice was completed in detail and provided to the resident and the resident's responsible party for one closed record sampled resident (Resident #142) out of three closed record sampled residents. The facility census was 140 residents. Review of the facility Transfer and Discharge policy and procedure, revised dated 6/2020 showed: -The purpose is to provide the residents with reasonable advance notice of the transfer or discharge before it occurs if possible. -Documentation of written or telephone acknowledgment of the resident ' s transfer by the residents personal representative may occur after the transfer in emergency situations. -The facility may use Notice of Transfer/Discharge or another comparable form to provide the resident of his/her personal representative with advance notice of the transfer or discharge. The notice will include the following information: --The reason the resident is being transferred/discharge; --The effective date of the transfer/discharge; --The name, complete address and telephone number to which the resident is being transferred; --A statement that the resident has the right to appeal the action to the state, contact information for the state entity which receives appeal hearing requests, and information for how to request an appeal; --The name, address, and telephone number of the State Long Term Care Ombudsman; --For residents with intellectual or developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals; and --For residents with a mental disorder, the mailing address and telephone number of the agency responsible for the protection and advocacy for individuals with mental disorders. -The facility will also send a copy of the Notice of Transfer/Discharge to the State Long Term Care Ombudsman for facility initiated changes. -Emergency Transfer/Discharge to a hospital or other related institution the facility will: --Notify the resident's Attending Physician; --Notify the receiving facility that the transfer is being made; --Prepare the resident for transfer --Prepare a transfer form to send with the resident; --Notify the resident's personal representative; and --Assist in obtaining transportation. 1. Review of Resident #142's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Progress Notes dated 12/14/24 showed: -The resident had a medical emergency. -The resident was sent to the hospital. -The resident's responsible party was notified. Review of the resident's Notice of Proposed Discharge form dated 12/14/24 showed: -The resident's name was written on the top of the form. -The form was not signed by the resident or the resident's responsible party. -The name/relationship of the person notified was not completed. -The date the discharge took place was not completed. -The reason for the discharge was not completed. Review of the resident's Progress Notes dated 12/21/24 showed: -The resident had a medical emergency and was sent to the hospital. -The guardian of the resident was notified. -The Physician was notified. Review of the resident's Notice of Proposed Discharge form dated 12/21/24 showed: -The resident's name was written on the top of the form. -The form was not signed by the resident or the resident's responsible party. -The name/relationship of the person notified was not completed. -The date the discharge took place was not completed. -The reason for the discharge was not completed. During an interview on 3/14/25 at 11:17 A.M., the Social Services Designee (SSD) said: -Nurses and Social Services were responsible for completing the Notice of Discharge form and providing it to the resident and the resident's responsible party as soon as possible. -The form should be signed before the resident leaves the facility if possible. -A copy of the filled out form would be mailed to the resident's responsible party. During an interview on 3/14/25 at 1:05 P.M., Registered Nurse (RN) A said: -Nurses were responsible for sending the Notice of Proposed Discharge forms with the resident upon discharge to the hospital. -He/she was not able to fill out the forms because in emergency situations they were too busy to remember them. -He/she said it was more important to get nursing forms, like the list of medications sent with the residents. -He/she was supposed to send the form with the resident but had not been completing these upon discharge for the residents. During an interview on 3/14/25 at 3:36 P.M., the Director of Nursing (DON) said: -Nurses were responsible for getting the documentation started. -Then the SSD would make sure the form was filled out to its entirely. -The SSD would send it to the resident's responsible party.

Based on interview and record review, the facility failed to ensure a bed hold agreement was completed in detail and provided to the resident and resident's responsible party for one closed record sampled resident (Resident #142) out of three closed record sampled residents. The facility census was 140 residents. Review of the facility bed hold policy and procedure, revised dated 6/2020 showed: -The purpose was to advise residents or his/her representatives in writing that the facility has a bed hold policy and will hold the resident's bed for the state specified period, if the resident is transferred to a general acute care hospital, as long as the resident or their representative notifies the facility within 24 hours of the transfer that they wish to have the facility hold the bed. -The facility notifies the resident or his/her representative, in writing, of the bed hold policy anytime the resident is transferred to general acute care hospital. -When the resident or their representative provides notice within 24 hours of transfer that the resident elects their right to have the bed held, the facility keeps that bed available for the state specified time period. --The resident and/or representative must complete the Bed Hold Agreement. 1. Review of Resident #142's Face Sheet showed the resident was admitted to the facility on [DATE]. Review of the resident's Progress Notes dated 12/14/24 showed: -The resident had a medical emergency. -The Physician was notified. -The resident was sent to the hospital. -The resident's responsible party was notified. Review of the resident's Bed Hold Agreement dated 12/14/24 showed: -The resident's name was written on the top of the form. -The form was not signed by the resident or the resident's responsible party. -The bed hold rate per day was not completed. -The effective date of the bed hold was not completed. -The expiration date of the bed hold was not completed. Review of the resident's Progress Notes dated 12/21/24 showed: -The resident had a medical emergency and was sent to the hospital. -The resident's responsible party was notified. -The physician was notified. Review of the resident's Bed Hold Agreement dated 12/21/24 showed: -The resident's name was written on the top of the form. -The form was not signed by the resident or the resident's responsible party. -The bed hold rate per day was not completed. -The effective date of the bed hold was not completed. -The expiration date of the bed hold was not completed. During an interview on 3/14/25 at 11:17 A.M., the Social Services Designee (SSD) said: -Nurses and Social Services were responsible for completing the Bed Hold Agreement documentation. -The form should be signed before the resident leaves the facility. -A copy of the completed form would be mailed to the residents responsible party. During an interview on 3/14/25 at 1:05 P.M., Registered Nurse (RN) A said: -Nurses were responsible for the Bed Hold Agreement forms. -He/she was not able to fill out the forms because in emergency situations they were too busy to remember them. -He/she said it was more important to get nursing forms, like the list of medications sent with the residents. -He/she said they did not know what the bed hold rate per day amount was so he/she could not fill this form out. During an interview on 3/14/25 at 3:36 P.M., the Director of Nursing (DON) said: -Nurses were responsible for getting the documentation started. -Then the SSD would make sure the form was filled out to its entirely. -The SSD would send it to the resident's responsible party.

Based on observation, interview and record review, the facility failed to ensure an individualized activity plan that was goal directed and incorporated the interest and ability of two sampled residents with dementia (Resident #22 and #90) out of 29 sampled residents. The facility census was 140 residents. Record review of the facility Activity policy and procedure dated 6/2020, showed: -The purpose was to encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. -The facility provides and activity program designed to meet the needs, interests and preferences of residents. -The activities are varied and work to address the needs and interests identified through the assessment process. -Activities are developed for individual, small group and large group participation. -The interdisciplinary team evaluates the activity assessment and considers the resident's medical condition and prognosis in identifying relevant recreational and cultural activities. -As needed activities are tailored to meet the needs of residents with cognitive impairment or other special needs. -Once the interdisciplinary team has identified relevant activities for the resident, the resident is given an opportunity to choose when, where and how they will participate in activities and social events. If the resident prefers not to attend organized group programs, room visits will be provided based on the assessed interests of the resident. 1. Review of Resident #22's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease (a progressive brain disorder, the most common cause of dementia, that gradually destroys memory and thinking skills, leading to difficulties with daily tasks and eventually, the inability to carry out even the simplest activities), failure to thrive, hemiplegia (paralysis) of the right dominant side, muscle wasting of the upper extremities, and cognitive communication deficit. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/9/25, showed the resident: -Had inattention, disorganized thoughts and significant memory loss. -Had no behavioral concerns. -Needed total assistance with bathing, dressing, toileting, transfering and eating and used a wheelchair for mobility. -The resident's activity preferences were not identified on this assessment. Review of the resident's Care Plan dated 12/18/24, showed the resident was dependent on staff for meeting emotional, intellectual, physical and social needs due to cognitive deficits and had little or no activity involvement related to disinterest and physical limitations. The goal was for the resident to express satisfaction with type of activities and level of activity involvement when asked through the review date. It showed the resident enjoyed church services, listening to music, playing bingo and was usually good at calling out the numbers, liked snacks and socializing. The resident said he/she also enjoyed watching football, participating in exercise groups, watching movies (comedies and westerns) and hobbies included shopping and his/her favorite colors are red, pink and white. Interventions showed: -The resident participated in activities weekly. -Invite/encourage the resident's family members to attend activities with resident in order to support participation. - Staff will provide Neen with activities she enjoys ie; Ice cream socials, monthly events, exercise groups, movies and television, music (Jazz and Blues). -Remind the resident that he/she may leave activities at any time, and was not required to stay for entire activity. -The resident needed one to one bedside/in-room visits and activities if unable to attend out of room events. -The resident needed a variety of activity types and locations to maintain interests. -The resident needed assistance/escort to activity functions. -Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. -Introduce the resident to residents with similar background, interests and encourage/facilitate interaction. -Invite the resident to scheduled activities. -Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. -Provide with activities calendar. Notify resident of any changes to the calendar of activities. -Review resident's activity needs with the family/representative. -Thank resident for attendance at activity function. Review of the resident's Special Programming One to One Log showed: -One to one activities for the resident occurred one time per week. -1/8/25-chair exercise arm movement; 1/15/25-played Connect 4 (game) dropping pieces in.; 1/22/25-no activity-resident sleeping; 1/29/25-listened to calming music. -2/5/25- had lunch and talked; 2/12/25-brushed hair and cleaned nails; 2/19/25-called out bingo numbers; 2/26/25-watched tv. -3/5/25-watched tv and talked about church; 3/12/25 went outside. Observation on 3/10/25 at 10:13 A.M., showed the resident was sitting in a high back wheelchair on the locked dementia unit with a daily chronicle (facility news paper) in front of him/her. The resident's hands was over his/her face and he/she was resting. There were no directed activities and no staff engagement in activities at this time. On the activity calendar on the wall showed 9:30 A.M. -daily chronicle; 10:00 A.M. IS (spirometer-a medical device used to measure the volume of air a person can breathe in and out) Program; 10:30 A.M. Waffle Social. From 10:13 A.M. to 12:21 P.M. showed there was no waffle social activity. Observation on 3/12/25 at 2:15 P.M., showed the resident was dressed and laying down in his/her bed. The television was on, the resident was awake but was resting. The activity calendar showed 2:30 P.M. Plant Making. The resident was not invited to any activity. There were no plant making activities that occurred at 2:30 P.M. on the unit. At 2:50 P.M. activity staff came onto the unit and provided popcorn to residents who accepted the snack. The resident had some popcorn and a drink. Observation on 3/13/25 at 11:10 A.M., showed the resident was sitting up in his/her high backed wheelchair dressed for the weather, and was sitting in front of the television in the sitting area. He/She was not watching the television. There was a group activity going on at this time that the resident was not invited to or brought over to passively participate in. The activity calendar showed there was no scheduled activity at this time. During an interview on 3/13/25 at 11:20 A.M., Hospice Nurse A said: -The resident was hard of hearing and had visual impairment and the staff took care of the resident, but he/she did not see them doing many activities with him/her. -The staff usually sat the resident in the television area, but the resident does not watch it. -He/She had spoken with the activity staff about having the resident sit with the group during activities. -He/She told the staff that the resident should be engaged and could participate in activities on the unit. -He/She had not seen anyone giving one to one activities to the resident, but earlier in the week they were playing Bingo and the resident was sitting in the tv area and he/she brought the resident to the table and the activity staff had the resident assist with calling out the numbers. -The resident liked jazz and would participate in activities. Observation on 3/13/25 at 2:45 P.M., showed the resident was laying down in his/her bed with his/her eyes closed resting comfortably. Activity staff came onto the unit and began gathering residents to play a bowling pong game. The resident remained resting in his/her room. The activity calendar showed Movie and Popcorn at 2:30 P.M. During an interview on 3/13/25 at 2:47 P.M., Certified Nursing Assistant (CNA) B said: -The resident does not really participate in activities due to his/her confusion. -They tried to bring the resident to activities daily. -The resident did not receive one to one activities and he/she had not seen activity staff do one to one activities with the resident. -This week the resident was able to assist with calling out the numbers during bingo. He/she repeated the number when the activity staff called it out. Observation 03/14/25 at 9:21 A.M., showed the resident was sitting up in his/her wheelchair in the tv area. The tv was on and there were three other residents sitting in front of the tv. The resident was not watching the tv, he/she was looking down at his/her hands and clothes. There was no activity at this time (the activity at 9:30 A.M. was Daily Chronicles). Nursing staff did not start an activity on or around 9:30 A.M. During an interview on 3/14/25 at 9:37 A.M., CNA C said: -They have activities on the unit daily, but most of the activities were group activities. -Some residents can participate in the activities and some cannot due to their cognitive status. -The resident does not participate in activities usually. They will give him/her snacks and he/she likes those but he/she slept a lot. -When the resident was up, he/she was usually in the tv area. -The resident does not have any one to one activities. -He/She had not seen the resident in any one to one activity provided by activity staff. -The activity staff follow the activity calendar and provide the activities listed on the calendar most of the time. -Nursing staff have papers and crayons that they have for the residents to color during the day or when the activity staff is not there to conduct activities. -There was usually the CNA and a nurse on the unit. -At 9:46 A.M., the CNA passed out snacks to residents that wanted or accepted one to include the resident. -There was no activity initiated. 2. Review of Resident #90's Face Sheet showed the resident was admitted on [DATE], with diagnoses including dementia with agitation, lack of coordination, impulse disorder, and cognitive communication deficit. Review of the resident's annual MDS dated [DATE], showed the resident: -Had inattention, disorganized thoughts and significant memory loss. -Had no behavioral concerns. -Needed supervision with bathing, dressing, toileting, transferring and eating and ambulated independently without using an assistive device. -Activity preferences that were very important to the resident included, listening to music, animals, going outside, keeping up with the news and participating in groups. Review of the resident's Care Plan dated 1/20/25, showed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. It showed the resident enjoyed listening to and dancing to music, physical games where he/she is moving around, watching tv and movies, and going outside. The goal was for the resident to maintain involvement in cognitive stimulation, social activities as desired through review date. Interventions showed staff would: -Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, meals. -Ensure that the activities the resident is attending are compatible with physical and mental capabilities; compatible with known interests and preferences; adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), compatible with individual needs and abilities; and are age appropriate. -Introduce the resident to residents with similar background, interests and encourage/facilitate interaction. -Invite the resident to scheduled activities. -Provide with activities calendar. Notify resident of any changes to the calendar of activities. -Provide a program of activities that is of interest and empowers the resident by allowing choice, self-expression and responsibility. -Escort resident to activities, thank resident for attendance at activity function. Review of the resident's Special Programming One to One Log showed: -The resident was provided with one activity per week. -1/6/25 coloring page with number matching; 1/13/25 played duck in the pond game; 1/20/25 danced to music; 1/27/25 danced and listened to music -2/3/25 resident was sleeping; 2/10/25 played choice in music and dancing; 2/17/25 walked around the building; 2/24/25 painted nails and brushed hair. -3/3/25 large print reading-recognized several words; 3/10/25 walked around the building. Observation on 3/10/25 at 10:15 A.M., showed the resident was dressed and ambulating on the locked dementia unit. There were no directed activities and no staff engagement in activities at this time. On the activity calendar on the wall showed 9:30 A.M. -daily chronicle; 10:00 A.M. IS Program; 10:30 A.M. Waffle Social. From 10:15 to 12:21 P.M. showed there was no waffle social activity. Observation on 3/11/25 at 9:54 A.M., showed the resident was sitting in the dining area in front of the nursing station. The resident got up and began wandering on the unit and into resident rooms. Staff immediately re-directed the resident back to the dining area where the resident sat down in a chair. Staff did not provide the resident with an activity or anything to occupy him/her. On the activity calendar showed 9:30 A.M. Daily Chronicle; 10:30 A.M., IS Program. There was no activity occurring and no staff engagement with the residents. Observation on 3/12/25 at 2:14 P.M., showed the resident was wandering on the unit up and down the hall. There were no activities occurring on the unit. At 2:28 P.M. staff provided residents with a choice of snack and beverage. The resident chose a snack and ambulated with his/her snack on the hall. At 2:50 PM activities staff came onto the unit and passed out popcorn to residents who wanted it and asked if they wanted to go play cards. The resident received popcorn and staff sat the resident down at the table and the resident ate his/her snack. After eating, he/she continued to wander on the unit. The activity calendar showed plant making activity At 2:30 P.M. and fresh air break at 3:30 P.M. Observation on 3/12/25 at 4:03 P.M. showed the resident participated in the fresh air activity (going outside). Observation on 3/13/25 at 11:02 A.M., showed the resident was ambulating on the unit. There was a group activity occurring on the unit that other residents were participating in. The resident would sit down for a while then would get up and begin ambulating around the unit again. The resident ambulated into another resident's room and staff immediately went to get the resident and walked with him/her on the unit, but did not bring him/her to the activity. Staff provided the resident a drink and the resident sat down and drank. Once he/she was finished, he/she began to wander on the unit. Observation on 3/13/25 at 2:41 P.M., showed the resident was wandering up and down the hall on the unit. The activity staff came onto the unit and asked residents who wanted to play a game yard pong. Nursing staff gave the resident a snack that he/she ate while standing at the nursing station. The resident did not participate in the activity and continued to wander on the unit after eating his/her snack. During an interview on 3/13/25 at 2:47 P.M., CNA B said: -The resident will only sit for a few minutes at a time and it was difficult to get him/her to participate in organized activities because he/she always walks. -They primarily will give the resident snacks and they will walk with him/her on the unit. -The resident was not on one to one activities and he/she had not seen the activity staff conduct one to one activities with the resident. -They really don't have any one to one activities on the unit. -The activity staff provide activities on the unit daily, but the resident rarely participates. - At 3:05 P.M., the activity staff stopped the resident and handed him/her a ball to toss into the bucket. The resident did so and then continued to wander on the hall while other residents took turns playing the game. Observation on 3/13/25 at 3:30 P.M., showed activity staff was walking with resident outside on the front patio with other residents (this was a planned activity). Observation on 3/14/25 at 9:20 A.M., showed the resident was wandering on the unit, ambulating up and down the hall. The activity Daily Chronicle was supposed to start at 9:30 AM. There was no activity staff on the unit and nursing staff was assisting residents with toileting and personal care. During an interview on 3/14/25 at 9:37 A.M., showed CNA C said: -They do have activities on the unit daily, but most of the activities are group activities. -Some residents can participate and some cannot due to their cognitive status. -The resident wandered all day long and sometimes would sit down during an activity but only for a very short period of time. -The resident does not receive one to one activities and he/she had not seen activity staff conduct one to one activities with the resident. -The resident participated in snacks, but would still wander on the unit. -They had to watch the resident to keep him/her from going into other resident rooms. -At 9:47 A.M., CNA C passed out snacks and was able to get the resident to sit down long enough to eat it, but then the resident got up when he/she was finished and continued to wander the hall. 3. During an interview on 3/14/25 at 10:17 A.M., the Activity Director said: -They have 3 activity staff-the Activity Director and two activity assistants. -He/She completes activities on the locked dementia unit and the assistants are on the other units. -They usually have three activity staff during the week and two on weekends. -The IS Program is a spirometer breathing program they initiated to try to encourage resident participation with breathing exercises. -They also have hydration station which is to encourage residents to drink water or some beverage. -They incorporate snacks which gets more participation with the activities. -On the locked unit he/she will do similar activities like bingo, [NAME] the table (dice rolling game) that are simple activities that the residents can participate in. He/She will modify the activity for the dementia residents. -He/She will also take residents outside to enjoy the weather and sometimes he/she will incorporate an activity while outside. - They do not have very much documentation of resident participation in activities on the locked unit. -He/She documented the one to one activities on the locked unit on paper and not in the electronic record. -Regarding Resident #22, he/she does more talking and listening activities like singing, karaoke and activities that do not require seeing because the resident does not see very well. He/She said he/she conducted one to one activities with the resident twice weekly. Placing the resident in the tv area was more for him/her to be able to listen to that to watch. He/She said he/she did not conduct one to one activities with the resident in his/her room and the only time the resident was in his/her room was when he/she was sleeping, so the one to one activities were done in the common area on the unit. He/She said he/she will turn on church activities for the resident and other shows he/she liked to watch and talks to the resident about them. -Regarding Resident #90, he/she conducts one to one activities with him/her twice weekly. He/She said the resident walked a lot so he/she does a lot of walking with the resident on the unit. He/She said the resident liked music so he/she ensures that they have music going. He/She said every other Thursday the beautician comes in and the resident gets his/her hair done. He/She said he/she will sit with the resident during his/her appointment and ask what hair style he/she wants. He/She said he/she did not know how much the resident understood this but is aware that he./she was getting his/her hair done. He/She said he/she tried to get the resident to participate in the group activities, and sometimes he/she will participate for short periods. The resident does participate in snacks. -When he/she is not in the building the assistant is supposed to do the activities in his/her absence. During an interview on 03/14/25 at 2:26 P.M., the Director of Nursing (DON) said: -There should be an activity program in place and activities should be done at the time scheduled. -Activities should be done per individual preference, likes and abilities. -For those residents with dementia or who have special needs he/she would expect staff to assess the individual and their activities should be individualized based on likes and what they used to do-they would get this information from family if possible. -Activities should be goal oriented and specific to the resident. -The spirometer is not the only activity on the unit but, they do use it as a group activity to encourage compliance and resident participation increasing breathing health-they do that activity along with snacks. -If the Activity Director was not in the building, there were two activity assistants who are expected to continue the activities and they should be following the activity calendar. -Resident #22 should have an individualized activity plan based on his/her ability and likes, and should be invited to all of the activities. -Resident #90 should have an individualized activity plan that should be time sensitive due to his/her ambulation and wandering, limited attention span. The resident may only participate in activities in short periods or in certain activities. He/She would expect the activities to be on the care plan and should be goal oriented specifically for this resident's ability to participate. -He/She expected all activity participation for each resident to be documented.

