Every finding on record at Lemay Nursing

Based on observation, interview and record review, the facility failed to ensure on-going resident centered therapeutic activities were provided to residents in the evenings and on weekends as an integral part of their psychosocial well-being. In addition, the facility failed to ensure that 1 on 1 activities were done more than one time a week. This deficient practice had the potential to affect all residents in the facility. The census was 46. 1. Review of the facility's May 2025 activity calendar, showed: -Monday through Friday, no activities offered after 2:00 P.M.; -Saturdays: 5/3/25, Self Directed Activities, 10:00 A.M., Bingo with volunteer and 3:30, House of Prayer Music Visit. 5/17/25 and 5/31/25 included bingo with volunteer at 10:00 A.M. All other Saturdays were Self Directed Activities, which included coloring, word puzzles, card and board games; -Sundays: Self-Directed activities, which include coloring and word puzzles, card and board games. 2. Review of the 1 on 1 list, provided by the facility, showed 14 residents receiving 1 on 1 activities. 3. During a group interview on 5/13/25 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. All six residents said the facility did not offer activities on the weekend. There is no one there to do activities on the weekend and throughout the week, none are offered after 4:00 P.M. There is a volunteer who came to the facility every other Saturday who did bingo with them. No activities were offered on Sundays. They wanted evening and weekend activities. 4. During an interview on 5/14/25 at 12:33 P.M., Certified Nursing Assistant (CNA) B said he/she sometimes worked the weekends and there was usually no activities for residents during the weekend. He/She saw someone doing bingo one Saturday but had not seen the person in awhile. The Activity Director (AD) left games and coloring books for the residents to use them while she was off on the weekends. Weekend activities were self-directed. 5. During an interview on 5/14/25 at 12:34 P.M., CNA C said there was no activity program on the weekend. Activities were self-directed. The AD left books and games for the residents. 6. During an interview on 5/14/25 at 12:49 P.M., Licensed Practical Nurse (LPN) E said there were no activities during the weekend. Activities were self-directed on the weekends. He/She saw someone assist with bingo on a Saturday, but could not recall how often they came. 7. During an interview on 5/14/25 at 3:13 P.M., the Activity Director (AD) said she had been at the facility since October, 2024. She was responsible for all the activities. She did not have an assistant. Activities after 4:00 P.M. were kind of iffy because when activities were done after 4:00 P.M., it would be a movie, but from what she heard, the residents didn't really come down for the movie. This would consist of maybe five people at the most. This was the only activity after 4:00 P.M., because she was not there after 4:00 P.M. because she lives about 40 minutes away, so sometimes she might be at the facility, but not for an activity. At those times, she might catch up on 1 on 1's or do computer work. Every other weekend, they have a volunteer who came to the facility at 10:00 A.M. and do bingo with the residents. He/She also would bring a friend sometimes who would do chair yoga with the residents. This is done just every other Saturday. Every first Sunday of the month, a music group who sings religious songs and hymns comes to the facility. The AD thought the residents deserved more but felt bad because she could not come on the weekends. It would be nice if she had help. If she had help, they could give the residents more of what they need regarding activities. She felt the residents should get activities after 4:00 P.M., but they do have plenty of self-directed activities. All of their board games are kept in the library because that is open space, so all their self-directed activities are easy access for them. They are either outside her office or in the library. The papers are updated every month. They have coloring papers, word games, board games, cards, etc. For residents who cannot do self-directed activities, she would see them and do 1 on 1's with them but that is only 1 time a week. They deserve more than that. 8. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she was not aware activities were not going on after 4:00 P.M. during the week and/or on the weekends. She said this was not true. They had activities on the weekends. It was not every Saturday and Sunday. A volunteer comes every other Saturday. The volunteer did not come in just for an hour. He/She would bring a yoga instructor with him/her and he/she would do chair yoga with the residents. The Administrator expected for activities for 1 on 1's to be done more than once a week.

Based on observation, interview and record review, the facility failed to follow their policy and ensure side rails were assessed as necessary on a quarterly and annual basis for six of 13 sampled residents(Residents #44, #5, #24, #9, #14 and #28). The census was 46. Review of the facility's Side Rails policy, dated 10/17/23, showed: -Policy: Assess resident side rail restraint needs on admission, annually and with any significant change in order to ensure the resident's highest practicable physical and psychosocial well-being. Review quarterly; -Procedure: -Nursing staff will assess need for side rails at time of admission, annually and with any significant change and place in the chart, reviewing quarterly; -Side rails will be evaluated quarterly and reduced/eliminated as possible. 1. Review of Resident #44's Bed Rail/Assist Bar Evaluation, showed one completed on 9/17, but did not specify the year. A half length and quarter length rail was indicated. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/26/25, showed: -admitted [DATE]; -Short and long-term memory problem; -No behaviors; -Upper and lower extremities: Impairment on one side; -Dependent on staff for mobility and transfers; -Diagnoses included fractures, hemiplegia (muscle weakness or paralysis on one side) and depression. Review of the resident's care plan, revised 3/3/25, showed: -Focus: The resident has actual/potential for falls. Gait/balance problems and paralysis; -Goal: The resident will be free of minor injury through review date; -Interventions: Enabler bar to assist with safe transfers. Review of the resident's May 2025 active physician's order, showed an order, dated 12/1/23, for bed rails. Quarter length related to impaired mobility and diagnoses of hemiplegia, unspecified affecting left nondominant side. Review of the resident's electronic medical record (EMR), viewed 5/13/25 at 10:50 A.M., showed no side rail assessment. Observation on 5/13/25 at 8:30 A.M., showed the resident lay on his/her back. Quarter length side rails were raised on both sides. The resident said he/she used the rails to help with positioning. Observation on 5/14/25 at 8:26 A.M., showed the resident lay in bed on his/her back. Side rails were raised on both sides. During an interview on 5/14/25 at 10:42 A.M., Certified Nursing Assistant (CNA) A said he/she was familiar with the resident and he/she used the side rails to assist with turning and positioning. 2. Review of Resident #5's EMR, showed a Device/Restraint Evaluation, dated 10/18/22. Resident uses a grab bar. Review of the resident's Bed Rail/Assist Bar Evaluation, showed one completed on 9/17, but did not specify the year. Review of the resident's quarterly MDS, dated [DATE], showed: -admitted [DATE]; -Rarely understood; -Dependent on staff for mobility and transfers; -Diagnoses included heart disease and dementia; -Bed rails not used. Review of the resident's care plan, revised 3/10/25, showed: -Focus: The resident has limited physical mobility; -Goal: The resident will maintain current level of mobility; -Intervention: Left and right quarter length assist rails for bed mobility. Review of the resident's May 2025 active physician's order, showed an order, dated 10/20/23: Resident has side rails, quarter length related to impaired mobility and diagnosis of abnormal posture and weakness. Observation on 5/12/25 at approximately 10:07 A.M., showed the resident sat in his/her wheelchair next to his/her bed. The resident's bed had raised quarter length side rails on both sides. The resident could not say what the side rails were used for. During an interview on 5/14/25 at 10:42 A.M., Certified Nursing Assistant (CNA) A said he/she was familiar with the resident and he/she used the side rails to assist with turning and positioning. 3. Review of Resident #24's quarterly MDS, dated [DATE], showed: -Short term memory problem; -Long term memory ok; -Had functional limitation of range of motion in both upper extremities. -Was dependent (helper does all the effort. Resident does none of the effort to complete the activity) for rolling left to right, to change positions from lying to sitting on the side of the bed and to go from sitting to standing; -Diagnoses included: coronary artery disease (CAD, arteries that supply blood to the heart muscle become narrowed or blocked), high blood pressure, renal insufficiency (kidneys unable to function properly), obstructive uropathy (normal flow of urine through the urinary tract is blocked or hindered), stroke and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). Review of the care plan, in use at the time of survey, showed: -Focus: resident has an Activities of Daily Living (ADL, grooming, dressing, bathing) self-care performance deficit; -Goal: will maintain current level of function in through the next review; -Interventions included: bed mobility, the resident can roll over in bed with use of the enabler rails. Review of the order summary report, dated 5/12/25, showed a physician order for bed side rails (1/4) related to impaired mobility and diagnoses of muscle weakness. Review of the device/restraint evaluation form, dated 10/18/22, showed resident used side rails. Observation and interview on 5/5/25 at 10:24 A.M., showed the resident lay in bed with U shaped side rails up on both sides. The resident said he/she used them to help him/her to stand up. Observation on 5/14/25 at 2:00 P.M., showed the resident lay in bed. Registered Nurse (RN) H assisted the resident to roll from his/her back onto his/her left side. The resident grabbed the side rail to help roll over. 4. Review of Resident #9's annual MDS, dated [DATE], showed: -Re-admitted [DATE]; -Cognitively intact; -Uses wheelchair for mobility; -Diagnoses included stroke, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hemiplegia or hemiparesis (neurological conditions that cause weakness or paralysis on one side of the body). Review of the resident's physician orders, dated 10/20/23, showed an order for quarter bed side rails related to mobility and diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. Review of the resident's medical record, showed no side rails assessment. Observation on 5/12/22 at 10:38 A.M., showed the resident had side rails on both sides of his/her bed. The side rails were down and the resident was not in bed. During an interview on 5/14/25 at 9:34 A.M., the resident said he/she used the side rails for positioning. 5. Review of Resident #14's significant change MDS, dated [DATE], showed: -Re-admitted [DATE]; -Moderately impaired cognitive skills for daily decision making; -Uses wheelchair for mobility; -Diagnoses included heart failure, diabetes, hip fracture and malnutrition. Review of the resident's physician orders, dated 4/8/25, showed an order for left and right quarter rail enabler bars to aide in bed positioning and transfers. Observation on 5/14/22 at 10:22 A.M., showed the resident had side rails on both sides of his/her bed. The side rails were down and the resident was not in bed. During an interview on 5/14/25 at 12:50 P.M., LPN E said he/she did not know why the resident had side rails on the bed, but he/she was able to use the rails, and he/she thought they were beneficial for the resident with turning and positioning. 6. Review of Resident #28's significant change MDS, dated [DATE], showed: -Re-admitted [DATE]; -Moderately impaired cognitive skills for daily decision making; -Impairment on one side of upper extremity; -Impairment on both sides of lower extremities; -Uses wheelchair for mobility; -Diagnoses included hip fracture, dementia, malnutrition, anxiety and depression. Review of the resident's physician orders, dated 10/20/23, showed an order of quarter bed side rails related to impaired mobility and diagnoses of unspecified injury at C4 level of cervical spinal cord, sequela (a condition which is the consequence of a previous disease or injury) and generalized muscle weakness. Review of the resident's medical record, showed no side rails assessment. Observation on 5/12/22 at 11:04 A.M., showed the resident's bed had one quarter side rail, to the resident's right side. The side rail was raised, while the resident sat in the wheelchair at bedside. During an interview on 5/14/25 at 11:00 A.M. the resident said he/she needed the side rail to get out of bed. During an interview on 5/14/25 at 12:33 P.M., CNA C said the resident's side rails were used for positioning and mobility. The resident used the right side rail only for mobility. He/She used it for standing or getting out of bed with one assist. 7. During an interview on 5/14/25 at 12:41 P.M., RN D said side rails were used for turning, positioning and safety. He/She had not assessed anyone for the use of side rails and was not sure who was responsible for assessing the use of side rails. During an interview on 5/14/25 at 12:49 P.M., LPN E said side rails were used for positioning and to prevent falls. Nursing did not assess for the use of side rails. He/She never assessed a resident for the use of side rails. If and when residents needed a side rail, he/she would let the Administrator or MDS nurse know. During an interview on 5/15/25 at 9:26 A.M., the MDS Coordinator said she was only responsible for the residents' care plans and MDS. During an interview on 5/14/25 at 2:53 P.M., the Director of Nursing (DON) said positioning devices are used by therapy and the U-rails are used for positioning. Therapy will assess residents upon admission, annually and with a change in condition. The nurses should report the change in condition and document it in the progress note. When asked to clarify, the DON said therapy would assess, then the nurses would be responsible for quarterly and annual assessments. She did not specify if the nurses or therapy had done side rail assessments. During an interview on 5/14/25 at 3:43 P.M., the Director of Rehab said therapy could be responsible for side rail assessments going forward, then nursing would be responsible for assessing the use of side rails quarterly, annually and as needed. He/She was not sure who assessed for side rails currently, but therapy had not done any assessments recently. During an interview on 5/15/25 at 12:19 P.M., the Administrator and DON said side rails should be assessed quarterly, annually and with a change in condition. 40291 42247 45083

Based on interview and record review, the facility failed to provide and offer nourishing snacks at bedtime. This affected all residents who ate at the facility. The census was 46. Review of the dietary records, showed mealtimes scheduled for the following: -Breakfast meal at 7:30 A.M.; -Lunch meal at 12:15 P.M.; -Dinner meal at 5:30 P.M. During a group interview on 5/13/25 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. The residents said the staff just started passing out snacks. They pass the snacks out during the day, but not after dinner. This started within the last week or two. During an interview on 5/14/25 at 12:33 P.M., Certified Nursing Assistant (CNA) B said he/she worked the evening shift and snacks were not passed out in the evening. Activities would pass out snacks after lunch. During an interview on 5/14/25 at 12:34 P.M., CNA C said residents did not receive snacks in the evening. During an interview on 5/14/25 at 12:41 P.M., Registered Nurse (RN) D said residents did not receive evening snacks very often. During an interview on 5/14/25 at 12:49 P.M., Licensed Practical Nurse (LPN) E said bedtime or evening snacks were not provided to the residents. The Minimum Data Set (MDS) Nurse often brought snacks with his/her own money and passed them out at night. During an interview on 5/14/25 at 1:15 P.M., the Dietary Manager said he normally left the facility around 5:00 P.M. He would send snacks to the nurse's station. Often when he returned the next day, the snacks were still in the same spot where he left them. He did not believe staff passed out the snacks. During an interview on 5/15/25 at 12:19 P.M., the Administrator said it was her expectation that snacks were to be given to the residents after dinner. Snacks were out at the nurse's station.

