Every finding on record at Lawson Manor & Rehab

Based on interview and record review, the facility failed to report Resident #1's missing narcotic (a highly addictive medication) medication to the state survey agency within the required time frame. This deficient practice affected one of four sampled residents. The facility census was 41. Review of the facility's Abuse Investigation and Reporting policy, dated July 2017, showed:-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management; -All alleged violations, including misappropriation of property will be reported by the facility Administrator, or designee, to the State licensing and certification agency; -An alleged violation of misappropriation of resident property, will be reported immediately but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or twenty-four hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury; -The Administrator, or designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation withing five working days of the occurrence of the incident; -Appropriate professional and licensing boards will be notified when an employee is found to have committed abuse.Review of Resident #1's electronic medical record on 01/09/2026, showed the resident's diagnoses included: Fracture of lower end of right femur, cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), osteoarthritis of knee (a chronic degenerative joint disease that causes cartilage in the joints to break down over time). Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 10/16/25, showed:-The resident had adequate hearing, clear speech;-He/She was able to make self-understood and understood others;-He/She scored 7 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicating the resident had severely impaired cognition;-He/She had limitations to both arms and both legs and used a wheelchair for mobility;-He/She was dependent on staff for Activities of Daily Living (ADLs), including bathing, dressing, toileting and personal hygiene;-He/She reported moderately rated pain. Review of the resident's comprehensive care plan, dated 01/05/26, showed interventions related to limited mobility related to weakness/activity intolerance, behaviors related to being combative during cares, communication related to aphasia/language impairment, risk for falls, depression, seizure disorder, skin integrity, and chronic pain. Review of the resident's discharge orders from the local hospital, dated 10/02/25 showed an order for oxycodone (a highly addictive pain medication used to treat moderate to severe pain) 5 milligrams (mg) tablet every eight hours as needed for moderate to severe pain. Review of the resident's Physician Order Sheet (POS) dated December 2025 showed an order for oxycodone 5 mg tablet every four hours as needed for pain. The start date for this order was 11/03/25. Review of the resident's progress notes Registered Nurse (RN) A documented, dated 10/03/25 showed:-RN A documented on 10/03/25 at 10:17 A.M. he/she gave the resident scheduled pain medication;-When he/she raised the head of the bed, the resident yelled out in pain;-RN A told the resident the pain medication would take about an hour to work; -When RN A returned to the resident, the resident said the pain was still really bad;-The resident had a new order for oxycodone as needed;-RN A removed three tablets from the emergency kit, one dose was given to the resident;-At 02:47 P.M., RN A documented the dressing was changed to the resident's surgical site and the resident screamed out in pain;-RN A left a message for Nurse Practitioner to increase the frequency of the resident's oxycodone to every four hours as needed.Review of progress note RN A documented, dated 11/03/25 showed: -At 01:38 P.M., The resident yelled out in pain of the right leg and knee;-The resident was given a pain pill approximately four hours ago;-RN A notified the Nurse Practitioner of the resident's pain and received a new order to increase the frequency of the oxycodone to every four hours as needed;-RN A gave the resident an additional pain pill. Review of the facility investigation, dated 12/22/25 showed:-On 12/22/25 at approximately 7:30 A.M., Licensed Practical Nurse (LPN) A reported to the Assistant Director of Nursing (ADON) that he/she believed that a card of oxycodone for the resident was missing;-LPN A believed there were three cards of the oxycodone for the resident on 12/19/15, his/her last worked shift;-When LPN A looked in the narcotic count book, he/she noticed the page for the missing card of oxycodone was folded over, something staff do if the medication card was empty or destroyed;-There was nothing written on the sheet to indicate where the card was;-The ADON notified the Director of Nursing (DON) regarding the missing card of oxycodone;-The DON verified with the pharmacy that three cards of oxycodone tablets, 180 tablets in total, had been delivered to the facility on [DATE] for the resident; -On 01/06/26 at approximately 07:00 A.M., LPN B notified the ADON and DON that RN A reported to work for the day shift and was not acting right, as if he/she was under the influence;-The DON arrived at the facility to speak with RN A;-RN A pulled the DON into the beauty shop and was not making sense while speaking with the DON;-The DON asked the ADON to assume RN A's duties;-RN A spoke with the DON and Administrator;-During this conversation, both the DON and Administrator determined RN A did not appear to be able to safely work his/her shift at the home;-The DON asked RN A if he/she had taken the missing card of the resident's oxycodone and RN A said he/she did take the missing card and had folded over the narcotic page to appear as if the medication was gone;-RN A was terminated from employment on 01/06/26. Review of the facility's emergency medication kit medication removal documentation book on 01/09/26 showed on 10/03/25 at 10:03 A.M., RN A signed out three 5mg tablets of oxycodone and indicated the medication was going to be given to the resident.Review of the resident's 10/25 Medication Administration Record (MAR) on 01/09/26 showed RN A administered one 5mg tablet of oxycodone to the resident on 10/03/25 at 10:30 A.M. There was no documentation in the resident's electronic medical record of the disposition of the other two tablets of oxycodone that were removed from the emergency medication kit. During an interview on 1/13/26 at 2:15 P.M., LPN A said:-He/She worked on 12/19/25 during the day shift;-On that day, there were three cards of oxycodone for the resident in the narcotic box with one card being used and two cards that were sent as back up from the pharmacy; -When he/she returned to work on 12/22/25, LPN A completed the narcotic count with the off going nurse, LPN C;-At that time, LPN A noticed there were only two cards of oxycodone for the resident;-LPN A and LPN C looked at the narcotic count sheet and saw the page for the missing card of oxycodone was folded over, which staff do when a medication was to be destroyed or returned to pharmacy;-There was nothing documented on the sheet;-LPN A notified the ADON of the missing card of oxycodone.During an interview on 1/13/26 at 2:25 P.M., the Nurse Practitioner (NP) said he/she was not notified of the missing medication until 01/13/26. During an interview on 1/13/26 at 2:40 P.M., the pharmacy representative said three cards of 5mg oxycodone tablets, 180 tablets total, were delivered to the facility on [DATE] and were signed for by LPN C. During an interview on 1/14/26 at 1:10 P.M., the DON said he/she expected staff to follow the facility policy regarding reporting missing medications.During an interview on 1/14/26 at 1:10 P.M., the Administrator said:-Missing medications should be reported to the state survey agency within two hours of the medication being noted missing;-Initially, the facility was not sure the resident's medications were missing; -He/She initially thought the medications would be found but the medications were not found; -The missing medications should have been reported to the State Survey Agency when they were noted missing on 12/22/25. Intake 2709249

Based on interview and record review, the facility failed to protect one resident (Resident #1) from misappropriation of his/her property, when an employee took the resident's narcotic (highly addictive prescription medication) medication. The facility census was 41. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, showed:-Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation;-The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:-Protect resident from misappropriation of property by anyone including, facility staff;-Develop and implement policies and protocols to prevent and identify theft, exploitation, or misappropriation of resident property. Review of Resident #1's electronic medical record on 01/09/2026, showed:-The resident's diagnoses included: Fracture of lower end of right femur, cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), osteoarthritis of knee (a chronic degenerative joint disease that causes cartilage in the joints to break down over time). Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 10/16/25, showed:-The resident had adequate hearing, clear speech;-He/She was able to make self-understood and understood others;-He/She scored 7 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicating the resident had severely impaired cognition;-He/She had limitations to both arms and both legs and used a wheelchair for mobility;-He/She was dependent on staff for Activities of Daily Living (ADLs), including bathing, dressing, toileting and personal hygiene;-He/She reported moderately rated pain. Review of the resident's comprehensive care plan, dated 01/05/26, showed interventions related to limited mobility related to weakness/activity intolerance, behaviors related to being combative during cares, communication related to aphasia/language impairment, risk for falls, depression, seizure disorder, skin integrity, and chronic pain. Review of the resident's discharge orders from the local hospital, dated 10/02/25 showed an order for oxycodone (a highly addictive pain medication used to treat moderate to severe pain) 5 milligrams (mg) tablet every eight hours as needed for moderate to severe pain. Review of the resident's Physician Order Sheet (POS) dated December 2025 showed an order for Oxycodone 5 mg tablet every four hours as needed for pain. The start date for this order was 11/03/25. Review of the resident's progress notes Registered Nurse (RN) A documented, dated 10/03/25 showed:-RN A documented on 10/03/25 at 10:17 A.M. he/she gave the resident scheduled pain medication;-When he/she raised the head of the bed, the resident yelled out in pain;-RN A told the resident the pain medication would take about an hour to work; -When RN A returned to the resident, the resident said the pain was still really bad;-The resident had a new order for oxycodone as needed;-RN A removed three tablets from the emergency kit, one dose was given to the resident;-At 02:47 P.M., RN A documented the dressing was changed to the resident's surgical site and the resident screamed out in pain;-RN A left a message for Nurse Practitioner to increase the frequency of the resident's oxycodone to every four hours as needed.Review of progress note completed by RN A, dated 11/03/25 showed: -At 01:38 P.M., The resident yelled out in pain of the right leg and knee;-The resident was given a pain pill approximately four hours ago;-RN A notified the Nurse Practitioner of the resident's pain and received a new order to increase the frequency of the oxycodone to every four hours as needed;-RN A gave the resident an additional pain pill. Review of the facility investigation, dated 12/22/25 showed:-On 12/22/25 at approximately 7:30 A.M., Licensed Practical Nurse (LPN) A reported to the Assistant Director of Nursing (ADON) that he/she believed that a card of Oxycodone for the resident was missing;-LPN A believed there were three cards of the Oxycodone for the resident on 12/19/15, his/her last worked shift;-When LPN A looked in the narcotic count book, he/she noticed the page for the missing card of oxycodone was folded over, something staff do if the medication card was empty or destroyed;-There was nothing written on the sheet to indicate where the card was;-The ADON notified the Director of Nursing (DON) regarding the missing card of Oxycodone;-The DON verified with the pharmacy that three cards of oxycodone tablets, 180 tablets in total, had been delivered to the facility on [DATE] for the resident; -On 01/06/26 at approximately 07:00 A.M., LPN B notified the ADON and DON that RN A reported to work for the day shift and was not acting right, as if he/she was under the influence;-The DON arrived at the facility to speak with RN A;-RN A pulled the DON into the beauty shop and was not making sense while speaking with the DON;-The DON asked the ADON to assume RN A's duties;-RN A spoke with the DON and Administrator;-During this conversation, both the DON and Administrator determined RN A did not appear to be able to safely and competently work his/her shift at the home;-The DON asked RN A if he/she had taken the missing card of the resident's Oxycodone and RN A said he/she did take the missing card and had folded over the narcotic page to appear as if the medication was gone;-RN A was terminated from employment on 01/06/26. Review of the facility's emergency medication kit medication removal documentation book on 01/09/26 showed on 10/03/25 at 10:03 A.M., RN A signed out three 5mg tablets of Oxycodone and indicated the medication was going to be given to the resident.Review of the resident's 10/25 Medication Administration Record (MAR) on 01/09/26 showed RN A administered one 5mg tablet of oxycodone to the resident on 10/03/25 at 10:30 A.M. There was no documentation in the resident's electronic medical record of the disposition of the other two tablets of Oxycodone that were removed from the emergency medication kit. During an interview on 1/13/26 at 2:15 P.M., LPN A said:-He/She worked on 12/19/25 during the day shift;-On that day, there were three cards of Oxycodone for the resident in the narcotic box with one card being used and two cards that were sent as back up from the pharmacy; -When he/she returned to work on 12/22/25, LPN A completed the narcotic count with the off going nurse, LPN C;-At that time, LPN A noticed there were only two cards of oxycodone for the resident;-LPN A and LPN C looked at the narcotic count sheet and saw the page for the missing card of Oxycodone was folded over, which staff do when a medication was to be destroyed or returned to pharmacy;-There was nothing documented on the sheet;-LPN A notified the ADON of the missing card of Oxycodone.During an interview on 1/13/26 at 12:01 P.M., LPN B said:-On 01/06/26, LPN B worked with RN A and RN A acted bizarre;-LPN B notified the ADON who was the manager on call of RN A's behavior. During an interview on 1/13/26 at 2:25 P.M., the Nurse Practitioner (NP) said:-The only correspondence from the staff at the home he/she received regarding the resident occurred on 10/19/25, notifying him/her of orders for controlled substances needed signed;-The NP did not give the any staff at the home an order to increase the frequency of the resident's Oxycodone;-He/She was never notified the resident had uncontrolled pain or yelling out in pain. During an interview on 1/13/26 at 2:40 P.M., the pharmacy representative said three cards of 5 mg Oxycodone tablets, 180 tablets total, were delivered to the facility on [DATE] and were signed for by LPN C. During an interview on 1/14/26 at 1:10 P.M., the DON said:-Facility nurses should count controlled substances at shift change, the on-coming and off-going nurse together;-They should count each medication cart for each hall;-The card count book should match the count of medications;-Nurses should count each number of pills with each card, and it should match the narcotic count sheets;-The nurses should then sign the sheet at the front of the narcotic count book;-Staff should be counting medications each time the medication room keys change hands as well; -If any medications are found to be missing, all staff will stay at the facility;-The DON will be notified, and an investigation will begin;-The on-coming nurse and off-going nurse will go for a drug test;-The Administrator and Regional Nurse Consultant will be notified of the missing medications;-He/She expected staff will not misappropriate resident medications. During an interview on 1/14/26 at 1:10 P.M., the Administrator said:-He/she expects staff to follow the facility's policy on counting controlled substances.-Missing medications should be reported to the state survey agency.-He/She expected staff will not misappropriate resident medications. Intake 2709249