Based on observation, interview and record review, the facility failed to ensure one sampled resident(Resident #104) did not keep smoking materials including cigarettes and a lighter in his/her room, and failed to ensure the resident was only smoking in the smoke area not in his/her room; and failed to ensure to protective oversite and supervision to maintain a safe environment during smoking breaks, and to failed ensure resident assigned smoking area was free of potential hazards including wood, nails and broken equipment for one sampled resident (Resident #103) out of 29 sampled residents. The facility census was 140 residents. Review of the facility's policy, Smoking by Residents, dated November 2023 showed: -Smoking was not allowed anywhere inside the facility. -The facility permits smoking only in the areas designated by the facility's Safety Committee. -The facility discourages smoking by residents and ensures that those resident who choose to smoke did so safely. -Residents who wanted to smoke would have been assessed for their ability to smoke safely prior to being allowed to smoke independently in those areas. -Residents who were not able to smoke independently and safely would have been accompanied by facility staff while smoking. -The facility would have created a Smoking Care Plan for the resident. -All smoking materials would have been stored in a secure area to ensure they were kept safe. -Example of a secure areas included; a labeled box in a locked medication room and clearly identified with the resident's name and room number. -Residents were prohibited from soliciting smoking materials from staff and visitors. -Response to resident non-compliance with smoking rules included: -First offense was a written letter issued to the resident and /or family regarding non-compliance. -Second offense was a written letter issued to the resident and/or family referencing the first offense letter and advising that a third offense results in the loss of smoking privileges. -Third offense was a letter issued to the resident and/or family outlining the non-compliant behavior. At this time the resident lost their smoking privileges. 1. Review of Resident #104's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Lack of coordination. -Need for assistance with personal cares. -Hemiplegia (weakness on one side of the body) and Hemiparesis (muscle weakness on one side of the body) following Cerebral Infarction (Stroke - a condition where blood flow to the brain was interrupted causing brain cells to die) affecting right dominant side. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/20/25 showed: -The resident was moderately cognitively impaired. -He/She put other residents at risk was not checked. -He/She put self at risk was not checked. -He/She had a stroke. -He/She had hemiplegia. Review of the resident's care plan dated 2/25/25 showed: -He/She was a smoker. -He/She would not smoke without supervision. -He/She would follow all facility smoking rules. -Staff would educate family members to go to the nurse when smoking items were brought into the the facility. -They (smoking materials) have to have been given to nursing to follow smoking policy and facility rules. -Staff was to notify Assistant Director of Nursing (ADON), Director of Nursing (DON), Social Services (SS), Physician, Nurse Practitioner (NP), and Administrator it rules were broken for smoking. -A copy of the smoker's contract was signed and in the resident's medical record. -Cigarettes or other smoking materials and lighter were required to have been stored at the nurses' station. -Staff was to instruct the resident about the facility policy on smoking; location, times, safety concerns. Review of the resident's Safe Smoking Evaluation dated 3/12/25 showed: -He/She was a smoker. -He/She knew the location of the designated areas for smoking. -He/She was able to get to those areas independently. -He/She was able to independently light smoking materials safely when observed. -He/She was able to extinguish smoking materials completely in an appropriate receptacle. -He/She was able to dispose of ashes or other tobacco related residue appropriately. -He/She was safe to smoke with minimal supervision. Observation on 3/13/25 at 1:05 P.M. showed: -There was a smell of smoke in the hallway outside of the resident's room. -The resident came out of the restroom and smoke flowed out of the resident's restroom. -The resident went over to his/her side of the room and opened the window. -The resident was alone in the room. -The Wound Care Nurse was down the hallway and was notified of the smell of smoke. -The Nurse smelled smoke from the resident's room. -The Nurse entered the resident's room. -Cigarette ashes were observed on the toilet seat in the resident's restroom. -The Nurse asked the resident if he/she had been smoking in the room. -The resident said no. -The Nurse asked if the resident's roommate had been smoking in the room and he/she said no. -The Nurse asked the resident if he/she had any cigarettes or a lighter in the room. -The resident gave the Nurse a pack of opened cigarettes, a pack of cigars, and a lighter. -The resident said he/she knew that he/she was not supposed to have smoking materials in the room, the smoking materials were to have been kept by the staff and locked in the smoking cart. -The resident said he/she knew he/she was not supposed to smoke in his/her room but he/she had smoked in the restroom. -The resident's roommate also had a pack of cigarettes sitting on his/her bedside tray table. -The Nurse said the resident had smoked in his/her room before. -If a resident was found smoking in their rooms they ask if they can come in and look for the cigarettes. -They take the cigarettes and lighter. -The Nurse provided education to the resident about smoking in his/her room. -The Nurse told the DON. -The residents were evaluated to smoke on their own and this resident was able to smoke without supervision. -They can only smoke in the smoking area in the back of the building. -The resident's family members most likely brought the smoking material into the building and did not give it to the nurse to have been stored securely. -There were residents in the same hallway who were on oxygen and it was dangerous to smoke around oxygen. During an interview on 3/13/25 at 1:25 P.M. the resident said: -He/She knew he/she was not supposed to have smoked in his/her room or had smoking material in his/her room but he/she had smoked and kept smoking material in his/her room. -They were only to smoke in the smoking area. -Nursing was to have kept his/her smoking material and they would hand out the smoking materials when the residents went out to smoke. -He/She would not say how he/she came to have had the smoking materials. -He/She had signed a smoking contract when he/she first came into the facility. -He/She would not say if he/she had been caught smoking in his/her room before. -He/She did not think he/she had received a letter from the facility about smoking in his/her room. -His/Her roommate was also a smoker but would not comment on the roommate smoking in the room or keeping smoking materials in their room. -He/She had seen cigarettes on the roommates side of the room. During an interview on 3/13/25 at 1:40 P.M. the resident's roommate said: -He/She was a smoker. -He/She declined to say if he/she or the roommate ever smoked in the room. -He/She denied that they kept smoking materials in the room. -The nurses were supposed to keep smoking materials at the nurses 'station. Review of the resident's chart on 3/13/25 at 2:00 P.M. did not show that he/she had previously been sent a letter concerning not smoking in the designated area. During an interview on 3/14/25 at 10:30 A.M. Certified Nursing Assistant (CNA) A said: -The resident was a smoker. -Residents were only to have smoked in the designated smoking area. -Residents were not supposed to have kept smoking material in their rooms. -Staff was to have kept smoking materials (cigarettes and lighters) locked in the cigarette cart. -When it was time to smoke the staff would hand the residents their smoking materials. -There was a staff member assigned to watch the smokers on their smoking breaks. -At the end of the smoke break the resident's should have handed the smoke materials back to the staff member for them to have locked it in the smoking cart. -The resident had been found smoking in his/her room before. -If he/she had found a resident smoking he/she would have taken the smoking materials away from the resident -He/She had to take smoking materials away from residents whose family had brought in the smoking materials and the residents had them in their rooms. -He/She then would have told the DON about the resident having smoking materials in their room or if they had been smoking anywhere in the building. -There were residents in that hall that were on oxygen and it would be dangerous if someone was smoking around them. During an interview on 3/14/25 at 11:10 A.M. Registered Nurse (RN) A said: -Residents were to have kept smoking materials in the cigarette cart not in their rooms. -Residents were not to have smoked in their rooms. -If a resident was found smoking in their rooms staff should have confiscated the smoking materials. -Staff should have told the DON if a resident had smoking materials in their room or had been found smoking in their room. -The resident should then have been educated about the smoking policy. -Smoking assessments should have been done quarterly. -The resident was able to smoke without supervision. -He/She did not know anything about the residents getting letters regarding their smoking. -He/She did not see that the resident had received a letter regarding smoking in his/her chart. -The resident had been caught smoking previously and had received education but nothing else. -There were other residents on that hallway where the resident resided that were on oxygen and it would have been dangerous if they were smoking in their rooms. During an interview on 3/14/25 at 2:25 P.M. the DON said: -If a resident was found smoking anywhere but the designated smoking area he/she expected staff to have told him/her and confiscate the smoking material and then tell him/her. -Smoking material should be locked in the smoking cart then handed out to the residents' at smoking time. -After smoking time the residents should have given the smoking material back to the staff to lock in the smoking cart. -Residents should not have had smoking materials in their rooms. -Social Services would educate the resident and family about their smoking policy. -The resident was able to smoke without supervision. -At this time they educated the resident about smoking he/she did not know anything about a letter. -There were residents on the same hallway who were on oxygen and that was why they were only supposed to have smoked in the designated area. 33409 2. Review of Resident #103's face-sheet showed he/she was admitted with diagnosis to include: stroke, Psychosis (a person's thoughts and perceptions are disrupted and they may have difficulty recognizing what is real and what is not), vascular Dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), Major Depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily). Review of the resident's quarterly MDS dated [DATE] showed: -The resident was cognitively intact able to make his/her needs known. -The resident did not have documentation during the look back period related to smoking. Review of the resident's POS dated 2/11/25 showed the resident: -The resident resides on secure unit due to diagnosis of Dementia. -May attend activities in dining area and other parts of the facility. Review of the resident's Alert charting dated 3/7/25 at 4:31 P.M., written by ADON A showed: -While the resident was outside on smoking break, staff noted the resident holding a 2 x 4 board with nails sticking out one end. -The resident attempted to bring the board into the building and staff informed him/her that could not bring board into the building. -The resident attempted to push pass then and staff ran into building closed the door. -The resident proceeded to punch the door glass window and cracked it. -Facility staff attempted to calm the resident and gave the resident another cigarette. -While the resident was smoking, the nurse was able to encourage the resident to give the nurse the board. -Facility staff called 911. -Police had arrived and spoke with the resident and the resident proceeded to shove the police officer. -The resident was sat down by the police while they attempted to speak to the resident. -Facility staff noted three large rocks and broken call light cord on the resident walker. -Police officer asked the resident if they could check his/her pockets and resident agreed. -The police officer obtained broken toothbrush, broken medical reacher (a device used to pick up items without bending or reaching) and broken plastic hanger. -He/she was ask why had these items and said because. -Emergency Medical Services (EMS) arrived and transported the resident to hospital. -The resident family member called with no answer. Review of the resident's Care Plan revision on 3/10/25 showed: -The resident has actual/potential to demonstrate physical behaviors related to the announcing of new administration for the United State on 11/6/24. -Intervention include monitoring, document and report to physician any danger to self or others. Analyze of key times, places, circumstances, triggers and what de-escalates behavior and document. Observation on 3/12/25 at 10:46 A.M., the outside smoke area showed: -A total of 13 residents and one staff member in the smoking area. -A few feet away was a maintenance garage, with broken medical equipment in front of garage door which residents would have access to. During an interview and observation on 3/13/25 at 2:50 P.M., with Maintenance staff A showed: -There were residents and staff outside smoking at that time. -The facility smoke area was located out back door by kitchen area and maintenance garage/shed. -The maintenance had pile of broken metal medical equipment in front of garage doors, which was only few feet away from where the resident's smoke. -The broken equipment would be assessable by the resident while in the smoking area. -There was a sidewalk between garage and facility building. -The walkway goes to backside of the facility and toward the dumpster area and parking area. -There were small to medium sized rocks placed between the building and sidewalk. -The smoking area was not a fenced off area. -Maintenance staff A said was not sure how the resident was able to bring in rocks the size of bricks, into the building. -He/she had previously found rocks in the resident room and he/she had remove the rocks found reported to nursing staff. -He/she felt the facility staff were not always watching the resident during smoke breaks. -He/she had seen the resident walk down the sidewalk toward dumpster area and back without staff monitoring the resident. During interview on 3/11/25 at 10:50 A.M., Director of Nursing (DON) said the resident during a smoke break obtained a board with nails and rocks. During an interview on 3/13/25 11:27 A.M., CNA G said: -The hospitality aid had brought the resident outside from the locked unit. -He/she was outside in smoke area while on his/her break. -He/she went inside and closed the door quickly before the resident could enter the building with the board. -The resident then punched the window with his/her fist and shattered the door glass. -He/she had called the DON and then police arrived took over the incident. -Resident was verbally and physically aggressive and police had taken broken call light cord, rocks and other items that the resident had on himself/herself and on the walker. -At the time of the incident there were other facility staff in the smoking area along with other resident. -He/she had not seen the resident go get the board with the nails. -He/she had received training on how calm a resident or to de-escalate the situation. During an interview on 3/13/25 at 11:48 A.M., Licensed Practical Nurse (LPN) B said: -He/she was notified of incident smoke area and that needed licensed nursing staff immediately to smoke area. -He/she went out and calmly ask the resident for the 2 x 4 board. -He/she obtain a cigarette to calm the resident down. -Police arrive and escorted the resident form smoking area and out of the front door of the building. -Hospitality staff were responsible for supervise the resident while on smoke breaks. During an interview on 3/13/25 at 3:38 P.M., Administrator said: -Due to recent behavioral during smoke breaks and collection of potential weapons such as rocks and other broken, the resident was not safe to be at the facility for his/her safety and for the safety other resident at the facility. During an interview on 3/14/25 at 11:59 A.M., Medical Record staff A said: -The facility uses smoking breaks to assist in calming the resident. -The resident required monitoring while outside. -He/she had not seen the resident wander away from the smoke section when he/she was outside. -Medical record staff would also assist in monitoring the residents on locked unit. During an interview on 3/14/25 at 12:05 P.M., CNA H said: -The facility's hospitality staff were responsible for taking the the resident out to smoke and monitor the resident while in the smoking area. -He/she had completed the facility dementia care training on handling resident with behaviors. During an interview on 3/14/25 at 12:19 P.M., Assistant Director of Nursing (ADON) B said: -The resident from the locked unit should be monitored at all the times on and off the unit. - He/she was not aware of the resident wandering away or walking down sidewalk during smoking breaks. -The facility was not aware how the resident obtained rocks and board with nails and had been brought into the facility. -Since the election in November the resident mental status changed and increase delusion and paranoid. During an interview on 3/14/25 at 2:30 P.M., DON said: -The facility hospitality aid would be responsible for monitoring of the resident during smoking breaks and would be provided the same training as Certified Nursing Assistant (CNA) on how to monitoring/redirection of the resident during smoking times and to notify their supervisor of incident occur while monitoring the resident. -The DON was not aware the resident had wandered down the sidewalk to the dumpster area or over to the maintenance garage area during a smoking break. -Maintenance staff would be responsible for cleanness of the area around the garage. -All facility staff would be responsible to ensure safety of the resident while outside smoking and known whereabouts all resident outside during smoking breaks. -Resident from locked unit were required to have supervised smoke breaks and should ensure those residents do not wander outside the assigned smoking area. COMPLAINT# MO 00250871

Based on observation, interview and record review, the facility failed to serve the physician ordered texture and portion size to one sampled resident (Resident #22) with swallowing difficulties and who was at risk for weight loss out of 29 sampled residents. The facility census was 140 residents. Review of the facility's Therapeutic Diet policy and procedure dated 12/2020, showed: -The purpose was to ensure that the facility provided therapeutic diets to residents that meet nutritional guidelines and physician orders. -Therapeutic diets would not be given without a physician's order. -The therapeutic diet would be reflected on the resident's diet tray card. -The Nutrition Services Manager was responsible for ensuring each food item was pureed and served separately for a pureed diet per the menu and recipe and food portions are equal to the written portion sizes. -The Nutrition Services Manager would periodically review the resident's tray card and the physician's nutrition orders to ensure the information is consistent. 1. Review of Resident #22's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease (a progressive brain disorder, the most common cause of dementia, that gradually destroys memory and thinking skills, leading to difficulties with daily tasks and eventually, the inability to carry out even the simplest activities), failure to thrive, hemiplegia (paralysis) of the right dominant side, muscle wasting of the upper extremities, and cognitive communication deficit. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/9/25, showed the resident: -Had inattention, disorganized thoughts and significant memory loss. -Needed total assistance with bathing, dressing, toileting, transferring and eating and used a wheelchair for mobility. -Received a mechanically altered therapeutic diet. -There was no documentation showing the resident had a chewing or swallowing concern. Review of the resident's Care Plan dated 12/18/24, showed: -The resident had nutritional problem or potential nutritional problem. Interventions showed: -Invite the resident to activities that promote additional intake. -The resident would eat all meals in the main dining room at assisted tables, staff to assist as needed. -Obtain and monitor lab/diagnostic work as ordered. Report results to the physician and follow up as indicated. -Provide and serve supplements as ordered: House supplement, house shake. -Provide, serve diet as ordered. Monitor intake and record every meal. -Registered Dietician to evaluate and make diet change recommendations as needed. -Weigh per facility protocol/physician order and as needed. Make every effort to do same time of day and use same method. Review of the resident's Physician's Order Sheet (POS) dated 3/2025, showed physician's orders for: - Regular diet, puree (food texture is finely ground like that of baby food or mashed potatoes) texture, thin consistency, comfort whole foods when requested by hospice (1/3/25). -House 2.0 Supplement one time a day 100 milliliters (ml) consistency (1/3/25). -Resident is at risk for malnutrition related to new admission and diagnosis; will weigh monthly thereafter. Dietician to consult as needed, per orders (12/11/24). -Use of a plate guard at meal time to promote independence with eating (12/2/24). Observation and record review on 3/10/25 at 12:06 P.M., showed the resident was in his/her high backed wheelchair sitting at the dining room table. The resident was served a pureed diet with potatoes, green vegetable, and brown pureed meat and vanilla pudding. Review of the resident's diet card showed a regular pureed diet with large portions. The portions on the resident's plate were a regular, not large portion size. Observation on 3/14/25 at 11:34 A.M., showed the resident was sitting in the TV area. At 11:54 A.M., nursing staff brought the resident to the dining table to feed the resident. The resident received a pureed diet of meat, mashed potatoes with gravy and peas. The resident was served a regular fruit cup of oranges. The resident did not receive large portions. Certified Nursing Assistant (CNA) E began feeding the resident. Review of the diet card showed resident was to receive pureed diet with large portions. Observation and interview on 3/14/25 at 12:00 P.M., showed CNA E said: -The resident was served a regular dessert and it was supposed to be pureed and he/she was supposed to be served large portions and was not. -He/She was going to page dietary to have them bring the correct dessert. At 12:00 PM he/she paged dietary. He/She informed the Dietary Manager that they had not provided the resident with a pureed dessert and had not provided large portions for the resident. -The dietary staff rarely served the resident large portions. -They really need to begin to look at the diet cards. During an interview on 3/14/25 at 12:21 P.M., showed CNA C said: -The resident normally received regular portions and rarely received large portions. -The resident was supposed to receive a pureed diet with large portions according to his/her diet card. -They feed the resident and the resident would usually eat most if not all of his/her meal. During an interview on 3/14/25 at 12:34 P.M., the Dietary Manager said: -When they are preparing the resident plates in the kitchen, the cook is supposed to prepare it by what is on the resident's diet card. -They made a mistake and did not give the pureed dessert. -The resident was supposed to receive large portions and they corrected this also today. -Nursing staff was also supposed to check the resident's diet card to ensure he/she received the correct diet and if the diet was wrong, they should notify the dietary staff. -Nursing staff had not informed them that the resident had not been receiving large portions. -He/She will ensure the resident's diet order is correct. During an interview on 3/14/25 at 2:26 P.M., the Director of Nursing (DON) said: -He/She expected the resident's physician ordered diet order to be followed. -The diet card should show the resident's ordered diet including dietary initiatives of the Registered Dietician. -If the resident's diet card showed double or large portions, he/she expected that to be followed. -The nursing staff was supposed to document the resident's meal consumption so they would be able to see if the resident was eating large portions. -Large portions usually was a Dietitian intervention so they should continue the intervention and let the Dietitian know what the resident is eating so he/she could decide whether to continue the intervention or not. -He/She expected nursing staff would document concerns about the resident's diet order to be documented in the resident's medical record. -He/She was made aware of the resident not receiving the correct diet and the dietary staff would correct it.

