Every finding on record at Life Care Center of Grandview

Based on observation, interview, and record review, the facility failed to protect one sampled resident (Resident #1) from physical abuse out of three sampled residents. On 5/24/26 Resident #2 entered Resident #1's room and hit Resident #1 on the left knee, left eye, and top of the left side of the head resulting in Resident #1 having a red mark on his/her left eye. The facility census was 108 residents.The Administrator was notified on 6/2/26 of the past noncompliance which began on 5/24/26. The facility immediately completed education for abuse & Neglect. The deficiency was corrected on 5/26/26. Review of the facility Abuse, Neglect, and Exploitation Prevention Issued 10/04/2022, reviewed 04/01/26, showed:-It was the policy of this facility to prevent and prohibit all types of abuse.-Abuse is willful, the individual must have acted deliberately, not that the individual must have intended to inflict injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish.-Physical abuse includes, but was not limited to, hitting, slapping, punching, biting, and kicking. 1. Review of Resident #1's admission Record showed he/she had been admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses:-Stroke with weakness and paralysis on the left non-dominant side.-Arterial Fibrillation (a-fib- irregular heart beat).-Anxiety.-Coronary Artery Disease (CAD - a narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart).-Congestive Heart Failure (CHF - impaired heart function). Review of Resident #1's Significant Change Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 3/25/26, showed the resident was cognitively intact. Review of Resident #1's Care Plan dated 2/4/26 showed he/she:-Had the potential to be verbally aggressive will cuss staff and residents and concocts situations related to ineffective coping skills and poor impulse control.-Uses an electric wheelchair to move around the facility. Review or Resident #2's admission Record showed he/she was admitted to the facility on [DATE] and re-admitted on [DATE] with the following diagnoses:-Stroke with weakness and paralysis on the right dominant side.-Parkinson's Disease (a brain disorder causing unintended or uncontrolled movements).-Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life).-Major Depressive Disorder (a serious mental health condition characterized by persistent, intense sadness or loss of interest impacting daily life).-Anxiety. Review of Resident #2's Annual MDS dated [DATE] showed:-The resident had no physical, verbal, or other behaviors.-He/She was cognitively intact. Review of Resident #2's Care Plan dated 4/21/25 showed he/she:-Can propel his/her wheelchair independently.-Had impaired cognitive ability and thought processes due to a urinary tract infection (UTI - a bacterial infection that affects any part of the urinary system) which decreased his/her typical cognitive ability, the resident thought it was 1988 and was working at the Ford plant.-Administer medications as ordered by the physician. Review of the facility Investigation dated 5/26/26 showed:-On 5/24/26 at approximately 7:00 P.M., Resident #2 was physically aggressive towards Resident #1.-Certified Medication Technician (CMT) A stated he/she heard yelling and went into Resident#1's room to escort Resident #2 out of Resident #1's room.-Resident #1 stated Resident #2 said that Resident #1 would let Resident #2 go to work a Ford on the elevator.-Resident #2 stated he/she aways went to work and used the elevator.-Resident #2 said Resident #1 had been shooting him/her in the arm and his/her whole body was shaking.-Resident #2 said Resident #1 would come into his/her room and mess with his/her television.-Resident #2 went to Resident#1's room to tell Resident #1 to stop and Resident #1 started calling him/her names so Resident #2 struck Resident #1.-Resident #1 said Resident #2 came into his/her room and said I got something for you then started hitting him/her, striking him/her in the left eye.-Resident #1 called for assist but no one came fast enough so Resident #1 struck Resident #1 with his/her pink cup in self-defense.Resident #1 had no injuries.-Resident #2 had redness and edematous (swelling) to the left eye. Review of the Police Report dated 5/24/26 at 7:38 P.M., showed:-Police Officer was dispatched to the facility due to a report of an assault on 5/24/26 at 7:38 P.M.-The offender was Resident #2, and the victim was Resident #1.-Upon arrival the officer contacted the facility nursing staff who stated Resident #1 and Resident #2 had a physical altercation.-The officer contacted Resident #1 who stated he/she was in his/her room when Resident #2 rolled across the hall into his/her room.-Resident #1 asked Resident #2 to leave and Resident #2 refused.-Resident #2 raised his/her fist and stated I've got something for you before striking Resident #1 in the left eye.-The officer's observation of the resident's left eye was red and swollen around the eye socket.-Resident #1 was checked by medics but declined going to the hospital.-Resident #1 stated he/she hit Resident #2 in the head with his/her pink cup after Resident #2 hit him/her.-The officer spoke with CMT A who separated Resident #1 and Resident #2.-CMT A stated he/she came into Resident #1's room and grabbed Resident #2's wheelchair and wheeled him/her back across the hall to his/her room. Review of Resident #1's Alert Note dated 5/24/26 at 11:50 P.M., showed:-Reported to Licensed Practical Nurse (LPN) A at 6:53 P.M., the resident had reported being hit by Resident #2.-The resident reported Resident #2 stated I got something for you.-The resident asked Resident #2 to leave.-Resident #2 began hitting Resident #1 and Resident #1 hit Resident #2 back.-Resident kept punching Resident #1 and punched Resident #1 in the left eye.-Resident #1 yelled for help, CMT A entered Resident #1's room and removed Resident #2 from the room. Review of Resident #1's Hospital Record dated 5/25/26 showed:-His/Her had a diagnosis of closed head injury and ankle pain.-The Computed Tomography (CT scan -a computer that takes data from several X-ray images of structures inside a human body and converts them into pictures on a monitor) did not reveal any acute traumatic injury. Review of Resident #2's Event Note dated 5/24/26 at 8:43 P.M., showed:-While LPN A was assessing Resident #1 from earlier incident with Resident #2.-Resident #2 opened his/her room door and began to yell and curse at Resident #1, from his/her room.-Resident #1's and Resident #2's rooms are straight across from each other.-Resident #2 was transported to a private room down the hall and was given water and the television was turned on to help calm Resident #2 down.-Resident #2 was assessed and did not have any injuries. During an observation and interview on 6/2/26 at 12:41 P.M., Resident #1 said:-It was not his/her fault Resident #2 came into his/her room. -Resident #2 came across the hall into his/her room and said, I got something for you and started hitting him/her with his/her fist in the left eye.-He/She pushed Resident #2 away in his/her wheelchair and Resident #2 slipped out of the wheelchair hitting Resident #1's left knee. During an interview on 6/2/26 at 1:13 P.M., LPN A said he/she:-Was notified of the incident by CMT A.-Assessed both residents for injuries Resident #1 had redness and some swelling to his/her left eye and Resident #2 had no injuries.-Notified the physician and received an order to send both residents to the hospital for evaluation and treatment.-Resident #1 refused to go to the hospital so notified the physician and was given an order to monitor the resident and send to the hospital if and changed.-Started neuro-check on Resident #1 as ordered by the physician due to possible head trauma.-Notified the Administrator, police and residents' families of the incident.-When Resident #2 returned from the hospital he/she was placed on one-to-one monitoring in his/her new room for safety. Review of CMT A's written statement dated 5/26/26 showed he/she:-Went to Resident #1's room and took Resident #2 out of the room and to another room.-Asked Resident #2 about what Resident #2 was doing he/she said that Resident #1 won't let him/her go to work at Ford on the elevator in Resident #1's room and that he/she woke up to go to work.-Resident #2 was in bed all day when he/she gave Resident #2 his/her medications.-Resident #2 said he/she worked here at Ford since 1985 and always went down on the elevator that was in Resident #1's room.-Resident#2 said Resident #1 comes and pours water and had a bowel movement in his/her bed.-Tried to redirect Resident #2 but it did not work.-Stayed with Resident #2 until transferred to the hospital. During an interview on 6/2/26 at 2:04 P.M., CMT A said he/she:-Heard a resident scream his/her name.-He/She was busy in the bathroom at that time.-He/She went to Resident #1's room and separated Resident #1 and Resident #2, by taking Resident #2 out of the room.-Resident #1 said Resident #2 had hit him/her.-Did not witness the residents hitting each other.-Resident #1 did have a redness to his/her left eye.-Stayed with Resident #2 while LPN A was assessing Resident #1. During an interview on 6/2/26 at 2:56 P.M., Resident #2 said he/she:-Had an incident with Resident #1.-Resident #1 aggravates him/her by shooting him/her with a needle causing him/her to shake and sprayed his/her toe with something causing him/her to lose his/her toenail when he/she was asleep. During an interview on 6/2/26 at 3:56 P.M., the Administrator said he/she:-Was notified of the incident between Resident #1 and Resident #2 on 5/24/26 around 7:30 P.M.-Went to the facility to help with the investigation and start training with the staff on abuse and neglect policy.-Finished all for the education on 5/26/26, no employee worked until they were educated.-Moved Resident #2 from 200 hall to 400 hall and was placed one-to-one for three days for resident safety. 3022682

Based on observation, interview, and record review, the facility failed to ensure appropriate medication and medical equipment storage in three medication carts out of four medication carts and in two out of two medication storage rooms. The facility census was 98 residents. Review of the facility's policy titled Medication Storage in Refrigerator/Freezer dated 9/9/25 showed:-The facility would ensure that medications and biologicals were stored at their appropriate temperatures according to manufacturer's specifications or per the United States Pharmacopeia guideline for temperature ranges.-A safe temperature for refrigeration was between the range of 36 degrees Fahrenheit and 46 degrees Fahrenheit.-The facility should monitor the temperature of medication storage areas at least two times a day.-The facility could use the Medication Refrigerator-Freezer Temperature Log to record and track temperatures.-If the nurse checked the temperature and it was out of range, the nurse should adjust the setting to increase or decrease the temperature accordingly.-The medication should also be removed and placed in an alternate storage area until the compartment returned to an acceptable temperature.-If there was excessive ice build-up in the freezer, the maintenance department should be notified to defrost the unit to ensure proper functioning.A policy related to medication or medical equipment storage was requested and not received prior to exit on 3/9/26.1. Observation on 3/5/26 at 11:10 A.M. of the Spring Bridge nurse cart showed:-One opened vial of Aplisol (tuberculin purified protein derivative, used as an aid in diagnosing Tuberculosis (a serious, contagious bacterial infection, primarily affecting the lungs), with the instructions to refrigerate after opening.-Five wound dressings that expired on 10/31/25.-One wound dressing that expired on 6/30/25.-One wound dressing that expired on 9/30/25.-One wound dressing that expired on 8/1/25.-Three Warfarin (a blood thinner), one milligram (mg) tablets that expired on 1/31/26.