Every finding on record at Hope Care Center

Based on observation, interview and record review, the facility failed to ensure appropriate sanitation of dish and cookware when the facility's dish machine was not dispensing an adequate amount of chemicals to sanitize the food prep and service items. The facility census was 16 residents.A policy regarding dishwasher maintenance or chemical disinfecting was requested and not received.1. Review of the facility's blank Daily Dietary Checklist, undated, showed the kitchen staff were to record water temperature and parts per million (PPM-a unit of concentration that expresses the amount of a substance within a million parts of a solution or mixture) of the sanitizer agent.Review of the facility's dishwasher manufacturers operation manual, undated, showed the minimum PPM chlorine (a chemical used as a disinfectant in water, a bleaching agent) required was 50 PPM.Review of the facility's Dish Machine Log dated August 2025, showed the dishwasher PPM was documented daily as 110 to 70 throughout the month.Observation on 9/4/2025 at 9:55 A.M., showed:-A dishwasher chemical sanitization test strip (a small strip of paper that changes color when exposed to water containing chlorine) indicated there was approximately 10 PPM of chlorine in the water. -The Kitchen Manager immediately ran the dishwasher and retested with a new test strip.-The second test showed it was darker than first test but still below 50 PPM.-There was a bucket located under the dishwasher with hoses that lead from the bucket to the dishwasher, allowing the chemicals to be fed to the dishwasher.-There was a small kink in the hose near the bucket.During an interview on 9/4/2025 at 9:55 A.M., the Kitchen Manager said:-The dishwasher used chemicals for sanitization of the facility's food preparation and service utensils.-He/She used test strips at least daily to check the PPM.-He/She expected the correct amount of chemical to be released to meet sanitization.-He/She noted the kink in the hose, maneuvered the hose and ran the dishwasher again.During an interview on 9/5/2025 at 9:16 A.M., the Kitchen Manager said he/she or the [NAME] checked the dishwasher daily and recorded on the dishwasher log. Observation on 9/5/2025 at 10:43 A.M., showed:-The dishwasher was run by kitchen staff, and a new test strip was used to test the water.-The test strip showed below 50 PPM.During an interview on 9/5/2025 at 1:56 P.M., the Maintenance Director said:-He/She used a Total Dissolved Meter (TDM-a handheld device that measured the total dissolved solids in a liquid) to measure the PPM in the dishwasher water.-The meter showed 70 PPM.-The Kitchen Manager went to the store to get new test strips.-He/She was unsure how old the test strips were.Observation on 9/8/2025 at 11:20 A.M., showed:-The [NAME] ran the dishwasher and used the test strip which showed the chlorine level to be not quite 50 PPM.-The cook ran the dishwasher again and the test strip showed approximately 40 PPM.During an interview on 9/8/2025 at 11:20 A.M., the [NAME] said:-He/She ran the dishwasher and tested the water with the new test strips.(it showed less than 50 PPM)-He/She ran the dishwasher again, using a new test strip, looked at the test strip and noted it was around 40 PPM.-He/She expected the dishwasher chemicals to be correct and use enough to reach 50 PPM.During an interview on 9/9/2025 10:01 A.M., the Administrator said:-The facility did not have policies regarding dishwasher maintenance or chemical disinfecting. -He/She provided a checklist that kitchen staff complete daily. -He/She expected the dishwasher to disinfect the dishes properly with the correct PPM.

Based on observation and interview, the facility failed to maintain two handrails firmly attached to the wall outside of resident rooms [ROOM NUMBERS]. This practice potentially affected at least 4 residents who resided in those rooms. The facility census was 16 residents.1. Observation on 9/5/24 at 11:38 A.M. and on 9/8/25 at 11:17 A.M., showed two handrails outside of resident rooms [ROOM NUMBERS] which were not firmly attached to the wall.During an interview on 9/8/25 at 11:17 A.M., the Maintenance Director said:-The handrail had not been loose that long.-A resident from resident room [ROOM NUMBER] used the handrail when he/she left his/her room.During an interview on 9/9/25 at 2:25 P.M., the Maintenance Supervisor said the handrails were checked once per month.

Based on observation and interview, the facility failed to prevent the presence of a black substance on the ceiling and failed to repair an eight foot (ft.) long area where a black substance leaked from the ceiling of Furnace room [ROOM NUMBER]. The facility also failed to maintain an outdoor handrail supporting system outside of the kitchen in good repair due to the crumbling of the concrete area which supported that handrail. This practice affected one non-resident use area and at least 7 residents who resided in that area of the facility, that would use the exit discharge (the portion of the means of egress between the building exit and the public way, street, alley, or other similar parcel of land essentially open to the outside air deeded, dedicated, or otherwise permanently appropriated for public use) which went through the service area next to the kitchen. The facility census was 16 residents.1. Observation on 9/8/25 at 9:59 A.M., with the Maintenance Director of furnace room [ROOM NUMBER], showed:-The presence of several areas of a black substance on the ceiling of the furnace room.-An eight ft. long leak from the ceiling to the floor of a black colored substance.During an interview on 9/8/25 at 10:01 A.M., the Maintenance Director said:-He/she was not sure about the origin of the black substance on the ceiling of furnace room [ROOM NUMBER].-The area of the black colored leak had additional leaking when it rained.2. Observation on 9/8/25 at 12:39 P.M., showed:-One post of a handrail at the outdoor exit discharge from the service passageway adjacent to the kitchen was in concrete that was crumbling away. -The crumbled area was 8 inches (in.) high, 12 in. wide and 6 in. long, with visible rust from the metal post.During an interview on 9/9/25 at 9:53 A.M. the Administrator said the concrete was in need of repair and that area had been overlooked previously.

Based on observation and interview, the facility failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination); and failed to separate damaged foodstuffs, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 13 residents with a licensed capacity for 16 residents at the time of the survey. 1. Observations on 6/11/24 at 10:53 A.M., during the facility basement inspection, showed there was no thermometer in the freezer in the Food Storage room. Observations on 6/11/24 at 11:16 A.M., showed there was a 7 pound (lb.) 3 ounce (oz.) can of baked beans that was dented on one side and stored on a shelf with other various undented cans. Observations on 6/12/24 at 9:18 A.M., during the follow-up kitchen inspection showed a yellow cutting board on the food preparation table next to the 3-tub sink was heavily scored to the point that plastic bits were flaking off. During an interview on 6/12/24 at 1:31 P.M., the Dietary Manager (DM) said: -After separating damaged foodstuffs from the regular, they send them back to the food vendor for a refund. -He/She would expect food to be free of foreign substances. -Damaged food preparation items are thrown away when found, especially cutting boards. -All refrigerators and freezers should have thermometers in them.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 13 residents with a licensed capacity for 16 residents at the time of the survey. 1. Observations on 6/11/24 at 11:17 A.M., during the initial kitchen Life Safety Code (LSC) inspection with the Dietary Manager (DM) present, showed a three-sink area, a chemical and high heat dish-washing machine, and a hand-washing sink. Observations on 6/12/24 between 9:33 A.M. and 3:57 P.M., during the initial facility LSC room-to-room inspections with the Maintenance Manager (MM), showed the following: -There was a facility-wide fire sprinkler system. -On the lower level there was a laundry room with clothes washers, two restrooms, and the Maintenance Office where the sprinkler risers (Fire sprinkler risers are, in a sense, where the plumbing outside a building ends and a fire sprinkler system begins. Each riser taps into a permanent source of water, such as a pipe connected to the city water system, a water tank, or reservoir.) were located. -On the main level there were at least 12 resident rooms with sinks and bathrooms, two bathhouses, a Main Dining Room with an ice machine, and a janitor's closet with a mop hopper sink. Review of the facility's water-borne pathogen prevention program in a binder entitled, Water Management Program, last reviewed on 7/14/23 and provided by the MM, showed the following: -There was no facility-specific risk management plan assessment that considered all elements of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -There was no facility-specific infection prevention and control program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There was a diagram on page 6 showing possible stagnation locations throughout the facility, but no assessments of each location's individual potential risk level. -At Appendix B2: Example Log Sheets and Checklists, there were 12 blank pages of various charts, checklists, and spreadsheets to be used by the facility including, but not limited to a Program Strategy, Potable Water Services Monitoring, At-Risk Water System Monitoring, Bacterial Indicator Test, and a Program Action Log, but none were completed or used as templates. -There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. -The 4-page report from the water lab company, dated 6/1/23, showed no test methods listed under that same heading on pages 2 through 4. During an interview on 6/12/24 at 2:47 P.M., the MM said the following: -The blank sheets in the binder are not used. -The company that created the program was sending someone out to periodically test the water for Legionella, but they said the facility was at low risk so testing was really only needed once a year. -He/She did occasional flushings, but they were not documented anywhere. During an interview on 6/13/24 at 12:16 P.M., the Administrator said the following: -Their water-borne pathogen program was based on the regulations and created by the MM and the previous Administrator. -He/She would expect that whoever created the Legionella program would know all the requirements.

Based on interview and record review, the facility failed to ensure the annual comprehensive Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) were completed timely for four sampled residents (Residents #59, #57, #1, #4) out of 8 sampled residents and one supplemental resident (Resident #160). The facility census was 13 residents. 1. Review of Resident #59's Face Sheet showed the resident was admitted on [DATE], with diagnoses including Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), malnutrition, depression, high blood pressure, diabetes, low back pain and neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's MDS assessments showed: -The resident's last annual assessment was dated 5/3/23. -The resident's annual assessment was due on 5/3/24. The electronic medical record showed this assessment was 26 days overdue. -There was a quarterly assessment dated [DATE] that showed in progress but was not completed (this assessment should have been the annual assessment). 2. Review of Resident #57's Face Sheet showed the resident was admitted with diagnoses including stroke, high blood pressure, glaucoma (a disease that damages your eye's optic nerve that can cause blindness), and history of transient ischemic attack (TIA- stroke-like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke). Review of the resident's MDS assessments showed: -The resident's last annual assessment was completed 5/3/24. -The resident's annual assessment was due on 5/3/24 and was shown in the electronic medical record as being 26 days overdue. -There was a quarterly assessment started on 6/21/24 and was shown in the electronic record as in progress but was not completed (this assessment should have been the Annual assessment). 50579 3. Review of Resident #160's Face Sheet showed the resident admitted [DATE] with diagnoses including urinary retention, anxiety, hemiplegia (paralysis of one side of the body following a stroke) of the right side, chronic pain, unspecified mood disorder, and a stage two pressure ulcer. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last annual assessment was completed 11/20/22 and was shown in the medical record as being 196 days overdue. -An annual assessment dated [DATE] was noted with a status of In Progress, but was incomplete and not submitted. 4. Review of Resident #4's Face Sheet showed the resident admitted [DATE] with diagnoses including cancer, depression, PTSD, and a personal history of other unspecified behavioral disorders. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last comprehensive assessment was the admission assessment, completed 4/13/23. -A comprehensive assessment was due 4/13/24, had not been completed, and was 46 days overdue. 5. Review of Resident #1's Face Sheet showed the resident admitted [DATE] with diagnoses including anxiety and depression. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last comprehensive assessment was a significant change assessment, completed 3/15/23. -A comprehensive assessment was due 3/15/24, had not been completed, and was 75 days overdue. 6. During an interview on 6/13/24 at 10:54 A.M., Licensed Practical Nurse (LPN) A said he/she does not complete the MDSs normally but as residents' care needs change, the nurse will let the MDS Coordinator know and the MDS Coordinator will update the residents' MDS assessments and care plans. During an interview on 6/13/24 at 11:12 A.M., the Director of Nursing (DON) said: -He/She expects for MDS to be completed and submitted timely. -Annual assessments should be completed according to the resident's MDS schedule yearly. -He/She was aware there were problems with the MDS submissions. -The former MDS Coordinator was not full time and the timeframe between when he/she left the position and when they found a new MDS Coordinator was when the submissions fell behind. -The current MDS Coordinator is in training and has not been able to get everything caught up yet but they are in the process of doing so.