Based on observation, interview, and record review, the facility failed to provide a nebulizer (a machine that turns liquid medicine into a mist that could have been easily inhaled) was available for respiratory treatments for one sampled resident, (Resident #10); failed to ensure the Continuous Positive Airway Pressure (CPAP a machine that delivers enough air pressure to a mask to keep the upper airway passages open during sleep) mask was correctly placed for one sampled resident, (Resident # 126) and failed to ensure oxygen equipment was stored in a sanitary manner for two sampled residents, (Resident #68 and Resident #126) out of 29 sampled residents. The facility census was 140 residents. Review of the facility's policy, Oxygen Administration, dated 6/2020 showed: -A physician's order was required to intiate oxygen therapy. -All oxygen tubing, humidifiers (a container for distilled water), masks, and cannulas (oxygen tubing) used to deliver oxygen would have been changed weekly and when visibly soiled. -Oxygen items would have been stored in a plastic bag to protect the equipment from dust and dirt when not in use. -Oxygen was to have been stored in a clean dry place. -For a face mask staff was to have placed the mask on face, applying it from the nose and over the chin. -Adjust the metal rim over the nose and contour the mask to the face. 1. Review of Resident #10's face sheet showed he/she was readmitted on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/21/25 showed: -He/She was cognitively intact. -He/She had resistor failure. -He/She had COPD. -Did not show any respiratory treatments. Review of the resident's March 2025 Physician's Order Sheet (POS) showed the following order Ipratroplum-Albuterol Inhalation Solution (a combination of medications used to open your airways and reduce inflammation in your lungs to breathe easier) 0.5 - 2.5 (3) milligram (mg)/3 mililter (ml) inhale orally every four hours as needed for shortness of air, dated 3/6/25. Review of the resident's care plan dated 3/6/25 showed: -He/She had COPD. -Staff was to give aerosol as ordered, dated 12/4/24. During an interview on 3/11/25 at 11:02 A.M. the resident said: -He/She had a bad night a couple of nights ago and it was hard to breathe. -He/She had asked for a nebulizer treatment. -The nurse had given him/her a inhaler treatment (breathing treatment) instead as there was no nebulizer in his/her room. -Two months ago he/she had moved from the 400 hall into his/her current room. -When the staff moved him/her they had brought the nebulizer machine and put it in his/her nightstand drawer. -Staff had not brought the mouthpiece with the machine so he/she was not able to use it. -He/She slept better at night after a nebulizer treatment. -He/She has asked several times for the staff to go back to his/her old room and look for the rest of the nebulizer, which they have not done. Observation on 3/11/25 at 11:05 A.M. showed: -The resident had a nebulizer machine in his/her nightstand. -The nebulizer was missing the tubing and mouthpiece. During an interview on 3/12/25 at 3:20 P.M. the resident said: -He/She had asked the staff again to look for the missing pieces of the nebulizer or could they get him/her a new one. -Staff did not provide the missing pieces nor did they obtain a new nebulizer. Observation on 3/12/25 at 3:25 P.M. showed the nebulizer was still in his/her nightstand without the missing pieces. During an interview on 3/13/25 at 11:00 A.M. Assistant Director of Nursing (ADON) A said: -There was a mouth piece to the nebulizer and it was in a bag in the resident's room. -He/She changed the mouthpiece out every week. -He/She gave the resident a breathing treatment with the nebulizer yesterday. Observation on 03/13/25 at 11:03 A.M. showed: -The nebulizer was still in the drawer of the nightstand. -There was no mouth piece anywhere in the room. During an interview on 3/13/25 at 11:05 A.M. the resident's roommate said: -The resident had woke him/her up trying to catch his/her breath the other night. -Nursing gave the resident a hand held puffer (inhaler) treatment. -They never brought the mouthpiece for the nebulizer after he/she had moved from the other hall. -The resident had asked staff a couple of times to look for the rest of his/her breathing machine in the old room. During an interview on 3/14/25 at 10:00 A.M. the resident said he/she did not have the tubing or mouth piece for his/her nebulizer until last night when staff finally brought a new one. 2. Review of Resident #126's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Obstructive Sleep Apnea (intermittent airflow blockage during sleep. Review of the resident's annual MDS assessment dated [DATE] showed: -He she was cognitively intact. -Pulmonary (breathing) issues was not checked. -CPAP was not checked. Review of the resident's care plan dated 2/19/25 showed: -He/She had altered respiratory status/ difficulty breathing related to Sleep Apnea dated 11/19/24. -He/She was to use the CPAP at bedtime and as needed when sleeping. -Staff was to monitor placement of mask, dated 2/10/25. Review of the resident's March 2025 POS showed the following orders: -Monitor placement of mask as needed for Sleep Apnea, dated 1/5/25. -Monitor placement of mask at bedtime for Sleep Apnea, dated 1/5/25. During an interview on 3/11/25 at 11:10 A.M. the resident said: -They have never cleaned the CPAP mask or nebulizer mouthpiece. -The jug of water on the floor was for CPAP. -He/She had a hard time keeping the CPAP mask on when he/she slept because of his/her facial hair. Observation on 03/11/25 11:14 AM showed he/she had a CPAP machine sitting on his/her nightstand. Observation on 3/11/25 at 1:40 P.M. showed: -The resident was asleep wearing the CPAP mask. -The CPAP mask was askew, not sitting straight on his/her face the oxygen was leaking out of the sides of the mask. Observation on 3/11/25 at 3:00 P.M. showed: -The resident was asleep wearing CPAP mask. -The resident's mask was askew, with oxygen leaking out the sides of the mask. Observation on 3/14/25 at 1:20 P.M. showed: -The resident was asleep in bed wearing the CPAP mask. -The mask was askew with oxygen leaking out of the sides. During an interview on 3/14/25 at 10:30 A.M. Certified Nursing Assistant (CNA) A said: -The Nurses take care of the oxygen equipment. -It was hard to keep the CPAP on Resident #126, he/she had a beard and it slips off sometimes when he/she sleeps. -If you wake him/her up to put the mask on he/she gets mad. -He/She had not seen the parts for Resident #10 nebulizer, if they moved from a different hall all their belongings should have came with them. -He/She had not been asked to look in the resident's old room for the nebulizer parts. During an interview on 3/14/25 at 11:00 A.M. Registered Nurse (RN) A said: -He/She would have expected a nebulizer to have all the pieces and been available for the resident to use as soon as there was a physician's order. -They have all the pieces for a nebulizer and would take less than five minutes to ensure all of the pieces were there or to get a new nebulizer with all the pieces. -The Nurses were in charge of the oxygen equipment. -The ADON goes around each week and checks on the oxygen equipment. During an interview on 3/14/25 at 2:25 P.M. the Director of Nursing (DON) said: -The Nursing staff was responsible for the oxygen equipment. -The ADON makes rounds on Mondays to audit the oxygen equipment. -There should have been all the components with the nebulizer or staff should have obtained a new one. -Staff were expected to follow the physician's orders. -If a resident did not have a CPAP mask on correctly it would not have been effective. 3. Review of Resident #68's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Respiratory failure (when the lungs can not properly exchange gases). -Malignant neoplasm of Larynx (cancerous cell in the voice box which helps you breathe and make noises). -Malignant neoplasm of left lung (cancerous cells in the lung). -Tracheostomy status (a surgical procedure to create an opening in the neck and into the windpipe to help a person breathe). Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She had respiratory failure. -Staff were to complete tracheostomy cares. -Oxygen therapy was not checked. Review of the resident's care plan dated 1/31/25 showed: -He/She had altered respiratory status/difficulty breathing. -Staff was to maintain a clear airway by encouraging resident to cough. If secretions could not be cleared, suction as ordered. -His/Her oxygen setting was oxygen via mask (a mask that provides a method to transfer breathing oxygen gas from a storage tank to the lungs) at two liters per minute. Review of the March 2025 Physicians' Order Sheet (POS) showed the following orders: -May suction every hour as needed for tracheostomy cares. -Oxygen at two liters per minute per trachea shield (a form of oxygen mask that delivers oxygen to a tracheostomy or stoma - the hole that remains after tracheostomy tube was removed) as needed for shortness of air. Observation on 3/10/25 at 10:35 A.M. showed: -The resident had a stoma with a trachea shield over it with oxygen turned on. -The oxygen was delivered by a concentrator (a medical device that delivers 95% pure oxygen) which had a humidifier reservoir (distilled water - purified water, which combines with the oxygen to decrease dryness when using oxygen). -There was no date on the oxygen tubing or trachea shield which showed when it had been changed. -The distilled water jug was sitting on the floor, there was no date which showed when the water jug had been opened. -The suction machine was sitting on the floor not in a bag. -The tubing to the suction machine was in a bag without a date on it. Observation on 3/11/25 at 10:40 AM showed: -The resident had a stoma with a trachea mask delivering oxygen. -There was no date which showed when it was changed. -The oxygen concentrator had a humidifier for distilled water. -The water jug was sitting on the floor, there was no date the jug of distilled water had been opened. -There was a suction machine sitting on the floor. -The suction machine was sitting on the floor not in a bag. -The tubing to the suction machine was in a bag without a date on it. Observation on 3/13/25 at 11:48 A.M. showed: -The resident was out of the room. -The oxygen mask and tubing was wrapped around the oxygen concentrator. -There was no bag for the oxygen tubing or mask. -The was a jug of water for the humidifier sitting on the floor with no opened date written on it. -The suction machine was sitting on floor, not in a bag. -The tubing that was attached to the suction machine was in a bag with no date on it. Observation on 3/13/25 at 1:35 P.M. showed: -The resident was lying in bed. -The resident had a stoma with a trachea mask delivering oxygen. -There was no date which showed when it was changed. -The oxygen concentrator had a humidifier for distilled water. -The water jug was sitting on the floor, there was no date the jug of distilled water had been opened. -There was a suction machine sitting on the floor. -The suction machine was sitting on the floor not in a bag. -The tubing to the suction machine was in a bag without a date on it. During an interview on 3/13/25 at 1:40 P.M. the resident: -Declined to talk as it was too hard for him/her. -He/She nodded his/her head yes that was the normal oxygen set up for him/her. -He/She shrugged his/her shoulders when asked if staff changes the oxygen equipment.

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident # 12) had received dental care out of 29 sampled residents. The facility census was 140 residents. Review of the facility's undated policy, Dental Services, showed: -All residents would receive appropriate oral cares if applicable on a daily basis. -It was the responsibility of each staff member within the nursing department to have ensured good oral care for each resident. -Assessment of the oral cavity and teeth was to have been performed upon admission and as necessary. -Observe mouth for any adverse conditions such as bleeding, swelling, unusual mouth odor or any complaint of pain or discomfort. -Note any such condition in the resident's chart and report the problem to the charge nurse. -Refer and or assist residents to obtain dental services as indicated for routine and emergency dental care including making appointment for the resident, if needed or requested and arranging transportation to and from the dentist's office. -Routine services included but were not limited to; -Annual inspections. -Dental cleaning, x-rays as needed. -Smoothing of broken teeth. -Emergency dental services included but were not limited to: -Acute or intolerable pain in teeth, gums, or palate. -Broken or damaged teeth. 1. Review of Resident #12's face sheet showed he/she had originally admitted to the facility on [DATE], readmitted on [DATE], with the following diagnoses: -Severe protein-calorie malnutrition (a condition in which a person does not consume enough protein and calories to meet their body's needs). -Hypokalemia, (a blood level that was below normal in potassium that could result in fatigue, muscle cramps, and abnormal heart rhythms). -Vitamin D deficiency (not getting enough vitamin D from foods or sunlight). -The facility had listed a dentist under care providers. Review of the resident's Dental Note, dated 1/17/23 showed: -Per the resident's request a limited intraoral (within the mouth), assessment was completed. -The resident had root fragments fractured at or below gumline. -Lone remaining tooth was in a poor state. -The resident had requested edentulation (teeth pulled) and dentures made. -A surgical access may have been indicated to remove residual fragments. -This should have been accomplished under a controlled setting for the safety of the patient. -Once (teeth) were removed and patient was well healed, an on site denture fabrication (denture impressions made) by the Dentist was possible. -Referral as noted to an Oral Surgery at nearby hospital. Review of the resident's Re-Admission Evaluation, dated 9/13/24 showed: -He/She was on a regular diet/mechanical soft (foods that were soft easy to chew and swallow, requiring minimal chewing) with chopped meat. -The evaluation did not address broken or missing teeth. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/8/25 showed: -He/She was moderately cognitively impaired. -Was at risk for malnutrition. -No natural teeth or tooth fragments was not checked. Review of the resident's care plan, dated 1/31/25 showed: -He/She had a self care deficit. -Staff was to assist with oral cares every shift. -He/She had the potential nutritional problem and was at risk for malnutrition. -Staff was to explain and reinforce to the resident the importance of maintaining the diet ordered. -Staff was to encourage the resident to comply, explain consequences of refusal such as malnutrition risk factors. -There was no documentation which addressed the resident's broken or missing teeth. Review of the resident's March 2025 Physician's Order Sheet (POS) showed: -Regular diet, regular texture, thin consistency. -There was no order to see the dentist. Record review of the resident's electronic medical record on 3/11/25 showed no information regarding dental services regarding teeth extractions and dentures. Observation and interview with the resident on 3/11/25 at 10:11 A.M. showed: -The resident only had one tooth on the bottom of his/her mouth. -He/She said he/she has only had one tooth on the bottom of his/her mouth for a couple of years. -He/She had not seen the dentist in the last year. -He/She said it was hard to eat regular food and most of the time his/her mouth hurts. -Observation of the resident's breakfast tray showed he/she had been served a regular tray. -He/She had told a staff member a couple of times that he/she would like to have his/her one tooth pulled as well as the broken teeth, then get a set of dentures. During an interview on 3/14/25 at 10:10 A.M. Certified Nursing Assistant (CNA) A said: -The resident only had a couple of teeth on the bottom. -The resident had problems eating sometimes. -The resident should have had dentures but did not have any. -He/She had not said anything to the nurse. During an interview on 3/14/25 at 10:20 A.M. CNA F said: -He/She had to help with the resident with oral cares. -He/She only had a couple of teeth on the bottom of his/her mouth. -He/She had problems eating and maybe should have had dentures. -He/She did not know if the resident had seen a dentist. -There was a dentist who came to the facility. -He/She had not said anything to the nurse because the resident had always had teeth issues. During an interview on 3/14/25 at 11:10 A.M. Registered Nurse (RN) A said: -He/She was not aware that the resident was missing any teeth or had any dental issues. -The residents should have been seen by the dentist at least once a year. -If a resident did not have any teeth the facility should have helped them obtain dentures. -The dentist came to the facility monthly. -Nursing should have documented in the resident's chart if he/she was missing teeth. -He/She did not see an order for the resident to see the dentist. -The Director of Nursing (DON) was ultimately responsible for ensuring the residents received the cares they needed. During an interview on 3/14/25 at 2:55 P.M. the DON said: -When a resident came into the facility or came back to the facility a complete head to toe assessment should have been performed by the admitting nurse, which should have included looking into their mouth and documenting the findings on the assessment sheet. -If a resident was missing teeth that should have been documented also on the resident's care plan. -The resident should have seen a dentist twice a year. -He/She would have expected the nursing staff to know if a resident was missing teeth especially if they had to help the resident do oral cares. -The resident should have seen the dentist within the first six months that they were admitted to the facility. -The dentist had seen the resident and the Social Worker (SW) should have made the appointment at the hospital to have his/her teeth pulled and fitted for dentures, this was missed somehow. -He/She would have expected the SW to have made the appointment for the resident with the oral surgeon within a couple of days. -There should have been an order to see the Dentist if the Dentist was on the face sheet listed as a provider and it was not done. -He/She was ultimately responsible for ensuring residents received the cares they needed and appointments were kept.

