Every finding on record at Lake Stockton Healthcare Facility

Based on interview and record review, the facility failed to fully implement their abuse and neglect prevention policies, when the facility failed to complete a criminal background check (CBC), an employee disqualification list (EDL - a list of individual prohibited from working in a long-term care facility in Missouri due to a finding of abuse or neglect) check, and a Nurse Aide (NA) Registry (list of individual with a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them from working in a certified facility) check for three sampled staff (Registered Medication Technician (RMT) G, Domestic Care Technician (DCT) M's, and Housekeeper (HK) N). The facility census was 85.Review of the facility's policy, Selection of Employee, dated September 2025, showed the following:-Applicants for employment will meet certain standard requirements before being accepted for employment with the organization;-To assure basic requirements are met for new employees and to assist in the selection of the best suited applicants for available positions;-Background checks will be performed for applicants being considered for employment;-Monitoring of the appropriate state agency disqualification list will be performed to ensure no applicant who will be performing direct resident care is on the list;-New employees are not authorized to begin work until completion of investigation of criminal background check and other required checks.1. Review of RMT G 's personnel file showed the following:-Hire date of 02/23/26;-The facility requested a criminal background check 03/31/26;-The facility completed a check of the Family Care Safety Registry (FCSR - includes multiple registry checks including EDL and CBC) and EDL on 03/31/26. 2. Review of DCT M's personnel file showed the following:-Hire date of 05/06/24;-The facility completed a check of the of NA Registry on 03/31/26.3. Review of HK N's personnel file showed the following:-Hire date of 10/28/24;-The facility completed a check of the of NA Registry on 03/31/26.4. During an interview on 04/02/26, at 12:25 P.M., the Business Office Manager said new employees complete new hire paperwork with the corporate human resource office. All background checks should all be completed prior to orientation and before starting work in the facility.During an interview on 04/02/26, at 1:45 P.M., the Director of Nursing (DON) said new employees should have all background checks done prior to orientation and working on the floor. The corporate office completes the paperwork.During an interview on 04/02/26, at 2:25 P.M., the Administrator said the following:-When a new employee is offered a position, the corporate human resource office completes the background checks;-There is a checklist which includes running the CBC, EDL, FCSR, and NA checks;-New hires should not start working until background checks are complete.

Based on observation, interview, and record review, the facility failed to provide residents with an approved call light system when the facility failed to have a process in place to notify staff of call light notifications when they could not be heard on the halls, when the electronic scroll boards were not accurate on all boards, when call light boxes were not functioning for two residents (Resident #5 and #36), and when one resident (Resident #59) did not have an pull string on his/her bathroom emergency call light out of a sample of 18 residents. The facility census was 85. Review showed the facility did not provide a policy related to call lights. 1. Review of Resident #36's face sheet (brief information sheet about resident) showed the following:-admission date of [DATE];-Diagnoses included congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated [DATE], showed the following:-Cognitively intact;-Use of walker and wheelchair;-Set up or clean-up assistance for oral hygiene, toileting hygiene,-Partial to moderate assistance with dressing, personal hygiene,-Supervision or touching assistance for sit to stand and transfer, showering. During an observation and interview on [DATE], at 11:00 A.M., the resident said his/her call light did not work. He/she had to go tell staff when he/she needed assistance. The resident pressed the call button and observation of the light on the outside of the door showed no call light illuminated. During interview and observation on [DATE], at 11:15 A.M., the resident pressed his/her call light. The light outside the room did not illuminate, the resident said it often does not light up. The scroll board at the nursing station did not show the resident's room as requiring assistance. 2. Review of Resident #5's face sheet showed the following:-admission date of [DATE];-Diagnoses included CHF, chronic kidney disease (CKD - kidneys are damaged and can't filter blood the way they should), and hemiplegia (paralysis of one side of the body) affecting left non-dominant side. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Cognitively intact;-Use of wheelchair;-Partial to moderate assistance with oral hygiene;-Substantial to maximal assistance with dressing;-Dependent on staff for toileting hygiene, showering, personal hygiene, transfers. During an interview on [DATE], at 1:00 P.M., the resident said his/her call light had not been working properly. Staff came in and switched the cord. He/she was unable to tell if the call light was illuminated on the outside the door. He/she was unable to get up on his/her own to get staff for assistance. 3. Review of Resident #59's face sheet showed the following:-admission date of [DATE];-Diagnoses included Alzheimer's disease. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact;-Use of wheelchair;-Substantial to maximal assistance with toileting. Observation on [DATE], at 7:35 A.M., showed the resident's bathroom emergency call light button without a pull string. During an interview on [DATE], at 2:10 P.M., the Director of Nursing (DON) said the call lights in resident bathrooms should have a string that reaches to the floor to ensure the resident can activate the call light if they fell on the floor. During an interview on [DATE], at 3:55 P.M., the Administrator said the resident's emergency call light button should have a pull string. 4. Observation on [DATE], at 11:33 A.M., showed the following: -The scroll board above 300 hall doors showed the time as 12:56 P.M., and showed no resident room numbers on the board;-The scroll board above 400 hall showed two room call lights, however the nurses' station scroll board did not show any lights on the 400 hall. 14. Observation on [DATE], at 8:30 A.M., the following was noted:-The 300 hall scroll board showed time as 9:53 A.M., with no call lights on;-The 400 hall scroll board showed two call lights on;-The 300 and 400 nurses' station scroll board showed two call lights on for the 300 hall and no call lights on for the 400 hall;-The 500 hall scroll board showed incorrect day of the week and two call lights on;-The 600 hall scroll board showed no call lights on;-The 500 and 600 nurses' station scroll board showed no call lights on. Observation on [DATE], at 12:41 P.M., of the call light scroll board in the secured unit showed the following:-A low battery alert for room [ROOM NUMBER], emergency spa;-Tamper warning, room [ROOM NUMBER], bed 2;-Tamper warning room [ROOM NUMBER], bed 2;-No call light was illuminated on the outside of room [ROOM NUMBER];-No lights on at the call box. During an interview on [DATE], at 12:50 P.M., Certified Medication Technician (CMT) B said there was no light on for room [ROOM NUMBER], bed 2, as the resident was not in the room. The battery was probably dead. During an interview on [DATE], at 2:10 P.M., the Director of Nursing (DON) said if the call light in spa was alarming and there was no one in the room, staff should put in a work order. During an interview and observation on [DATE], at 1:45 P.M., the Assistant Maintenance Superintendent said the lights on the secured unit were not used often. If the call light battery died, it would not work at all. The call light battery in room [ROOM NUMBER]-2 may be dead. 5. During an interview on [DATE], at 11:36 A.M., Registered Nurse (RN) A said the following:-Scrolling boards are located at each nursing station. The boards show which call lights are on for the hall;-The facility recently added scrolling board in each of the halls;-The hall scrolling boards and the scrolling boards at the nurses' station do not match due to a recent upgrade and the software being incompatible;-The system is a wireless system. The lights and scroll board are only visible and there is no audible sound;-The facility used to utilize pagers. During an interview on [DATE], at 12:50 P.M., Certified Medication Technician (CMT) B said the following:-The call lights do not sound when turned on;-The call lights were visible at the resident doors and at the scroll board at the nursing station;-The new boards are located at entrance of 300, 400, 500, and 600 halls;-If a scroll board shows a tamper warning or a low battery warning, staff should put a work order in the computer system for maintenance. During an interview on [DATE], at 12:55 P.M., RN C said the following:-If a call light had been turned on, the board at the nursing station showed the room number;-He/she did not know what a tamper warning meant on the scroll board, but would submit the concern to maintenance;-There was no noise from call light or scroll board;-Staff should be up and down the halls to see the call lights. During an interview on [DATE], at 1:25 P.M., CNA D said the following:-He/she looks up and down the halls while working to monitor for call lights;-The scroll boards at the entry of hallways do not work, but staff can check the scroll board at nurses' desk;-Staff used to have pagers that beeped and vibrated if a resident rang their call light; -If staff have concerns with the call light system, they should put in a work order for maintenance to review. During an interview and observation on [DATE], at 1:45 P.M., Assistant Maintenance Superintendent said the following:-The system was installed to make a more homelike environment without the beeping noise of call lights. There is no audible sound at the nursing station or at the residents' rooms;-The facility used to have pagers, but they have all been lost or misplaced. New pagers have been ordered;-Each nursing station has a scrolling board;-The facility recently added scroll boards above the 300, 400, 500, 600 hall entry area to help with call light visibility; -The 300 hall scroll board does not work with the old system, as there was a communication issue between the boards;-The signal from the call light box goes to the scroll board above hall, to the nursing station, and to the pagers, if available;-It can take a few seconds for the connection to be made. Staff should be checking the scrolling boards at nursing stations and the call lights outside the resident's room; -A tamper warning message means someone pulled too hard, and the call light cord came out of the wall. If this occurs, staff should put in a maintenance order;-The call light does not illuminate at the resident room if pulled from the wall. The call light box in the room will initially illuminate but the light will turn off after a short time;-A low battery warning indicates a low battery in the resident room. If this occurs, staff should put in a work order for maintenance. The call system is made to work even if there is a low battery;-Maintenance staff check work orders periodically throughout the day and should be done by the end of the workday. During an interview on [DATE], at 2:10 P.M., the Director of Nursing (DON) said the following:-The scrolling screens at nursing stations and the lights outside the resident rooms notify staff if a resident pressed their call light;-Aides and charge nurses used to carry pagers, but they all broke or disappeared;-Maintenance staff were trying to find compatible pagers with the call system;-If the system did not work, staff should do frequent walking rounds; -If the scroll board shows a low battery or tamper warning, staff should put in a maintenance work order; -The scroll boards over 300, 400, 500, and 600 halls do not work correctly, but the nursing station board works. During an interview on [DATE], at 2:20 P.M. and 4:15 P.M., the Administrator said the following: -The facility had a wireless call light system;-The system did not have any audible sound except in the visitor bathrooms;-Currently, the facility does not have pagers. The facility attempted to purchase pagers that were compatible with the system;-The facility added scroll boards at the entry of 300, 400, 500, and 600 halls;-The newly installed boards and the old boards do not work together;-The scrolling boards above the halls are inaccurate;-Too many call lights going off at the same time causes the system to clog;-Maintenance staff randomly checks call light monthly or quarterly;-If staff have concerns with the call system, they should turn in a work order for maintenance;-If a resident voices call light concerns, he would review the cameras. Often it is discovered the resident has turned off the light.

Based on interview, and record review, the facility failed to ensure all residents maintained acceptable parameters of nutritional status when staff failed to document an unplanned weight loss, failed to notify the registered dietician (RD) of the weight loss, failed to modify care plan to reflect the weight loss, and failed to implement new interventions after a continued unplanned weight loss one resident (Resident #41). The facility census was 85.Review of the facility policy titled 'Patient Weights, revised April 2022, showed in long-term care setting, weights will be done on admission, monthly, and as needed or as ordered. 1. Review of Resident #41's face sheet (admission data) showed the following information:-admission date of 10/10/20;-Diagnoses included other symptoms and signs involving cognitive functions and awareness. Review of the resident's vital signs showed the following:-On 12/06/25, at 8:39 A.M., showed the resident weighed 160 pounds 3.2 ounces;-On 12/13/25, at 12:30 P.M., showed the resident weighed 160 pounds;-On 12/21/25, at 6:58 A.M., showed the resident weighed 158 pounds. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) Coordinator/Registered Nurse (RN) J's note, dated 12/26/25, at 1:31 P.M. showed the following:-Weight meeting on 12/26/25;-Last documented weight 158 pounds;-Weight is stable;-Continue to monitor intake. Review of the resident's vital signs dated 1/03/26, at 5:07 P.M., showed the resident weighed 156 pounds 12.8 ounces. Review of the physician's note, dated 01/20/26, showed the following:-Routine rounds;-Weight 156 pounds 12.8 ounces;-The resident denied any pain or problems. The nursing staff have no new concerns. Review of the resident's NP's visit, dated 01/26/26, showed the resident's current weight was 159 pounds, on a five-foot one inch frame, with a Body Mass Index (BMI-a way to look at whether a person is at a healthy weight) of 30.1% (obesity is BMI of 30 or more). Review of the Registered Dietitian's (RD) note dated 01/31/26, at 1:56 P.M. showed the following:-Quarterly nutrition assessment;-BMI 29.6 (overweight for BMI of 25-29.9) calculated by electronic medical record 156 pounds;-Resident seen in the common area of the special care unit. Staff without concerns for his/her nutrition needs. Staff state the resident was predominantly independent with eating with an occasional reminder to continue to eat. The resident weight was stable (plus/minus 5 pounds) over the past three months. Continue current diet without change. No nutrition intervention. Review of the resident's vital signs dated 02/05/26, at 7:46 A.M. showed the resident's weight was 146 pounds 3.2 ounces (a 10-pound weight loss since the RD visit on 01/31/26). Review of the MDS Coordinator/ RN note dated 02/06/26, at 3:21 P.M., showed the following:-Weight meeting on 02/06/25;-Last documented weigh of 146 pounds 3.2 ounces;-Has lost 10 pounds in one month;-No supplements taken;-Consumed 25-75% of his/her meals;-Plan to continue to monitor.(Staff did not document physician or RD notification of the weight unplanned weight loss.)Review of the resident's MDS quarterly assessment dated [DATE], at 2:33 P.M., showed registered medication technician (RMT)/social service staff documented the resident's energy levels had decreased. The resident's appetite decreased significantly, with a reported weight loss of 10 pounds in the last month. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Short- and long-term memory problem;-Moderately impaired decisions, cues/supervision required;-Weight of 146 pounds;-Loss of 5% or more in last month or loss of 10% or more in the past six months;-Not on physician-prescribed weight loss regimen;-Required supervision or touching assistance with eating. Review of the resident's nurse's note dated 02/17/26, at 6:33 P.M. showed a nurse documented the resident received nurse practitioner geri-psych recommendation to stop Zoloft (treats depression) for depression and increase melatonin to 10 milligrams and start trazodone (an antidepressant) for insomnia and depression. Review of the resident's vital signs dated 02/22/26, at 11:00 A.M., showed the resident's weight was 140 pounds eight ounces (a six-pound weight loss in 16 days).Review of the resident's medical record showed staff did not document physician or RD notification of the unplanned weight loss. Review of the resident's nurse practitioner's (NP) note, dated 02/27/26, showed the following:-The resident's vital signs were stable;-The resident's current weight was stable at 140 pounds, on a five-foot one-inch frame, with a BMI of 26.5% (overweight for BMI of 25-29.9). Review of the resident's vital signs dated 03/02/26, at 9:31 A.M. showed the resident's weight was 140 pounds 12.8 ounces. Review of the NP's visit, dated 03/10/26, showed the resident's weight was currently 140 pounds and stable over the month. The resident was down 16 pounds over the past two months. Continue to monitor closely. Review of the resident's psych follow-up consultation dated 03/14/26, at 10:56 A.M. showed the following:-The provider documented the resident's energy levels have decreased and his/her appetite has decreased significantly, resulting in a ten-pound weight loss in the last month. The resident had trouble concentrating, which could be due to significant hearing loss. Despite reports of appearing more depressed, the resident did not show outward signs of hopelessness, and the resident reported it's wonderful to be alive;-The planned initiation of Remeron (an antidepressant that and can also increase appetite) will address a potential depressive component as well as appetite and sleep;-The resident's insomnia and poor appetite to be managed by discontinuing trazodone and starting Remeron 7.5 mg at bedtime;-The primary clinical concerns was the resident's significant weight loss of 10 pounds in the last month, decreased appetite and decreased energy;-The overall plan has been changed from conservative monitoring to active management with a medication change to address the resident's significant weight loss and insomnia. Review of the resident's nurse's note dated 03/17/26, at 5:37 P.M. showed a nurse documented geri-psych consultant recommended to discontinue trazodone and start Remeron 7.5 mg at bedtime for appetite due to weight loss and insomnia/depression. Review of the resident's physician order, dated 03/17/26, showed an order with start date of 03/17/26 for Remeron 7.5 mg by mouth at bedtime for depression. Review of the resident's vital signs dated 03/28/26, at 9:00 A.M showed the resident's weight was 141 pounds 11.2 ounces. Review of the RD's progress note dated 03/30/26, at 11:40 A.M., showed the following:-Last documented weight 141 pounds 11.2 ounces;-Weight change: negative 9.6% in three months, negative 14% in six months;-Soda pop with every meal, double dessert with lunch, and the resident was allowed soft breads, cakes, cookies;-Resident with decreasing weight trend as well as decreasing oral intake. Body Mass Index 26.8 (overweight for BMI of 25-29.9). Continue to monitor weight and intake. Resident may benefit to move to assisted table to have cueing to continue eating. Review of the resident's care plan, reviewed 04/02/26 showed the following:-The resident has a minced and moist 5 diet due to holding food in his/her mouth and spits the food out;-The resident's appetite has significantly decreased;-The resident had a diagnosis of major depressive disorder, the resident has times of being down, feeling hopeless, feeling tired and having little appetite.(Staff did not update the resident's care plan related to the unplanned weight loss or current interventions in place.) During an interview on 03/31/26, at 5:45 P.M., Certified Nurse Aide (CNA) I said the following:-Staff should report to the nurse of a change in weight;-The nurses inform the aides of weights to obtain;-Staff switched the resident's diet from regular to minced and moist;-The resident required cueing to eat and does a little better;-The resident had a weight loss.During an interview on 04/01/26, at 11:52 A.M., Registered Nurse (RN) C said the following:-Staff compare weights from the last weight on the vital sign sheet;-The aides get the weights on the residents;-The charge nurse oversees the aides obtaining residents' weights;-Staff report residents' weight loss to RN J;-He/she did not attend the weight meetings which include administration staff;-Kitchen staff or RN J informed nurses of an intervention or diet change for a resident;-Staff started the resident on Remeron on 03/17/26. During an interview on 04/01/26, at 1:15 P.M., the Dietary Manager (DM) said the following:-She and RN J were the weight team;-She prints out weights once a week on Friday and reviews them;-The Registered Dietician comes to the facility two times a month, she gives the RD a list of new residents;-The RD reviews new residents, annual assessments, and weights;-RN J and the RD calculate the percentage of weight loss of residents;-RN J documents on the residents related to weight loss;-She did not document on residents who have a weight loss, she is still learning his/her position;-The RD sends recommendations after her visit and notifies her and RN J;-She did not see orders for supplements or interventions for the resident until the Remeron on 03/17/26;-The last time the RD saw the resident was 01/31/26.During an interview on 04/02/26, at 8:44 A.M. RN P said the following:-Nurses notify the physician of a weight loss;-RN J monitored weight loss of residents;-He/she was not aware of the resident's weight loss;-The resident was slow and normally feeds himself/herself. During an interview on 04/01/26, at 1:32 P.M., the RD said the following:-She comes to the facility three days a month;-The DM is in charge of the weekly weight meetings;-The DM notified her of residents' weight loss;-She prints out a weight report of the residents every time she visits the resident;-She assesses residents if they have a weight loss or gain and she asks residents about appetite and supplements;-The weight report only shows 30-day, three month and 6 month weights;-She only saw her progress note of the resident's 01/31/26 visit and the visit yesterday (03/31/26);-She considered the resident's weight loss semi beneficial, the resident's BMI was high, right now the resident's BMI was 26% (overweight for BMI of 25-29.9). This should be documented and care planned if beneficial;-She expects staff to notify her if a resident has 7.5% weight loss for three months;-She had the resident's 01/31/26 weight and the 02/05/26 weight of 146 lbs;-Staff should have informed her of the resident's weight loss. She feels she should have had a note for February 2026 for the resident's weight loss and did not know why she did not. During an interview on 4/01/26 at 2:20 P.M. MDS/Care Plan Coordinator/RN J said the following:-She prints out the weight report every week and reviews the weights;-The aides weighed the residents. The nurses were responsible for the aides obtaining the weights;-He/she evaluated residents with weight loss triggers which included anyone had greater than 5% in one month, or 10% in 6 months of weight loss or weight gain;-He/she and the DM had a weight meeting weekly and review one hall at a time;-He/she and the DM discussed options if a resident has a significant weight loss and he/she documents a weight meeting note in the resident's chart;-The RD comes to the facility weekly;-He/she or the Director of Nursing (DON) entered orders into the computer of supplements;-The RD reviewed the weight report and messaged him/her or the Administrator of recommendations and documents in the resident's chart;-He/she copied the note and sent the recommendation to the provider;-He/she did not see any messages to the physician of the resident's weight loss from 01/03/26 through 03/03/26.During an interview on 04/02/26, at 10:55 A.M. the NP said the resident had a steady decline of weight loss. She expected staff to document the resident's weight loss.During an interview on 04/02/26, at 12:13 P.M. the Director of Nursing (DON) said the following:-The DM and RN J run a weight report;-She and the DM and RN J met weekly for weight meetings;-The weight team reviewed percentages of weight loss, how a resident eats, staff should document weights;-She expected staff to document and notify the RD and provider of a resident's weight loss. During an interview on 04/02/26, at 2:25 P.M., the Administrator said he expected staff to document on weight loss.