Based on observation, interviews, and record review, the facility failed to maintain a safe and effective medication system when staff did not follow facility policies and procedures in counting narcotic medications, a card of oxycodone medication (a highly addictive prescription medication used to treat severe pain), for one resident (Resident #1). Additionally, staff removed multiple doses of oxycodone from the facility's emergency medication kit at one time without the need for all of the doses to be removed from the emergency medication kit. The facility census was 41. Review of the facility policy titled, Controlled Substances, dated November 2022, showed:-The facility was supposed to comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications; -Controlled substances are counted upon delivery;-The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together;-Both individuals sign the designated controlled substance record; -Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected;-The charge nurse on duty maintains the keys to controlled substance containers. The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers. -Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.-The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: Records of personnel access and usage, medication administration records, declining inventory records, and destruction/waste/return to pharmacy records; -Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count; -The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services; -The director of nursing services documents irreconcilable discrepancies in a report to the administrator;-If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing services notifies the administrator and consulting pharmacist immediately;-The administrator, consultant, pharmacist, and/or director of nursing services determine whether other actions are needed, such as notification of police or other enforcement personnel;-The medication regimen of residents using medications that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met, such as a resident receiving a pain medication complains of unrelieved pain; -Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet; -Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances;-Some controlled substances may be stored in the emergency medication supply;-Reconciliation of controlled substances in the emergency supply is conducted at intervals established by the director of nursing services. Review of Resident #1's electronic medical record on 01/09/2026, showed:-The resident's diagnoses included: Fracture of lower end of right femur, cognitive communication deficit (a difficulty with communication that's caused by an underlying issue with cognition), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing a significant impairment in daily life), osteoarthritis of knee (a chronic degenerative joint disease that causes cartilage in the joints to break down over time). Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 10/16/25, showed:-The resident had adequate hearing, clear speech;-He/She was able to make self-understood and understood others;-He/She scored 7 on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents), indicating the resident had severely impaired cognition;-He/She had limitations to both arms and both legs and used a wheelchair for mobility;-He/She was dependent on staff for Activities of Daily Living (ADLs), including bathing, dressing, toileting and personal hygiene;-He/She reported moderately rated pain. Review of the resident's comprehensive care plan, dated 01/05/26, showed interventions related to limited mobility related to weakness/activity intolerance, behaviors related to being combative during cares, communication related to aphasia/language impairment, risk for falls, depression, seizure disorder, skin integrity, and chronic pain. Review of the resident's discharge orders from the local hospital, dated 10/02/25 showed an order for oxycodone (a highly addictive pain medication used to treat moderate to severe pain) 5 milligrams (mg) tablet every eight hours as needed for moderate to severe pain. Review of the resident's Physician Order Sheet (POS) dated December 2025 showed an order for oxycodone 5 mg tablet every four hours as needed for pain. The start date for this order was 11/03/25. Review of the resident's progress notes Registered Nurse (RN) A documented, dated 10/03/25 showed:-RN A documented on 10/03/25 at 10:17 A.M. he/she gave the resident scheduled pain medication;-When he/she raised the head of the bed, the resident yelled out in pain;-RN A told the resident the pain medication would take about an hour to work; -When RN A returned to the resident, the resident said the pain was still really bad;-The resident had a new order for oxycodone as needed;-RN A removed three tablets from the emergency kit, one dose was given to the resident;-At 02:47 P.M., RN A documented the dressing was changed to the resident's surgical site and the resident screamed out in pain;-RN A left a message for Nurse Practitioner to increase the frequency of the resident's oxycodone to every four hours as needed.Review of the facility investigation, dated 12/22/25 showed:-RN B, who worked on 12/21/25, said he/she didn't recall how many cards of oxycodone were present at that time;-LPN B, who last worked 12/20/25 and 12/21/25, said he/she recalled seeing two cards of the resident's oxycodone, but could not recall if there were three cards;-RN C, who last worked 12/20/25, said there were three cards of the resident's oxycodone at that time;-LPN C, who worked 12/19/25, 12/20/25 and 12/21/25, said he/she could not recall how many cards were present at that time, but recalled the narcotic count was correct at shift change; -When the DON reviewed the narcotic count book, none of the nurses interviewed that signed the Controlled Drug Count sheet that indicated the nurses had completed the medication count between shift for any of the dates mentioned in their interviews;-When the DON reviewed the narcotic count book, none of the nurses interviewed signed the Controlled Drug Count sheet that indicated the nurses had completed the medication count between shift for any of the dates mentioned in their interviews;-In reviewing the Daily Controlled Substances Audit form, where staff verify the card count is correct, the nurses were signing on the form, but not actually completing the required count;-When medication cards were destroyed, the nurses documented put +1 or -2 but were not initialing who added or subtracted a card or what card was added or subtracted. -Review of the facility's emergency medication kit medication removal documentation book on 1/9/26 showed on 10/3/25 at 10:03 A.M., RN A signed out three 5mg tablets of Resident #1's oxycodone.Review of Resident #1's October 2025 Medication Administration Record (MAR) on 1/9/26 showed:-RN A administered one 5mg tab of oxycodone to Resident #1 on 10/3/25 at 10:30 A.M. -There is no documentation in the resident's electronic medical record of the disposition of the other two tablets of Oxycodone that were removed from the emergency medication kit. During an interview on 1/13/26 at 2:15 P.M., LPN A said:-He/She worked on 12/19/25 during the day shift;-On that day, there were three cards of oxycodone for the resident in the narcotic box with one card being used and two cards that were sent as back up from the pharmacy; -When he/she returned to work on 12/22/25, LPN A completed the narcotic count with the off going nurse, LPN C;-At that time, LPN A noticed there were only two cards of oxycodone for the resident;-LPN A and LPN C looked at the narcotic count sheet and saw the page for the missing card of oxycodone was folded over, which staff do when a medication was to be destroyed or returned to pharmacy;-There was nothing documented on the sheet;-LPN A notified the ADON of the missing card of oxycodone;-He/She said the nurses should always count the narcotic medication/controlled substances at change of shift and make sure the counts match the narcotic count book;-Normally, LPN A would remove multiple doses at one time from the emergency medication kit;-He/She had been trained by other nurses at the facility to do it this way. During an interview on 1/13/26 at 12:01 P.M., LPN B said:-On-going and off-going nurses should count the controlled substances/narcotic medication together and make sure all the counts match with the narcotic count sheet;-When taking medication from the emergency medication kit, the number of doses removed would depend on if it was a weekend and the pharmacy wouldn't deliver the medications until Monday, or any other reason the medication wouldn't be available for a while;-LPN B would remove multiple doses at one time, maybe eight or nine, then write on the emergency kit notebook how many tablets were taken out;-If all the medication was not used by the end of the shift, the staff would include these removed doses in the narcotic count; -LPN B did not know this was not an acceptable way to do this, because he/she was trained by other nurses at the facility to do it this way. During an interview on 1/14/26 at 1:10 P.M., the DON said:-Facility nurses should count controlled substances at shift change, the on-coming and off-going nurse together;-They should count each medication cart for each hall;-The card count book should match the count of medications;-Nurses should count each number of pills with each card, and it should match the narcotic count sheets;-The nurses should then sign the sheet at the front of the narcotic count book;-Staff should be counting medications each time the medication room keys change hands as well; -Staff should only remove one dose at a time from the emergency medication kit, as the medication is needed;-It should be documented in the carbon notebook for the emergency kit and faxed to the pharmacy. During an interview on 1/14/26 at 1:10 P.M., the Administrator said he/she expected staff to follow the facility's policy on counting controlled substances, including removing only one dose from the emergency medication kit at a time. Intake 2709249

Based on observation, interview, and record review, the facility failed to protect Resident#1's right to be free from abuse when he/she was choked around the neck by another resident (Resident #2) causing redness to Resident #1's neck and Resident #1 feared Resident #2. Facility census was 48.Review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, showed:-Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment resource allocation to support the following objectives: -Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and/or any other individual; -Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents, neglect of residents, theft/exploitation/misappropriation of resident property; -Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities. Review of the facility's Resident Rights policy, dated February 2021, showed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' rights to be free from abuse, neglect, misappropriation of property and exploitation. 1.Review of Resident # 1's electronic medical record showed:-The resident was admitted to the facility on [DATE];-Diagnoses included: Depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in life), anemia (the blood doesn't have enough health red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen through the body), dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (a mental health disorder characterized by severe, ongoing anxiety that interferes with daily activities), and chronic kidney disease (a longstanding disease of the kidneys, leading to kidney failure). Review of the resident's admission Minimum Data Set (MDS, a federally mandated assessment completed by staff), dated 7/20/2025, showed:-He/She had adequate hearing, clear speech, understands others and makes self understood;-He/She scored nine on the Brief Interview for Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly residents). This score indicated moderately impaired cognition.Review of the resident's comprehensive care plan, dated 8/18/25, showed: -Interventions related to physical aggression;-He/She had the potential to be physically aggressive to his/her spouse due to diagnoses of dementia, anxiety and depression;-He/She has received physical aggression from his/her spouse, who has been observed with his/her hands around Resident #1's neck;-Staff are to administer medications as ordered and monitor/document behaviors every shift;-Resident #1 was to only have supervised visits with his/her spouse for safety;-Rooming situation is to be re-evaluated as needed. Review of Resident #1's August 2025 progress notes showed the following:-8/3/2025 at 10:00 P.M.: Resident #1 was observed in his/her room laying on the bed. Resident #2 was observed standing over Resident #1 with his/her hands around Resident #1's neck. The residents were separated. After assessment, redness and tenderness were present around Resident #1's neck. He/she rated the pain of 3/10 and refused pain medication; -8/4/2025 at 1:34 P.M.: The administrator conducted an interview with Resident #1 regarding the incident involving Resident #2. Resident #1 stated he/she did not clearly recall the incident. When asked if he/she felt safe sharing a room, Resident #1 responded he/she did feel safe and wishes to share a room. Resident #1 denied any pain or discomfort and stated he/she felt safe at the facility. The administrator spoke with Resident #1's legal guardian, who expressed that if both residents felt safe, the guardian would prefer the residents continue to share a room, noting recent life transitions have already been difficult for them and further separation may lead to increased emotional distress. Resident #1 verbalized relief and happiness upon learning the resident would be allowed to return to the shared room; -8/15/2025 at 1:11PM: Resident #1 was interviewed following an incident involving Resident #2 on 8/15/2025. Resident #1 denied fear of Resident #2 and expressed the desire to continue residing in their shared room. Resident #1 was informed that, for safety, Resident #2 was relocated to a different room at this time. The resident was assessed and found to have no injuries. 2.Review of Resident #2's electronic medical record showed:-He/She was admitted to the facility on [DATE];-Diagnoses included: anemia, type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), chronic kidney disease, dementia, and anxiety disorder.Review of the resident's admission MDS, dated [DATE], showed:-He/She had adequate hearing, clear speech, understands others and make self understood;-He/She scored 10 on the BIMs. This score indicates moderately impaired cognition. Review of the resident's comprehensive care plan, dated 8/18/2025, showed: -Interventions related to impaired cognition related to dementia; -Staff were to administer medications as ordered and monitor for behaviors each shift;-Staff were to keep the resident's routine as consistent as possible;- Staff were two engage the resident in simple, structured activities that avoid overly demanding tasks. Review of Resident #2's August 2025 progress notes showed the following:-8/3/2025 at 10:00 P.M.: The nurse was called to the secure unit due to staff observing Resident #2 standing over Resident #1, with his/her hands around Resident #1's neck, shaking him/her. Staff redirected Resident #2. Resident #2 stated he/she was frustrated and could not stop what he/she did. Resident #2 could not explain why he/she was frustrated but did state he/she was sorry and would not do it again. Resident #2 stated he/she wanted the beverage Resident #1 had and it was taking too long. The physician was notified and gave orders for a medication change for Resident #2. Resident #2's legal guardian was notified and stated they support the residents continuing to share a room, provided both residents continue to feel safe. -8/4/2025 1:56 P.M.: The administrator completed an interview with Resident #2 regarding an incident that occurred with Resident #1. Resident #2 could not recall the incident. When prompted to describe what he/she could remember, Resident #2 stated that he/she believed he/she and Resident #1 had an argument, but could not recall the nature or cause of the argument. When informed that he/she was observed with his/her hands around Resident #1's neck, Resident #2 appeared visibly surprised and responded he/she didn't know why he/she would have done that. Resident #2 stated he/she feels safe and wants to continue to share a room with Resident #1; -8/15/2025 11:00 A.M.: At approximately 4:00 A.M., staff heard screaming from Resident #1 and #2's room. Upon entering, staff observed Resident #2 standing at the foot of Resident #1's bed. When asked what occurred, Resident #1 stated he/she had been asleep when Resident #2 attempted to choke Resident #1, removed Resident #1's call light to prevent him/her for calling for help, and tried to pull him/her off the bed by the legs. Resident #2 was immediately relocated to another room. While being removed from the room, Resident #2 told Resident #1 that he/she is going to get it when Resident #2 gets home. The physician and guardian were notified of the incident. The guardian requested Resident #2 be transferred to inpatient psychiatric care for further evaluation and management; -8/15/2025 7:01 P.M.: Resident #2 returned from the local hospital with no new orders and a suggestion to follow up with his/her primary care provider. 3. During an interview on 8/18/2025 at 2:50 P.M., Licensed Practical Nurse (LPN) A said:-LPN A worked the night shift 8/14/25 into 8/15/25;-At approximately 4:00 A.M., the staff on the locked unit called LPN A to the unit. Staff stated that they heard a scream from Resident #1 and #2's room. When they entered the room, Resident #2 was observed standing at the foot of Resident #1's bed. LPN A assisted staff in separating the residents and relocated Resident #2 to a different room for safety. Resident #2 told LPN A this did not concern the staff and to go away;-LPN A then assessed Resident #1 and asked him/her what happened. Resident #1 told LPN A that Resident #2 first took the call light away so Resident #1 could not call for help. Then Resident #2 put his/her hands around Resident #1's neck and choked him/her. Resident #2 then attempted to pull Resident #1 from the bed by pulling on his/her left foot. After the assessment, it was noted Resident #1 had redness around the neck, but no other noted injuries. During the assessment, Resident #1 told LPN A he/she feared Resident #2; -He/She notified the Administrator and Director of Nursing (DON). The DON notified the residents' legal guardian and physician. Law enforcement and Emergency Medical Services (EMS) were called and arrived at the facility. EMS assessed Resident #1 and found no injuries, and the resident was not taken to the hospital. Law enforcement took statements from all staff involved. Resident #2 was placed on one-to-one supervision when out of his/her room;-LPN A had received no instruction or guidance as to Resident #2's behaviors or need for monitoring when starting his/her shift on 8/14/2025. Review of the statement from Certified Nurses Assistant (CNA) A provided to law enforcement on 8/15/25 showed:-CNA A heard screaming at 3:45 A.M. coming from Resident #1 and #2's room. CNA A ran into the room and found Resident #2 at the end of Resident #1's bed. When asked what happened, Resident #1 stated Resident #2 grabbed his/her left ankle and told Resident #1 to shut up. Resident #1 stated that Resident #2 choked him/her, and CNA A observed a red mark on Resident #1's neck. Resident #1 also stated that Resident #2 took the call light away from him/her;-CNA A assisted Resident #2 to a different room and then completed a statement. During an interview on 8/18/25 at 1:59 P.M., LPN B said:-He/She was not working at the time of either incident involving Resident #2. LPN B received instructions from the nurse on the previous shift that Resident #2 is on one-to-one supervision when out of his/her room; -Earlier the morning of 8/18/25, LPN B was walking down the hall of the locked unit. He/she looked into Resident #2's room and did not see him/her in the room. LPN B then looked into Resident #1's room. Resident #1 was sitting in the room, eating breakfast. Resident #2 was standing in the room near the door to the bathroom. LPN B escorted Resident #2 from the room to the dining room. The staff members on the locked unit were assisting other residents in cleaning up after breakfast;-LPN B assessed Resident #1. Resident #1 stated he/she was doing well and continued eating his/her breakfast. During an interview on 8/18/25 at 3:11 P.M., the DON said:-Resident #2 was on one-to-one supervision when out of his/her room. This means the staff monitor for when the resident leaves his/her room. When out of the room, staff should be within reach of the resident;-The DON expected staff to notify the charge nurse if they need to step away to assist a resident who required two staff assistance so the charge nurse can come monitor the resident who is on one-to-one supervision. During an interview on 8/18/25 at 3:11 P.M., the Administrator said:-When a resident was on one-to-one supervision, staff was to be within arm's reach of the resident, or what is safest for the staff and resident; -The Administrator expected staff to notify the charge nurse if they need to step away to assist a resident who requires two staff assistance so the charge nurse can come monitor the resident who is on one-to-one supervision. Observation of Resident #1 on 8/18/25 at 1:51 P.M., Resident #1 was noted to be laying in his/her bed, awake. During an interview, Resident #1 said he/she is doing well and feels safe at the facility. He/she has no concerns but would like to share a room with Resident #2 again. Observation of Resident #2 on 8/18/25 at 1:57 P.M., Resident #2 was noted to sitting in the dining room, watching other residents during an activity. During an interview, Resident #2 said he/she is doing well and feels safe at the facility. He/she has no concerns. Intake 2590597