Based on observation, interview and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) by expanding the use of gowns and gloves during high-contact resident care activities) were implemented for one sampled resident (Resident #82) with a foot wound and receiving intravenous (IV-a way of giving a drug or other substance through a needle or tube inserted into a vein) antibiotic therapy; and out of 29 sampled residents. The facility census was 140 residents. Review of the facility's Standard and Enhanced Precautions policy and procedure dated 4/1/24, showed the purpose was to ensure the use of appropriate personal protective equipment (PPE-protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) to improve infection control as required in the care of residents. The policy showed: -Enhanced barrier precautions should be used for any residents who meet the above criteria wherever they reside in the facility. -EBP refers to an infection control intervention designed to reduce transmission of MDRO organisms that employs targeted gown and glove use when contact precautions do not otherwise apply and/or transmission such as presence of a medical device and wounds. -For residents whom EBP is indicated, EBP should be used when performing the following high contact resident care activities-dressing, bathing, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care or any skin opening requiring a dressing. -EBP are intended to be in place for the duration of the resident's stay in the facility or until resolution of the wound or discontinuation of the medical device that placed them at high risk. -Use of EBP are not recommended when performing transfers in common areas such as dining or activity rooms where contact is anticipated to be shorter in duration and not in the resident's environment (room). 1. Review of Resident #82's Face Sheet showed the resident was admitted on [DATE], with diagnoses including stroke with paralysis, diabetes, high blood pressure, seizures, malnutrition, peripheral vascular disease (a circulatory condition characterized by the narrowing, blockage, or spasm of blood vessels outside the heart and brain, leading to reduced blood flow and potential tissue damage) and aphasia (a communication disorder that affects the ability to speak and write). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/24/25, showed the resident: -Was alert with significant memory problems. -Was totally dependent on staff for bed mobility, transfers, toileting, bathing dressing, eating and mobility. -Did not show the resident had any wounds, but showed the resident had ointments and dressings that were applied during the look back period. Review of the resident's Care Plan dated 2/14/25, showed the resident had a vascular wound (a wound on the skin that develops due to poor blood circulation) to his/her right heel due to vascular insufficiency (poor blood circulation). Interventions showed: -Follow physician's orders. Monitor/document side effects and effectiveness. -Inspect the resident's feet daily, especially between the toes. Report changes to the nurse. -Monitor/document wound: size, depth, margins, signs and symptoms of infection. Document progress in wound healing on an ongoing basis. Notify physician as indicated. -Observe extremities for signs/symptoms of poor tissue improvement. Document changes Report significant findings to physician. -Teach the resident/family/caregiver to avoid risks for skin injury and decreased circulation. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaks out of blood vessels) and any other notable changes or observations. Review of the resident's Treatment Administration Record (TAR) dated 2/2025 and 3/2025, showed treatment orders for: - Wound care to right heel: clean with normal saline (salt water)/wound cleaner, pat dry, apply calcium alginate to wound bed, cover with dry dressing daily and as needed every day shift and every 8 hours as needed (2/21/25). -The TAR showed the resident was receiving treatment as ordered daily. -There were no physician's orders for EBP. Review of the resident's Physician's Order Sheet (POS) updated 3/11/25, showed physician's orders for: -Enhanced Barrier Precautions related to the resident's right heel: Staff members will wear a clean gown and gloves while performing high contact resident care activities to include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or toileting assistance, and/or caring for indwelling medical devices every shift for peripheral vascular disease (3/11/25). Observation 3/11/25 at 10:14 A.M., showed there was no EBP sign or PPE on the door or around it. The resident was in bed and there was a bandage on his/her right ankle (undated) and the resident had a dressing on his upper left arm that was dated 2/26/25 (IV access area). There was an IV pole beside his bed but there was no bag. At 10:17 A.M., Certified Nursing Assistant (CNA) D came in to check on the resident. He/She was not wearing any PPE. He/She adjusted the resident's position in bed, rolled the resident to the side to check him/her for incontinence, straightened the linens and bed pad. He/She then gathered the resident's trash and soiled linen and left the room. During an interview on 3/11/25 at 10:21 A.M. CNA D said: -The resident was on an IV for an infection in his/her wound. -He/She was not sure how often the nurse changed the dressing on the resident. -He/She did not always work with the resident. Observation on 3/12/25 at 2:03 P.M., showed there was no EBP sign on the door and no PPE for staff to use when providing care to the resident. The resident was in his/her room in bed. The resident's right ankle was wrapped with dressing dated 3/12/25. The resident no longer had a dressing on his/her arm where the IV access was. Observation and interview on 3/13/25 at 9:42 A.M., showed there was no EBP sign on the resident's door nor was there PPE for staff to use when providing direct care to the resident. The resident was laying down in his bed and the dressing was on his/her right foot. At 9:45 A.M., CNA E went to the resident's room and placed a EBP sign on the resident's door and began hanging a rack with PPE supplies on the door. CNA E said: -He/She had just received the updated wound report and went to place this on the resident's door. -The resident has had a wound, but there was no EBP sign and PPE on the resident's door until now. -He/She said they were to put the signage and PPE on the door whenever a resident had a wound, ostomy (any artificial opening in the body), IV or infection and staff were to put PPE on whenever they interacted with the resident. -He/She did not know why the resident had not had an EBP sign on the door or PPE available prior to today. Observation and interview on 3/13/25 at 9:47 A.M., showed CNA D went into the resident's room as CNA E was hanging the EBP sign and PPE on the resident's door. CNA D did not put on a gown or gloves before or upon entering the resident's room and checked on the resident. He/She took a clean cloth and wiped the resident's face then gathered his/her trash and sanitized his/her hands before leaving the resident's room. CNA D said: -He/She was unaware that the resident was supposed to be on EBP and the resident did not have a sign on the door or PPE prior to just now. -Those residents who were on EBP had signs on the door and PPE so the nursing staff knew they needed to put on gowns and gloves when providing care and interacting with the resident. -No one had communicated that the resident should have been on EBP since he/she had a wound. -The resident has had the wound on his/her foot for a couple weeks and he also had the IV, but it was not communicated that he/she was also on EBP, so he/she provided cares to the resident as he/she normally would without putting on PPE. -Usually if a resident had a wound or any openings on the body, they were supposed to wear PPE. -He/She had just transferred the resident into bed so that the nurse could do his/her wound care but he/she had not worn a gown or gloves. -Now that the resident has the EBP sign and PPE he/she would put the PPE on upon entering the resident's room. During an interview on 3/13/25 at 1:06 P.M., Certified Medication Technician (CMT) A said: -EBP signs are on the doors with the PPE for any resident with any open orifices or wounds. -They are supposed to put on PPE if they are going in to provide care to the resident. -The resident has had wounds for a while on his/her toes and on his/her foot that have been getting treated daily. -He/She had not seen nursing staff wearing PPE when providing care to the resident. -The resident probably should have had the EBP sign on the door and PPE available for the staff to wear prior to this week. During an interview on 3/14/25 at 2:26 P.M., the Director of Nursing (DON) said: -Residents on EBP are those residents who have openings, any kind of devices, wounds, catheters, ostomies IV and residents on dialysis. -The protocol is to assess the resident, put up the EBP equipment and sign on the door and they also put the order for EBP on the resident's POS and let the staff know that the resident is on EBP. -Staff has been educated on EBP protocol. -He/She was informed yesterday there was a resident with a wound and the EBP was not in place and should have been. They notified Central Supply who put the EBP in place and put the sign on the door. -Any of the staff can place the EBP sign and PPE for those residents who they have identified. 39469

Based on observation, interview, and record review, the facility failed to obtain a physician order for self-administration of medication at bedside and failed to evaluate and document the ability to self-administer medication for one sample resident (Resident #3) out of 12 sampled residents. The facility census was 137 residents. Review of the facility's policy titled Resident Self-Admin Meds Clinically Appropriate dated August 2020 showed: -If a resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out the responsibility during the care planning process. -For residents who self-administer, the interdisciplinary team verified the resident's ability to self-administer medications by means of skill assessment conducted on a monthly basis or when there was a significant change in condition. -The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage were recorded in the resident's medical record on the care plan for each medication authorized for self-administration, the label would contain a notation that it may be self-administered. -If the resident demonstrated the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage would be conducted. -When the interdisciplinary team determined that the bedside or in-room storage of medications would be a safety risk to other residents, the medications of the residents permitted to self-administer would be stored in the central medication cart or medication room. 1. Review of Resident #3's face sheet showed he/she readmitted to the facility on [DATE] with the following diagnoses: -Insomnia (persistent problems falling and staying asleep) Due to Other Mental Disorder. -Scoliosis (abnormal lateral curvature of the spine). -Spondylosis (a general term for age-related wear and tear of the spinal discs). Review of the resident's Prospective Payment System (PPS) five-day Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) assessment dated [DATE] showed the resident was cognitively intact. Review of the resident's care plan dated 12/24/24 showed: -No focus or intervention related to self-administration of medications. -He/She received pain medications. Review of the resident's Physician Order Sheet dated January 2025 showed: -No order for the resident to be able to self-administer any medication. -An order for Melatonin (a sleep supplement) tablet three milligrams (mg), give two tablets by mouth at bedtime for Insomnia. -An order for Tylenol (Acetaminophen- used to treat pain and reduce fevers) tablet 325 mg, give two tablets by mouth every six hours as needed for pain. Observation on 1/9/25 at 10:56 A.M. of the resident's room showed: -A bottle of Melatonin 10 mg. -An empty bottle of Extra Strength Tylenol 500 mg. -Both bottles were in the bottom drawer of his/her nightstand. During an interview on 1/9/25 at 10:56 A.M. the resident said: -He/She thought a staff person came around and had him/her sign something related to his/her medications, but he/she was unsure of what it was. -The staff were not aware that he/she had medication stored in his/her room. -His/Her family gave him/her the medication. -He/She had taken the last of his/her Tylenol that day. During an interview on 1/9/25 at 12:27 P.M. Certified Medication Technician (CMT) A said: -He/She had previously found medications at the resident's bedside. -The staff had found pill bottles in his/her room previously and removed them. -The resident did not have an order to self-administer medications. -He/She did not think that the resident had any medications in his/her room at that point in time. -The resident had an order for Tylenol 325 mg, take two for a total of 650 mg, as needed for pain. -He/She was unsure about the resident's dosage of Melatonin. -He/She had never seen the resident's family member before, so he/she was unsure if the he/she had brought medications to the resident in the past. -The resident should not have any medications at his/her bedside or stored in his/her room. -An assessment needed to be completed by the nurses and an order needed to be obtained in order for residents to keep medications at their bedside. -He/She did not think the resident would qualify as a candidate to have medications stored in his/her room. During an interview on 1/9/25 at 12:50 P.M. the Director of Nursing (DON) said: -The resident did not have a current order for the resident to keep any medications at bedside. -The resident did not have a current assessment for the resident to keep medication at bedside. -The resident should not have any medication stored in his/her room. -He/She was unaware that the resident had medications in his/her room until he/she had only just been told about them. During an interview on 1/9/25 at 1:33 P.M. the resident said: -He/She had taken the Tylenol that was in his/her room at least two times a day for the pain in his/her back. -He/She had taken two tablets of his/her Melatonin and what the facility gave him/her equaling 26 mg of Melatonin at night, every night since she has had the bottle of the Melatonin in his/her room. -He/She had been given the bottles of medication after he/she had gotten back from the hospital on [DATE]. During an interview on 1/9/25 at 1:38 A.M. Licensed Practical Nurse (LPN) A said: -The resident was not allowed to keep any medication at his/her bedside. -The resident would need to have a doctor's order to have medication stored at his/her bedside. -He/She was unsure if the resident had any medication stored in his/her room at that point in time. -He/She was unaware that medications had been taken out of the resident's room previously. -He/She was unsure of how the resident could have received the bottles of medication to keep in his/her room. -He/She was unaware that the resident had been giving himself/herself extra doses of Tylenol and Melatonin. -The bottles of medication needed to be taken out of the resident's room. During an interview on 1/9/25 at 1:48 P.M. the DON said: -Residents who wanted to self-administer any medication needed to have an assessment completed. -The nurses were responsible for completing the self-administration assessment. -There is a form in the facility's electronic charting system that nurses can use to complete the assessment. -Residents were able to ask for an assessment to be completed if they wanted to keep any medications at their bedside. -He/She was responsible for ensuring the completion of self-administration assessments. -The resident had not expressed that he/she wanted to have any medications kept at his/her bedside. -If the resident had expressed that he/she wanted to keep medications at his/her bedside, then the facility would have informed the physician and completed an assessment. -He/She did not think the resident would be a candidate to keep medications at his/her bedside due to being non-compliant with other policies in the facility. During an interview on 1/10/25 at 12:17 P.M. the Psychiatric Nurse Practitioner (NP) said: -It was not appropriate for the resident to have medication at his/her bedside. -He/She expected the staff to watch the residents take all medication. -No resident should have medications at their bedside unless there is an assessment. -He/She did not believe that the facility let residents keep medications at their bedside. MO00247016

Based on interview, and record review, the facility failed to ensure the Transportation Driver (TD) A followed protocol related to safely securing a resident's wheelchair according to facility policy and training, affecting one sampled resident (Resident #3), who fell backwards in his/her wheelchair during transport, out of seven sampled residents. The facility census was 134 residents. On 11/8/24, the Administrator was notified of the past noncompliance which took place on 10/18/24. TD A reported the accident to his/her supervisor who provided immediate training. Drivers received documented education on 10/21/24 related to wheelchair safety during transport. The facility did an investigation and found TD A did not follow facility policy, protocols, and training related to securing the resident's wheelchair and the employee was disciplined. The deficiency was corrected on 10/21/24. Review of the facility's Vehicle Safety Program, undated showed the Administrator was responsible for ensuring the training of drivers prior to authorized driving privileges, including the proper use of restraint systems and wheelchair lifts. Review of the facility's Vehicle and Driver Safety policy, undated, showed: -All drivers and passengers operating or riding in company vehicles must wear seat belts. -All drivers must ensure that proper vehicle restraint system is used for all passengers in wheelchairs. -Report any mechanical or repair needs immediately to the Administrator. 1. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Stroke -Amputation below his/her left knee. -Amputation above his/her right knee. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 9/26/24 showed the resident: -Was cognitively intact. -Had lower extremity impairments on both sides. -Used a manual wheelchair. Review of the resident's internal Incident Investigation, dated 10/18/24 showed: -A Fall report showing: --The resident stated he/she fell on the bus, but he/she didn't acquire any new injuries. --The nurse performed a full-body asses and gathered vital signs (measures basic body functions including body temperature, heart rate, respiration rate and blood pressure). Resident has full range of motion (ROM) and no new skin issues. No injuries. Resident has chronic pain and no acute pain due to the fall. --No injuries observed at the time of the fall. --Pain level was zero on a scale of zero to 10, with zero being no pain at all. --The resident was oriented to self, place, time, and situation. --Neurological evaluations (assessments of the resident's mental status, sensory and motor function) were within normal limits. Lower extremities were generally weak. --A progress note, written on 10/21/24 showed the resident had a fall during transport with his/her wheelchair tipping backwards. Resident assessment was completed with no new injuries. Resident has chronic pain with no acute pain due to fall. Assessment of transportation van completed with statement obtained from bus driver. --It was identified that the resident was not appropriately strapped in the vehicle per protocol. Education and training to both van drivers. Checklist in place for transportation to utilize prior to daily transport. Resident has pain medication available. During an interview on 10/31/24 at 9:50 A.M. the resident's Nurse Practitioner (NP) said: -He/She was notified when the resident fell backwards hitting the floor of the facility van when it was being driven. -He/She visited the resident most recently on 10/24/24 and found he/she had no injuries from the fall. Review of a statement, undated, by the Transportation Coordinator (TC) showed: -On 10/18/24 he/she received a call from TD A stating he/she was turning and hit a bump, causing the resident to fall backwards. TD A stated he/she only used three harness straps when four are provided. -He/She re-educated TD A on how to properly use the harness straps and how to use the lift safety features. During an interview on 11/8/24 at 10:08 A.M. the TC said: -The resident had a manual wheelchair which should have been secured with four belt locks. Two attached to the right and left sides of the front of the wheelchair and two attach to the right and left sides of the back of the wheelchair. There was also a cross body seat belt. -TD A normally drove the facility bus, but the bus wheelchair lift was messed up on 10/18/24 so he/she had to drive the van that day. The bus lift was currently fixed. -He/She got a call from TD A on 10/18/24 saying he/she was transporting the resident and the resident's wheelchair fell backwards. TD A said he/she had gotten a call to pick up another resident that was close to the area. The resident was already in the van. The other resident also uses a wheelchair. TD A tried to make room for the other resident. It took eight belts to secure two wheelchairs, but TD A couldn't find one of the belts and used only three belts to secure the resident's wheelchair instead of four. -He/She alerted the resident's charge nurse of the incident who was ready to assess the resident when he/she arrived back to the facility. There were no injuries reported. -The resident was laughing upon his/her return and acting like his/her regular self. -He/She wasn't aware of any other time a wheelchair had ever fallen over. -He/She ended up finding the eighth wheelchair attachment belt in a bag on the van. -Besides the four wheelchair attachment belts there was also a seat belt that went over each resident being transported in a wheelchair. He/She didn't know if the resident was wearing the seat belt at the time of the accident. Review of a statement dated 10/21/24 by TD A showed: -On 10/18/24 he/she was waiting for the resident to finish his/her appointment when he/she received a call that another resident wasn't feeling well and needed to be picked up early from his/her treatment appointment at a different location. -He/She texted his/her supervisor, TC to inform him/her about the early pick up. -When the resident was done with his/her appointment he/she made room for the second resident he/she was to pick up. The resident's wheelchair was missing the fourth strap. -As he/she was pulling off from a stop sign the resident fell back in his/her wheelchair. He/She pulled over immediately to check on the resident and position it upright. -The resident said he/she was OK and nothing hurt. -He/She moved the resident to a secure position on the vehicle. -He/She immediately headed back to the facility and had informed his/her supervisor so he/she could let nursing know. During an interview on 11/8/24 at 10:55 A.M. TD A said: -He/She normally drove the bus, but also drove the van. -On 11/18/24 he/she took the van and was waiting on the resident to get out of his/her appointment when he/she got a call that another resident was sick and needed to be picked up early from his/her appointment at a center nearby. When the resident came out to the van he/she positioned his/her wheelchair closer to the front of the van to make room for the resident he/she was about to pick up who also used a wheelchair. -He/She noticed there were only seven wheelchair belt straps when there should have been eight to secure the two wheelchairs. He/She used only three of the four wheelchair straps to secure the resident's wheelchair, assuming three straps would be sufficient to secure the resident's wheelchair. He/She tightened all three straps as normal. -He/She had always had the correct number of wheelchair straps to secure wheelchair before 10/18/24. -He/She drove out of the office parking lot and soon came to a stop sign. -When he/she took off from the stop sign the resident fell backwards. All three straps were still in place. He/She assumed the wheelchair wiggled a little bit and loosened the front strap. He/She didn't realize the eighth strap was in the van at the time and didn't know there were full body seatbelts he/she was to use. -TD B trained him/her on how to use equipment. The same type of wheelchair belt straps were used in both the van and bus to secure wheelchairs. TD B had never told him/her about the full body seat belt straps that were in both vehicles. At the time he/she first started his/her supervisor was the Activities Director. He/She never showed him/her the full body seat belts either. -After the resident fell backwards he/she moved the resident's wheelchair back and secured it with four straps. -He/She called the facility and brought the resident back without picking up the other resident. During an interview on 11/8/24 at 11:28 A.M. the resident said: -The incident in the van happened on October 18th. -Following a doctor's appointment TD A put him/her on the van and said he/she was going to pick up another resident. -TD A pushed his/her wheelchair up towards the front of the van. -They were heading west and came to a stop sign. When the driver took off there was a slight hill. The next thing he/she knew he/she fell backwards. The whole wheelchair went backwards. -TD A pulled over, opened the back door, and put him/her in an upright position in his/her wheelchair. -He/She thought TD A had put the straps on his/her wheelchair. He/She was eating a bag of chips at the time and didn't pay much attention. -TD A positioned his/her wheelchair at the back of the van after the fall and said he/she would take him/her back to the facility. -His/Her head, neck and shoulders hurt a few days after the fall and he/she went to the emergency room (ER). During an interview on 11/8/24 at 12:55 P.M. the Director of Nursing (DON) said: -The resident went to the ER on his/her own. -The hospital hadn't sent any reports of the ER visit. -Had there been any negative findings the hospital would have contacted them. -The resident was out of the facility on leave and had been for several days and he/she wasn't sure if the resident was coming back. They were trying to contact the resident, but he/she wouldn't answer their calls. -They were unable to request the resident's medical record because they didn't know if the resident would be returning to the facility. During an interview on 11/8/24 at 1:17 P.M. Licensed Practical Nurse (LPN) A said: -He/She assessed the resident when he/she returned from his/her appointment on 10/18/24. The resident said he/she was not in pain at the time and he/she started neurological checks. The resident stated he/she never hit his/her head and didn't complaint of any pain. -The resident called the paramedics himself/herself several days after the fall. The paramedics asked if he/she was in pain and the resident said he/she wasn't in pain, but wanted paperwork related to the fall. The resident never complained of head, neck, shoulder, or any other pain prior to calling the paramedics. -The resident never complained of new pain to him/her after the fall in the van. As long as he/she had a cigarette he/she was alright. During an interview on 11/8/24 at 1:28 P.M. the Activity Director said: -He/She educated both TD A and TD B on securing wheelchairs in the van upon hire. Both drivers also had training several months ago at the same time from the Corporate HR person on van safety. -There were four straps used to secure each wheelchair which had to be attached to the wheelchair itself, not on the wheels of the wheelchair. All four straps should always be used. Straps were attached to the right and left front of the wheelchair and the left and right back of the chair. Each strap had a lever in which the strap could be tightened. There were also seat belts that went over the resident's body as well when they are riding in a wheelchair. Both drivers were educated on all these safety precautions. -They also went to the van and both drivers were asked to do a return demonstration of how to attach the wheelchair straps and seat belts. The Corporate HR person showed them how there could be movement with the wheelchair if the straps were attached to the wheels instead of the wheelchair itself. He/She also showed them how to tighten the wheelchair straps and to always put the wheelchair breaks on during transport. -The seat belt prevents residents from falling forward, but didn't prevent the wheelchairs from falling backward. The four wheelchair floor straps prevented the wheelchair from falling backwards as well as from falling forwards. -A wheelchair shouldn't fall backwards if it was strapped in correctly. During an interview on 11/8/24 at 1:50 P.M. the DON said: -There were four straps and a wheelchair seat belt that were used to secure each wheelchair during transport. -Drivers were expected to follow the policy/procedure and training's related to properly securing wheelchairs. MO00244138