Based on observation and interview, the facility failed ensure the ice machine had an air gap to prevent backflow from the drain pipe into the ice machine, potentially contaminating the contents of the ice machine. The census was 46. Observations on 5/12/25 at 9:53 A.M., 5/13/25 at approximately 8:30 A.M. and 5/14/25 at 8:07 A.M., 10:22 A.M. and 11:32 A.M., showed the ice machine located in the kitchen. The ice machine drain tubing extended down from the ice machine with the lower end of the drain tubing directly in the drain pipe. During an interview on 5/14/25 at 11:50 A.M., the Dietary Manager said he was not aware if there was an air gap from the drain tubing and drain pipe of the ice machine. When shown the tubing and drain, he said he would have to ask the Maintenance Director. During an interview on 5/14/25 at 11:53 A.M., the Maintenance Director said there was no air gap. The facility purchased the new ice machine around December 2024 and he had not yet created the air gap. The ice machine should have an air gap to prevent any backflow from the drainage pipe entering into the ice machine. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she would expect the ice machine to have an air gap.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS), for two residents who required EBP for wound treatment or a medically inserted device (urinary catheter, a sterile tube inserted into the bladder through the urinary tract to drain urine) (Residents #14 and #20). In addition, staff failed to cleanse the shared blood sugar machine (Accu-check) with approved cleansing products between each resident use. Additionally, the facility failed to ensure newly hired employees were provided a two-step Mantoux Purified Protein Derivative (PPD, used to test for tuberculosis (TB, a serious infectious disease caused by bacteria that often affects the lungs) infection) tuberculin skin test for three employees who had no documentation showing they received their first or the second step TB test (Employees A, E and F), two employees who received their first step after their hire date and had no documentation of receiving the second step (Employee C and D) and one employee who had no documentation of receiving the second step (Employee B) out of 10 employees sampled. The census was 46. Review of the facility's EBP policy, reviewed/revised 12/12/23, showed: -Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves; -An order for EBP will be obtained for residents with any of the following: -Wounds (e.g., chronic wounds such as pressure ulcers (injury to the skin and/or underlying tissue, as a result of pressure or friction), diabetic foot ulcers (an open wound or sore on the foot that occurs in people with diabetes), unhealed surgical wounds, and chronic venous stasis ulcers (ulcers caused by decrease in blood circulation)); -Indwelling medical devices (e.g., urinary catheters) even if the resident is not known to be infected or colonized with a MDRO; -Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray; -High contact resident care activities include: -Device care or use: urinary catheters: -Wound care: any skin opening requiring a dressing. Review of the facility's Glucometer (device used to measure blood sugar) Testing & Infection Control policy, dated 10/19/23, showed: -Policy: to standardize the treatment of Diabetes Mellitus (DM) through proper blood glucose (sugar) testing while maintaining proper infection control; -Procedure: A licensed nurse will: -Disinfect Accu-Check machines with germicidal (solution that kills or inactivates microorganisms, including bacteria, viruses, and fungi) disposable wipe between each resident. Wipe all contact surfaces, wrap wipe around machine to maintain 2-5-minute wet contact time. (By rotating machines between residents, the required 2-5 minutes will be achieved); -Set up equipment on clean surface (may use paper towel)-Accu-Check machine, test strip, alcohol wipe, disposable lancet, etc.; -Obtain Accu-Check; -Disinfect machine, remove gloves and wash hands. Review of the facility's Tuberculosis Infection Control policy, dated 6/24, showed: -The Infection Preventionist (IP) is responsible for oversite of the facility's TB program and reports activities to the facility's Quality Assurance and Assessment (QAA) committee; -TB infection: Residents and staff are tested for latent TB infections and screened for TB disease, if infected with TB; -Staff with a positive test are referred to occupational health care provider for evaluation. Review of the CDC guidance for Clinical Testing Guidance for TB: TST (TB skin test), dated 1/31/25, showed: -Background: The TB skin test is a test used to determine if a person is infected with TB bacteria. In this test, a standardized solution made with PPD, which is derived from tuberculin, is injected under the skin; -Determining an approach: -Two-step testing is a strategy used to reduce the likelihood that a boosted reaction will be misinterpreted as a recent infection if the person must be tested again. Two-step testing should be used for the initial (baseline) skin testing of persons who will be retested periodically. If the TB skin test is used for baseline testing of U.S. health care personnel, use two-step testing; -If the first TB skin test result is negative, a second TB skin test should be done one to three weeks later. Review of the ltc.health.mo.gov website, undated, showed, All new Long-Term Care facility employees who work 10 or more hours per week are required to obtain a Mantoux PPD (TB test) two-step tuberculin test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. It is the responsibility of each facility to maintain a documentation of each employee's tuberculin status. 1. Review of Resident #14's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/11/25, showed: -Moderately impaired cognitive skills for daily decision making; -Diagnoses included heart failure, diabetes, hip fracture, and malnutrition; -Risk of pressure ulcers; -Infection of the foot, diabetic ulcer, surgical wounds. Review of the resident's electronic Physician's Order Sheet (ePOS), showed: -On 4/8/25, Specialized Wound Care Management evaluation and treatment and treatment as indicated one time only related to osteomyelitis (infection of the bone), sepsis, Type II diabetes mellitus with diabetic peripheral angiopathy without gangrene (blood vessels in the legs or arms become narrowed or blocked, reducing blood flow without causing open wounds) for 12 months; -On 5/10/25, cleanse medial left toe with Vashe (wound solution) and apply betadine (antiseptic), cleanse with Vashe and apply skin prep to lateral left foot, cleanse with Vashe and apply Santyl (wound debriding ointment) to left heel wound bed and cover with Aquacel foam dressing every day and as needed, every dayshift for wound care; -No physician order for EBP. Observation and interview on 5/14/25 at 9:37 A.M., showed no EBP sign on or the by resident's door. Licensed Practical Nurse (LPN) E was in the resident's room with Nurse Practitioner (NP) F, providing wound treatments to the resident. NP F said they were just finishing up the resident's treatment. He/She then applied a foam dressing to the resident's left heel. LPN E and the NP F wore gloves. Neither wore gowns. 2. Review of Resident #20's admission MDS, dated [DATE], showed: -Cognitively intact; -Has indwelling catheter; -Diagnoses included abnormal or irregular heartbeat, high blood pressure, septicemia (blood poisoning), urinary tract infection (UTI), seizure disorder, malnutrition and respiratory failure; -Risk of pressure ulcers; -Has one or more unhealed pressure ulcers at Stage I or higher. Review of the resident's ePOS, dated 4/14/25, showed: -Cleanse lateral right foot with wound cleanser or NS (normal saline), apply zinc oxide to wound border and foam daily or dry dressing daily and PRN (as needed) every day shift every three days for wound treatment; -Cleanse right and left gluteus (buttock) with wound cleanser or NS and apply foam or dry dressing every three days or as needed every day shift every three days for wound treatment; -Cleanse right heel with wound cleanser or NS paint with thin layer of betadine and leave OTA (open to air) every day shift for wound treatment; -EBP related presence of indwelling catheter; -Indwelling catheter 16 French (Fr) 10 milliliter (ml) balloon. Observation and interview on 5/12/25 at 1:20 PM, showed Certified Nurse Assistant (CNA) A entered the resident's room. He/She said the PPE supplies on the wall were for the staff to use as needed when providing care to any residents. He/She did not specify the resident was on EBP. Observation on 5/14/25 at 10:27 A.M., showed no EBP sign on or by the resident's door. There were PPE supplies on the wall in the hallway, by the resident's door. Registered Nurse (RN) D assisted NP F in providing wound treatment. Both staff wore gloves but no gowns. RN D touched and moved the indwelling catheter when repositioning the resident. During an interview on 5/14/25 at 2:51 P.M., the Director of Nursing (DON) said there should be PPE on the residents' doors who had wounds, open areas and catheters. Staff should wear PPE when providing care to residents on EBP. Staff do not need to wear PPE if they will not be in close contact with residents or will not be in the room more than 15 minutes. PPE was to be worn when providing resident care. She expected staff to wear PPE appropriately. There should be an EBP sign on the door, but they were currently not utilizing signs. EBP residents' information were only located at the nurse's station. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she expected staff to wear PPE while providing care to residents on EBP. 3. Observation on 5/13/25 at 7:50 A.M., showed LPN E cleaned the blood sugar machine with an alcohol pad and placed the blood sugar machine on a barrier. LPN E performed the blood sugar test and cleaned the blood sugar machine with alcohol and wrapped the blood sugar machine with a paper towel. Observation on 5/13/25 at 8:05 A.M., showed LPN E used the same blood sugar machine to perform a blood sugar test on another resident. Then, he/she used an alcohol pad and cleaned the blood sugar machine and wrapped it in a paper towel. During an interview on 5/14/25 at 2:51 P.M., the DON said the blood sugar machines should be cleaned in between use with alcohol wipes. Observation and interview on 5/15/25 at 9:16 A.M., showed no germicidal disposable wipes in nurse medication cart 1. The cart contained the residents' insulin medications and blood sugar machines. LPN E said he/she used alcohol wipes to clean the blood sugar machines in between uses. Nurse medication cart 2 contained two tubs of germicidal disposable wipes, and a tub of bleach wipes. LPN G said he/she used germicidal disposable wipes for disinfecting the blood sugar machines and hard surfaces and used the bleach wipes for biohazard cleaning. During an interview on 5/15/25 at 12:19 P.M., the DON said staff may need to use multiple alcohol pads to clean the blood sugar machines. The Administrator expected the staff to follow their policy in cleaning the blood sugar machines. 4. Review of Employee A's employee file, showed: -Date of hire: 3/21/25; -No documentation the first or second step TB test was administered. Review of Employee E's employee file, showed: -Date of hire: 3/18/25; -No documentation the first or second step TB test was administered. Review of Employee F's employee file, showed: -Date of hire: 4/3/25; There was no documentation showing the first or second step TB test was administered. Review of Employee C's employee file, showed: -Date of hire: 6/24/25; -The first step was administered on 7/16/24 and read on 7/18/24; -No documentation the second step TB test was administered. Review of Employee D's employee file, showed: -Date of hire: 9/25/24; -The first step was administered on 12/3/24 and read on 12/6/24; -No documentation the second step TB test was administered. Review of Employee B's employee file, showed: -Date of hire: 11/14/24; -The first step was administered on 11/20/24 and read on 11/22/24; -No documentation the second step TB test was administered. During an interview on 5/14/25 at 1:40 P.M., the Administrator said employees should have a TB test completed upon hire, and at least one test should be completed prior to starting. Any nurse could administer/read the TB test. The DON should track the TB test administrations to ensure the second steps were completed. The Administrator expected all employees to have their TB tests completed. 45083

Based on interview and record review, the facility failed to follow their antibiotic stewardship policy by failing to collect data regarding residents' antibiotic treatments and reviewing and documenting that data on the facility approved antibiotic surveillance tracking form. This deficient practice had the potential to affect all residents receiving antibiotics. The census was 46. Review of the facility's Antibiotic Use Stewardship policy, dated 9/2/18, showed: -Policy Statement: To develop on going best practices to improve antibiotic use; -Policy: Antibiotic prescribing will be monitored & tracked monthly utilizing best practice standards developed by the Centers for Disease Control and Prevention (CDC) and other professionals; -Procedure: -Director of Nursing (DON)/designee will track dose, duration & indication of antibiotics prescribed monthly; -Ensure availability of preferred drugs in emergency inventory ; -Have Pharmacy Consultant review antibiotic usage & culture results monthly & make recommendations to DON for timely follow through; -Have Laboratory provide antibiogram (Antibiotic sensitivity testing or antibiotic susceptibility testing) routinely; -DON, Medical Director & Laboratory will collaborate on best practices of microbiology testing; -Use of antibiotic time out will be implemented by DON; -Report findings at Quality Assessment and Performance Improvement (QAPI) meetings. During an interview on 5/13/25 at 10:28 A.M., the DON said she was still working on the antibiotic stewardship information. She said the Minimum Data Set (MDS, a federally mandated assessment completed by facility staff) Coordinator had the antibiotic stewardship and surveillance. During an interview on 5/14/25 at 11:40 A.M., the MDS Coordinator said she was not responsible for the antibiotic stewardship or surveillance. In the past the Assistant Director of Nursing (ADON) or the DON completed this. During an interview on 5/14/25 at 11:45 A.M., the DON said she did not have the antibiotic stewardship or surveillance, but she could see what she could pull together because she had the reports and the MDS Coordinator had some information written down. Observation and interview on 5/14/25 at 2:51 P.M., showed the DON provided two sheets of paper which were labeled Infection Control/Antibiotic Surveillance Log. One sheet was for March 2025 and the other was for April 2025. Each sheet contained columns, and each column had the residents' information who were on antibiotics, such as their names, room numbers, infection sites, date of lab and pathogen, antibiotic ordered, antibiotic susceptible, if they were facility acquired, precautions, date treated, if they met the criteria, and date resolved. The DON said she had just completed those two sheets based on the MDS Coordinator's records. There were no records prior to March 2025. During an interview on 5/15/25 at 9:26 A.M., the MDS Coordinator said she had never done antibiotic tracking. She was only responsible for the residents' care plans and MDS. During an interview on 5/15/25 at 10:08 A.M., the DON said she was starting the antibiotic surveillance log sheet for May 2025. She said there were two or three residents on antibiotics; however, she was unable to provide names when requested. There was not an antibiotics tracking system prior to the survey. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she would expect the facility to follow their antibiotic stewardship policy. The DON said moving forward she would make sure the antibiotic stewardship was completed per their policy.

Based on interview, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Control Preventionist (ICP) for the facility's infection prevention control program. The census was 46. During the entrance conference on 5/12/25 at 9:14 A.M., the Administrator said the facility did not have an ICP. During an interview on 5/14/25 at 2:51 P.M., the Director of Nursing (DON) said the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Coordinator was in the process of getting her ICP certification. The DON just started her ICP classes for certification as well. During an interview 5/15/25 at 12:19 P.M., the Administrator said she expected the facility to have a certified ICP.