Based on record review and interview, the facility failed to ensure Minimum Data Sets (MDS, a federally mandated assessment tool to be completed by facility staff for care planning) were completed quarterly for 8 residents (Residents #3, #5, #59, #57, #4, #1, #2, and #161) out of 8 sampled residents. The facility census was 13 residents. 1. Review of Resident #3's Face Sheet showed the resident was admitted on [DATE], with diagnoses including urinary tract infection, diabetes, vitamin deficiency, glaucoma (a disease that damages your eye's optic nerve that can cause blindness), high blood pressure, heart disease, paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), pain and edema (fluid in the tissues). Review of the resident's MDS assessments showed: -The resident's last Annual assessment was completed on 6/25/2023. -The resident's Quarterly assessment was due on 3/27/24. It was not completed and showed in the electronic medical record as being 63 days overdue. 2. Review of Resident #5's Face Sheet showed the resident was admitted on [DATE], with diagnoses including a below the knee amputation. Review of the resident's MDS assessments showed: -The resident's Admission assessment was completed on 11/29/23. -The resident's Quarterly assessment was due on 5/31/24. It was not completed and showed in the electronic medical record as being 2 days overdue. The electronic record showed the assessment was in process on 5/29/24. 3. Review of Resident #59's Face Sheet showed the resident was admitted on [DATE] with diagnoses including Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), malnutrition, depression, high blood pressure, diabetes, low back pain and neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's MDS assessments showed: -The resident's last annual assessment was dated 5/3/23. -The resident's quarterly assessment was due on 2/3/24. It was not completed and showed in the electronic medical record as being in process. This assessment was also shown as being 116 days overdue. 4. Review of Resident #57's Face Sheet showed the resident was admitted with diagnoses including stroke, high blood pressure, glaucoma, and history of transient ischemic attack (TIA-stroke-like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke). Review of the resident's MDS assessments showed: -The resident's last Annual assessment was completed 5/3/24. -The resident's Quarterly assessment was due on 2/3/24. It was not completed and showed in the electronic medical record as being 116 days overdue. 50579 5. Review of Resident #4's Face Sheet showed the resident admitted [DATE] with diagnoses including cancer, depression, PTSD, and a personal history of other unspecified behavioral disorders. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last quarterly assessment was completed 1/14/24. -A quarterly assessment was due 4/15/24, had not been completed, and was 44 days overdue. 6. Review of Resident #1's Face Sheet showed the resident admitted [DATE] with diagnoses including anxiety and depression. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last quarterly assessment was completed 12/16/23. -A quarterly assessment was due 3/17/24, had not been completed, and was 73 days overdue. 7. Review of Resident #2's Face Sheet showed the resident admitted [DATE] with diagnoses including high blood pressure and hemiplegia (partial or complete paralysis on one side of the body) on the right side. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last quarterly assessment was completed 12/19/23. -A quarterly assessment was due 3/20/24, had not been completed, and was 70 days overdue. 8. Review of Resident #161's Face Sheet showed the resident admitted [DATE] with diagnoses including seizures, dementia, hemiplegia, and insomnia. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last quarterly assessment was completed 12/11/23. -A quarterly assessment was due 3/12/24, had not been completed, and was 78 days overdue. 9. During an interview on 6/13/24 at 10:54 A.M., Licensed Practical Nurse (LPN) A said: -He/She said she does not complete the MDS but normally as residents' care needs change, the nurse will let the MDS Coordinator know and the MDS Coordinator will update the resident's MDS and care plan. During an interview on 6/13/24 at 11:12 A.M., the Director of Nursing (DON) said: -He/She expects for MDS to be completed and submitted timely. -Quarterly MDS should be completed every three months as scheduled. -He/She was aware there were problems with the MDS submissions. -The former MDS Coordinator was not full time and the timeframe between when he/she left the position and when they found a new MDS Coordinator was when the submissions fell behind. -The current MDS Coordinator is in training and has not been able to get everything caught up yet but they are in process of doing so.

Based on interview and record review, the facility failed to follow facility policies and procedures for checking the Nurse Aide Registry for federal indicators of abuse as part of the Criminal Background Check (CBC) and in accordance with state requirements for two of four employees sampled for the criminal background screening. The facility census was 13 residents. Review of the facility's revised Abuse and Neglect policy and procedure dated 1/1/2024, showed: -All potential employees will be screened and trained to ensure that individuals with a documented history of abuse or other inappropriate conduct are not hired, and that all employees are properly trained regarding abuse of residents. -All employees will be screened prior to contact with facility residents, and quarterly, as follows: Federal Indicator List. 1. Review of two employee records showed: -Licensed Practical Nurse (LPN) B was hired on 2/5/24, and there was no Nurse Aide Registry Check completed. -Cook A was hired on 4/8/24, and there was no Nurse Aide Registry Check completed. During an interview on 6/12/24 at 12:16 P.M., the Human Resource Manager said: -He/She was not aware that the nurse aide registry was supposed to be completed on all employees. -He/She was going to complete an audit on all employee records to ensure the nurse aide registry is completed and in all employee files. -He/she was responsible for completing background checks.

Based on observation, interview and record review, the facility failed to ensure staff administered medications with a rate less than 5%. Facility staff made eight medication errors out of 29 attempts, resulting in a medication error rate of 27.59%. This affected three of seven sampled residents (Residents #2, #4, and #160) for medication pass. The facility census was 13. A facility policy titled Medication Administration-General Guidelines, dated 9/1/2006, showed: -Medications were to be administered per physician orders. -Medications were to be administered within 60 minutes of the ordered time. -The individual who administered the medication was to document the administration directly after the medication was given. 1. Resident #160's Physician Order Sheet (POS), obtained 6/13/24, showed: -An order for Carbidopa-Levodopa (a medication given for tremors) 25 milligrams (mg) Carbidopa/100 mg Levodopa, four times daily (9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M.) -An order for Lorazepam (a controlled medication given for anxiety) 0.5 mg, three times daily (between 7:00 A.M.-10:00 A.M., between 11:00 A.M.-1:00 P.M., and between 7:00 P.M.-9:00 P.M.) During an interview on 6/13/24 at 7:20 A.M., Certified Medication Technician (CMT) A said: -The night nurse would often pass some day shift medications but would not document the medications as given. -He/She would have to look through the medication cart to see who had received medications and who had not. -The only way to tell if the medications had been given was to look at the timed/dated pill packs that some of the medications came from the pharmacy in to see if they were missing. -If the medication pack was missing, he/she would assume all the resident's morning medications had been given, even if they were not documented as given by the night shift nurse. During an observation of the medication pass on 6/13/24 at 7:30 A.M.: -CMT A reviewed Resident #160's Medication Administration Record (MAR). -The MAR indicated the only medication due for the resident was Carbidopa-Levodopa. -CMT A said the night nurse gave many of the morning meds, and he/she was unsure which had been given. -After review of the resident MAR, CMT A removed a Lorazepam 0.5 mg tablet from the locked narcotic box and signed the tablet out of the narcotic book. -CMT A administered the 0.5 mg Lorazepam tablet to the resident. -CMT A documented in the MAR that he/she gave Carbidopa-Levodopa, but did not document that he/she gave Lorazepam. Surveyor reconciliation of the medication administration on 6/13/24 at 8:14 A.M., showed Carbidopa-Levodopa had been signed out at 7:00 A.M. by Licensed Practical Nurse (LPN) B and again at 7:30 A.M. by CMT A. Further reconciliation revealed LPN B had documented the Lorazepam being given at 6:14 A.M. During an interview on 6/13/24 at 8:24 A.M., CMT A said he/she had given the resident only Lorazepam at the 7:30 A.M. administration. During review of the MAR and an interview on 6/13/24 at 8:28 A.M., CMT A then said he/she administered both Lorazepam and Carbidopa-Levodopa to the resident and he/she did not know why the MAR documentation did not show he/she gave the Lorazepam. CMT A verified the MAR showed Lorazepam was administered at 6:14 A.M., but that he/she gave the resident a second dose at 7:30 A.M. Review of the resident's medication administration record (MAR) on 6/13/24, showed: -One documented administration of Lorazepam at 6:14 A.M. by LPN B. -A documented administration of Carbidopa-Levodopa at 7:32 A.M. by CMT A. -The CMT documented in error that he/she gave the Carbidopa-Levodopa, when he/she gave the resident a second dose of Lorazepam instead. During an interview on 6/13/24 at 8:30 A.M., the Director of nursing (DON) said: -He/she would not expect the Carbidopa-Levodopa to be documented if not given. -The Lorazepam appeared to be given to the resident twice within a one-hour timeframe. 2. Review of Resident #4's POS on 6/13/24 showed physician orders for: -Metoprolol (a drug given for high blood pressure and an elevated heart rate) 50mg tab to be given at 9:00 A.M. -Gabapentin (a drug given for nerve pain) 100 mg to be given at 9:00 A.M. -Cyclobenzaprine (a drug given for muscle spasms) 10mg to be given at 9:00 A.M. During an interview on 6/13/24 7:34 A.M., CMT A said Resident #4 had already had his/her medications administered because some had been documented on by night shift and the pill pack containing all of the medications was missing, so he/she would not be giving the resident any medications that morning. Review of the resident's MAR on 6/13/24 at 7:35 A.M., at that time, indicated Gabapentin, Metoprolol and Cyclobenzaprine had not been administered and were due at 9:00 A.M. During an interview on 6/13/24 at 7:36 A.M., CMT A stated again he/she would not be administering those medications, as they had already been given by the night shift and were not in the medication cart. Review of the MAR provided by the facility on 6/13/24 at 11:00 A.M., showed the doses of Gabapentin, Metoprolol, and Cyclobenzaprine had not been administered. 3. Review of Resident #2's POS showed physician orders for: -Acetaminophen (an over-the-counter pain medication) 500 mg, two tablets, at 8:00 A.M. -Metoprolol 50mg to be given at 9:00 A.M. -Tramadol (a narcotic pain medication) to be given at 9:00 A.M. -Linzess (a drug for maintaining healthy bowel movements) to be given at 9:00 A.M. During an observation on 6/13/24 at 8:01 A.M.: -CMT A took two Acetaminophen 500 mg tablets from the medication cart and attempted to administer them to the resident. -The resident declined and said he/she had already received all their medications that morning, including the Acetaminophen. -No medications were administered. -CMT A returned to the medication cart and documented Acetaminophen, Metoprolol, Tramadol and Linzess as administered at 8:08 A.M. Review of the resident's MAR provided by the facility on 6/13/24, showed the medications had been documented as administered at 8:08 A.M. 4. During an interview on 6/13/24 at 8:30 A.M., the Director of nursing (DON) said: -Night shift may pick and choose some medications to administer for the day shift. -He/She expected medications to be given no earlier than one hour before or no later than one hour after the time on the MAR. -He/She expected any medications given by the night shift to be documented by the staff administering the medication. -He/She would not expect the day shift to have to guess who had received medications. -He/she expected staff to only document administration of medications they had administered themselves. -He/she expected the medications to be documented as they were given, not hours later.