Based on interview and record review, the facility failed to ensure controlled substances (is generally a drug or chemical whose manufacture, possession and use is regulated by a government, such as illicitly used drugs or prescription medications that are designated by law) were counted during change of shift or when keys were transferred to another responsible party resulting in a total of 60 tablets Oxycodone Immediate Release (a narcotic pain medication) 30 milligram (mg) that were not accounted for for one sampled resident (Resident #3) out of the three sampled residents. The facility census was 126 residents. On 9/20/23, the Administrator was notified of the past noncompliance which took place on 9/1/23. Licensed Practical Nurse (LPN) reported unaccounted for controlled substances to Human Resources (HR) on 9/1/23. HR then informed the Director of Nursing (DON). DON and the Administrator completed a full in house audit of controlled substances on 9/1/23. Education related to controlled substances count was provided to facility staff on 9/1/23. The problems with controlled substances documentation were identified with Resident #3. The deficiency was corrected on 9/2/23. Record review of the Facility's Policy titled Storage of Controlled Substances with a revision date of October 2020 showed: -The DON, in collaboration with the consultant pharmacist, maintained the facility's compliance with federal and state laws and regulations in the handling of controlled substances. -Only authorized licensed nursing and pharmacy personnel would have access to controlled substances. -The medication nurse on duty maintained possession of the key to controlled substance storage areas. -At each shift change, or when keys are transferred, a physical inventory of controlled substances, including refrigerated items, was conducted by two licensed personnel and it was documented. -Any discrepancy in the controlled substance counts would be reported to the Director of Nursing immediately and/or in accordance with the facility policy. 1. Review Resident #3's Admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Nondisplaced fracture (one in which the bone cracks or breaks but retains its proper alignment) of shaft of left clavicle (collarbone), subsequent encounter for fracture (broken bone) with routine healing. -Wedge compression fracture (the front of the vertebral body collapses but the back does not, meaning that the bone assumes a wedge shape) of T11-T12 (vertebra of the chest numbered 1-12) vertebra, subsequent encounter for fracture with routine healing. Review of the resident's undated facility pharmacy services report showed: -One card of Oxycodone 30 mg was received by the facility on 9/1/23. -One card of Oxycodone 20 mg was received by the facility on 9/1/23. Review of Verification of Controlled Substances for September 2023 for the North hall showed: -Three sections, one for each shift. Each section had columns for date, shift time, +/- card, card count, on-coming nurse signature, and off-going nurse signature. -On 9/1/23 no shift time documented for two shifts. -On 9/1/23 number of cards was not listed for two shifts. -On 9/1/23 for first shift only one count of controlled substances was performed. -No documentation two cards of Oxycodone was received during the shift for Resident #3. Review of facility investigation dated 9/1/23 showed: -Initial Report Form showed: --A staff member reported to Human Resources (HR) that he/she discovered two cards of Oxycotin (a narcotic pain medication) were missing from the 100/200 medication cart. --The nurse did not report the missing medications to the DON or the Administrator. --Medications were delivered by the pharmacy at 1:00 A.M. and placed in the medication cart by the night shift nurse. --The day shift nurse accepted the medication cart without counting the narcotics. --The day shift nurse placed a narcotic order to the pharmacy alleging the Medical Director had given her the order. The Medical Director denied giving the order. --Law Enforcement was contacted. --Staff were suspended pending facility investigation. -Certified Medication Technician (CMT) A's written statement showed: --He/she counted the medication cart with the night nurse (LPN) A. --The day nurse (LPN B) came to the medication cart and was asked if he/she would like to recount the medication cart and he/she said no. -LPN A's written statement showed: --He/she received a delivery from the pharmacy of approximately six blue bags. --He/she signed the pharmacy copy of the medications and returned it to the driver. --There were two cards of narcotics for Resident #3, he/she placed them in medication cart. --He/she counted the medication cart with the CMT and left the facility. -LPN B's written statement showed: --LPN A was the night nurse and had already left for the day and had counted the medication cart with CMT A (prior to his/her arrival for the day shift). --He/she called the pharmacy to reorder medications that needed to be refilled. --The pharmacy said the medications that he/she requested had been delivered the night before. --There were no cards and no paper for the medications requested. --He/she went to HR to report the missing medications. --HR told him/her to call the pharmacy and reorder the missing medications. -Pharmacy delivery records of narcotics from 1/1/23 thru 9/1/23 including the Oxycodone 20 /mg and Oxycodone 30 mg for Resident #3 was delivered on 9/1/23 and signed for by LPN /A. Review of facility in-services performed on 9/1/23 showed: -Medication cart management. -Counting of narcotics cards. -Narcotic cards verification. During an interview on 9/20/23 at 9:00 A.M., LPN B said: -He/she had been on vacation the past week. -He/she was running late on 9/1/23, when he/she arrived at the facility he/she saw a LPN A and CMT A counting the controlled substances. -He/she was asked if he/she wanted to recount the controlled substances; he/she said no and took the controlled substances keys. -He/she discovered controlled substances were missing and went to HR office. -He/she informed the HR person that he/she had the sign out sheet for narcotic cards, but did not have the corresponding card for the sign out sheets and that he/she had two cards of narcotics that were missing. -He/she did not notify the DON or Administrator because he/she felt that neither person would have done anything about it. -He/she called the pharmacy to reorder the missing medication. -He/she seemed to be the only person who ordered the controlled medications. -He/she denied taking any controlled substances. During an interview on 9/20/23 at 9:10 A.M., LPN A said: -He/she accepted the narcotics from the pharmacy on 9/1/23. -He/she signed for the narcotics but did not verify the narcotics in the pharmacy bag. -He/she locked the bag in the medication cart. -Then about 5:30 A.M., he/she opened the bag and put the sign out cards in the narcotic book and put the narcotic cards in the card. -He/she did not update the Narcotic Count Sheet to reflect the addition of the two cards for Resident #3, just put the narcotic sign sheets in the book. -The two additional cards would have been reflected in the count due to the card would match the sign out sheet. -LPN B was not at the facility at shift change and time to count the medication, so he/she counted the controlled substances with CMT A. -All narcotics were accounted for at the time of the count. -Approximately 6:30 A.M., as CMT A and him/her were finishing the count, LPN B arrived. -LPN B refused to recount the controlled substances and just took the keys for the controlled substances. -He/she knew you were supposed to count the controlled substances anytime you took possession of controlled substances. -He/she denied taking any controlled substances. -He/she was unsure how the controlled substances came up missing. During an interview on 9/20/23 at 9:58 A.M., CMT A said: -LPN A was the off going nurse, and he/she was the on-coming CMT. -LPN B was not at the facility at the time shift change was to have occurred. -He/she counted the controlled substances with LPN A. -All the controlled substances were accounted for and no controlled substances were missing. -The narcotic count included the two new cards that were added and was reflected in the narcotic count. -The night nurse did not add the new cards to the +/- column of the narcotic count sheet, but the sign out forms were in the book and the medications were accounted for. -LPN B arrived at the facility as the count was being finished. -He/she asked LPN B if he/she wanted to recount the controlled substances, and LPN B said no he/she saw the count was done and just took the keys. -He/she knew that anytime you took possession the controlled substances a count was supposed to be performed to ensure all controlled substances were accounted for. -He/she denied taking any of the controlled substances. -He/she was unsure how the controlled substances came up missing. During an interview on 9/20/23 at 10:08 A.M., HR staff person said: -LPN B came to his/her office and reported that controlled substances were missing. -He/she was unsure of the time LPN B came to his/her office, but it was still morning. -He/she asked why LPN B did not go to the DON or the Administrator. -LPN B told him/her that if anything was going to be done that staff should go to him/her because he/she made sure things got done. -Once LPN B left his/her office he/she immediately went to the DON to report this. During an interview on 9/20/23 at 10:32 A.M., LPN C said: -Staff were were supposed to add or subtract any new cards to the count sheet then count all the cards to make sure the numbers matched. -Then staff would count the cards and verify with sign out sheets to ensure the each card had the correct number of pills per cards. -On 9/1/23 he/she received an in-service on controlled substance count as to when it was to be done and how to do it. -Controlled substances were to be counted at the beginning of the shift and end of shift with another nurse or CMT. During an interview on 9/20/23 at 10:37 A.M., Registered Nurse (RN) A said: -Staff were were supposed to add or subtract any new cards to the count sheet then count all the cards to make sure the numbers matched. -Then staff would count the cards and verify with sign out sheets to ensure the each card had the correct number of pills per cards along with the correct resident. -Controlled substances were to be counted at the beginning and end of the shift with another nurse, or whoever was taking possession of the medication cart. -He/She had received an in-service on 9/1/23 about controlled substances count. During an interview on 9/20/23 at 10:39 A.M., CMT B said: -Controlled substances were to be counted at the beginning and end of the shift, and anytime you gave your keys to someone to watch the medications cart. -He/she had received an in-service on controlled substances count. During an interview on 9/20/23 at 10:50 A.M., the acting DON said: -The facility immediately performed an inventory of all the controlled substances to discover what was missing. -The facility interviewed the nurses who were responsible for the North medication cart where the missing controlled substances were discovered. -The facility called the police and reported the missing controlled substances to them. -The facility also notified the Drug Enforcement Agency (DEA) of the missing medication. -Education was started for all nurses and CMT's on controlled substances count. -It was his/her expectation that staff would verify the medications delivered when pharmacy delivered the medications before accepting and signing the delivery receipt form. -It was his/her expectation that the nurse who received the medications would immediately take the medications to the medication cart and put the medications up, and to update the narcotic count sheet adding any new cards in the +/- column of the count sheet. -It was his/her expectation that the nurses would count the narcotics before his/her shift and at the end of his/shift with the on-coming off going nurse. -It was his/her expectation that the nurses would first count all the cards to ensure the numbers matched, and then count each card with residents name, medication and number of pills per each sign out sheet and medication card to ensure all the numbers matched. MO00223910 - -

Based on observation, interview, and record review, the facility failed to put measures in place to prevent further injury following an incident in which one sampled resident (Resident #120) out of 27 sampled residents knocked over a large, heavy metal activity cabinet, resulting in the resident sustaining a fractured wrist. The facility also failed to complete a smoking assessment and care plan for one sampled resident (Resident #15) who smoked cigarettes to ensure a safe smoking plan out of 27 sampled residents. The facility census was 125 residents. Review of the facility's Accidents and Incidents - Investigating and Reporting policy statement, undated showed: -All accidents and incidents involving residents, employees, visitors, vendors, etc, occurring on the premises shall be investigated and reported to the administrator. -The nurse supervisor/charge nurse or the department director or supervisor shall promptly initiate and document investigation of accidents and incidents. -The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. -The director of nursing services shall ensure the administrator receives a copy of the Report of Incident/Accident form for each occurrence. -Incident/Accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of the facility policy Care Planning revised 6/2020 showed: -A comprehensive person-centered care plan would be developed for every resident. -Changes may be made to the care plan on an on-going basis. Record review of the facility's undated Alzheimer's Special Care Services Disclosure showed the program philosophy as: The Special Care Program team will strive towards attaining the highest physical, mental, social, and spiritual well-being of the residents while also providing a safe and secure environment for individuals requiring cares and services individualized to the needs of each person and those of the unit's residents as a whole. 1. Review of Resident #120's Face sheet showed the resident was admitted to the facility on [DATE] . The resident's diagnoses included: -Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Psychotic disorder (a mental disorder in which there is a severe loss of contact with reality) with hallucinations (sensory perceptions that do not result from an external stimulus and that occurs in the waking state). -Displaced comminuted fracture (bone broken in a least two places) of shaft of radius (slightly thicker of two forearm bones), right arm onset 4/6/23. Review of the resident's internal Fall Investigation, dated 4/5/23 at 10:15 A.M. showed: -Incident Description: The Certified Nurse Assistant (CNA) stated he/she was in a resident's room when he/she heard a boom. He/She came out into the hallway and the resident (Resident #120) was sitting with his/her back against the wall and noticed the activity shed (large metal cabinet) was lying on the floor about a foot away from the resident. The CNA immediately got the licensed nurse. Upon arrival the resident was noted to be holding his/her foot and wrist. No obvious injury was noted. The resident was unable to give a description. -Immediate Action Taken: The resident was assessed head to toe. Range of motion (ROM - the range on which a joint can move) times four extremities with no problem. Assisted to a standing position by two nursing staff. Walking with no issues. Resident complained of right foot and wrist pain. The physician was notified. Orders were obtained for a stat (immediate) x-ray to the right foot to rule out injury. The resident was educated on falls and safety precautions and a message was left for the resident's responsible party and the Director of Nursing (DON) was notified. The resident was not taken to the hospital immediately following the incident. -Mental Status: The resident was forgetful, oriented to self, impulsive, and lacked safety awareness. -Injuries: No injuries were noted post incident. -Predisposing Environmental Factors: Furniture. -Predisposing Physiological Factors: Confusion. -Predisposing Situational Factors: admitted within last 72 hours and wandering. -Witnesses: No witnesses found. -There were no recommendations or follow-up plans showing what staff were to do to prevent similar accidents in the future. Review of the resident's nursing note dated 4/5/23 at 10:37 P.M. showed the resident complained of right wrist pain after recent fall. New orders received for x-ray. Review of the resident's radiology report, dated 4/6/23 showed a comminuted fracture (bone that is broken in two or more places) involving the distal radius (portion of the radius bone closest to the thumb) with six millimeter (mm) displacement. There is associated soft tissue swelling and osteopenia (low bone mass). Review of the resident's Fall Care Plan, initiated 4/6/23 showed: -The resident had a fall with a major injury to his/her right distal radius with osteopenia. -Details of the fall showed the CNA heard a boom. The CNA saw the resident in the hallway with his/her back against the wall. The activity shed was lying on the floor about a foot from the resident. The CNA got the nurse and the resident was noted to be holding his/her head and foot (Note: the fall incident note showed the resident was holding his/her foot and wrist). No obvious injury was noted. Resident assessed head to toe. ROM times four with no problems. Resident complained of right foot pain. -Interventions initiated 4/6/23 included: --Order for stat x-ray of right foot to rule out injury. --Resident educated on fall and safety precautions. --Neurological checks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs). --Promote activities that promote exercise and strength building when possible. -Note: The care plan did not mention if the activity cabinet was removed or secured or if other items on the unit might need to be secured for the resident's safety. The care plan and the resident's other care plans did not mention if the resident was observed to have behaviors and/or cognitive issues which might contribute to similar future accidents. Review of the resident's nursing note written 4/6/23 at 4:56 P.M. showed the resident came back from the medical center with a cast (type of cast is not identified) and a splint (holds bones or injured areas still and can be removed) and a sling (supports an injured area). The resident was stable and complained of no pain at that time. The resident was at the table eating dinner with some feeding assistance due to issues with immobilization. Review of the resident's nursing notes dated 4/8/23 showed: -A note written at 4:54 P.M. showed the resident was unable to keep splint on broken arm. He/She kept taking it off. -The physician gave orders to send to the emergency room (ER) and see if they will put on a different cast considering he/she has 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). Paramedics took resident to the hospital ER. Review of nursing notes from 4/6/23 through 7/11/23 showed there were no notes showing any interventions or actions taken to prevent similar accidents in the future. Review of the resident's Admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 4/11/23 showed the resident: -Was severely cognitively impaired. -Wandered four to six days during the past seven. -Had one fall since his/her admission with a major injury. -Was diagnosed with having a fracture. During an interview on 7/18/23 at 10:04 A.M., Family Member A said: -The resident had an accident right after his/her admission. -He/She had been told the following by the facility: --The resident was trying to open a locked cabinet. When the resident pulled on the cabinet it fell and staff heard the noise. --He/She was told the resident fell backward or moved away from the cabinet and might have put his/her hands out to break the fall. The fall was unwitnessed. --The ER put the resident in a fiberglass cast or brace, but the resident kept talking it off so an orthopedic specialist had to put the resident in a regular cast. During an interview on 7/19/23 at 2:29 P.M., CNA B said: -He/She was the CNA who was on the unit when the activity cabinet fell in April. (At this point CNA B pointed to a metal cabinet in the resident's hallway and said it was the cabinet that the resident had tipped over.) -He/She hadn't seen the accident, but heard a loud noise when the cabinet fell . It landed with the cabinet doors facing downward on the floor. -The cabinet was so heavy that he/she and the nurse were barely able to set it back upright. -There was nothing he/she was made aware of staff needed to do to prevent the resident from further accidents except to redirect him/her. -The resident wanders about the unit. Staff were just supposed to redirect the resident if he/she goes into other resident rooms or wanders unsafely. -He/She didn't know if the cabinet had been secured to prevent further injury. Observation on 7/19/23 at 2:30 P.M. of the cabinet in the resident's hallway showed: -It was made of metal and measured approximately five to five and one-half feet high, three feet wide and one to one and one-half feet deep. -The cabinet doors were locked. -The surveyor placed a hand on the top of the cabinet and was able to rock it forward. It was heavy when attempting to lift the cabinet. -The cabinet had not been secured to the wall or in any other manner. During an interview on 7/20/23 at 3:43 P.M., CNA F said: -He/She had worked at the facility for about a month, but had not heard that the resident knocked the activity cabinet down or what staff were to do to keep the resident from getting hurt from similar accidents. -The resident wandered around the unit and sometimes would go into other resident rooms. Staff are just supposed to watch for that and redirect him/her. During an interview on 7/21/23 at 9:10 A.M., the resident's physician said: -He/She was aware of the accident in which the resident sustained a broken arm when the cabinet fell . -The cabinet had to be secured on the unit to ensure the resident's and other residents' safety; otherwise, it could fall on residents. -The facility was responsible for ensuring the residents were safe. During an interview on 7/21/23 at 9:32 A.M., Assistant Director of Nursing (ADON) B said: -The Interdisciplinary Team (IDT) discussed the accident with the cabinet after the incident. He/She couldn't recall if they discussed securing the cabinet or removing it from the unit. Staff were supposed to monitor and keep a close eye on the resident to prevent further accidents. -The cabinet should have either been removed from the unit if not needed or secured to the wall. He/She was not sure if a work order had been submitted for maintenance to do that. During an interview on 7/21/23 at 10:33 A.M. the Administrator said: -He/She and the Director of Nursing (DON) look at all falls with injuries. Those with injuries of unknown origin are reported to the State. -The falls and injuries are discussed in morning clinical meetings to develop plans and interventions to prevent further falls and accidents. -Interventions should be appropriate for the residents. -If a resident is on a locked unit, their dementia would be severe and education might not be an appropriate or effective intervention for them. -Falls and accidents are investigated and the investigation should show what should be done going forward to prevent further accidents and injuries. -If a resident is climbing on or unsafely touching furniture the furniture should either be secured or removed immediately. -The cabinet in the resident's hall was supposed to have been secured by the Maintenance Director who left the facility three weeks ago. The previous Maintenance Director reported to him/her the cabinet had been secured. During an interview on 7/21/23 at 1:10 P.M., the Director of Nursing (DON) said: -The accident involving the activity cabinet was discussed by the IDT in April, 2023. At the time they discussed maintenance would secure the cabinet to the wall on the unit. -His/Her expectation was the maintenance work would have been done immediately to secure the cabinet. -The Administrator is the main person responsible for environmental audits to make sure the environment is safe. -Staff were to monitor the resident's wandering closely and provide redirection as needed. -The facility had a Quality Assurance and Performance Improvement (QAPI) meeting on 7/20/23 and discussed securing the cabinet at the time. -He/She knew the cabinet had been secured on 7/20/23 because he/she checked that it had been completed himself/herself. 