Based on interview and record review, the facility failed protect one sampled resident's (Resident #1) right to be free from physical abuse when Resident #2 grabbed Resident #1 by his/her arms and pushed him/her backwards causing Resident #1 to fall and sustain a skin tear approximately 3 inches in length to the underside of the resident's left arm. The facility census was 44.On 7/30/25, the Administrator was notified of the past noncompliance which began on 7/23/2025. The facility administration immediately conducted an investigation and corrective actions were implemented. The noncompliance was corrected on 7/28/25. Review of the facility's Abuse Policy, revised April 2021.,showed: -The residents have the right to be free from abuse. -The facility's abuse, policy consists of a facility-wide commitment and resource allocation to support protecting residents from abuse, from other residents, staff, or any individual. -The facility will develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. - Ensure adequate staffing and oversight. -Provide staff orientation and training programs to include abuse prevention and the management of verbally or physically aggressive resident behaviors.1.Review of Resident #1's admission face sheet., showed: The resident resided on secured memory care unit. Diagnoses included: Alzheimer's dementia, history of spinal fractures, and weakness.Review of Resident #2's admission face Sheet showed the resident was a new admission as of 7/3/25 with a diagnoses of severe dementia, and delusional disorders. The resident was under guardianship, and resided on the secured memory unit. Observation of the resident on 7/30/25 at 2:25 P.M., showed resident lying in bed, awake with significant confusion, not alert to surroundings or self. Left underside of forearm showed a healing skin tear approximately 3 inches in length. Resident was unable to explain how it happened.Review of Resident #1's Nursing Progress notes., showed that on 7/23/25 around 2:14 P.M. resident was found sitting on the floor in the hallway with legs out in front of him/her. Resident #1 sustained a skin tear when resident #2 pushed resident backwards out of his/her room. Resident #2 admitted to removing the resident out of his/her room. Resident #1's skin tear was treated with triple antibiotic ointment and a Band-Aid, family and physician had been notified.Review of the facility's abuse investigation report dated 7/28/25, showed the abuse of the resident occurred on 7/23/25, the report does not have a time indicated as to when it happened. The resident was identified as independent with ambulation and had been ambulating on 7/23/25 on the hallway of the secured unit. The resident entered into Resident #2's room, and Resident #2 placed his/her hands on Resident #1 and guided the resident backwards out of the room's doorway causing Resident #1 to fall and sustained a skin tear to left arm. Resident #2 reported that Resident #1 should not have been in his/her room. Resident #1 was treated for the skin tear and Resident #2 was placed on 1:1 monitoring (one staff person is assigned to monitor the resident continually). No witnesses were indicated on the facility investigation report. A Velcro stop sign was placed on Resident #2's door to detour Resident #1 from entering Resident #2's room again.During an interview on 7/30/25 at 11:30 A.M., CNA-A said on 7/23/25 he/she heard resident #2 yelling down the hall, and saw resident #1 on the floor. Resident #1 had a new skin tear to the left arm. CNA-A called for the nurse. Resident #2 was cussing and yelling and punching his fists and shaking them at people. CNA A said resident #2 had a short fuse and can become agitated and aggressive easily. Resident #2 was placed on 1:1 monitoring on 7/23/25 after resident #1 was picked up off the floor. CNA A reported that Resident #2 had to be sent out to the hospital earlier in the month for hitting, kicking at staff, and threatening others on the unit. CNA A stated he/she had not received any training on how to de-escalate resident #2's behaviors.Observation on 7/30/25 at 1:11 P.M., showed the resident up and independent with ambulation on the secured memory unit walking closely next to others on the hall. He/she was alert, with extreme confusion, and an unsteady gait. Velcro stop sign hanging off the door frame and not up to detour confused resident's on the memory care unit from wondering into the resident #2's room.Review of resident's nursing progress note records showed that on 7/3/25 day of admission resident was verbally abusive towards others, using foul language and exit seeking. Then, 2 days later on 7/5/25 at 10:32 A.M., the resident was verbally abusive, screaming at staff, slamming doors continually, and frightening other residents. Local law enforcement was called and arrived at the facility around 10:40 A.M., resident begun hitting, kicking, and punching at law enforcement. The resident was removed from the facility in hand cuffs and taken to local ER (Emergency Room) for a mental health evaluation. On 7/6/25 the resident was returned to the secured unit at the facility with new order for prescription Seroquel (an anti-psychotic used to treat behaviors). On 7/13/25 nursing notes showed that the resident was agitated, belligerent, verbally abusive and refusing medications. On 7/23/25 at 2:19 P.M. Nursing notes showed charge nurse was informed that resident had pushed another resident out of his/her room, causing resident #1 to fall on the ground. Resident #2 told nursing staff he/she had pushed resident #1 and that resident #1 fell. Resident #2 was escorted to his/her room and 1:1 monitoring initiated. Police contacted and came to the facility. Guardian and physician notified. DON (Director of Nursing) and the Administrator notified. Review of resident #2's care plan, dated 7/21/25 showed the resident required the memory care unit for dementia care and elopement risks. On 7/24/25 the day after Resident #1 was pushed down, the care plan was updated to show that resident could become physically aggressive towards others and interventions included placing resident on 1:1 monitoring and to guide the resident away from the source of the distress and if resident's response is aggressive, staff are to walk away and re-approach later. The care plan did not address interventions for the staff to take with the resident when the resident physically assaults others. The care plan was not updated with interventions when witnessed behaviors initially began on 7/5/25.Review of resident's physician ordered behavior monitoring was initiated on 7/21/25 and showed the resident's behavior monitoring record was not completed accurately on 7/23/25 when the resident pushed another resident down. The staff documented that the resident had no behaviors that day. On 7/24/25 the behavior record indicated no behavior, however the nurses notes indicated the resident did have behaviors that day. On 7/27/25 the behavior monitoring documentation was omitted.During an interview 7/30/25 at 10:58 A.M., CMT A said Resident #2 was unpredictable and had witnessed violent behaviors with the resident starting on 7/5/25 with hitting, punching and throwing things over anything that might upset him/her. CMT A said he/she had no training on how to manage behaviors like that while working on the secured unit. CMT A worries about the safety of other residents because of this resident's history since admission to the facility. On 7/23/25 CMT A observed resident #1 requiring assistance off the floor outside of resident #2's room, and the nurse was taking care of resident #1's skin tear of the arm. Observed resident #2 saying he/she wanted resident #1 out of his/her room. The resident was placed on 1 on 1 monitoring after the event.During an interview on 7/30/25 at 11:40 A.M., CNA B said Resident #2 becomes easily agitated at other residents. CNA B heard resident #2 yelling went to investigate and saw Resident #1 sitting on the floor outside of Resident#2's room in the hallway. Resident #1 had a skin tear and nurse cared for the skin tear. Resident #2 was placed on 1 on 1 monitoring with a stop sign hooked to the door to hopefully stop other residents from going into Resident #2's room.During an interview on 7/30/25 at 1:15 P.M. the Administrator and the Regional Director of Operations said the facility failed to assess, identify, and care plan for behavioral risk, resulting in physical harm to another resident. Immediate actions were being implemented to include staff training and monitoring ongoing for 90 days and through Quality Assurance (QAPI) oversight.Intake 2570182

Based on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner in the memory care unit, failed to maintain the dining room in a clean and sanitary manner, and failed to ensure the kitchen serving area was is good repair. This had the potential to affect all residents residing on the memory care unit. The facility census was 42. The facility did not provide the requested policy on cleaning and repair of the kitchen. 1. Observation of the dining room and food serving area of the memory care unit on 06/02/25 at 10:38 A.M. showed: -The inside of the microwave was covered with food debris; -The inside of the refrigerator has a brown sticky substance in the bottom of the refrigerator with red droplet marks running down the inside walls of the refrigerator; -A plate of covered food with no name and no date was in the refrigerator; -Five packets of mustard were setting the side of the refrigerator; -The door of the refrigerator and the inside of the shelves have particles of food debris and spatter marks on the inside; -The freezer had food debris and a brown liquid in the bottom of it; -The inside door to the freezer had dirt and debris in it; -The base boards in the dining room along the sink area dirty with food particles and splatters; -The walls in the dining room have scuff marks and scratches; -There are droplet marks running down the wall of the dining by the sink; -The legs and pedestals of dining room tables covered in dust and debris; -The legs of the dining room chairs are covered in dust and debris; -The light fixture in the kitchen closest to the TV is missing a cover and one of the bulbs is burnt out; -Along the wall in the dining room, the wall along the hall, there is white areas where the walls have been gouged and the paint is missing along both sides of the wall; -There are multiple flies crawling on the tables and crawling on the residents; -The table legs the chair legs and parts of the chairs in the dining room are covered with dirt debris and food spatters. The floor has debris and particles on it. 2. Observation of the kitchen and food storage and interviews with NA D and NA F on 06/03/25 at 11:32 A.M., showed: -The inside of the microwave was covered with food debris; -The inside of the refrigerator was covered with a brown sticky substance in the bottom of the refrigerator with red droplet marks running down the inside walls of the refrigerator; -A plate of covered food with no name and no date sat in the refrigerator; -The door of the refrigerator and the inside shelves had particles of food debris and spatter marks on the inside; -A pitcher dated 06/03/25 with a yellow liquid in it and a pitcher of a red liquid dated 06/03/25 are still setting in the refrigerator; unknown what the liquid was; -The freezer had food debris and a brown liquid in the bottom of it; -The inside door to the freezer had dirt and debris in it; -The base boards in the dining room along the sink area dirty with food particles and splatters; -The walls in the dining room have scuff marks and scratches; -There are droplet marks of a liquid substance running down the wall of the dining room by the sink; -The legs and pedestals of dining room tables was covered in dust and debris; -The legs of the dining room chairs had covered in dust and debris; -The dining room floor was covered in dirt and debris; -The light fixture in the kitchen closest to the TV was missing a cover and one of the bulbs was burnt out; -Along the wall in the dining room, the wall along the hall there was white areas where the walls had been gouged and the paint was missing along both sides of the wall; -The table legs the chair legs and parts of the chairs in the dining room had covered dirt debris and food spatters; -Nurse Aide (NA) D said he/she does not clean the refrigerator, freezer, microwave or the dining room tables and floor, housekeeping did that; -NA F said that housekeeping does all the clearing of the kitchen area in the memory care unit and maintenance does any repairs. -NA D and NA F said the refrigerator, freezer, microwave should be clean and sanitary; -NA D and NA F said the dining room floors should be clean and in good repair. 3. During an interview on 06/04/25 at 09:18 A.M., Housekeeper A said: -He/She mops and sweeps the halls and the resident rooms and does the deep cleaning; -The Certified Nurses Aides (CNA) take care of the cleaning of the refrigerator and the microwave; -The maintenance department takes care of repairs and replacing of light bulbs. During an interview on 06/04/25 at 09:46 A.M., the Housekeeping Supervisor said: -She deep cleans the dining room once a week, that includes wiping off the chairs, mopping, sweeping, and cleaning of window sills; -She is not responsible for cleaning the microwave or the refrigerator and freezer; -The CNAs are responsible for cleaning the kitchen area including the microwave, refrigerator and freezer; - Maintenance is responsible for repairs or missing light bulbs or covers; - She expects the dining room to be clean and good repair and home like. During an interview on 06/04/25 at 10:01 A.M., the dietary manager (DM) said: - Dietary brings the food down from the main the kitchen to the memory care unit and stocks the refrigerator; -The dietary department does clean the refrigerator and the microwave or any of the cleaning on the memory care unit; -The Cans are responsible for keeping the area clean and maintenance is responsible for the repairs. During an interview on 06/04/25 at 11:15 A.M., the MDS Coordinator (MDS) who is also the nurse on the memory care unit said: -She did not know who was responsible for cleaning the microwave, refrigerator, freezer and the dining area; -Maintenance was responsible for repairs; -She expects the memory care unit, including the dining room, to be clean, sanitary and home like. During an interview on 06/04/25 at 01:18 P.M., the Maintenance Supervisor said: - He has been here about a year and is responsible for the repairs of the facility; - He is responsible for repairing the walls, base boards, and any repairs in the facility; - He is made aware of repairs that are needed by a book a the nurses desk. The staff write down the repair that is needed and he checks the book everyday; - If it is not reported he usually sees it and will fix it; - He did not get a report of the baseboards being nicked or the walls in the dining needing repairs; - He is responsible for changing any light bulbs that are out; -The building should be in good repair. During an interview on 06/05/25 at 05:11 P.M., the Administrator said: -The aides are responsible for wiping down the tables and sanitizing and spot cleanups; -He expects housekeeping to do the major cleaning on the memory care unit; -He expects housekeeping to ensure the microwave, the refrigerator and freezer are clean and sanitary; -He expects Maintenance to ensure repairs are made to the walls and that light bulbs are being replaced when needed; -He expects the resident to have a safe, clean and sanitary environment that is in good repair.