Based on interview, and record review, the facility failed to provide care per standards of practice when staff failed to follow a physician order for daily weights, failed to consistently document weights, and failed to notify the physician on two occasions of a significant weight gain for one resident (Resident #43) with a diagnosis of congestive heart failure (CHF- chronic, progressive condition where the heart cannot pump blood effectively causing fluid buildup in the lungs and body) with bilateral lower extremity edema (swelling of both legs, ankles, or feet caused by abnormal fluid buildup in the tissues). The facility census was 85. Review of facility policy titled 'Patient Weights, dated April 2022, showed the following:-Facility weights will be done on admission, monthly, and as needed or as ordered;-The purpose is to monitor weight gain or loss. Review of a facility policy titled Changes in Resident Condition: Notification Guidelines, dated January 2025 , showed the following:-Physicians, residents, and families will be notified in a timely manner of changes in clinical conditions and environmental changes affecting the resident;-The purpose is to provide timely communication of condition and environmental changes to care providers, residents, and their families;-When resident changes are noted nursing staff will notify the resident's attending provider and the resident's legal representative or family member.-Messaging within the electronic medical record should be used for nonurgent information and should include a thorough assessment, detailed information, and/or specific resident details that need to be communicated to the provider;-A nurse's note in the electronic medical record should be completed after a provider phone call regarding any urgent resident changes, after receiving orders from a provider in person or through phone call, and after conversations with a provider regarding a resident that would be pertinent to include in the medical record;-Notification will occur as soon as possible when there is a significant change in the resident's acute medical condition; deterioration in health status in either life threatening or clinical complications; or the need to alter treatment significantly including but not limited to a need to discontinue a treatment or commence a new form of treatment. 1. Review of Resident #43's face sheet (a general information sheet) showed the following:-admission date of 08/06/24;-Diagnoses include CHF, chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood), and bilateral edema of lower extremities.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 02/25/26, showed the following:-Resident had moderate cognitive impairment; -Diagnoses include heart failure and respiratory failure;-Resident had taken a diuretic (medication that removes excess fluid from body);-Required substantial to maximum staff assistance for toileting, showering, and dressing and transfers.Review of resident's care plan, revised 04/02/26, showed the following:-Resident required substantial assistance bathing, dressing, and locomotion;-Staff should monitor weight as ordered;-Staff should complete a resident edema assessment twice daily.Review of the resident's current Physician Order Sheet (POS) showed the following:-An order, dated 11/14/25, for Lasix (medication used to treat fluid retention) 40 milligrams (mg) tablet, give one tablet once a day;-An order, dated 11/14/25, for Lasix 20 mg tablet, give one tablet once daily at 1:00 P.M.;-An order, dated 06/03/25, to cleanse the lower extremities with wound cleanser and pat dry, apply two-step zinc compression wraps from toes to knees on bilateral lower extremities. Change every Sunday and then change every Tuesday and Friday after shower.Review of the resident's medical record showed the resident weighed 220 pounds on 02/07/26. Review of the resident's physician progress note, dated 02/09/26, showed the following:-The resident needed daily weights;-Resident had chronic edema to the bilateral lower extremities;-Edema to bilateral lower extremities was 1+ pitting edema (a mild form of fluid accumulation characterized by a slight, 2 millimeter (mm) indentation that rebounds immediately upon pressure);-Resident continued Lasix 40 mg daily and Lasix 20 mg at 1:00 P.M.;-He/she currently utilized compression wraps by nursing staff twice weekly;-Resident to continue current medication;-Nursing staff to notify provider of any worsening of condition.Review of the resident's current POS did not show an order for daily weights.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 02/08/26 and 02/09/26.Review of the resident's medical record showed a weight of 235.8 pounds on 02/10/26 (weight gain of 15.8 pounds in 3 days). Review of the resident's nursing progress notes showed staff did not document physician notification of the 15.8-pound weight gain.Review of the resident's medical record showed a weight of 236 pounds on 02/11/26. Review of the resident's nursing progress notes showed staff did not document notification of the physician of a 16-pound weight gain.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 02/12/26 through 02/16/26. Review of the resident's medical record showed a weight of 234 pounds on 02/17/26.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 02/18/26 through 02/19/26. Review of the resident's medical record showed a weight of 226 pounds on 02/20/26. (weight loss of 10 pounds).Review of the resident's medical record showed staff did not document a check of the resident's weight document on 02/21/26. Review of the resident's medical record showed a weight of 225.8 pounds on 02/22/26.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 02/23/26. Review of the resident's NP progress note, dated 02/24/26, showed the following: -The resident needed daily weights;-Resident had chronic edema to the bilateral lower extremities;-Edema to bilateral lower extremities was 1+ pitting edema;-Resident continued Lasix 40 mg daily and 20 mg at 1:00 P.M.;-He/she was currently utilizing compression wraps by nursing staff twice weekly;-Resident to continue current medication;-Nursing staff to notify provider of any worsening of condition. Review of the resident's medical record showed staff did not document a check of the resident's weight document on 02/24/26 through 03/01/26.Review of the resident's NP progress note, dated 03/02/26, showed the following: -The resident needed daily weights;-Resident had chronic edema to the bilateral lower extremities;-Edema to bilateral lower extremities was 1+ pitting edema;-Resident continued Lasix 40 mg daily and 20 mg at 1:00 P.M.;-He/she is currently utilizing compression wraps by nursing staff twice weekly;-Resident to continue current medication;-Nursing staff to notify provider of any worsening of condition. Review of the resident's medical record showed staff did not document a check of the resident's weight document on 03/02/26 through 03/04/26.Review of the resident's medical record showed a weight of 240 pounds on 03/05/26 (weight gain of 14.2 pounds).Review of the resident's nursing progress notes showed staff did not document physician notification of the 14.2-pound weight gain.Review of the resident's medical record showed a weight of 239.8 pounds on 03/07/26.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 03/08/26 through 03/10/26.Review of the resident's medical record showed a weight of 235.8 pounds on 03/11/26.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 03/12/26.Review of the resident's medical record showed a weight of 237 pounds on 03/13/26.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 03/14/26 through 03/19/26.Review of the resident's medical record showed a weight of 236.5 pounds on 03/20/26.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 03/21/26 through 03/24/26.Review of the resident's medical record showed a weight of 231 pounds on 03/25/26.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 03/26/26 through 03/28/26.Review of the resident's medical record showed a weight of 228 pounds on 03/29/26.Review of the resident's medical record showed staff did not document a check of the resident's weight document on 03/30/26.Review of the resident's NP progress note, dated 03/30/26, showed the following: -Resident had chronic edema to the bilateral lower extremities;-Resident continued Lasix 40 mg daily and 20 mg at 1:00 P.M.;-Resident to continue current medication. Review of the resident's medical record showed a weight of 240.8 pounds on 03/31/26.Review of the resident's nursing progress note dated 03/31/26, at 6:54 P.M., showed the following: -The nurse notified the NP of resident's change of condition;-NP assessed and placed new orders to change Lasix to Bumex (medication used to treat fluid retention) to start tomorrow and an order for a one-time dose of Lasix now;-The nurse noted edema to the resident's right hand;-The nurse noted increased edema and a 10-pound weight gain since 03/29/26 upon assessment.Review of the current POS showed the following:-An order dated 04/01/26, for Bumex 2 mg tablet once daily with no diagnosis listed;-An order dated 04/01/26, to discontinue Lasix.Review of a nursing progress note dated 04/01/26, at 5:10 A.M., showed a daily weight result of 232 pounds.During an interview on 04/02/26, at 9:30 A.M., Certified Nurse Assistant (CNA) E said the following:-CNA's were responsible for resident weights;-The nurse listed the weights for the day on the vital sign sheet;-The resident was a daily weight;-Resident weights are documented in the medical record after they are completed, and the vital sign sheet is left on the nurse's desk;-Residents are on daily weights to monitor fluid in the body;-The resident's legs were really swollen;-Staff elevate and wrap the resident's legs to help with swelling;-He/she would notify the nurse of increased swelling.During interview on 04/02/26, at 12:45 P.M., Registered Nurse (RN) F said the following:-CNA's were responsible for completing resident weights; -The nurse would create a list of weights to be completed for the CNA's daily;-The CNA's complete the weights and notify the nurse;-The resident was on daily weights;-He/she would notify the physician of a 15-pound weight gain;-He/she would give a PRN Lasix if a residents had a 3-pound weight gain in one day;-The resident did not have a PRN Lasix order;-The physician should be notified of a 3-pound weight gain in 24 hours or a gain of 5 pounds in a week;-Weight gain and physician notification should be documented in notes;-The resident should have been reweighed to double check weight gain;-The NP was notified of the resident's weight gain on Tuesday 03/31/26.During an interview on 04/02/26, at 10:45 A.M., the Nurse Practitioner (NP) said the following:-Staff notified him/her of the resident's weight gain during a facility visit on Tuesday;-The resident had increased edema and was not feeling well;-The resident had a swollen hand and eyelids;-The NP changed his/her orders to include an extra Lasix pill and change current Lasix order to Bumex;-The resident should be on daily weights;-Some residents have an as needed Lasix for weight gain, but he/she was unsure if the resident had one;-Staff should notify the physician or NP of a weight gain of 5 pounds in one day or use of an as needed Lasix two days in a row.During an interview on 04/02/26, at 2:37 P.M., RN A said the following:-CNA's obtain weights on night shift before breakfast;-Residents with CHF should have weights monitored daily;-He/she would reweigh the resident if they had a 10-pound weight gain;-He/she would notify the physician of a weight gain of three pounds;-The physician should be notified of a 3 pound or more gain in weight due to a diagnosis of CHF;-A 3-pound weight gain would initiate a flag in the medical record;-A 10-pound weight gain is extreme and would indicate a change in condition;-He/she would monitor the resident's cardiac status, lung sounds, and edema for a possible weight gain;-Physician notification and assessment should be documented;-CHF and edema should be included on a resident's care plan.During an interview on 04/02/36, at 2:50 P.M., Licensed Practical Nurse (LPN)/Infection Preventionist said the following:-A weight that is due should show up on the work list in the medical record;-The resident was on daily weight and had been for a long time;-Residents with a CHF diagnosis should have orders for daily weights upon admission;-He/she would reweigh a resident with an unusual weight gain;-He/she had talked to the family about the resident's weights;-He/she would notify the physician of a wright gain of 3 pounds in a day or 5 pounds in a week;-The CNA should notify the charge nurse of any out-of-range weights;-He/she would notify the physician and assess the resident;-He/she would document the assessment and notification to the physician.During an interview on 04/02/36, at 1:10 P.M., the Director of Nursing (DON) said the following:-The resident had an intervention to obtain weights; -The resident should be a daily weight;-The resident had an order for weight to be obtained every 30 days, and he/she changed the orders to daily weights;-The physician inputs his/her own orders unless nurses call for an order;-The physician will at times give a verbal order to nurses;-Staff should notify the physician of a weight gain of 3 pounds in a day or 5 pounds in a week;-Staff should have reweighed the resident after weight gain and notified the physician and documented;-The note in the physician progress note regarding daily weights could be an order and should be followed.During an interview on 04/02/26, at 3:10 P.M., the Administrator said staff should complete daily weights everyday unless the resident refused. The physician or NP should be notified of a resident weight gain, and the nurse should document any notification.

Based on interview and record review, the facility failed to report all allegations of possible abuse within two hours of the allegation being made to the State Survey Agency (SSA) when the facility did not report an allegation of physical abuse between to residents (Resident #1 and #2) to the Department of Health and Senior Services (DHSS). A sample of five residents were sampled. The facility census was 85.Review of the facility's policy titled Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, revised 08/2021, showed the following:-Facility staff, employees, and physicians will follow regulations and standards in the identification of and procedures for handling alleged victims of abuse;-Facility purpose is to guide staff, employees, physicians, and any mandated reporter within the facility in identifying victims of abuse and provide a reporting mechanism in accordance with all local, state, and federal laws; -In the event a staff member with responsibility for the care of a person [AGE] years of age or older or adults with disabilities ages 18 to [AGE] years of age has reasonable cause to suspect that an individual has been subjected to abuse or neglect, receives an allegation of abuse or neglect, or observes this individual being subjected to conditions or circumstances which would reasonably result in abuse or neglect, that individual shall immediately make a report to the DHSS or the appropriate facility designee;-The facility designee will report or assist the person with direct knowledge of the concern to report immediately, within two hours of the allegation is for mental, physical, verbal, or sexual abuse or there has been bodily injury related to abuse. If not abuse and there is no injury, the designee should report within 24 hours of the observation or allegation;-The report is made to the DHSS at the hotline, or in cases involving long-term care (LTC), the report shall be made first to the Regional DHSS office (if during regular business hours) or the hotline if after hours;-A fax notice or email to the regional DHSS during hours the hotline is closed (midnight to 7 A.M.) is acceptable for the two hour notice but a follow up call is required;-The DHSS website can also be utilized to report concerns, complaints, or allegations of patient/resident abuse/neglect (sexual, physical, or verbal) by another patient, resident, employee, vendor, or visitor; -Hotline information may also be reported to law enforcement, but all suspected cases and/or allegations of elder abuse or abuse of persons with disability must be reported to DHSS;-This policy does not preclude others from reporting suspected abuse or neglect, including other staff members and physicians directly involved with the patient;-In LTC, the facility designee, which is the facility administrator, administrator on-call, director of nursing (DON), or registered nurse (RN) on-call, shall be responsible for reporting suspected abuse or neglect. 1. Review of Resident #1's face sheet (a document that gives a patient's information at a quick glance) showed the following:-admission date of 03/15/24;-Diagnoses included Alzheimer's disease (a progressive brain disorder, the most common cause of dementia, characterized by gradual memory loss, impaired thinking, and changes in behavior, impacting daily function over time). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 12/15/25, showed the following:-The resident had severe cognitive impairment;-The resident had no behaviors.Review of the resident's care plan, revised 01/01/26, showed the staff did not care plan any prior resident-to-resident altercations. following:-Resident was independent with ambulation and did not use an assistive device;-Resident had memory loss due to Alzheimer's dementia;-Resident may have times where he/she gets disoriented about where he/she is or why; -Please allow the resident extra time to process information;-Resident may need reassurance that he/she was safe;-Staff to avoid changes in the resident's environment;-Resident was sometimes resistant to cares and could get aggressive at times;-Staff to reinforce positive behavior;-If agitated staff to leave and reapproach later;-Staff to reduce excessive stimuli;-Staff to use a calm reassuring approach;-Staff to maintain a non-defensive stance;-Staff to assess for trigger situations such as pain, personal loss, relocation, conflict or prior history.(Staff did not care plan any prior history of resident-to-resident altercations.) Review of the resident's progress note dated 10/17/25, at 1:22 P.M., showed the following: -A Fall Communication Form dated 10/17/25, at 12:45 P.M., for an unwitnessed fight and fall;-Resident #1 was finishing eating lunch. A family member of another resident visiting at lunch stated Resident #1 threw his/her spoon at Resident #2. Resident #1 then got up from his/her chair and went at Resident #2 and pushed Resident #2 over while seated in the dining room chair;-Both residents went down with Resident #2 still in the chair and Resident #1 on top of Resident #2;-Resident #1 hit his/her head on the office chair located near the laptop station the certified nurse aides (CNAs) use for documenting;-The nurse and CNA approached the resident. Resident #1 was already in a partial standing position. The CNA assisted the resident to a full upright position and encouraged him/her to sit in a dining room chair for assessment;-Resident #1 had no visible signs of injury post fall, and his/her vital signs were stable. Staff to continue to monitor closely and notified the resident's family. (Staff did not document reporting the event to DHSS.)2. Review of Resident #2's face sheet showed the following:-admission date of 11/29/24;-Diagnoses included sick sinus syndrome (a group of heart rhythm disorders where the heart's natural pacemaker (the SA node) fails, causing a heartbeat that's too slow (bradycardia), too fast (tachycardia), or alternates between slow and fast rhythms (tachy-[NAME] syndrome)). Review of the resident's annual MDS, dated [DATE], showed the following:-The resident had severe cognitive impairment;-The resident had verbal behaviors one to three days. Review of the resident's care plan, revised 01/01/26, showed the following:-Resident required supervision for ambulation. The resident used a wheelchair for locomotion. The resident required substantial assistance with propelling his/her wheelchair;-Resident was unable to express his/her needs and wants to staff due to his/her diagnosis of Alzheimer's and dementia; -Resident may repeat him/herself frequently so do not be offended if he/she asked the same questions repeatedly;-Staff to allow resident extra time to process information;-Resident may need reassurance that he/she was safe;-Staff to avoid changes in resident's environment;-Resident sometimes had amorous behaviors toward a peer and needed to be redirected by staff;-Resident had outbursts of yelling at times;-Staff to reinforce positive behavior. If agitated, leave and reapproach later;-Staff to reduce excessive stimuli;-Staff to use a calm, reassuring approach;-Staff to maintain a non-defensive stance;-Staff to assess for trigger situations such as pain, personal loss, relocation, conflict or prior history.(Staff did not care plan any prior history of resident-to-resident physical altercations.) Review of the resident's progress notes dated 10/17/25, at 1:41 P.M., showed the following: -A Fall Communication Form dated 10/17/25, at 12:45 P.M., for an unwitnessed fall-The resident was sitting in the dining room finishing lunch. The nurse and CNA approached the resident and another resident both on the floor;-A family member visiting at lunch stated that Resident #1 threw his/her spoon at Resident #2 and then got up from the chair and went to Resident #2, pushing Resident #2 over while seated in the dining room chair. Both residents went down with Resident #2 still in the chair and Resident #1 on top of Resident #2;-The nurse and two CNAs assisted Resident #2 to a dining room chair with the use of a gait belt and assessed for visible signs of injury. No injuries were observed, and vital signs were stable;-Staff seated the resident in dining room chair for post fall assessment and continued to monitor per post fall protocol;Staff notified the resident's family.(Staff did not document reporting the event to DHSS.)3. Review of the facility's investigation, dated 10/17/25, showed the following: -Notified by Licensed Practical Nurse (LPN) G that resident had an incident with another resident in the unit during lunch. Incident was witnessed and handled by a LPN and a certified nursing assistant (CNA). Per primary nurses' report, there were no injuries noted to either resident. Residents were separated and monitored closely without further behaviors during this shift. Due to memory status of residents LPN was unable to interview participants and other residents; -Primary nurse instructed by this DON to interview staff who were present and complete event report. Administrator contacted by DON to inform of incident when contacted by primary nurse. Due to no further behaviors this shift, both resident's constant state of confusion no further investigation felt to be beneficial;-Event information for Resident #1, dated 10/17/25 at 12:45 P.M., for a fall-other that occurred showed a nurse and a CNA approached this resident and another resident on the floor. Resident #1 was trying to get up from the floor. A family member of another resident visiting at lunch stated Resident #1 threw his/her spoon at Resident #2, then he/she got up from his/her chair and went at Resident #2 pushing him/her over while seated in the dining room chair. They both went down. Resident #2 in the chair and Resident #1 on top of Resident #2. Resident #1 hit his/her head on the office chair located near the laptop station the CNAs use for documenting;-The nurse and CNA assisted Resident #1 into a chair to assess for wounds and none were observed. The incident severity was no harm (minor) with increased monitoring. Staff notified the DON, family, and physician;-There was no manager follow-up on the form;-Corrective action was fall team reviewed and care plan updated. Referrals were sent to the DON and Administrator. (Staff did not document DHSS notification.);-Event information for Resident #2, dated 10/17/25 at 12:45 P.M., an unwitnessed fall occurred showed prior to fall, the resident was sitting in the dining room finishing lunch. A nurse and CNA approached this resident and another resident on the floor. This resident was trying to get up from the floor. A family member of another resident visiting at lunch stated Resident #1 threw his/her spoon at Resident #2, then Resident #1 got up from his/her chair and went at Resident #2 pushing him/her over while seated in the dining room chair. They both went down, Resident #2 in the chair and Resident #1 on top of Resident #2. Resident #1 hit his/her head on the office chair located near the laptop station the CNAs use for documenting;-A nurse and two CNAs assisted Resident #2 to a dining room chair with use of a gait belt and assessed for visible signs of injury with none observed. His/her vital signs were stable;-List Interventions put into place at time of fall included seated resident in dining room chair for post fall assessment and continued monitoring per post fall protocol. Incident severity was no harm (minor) with increased monitoring;-Staff notified the DON, resident's family, and physician. There was no manager follow-up on the form. Corrective action was fall team reviewed and care plan updated. (Staff did not document DHSS notication.) 4. During an interview on 01/01/26, at 9:29 A.M., CNA A said if he/she witnessed abuse, he/she reported to the charge nurse immediately and reported to DHSS within 24 hours. During an interview on 01/01/26, at 12:29 P.M., CNA B said the following: -If he/she witnessed a resident-to-resident altercation, he/she separated the residents and reported to the charge nurse immediately;-He/she filled out a report of concern (ROC) that would be sent to the Administrator and DON;-The DON or Administrator reported to DHSS immediately.During an interview on 01/01/26, at 12:44 P.M., Certified Medication Technician (CMT) C said the following:-If he/she witnessed a resident-to-resident altercation, he/she separated the residents and reported to the charge nurse immediately;-The DON or Administrator reported to DHSS within 24 hours;-The DON or Administrator should have reported the altercation between Resident #1 and Resident #2 to DHSS. During an interview on 01/01/26, at 1:01 P.M., CNA D said the following:-If he/she witnessed a resident-to-resident altercation, he/she separated the residents and reported to the charge nurse immediately;-The DON or Administrator reported to DHSS within 24 hours;-If Resident #1 and Resident #2 had an altercation, the DON or Administrator should have reported to DHSS.During an interview on 01/01/26, at 1:13 P.M., Licensed Practical Nurse (LPN) E said the following: -If he/she witnessed a resident-to-resident altercation, he/she separated the residents and reported to the DON immediately. He/she also sent the residents out for psychiatric consult, notified the resident physician and responsible party, assessed the residents for injuries, and completed an incident and ROC report;-The altercation was reported by the DON or Administrator to DHSS, but he/she did not know how long they had to report;-If Resident #1 and #2 had an altercation, the DON or Administrator should have reported the incident to DHSS. During an interview on 01/01/26, at 2:25 P.M., Registered Nurse (RN) F said the following:-If a CNA or CMT witnessed a resident-to-resident altercation, they should separate the residents and report to the charge nurse immediately;-The charge nurse assessed the residents and reported to the DON immediately;-The DON or Administrator reported to DHSS within two hours;-The DON or Administrator should have reported the altercation between Resident #1 and #2 to DHSS.During an interview on 01/01/26, at 2:43 P.M., the DON said the following:-If staff witnessed a resident-to-resident altercation, the CNA or CMT reported to the charge nurse immediately and the charge nurse reported to the DON or Administrator immediately after the residents were assessed;-The Administrator reported to DHSS within two hours;-The charge nurse notified the physician and residents responsible parties and placed the residents on increased monitoring if needed;-All allegations of abuse were reported to DHSS within two hours;-On 10/17/25, he/she received a call from the charge nurse that Resident #1 threw a spoon at Resident #2 and then Resident #1 went over to Resident #2 and the nurse was not sure if Resident #1 shoved Resident #2 or if Resident #1 tripped and fell on Resident #2. The nurse reported that both residents fell with Resident #2 still in the chair;-Staff separated the residents and the nurse assessed and neither had any injuries;-He/she asked the nurse to make an incident report;-The incident between the residents should have been reported to DHSS. He/she did not report to DHSS and did not know if anyone else did;-He/she was responsible for ensuring staff know when to report abuse.During an interview on 01/01/26, at 1:46 P.M. and 3:04 P.M., the Administrator said the following:-If staff witnessed a resident-to-resident altercation, the CNA or CMT separated the residents and reported to the charge nurse immediately. The charge nurse assessed the residents and reported to the on-call RN immediately and notified the residents' responsible parties and physicians. The on-call RN reported to the DON and Administrator immediately;-He reported to DHSS within two hours;-All allegations of abuse were reported to DHSS;-He called the DON and agreed to keep the residents separated;-He did not report the incident to DHSS because he thought if two confused residents were involved and there was no harm, he did not have to report to DHSS;-He should have been reported the incident to DHSS;-He was ultimately responsible for ensuring all staff know what to report and when to report it.#2705258