2. A smoking policy was requested from the facility but not received. Review of Resident #15's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 3/1/23 showed the resident was cognitively intact. Review of the resident's Safe Smoking Evaluation dated 5/9/23 showed the resident did not smoke. Record review of the resident's care plan revised on 5/9/23 showed the resident was a former smoker. Observation on 7/17/23 at 10:30 A.M. showed the resident in his/her wheelchair in the front outside area smoking a cigarette attended by staff and other residents. Observation on 7/18/23 at 9:25 A.M. showed the resident in his/her wheelchair in the front outside area smoking a cigarette attended by staff and other residents. During an interview on 7/19/23 at 9:38 A.M. the resident said he/she did smoke cigarettes outside and was always attended by staff. During an interview on 7/20/23 at 11:55 A.M. CNA C said: -The resident went through periods when he/she stayed in his/her room and did not smoke cigarettes outside. -The resident has been smoking outside for the last two months. During an interview on 7/20/23 at 2:16 P.M. Licensed Practical Nurse (LPN) A said: -When a resident was smoking outside, they had to be attended by the staff for safety. -Nurses did not complete smoking assessments or the care plans. -The smoking assessments were completed to ensure any risks for the resident. -The ADONs would complete the smoking assessments and the care plans. -The resident was a smoker and would smoke outside attended by staff members. During an interview on 7/21/23 at 8:41 A.M. the MDS Coordinator said: -He/She was responsible for care planning for the residents. -Nurses can update care plans and sometimes they update care plans. -Sometimes the ADONs updated the care plans based on physician's orders. -He/She reviewed the care plans quarterly to update and ensure they are complete and reflect current condition of the resident. -The resident should have a smoking care plan. During an interview on 7/21/23 at 9:00 A.M. Assistant Director of Nursing (ADON) B said: -He/She was responsible for completing the smoking assessments. -The MDS Coordinator was responsible for care planning. -He/She did not update the care plans very much. -The resident did not smoke cigarettes all the time. -He/She would occasionally smoke. -The smoking assessment should have been updated and a care plan created since the resident was smoking. During an interview on 7/21/23 at 1:10 P.M. the Director of Nursing (DON) said: -The ADONs completed the smoking assessments for the residents. -The MDS Coordinator was responsible for updating the care plans for the residents. -The resident should have a smoking assessment showing they smoked cigarettes and a care plan for smoking. 26996

Based on observation, interview, and record review, the facility failed to monitor weights upon admission for one sampled resident (Resident #10) who had a significant weight loss of 28 pounds, a 13.96% loss in 3 1/2 weeks, to notify the resident's physician of the Registered Dietician's (RD) recommendations in a timely manner so the recommendations could be implemented before the resident's weight loss became significant, and to have an individualized comprehensive dietary care plan; to monitor and record weights and notify the resident's physician in a timely manner for one sampled resident (Resident #11) with a gradual significant weight loss; and to ensure hydration opportunities and assistance were provided to three sampled residents (Residents #6, #120, and #104) who were dependent upon staff for their hydration needs out of 27 sampled residents. The facility census was 125 residents. Review of the facilities Nutrition/hydration Management policy and procedure, not dated, showed: -Each resident maintains acceptable parameters of nutrition status, such as body weight; -Ongoing assessment, monitoring, evaluation and identifying new instances of unplanned weight loss or gain; -Residents are weighed upon admission and re-admission and then at least weekly for four weeks then monthly if weight is stable; -A comprehensive care plan is developed by the interdisciplinary team that addresses nutrition/hydration and an individualized nutrition/hydration management program based on individualized assessed needs; -The facility is responsible for ensuring timely medical/dietary consultation with unplanned weight loss and if the nutrition/hydration management program is no longer effective; -Residents shall receive assistance with meals in a manner that meets the individual needs of each resident; -Based on clinical judgement licensed nurses would weigh residents as needed based on clinical presentation. 1. Review of Resident #10's Face Sheet showed he/she was admitted to the facility on [DATE], with the following diagnoses: -Alzheimer's Disease (a progressive mental deterioration that can occur due to generalized deterioration of the brain). -Muscle wasting (a weakening, shrinking and loss of muscle caused by disease or lack of use) and atrophy (a wasting away of body tissue) in left and right hand. -Cognitive and communication impairment. -Mild protein-calorie malnutrition (lack of dietary protein and calories). Review of the resident's electronic medical record weights showed: -On 6/29/23 he/she weighed 182 pounds (lbs.). -On 7/20/23 he/she weighed 156.6 lbs. --NOTE: A 13.96% weight loss in less than a month. -There was no documentation by the facility staff of the resident's weight being obtained or monitored weekly upon admission to the facility, Review of the resident's electronic medical record for eating: Self Performance showed he/she was independent with no help or staff set-up for all meals 6/30/23 through 7/19/23. Review of the resident's Admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by the facility staff for care planning) dated 7/1/23 showed he/she: -Was severely cognitively impaired. -Had short term and long term memory loss. -Had severely impaired decision making and inattention. -Needed set-up, supervision, over sight, encouragement and cueing with meals. -Had weight loss of 5% or more in the last month or 10% or more in the last six months. -Was eating 25% or less of meals. Review of the resident's dietary care plan dated 7/3/23 showed: -He/she had nutritional problem or potential nutritional problem and was at risk for malnutrition. -Staff were to provide regular diet. -Registered Dietitian (RD) was to evaluate and make diet change recommendations as needed. -Staff were to alert the RD if consumption is poor for more than 48 hours. -Staff were to monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. -Staff were to offer substitutes as requested or indicated. -He/she was independent with eating after set-up assist. Review of the resident's electronic medical record. Meal Intake showed: -He/she consumed 0-25% of meals on 7/9/23. -He/she consumed 0-25% of meals on 7/10/23. -He/she refused meals on 7/11/23. -He/she consumed 0-25% of meals on 7/14/23. -He/she consumed 0-25% of meals on 7/15/23. -He/she refused meals on 7/16/23. Review of the resident's Nutrition assessment dated [DATE] by RD showed: -Per hospital records he/she had history of 18 pound (9%) weight loss in 4 months. -He/she had in-adequate intake as evidenced by facility intake record and staff report. -RD recommended to add Ensure (a liquid dietary supplement) 8 ounces (oz.) twice a day or 2.0 supplement (a liquid dietary supplement) 120 milliliters (mls) twice a day to aid in weight maintenance due to history of weight loss and current inadequate meal intake. Review of the resident's Medical Director Progress note dated 7/11/23 showed staff were to monitor his/her weights weekly, give multi-vitamin and health shakes as ordered due to weight loss risk. Review of the resident's Physician Order Sheet dated 7/2023 showed there were no physician orders for RD recommended dietary supplements. Observation on 7/20/23 at 11:35 A.M., showed: -There were three staff in the dining room and resident's were eating at the dining tables. -The resident was sitting in the dining room, not at the table, watching television. -He/she was approached by staff and asked resident if he/she wanted to eat and the resident responded Don't come up on me that way! and No I'm not eating! -The staff did not re-approach him/her, did not try to accommodate the resident and set meal up in front of where he/she sat. The staff did not encourage or cue the resident. -He/she did not eat lunch. During an interview on 7/20/23 at 1:32 P.M. the RD said: -All RD recommendations are sent in an email to the facility Administrator, Director of Nursing (DON) and Dietary Manager. -The facility is responsible for following up with the physician with his/her recommendations. -He/she did not know what the facility policies were regarding weight monitoring. -The facility is responsible for developing the individualized comprehensive dietary care plan. -He/she was not made aware by the facility that the resident was not eating and not receiving his/her recommended supplements. During an interview on 7/20/23 at 3:00 P.M. the Nurse Practitioner said: -He/she would expect facility to notify the medical practice if a resident is not eating and/or having weight loss. -He/she would expect the facility to weigh residents on admission and weekly for four weeks. -He/she was not aware if a Practitioner was notified of the resident's poor intake, weight loss and RD recommendations. -His/her expectation is that facility would document when a provider is notified. -The facility RD recommendations are placed in the physicians folder at the facility to be addressed and returned to the DON. Observation on 7/21/23 at 7:35 A.M., showed: -Two staff members were in the dining room. -The resident was sitting up in his/her wheelchair at a dining room table with a food tray in front of him/her. -He/she was attempting to open up his/her butter packet from 7:35 A.M. to 7:39 A.M., then put back on tray un-opened. -At 7:55 A.M., he/she finished eating one sausage patty with his/her fingers and drank two glasses of fluid independently. -He/she took the lid off of the hot cereal, was unable to locate spoon and sat there not eating. Staff were not encouraging or cueing the resident. -At 7:59 A.M., a staff member came to remove him/her from the table to get his/her blood pressure so he/she could administer the resident's medication. The resident became upset. No staff encouraging, cueing or assisting the resident with his/her meal. -At 8:09 A.M., the resident was at the table not eating. No staff encouraging, cueing or assisting the resident with his/her meal. -At 8:14 A.M., the resident was at the table and fell asleep. -At 8:18 A.M., staff took his/her food tray away. Staff did not ask resident if he was finished or if he needed assistance. Toast, hot cereal and scrambled eggs were not eaten. -No supplements were on his/her tray, he/she consumed less than 25 percent (%) of his/her meal. Review of the resident's electronic medical record showed no documentation the resident's physician and/or responsible party were notified of the resident's significant weight loss. During an interview on 7/21/23 at 9:07 A.M., Certified Nursing Assistant (CNA) A said: -He/she has worked at the facility for 8 or 9 years and is familiar with the resident's care. -The resident eats his/her meals in the dining room. -He/she provides assist, encouragement and cues if the resident is not eating. -He/she currently does not give the resident dietary supplements. -He/she communicates to the nurse if a resident is not eating. -He/she was not aware the resident was having weight loss. -The nurse is responsible for monitoring residents' weights. During an interview on 7/21/23 at 9:48 A.M., Certified Medical Technician (CMT) A said: -He/she is familiar with the resident's care. -He/she provides setup and encouragement to the resident when he/she is not eating. -He/she reports to the nurse if a resident is not eating. -He/she is not aware of the resident losing weight. -The nurse and Assistant Director of Nursing (ADON) are responsible for monitoring the resident weights; -He/she was not aware of the facility weight policies. During an interview on 7/21/23 at 12:35 P.M., Licensed Practical Nurse (LPN) A said: -He/she is not responsible for the resident's dietary recommendations, weights and meal intake monitoring. The DON and ADON are responsible. -He/she was not aware of the resident's weight loss or poor intake. -He/she would get resident care updates through shift report or from the ADON. During an interview on 7/21/23 at 1:11 P.M., the DON said: -He/she would expect residents to weigh on admission followed by weekly weights times four weeks then monthly if no weight or nutritional concerns are identified. -He/she would expect nursing to notify the physician if resident is not eating, refusing meals, poor intake or weight loss. -He/she receives the dietary recommendations, provides them to the physician for orders and the DON and ADON are responsible for implementing orders in the resident's medical record. -He/she was not aware of the resident's weight loss or inadequate meal intake. -He/she would expect an individualized comprehensive dietary care plan. -He/she is responsible for residents weight, food intake and care plan audits. During a phone interview on 7/24/23 at 9:51 A.M., Resident #10's responsible party said he/she has visually noticed that resident has lost weight. 2. Review of Resident #11's Admission Record showed he/she admitted to the facility on [DATE] with the following diagnoses: -Dysphagia (inability or difficulty swallowing). -Hypokalemia (low Potassium). -Muscle weakness. -Vitamin D deficiency. -Pressure-induced deep tissue damage (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear). Review of the resident's Physician Orders showed: -House shake three times a day after meals for weight loss order dated 7/5/20. -Offer bedtime snack for supplement order dated 9/16/20. -The resident's diet order was regular diet mechanical soft texture regular/thin consistency, for difficulty in chewing dated 12/4/20. Review of the resident's Quarterly MDS dated [DATE] showed: -He/she had severe cognitive impairment. -He/she required extensive assistance from staff with activities of daily living. -The resident need set up help with meals. -The resident's weight was stable no gain or loss of 5% or greater from previous assessment. -The resident's weight was 92 pounds. Review of resident's weights showed: -On 6/8/22 the resident weighed 89.2 pounds. --No weights were document from 6/9/22 through 9/21/22. -On 9/22/22 the resident weighed 93.4 pounds. --The resident had a 4.71% weight gain over 90 days. --No weights documented from 9/23/22 through 12/4/22. -On 12/5/22 the resident weighed 87.6 pounds. --The resident had a 6.21% weight loss over 90 days. --No documentation that physician or RD were informed or weight loss, or new orders. --No weights were documented from 12/6/22 through 2/21/23. -On 2/22/23 the resident weighed 84.0 pounds. --The resident had a 4.11% weight loss over 90 days. --No weights were documented from 2/23/23 through 5/18/23. Review of the resident's Quarterly MDS dated [DATE] showed: -He/she had severe cognitive impairment. -He/she required extensive assistance from staff with activities of daily living. -The resident need set up help with meals. -The resident had a weight loss of 5% or greater from previous assessment and not on a weight loss regimen. -The resident's weight was 84 pounds. Review of the resident's May 2023 Physician Orders showed: -No order for weights to be taken or frequency of weights. -The resident was on a house supplement 120 milliliters (ml) with meals dated 5/24/23. -Prostat (protein supplement) two times a day order dated 5/11/23. Review of resident's weights showed: -On 5/19/23 the resident weighed 79.4 pounds. --The resident had a 5.48 pound weight loss over 90 days. --Physician notified and house supplement started to be given with each meal and protein supplement to be given twice a day. --No RD notes for this time frame. -On 6/15/23 the resident weighed 80.8 pounds. --No weights were documented from 6/16/23 thru the end of the survey. Review of the resident's meal intake from 6/19/23 through 7/19/23 showed the facility staff documented the resident consumed 75% of his/her meals. Review of the resident's Nutrition/Dietary Notes dated 6/28/23 showed: -He/she was underweight. -His/her body mass index (BMI - a number calculated from one's height and weight that is a fairly reliable indicator of most adults' body fat (excluding athletes and the elderly. According to the American Dietetic Association, a BMI of less than 18.5 is underweight, a normal BMI range is 18.5-24.9, a BMI range of 25-29.9 is considered overweight and a BMI of over 30 is considered obese) was 15.3. -He/she had dietary supplements ordered. Observation on 7/19/23 at 8:33 A.M. showed the resident was feeding himself/herself breakfast. A CNA was standing at bedside encouraging the resident to eat when the resident became distracted and stopped eating. The resident ate 100% of the meal and consumed approximately 50% of his/her supplement drink. During a phone interview on 7/17/23 at 8:57 A.M., the representative said he/she was concerned with the resident's weight and that he/she did not think the facility was tracking the resident's weight related to the resident's weight loss. The representative said he/she had told the nurse about his/her concerns of the resident's weight, but was unsure of the nurse's name. During an interview on 7/20/23 at 8:53 A.M., CNA E said: -It was his/her expectation that residents would be weighed by the doctors' orders. -The CNA's were responsible for weighing the residents. -He/she knew who was due for weights because it came up on the task listing that the CNA's do. -He/she was unsure if this resident had a weight change. -He/she was unsure if this resident had refused weights. -All residents would be weighed monthly at a minimum. -If a resident had no weight orders, the charge nurse would be notified. -He/she did not know this resident did not have a weight order. -When a resident had a change in weight he/she would notify the nurse. During an interview on 7/20/23 at 9:11 A.M., LPN B said: -The CNA's were responsible for weighing the residents. -It comes up in the CNA's task listing who is due for weights by the order that is put in the computer. When a resident did not have a weight order it would not trigger the CNA's to weigh the resident. -He/she was unaware if the resident had a weight change. -He/she was unaware if the resident refused weights, but the resident did refuse other cares. The resident needed a lot of re-education at times. -He/she knew that the resident had lost weight in the past and was started on nutritional supplements. -The doctor is notified of any significant weight loss. -He/she thought RD was notified and involved in residents care. -Some residents were weekly weights and some were monthly weights most residents were monthly weights. -At a minimum a resident would have had a monthly weight. -A resident would have a weight order in the physician orders and this order would have stated the frequency. -A resident with no orders for weights, the doctor would be called to request an order for weights. -There was no order when do weights for the resident. During an interview on 7/21/23 at 1:10 P.M., DON said: -It was his/her expectation that resident would be weighed monthly. -The CNA's were responsible for weighing residents. -The CNA's know who is supposed to weighed because it populates on the task listing based on the order that was entered in the system. -If the resident did not have a weight order, the system could not populate the task listing for the CNA's to do. -The system would generate a notice if a resident had a significant weight loss. -He/she was knew the resident had a weight loss. -He/she did not know if the resident refused weights, but this resident would refuse cares. -When a resident had a significant weight loss the physician and RD would be notified. -RD was involved with residents current weight loss. -It was his/her expectation that the company policy would be followed. -The company policy was that a resident would be weighed weekly times four weeks then monthly. -He/she was responsible for auditing weights. -It was his/her expectation that all residents would have a weight order on the residents chart. -It was his/her expectation that if a resident did not have an order for weights to be performed that the charge nurse would call the doctor and get an order for weights. -It was best nursing practice that all residents have a weight performed monthly if there were no medical conditions that would dictate more frequent weights. 3. Review of Resident #6's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Unspecified 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). -Unspecified psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). Review of the resident's quarterly MDS, dated [DATE] showed the resident: -Was severely cognitively impaired. -Was rarely understood and rarely could understand others. -Had trouble concentrating 12 to 14 days out of 14. -Required supervision and oversight for cuing and/or encouragement during meals. Review of the resident's Impaired Cognition Care Plan, revised on 5/2/23 showed: -The resident required cueing, reorientation, and supervision as needed. -Staff were to present one thought, idea, question or command at a time. Review of the resident's Physician Order Sheet dated 7/2023 showed the resident was on a regular diet, regular texture with thin (regular) liquids. Observation on 7/19/23 between 11:50 P.M. and 12:30 P.M. showed: -At 12:08 P.M. the resident's eight ounce glass (the only beverage which the resident had been given) was empty. -At 12:13 P.M. the resident looked up and said he/she was still thirsty and asked for something else to drink while CNA B was leaving the dining room and briefly going into a resident room. CNA B did not appear to hear the resident's request. CMT C was at the nursing station near the dining area and did not appear to hear the resident. CNA B moved back and forth between the dining area and resident rooms. -At 12:22 P.M. the resident raised his/her cup and looked into the bottom of the glass and sat the glass back down. The resident was not offered any other beverage. Observation on the unit on 7/20/23 between 11:40 A.M. and 12:40 P.M. showed: -CMT C was at the nursing station near the dining area in front of the computer. -The resident was at the dining table with his/her food and one eight ounce glass of a thin liquid beverage; -At 11:56 A.M. the resident's glass was empty. The resident picked the glass up, looked inside the glass and set it back down on the table. -At 11:59 A.M. Hospitality Aide (HA) A passed by the resident without checking for the empty glass and sat behind the nursing station. -At 12:03 P.M. the resident picked up his/her empty glass a second time, looked into the bottom of it and then sat it back on the table. -CNA B had been going in and out of resident rooms between times spent in the dining area. -None of the three staff offered the resident another beverage. 