Based on interview and record review, the facility failed to ensure the completion of a necessary significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment) for one resident with a hospice admission (Resident #161) out of 8 sampled residents. The facility census was 13. Review of a facility policy titled Minimum Data Set Assessments, dated 6/13/24, lacked information regarding triggering an MDS assessment and timing of assessments. Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual (a federally published guide for facility staff to complete and submit MDS assessments accurately and timely) instructed facilities to set a Significant Change Assessment Reference Date (ARD, the date of assessment initiation) no later than 14 days following the determination that a significant change had occurred. The RAI includes a hospice admission as a significant change and guides facilities to complete a Significant Change MDS assessment. 1. Review of Resident #161's Progress Note dated 4/10/24 at 1:13 P.M., showed the resident was admitted to Hospice A on 4/10/24. Review of the resident's Physician Order Sheet (POS) on 6/13/24 showed an order for admission to hospice placed on 5/1/24 to begin on 4/22/24. Note: the physician's orders did not get entered timely into the resident's medical record. Review of the resident's MDS assessments showed: -His/Her last assessment to be completed was a Quarterly Assessment, dated 12/11/23. -A Significant Change Assessment with the status of In Progress and an ARD of 5/24/24, 44 days from the hospice admission. During an interview on 6/12/24 at 11:48 A.M., Licensed Practical Nurse (LPN) A said: -He/she was recently hired by the facility in April and was responsible for completing MDS assessments. -He/she opened the Significant Change Assessment, but it was too late. -The Significant Change MDS Assessment should have been completed by now, but it has not. During an interview on 6/12/24 at 12:34 P.M., the Director of Nursing (DON) said: -LPN A was responsible for completing MDS assessments. -The Significant Change Assessment was the responsibility of the previous Assistant Director of Nursing (ADON), but he/she no longer worked at the facility. -Staff thought it was too late to complete the Significant Change Assessment, so it was not done. -MDS has been an ongoing problem for the facility. -The past ADON did not complete MDS assessments timely. -He/She expected MDS assessments to be completed within an acceptable timeframe per the RAI Manual.

Based on observation, interview and record review, the facility failed to ensure the care plans were updated as residents' care and needs changed for two sampled residents (Residents #59 and #161) out of 8 sampled residents. The facility census was 13 residents. 1. Review of Resident #59's Face Sheet showed the resident was admitted on [DATE], with diagnoses including Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), malnutrition, depression, high blood pressure, diabetes, low back pain and neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). 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 11/3/23, showed the resident: -Was alert and oriented with no confusion or behaviors. -Had no upper or lower extremity impairments and ambulated independently. -The resident had no significant weight loss or weight gain and did not have any chewing or swallowing problems. -The resident did not have another MDS completed or submitted since 11/3/23. Review of the resident's Nutrition Notes, dated 2/8/24, showed: -The resident's weight on 2/3/24 showed 160.5 pounds (Lbs.) down 8.7 percent in one month, down 16.3 percent in three months, and down 17.5 percent in six months. -The resident received a regular diet with chopped meat. -The resident's meal intake is usually between 75-100 percent. -The staff reports the resident eats well, was trying to lose weight, and eats less between meals. -The resident's skin was intact. -Notes showed the resident was happy with weight loss. His/Her intake met his/her nutritional needs. Continue plan of care and monitoring. Review of the resident's Care Plan dated 2/29/24, showed the resident had poor oral health which led to oral/dental health problems. The resident was able to perform oral care independently. The resident received a regular diet and did receive dental services from the facility dentist and has upper and lower dentures. Interventions showed staff would: -Serve the resident's diet as ordered and chop meats upon request. -Consult with the facility dentist as needed for oral management. -Consult with the Dietician if chewing and swallowing problems change. -Monitor the resident, report and document any signs/symptoms of oral/dental problems that need attention. -Assist the resident as needed with nutritional choices to achieve his/her weight loss goal. -Educate the resident regarding nutritional needs and requirements. -Encourage the resident to consume adequate protein to maintain stable blood sugars. -Encourage the resident to consume nutritious foods. Review of the resident's Weight Record showed the resident was on weekly weights for monitoring. The resident's monthly weights showed: -1/27/2024 =162.4 pounds (Lbs.) -2/24/2024 =164.8 Lbs -3/30/2024 =156.6 Lbs -4/27/2024 =151.8 Lbs -5/25/2024 =150.8 Lbs -6/8/2024 =145.8 Lbs -The documentation showed the resident's weight loss of 10.49 percent in 6 months, 6.45 percent in 3 months, and 2.68 percent in one month was not significant weight loss but his/her weight loss was gradual. Review of the resident's Physician's Order Sheet (POS), dated 6/2024, showed physician's orders for: -Regular modified diabetic diet with chopped meats (8/22/23). -Weekly weights on Saturday, notify the physician for weight gain or loss of more than 5 pounds (1/6/24). -Cholecalciferol Tablet 1000 UNIT Give 2 tablet by mouth one time a day related to protein calorie malnutrition (3/21/24). -Glucerna shake at breakfast (4/16/24). -Trulicity pen injection 0.75 milligrams (mg) inject 1.5 mg subcutaneously (beneath the skin) once daily for diabetes (5/30/24). Review of the resident's electronic record showed no additional notes showing the resident had any problems with weight loss or justification for weight loss interventions after 2/29/24. Documentation showed there was no problems with the resident's gums, however the documentation showed that the facility dentist made adjustments to the resident's dentures. There was no documentation showing this affected the resident's intake. Review of the resident's Care Plan dated 6/12/23, showed there was no update to the resident's nutritional status to show the resident had weight loss that was being monitored, had a weight loss goal, was placed on a health shake, was taking medication that directly affected his/her weight loss or if the resident had reached weight loss goals or what the current status nutritional status of the resident was. Observation and interview on 6/12/24 at 9:19 A.M., showed the resident was in his/her bed resting but was awake. The resident was not wearing dentures. The resident was alert and oriented and said: -The facility dentist came and got his/her dentures to readjust them because they didn't fit anymore due to him/her losing weight. -He/She currently had his/her dentures, but it has taken him/her time to get used to wearing them. -It really had not affected him/her being able to eat. -He/She was trying to lose weight, but he/she was also on Trulicity, which induced weight loss. -During the time he/she was without his/her dentures he/she wasn't eating as much, but he/she did not mind the weight loss. Once he/she got the new dentures, he/she continued to lose weight, but he/she thought his/her continued weight loss was due to the Trulicity. Observation on 6/12/24 at 12:01 P.M., showed the resident sitting in the dining room eating a regular diet of pork loin, sweet potato, cabbage with choice of beverage. He/She was not wearing his/her dentures and was eating independently without an assistive device or staff assistance. The resident was eating without choking, coughing or swallowing difficulty. He/She ate 75 percent of his/her meal and once he/she was done, he/she got up and ambulated out of the dining room. During an interview on 6/12/24 at 2:50 P.M., Licensed Practical Nurse (LPN) A said: -The resident had weight loss that was self-initiated by the resident. -The resident wanted to lose some weight and stopped eating as much. -The resident was also started on Trulicity for diabetes, which also has a side effect of weight loss and so some of her weight loss also came from the medication. -The resident had not had any issues eating and ate independently. -The resident usually ate without his/her dentures but does have and wear dentures. -He/She was not sure if the resident's continued weight loss was self induced. -She said the information regarding the resident's weight loss and interventions should be in the resident's care plan. 50579 2. Review of Resident #161's hospice facility admission orders, dated 4/10/24 and signed by a hospice Registered Nurse (RN), showed: -The resident was admitted to hospice services on 4/10/24. -An order for oxygen at 2 liters per minute as needed (PRN). -An order for Morphine (a narcotic pain medication) 5 milligrams (mg) every one hour as needed for pain or dyspnea (difficulty breathing). -An order for Lorazepam (a controlled medication used for anxiety) 0.5 mg every four hours as needed for anxiety. Review of the resident's POS on 6/13/24, showed orders for admission to hospice services and PRN oxygen. Review of the resident's undated Care Plan on 6/13/24 showed: -No information or direction for staff on the PRN oxygen order. -No information regarding indication, side effect monitoring or direction for staff on the Morphine or Lorazepam orders. -No indication the resident was admitted to hospice services, the date of service initiation, medication information, or what services the hospice agency would provide to the resident. 3. During an interview on 6/13/24 at 10:54 A.M., LPN C said: -The nurse usually will let the MDS Coordinator know when residents' care needs have changed, and the MDS Coordinator will update the resident's care plan. -The nurses will implement what the change in care is and write and implement new physician's orders (if there is a change in orders), but the nurses do not document any updates to the care plans. During an interview on 6/13/24 at 11:12 A.M., the Director of Nursing (DON) said: -Regarding the resident care plans, both the former and current MDS Coordinator did not keep up with updating care plans. -The care plans were already past due because the MDS's were past due. -The MDS Coordinator is not the only person who can update the care plan, but this is how it was done before now. -He/She has been assisting with updating the care plans as residents' care changes. -The nurses can update the care plans as the residents' care changes. -The quarterly updates to the care plans will be done with the MDS.

Based on interview and record review, the facility failed to transcribe medication orders accurately and periodically reconcile physician orders when an antipsychotic medication was added to a resident's medical record without an order for one resident (Resident #161) of 5 residents sampled for unnecessary medications. The facility census was 13. A policy for order transcription and medication reconciliation was requested on 6/13/24 but was not received prior to exit. 1. Review of #161's face sheet showed diagnoses including seizures, dementia without behavioral disturbances, adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior), stroke, and insomnia (difficulty sleeping). Review of the resident's hospice facility admission orders, dated 4/10/24 and signed by a hospice Registered Nurse (RN), showed: -The resident was admitted to hospice services on 4/10/24. -A section of the orders titled Comfort Kit orders had standing orders and instructions to circle NO for all declined orders and draw a line through the order. -An order circled NO for Haloperidol (an antipsychotic drug used to treat certain types of severe mental disorders that can cause major, lasting side effects) 2 milligrams per milliliter (mg/ml), 1mg by mouth or sublingually (under the tongue) every four hours as needed for delirium, agitation, nausea and/or vomiting. -The order for Haldol had a line through the text and an X to the left of the order. Review of the residents Physician Order Sheet (POS) on 6/13/24, showed an order for Haloperidol 1mg sublingually, every four hours as needed for delirium, agitation, nausea and/or vomiting beginning on 4/10/24 with no end date. Review of the residents Medication Administration Record (MAR) since 4/10/24 showed the resident had not received any Haloperidol. During an interview on 6/12/24 at 12:05 P.M., Licensed Practical Nurse (LPN) A said he/she had not input any hospice admission orders yet but would think that a medication that was circled no with a line through the text would be a non-valid order and should not have been input into the resident's record. During an interview on 6/12/24 at 12:34 P.M., the Director of Nursing (DON) said: -The nurse would be responsible for transcribing hospice orders from the sheet and inputting them into the resident record. -The nurse on duty on 4/10/24 put the hospice orders in the computer and the DON verified the orders. -Medication orders should be reconciled once per month to ensure accuracy. -He/she had not reconciled medications in the previous two months. -The Haloperidol order should not have been input into the resident's medical record and should have at least been discontinued after 14 days per standard of practice for antipsychotic drugs.