Based on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 42. Review of the facility policy, Surety Bond, dated 3/2021, showed: -Our facility had a current surety bond to assure the security of all residents' personal funds deposited with the facility; -All funds (including refundable deposits) entrusted to the facility for a resident are covered by the facility on behalf of its residents; -The purpose of a surety bond is to guarantee that the facility will pay for the resident for losses occurring from any failure by the facility to hold, account for, safeguard, and manage the residents' funds. Review of the facility maintained Resident Trust Bank Statements for the period 05/2024 through 04/2025, showed an average monthly balance of $56,867.19. Review of the facility-maintained Accounts Receivable (A/R) Aging Report, dated May, 2025 showed the facility held a balance of resident funds in the amount of $21,643.84. Review on 06/05/25 of the Department of Health and Senior Services approved bond list showed the facility had a $105,000 approved bond, making the bond insufficient by $13,500.00. During an interview on 06/05/25 at 12:24 P.M., the Administrator said he/she was not aware of the bond amount being insufficient.

Based on record review and interview, the facility failed to ensure resident funds were placed in an account separate from the facility operating account when the facility did not provide residents with refunds from their personal funds from the facilities operating account in a timely manner for six residents (Resident #38, #148, #149, #150, #151 and #152). The facility census was 42. Review of the facility policy, Conveyance of Resident Funds, dated 3/2001, showed: -Any funds on deposit with the facility are refunded to the resident, the resident representative, or the resident's estate, upon discharge, eviction or death; -The resident's personal funds and final accounting of funds are returned to the resident, the resident representative, or to the resident's estate, within 30 days from the date of the resident's discharge, death, or eviction from the facility. Review of the Resident's funds account on 6/9/25 showed the facility held funds owed to the residents, as follows: - $917.00 owed to Resident #38 - $20,631.77 owed to Resident #148 - $23.25 owed to Resident #149 - $5.97 owed to Resident #152 - $54.78 owed to Resident #150 - $11.07 owed to Resident #151 During an interview on 06/04/25 at 2:13 P.M., the Business Office Manager said the facility was going through a transition of a new Administrator, Social Service staff changes and the credits owed to the residents fell through the cracks. During an interview on 06/04/25 at 2:47 P.M., the Administrator said the credits owed to the residents were identified on either Monday or Tuesday of the same week the surveyors were at the facility.

2. Review of resident's Outside the Hospital Do Not Resuscitate Order (OHDNR) signed [DATE] showed the resident code status as DNR. Review of Resident #33's admission Assessment, dated [DATE], showed: -Resident had moderate cognitive impairment; -Diagnoses included stroke, diabetes, ashtma, depression, and anxiety. Review of physician's orders, dated [DATE], showed an active order for DNR (Do Not Resuscitate), as of [DATE]. Review of the resident's care plan, dated, [DATE], showed: -Resident was a full code -Resident's wishes would be followed through the next review date. -Check POS for current code status. During an interview on [DATE] at 11:29 A.M., the Administrator said all locations where the code status is listed should match. Based on observation, interview, and record review, the facility failed to ensure the Do Not Resuscitate Order's (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) for residents (Resident #8 and Resident #33) were correctly listed in all locations of the residents medical record (care plan, admission record, door frame identifier, and physician order sheet (POS)). This affected two of 13 sampled residents. The facility census was 42. Review of the facility's policy titled, Advance Directives, dated [DATE], showed: - The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment; - Advanced directives will be honored in accordance with the state law and facility policy; - The resident is provided with written information concerning the right to refuse or accept treatment and to formulate an advance directive if he or she chooses to do so; - The interdisciplinary team conducts ongoing review of the residents decision-making capacity and invokes the resident representative or health care agent if the resident is determined not to have decision-making capacity. Changes are documented in the care plan and medical record; - The Director of Nursing Services or designee notifies the attending physician of advance directives (or changes in Advance Directives) so that appropriate orders can be documented in the residents medical record and plan of care; - The residents wishes are communicated to the residents direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record. - The policy did not address the heart stickers or the color of the heart stickers; 1. Review of Resident #8's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: - Resident had severe cognitive impairment; - Required substantial assistance for Activities of Daily Living (ADL's); - Diagnoses included: heart failure, high blood pressure, arthritis. Review of Comprehensive Care Plan, dated [DATE], showed: - Resident had an ADL self-care performance deficit as evidenced by activity intolerance, impaired balance, limited mobility, and pain; - Do not resuscitate status with the instruction for staff to check physician order sheet (POS) for current code status; - Resident was receiving hospice services; - Staff will monitor, record, and report changes in condition to the physician. Review of the reidents POS, dated [DATE], showed no current code status order, ordered by physician. Review of the resident's admission face sheet record, showed there was no current code status listed. Observation and interview on [DATE] at 09:20 A.M., showed there was not a code identifier on the Resident's door frame. Nursing Assistant (NA) F said the heart stickers let staff know what residents are DNR. Observation on [DATE] at 10:30 A.M., showed there was not a code identifier on the Resident's door frame. Observation on [DATE] at 09:00 A.M., showed there was not a code identifier on the Resident's door frame. During an interview on [DATE] at 02:40 P.M., Certified Nursing Assistant (CNA) B said: - He/she would determine if a resident is DNR status by the heart sticker on the doorframe; - A green heart sticker means go ahead and perform cardiopulmonary resuscitation (CPR) and a purple heart sticker is for DNR status; - A book in the nurse's office lists residents who have a DNR order; - Aides do not have access to view care plans and are told by nurses what cares need provided. During an interview on [DATE] at 02:50 P.M., NA F said: - He/she knows if a resident is DNR status by the color of the heart sticker on the residents door frame, purple; - Staff can also look in the DNR book in the nurse's office, in the resident's care plan and in point click care (PCC). During an interview on [DATE] at 03:12 P.M., NA G said: - He/she was unsure about DNR status meaning or how to find that information; - He/she would go to the charge nurse with questions concerning a residents code status. Observation on [DATE] at 08:30 A.M., showed no code status identifier on the Resident's door frame. During an interview on [DATE] at 09:30 A.M., the Director of Nursing said: - The reisdnts DNR status is listed in a book in the nurse's closet; - A green heart sticker on the resident doorframe means full code, go and do CPR, and purple heart sticker is DNR status; - If there is no heart sticker on the door frame then staff should code them; - If a resident is on hospice services then it would depend on the progression of disease and is not necessarily a DNR status; - DNR residents should come in to the facility with a purple paper, Outside the Hospital Do Not Resuscitate (OHDNR) order; - He/She was unsure about needing provider orders for full code or DNR, but then said yes the DNR order should be in the POS. During an interview on [DATE] at 10:15 A.M., Licensed Practical Nurse (LPN) A said: - Residents DNR status is listed in PCC, a book with DNR's in the nurse's office, and is listed outside the resident room doors; - A green heart sticker means full code, DNR is a purple heart sticker, and if no heart sticker then staff should check the resident's PCC; - He/She will always check the resident's chart if unsure about code status;

Based on observation, interview, and record review, the facility failed to acknowledge, assess, provide supportive services, or develop a care plan that showed interventions for facility staff to utilize to protect the resident and prevent trauma from recurring for one resident who was identified as having a past tramatic event (Resident #19), out of 12 sampled residents. The facility census was 42. Review of facility policy, Trauma Informed Care, dated 2001, showed: -Purpose: To guide staff in providing care that is trauma-informed in accordance with professional standards of practice; -Trauma results from an event, series of events, or set of circumstances that is experienced by the individual as physically or emotionally harmful or life threatening that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being; -Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporate knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. -All staff were provided in-service training about trauma and trauma informed care in the context of a healthcare setting; -Traumatic events which may affect residents during their lifetime include: physical, sexual, or emotional abuse; neglect; interpersonal or community violence; serious injury or illness; bullying; forced displacement; racism; war; and generational or historical trauma; -For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization; -Organizational strategies included: a) Evaluated the need for trauma-informed practices as part of the facility assessment; b) Developed an organizational culture that supports all Trauma-Informed and Resilience-Oriented domains, which included: Universal and early screening and assessment; resident-centered care and services; educated and responsive staff; evidence-based and emerging best practices for trauma informed care; safe and secure environments; ongoing performance evaluation and improvement; community outreach and partnerships; -Selected screening and assessment tools in collaboration with the QAPI committee; -Included trauma-informed care as part of the QAPI process, so that needs and problem areas were identified and addressed; -Developed relationships with community support organizations for services, referrals, training, and information; -Established an environment of physical and environmental safety for residents and staff; -Performed universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events; -Assessments involved an in-depth process of evaluating the presences of symptoms, their relationship to trauma, as well as the identification of triggers; -Developed individualized care plans that addressed past trauma in collaboration with the resident and family, as appropriate; -Identified and decreased exposure to triggers that may re-traumatize the resident; -Recognized the relationship between past trauma and current health concerns (e.g. substance abuse, eating disorders, anxiety, and depression); -Ensured that residents had a sense pf psychological, social, cultural, moral, and physical safety; -Practiced listening without judgement. 1. Review of the resident #19's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/09/25, showed: -Cognitive skills intact; -Resident experienced little interest or pleasure in doing things nearly everyday; -Resident felt down, depressed, or hopeless nearly everyday; -Resident felt tired or had little energy nearly everyday; -Diagnoses included, PTSD (post tramatic stress disorder a mental health condition that can develop after experiencing or witnessing a traumatic event).), depression Review of the resident's admission trauma informed care screening dated, 01/22/25 showed: -The resident has experienced a loved one die through homicide or suicide; -The resident tries not to think of the event and goes out of his/her way to avoid things that remind the resident of the event; -The resident feels constantly on guard and easily startled; -The resident feels guilty and/or cannot stop blaming himself/herself or others for the event. Review of the resident's care plan, dated 5/20/2025, showed: -The resident exhibits behaviors at times, including impulsivity, resistive to care, putting self on the floor; -The resident exhibits poor impulse control, and seeks attention; -The resident's care plan did not address past trauma or PTSD; -The care plan did not address staff interventions to assist with preventing behaviors associated by a tramatic response; -The care plan did not address a past history of suicidal thoughts or behaviors or self harm; Review of the resident's initial psychiatric evaluation dated 05/30/25 showed: -The resident had a history of suicidal behavior; -The resident had a history of self harm; -The staff are to monitor the resident for any changes in mood or behavior; -Staff are to provide personal 1:1 time with the resident. During an interview on 06/02/2025 at 11:19 A.M., the resident said: -He/She had been asking staff for some mental help or grief counseling since he/she arrived at the facility; -He/She lost her daughter to suicide; -He/She was so desperate recently that he/she called the suicide hotline to talk to someone, not because he/she was suicidal. Observation and interview on 06/03/25 at 09:57 A.M. showed: -The resident asked the activity director for cigarettes; -The resident said he/she was having a nervous breakdown; -The activity director told the resident he/she could not have cigarettes because he/she is not a smoker; -The resident yelled at the activity director to let him/her smoke; -The staff did not do 1:1 time with the resident; -The activity director said he/she had no special instructions for the resident's care; -The activity director said he/she was not aware the resident had a history of trauma. Observation on 06/03/25 at 10:15 A.M., showed: -The resident at the physical therapy doors; -The doors were closed with staff inside; -The resident was yelling, you said you would see me today; -The resident hit on the doors with his/her fist; -The therapist came to the door and told the resident he/she it was not his/her turn yet; -The resident yelled at the therapist; -The door to the business office and the door to the administrator's office was open; -No staff came to assist the resident. During an interview on 6/03/2025, at 11:22 A.M. the resident's family said: -The resident's husband passed away a year ago; -The resident's daughter passed away from suicide nine years ago; -The resident's granddaughter passed away five years ago; -The resident endured many years of domestic violence at the hands of his/her spouse; -He/She talked to staff about the resident's need for therapy; -The facility did not ask about the resident's history of trauma when admitted ; -The resident would benefit from therapy or counseling; -He/She expects staff to treat his/her family member with dignity and respect. During an interview on 06/05/25 at 04:15 P.M., Nurse Aide (NA) C said: -He/She has worked at the facility for two months; -The resident can be difficult to deal with at times; -The resident just needs some one to talk to; -The resident will sometimes hit the wall with his/her fists and yell; -He/She did not know if the resident had a diagnosis of PTSD or any past trauma; -He/She would expect PTSD to be in the resident's care plan; -He/She would expect the resident's triggers or any interventions to be on the care plan; -The staff should know the resident's triggers as not to retraumatize the resident; -He/She had no special training or instructions on now to take care of the resident. During an interview on 6/05/25 at 04:25 P.M., NA B said: -He/She has worked at the facility one month; -The resident is loud and seeks attention; -The resident is redirectable if you take time to talk to him/her; -He/She did not know if the resident had any past trauma or PTSD; -He/She did not know what the resident's triggers were or are how to mitigate them; -It is important to not trigger resident's with PTSD because it brings up past memories of trauma. During an interview on 6/05/25 at 04:45 P.M., Licensed Practical Nurse (LPN) A said: -He/She has worked at the facility for seven months; -The resident yells and gets mad at random things; -Staff redirect the resident the best way possible -There are no residents that he/she was aware that had a diagnosis of PTSD; -He/She would expect the PTSD to be included in the resident's care plan along with triggers and interventions to avoid triggers; -It is important for all staff that provide care to the resident, know the triggers and to avoid triggers that can escalate the resident's behaviors; -He/She does not know who is responsible to complete the trauma assessments at the facility. During an interview on 6/05/25 at 04:55 P.M., the Social Services Designee (SSD) said: -He/She started as SSD in November 2024; -He/She is responsible for doing the trauma assessments; -He/She said the resident did not have a history of trauma when he/she came; -The facility first learned of the resident's trauma in March of this year when the resident's son called after a hospital stay; -The resident's trauma should have been documented and care planned as soon as the facility was made aware back in March; -The resident's trauma assessment indicated there was trauma and he/she should have ensured that this was care planned; -He/She would expect the PTSD to be included in the resident's care plan along with triggers and interventions to avoid triggers; -It is important for all staff that provides care to the resident to know the triggers and to avoid triggers that can escalate the resident's behaviors. During an interview on 06/05/25 at 05:18 P.M., the Director of Nursing (DON) said: -He/She was not aware that the resident had past trauma and a diagnosis of PTSD; -Trauma history should be documented on admission using the trauma screening; -A plan should be in place for the resident to address the resident's triggers and a plan to mitigate them; -The staff should know the resident's triggers so they do not retraumatize the resident; -The family should be involved in obtaining the history of past trauma upon admission if possible; -If trauma history is discovered later or a new traumatic event occurs this information should be added to the plan of care as soon as possible; -The facility should offer counseling or psychiatric services if needed; -She was not aware of any counseling or therapy the resident was attending. During an interview on 06/05/2025 at 05:30 P.M., the Administrator said: -The resident had a history of using county mental health services; -He had been trying to get a psychiatrist to see the resident; -He is trying to get the resident into group therapy; -He brought in psychiatric nurse practitioner in April who has met with the resident; -The resident did not want to see the nurse practitioner; -The resident has not been on any structured 1:1 therapy as instructed by the nurse practitioner on 05/30/25; - A few months ago the resident called the fire department and told them he/she was going to kill himself/herself; - The resident calls the staff names; - He would expect the facility to address the resident's PTSD and history of trauma as soon as they were aware; - He would expect the resident to have a plan to deal with his/her PTSD because the admitting trauma informed care screening showed he/she had past trauma; -He would expect the resident's care plan to address the trauma and provide interventions within seven days; -He would expect the facility to address the resident's PTSD and history of trauma; -He would expect staff to know the triggers and know how to mitigate them.