4. Review of Resident #104's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Unspecified Dementia. -Severe protein-calorie malnutrition. -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). Review of the resident's Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) Care Plan, dated 2/9/23 showed: -The resident had self-care performance deficits related to dementia. -The resident required assistance of one staff for set up and encouragement to maximize independence with eating. He/she is on a regular diet, regular texture and thin liquids. Review of the resident's annual MDS, dated [DATE] showed the resident: -Was severely cognitively impaired. -Was sometimes understood by others. -Had trouble concentrating and had disorganized thinking. -Could eat and drink without staff assistance when food and drink was provided. Review of the resident's Physician Order Sheet dated 7/2023 showed the resident was on a regular diet, regular texture with thin liquids. Observation on 7/19/23 at 8:30 A.M. and between 10:15 A.M. and 11:05 A.M., showed: -At 10:20 A.M. the resident was standing near the nursing station and told the surveyor he/she wanted ice water and soda. -The resident had an empty plastic container in his/her hands which he/she wanted filled. -CMT C, who was sitting behind the nursing station at the time, responded we got it under control and then told the resident staff would get his/her money for a soda. CNA B was in a resident's room at the time. -When CNA B came back out of the resident's room and to the nursing station a few minutes later CMT C did not tell CNA B of the resident's request for ice water and soda and did not get the resident anything to drink. During an interview on 7/20/23 at 8:22 A.M. HA A said: -If the resident is hungry or thirsty he/she will ask staff to go to the vending machine for him/her. When the resident says he/she is thirsty that means he/she wants a soda. -He/she didn't work the previous day and didn't know who, if anyone, goes to the vending machine for the resident when he/she wasn't there. 5. Review of Resident #120's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Alzheimer's disease. -Psychotic disorder (a mental disorder in which there is a severe loss of contact with reality) with hallucinations (sensory perceptions that do not result from an external stimulus and that occurs in the waking state). Review of the resident's quarterly MDS, dated [DATE] showed the resident: -Was severely cognitively impaired. -Sometimes was able to make himself/herself understood. -Had fluctuating inattention and fluctuating disorganized thinking. -Was able to eat and drink independently when provided food and beverages. Review of the resident's Impaired Cognition Care Plan, initiated 4/18/23 showed: -Cue, reorient, and supervise resident as needed. -Keep the resident's routine consistent. -Present one thought, idea, question or command at a time. Review of the resident's Physician Order Sheet dated 7/2023 showed the resident was on a regular diet, regular texture with thin liquids. Observation on 7/19/23 between 11:50 P.M. and 12:30 P.M. showed: -At 12:04 P.M. CNA B told the resident to come to the table to eat. -He/she gave the resident a six ounce glass of water filled to approximately five ounces and an eight ounce glass filled to approximately six ounces of what looked like juice or drink mix. -By 12:18 P.M., the resident had eaten some of his/her food, but had not reached for his/her beverages. -The resident was not asked if he/she wanted his/her beverages and the beverages were not moved within a closer reach of the resident to encourage him/her to drink. During an interview on 7/20/23 at 8:22 A.M. HA A said: -The resident didn't usually need any prompting to eat or drink. -If he/she notices the resident isn't drinking during his/her meal he/she puts a straw in the resident's cup to encourage him/her to drink. 6. Observation on 7/17/23 between 5:10 A.M. and 7:40 A.M. and between 8:15 A.M. and 8:35 A.M. showed there was no water container in any residents' room, no cups in residents' rooms with which to get water, and no hydration station or pitcher of water at the nursing station or anywhere else on the unit except on the medication cart. None of the residents were offered beverages except during meal times. Observation on 7/18/23 between 1:00 P.M. and 1:20 P.M., showed there was no water container or cups in any residents' room and no hydration station or pitcher of water at the nursing station. None of the residents were offered beverages. Observation on 7/19/23 between 2:05 P.M. and 2:50 P.M. showed: -There was no water container or cups in any residents' room and no hydration station or pitcher of water at the nursing station. -During this time none of the residents on the unit were offered any beverages. Observation on 7/20/23 between 8:20 A.M. and 10:25 A.M. showed: -There was no water container or cups in any residents' room and no hydration station or pitcher of water at the nursing station. -At 10:00 A.M. a Dietary staff person set down a snack tray on the nursing desk. He/she did not bring beverages. -During this time none of the residents on the unit were offered any beverages. During an interview on 7/20/23 at 8:22 A.M. HA A said he/she didn't check with residents related to hydration at any certain time, but he/she gave residents water if they specifically asked for it. During an interview on 7/20/23 at 10:02 A.M. CNA B said: -Dietary does not bring beverages when they bring the snacks. Dietary used to bring mini cans of soda, but they haven't brought that in a while. -The only times the residents on the unit drank fluids was at meal times because if staff brought ice water to the residents' rooms they would spill it. -Dietary brings coffee, water and juice at meal times. -If there was water left over from lunch he/she will keep it on the unit at the nursing station for residents to have later; -The Hospitality Aide fills the ice chest some time during the shift. Sometimes it is earlier in the shift and sometimes later. There may or may not be ice in it right now. If he/she was working by himself/herself he/she had to wait for another staff to come to get ice. The ice was not accessible to residents, so staff had to get it for them if they ask for it. Observation on the unit on 7/20/23 between 11:00 A.M. and 11:20 A.M. and 3:40 P.M. and 4:30 P.M., showed no residents were offered water during that time. During an interview on 7/20/23 at 3:40 P.M. CNA F said: -They kept a cooler with ice in it and sometimes had a pitcher of water at the nursing station. -If a resident asks for water staff will give it to them. Only bedridden residents were actually offered water because the others on the unit could ask for it. During an interview on 7/21/23 at 9:32 A.M. ADON B said: -Staff should offer water or juice to residents on the special care unit throughout the day, at least every two to three hours. -There should always be a pitcher of ice water and juice on the unit. -The ice chest should be filled every shift so that there is always ice in it. -If residents ask for something to drink, staff should be getting them a drink right away. -At meal times if the resident has finished their drink staff should assist them in getting another one. During an interview on 7/21/23 the DON said: -Staff should offer water to residents on the special care unit on a regular basis. -If they give the resident a snack they should have something available to drink with it as well. -Staff should be prompting and assisting residents on the special care unit with hydration during meals and between meals. 43345 19016

Based on interview and record review, the facility failed to protect one sampled resident (Resident #2) from abuse when Resident #1 pushed Resident #2 and he/she sustained a fractured hip out of 6 sampled residents. The facility census was 135 residents. On 10/17/22 the Administrator was notified of the past noncompliance which occurred on 9/30/22. On 9/30/22 the facility administration was notified of the incident and the investigation was started. Staff had been educated on the resident behaviors, interventions were in place at the time of the resident to resident incident. The facility staff immediately separated Resident #1 and Resident #2. Resident #2 was sent to the hospital on 9/30/22 and admitted with a fractured hip. Resident #1 was sent to the hospital, evaluated and returned without any change in orders. The deficiency was corrected on 9/30/22. Record review of the facility policy titled Abuse Prevention and Prohibition Program dated 8/2020 showed: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. -Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation resident property. -Residents identified by staff as being self-injurious or exhibiting abusive behavior that requires professional services not provided in the facility, will be reviewed by the Interdisciplinary team and/or physician. -The facility conducts an ongoing review and analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse. -Resident assessments and care planning are performed to monitor resident needs and address behaviors that may lead to conflict. Record review of the facility policy titled Behavior-Management dated 6/2020 showed: -The concept of behavior management is an interdisciplinary process. -Key components of this process are: --Identifying residents whose behaviors may pose a risk to self or others. --Developing individual and practical care strategies based on assessed needs. --Implementing the behavior management program; and -Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including the effectiveness of psychoactive drugs. -The goal of any behavior management process is to maintain function and improve quality of life. -The goal of the interdisciplinary team is to promptly identify behavior management issues and develop an effective management program. 1. Record review of Resident #2's facility face sheet showed he/she was admitted to the facility on [DATE] with diagnoses that include: -Chronic Obstructive Pulmonary disease (a group of lung diseases that block air flow and make it difficult to breathe). -Acute Respiratory failure with hypoxia (acute or chronic impairment of gas exchange between the lungs and the blood causing shortness of breath). -Uropathy (a blockage in the urinary tract). -Chronic Kidney disease. -Depression. -Hypertension (high blood pressure). -Hyperlipidemia (high cholesterol). Record review of the resident's annual Minimum Data Set (MDS-a federally mandated tool that facilities use for care planning), dated 7/6/22 showed: -His/her BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. -He/she was independent with ADL's (Activities of Daily Living - those activities that people perform everyday). -He/she had no untoward behaviors were reflected in this assessment period. -He/she was steady while standing and ambulating. Record review of the resident's care plan dated 5/2/22 showed: -The resident had a behavior issue, with interventions that included: -Administer medications as ordered and monitor/document side effects and effectiveness. -Explain all procedures to the resident before starting and allow the resident to adjust to changes. -If reasonable, discuss the resident's behavior and explain why behavior is inappropriate or unacceptable to the resident. -Intervene as necessary to protect the rights and safety of others. Record review of the resident's Pre-Admission Screening for Mental Illness/Mental Retardation or Related Condition (PASSR), dated 7/7/2021 showed: -Has been diagnosed as having a major mental disorder: --Anxiety. --Major Depressive Disorder. -Placement in a nursing facility is not due to dementia or related disorder. -Has not received intensive psychiatric treatment in the past two years. 2. Record review of Resident #1's facility face sheet showed the resident admitted to the facility on [DATE] with diagnoses that include: -Schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder). -Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). -Delusional disorder (a belief or altered reality that is persistently help despite evidence or agreement to the contrary, generally in reference to a mental disorder). -Chronic Obstructive Pulmonary disease. -Diabetes. -Dementia (a group of thinking and social symptoms that interferes with daily functioning). -Heart failure. -Psychotic disorder (a mental disorder characterized by a disconnection from reality). Record review of the resident's quarterly MDS dated [DATE] showed: -His/her BIMS score of 4, which indicated the resident was severely cognitively impaired. -He/she required supervision with all ADL's. -He/she had no untoward behaviors were reflected in this assessment period. -He/she was not steady while standing and ambulating. Record review of the resident's care plan dated 5/11/22 showed: -Has impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making. -Administer medications as ordered and monitor/document for side effects and effectiveness. -Present just one thought, idea, question or command at a time. -Monitor/document/report as needed, any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others. -Face the resident when speaking and use eye contact and reduce any distractions such as TV, radio, etc. Record review of the resident's PASSR, dated 6/25/15 showed: -Bipolar disorder. -Major depression. -Dementia-neurocognitive-mild severity. -Schizophrenia. -Path to safety - cogntivie impairment. Record review of the resident's nursing progress notes dated 9/29/22 at 3:00 P.M., showed: -Resident #2 approached Licensed Practical Nurse (LPN) C and requested a pain pill. -Before LPN C could administer the pain pill, Resident #1 and Resident #2, started exchanging words with one another. -The exchange became heated, and the residents had to be separated. -These was no physical contact between the residents, at the nurses station, as the residents were being supervised. Record review of the resident's nursing progress notes dated 9/22/22 at 2:55 P.M., showed: -Nurse Practitioner (NP) notified this writer of a resident to resident altercation resulting in Resident #1 spitting into Resident #2's room. -Residents were interviewed independently and agreed this was a one time event, and they would steer clear of each other. 3. Record review of the facility investigation dated 9/30/22 showed: -Predisposing environmental factors - furniture (pool table and cue sticks). -Predisposing physiological factors - non compliance. -Predisposing situation factors - reported by nurse that Resident #2 was waiting on pain medication. -Description statement of the incident from Assistant Director of Nursing (ADON): --He/she was charting at the nurses station when Resident #1 and Resident #2 began yelling at one another. --Three staff members were headed over to where the altercation was occurring by the pool table, verbally telling the residents to stop. --Resident #1 slammed Resident #2 into the bar and hit Resident #2 with the pool stick. --The residents' spun around and Resident #2 was pushed to the floor. --Staff separated resident and notified supervisors. -Description from (LPN) E, statement of the incident: --Heard yelling and saw Resident #1 and Resident #2 pushing each other and then Resident #1 pushed Resident #2 on the floor. -Description from LPN B, statement of the incident: --Heard something hit the glass window to the administrators office. --Looked over and Resident #1 was against the bar with a pool stick in his/her hand. --Resident #1 had Resident #2 pinned against the bar. --By the time staff got over to the two residents, Resident #1 had pushed Resident #2 down to the ground. During an interview on 10/1/22 at 10:50 A.M., Certified Nursing Assistant (CNA) C said: -Last evening around 7:30 - 8:00 P.M., the residents were out in the area in front of the nurses station. -He/she heard hollering, staff ran towards the residents, as they were pushing each other. -Resident #2 landed on the floor. -Resident #1 was holding a pool stick, but did not see him/her hit anyone with the pool stick. During an interview on 10/3/22 at 9:30 A.M., Resident #2 said: -He/she was in the hospital. -Resident #1 was always yapping, yapping, yapping. -Don't like that guy, never liked that guy. -Had three bad contacts with Resident #1, and he/she lived on a different hall. -One time Resident #1 came into his/her room and spit into the room. --He/she called the police, and was told there was nothing they could do because the resident was mentally retarded. -Second time, he/she was at the nurses station getting a pain pill, and saw Resident #1 with a pool stick walking his/her way. --Called the police again, and they did nothing. -Third time Resident #1 was with a pool stick again, and he/she is in the hospital with a broken hip. --Resident #1 was a menace to everyone there. --He/she was sitting in the lobby by the pool table, and Resident #1 was pointing at him/her and had that pool stick in the other hand. --He/she just got up and started wrestling it away from Resident #1. --He/she was knocked down. -He/she was there before Resident #1 in the facility. -Resident #1 gets into it with staff, but mainly was focused on him/her. -Resident #1 always wants to go to battle. -He/she was not afraid of the resident, but knows Resident #1 was capable of hurting him/her. -He/she had not told the Administrator or the DON how he/she felt, because they were new, but ADON had talked to him/her. -He/she will go back to the facility for rehabilitation. -The hospital did surgery on his/her right hip on 10/1/22. During an interview on 10/3/22 at 1:00 P.M., with the ADON, he/she said: -He/she had visited with both Resident #1 and Resident #2 and both had agreed that they would stay away from each other. -If the residents were in the common area at the same time, staff were educated to monitor and supervise the residents closely. During an interview on 10/3/22 at 1:15 P.M., the DON said: -There have been several incidents with these residents in the past 30 days. -The first incident occurred when Resident #1 allegedly spit into Resident #2's room. --Both residents agreed that this was a one time incident and no further action was needed. -The second incident occurred when the two residents were in the common area and began exchanging words. --The residents were under close supervision, so the staff intervened immediately. --The residents both agreed to stay away from each other. -This third incident occurred when Resident #1 approached Resident #2 at the pool table. --All at once things escalated. --Resident #1 had no recent behaviors. --Both residents had previously scheduled appointments with the facility Psychiatrist who would be in the facility the next week. --Resident #2 was in the hospital with a fractured hip. --Resident #1 was sent out to the emergency room for evaluation after the incident, and was sent directly back to the facility. During an interview on 10/3/22 at 1:45 P.M., Resident #1 said: -Resident #2 wanted to drink coffee with him/her, and make him/her a punk. -Resident #2 always sat by him/herself. -Resident #2 grabbed the pool stick, but no punches were thrown. -He/she was mad because there wasn't any coffee and was mad Resident #2 knew his/her name. During an interview on 10/3/22 at 2:00 P.M., the Staffing Coordinator said: -He/she was at the nurses station and heard a click, click sound, looked up and the residents were going at it. --The DON had just given us training on what to do when residents become aggressive. --Resident #1 had a pool stick on Resident #2. --He/she had the pool stick in one hand, but wasn't hitting the resident with it. --Resident #2 pushed Resident #1 off, in self defense, and Resident #2 fell down. During an interview on 10/3/22 at 2:30 P.M., Nurse Practitioner (NP) A, who is the NP for Primary care physician for Resident #1 and Resident #2, said: -Immediately the office wants to be notified. -Going forward, both would be sent out for a psychological evaluation, depending on the time of day, however, most often the hospital would send them right back. -The medications were reviewed and labs are drawn if that is indicated. -Something for behavior and mood stabilization would be started if that was needed. -Prior to this incident, the staff were doing behavior monitoring. -Before this incident, he/she had never known Resident #1 to be physical. -Resident #1 had been started on an anti-anxiety medication. During an interview on 10/4/22 at 9:30 A.M., Physician A said: -He/she expected the facility staff to follow policy and training. -Facility staff were expected to monitor and supervise Resident #1 and Resident #2 when in the common area. During an interview on 10/4/22 at 10:00 A.M., LPN B said: -He/she was around the corner, and when he/she saw the residents and then Resident #2 was on the floor. -Part of the intervention for these residents was to keep them separated when they are in the common area. -Resident #2 had been watching TV and Resident #1 was way over by the pool table when they were last seen. -It all happened really fast. During an interview on 10/4/22 at 10:30 A.M., LPN C said: -He/she was at the nurses station charting when incident occurred. -Education had been provided to the staff to observe and monitor the two residents closely and keep them separated. -The DON had just given us training on things to do if residents become aggressive. -This escalated very quickly. -Staff were monitoring the residents and simply did not get to the residents in time to prevent this incident. MO00207765

Based on observation, interview and record review, facility staff failed to closely monitor and implement fall interventions for one newly admitted resident assessed at high risk for falls (Resident #27). The resident fell from the commode after staff left him/her unattended and the resident sustained [REDACTED]. Additionally, facility staff failed to ensure they completed a thorough and accurate fall investigation for two additional sampled residents (Resident #29 and #31), failed to ensure the resident's call light was within reach for one resident with a history of falls (Resident #31), failed to investigate and complete neurochecks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) after a fall for one additional sampled resident (Resident #35), and failed to provide protective oversight for one resident (Resident #25) who exhibited exit-seeking behavior and eloped on one occasion, and failed to conduct thorough investigations to ensure the safety of the resident. The facility census was 137. Record review of the facility's undated Admission Nursing Assessment policy showed: -A nursing assessment form is used for assessing all residents on admission in addition to the MDS (Minimum Data Set - a federally mandated assessment tool required to be completed by facility staff for care planning). -The charge nurse initiates a nursing assessment on newly admitted residents that are admitted during their shift. -An interim plan of care is initiated based on the assessment. -Nurses on all shifts participate in the resident assessment process as needed. Record review of the facility's Fall Management policy and procedure, revised 6/30/14, showed: -It is the policy of this center to assess residents for risk of falls. The center will identify and analyze fall risk, implement an investigation, monitor plans for effectiveness and modify interventions as necessary. -Risk refers to any external factor or characteristic of an individual resident that influences the likelihood of a fall. -Upon admission the licensed nurse completes a Fall Risk Review form. -The licensed nurse will develop a Plan of Care addressing the fall risk factors. 