Based on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary (SNFABN) Form CMS-10055 (2018) notice to one of two residents (Resident (#7) that remained in the facility for long-term care with Medicare A days available in the sample of 20 residents. Review of the instructions titled, Form Instructions Skilled Nursing Facility (SNFs) Advanced Beneficiary Notice of Non-Coverage SNFABN located on the Center for Medicaid and Medicare (CMS) website at cms.gov showed the following: -Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary or considered custodial. 1. Review of Resident #7's Face Sheet, in the electronic medical record (EMR) under the Demographic tab, showed the following: -Resident was admitted to the facility on [DATE]; -Resident was hospitalized in early February 2024 for pneumonia and returned to the facility; -Resident received intravenous (IV) antibiotics and was issued a Notice of Medicare Non-Coverage (NOMNC) on 02/23/24 with the last covered day of 02/26/24 when his/her IV ended. Review of the resident's EMR showed staff did not document the resident was issued a SNFABN in addition to the NOMNC since he/she was remaining in the facility and still had Medicare A days available. During an interview on 03/21/24, at 5:15 P.M., the Social Services Director (SSD) said she was not aware the resident should have received a SNFABN. During an interview on 03/21/24, at 7:03 P.M., the Social Worker (SW) said she had searched the company's policies on the intranet and reached out to two other buildings owned by the same group and was told by both we don't have a policy for NOMNCs and SNFABNs.

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination when staff stacked dishes while still wet and stored dented cans with other cans to be used by staff for food preparation. The facility census was 85. 1. Record review of the facility policies showed the facility did not provide a policy regarding air-drying dishes and/or utensils. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; - Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Observation of the kitchen on 4/25/2022, beginning 9:14 A.M., showed the following: -A large measuring cup sat upside down, on a metal shelf, with visible moisture seen inside the cup; -Five trays sat on a metal cart that held 90 juice glasses, in an upside down position. Several were stacked on top of one another while wet (trapping water between the glasses); -Twelve plates stacked, still wet; (trapping water between the plates); -Fifteen bowls stacked, still wet. (trapping water between the bowls). Observation of the kitchen on 4/27/2022, at 11:12 A.M., showed the following: - A large fan blew on a metal shelf that held dishes to dry; -Twenty-eight juice glasses, stacked upside down with water inside (air unable to get inside the glasses to dry). During an interview on 4/27/22, at 11:22 P.M., Dietary Cook H, said the following: -He/she knew staff could not stack dishes if they still have any water inside them; -He/she did not know if this applied to everything, but knows glasses/cups cannot be left like that. During an interview on 4/27/22, at 11:35 P.M., Service Leader I said the following: -He/she did not realize the glasses could stacked; -He/she did notice that there was still water inside some of the glasses. During an interview on 4/27/22, at 11:47 P.M., Dietary Middle J said the following: -He/she did not know the glasses could not sit the way they were and understood it is to prevent bacterial growth. During an interview on 4/27/2022, at 11:57 P.M., the Dietary Manager, said the following: -He/she did not know that dishes could not be set up where they are stacked, before they are completely dried. 2. Record review of the (undated) facility policy titled, A Guide to Evaluating Dented Cans, from the Department of Health and Environment, showed dented cans can cause serious illness if the food inside is eaten. Record review of the 2017 Food Code, issued by the Food and Drug Administration, showed the following information: - Food packages should be in good condition and protect the integrity of the contents so the food is not exposed to potential contamination; - Food held for credit, such as damaged products, should be segregated and held in an area separate from other food storage. - Food packages that are damaged, spoiled or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods and should be kept in separate and segregated areas; - Damaged packaging may allow the entry of bacteria or other contaminants into the contained food. Observation of the kitchen on 4/25/22, beginning 9:14 A.M., showed the following in the dry food storage area; - One, 6 pound (lb),12 ounces (oz) dented can of chili with beans; - One, 7- lb., 3 oz dented can of baked beans; - One, 3 lb., 2 oz dented can of cream of chicken soup; - One, 7 lb. dented can of lemon pudding; - One, 7 lb. dented can of apple pie filling. During an interview on 4/27/22, at 11:22 P.M., Dietary Cook H said the following: -He/she knows they are not to use any dented cans and they try to pull out any that are found and put them to the side so they are known as not to use; -He/she did not realize there were any dented cans on the shelf with the other cans. During an interview on 4/27/22, at 11:35 P.M., Service Leader I, said the following: -He/she did not know of any dented cans; -He/she did not know for sure if the cans could be used or not. During an interview on 4/27/22, at 11:47 P.M., Dietary Middle J said the following: -He/she had not ever been told about the dented cans. During an interview on 4/27/22, at 11:57 P.M., the Dietary Manager said the following: -He/she is aware of the fact that dented canned goods cannot be mixed with other cans and are not to be used; -He/she is not sure how the cans were mixed up together. During a group interview with the DON, Administrator and the Chief Operations Officer (COO) on 4/29/22, at approximately 2:30 P.M., the following was said: -They all said the Dietary Manager knows not to keep dented cans and feels this was probably an oversight from another staff putting the cans there.

Based on interview and record review, the facility failed to have a registered nurse (RN) work for eight consecutive hours seven days per week and failed to ensure the Director of Nursing (DON) did not serve as charge nurse with a census of greater than 60. The facility census was 85. Record review showed the facility did not provide a policy regarding RN staffing. 1. Record review of the facility provided nurse schedules, dated 01/01/2022 through 01/31/2022, showed no RN coverage on any shift for the following dates: -1/4/2022; -1/8/2022; -1/9/2022; -1/10/2022; -1/13/2022; -1/14/2022; -1/18/2022; -1/19/2022; -1/22/2022; -1/26/2022. Record review of the facility provided nurse schedules, dated 02/01/2022 through 02/28/2022, showed no RN coverage on any shift for the following dates: -2/2/2022; -2/11/2022; -2/19/2022; -2/20/2022; -2/23/2022; -2/25/2022. Record review of the facility provided nurse schedules, dated 03/01/2022 through 03/31/2022, showed no RN coverage on any shift for the following dates: -3/1/2022; -3/2/2022; -3/5/2022; -3/6/2022; -3/11/2022. Record review of the facility provided nurse schedules, dated 04/01/2022 through 04/29/2022, showed no RN coverage on any shift for the following dates: -4/8/2022; -4/11/2022; -4/12/2022. During an interview on 4/29/2022, at 1:48 P.M., the DON said the regulation requires a RN to be on shift for eight hours per day. She said that she tries to ensure there is a RN on every day. She has had to work as charge nurse at times to ensure nurse coverage on the floor, but did not specify which dates. The facility resident census had been in the 80's to low 90's since January 2022. During an interview on 4/29/2022, at 1:59 P.M., the administrator said facility staffing had been a challenge and the facility is utilizing contract and agency staff to assist. The DON was responsible to schedule the nursing staff.

Based on record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when the facility failed to ensure employee [CONDITION(S)] (TB - a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests were completed and documented per standards of practice and facility policy for four staff members. The facility census was 85. Record review of the Centers for Disease Control and Prevention website, updated 3/8/2021, showed the following information: -The TB skin test is performed by injecting a small amount of fluid (called [MEDICATION(S)]) into the skin on the lower part of the arm; -A person given the [MEDICATION(S)] skin test must return within 48 to 72 hours to have a trained health care worker look for a reaction on the arm; -Results should be documented in millimeters (mm); -A second skin test should be administered one to three weeks later; -The test should be read 48 to 72 hours after administration; -The results should be documented in mm. Record review of the facility's TB policy titled, Employee Health, last revised April 2022, showed the following information: -Two-step [MEDICATION(S)] skin test (TST) will be read 48 to 72 hours after injection; -Health and Communicable Disease Screening form will be reviewed by a designated registered nurse (RN) for signs and symptoms of potential communicable disease before resident contact. (The policy did not address how soon to complete the second step of the initial TB screening test.) 1. Record review of Laundry Aide N's personnel record showed the following information: -Hire/start date of 10/5/2020; -Staff administered the first step TB test on 10/2/2020; -Staff read the results of the first step on 10/5/2020; -Staff did not document administering a second step TB test. 2. Record review of Certified Nurse Aide (CNA) O's personnel record showed the following information: -Hire/start date of 8/2/2021; -Staff did not document administration date of the TB test first step; -Staff documented staff read the first step TB test on 8/2/2021; -Staff documented a second step TB test completed on 9/15/2021 (six weeks after the first step was read); -Staff read the second step on 9/17/2021. 3. Record review of Dietary Aide P's personnel record showed the following information: -Hire/start date of 12/20/2021; -Staff did not document the date of the first step TB test administered; -Staff documented staff read the first step TB test on 12/20/2021; -Staff did not document a second step administered or read. 4. Record review of Floor Technician Q's personnel record showed the following information: -Hire/start date of 1/31/22; -Staff administered the first step TB test on 1/28/2022; -Staff read the results of the first step TB test on 1/31/2022; -Staff documented a second step TB test completed on 4/5/2022 (over two months after the first step was administered and read); -Staff did not document a second step TB test being read. 5. During an interview on 4/29/2022, at 9:47 A.M., Registered Nurse (RN) D said the following: -He/she will give TB shots sometimes on the weekends; -When he/she does give a TB shot on a weekend, he/she will place all the coordinating paperwork under the Assistant Director of Nursing's (ADON) door. 6. During interviews on 4/27/2022, at 2:30 P.M., and on 4/28/22, at approximately 10:55 A.M., the Quality Service Improvement Registered Nurse (QSI RN) said the following: -Agency staff used to complete some of the TB tests, but he/she is now looking into this, because they did not always get them entered into the computer. 7. During interview on 4/29/22, at 3:16 P.M., the Administrator said the following: -The DON took over TB testing and screening recently. 8. During a group interview with the DON, Administrator, and the Chief Operations Officer (COO) on 4/29/22, at approximately 2:30 P.M., the following was said: -The facility has had some turnover and it caused a some TB test documentation to be lost in the meantime; -The Administrator said he feels like the testing is being done correctly, but that it is not being documented as it should be, to show it is being completed; -The Administrator and DON said the process is to have the first step completed at the facility on a Friday; -The new hire will then go to the main office in [NAME], the following Monday to have the TB skin test read; -The new hire may then start the position on Tuesday; -The second step is given at the facility and read three days later at the facility; -The DON said keeping track of them had become overwhelming so they have thought of new ways to keep track of staff TB's.