Based on observation, interview and record review, the facility failed to complete an inspection of bed frames, mattresses and side rails as part of a regular maintenance program to identify areas of possible entrapment for six residents (Residents #44, #5, #24, #9, #14 and #28) of 13 sampled residents with side rails. The census was 46. Review of the facility's Side Rails policy, dated 10/17/23, showed: -Policy: Assess resident side rail restraint needs on admission, annually and with any significant change in order to ensure the resident's highest practicable physical and psychosocial well-being. Review quarterly; -Procedure: -Side rails will be evaluated quarterly and reduced/eliminated as possible. 1. Review of Resident #44's hand written Bed Rail/Assist Bar Evaluation, showed one completed on 9/17, but did not specify the year. A half length and quarter length rail was indicated. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/26/25, showed: -Short and long-term memory problem; -No behaviors; -Upper and lower extremities: Impairment on one side; -Dependent on staff for mobility and transfers; -Diagnoses included fractures, hemiplegia (muscle weakness or paralysis on one side and depression. Review of the resident's May 2025 active physician's order, showed an order, dated 12/1/23, for bed rails. Quarter length related to impaired mobility and diagnoses of hemiplegia, unspecified affecting left nondominant side. Review of the resident's electronic medical record, viewed 5/13/25 at 10:50 A.M., showed no maintenance assessment for the use of side rails. Observation on 5/13/25 at 8:30 A.M., showed the resident lay on his/her back. Quarter length side rails were raised on both sides. The resident said he/she used the rails to help with positioning. 2. Review of Resident #5's electronic medical record, showed a Device/Restraint Evaluation, dated 10/18/22. Resident uses a grab bar. Review of the resident's hand written Bed Rail/Assist Bar Evaluation, showed one completed on 9/17, but did not specify the year. Review of the resident's quarterly MDS, dated [DATE], showed: -Rarely understood; -Dependent on staff for mobility and transfers; -Diagnoses included heart disease and dementia; -Bed rails not used. Review of the resident's May 2025 active physician's order, showed an order, dated 10/20/23: Resident has side rails, quarter length related to impaired mobility and diagnoses of abnormal posture and weakness. Observation on 5/12/25 at approximately 10:07 A.M., showed the resident sat in his/her wheelchair next to his/her bed. The resident's bed had raised quarter length side rails on both sides. The resident could not say what the side rails were used for. Review of the resident's electronic medical record, viewed 5/14/25 at 1:00 P.M., showed no maintenance assessment for the use of side rails. 3. Review of Resident #24's quarterly MDS, dated [DATE], showed: -Short term memory problem; -Long term memory ok; -Had functional limitation of range of motion in both upper extremities. -Was dependent (helper does all the effort. Resident does none of the effort to complete the activity) for rolling left to right, to change positions from lying to sitting on the side of the bed and to go from sitting to standing; -Diagnoses included: coronary artery disease (CAD, arteries that supply blood to the heart muscle become narrowed or blocked), high blood pressure, renal insufficiency (kidneys unable to function properly), obstructive uropathy (normal flow of urine through the urinary tract is blocked or hindered), stroke and Parkinson disease. Review of the care plan in use at the time of survey, showed: -Focus: resident has an Activities of Daily Living (ADL, grooming, dressing, bathing) self-care performance deficit; -Goal: will maintain current level of function in through the next review; -Interventions included: bed mobility, the resident can roll over in bed with use of the enabler rails. Review of the medical record, showed: -A physician order for bed side rails (1/4) related to impaired mobility and diagnoses of muscle weakness; -No documentation of maintenance inspection for possible areas of entrapment. Observation and interview on 5/5/25 at 10:24 A.M., the resident lay in bed with the top U shaped side rails up on both sides . The resident said he/she used them to help him/her to stand up. Observation on 5/14/25 at 2:00 P.M., the resident lay in bed. Registered Nurse (RN) H was assisting the resident to roll from his/her back onto his/her left side. The resident grabbed the side rail to help roll over. 4. Review of Resident #9's annual MDS, dated [DATE], showed: -Re-admitted [DATE]; -Cognitively intact; -Uses wheelchair for mobility; -Diagnoses included stroke, Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), hemiplegia or hemiparesis (neurological conditions that cause weakness or paralysis on one side of the body). Review of the resident's ePOS, dated 10/20/23, showed an order for 1/4 bed side rails related to mobility & diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side. Review of the resident's medical record, showed no side rails assessment. Observation on 5/12/22 at 10:38 A.M., the resident had side rails on both sides of his/her bed. During an interview on 5/14/25 at 9:34 A.M., the resident said he/she used the side rails for positioning. 5. Review of Resident #14's significant change MDS, dated [DATE], showed: -Re-admitted [DATE]; -Moderately impaired cognitive skills for daily decision making; -Uses wheelchair for mobility; -Diagnoses included heart failure, diabetes, hip fracture and malnutrition. Review of the resident's ePOS, dated 4/8/25, showed an order for left and right 1/4 rail enabler bars to aide in bed positioning and transfers. Observation on 5/14/22 at 10:22 A.M., showed the resident had side rails on both sides of his/her bed. During an interview on 5/14/25 at 12:50 P.M., LPN E said he/she did not know why the resident had side rails in bed, but he/she was able to use the rails, and he/she thinks they were beneficial for the resident with turning and positioning. 6. Review of Resident #28's significant change MDS, dated [DATE], showed: -Re-admitted [DATE]; -Moderately impaired cognitive skills for daily decision making; -Impairment on one side of upper extremity; -Impairment on both sides of lower extremities; -Uses wheelchair for mobility; -Diagnoses included hip fracture, dementia, malnutrition, anxiety and depression. Review of the resident's ePOS, dated 10/20/23, showed an order for 1/4 bed side rails related to impaired mobility and diagnosis of unspecified injury at C4 level of cervical spinal cord, sequela (a condition which is the consequence of a previous disease or injury) and generalized muscle weakness. Review of the resident's medical record, showed no side rails assessment. Observation on 5/12/22 at 11:04 A.M., showed the resident's bed had one 1/4 side rail, to the resident's right side. The side rail was raised up, while the resident was up sitting in the wheelchair at bedside. During an interview on 5/14/25 at 11:00 A.M. the resident said he/she needed the side rail to get out of bed. During an interview on 5/14/25 at 12:33 P.M., Certified Nurse's Aide C said the residents' side rails were use for positioning and mobility. Resident #28 used right side rail only for mobility. He/She used it for standing up or getting out of bed with one assist. 7. During an interview on 5/15/25 at 9:21 A.M., the Maintenance Director said he was responsible for completing routine inspections of bed rails, but had not done it in about a year. During an interview on 5/15/25 at 12:19 P.M., the Administrator and DON said side rails should be assessed quarterly, annually and with a change in condition. The administrator would expect maintenance to also assess for entrapments and document the assessments quarterly, annually and during a change in condition. 40291 42247 45083 -

Based on interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 18 CNAs who worked for the facility for at least one year. Two Certified Medication Technicians (CMTs), (CMT L and CMT K) and eight CNAs (CNA J, CNA I, CNA M, CNA N, CNA O, CNA P, CNA Q, and CNA R), were sampled. The facility failed to document the date and length of time the training was provided for 10 of 10 sampled staff. The census was 46. 1. Review of CMT L's employee file, showed: -Date of hire: 9/8/22; -Evaluation date: 9/8/24, in the date column, 21 topics were checked; -The in-service failed to show the date and length of time the training was provided. 2. Review of CMT K's employee file, showed: -Date of hire: 1/9/24; -Evaluation date: 1/9/25, in the date column, 26 topics were checked; -The in-services failed to show the date and length of time the training was provided. 3. Review of CNA J's employee file, showed: -Date of hire: 5/25/18; -Evaluation date: 5/23/24, in the date column, 11 topics were checked; -The in-services failed to show the date and length of time the training was provided. 4. Review of CNA I's employee file, showed: -Date of hire: 6/10/22; -Evaluation date was blank, in the date column 13 topics were checked; -The in-services failed to show the date and length of time the training was provided. 5. Review of CNA M's employee file, showed: -Date of hire: 4/5/24; -Evaluation date: 4/5/25, in the date column 27 topics were checked; -The in-services failed to show the date and length of time the training was provided. 6. Review of CNA N's employee file, showed: -Date of hire: 4/6/10; -Evaluation date: 4/6/24, in the date column 26 topics were checked; -The in-services failed to show the date and length of time the training was provided. 7. Review of CNA O's employee file, showed: -Date of hire: 9/9/20; -Evaluation date: 9/9/24, in the date column 22 topics were checked; -The in-services failed to show the date and length of time the training was provided. 8. Review of CNA P's employee file, showed: -Date of hire: 7/20/23; -Evaluation date: 7/20/24, in the date column 20 topics were checked; -The in-services failed to show the date and length of time the training was provided. 9. Review of CNA Q's employee file, showed: -Date of hire: 8/17/22; -Evaluation date: 8/17/24, in the date column 21 topics were checked; -The in-services failed to show the date and length of time the training was provided. 10. Review of CNA R's employee file, showed: -Date of hire: 10/9/18; -Evaluation date: 10/9/24, in the date column 11 topics were checked; -The in-services failed to show the date and length of time the training was provided. 11. During an interview on 5/13/25 at 10:28 A.M., the Director of Nursing (DON) said she started at the facility at the end of March 2025 and she did not know the dates or the length of time the education was provided. 12. During an interview on 5/14/25 at 11:50 A.M., the Administrator said she would expect for the CNAs to complete their 12 hours of required education yearly. The date and length of education should be tracked along with the topic discussed. The DON was responsible for tracking the CNA education.

Based on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation, for one resident (Resident #48). The sample was 13. The census was 46. Review of the facility's Discharge Summary and Plan policy, reviewed 2/21, showed: -The discharge plan, instructions and summary provides a recapitulation or summary of the resident's stay; -Discharge planning will begin upon admission to the facility; -Admitting nurse will document the resident, family/caregiver stated reason for admission and the resident, family/caregiver plan for discharge; -Case Manager or Minimum Data Set (MDS, a federally mandated assessment completed by facility staff) nurse will make post discharge follow up calls and complete the discharge post discharge, follow up phone call assessment in the resident record. Review of Resident #48's Admission Record, showed: -admitted [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD, a condition caused by damage to the airways or other parts of the lung), congestive heart failure (CHF, a condition where the heart cannot pump blood effectively), pulmonary edema (PE, a condition caused by too much fluid in the lungs), respiratory failure (a condition that makes it difficult to breathe on your own), and stage IV chronic kidney disease. Review of the resident's Census List, showed: -On 4/23/25 at 10:06 A.M., Status: Active, Action Code: Actual admission; -On 4/23/25 at 5:30 P.M., Status: Stop Billing, Action Code: discharge date . Review of the resident's health records, showed: -No physician orders for discharge; -No documentation in progress notes of resident's discharge or if resident left against medical advice (AMA); -No signed against medical advice (AMA); -No discharge summary report; -No post discharge documentation. During an interview on 5/14/25 at 2:51 P.M., the Director of Nursing (DON) said the resident came to the facility and left right away. She was notified the resident wanted to change his/her physician. She was not in the facility at that time and needed time to review the resident's records and start the process of changing physician and getting orders. She was notified by staff the resident left the facility with family just few hours after admission. The discharge process was not completed. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she expected staff to complete the resident's discharge process and documentation.