-One opened bottle of Acidophilus (a probiotic that aids in digestion and nutrient absorption) capsules, with the instructions to refrigerate after opening.-One wound dressing kit that expired on 1/1/26.2. Observation on 3/5/26 at 11:25 A.M. of the 300-hall medication cart showed:-Approximately thirty loose pills at the bottom of two different drawers of the medication cart.-A powdery substance underneath the loose pills of two different drawers of the medication cart.3. Observation on 3/5/26 at 11:35 A.M. of the East side medication room showed:-One 24-gauge needle that expired on 4/30/25.-Two 22-gauge needles that expired on 3/31/25.-One 22-gauge needle that expired on 4/1/22.-One refrigerator that had no temperature log within plain sight.-The refrigerator temperature was 50 degrees Fahrenheit.4. Observation on 3/5/26 at 11:45 A.M. of the Spring Bridge medication room showed:-One wound dressing that expired on 4/1/23.-One wound dressing that expired on 2/1/26.-Three wound dressings that expired in March 2020.-Four wound dressings that expired on 3/1/24.-Two wound dressings that expired on 2/28/25.-Two wound dressings that expired on 9/30/21.-Five wound dressings that expired on 7/31/25.-Eight wound dressings that expired on 3/31/25.-Two wound dressings that expired on 9/30/22.-Two wound dressings that expired on 1/6/26.-One wound dressing that expired on 2/28/26.-Four wound dressings that expired on 4/1/24.-Three wound dressings that expired on 7/1/25.-Six 24-inch extension tubing sets that expired on 10/2/25.-One wound dressing that expired on 10/2/25.-The medication refrigerator freezer area had a significant amount of ice buildup of an inch or greater.5. Observation on 3/5/26 at 12:05 P.M. of the Spring Terrace nurse/treatment cart showed:-One opened bottle of Acidophilus capsules, with the instructions to refrigerate after opening. -One nasal spray that expired in January 2026.-One 472 milliliter (ml) bottle of Potassium Chloride Oral Solution (used to prevent low potassium levels) in which the label was covered in the medication and the lid had crusted medication surrounding it.6. During an interview on 3/9/26 at 9:42 A.M. Certified Medication Technician (CMT) A said:-Expired medications should not be stored in medication carts.-Expired medical supplies should not be stored in medication carts or medication rooms.-The night shift nurses were responsible for checking the medication refrigerator temperatures.-He/She was unsure if there was an exact time frame of when a freezer needed to be de-frosted but thought that if it looked like ice was building up, then staff should go ahead and de-frost the freezer.-Staff should follow the manufacturer's recommendations for storage after medications were opened.-Certified staff were to check the medication carts daily.-He/She was unsure of the facility's protocol related to medication storage.-Loose pills should not be stored in medication carts and should be appropriately disposed of when found.-Medication residue should not be in the medication carts and should be cleaned out when found.-All liquid medication containers should be clean and free from any drips.During an interview on 3/9/26 at 10:00 A.M. Registered Nurse (RN) B said:-Expired medications should not be stored in medication carts.-Expired medical supplies should not be stored in medication carts or medication rooms.-The night shift nurses were responsible for checking the medication refrigerator temperatures.-If he/she noticed that the temperature had not been recorded on the log, then he/she would record the temperature on the log.-He/She was unsure what the typical temperature range was for storing medications in the refrigerator.-If he/she noticed too much accumulation of ice in the medication freezers, then he/she would call maintenance and unplug the unit.-Staff should follow the manufacturer's recommendations for storage after medications were opened.-Staff were responsible for checking medication carts every other day.-He/She was unsure of the facility's protocol related to medication storage but thought that nurse management checked the medication carts and medication rooms regularly.-Loose pills should not be stored in medication carts and should be appropriately disposed of when found.-Medication residue should not be in the medication carts and should be cleaned out when found.-All liquid medication containers should be clean and free from any drips.During an interview on 3/9/26 at 10:27 A.M. Licensed Practical Nurse (LPN) C said:-Expired medications should not be stored in medication carts.-Expired medical supplies should not be stored in medication carts or medication rooms.-The night shift nurses were responsible for checking the medication refrigerator temperatures.-If he/she was unable to find the refrigerator temperature log and felt that the temperature was too high, then he/she would remove the medications, put them in a different medication refrigerator, and call maintenance.-Medication refrigerators with freezers should not have any build-up of ice.-Staff should follow the manufacturer's recommendations for storage after medications were opened.-Medication carts were checked each shift.-Nurse management checked the medication carts and medication rooms monthly to ensure appropriate storage of medication and medical supplies.-Loose pills should not be stored in medication carts and should be appropriately disposed of when found.-Medication residue should not be in the medication carts and should be cleaned out when found.-All liquid medication containers should be clean and free from any drips.During an interview on 3/9/26 at 11:52 A.M. the Director of Nursing (DON) said:-Expired medications should not be stored in medication carts.-Expired medical supplies should not be stored in medication carts or medication rooms.-The night shift nurses were responsible for checking the medication refrigerator temperatures.-If staff were unable to find the refrigerator temperature log and felt that the temperature was too high, then he/she expected the staff to remove the medications, put them in a different medication refrigerator, and call maintenance.-A refrigerator temperature of 50 degrees Fahrenheit was too high.-He/She expected staff to de-frost the freezers when there was an accumulation of ice.-Staff should follow the manufacturer's recommendations for storage after medications were opened.-He/She expected staff to check medication carts every shift.-He/She had only been at the facility for two weeks and was unsure of the facility's protocol/process related to medication storage.-In his/her prior facilities he/she checked the medication carts and medication rooms weekly.-Loose pills should not be stored in medication carts and should be appropriately disposed of when found.-Medication residue should not be in the medication carts and should be cleaned out when found.-All liquid medication containers should be clean and free from any drips.-If the liquid medication bottle could not be wiped clean, then he/she expected staff to dispose of the medication appropriately.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 98 residents with a licensed capacity for 172 residents at the time of the survey. 1. Review of the facility's floorplan map, dated 9/7/2023 and provided by the Director of Maintenance (DOM), showed the building was basically laid out in three sections: an older long-term care unit, a rehabilitation unit, and a memory care unit, with administrative and nursing offices, a kitchen/kitchenette, and a laundry area. Review of the facility's 24-page water-borne pathogen infection prevention and control policy and procedure of loose pages kept in a plastic sheet protector entitled Water Management Program, Life Care Center of Grandview, updated 2/23/26 and provided by the DOM, showed:-There was no facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188.-A completed CDC toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens was missing.-No CDC Legionella Environmental Assessment Form had been done.-There was a written explanation of the water flow that identified and indicated specific potential risk areas of growth within the building with assessments of each individual area's potential risk level, but no accompanying schematic, flowchart, or diagram of the facility's water system.-No documentation of any site log-book being maintained with dated cleanings, sanitizings, descalings, and inspections was included or mentioned.-Table 13: Activity Log for Flushing Vacant/Unoccupied Rooms (Add, edit, or delete as needed) was blank.-At Table 14: Multi-Unit Building Description (add edit or delete as needed) it listed: 100 Hall - 14 rooms, 20 sinks, 2 showers, 2 bathtubs; 200 Hall - 16 rooms, 19 sinks, 2 showers, 1 bathtub; 300 Hall - 15 rooms, 19 sinks, 6 showers; 400 Hall - 14 rooms, 24 sinks, 2 showers, 1 ice machine; 400 Hall - 14 rooms, 24 sinks, 2 showers, 1 ice machine; 500 Hall - 15 rooms, 19 sinks, 1 shower, 1 bathtub; and 600 Hall - 13 rooms, 20 sinks, 3 showers, 2 bathtubs, 1 ice machine.-The questions and answers for Table 20: Ice Machine Protocols were, Who is responsible for maintaining ice machines? Maintenance Department works with vendor, How often are ice machines cleaned? Quarterly cleaning, and How often are ice machines sanitized? Annually and when issues arise.- Table 21: Ice Machine Maintenance Checklist (Add, edit, or delete as needed) was blank.Observation on 3/2/26 between 11:43 A.M. and 1:19 P.M. during the initial Life Safety Code (LSC) kitchen inspection showed there was a steam table (also referred to as a hot food table, specifically, steam tables are designed to hold food at steady, safe serving temperatures, but not designed to cook or warm foods from a raw state), a 3-sink sanitizing area, a low-heat, chemical dishwashing machine, a hand-washing sink, and an ice machine.Observation on 3/4/26 between 10:09 A.M. and 12:39 P.M. during a LSC walk-through inspection with the DOM showed the following: -The city municipal water supply first entered the facility through a northern main pipe in the 200 Hall fire sprinkler Riser Room (a dedicated space for fire protection equipment).-The building was equipped with a complete fire sprinkler system with sidewall and ceiling mounted sprinkler heads located throughout the facility.-Two public restrooms were in the front administrative office hall with an additional restroom by the Rehab Gym nurse's desk.-A medication room with sink was located behind each of the two separate main nurse's desks.-There were housekeeping closets with floor mop sinks or ceramic service sinks (mop/service sinks are used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water) and hot/cold water piping throughout the facility.-There were at least two commercial clothes washers in the laundry area.-There were four bathhouses with showers and/or baths in the facility. -There was a Beauty Shop with a sink next to the 200 Hall. -There was a steam table and sink in the kitchenette off the Rehab Dining room. -In the 500 Hall Riser Room there was a hot water heater for the 500 and 600 halls and a hot water heater across from the Director of Nursing (DON) office was for the 100 and 300 halls.During an interview on 3/4/26 at 1:14 P.M. the DOM said:-He/She oversaw the Water Management Program.-The water heater across from the DON's office had gone out that morning so it was being replaced.-There were four total water heaters in the facility.During an interview on 3/9/26 at 10:34 A.M. the DOM said:-He/She assisted with creating the Legionella program by identifying risk areas.-Overseeing the program entailed doing routine flushing in empty resident rooms and running their sinks every month.-They also annually conducted tests for Legionella.During an interview on 3/9/26 at 10:49 A.M. the Administrator said:-He/She was educated on the Legionella prevention requirements during in-services and corporate zoom meetings.-He/She helped update the Legionella program. -When they started there about 15 months ago it was already in process.