Based on observation, interview and record review the facility failed to ensure initial and quarterly smoking assessments were completed to establish a resident's capacity for smoking and establish a baseline for the resident's ability to smoke, determine assistance as necessary, and ensure safe smoking habits were in place and continuing for two sampled residents (Residents #3 and #59) out of 9 residents who smoked in the facility. The resident sample was 8 residents. The facility census was 13 residents. Review of the facility Smoking policy and procedure, dated 9/25/23, showed the purpose was to establish a healthy environment for residents, visitors and employees. Additionally, the facility must comply with federal, state and local regulations regarding smoking in healthcare facilities. The policy showed: -Residents may smoke outside of the building in designated areas and away from the facility's exterior doors. -Employees are responsible for reminding residents, visitors and other employees of the smoking policy if they see someone violating the smoking policy. -Residents, family members and visitors will be notified -Smoking assessments will be completed upon admission, quarterly and with significant change of condition in conjunction with the Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff for care planning. -Generally, all residents will be supervised smoking upon admission and up to 72 hours after admission. -Residents who have been assessed as having the cognitive and functional ability to smoke independently may smoke in the designated areas independently as desired. These residents may keep their cigarettes and smoking materials. 1. Review of Resident #3's Face Sheet showed the resident was admitted on [DATE], with diagnoses including glaucoma (a disease that damages your eye's optic nerve that can cause blindness), high blood pressure, heart disease, paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), pain and edema (fluid in the tissues). 1. 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 1/26/23, showed the resident: -Was alert and oriented without confusion or behaviors. -Had bilateral lower extremity impairment and mobilized in a wheelchair. -Needed moderate to total assistance with transfers, bathing, dressing (lower body), and toileting. -The MDS did not show the resident used tobacco products. Review of the resident's Care Plan dated 5/2/24, showed: -The resident smoked cigarettes. -Interventions instructed staff to: --Instruct the resident about smoking risks and hazards and smoking cessation aids available. --Instruct the resident on the facility smoking policy. --Notify the charge nurse immediately if the resident violates the facility smoking policy. --Observe the resident for signs of cigarette burns on his/her skin and body. -Resident was educated on not throwing cigarette butts into the grass and not to smoke under the awning. --The resident was able to light his/her own cigarette and keep his/her own lighter. --The resident was able to smoke unsupervised. Review of the resident's electronic medical record showed there was no documentation showing the facility staff completed an initial smoking assessment, annual smoking assessment or any quarterly assessments thereafter on the resident. There was no documentation showing the resident's continued ability to safely smoke and abide by the facility smoking policy. Observation on 6/12/24 at 9:28 A.M., showed the resident was sitting in his/her wheelchair outside smoking. He/She was positioned upright without any noticed contracture or loss of upper body control. The resident was in the designated smoking area with other peers smoking safely. There was staff outside with the residents. 2. Review of Resident #59's Face Sheet showed the resident was admitted on [DATE], with diagnoses including high blood pressure, diabetes, low back pain and neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's most recent quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with no confusion or behaviors. -Had no upper or lower extremity impairments and ambulated independently. -Was independent with bathing, dressing, toileting, transferring and eating. -The MDS did not show the resident used tobacco products. Review of the resident's Care Plan dated 3/2/23 showed: -The resident smoked cigarettes. -Interventions instructed staff to: --Instruct the resident about smoking risks and hazards and smoking cessation aids available. --Instruct the resident on the facility smoking policy. --Notify the charge nurse immediately if the resident violates the facility smoking policy. --Observe the resident for signs of cigarette burns on his/her skin and body. -The resident was educated on not throwing cigarette butts into the grass and not to smoke under the awning. --The resident was able to light his/her own cigarette and keep his/her own lighter. --The resident was able to smoke unsupervised. Review of the resident's electronic medical record showed there was no documentation showing the facility staff had completed an initial smoking assessment, annual smoking assessment or quarterly smoking assessments on the resident. There was no documentation showing the resident's continued ability to safely smoke and abide by the facility smoking policy. Observation on 6/11/24 at 2:00 P.M., showed the resident was sitting outside dressed for the weather smoking in the designated smoking area. He/She was smoking safely without assistance. When he/she was finished, he/she disposed of the smoking materials in the self-enclosed receptacle. 3. During an interview on 6/13/24 at 10:54 A.M., Licensed Practical Nurse (LPN) C said: -The nurses complete the initial smoking assessments, and they are in the resident's electronic medical record. -She said all smoking assessments are done in the facility electronic record system, not on paper. -The nurses should be completing quarterly smoking assessments, but he/she really had not seen any smoking assessments on residents that smoke. During an interview on 6/12/24 at 11:42 A.M., the Director of Nursing (DON) said: -He/She was not able to find the smoking assessments for the residents requested. -He/She did not realize that the smoking assessments had not been populating in the facility's electronic record system. -He/She was unable to find the handwritten smoking assessments except for one. -He/She completed the requested smoking assessments today and was auditing all of the files for the residents who smoke to ensure there are smoking assessments in their records. During an interview on 6/13/24 at 11:12 A.M., the DON said: -There were 9 residents who smoked in the facility and he/she was able to find smoking assessments on 5 residents. -He/She completed smoking assessments, in the electronic medical record, on everyone who smoked. -The residents should have an initial/annual smoking assessment and staff are supposed to complete quarterly assessments thereafter. -He/She did not find any quarterly assessments in the electronic records for the residents that smoked. -He/She discussed this in their team meeting and realized that the assessments were not being done appropriately and they are now going to ensure the assessments are going to be done with the quarterly MDS.

Based on observation, interview and record review, the facility failed to ensure medications were administered without significant errors when staff administered Lorazepam (a controlled medication given for anxiety) two times within one and one-half hours. This affected one resident (Resident #160) out of seven sampled residents for medication pass. The facility census was 13. A facility policy titled Medication Administration-General Guidelines, dated 9/1/2006, showed: -Medications were to be administered per physician orders. -Medications were to be administered within 60 minutes of the ordered time. -The individual who administered the medication was to document the administration directly after the medication was given. 1. Review of Resident #160's Physician Order Sheet (POS), obtained 6/13/24, showed: -An order for Carbidopa-Levodopa (a medication given for tremors) 25 milligrams (mg) Carbidopa/100 mg Levodopa, four times daily (9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M.) -An order for Lorazepam (a controlled medication given for anxiety) 0.5 mg, three times daily (between 7:00 A.M.-10:00 A.M., between 11:00 A.M.-1:00 P.M., and between 7:00 P.M.-9:00 P.M.) During an interview on 6/13/24 at 7:20 A.M., Certified Medication Technician (CMT) A said: -The night nurse would often pass some day shift medications but would not document the medications as given. -He/She would have to look through the medication cart to see who had received medications and who had not. -The only way to tell if the medications had been given was to look at the timed/dated pill packs that some of the medications came from the pharmacy in to see if they were missing. -If the medication pack was missing, he/she would assume all the resident's morning medications had been given, even if they were not documented as given by the night shift nurse. During an observation of the medication pass on 6/13/24 at 7:30 A.M.: - Certified Medication Technician (CMT) A reviewed Resident #160's Medication Administration Record (MAR). -The MAR indicated the only medication due for the resident was Carbidopa-Levodopa. -CMT A said the night nurse gave many of the morning meds, and he/she was unsure which had been given. -After review of the resident's MAR, CMT A removed a Lorazepam 0.5 mg tablet from the locked narcotic box and signed the tablet out of the narcotic book. -CMT A administered the 0.5 mg Lorazepam tablet to the resident. -CMT A documented that Carbidopa-Levodopa was given in the MAR, but did not document Lorazepam in the MAR. Surveyor reconciliation of the medication administration on 6/13/24 at 8:14 A.M., showed Carbidopa-Levodopa had been signed out at 7:00 A.M. by Licensed Practical Nurse (LPN) B and again at 7:30 A.M. by CMT A. Further reconciliation revealed LPN B had documented the Lorazepam being given at 6:14 A.M. During an interview on 6/13/24 at 8:24 A.M., CMT A said he/she had given the resident only Lorazepam at the 7:30 A.M. administration. During an interview on 6/13/24 at 8:28 A.M., during review of the MAR, CMT A said he/she administered both Lorazepam and Carbidopa-Levodopa to the resident and he/she did not know why the MAR documentation had not shown the Lorazepam. CMT A verified the MAR showed Lorazepam was administered at 6:14 A.M., but that he/she gave it at 7:30 A.M. Review of the resident's MAR on 6/13/24, showed: -One documented administration of Lorazepam at 6:14 A.M. by LPN B. -A documented administration of Carbidopa-Levodopa at 7:32 A.M. by CMT A. During an interview on 6/13/24 at 8:30 A.M., the Director of nursing (DON) said: -Night shift may pick and choose some medications to administer for the day shift. -He/She expected any medications given by the night shift to be documented by the staff administering the medication. -He/She would not expect the day shift to have to guess who had received medications. -He/she expected staff to only document administration of medications they had administered themselves. -The Lorazepam appeared to be given to the resident twice within a one-hour timeframe.

Based on observation and interview, the facility failed to maintain the floor area behind and under the dishwasher free of food debris and grime;to maintain the floor behind the reach in fridge with the clear glass, free of food debris; to maintain the toaster free of a heavy buildup of bread crumbs; to maintain the six burner stove free from a buildup of burnt--on grime; to prevent a buildup of dust on sprinkler head and the emergency light fixture in the kitchen; to maintain the gasket (a piece of rubber or some other material that is used to make a tight seal between two parts that are joined together) of a freezer in storage room [ROOM NUMBER] in good repair; to prevent an opened bag of corn meal from being stored in dietary storage room [ROOM NUMBER]; to maintain the floor of dietary storage room free of debris; and to ensure the Dietary Aide (DA) A checked the temperature of a hamburger, a potentially hazardous food (PHF - foods that must be kept at a particular temperature to minimize the growth of food poisoning bacteria that may be in the food ) after it was cooked and before placing the burger on a bun. This practice potentially affected all residents. The facility census was 14 residents. 1. Observations on 1/24/23 from 9:35 A.M. through 10:45 A.M., showed: - A buildup of food and dust debris was on the floor behind and under the dishwasher area on the floor. - A buildup of food debris was on the floor under and behind fridge. - A large amount of bread crumbs was stuck inside the toaster and on the removable plates of the toaster. - A buildup of burnt-on debris on the stove top of the six burner stove. - A heavy dust buildup was present on the sprinkler head above reach-in fridge. - A handle of a butter brush that was not easily cleanable. - A pot that was used to to keep the melted margarine on one of the burners of the six burner stove with a layer of grease and food debris on the outside. - An open bag of corn meal, was present in dietary storage room [ROOM NUMBER]. - A buildup of debris was present on the floor behind the refrigerator in dietary storage room [ROOM NUMBER]. - An area of a damaged gasket of freezer #1 that was 20 inches (in.). high by 28 in. wide. During an interview on 1/24/23 at 9:46 A.M., the Dietary Manager (DM) said: - A complaint was made by another non-dietary employee about how the outside of the toaster looked. - He/she was the only one that worked in the kitchen full time until about 2-3 weeks prior to the survey. - The last time he/she cleaned the burnt on debris on the metal grates, was before Thanksgiving of 2022. - Another employee opened the bag of cornmeal, but may not have been able to lift that bag, so that employee just left the bag there. - There was a plumbing problem in the past which caused the debris to be placed on the floor. - He/she had a hard time closing the freezer door in dietary storage room [ROOM NUMBER], but he/she did not know why it was hard to close the freezer until that day (1/24/23), because he/she saw the gasket was damaged. 2. Observation on 1/24/23 at 11:46 A.M. Dietary Aide (DA) A placed a frozen hamburger in the frying pan. Observation on 1/24/23 at 11:51 A.M., DA A removed the burger from the frying pan and placed it in a bun for service to a resident who asked for alternate that day, without measuring the temperature to find out if it was fully cooked to proper temperature of 165 F (degrees Fahrenheit). During an interview on 1/24/23 at 12:29 P.M., DA A said he/she went by how the burger looked because he/she knew how the resident wanted it cooked.