Based on observation, interview and record review, the facility failed to assess one resident for the use of a belt restraint (Resident #44). The resident had a belt restraint on his/her wheelchair. The facility failed to assess the resident for its use, obtain a physician's order and document the use in the resident's care plan. In addition, the facility failed to ensure staff accurately documented medications, treatments, pain assessments, and behavior monitoring for two residents (Residents #19 and #6). The sample size was 13. The census was 46. Review of the facility's Restraints policy, dated 9/2/29, showed: -Policy Statement: Restraints are devices that prevent or restrict certain actions and/or behaviors and are not easily removed. There are Federal Regulations that govern the use of restraints on residents in long-term care facilities. Restraint usage can increase the scope and severity of injury. It is the goal of the facility to be restraint free in accordance with clinical best practices; -Policy: In order to provide the best possible care to residents, both physically and emotionally and comply with federal requirements governing same, facility shall restrict the use of restraints, both chemically and physically. Restraints shall only be used in the facility when they are required to temporarily treat a life-threatening situation or to treat the resident's medical condition. In non-life threatening situations, restraints will be used only after assessment, physician order, explanation to resident and or legally authorized representative, when the benefits outweigh the risks and the resident and his/her legally authorized representative does not refuse; -Procedure: -All residents, their legally authorized representative, and responsible parties shall be given a copy of the Use of Restraints/Informed Consent for the Use form; -Physician orders for restraints will be obtained by nursing staff, always ensuring the least restrictive device is used. Orders will be time framed and include the medical reason for use; -Restraint usage will be reviewed on admission, quarterly and annually and with any significant change. Restraint usage will be care planned and the reason for the use of the restraint will be discussed with the resident and/or responsible party; -Restraints will be monitored at least every 30 minutes and released every two hours unless contraindicated. 1. Review of Resident #44's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/26/25, showed: -No information regarding cognition; -No behaviors; -Used a manual wheelchair; -Dependent on staff for all mobility and personal hygiene; -Diagnoses included fractures, hemiplegia (muscle weakness or partial paralysis on one side of the body) and depression; -Restraints not used. Review of the resident's care plan, in use during the time of the investigation, updated 3/3/25 and viewed on 5/12/25 at 5:14 P.M., showed no information regarding the use of a restraint or wheelchair belt. Review of the resident's May 2025 Physician's Order Sheet (POS), viewed 5/12/25 at 5:10 P.M., showed no order for the use of a restraint or wheelchair belt. Review of the resident's Assessment forms, viewed 5/13/25 at 10:50 A.M., showed no assessment for the use of a restraint. Observation on 5/13/25 at 8:30 A.M., showed the resident lay in bed on his/her back. The resident's wheelchair was next to his/her bed, with a belt sitting on the seat of the wheelchair. Observation on 5/14/25 at 10:21 A.M., showed the resident in the dining room participating in activities. He/She sat in his/her wheelchair with a black belt wrapped loosely around his/her waist. Observation and interview on 5/14/25 at 12:26 P.M., showed the resident sat in the dining room in his/her wheelchair. The belt was loosely wrapped around the resident's waist. The resident's boy/girlfriend was present and said they had a hard time tightening the belt. The resident said he/she used the belt to keep from falling and knew how to release the belt, if needed. He/She said the belt was necessary to prevent falling out of the wheelchair. During an interview on 5/14/25 at 10:42 A.M., Certified Nursing Assistant (CNA) A said he/she was familiar with the resident. He/She thought the belt was built into the wheelchair. The resident used the belt to prevent falling from the wheelchair. During an interview on 5/14/25 at 12:33 P.M., CNA C said the resident used the belt restraint to keep from falling out of the wheelchair. During an interview on 5/14/25 at 12:41 P.M., Licensed Practical Nurse (LPN) D said he/she was familiar with the resident and was not aware of the resident using a belt restraint. If there was a belt restraint used, there should be a physician's order for its use. During an interview on 5/14/25 at 12:49 P.M., LPN E said he/she was familiar with the resident and never noticed a belt on the resident's wheelchair. If the resident used a belt restraint, it was to keep him/her from falling out of the wheelchair. The resident has involuntary movements and may need it to prevent falls from the wheelchair. During an interview on 5/14/25 at 2:53 P.M., the Director of Nursing (DON) said they did not have anyone at the facility using a restraint or a wheelchair belt. When asked about the resident, the DON said she was not aware the resident had a belt restraint on his/her wheelchair. If there was a belt on the wheelchair, there should be a physician's order, an initial assessment should be done, along with quarterly assessments and during changes in condition. It should be documented on the care plan and the resident should be assessed every two hours to ensure he/she could release the belt. During an interview on 5/15/25 at 12:19 P.M., the Administrator and DON said they initially did not know the resident had the belt on his/her wheelchair. When it was discovered, they immediately obtained a physician's order, entered it onto the care plan and assessed the resident. The resident should have been assessed prior to wearing the belt restraint. 2. Review of Resident 19's medical record, showed: -Intact Cognition; -Diagnoses included diabetes mellitus (DM, metabolic disease), hyperlipidemia (high cholesterol), stroke, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), and epilepsy (seizure disorder). Review of the resident's Nurse Medication Administration Record (NMAR), dated 4/1/25 to 4/30/25, showed: -An order to check blood glucose before meals. If blood glucose is less than 50 or greater than 500 please call doctor right away. If blood sugar is less than 100 at bedtime, take a snack (one carbohydrate and one protein) with meals related to type 2 diabetes mellitus with unspecified complication; -An order to monitor every shift for opioid usage side effects: Blue or purple skin, fingernails, or lips. Unresponsive to voice or touch. Loss of consciousness. Pinpoint sized pupils. Bradycardia (slow heart rate) or hypotension (low blood pressure). Slow, shallow, irregular or stopped breathing. Pale, clammy, cool skin. Extreme sleepiness or lethargy. Breathing difficulty with choking sounds, gasping, gurgling or snoring noise. Limp, lifeless body movement. Every shift for opioid usage. Review of the resident's POS, showed no physician orders for checking the blood glucose levels or for monitoring opioid usage. 3. Review of the Charting and Documentation Policy, dated February 2021, showed: -Policy: -Chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations; -Be concise, accurate, and complete and use objective terms. Document only the facts. Use only approved abbreviations and symbols; -Chart as often as necessary and as need arises; -Charting Errors: -Do not erase/delete any error. Erasures or deletions of any type may must not be made in the medical record -Draw a single line through the error and write the correction above the error, and initial the change. Do not use white out; -Do not leave blank lines. Draw a single line through a blank line. Review of Resident's #19 medical record, showed: -Intact Cognition; -Diagnoses included diabetes mellitus, hyperlipidemia (high cholesterol), stroke, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and epilepsy (seizure disorder). Review of the resident's POS, dated 5/13/25, showed: -An order dated 4/26/24, for Amlodipine Besylate Tablet 10 milligram (mg) tablet, give 1 tablet by mouth one time a day for hypertension; -An order dated 1/23/25, for Furosemide Tablet 20 mg tablet, give 1 tablet by mouth one time a day for congestive heart failure; -An order dated 6/12/24, for Ginger Oral Capsule 500 mg, give 1 capsule by mouth one time a day for supplement; -An order dated 3/4/25, for Keppra Tablet 500 mg, give 500 mg by mouth every 12 hours related to convulsion disorder with seizures or convulsions; -An order dated 2/14/25, for Lipitor Oral tablet 40 mg, give 1 tablet by mouth at bedtime related to diabetes mellitus with unspecified complications; -An order dated 7/23/23, for Clonidine HCI Oral Tablet 0.1 mg, give 1 tablet by mouth three times a day for hypertension; -An order dated 3/15/25, track and document hours of sleep each shift related to melatonin use. Every evening and night shift related to insomnia; -An order dated 2/19/25, for Nystatin powder, apply to breast, right flank, axilla topically every shift for redness/irritation; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -An order dated 8/6/24, for Lisinopril Oral Tablet 10 mg, give 10 mg by mouth one time a day for hypertension related to cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery; -An order dated 12/27/21, for Melatonin tablet 3 mg, give 3 mg by mouth at bedtime for insomnia; -An order dated 3/15/23, for Saccharomyces Boulardii oral capsule 250 mg, give 1 capsule by mouth one time a day for diarrhea; -An order dated 12/13/17, for Acetaminophen Oral Tablet 325 mg, give 2 tablets by mouth two times a day for mild pain . Do not exceed 4000 mg in 24 hours; -An order dated 1/2/25, for Kasaglar Kwikpen subcutaneous solution pen-injector 100 unit/ml (insulin glargine). Inject 14 units subcutaneously at bedtime related to type 2 diabetes mellitus with unspecified complications; -An order dated 7/10/23, for Glipizide Oral Tablet 10 mg, give one tablet by mouth in the morning related to type 2 diabetes mellitus with unspecified complications; -An order dated 8/3/23, for Tramadol HCI tablet 50 mg, give 1 tablet by mouth two times a day for osteoarthritis. Review of the resident's Medication Administration Record (MAR), dated 4/1/25 to 4/30/25, showed: -An order dated 4/26/24, for Amlodipine Besylate Tablet 10 mg tablet, give 1 tablet by mouth one time a day for hypertension; -Documentation showed one out of 30 opportunities left blank; -An order dated 1/23/25, for Furosemide Tablet 20 mg tablet, give 1 tablet by mouth one time a day for congestive heart failure; -Documentation showed one out of 30 opportunities left bank; -An order dated 6/12/24, for Ginger Oral Capsule 500 mg, give 1 capsule by mouth one time a day for supplement; -Documentation showed one out of 30 opportunities left blank; -An order dated 2/14/25, for Lipitor Oral Tablet 40 mg, give 1 tablet by mouth at bedtime related to diabetes mellitus with unspecified complications; -Documentation showed two out of 30 opportunities left blank; -An order dated 3/4/25, for Keppra tablet 500 mg, give 500 mg by mouth every 12 hours related to convulsion disorder with seizures or convulsions; -Documentation showed six out of 60 opportunities left blank; -An order dated 7/23/23, for Clonidine HCI oral tablet 0.1 mg, give 1 tablet by mouth three times a day for hypertension; -Documentation showed four out of 90 opportunities left blank; -An order dated 8/6/24, for Lisinopril Oral Tablet 10 mg, give 10 mg by mouth one time a day for hypertension related to cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery; -Documentation showed one out of 30 opportunities left blank; -An order dated 12/27/21, for Melatonin tablet 3 mg, give 3 mg by mouth at bed; -Documentation showed one out of 30 opportunities left blank; -An order dated 12/13/17, for Acetaminophen Oral Tablet 325 mg, give 2 tablets by mouth two times a day for mild pain. Do not exceed 4000 mg in 24 hours; -Documentation showed three out of 60 opportunities left blank; -An order dated 1/2/25, for Kasaglar Kwikpen subcutaneous solution pen-injector 100 unit/ml. Inject 14 units subcutaneously at bedtime related to type 2 diabetes mellitus with unspecified complications; -Documentation showed one out of 30 opportunities left blank; -An order dated 7/10/23, for Glipizide oral tablet 10 mg, give one tablet by mouth in the morning related to type 2 diabetes mellitus with unspecified complications; -Documentation showed one out of 30 opportunities left blank; -An order dated 8/3/23, for Tramadol HCI tablet 50 mg, give 1 tablet by mouth two times a day for osteoarthritis; -Documentation showed one out of 30 opportunities left blank; Review of the Treatment Administration Record (TAR), dated 4/1/25 to 4/30/25, showed: -An order dated 3/15/25, track and document hours of sleep each shift related to melatonin use. Every evening and night shift related to insomnia; -Documentation showed three out of 60 opportunities left blank; -An order dated 2/19/25, for nystatin powder, apply to breast, right flank, axilla topically every shift for redness/irritation; -Documentation showed two out of 90 opportunities left blank; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -Documentation showed two out of 90 opportunities left blank; Review of the resident's MAR, dated 5/1/25 to 5/31/25, showed: -An order dated 8/3/23, for tramadol HCI tablet 50 mg, give 1 tablet by mouth two times a day for osteoarthritis; -Documentation showed one out of 12 opportunities left blank; Review of the resident's TAR, dated 5/1/25 to 5/31/25, showed: -An order dated 3/15/25, track and document hours of sleep each shift related to melatonin use. Every evening and night shift related to insomnia; -Documentation showed one out of 24 opportunities left blank; -An order dated 2/19/25, for Nystatin powder, apply to breast, right flank, axilla topically every shift for redness/irritation; -Documentation showed two out of 36 opportunities left blank; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -Documentation showed one out of 36 opportunities left blank; 4. Review of Resident #6's medical record, showed the following: -Severely impaired cognition; -Diagnoses included atrial fibrillation (a-fib, irregular heart rhythm), heart failure, diabetes mellitus, hypertension, hyperlipidemia (high cholesterol), dementia, osteoporosis, depression, chronic obstruction pulmonary disease (COPD, lung disease) and respiratory disease. Review of the resident's POS, dated 5/13/25 showed: -An order dated 8/6/23, for Anticoagulant medication. Monitor for discolored urine, black tarry stools, sudden severe headache, a&v1, diarrhea, muscle and joint pain, lethargy, bruising, sudden changes in mental status and/or signs or symptoms (s/s), shortness of breath (SOB), and nose bleeds; -An order dated 6/3/24, for Antidepressant medication. Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior; -An order dated 6/3/24, for antipsychotic medication. Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting, lethargy, drooling, Extrapyramidal symptoms (EPS) symptoms, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -An order dated 4/19/25, to validate function every shift related to dementia in other diseases classified elsewhere, unspecified severity with agitation; -An order dated 4/5/22, for Amlodipine Besylate Tablet 10 mg tablet, give 1 tablet by mouth one time a day related to hypertension; -An order dated 4/5/22, for Aspirin 81 tablet delayed release, give 1 tablet by mouth one time a day related to atherosclerotic heart disease of native coronary artery without angina pectoris; atherosclerotic of aorta; -An order dated 8/5/24, for Bisacodyl oral tablet delayed release 5 mg tablet, give 1 tablet by mouth in the evening for constipation; -An order dated 9/11/24, for Famotidine Oral Tablet 20 mg Tablet, give 1 tablet by mouth one time a day for gastroesophageal reflux disease (GERD, acid reflux); -An order dated 8/5/24, for Miralax Oral Packet 17 mg, give 1 packet by mouth one time a day for constipation; -An order dated 4/7/22, for Sertraline HCI Tablet 25 mg, give 25 mg one time a day for depression related to major depressive disorder; -An order dated 9/17/24, for Vitamin C Oral Tablet, give 1 tablet by mouth one time a day for GERD; -An order dated 9/27/23, for Acetaminophen Oral Tablet 500 mg, give 1000 mg by mouth two times a day for pain per Hospice; -An order dated 4/5/22, for Carvedilol Tablet 6.25 mg, give 25 mg one tablet two times a day related to atherosclerotic heart disease of native coronary artery without angina pectoris; hypertension; -An order dated 11/15/22, for Quetiapine Fumarate Oral Tablet 50 mg, (give 1 tablet by mouth two times a day for psychosis, verbal/physical aggression related to dementia in other diseases classified elsewhere unspecified severity, with agitation; -An order dated 1/7/25, for Med Pass Supplement three times a day for dietary supplement, give 120 milliliters (ML); Review of the resident's MAR, dated 4/1/25 to 4/30/25, showed: -An order dated 4/5/22, for Amlodipine Besylate Tablet 10 mg tablet, give 1 tablet by mouth one time a day related to hypertension; -Documentation showed one out of 30 opportunities left blank; -An order dated 4/5/22, for Aspirin 81 tablet delayed release, give 1 tablet by mouth one time a day related to atherosclerotic heart disease of native coronary artery without angina pectoris; atherosclerotic of aorta; -Documentation showed one out of 30 opportunities left blank; -An order dated 8/5/24, for Bisacodyl oral tablet delayed release 5 mg tablet, give 1 tablet by mouth in the evening for constipation; -Documentation showed one two of 30 opportunities left blank; -An order dated 9/11/24, for Famotidine Oral Tablet 20 mg tablet, give 1 tablet by mouth one time a day for GERD; -Documentation showed one out of 30 opportunities left blank; -An order dated 8/5/24, for Miralax Oral Packet 17 mg, give 1 packet by mouth one time a day for constipation; -Documentation showed one out of 30 opportunities left blank; -An order dated 4/7/22, for Sertraline HCI Tablet 25 mg, give 25 mg one time a day for depression related to major depressive disorder; -Documentation showed one out of 30 opportunities left blank; -An order dated 9/17/24, for Vitamin C Oral Tablet, give 1 tablet by mouth one time a day for GERD; -Documentation showed one out of 30 opportunities left blank; -An order dated 9/27/23, for Acetaminophen Oral Tablet 500 mg, give 1000 mg by mouth two times a day for pain per Hospice; -Documentation showed two out of 60 opportunities left blank; -An order dated 4/5/22, for Carvedilol Tablet 6.25 mg, give 25 mg one tablet two times a day related to Atherosclerotic heart disease of native coronary artery without angina pectoris; hypertension; -Documentation showed three out of 60 opportunities left blank; -An order dated 11/15/22, for Quetiapine Fumarate Oral Tablet 50 mg, give 1 tablet by mouth two times a day for psychosis, verbal/physical aggression related to dementia in other diseases classified elsewhere unspecified severity, with agitation; -Documentation showed three out of 60 opportunities left blank; -An order dated 1/7/25, for Med Pass Supplement three times a day for dietary supplement, give 120 milliliters (ML); -Documentation showed four out of 90 opportunities left blank. Review of the resident's TAR, dated 4/1/25 to 4/30/25, showed: -An order dated 8/6/23, for Anticoagulant medication. Monitor for discolored urine, black tarry stools, sudden severe headache, diarrhea, muscle and joint pain, lethargy, bruising, sudden changes in mental status and/or s/s, SOB and nose bleeds; -Documentation showed two out of 90 opportunities left blank; -An order dated 6/3/24, for antidepressant medication. Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior; -Documentation showed two out of 90 opportunities left blank; -An order dated 6/3/24, for antipsychotic medication. Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting, lethargy, drooling, EPS symptoms, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue; -Documentation showed two out of 90 opportunities left blank; -An order dated 8/6/23, for Black Box Warning: Monitor for adverse cardiovascular effects, infections (especially respiratory), falls, blood nose and lipid elevations, abnormal involuntary movements, cerebrovascular adverse events, sedation, and death every shift for psychotic features related to dementia in other diseases classified elsewhere with behavioral disturbances; -Documentation showed two out of 90 opportunities left blank; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -Documentation showed two out of 90 opportunities left blank. Review of the resident's TAR, dated 5/1/25 to 5/31/25, showed: -An order dated 8/6/23, for Anticoagulant medication. Monitor for discolored urine, black tarry stools, sudden severe headache, diarrhea, muscle and joint pain, lethargy, bruising, sudden changes in mental status and/or s/s, SOB and nose bleeds; -Documentation showed two out of 36 opportunities left blank; -An order dated 6/3/24, for antidepressant medication. Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior; -Documentation showed two out of 36 opportunities left blank; - -An order dated 6/3/24, for antipsychotic medication. Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea/vomiting, lethargy, drooling, EPS symptoms, tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue; -Documentation showed two out of 36 opportunities left blank; -An order dated 8/6/23, for Black Box Warning: Monitor for adverse cardiovascular effects, infections (especially respiratory), falls, blood nose and lipid elevations, abnormal involuntary movements, cerebrovascular adverse events, sedation, and death every shift for psychotic features related to dementia in other diseases classified elsewhere with behavioral disturbances; -Documentation showed two out of 36 opportunities left blank; -An order dated 5/23/23, for pain assessment every shift for admission protocol; -Documentation showed two out of 36 opportunities left blank; -An order dated 4/19/25, to validate function every shift related to dementia in other diseases classified elsewhere, unspecified severity with agitation; -Documentation showed two out of 36 opportunities left blank; 5. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she expected residents' records to be accurate and complete. There should not be any holes on the MARs and/or TARs. 40291