Based on interview and record review, the facility failed to complete Employee Disqualification List (EDL-a Missouri State screening tool used to check if an individual was prohibited from working with residents due to past abuse, neglect, or misappropriation of property) background checks for ten out of ten sampled employees. The facility census was 98 residents. Review of the facility's Missouri Employee Disqualification List Policy, dated 12/5/25, showed:-The facility checked the EDL in accordance with state requirements.-The facility did not knowingly employ anyone who was listed on the EDL.-The Executive Director of the facility ensured that:--Prior to offer of employment being made, the applicant was screened and was not listed on the EDL.-Documentation of the pre-offer and quarterly screenings were maintained at least seven years.-The acting Regional [NAME] President awas responsible for ensuring the requirements of this policy were met in the absence of an Executive Director.1. Review of the facility's list of employees hired since the facility's last annual survey showed:-Employee A was hired 9/17/25.-Employee B was hired 4/21/25.-Employee C was hired 11/18/25-Employee D was hired 3/19/25-Employee E was hired 3/6/25-Employee F was hired 4/16/25.-Employee G was hired 9/2/25-Employee H was hired 10/8/25.-Employee J was hired 11/10/25-Employee K was hired 3/12/25.Review of the facility's EDL background checks showed:-Employee A's EDL was completed 10/1/25.-Employee B's EDL was completed 5/5/25.-Employee C's EDL was completed 12/1/25.-Employee D's EDL was completed 4/1/25.-Employee E's EDL was completed 4/1/25.-Employee F's EDL was completed 5/5/25.-Employee G's EDL was completed 10/1/25.-Employee H's EDL was completed 11/3/25.-Employee J's EDL was completed 12/1/25.-Employee K's EDL was completed 4/1/25.During an interview on 3/6/26 at 9:42 A.M., the Administrator said:-The EDL checks were done upon hire and then quarterly. -He/She was unaware the background checks were not completed prior to hire date.-Currently, Corporate Compliance was responsible for completing the EDL checks.During an interview on 3/9/26 at 11:52 A.M, the Administrator said: -The EDL background checks were completed by the Staff Development Coordinator and Human Resources.-They were supposed to be completed prior to hire.-It was documented in the employee's file.-If it was not in the facility records it was not completed.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate under five percent (%) with a medication error rate of 88%. This affected two sampled residents (Resident #12 and #89) and two supplemental residents (Resident #51 and #72) out of 20 sampled residents and two supplemental residents. The facility census was 98 residents. Review of the facility's policy titled Administration of Medications dated 9/9/25 showed:-The facility would ensure medications were administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.-A medication error was defined as an observed or identified preparation or administration of medications or biologicals which were not in accordance with:--The prescriber's order.--Manufacturer's specifications regarding the preparation or administration of medication or biological.--Accepted professional standards and principles which applied to professionals providing services.--Accepted professional standards and principles included various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils.-Staff who were responsible for medication administration would adhere to the ten Rights of Medication Administration which included:--Right drug.--Right resident.--Right dose.--Right route.--Right time and frequency.--Right documentation.--Right assessment.--Right to refuse.--Right evaluation/response.--Right education and information.Review of the facility's policy titled Insulin Pen Administration dated 5/27/25 showed:-The facility would ensure residents with orders for insulin (a hormone produced in the pancreas which regulates the amount of glucose (sugar) in the blood) administration using a pen delivery device was performed in accordance with current standards or practice and manufacturer's guidance.-The insulin pen should be primed prior to each use (in accordance with manufacturers guidelines) to prevent the collection of air in the insulin reservoir. -General guidance on priming an insulin pen in the absence of manufacturers guidance included:--Dial two units by turning the dose selector clockwise.--With the needle pointing up, push up on plunger, and watch to see that as least one drop of insulin appears at the tip of the needle.--If not, repeat this procedure until at least one drop of insulin appears.1. Review of Resident #51's admission Record showed he/she admitted to the facility with a diagnosis of Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Recurrent, Moderate.Review of the resident's Order Summary Report dated March 2026 showed the following orders:-Brimonidine Tartrate Ophthalmic Solution (used to help lower eye pressure) 0.15%, instill one drop in both eyes two times a day.-Dorzolamide HCl-Timolol Maleate Ophthalmic Solution (used to treat high eye pressure) 2-0.5%, instill one drop in both eyes two times a day.-Vitamin B12 (a supplement) Oral Tablet 500 micrograms (mcg), give one tablet by mouth one time a day.Review of the resident's Medication Administration Audit Report dated 3/4/26 showed:-The following medications were to be administered at 8:00 A.M.:--Brimonidine Tartrate Ophthalmic Solution 0.15%.--Dorzolamide HCl-Timolol Maleate Ophthalmic Solution 2-0.5%.--Vitamin B12 500 mcg.Observation on 3/4/26 at 9:00 A.M. of the resident's medication administration completed by Registered Nurse (RN) A showed:-The following medications were given at 9:04 A.M.:--Brimonidine Tartrate Ophthalmic Solution 0.15%.--Dorzolamide HCl-Timolol Maleate Ophthalmic Solution 2-0.5%.--Vitamin B12 500 mcg.2. Review Resident #72's admission Record showed he/she admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation).Review of the resident's Order Summary Report dated March 2026 showed the following orders:-Rivaroxaban (a blood thinner) 20 milligrams (mg), give one tablet one time a day.-Amlodipine (used to treat high blood pressure) 10 mg, give one tablet by mouth one time a day.-Atorvastatin (used to treat high cholesterol) 40 mg, give one tablet by mouth one time a day.-Bumetanide (used to treat fluid retention) 1 mg, give one tablet by mouth one time a day.-Carvedilol (used to treat high blood pressure) 12.5 mg, give one tablet by moth two times a day.-Duloxetine (used to treat depression) 40 mg, give one capsule one time a day.-Losartan Potassium (used to treat high blood pressure) 100 mg, give one tablet by mouth one time a day.-Sennosides-Docusate Sodium (used to treat constipation) 8.6-50 mg, give one tablet by mouth two times a day.-Spironolactone (typically used to treat high blood pressure or fluid retention) 25 mg, give one tablet by mouth one time a day.-Umeclidinium-Vilanterol (used for long-term maintenance of COPD) 62.5-25 mcg/actuation (act), one inhalation one time a day.Observation on 3/4/26 at 9:05 A.M. of the resident's medication administration completed by RN A showed he/she:-Prepared the resident's medications and placed them in a 30 milliliter (ml) cup.-Could not find the resident.-Wrote the resident's name on the cup and placed the medication back into the medication cart.Observation on 3/4/26 at 9:54 A.M. showed RN A gave the resident his/her medication at that time.Review of the resident's Medication Administration Audit Report dated 3/4/26 showed:-The following medications were due at 8:00 A.M.:--Rivaroxaban 20 mg.--Amlodipine 10 mg.--Atorvastatin 40 mg.--Bumetanide one mg.--Carvedilol 12.5 mg.--Duloxetine 40 mg.--Losartan Potassium 100 mg.--Sennosides-Docusate Sodium 8.6-50 mg.--Spironolactone 25 mg.--Umeclidinium-Vilanterol 62.5-25 mcg/act.-RN A documented the Rivaroxaban 20 mg as administered at 9:05 A.M.-RN A documented the Amlodipine 10 mg as administered at 10:07 A.M.-RN A documented the Atorvastatin 40 mg as administered at 9:06 A.M.-RN A documented the Bumetanide one mg as administered at 9:07 A.M.-RN A documented the Carvedilol 12.5 mg as administered at 10:08 A.M.-RN A documented the Duloxetine 40 mg as administered at 10:08 A.M.-RN A documented the Losartan Potassium 100 mg as administered at 10:08 A.M.-RN A documented the Sennosides-Docusate Sodium 8.6-50 mg as administered at 9:08 A.M.-RN A documented the Spironolactone 25 mg as administered at 10:08 A.M.-RN A documented the Umeclidinium-Vilanterol 62.5-25 mcg/act as administered at 9:08 A.M.3. Review of Resident #12's admission Record showed he/she admitted to the facility with a diagnosis of Traumatic Subarachnoid (layer of the membranes surrounding the brain) Hemorrhage (a life-threatening type of stroke caused by sudden bleeding into the space surrounding the brain) with Loss of Consciousness Status Unknown, Subsequent Encounter.Review of the resident's Order Summary Report dated March 2026 showed the following orders:-Amantadine HCl (primarily used to treat Parkinson's Disease (a progressive, neurodegenerative brain disorder, affecting movement and central nervous system function) 100 mg, give one tablet by mouth one time a day.-Armodafinil (typically used to treat narcolepsy (a chronic neurological disorder that disrupts the brain's ability to regulate sleep-wake cycles, leading to extreme, uncontrollable daytime sleepiness) 50 mg, give two tablets by mouth one time a day.-Atorvastatin 10 mg, give one tablet one time a day.-Carvedilol 12.5 mg, give one tablet by mouth two times a day.-Doxazosin (used to treat high blood pressure) two mg, give one tablet by mouth one time a day.-Metformin HCl (used to treat Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin) 1000 mg, give one tablet by mouth one time a day.-Losartan Potassium 25 mg, give one tablet by mouth one time a day.Observation on 3/4/26 at 9:18 A.M. of the resident's medication administration completed by RN A showed he/she:-Prepared the resident's medication.-Was unable to locate the resident's Armodafinil 50 mg.-Documented that he/she would reorder the resident's Armodafinil 50 mg from pharmacy.-Gave the resident all his/her ordered medication except for the Armodafinil 50mg.Review of the resident's Medication Administration Audit Report dated 3/4/26 showed:-The following medications were to be administered at 8:00 A.M.:--Amantadine HCl 100 mg.--Armodafinil 50 mg.--Atorvastatin 10 mg.--Carvedilol 12.5 mg.--Doxazosin two mg.--Metformin HCl 1000 mg.--Losartan Potassium 25 mg.-RN A documented the Carvedilol 12.5 mg as administered at 10:19 A.M.-RN A documented the Doxazosin two mg as administered at 10:19 A.M.-RN A documented the Losartan Potassium as administered at 10:19 A.M.Review of the resident's Electronic Medical Record (EMR) on 3/5/26 showed no documentation related to notifying the resident's physician related to the resident's missed dose of Armodafinil 50 mg.4. Review of Resident #89's admission Record showed he/she admitted to the facility with a diagnosis of Diabetes Mellitus Type II (DM II) with Unspecified Diabetic Retinopathy (an eye complication of diabetes caused by high blood sugar damaging retinal blood vessels) with Macular Edema (the swelling or thickening of the central part of the retina).Review of the resident's Order Summary Report dated March 2026 showed the following orders:-Insulin Glargine (a long-acting insulin) 100 unit/ml, inject 30 unit subcutaneously (under the skin) two times a day.-Novolog (a fast-acting insulin) FlexPen Subcutaneous Solution Pen Injector 100 unit/ml, inject as per sliding scale (when the dosage of fast-acting insulin is adjusted based on blood glucose (sugar) levels, if between 201-250 give four units.Observation on 3/4/26 at 9:50 A.M. of the resident's medication administration completed by RN A showed he/she:-Removed the insulin pens from the medication cart.