Based on observation, interview, and record review, the facility failed to ensure staff cleaned and maintained a continuous positive airway pressure machine ([CONDITION(S)] - treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #37). Staff failed to have a physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] #49), and failed to address in the care plan the use of oxygen for one resident (Resident #49), out of a sample of 23 residents. The facility had a census of 85. Record review of the facility's policy titled, Cleaning Personal Reusable Respiratory Equipment, last revised July 2020, showed the following information -Oxygen concentrator (medical device that gives you extra oxygen): clean the cabinet filter weekly or more often as needed; -Wipe the outside of cabinet with disinfectant wipe; -Clean humidifier (a plastic bottle filled with water that adds moisture to the supplemental oxygen) daily; -Soak in Control III solution (powerful, safe, and effective disinfectant for sanitizing [CONDITION(S)] equipment including masks, cushions, tubing, and humidifier chambers without causing them to dry out or crack) for 10 minutes; -Change nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) or mask at two week intervals; -Change oxygen connector tubing every two weeks; -[CONDITION(S)] disposable filters are replaced yearly; -Masks should be cleaned with mild soap and rinsed with water daily; -Tubing should be cleaned with mild soap, rinsed thoroughly, soaked in Control III, rinsed, and air dried weekly; -Unit should be wiped with disinfectant wipe weekly; -Head gear should be hand or machine washed weekly and as needed. 1. Record review of Resident #15's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's annual Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 1/31/2022, showed the following information: -Cognitively intact; -Oxygen use while a resident. Observation and interview on 4/25/2022, at 10:03 A.M., showed the resident sat in a wheelchair in his/her room. The oxygen tank was turned on to four liters. The oxygen tubing or humidifier did not have a date. The resident said he/she used oxygen every day and night and the staff ensure the oxygen tank on the wheelchair is full for when he/she goes to meals or activities. He/she did not know when the staff changed the oxygen tubing. Record review of the resident's care plan, last reviewed on 4/28/2022, showed the following information: -Resident became short of breath very easily; -Staff should apply 4 liters/minute (lpm) of oxygen per nasal cannula (NC - a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) to keep oxygen saturation (O2 sats - reading on a pulse oximeter shows the percentage of oxygen in someone's blood) above 90%; -Staff should change oxygen supplies every 15 days. Record review of the resident's current physician order sheet (POS), dated 4/29/2022, showed the following information: -An order, dated 2/5/2019, directed staff to order respiratory supplies as needed; -There was no order for oxygen use or changing of supplies. Observation on 4/29/2022, at 10:28 A.M., showed the oxygen tank in the resident room on at five liters with oxygen tubing laying on the resident bed. The resident was not in the room. The oxygen humidifier was full with water. The tubing and humidifier bottle did not have a date. 2. Record review of Resident #37's face sheet showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -[CONDITION(S)] machine use not marked. Observation on 4/25/2022, at 3:33 P.M., showed the resident in bed. The resident's [CONDITION(S)] machine was on the bedside table, with no water in the humidifier holding tank. There was a brown appearance in the holding tank. The [CONDITION(S)] headgear and face mask hung from a hook on the wall above the bedside table. The headgear was gray cloth and had brown dirt appearance on the interior of the cloth area that touches the cheeks, face, and forehead. Two one gallon containers of distilled water sat on the resident's bedside table, one empty and one 3/4 full. During an interview on 4/26/2022, at 9:59 A.M., the resident said the [CONDITION(S)] machine is cared for by staff and the staff place orders for supplies as needed. He/she is not able to reach the machine or mask due to limitations from [CONDITION(S)]. Record review of the resident's care plan, last reviewed on 4/27/2022, showed staff did not care plan regarding the use of a [CONDITION(S)] machine or the care of the machine. Record review of the current physician's orders, dated 4/29/2022, showed the following information: -[MEDICATION(S)] (antibiotic) 250 mg (milligram) three times per day, to be taken from 4/22/2022 to 5/2/2022 due to respiratory infection; -No order for [CONDITION(S)] use, changing, and/or cleaning of supplies. Observation on 4/29/2022, at 10:20 A.M., showed the resident's [CONDITION(S)] humidity tank with no water, with brown coloration in the sides and bottom of the water tank. The headgear with mask had a brown discoloration on the interior of the gray cloth straps. Two distilled water containers, one empty and one 3/4 full sat on the bedside table, with approximately no change in amount from 4/25/2022. 3. Record review of Resident #22's face sheet (a document that gives basic profile information about the resident) showed the following information: -admitted to the facility on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's admission MDS, dated [DATE], showed the following information: -Used oxygen while not a resident; -Used oxygen while a resident. Observation on 4/25/2022, at 12:07 P.M., showed the resident sat at a dining room table eating lunch, with his/her rolling walker next to his/her chair. A portable oxygen tank rested in a holder attached to the walker with a flow rate of 3 lpm. The resident had a nasal cannula in place (tubing positioned to allow air flow into the nose), and the tubing had a label attached, dated 3/12/2022. Observation on 4/26/2022, at 12:12 P.M., showed the resident sat at a dining room table. The resident used oxygen via a nasal cannula running from a portable tank attached to his/her rolling walker. The tubing was labeled 3/12/2022. Observation on 4/26/2022, at 12:17 P.M., showed an oxygen concentrator in the resident's room. The nasal cannula tubing was attached to a bubbler (provides moisture for the supplemental oxygen), coiled on top of the concentrator, labeled with the date 3/12/2022. Record review of the resident's care plan, as of 4/27/2022, showed the following information: -Oxygen orders of oxygen at 3 lpm; -Change tubing every 30 days. During observation and interview on 4/27/2022, at 11:30 A.M., the resident sat in a chair outside the door to his/her room. The resident utilized oxygen via nasal cannula running from a portable tank attached to his/her rolling walker; the tank indicated a flow rate of 3 lpm. The nasal cannula tubing was labeled with the date of 3/12/2022. The resident said he/she used oxygen continuously; either by portable tank or the concentrator in his/her room. The resident said he/she had not seen staff change the nasal cannula tubing and did not know when or how often it might be changed. Record review on 4/27/2022, at 3:25 P.M. of the resident's current physician orders showed no orders for the use of supplemental oxygen or for changing the tubing. During an interview on 4/27/2022, at 3:25 P.M., Quality Service Improvement Registered Nurse (QSI RN) said there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Record review of Resident 49's face sheet showed the resident admitted to the facility on [DATE]. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident did not have shortness of breath and did not use oxygen. Record review of the resident's care plan, last reviewed 3/23/22, showed staff did not care plan the resident's oxygen use. Observation on 4/25/22, at 10:35 A.M., showed the resident in bed with oxygen administered at 1 lpm via nasal cannula (NC). The humidity water bottle on the oxygen concentrator showed a date of 3/12/22, and the oxygen tubing did not have a date documented. Record review of the resident's physician order sheet (POS), as of 4/25/2022, showed no order for oxygen or changing of the oxygen tubing. Record review of the resident's nurse's note dated 4/26/22, at 7:24 A.M., showed a nurse documented the physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 4/26/22, at 9:50 A.M., showed the following: -The resident in bed without his/her nasal cannula in his/her nose. The oxygen concentrator was set at 2 1/2 lpm; -The oxygen concentrator did not have an humidifier (a plastic bottle filled with water that adds moisture to the supplemental oxygen); -The resident's oxygen tubing stretched over to rest inside an open bedside table drawer. It did not have a date documented on it; -The resident said he/she went to the bathroom and forgot to put his/her oxygen back on. He/she placed the nasal cannula in his/her nose and the tubing around his/her ears. During interviews on 4/26/22, at 10:40 A.M., and on 4/28/22, at 11:04 A.M., Licensed Practical Nurse (LPN) F said the following: -The resident had been on oxygen at one to two lpm of oxygen as needed. The LPN thought the night nurse increased the resident's oxygen over the weekend for shortness of breath; -LPN F could not find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she thought the weekend night shift charge nurse sent a message to the physician, but could not enter the physician's order in the computer for the resident's increased oxygen and had asked LPN F to put in the oxygen order (for the increase of two to three liters of oxygen) for the resident; -The resident's water bottle for the oxygen concentrator should have been replaced with a new bottle of water. Observation on 4/27/22, at 12:50 P.M., showed the resident in bed wearing his/her nasal cannula. The oxygen concentrator administered oxygen at 2 and 1/2 lpm. LPN F spoke with the resident in the room, did not address the lack of a humidifier on the resident's concentrator, and left the room. Observation on 4/28/22, at 10:23 A.M., showed the resident in bed without his/her nasal cannula. The oxygen concentrator, set to deliver two liters of oxygen, did not have a humidifier attached. The undated oxygen tubing lay in the resident's open drawer. The resident said he/she forgot to put the oxygen back on after going to the bathroom just a few minutes ago. He/she put the oxygen with nasal cannula back on to use. Observation and interview on 4/28/22, at 10:53 A.M., showed the following: -Certified Medication Technician (CMT) B said the resident's oxygen concentrator needed a humidifier. He/she did not know when staff removed the previous humidifier; -CMT B checked the storage room on the hall and found no humidifiers on the shelf. He/she checked the central supply room on another hall which also did not have any humidifiers. He/she checked central supply room office next to the special care unit and found a humidifier and placed it on the resident's concentrator. 5. During an interview on 4/28/22, at 10:53 A.M., CMT B said the following: -The night staff changed the oxygen tubing every one to two weeks; -Staff should attach a piece of tape with the date when they replaced the tubing; -Staff did not date the humidifier, but should check the oxygen concentrator and humidifier when they entered a resident's room. 6. During an interview on 4/28/2022, at 10:03 A.M., CMT E said staff changed oxygen tubing on night shift. He/she said this information should be on the work list in the computer. 7. During interview on 4/28/22, at 10:58 A.M., Central Supply Staff K said the following: -Residents who received oxygen should have a physician's order for oxygen; -The night shift staff changed and dated the oxygen tubing on Tuesdays, but any staff could change the tubing; -Staff should date the humidifier bottle when they changed it; -Nurses should ensure staff changed and dated residents' oxygen tubing, and replaced and dated the oxygen concentrators humidifier bottles. 8. During interview on 4/28/22, at 11:04 A.M., LPN F said the following: -If the physician ordered oxygen for a resident, staff obtained an oxygen concentrator then attached and dated the new tubing and humidifier; -The night shift changed the oxygen tubing on Tuesday nights. 9. During an interview on 4/28/2022, at 6:54 P.M., LPN D said staff would complete care for [CONDITION(S)] and oxygen machine if there was a scheduled order. The order should be written for soaking/cleaning of [CONDITION(S)] or oxygen. He/she often added distilled water to the [CONDITION(S)] holding tank. 10. During an interview on 4/29/2022, at 10:05 A.M., Registered Nurse (RN) C said [CONDITION(S)] tubing and masks should be cleansed once per week during the day shift. The [CONDITION(S)] masks should be changed on the night shift. There was no place to document that this work had been completed. The night shift chore sheet included the oxygen tubing and water bottles for oxygen should be changed on the 1st and 15th of each month. The only way the day shift knew if this task was completed is if the label had a date on the tubing. 11. During an interview on 4/29/2022, at 4:06 P.M., the Director of Nursing (DON) said staff should be changing oxygen tubing and cleaning filters every Tuesday; it is called tubing Tuesday. She expects them to date the tubing. The oxygen humidifier tank should be dated when opened and changed when empty. The oxygen and [CONDITION(S)] should have an order. 12. During an interview on 4/29/2022, at 4:06 P.M., the administrator said staff should be changing oxygen tubing on Tuesdays every two weeks; he/she expects them to date the tubing.

Based on observation, interview, and record review, the facility failed to ensure the staff provided showers, baths, or grooming assistance as preferred for three residents (Resident #37, #47, and #74) who were unable to perform their own activities of daily living of showering/bathing or grooming. The facility had a census of 85. Record review showed the facility did not provide a policy for showers and grooming or a copy of a facility shower schedule for residents. 1. Interviews and observations during the Resident Council Meeting on 4/26/2022, at 10:49 A.M., showed the following: -Residents #25, #30, #42, #44, #47, #61, #67, #75, and #81 attended the meeting; -All nine residents in attendance agreed residents were not getting enough showers; -Resident #30 did not speak, but shook his/her head up and down in agreement; -Resident # 61 said he/she tries to get the Jacuzzi because it makes him/her feel better and helps his/her legs feel better, but it just does not happen very often; -Resident #75 said staff has a showering schedule, but he/she is not sure who makes it to the top of the list for showers; -Resident #47 said he/she had concerns about showers. An aide said the residents can only have one shower a week; -Resident #75 said he/she needs more showers because he/she is an incontinent person and needs more than what he/she gets; -Resident #42 said he/she has had to wait quite a bit of time in between showers but has not been counting days; -Resident #42 said he/she knows it does stretch out quite a bit more than what you would expect and knows it sure does make him/her feel better though when he/she gets a shower. 2. Record review of Resident #74's face sheet showed the resident admitted to the facility on [DATE]. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 3/28/2022, showed the following: -Intact cognition; -Required staff supervision for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Record review of the resident's care plan, dated 11/9/2020 and last reviewed 4/27/2022, showed the following: -Supervision for some ADLs (activities of daily living - dressing, grooming, bathing, eating, and toileting, and independent with others); -The resident needed supervision from staff for personal hygiene and toilet use and limited assistance for bathing. (Staff did not care plan the resident's bathing preferences.) Record review of the resident's bathing documentation report, dated 1/1/2022 to 4/29/2022, showed the following: -On 1/9/2022, tub bath with one staff, with limited assistance; -On 1/16/2022, bathing independent with set up help only (seven days since the previous shower/bath); -On 1/1920/22, shower independent with set up help only; -On 1/26/2022, tub bath with extensive assistance with one staff physical assistance (seven days since the previous shower/bath); -On 1/30/2022, tub bath with extensive assistance with one staff physical assistance; -On 2/7/2022, 2/9/2022, and 2/13/2022, staff did document bathing type, location, self-performance and staff support provided; -On 2/16/2022, tub bath with limited assistance of one staff for physical assistance; -On 2/21/2022, shower with limited assistance of one staff (five days since the previous bath/shower); -On 3/4/2022, shower with one person physical assistance (11 days since the previous bath/shower); -On 3/6/2022, shower with limited assistance of one staff; -On 3/10/2022, tub bath with extensive assistance; -On 3/15/2022, tub bath with limited assistance (five days since the previous bath/shower); -On 3/20/2022, shower was independent with setup help only (five days since the previous bath\shower); -On 3/24/2022, shower was with supervision of one staff; -On 3/30/2022, tub bath with limited assistance with one staff (six days since the previous bath/shower); -On 4/6/2022, tub bath with limited assistance with one staff (seven days since the previous bath/shower); -On 4/20/2022, tub bath with limited assistance with one staff (14 days since the previous bath/shower); -On 4/24/2022, tub bath with limited assistance with one staff. Record review of the resident's record showed staff did not document the resident had refused any baths/showers. Observations and interviews on 4/25/2022, at 11:50 A.M., and on 4/27/2022, at 11:21 A.M., showed the following: -The resident said he/she went to the sauna/shower room for his/her showers, but he/she had to work around the staff's schedule since they assisted many residents with their baths and showers; -In the resident's room, a calendar hung on the wall. The resident placed a large X on 3/31/22. He/she wrote 3/31/22 sauna and hair washed and had written on the calendar and said he/she had his/her hair colored on 4/18/22 where they washed his/her hair only. No bath or shower documented on the calendar since 3/31/22; -The resident said he/she didn't remember the last time he/she had a shower or bath. 3. Record review of Resident #37's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, last reviewed on 4/27/2022, showed staff did care plan the resident's shower/bath needs or preferences. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Total dependence on staff for bed mobility, transfers, dressing, personal hygiene, and bathing; -Indwelling catheter; -Always incontinent of bowel. Record review of the resident's medical record, dated 01/05/2022 to 04/24/2022, showed the following dates the resident received a shower: -On 1/5/2022; -On 1/23/2022 (18 days since last shower); -On 2/6/2022 (14 days since last shower); -On 2/16/2022 (10 days since last shower); -On 2/22/2022 (6 days since last shower); -On 3/2/2022 (8 days since last shower): -On 3/6/2022 -On 3/17/2022 (11 days since last shower); -On 3/26/2022 (9 days since last shower); -On 4/1/2022 (5 days since last shower); -On 4/19/2022 (18 days since last shower); -On 4/24/2022 (5 days since last shower). Record review of the resident's record showed staff did not document the resident had refused any baths/showers. During interviews on 4/26/2022, at 9:46 A.M., and on 4/28/2022, at 10:14 A.M., the resident said the following: -He/she usually received one shower per week, but sometimes it was longer than one week; -He/she would prefer more showers each week, but there are too many other residents and not enough staff; -Staff try to ensure he/she received a shower once per week and he/she does not complain unless it gets real bad; -He/she has frequent odors and sweat under his/her breast, arms, and abdominal folds; -Staff try to assist with cleaning those areas when he/she requests; -It would be nice to receive more showers than once per week. 4. Record review of Resident #47's face sheet showed the following information: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance from staff for bed mobility, transfers, personal hygiene, dressing, and bathing; -Always incontinent of urine; -Occasionally incontinent of bowel. Record review of the resident's care plan, last reviewed on 3/22/2022, showed staff did not care plan regarding the resident's shower/bath preferences. Record review of the resident's medical record, date 01/03/2022 to 04/20/2022, showed the resident received a shower on the following dates: -On 1/3/2022; -On 1/12/2022 (nine days since last shower); -On 1/26/2022 (14 days since last shower); -On 2/6/2022 (11 days since last shower); -On 2/13/2022 (seven days since last shower); -On 2/16/2022; -On 2/21/2022 (five days since last shower); -On 2/26/2022 (five days since last shower); -On 3/4/2022 (six days since last shower); -On 3/15/2022 (eleven days since last shower); -On 3/24/2022 (nine days since last shower); -On 3/31/2022 (seven days since last shower); -On 4/12/2022 (12 days since last shower); -On 4/20/2022 (8 days since last shower). Record review of the resident's record showed staff did not document the resident had refused any baths/showers. During interviews on 4/25/2022, at 10:55 A.M., and 4/28/2022, at 10:37 A.M., the resident said the following: -The facility is sometimes short staffed and he/she had gone eleven days without a shower; -He/she had [CONDITION(S)] (condition that makes skin red and itchy), so he/she was okay with receiving a shower once per week, but 11 days was too long and he/she needed a little more bathing than he/she was getting. -He/she generally received a shower every eight to nine, but he/she really would like to not go longer than seven days; -He/she liked to have his/her hair washed during the shower, but sometimes it was not done with the shower and had to be done at the hair salon; -He/she needed peri-care (cleaning of the private areas) every morning because he/she wears an incontinent brief and sometimes this care could be done better; -The resident could not do this on his/her own due to left arm and leg immobility. 5. During an interview on 4/28/2022, at 10:20 A.M., Certified Nurse Aide (CNA) A said the daily shower schedule for the 300/400 hall was outdated; some residents listed were no longer there, and other residents needed to be added to the list. If there is no assigned bath aide for the day, the hall aides would try to give showers, but with only one aide working on each hall, it wasn't really possible to complete all showers. They try to do showers once or twice weekly. On the 300/400 halls, if they give a shower they are supposed to initial the monthly calendar under that resident's name, and they should complete the computer entry showing the type of bathing/tasks done. The aides only fill out the form entitled Skin Monitoring: Comprehensive CNA Shower Review if a problem is noted to the resident's skin during a shower; not with every shower. 6. During an interview on 4/28/22, at 10:40 A.M., CNA G said the following: -Most of the residents used the shower in their rooms; -The staff know when a resident takes a shower because they will ask for towels and washcloths so they know they took a shower; -There was a bath list on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -This list tells when the last bath was done; -They have a daily bath list behind the main list for every day; -They log in to the resident's electronic medical record to the bath/shower assessment and document what they did for the resident; -It is a checklist and they could check off all on the list such as nail care, perineal care, use lotion; -If there was only one nurse aide working, they don't get showers done; -Usually there was one shower aide on each side; -If there was a third nurse aide, they did showers, but usually there was one shower aide on each side; -They try to do showers twice weekly if not more; -If a resident refused a shower, staff asked the resident again, but it depends on the time of day; -If a resident asks for a bath or shower, they give one, but basically go off the list for when the resident had the last one or needed their second bath or shower for the week. 7. During interviews on 4/28/2022, at 10:12 A.M. and 10:30 A.M., Certified Medication Technician (CMT) B said the following: -He/she had not given a bath or shower to any resident today; -Some residents took a shower in their bathrooms and some go to the shower room; -When a resident needs more assistance, they go to the shower room; -There was a schedule for the residents' showers and it was in the computer for each hall. They could print this out for each resident too; -He/she did not know who printed out the shower schedule, but thought the nurse did this for the nurse aides; -Staff document the completed shower tasks (shower, nail care) in the computer; -On the 500/600 halls there was no printed daily shower schedule or monthly calendar to initial; -Those halls go by a morning printout showing the days or times/weekly each resident is scheduled for showers/baths; -That list shows the history of showers/baths given or refused within a designated timeframe. They don't always have a designated shower aide for the 500/600 halls; the hall aides do the showers. 8. During an interview on 4/26/22, at 10:40 A.M., LPN F said the nurse aides give their own showers on the halls. The aides had given several showers this morning. Every resident has showers one to two times per week and sometimes some residents get three to four showers a week. The goal was for a resident to have a shower two to three times a week and at least once weekly. Some residents want a shower every day and they try to accommodate this. There was a shower aide on the 300-400 halls today. There was no shower aide here today for the 500-600 halls. 9. During interview on 4/29/22, at 9:35 A.M., Registered Nurse (RN) C said the following: -There were lots of residents who refused a shower because they thought the shower room was cold or it was during the middle of dinnertime, or when visitors were here; -Staff were supposed to go back and ask the resident again about a shower. 10. During an interview on 4/29/2022, at 11:21 A.M., the DON said if residents' showers were not done, the CNA should pass on that information to the charge nurse and to the next shift. Staff should document if a resident refused a shower/bath. Agency CNAs did not document on the electronic charting system, but nurses did chart electronically. 11. During a group interview with the Director of Nursing (DON), Administrator and the Chief Operations Officer (COO) on 4/29/22, at approximately 2:30 P.M., the following was said: -Showers are being given by staff; -Residents are clean and have no odors; -There was a time during Covid that there was some turnover and some issues may have developed but residents are getting showers; -The Administrator and DON believes this is a documentation issue and not a showering issue; -The Administrator and DON feel the agency staff that is used are not documenting how they are supposed to be documenting; -Another issue is that the residents may want a shower at a certain time and it may not be possible to fill that request; -They said several baths are made-up during the evenings.