1. Record review of Resident #27's Emergency Department Report from the hospital, dated 7/21/15, showed the following: -The resident was taken to the hospital on [DATE] from his/her home after falling; -He/she complained of right leg pain at the hospital and had a small contusion to his/her anterior right thigh; -The resident had dementia; -The resident was under hospice care (care designed to give support to individuals in the final phase of a terminal illness and focus on comfort and quality of life rather than a cure), and they had arranged for respite care at the facility; -The resident's condition leading to admission was provided. Record review of the resident's Nurses Notes, dated 7/21/15 at 9:50 P.M., showed staff documented the resident was admitted to the facility from the hospital. Staff assessed the resident as: -Arrived at the facility by ambulance, accompanied by an attendant and a family member; -Alert and oriented to person and place; -On hospice care; -On a pureed diet; -Incontinent of bowel and bladder; -Had a bruise to his/her right upper leg. Record review of the resident's Admission Resident Data Set, dated 7/21/15 at 9:59 P.M., showed staff documented: -The resident was admitted from the hospital and arrived at the facility by ambulance; -The resident had modified independent cognitive skills for decision making; -The resident was receiving hospice and respite care; -The resident required extensive assistance with bed mobility, transfers, toileting, and eating; -The resident was always incontinent of bowel and bladder; -The resident sustained [REDACTED]. -The resident was chair bound; -The resident had a balance problem while standing and required the use of assistive devices. -The resident had a bruise on his/her right upper thigh. Record review of the resident's Initial Care Plan, dated 7/22/15, showed: -The purpose was to provide for immediate care of residents on admission; -Under Orientation to His/Her Room staff documented they explained the call light, oriented him/her to the bathroom, and acquainted him/her with the routine; -Under Pressure Ulcer Risk, incontinent was checked; -Under Pain, scale was checked and zero was noted; -Under Fall Risk, encourage the use of the call light and assess for possible contributors was checked; -Under Foley Catheter, not applicable was noted; -No other areas were checked and no specific notations/instructions related to the resident were a part of the initial care plan. Record review of the resident's nurses' notes, dated 7/22/15 at 8:35 P.M., showed staff documented: -The resident was in bed with his/her eyes open; -Was able to make his/her needs known; -Was fed at meal time; -Would continue to receive assistance with ADLs (Activities of Daily Living). Record review of the resident's nurses' notes, dated 7/22/15 at approximately 11:00 P.M., showed staff documented the CNA (Certified Nurse Assistant) called staff to the resident's room. The nurse administered first aid and assessed the resident. The resident lay on the floor with his/her head in a pool of blood. The nurse called 911. Record review of the resident's Nursing Home to Hospital Transfer Form, dated 7/22/15 at 11:25 P.M., showed staff documented the resident: -Had facial/head bleeding as his/her reason for being transferred to the hospital; -Vital signs were not obtained before the ambulance arrived; -Had a Usual Mental Status of alert, oriented, follows instruction; and -Had a Usual Functional Status of ambulates with assistive device. Record review of the resident's nurses' notes, dated 7/22/15 at 11:45 P.M., showed staff documented: -Facility staff contacted hospice to inform them of the resident's condition and to let them know the resident was being sent to the hospital. -Facility staff did not have a face sheet with the DPOA (Durable Power of Attorney) information. Record review of the facility's Report of Alleged Incident/Accident signed by Licensed Practical Nurse (LPN) E on 7/23/15 and signed by the Director of Nursing (DON) on 7/24/15, showed the following: -The date of the alleged incident was 7/22/15 at 11:00 P.M. -Staff was unable to obtain vital signs because the ambulance arrived quickly. -The resident was found lying on the floor with his/her head in a pool of blood in his/her room. -The resident was bleeding from his/her head. -The fall required hospitalization . -The resident's contributing [DIAGNOSES REDACTED]. -The identified conditions of the resident which may have contributed to the incident were fall risk, forgetful and lethargic. -The Result of the Investigation section of the report showed the resident got himself/herself to the bathroom without assistance and fell getting up from the toilet and getting back in bed. The resident was on respite and was ambulatory at home with falls. -The Additional Interventions and Actions To Prevent/Minimize Potential Reoccurrence section of the investigation report showed: --The resident was sent to the hospital. --The resident's daughter was called and she said she would not bring the resident back. --The hospital called and said they were going to keep the resident for observation. Record review of LPN E's Incident/Accident Investigation Interview report dated 7/22/15 showed: -It was a non-witness statement. -The documented summary of LPN E's knowledge of the incident was the Resident was found lying down with his/her head in a pool of blood. The CNA called staff in from the patient's room. Registered Nurse (RN) D administered first aid and LPN E called 911 and the resident was sent to the hospital. Record review of the resident's hospital Emergency Department Notes showed: -The resident was seen in the emergency department on 7/23/15 at 12:45 A.M. -He/she suffered a laceration to the right side of his/her head and had bleeding controlled by Emergency Medical Service (EMS). EMS noted approximately 100 milliliters of blood at the scene (in the resident's room). -Radiology results showed the resident sustained [REDACTED]. During an interview on 8/17/15 at 11:46 A.M. CNA K said: -He/she remembered the resident. The resident was only at the facility for one or two days. -The resident could not go to the restroom on his/her own. -The resident was high risk for falls. -Even if the resident was taken to the restroom staff could not leave him/her because the resident would try to get up on his/her own. -Staff could not safely leave the resident in the restroom. During an interview on 8/17/15 at 11:55 A.M. CNA L said: -He/she did not work directly with the resident because the resident was on the front end of the hall. -He/she only knew the resident could not be left alone on the toilet because CNA K told him/her. During an interview on 8/17/15 at 1:20 P.M. CNA M said: -He/she (CNA M) worked the late night shift (10:30 P.M. - 6:30 A.M.) the night the resident fell ; -The resident was sitting on his/her bedside commode when he/she went in to check on the resident; -He/she did not know how the resident got onto the commode; -He/she stood at the doorway and asked the resident if he/she needed anything. The resident said no, so he/she told the resident he/she would be back; -He/she went to put leg warmers on another resident, sat down for a second, and then went back to the resident's room; -When he/she got back to the resident's room the resident was on the floor; -The resident was lying on the floor next to his/her bedside commode which was next to the resident's bed; -The resident was responsive, his/her face was busted; -He/she immediately told the nurses the resident was on the floor; -When a new resident is admitted the nurse usually tells the CNAs what they need to know about caring for the resident; -He/she did not know anything about this resident's needs. -Report had not been done and he/she had not been told anything about the resident. During an interview on 8/18/15 at 2:50 P.M., RN D said: -The resident arrived at the facility on 7/21/15 at a little after 9:00 P.M; -The resident was alert and could answer questions; -The resident was very frail and was not walking; -The resident could not transfer himself/herself; -The resident would ask to use the restroom at times and at other times would not; -The CNAs were informed about the new resident;-The resident was oriented by staff to use of the call light to alert staff for assistance; -The night the resident fell , he/she was on the bedside commode that hospice provided; -The resident turned on his/her call light around 10:00 P.M. and asked to be on the bedside commode; -He/she assisted the resident with getting out of bed and onto the bedside commode; -He/she went to the nurses' station to talk to the night shift nurse who was relieving him/her and returned to check on the resident; -He/she saw the night shift CNA and informed him/her of the resident sitting on the bedside commode. The CNA checked on the resident; -The resident was frail, had just arrived and the facility staff were not aware of the resident's abilities; -When he/she helped the resident onto the commode it was after 10:30 P.M; -He/she was waiting on the night shift staff to arrive, but did check on the resident; -The resident had been assessed as being dependent upon staff. -Normally a resident who is dependent upon staff should not be left alone on the toilet or commode. -In this instance the resident had been assisted to the bedside commode, was sitting stable in an upright position and he/she told the resident he/she would be back; -He/she checked on the resident twice and the call light was beside the resident. During an interview on 8/18/15 at 1:33 P.M. the DON said: -The admission process is a 24-hour process; -When a new resident is admitted from the hospital, the facility gets a report from the hospital immediately, but it takes 24 hours to get everything in place; -The hospital does not always notify us of all of the resident's needs; -Charge nurses receive the information and handle the admission of the resident; -The charge nurse on duty gives a verbal report to the CNA on what needs to be done to care for a newly admitted resident; -A care card should be in place after 24 hours; -The unit managers are responsible for ensuring the initial care plans are completed; -If the resident was admitted as a high fall risk resident, he/she would have to be watched carefully; -Incident reports are started by the unit managers and forwarded to the DON; -If someone witnesses an incident, the nurse should have the witness fill out a witness form; -When an investigation is completed, the DON signs it, showing it is completed and thorough; During an interview on 8/27/15 at 11:18 A.M. the resident's Physician said: -The resident was a high fall risk resident; -He/she was contacted when the resident fell ; -The resident was sent out to the hospital because the fall resulted in the resident sustaining a head injury. He/she did not know the extent of the injury. 2. Record review of Resident #29's face sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -High blood pressure; -Muscle weakness; -[DIAGNOSES REDACTED] (high levels of fats in the blood); -Depressive disorder. Record review of the resident's Report of Alleged Incident/Accident, dated 7/6/15 at 3:30 P.M., showed: -The resident had a non injury fall; -This was the second non-injury fall the resident had that day; -The resident's initial non-injury fall took place on 7/6/15 at 6:00 A.M. -Prior to the incident at 6:00 A.M., he/she experienced increased weakness. Record review of the resident's medical record showed no Report of Alleged Incident/Accident for the incident dated 7/6/15 at 6:00 A.M., -On 8/14/15 at 10:00 A.M. the report was requested from the DON, the report was not received; -On 8/17/15 at 1:30 P.M. the report was requested from the DON, the report was not received. He/she reported that he/she was unable to find the report from the earlier fall, he/she just sees it's reference in the second fall report; and -On 8/18/15 at 9:00 A.M. the report was requested from the Administrator in writing, the report was not received. 3. Record review of Resident #35's face sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -High blood pressure; -Kidney disease (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes); -Diabetes; -[DIAGNOSES REDACTED] (below normal function of the thyroid gland); -Anemia (low volume of red blood cells in the blood stream); -[DIAGNOSES REDACTED]; -Muscle weakness; -Depressive disorder. Record review of the resident's nurse's notes, dated 6/1/15, showed staff documented the resident was on follow-up monitoring for a non-injury fall. Review of the resident's medical record showed no Report of Alleged Incident/Accident for the non-injury fall documented in the nurse's notes on 6/1/15. Record review of the resident's nurse's notes, dated 7/9/15, showed staff documented: -The resident was very impulsive when staff assisted him/her during a transfer; -He/she lost his/her balance; -Facility staff re-educated the resident about being patient, and administered as needed (PRN) pain medication. Record review of the resident's closed record showed no Report of Alleged Incident/Accident for the fall on 7/9/15. Record review of a Report of Alleged Incident/Accident, dated 7/13/15, showed staff documented: -The resident fell on [DATE] at 5:50 P.M.; -Staff did not record any information regarding neurochecks on 7/13/15 after the resident's fall. During an interview on 8/1/15 at 12:45 P.M., the DON said: -staff are expected to complete neurochecks after a resident falls. 3. Record review of Resident #31's Admission Record showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Gout-(arthritic changes in the joints such as the knee); -High blood pressure; -Congestive Heart Failure (disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body); -[DIAGNOSES REDACTED](abnormal heart rhythm); -End-stage Renal Disease (ESRD - the complete or almost complete failure of the kidneys to function); -Generalized pain. Record review of the resident's Admission Resident Data Set, dated 7/10/15, showed staff assessed the resident as: -Understands others and understood by others. -Moderate visual impairment. -Alert with modified independent cognitive skills (experienced some difficulty in new situations only). -Required extensive staff assistance for bed motility and toileting. -Required total staff assistance for transfers. Record review of the resident's Fall Risk Assessment, dated 7/10/15, showed staff assessed the resident as high risk for falls. Record review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as: -Usually able to understand others and was usually understood by others; -Cognitively intact; -No visual impairment; -Required extensive staff assistance for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Record review of the resident's Report of Alleged Incident/Accident, dated 8/2/15, showed staff documented: -The resident had an unwitnessed fall from his/her bed to the floor resulting in a hematoma (bruise) with bleeding to the resident's forehead. -The resident was sitting on the side of his/her bed playing cards then fell forward to the floor. -The resident was sent to the hospital for evaluation. -The report was signed by the DON on 8/3/15. -The report was not signed by the Administrator as of 8/17/15. -Staff education included asking the nurse before sitting the resident up or to stay with the resident in his/her room while the resident was sitting up. -Interventions included: place grip strips on the floor next to the bed to help prevent slipping when the resident is sitting on the side of the bed and to help prevent the over bed table from slipping when the resident is using it, and therapy will follow up with the resident to evaluate and treat. -The investigation did not address the location or availability of the resident's call light at the time of the fall. Record review of the resident's Fall Care Plan, dated 8/3/15, showed: -The resident was at risk for falls due to impaired mobility, debility, and lower extremity weakness. -The resident will have less than two falls per week for 90 days. -Place the call light within reach at all times. -When the resident is in bed, place all necessary personal items within reach. -Grip strips next to the bed to help prevent the resident from slipping when he/she sits on the side of the bed and to help stabilize the over bed table when the resident plays cards or other things. Observation of the resident on 8/17/15 at 9:30 A.M., showed the resident sat in the wheelchair in his/her room near the foot of the bed next to the door. The resident's call light was attached to the divider curtain in the center of the room and was out of the resident's reach. Observation of the resident on 8/17/15 at 10:00 A.M., showed the resident lay in bed with the call light attached to the divider curtain and out of the resident's reach. During an interview on 8/17/15 at 10:15 A.M., the resident said: -He/she fell out of bed while playing cards. -The resident tried to call out for assistance and hold on to the side of the bed as best as he/she could when he/she felt his/her feet slipping. The call light was draped over his/her television and out of his/her reach at the time. -The resident fell on his/her face, which resulted in a large lump and small cut on his/her forehead. The resident went to the hospital for tests before coming back to the facility after the fall. He/she thinks the large lump on his/her forehead has become smaller since the fall. During an interview 8/17/15 at 2:00 P.M., CNA F said the resident's call light should be in reach of the resident at all times. During an interview on 8/18/15 at 12:30 P.M., the DON said: -All fall investigations reported to the surveyors were completed investigations. -Fall investigations should include the signatures of the DON and Administrator to verify the investigations were completed. -Fall investigations should include interviews with any witnesses, including staff and residents. -Fall investigations should include observations of the resident's environment, including availability of the resident's call light. 4. Record review of the facility's Elopement policy, revised 5/9/08, showed: -The policy is to protect residents from wandering away from the facility, as well as begin an immediate search if a resident is missing; -Post elopement assessment and action; -The charge nurse completes an incident or accident report; -The report should contain at minimum the following; -Date and time the resident was determined to be missing; -Location within the building, immediate grounds, or offsite where the resident was found; -If the resident had any injuries; -The Administrator will ensure the investigation is complete and that there are identified causal factors related to the elopement with an action plan to prevent reoccurrence; -New employees will be in-serviced related to elopement during orientation. Record review of Resident #25's Face Sheet showed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). Record review of the resident's Risk for Wandering assessment, completed 6/30/15, showed staff assessed the resident as: -Oriented, able to verbalize, and demonstrated the acceptance of placement at the facility; -Exhibited routine or sporadic confusion; -Exhibited anxious or pacing behaviors; -had a history of [REDACTED]. -At high risk for elopement and needed immediate interventions. Record review of the Social Services Progress Notes, dated 7/1/15, showed staff documented: -The resident transferred to the facility from another facility due to needing a locked unit. -The resident was alert and oriented to him/herself only. Record review of the resident's nurse's notes, dated 6/30/15 at 7:00 P.M., showed staff documented: -The resident was anxious and trying to get out of the doors on the Secured Care Unit (SCU). -The resident was looking for his/her spouse. Record review of the resident's daily charting, dated 7/1/15 at 3:45 P.M., showed staff documented: -The resident was trying to get off of the SCU by opening exit doors. Record review of the resident's daily charting, dated 7/2/15 at 9:30 P.M., showed staff documented: -The resident was trying to exit by opening the doors on the SCU. Record review of the resident's daily charting, dated 7/3/15 at 5:00 A.M., showed staff documented: -The resident was restless and exit-seeking. Record review of the resident's nurse's notes, dated 7/4/15 at 7:35 P.M., showed staff documented: -The resident went out the back door (of the SCU to an outside area). -The CNA brought the resident back in. -The DON was notified. Record review of the resident's Report of Alleged Incident/Accident, dated 7/4/15 at 7:35 P.M., showed staff documented: -Brief description of alleged incident/accident: -The back door alarm went off; -The resident stepped out the back door and the CNA brought the resident back inside. -The incident was marked as an elopement. -Results of investigation: -The resident was on a locked unit, in an unfamiliar place, and was a new admission. -Additional interventions: -The resident was easily redirected and placed on fifteen-minute checks. -The resident's condition prior to the incident was not completed. -The incident was not marked as being witnessed or an unwitnessed incident. -There were no results of the investigation. -The report was signed by the DON on 7/6/15. -The report was signed by the Administrator on 7/7/15. -The DON gave this investigation to the survey team on 8/17/15 at 9:40 A.M. Record review of the resident's Incident/Accident Investigation Interview, dated 7/5/15 (for the elopement on 7/4/15), completed by a CNA showed: -The resident had been pushing on all doors trying to get out. -The resident kept pushing on the door until it opened and went out the back door (outside). -The CNA got the resident and brought him/her back inside. Record review of the resident's nurse's notes, dated 7/5/15 at 6:30 A.M., showed staff documented: -The back door alarm (on the SCU) went off and the resident stepped out the back door. -The CNA brought the resident back inside. -The resident was placed on fifteen-minute checks. --There was no Report of Alleged Incident/Accident completed for this incident. Record review of the resident's nurse's notes, dated 7/8/15 at 7:00 P.M., showed staff documented: -The resident was exit-seeking and opening doors. -Redirection was not effective. -The staff would continue to monitor. Record review of the resident's nurse's notes, dated 7/11/15 at 9:30 P.M., showed staff documented: -The resident made it through the exit door (the back door to the outside) two times; -He/she explained to the resident he/she could not use the back door because it makes the alarm go off; -There was no Report of Alleged Incident/Accident completed for this incident. Record review of the resident's nurse's notes, dated 7/13/15 at 7:00 P.M., showed staff documented: -The resident eloped from the 700 hall (SCU); -The door alarm did not work; -A therapist brought the resident back to the SCU; -The resident was exit-seeking; -The staff would continue to monitor. Record review of the resident's Report of Alleged Incident/Accident, dated 7/13/15 at 7:00 P.M., showed staff documented: -The Certified Medication Technician (CMT) notified this nurse that the resident got out of the unit through the 700 hall door to the hallway; -The door alarm did not work and the door alarm never sounded; -The resident could have followed behind a visitor before the door had a chance to reset; -The door alarm was working at the moment; -The incident was marked as an elopement; -The resident's condition prior to the incident was not completed; -The incident was not witnessed by the staff; -The results of the investigation: -The resident was looking for his/her spouse; -Additional interventions and actions to prevent reoccurrence: -The staff were to help the resident use the phone to call his/her spouse; -Activities staff were to walk with the resident three times per week off the SCU; -The staff were to walk with the resident outside; -The report was not signed by the DON or Administrator; -The therapist did not complete a witness statement. Record review of the Incident/Accident Investigation Interview, dated 7/13/15, completed by CMT B showed: -He/she was in another resident's room assisting the resident to bed. -When CMT B came out of the other resident's room, Resident #25 had left the hall. -CMT B was walking around looking for the resident when a therapist approached and asked if CMT B could identify a person the therapist met off the 800 hall. -CMT B informed the therapist that the person was a resident from the SCU. -CMT B took the resident back to the SCU and sat him/her down by the television area. -One of the problems was the resident kept trying to get off the unit to go see his/her spouse. -CMT B informed the charge nurse about the situation. Record review of the resident's admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Did not wander; -Independent with ambulation, but required staff supervision while ambulating. Record review of the resident's daily charting, dated 7/14/15 at 7:20 A.M., showed LPN C documented: -He/she was notified by a floor technician that the resident was in the parking lot; -The resident was found in the back of the building (outside) ambulating; -LPN C assisted the resident back inside the building; -Staff assessed the resident without any injury; -Staff placed the resident on fifteen-minute checks; -All of the doors (on the SCU) were secure. Record review of the resident's Report of Alleged Incident/Accident, dated 7/14/15 at 7:20 A.M., showed staff documented: -The floor technician observed the resident in the parking lot this morning. -The resident wore proper shoes and clothing; -The resident said he/she was just walking around by the parking lot of the SCU exit door; -Staff did not mark the incident type; -Staff did not document the resident's condition prior to the incident; -The incident was not witnessed by the staff; -Results of the investigation: -The resident liked to take walks and the resident was also looking for his/her spouse; -Identify any condition of the resident involved which may have contributed to the incident: -The SCU exit door's green light was on and the door was unarmed; -Additional interventions and actions to prevent reoccurrence: -Activities staff and staff to walk with the resident either outside or off of the unit; -Call the resident's spouse on the phone; -Place an orange mesh and stop sign across the back door (of the SCU); -Place a plastic cover on the alarm panel at the nurses' station to prevent the alarm from accidentally getting turned off; -The report was not signed by the Administrator or the DON; -The floor technician and CNAs did not complete staff witness statements about the incident. Record review of the resident's daily charting, dated 7/15/15 at 4:30 P.M., showed staff documented: -The resident tried to get out the hall door of the SCU. Record review of the resident's care plan, last updated on 7/22/15, showed: -The resident had exit-seeking behaviors including looking for his/her spouse or wanting to take a walk; -The goal was to decrease the resident's exit-seeking behaviors; -Approaches: -On 7/1/15: Redirect the resident by offering fluids/snacks. Administer PRN medications when non-pharmaceutical interventions were not effective. Call the spouse when the resident was looking for him/her. Give the resident a shower because showers calm the resident down; -On 7/13/15-7/14/15: The resident liked to walk. The activity staff would walk with the resident three times per week. The nursing staff would take the resident outside for a walk. Place orange mesh across the exit door and place a stop sign on the door. Place a plastic cover across the alarm panel to prevent accidentally turning off the alarm. Offe