-Said the resident's blood sugar had been 220 mg/deciliter (dL).-Put a needle on both of the insulin pens.-Dialed the Insulin Glargine pen to 30 units without priming the insulin pen.-Dialed the Novolog pen to four units without priming the insulin pen.-Administered the insulins.Review of the resident's Medication Administration Audit Report dated 3/4/26 showed:-The Insulin Glargine 30 units was to be given at 8:00 A.M.-The Novolog FlexPen 4 units was to be given at 7:00 A.M.-RN A documented the Novolog FlexPen four units as administered at 8:15 A.M.-RN A documented the Insulin Glargine 30 units as administered at 10:59 A.M.5. During an interview on 3/4/26 at 9:57 A.M. RN A said:-He/She would not have done anything differently during Resident #12's, Resident #51's, Resident #72's, and Resident #89's medication administration.-He/She could not remember if he/she had primed Resident #89's insulin pens.During an interview on 3/9/26 at 9:37 A.M. Certified Medication Technician (CMT) A said:-If a medication was ordered to be given at 8:00 A.M., then the medication could be given one hour before or one hour after the scheduled time and would be considered as given on time.-If a medication was given late then the medication would be less effective.-If he/she were unable to give a resident's medication, then he/she would notify the charge nurse.-A doctor would not need to be notified if a medication was not able to be given to a resident.-He/She would not consider Resident #12's, Resident #51's, Resident #72's medication as given late.During an interview on 3/9/26 at 9:53 A.M. RN B said:-If a medication was ordered to be given at 8:00 A.M., then the medication could be given one hour before or one hour after the scheduled time and would be considered as given on time.-If a medication was given late then the medication would be less effective.-Insulin pens needed to be primed before use.-Insulin pens needed to be primed before use because it ensured that the resident received the full dose of insulin.-RN A should have primed Resident #89's insulin pens before use.-If he/she was unable to give a resident their medication, then he/she would notify the resident's physician and document a progress note.-RN A's action related to Resident #12's Armodafinil 50 mg was inappropriate.-RN A should have called Resident #12's physician related to not being able to give the Armodafinil 50 mg.-Resident #12's, Resident #51's Resident #72's, and Resident #89's medications were all administered late.-When medications were administered to a resident, the time in which they were actually administered should be reflected in the resident's EMR.-RN A should have documented Resident #12's, Resident #51's, Resident #72's, and Resident #89's medication administration accurately.During an interview on 3/9/26 at 10:15 A.M. Licensed Practical Nurse (LPN) C said:-If a medication was ordered to be given at 8:00 A.M., then the medication could be given one hour before or one hour after the scheduled time and would be considered as given on time.-Insulin pens needed to be primed before use.-Insulin pens needed to be primed before use because it ensured that the resident received the full dose of insulin.-RN A should have primed Resident #89's insulin pens before use.-If he/she was unable to give a resident their medication, then he/she would notify the resident's physician and document a progress note.-RN A's action related to Resident #12's Armodafinil 50 mg was inappropriate.-RN A should have called Resident #12's physician and received an order to hold the medication.-Resident #12's, Resident #51's Resident #72's, and Resident #89's medications were all administered late.-When medications were administered to a resident, the time in which they were actually administered should be reflected in the resident's EMR.-RN A should have documented Resident #12's, Resident #51's, Resident #72's, and Resident #89's medication administration accurately.During an interview on 3/9/26 at 11:52 A.M. the Director of Nursing (DON) said:-If a medication was ordered to be given at 8:00 A.M., then the medication could be given one hour before or one hour after the scheduled time.-When medications were given late it could cause unwanted medication interactions.-Insulin pens needed to be primed before use.-Insulin pens needed to be primed before use because it ensured that the resident received the full dose of insulin.-RN A should have primed Resident #89's insulin pens before use.-He/She would expect staff to notify a resident's physician and document a progress note if they were unable to give a medication to the resident.-RN A's action related to Resident #12's Armodafinil 50 mg was inappropriate.-RN A should have called Resident #12's physician and notified everyone.-Resident #12's, Resident #51's Resident #72's, and Resident #89's medications were all administered late.-When medications were administered to a resident, the time in which they were actually administered should be reflected in the resident's EMR.-RN A should have documented Resident #12's, Resident #51's, Resident #72's, and Resident #89's medication administration accurately.

Based on observation, interview and record review, the facility failed to prevent one sampled resident (Resident #15) with a history of intrusive and unsafe wandering out of 20 sampled residents from wandering into other resident rooms; and failed to document the frequency of the resident's intrusive and potentially unsafe wandering. The facility census was 98 residents. Review of the facility's Behavior Management policy, dated 1/3/22 and reviewed 12/1/25, showed:-The facility would initiate behavior monitoring, behavior management care planning, and utilize Kardex (provides a snapshot of a resident's daily care needs, covering medications, treatments, care plans, and communications) as indicated by assessment findings, resident/responsible party conversations, and observations.-The Social Services worker was primarily responsible for initiation of the Behavior Management Care Plan.-Behavioral health care and services will be person-centered and will maximize resident dignity, autonomy, privacy, socialization, independence, choice, and safety.1. Review of the Resident #15's admission Record showed the resident admitted to the facility with the following diagnoses:-Vascular dementia (a loss of mental function due to destruction of brain tissue related to reduced or blocked blood supply, often caused by large or several small strokes).-Cognitive communication deficit (communication difficulties such as trouble with word-finding and language organization stemming from underlying cognitive impairments common with strokes, brain injuries, and dementia).Review of the resident's elopement risk care plan, dated 10/18/23, showed:-Encourage the resident to participate in activities to divert from exit seeking behavior.-Provide safe wandering.-The resident was to reside on the secured unit.Review of the resident's wandering care plan, dated 10/18/23, showed:-The resident wandered into other resident rooms and could be agitated at times.-Staff were to redirect.-NOTE: The care plan had no intervention for any increased monitoring or supervision (such as line of sight, one on one supervision, 10 or 15 minute checks, or other increased monitoring). It did not show how staff were to proactively keep the resident from wandering into other resident rooms.Review of the resident's activity/social needs care plan dated 10/26/23 showed:-The resident enjoyed doing hair, going outside, crafts, drawing, family visits, movies, music, reading, religious services, and television.-Staff should invite the resident to activities.Review of the resident's Level I Pre-admission Screening and Resident Review (PASRR - a federally mandated screening for persons with serious mental illness or intellectual/developmental disability to assure appropriate placement in a Medicaid Certified bed facility) dated 10/27/23 showed:-The resident had a primary diagnosis of major neurocognitive disorder (a significant, progressive decline in cognitive abilities-such as memory, language, or executive function-that interferes with a person's independence in daily tasks).-The resident's most significant behavioral symptom was wandering.-The resident required a secured unit to allow for safe wandering.Review of the resident's Level II PASRR (a comprehensive evaluation required for nursing home applicants who trigger positive on the Level I screen for serious mental illness, intellectual disability, or related conditions which determines if the individual requires nursing care and specialized services), dated 11/2/23 showed:-The resident was unable to find his/her room despite his/her name being posted on the door.-The resident responded well to redirection. Staff provides redirection and reorientation with positive results.-The resident was unable to care for his/her basic needs unassisted and had extensive cognitive impairment with impaired concentration, consistent confusion, and severe memory impairment.Review of the resident's behavioral care plan, dated 6/4/24 showed:-The resident could potentially be verbally and physically aggressive.-He/She often undressed and walked around the unit and liked to go barefoot.-Staff were to observe and report resident posing a danger to himself/herself and others. Redirect when the resident undressed and encourage him/her to put on clothing. Provide music.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 8/26/25 showed the resident:-Was severely cognitively impaired and was inattentive.-Had no wandering behaviors.-Found it very important to listen to music, attend religious services, and spend time outdoors. -Found it somewhat important to look at magazines and be with groups of people.Review of the resident's progress notes dated October 2025 showed:-On 10/22/25 at 5:18 P.M. the resident was noted to be in a peer's room. Both were naked from the waist down with Resident #15 laying across the bed and the other resident standing in front of him/her. Staff were able to separate immediately. Skin assessment was performed with no apparent injury. Family and physician notified with new order received for continuous monitoring for behavior management.Review of the facility's internal investigation for the 10/22/25 incident, showed:-Three witnesses provided statements.-The investigation narrative showed on 10/22/25 at approximately 3:15 P.M. a Certified Nursing Assistant (CNA) was checking on residents. He/She opened a resident's door and found him/her standing at the side of the bed with his/her genitalia exposed and stating he/she was approached about having sex, but nothing happened. Resident #15 was reclined on the bed with legs in the air. The CNA called for his/her coworkers who called the Director of Nursing (DON). Immediate investigation initiated. Skin assessments completed and no injuries or evidence of intimate contact noted. Residents separated and diversional activities offered. Guardians, physicians, the DON, Executive Director, Regional contact notified.-Interventions were staff education regarding monitoring of residents. Diversional activities were provided with no further incidents. -Resident #15 was placed with a staff member to monitor.Review of the resident's progress notes dated November 2025 showed on 11/3/25 the Nurse Practitioner note showed the resident's caregiver reported the resident had been active and alert and having sexual inappropriateness with another resident. Both residents were under close observation.Review of the resident's progress notes dated November 2025 to 2/12/26 showed no documentation of the number of times during a shift the resident was known to wander into another resident's room or any documentation of potentially unsafe wandering. Review of the resident's Treatment Administration Record (TAR) dated February 2026 showed:-There was no documentation of how many times per shift the resident was wandering into other resident rooms.