Refer to Event ID NI0V12. Based on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for six sampled newly hired employees. The facility census was 46.

Refer to Event ID NI0V12. Based on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of hire. The facility census was 46.

Refer to Event ID NI0V12. Based on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl patch ( A controlled opiate, A schedule II naroctic pain patch ) on two different dates. The Administrator and DON failed to conduct an investigation when Licensed Practical Nurse (LPN) B called to report the missing patch on 11/11/24 and when LPN A reported the patch missing to the DON on 11/13/24. This affected one of one sampled residents. The facility census was 46.

Based on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of hire. The facility census was 46. The facility did not provide an NA certification policy. Review of the NA employee list showed: -NA A employed since 6/24/24; -NA B employed since 4/26/24; -NA C employed since 7/15/24; -NA D employed since 7/16/24; -NA E employed since 6/7/24; -NA F employed since 2/12/24. During an interview on 12/4/24 at 11:29 A.M., NA A said: -He/She was not enrolled in any Certified Nurse Aide class; -He/She had worked in facility since July 2024, and worked in facility last year from July 2023-November 2023. During an interview on 12/4/24 at 12:48 P.M., NA B said: -He/She was not enrolled in CNA class after working for the facility for six months; -He/She was told several times that he/she would be put in the next CNA class but has never been enrolled in any class. During an interview on 12/4/24 at 1:40 P.M., NA F said: -He/She had worked in the facility for 10 months and had not been enrolled in CNA class; During an interview on 12/4/24 at 2:40 P.M., Licensed Practical Nurse (LPN) A said: -He/She was concerned that facility had a limited number of CNAs, and that he/she was often left with only NA's who could work. During an interview on 12/4/24 at 3:04 P.M., Administrator said: -He/She expected the Director of Nursing (DON) to ensure competency of facility nurse aides; -Certified Nurse Assistance training was being offered at their sister facility; -NA A, NA B, NA C, NA D, NA E, NA F had not been enrolled in class, but would be scheduled to start CNA class in January 2025. During an interview on 12/4/24 at 3:30 P.M., DON said: -He/She was responsible for nurse aide competencies; -Facility had an operational change and had not gotten nurse aides enrolled in class; -He/She had nurse aides scheduled to be enrolled in next class being offered at sister facility in January. MO245460

Based on interview and record review, the facility failed to ensure six nurse aides (NA) completed a competency evaluation program approved by the state within four months of hire. The facility census was 46. The facility did not provide an NA certification policy. Review of the NA employee list showed: -NA A employed since 6/24/24; -NA B employed since 4/26/24; -NA C employed since 7/15/24; -NA D employed since 7/16/24; -NA E employed since 6/7/24; -NA F employed since 2/12/24. During an interview on 12/4/24 at 11:29 A.M., NA A said: -He/She was not enrolled in any Certified Nurse Aide class; -He/She had worked in facility since July 2024, and worked in facility last year from July 2023-November 2023. During an interview on 12/4/24 at 12:48 P.M., NA B said: -He/She was not enrolled in CNA class after working for the facility for six months; -He/She was told several times that he/she would be put in the next CNA class but has never been enrolled in any class. During an interview on 12/4/24 at 1:40 P.M., NA F said: -He/She had worked in the facility for 10 months and had not been enrolled in CNA class; During an interview on 12/4/24 at 2:40 P.M., Licensed Practical Nurse (LPN) A said: -He/She was concerned that facility had a limited number of CNAs, and that he/she was often left with only NA's who could work. During an interview on 12/4/24 at 3:04 P.M., Administrator said: -He/She expected the Director of Nursing (DON) to ensure competency of facility nurse aides; -Certified Nurse Assistance training was being offered at their sister facility; -NA A, NA B, NA C, NA D, NA E, NA F had not been enrolled in class, but would be scheduled to start CNA class in January 2025. During an interview on 12/4/24 at 3:30 P.M., DON said: -He/She was responsible for nurse aide competencies; -Facility had an operational change and had not gotten nurse aides enrolled in class; -He/She had nurse aides scheduled to be enrolled in next class being offered at sister facility in January. MO245460

Based on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for six sampled newly hired employees. The facility census was 46. Review of facility policy, employee screening for tuberculosis, revised March 2021, showed: -All employees are screened for latent tuberculosis infection and active TB disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment. -Newly hired employee is screened for LTBI and active TB disease after an employment offer had been made but prior to employee's duty assignment. Observation on 12/4/24 at 1:00 P.M. showed Director of Nursing (DON) could not locate requested employee sample of TB tests for the following employees: -Dietary Aide A, date of hire 10/17/24; -Certified Nurse Aide (CNA) A, date of hire 10/16/24; -Nurse Aide (NA) G, date of hire 10/11/24; -NA H, date of hire 10/24/24; -NA I, date of hire 11/6/24; -Certified Medication Technician (CMT) A, date of hire 11/17/24. During an interview on 12/4/24 at 1:20 P.M., Director of Nursing (DON) said: -He/She could not locate TB tests of sampled employees including Dietary Aide A, CNA A, NA G, NA H, NA I, and CMT A; -TB testing should be completed upon hire; -The TB testing process fell a part when he/she stopped doing the hiring; -He/She did not follow up to ensure TB testing was being completed on all new hires. During an interview on 12/4/24 at 3:04 P.M., Administrator said: -He/She expected TB testing to be completed before employee starts employment; -He/She expected documentation of the TB testing to be maintained by the facility. MO245460

Based on record review, the facility failed to ensure staff provided care in a manner to prevent infection when the facility failed to ensure the required two step tuberculosis (TB, a communicable disease that affects the lungs characterized by fever, cough, and difficulty in breathing) screening test was administered upon hire for six sampled newly hired employees. The facility census was 46. Review of facility policy, employee screening for tuberculosis, revised March 2021, showed: -All employees are screened for latent tuberculosis infection and active TB disease, using tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment. -Newly hired employee is screened for LTBI and active TB disease after an employment offer had been made but prior to employee's duty assignment. Observation on 12/4/24 at 1:00 P.M. showed Director of Nursing (DON) could not locate requested employee sample of TB tests for the following employees: -Dietary Aide A, date of hire 10/17/24; -Certified Nurse Aide (CNA) A, date of hire 10/16/24; -Nurse Aide (NA) G, date of hire 10/11/24; -NA H, date of hire 10/24/24; -NA I, date of hire 11/6/24; -Certified Medication Technician (CMT) A, date of hire 11/17/24. During an interview on 12/4/24 at 1:20 P.M., Director of Nursing (DON) said: -He/She could not locate TB tests of sampled employees including Dietary Aide A, CNA A, NA G, NA H, NA I, and CMT A; -TB testing should be completed upon hire; -The TB testing process fell a part when he/she stopped doing the hiring; -He/She did not follow up to ensure TB testing was being completed on all new hires. During an interview on 12/4/24 at 3:04 P.M., Administrator said: -He/She expected TB testing to be completed before employee starts employment; -He/She expected documentation of the TB testing to be maintained by the facility. MO245460