Based on observation and interview, the facility failed to maintain the handrails located at the following locations: outside resident rooms [ROOM NUMBERS], outside resident room [ROOM NUMBER], between resident rooms [ROOM NUMBERS], and between resident rooms [ROOM NUMBERS]. The facility census was 14 residents. 1. Observations with the Maintenance Director (MD) on 1/26/23, showed: - At 12:09 P.M., the two hand rails outside resident rooms [ROOM NUMBERS], moved back and forth when they were held. - At 12:14 P.M., the hand rail outside resident room [ROOM NUMBER], moved back and forth, when it was held. - At 12:20 P.M., the hand rail on the wall between resident rooms [ROOM NUMBERS], moved back and forth when it was held. - At 12:29 P.M., the hand rail on the wall outside resident rooms [ROOM NUMBERS], moved back and forth when it was held. During an interview on 1/30/23 at 2:22 P.M., the MD said he/she: - Checked the hand rails as he/she walked by the hand rails. - Checked the handrails as much as he/she could. - Replaced the brackets of one of the hand rails, around the Christmas Holiday season in 2022. - Relied particularly on housekeeping staff particularly to let him/her know because the housekeeping department cleaned the handrails once per month.

Based on observation, interview and record review, the facility failed to ensure proper behavioral health management was implemented and support services were offered to assist in promoting healthy psychosocial functioning and failed to initiate interventions that would prevent negative interactions/incidents between two sampled residents (Resident #4 and #10) who were in a relationship, and two sampled residents (Resident #4 and Resident #12), who had a physical altercation out of nine sampled residents. The facility census was 14 residents. 1. Record review of Resident #4's undated face sheet showed he/she was admitted to the facility with the following diagnoses: -Other Recurrent Depressive Disorders (a mental health disorder characterized by a feeling of profound and persistent sadness or disrepair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Other Psychoactive Substance Abuse, Uncomplicated (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). Record review of the resident's progress note dated 10/15/22 showed he/she was very inebriated (effected by alcohol or drugs especially to the point where physical and mental control is markedly diminished). Record review of the resident's behavior note dated 10/16/22 showed: -He/she was arguing with another resident (Resident #10) in his/her room. -Both residents had been drinking. Record review of the resident's progress note dated 10/18/22 showed he/she was inebriated and was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 10/20/22 showed: -He/she was inebriated. -He/she was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 10/20/22 showed: -He/she was inebriated. -He/she was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 10/23/22 showed he/she appeared to be intoxicated. Record review of the resident's administration note dated 10/25/22 showed he/she was drinking excessively. Record review of the resident's administration note dated 10/27/22 showed he/she was drinking excessively. Record review of the resident's administration note dated 10/29/22 showed the resident: -Was drinking too excessively. -Had requested a wheelchair to sit in. -Had not been exhibiting any inappropriate behavior. Record review of the resident's administration note dated 10/30/22 showed the resident: -Had been drinking and was inebriated. -Had declined using a wheelchair. Record review of the resident's behavior note dated 11/5/22 showed he/she had left the facility without signing out and did not notify the nurse. Record review of the resident's social service note dated 11/8/22 showed: -The resident had been consuming an extreme amount of alcohol several times a week. -The resident could get very uncontrollable and aggressive as a result of drinking. -The Administrator and the Social Service Director (SSD) had made several attempts to redirect the resident's behaviors. -The resident said he/she was going to drink because he/she was a grown up and denied having any behaviors. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 11/27/22 showed: -The resident had a Brief Interview for mental Status (BIMS) score of 14 out of 15 which indicated he/she was cognitively intact. -The resident did not have any physically aggressive behaviors towards others. -The resident did have verbally aggressive behaviors towards others. -The verbal behaviors occurred 1-3 times during the look back period. Record review of the resident's administration note dated 12/2/22 showed he/she had been arguing with another resident and needed to be separated. Record review of the resident's administration note dated 12/11/22 showed: -He/she had been drinking excessively. -He/she was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 12/20/22 showed: -He/she had been drinking. -He/she was loudly cussing at a peer. Record review of the resident's administration note dated 12/24/22 showed: -He/she was very drunk. -He/she was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 12/25/22 showed he/she had been drunk that day. Record review of the resident's care plan dated 12/31/22 showed: -The problem identified: --The resident has a psychosocial well-being problem related to ineffective coping skills due to alcohol consumption. --The resident is/has potential to be verbally aggressive related to ineffective coping skills and alcohol consumption. --The resident is/has potential to be physically aggressive related to poor impulse control. --The resident is an elopement risk related to leaving facility leaving the facility without notifying staff or signing out. -Interventions included: --Consult with Pastoral care, Social services, and Psychiatric services. --Monitor/document the resident's usual response to problems/ ---How the resident makes his/her own changes. ---How the resident expects others to control his/her problems. --Resident had a history of making false accusations about physical harm while intoxicated. --- Monitor for signs and symptoms of physical harm and call the Administrator immediately. --Psychiatric/Psychogeriatric consult as indicated. -NOTE: There were no new interventions put into place following the instances the resident was impaired as a result of his/her drinking. -NOTE: There were no new interventions put into place that addressed being an elopement risk. -NOTE: There was no problem identified or interventions in place that addressed the resident having a potential relationship with another resident (Resident #10). Record review of the resident's behavior note dated 12/31/22 showed the resident left the facility and refused to return to the facility even though facility staff tried to redirect the resident. Record review of the resident's administration note dated 1/1/23 showed he/she was intoxicated, slurring his/her speech, and was unsteady. Record review of the resident's social service note dated 1/3/23 showed: -The resident had an altercation with another resident on 12/30/22. -The Administrator and SSD asked the resident if he/she wanted to get help regarding his/her drinking. -The resident agreed to go to an inpatient treatment facility. -During the intake process of the inpatient treatment facility the resident changed his/her mind about going inpatient. -The SSD would continue to follow the resident on a weekly basis. Record review of the resident's administration note dated 1/5/23 showed he/she had been drinking excessively and was drunk. Record review of the resident's administration note dated 1/7/23 showed he/she had been drinking excessively. Record review of the resident's administration note dated 1/8/23 showed: -He/she had been drinking. -He/she walked to the liquor store twice that day. Record review of the resident's administration note dated 1/17/23 showed he/she was inebriated. During an interview on 1/24/23 at 2:05 P.M. the resident said I have already talked with a lot of people about the situation and I do not want to answer any more questions. There is nothing more that can be done. During an interview on 1/26/23 at 12:15 P.M. the resident said: -The facility had offered him/her therapy services in the past and he/she had not accepted the offer. -The facility offered Alcoholics Anonymous (AA) the following day after the altercation on 12/20/22. -The facility had told him/her that he/she was going to a different facility to get help, but the facility told him/her that there were no beds available. -He/she did not want any treatment. -The facility had never sent him/her out for a psychiatric/psychological evaluation and he/she never had one completed. -He/she was not an alcoholic and did not have a drinking problem. -He/she only had problems when he/she was drinking. -He/she would go back to his/her room after drinking and sometimes would curse and yell. -I drink too much sometimes. -I need to watch how much I drink. -When he/she was drinking that he/she needed to go to his/her room when he/she was angry. -He/she did not remember having a contract about his/her behaviors and drinking. -He/she was open to having someone come into the facility to talk about how to better manage his/her alcohol. 2. Record review of Resident #10's undated face sheet showed the resident admitted to the facility with a diagnosis of Alcohol Abuse with Intoxication, Unspecified (a habitual misuse of alcohol). Record review of the resident's nurse's note dated 10/03/22 showed: -The resident had been following another resident (Resident #4) continuously throughout the day. -Licensed Practical Nurse (LPN) A saw the resident and the other resident (Resident #4) arguing three times throughout the day. -LPN A also saw the resident drinking. Record review of the resident's social service note dated 10/10/22 showed: -When the resident drank alcohol he/she could become rude and aggressive towards other residents. -The resident denied having any behaviors while drinking. -The Administrator had spoken to the resident about his/her behavior with another resident. Record review of the resident's annual MDS dated [DATE] showed: -The resident had a BIMS score of 14 out of 15, which indicated he/she was cognitively intact. -The resident had not exhibited any verbal or aggressive behaviors towards others. Record review of the resident's care plan dated 12/2/22 showed: -The problem identified: --The resident had the potential to be physically aggressive related to alcohol consumption. --The resident was an elopement risk/wanderer related to history of attempts to leave the facility without notifying staff. -Interventions included: --When the resident becomes agitated, intervene before agitation escalates. --Guide the resident away from the source of distress. --Engage the resident calmly in conversation. ---If the resident response was aggressive, staff were to walk calmly away, and approach later. -NOTE: There were no interventions put into place that addressed the residents being an elopement risk. -NOTE: There was no problem identified or interventions put into place that addressed the resident having a potential relationship with another resident (Resident #4). During an interview on 1/17/23 at 11:10 A.M. the resident said: -On 12/1/22, the other resident (Resident #4) fell pretty hard and he/she could not pick up the other resident (Resident #4). -The neighbors had come to help pick up the other resident (Resident #4). -The other resident (Resident #4) could get belligerent when drinking hard liquor. -He/she had not been drinking the night of 12/1/22. During an interview on 1/24/23 at 12:19 A.M. the resident said he/she liked Resident #4 but was not in a relationship with Resident #4. 3. Record review of the incident report dated 12/1/22 showed: -Resident #4 and Resident #10 were in a relationship. -Resident #4 and Resident #10 left the facility without signing out after dinner. -Resident #4 and Resident #10 came back to the facility intoxicated. -Resident #4 asked Certified Nurses Aide (CNA) C if there was a scratch on his/her face. -CNA C saw what looked like a scratch and showed the scratch to Registered Nurse (RN) A. -Resident #4 said Resident #10 scratched his/her face. -Resident #4 was placed on a one-to-one observation due to his/her intoxication. -Resident #10 said when they were out, Resident #4 tripped and fell . -Resident #10 said a neighbor helped Resident #4 up from the ground. -Resident #10 said he/she did not physically hurt Resident #4. -Resident #4 was intoxicated and could not remember all of the events. -Resident #4 said he/she remembered that he/she fell and people helped him/her up. -Resident #4 said he/she was mad at Resident #10 and lied about Resident #10 scratching his/her face. 4. During an interview on 1/17/23 at 10:00 A.M. the Administrator said: -Resident #4 and Resident #10 were in a relationship. -When both residents drank the relationship was not good. -Resident #4 exhibited behaviors when drinking. -Resident #10 could get aggressive towards Resident #4 when drinking. During an interview on 1/17/23 at 11:24 A.M. Resident #4 said he/she fell at the park and Resident #10 did not scratch him/her. During an interview on 1/25/23 at 1:19 P.M. CNA B said: -He/she would consider Resident #4 and Resident #10 in a relationship. -When Resident #4 was not drinking he/she did not exhibit any behaviors. -When Resident #4 was drinking was when he/she started to exhibit behaviors such as cussing. -There had been incidents in the past with Resident #4 and Resident #10. -Most of the incidents between the two residents happened during the night time. -He/She was unsure what kind of services or therapies Resident #4 had been receiving. -He/She knew that the Administrator, Director of Nursing (DON), and SSD had talked with Resident #4 about his/her behaviors. -When Resident #4 and Resident #10 were exhibiting behaviors and/or drinking he/she was to separate the residents. -He/she would tell the charge nurse if a resident was exhibiting any behaviors and the charge nurse would call the Administrator or DON if the behaviors were escalating. During an interview on 1/25/23 at 1:28 P.M. LPN A said: -He/she would not consider Resident #4 and Resident #10 in a relationship. -When Resident #4 was not drinking he/she could be mellow. -Resident #4 did not exhibit behaviors towards Resident #10 when sober, he/she only argued with the resident. -Was not sure if Resident #4 and Resident #10 had any altercations prior to the incident on 12/1/22. -Was not sure if Resident #4 was receiving any services or therapies. -He/she would document any behaviors in a behavioral note or progress note. -When charting a behavior he/she would chart the behavior, any triggers that caused the behavior, and any interventions that were done. During an interview on 1/25/23 at 2:44 P.M. the SSD said: -He/she had previously developed a contract with Resident #4 regarding his/her alcohol consumption and behaviors. -After the altercation on 12/30/22 there were no attempts made for Resident #4 to go to AA or request anyone from AA to come to the facility. -There were interventions in place for when the residents were intoxicated, but not to keep the residents from consuming alcohol. During an interview on 1/25/23 at 2:57 P.M. CNA D said: -He/she thought that Resident #4 and Resident #10 were in a relationship. -When Resident #4 was sober, he/she did not exhibit any behaviors. -When Resident #4 was drinking he/she could get really loud and verbally aggressive towards staff and Resident #10. -Did not know if there were any previous incidents between Resident #4 and Resident #10. -Was not sure if Resident #4 was receiving any services or therapies. -When Resident #4 was intoxicated he/she would place