-There was no documentation of how many times per shift the resident had unsafe wandering. Review of the resident's quarterly MDS, dated [DATE], showed the resident had no wandering behaviors.Review of the resident's progress notes dated 2/13/26 to 3/4/26 showed no documentation of the resident's wandering into other resident rooms or other potentially unsafe wandering.Review of the resident's TAR dated March 3/1/26 to 3/3/26 showed:-There was no documentation of how many times per shift the resident was wandering into other resident rooms.-There was no documentation of how many times per shift the resident had unsafe wandering.Continuous observation on 3/2/26 between 9:33 A.M. and 11:25 A.M. showed:-At 9:33 A.M. residents were in the large activity/dining room watching a music video. -The resident wandered in the area and back out into the resident room hallway.-At 9:54 A.M. the resident was observed wandering up and down the hallway and going from resident room to resident room on both the left and right sides of the hall. Occasionally he/she went past the nurses' desk and into the hall behind the large activity/dining room.-At 10:10 A.M. a staff person took the resident by the hand and walked with him/her to the resident's own room.-At 10:11 A.M. the resident came out of his/her room and continued wandering the hallway.-At 10:15 A.M. the resident wandered into the open door of room [ROOM NUMBER] which was not occupied by another resident at that time.-At 10:37 A.M. the resident was again wandering the hall.-At 11:01 A.M. the resident was lying quietly on his/her left side facing away from the open door in the second bed in room [ROOM NUMBER]. The facility census showed the second bed in room [ROOM NUMBER] was assigned to a resident. The room did not have any residents in it at that time. Continuous observation on 3/3/26 between 2:39 P.M. and 2:55 P.M. showed:-At 2:39 P.M. the resident walked into the open door of room [ROOM NUMBER], which was occupied by another resident. The resident in room [ROOM NUMBER] placed a hand on each of Resident #15's arms and tried to guide him/her to the door towards the hallway. A staff person in the hallway took Resident #15's hand and verbally encouraged him/her to come out of room [ROOM NUMBER].-At 2:49 P.M. Resident #15 walked into the open door of room [ROOM NUMBER] and walked to the second bed which the census showed was assigned to another resident. He/She laid down with his/her head at the foot of the bed and his/her feet facing the head of the bed. The room did not have any residents in it at that time. -At 2:53 P.M. a staff person going down the hall noticed the resident from the open door of room [ROOM NUMBER] and told the resident he/she would show him/her to his/her own room. The resident cooperatively left with the staff person.Review of the resident's physician orders dated 3/4/25 showed the resident had no current orders for any increased monitoring or supervision.Observation on 3/4/26 at 9:50 A.M., 10:03 A.M., 6:52 P.M., 8:00 P.M. and 8:24 P.M. showed the resident was in his/her own bed lying still as if asleep. During an interview on 3/4/26 at 8:01 P.M. CNA F said:-When he/she came onto the unit on 10/22/25 other staff were already with Resident #15 and the other resident who he/she heard was also undressed from the waist down. Both residents were placed on 1:1 staffing for five days. Since then, Resident #15 had not had any increased level of supervision or any other similar incident.-Resident #15 would undress a couple of times a week during the evening shift. The resident would wander and take his/her clothes off or often just his/her top off.-Staff tried to keep the resident in the common area, but as soon as staff were busy with another resident, Resident #15 would get up and wander off. He/She sometimes wandered non-stop.-Resident #15 would wander into someone's room and turn the water on and leave it running or get into someone's bed. Staff were supposed to redirect the resident, but he/she wandered so much it was hard to keep the resident out of other residents' rooms.Continuous observation on 3/5/26 between 10:48 A.M. and 11:20 A.M. showed:-At 10:48 A.M. the resident was standing near the large dining/activity room tables and headed down the resident room hallway. The Licensed Practical Nurse (LPN) was at the medication cart and two CNAs were in the large activity room/dining room trying to engage residents in table activities.-At 10:57 A.M. the resident returned to the large activity/dining room and one of the CNAs danced to music with the resident.-At 11:00 A.M. the resident wandered down the resident room hallway. -At 11:02 A.M. the resident was lying in the second bed in room [ROOM NUMBER] on his/her right side facing the hall. The room door was open. The room did not have any other residents in it at that time. -At 11:07 A.M. the LPN went down the hall checking resident rooms and towards the end of the hall found the resident in the second bed of room [ROOM NUMBER]. He/She took the resident's hand and led him/her to the large activity/dining room where the music video and table games were taking place.-At 11:10 A.M. the resident walked into room [ROOM NUMBER] and the LPN immediately encouraged him/her to come out.-At 11:11 A.M. the unit phone rang and the LPN went to the nurses' desk to answer it. Resident #15 wandered back into the open door of room [ROOM NUMBER]. -At 11:12 A.M. the resident exited the room while the LPN was still on the phone.-At 11:13 A.M. the resident wandered into the open door of room [ROOM NUMBER] and sat on the side of the second bed and then laid down on his/her right side, facing the door.-At 11:15 A.M. the resident walked out of room [ROOM NUMBER] and into the large activity/dining room where residents were engaged in table games and listening to music. The two CNAs were still in the activity area engaged with other residents.During an interview on 3/6/26 at 11:56 A.M. the Social Services Assistant said:-He/She had been informed of the 10/22/25 incident involving Resident #15 and another resident. There had been no other similar incidents.-It was common for the resident to wander in and out of resident rooms and lie in other residents' beds.-He/She was not aware of any verbal or physical conflicts with any other resident related to the resident's wandering.-Social Services was responsible for behavioral care plans. -Staff were supposed to redirect the resident from wandering into other residents' rooms.Continuous observation on 3/9/26 between 9:30 A.M. and 9:42 A.M. showed:-A housekeeper was cleaning resident rooms.-At 9:30 A.M. Resident #15 was in the second bed of room [ROOM NUMBER].-At 9:32 A.M. the resident got up and came out of the room into the hallway.-At 9:33 A.M. the resident went into the open door of room [ROOM NUMBER]. The facility census and names on the door showed two other residents occupied room [ROOM NUMBER].-At 9:34 A.M. the resident came out of room [ROOM NUMBER] and entered the open door of room [ROOM NUMBER]. He/She sat on the second bed.-At 9:37 A.M. the resident got up and walked into the hallway.-At 9:38 the resident walked past a wet floor caution sign into the open door of room [ROOM NUMBER]. The facility census showed the room was occupied by two other residents.-At 9:39 A.M. the resident walked out of the room into the hallway.-At 9:40 A.M. the resident walked into the open door of room [ROOM NUMBER]. The census showed the first bed in room [ROOM NUMBER] was assigned to a resident and the second bed was not currently occupied by a resident. The resident laid down on the second bed in room [ROOM NUMBER] on his/her right side, facing the door.-At 9:42 A.M. the resident got up and walked over to the sink. He/She stood over the sink and stared at it for many seconds and then wandered back into the hallway.During an interview on 3/9/26 at 9:43 A.M. Housekeeper A said:-When he/she cleaned on the unit, Resident #15 normally wandered the hall and went in and out of other residents' rooms.-He/She didn't know what the resident's interventions were or been told if he/she was supposed to do anything or notify anyone when the resident was in another resident's' room.During an interview on 3/9/26 at 10:14 A.M. CNA G said:-The resident wandered in and out of other resident's rooms all day unless he/she was taking a nap.-Staff tried to keep Resident #15 out of other resident rooms by closing the other resident room doors. When room doors were closed the resident didn't wander into the rooms.-Staff kept Resident #15's door open so he/she would go in there. -Other residents on the unit were all able to open their own closed door.-The resident would try to turn on sinks in other resident rooms and would get in other residents' beds. Multiple times the sinks had overflowed from the resident leaving them on.-On 10/22/25 another CNA found Resident #15 undressed from the waist down in another resident's room. The other resident was also undressed from the waist down. The other CNA called him/her to the room. When he/she got to the room he/she found Resident #15 sitting at the foot of the bed undressed from the waist down and the other resident near the sink undressed from the waist down. -Sometimes the resident undresses himself/herself and probably had been found undressed in other resident rooms but had not had another incident where he/she was found partially undressed with another resident. The resident hadn't undressed himself/herself as much in the past year.-He/She was not aware of any altercations the resident had with any other resident when he/she wandered into their room. -The resident in room [ROOM NUMBER] would tell staff when Resident #15 wandered into his/her room. -The family member of the resident in room [ROOM NUMBER] had informed staff when Resident #15 was in room [ROOM NUMBER] when he/she visited. If the door was closed Resident #15 won't go in there. -The resident was not on any increased level of supervision or checks, although staff knew to redirect the resident when they noticed he/she was heading toward or was in another resident's room.During an interview on 3/9/2 at 11:04 A.M. LPN D said:-He/She tried to make room rounds every 30 minutes to make sure the resident was safe and not in another resident's room. He/She redirected the resident by gently taking his/her hand and walking with him/her to his/her own room.-There had been no resident-to-resident altercations, and the resident had not undressed in another resident's room in the past several weeks. He/She had not heard of any altercations or unsafe wandering having happened in several months. If there was any unsafe wandering the nurse should have documented that in the resident's progress notes. -He/She thought if other resident doors were shut except the resident's the resident would likely just open the other resident room doors and wander in.-To prevent the resident from entering other resident rooms, it would take a lot of observations and redirection. -When staff turn their backs, the resident just wandered to the next spot. -Staff couldn't keep the resident out of other resident rooms or redirect him/her from going into them without constant monitoring.During an interview on 3/9/26 at 11:45 A.M. the Director of Nursing (DON) said:-He/She would expect staff to try to redirect someone from going into another resident's room and to provide lots of activities as a diversion.-He/She had only been at the facility a couple of weeks and didn't know Resident #15 well enough to know what activities he/she could focus on or what interventions would work best to prevent wandering into other resident rooms.-The resident's wandering should be care planned and include effective interventions. -Direct care staff should use the Kardex to see what interventions they should use.-The nurse was responsible for documenting resident behaviors in the progress notes.