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice when staff failed to transcribe a new order, resulting in the treatment not administered for one resident (Resident #24). The sample was 13. The census was 46. Review of the facility's Medical Provider Orders policy, dated reviewed/revised 4/17/22, showed: -If using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy; -When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order; -Validate the new order in the electronic Medication Administration Record (MAR)/Treatment Administration Record (TAR); Review of the facility's Medication Orders policy, dated effective 6/1/18, showed: -Orders sent with the resident from an office visit, the nurse on duty at the time the order is received enters it on the physician order sheet telephone order sheet/electronic medical record depending on facility protocol and notes the order as follows: Noted time, date, nurse signature; -If the order is from a prescriber other than the attending physician, the order is verified with the current attending physician; -Written Transfer Orders (sent with a resident by a hospital or other health care facility): -Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission; -If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered. The nurse documents verification on the admission order record by entering the time, date, and signature; -The nurse who transcribes the orders to the physician order sheet electronic medical record and MAR documents on the admission form the date, the time and by whom the orders were noted. Review of the facility's Charting and Documentation policy, dated reviewed 2/21, showed: -Documentation pertaining to residents' leave of absence (i.e., trips to physician's office, treatments, home, emergency room , or another therapeutic leave) should include: -Date and time resident left the facility. -Reason for resident leaving the facility. -Date and time resident returned. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/22/25, showed: -Short term memory problem; -Long term memory ok; -Dependent (helper does all the effort. Resident does none of the effort to complete the activity) for grooming, dressing and bathing; -Diagnoses included coronary artery disease (CAD, arteries that supply blood to the heart muscle become narrowed or blocked), high blood pressure, renal insufficiency (kidneys unable to function properly), obstructive uropathy (normal flow of urine through the urinary tract is blocked or hindered), stroke and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors); -Had an indwelling catheter (a sterile tube inserted into the bladder to drain urine); -Always incontinent of bowel and bladder; -Moisture Associated Skin Damage (MASD, skin's barrier is compromised due to prolonged exposure to moisture and its contents); -Had applications of ointments/medications other than to feet. Review of the care plan, in use at the time of survey, showed: -Focus: The resident has bladder incontinence; -Interventions included: check the resident every two hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes; has catheter; Review of the progress notes dated 4/8/25 through 4/9/25, showed: -On 4/8/25 at 3:40 P.M., showed, resident complained of penile pain. Registered Nurse (RN) assessed area. Catheter was displaced and area bleeding. RN informed the doctor and removed the catheter. The doctor ordered Keflex (antibiotic) three times a day for 10 days. He/She also ordered Lotrimin topically until healed. RN replaced catheter. Referral to urologist order completed and sent to appropriate staff to schedule; -On 4/8/25 at 4:10 P.M., per family request resident was sent to the hospital emergency room (ER) via emergency medical service (EMS) to evaluate penis tear from catheter; -On 4/9/25 at 5:41 A.M., resident returned to facility via ambulance and two emergency medical technicians (EMTs) from hospital due to penis injury. Arrived at 2:15 A.M. with new order for Nystatin to affected area twice daily. Review of the After Visit Summary from the ER, dated 4/8/25, showed: -Reason for visit: penis injury; -Diagnosis: inflammation of penis; -Instructions: patient's penis must be properly cleaned with soap and water twice daily, clean thoroughly prior to applying prescribed Nystatin cream; -Your medications have changed: start taking Nystatin (myostatin, antifungal) 100,000 unit/gram cream, apply to affected area two times daily. Review of the Treatment Administration Record (TAR), dated 4/9/25 through 4/23/25, showed: -A physician order for Nystatin-Triamcinolone Cream (combination medication containing an antifungal and corticosteroid) 100000-0.1 unit/gram-%, apply topically two times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry and apply cream to coccyx and scrotal area. Do not cover; -A.M.: on 4/9 through 4/23, administered; -P.M.: on 4/9 through 4/13, administered, 4/14 was blank, on 4/15 a 7 (sleeping) was documented, on 4/16 through 4/23, administered; -A physician order for Triad hydrophilic wound dress external paste, apply to coccyx and scrotal area topically three times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry then apply a liberal amount of cream to coccyx and scrotal area. Do not apply any dressing to area; -A.M. and Noon: on 4/9 through 4/23, administered; -P.M.: on 4/9 through 4/13, administered, 4/14 was blank, on 4/15 a 7 (sleeping) was documented, on 4/16 through 4/23, administered. Review of the progress notes, dated 4/9/25 through 4/23/25., showed no documentation of the order for Nystatin from 4/9/25 was verified with the resident's physician and there was no documentation showing the physician wished to continue the Nystatin/Triamcinolone cream. Review of the progress notes, showed no documentation the resident went to the ER and returned to the facility. There was no documentation new treatment orders were verified with the physician or documentation showing the physician did not want to change the treatment. Review of the After Visit Summary from the ER, dated 4/23/25, showed: -Reason for visit: urinary catheter problems; -Diagnosis: inflammation of the penis; -Instructions: we discussed case with the urologist who is recommending Nystatin cream, local wound care, barrier creams as needed given the catheter is flowing appropriately; -Changes to your medication list: -Nystatin 100,000 unit/gram cream. Apply to affected area two times daily. What changes, another medication with the same name was added, make sure you understand how and when to take each; -Nystatin 100,000 unit/gram powder (Nystop, antifungal), apply to affected area twice daily. You were already taking a medication with the same name and this prescription was added. Make sure you understand how and when to take each; -This list has two medications that are the same as other medications prescribed for you. Read directions carefully and ask your doctor or other care provider to review them with you. Review of the TAR, dated 4/23/25 through 4/30/25, showed: -A physician order for Nystatin-Triamcinolone Cream 100000-0.1 unit/gram-%, apply topically two times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. pat dry and apply cream to coccyx and scrotal area. Do not cover; -A.M. and P.M., documented as administered; -A physician order for Triad hydrophilic wound dress external paste, apply to coccyx and scrotal area topically three times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry then apply a liberal amount of cream to coccyx and scrotal area. Do not apply any dressing to area; -A.M., Noon and P.M., documented as administered. Review of the progress notes, showed: -On 4/27/25 at 6:59 A.M., continues antibiotic monitoring related to torn skin surrounding urethra and catheter placement. Resident complained of positional discomfort this shift. Area remains swollen; -On 4/28/25 at 4:03 A.M., continues antibiotic monitoring related to torn skin surrounding urethra and catheter placement. Area remains swollen. Review of the TAR, dated 5/1/25 through 5/12/25, showed: -A physician order for Nystatin-Triamcinolone Cream 100000-0.1 unit/gram-%, apply topically two times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry and apply cream to coccyx and scrotal area. Do not cover; -A.M., administered; -P.M. on 5/1 and 5/2, administered, 5/3 was blank, 5/4 through 5/11, administered; -A physician order for Triad hydrophilic wound dress external paste, apply to coccyx and scrotal area topically three times a day for dermatitis. Cleanse coccyx and scrotal area with wound cleanser. Pat dry then apply a liberal amount of cream to coccyx and scrotal area. Do not apply any dressing to area; -A.M., Noon, administered; -P.M. on 5/1 and 5/2, administered, on 5/3 blank, 5/4 through 5/11, administered. Observation and interview on 5/12/25 at 10:18 A.M., showed the resident lay in bed. The resident said he went to the hospital recently for an infection in his penis. The facility did not provide his treatment, and he had to go back a few weeks later. He did not feel like his catheter was set right because sometimes urine runs down his penis and he gets liquid in his brief and sometimes he has pain. Review of the order summary report, dated 5/12/25, showed: -Nystatin-Triamcinolone Cream 100,000-0.1 unit/gram-1%, apply topically two times a day for dermatitis. Cleanse coccyx (tailbone) and scrotal area with wound cleanser. Pat dry and apply cream to coccyx and scrotal area. Do not cover. Start date was 9/30/24; -Triad hydrophilic wound dressing external paste (wound dressing) apply to coccyx and scrotal area with wound cleanser. Pat dry then apply a liberal amount of cream to coccyx and scrotal area. Do not apply any dressing to area, start date was 10/28/24. Observation and interview on 5/14/25 at 2:00 P.M., showed Registered Nurse (RN) H assisted the resident to roll onto his side and cleaned his buttocks/coccyx with wound cleanser and applied Nystatin/Triamcinolone cream, then applied Triad paste to the same area. Then, the nurse assisted the resident to roll back on his back. The shaft of the penis just below the tip of the penis was red and inflamed. The nurse described the area as excoriated and said the resident did not have a treatment ordered and he/she would need to call the doctor. The resident said it hurt a little RN H cleaned the area and left it open to air. Once the nurse returned to the desk, he/she checked the order in the computer and expanded the treatment orders out and said the creams should be applied to both the coccyx and the scrotal area and he/she would go back and apply the creams to the scrotal area. During an interview on 5/14/25 at 2:00 P.M., RN H said when a resident goes out for a doctor's appointment/hospital, it should be documented in the progress notes when the resident left and when they returned. When the resident returned from the appointment/hospital, he/she would take a picture of the paperwork and send it to the doctor to review. The nurse on duty was responsible for verifying and entering the orders into the computer. If a physician did not want to change an order, that should be documented in the progress notes. During an interview on 5/14/25 at 2:51 P.M. and on 5/15/25 at 2:19 P.M., the Director of Nursing (DON) said when a resident leaves the building and when they return, it should be documented. Agency staff do not always document. When the resident returned, the nurse who was on duty was responsible for verifying the orders with the physician and entering the orders into the computer. Staff should also document if the physician did not want to change the order. On 4/8/25, the DON saw the resident before he went to the hospital and said the skin tear looked like the catheter was pulled and his skin looked like erosion from the catheter being in place for a while. On 4/23/25, the DON did not know if the resident went to the hospital or if he went out for a follow up appointment. She did not know if he returned with any new orders or not. Nystatin/Triamcinolone cream and Nystatin cream and Nystatin powder are not the same medication, this would be a medication error. The staff may have assumed they were the same medication. The DON said she would verify the order with the physician. The DON expected staff to verify the orders with the physician when they return to the facility, and document it. If the admitting nurse was unable to complete the task, the nurse should pass it on to the next shift or let the DON know. During an interview on 5/15/25 at 12:19 P.M., the Administrator said she expected staff to follow the facility's policies and procedures.

Based on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining water temperatures in resident rooms on the 100 hall and in the unlocked and accessible staff break room, between 105 degrees Fahrenheit (F) and 120 degrees F. This affected five sampled resident rooms, which included Resident #5. The temperatures at the sinks measured as high as 143 F. The sample size was 13. The census was 46. 1. Observations on 5/12/25 of the unlocked accessible employee break room handwashing sink, showed: -At 10:35 A.M., the water measured 137.8 F.; -At 11:50 A.M., the water measured 143 F.; -At 2:20 P.M., the water measured 139.0 F. Review of the facility's temperature logs, showed no documentation of temperatures for the employee break room. 2. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/17/25, showed: -Severe cognitive impairment; -Uses a manual wheelchair; -Diagnoses included dementia. Observations on 5/12/25 of the resident's room handwashing sink, showed: -At approximately 10:07 A.M., the water measured at 130.0 F; -At 10:40 A.M., the water measured 124.2 F.; -At 12:10 P.M. and 12:20 P.M., the water measured 130.0 F. Observations on 5/13/25 at 8:25 A.M., 5/14/25 at 10:39 A.M. and at 12:25 P.M., showed the resident wandered in his/her wheelchair throughout the facility. 3. Observation on 5/12/25 at 11:50 A.M., of resident room [ROOM NUMBER]'s handwashing sink, showed the water temperature measured 130.0 degrees F. 4. Observation on 5/12/25 at 12:15 P.M. of resident's room [ROOM NUMBER]'s handwashing sink, showed the water temperature measured 130.0 degrees F. 5. Observation on 5/12/25 of resident's room [ROOM NUMBER]'s handwashing sink, showed: -At approximately 10:08 P.M., the water temperature measured 130.0 degrees F; -At 12:20 P.M., the water temperature measured 130.0 degrees F. 6. Observation on 5/12/25 at approximately 10:09 A.M., of resident's room [ROOM NUMBER]'s handwashing sink, showed the water temperature measured 130.0 degrees F. 7. Observation of the boiler room, on 5/12/25 at 11:55 A.M., showed: -One large tank on the left side of the room. The temperature at the tank showed 120 F.; -Two smaller water tanks on the right side of the room. The temperature on both tanks read 130 F.; -Piping ran from the tanks to a mixing valve. The temperature on the mixing valve read 130 F. During an interview on 5/12/25 at 12:00 P.M. and at 2:20 P.M., the Maintenance Director said the larger tank supplied water to the laundry and staff break room. The two smaller tanks supplied water to the resident rooms. He took water temps about two times a week in a different resident room or shower room and documented them in a log. He used a digital thermometer but did not know it needed to be calibrated. He knew the temperatures needed to be between 105 F and 120 F. He knew the water was hot in the staff break room but thought it was okay since it was not a resident use room. Temperatures in the break room could run 145 F., but it needed to be hot for the laundry. The temperatures could run warmer on the 100 hall but if he found one that was too high, he would adjust the mixing valve to adjust it. They did not have a policy for water temperatures but followed the state guidelines. 8. During an interview on 5/12/25 at 3:15 P.M., the Administrator said she knew water temperatures needed to be between 105 degrees F and 120 degrees F but thought this was only in resident use areas. They had a sign on the staff break room door stating the room was for staff only. She did not know the temperatures were too high on the 100 hall.

Based on interview and record review, the facility failed to follow their policy when staff failed to ensure one resident's dialysis (a procedure that cleanses the blood of its impurities) communication logs were completed for all appointments (Resident #42). The facility identified one resident who received dialysis services. The sample was 13. The census was 46. Review of the facility's Dialysis Communication policy, dated 2/21, showed: -Director of Nursing (DON) or designee will contact dialysis unit to establish the communication, explain the facility will be sending a communication form that will facilitate the sharing of resident information surrounding dialysis; -A dialysis communication form will be used to send information to and from the facility to the dialysis center and back; -The nurse in charge of the care of the resident on the days of scheduled dialysis shall initiate the dialysis communication form and will ensure the form is sent with the resident; -Upon return of the resident from the dialysis center, the nurse in charge of the resident will review the communication form and will obtain necessary post dialysis information; -If there are any questions regarding the completion of the form or needs of the resident, the nurse will call the dialysis center for a telephone report of any significant information needed; -The nurse will complete post dialysis information on the dialysis communication form; -Completed form will be scanned into the electronic health record. Review of Resident #42's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/5/25, showed: -Short and long-term memory was ok; -Make decisions regarding task of daily life: severely impaired, never/rarely made decisions; -Received dialysis while a resident; -Diagnoses included end stage renal disease (ESRD, chronic irreversible kidney failure). Review of the care plan, in use at the time of survey, showed: -Focus: the resident needs hemodialysis treatment related to renal failure; -Goal: The resident will have no signs symptoms of complications from dialysis through the review date; The resident will have immediate intervention should any signs/symptoms of complications from dialysis occur through the review date; -Interventions included: dialysis access-left arm arteriovenous fistula (AVF, abnormal connection between an artery and vein) used for access. History of left forearm AVF-thrombosis (a blood clot within the AVF) 1/13/25; -Encourage resident to go for scheduled dialysis appointments. Resident receives dialysis on Monday (M)-Wednesday (W)-Friday (F); -Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and blood pressure immediately. -Review communication form or flow sheet after treatment & implement new orders or recommendations. Review of the order summary sheet, dated 5/12/25, showed a physician order for dialysis every M-W-F; Review of the dialysis communication forms, dated 4/1/25 through 5/12/25, showed: -On 4/2 and 4/4/25, the post dialysis facility information was blank; -There were no other dialysis communication forms in the medical record. During an interview on 5/14/25 at 12:50 P.M., Registered Nurse (RN) D said a pre-dialysis assessment should be completed before a resident went out for dialysis. The assessment included checking the access site, vital signs and weight. There used to be a pop up in the computer for the assessment, currently he/she documents under the vital signs tab. Review of the vital signs tabs, dated 4/1/25 through 5/11/25, showed: -On 4/2, 4/4, 4/7, 4/9, 4/11, 4/16, 4/25, 4/28, 4/28, 5/1, 5/2, 5/5, 5/7 and on 5/9/25, there were no pre-dialysis., temperatures, respirations and blood pressures documented. During an interview on 5/14/25 at 1:40 P.M. and 5/15/25 at 12:19 P.M., the Administrator said the facility communicates all the time with the dialysis center and they will call the facility if there are any changes. The nurse should check the resident's weight and vital signs pre and post dialysis. This information is documented on the dialysis communication form. The assessments have been completed sporadically because the agency staff do not always do it. Once they are completed, they are uploaded into the computer. The Administrator expected the charge nurse to complete the dialysis communication form and to follow the facility's policy and procedures.

Based on interview and record review, the facility failed to ensure residents had access to mail delivered on the weekend. This had the potential to affect all residents at the facility. The census was 46. Review of the facility's Residents' Right policy, revised December 2016, showed: -Policy Statement: -Employees shall treat all residents with kindness, respect, and dignity; -Policy Interpretation and Implementation: -Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness, and dignity; -Communication with and access to people and services, both inside and outside the facility; -Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; -Be supported by the facility in exercising his or her rights; -Access to a telephone, mail, and email; -Communicate in person and by mail, email, and telephone with privacy; Review of the admission packet provided to the residents, showed: -Authorization to have mail opened: -You have the right to send and promptly receive mail unopened. If you wish your mail to be opened and (if needed), to be read to you by the facility, the facility will do so. During a group interview on 5/13/25 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. The residents said they did not receive mail on Saturdays. The Activity Director (AD) was not there on Saturdays so they did not get their mail on Saturdays. One resident said he/she was waiting on a package. It arrived on a Saturday. He/She saw it in a bin and had to wait until Monday because no one was available to give it to him/her. During an interview on 5/15/25 at approximately 11:30 A.M., the Activity Director said there is no mail delivered on Saturdays. She is responsible for giving out the mail and she does not work on Saturdays. During an interview on 5/15/25 at 12:19 P.M., the Administrator said residents should receive mail on Saturdays. The Administrator was not aware the residents were not receiving mail on Saturdays.

Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice when one resident (Resident #3) had a significant increase in pain identified on 12/18/24 and had to wait over 12 hours for an x-ray order to be obtained. The x-ray completed on 12/19/24 showed the resident had a right hip fracture and the resident was sent to the hospital for further evaluation and treatment. The sample was 6. The census was 48. Review of the facility's Change in Condition Nursing Intervention policy, dated 2/18/16 and revised 9/19/19, showed: -Policy Statement: Because of the age and condition of residents in a nursing home, they are subject to many changes in condition. Changes in condition require assessment and documentation by a licensed nurse; -Policy: To assure that all residents receive appropriate care in accordance with acceptable medical practice and standards, changes in condition will be assessed in a timely manner with appropriate interventions and countermeasures as necessary. hospitalization s/re hospitalization s are to be prevented whenever possible by clinical interventions within the scope of the skilled facility; -Procedure: Evaluate resident's overall physical and mental status. Check vital signs (Blood Pressure (BP), pulse, temperature, respirations, Oxygen saturation (percentage of oxygen in the blood) and glucose (blood sugar) for diabetics). -Document actions in Nurses Notes, Physician Order Sheet (POS), Medication Administration Record (MAR) and Care Plan accordingly; -Following any hospitalization /rehospitalization , even if only for emergency room (ER)/observation visit, review with resident, physician and family the interventions and care plan; -All charts are to be opened and documented on each shift following a change in condition. Review of Resident #3's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/30/24, showed: -Severe cognitive impairment; -Bilateral lower extremity impairment, uses wheelchair for mobility; -Dependent, helper does all effort and resident does none of the effort to complete activity, for eating, oral hygiene, toileting, shower/bath, upper and lower body dressing, and personal hygiene; -Frequently incontinent of bladder, always incontinent of bowel; -Diagnoses included heart failure, end stage renal disease (ESRD), Alzheimer's disease, hip fracture, anxiety, and depression. Review of the resident's Electronic Medical Record, showed: -A progress note on 12/18/24 at 6:02 P.M., placed a call to hospice, per Administrator's request, to obtain a right hip x-ray for resident. Spoke with Nurse Practitioner (NP) who states he/she will reach out to on call nurse and have him/her fax order to facility so that company can be contacted to come out and obtain x-ray. Awaiting response from hospice; -A progress note on 12/19/24 at 7:10 A.M., resident complains of right hip pain this morning and is guarding extremity, call placed to hospice for an order for an x-ray. Awaiting return call from on call nurse with order approval; -A progress note on 12/19/24 at 7:46 A.M., hospice nurse called back at 7:40 A.M. and gave orders from hospice physician to obtain an x-ray of the right hip. Order noted at this time. Resident awake, alert, and screams out loud in pain when nurse attempts to assess. Call placed to physician, follow up with hospice and Director of Nursing (DON). Call placed to hospice, awaiting call back from hospice Registered Nurse (RN); -An order dated 12/19/24 at 8:00 A.M., two view hip x-ray for post fall pain. -A progress note on 12/19/24 at 9:06 A.M., x-ray completed at this time; -A Hospice, Facility Communication Note, dated 12/19/24 at 10:15 A.M. through 11:15 A.M., Resident assessed obvious deformity to right lower extremity. Yesterday received call resident having pain and x-ray order received and called to nurse at 2:17 P.M. Resident being sent to hospital for fracture; -An x-ray report, dated 12/19/24 at 10:15 A.M. showed acute fracture of the intertrochanteric hip (area where the muscles of the thigh and hip attach). Osteopenia (bone loss, condition that occurs when the body does not make new bone as quickly as it absorbs old bone); -A progress note on 12/20/24 at 1:26 P.M., resident went out to the hospital yesterday. Facility received a call today stating that he/she will not be returning. No explanation at this point. Family plans to pick up his/her belongings tomorrow on 12/21/24; -A progress note on 12/23/24 at 9:14 A.M., resident family called over the weekend and stated that he/she will be coming back to this facility. This is after they called last week and stated that he/she would not be. Unsure as to what changed their minds but he/she is expected back today; -A progress note on 12/23/24 at 3:40 P.M., resident was returned to facility from hospital via emergency medical services (EMS) accompanied by family. Vital signs stable. Incision to right hip clean dry and intact with 11 intact staples noted. Physicians notified; -No documentation of the circumstances that resulted in the need to request an order for an x-ray on 12/18/24 or assessment of the resident. During an interview on 1/8/25 at 12:30 P.M., the Administrator said the resident did not have a fall. She started an investigation after the resident went to the hospital to investigate the cause of the injury. The resident was very active before the resident broke his/her hip. He/She was up walking around. Their investigation showed no fall occurred. She thinks based on the results showing osteopenia that the resident possibly broke it while turning over in bed. During an interview on 1/8/25 at 12:40 P.M., Licensed Practical Nurse (LPN) E said nurses are expected to document that in the EMR. Pain assessments are expected to be done every shift and as needed per the physician order. During an interview on 1/8/25 at 1:20 P.M., the Administrator said from her understanding, staff got the order for the x-ray on 12/18/24 but it was the company who was unable to come out to obtain the x-ray until 12/19/24 and caused the delay. Upon reading the progress note, the Administrator said it looks like that was not the case and they were waiting on hospice to return the call for the order. She was not aware staff were waiting on hospice, even though the progress note states that the Administrator was aware that the nurse was awaiting orders from hospice. She thinks the note may be referring to the previous DON being aware. The Administrator said she would expect the nurse to call the physician and get the order for an x-ray so the resident did not have to wait for hospice, who did not call back within a reasonable amount of time. They should not have waited until the next day to get an order with the resident showing signs of being in pain. MO00246826

Based on interview and record review, the facility failed to ensure services provided meet professional standards of practice when a facility nurse pre-pulled medications for residents, documented the medications as administered, and never administered the medications. This resulted in nine residents not receiving their ordered medications (Residents #4, #5, #11, #7, #9, #8, #10, #1 and #12). The census was 44. The sample was 14. The administrator was notified on 6/21/24, of the past non-compliance. The facility educated staff of the requirement to administer medications at the time they are pulled and that only the staff person who pulls the medications are allowed to administer the medication. The facility conducted an investigation to determine which residents were affected and are monitoring ongoing compliance. The deficiency was corrected on 6/10/24. Review of the Controlled Substance Policy, revised 2/2021, showed: Controlled substances are subject to special handling, storage. disposal and record-keeping requirements. The facility will maintain compliance with these special provisions. Procedures: -Controlled substances in Schedules II, III and IV are subject to special handling, storage, disposal and record-keeping requirements. Such drugs are to be accessible only to authorized nursing and pharmacy personnel. The Director of Nurses is responsible for the control of such drugs; -Drugs listed in Schedules II, III, and IV are to be stored under double-lock conditions. The key to the separately locked storage area is not the same key that is used to gain access to other drugs. The medication nurse on duty at the time will maintain possession of the key. The key must remain in the possession of the licensed nurse that completed the count at all times during their shift. Should it be necessary to give the keys to another licensed nurse( ex. Leaving the facility for lunch) a count will be done to verify the inventory. A count will be done again when the keys are returned to the original licensed nurse; -The authorized person receiving and checking in a drug in Schedules II, III, and IV is to prepare a controlled substance proof of use record form for that medication, if one is not provided by the pharmacy. Thereafter. a physical inventory of that medication will be made at the change of each nursing shift. Shift Verification Count Sheets/Packages shall be completed at the change of each shift; -The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift. The count is to be performed by the on coming licensed nurse and the off-going licensed nurse. The oncoming nurse will be responsible for looking at the medication to verify the amount of medication present at the time of the count. The off-going nurse will be responsible for viewing the Controlled Substance Proof of Use Record to verify the amount on the record at the time of the count. Both nurses will sign on the NARCOTIC SIGN IN & OUT SHEET that the count was completed; -Any discrepancy in the inventory of a controlled substance is to be reported to the Director of Nurses immediately. The Director of Nurses is responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. The discrepancy of a controlled substance is to be reported to the Administrator and the Regional Nurse immediately. If a discrepancy is not reconciled. the Director of Nurses is to document the details on the audit record, including the possible shift or persons responsible for the discrepancy, and the efforts made to reconcile it. Review of an undated picture, showed 11 medication cups sat on top of a medication cart. Each medication cup contained one pill. Names written on the bottoms of the cups and visible through the cup included Residents #4, #5, #11, #7, #9, #8, #10, #1, and #12. The name of the pill not identified. 1. Review of Resident #4's medical record, showed: -Diagnoses included osteoarthritis of the knee; -An order dated 4/25/24 for tramadol HCL (pain medication) 50 milligram (mg) for pain related to osteoarthritis of the knee, at bedtime; -Scheduled administration time 10:00 P.M.: -A narcotic medication run sheet, showed Licensed Practical Nurse (LPN) A pulled the tramadol 50 mg on 6/8/24 at 3:06 P.M.; -A progress note dated 6/10/24 at 10:40 A.M., showed the resident did not receive his/her tramadol 50 mg on 6/8/24. Physician made aware. 2. Review of Resident #5's medical record, showed: -Diagnoses included epilepsy (seizure disorder) and attention-deficit hyperactivity disorder; -An order dated 12/27/23, for lorazepam (Ativan, used to treat anxiety) 0.5 mg three times a day for anxiety: -Scheduled administration times at 9:00 A.M., 12:00 P.M., and 5:00 P.M.; -A narcotic medication run sheet, showed LPN A pulled lorazepam 0.5 mg on 6/8/24 at 10:21 A.M., 3:03 P.M., and 3:07 P.M.; -A progress note dated 6/10/24 at 10:17 P.M., showed the resident did not receive his/her Ativan on 6/8/24. Physician made aware. 3. Review of Resident #11's medical record, showed: -Diagnoses included anxiety disorder; -An order dated 5/21/24, for lorazepam 0.5 mg two times a day related to anxiety disorder: -Scheduled administration times 9:00 A.M. and 5:00 P.M.; -A narcotic medication run sheet, showed no documentation the lorazepam 0.5 mg was pulled for the resident; -A progress note dated 6/10/24 at 10:32 A.M., showed the resident did not receive his/her Ativan 0.5 mg on 6/8/24. Physician made aware. 4. Review of Resident #7's medical record, showed: -Diagnoses included fracture of the left arm; -An order dated 6/6/24, for oxycodone (narcotic pain medication) 5 mg every 12 hours as needed for pain related to fracture of the left arm; -A narcotic medication run sheet, showed LPN A pulled oxycodone 5 mg on 6/8/24 at 3:07 P.M.; -A progress note dated 6/10/24, showed the resident did not receive oxycodone on 6/8/24. Physician made aware. 5. Review of Resident #9's medical record, showed: -Diagnoses included injury at the cervical (neck) of spinal cord and anxiety disorder; -An order dated 4/9/24, for hydrocodone-acetaminophen (Norco, narcotic pain medication that also includes Tylenol) 5-325 mg, one tablet four times a day for pain related to cervical injury: -Scheduled administration times 9:00 A.M., 12:00 P.M., 5:00 P.M., 9:00 P.M.; -An order dated 4/22/24, for clonazepam (used to treat anxiety) 1 mg at bedtime for insomnia related to anxiety disorder: -Scheduled administration time liberalized at bedtime; -A narcotic medication run sheet, showed: -LPN A pulled hydrocodone/acetaminophen 5-325 mg on 6/8/24 at 3:06 P.M.; -LPN A pulled clonazepam 1 mg on 6/8/24 at 3:06 P.M.; -A progress note dated 6/10/24 at 10:38 A.M., showed the resident did not receive his/her clonazepam or Norco on 6/8/24. Physician made aware. 6. Review of Resident #8's medical record, showed: -Diagnoses included anxiety disorder; -An order dated 4/2/24, for diazepam (Valium, used to treat seizures, can also treat anxiety) 5 mg two times a day related to anxiety disorder: -Scheduled administration times 9:00 A.M. and 5:00 P.M.; -A narcotic medication run sheet, showed LPN A pulled diazepam 5 mg on 6/8/24 at 10:21 A.M. and 3:08 P.M.; -A progress note dated 6/10/24 at 10:19 A.M., showed the resident did not receive his/her Valium on 6/8/24. Physician made aware. 7. Review of Resident 10's medical record, showed: -Diagnoses included chronic pain; -An order dated 4/28/24, for Ultram (tramadol) 50 mg two times a day for chronic pain: -Scheduled administration times liberalized in the AM and PM; -A narcotic medication run sheet, showed LPN A pulled tramadol 50 mg on 6/8/24 at 10:22 A.M. and 3:08 P.M. -A progress note dated 6/10/24 at 10:21 A.M., showed the resident did not receive his/her tramadol 50 mg on 6/8/24. Physician made aware. 8. Review of Resident #1's medical record, showed: -Diagnoses included dementia and agitation; -An order dated 6/9/24, for Ativan 0.5 mg two times a day for agitation: -Scheduled administration times 9:00 A.M. and 5:00 P.M.; -A narcotic medication run sheet, showed LPN A pulled lorazepam 0.5 mg on 6/8/24 at 3:06 P.M.; -A progress note dated 6/10/24 at 10:36 A.M., showed the resident did not receive his/her Ativan 0.5 mg on 6/8/24. Physician made aware. 9. Review of Resident #12's medical record, showed: -Diagnoses included diabetes, stroke, and osteoarthritis; -An order dated 8/3/23, for tramadol 50 mg two times a day for osteoarthritis: -Scheduled administration times liberalized in the AM and PM; -A narcotic medication run sheet, showed LPN A pulled tramadol 50 mg on 6/8/24 at 3:08 P.M.; -No progress note to show that the resident did not receive this medication. 10. Review of the Medication Destruction Log, showed on 6/10/24, narcotic medications for Residents #4, #5, #11, #7, #9, #8, #10, #1, and #12 that were pulled on 6/8/24 and not given were wasted. 11. During an interview on 6/21/24 at 9:50 A.M., LPN A said nurses and Certified Medication Technicians (CMT) are not supposed to pre-pop medications, especially narcotic medications. Medications are to be given after they are removed and signed out. All narcotic medications are signed out on the computer. The facility does not have paper narcotic count or sign out sheets. LPN A said he/she does not pre-pop medications. 12. During an interview on 6/21/24 at 10:45 A.M., the Director of Nursing (DON) said approximately two weeks ago, on 6/8/24, Agency Nurse C was scheduled to work overnight. Around 4:00 A.M. on 6/9/24, he/she came across a cart that had what appeared to be narcotics not given. Agency Nurse C called to report this to her. Agency Nurse C also sent text messages and pictures of his/her concern. The picture showed 11 medication cups sat on top of a medication cart. Each medication cup contained one pill. Names written on the bottoms of the cups and visible through the cup included Residents #4, #5, #11, #7, #9, #8, #10, #1, and #12. The name of the pill not identified. The DON said she came to the facility later that morning. Agency Nurse C did not pass his/her 6:00 A.M. medications due to his/her concern with the medications left on the cart. The DON said nurses and CMTs have different medication records. A nurse is not supposed to give another nurse or a CMT their medications to pass, especially narcotics. On nights, there are no CMTs and the nurse is to pass all medications. The nurse should have passed those medications on the evening shift but he/she popped the medications and gave to CMT B to pass. CMT B never gave the medications but they were marked as given by LPN A. They called the doctor and destroyed the medications. They also completed medication error reports on each medicine. The DON said she talked to CMT B and informed the CMT that he/she should have notified management. The CMT said that he/she did not report the incident initially because he/she was worried about conflict and felt intimidated. 13. During an interview on 6/21/24 at 11:22 A.M., CMT B said LPN A asked him/her to pass the medications on the medication cart. CMT B said when he/she told LPN A no, LPN A laughed like he/she did not believe that he/she would not pass the medications. CMT B said this is an ongoing behavior from LPN A. LPN A just left them on the medication cart when he/she left the facility. CMT B said he/she has not been asked to do that since the incident. CMT B said the DON talked to him/her and asked CMT B to notify the DON if this happens again. 12. During an interview on 6/21/24 at 1:43 P.M. with the Administrator, DON, and Corporate Nurse, they said they would expect staff to follow facility policies. Staff should document accurately and should not document a medication as administered if it was not. Staff should not pull medications and ask another staff person to administer the medications. Medications should be administered at the time they are pulled. MO00237365