Based on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl patch ( A controlled opiate, A schedule II naroctic pain patch ) on two different dates. The Administrator and DON failed to conduct an investigation when Licensed Practical Nurse (LPN) B called to report the missing patch on 11/11/24 and when LPN A reported the patch missing to the DON on 11/13/24. This affected one of one sampled residents. The facility census was 46. Review of facility policy, Abuse Investigation and Reporting, Revised July 2017, showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, shall be thoroughly investigated by facility management. -Individual conducting the investigation will as a minimum: -Review the completed documentation forms; -Review the resident's medical record to determine events leading up to the incident; -Interview the person(s) reporting the incident; -Interview any witnesses to the incident; -Interview the resident (as medically appropriate); -Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; -Interview staff members (on all shifts) who have had contact with the resident during the period of alleged incident; -Interview the resident's roommate, family members, and visitors; -Interview other residents to whom the accused employee provides care or services; and -Review all events leading up to the alleged incident. 1. Review of Resident #1's, Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/30/24, showed: -Cognition is severly impaired; -He/She was dependent for upper and lower body dressing, mobility, and personal care; -He/She had been on a scheduled pain medication regimen; -He/She made vocal complaints of pain within the assessment reference date (The look back period for the assessment). -He/She was taking high-risk drugs including an opioid (a broad group of pain-relieving medicines that work with brain cells); -Diagnoses included: Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and ability to perform everyday tasks), cognitive communication deficit (a difficulty communicating effectively due to underlying cognitive impairment), reduced mobility, malaise (a general feeling of discomfort, illness, or lack of well-being) Review of care plan, undated, showed: -He/She had potential for pain -Administer pain medication as ordered; -Turn and repposition according to turn schedule; -Observe for factors that increase/decrease my pain; -Observe for intolerable pain; -Measure my pain level using pain scale 1 to 10; -Coordinate with my physician to manage my pain medication for optimum control of my pain; -Coordinate care with hospice to maintain comfort; -Observe for non-verbal signs of pain ie. facial expressions, pulling away, fighting; Review of physician's orders, dated 12/4/24, showed: -Initial order started 10/14/24, Check fentanyl patch every shift, to ensure fentanyl patch is intact; -Fentanyl transdermal patch dosage increased on 11/15/24, to 50 MCG/HR (Fentanyl), apply 1 patch transdermal every 72 hours for pain. -Current physician orders as of 12/4/24 show fentanyl transdermal patch 72 hour 50 mcg/hr (fentanyl), apply 1 patch transdermal every 72 hours for pain, Review of controlled medication sheets for Resident #1's fentanyl patch showed: -Page 53: Fentanyl 25 mcg, 1 patch every 72 hours, balance forwarded was 2 -On 11/6/24, at 4:00 A.M., 1 dose was given, balance was 1 patch; -On 11/11/24 at 12:48 A.M, nothing entered as given, balance was 0; -On 11/19/24 entry showed count corrected, balance was 1 patch; -On 11/19/24, entry showed at 8:00 A.M. fentanyl was administered, and balance was 0. -On Page #54: Fentanyl 50 mcg, apply 1 patch every 72 hours showed: -On 11/7/24, at 8:00 P.M., 2 patches were received from the pharmacy; -On 11/8/24, at 8:30 A.M., 1 patch was given, balance remaining was 1 patch -On 11/18 an entry was made with a line through it that showed balance was 0 patches, but no administration time was entered; -On Page #55, fentanyl 50 mcg, change every 72 hours showed: -On 11/11/24, balance was 5 patches; -On 11/12/24, 1 dose was given, no time of administration entered, and balance was 4 patches; -On 11/13/24 at 6:49 A.M., 1 patch was administered, balance remaining was 3 patches; -On 11/15/24 at 10:30 A.M., 1 patch was administered, balance remaining was 2 patches; -On 11/18/24 at 1:00 P.M., 1 patch was administered, balance remaining was 1 patch; -On 11/21/24 at 9:27 A.M., 1 patch was administered, balance remaining was 0 patches. -On Page #60, fentanyl 50 mcg, apply one patch topically, showed page was started 11/18/24; -On 11/18/24, balance received from pharmacy was 5 patches; -On 11/24/24 at 8:00 A.M., 1 patch was administered, balance remaining was 4 patches; -On 11/27/24 at 8:00 A.M., 1 patch was administered, balance remaining was 3 patches; -On 11/30/24 at 8:00 A.M., 1 patch was administered, balance remaining was 2 patches; -On 12/3/24 at 9:30 A.M., 1 patch was administered, balance remaining was 1 patch; -On 12/3/24 at 9:30 A.M., 1 patch was administered, balance remaining was 0 patches, and a note written by DON showed stuck to op-site/tegaderm (sticky bandage that holds patches in place) had to replace patch. Review of Medication Administration Record, dated 11/1/24 to 12/4/24, showed: -Unknown start date, Fentanyl transdermal patch 72 hour 25 mcg/hr (fentanyl), apply 1 patch transdermal one time a day every 3 days for pain, discontinued on 11/7/24 at 3:50 P.M. -Administered 11/5/24 by LPN C; -Unknown start date, fentanyl transdermal patch 72 hour 50 mcg/hr (fentanyl), apply 1 patch transdermal every 72 hours for pain, apply 1 50 mcg/hr patch topically and change every 72 hours and remove per schedule, discontinued on 11/15/24 at 8:35 A.M; -Administered 11/8/24 at 9:01 A.M. by LPN D; -Administered 11/11/24 at 11:49 A.M. by Assistant Director of Nursing (ADON); -Administered 11/14/24 at 7:37 by LPN A; -Unknown start date, fentanyl transdermal patch 72 hour 50 mcg/hr (fentanyl), apply 1 patch transdermal every 72 hours for pain, apply one -50 mcg/hr patch topically and change every 72 hours and remove per schedule; -Administered 11/15/24 at 8:38 A.M. by LPN D; -Administered 11/18/24 at 1:00 P.M., by LPN A -Administered 11/21/24 at 9:50 A.M., by LPN A; -Administered 11/24/24 at 5:40 P.M. by LPN D; -Administered 11/27/24 at 8:12 by Registered Nurse (RN) A; -Administered 11/30/24 at 9:58 A.M. by LPN D -Administered 12/3/24 at 9:26 A.M. by DON. Review of progress notes, dated 11/4/24 to 12/5/24, showed: -On 11/6/24, LPN C wrote resident complained of pain, nurse applied fentanyl patch at 4:00 A.M; -On 11/7/24, New order entered showed fentanyl transdermal patch 72 hour 50 mcg/HR (fentanyl) controlled drug, apply 1 patch transdermal every 72 hours for pain, apply one 50 mcg/hr patch topically and change every 72 hours and remove per schedule; -On 11/8/24, LPN D wrote fentanyl 50 mcg patch placed on during morning to upper left back; -On 11/11/24, LPN B wrote resident fentanyl patch not present on residents back as was reported to this nurse, new patch applied this morning, secured with op-site to right scapula. DON notified. -On 11/15/24 at 8:21 P.M., LPN B wrote resident was jerking arms and legs spontaneously During an interview on 12/4/24 at 9:10 A.M., Licensed Practical Nurse (LPN) A said: -He/She went to check for Fentanyl patch on resident #1 on 11/13/24 and could not find the patch; -He/She got Certified Medication Technician (CMT) A to go look for patch with him/her and CMT could not locate the patch; -He/She looked in blankets and found the adhesive dressing cover to the patch but could not locate the patch; -He/She also checked trash in room and could not locate fentanyl patch; -The patch had last been applied on 11/12/24; -He/She notified the Director of Nursing that the patch was missing on 11/13/24; During an interview on 12/4/24 at 11:02 A.M., Director of Nursing (DON) said: -He/She was made aware by LPN A of Resident #1's fentanyl patch was missing on 11/13/24; -He/She found transdermal cover to patch but the patch was not located; -The bed had already been stripped, and he/she assumed it may have ended up in laundry; -He/She did not do an investigation but guessed she probably should have completed one; -He/She just spoke with hospice nurse and LPN A verbally to investigate the missing patch; -He/She did not document anything in regards to his/her verbal investigation; -After fentanyl patch was found missing on 11/13/24, LPN A started placing patch lower and out of resident's reach; -He/She did not recall Resident #1's patch to be missing on any other dates; -He/She did not recall LPN B calling him/her on 11/11/24 regarding Resident #1 having fentanyl patch missing. During an interview on 12/4/24 at 11:29 A.M., Nurse Aide A said: -He/She provided cares to Resident #1; -He/She had not seen Resident #1 without his/her pain patch while providing cares; -He/She had been told by an overnight employee but was not sure which employee that Resident #1's fentanyl patch was missing and had been seen on his/her night stand and to notify nurse if the fentanyl patch had been found; -In last few weeks Resident #1 had episode of jerking really bad and appeared as if he/she was experiencing pain. During an interview on 12/4/24 at 12:48 P.M., Nurse Aide B said: -He/She was aware of Resident #1's fentanyl pain patch cover being found on resident's bed side table but could not remember the specific date. During an interview on 12/4/24 at 1:18 P.M., Corporate Consultant said: -He/She expected a full investigation to be completed when the fentanyl patch was found missing; -He/She expected statements to be gathered, physician to be notified; -He/She found that his/her facility staff did not do anything in regards to an investigation; -He/She was not made aware of the missing fentanyl patches until he/she arrived on-site to facility today. During an interview on 12/4/24 at 2:40 P.M., LPN A said: -He/She discovered at 10:45 A.M. today that Resident #1 did not have his/her pain patch on; -He/She went and got the DON to report; -The DON reported that he/she had placed the fentanyl patch on the resident on12/3/24 because he/she was working as the charge nurse; -He/She did not have an additional fentanyl patch to replace missing patch today so had to call in a new order; -The DON told him/her that he/she had to waste a fentanyl patch on 12/2/24 because he/she had placed the fentanyl patch on Resident #1 backwards; -He/She did not notify the physician of the missing patch today or on 11/13/24; -He/She had to administer as needed pain medication due to not having another patch. During an interview on 12/4/24 at 3:04 P.M., Administrator said: -He/She expected an investigation to be completed when a fentanyl patch was found to be missing off a resident; -He/She would have expected the investigation to be documented; -The DON had not informed him/her about the missing fentanyl patch on 11/11 or 11/13; -He/She had not been made aware of the missing fentanyl patch until today; -He/She would have expected the physician to be notified. During an interview on 12/4/24 at 3:35 P.M., DON said: -He/She became aware of missing fentanyl patch this morning by LPN A; -He/She was not able to locate patch; -He/She discovered resident's bed had been stripped; -He/She did check laundry but was not able to locate the missing fentanyl patch; -He/She contacted the physician's group who referred him/her to hospice about the missing patch; -He/She spoke with hospice and looking at a different narcotic for resident due to the ongoing missing fentanyl patches. MO245460

Based on interview and record review, the facility Administrator and Director of Nurses (DON) failed to investigate misappropriation of resident property when Resident #1 was found without a fentanyl patch ( A controlled opiate, A schedule II naroctic pain patch ) on two different dates. The Administrator and DON failed to conduct an investigation when Licensed Practical Nurse (LPN) B called to report the missing patch on 11/11/24 and when LPN A reported the patch missing to the DON on 11/13/24. This affected one of one sampled residents. The facility census was 46. Review of facility policy, Abuse Investigation and Reporting, Revised July 2017, showed: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, shall be thoroughly investigated by facility management. -Individual conducting the investigation will as a minimum: -Review the completed documentation forms; -Review the resident's medical record to determine events leading up to the incident; -Interview the person(s) reporting the incident; -Interview any witnesses to the incident; -Interview the resident (as medically appropriate); -Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; -Interview staff members (on all shifts) who have had contact with the resident during the period of alleged incident; -Interview the resident's roommate, family members, and visitors; -Interview other residents to whom the accused employee provides care or services; and -Review all events leading up to the alleged incident. 1. Review of Resident #1's, Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/30/24, showed: -Cognition is severly impaired; -He/She was dependent for upper and lower body dressing, mobility, and personal care; -He/She had been on a scheduled pain medication regimen; -He/She made vocal complaints of pain within the assessment reference date (The look back period for the assessment). -He/She was taking high-risk drugs including an opioid (a broad group of pain-relieving medicines that work with brain cells); -Diagnoses included: Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and ability to perform everyday tasks), cognitive communication deficit (a difficulty communicating effectively due to underlying cognitive impairment), reduced mobility, malaise (a general feeling of discomfort, illness, or lack of well-being) Review of care plan, undated, showed: -He/She had potential for pain -Administer pain medication as ordered; -Turn and repposition according to turn schedule; -Observe for factors that increase/decrease my pain; -Observe for intolerable pain; -Measure my pain level using pain scale 1 to 10; -Coordinate with my physician to manage my pain medication for optimum control of my pain; -Coordinate care with hospice to maintain comfort; -Observe for non-verbal signs of pain ie. facial expressions, pulling away, fighting; Review of physician's orders, dated 12/4/24, showed: -Initial order started 10/14/24, Check fentanyl patch every shift, to ensure fentanyl patch is intact; -Fentanyl transdermal patch dosage increased on 11/15/24, to 50 MCG/HR (Fentanyl), apply 1 patch transdermal every 72 hours for pain. -Current physician orders as of 12/4/24 show fentanyl transdermal patch 72 hour 50 mcg/hr (fentanyl), apply 1 patch transdermal every 72 hours for pain, Review of controlled medication sheets for Resident #1's fentanyl patch showed: -Page 53: Fentanyl 25 mcg, 1 patch every 72 hours, balance forwarded was 2 -On 11/6/24, at 4:00 A.M., 1 dose was given, balance was 1 patch; -On 11/11/24 at 12:48 A.M, nothing entered as given, balance was 0; -On 11/19/24 entry showed count corrected, balance was 1 patch; -On 11/19/24, entry showed at 8:00 A.M. fentanyl was administered, and balance was 0. -On Page #54: Fentanyl 50 mcg, apply 1 patch every 72 hours showed: -On 11/7/24, at 8:00 P.M., 2 patches were received from the pharmacy; -On 11/8/24, at 8:30 A.M., 1 patch was given, balance remaining was 1 patch -On 11/18 an entry was made with a line through it that showed balance was 0 patches, but no administration time was entered; -On Page #55, fentanyl 50 mcg, change every 72 hours showed: -On 11/11/24, balance was 5 patches; -On 11/12/24, 1 dose was given, no time of administration entered, and balance was 4 patches; -On 11/13/24 at 6:49 A.M., 1 patch was administered, balance remaining was 3 patches; -On 11/15/24 at 10:30 A.M., 1 patch was administered, balance remaining was 2 patches; -On 11/18/24 at 1:00 P.M., 1 patch was administered, balance remaining was 1 patch; -On 11/21/24 at 9:27 A.M., 1 patch was administered, balance remaining was 0 patches. -On Page #60, fentanyl 50 mcg, apply one patch topically, showed page was started 11/18/24; -On 11/18/24, balance received from pharmacy was 5 patches; -On 11/24/24 at 8:00 A.M., 1 patch was administered, balance remaining was 4 patches; -On 11/27/24 at 8:00 A.M., 1 patch was administered, balance remaining was 3 patches; -On 11/30/24 at 8:00 A.M., 1 patch was administered, balance remaining was 2 patches; -On 12/3/24 at 9:30 A.M., 1 patch was administered, balance remaining was 1 patch; -On 12/3/24 at 9:30 A.M., 1 patch was administered, balance remaining was 0 patches, and a note written by DON showed stuck to op-site/tegaderm (sticky bandage that holds patches in place) had to replace patch. Review of Medication Administration Record, dated 11/1/24 to 12/4/24, showed: -Unknown start date, Fentanyl transdermal patch 72 hour 25 mcg/hr (fentanyl), apply 1 patch transdermal one time a day every 3 days for pain, discontinued on 11/7/24 at 3:50 P.M. -Administered 11/5/24 by LPN C; -Unknown start date, fentanyl transdermal patch 72 hour 50 mcg/hr (fentanyl), apply 1 patch transdermal every 72 hours for pain, apply 1 50 mcg/hr patch topically and change every 72 hours and remove per schedule, discontinued on 11/15/24 at 8:35 A.M; -Administered 11/8/24 at 9:01 A.M. by LPN D; -Administered 11/11/24 at 11:49 A.M. by Assistant Director of Nursing (ADON); -Administered 11/14/24 at 7:37 by LPN A; -Unknown start date, fentanyl transdermal patch 72 hour 50 mcg/hr (fentanyl), apply 1 patch transdermal every 72 hours for pain, apply one -50 mcg/hr patch topically and change every 72 hours and remove per schedule; -Administered 11/15/24 at 8:38 A.M. by LPN D; -Administered 11/18/24 at 1:00 P.M., by LPN A -Administered 11/21/24 at 9:50 A.M., by LPN A; -Administered 11/24/24 at 5:40 P.M. by LPN D; -Administered 11/27/24 at 8:12 by Registered Nurse (RN) A; -Administered 11/30/24 at 9:58 A.M. by LPN D -Administered 12/3/24 at 9:26 A.M. by DON. Review of progress notes, dated 11/4/24 to 12/5/24, showed: -On 11/6/24, LPN C wrote resident complained of pain, nurse applied fentanyl patch at 4:00 A.M; -On 11/7/24, New order entered showed fentanyl transdermal patch 72 hour 50 mcg/HR (fentanyl) controlled drug, apply 1 patch transdermal every 72 hours for pain, apply one 50 mcg/hr patch topically and change every 72 hours and remove per schedule; -On 11/8/24, LPN D wrote fentanyl 50 mcg patch placed on during morning to upper left back; -On 11/11/24, LPN B wrote resident fentanyl patch not present on residents back as was reported to this nurse, new patch applied this morning, secured with op-site to right scapula. DON notified. -On 11/15/24 at 8:21 P.M., LPN B wrote resident was jerking arms and legs spontaneously During an interview on 12/4/24 at 9:10 A.M., Licensed Practical Nurse (LPN) A said: -He/She went to check for Fentanyl patch on resident #1 on 11/13/24 and could not find the patch; -He/She got Certified Medication Technician (CMT) A to go look for patch with him/her and CMT could not locate the patch; -He/She looked in blankets and found the adhesive dressing cover to the patch but could not locate the patch; -He/She also checked trash in room and could not locate fentanyl patch; -The patch had last been applied on 11/12/24; -He/She notified the Director of Nursing that the patch was missing on 11/13/24; During an interview on 12/4/24 at 11:02 A.M., Director of Nursing (DON) said: -He/She was made aware by LPN A of Resident #1's fentanyl patch was missing on 11/13/24; -He/She found transdermal cover to patch but the patch was not located; -The bed had already been stripped, and he/she assumed it may have ended up in laundry; -He/She did not do an investigation but guessed she probably should have completed one; -He/She just spoke with hospice nurse and LPN A verbally to investigate the missing patch; -He/She did not document anything in regards to his/her verbal investigation; -After fentanyl patch was found missing on 11/13/24, LPN A started placing patch lower and out of resident's reach; -He/She did not recall Resident #1's patch to be missing on any other dates; -He/She did not recall LPN B calling him/her on 11/11/24 regarding Resident #1 having fentanyl patch missing. During an interview on 12/4/24 at 11:29 A.M., Nurse Aide A said: -He/She provided cares to Resident #1; -He/She had not seen Resident #1 without his/her pain patch while providing cares; -He/She had been told by an overnight employee but was not sure which employee that Resident #1's fentanyl patch was missing and had been seen on his/her night stand and to notify nurse if the fentanyl patch had been found; -In last few weeks Resident #1 had episode of jerking really bad and appeared as if he/she was experiencing pain. During an interview on 12/4/24 at 12:48 P.M., Nurse Aide B said: -He/She was aware of Resident #1's fentanyl pain patch cover being found on resident's bed side table but could not remember the specific date. During an interview on 12/4/24 at 1:18 P.M., Corporate Consultant said: -He/She expected a full investigation to be completed when the fentanyl patch was found missing; -He/She expected statements to be gathered, physician to be notified; -He/She found that his/her facility staff did not do anything in regards to an investigation; -He/She was not made aware of the missing fentanyl patches until he/she arrived on-site to facility today. During an interview on 12/4/24 at 2:40 P.M., LPN A said: -He/She discovered at 10:45 A.M. today that Resident #1 did not have his/her pain patch on; -He/She went and got the DON to report; -The DON reported that he/she had placed the fentanyl patch on the resident on12/3/24 because he/she was working as the charge nurse; -He/She did not have an additional fentanyl patch to replace missing patch today so had to call in a new order; -The DON told him/her that he/she had to waste a fentanyl patch on 12/2/24 because he/she had placed the fentanyl patch on Resident #1 backwards; -He/She did not notify the physician of the missing patch today or on 11/13/24; -He/She had to administer as needed pain medication due to not having another patch. During an interview on 12/4/24 at 3:04 P.M., Administrator said: -He/She expected an investigation to be completed when a fentanyl patch was found to be missing off a resident; -He/She would have expected the investigation to be documented; -The DON had not informed him/her about the missing fentanyl patch on 11/11 or 11/13; -He/She had not been made aware of the missing fentanyl patch until today; -He/She would have expected the physician to be notified. During an interview on 12/4/24 at 3:35 P.M., DON said: -He/She became aware of missing fentanyl patch this morning by LPN A; -He/She was not able to locate patch; -He/She discovered resident's bed had been stripped; -He/She did check laundry but was not able to locate the missing fentanyl patch; -He/She contacted the physician's group who referred him/her to hospice about the missing patch; -He/She spoke with hospice and looking at a different narcotic for resident due to the ongoing missing fentanyl patches. MO245460