Based on interview and record review, the facility failed to ensure consistent documentation of daily activity participation and quarterly activity progress for one sampled resident (Resident #70) out of 20 sampled residents. There was insufficient documentation to show that an activity program was consistently provided for the resident or that the resident had been informed when activities were taking place. The facility census was 98 residents. Review of the facility's Therapeutic Activities Program policy, revised 9/26/25, showed the facility must provide, based on the comprehensive assessment, care plan, and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.1. Review of Resident #70's admission Record showed the resident was admitted with the following diagnoses:-Stroke affecting right, dominant side.-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).-Major depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable).Review of the resident's Activities care plan, revised 7/2/24, showed:-Encourage ongoing family involvement.-Invite resident to scheduled activities such as music, movies, dancing, Bingo, going outside, religious activities, exercise, and food-related socials.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/15/25, showed the resident:-Was moderately cognitively impaired.-It was somewhat important for the resident to participate with groups of people and read and very important to be outside, have family involvement, and attend religious services. Review of the resident's daily participation documentation dated December 2025 to March 5, 2026, showed:-There was no documentation available for December 2025.-There was no documentation available for January 2026. Review of the resident's past two quarterly Activity Participation notes showed:-On 2/13/26 the resident had not had a change in activity choice or level in the past 90 days. -Activities would proceed with current plan of care.--The 2/13/26 note did not show the types and frequency of activities offered during the quarter or explain the resident's level of participation.-NOTE: There was no quarterly Activity Participation note for November 2025. During an interview on 3/2/26 at 12:11 P.M. the resident's family member said:-When he/she visited, the resident would be in his/her room with the door shut and an activity would be taking place on the unit.-He/She was concerned that the resident might not be informed of the activity because the resident normally participated if aware the activity was going on.-He/She was concerned the resident might be bored at times because he/she had started re-arranging things in his/her room.-He/She had not yet said anything to staff about his/her concerns but was concerned enough that he/she planned to say something.During an interview on 3/4/26 at 8:16 P.M. Certified Nurse Assistant (CNA) F said:-The resident enjoyed music and would participate in activities if staff let him/her know activities were taking place.-If staff didn't let him/her know an activity was going on, the resident would stay in his/her room with his/her door shut.During an interview on 3/5/26 at 11:58 A.M. the Activities Director said:-He/She was responsible for completing admission, annual, and change of condition Activity assessments.-There used to be another Activity Director who worked on the resident's unit. He/She left the facility around the end of January 2026 and was responsible for activity assessments and preparing and presenting activities on the resident's unit as well as completing daily activity participation documentation and quarterly activity progress notes for that unit.-Since the other Activity Director left, the activity assistants were expected to help on the resident's unit and provide activities. -He/She expected the activity assistants to complete activity participation documentation following each activity. -He/She had completed quarterly progress notes for the resident's unit after the other Activity Director left.-He/She did not know where the other Activity Director filed the activity participation documentation for the resident's unit. -Quarterly activity progress notes should be in the resident's electronic record.During an interview on 3/9/26 at 10:07 A.M. CNA G said:-The resident stayed in his/her room unless someone came and got him/her and asked him/her to join in the activity.-The resident wouldn't be aware an activity was going on unless staff told him/her and encouraged him/her to join.-The activities staff as well as nursing staff were responsible for ensuring the residents knew an activity was going on.-Activities staff were responsible for completing daily activities participation documentation.During an interview on 3/9/26 at 11:15 A.M. Licensed Practical Nurse (LPN) D said:-The resident tended to nap with his/her door closed in his/her room and wouldn't know an activity was going on unless activity or nursing staff let him/her know.-Activity participation documentation was completed by activities staff.During an interview on 3/9/26 at 11:45 A.M. the Director of Nursing (DON) said:-Whoever did an activity was responsible for documenting activity participation for residents. The activity participation should be completed after each activity provided or at least daily for each resident.-Activity progress notes should be completed by the Activity Director on a quarterly basis and show the resident's participation.-He/She had only been at the facility a couple of weeks, but either he/she, the Administrator, or a designee should be auditing resident records to ensure activities were offered and activity participation progress was being documented.

Based on observation, interview, and record review, the facility failed to store a nebulizer (a device used to administer medication to people in the form of a mist inhaled into the lungs) mask in a plastic bag for one sampled resident (Resident #16) out of 20 sampled residents. The facility census was 98 residents. Review of facility policy entitled Oxygen Administration (Infection Control, Safety, and Storage) revised 9/30/25 showed:-The facility must have ensured that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. -Stored respiratory supplies in a bag labeled (i.e., residents name) when not in use. 1. Review of Resident #16's admission Record showed he/she was admitted to the facility with the following diagnosis: -Asthma (a chronic respiratory condition that caused airway inflammation, swelling, and mucus production, that resulted in breathing difficulties, wheezing, chest tightness, and coughing).-Respiratory failure unspecified whether with hypoxia (low oxygen) or hypercapnia (elevated carbon dioxide).Review of the resident's Order Summary Report (OSR) dated 11/21/25 showed:- Monitor every shift related to asthma. Did the resident experience signs or symptoms of shortness of breath (SOB) when laid flat or avoided lying flat due to signs or symptoms of SOB (increased respiratory rate, pursed lip breathing, a prolonged expiratory phase, audible respirations, gasping for air, interrupted speech pattern, use of accessory muscles, anxiety, restlessness etc.)? -Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg)/3 milliliter (ml) 3 ml inhaled orally via nebulizer four times a day related to respiratory failure.Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 1/5/26 showed:-The resident was cognitively intact. -Scheduled respiratory treatments were skipped. Review of the resident's care plan dated 2/26/26 showed:-The resident had altered respiratory status/difficulty breathing related to recent hospitalstay for respiratory failure.-Staff were to administer medication as ordered.-NOTE: Storage of the nebulizer mask was not addressed. -NOTE: Resident noncompliance was not addressed. Observation on 3/2/26 at 9:21 A.M. of the resident's room showed:-The nebulizer mask was set upright on the nebulizer machine not stored in plastic bag.-There was no plastic bag near the nebulizer for storage of the nebulizer mask. Observation on 3/2/26 at 2:32 P.M. of the resident's room showed:-The nebulizer mask was set upright on the nebulizer machine not stored in plastic bag.-There was no plastic bag near the nebulizer for storage of the nebulizer mask. Observation on 3/3/26 at 9:21 A.M. of the resident's room showed:-The nebulizer mask was set upright on the nebulizer machine not stored in plastic bag.-There was no plastic bag near the nebulizer for storage of the nebulizer mask. During an interview on 3/4/26 at 7:58 A.M., Licensed Practical Nurse (LPN) B said:-Nebulizers were to be stored in a dated plastic bag when not in use. -The plastic bag would be dated and changed out weekly. -When a nebulizer mask was found not in a plastic bag it would be replaced and placed in the plastic storage bag. -When a resident was not compliant with the storage of the respiratory item the resident would be educated about the importance of it, and the MDS Coordinator would be notified so the care plan could then be updated. During an interview on 3/6/26 at 8:48 A.M., Certified Nursing Assistant (CNA) E said:-A nebulizer mask should have been stored in a plastic bag. -If a nebulizer mask was not stored in a plastic bag, he/she would discard it and get a new one and put it in the plastic bag. -When a resident was non-compliant he/she would educate the resident on the importance of storing the nebulizer mask in a the plastic bag , and he/she would notify the nurse.During an interview on 3/6/26 at 8:51 A.M., Registered Nurse (RN) A said:-The nebulizer masks were to be stored in a dated plastic bag when not in use.-When the nebulizer mask was not stored in the plastic bag, he/she would get a new nebulizer mask and place it in the plastic bag. -The MDS Coordinator would be informed that resident was noncompliant on the storage of nebulizer mask, so the care plan could be updated for education and noncompliance. -When a resident was not compliant with the storage of the respiratory item the resident would be educated about the importance of it.During an interview on 3/9/2026 11:52 A.M., the Director of Nursing (DON) said:-He/She expected nebulizer masks to be stored in dated plastic bags when not being used.-He/She expected when a nebulizer mask was found not stored in a plastic bag that it would be replaced and the new nebulizer mask was placed in the plastic bag. -He/She expected staff would have educated the resident on the importance of storing nebulizer masks in plastic bags when not in use.-When a resident was noncompliant with the storage of respiratory items he/she expected the MDS Coordinator to be notified and to update the care plan.

Based on observation, interview, and record review, the facility failed to ensure a resident who required dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) received ongoing assessments of the dialysis site; and failed to have orders for dialysis for one sampled resident (Resident #38) out of 20 sampled resident. The facility census was 98. Review of the facility policy Area of Focus: Dialysis (a process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane) reviewed 12/01/25 showed:-The two types of dialysis that were currently in common use are hemodialysis (HD-process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) and peritoneal dialysis (PD- kidney failure treatment that uses the lining of your abdomen (peritoneum) to filter waste and extra fluid from your blood using a surgically placed catheter).-The facility must have ensured that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and residents' goal and preferences. -Assessed for any signs/symptoms of infection, such as redness or edema at the vascular access site.-Assessed vascular access site for signs of clotting every eight hours.-Documented in the clinical nursing record: dialysis treatment completed, order changes, condition of shunt site, complaints from the resident (if applicable), and whether physician and responsible party notification. -Physicians shall have established an order for the amount of time required for the resident to be on dialysis.-Monitored vascular access site on a routine basis. 1. Review of Resident #38's admission Record showed the resident was admitted with the following diagnosis:-End Stage Renal (Kidney) disease (the final, irreversible stage of chronic kidney disease, and they can no longer support life). -Dependence on Renal (Kidney) dialysis.Review of resident's undated comprehensive care plan showed:-Hemodialysis (HD) related to end stage renal disease.-The resident would have no signs or symptoms of complications from dialysis through the review date.-Dialysis at dialysis facility Tuesday, Thursday, and Saturday chair time 11:00 A.M. to 3:00 P.M.-Dialysis treatments as ordered.-Dry weights obtained from dialysis center.-Had a tunneled dialysis catheter (a soft, flexible tube placed into a large vein (usually in the neck, chest, or groin) to provide immediate, temporary access to the bloodstream for hemodialysis, or for peritoneal dialysis) to right upper chest, until shunt was placed. -Observe for bleeding at dialysis access site.Review of resident's Progress Notes dated 2/16/2026 showed:-The resident returned to facility via stretcher accompanied by emergency medical services (EMS), at 5:10 P.M. temporary dialysis catheter on right upper chest, and arteriovenous (AV) fistula (the preferred long-term vascular access for hemodialysis, created by surgically joining an artery to a vein, usually in the forearm) on left upper arm.-The resident was compliant during assessment, with no issues. Review of the resident's Electronic Medical Record (EMR) showed that from readmission to 2/16/26 there was:-No dialysis orders in place.-No orders for when the resident was to attend dialysis.-No orders for site and type of access the resident had.-No orders for monitoring dialysis site nor how often. -No documentation that the resident's dialysis site was being monitored or assessed. Observation on 3/1/22 at 1:00 P.M. of resident showed:-He/She was sitting in his/her wheelchair. -He/She had a dialysis catheter on the right side of his/her chest with a clean, dry, intact dressing. During an interview on 3/4/26 at 7:58 A.M., Licensed Practical Nurse (LPN) B said:-He/She was unfamiliar with the resident.-There should be orders for when the resident went to dialysis and when to assess the dialysis site. -The dialysis site should be assessed every shift for bleeding and signs of infection. -The assessments should have been documented in the residents EMR.-If a resident received dialysis and there were no orders he/she would have called the doctor and obtained the orders. During an interview on 3/6/26 at 8:51 A.M., Registered Nurse (RN) A said:-The resident had a dialysis catheter in his/her chest. -Dialysis access should be assessed every shift and should be charted in the computer in the resident medical chart. -He/She would expect the resident to have orders for what type of site and what would be monitored.-There should be orders to monitor for signs and symptoms and of infection and bleeding. -The site needed monitored for infection and bleeding, because if infected the site needed to be changed, and if bleeding the resident needed to be sent to the hospital. -If there were no orders, then the doctor would need to be contacted, and orders received for dialysis.-The resident had orders before last hospitalization.-He/She guessed that the old orders were not restarted upon admission and that was a mistake. During an interview on 3/9/2026 11:52 A.M., the Director of Nursing (DON) said:-It was his/her expectation that a nurse would know the type of dialysis access a resident had. -It was his/her expectation that the nurses knew how to assess the dialysis access. -It was his/her expectation that a resident that required dialysis would have orders for when and where to go for dialysis to include chair time, and when and how often to assess the dialysis site. -A dialysis site would be monitored every shift for infection, drainage and depending on the access a thrill (a fine, palpable vibration felt on the skin) and bruit (an abnormal, rushing or blowing sound heard through a stethoscope over a blood vessel) would be monitored and it would be charted in the EMR. -The nurse that readmitted the resident to the facility should have caught that there were no dialysis orders and called the doctor. -The team should have caught the missing dialysis orders in the morning meeting.