Based on observation, interview, and record review, the facility failed to ensure timely and complete nail care was provided two residents (Resident #49 and #75) who required assistance with nail care. The facility had a census of 85. Record review showed the facility did not provide a policy for showers and grooming. 1. Record review of Resident #49's face sheet (a document that gives resident information at a quick glance) showed the resident admitted to the facility on [DATE]. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 3/7/22, showed the following information: -Intact cognition; -Supervision with setup help only for bed mobility, transfers, and toilet use; -Independent from staff with personal hygiene (included combing hair and brushing teeth); -Physical help limited to transfer only for bathing and no set up help or physical help needed by staff; -Impairment in both upper and lower extremities on both sides. Record review of the resident's care plan, last reviewed 3/22/22, showed the following information: -Resident had poor vision. The activity assistant helped keep the resident's nails looking nice. The resident enjoyed getting his/her hair washed and put up in the beauty shop weekly; -Mostly independent with ADLs (activities of daily living -dressing, grooming, bathing, eating, and toileting) and needed set-up assistance for personal hygiene and used a wheelchair for locomotion. Observation on 4/25/22, at 10:35 A.M., showed the resident in bed with long fingernails, with dark debris underneath several of the fingernails. During an interview on 4/25/22, at 10:35 A.M., the resident said the following: -He/she wanted his/her fingernails and toenails clipped since they were too long; -He/she could barely see to cut his/her own fingernails and toenails. Observation on 4/26/22, at 9:50 A.M., showed the resident in bed with his/her fingernails long with dark debris underneath his/her fingernails. During an interview on 4/26/22, at 9:50 A.M., the resident said staff had not cut his/her fingernails and toenails yet. Observation and interview on 4/27/22, at 12:50 P.M., showed the resident asked Licensed Practical Nurse (LPN) F if someone could cut his/her fingernails. The resident's fingernails were long with dark debris visible underneath several fingernails. LPN F asked if the nurse aides had offered to cut his/her fingernails during a shower and the resident said no they did not offer to cut his/her nails. LPN F said he/she would have one of the nurse's aide soak his/her fingernails and then cut the fingernails. The resident's toenails were long, thick and curled. LPN F said the podiatrist (foot doctor) was to come tomorrow on 4/28/22 and the resident was on the list to see the foot doctor. During an interview on 4/29/22, at 1:00 P.M., the resident said the following: -His/her fingernails needed cut every two weeks; -A lot of times staff were too busy to clean and trim his/her nails; -No documented refusals of showers. 2. Record review of Resident #75's face sheet showed the resident admitted to the facility on [DATE]. Record review of the resident's admission MDS, dated [DATE], showed the following: -Intact cognition; -Required extensive assistance of one staff for bed mobility, toilet use, and personal hygiene; -Required limited assistance of one staff for transfers and walking in the room; -Required physical help of one staff for transfer only for bathing; -Frequently incontinent of urine. Record review of the resident's care plan, dated 4/6/22, showed the following: -Required assistance with ADLs. Observation on 4/29/22, at 1:06 P.M., showed the resident sat in his/her recliner in the room. His/her fingernails were long with yellow debris visible underneath his/her nails. His/her hands trembled slightly. During interview on 4/29/22, at 1:06 P.M., the resident said the following: -He/she had asked staff to cut his/her fingernails since they grow fast; -It was a little hard for him/her to cut his/her fingernails and toenails because his/her hands shook a little; -The Activity Director offered to cut his/her fingernails today, but no one had offered to cut his/her nails before today. 3. During interviews on 4/28/2022, at 10:12 A.M. and 10:30 A.M., Certified Medication Technician (CMT) B said the following: -When he/she gave a shower to a resident, he/she washed their back and all parts of the body the resident could not reach like between toes, then after the shower, he/she performed nail care like clipping fingernails and toenails; -Staff document the completed shower tasks (shower, nail care) in the computer. 4. During a group interview with the Director of Nursing (DON), Administrator and the Chief Operations Officer (COO) on 4/29/22, at approximately 2:30 P.M., showed the following was said: -There was a time during Covid that there was some turnover and some issues may have developed but residents are getting showers; -The Administrator and DON believes this is a documentation issue and not a showering issue; -The Administrator and DON feel the agency staff that is used are not documenting how they are supposed to be documenting.

Based on observation and interview, the facility failed to post daily nurse staffing information in a clear and readable format in a prominent place readily accessible to residents and visitors. The facility census was 85. Record review showed the facility did not provide a policy regarding posting of staffing information. 1. Observation on 4/25/2022, at 10:59 A.M., showed the nurse staffing information not posted at the 100/200, 300/400, or 500/600 nurses' stations, or any other common areas. Observation on 4/26/2022, at 12:07 P.M., showed the nurse staffing information not posted at the 100/200, 300/400, or 500/600 nurses' stations, or any other common areas. Observation on 4/27/2022, at 11:06 A.M., showed the nurse staffing information not posted at the 100/200, 300/400, or 500/600 nurses' stations, or any other common areas. Observation on 4/29/2022, at 1:39 P.M., showed the nurse staffing information not posted at the 100/200, 300/400, or 500/600 nurses' stations, or any other common areas. During observation and interview on 4/29/2022, at 2:00 P.M., Registered Nurse (RN) C, Certified Nursing Assistant (CNA) G, and Certified Medication Technician (CMT) E were at the 300/400 nurses' station. CMT E said the night shift used to print out the nursing hours and he/she had not seen it for a while. The staff looked through the desk drawers and could not locate the information. During interviews on 4/29/2022, at 1:53 P.M. and 3:03 P.M., the Business Office Manager said the nurse schedule was posted by the time clock. He/she said the daily staffing hours used to be posted at the front office on the window. He/she verified there is a daily nursing schedule at each nurses' station that has the personnel scheduled to work for the entire day. This schedule is not visible to residents or visitors and it does not have the hours; but, it shows the shift times that staff are scheduled to work. During an interview on 4/29/2022, at 1:48 P.M., the Director of Nursing (DON) said she did not have any nurse staffing information posted. The daily staff schedule was at each nurses' desk; but, it was not posted for residents or visitors to view. During an interview on 4/29/2022, at 1:58 P.M., the administrator said the nurse staffing posting had been located at the East nurses' station, but possibly was taken down.

Based on interview and record review, the facility failed to implement the facility policy to have systems in place to ensure there were adequate numbers of staff certified in cardiopulmonary resuscitation (CPR - a process of providing rescue ventilation and chest compressions to maintain circulation of blood) available when non-CPR certified staff were used to complete CPR on one resident (Resident #1). The facility census was 79. Record review of the facility's policy, Code Blue, NUR,d+[DATE], revised ,d+[DATE], showed the following: -The American heart Association's protocols have been approved by the facility staff for utilization in the event of respiratory and/or [CONDITION(S)] and for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Provide an expedient means for the notification and mobilization of key staff for a code blue in order to provide for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Upon determination of patient arrest, initiate CPR per Basic Life Support (BLS) guidelines; -Upon determination of patient arrest, initiate CPR per BLS guidelines and activate emergency medical services; -In the event that a number of people responding to the code is either insufficient or too great to allow for maximum performance of the team, the code blue team leader has the responsibility of excusing personnel or requesting additional personnel as needed; -Education included review of code cart and code blue policy for nursing staff annually; -Mock code scenarios are completed throughout the fiscal year as determined by educator team in critical care committee. 1. Record review of Resident #1's admission record showed the following: -admitted [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's advanced directives showed the resident was full code (a status that means a resident wants CPR in the event that his/her heart or breathing stops). Record review of the resident's progress notes showed the following: -On [DATE], at 12:23 A.M., staff noted at approx. 11:36 P.M. resident was on the floor. Upon entering the room, observed resident sitting on the floor on his/her knees with his/her upper torso slumped forward. Staff rolled resident over. Resident was not responsive, breathing but no pulse felt. After confirming resident's code status, staff began compressions at 11:43 P.M. The AED (automated external defibrillator - used to help those experiencing sudden [CONDITION(S)]) obtained by a certified nurse aide (CNA). Started analyzation with AED at 11:50 P.M. Resident was not a candidate for shock and staff resumed compressions. At 11:53 P.M. EMS (emergency medical services) arrived. EMS received order from medical services to stop compressions at midnight. During an interview on [DATE], at 11:23 A.M., Registered Nurse (RN) J said the following: -The resident had been found not breathing and without a pulse; -He/she ran to the desk to check the resident's code; -He/she called Licensed Practical Nurse (LPN) L to come assist; -He/she ran back to the resident's room and began compressions; -He/she performed CPR for about 15 minutes and became fatigued; -There were three CNAs present, but one had left to get a glucometer (tool used to monitor a person's blood sugar levels) and never returned; -He/she asked the two remaining CNAs if they were CPR certified and they said no; -He/she continued CPR as long as he/she could then showed the two CNAs how to do compressions; -LPN L came to assist, but had been recently injured. RN J could not recall if he/she asked LPN L to assist with compressions; -He/she did not ask for other CPR certified staff to come assist; -He/she could not recall if he/she asked the CNAs to find another staff who were CPR certified. Record review of RN J's personnel file showed the RN had a current CPR certification. During an interview on [DATE], at 12:59 P.M., CNA D said the following: -He/she was not CPR certified. He/she had been scheduled to go, but it was canceled; -He/she found the resident unresponsive in the resident's room, then ran to get RN J; -RN J initiated CPR; -RN J asked CNA D to take over due to fatigue. RN J instructed him/her how to perform CPR; -He/she performed CPR on the resident. Record review of CNA D's personnel file showed the facility did not have verification of CPR certification for the CNA. During an interview on [DATE], at 8:26 P.M., CNA G said the following: -He/she is CPR certified; -CNA D asked him/her to come help with an unresponsive resident; -CNA D had told RN J, who had not arrived yet; -He/she checked the resident for breathing and/or a pulse. He/she did not know if there was a pulse for sure. CNA D thought the resident had shallow breathing; -RN J told staff to get the glucometer, but he/she did not know if RN J meant for CNA G to get it. He/she left to go assist with call lights instead; -CNA D approached him/her and asked if he/she could come help with compressions; -He/she saw CNA E perform compressions correctly, did not think they needed his/her assistance, and returned to answer call lights; -He/she assumed the other CNAs were CPR certified; -LPN L helped with phone calls and paperwork. Record review of CNA E's personnel file showed the facility did not have verification of CPR certification for the CNA. During an interview on [DATE], at 3:38 P.M., the Director of Nursing (DON) said the following: -CNA D found the resident face down and yelled for RN J; -CNA D ran to get another CNA to come help. They rolled the resident onto the floor; -RN J confirmed the resident's code, went back to the room, and began CPR; -RN J called LPN L for assistance; -RN J performed CPR until he/she was too exhausted. RN J asked CNA D and CNA E to take over due to fatigue. CNA D and CNA E told RN J they were not CPR certified. During an interview on [DATE], at 3:10 PM, CNA B said the following: -All staff were expected to be CPR certified; -CPR certification was done through the facility; -He/she thought new hires must be CPR certified prior to starting. During an interview on [DATE], at 3:22 PM, CNA C said the following: -CPR certification was done outside of the facility; -Staff are required to be CPR certified. During an interview on [DATE], at 3:45 PM, Registered Nurse (RN) K said CPR certification was required for all staff, including CNA's. He/she was unaware of any staff not CPR certified. During an interview on [DATE], at 5:48 P.M., the DON said staff are to be CPR certified as soon as possible upon hire, but it had been difficult to get staff certified. During an interview on [DATE], at 7:54 A.M., LPN H said the following: -He/she is CPR certified; -If a resident were to code, he/she would confirm what the resident's code status was, have a non-certified staff call 911, grab the crash cart and AED, which he/she began CPR; -Another CPR certified person should be available during a code. During an interview on [DATE], at 2:07 P.M., LPN I said the following: -He/she would expect staff to call for help and not leave a resident found unresponsive; -The nurse should delegate obligations like who to call 911, grab the AED or the crash cart; -The staff would check for breathing and start CPR as quickly as can; -A CPR certified staff would switch off during CPR; -He/she would ask if a CNA had CPR certification at the beginning of shift to know who would be able to assist during a code; -He/she would only use a non-certified person to assist with compressions as a last resort. During an interview on [DATE], at 3:38 P.M., the DON said the following: -CNA's not CPR certified would notify the nurse immediately if they found an unresponsive resident; -CPR certified staff would check for a pulse and breathing, confirm the resident's code status and would then begin chest compressions; -Staff CPR certification required all nursing staff need to be CPR certified. CPR classes were done sporadically at the facility, but had to postpone in November due to staffing issues. MO 998

Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent one resident (Resident #1), who resided on the special care unit and exhibited exit seeking behavior previously, from exiting the facility resulting in the resident's elopement and death. The facility census was 76. The administrator, was notified on [DATE], of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. On [DATE], the administrator became aware of elopement and death of the resident. The administrator tested the doors, brought in additional staff, and began interviewing staff on elopement protocol and staff coverage of the special care unit as they arrived for their next shift. The IJ was removed and corrected on [DATE]. Record review of the facility's policy for Missing Patient/Resident, revision dated (MONTH) (YEAR), showed the following: -When a resident is believed to be missing from the facility, staff should immediately notify the charge nurse; -After being notified about the possible missing resident, the charge nurse should page overhead that there is a missing adult; -After the announcement, all available staff should report to the nurse station to assist in a search of the facility for the missing resident; -Charge nurse should notify other facility staff (such as the administrator) and also the resident's physician and family or guardian; -If there are security personnel, a second search of the facility and grounds should be completed. 1. Record review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted d [DATE]; -[DIAGNOSES REDACTED]. -Resided on the 100 hall of the special care unit (SCU). Record review of the resident's physician order [REDACTED]. -Dated [DATE], [MEDICATION NAME] (an antipsychotic medication) 25 milligrams (mg) every four hours while awake; -Dated [DATE], [MEDICATION NAME] 10 mg every four hours while awake; -Dated [DATE], [MEDICATION NAME] 25 mg (solution) to be injected every four hours as needed. Record review of the resident's nurse's notes dated [DATE] at 8:00 P.M., showed the following: -The resident had gone into the courtyard off the SCU; -The resident was very angry, yelling, picking up rocks and trying to break the windows with rocks and hitting staff; -physician's orders [REDACTED]. Record review of the resident's psychiatric admission assessment, dated [DATE], showed the following: -The resident was placed in the nursing home yesterday ([DATE]); -The resident attempted to elope and was throwing rocks at the windows; -The resident was scratching, hitting and attempting to bite staff. Review of the resident's nurse's note dated [DATE], showed staff documented the resident was readmitted to the facility. Record review of an elopement risk assessment dated [DATE], showed staff identified the resident as a high risk for elopement. Record review of the resident's admission evaluation and interim care plan dated [DATE], showed the following: -Dated [DATE], a geriatric depression scale should be completed as needed -Dated [DATE], an elopement risk assessment should be completed every 90 days; -Dated [DATE], behavioral monitoring should be completed every shift; -Dated [DATE], when addressing the resident, staff should: reinforce positive behavior; if resident is agitated and it is safe to do so, leave and re-approach later; reduce excessive stimuli; use a calm, reassuring approach; maintain a non-defensive stance; assess for trigger situations such as pain, personal loss, relocation, conflict, or prior history. (Staff did not care plan the resident's prior elopement attempt or any interventions to prevent future elopements.) Record review of the resident's nurse's note dated [DATE] at 10:30 P.M., showed staff documented the resident was hard to redirect, wanting to leave, and argumentative. Staff administered an as needed [MEDICATION NAME] 25 mg injection and an as needed pain medication at that time. Record review of the resident's 5-day Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated [DATE], showed the following: -admitted d [DATE]; -Cognitively intact; -Fluctuating inattention and disorganized thinking; -Limited staff assist of one required for bed mobility, toilet use, and personal hygiene; -Supervision (no physical assistance) required with walking in his/her room or hall area; -[DIAGNOSES REDACTED]. Record review of the facility's preliminary investigation dated [DATE], showed the following summary:-Event occurred on [DATE] at 7:45 P.M.; -At approximately 7:45 P.M., the resident eloped from the north door of the special care unit; -A certified nurse aide (CNA) was present on the hall, but providing care to another resident; -A nurse was monitoring the other side while the other CNA went on break; -The CNA reported hearing the door alarm, but could not leave the other resident at that time due to cares; -The CNA finished within a couple of minutes and went to check on where the alarm was coming from. At this time the alarm was only beeping and he/she did not hear it over residents watching television; -Initially the CNA thought it was a visitor who had left through the main doors; -When the CNA realized this was not the case he/she noticed the resident was not in the day area and another resident told him/her someone had opened the back door; -The CNA notified the nurse of the possibly missing resident and started checking rooms. The nurse checked the immediate area outside the door at approximately 7:52 P.M. and initiated a code alert/missing resident notice throughout the building; -A CNA, nurse and certified medication technician (CMT) left the building to look for the resident; -At 7:58 P.M., the CMT reported seeing unusual traffic patterns on the highway and began running that direction; -The CMT reported seeing stopped cars and a body in the road. Record review of the facility's preliminary investigation dated [DATE], showed the following timeline based on a camera audit and witness recollection: -At 7:45 P.M., resident observed on camera going to a door and appeared to read the directions press and hold, door will release in 15 seconds. The resident pressed the bar a couple of times, but the door did not open. The resident stopped and seemed about ready to move on when he/she tried the door one more time and the door opened. The resident immediately exited and the alarm sounded initially and continued to beep; -At 7:46 P.M., resident in back parking lot and walking quickly toward the far end of the building. The resident did not appear to be trying to get back in the building and passed multiple doors; -At 7:48 P.M., CNA reports checking the main doors; -At 7:49 P.M., resident in south parking lot walking down sidewalk at opposite end of the building; -At 7:50 P.M., CNA checks resident room and alerts nurse of possible missing resident; -At 7:51 P.M., resident walking quickly up the main drive away from building; -At 7:52 P.M., code alert initiated and search fully implemented; -At 7:55 P.M. to 8:00 P.M., nurse calls on-call nurse and 911. Multiple staff looking for resident outside when CMT notices unusual traffic on the highway. Observation and record review on [DATE] at 2:55 P.M. of the special care unit (SCU) and the facility layout, showed the following: -It was comprised of the 100 and 200 halls. Together, the halls formed a V-shape with a large central, glass-enclosed nurse's station on the joining end; -The nurse's station had a door to access each hall. The doors of the station have windows. There are large windows looking out onto each of the halls; -There were three sets of doors for exiting each hall (not including the door to the nurse's station). One set of doors led to the rest of the facility. One door led to the enclosed courtyard (which was shared by both halls of the SCU). The remaining exit, at the end of each hall, led to the open facility campus (grass and a parking lot); -Each of the three exits had a delayed-egress locking arrangement (when pressure is applied to the door, a person must wait 15 seconds before the magnetic lock releases and allows the person to exit. These doors had an additional requirement that 5 seconds of continuous pressure allowed the 15-second process to be initiated. It was not necessary to have 15 seconds of continuous pressure for the door to be opened). -On [DATE] at 5:20 P.M., the exterior door at the end of the hall (the door that Resident #1 used to elope) was tested and worked as described above. There was a local alarm on the door that went off when pressure was applied on the door and also when the door was opened. Record review of the facility's census showed there were 15 residents on the SCU 100 hall and 15 residents on the SCU 200 hall (for a total of 30 residents in the SCU) at the time the resident eloped. During an interview on [DATE] at 2:50 P.M., the administrator said that around 30 residents was the average census for the SCU (15 residents on each hall). Record review of facility's staffing sheets for the month of (MONTH) (Oct. 1 through Oct. 28, 2019) showed the following: -Staffing varied on the SCU; -The sheets listed the SCU and did not differentiate staff working on the 100 or 200 hall; -The sheets showed staffing for the second shift (2:00 P.M. to 10:00 P.M.) as four or five staff on 14 out of 28 days; -For the other 14 days of the time reviewed, three staff worked between both halls of the SCU. -On [DATE], a CMT and two CNAs worked the SCU (there was no nurse scheduled). -On [DATE], there was one nurse and two CNAs working on the SCU; -For (MONTH) ,[DATE], 2019, two staff worked on the SCU for the third shift (10:00 P.M. to 6:00 [NAME]M.). During an interview on [DATE] at 7:55 P.M., CNA [NAME] said that he/she was the only staff on the 100 hall on the evening the resident eloped. There were usually 14 residents on the 100 hall. Usually, staffing on the SCU consisted of him/her, another CNA, and a nurse or certified medication technician (CMT). When there was no CMT, it was the responsibility of the nurse to pass medications. It can get difficult on the hall, having only one staff present, especially when some of the residents are going through sundowning (a condition when some people with dementia have a more difficult time, or become increasingly confused or agitated, especially in the evening - about the time the sun goes down). CNA [NAME] said there have been three other residents who have recently made it out the door at the end of the halls. Approximately one month ago, he/she was working by himself/herself on the 100 hall when Resident #6 left the building. Although he/she followed the resident out of the building almost immediately, he/she left his/her cell phone inside the building. There was no way to immediately contact additional staff for assistance, and no way that other staff would immediately know that a resident had left the building or that he/she had left the building. With difficulty, he/she eventually redirected Resident #6 back into the building. Before that happened, however, a resident had informed a visiting family member that a resident and staff had left the building. This staff was outside with Resident #6 for approximately ,[DATE] minutes and during that time there was no staff on the 100 hall. CNA [NAME] said there had been a meeting at the facility ,[DATE] weeks ago. At the meeting, staff discussed attempting to replace the current (delayed egress) doors with a more secure arrangement. He/she spoke with several at the facility, including charge nurses about the difficulty and concerns of being the only staff on a hall at times. He/she had concerns that a resident might fall, or a resident may have a different accident while he/she was providing cares (like assisting a resident in the bathroom). At times when there is just one staff on a hall, doors must be kept open a bit, even when staff is performing personal care. If there is a problem, working staff cannot simply walk over to another hall for assistance. CNA [NAME] said he/she specifically noted to nurses his/her concern that the door at the end of the hall opened into the grass and parking lot and did open to a fenced-in area or other part of the facility. There was concern that a resident could easily leave through that door and easily be injured once outside. Whenever the CNA brought up the concern of the staffing level or door arrangement, the supervisors' response was that there would be no additional staff. CNA [NAME] said prior to being discharged from the facility and temporarily admitted to the wellness center, the resident had used a delayed egress door that led out into the fenced-in courtyard. After that occurred, the Director of Nursing (DON) placed an additional staff on the hall, for the evening. On the evening when the resident eloped ([DATE]), CNA [NAME] was the only staff on the hall at the time. He/she was assisting a resident who was a fall risk with care, and could not immediately respond when the door alarm went off. The door alarm was the same as the alarm on the two other sets of doors in the hall and it was not immediately suspected that the resident had left the building. Additionally, staff sometime set off the door alarms that lead to the other area of the building. Since he/she was the only staff on the 100 hall, he/she had to walk over to the 200 hall and notify the nurse who was passing medications. The other staff was on break at the time, and there was no staff at the nurse's station. During an interview on [DATE], at 3:21 P.M., Registered Nurse (RN) B said that the resident had moments of wanting to go home on the evening of [DATE]. Staff spoke to the resident at that time and it appeared to have convinced the resident to stay for the night (at the facility). At the time the resident left the building (eloped), he/she was the only staff working the 200 hall. There was no staff in the central nurse's station at the time of the elopement and there was only one other staff (CNA E) working the 100 hall at the time. The scheduled staffing arrangement for [DATE] was for one CNA to work the 100 hall, one CNA to work the 200 hall, and him/her to float, or take the place of a CNA in the hall when the CNA went on break. At the time the resident eloped from the building, one CNA was on break. He/She did not hear any door alarm when the resident eloped. He/She was notified that a resident might be missing when CNA [NAME] came over from the other hall to inform him/her. At that time, he/she went to the 100 hall to search the interior/room to room for the resident. There was no alarm going off at that time, no indication that the resident had left the building, and both staff assumed that the resident was still inside the building. Another resident in the 100 hall alerted him/her and CNA [NAME] that someone went out the (exterior) exit. CNA [NAME] immediately went outside to quickly look for the resident, but did not quickly see anyone. Meanwhile, he/she made calls for additional staff assistance in searching for the missing resident and to notify the facility administrator and other contacts per facility procedure. RN B said only one resident in the SCU (100 and 200 halls) had a Wanderguard (or Code Alert) bracelet (a small bracelet worn by residents usually at risk for wandering or leaving. The bracelet has a small sensor that locks certain doors to impede the resident from unauthorized exit). Resident #1 did not have a Wanderguard. He/She was told that the Wanderguard would not work in the SCU (would not impede or slow any resident from exiting). On the evening the resident eloped, he/she was unsure why the exterior door (used by Resident #1 to leave) was not alarming when he/she went over to search for the resident. He/She said that facility staffing on the SCU is insufficient at all times. He/she told the DON that the SCU was not secure enough. He/she felt the exit doors with a 15 second delayed egress was not enough to keep residents safe. The doors, along with the staffing numbers had been an ongoing, significant concern of his/hers and other staff. During an interview on [DATE] at 3:27 P.M., Nurse Aide (NA) F said he/she was assigned on the 200 hall, but had been on break when the resident eloped. He/She did not hear any alarm or other notification, but when coming back from break was informed by staff that a resident was missing. Prior to taking break, NA F had been the only staff fully assigned to the hall. That evening ([DATE]) the nurse for the SCU was at the nurse's station, and assisted some on the 100 hall and some on the 200 hall. NA F said the SCU was really understaffed usually and definitely understaffed on the evening the resident eloped. During an interview on [DATE] at 1:22 P.M., CNA A said he/she was working the evening the resident eloped, but was working on the other side of the building. He/she was notified about a missing resident when staff made the announcement on the overhead page. He/She then went to the SCU nurse's station. When he/she arrived, he/she could not hear any alarms. With other staff searching the interior of the building, he/she went out the exterior exit at the end of 100 hall. He/she did not see any resident and continued around the building and eventually to the main road. At the main road, he/she found the resident lying in the road, already deceased . During an interview on [DATE], at approximately 5:40 P.M., Licensed Practical Nurse (LPN) D said for all the doors in the SCU, there are only local alarms at the doors. If a door alarm goes off, there is no additional information at the nurse's station (or other central area) that the alarm has sounded or that the door was opened. During an interview on [DATE] at 6:00 P.M., the administrator said to prevent another possible elopement, the facility was looking into extending the courtyard fence to cover all the way past the doors at the ends of 100 and 200 halls. The facility had already taken steps to have a new arrangement for the doors at the ends of the halls to be locked (not on delayed egress), unless the doors were unlocked by staff by special arrangement. The administrator confirmed that there was currently no other notification that the door had been opened (other than the local door alarm); there was no notification at the nurse's station or in another hall or area. On [DATE] at 7:35 P.M., CNA C said there are usually two staff scheduled for the 200 hall due to the heavier care needs of the residents on that hall. During an interview on [DATE] at 3:57 P.M., RN G said he/she had been working in another area of the building on [DATE], and participated in looking for the resident. The evening staff for the SCU usually consisted of one CNA for each hall and one nurse to cover both halls. The nurse also had the responsibility to pass all resident medications on both halls. He/She and two aides was insufficient for the SCU, especially when the nurse is passing medication and a CNA is busy providing personal care. At those times, neither the nurse nor the CNA could provide immediate help. RN G said I think everyone has mentioned needing additional staff. However, the supervisors have generally replied that there is enough staff, they just need to be reorganized. During an interview on [DATE] at 8:45 [NAME]M., the administrator said there was no specific facility policy on staffing, like staff requirements on the SCU. During an interview on [DATE] at 1:17 P.M., LPN H said that when both doors of the nurse's station are open to each hall, it is likely staff can hear door alarms from either hall. However, when both doors are closed at the nurse's station, then staff is unlikely to hear the door alarms from the opposite hall they are working. When he/she is providing personal care, he/she asks other staff to come onto the same hall to assist (if other staff is available.) If a staff member working a hall goes on break, then the nurse will usually go and cover that hall. If a nurse leaves to cover a hall, then the doors to the nurse's station will be closed. During an interview on [DATE] at 1:45 P.M., CNA I said door alarms could be heard from both halls while in the nurse's station and the alarms could sometimes be heard in the hall while working in the opposite hall. However, it was difficult for staff to get to the alarming door in a timely fashion when working in the nurse's station or on the other hall. During an interview on [DATE] at 2:20 P.M., the administrator said for SCU staffing, there is typically one CNA working each hall and a nurse in the middle covering both halls. He said that he had heard some concerns regarding staffing and staff being able to complete tasks and look out for the residents. These concerns led to the change of allowing staff to carry cell phones on them at all times. Walkie-talkies are also available for use. In regard to hearing the door alarms, they can be heard in the nurse's station, even with the doors closed. Staff might be able to hear the door alarm from the other hall when working in the SCU and the doors to the nurse's station are closed. When the administrator first started at the building in (MONTH) 2019 he heard from some SCU staff about concerns of residents eloping or concerns that residents could elope. It was at that time, the facility took some steps to change, like more secure doors. During an interview on [DATE] at 3:55 P.M., the administrator said the resident's actions appeared purposeful and he/she appeared to read the sign on the door. He did not feel additional staff would have made a difference as that staff could have been tied up with another resident. The resident returned from the psychiatric stay a different resident and less agitated. The elopement history should have been care planned. He tested the door the resident went out the night the elopement occurred. He could hear the alarm in the nurse's station. The alarm was harder to hear as one goes down the other hall and might not be heard over a television or if staff were in a resident's room. When there are three staff on the SCU, it was the nurses' decision whether to have staff from the other halls come in the unit and help provide floor coverage during breaks. If it was a slow night they might not ask for help to cover during breaks. MO 363

Based on observation, interview, and record review, the facility failed to ensure staff treated residents with respect and dignity when staff used derogatory names for residents in front of three residents (Resident #5, #31, and #48) and did not provide dignity bags for catheter (a sterile tube inserted into the bladder to drain urine) drainage bags for three residents (Resident #36, #47, and #271). A sample of 23 residents was selected for review. The facility census was 72. 1. Record review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/8/19, showed the following information: -admitted to the facility on [DATE]; -Severely cognitively impaired; -[DIAGNOSES REDACTED]. -Required supervision with setup only for eating. Observation on 6/3/19, at 12:17 P.M., showed the following: -Certified Nursing Assistant (CNA) B assisted the resident to eat; -CNA B did not interact with the resident. Observation and interview on 6/3/19, at 12:22 P.M., CNA B said: -After he/she finished with the resident, he/she would assist the other feeders; -He/she took one resident after the other until all of the feeders are fed; -The comments were where the resident could hear. 2. Record review of Resident #31's quarterly MDS, dated [DATE], showed the following information: -Original admission date of [DATE]; -Moderately cognitively impaired; -[DIAGNOSES REDACTED]. -Required supervision with setup only for eating. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Original admission date of [DATE]; -Moderately cognitively impaired; -[DIAGNOSES REDACTED]. -Required supervision and setup only with eating. Observation and interview on 6/5/19, beginning at 12:04 P.M., showed the following: -Resident #31 and #48 sat at the table together next to the hot food cart; -CNA C and CNA D stood beside the hot food cart; -CNA C said to CNA D only the feeders trays are left. 3. During an interview on 6/7/19, at 11:26 A.M., CNA C said: -The residents should never be called feeders; -The resident should be treated with dignity and respect and addressed by their names. 4. During an interview on 6/7/19, at 12:05 P.M., CNA B said: -Residents should be treated with dignity and respect; -Residents should never be called derogatory names such as feeders or honey, always use their first names or their preferred names; -He/she should not have used the term feeder. 5. During an interview on 6/7/19, at 2:19 P.M., the Director of Nursing (DON) said: -Facility staff should treat all residents with dignity and respect; -Facility staff should never use derogatory names in front of or towards a resident; -Facility staff should never call residents feeders. 6. Record review of Resident #271's face sheet (basic information sheet), showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's urinary catheter assessment dated [DATE], at 4:13 P.M., showed the urinary catheter present on admission. Record review of the resident's initial care plan dated 5/15/19, at 5:35 P.M., showed the resident had an indwelling catheter. Observation on 6/3/19, at 2:02 P.M., showed the following: -Catheter drainage bag hung underneath the wheelchair; -Catheter drainage bag did not have a dignity bag covering it and urine was visible. Observation on 6/4/19, at 2:44 P.M., showed the following: -Catheter drainage bag hung underneath the wheelchair; -Catheter drainage bag did not have a dignity bag covering it and urine was visible. Observation on 6/5/19, at 9:01 A.M., showed the following: -Catheter drainage bag hung underneath the wheelchair; -Catheter drainage bag did not have a dignity bag covering it and urine was visible. Observation on 6/6/19, at 10:58 A.M., showed the following: -Catheter drainage bag hung underneath the wheelchair; -Catheter drainage bag did not have a dignity bag covering it and urine was visible. Observation on 6/7/19, 11:01 A.M., showed the following: -Catheter drainage bag hung underneath the wheelchair; -Catheter drainage bag did not have a dignity bag covering it and urine was visible. 7. Record review of Resident #36's face sheet showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Observation on 6/3/19, at 12:16 P.M., showed the resident sat in a wheelchair in the dining room. An indwelling urinary catheter bag hung on the back of the chair, facing out. The collection bag did not have a dignity bag covering it. Observation on 6/5/19, at 1:04 P.M., showed the resident rested in bed. His/her catheter collection bag hung on the outer bed rail, facing and visible from the doorway. 8. Record review of Resident #47's face sheet showed the following information: -readmitted to the facility from the hospital on [DATE]; -[DIAGNOSES REDACTED]. Observation on 6/3/19, at 11:55 A.M., showed the resident sat in a wheelchair at the dining room table. His/her catheter collection bag hung underneath the chair, without a dignity bag to cover the visible urine it contained. Observation on 6/5/19, at 11:45 A.M., showed staff wheeled the resident's wheelchair into the dining room. The resident's catheter collection bag hung underneath the chair, without a dignity bag to cover the visible urine it contained. Observation on 6/6/19, at 9:21 A.M., showed the resident sat in a wheelchair in the lounge area. The resident's catheter collection bag hung underneath the chair, without a dignity bag to cover the visible urine it contained. 9. During an interview on 6/7/19, at 11:26 A.M., CNA C said: -The catheter drainage bag should be placed into a dignity bag; -The residents who have catheters do not currently have dignity bags. 10. During an interview on 6/7/19, at 12:05 P.M., CNA B said: -The catheter drainage bag should be in a dignity bag; -The catheter bags that they use now are not considered dignity bags, they are supposed to be in the blue bags. 11. During an interview on 6/7/19, at 11:25 A.M., Licensed Practical Nurse (LPN) A said catheter drainage bags should be in a dignity bag at all times. 12. During an interview on 6/7/19, at 11:51 A.M., LPN F said catheter drainage bags should be in dignity bags at all times. 13. During an interview on 6/7/19, at 2:19 P.M., the Director of Nursing (DON) said catheter drainage bags should be put inside of the blue cloth dignity bags.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to meet the needs of the residents. The facility failed to provide bath/showers for six residents (Resident #4, #14, #15, #35, #65 and #42), toileting assistance/supervision for three residents (Resident #5, #9, and #61), and failed to provide a meal and meal assistance to one resident (Resident #14) in a timely manner. A sample of 23 residents was selected for review. The facility census was 72. 1. Record review of Resident #15's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/27/19, showed the following information: -Severely cognitively impaired; -Require extensive assistance with bed mobility, transfers, dressing, grooming, bathing, and personal hygiene. Record review of the resident's care plan, dated 3/5/19, showed the following information: -Resident lived in the special care unit and needed lots of direction and supervision; -Resident sometimes fights with staff wanting to give a bath; -Required extensive assistance for dressing and grooming. -Staff did not care plan any interventions for activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting). Record review of the resident's bath assessments, dated 4/1/19 through 6/7/19, showed staff documented staff provided showers/baths on the following dates: -On 4/4/19; -On 4/9/19 (five days later); -On 4/12/19 (three days later); -On 4/16/19 (four days later); -On 5/2/19 (sixteen days later). Record review of the resident's shower history showed no showers documented as given since 5/2/19. 2. Record review of Resident #4's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -Required extensive assistance with dressing, grooming, and personal hygiene. Record review of the resident's care plan, dated 5/23/19, shows the following information: -Required one staff assist for bathing; -Required limited to extensive assist for personal hygiene; -Staff did not care plan any interventions for activities of daily living (ADLs). Record review of the resident's bath assessments, dated 4/1/19 through 6/7/19, showed staff documented staff provided/attempted showers on the following days: -On 4/3/19, resident refused; -On 4/10/19 (seven days later); -On 4/12/19 (two days later); -On 4/17/19 (five days later); -On 4/24/19 (seven days later); -On 5/1/19 (eight days later); -On 5/15/19 (14 days later). Record review of the resident's shower history showed staff did not document any showers completed since 5/15/19. 3. Record review of Resident #35's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -Required extensive assistance with bed mobility, transfers, dressing, grooming, bathing, and personal hygiene. Record review of the resident's care plan, dated 5/21/19, showed the following information: -Required supervision for ambulation; -No assistive devices used; -Required extensive assistance for bathing, bed mobility, dressing, and personal hygiene. -Staff did not care plan any interventions for ADLs. Record review of the resident's bath assessments, dated 4/10/19 through 6/7/19, showed staff provided showers on the following dates: -On 4/11/19; -On 4/17/19 (six days later); -On 4/23/19 (six days later); -On 4/30/19 (six days later). Record review of the resident's shower history showed staff did not document any showers provided since 4/30/19. Observation 6/3/19, at 10:26 A.M., showed the following: -Resident was seated at a table in the dining room with his/her head resting on his/her chest; -Resident still wore the bib from breakfast, which had food particles and a brown stain on it; -Resident's hair was not brushed. 4. Record review of Resident #14's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -Required extensive assistance with bed mobility, transfers, dressing, grooming, bathing, and personal hygiene. Record review of the resident's care plan, updated 3/5/19, showed the following information: -Required limited to total assistance with all ADLs, consider ambulation, assistive devices, bathing, bed mobility, dressing, eating, locomotion, personal hygiene, safety device, toilet use, and transfers; -Staff did not care plan interventions for the resident's ADLs. Record review of the resident's bath assessments, dated 4/1/19 through 6/7/19, showed staff provided showers on the following dates: -On 4/4/19; -On 4/10/19 (six days later); -On 4/17/19 (six days later); -On 4/24/19 (six days later); -On 5/9/19 (15 days later); -On 6/5/19 (27 days later). 5. Record review of Resident #65 ' s face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's 14 Day MDS, dated [DATE], showed the following information: -Moderately cognitively impaired; -Required extensive assistance with bed mobility, transfers, dressing, grooming, bathing, and personal hygiene. Record review of the resident's bath assessments, dated 5/6/19 through 6/7/19, showed staff documented providing the resident a shower on 5/20/19 (fourteen days after admission). Record review of the resident's shower history showed staff did not document providing any additional showers since 5/20/19. Observation on 6/4/19, at 2:46 P.M., showed the following: -The resident seated in his/her wheelchair in the television area by the nurses' station; -The resident's head rested on his/her chest with eyes closed; -The resident's hair was not combed; -The resident's shirt was dirty and covered in dark brown stains; -The resident had an odor of urine. Observation on 6/4/19, at 4:02 P.M., showed the following: -Resident was seated in his/her wheelchair in the television area by the nurses' station; -Resident's hair was not combed; -Resident's shirt was dirty and covered in dark brown stains; -Resident had an odor of urine. 6. During an interview on 6/6/19, at 1:57 P.M., Certified Nurse Aide (CNA) [NAME] said the only time the residents in the Special Care Unit (SCU) receive showers or baths is when there is a third person working. There is not time for the certified medication technician (CMT) to help with showers right now. The residents in the SCU have not gotten showers for the past month or longer. There is not enough staff to accurately complete their jobs and things like answering call lights, showers, and meal times suffer because of it. It is especially bad on the SCU because there is usually just an aide and a nurse. The CMT does not have time to assist because of the heavy med passes. 7. Record review of Resident #42's quarterly MDS, dated [DATE], showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Required extensive assistance for ADLs, including transfers, bathing, dressing, and incontinent care. Record review of the resident's bath assessments, dated 4/1/19 through 6/7/19, showed staff staff provided showers on the following dates: -On 4/7/19; -On 4/15/19 (eight days later); -On 4/22/19 (seven days later); -On 4/25/19; -On 5/2/19 (seven days later); -On 5/14/19 (twelve days later); -On 6/6/19 (23 days later). 8. During an interview on 6/6/19, at 9:24 A.M., CNA H said the following: -If there's only aide on the hall, they don't usually get the baths done. They try to make them up or ask the next shift to do them. 9. During an interview on 6/7/19, at 11:25 A.M., Licensed Practical Nurse (LPN) A said residents are supposed to get showers twice a week. Some do not get two a week because of lack of staff. 10. During an interview on 6/7/19, at 11:26 A.M., CNA C said residents should get two showers per week, but it is not happening. He/she came in last month on his/her day off and did several, but did not get paid for it. He/she could not clock in. 11. During an interview on 6/7/19, at 12:05 P.M., CNA B said residents should get two to three showers per week but they are not happening. Staff try to get them as they can, but they are short staffed. Resident care, like showers, meal assistance, and changing residents are not being completed timely due to short staffing. 12. During an interview on 6/7/19, at 2:19 P.M., the Director of Nursing (DON) said the facility is staffed with a nurse at each desk (three) for all shifts. If there is no nurse on the West hall, the nurse from the SCU covers the West hall. There is no nurse on the West hall two to three days a week. There is one aide scheduled for each hall for all shifts. The West hall has an aide and a med tech during the day, and there is a med tech overnight on West working also as an aide. The nurses pass medications overnight on the other halls. Baths and showers should be given twice weekly, but if they can't, staff should provide a sponge bath and make sure the residents are clean and odor free. They document sponge baths in the same place on bath assessments. 13. Record review of Resident #5's annual MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Required extensive assistance for transfers, dressing, toilet use, and personal hygiene. Observation on 6/6/19, at 11:05 A.M., showed the following: -CNA [NAME] toileted the resident; -CNA [NAME] left the bathroom and entered the main dining area of the special care unit; -CNA [NAME] left the bathroom door and the room door open to the main dining area. During an interview on 6/6/19, at 1:57 P.M , CNA [NAME] said the following: -The resident needed to use the bathroom, so he/she assisted the resident to the toilet; -The CNA left the bathroom and room door open so that he/she would be able to check on the resident and still watch the other residents in the main dining area; -If the door is closed then he/she cannot ensure the safety of the other residents or hear when the resident is finished; -He/she was the only aide working on the unit at that time; -There is only one CNA, one CMT, and sometimes a nurse who work on the SCU at a time; -Most of the time the CNA works one hall and the nurse has to act as a CNA on the other hall;-The CMT does not have time to assist as a CNA due to the heavy medication passes that have to be completed; 14. Record review of Resident #61's annual MDS, dated [DATE], showed the following information: -Cognitively intact; -Required supervision for transfers; -Required limited assistance for dressing; -History of one non-injury fall and one non-major injury fall since previous assessment. During an interview on 6/5/19, at 1:36 P.M., the resident said he/she sat on the toilet for 45 minutes one time recently because nobody would answer his/her call light. He/she started pounding on the wall and they finally came to assist him/her. There was only one aide working that hall at the time. 15. Record review of Resident #9's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's annual MDS, dated [DATE], showed the following information: -Moderately cognitively impaired; -Required extensive assistance with bed mobility, transfers, toilet use, dressing, grooming, and personal hygiene; -Frequently incontinent of bladder; -Always continent of bowel; -Staff manage the resident's urinary and bowel movement needs with a toileting program. Observation on 6/3/19, at 12:22 P.M., showed the resident's family member asked CNA B to lay the resident down. CNA B told the resident's family member it would be at least another 30 minutes before he/she could lay the resident down. During an interview on 6/3/19, at 12:22 P.M., CNA B said residents have to wait after a meal to get laid down or toileted because he/she is still assisting people to eat. During an interview on 6/3/19, at 2:15 P.M., the resident's family member said the resident is having accidents (incontinent episodes) because no one can take him/her to the bathroom. 16. Record review of Resident #14 ' s face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely cognitively impaired; -Required extensive assistance with bed mobility, transfers, dressing, grooming, bathing, and personal hygiene. Record review of the resident's care plan, updated 3/5/19, showed the following information: -Required limited to total assistance with all ADLs, consider ambulation, assistive devices, bathing, bed mobility, dressing, eating, locomotion, personal hygiene, safety device, toilet use, transfers; -Staff did not care plan any interventions for the resident's ADLs. Observation on 6/3/19, beginning at 11:47 A.M., showed the following: -Certified Nurses' Aide (CNA) B seated all residents except Resident #14 at the tables in the dining area and placed food protectors on each of them; -The food cart was delivered to the SCU at 11:50 A.M. and CNA B began to pass trays; -At 12:05 P.M., CNA B had completed passing the meal trays to the residents seated at the tables; -CNA B assisted one resident with eating; -Resident #14 lay in bed on his/her right side with eyes open during the noon meal; -Staff did not take a lunch tray to Resident #14 in his/her room. During an interview on 6/3/19, at 12:22 P.M., CNA B said Resident #14 will have to wait until the aide is finished with this feeder. He/she is the only person in the unit. Some days, he/she will have more than one or two feeders and they will just have to wait until he/she gets finished with the other one. There are several days that there are 6-8 feeders. He/she feeds one right after the other until he/she is finished and it can take up to two hours. During an interview on 6/7/19, at 12:05 P.M., CNA B said Resident #14 did not receive his/her meal or receive meal assitance on 6/3/19 until after 1:00 P.M. due to him/her assisting other residents. The entire meal was not completed until after 2:00 P.M. because he/she was alone on the SCU. MO 874