the resident in a wheelchair and would assist in monitoring the resident. -When a resident was exhibiting behaviors he/she would tell the charge nurse and intervene if able. -He/she would intervene by redirection. During an interview on 1/26/23 at 6:03 A.M. LPN C said: -Resident #4 and Resident #10 were in a relationship. -Resident #4 and Resident#10 had no issues when sober. -Resident #4 did exhibit behaviors towards Resident #10 when Resident #4 was drinking. -Both residents could exhibit behaviors towards each other, mainly arguing. -Resident #4 could get really loud, cuss, and be generally verbally aggressive towards others. -Could not think of any altercations between the residents prior to the incident on 12/1/22. -Was not sure what services or therapies Resident #4 was receiving. During an interview on 1/26/23 at 10:58 A.M. Registered Nurse (RN) A said: -He/she charted behaviors with a behavioral note. -Some residents have behavioral monitoring as an order and would have to get charted on every shift. -When documenting behavior notes the behavior and the interventions needed to be documented. -When Resident #4 and Resident #10 were drinking his/her responsibility was to monitor the residents and if a conflict had occurred they would intervene and separate the residents. -Resident #4 was not receiving any services or therapy at that time. -Resident #4 had declined services and therapy in the past. -If he/she had asked Resident #4 about receiving services or therapy he/she would document the offer and acceptance/refusal. -If a resident was exhibiting a behavior the staff need to be knowledgeable of the behavior and monitor for the behavior throughout the shift. -He/she would delegate tasks to the CNA's to assist with monitoring. -He/she had talked with Resident #4 about the consequences of drinking alcohol. -He/she tried to document those conversations with Resident #4, but shifts could get busy. During an interview on 1/26/23 at 11:17 A.M. the SSD said: -The resident had a contract in the past, it was a blanket statement that Resident #4 signed then disregarded it. -Could not provide documentation of the contract. -Resident #4 did not get drunk while he/she was at the facility. -If Resident #4 was drinking during the day, Resident #4 was re-directable. -It was hard to document each incident that Resident #4 or Resident#10 had because the residents do not remember what happened and neither do the staff. -He/she was not present during the time of the altercation on 12/1/22. -He/She thought the Administrator was responsible for writing a note of the altercation in his/her absence. -Resident #4 was not accepted into inpatient rehabilitation because Resident #4 would be returning back to the facility. -He/she did not document all of the offers and refusals because he/she had done it so often. -Resident #4 could tell anyone how much the SSD offered services. -He/she was unsure if he/she needed to document the offers and refusals. During an interview on 12/26/23 at 12:12 P.M. the ADON said: -The Administrator and DON were responsible for the initial investigation of the incident from 12/1/22. -The facility provided oversight and protection with monitoring for residents, but when management would leave in the evening that was when most events and incidents would happen. -Resident #4 and Resident #10 have done activities together and had no issues. -When alcohol became involved that was when Resident #4 and Resident #10 would start exhibiting behaviors. -Resident #4 would be verbally aggressive and would curse at Resident #10 and staff while intoxicated. -He/she would stay late and that would refrain Resident #4 and Resident #10 from drinking. -A follow-up should have been done after the incident from 12/1/22. -The Covid-19 pandemic caused issues with getting services into the facility. -He/she had not attempted to offer services or therapies to Resident #4 since the pandemic. -When Resident #4 refused services in the past it was hard to continue to offer services. -Thought Resident #4 would benefit from a psychiatric evaluation and therapy, but no one had offered Resident #4 those services. -Behaviors needed to be documented and should be documented with the behavior and the follow-up that was done. -Social Service would need to get involved and follow-up with residents regarding the behavior. -The doctor should also be involved and notified of resident behaviors and get orders as needed for the residents. During an interview on 1/26/23 at 1:21 P.M. CNA B said: -When Resident #4 was intoxicated he/she would be the instigator towards Resident #10. -Resident #10 would then exhibit behaviors in response to Resident #4's instigation. -Resident #4's behaviors would then become worse. During an interview on 1/26/23 at 1:22 P.M. the ADON said: -Resident #10 received behavioral health services. -Resident #10 had recently been assigned a Guardian. -Resident #10 was not assigned a Guardian as a result of the incident on 12/1/22. -He/she felt that Resident #10's needs were being met with the assignment of the Guardian. -Resident #10 would usually follow his/her redirections. -Resident #10 did not usually have behaviors when sober. -Nurses did not normally document all incidents with Resident #10 because he/she was able to be easily re-directed and would usually stop the behavior. -Every shift Resident #10 had behavioral monitoring, when marked no, the documentation did not show-up on the Electronic Medical Record (EMR). - He/she did not think anything different could have been done with Resident #10 following the situation on 12/1/22. During an interview on 1/26/23 at 1:40 P.M. the Administrator said: -When residents have behaviors there were procedures that were in place such as behavior contracts. -There was no specific policy for Behavioral Management. During an interview on 1/26/23 at 1:54 P.M. the SSD said: -He/she did not think anything could have been done differently for Resident #10 after the 12/1/22 incident. -Did not think Resident #10 needed anymore assistance besides the psychiatric services he was already receiving. -Did not think the Guardian was helping Resident #10's behaviors. During an interview on 1/26/23 at 2:04 P.M. the Administrator said: -Resident #4 and Resident #10 were in a relationship. -There have been attempts made for Resident #4 to receive services. -There had been issues in the past with Resident #4 refusing services and inpatient settings not having beds. -The SSD was available to come up and help with behavioral issues with the residents and he/she was always available by phone call to help alleviate altercations. -He/she had tried to stop Resident #4 from leaving the facility to drink in the past, but had not documented it. -He/she thought that the Guardian was helping Resident #10's behaviors. During an interview on 1/26/23 at 2:40 P.M. the DON said: -The incident report showed that Resident #4 had lied about the physical contact with Resident #10 and that was reflected in the conclusion. -Resident #4 was verbally aggressive with everyone, and not just with Resident #10. -Resident #4 and Resident #10 had an on-again/off-again relationship. -The relationship was that way due to their drinking. -Resident #4 usually exhibited verbally aggressive behavior while drinking. -Resident #10 did not usually exhibit behaviors while drinking to Resident #4, or anyone. -The separation of Resident #4 and Resident #10 was the best thing to do when they were intoxicated. -Resident #4 and Resident #10 were not currently receiving services for alcohol abuse. -Resident #4 had usually refused services. -He/she did not think that Resident #10 would have anymore issues with the assignment of the Guardian. -The facility was terrible at documentation, as there had been multiple attempts made to offer services to Resident #4 that had not been documented. -He/she expected all staff to document when offering a service and the response. -He/she expected the nurses to document behavioral monitoring in the resident EMR. -He/she expected the nurses to document the behavior and the intervention. -He/she was responsible for the follow-up of behavior documentation. -He/she expected the nurses to report behaviors at shift change. -He/she expected the SSD to perform post altercation/incident interviews. -He/she expected all staff to assist with any behaviors that were exhibited. -He/she expected care staff to perform preventative measures when residents were drinking before a behavior could be exhibited. -All staff were aware that Resident #4 and Resident #10 needed to be separated when intoxicated. During an interview on 1/27/23 at 12:26 P.M. the DON said: -He/she expected staff to monitor residents when they were drinking to keep them safe from themselves and others. -He/she had told staff that when a resident became verbally or physically aggressive from drinking, that resident was to not have contact with any other resident. -He/she was unsure how to control Resident #4 when he/she drank. -The facility had verbal conversations with Resident #4 and he/she had agreed to not be around other residents when drinking. -The facility had not developed a written contract with Resident #4 regarding his/her behavior. -He/she had provided a resource for counseling services with telehealth options to the Administrator, but was not sure what happened after that. -He/she would expect all interventions that the facility had attempted with Resident #4 to be documented. 21003 5. Record review of Resident #12's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including depression. There was no documentation showing the resident had a diagnosis of post traumatic stress disorder (PTSD- a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event. Symptoms may include nightmares or unwanted memories of the trauma, avoidance of situations that bring back memories of the trauma, heightened reactions, anxiety, or depressed mood). Record review of the resident's Physician's Order Sheet (POS) dated 1/2023, showed the resident had a diagnosis of depression and there were physician's orders for Amitriptyline 10 milligrams (mg) daily for depression. Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. There were no diagnoses showing the resident had substance or alcohol abuse. Record review of the resident's Nursing Notes dated 4/21/22 to 7/27/22, showed the resident exhibited no behaviors. There was no documentation showing the resident expressed any prior trauma, substance or alcohol use/abuse, fear, anxiety or depressive symptoms. Record review of the resident's Care Plan dated 4/25/22, showed no area related to depression and no goals to maintain the resident's psychosocial and mental health. There were no interventions showing the resident had depression, received medication for depression or had any depression symptoms. There was no documentation showing the resident had past trauma, physical or verbal abuse, substance or alcohol abuse or any triggers that would cause the resident trauma. There were no interventions that showed any preventive interventions, how the facility would address these behaviors if they occurred and how the facility would provide support to the resident. Record review of the resident's undated Social Service Assessment showed: -The resident had no documented diagnoses of depression, PTSD, substance/alcohol abuse, psychosis or trauma. -The section titled, Significant Life Experiences, showed the resident had several marriages and divorces and was widowed from his/her last marriage. -Had a history of substance abuse addiction that resulted in loss of custody of two children, which he/she was able to regain. -It was noted the resident did not want to continue the interview at that time. -The section titled, Significant Medical and Psychiatric History, showed the resident wanted to resolve issues related to diabetes and insulin management and dental concerns. There was no documentation showing the resident had ever had any counseling/therapy or treatment for depression or substance abuse or was receiving therapy or treatment at the time the assessment was completed. -The assessment did not address alcoholism or any physical or verbal abuse. Record review of the resident's quarterly Social Service Notes showed: -On 5/5/22 the resident had been homeless and a substance abuser that could no longer take care of himself/herself and needed assistance and was ready to get his/her life .cleaned up and back on track. The note did not show how the facility was supporting him/her or whether the resident had any current supports. -On 7/13/22 the resident seemed to be doing better, enjoyed living at the facility and visits with family. The note showed the resident sat outside and drank liquor while listening to music. It did not show if the resident had any behaviors associated with drinking alcohol. -The notes did not show the facility offered or were providing any supportive services to the resident to address depression or alcohol/substance abuse. Record review of the resident's Nursing Notes from 7/27/22 to 12/30/22, showed there were no notes showing the facility provided a psychiatric/psychological evaluation on the resident to address his/her trauma and did not show that any counseling or supportive services were provided to the resident. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with no confusion. -Had no psychosis, hallucinations or delusions. -Had a diagnosis of depression and had depressive symptoms-feeling bad about self, hopeless, depressed, little interest in doing things and trouble concentrating on things during the look back period. -Received anti-depressant medication, and did not receive any anti-psychotic medications. -Did not show the resident had any substance or alcohol abuse and did not show the resident had any mood or behaviors related to physical or verbal abuse, or was physically or verbally abusive towards self/others. Record review of the resident's Behavior Notes showed: -On 12/30/22 the resident was outside when another resident (former roommate) hit him/her. They both began to fight each other, falling to the ground, punching each other in the face and pulling each other's hair. Staff attempted to separate the residents but was but unsuccessful. Police had to be called along with the ambulance. The resident's physician, Administrator and SSD were also notified. Documentation showed the emergency services completed a full body assessment of the resident and found no reason to transport him/her for further services/hospitalization . The note showed the resident was not transported to the police station. The notes did not show any immediate behavioral interventions the facility initiated or any long-term interventions implemented. Record review of the resident's Incident/Investigation Report dated 12/30/22 showed: -On 12/30/22 the resident was observed on the ground fighting with another resident. -The resident said he/she was called a bitch and was hit by the other resident. -The resident was oriented to person, place and time, was ambulatory without assistance. -The resident sustained a scratch to his/her face by his/her lip with no additional injuries. -The predisposing factor was that the resident was intoxicated. -The report did not show new interventions implemented to prevent further incidents of this type. Record review of the resident's Care Plan updated 12/31/22 showed the resident had potential to be physically aggressive related to anger, poor impulse control. Interventions showed staff would: -Analyze the times of day, places, triggers, and what de-escalates the resident's behavior and document. -Separate the resident and complete constant monitoring as scheduled to ensure safety of the resident until further notice. -Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff when agitated. -Monitor and document obse