-He/She had just started at the facility.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #70) with a history of physical and sexual trauma (an event or series of events experienced by a person as physically or psychologically harmful or threatening) out of 20 sampled residents had triggers (psychological stimulus that prompts recall of previous traumatic events) identified and interventions for staff to help mitigate triggers and avoid re-traumatization in the resident's Trauma Informed Care (TIC - an approach to care that recognizes and responds to the effects of trauma on a person) care plan. The facility census was 98 residents. Review of the facility's Person-Centered Care Planning policy, dated 8/16/22 and reviewed 8/29/25, showed:-Trauma-informed care was an approach to delivering care that involved understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma in care plans, policies, procedures, and practices to avoid re-traumatization.-The facility will include the resident, and if applicable, the resident's representative participation in developing the person-centered plan. For residents with a history of trauma, the care plan will include the interventions for care and account for the resident's experiences and preferences to eliminate or mitigate triggers that may cause additional trauma for the resident.1. Review of Resident #70's admission Record showed the resident admitted with the following diagnoses:-Stroke affecting right, dominant side.-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses).-Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety).-Major depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable).Review of the resident's past two TIC assessments showed:-On 10/1/24 a family member provided information about the resident's past trauma related to sexual abuse as a child due to the resident's cognitive deficit. The family member was unaware of any known triggers related to the trauma.-On 7/25/25 a family member provided information related to the resident's history of sexual assault. The family member was unaware of any known triggers related to the trauma.Review of the resident's psychosocial well-being care plan, dated 5/14/25 showed:-The resident was easily distracted and found it difficult to concentrate.-The resident had ineffective coping surrounding his/her history of sexual assault from a family member.-Interventions included:--Consult pastoral care, social services, psychological services, and the physician.--Provide support to identify precipitating factors/stressors.--Provide support to identify problems that cannot be controlled. And identify solutions to present problems.--When conflict arises remove resident to a calm safe environment and allow resident to share feelings, allowing time to answer questions and to verbalize perceptions and fears.-NOTE: The psychosocial care plan did not identify possible triggers or specify what staff should do to lessen the likelihood of re-traumatization. Review of the resident's trauma care plan, dated 7/25/25 showed:-The resident experienced significant trauma related to sexual assault as a child.-The Interdisciplinary Team (IDT) shall meet proactively to discuss care strategies that consider safety, trustworthiness, peer support, collaboration, empowerment, choice, culture, history, and being sensitive and respectful concerning gender issues.-The IDT will reinforce that trauma refers to experiences that cause intense psychological stress reactions. The resident will be provided culturally competent, sensitive trauma-informed care in accordance with professional standards accounting for the resident experience and preferences to eliminate or mitigate triggers that may re-traumatize.-NOTE: The trauma care plan did not show strategies that staff could use to help the resident feel safe and build trust; what staff could do to help build peer support; how they would collaborate with the resident; and what they would do specifically to provide a sensitive and respectful environment concerning gender issues. The care plan did not show what the resident's possible triggers were likely to be or what staff could do specifically to help mitigate possible triggers that might re-traumatize the resident.Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/15/25 showed the resident was moderately cognitively impaired.Review of the resident's nursing progress note dated 2/24/26 at 2:30 P.M. showed:-The resident was asleep and his/her roommate attempted to awaken the resident. -The resident screamed. -The nurse ran into the room and walked the roommate to the nurses' station. -The resident went back to sleep.During an interview on 3/5/26 at 9:40 A.M. the Social Services Assistant (SSA) said:-He/She did TIC assessments upon admission, annually, when there was a significant change in the resident's condition, or any time there was a newly known trauma.-The TIC assessment should reflect any past trauma or known triggers.-The MDS Coordinator was responsible for the TIC care plan and used the TIC assessment to do the care planning.-He/She was responsible for asking the resident or their responsible party about the resident's past trauma and any known triggers.-The resident's care plan should show any likely possible triggers and what staff can do to help the resident.During an interview on 3/5/26 at 1:10 P.M. the resident's family member (Family Member A) said:-The resident had an extensive history of sexual abuse as a child.-About a month ago the resident was awakened from sleep by his/her former roommate who was sitting on his/her bed. The staff let him/her know this had been highly disturbing to the resident. When the resident was highly upset, he/she would scream or yell out. He/She thought the experience could have triggered the resident's past trauma, but didn't know for sure. -The resident became upset if someone's tone of voice was loud and/or disrespectful, which could in part remind the resident of his/her childhood experiences.-The resident startled very easily. If touched or someone tried to assist the resident with cares without first explaining what they were about to do the resident would jump. Staff should always explain first so the resident wasn't fearful. The resident's familiar staff knew to do this. Staff on the unit should be as consistent, and familiar staff whom the resident trusts should work with the resident as much as possible.-He/She thought the resident would be significantly more comfortable and feel safer if a familiar, trusted, staff person of the same sex assisted the resident with showers, getting dressed and undressed, changed his/her disposable brief, and assisting with intimate cares. The resident wouldn't want a staff member of the opposite sex to bathe him/her, help him/her undress, or change his/her brief.-Approaches to care should reflect the resident's needs related to his/her past trauma and be clearly explained in his/her care plan.During an interview on 3/9/26 at 10:14 A.M. Certified Nurse Assistant (CNA) G said:-He/She had attended TIC training at the facility.-The education described different types of trauma and a resident's possible response and triggers to the response. For instance, a resident might clench up or refuse to be undressed. This could indicate fear if they were abused in the past. A person might become upset or scream if they heard a loud noise if they heard that during a traumatic experience.-He/She didn't know of the resident's past trauma and didn't know if the resident's care plan mentioned his/her triggers or interventions, but the care plan should show how staff were to help the resident with a trauma history.-He/She knew if anyone spoke loudly or sternly to the resident the resident would start screaming and yelling. The resident didn't like to be ordered around or spoken to like he/she was a child. Staff should tell the resident gently what they wanted him/her to do and why instead of ordering him/her to do it.-The resident startled easily in his/her sleep or if another resident walked into his/her room without knocking or he/she was touched unexpectantly. In any of these situations the resident would jump as if very startled. If another resident entered his/her room the resident would scream for someone to get the resident, or he/she would become upset and stern with the other resident and staff had to come and get them.-Staff should always explain what cares they were about to do and why and use a gentle, non-confrontational approach. Staff who provided cares should be familiar and trusted by the resident. Almost all the CNAs who provided care were the same sex as the resident, which he/she thought the resident would much prefer.During an interview on 3/9/26 at 11:18 A.M. Licensed Practical Nurse (LPN) D said:-He/She received TIC education at the facility within the past six weeks. The training included examples of past trauma like someone having gone through a war, been assaulted in prison, and other traumatic experiences. They talked about possible triggers and how staff might help.-If someone had a history of trauma there should be a TIC care plan which showed the resident's triggers and ways staff could help the resident.-He/She did not know the resident's prior trauma, his/her possible triggers, or interventions related to trauma.-He/She knew the resident didn't like loud noises. Staff should use a soft, non-confrontational approach and give the resident time to respond.-Staff should knock and let the resident respond before entering his/her room and discretely ask him/her what he/she needed. They should let the resident know before checking his/her briefs for wetness and provide as much privacy as possible. They should say the resident's name and explain the care they were about to provide before starting.-Ideally care should be provided to the resident by a staff member of the same sex. In general, the unit used mainly staff members of the same sex to provide showers and change clothes and briefs for residents.-The resident's vision was compromised, especially on the right side, so anything that entered his/her space abruptly or any sudden movement made the resident jump. Loud noises or anything unexpected caused the resident to jump and look startled and should be avoided whenever possible.During an interview on 3/9/26 at 11:45 A.M. the Director of Nursing (DON) said:-The facility was responsible for providing TIC to all facility staff.-TIC care plans should include the resident's known or likely triggers. -Staff should know how to avoid triggering the resident and what approaches worked best with them.-The care plan should show this information as well as the Kardex (a quick reference tool providing a concise summary of the resident's care needs) which was used by staff providing the residents' direct cares.

Based on interview and record review, the facility failed to provide pre-treatment medication for one sampled resident (Resident #35) out of 20 sampled residents, prior to his/her dental appointment, causing a delay in his/her dental care leading to unnecessary pain between procedures. The facility census was 98 residents. Review of the facility's Physician Orders Policy, dated 2/11/26, showed:-All physician/practitioner orders, including verbal/telephone orders, were recorded in the medical record for each resident and must be signed and dated within 14 days by the ordering physician, physician assistant or nurse practitioner.-The receiving nurse, therapist, or approved dietician immediately enters the telephone or verbal orders into the clinical software.Review of the facility's Administration of Medications policy, dated 9/9/25, showed:-The facility ensured medications were administered safely and appropriately per physician order to address the resident's diagnoses and signs and symptoms.-Medication administration was the responsibility of those individuals who were authorized to administer medications.A policy specifically related to dental and oral care was requested and not received.1. Review of Resident #35's face sheet, undated, showed he/she admitted with the following diagnoses:-Type 2 Diabetes (a chronic condition where the body cannot properly use or make enough of a hormone called insulin, leading to high blood sugar levels).-Protein calorie malnutrition.-Anxiety disorder (excessive, persistent, and uncontrollable fear or worry that interferes with daily life).Review of the resident's dental care treatment summary dated 1/26/26 showed the resident was unable to be to be seen for treatment as the resident was not provided the necessary pre-treatment prior to procedure.Review of the resident's Progress Notes, dated 1/26/26, showed:-The dental instructions for pre-treatment were provided to nursing staff.-The pre-treatment was required prior to the procedure.Review of the resident's Progress Notes, dated 2/17/26, showed the resident was ordered to receive dental pre-treatment prior to next dental appointment.Review of the resident's Quarterly Minimum Data Set (MDS- a standardized, federally mandated assessment tool used in nursing homes to evaluate a resident's functional, medical, psychosocial, and cognitive status) dated 2/19/26, showed the resident was cognitively intact.Review of the resident's Physician Order Summary, dated March 2026, showed:-The resident was permitted to see the dentist as needed.-There were no orders for pre-treatment for dental visits.During an interview on 3/2/26 at 1:31 P.M., the resident said:-He/She had not seen the dentist the last time the dentist was at the facility.-He/She was supposed to take some type of medicine before the appointment, but it was not given to him/her.-He/She had to wait for the next time the dentist came to get the work done.-The resident reported being in pain, but received pain medication and it helped. During an interview on 3/4/26 at 7:43 A.M., Licensed Practical Nurse (LPN) B said:-The resident did complain to him/her about dental pain.-He/She did see it on reports that the resident had complained about dental pain to other staff. -There were a few times the resident did not get to the dentist due to pain. During an interview on 3/5/26 at 9:32 A.M., the Social Services Assistant (SSA) said:-There were some communication issues with the dental company regarding the resident's dental treatment.-The orders for the pre-treatment were not transmitted on time.-The orders were received on 2/17/26 and the resident was on the list to see the dentist this week.During an interview on 3/6/26 at 2:11 P.M., the Director of Nursing (DON) said:-The resident did not receive the premedication for his/her dental treatment scheduled for 1/26/26.-It was ordered.-The order was received on 2/17/26 and it was on hand for the next scheduled dental visit.During an interview on 3/9/26 at 11:52 A.M., the DON said:-If residents were ordered a pre-treatment needed for dental visits, it was the nurse on duty who was responsible for getting the orders on the Physician Order Summary. -The nurse transcribed the order to be sure it was on the order summary and the Medication Administration Record (MAR).-The order initially went to the dentist, which was then emailed to Social Services, who was responsible for getting the order to the nurse.-If the resident received the pre-treatment, it would have been documented on the MAR.-The order should have been entered, and the resident should have received the pre-treatment medication on 1/26/26.