Based on observation, interview, and record review, the facility failed to ensure staff prepared and served food in accordance with professional standards when staff stacked dishes while still wet. The facility had a census of 72 residents. 1. Record review of the 2013 Missouri Food Code showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried; -May not be cloth dried. Observation of the kitchen on 06/03/19, at 10:20 A.M., showed the following: -Four medium steam pans stacked wet; -Four small steam pans stacked wet. Observation of the kitchen on 06/06/19, at 2:00 P.M., showed the following: -Four stacks of six small fruit cups stacked wet; -Eight small fruit cups stacked wet; -Twelve small fruit cups stacked wet; -Two small saucers stacked wet. During an interview on 06/06/19, at 2:52 P.M., Dietary Aide (DA) I said he/she makes sure dishes are clean and dry prior to putting away. During an interview on 06/06/19, at 2:58 P.M., DA J said he/she ensures dishes are clean and dry before storing. During an interview 06/06/19, on 3:00 P.M., the Dietary Manager (DM) said staff need to ensure dishes are clean and dry before putting the dishes away. During an interview on 6/11/19, at 3:45 P.M., the administrator said the facility did not have a policy on dish storage.

Based on observation, interview, and record review, the facility staff failed to document completion of required [MEDICAL CONDITION] (TB - cause by bacteria that usually attack the lungs) testing or screening for five residents (Resident #10, #14, #15, #42, #271). A sample of 23 residents was selected for review. The facility census was 72. 19 CSR 20-20.100 - General requirements for [MEDICAL CONDITION] Testing for Residents in Long-Term Care Facilities showed the following information: -Long-term care facilities shall screen their residents for [MEDICAL CONDITION]. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test. If the initial test is negative, the second test should be given one to three weeks later; -All skin test results are to be documented in millimeters (mm) of induration; -All longterm care facility residents shall have a documented annual evaluation to rule out signs and symptoms of [MEDICAL CONDITION] disease. 1. Record review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/18/19, showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's immunization record showed staff did not document an annual screening for signs and/or symptoms of [MEDICAL CONDITION] (TB). During an interview on 6/5/19, at 2:30 P.M., the Director of Nursing (DON) said they could not locate documentation regarding the annual TB screening for Resident #42, which was due in (MONTH) 2019. 2. Record review of Resident #15's face sheet showed the following information: -admission date of [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's quarterly MDS, dated [DATE], showed the following information; -Severely cognitively impaired; -Extensive assistance required with bed mobility, transfers, dressing, grooming, bathing, and personal hygiene. Record review of the resident's immunization record showed staff did not document an annual screening for signs and/or symptoms of [MEDICAL CONDITION] (TB). 3. Record review of Resident #14's quarterly MDS, dated [DATE], showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's immunization record showed staff did not document an annual screening for sign and/or symptoms of TB. 4. Record review of Resident #10's 30-day MDS, dated [DATE], showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's immunization record showed staff did not document an admission two-step screening for signs and/or symptoms of TB. During interviews on 6/6/19, at 10:22 A.M., and 6/7/19, at 2:19 P.M., the DON said facility staff missed administering, reading, and documenting the TB tests for the resident. 5. Record review of Resident #271's face sheet (basic information sheet), showed the following information: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. Record review of the resident's immunization record showed staff did not document an admission two-step screening for signs and/or symptoms of TB. During interviews on 6/6/19, at 10:22 A.M., and 6/7/19, at 2:19 P.M., the DON said facility staff missed administering, reading, and documenting the TB tests for the resident. 6. During interviews on 6/6/19, at 10:22 A.M., and 6/7/19, at 2:19 P.M., the DON said the following: -The first step of the TB test is given on admission and read two to three days later; -The second step is given 10 days later and read two to three days later; -Nurses administer the tests and record the data in millimeters; -Annual TB screening is completed after the first year on the resident's anniversary date.

Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for the transfer, for four residents (Residents #18, #47, #64, and #73) out of 23 sampled residents. The facility failed to develop a policy regarding notifications upon transfer to a hospital. The facility census was 72. Record review of the facility's policy and procedure titled, Transfer of Patients/Residents, Last reviewed 5/2019, showed the following information: -Residents may be transferred upon order of the physician or upon patient/family request and preference; -Residents requiring diagnostic, definitive, and/or long-term care not provided at the facility will be transferred to another facility capable of providing such care upon order of the physician; -No resident shall be arbitrarily transferred; -Attempts shall be made to contact the resident's family/significant other if not present; such attempts shall be documented in the medical record; (The policy did not include information regarding written notification to the resident, resident's responsible party, or the Ombudsman of the transfer.) 1. Record review of Resident #18's nurses' notes showed the following information: -admitted to the facility on [DATE]; -On 5/3/19, at 3:17 A.M., staff found the resident on the bathroom floor with a laceration and a puncture wound to the right side of his/her forehead. He/she was alert and talking. Staff made all notifications and sent the resident to the hospital via ambulance. (Staff did not document they sent a written notice of the transfer to the resident or the resident's representative.); -On 5/7/19, at 4:28 P.M., the resident readmitted to the facility. Record review of the resident's medical record did not show a copy of any written notice provided to the resident or resident's representative regarding the transfer on 5/3/19. 2. Record review of Resident #64's nurses' notes showed the following information: -admitted to the facility on [DATE]; -On 5/6/19, at 9:52 A.M., staff transferred the resident to the hospital due to shortness of breath, an elevated temperature of 103.8 degrees Fahrenheit, rapid heart rate of 120 beats per minute (bpm), congestion, and loose cough. )Staff did not document they sent a written notice of the transfer to the resident or resident's representative.); -On 5/10/19, the resident readmitted to the facility. Record review of the resident's medical record did not show a copy of any written notice provided to the resident or the resident's representative regarding the transfer on 5/6/19. 3. Record review of Resident #47's nurses' notes showed the following information: -admitted to the facility on [DATE]; -On 4/19/19, at 11:42 A.M., staff documented they transferred the resident to the hospital due to shortness of breath, poor oxygen levels in the blood, irregular and rapid heart beat, and crackles heard in the lungs. (Staff did not document they sent a written notice of the transfer to the resident or resident's representative.); -On 4/23/19, at approximately 8:45 P.M., the resident readmitted to the facility. Record review of the resident's medical record did not show a copy of any written notice provided to the resident or the resident's representative regarding the transfer on 4/19/19. 4. Record review of Resident #73's nurses' notes showed the following information: -admitted to the facility on [DATE]; -On 04/01/19, the resident complained of not feeling well and feeling weak. Resident's heart rate was irregular and [MEDICAL CONDITION] (faster that normal resting heart rate, generally greater than 100 bpm). Staff obtained orders from the physician to transfer the resident to the emergency room (ER); -On 04/05/19, the resident readmitted to the facility; -On 04/08/19, the resident had diarrhea and [MEDICAL CONDITION] (body or region of the body deprived of adequate oxygen supply at the tissue level) and used accessory muscles to breathe. Staff received an order from the physician to transfer the resident to the hospital; -On 04/20/19, the resident readmitted to the facility; -On 04/27/19, the resident was pale, had an irregular heart beat, and a murmur. The resident said he/she did not feel right, and felt weak and faint. The facility staff received an order to transfer the resident to the hospital. Record review of the resident's medical record did not show a copy of any written notice provided to the resident or the resident's representative regarding the transfers on 04/01/19, 04/08/19, or 04/27/19. 5. During an interview on 6/6/19, at 4:15 P.M., the acting administrator and the Social Services Director said they do not send written notifications regarding a resident's transfer to the hospital.