Based on observation, interview, and record review, the facility failed to ensure one resident's visitation rights were not restricted when Resident #6 had a visitor that was asked to leave and not permitted to visit the resident. This affected one of six sampled residents (Resident #6). The facility census was 47. Review of facility policy, Resident Rights, undated, showed: -Resident has right to receive visitors of their choosing at time of their choosing and interact and participate with members of community and activities inside and outside facility, subject to resident's right to deny visitation, and in a manner that did not impose on rights of another resident. -Facility must provide immediate access, subject to resident's right to deny or withdraw consent at any time to any resident by: -Immediate family and other relatives of resident; -Facility must have written policies and procedures regarding visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction, and must inform each resident of right to receive visitors whom they designate and their right to withdraw or deny such consent any time. Review of facility policy, visiting hours, undated, showed: -Resident has right to receive visitors of his or her choosing at the time of his or her choosing, subject to resident's right to deny visitation when applicable, and in a manner that did not impose on the rights of another resident. -The facility will ensure all visitors enjoy full and equal visitation privileges consistent with resident preferences. -The facility will provide immediate access to any resident subject to the resident's rights to deny or withdraw consent at any time. -The facility will have immediate access to the resident by any of the following: -Others who are visiting with the consent of resident; -Visiting hours will be posted to encourage reasonable restrictions. 1. Review of Resident #6's admission minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 8/14/24, showed: -He/She was cognitively intact; -He/She had clear speech and was able to make self-understood and understand others; -It was very important to have family or close friends involved in discussions about his/her care; -He/She was independent with mobility, personal hygiene, dressing, and eating; -Diagnoses included: anxiety (feeling of fear, dread, or uneasiness that could be normal reaction to stress), depression (mental condition that involved persistent feelings of sadness and loss of interest in activities), manic depression (serious mood disorder that can affect how person feels, thinks, or acts), diabetes ( a condition resulting in too much sugar in the blood), and bipolar disorder (a mental illness that can cause extreme mood swings, along with changes in energy, activity levels, and concentration). Review of physician's orders, dated 10/23/24, showed: -Activities as tolerated or desired; Review of care plan, undated, showed: -Resident had an activity of daily living self-care performance deficit due to limited mobility; -Encourage resident to participate to fullest extent possible with each interaction. During an interview on 10/23/24 at 8:51 A.M., Resident said: -His/Her friend, Visitor A, came to see him/her; -The Business Office Manager (BOM) would not let his/her friend come to see him/her; -It upset him/her that his/her friend could not come and visit them; -He/She was his/her own person and did not have a guardian; -The visitor who was denied access had been former employee of facility; -He/She had a friendship with the individual and wanted to be allowed his/her right to have visits. During an interview on 10/23/24 at 9:19 A.M., BOM said: -He/She had never denied visits to anyone; -If an employee was terminated from the facility they were not allowed back into the building; -He/She was not aware of any former employees that had been at the facility to visit a resident that he/she had turned away; -There was no visiting hours at facility, people could visit at time of choosing; -He/She was not aware of turning any visitors that came to facility to see Resident #6. During an interview on 10/23/24 at 10:25 A.M., Director of Nursing (DON) said: -Facility did not have set visiting hours; -He/She was aware of one former employee that had came to facility after hours, the former Assistant Director of Nursing (ADON), and he/she had been escorted out of facility due to making staff uncomfortable and exhibiting disturbing behaviors. During an interview on 10/23/24 at 10:42 A.M., Licensed Practical Nurse (LPN) A said: -He/She was aware of one resident, Resident #6, who had been denied a visit from visitor A by the BOM; -The BOM told Visitor A that he/she could not come into the facility; -Visitor A was a former employee; -He/She observed Visitor A being denied access on two visit attempts; -Resident #6 was his/her own person and able to make his/her own decisions. During an interview on 10/23/24 at 11:20 A.M., ADON said: -He/She was not aware of any residents being denied visits; -Former employees were allowed to come back into facility to visit residents. During an interview on 10/23/24 at 11:38 A.M., Visitor A said: -He/She had previously worked at the facility; -He/She voluntarily quit and left the faciity on good terms; -He/She attempted to visit Resident #6 on 9/1/24, 9/4/24, and 9/9/24; -On his/her first attempt on 9/1/24 he/she was in facility applying for a position, after he/she completed the application he/she went down the hallway to visit the resident; -The BOM came out of his/her office and yelled at him/her saying he/she was not allowed to go down the hallway; -When he/she returned for an interview, he/she inquired with the Administrator if he/she could visit the resident and the Administrator said he/she was not allowed to be there; -During a third attempt to visit the resident, the Administrator again said he/she was not allowed; -He/She had been Certified Nurse Aide in the facility a long time and quit working at the facility at end of November 2023. During an interview on 10/23/24 at 12:09 P.M., DON said: -Resident #6 was his/her own responsible party; During an interview on 10/23/24 at 11:45 A.M., Administrator said: -He/She had never turned resident's visitors away from facility; -He/She had not turned away the former staff member; -Visitors were allowed to visit the facility at any time; -He/She did not turn away Visitor A; -Visitor A had been terminated and was on the facility do not rehire list; -He/She expected residents with capacity and were their own person to be allowed to have access to visitors of their own choosing. MO243891