Based on observation and interview, the facility failed to maintain an exhaust pipe in the attic space over the storage room, in good repair to prevent that pipe from emitting steam into the attic area. This practice potentially affected at least five residents who resided in that part of the facility. The facility census was 14 residents. 1. Observation with the Maintenance Director (MD) on 1/26/23 at 10:43 A.M., showed: - One exhaust pipe in the attic area which emitted steam which caused several of the nearby wood beams to become wet. - The pipe was warm when it was held. During an interview on 1/26/23 at 10:47 A.M., the MD said that pipe came from the furnace room and he/she did not know that pipe emitted steam which could possibly cause some decay on the wood beams.

Based on observation, interview and record review, the facility failed to maintain the wall mounted fans in resident rooms 10, 11, 8, 12, 7, 4 and 2 free of a heavy buildup of dust and to maintain a stand-up lift used to transfer one sampled resident (Resident #6) free from a crack in the base out of nine sampled residents. The facility census was 14 residents. 1. Observations with the Maintenance Director (MD) on 1/26/23 between 11:10 A.M. to 12:29 P.M., showed resident's rooms 10, 11, 9, 12, 8, 7, 4 and 2 had wall mounted fans and all had a heavy build up of dust on the fan blades and plastic grate. Record review of Resident #214's, quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 4/15/22, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS - an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident ' s attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 15 out of 15 indicating he/she was cognitively intact. During an interview on 1/26/23 at 12:01 P.M., the resident said it had been a while since he/she saw housekeeping clean the fan. During an interview on 1/26/23 at 2:30 P.M., the housekeeping Supervisor said: - The wall mounted fans should be cleaned weekly. - He/she was without housekeeping help since April of 2022. - He/she saw several fans in resident rooms which were real dusty. 2. Observation with the MD on 1/26/23 at 12:21 P.M., showed a three inch (in.) crack on the base of a stand-up lift in resident room [ROOM NUMBER] that was occupied by Resident #6 During an interview on 1/26/23 at 12:22 P.M., the MD said the stand-up lift was not cracked at the beginning of 1/23. During an interview on 1/26/23 at 12:24 P.M., Certified Nurse's Assistant (CNA) A said: - He/she assisted Resident #6 with a transfer that morning. - He/she inspects the wheels of the stand-up lift, ensure that the brakes of the stand-up lift, and he/she inspected the sling (a device designed to be suspended from and attached to the patient lift boom and swivel bar of a mechanical lift). - He/she did not necessarily check the base where the resident stood. -This was the only resident who used the stand-up lift on. During a phone interview on 1/30/23 at 12:01 P.M., the Director of Nursing (DON) said the CNAs should be looking at the lifts and he/she absolutely expected them to inspect the lift every time before they use it.

Based on interview and record review, the facility failed to notify the Ombudsman (a network of ombudsmen volunteers serving residents of nursing homes and residential care facilities to provide support and assistance with their problems or complaints) for one sampled resident's (Resident #1) discharge to the hospital out of nine sampled residents. The facility census was 14 residents. Record review of the facility's undated Bed Hold policy and procedure showed: -Documentation related to the resident's bed hold rights and financial responsibilities and the responsibilities of the facility regarding bed holds. -The document did not show that part of the policy was to notify the Ombudsman of all discharges/transfers from the facility and it did not show that notification should be completed at least monthly. 1. Record review of Resident #1's Face Sheet showed the resident was admitted on [DATE], with diagnoses including human immunodeficiency virus (HIV- a virus that attacks the body's immune system, preventing the body from fighting infection), diabetes, blindness, and depression. Record review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) assessments showed: -A discharge MDS assessment dated [DATE], showed the resident was discharged on [DATE]. The document showed the resident's discharge was unplanned, to the hospital with return anticipated. -An entry MDS assessment dated [DATE], showed the resident returned to the facility from the hospital. Record review of the resident's Nursing Notes showed: -9/14/22 the writer called and spoke with the hospital nurse who said the resident had a small bowel obstruction and was not having any pain at this time. Would continue follow up as needed. -9/18/22 the Charge nurse received a call from the Social Worker at the hospital and stated the resident was doing better and would be returning to the facility tomorrow. He/she would be on an antibiotic for urinary tract infection and fluids were encouraged. -9/20/22 the resident returned to the facility at 3:25 P.M., and was alert and pleasant after his/her hospitalization for ileus (a condition in which the bowel does not work correctly, but there is no structural problem causing it). The resident denied pain. The nurse completed a full body assessment without any concerns. The resident had a large bowel movement and the physician was notified of the resident's return to the facility. -9/22/22 The nurse documented hospital follow up note stating the resident was discharged from the hospital on 9/20/22 in the afternoon. He/she denied pain and had a good appetite. No concerns were noted. Record review of the resident's Physician's Notes dated 9/20/22, showed: -The resident's was being seen after his/her recent hospitalization for ileus. -The physician completed an examination of the resident and the resident acknowledged having a bowel movement and had no complaints at that time. The physician was going to continue to monitor the resident. During an interview on 1/26/23 at 10:32 A.M., the Social Service Director (SSD) said: -He/she completed an initial bed hold agreement with every resident upon the resident's admission. -He/ she was unaware about needing to notify the Ombudsman of all transfers/discharges monthly. -He/she would be responsible for that task but, he/she was not given instruction to send the Ombudsman a monthly discharge/transfer list and had never done that. -The Ombudsman was in the facility last month and discussed the services they provided, but he/she did not say anything about sending out a list of discharges to him/her monthly. -He/She would begin providing this information. During and interview on 1/27/23 at 12:26 P.M., the Director of Nursing (DON) said: -He/she was aware that the Ombudsman should be provided a monthly report of the discharges on an ongoing bases. -He/she did not know that it was not being provided monthly. -He/she thought the SSD was responsible for providing this information to the Ombudsman.