Based on record review and interview, the facility staff failed to ensure one cognitively impaired resident in the special care unit (SCU) was free from sexual abuse from a resident (Resident #8) who displayed sexual and physical aggressive behaviors towards other residents. Fourteen residents were chosen for review. The facility census was 53. Record review of the facility's Elder and Persons with Disability Abuse Policy, revised (MONTH) (YEAR), showed the following: -The policy purpose was to guide staff and any other mandated reporter in identifying victims of abuse and provide a reporting mechanism in accordance with all local, state, and federal laws; to provide a safe and efficient care for the residents; and to keep residents free from abuse, mistreatment and neglect; -The organizations designee will be responsible for immediately initiating and conducting an investigation of the alleged abuse/neglect. During the investigation, residents will be protected from harm by interrupting the source of activity relating to the suspected abuse or neglect, providing education on appropriate behavior, and redirecting the resident as appropriate. Residents will be removed from area or distanced from the individual suspected of abuse/neglect. -Staff will complete a Quality Report Measure (QRM) Event Report for further investigation by the administrator, nursing administration and/or other disciplines within the facility in order to ensure resident safety and quality of care. The investigation will be completed by the administrator or designee and a summary submitted to DHSS within five working days. 1. Record review of Resident #1's face sheet showed the facility admitted the resident on 12/21/15 with [DIAGNOSES REDACTED]. Record review of Resident #1's annual Minimum Data Set (MDS), federally mandated assessment tool completed by facility staff, dated 11/02/17, showed the following: -The resident's decision making skills were severely impaired with long and short term memory problems; - Displayed physical behavior symptoms directed toward others occurred 1 to 3 days; - Had inattention and altered level of consciousness; - Ambulatory with limited assistance for mobility. Record review of Resident #8's face sheet showed an original admission date of [DATE]. [DIAGNOSES REDACTED]. -Alcohol-induced persisting dementia; -Anxiety; -Major [MEDICAL CONDITION]; -Delusional disorder; -Other sexual dysfunction. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes, completed by certified nurse aides (CNA), showed the following information: -On 08/12/17 at 8:04 P.M., the resident had been making sexual comments to staff and residents. Record review of Resident #1's (MONTH) (YEAR) behavioral monitoring sheets showed a CNA documented the following: -On 08/15/17, at 9:56 P.M., the resident did not like the attention of another resident. The resident stated that he/she felt nervous with the resident around and did not want to go anywhere with him/her. The CNA reassured the resident that the resident was safe and put the resident to bed. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the on the following dates staff documented the resident displayed inappropriate sexual behavior: -On 08/16/17, three times; -On 08/17/17, three times; -On 08/18/17, once; -On 08/20/17, four times. Record review of Resident #8's (MONTH) (YEAR) nurses' notes showed the following: -On 08/20/17 at 4:50 P.M., a nurse documented Resident #8 made sexual comments towards staff members and was found masturbating on more than one occasion. The physician ordered [MEDICATION NAME] (an antidepressant); -On 08/20/17 at 6:45 P.M., a nurse documented Resident #8 continued to have behaviors, kissing another resident. Staff redirected the resident to the table and gave him/her a newspaper to read. Record review of Resident #8's admission MDS, dated [DATE], showed the following information: -Cognition moderately impaired; -Inattention comes and goes; -Physical behavior symptoms directed towards others (e.g., hitting, kicking, scratching, grabbing, abusing others sexually); -Other behavior symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds); -Behavior symptoms did not put others at significant risk or physical injury; -Behavior symptoms did not intrude on the privacy or activity of others; -Behavior symptoms did not significantly disrupt care or living environment; -Ambulates independently; -Not steady, but able to stand and transfer self, without human assistance; -Receives antipsychotic (medication that treats psychotic behaviors) medication seven days a week. Record review of Resident #8's psychoactive medication review assessment and recommendation, dated 08/21/17 at 9:10 A.M., showed the following; -Current medications included [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]), [MEDICATION NAME] (hormone medication used to treat or manage sexual behaviors), [MEDICATION NAME] (medication used to treat depression and anxiety), and [MEDICATION NAME] (antipsychotic medication used to treat thought disturbance); -Resident continued to display [MEDICAL CONDITION] towards staff and other residents. Consider a change from oral [MEDICATION NAME] to a weekly Depo-[MEDICATION NAME] injections (hormone medication used to treat or manage sexual behaviors). Hyper-sexuality requires a much higher dose than other indications; consider Depo-[MEDICATION NAME] weekly for hyper-sexuality; -Physician reviewed and agreed to the above. Record review of Resident #8's care plan, dated 08/21/17, showed the following information: -admitted from skilled nursing home in nearby city where he/she had behavior problems; -Alert, but not very cooperative; -Placed in the Special Care Unit (SCU) for his/her safety; -Ambulates independently; -Inappropriate sexual behavior; -Interventions included staff to reinforce positive behavior; if agitated leave and re-approach later; reduce excessive stimuli; use calm reassuring approach; maintain a non-defensive stance; and assess for trigger situations such as pain, personal loss, relocation, conflict or prior history. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed on the following dates staff documented inappropriate sexual behavior including trying to kiss staff on the neck, rubbing residents' of the opposite sex arms up and down: -On 08/25/17, twice; -On 08/27/17, once; -On 08/28/17, once; -On 08/29/17, twice; -On 08/30/17, once; -On 08/31/17, twice. Record review of Resident #8's physician's progress notes, dated 09/01/17, showed the following: -Case was discussed with facility social worker; -Staff report the resident was still having sexual inappropriate advances toward residents of the opposite sex; -Just started treatment and resident has only had one dose of Depo-[MEDICATION NAME] (hormone medication used to treat or manage sexual behaviors); -Consensus that need to give treatment a little more time; -If problems continue consult psychiatry. Record review of Resident #8's care plan showed staff did not update the care plan regarding the increased behaviors or new interventions. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed staff documented inappropriate sexual behavior on the following dates: -On 09/01/17, three times; -On 09/02/17, twice; -On 09/03/17, three times. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following: -On 09/04/17 at 6:25 A.M., inappropriate sexual behavior - at 12:00 A.M., Resident #8 was up trying to kiss on a neighboring resident. Staff re-directed Resident #8 and he/she ignored staff and continued to kiss on the resident. Resident #8 finally went to the bathroom undressed and went to bed. At 5:30 A.M., the resident woke up and continued the same behavior kissing on the same resident; -On 09/04/17 at 8:24 A.M., Resident #8 was very hard to re-direct away from other residents, continues to try and kiss them and hold their hands. This was causing anxiety and frustration for these residents. Resident #8 also grabbed at a housekeeper and he/she wanted to rub him/her. Staff re-directs Resident #8 and tells the resident he/she is being inappropriate and in just a few minutes he/she is doing the same thing again; -On 09/04/17 at 9:27 A.M., inappropriate sexual behavior - Resident #8 has been kissing on another resident several times and staff tried to re-direct, but Resident #8 kept going back to the resident. Staff took other resident to his/her room to lay down. Resident #8 went into the resident's room later and was leaning over the resident and kissing him/her. Staff spoke to Resident #8 and when he/she turned around he/she was masturbating in front of the resident. Staff removed Resident #8 from the other resident's room and shut room door. Staff had given Resident #8 an as needed anxiety medication earlier in the morning and that did not seem to help resident. Resident has been up and down all night. Resident has been touching this staff, an aide, a housekeeper, and other residents; -On 09/04/17 at 5:48 P.M., inappropriate sexual behavior - Resident #8 keeps coming to the kitchen and asking staff where another resident is spending the night. Resident #8 wants to find a room for him/her and other resident to share. Staff have re-directed the two residents several times. Resident #8 keeps trying to hold the other resident's hands and arms; -On 09/04/17 at 10:34 P.M., inappropriate sexual behavior - Resident #8 kept kissing and touching another resident. Resident #8 would tell staff they needed a room together. Resident #8 was encouraged by other resident, but the other resident gets annoyed with Resident #8's attention. Resident #8 makes passes at other residents; -On 09/04/17 at 10:35 P.M., Resident #8 was kissing on resident when staff tried to re-direct resident to sit in another chair, resident stated at least he/she wasn't having sex with resident. Resident #8 went back to sit next to the resident and was leaning over him/her fussing with resident's blanket. The other resident became angry and staff had to separate the two residents. Record review of Resident #1's (MONTH) (YEAR) behavioral monitoring sheets showed a CNA documented the following: -On 09/04/17, at 6:18 A.M., the resident was up half of the night saying he/she was scared. Staff offered the resident a snack. Neighboring resident trying to kiss on him/her. Record review of the Resident #8's (MONTH) (YEAR) nurses' notes showed the following information: -On 09/04/17 at 9:51 A.M., a nurse documented Resident #8 having significantly increased behaviors this morning. The resident was observed in a room of another resident, [MEDICATION NAME] kissing the resident and masturbating at the same time. The Director of Nursing (DON) was notified and she recommended the physician be notified. Physician was notified and new orders received for a one time dose of [MEDICATION NAME] (medication that can be used to treat residents with agitation) and [MEDICATION NAME] (an antianxiety medication) every six hours as needed for inappropriate behaviors. Orders implemented without delay. Currently the resident was resting in his/her own room/bed, will continue to monitor. Record review of Resident #8's care plan showed staff did not update the care plan regarding the increased behaviors, the new medications, or new interventions. Record review of the Resident #8's (MONTH) (YEAR) behavior monitoring notes showed staff documented inappropriate sexual behavior on the following dates: -On 09/06/17, once; -On 09/07/17, four times; -On 09/08/17, once. Record review of Resident #8's physician's progress notes, dated 09/08/17, showed the following: -In general the resident was doing fairly well, however, there was a concern about his/her sexual behavior with inappropriate remarks and even being in another resident's room; -An aggressive regimen of hormones, antidepressant medicine, and as needed [MEDICATION NAME] when the resident has aggressive like behavior; -[DIAGNOSES REDACTED]. Record review of Resident #8's care plan showed staff did not update the care plan regarding the increased behaviors, the medication intervention, new interventions, or hyper-sexuality diagnosis. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed staff documented inappropriate sexual behavior on the following dates: -On 09/09/17, twice; -On 09/10/17, three times. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes, dated 09/10/17 at 1:37 P.M., showed a licensed practical nurse (LPN) documented nothing had been reported by nursing staff related to the behavior monitoring. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed staff documented inappropriate sexual behavior on the following dates: -On 09/12/17, once; -On 09/13/17, twice; -On 09/14/17, once. Record review of Resident #8's (MONTH) (YEAR) nurses' notes showed the following information: -On 09/15/17, pharmacist recommended the [MEDICATION NAME] dose be increased, however, this would require two injections be given at the same time due to how the medication is formulated. So the recommendation was to give Depo-[MEDICATION NAME] (hormone medication used to treat or manage sexual behaviors) by mouth, plus the injection weekly. The physician approved the order. Record review of Resident #8's care plan showed staff did not update the care plan regarding the increased behaviors, the medication change, or new interventions. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 09/15/17 at 9:19 P.M., Resident #8 was very busy approaching other residents, trying to get them to go with him/her. Resident #8 also wanted to kiss staff and kissing and touching other residents. Resident #8 was re-directable until after supper where he/she was found in another resident's room. Resident #8 said he/she did not care if the resident was married, he/she was going to bed with him/her; -On 09/17/17 at 9:40 P.M., Resident #8 tried to get another resident to go to his/her room with him/her and was repetitive with a specific resident. Resident #8 was too involved in another resident's activities of daily living (ADL's - dressing, grooming, bathing, eating, and toileting). Resident #8 stated he/she and the other resident were getting married, he/she didn't care if the other resident was already married and he/she was going to take and do whatever he/she wanted with the resident; -On 09/18/17 at 1:58 P.M., inappropriate sexual behavior - Resident #8 tried to get to Resident #1 to kiss and hold his/her hand. Staff trying to prevent, but Resident #8 kept coming right back to Resident #1; -On 09/19/17 at 6:12 P.M., Resident #8 wanted to take resident of opposite sex home with him/her. Staff could not re-direct due to other resident refusing to go with staff; -On 09/19/17 at 7:11 P.M., Resident #8 kissed on a resident of the opposite sex and then during dinner he/she and another resident had packed their belongings and wanted to leave the facility as staff re-directed, Resident #8 swung trying to hit staff; -On 09/20/17 at 10:36 A.M., inappropriate sexual behavior - Resident #8 will not sit for any length of time and goes between staff asking questions or kissing another resident of the opposite sex; -On 09/20/17 at 7:34 P.M., inappropriate sexual behavior - Resident #8 paced back and forth between his room and another resident's room. Every time he/she approached the resident he/she would kiss and touch his/her arms. Resident #8 tried to open the main SCU doors several times and would not sit down for any length of time; -On 09/20/17 at 9:58 P.M., inappropriate sexual behavior - found Resident #8 and Resident #1 in Resident #8's room. Resident #8 was naked and Resident #1 had only underwear on. Resident #8 was attempting to have sex with Resident #1. Told residents that Resident #1 needed to come with this aide and aide helped Resident #1 put clothing back on. Told Resident #8 he/she needed to get his/her night clothes on, so he/she could get ready for bed. Resident #8 was not happy with aide; -On 09/21/17 at 9:47 A.M., Resident #8 touching Resident #1's face and telling female resident to sit down so he/she can look at him/her. Resident #8 was getting upset because the aides are trying to keep the residents apart. Record review of Resident #1's (MONTH) (YEAR) behavioral monitoring sheets showed a CNA documented the following: -On 09/21/17, at 3:42 A.M., the resident walked out of his/her room naked and was saying he/she was going to have a baby. The CNA redirected the resident and asked how he/she was doing and asked if he/she wanted a new gown and helped him/her put it on. The CNA then asked if the resident would like a snack. The resident then stopped talking about a baby and wanted to go lie down and slept the rest of the night; -On 09/21/17, at 9:44 A.M., the resident has been stating He/she wants to go and he/she needs to get it out. The resident has been up and down and can't sit still. The resident has been holding his/her belly stating this is just horrible. The resident stated my water broke and the CNA took the resident to the bathroom. Record review of Resident #1's nurses' notes on 09/21/17 showed the following: -On 09/21/17 at 10:15 A.M., a Certified Medication Technician (CMT) from the SCU notified the nurse that the resident had been walking around the unit this morning stating, My water broke, I think I am going to have to get rid of this baby. The resident has also reportedly been having moments of escalated behavior. He/She is able to be redirected at times and not at other times. Record review of Resident #8's (MONTH) (YEAR) nurses' notes showed the following information: -On 09/21/17 at 8:09 A.M., Depo-[MEDICATION NAME] injection given to Resident #8 on left side of buttocks; -On 09/21/17 at 10:19 A.M., a nurse documented a verbal order was received from the physician to discharge Resident #8 to a mental health facility and family was notified. -On 09/21/17 at 1:49 P.M., family member transported the resident to the hospital. Record review of Resident #8's psychiatric hospital discharge summary, dated 09/28/17, showed the resident was admitted on [DATE] for sexual aggression. Resident had been found in bed naked with another resident; slapped staff; and wanted to take resident home. Behaviors had been escalating from patting and touching to more sexually explicit behaviors. Record review of Resident #8's (MONTH) (YEAR) nurses' notes showed on 09/28/17 at 3:45 P.M., the resident was readmitted back to the facility. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 09/28/17 at 8:49 P.M., inappropriate sexual behavior - Resident #8 upsetting other residents when trying to get them to go with him/her. Resident #8 kissed all the residents of the opposite sex on the forehead and rubbing their hands and faces. Resident #8 asked staff to go to bed with him/her. Record review of Resident #8's physician's re-admission progress note, dated 09/29/17, showed the following: -Resident admitted with [MEDICATION NAME] (medication used to treat depression) for depression, [MEDICATION NAME] as needed for anxiety, [MEDICATION NAME] for anxiety and off label use for sexually inappropriate behaviors, [MEDICATION NAME] (medication used to treat sleep disorder) for [MEDICAL CONDITION] and [MEDICATION NAME] for thought disturbance; -The patient tolerated these changes well; -The medication changes definitely seem to have a noticeable difference; -While the resident still had some occasional sexually inappropriate behavior, it was not at the extent of what he/she had been experiencing and was easily re-directed by staff. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 09/29/17 at 3:49 A.M., inappropriate sexual behavior - Resident #8 had an accident in bed and while aide was making bed, the resident poked aide on his/her bottom with television remote control and began grabbing aide's bottom, when aide asked the resident to stop, the resident said oh she's mad and did it several more times; -On 09/29/17 at 6:29 A.M., inappropriate sexual behavior - Resident #8 came walking down the hall with underwear down and private area exposed masturbating down the hall and into the dining room. Staff re-directed the resident back to room. Record review of the Resident #8's (MONTH) (YEAR) nurses' notes showed the following information: -On 09/29/17 at 10:30 A.M., Resident #8 had behaviors that included walking in the hallway with his/her hands in underwear, moving back and forth rhythmically. The physician here to see resident. An order was given to hold [MEDICATION NAME], reinstate Depo-[MEDICATION NAME] injections, continue [MEDICATION NAME] as needed, and notify physician prior to administering the [MEDICATION NAME], to allow physician to gain a better understanding/a better picture of the frequency and type of behaviors the resident is having. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 09/29/17 at 11:46 A.M., inappropriate sexual behavior - Resident #8 came walking down the hall in just his/her underwear and masturbating, staff re-directed the resident back to room.; -On 09/30/17 at 8:25 P.M., Resident #8 held hands with another resident and walking down hall with him/her, staff re-directed and resident became agitated and said he/she can touch resident if he/she wants; -Resident #8 cursing more than usual. Record review of Resident #8's care plan showed staff did not update the care plan regarding the hospitalization , the medication changes, or new interventions. Record review of Resident #8's (MONTH) (YEAR) nurses' notes showed the following: -On 10/01/17 at 8:50 A.M., a nurse documented the resident received [MEDICATION NAME] due to walking down the hallway with no clothes on and fighting staff when assisting the resident with his/her clothes. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 10/02/17 at 11:42 A.M., Resident #8 was in and out of room of other residents; -On 10/02/17 at 1:55 P.M., after the resident sat down next to another resident who was sitting with spouse. Resident #8 stated to the resident's spouse that he/she had a knife and would use it. The resident's spouse said he/she would take care of Resident #8 if he/she did anything with his/her spouse. Record review of Resident #8's physician's progress notes, dated 10/02/17, showed no concerns related to sexually inappropriate behaviors or physical aggression. Record review of Resident #8's (MONTH) (YEAR) nurses' notes showed the following: -On 10/03/17 at 4:19 P.M., [MEDICATION NAME] was given to Resident #8. The resident was wandering the halls in and out of other residents' rooms several times and hard to redirect. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 10/04/17 at 7:25 P.M., the resident was kissing a resident; -On 10/05/17 at 9:00 P.M., the resident completely stripped clothing off while in the bathroom staff re-directed and later came out of room in only his/her underwear;. -On 10/15/17 at 11:39 A.M., while the aide assisted the resident with shaving, the resident said leave my hands alone and I will give you something to play with; - On 10/16/17 at 2:09 P.M., the resident grabbed aide by the arm and tried to kiss him/her. Record review of Resident #8's physician's progress notes, dated 11/15/17, showed the following; -Resident seen for routine exam, unfortunately the resident spends most of his/her time in a geri-chair (reclining wheel chair); -The sleep problem (in the recent past the resident would stay up all night), behavior problem (hitting) and sexual behavior problem (undressing and trying to go to bed with one of the female resident's) had resolved with the facility's aggressive medication regimen; -No concerns related to sexually inappropriate behaviors or physical aggression noted. Record review of Resident #8's physician's progress notes, dated 12/01/17, showed the following: -Resident returned from a recent hospitalization and all [MEDICAL CONDITION] medication had been discontinued; -The facility's psychiatrist had offered to help manage the resident's behaviors and hyper-sexuality; -Hospital course showed the resident was nearly non-verbal and medicated to the point of being immobile most days. The resident had been heavily medicated due to hyper-sexuality and aggressive behaviors at the skilled nursing home (SNF). The resident gradually improved and was medically stable to return to the SNF. Record review of Resident #8's physician's progress notes, dated 12/08/17, showed no concerns related to sexually inappropriate behaviors or physical aggression. Record review of Resident #8's physician's progress note, dated 12/15/17, showed the following: -Nothing has really changed since last visit; -The resident continues to require one-on-one care from staff; -No concerns related to sexually inappropriate behaviors or physical aggression noted. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 12/19/17 at 10:08 A.M., Resident #8 began cursing at staff really loud and upset other residents; -On 12/19/17 at 12:45 P.M., Resident #8 punched and cursed at staff which upset other residents; -On 12/23/17 at 10:34 A.M., the resident required one-on-one care due to being impulsive and very difficult to re-orientate; -On 12/24/17 at 12:27 P.M., the resident refused to stay seated and kissed another resident and when staff asked the resident to stop, the resident smiled and said he/she had already done it and there was nothing the staff could do; -On 12/28/17 at 10:31 A.M., the resident cursed a resident who was asleep at the dining room table; -On 12/28/17 at 11:36 A.M., the resident took other residents' drinks and when staff re-directed the resident cursed staff and other residents became upset; -On 12/31/17 at 7:41 P.M., the resident sat in a chair and held another resident's hand. Staff asked Resident #8 to sit in a different chair away from resident. Staff overheard Resident #8 tell resident he/she was going to take him/her to bed. Staff told Resident #8 that residents don't go residents of the opposite sex's rooms; -On 12/31/17 at 9:46 P.M., Resident #8 too friendly with residents and staff. Resident #8 was also upset that other residents of the same sex live at the facility. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 01/01/18 at 9:37 A.M., the resident said his/her hand was asleep and staff said oh really why was that and the resident said lack of women, while resident said this he/she smiled and laughed and then said I'm just kidding with you; -On 01/04/18 at 2:38 A.M., while staff was assisting another resident with cares Resident #8 climbed in bed with another resident with nothing on, but his/her underwear. Staff re-directed and resident became angry when staff would not allow him/her to go back into resident's room; -On 01/04/18 at 9:24 A.M., the resident followed a resident around trying to go in his/her room, staff re-directed; -On 01/04/18 at 1:37 P.M., resident exposed his/her genitalia in front of Resident #1 in the dining room; -On 01/05/18 at 9:42 P.M., started getting too friendly with another resident; -On 01/06/18 at 10:25 P.M., the resident cornered staff and tried to kiss him/her; -On 01/09/18 at 7:59 A.M., when being re-directed the resident began punching and cursing staff and said he/she would do what he/she wants when he/she wants; -On 01/09/18 at 9:36 A.M., resident went into another resident's room and when re-directed started throwing punches and calling staff names; -On 01/09/18 at 8:30 P.M., resident held hands and kissed another resident on the lips, hands, cheeks and forehead. When re-directed the resident said he/she just liked how the resident looked and could not contain him/herself anymore; -On 01/09/18 at 9:59 P.M., while staff were assisting a resident with getting into his/her pajamas Resident #8 entered another resident's room and looked at the resident. Staff told Resident #8 he/she could not do that and he/she said he/she did not care and he/she was going to do what he/she wanted; -On 01/11/18 at 9:51 A.M., the resident continued to walk in and out of residents' rooms and refused to stay out of other residents' rooms when re-directed, resident said he/she will do what he/she wants. Re-direction was not working; -On 01/13/18 at 5:22 A.M., resident required one-on-one care due to being impulsive and very difficult to re-orientate; -On 01/13/18 at 8:51 P.M., resident held another resident's hand. When asked to stop Resident #8 got mad and let go of the resident's hand. Another resident approached Resident #8 and rubbed on the upper part of his/her leg, staff re-directed and both residents not happy the situation was stopped. Record review of Resident #8's physician's progress notes, dated 01/19/18, showed the following: -The resident continued to be a challenge to manage; -The resident doesn't sleep well at night and naps during the day; -No concerns related to sexually inappropriate behaviors or physical aggression noted. Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 01/20/18 at 2:15 P.M., required one-on-one care due to being impulsive and difficult to re-orientate. Record review of Resident #8's care plan, updated on 01/22/18, showed the following information: -The resident continued to have sexual behaviors towards staff and peers. Redirection is difficult due to his/her dementia; -The resident had a psychiatric stay and has been off his/her [MEDICAL CONDITION] medications since 01/16/18; -Physician ordered [MEDICATION NAME] (antipsychotic medication used to treat dementia related [MEDICAL CONDITION]) two times a day to help with Alzheimer's and alcohol induced dementia. (Staff did not update the care plan to show the need for one-on-one cares.) Record review of Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the following information: -On 01/23/18 at 4:15 A.M., inappropriate sexual behavior note with no detail in the notes; -On 01/25/18 at 11:23 A.M., resident stood in the dining room with his/her pants down to his/her knees, several other residents in the dining room; -On 01/28/18 at 9:05 A.M., the resident made sexual gestures and comments to staff; -On 01/29/18 at 9:48 A.M., Resident #8 was noted to have another resident's shirt up and did not want to be distracted from it when he/she was discovered. Required one-on-one monitoring frequently due to being spontaneous and impulsive; -On 01/31/18 at 10:12 P.M., resident was touching his/her genitalia. Staff re-directed the resident to stop, because he/she was in a public place in the dining room. Staff asked resident if he/she needed to use the restroom or if he/she was hurting or if he/she wanted to lay down and he/she said no. When asked for the second time to stop the resident told staff no. Record review of Resident #8's medical record showed no documentation of one-on-one monitoring for (MONTH) (YEAR). Record review of the Resident #8's (MONTH) (YEAR) behavior monitoring notes showed the fo