Based on interview and record review, the facility failed to provide protective oversight for one resident (Resident #1), who displayed behaviors of self-harm including a recent attempt to commit suicide on [DATE], and failed to verbally communicate with the resident's physician regarding the residents behaviors of attempted self harm and of the resident's death, at the time the death occurred. The facility additionally failed to provide appropriate interventions and monitoring when they relied on the resident's roommate to alert staff when he/she determined the the resident needed assistance. The facility census was 45. A review of the facility's Accidents and Incident Policy with a revision date of [DATE], showed: - All accidents or incidents involving residents occurring on the facility premises shall be investigated and reported to the administrator; -The nurse supervisor/charge nurse and/or the department or supervisor shall promptly initiate and document investigation of the accident or incident; -The following data shall be include on the report: o The date and time of the incident; o The nature of the injury; o The circumstances surrounding the incident; o The time the injured person's attending physician was notified as well as the time the physician responded and his/her instructions; o The dated and time the injured person's family was notified; o Other pertinent information; o The signature and title of the person completing the report; o The Director of Nursing (DON) shall ensure the administrator receives a copy of the Report of Accident form for each occurrence. Review of the facility's policy, Behavior Health Services, revised, February 2019, showed: -The facility will provide residents with behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being; -Residents who exhibit signs of emotional/psychosocial distress will receive services and support and address their individual needs; -Staff must promote safety, privacy, socialization and dignity as appropriate for each resident and trained in ways to support residents in distress; -Staff training includes recognizing changes in behavior that indicate psychological distress; -Staff will implement care plan interventions that are relevant to the resident and appropriate to his/her needs; -Staff will monitor care plan interventions and report changes in condition; -Staff will follow protocols, and guidelines related to the treatment of mental disorders, psychosocial adjustment difficulties and history of trauma. Review of the facility's policy, Behavioral Assessment, Intervention and Monitoring, revised, [DATE], showed: -The facility will provide residents with behavioral health services as needed; -Behavioral symptoms will be identified using facility-approved behavioral screening tools; -Residents will have minimal complications associated with the management of altered or impaired behavior; -Behavior can be a way for an individual in distress to communicate needs or express thoughts that cannot be articulated; -The nursing staff will identify, document and inform the physician about specific details regarding changes in an individual's mental status or behavior; -The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms including at a minim, physical changes such as constipation or pain or emotional changes such as depression and anxiety; -Interventions will be individualized; -Interventions will be based on assessment details that will include the frequency of behavioral symptoms, outcomes and locations of behaviors. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated [DATE]., showed: -The resident had severe cognitive impairment; -The resident used no speech; -The resident is rarely understood; -The resident has physical directed behaviors directed toward others; -The resident is totally dependent on staff for activities of daily living (ADL's), bed mobility and maximum assistance for transfers and ambulation; -Diagnoses include, quadriplegia (paralysis of all four limbs of the body), traumatic brain injury (injury to the brain caused by a forceful bump, blow, or jolt to the head or body) can be caused by a forceful bump, blow, or jolt to the head or body, that pierces the skull and enters the brain), and low blood pressure. Review of the resident's care plan revised on [DATE] showed: -The care plan did not address behaviors associated with traumatic brain injury. -The care plan did not address displays of self harm; -The care plan did not address mental health needs. -The care plan did not address how staff are to care for a resident with known behavior of self harm by placing items around his/her neck. -The resident had a Do Not Resuscitate Order (no heroic life saving measures or chest compressions). Review of physician progress notes dated [DATE] showed: -The resident can move his/her right side well; -The resident can follow simple commands. Review of nurse's notes dated [DATE] at 8:00 P.M., showed: -The resident's roommate had his/her call light on and yelling for the nurse; -The resident was half on the fall mat and half off the bed; -The resident was not breathing, had no pulse and the resident's skin was gray in color; -The resident's chin was tucked in toward his/her chest and liquid was bubbling up in the resident's mouth; -The resident suddenly took a breath and stopped breathing again; -The nurse and a nursing aide moved the resident back in bed when he/she started agonal (condition that occurs when someone who is not getting enough oxygen and is gasping for air) breathing; -The physician was called and a message was left on his/her voicemail to call the facility as soon as possible; -The resident was breathing and awake at this time; -The resident's responsible party was called and he/she said not to send to the ER and just to monitor the resident; -At 8:30 P.M., the nurse called the physician again and the physician said he/she would recommend sending the resident to the ER but if the responsible party did not want to do that he/she would abide by the responsible party's request. Review of physician progress notes dated [DATE] showed: -The resident has no new changes in his/her condition; -Physical assessment and vital signs good; -The resident was able to close his/her eyes on demand; -The resident can understand most of what is being said to him/her. A review of nurse's notes dated [DATE] at 6:00 A.M., showed: -The resident was found on fall mat face down between the wall and the bed; -The physician was notified of the fall by fax; -No apparent injuries. A review of nurse's notes dated [DATE], showed: -The resident was yelling and restless; -The resident pulled the Cardiopulmonary Resuscitation (CPR - is an emergency lifesaving procedure performed when the heart stops beating) tag (tag used to deflate the bed in quickly, in case CPR needs to be administered), out of the bed and was trying to reach the cords of the bed and the call light cord. - Documentation did not show an assessment to determine the needs of the resident or to determine the cause of the resident's behavior. A review of nurse's note dated [DATE] showed the resident pulled the CPR tag from the bed two times during the shift. The note did not show staff assessed or interviewed the resident to determine the cause of the behavior. A review of nurse's noted dated, [DATE], showed: -The resident turned himself/herself sideways in bed and grabbled the strap on the bed cushion and was attempting to wrap the strap around his/her neck; -Physician faxed regarding the residents behavior. -The note did not include documentation of any assessment or investigation of the incident. Review of the residents care plan showed no new interventions or monitoring. A review of a fax sent to Physician a, dated [DATE], with a stamped time of 10:30 A.M., showed: -The resident becomes combative and aggressive at times; -The resident appears depressed; -Requesting to start him/her on an antidepressant; -The fax was signed by LPN A. Review of the residents care plan showed no new interventions or monitoring. Review of nurse's notes dated [DATE] at 6:35 P.M. showed: -The resident was found unresponsive in his/her room by the facility staff and determined that the resident was without heart sounds, respirations or pulse. -RN B was called to the resident's room by Dietary Aide A where the resident was found on the floor; -The resident's torso was off the bed and his/her head was on the floor; -The resident's hands and face were purple; -The resident had no heartbeat, and no respirations; -Family member A was notified of the resident's death by phone; -The DON was notified by phone; -Facility did not start CPR, because the resident was a DNR. -No documentation that the resident's physician had been notified of his/her death was found in the resident's record. During an interview on [DATE] at 9:16 A.M., Dietary Aide A said: - He/she went to pass the hall trays and the Resident #1 was on the floor and not moving so he/she told the nurse; -He/she was unaware of any interventions related to the residents care. During an interview on [DATE] at 9:44 A.M., Registered Nurse (RN) B said: -He/she had checked on Resident #1 on [DATE] at around 5:30 P.M., and he/she was fine; -On [DATE] at around 5:50 P.M., he/she was in the dining room assisting the residents when Dietary Aide A asked him/her to check on Resident #1 because he was on the floor and not moving; -He/she knew he was deceased as soon as he/she looked at him; -RN B told dietary aide A to get Certified Medication Technician (CMT) A to assist him/her; -The resident was half way on the floor, the bed was in the low position and the resident's head was on the floor mat and his torso still on the bed; -The resident was face up with the top of his head on the fall mat and his/her chin tucked in towards his/her chest; -He/she assessed the resident for signs of life and found no pulse, no respirations and no heart sounds; -The resident's face and hands were purple and he/she had no pulse or respirations; -He/she was afraid this was eventually going to happened because the resident had wrapped cords around his/her neck before and thrown himself/herself on the floor in this position before; -He/she -There was no changes in the resident's care after the displays of self harm; -The staff depended on the resident's roommate to notify them if the resident was ok; -Should have dedicate staff to monitor residents that display self harm; -He/she would monitor the resident by looking in his/her room when he/she had time; -The aides were instructed to check when they went by his/her room and every two hours; -He/she was unaware of any interventions that addressed the resident's displays of self harm. -The resident could use his/her/her right side and that is how he/she would put himself/herself on the floor and grab the cords; -The resident does not have a call light because he/she wraps it around his/her neck that is why he/she is in a room with Resident #2 so he/she can keep an eye on him/her; -The staff go by the resident's room and try to check on him/her often, but his/her roommate wants the door closed sometimes; -He/she thought the resident's actions were a cry for help and that the resident wanted to end his/her life; -He/she had previously told the DON and the administrator but they both said Resident #1 is not capable of thinking or doing something like that because he/she suffers from a severe brain injury and is quadriplegic. During an interview on [DATE] at 10:12 A.M., Licensed Practical Nurse (LPN) B said: -He/she found Resident #1 on the floor, face up and chin tucked into neck with no pulse or respirations back in July of this year; -The resident was gray and he/she thought initially that the resident had passed away but color and breathing returned; -A fall mat was put in place and a bolster mattress, but he/she told the administration he/she though the resident was purposely try to throw himself/herself on the floor in this position to end his/her life. -There was no changes in the resident's care after the displays of self harm; -It is not a good standard of practice to depend on another resident to monitor a resident that has displayed behaviors of self harm; -The resident should have been on 1:1 after the incident in July and after he/she started to wrap cords around his/her neck; -He/she was unaware of any interventions related to the displays of self harm. -He/she said she told the administrator and the DON but no one took it seriously. During an interview on [DATE] at 10:43 A.M., Certified Nurse's Aide (CNA) B said: -Resident #1 was constantly throwing himself/herself on the floor; -The resident tried to wrap cords around his/her neck in the past; -The staff had to move a bedside table out of his/her reach before because he/she would grab it and try to get to the floor; -The resident did not have a call light because of the cords; -Resident #2, his/her roommate would call for staff if Resident #1 was trying to get onto the floor or wrap something around his/her neck. -He/she told the administrator and DON but the only interventions were a fall mat and bolstered mattress; -No changes in the residents care were made after he/she told the administrator and the DON; -No interventions were put in the resident's care plan to monitor that cords or straps were out of the resident's reach; -The resident should have been monitored more closely with assigned staff; -It was not safe to ask the resident's roommate to keep an eye on him; -He/she unaware of any other interventions. -Most staff new to keep the cords out of reach but there were times when he/she came back to work after days off to find the cords within reach of the resident. 2. A review of Resident #2's quarterly MDS, dated [DATE], showed: -The resident has no cognitive impairment; -The resident is dependent on staff for ADL care; -Diagnoses included, Cerebral Palsy (a disorder that effects a person's ability to move and maintain balance), stroke and high blood pressure. Review of Resident #2's care plan dated [DATE], showed: -The resident requires staff assistance for bed mobility and transfers; -The resident is dependent on staff for ADL's. During an interview on [DATE] at 2:13 P.M., Resident #2 said: -Resident #1 could not use the call light and that is why the facility staff roomed him/her with Resident #1; -He/she observed Resident #1 grab the cord of the call light, the bed, or the strap on his/her bed cushion multiple times and tried to put the cord around his/her neck; -The staff would try to keep the cords out of reach but Resident #1 would still get a hold of a cord sometimes; -Resident #1 could use his/her right arm and pull himself/herself on the floor; -Resident #1 has wrapped a cord around his/her neck several times and he/she has notified staff; -Sometimes Resident #1 would wrap the bed sheet around his/her neck and then Resident #2 would ring for the nurse; -Resident #1 started yelling out more often in the last weeks. -It made him anxious for staff to place him/her in the room with Resident #1 because he/she felt responsible to supervise and get help for Resident #1 when needed. During an interview on [DATE] at 2:38 P.M., Resident #2 said: -He/she eats in his/her room most of the time; -Resident #1 had a feeding tube so he/she was in the room during meals; -The night Resident #1 died , he/she noticed Resident #1 had been more quiet than usual but did not think anything about it; -When Dietary Aide A brought his/her supper tray in he/she asked him/her if Resident #1 was ok and that is when he/she noticed Resident #1 was not moving; -RN B came into the room and told Dietary Aide A to go get CMT A; -CMT A and RN B closed the curtain between Resident #1 and Resident #2 and that was all he/she knew. During an interview on [DATE] at 3:01 P.M., DON said: -He/she was made aware of Resident #1's death by the charge nurse on duty; -No investigation was done because it was a natural death, the resident had a lot of health conditions and was a DNR (Do Not Resuscitate) code status; -The facility put interventions in place to prevent falls; -A fall mat was put in place, a bolstered mattress was in place and cords were out of the residents reach; -The resident was in a room with Resident #2 because Resident #1 would ring his/her call light to let the staff know if either one of them needed help; -He/she said the facility should not have relied on the resident's roommate to monitor the resident's safety; -He/she had been told about the resident attempting to grab cords but he/she did not consider this behavior self harm; -Resident #1 did not have the mental capacity to a decide to take his/her life; -The staff checked on Resident #1 every time they walked by his/her room; -These checks are not documented because the staff checks on everyone at least every two hours; -Resident #1's physician was notified by the charge nurse of his/her death; -A resident's physician should be notified of any significant change in their condition or a resident's death as soon as possible. During an interview on [DATE] at 3:38 P.M., The Administrator said: -He/she was made aware of Resident #1's death by the DON; -The resident suffered from a TBI and was a quadriplegic and he/she believed that contributed to his/her death; -Fall interventions were put in place because the resident kept putting him/herself the floor; -He/she did not know if keeping cords out of the resident's reach was addressed on the resident's care plan; -He/she was aware that the Resident #1 had a history of wrapping cords around his/her neck but the staff were aware and kept the cords out of reach; -He/she would expect staff to check on Resident #1 at least every two hours or more; -He/she did not do an investigation into Resident #1's death because the resident suffered from a TBI, and the resident was a DNR code status; -He/she said the facility should not have relied on the resident's roommate to monitor the resident's safety; -He/she had been told about the resident grabbing cords; -Resident #1 was not capable of mentally making that decision to take his/her life because of the his/her TBI; -He/she said the facility was following its policy and procedure related to the resident's care and death at the facility; -All fall interventions should be care planned; -If a resident exhibits self harming behaviors the physician should be called and safety interventions put into place; -A resident's physician should be notified of any significant change in their condition or a resident's death. During an interview on [DATE] at 11: 16 A.M. Certified Medication Technician (CMT) A said: -The staff tried to look into the resident's room whenever we walked by; -The resident did not have a call light because he/she tried to wrap it around his/her neck several times; -The resident would try to pull himself/herself on the floor with his/her right arm; -The resident started becoming more agitated and restless about three weeks ago; -He/she thought he/she was giving up because he/she did not want to come out of his/her room as much; -He/she said the facility should not have depended on the resident's roommate to monitor the resident's safety. During an interview on [DATE] at 11:35 A.M., LPN A said: -He/she sent Physician a fax on the morning of [DATE]; -The night shift staff told her the information in report that morning; -He/she did not witness any of the behaviors himself/herself; -He/she could not remember which staff told her about the behaviors. During an interview on [DATE] at 9:33 A.M. the Social Services Director (SSD) said: -There had been a change in the resident's mood within the last two or three weeks; -The resident used to like to listen to music and set outside; -During the last two or three weeks the resident did not want to go outside or listen to music; -The resident did not want to joke around or do anything that he/she used to; -He/she had a lost look in his/her eyes; -He/she could not remember if he/she told the DON or administrator; -The changes in the resident's mood should be care planned. During an interview on [DATE] at 10:12 A.M., family member A said; -Resident #1 was in a room with another resident because the facility said they needed someone to help keep an eye on him/her; -He/she was told by Resident #1's roommate, Resident #2, that Resident #1 had attempted to wrap cords around his/her neck and kept throwing himself/herself on the floor; -The facility did not inform him/her that Resident #1 was trying to wrap things around his/her neck or kept throwing himself/herself out of bed; -Resident #2 said he/she was monitoring Resident #1 and he/she would ring or yell for yelp if Resident #1 was on the floor or was trying to wrap something around his/her neck; -He/she considered the accident that resulted in the resident's TBI was a traumatic event; -The resident would have benefited from mental health services; -The facility did not contact her about setting up mental health service for the resident; -The resident has not seen a mental health professional; -The facility did not watch Resident #1 close enough; -He/she was told about Resident #1's death by another family member and not the facility; -He/she is supposed to be the first person to be called. During an interview on [DATE] at 12:08 P.M. Physician A said: -He/she considered the accident that resulted in the resident's TBI was a traumatic event; -He/she did not recall if the facility notified him/her that Resident #1 had wrapped cords around his/her neck; -He/she did not recall if the facility notified him/her that Resident #1 was found on the floor with his/her chin tucked into his/her neck back on [DATE], with no pulse, no respirations and purple in color; -The facility might have notified him/her of he/she could not remember off hand; -He/would expect the staff to monitor a resident that was displaying behaviors of self harm; -The facility did not notified him/her that Resident #1 had died on [DATE]; -He/she had just talked to someone at the facility yesterday about this and the facility said they notified him/her by phone but he/she looked back in his phone records and messages and did not find one from the facility notifying him of Resident #1's death. -He/she would expect the facility to keep trying to get a hold of him/her when there is a significant change in a resident's status or a death; -He/she did not find out about Resident #1's death until he/she rounded at the facility on Saturday [DATE]; -He/she would expect to be notified with any significant changes to Resident #1's condition; -He/she would expect to be notified when a resident expires; -He/she was not anticipating Resident #1's death. MO226835