Based on interview and record review, the facility failed to protect two sampled residents (Resident #1 and Resident #2) from resident to resident abuse when on 9/22/22 Resident #2 slapped Resident #1 in the face with his/her hand, which caused facial bruising and swelling after Resident #1 reported to have bitten Resident #2 when in an altered state, out of six sampled residents. The facility census was 14 residents. On 10/5/22 the Administrator was notified of the past noncompliance which occurred on 9/22/22. On 9/22/22 the facility administration was notified of the incident and the investigation was started. The residents had no prior history of physical domestic violence. The residents were separated and were counseled. No employees were allowed to work prior to reeducation. The deficiency was corrected on 9/22/22. Record review of the facility's Reporting Abuse and Neglect policy dated 7/1/2007 showed: -The person first aware of the incident should immediately report all available information to the highest level supervisor (generally the charge nurse) that was present in the facility. -The supervisor would then notify the Administrator, Director of Nursing, Assistant Director of Nursing or Director of Social Services who would make the call to the Division of Aging and begin collecting evidence and documentation. -The supervisor to whom the report was made would begin an investigation of the event by gathering documentation from all people who have knowledge of the event. All staff members involved in the event would immediately complete documentation of the event. -An incident report/accident report would be initiated and filled out by the supervisor. The report should be completed in its entirety. -If the incident was resident to resident, the parties would be separated, nursing staff would be assigned for close supervision, the environment rearranged, if necessary and immediate discharge might occur. 1. Record review of Resident #1's Admission Record face sheet showed he/she was admitted to the facility on 2//10/14 with the following diagnoses: -Psychoactive substance abuse (a condition in which the use of a legal or illegal drug causes physical, mental, emotional or social harm. -Depressive disorders (a mental health disorder characterized by a persistent feeling of sadness or lost of interest in activities, causing significant impairment in daily life). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 8/27/22 showed the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 14 of 15. Record review of the resident's care plan showed: -He/she had an actual psychosocial well-being problem related to ineffective coping due to alcohol consumption. -He/she was offered only a limited amount of alcohol to aid in decreasing falls and emotional distress. -He/she was monitored by staff for feelings relative to isolation, unhappiness, anger or loss. -The resident was allowed time to answer questions, and to verbalized feelings, perceptions and fears. -The resident was offered consults with psychiatric services, social services or pastoral care. 2. Record review of Resident #2's admission record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Alcohol abuse with intoxication. -Cocaine abuse. Record review of the resident's quarterly MDS dated [DATE] showed the resident was cognitively intact, with a BIMS score of 14 of 15. Record review of the resident's care plan dated 9/22/22 showed: -The resident had the potential to be physically aggressive related to alcohol consumption. -The facility staff would analyze times of day, places, circumstances, triggers and what would deescalate behavior and document. -The facility staff would monitor, document and report any signs of the resident posing a danger to him/her self or others. -When the resident would become agitated, staff would intervene before agitation escalated. The resident would be guided away from the source of distress. -Staff should engage calmly in conversation; if response was aggressive staff were to calmly walk away and approach later. -Staff were to provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation and assist in setting goals for more pleasant behavior. -Staff were to encourage the resident to seek out a staff member when agitated and give the resident as many choices as possible about care and activities. 3. Record review of the facility's investigation, dated 9/22/22 showed: -RN A stated he/she had performed his/her safety checks and noticed Resident #1 was not in his/her room. -He/she heard Resident #1 say, that hurts, from the adjacent room. -He/she opened the door and saw Resident #1 sitting on the floor and witnessed Resident #2 open hand slap Resident #1 on the left side of his/her face. -RN A immediately removed Resident #1 from the room and put him/her on a 1:1 observation. -RN A said he/she just wanted to keep Resident #1 safe until management staff came in. -RN A notified the Assistant Director of Nursing (ADON) at approximately 8:00 A.M. -The ADON notified the Social Services Director and the police. -The Administrator and Director of Nursing (DON) were then notified. -The incident was reported to the State Agency at approximately 10:00 A.M. -The residents were moved to rooms at opposite ends of the facility. Record review of Resident#1's skin assessment dated [DATE] at 9:44 A.M. showed: -The resident had a swollen left eye with bruising and an abrasion under the left eye. -Bruising was noted to the left eye and left cheek. Record review of Resident #1's progress note, dated 9/22/22 at 10:08 A.M., showed: -The resident had facial bruising to the left side of the face and left cheek, and under the left eye. -He/she had abrasions to the chin. -He/she was moved to a safe area of the facility. Record review of Resident #2's incident report dated 9/22/22 showed: -The resident was oriented to person, place, time and situation. -RN B witnessed the resident open hand slap another resident, causing bruising to the left side of Resident #1's face. -The other resident was removed by the nurse and Certified Nursing Assistant (CNA) and 1:1 observation was initiated. During an interview on 10/5/22 at 10:30 A.M., Resident #1 said: -He/she and Resident #2 were just arguing. -He/she and Resident #2 were in a relationship. -They had been together for two months. -Resident #2 had never been violent toward him/her before. -He/she did not remember why he/she was angry. -He/she bit Resident #2, but did not know why. -He/she had never bit him/her before. -The nurse found him/her after Resident #2 hit him/her and separated them. -He/she went back to his/her own room and someone stayed with him/her. -He/she did not want the staff to call the police. -Living on opposite sides of the building had made things better. -They were doing fine now. -He/she had never seen Resident #2 that angry before, but he/she felt safe with him/her. -Resident #2 apologized to him/her. -He/she could get bruised easily -No other residents saw the incident. During an interview on 10/5/22 at 10:40 A.M., Resident #2 said: -Resident #1 was angry and bit him/her. -He/she pushed Resident #1 off him/her and then slapped him/her. -Resident #1 had been drinking and had a bad attitude when he/she drank. -He/she and Resident #1 were in a relationship. -They were both consenting to be in the relationship. -They had never had any physical violence between them before. -They both apologized and accepted, so all was fine. -He/she didn't think anything like that would happen again. -They made an agreement not to drink around each other. During an interview on 10/5/22 at 12:50 A.M., CNA A said: -He/she had never witnessed any violent episodes between any residents. -These two residents had previously argued, typically when drinking, but had not gotten violent. -The two residents were in a romantic relationship. -No residents had complained about them, as far as he/she knew. -Everyone mostly got along. -He/she did 1:1 observation with the resident for his/her complete day shift. -The residents had behaved normally during that time. -Resident #1 and Resident #2 did not interact for the whole day and were kept separated. -Resident #2 started accusing Resident #1 of biting him/her when the police arrived. -The police said the bite mark was not fresh. During an interview on 10/5/22 at 1:12 P.M., the ADON said: -He/she had never seen the two residents behave violently. -They had argued a lot, especially when drinking, but had not gotten physical. -Neither had previously been violent with each other or any other residents. -Their relationship was consensual, without coercion, by either resident. -He/she was the person who assessed the resident's face for injury, after the incident. -The night shift nurse told him/her about the incident when he/she came in to work that morning. -Resident #1 did not say anything about biting the other resident at that time. -He/she told Resident #1 his/her face was bruised and offered to call the police and press charges. -The resident did not want the police called. During an interview on 10/5/22 at 1:12 A.M., the DON said: -They would not have known about this incident if the nurse had not been doing safety checks. -Resident #1 initially denied biting Resident #2 to everyone, including the police. -There was one nurse and one CNA in the facility at the time of the incident. -Resident #2 had no visible bite mark. -Both residents were intoxicated the time of the incident and Resident #1 was especially intoxicated. -Resident #1 was in Resident #2's room annoying him/her due to his/her drinking. -Resident #1 felt guilty because of this and would say whatever Resident #2 told him/her to say. -The residents' rooms were previously side by side. -The two residents went into each other's rooms frequently. -The two residents were in a relationship and had consensual sex. -Resident #1 admitted in the past that they could be aggressive when having sex. -The facility had no specific written policy on use of alcohol in the facility. -The facility had conversations with the residents about controlling their alcohol use. -Resident #2 was the aggressor, and that was why he/she received a 30-Day Discharge Notice. -The two residents did not have issues when they were not drinking. -The resident were moved to rooms on opposite ends of the facility. -Since the incident, the residents were not to have contact with each other when drinking, and both residents agreed to this. -Both residents did exactly what was asked of them since the incident. During an interview on 10/5/22 at 1:30 P.M., the Administrator said: -Alcohol rehabilitation had been offered to both residents previously and both declined. -There was also counseling available for domestic violence for residents. -The facility did not have a specific policy related to alcohol use by the residents. -The facility has had resident council meetings where controlling drinking was specifically addressed. -They have also met with individual residents and offered counseling or rehabilitation. -Both of these residents had declined counseling. -Resident #1 was feeling guilty because he/she was drunk and had been saying anything Resident #2 tells him/her. -Both residents were trying to keep Resident #2 from getting in trouble. -Resident #2 got the 30-Day Notice of Discharge because he/she was the aggressor. -Resident #2 was cited with domestic assault by the police and had a court date. -The staff had been in-serviced about resident abuse and safety. -The facility standard of practice was to try to protect residents if they have been drinking. During a telephone interview on 10/6/22 at 2:40 P.M., RN A said: -Both Resident #1 and Resident #2 had been drinking together out on the facility porch. -Resident #1 was initially in his/her wheelchair, as he/she was safer there when drinking. -He/she had helped Resident #1 into bed. -He/she heard a noise and found Resident #1 was no longer in his/her bed. -He/she had been doing room checks every 10 to 15 minutes, and during the last one heard arguing and that hurts' coming from Resident #2's room. -He/she opened the door to Resident #2's room and found Resident #1 sitting on the floor. -He/she heard Resident #2 say, I am done and saw him/her slap Resident #1 on the left cheek. -Resident #1 said he/she fell on the floor. -He/she took Resident #1 out of Resident #2's room and either he/she or CNA B was with him/her the rest of the shift. -He/she did vital signs and neuro checks on Resident #1. -The skin assessment was done by the day shift nurse. -He/she had never known either resident to get physical previous, they would just argue. During an interview on 10/21/22 at 12:30 P.M., the DON said: -Resident behaviors were being documented every shift. -Resident #1's behaviors were all alcohol related. -When he/she is intoxicated, he/she was encouraged to use his/her wheelchair, go to bed, or sit on the common area sofa where he/she could be seen between two nurses' stations. -When Resident #1 was drinking, she was being kept away from Resident #1. -The residents were compliant with this, but if they were not, they would be put on 1:1 observation. -Nobody saw Resident #1 fall. -Resident #1 was alert and oriented and would know if someone hurt him/her. -Resident #1 bruised easily and bruises stayed on him/her for a while. -He/she had not seen the two residents arguing. -An investigation was done about Resident #1's arm bruises, and no evidence of abuse was found. -Residents who argue or fight were separated. -The facility would not keep aggressive people at the facility. During an interview on 10/21/22 at 1:05 P.M., the Administrator said: -Resident #1 never had any physically aggressive events previously. -Resident #2 had drinks every day. If he/she seemed intoxicated the staff would have him/her use his/her wheelchair, go to bed, or watch TV in the common area. If he/she was non-compliant she would have 1:1 observation. During an interview on 10/21/22 at 1:30 P.M., the ADON said: -With the incident of Resident #1's bruising of unknown origin, there was not any violence or physical abuse between the residents. -The resident had been drinking during the day and had no issues. -He/she did resident room checks every hour. -The residents were to stay apart when they were drinking. -If the residents argued, they were kept separated and redirected. During an interview on 10/21/22 at 1:55 P.M., CNA B said: -The two residents liked to talk down to each other. -The staff kept them separated and kept their eyes on the residents when they did this. -To keep Resident #1 safe, the staff kept him/her near the nurse's station. -If Resident #1 went out to smoke, a staff person went with him/her. -He/she had never seent the two residents get physical with each other. -Resident #1 told him/her the bruises on his/her arms were from a fall, and Resident #2 helped him/her up. -The two residents could be together unless they had been drinking. -Resident #1 could get loud when drinking, but had not gotten physical that he/she was aware of. -Resident #2 sometimes would say thinks that were not true. During an interview on 10/21/22 at 2:05 P.M., CNA A said: -Resident #1 and Resident #2 were kept separated when drinking. -Resident #1 said he/she had a fall and Resident #2 helped him/her up by the arm, which accounted for the bruising he/she had sustained. -He/she had never seen Resident #2 get violent while drinking. MO00207338