Based on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated (Resident #1) when a resident (Resident #2) punched the resident in the back of the head with a closed fist three times. Resident #2 attempted to strike Resident #1 a fourth time but staff intervened and separated the residents. These two residents had an incident occur approximately one month ago, in which Resident #2 hit Resident #1 in the eye. This incident caused Resident #1 to have a laceration over his/her left eyebrow. The sample was 3. The census was 47. Review of the facility's undated Abuse, Prevention and Prohibition policy, showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family member or legal guardians, friend, or other individuals; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review of Resident #1's medical record, showed: -A quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/7/24, showed: -Resident is rarely/never understood; -Diagnoses included dementia and depression. -A progress note, dated 3/4/24 at 9:43 A.M., showed resident was sitting in the dining room eating at the table with another resident when the other resident reached out and hit this resident in the face causing resident's left eye (above) to bleed. Placed a call to the physician, physician made aware. Also, placed a call to the resident's family and made aware of the incident. The resident's left eye was cleaned and applied triple antibiotic ointment and bandage. The resident denies pain at this time. -A progress note, dated 4/24/24 at 1:16 P.M., showed resident's Power of Attorney (POA) contacted and informed of another resident hitting him/her in the back of his/her head. POA informed that education was provided to both residents and separated before incident escalated. Vital signs taken and within normal limits. Physician notified. -Review of the medical record, did not show skin assessment or neurological assessment performed after the resident-to-resident altercation for Resident #1. Review of the resident's care plan, revised 1/4/24, showed: -Focus: The resident has a communication problem: Hard of Hearing (HOH); -Goal: The resident will be able to make basic needs known on a daily basis through review date; -Intervention: Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Ensure/provide a safe environment, encourage resident to continue stating thoughts even if resident is having difficulty; -Focus: The resident has a behavior problem; -Goal: The resident will have a reduction in behavior problems: verbal and physical aggression, anxiety, refusal of care by review date; -Interventions: Administer antipsychotic medications as ordered, monitor behavior episodes and attempt to determine underlying cause, anticipate and meet the resident's needs, caregivers to provide opportunity for positive interaction, attention. Observation and interview on 4/30/24 at 9:55 A.M., showed Resident #1 in his/her room. The resident sat in his/her wheelchair. The resident was unable to answer about any incidents with another resident. The resident turned away and started to talk to himself/herself. Review of Resident #2's medical record, showed: -A quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included non-traumatic brain dysfunction and Alzheimer's dementia; -A progress note, dated 3/4/24 at 9:23 A.M., showed resident was in the dining room having breakfast and another resident was sitting at the same table when this resident reached and hit the other resident causing the other resident to bleed. The other resident was removed from the situation immediately and administrator was informed. Physician made aware and family made aware. -A progress note, dated 4/24/24 at 3:41 P.M., showed Certified Nursing Assistant (CNA) brought the resident to the Director of Nursing (DON) and communicated that he/she had hit another resident while in dining room for lunch. Resident noted to be in a clam state sitting with legs crossed with elbow on right arm rest with fact resting on hand. Asked resident what happened in the dining room between him/her and the resident. Resident stated (he/she) was talking shit and I turned around and hit (him/her) back of head. I asked him/her to demonstrate with this nurse with his/her arm. Resident with closed fist hit on this nurse arm three times non forcibly. Asked if this is how hard that he/she hit him/her and the resident stated yes. Per this nurse, inspected his/her hands. No bruising, swelling, or bleeding or any injury to hand noted. Resident extensively encouraged about not to hit anybody and if he/she feels like he/she is becoming agitated to seek out staff assistance for interventions which would including calling his/her son/daughter for him/her to talk. Resident in agreement. Spoke with resident's son/daughter and made him/her aware of interventions. Son/Daughter thanked this nurse for calling and will talk to the resident. Resident assisted into bed per resident request. No skin issues. Denied any pain or discomfort. Review of Resident #2's care plan, dated 4/26/24, showed: -Focus: The resident has potential to demonstrate physical behaviors when agitated/overstimulated; -Goal: Resident will not harm self or others through the review date; -Intervention: Resident has a history of striking others when agitated, when resident becomes agitated intervene before agitation escalates. -Focus: The resident has a behavior problem; -Goal: The resident will have fewer episodes of behavioral outburst/aggressive behavior by the review date; -Intervention: Intervene as necessary to protect the rights and safety of others, monitor behavior episodes and attempt to determine underlying cause, anticipate and meet the resident's needs. -Focus: The resident has a mood problem; -Goal: The resident will have improved mood state, happier, calmer appearance, no signs/symptoms of depression, anxiety or sadness through the review date; -Intervention: Behavioral health consults as needed, monitor/document/report to physician as needed mood patterns signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. During an interview on 4/30/24 at 9:45 A.M., Resident #2 said he/she did not recall the incident. He/She said there are no issues with any resident. Review of the facility's investigation, showed on 4/24/24 at approximately 11:40 A.M.: -Summary of alleged incident: While in the dining room, Resident #2 hit Resident #1 in the back of the head about three times. This was stopped and witnessed by a CNA who removed him/her and brought him/her to the DON office to report the issue. -Conclusion of the investigation, provided by the Administrator on 4/30/24, showed: On 4/24/24 at roughly 11:40 A.M., residents were gathering in the dining room for lunch. Resident #1 was sitting at his/her table rambling nonsense. Resident #2 was wheeling himself/herself into the dining room and upon passing Resident #1's table, he/she got upset with what Resident #1 was saying and hit him/her in the back of the head. CNA C immediately stopped Resident #2 and Certified Medication Technician (CMT) B assisted in separating the two residents. Both residents were assessed by the nurse with no findings. POAs, Physician, and Psychiatrist were notified. -Resident #2 has a medical diagnosis of dementia with mood disorder and Resident #1 has a medical diagnosis of dementia with agitation. Both residents are wheelchair bound and self propelling/wanderers. The psychiatrist, saw both residents today, 4/25/24, and they have no recollection of the incident and there were no changes made. -Resident #2 recently saw neurologist, 4/5/24, and Remeron (antidepressant, used to treat depression) was increase to 30 milligrams (mg). During this appointment, the neurologist educated the resident's POA on the significant progression of (his/her) dementia and stated (he/she) doesn't have much longer. On 4/22/24, the care plan was held with the resident's POA to discuss his/her decline mentally and physically and as a result, hospice evaluated/started 4/24/24. -Staff were educated about Resident #1 being moved to a back table in the dining room away from the entrance of the dining room to reduce the two residents crossing paths and educated about keeping residents separated when possible. During an interview on 4/30/24 at 9:50 A.M., CMT B said he/she heard about the first incident and was told to keep them apart. The day of the second incident, he/she was at the medication cart in the dining room passing medications. The resident sat facing the front of the dining room and Resident #2 sat at the table behind Resident #1. CMT B said he/she saw Resident #2 hit Resident #1 in the back of his/her head two to three times with a closed fist. Resident #2 looked back before attempting to hit Resident #1 again. Another aide, CNA C, got a hold of the resident's arm before he/she could hit Resident #1 a fourth time. CMT B said he/she went to Resident #1 and took the resident out of the dining room. CMT B asked the resident if he/she was ok. The resident responded, why would (he/she) do me like that? CMT B said when he/she asked Resident #1 if he/she hurt and wanted Tylenol, the resident responded yes. CMT B is not sure why Resident #2 struck Resident #1. Resident #1 was rambling/mouthing like he/she normally does. The next thing you know, Resident #2 turned around and hit him/her. CMT B guessed Resident #1's voice gets to Resident #2. CMT B said a couple days later, Resident #1 sat at the back of the dining room and Resident #1 started to go after Resident #1 again. CMT B said he/she went right over to Resident #2 and redirected him/her out of the dining room before the resident got to Resident #1 a third time. CMT B brought the resident to the hallway outside of his/her room. CMT B told the Charge Nurse about that incident. CMT B said he/she feels bad for Resident #1. It almost seems like Resident #2 is now going after him/her. Resident #1 suffered a cut above his/her left eyebrow after the first incident. This time, there were no visible injuries. CMT B does not understand why Resident #2 attacked Resident #1 again. Staff really have to keep them apart. CMT B said the psychologist was at the facility the other day. CMT B felt Resident #2 knew what he/she was doing even though he/she does have a decline. The day the second incident occurred, the DON and CNA asked the resident a couple questions. The resident told the nurse he/she was going after Resident #1. Staff just have to keep watching and make sure Resident #2 stays away from Resident #1. During an interview on 4/30/24 at 10:00 A.M., the Social Worker (SW) said there have been two incidents between Resident #2 and Resident #1. She did not see either incident. Both happened in the dining room. The SW was told Resident #2 hit Resident #1. Resident #1 got to rambling and not sure if that annoyed Resident #2. Resident #2 tried to tell her that he/she did not hit Resident #1. When the SW told the resident there were witnesses, the resident just said ok. Resident #1 is very loud and talks about anything and everything. Resident #1 was not sent out after the second incident and she is not aware of any incidents since that second one. She believes they moved Resident #1's spot in the dining room. Resident #2 has memory issues but is more with it than Resident #1. During an interview on 4/30/24 at 10:05 A.M., Dietary Aide E said he/she saw Resident #2 hit Resident #1 once. Resident #2 stays next to the dining room door so staff can keep closer eye on him/her. Resident #1 sits in the back on the other side of the dining room. Dietary Aide E feels bad for Resident #2 because he/she is not really with it. During an interview on 4/30/24 at 11:35 A.M., Licensed Practical Nurse (LPN) A said he/she was in the DON's office when the second incident occurred. CNA C brought the resident into the DON's office and said Resident #2 had just hit Resident #1. LPN A asked Resident #2 what happened. Resident #2 said Resident #1 was talking shit. Resident #2 then showed LPN A how he/she hit Resident #1 with a closed fist. LPN A assessed the resident's hand, then assessed Resident #1. LPN A said Resident #1 was assessed the next day as well. LPN A said everyone was inserviced and moved Resident #1 to a different table so not to be in close proximity to Resident #2. LPN A had not been told of another attempt. He/She has not seen behavior issues for Resident #2. Resident #1 is not with it. Staff did not say if Resident #1 provoked Resident #2. Resident #2 just said Resident #1 was just talking shit. LPN A knows every shift was inserviced but not sure if all staff was in-serviced or just nursing staff. During an interview on 4/30/24 at 11:45 A.M., the resident witness said he/she only knew about the second incident. He/She was at the table with Resident #1. He/she said Resident #2 hit Resident #1 in the back of the head/shoulder with a closed fist. Now the facility is keeping them separated. During an interview on 4/30/24 at 11:50 A.M., CMT F said Resident #1 sat in the front of the dining room at first. Then after the second incident, he/she was moved to the back of the dining room. Resident #2 has a history of behaviors and this was the second incident. CMT said Resident #2 has not tried to go after Resident #1 since the second incident. Staff keep them separated. During an interview on 4/30/24 at 1:04 P.M., the DON said after the first incident, they moved Resident #2 closer to the inside of the dining room by the kitchen so more staff can keep an eye on him/her. The psychologist came out to do a consult and medication review. So far they did not change behavior interventions, the resident had never hit anyone before these incidents. For the second incident, the CNA said he/she propelled Resident #2 and as he/she passed Resident #1, the resident struck at him/her. The CNA said they were able to pull the resident back. The DON said now that they have Resident #1 moved, the two residents should not have to cross paths because Resident #1 has to go a separate way. Both residents can propel themselves. The DON believed Resident #1 was already seeing psychologist and that Resident #2 saw the psychologist after the first incident. The DON does not think it is possible it will happen again. The staff know now and will really monitor. The DON is not sure if Resident #2 smokes but Resident #1 should not be in the way. The smoke time is well after lunchtime. She expected staff to know what both residents look like and to keep them separated. She said they did a neurological assessment, skin assessment, head, and pain assessment on Resident #1. She said it is hard for them to completely avoid each other but now there should be no way to cross paths in the dining room. During an interview on 4/30/24 at 1:24 P.M., CNA C said he/she was in the dining room for the second incident. She was sitting at the back of the dining room, feeding residents. Different aides were bringing residents in the dining room. Resident #1 was already seated. Resident #2 propelled him/herself in the dining room. He/She went behind Resident #1 and hit the resident in the back of the head at least twice. CNA C heard CMT B yell out. He/She went over to Resident #2 and grabbed his/her arm before he/she struck the resident again. CNA C then propelled the resident out of the dining room to the DON's office to inform the DON of the incident. CNA C said staff had been instructed to watch Resident #2 before the second incident. Resident #2 told the DON when he/she wheeled past Resident #1, the resident was talking crap, so he/she hit the resident. CNA said she felt like Resident #2's dementia has worsened. Resident #2 has not acted normal for a while. She is not aware of Resident #2 attempting to go up to Resident #1 after the second incident. CNA C said it is possible for Resident #2 to go over to Resident #1 but there is always an aide in the dining room when they are in there. After the first incident, staff were told to keep them separate. Staff were inserviced and just told to keep an eye on them. Staff are supposed to report if Resident #2 makes any attempt towards Resident #1. During an interview on 4/30/24 at 1:50 P.M., a housekeeping staff cleaning the dining room said the smoke break was already over. The afternoon smoke break is typically between 1:00 P.M. and 1:30 P.M. Staff has already taken the residents who smoke outside. They go outside through the far door in the back, which is the next door down from where Resident #1 sat. During an interview on 4/30/24 at approximately 2:30 P.M., the Administrator said she expected staff to keep both residents separated and safe. MO00235200

Based on interview and record review, the facility failed to ensure one resident (Resident #2), diagnosed as having dementia with behavioral disturbance and exhibiting increased symptoms/behaviors such as striking the same resident (Resident #1) in the head twice on two separate occasions (3/4/24 and 4/24/24), received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being, by failing to implement an ordered psychiatric consult or update the resident's care plan until after the second incident. The first incident caused a laceration above Resident #1's left eyebrow. The sample size was 3. The census was 47. Review of Resident #2's hospital records, prior to the facility admission, dated 9/26/23, showed: Patient is presenting with concern for self neglect and possible injury to himself/herself with firearm. He/She was brought in by family to emergency room (ER) on 9/23 after reportedly hitting his/her head near the support beam of his/her car port. He/She reports to me no loss of consciousness. Apparently family recently checked on him/her and found a hole in the ceiling as well as a shotgun that appeared to have been moved with blood on it as well. They were concerned that patient may have been using the shotgun inappropriately and could have hurt himself/herself. Per notes, patient denies touching the gun. He/She was recommended for admission to the behavioral health center for assessment and treatment for mood disorder as well as dementia with behavioral disturbances. Upon my exam he/she is stable and appears calm. He/She reports no major medical issues at this time and feels ok overall. He/She is not able to tell me which medications he/she takes for his/her chronic medical conditions however. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/25/24, showed: -Severe cognitive impairment; -Diagnoses included non-traumatic brain dysfunction and Alzheimer's dementia. Review of the resident's electronic Physician Order Sheet (ePOS) showed: -An order, 10/4/23, Remeron (antidepressant) oral 15 milligrams (mg). One tablet by mouth at bedtime related to Alzheimer's disease with early onset; -An order, dated 2/9/24, Refer to psychiatrist for psychiatric evaluation per physician request. Review of the resident's medical record, showed: -A progress note, dated 3/4/24 at 9:23 A.M., resident was in the dining room having breakfast and another resident was sitting at the same table when this resident reached and hit the other resident causing the other resident to bleed. The other resident was removed from the situation immediately and Administrator was informed. Physician made aware and family made aware; -A progress note, dated 3/13/24 at 12:48 P.M., resident brought from dining room to nursing station per Certified Nursing Assistant (CNA) due to started crying in dining room and had not eaten lunch. This nurse asked him/her why he/she was crying. The resident verbalized that he/she wanted to see his/her son/daughter. Asked if resident would like nurse to call son/daughter. Resident stated yes. Per this nurse, called his/her son/daughter and resident talked to him/her. The resident stopped crying and was asked if he/she would like for his/her lunch to be brought to room. Resident declined at this time verbalized he/she was going to his/her room to lay down; -A progress note, dated 4/5/24 at 12:36 P.M., resident returned from neurologist appointment accompanied by son/daughter. Paperwork given upon return with new orders as follow: Increase Remeron to 30 mg at bedtime. Order noted and sent to primary care physician and other providers in his/her network in agreement at this time. Review of the resident's ePOS, showed: -An order, dated 4/5/24, Refer to psychiatrist for psychiatric evaluation per physician request; -An order, dated 4/5/24, Remeron oral 30 mg. One tablet by mouth at bedtime related to Alzheimer's disease with early onset. Review of an Initial Psychiatric Evaluation, dated 4/11/24, by the Nurse Practitioner (NP) for the psychiatrist, showed: -Presenting problem: Resident is referred for a psych evaluation. Resident has a history of major neurocognitive disorder (MNCD, an acquired neuropsychiatric disorder, characterized by a clinically significant decline from a previous level of cognitive functioning) with depression; -Medical: Diabetes, chronic kidney disease, stroke, falls, current urinary tract infection (UTI); -Mental Status: Oriented to person only. Insight/judgement are fair. Sleep and appetite fair. Isolative to room. Little participation in activities. Current treatment for UTI. Mood fair. Denies anxiety. Denies psychotic symptoms; -Plan: Continue the recently increased Remeron dose for depression. Encourage out of room activities. Consider treatment for MNCD. Psychiatrist to see in one month. Review of the progress notes, showed: -4/25/24 at 8:10 A.M., reached out to psychiatrist regarding incident that took place yesterday with altercation with another resident for a medication review. Psychiatrist states he/she will be in the facility as soon as he/she can to evaluate/treat; -4/24/24 at 3:41 P.M., CNA brought the resident to the Director of Nursing (DON) and communicated that he/she had hit another resident while in dining room for lunch. Resident noted to be in a clam state sitting with legs crossed with elbow on right arm rest with fact resting on hand. Asked resident what happened in the dining room between him/her and the resident. Resident stated (he/she) was talking shit and I turned around and hit (him/her) back of head. I asked him/her to demonstrate with this nurse with his/her arm. Resident with closed fist hit on this nurse arm three times non forcibly. Asked if this is how hard that he/she hit him/her and the resident stated yes. Per this nurse, inspected his/her hands. No bruising, swelling, or bleeding or any injury to hand noted. Resident extensively encouraged about not to hit anybody and if he/she feels like he/she is becoming agitated to seek out staff assistance for interventions which would including calling his/her son/daughter for him/her to talk. Resident in agreement. Spoke with resident's son/daughter and made him/her aware of interventions. Son/Daughter thanked this nurse for calling and will talk to the resident. Resident assisted into bed per resident request. No skin issues. Denied any pain or discomfort. Review of the Psychiatric Evaluation, dated 4/25/24, showed: -Chief Complaint: Resident referred emergently for a psychiatric consultation by the primary care physician. The resident apparently had gotten in an altercation with an older resident earlier today though it is unclear what exactly caused that. The resident himself/herself could provide very little in terms of specific or meaningful complaints; -Past Psychiatric History: Is notable for history of dementia of the Alzheimer's type as well as depression. It is unclear if he/she had previously been seen by a mental health professional; -Mental Status Examination: The patient was alert and oriented to person only. His/Her mood is good. His/Her affect is pleasantly confused. His/Her speech is elicitable though limited to brief replies. Judgment and insight are poor as is focus and concentration. Thought processes are somewhat illogical and nonlinear. There are no overt hallucinations or delusions noted at this time. He/She reportedly is eating adequately and sleeping adequately. No real change in his/her cognitive, function, or affective presentation is appreciated; -Assessment: Major neurocognitive disorder most likely of the Alzheimer's type with agitation. -Recommendations: -At this time we will monitor the patient's symptoms closely for any repeat episodes of agitation and their possible triggers. That being said, he/she may benefit from a regular dose anti-agitant medication; -We will continue the memantine (medication used to treat memory loss and the symptoms of Alzheimer's disease) and mirtazapine (Remeron) at their current dosages for now. I do note that he/she has lost a bit of weight lately; -We will communicate our findings and recommendations to primary care physician and the staff; -A message was left for the patient's power of attorney to update them relative to my psychiatric recommendations and to try and obtain more history; -Follow up in approximately one month by the nurse practitioner and myself for psychotropic medication management and supportive psychotherapy. Review of the resident's care plan, dated 4/26/24, showed: -Focus: The resident has potential to demonstrate physical behaviors when agitated/overstimulated; -Goal: Resident will not harm self or others through the review date; -Intervention: Resident has a history of striking others when agitated, when resident becomes agitated intervene before agitation escalates; -Focus: The resident has a behavior problem; -Goal: The resident will have fewer episodes of behavioral outburst/aggressive behavior by the review date; -Intervention: Intervene as necessary to protect the rights and safety of others, monitor behavior episodes and attempt to determine underlying cause, anticipate and meet the resident's needs; -Focus: The resident has a mood problem; -Goal: The resident will have improved mood state, happier, calmer appearance, no signs/symptoms of depression, anxiety or sadness through the review date; -Intervention: Behavioral health consults as needed, monitor/document/report to physician as needed mood patterns signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. Review of a Social Service progress note, dated 4/30/24/24 at 12:58 P.M., showed it was reported to Social Services (SS) that on several occasions, once with a hospice worker and once with Administration that resident has been getting a bit handsy. He/She is not touching in inappropriate places but is doing things such as running his/her hand up a person's arm. The resident was recently signed up for hospice and it was on of their staff that he/she did this with. He/She recently has had a few incidents of hitting another resident as well. SS has spoken with him/her about these, however with his/her decreased cognition/memory, it is doubtful that he/she remembers. Staff were in-serviced and were made aware of this change in his/her behavior. This is not the norm for him/her. SS will continue to monitor and assist as needed. Review of the care plan, showed no interventions to address the resident's inappropriate touching of others. During an interview on 4/30/24 at 9:50 A.M., Certified Medication Technician (CMT) B said he/she heard about the first incident and was told to keep them apart. The day of the second incident, he/she was at the medication cart in the dining room passing medications. The resident sat facing the front of the dining room and Resident #2 sat at the table behind the other resident. CMT said he/she saw Resident #2 pound the other resident in the back of his/her head two to three times with a closed fist. Resident #2 looked back before attempting to hit the other resident again. Another aide, CNA C, got a hold of the resident's arm before he/she could hit the other resident a fourth time. CMT B said he/she went to the other resident and took the resident out of the dining room. CMT B asked the resident if he/she was ok. The resident responded, why would (he/she) do me like that? CMT B said when he/she asked the other resident if he/she hurt and wanted Tylenol, the resident responded yes. CMT B is not sure why Resident #2 struck the other resident . The other resident was rambling/mouthing like he/she normally does. The next thing you know, Resident #2 turned around and hit him/her. CMT B guessed the other resident's voice gets to Resident #2. CMT B said a couple days later, the other resident sat at the back of the dining room and the other resident started to go after the other resident again. CMT B said he/she went right over to Resident #2 and redirected him/her out of the dining room before the resident got to the other resident a third time. CMT B brought the resident to the hallway outside of his/her room. CMT B told the Charge Nurse about that incident. CMT B said he/she feels bad for the other resident. It almost seems like Resident #2 is now going after him/her. The other resident suffered a cut above his/her left eyebrow after the first incident. This time, there were no visible injuries. CMT B does not understand why Resident #2 attacked the other resident again. Staff really have to keep them apart. CMT B said the psychologist was at the facility the other day. CMT B feels that Resident #2 knows what he/she is doing even though he/she does have a decline. The day the second incident occurred, the DON and CNA asked the resident a couple questions. The resident told the nurse he/she was going after the other resident. Staff just have to keep watching and make sure Resident #2 stays away from the other resident. During an interview on 4/30/24 at 10:00 A.M., the Social Worker (SW) said there have been two incidents between Resident #2 and the other resident. She did not see either incident. Both happened in the dining room. The SW was told Resident #2 hit the other resident. The other resident got to rambling and not sure if that annoyed Resident #2. Resident #2 tried to tell her that he/she did not hit the other resident. When the SW told the resident there were witnesses, the resident just said ok. The other resident is very loud and talks about anything and everything. Resident #2 has memory issues. During an interview on 4/30/24 at 1:04 P.M., the DON said after the first incident, they moved Resident #2 closer to the inside of the dining room by the kitchen so more staff can keep an eye on him/her. The psychologist came out to do a consult and medication review. So far they did not change behavior interventions, the resident had never hit anyone before these incidents. For the second incident, the CNA said he/she propelled Resident #2 and as he/she passed the other resident, Resident #2 struck at him/her. The CNA said they were able to pull the resident back. The DON said now that they have the other resident moved, the two residents should not have to cross paths because Resident #1 has to go a separate way. The DON believed Resident #1 was already seeing psychologist. The DON does not think it is possible it will happen again. The staff know now and will really monitor. She said it is hard for them to completely avoid each other but now there should be no way to cross paths in the dining room. During an interview on 4/30/24 at approximately 2:30 P.M., the Administrator said she is not sure why the resident had a psychiatrist consult order for 2/9/24 and 4/5/24 but he/she was not seen until April 11th. She expected staff to keep both residents separated and safe. She expected staff to notify management of any changes to behavior. MO00235200

Based on observation, interview, and record review, the facility failed to ensure one resident's rights to be free from physical abuse was not violated (Resident #1) when a resident (Resident #2) hit the other resident in the eye. This resulted in a laceration. The census was 45. The sample was 3. The Director of Nursing (DON) was notified on 3/08/24, of the past non-compliance. The facility immediately took steps to protect the resident and set interventions in place to prevent further abuse. Staff were in-serviced on resident safety. The deficiency was corrected on 3/4/24. Review of the facility's undated Abuse, Prevention and Prohibition policy, showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Resident must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family member or legal guardians, friend, or other individuals; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Review of Resident #1's medical record, showed: -A quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 2/7/24, showed: -Resident is rarely/never understood; -Diagnoses included dementia and depression. -A progress note, dated 3/4/24 at 9:43 A.M., showed resident was sitting in the dining room eating at the table with another resident when the other resident reached out and hit this resident in the face causing resident's left eye (above) to bleed. Placed a call to the physician, physician made aware. Also, placed a call to the resident's family and made aware of the incident. The resident's left eye was cleaned and applied triple antibiotic ointment and bandage. The resident denies pain at this time. Observation and interview on 3/8/24 at 7:54 A.M., of Resident #1, showed the resident sat in the main dining room. He/She had a small scab above the left eyebrow. The resident was unable to answer how the injury occurred. Review of Resident #2's medical record, showed: -A quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included non-traumatic brain dysfunction and Alzheimer's dementia; -A progress note dated 3/4/24 at 9:23 A.M., showed resident was in the dining room having breakfast and another resident was sitting at the same table when this resident reached and hit the other resident causing the other resident to bleed. The other resident was removed from the situation immediately and administrator was informed. Physician made aware and family made aware. During an interview on 3/8/24 at 8:04 A.M., Resident #2 said he/she did not recall the incident. Review of the facility's investigation, showed on 3/4/24 at 8:25 A.M.: -Summary of alleged incident: While in the dining room, Resident #1 was rambling at Resident #2. Resident #2 made a grimace and then hit Resident #1. Resident #2 said Resident #1 aggravates him/her. Residents separated. Resident #2 has a laceration to the eye. Nurse provided assistance. Physicians and power of attorneys (POAs) notified. Social Services will provide one on one observation; -Both residents were in the dining room just finishing breakfast. Staff were in and out taking residents to their rooms. Resident #1 was rambling nonsense to Resident #2, aggravating him/her and he/she hit Resident #1 causing a 1 centimeter (cm) by 0.5 cm laceration to the left eyebrow. Resident #2 then proceeded to shake Resident #1's chair from behind. Certified Nursing Assistant (CNA) B got Resident #2 to stop and then notified another staff member, then took Resident #1 to the nurse. Both residents are alert and oriented to person only. Physicians and POAs notified. Education is being provided to staff about keeping the residents separated. Urine analysis will also be collected from Resident #2 due to this not being a normal behavior. Social Services complete one on ones with both residents. No other residents have expressed fear. Resident #1 is pleasantly confused, signed by the administrator on 3/4/24. During an interview on 3/8/24 at 8:47 A.M., the Assistant Director of Nursing (ADON) said on 3/4/24, she was working as the charge nurse on the hall. A Certified Nursing Assistant (CNA) brought Resident #1 to her and said another resident hit him/her in the head. The resident was bleeding. Licensed Practical Nurse (LPN) A cleaned up the resident's head while she informed the management, physicians and responsible parties. No sutures were required. The abrasion was superficial. During an interview on 3/8/24 at 8:55 A.M., LPN A said he/she was at the medication cart. The ADON said Resident #2 hit Resident #1 in the dining room. There was blood on Resident #2's head. He/She got supplies and cleaned the wound and got vital signs. The Administrator began the investigation. During an interview on 3/8/24 at 10:40 A.M., a tablemate to Resident #1 and Resident #2 said he/she saw the altercation. He/She said Resident #1 always talks and points and said something to Resident #2 while pointing. Resident #2 swiped and hit Resident #2. It happened so fast. Resident #1 grabbed his/her eye and when he/she lowered his/her hand down, there was blood. Staff in the area ran over to help. During an interview on 3/8/24 at 11:07 A.M., with the DON, she said they would expect residents to be free from abuse, it is their right. Resident #2 had never been aggressive with anyone prior to this incident.