Based on interview and record review, the facility failed to notify one closed record sampled resident's (Resident #108) responsible party after the resident fell on 2/14/26 out of two closed record sampled residents. The facility census was 98 residents. On 3/9/26 the Administrator was notified of the past noncompliance which occurred on 2/14/26. On 2/15/26 the facility administration was notified a resident's responsible party was not notified of a change in condition and the investigation was started. The resident's family was notified on 2/15/26. No employees were allowed to work prior to reeducation. The deficiency was corrected on 2/15/26. Review of the facility's policy titled Change in Resident's Condition or Status dated 8/29/25 showed the facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her own authority, the resident's representative(s) where there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention.1. Review of Resident #108's admission Record showed he/she was admitted to the facility for a respite stay on 2/13/26 with the following diagnoses:-History of Falling.-Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses).Review of the facility's Event Note dated 2/14/26 at 5:07 P.M. showed:-The resident was standing behind a door on the locked memory care unit.-A staff member had opened the door and startled the resident.-The resident then fell to the floor.-The resident fell on his/her right side.-The resident was non-verbal but moaned in pain when his/her right leg was touched.-The resident still had some range-of-motion (ROM) to the right leg.-The resident's hospice (end of life care) company was notified.-The hospice company reported that a nurse was going to see and assess the resident at the facility.Review of the facility's Event Note dated 2/14/26 at 9:30 P.M. showed:-A hospice nurse had come to assess the resident.-The resident had made no complaints of pain at that time.-The resident was able to move his/her leg without complaint.-No new orders were received at that time.-The hospice nurse would follow-up and inform the resident's family.Review of the resident's fall investigation dated 2/16/26 showed:-The hospice nurse stated that he/she would notify the family related to the fall.-There was no noted follow-up completed by the facility to ensure that the resident's family had been notified.Review of the resident's Electronic Medical Record (EMR) on 3/6/26 showed no documentation on 2/14/26 that indicated that the resident's responsible party was notified of the resident's fall.During an interview on 3/6/26 at 2:50 P.M. the Administrator said he/she was aware that the resident's family had not been notified by the facility related to the resident's fall on 2/14/26 until 2/15/26.During an interview on 3/9/26 at 9:34 A.M. Certified Medication Technician (CMT) A said:-Nurses were responsible for notifying a resident's responsible party after a change in condition.-A resident's responsible party should be notified immediately after a change in condition was noticed.-The facility would still be responsible for ensuring that a resident's responsible party was notified after a change in condition even when a hospice nurse said they would notify the family.-The resident's family should have been notified immediately after the resident fell. During an interview on 3/9/26 at 9:49 A.M. Registered Nurse (RN) B said:-Nurses were responsible for notifying a resident's responsible party after a change in condition.-A resident's responsible party should be notified immediately after a change in condition was noticed.-Usually, he/she would call the doctor first and then notify the family.-The facility would still be responsible for ensuring that a resident's responsible party was notified after a change in condition even when a hospice nurse said they would notify the family.-The facility did not need to ensure the hospice company notified the resident's family because the facility would be responsible for their own notification. -The resident's family should have been notified immediately after the resident fell.During an interview on 3/9/26 at 10:12 A.M. Licensed Practical Nurse (LPN) B said:-Nurses were responsible for notifying a resident's responsible party after a change in condition.-A resident's responsible party should be notified immediately after a change in condition was noticed.-The facility would still be responsible for ensuring that a resident's responsible party was notified after a change in condition even when a hospice nurse said they would notify the family.-The resident's family should have been notified sooner related to the resident's fall.During an interview on 3/9/26 at 11:52 A.M. the Director of Nursing (DON) said:-Nurses were responsible for notifying a resident's responsible party after a change in condition.-A resident's responsible party should be notified immediately after a change in condition was noticed.-He/She expected the staff to follow the facility's policy on notification of change in condition regardless of a hospice nurse stating he/she would notify the family.-The resident's family was notified too late and should have been notified immediately after the resident fell on 2/14/26. 2748480

Based on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #2, Resident #4, and Resident #11) were free from abuse when on 10/10/25 Resident #1 slapped Resident #2 in the back of the head; on 10/16/25 when Resident #3 punched Resident #4 in the face multiple times which caused Resident #4 to have a small laceration to his/her right eyebrow, bruising to his/her right orbital area of his/her face, and multiple small cuts to the back of his/her head, and on 10/23/25 when Resident #3 poured hot sauce on Resident #11's face. 13 residents were selected for sample. The facility census was 106 residents.Review of the facility's policy titled Abuse-Identification of Types dated 5/6/25 showed:-Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish.-Physical abuse included but was not limited to:--Hitting.--Slapping.--Punching.--Biting.--Kicking. -Verbal abuse was considered a type of mental abuse (the use of verbal or non-verbal conduct which causes or has potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation).-Verbal abuse included the use of oral, written, gestured communication, or sounds, to residents within hearing distance regardless of age, ability to comprehend, or disability.-Examples of mental and verbal abuses included, but was not limited to:--Harassing a resident.--Mocking, insulting, ridiculing.--Yelling or hovering over a resident, with the intent to intimidate. 1. Review of Resident #1's admission Record showed he/she was admitted to the facility with a diagnosis of Hemiplegia (paralysis of one side of the body) Following Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain) Affecting Left Non-Dominant Side.Review of Resident #1's undated care plan showed the resident had potential to be verbally aggressive and would cuss at staff/residents and concoct situations related to ineffective coping skills and poor impulse control.Review of Resident #1's Annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/11/25 showed:-The resident was cognitively intact.-The resident had not exhibited any physical behavioral symptoms directed towards others during the look back period.Review of Resident #2's admission Record showed he/she was admitted to the facility with the following diagnoses:-Anxiety Disorder (any group of mental conditions characterized by excessive fear or apprehension about real or perceived threats), Unspecified. -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Unspecified.-Schizoaffective Disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania or depression).-Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.-Anoxic Brain Injury (occurs when the brain is deprived of oxygen for an extended period.Review of Resident #2's undated care plan showed:-The resident had potential for a behavioral problem related to accusatory behaviors and was easily agitated when he/she could not fully express himself/herself. -The resident had impaired cognitive ability/impaired thought processes related to Anoxic Brain Injury.Review of Resident #2's Quarterly MDS dated [DATE] showed:-The resident was cognitively intact.-The resident did not exhibit any verbal behavioral symptoms within the look back period.Review of the facility's investigation summary completed on 10/11/25 showed:-There were no witnesses to the altercation.-On 10/10/25 around 12:00 P.M. Resident #2 stated he/she was struck in the back of the head by Resident #1. -Resident #2 stated that he/she and Resident #1 were passing each other in the hallway and Resident #1 swung his/her purse at him/her striking him/her in the back of the head.-Resident #2 initially stated that nothing happened prior to Resident #1 swinging his/her purse at him/her. -Resident #2 then stated that he/she had called Resident #1 a witch, not a bitch. -Resident #2 was upset because Resident #1 would always get what he/she wanted, and he/she had to wait. -Resident #2 also said, I really didn't mean to upset Resident #1, but it just burns me that he/she is getting her way all the time. -No injury was noted. -Resident #2 denied pain or psychosocial distress. -Resident #2 was educated on boundaries, conflict resolution, and therapeutic communication.-Resident #2 was also moved to a different side of the facility. -Resident #1 stated that he/she was passing the resident in the hall in his/her wheelchair and Resident #2 called him/her a bitch. -Resident #1 stated that he/she was upset and frustrated that he/she had called him/her a name and turned around and swung at him/her with his/her hand. -Resident #1 made contact with the back of Resident #2's head. -Resident #1 also told Resident #2 that he/she should not use words like that. -No injuries were noted. -Resident #1 was educated on therapeutic communication, conflict resolution, and notifying staff with concerns. -The facility did not think that the situation was counted as abuse because they believe that Resident #1 had reacted to being called a derogatory name by a peer.During an interview on 10/21/25 at 9:48 A.M. Resident #2 said: -He/She had passed Resident #1 in the hallway. -He/She didn't do anything and didn't call him/her any names. -It really hurt at the time of the altercation-He/She would consider the situation as abuse.-He/She was always having issues with Resident #1. -Resident #1 stared him/her down in the lunchroom and he/she was always banging on the kitchen door demanding food.During an interview on 10/21/25 at 9:59 A.M. Resident #1 said: -The situation happened about a week and a half ago. -He/She had passed Resident #2 in the hallway. -He/She told Resident #2 he/she was trying to get to the business office. -Resident #2 then called him/her a bitch. -The facility's receptionist heard Resident #2 call him/her a bitch. -Resident #2 had said it three times. -He/she told Resident #2 that he/she would give Resident #2 one more chance not to call him/her a bitch again or that he/she would slap Resident #2. -The following day he/she had passed Resident #2 in the hallway again. -Resident #2 called him/her a bitch again. -The next morning it happened again. -He/she told Resident #2 to not call people that. -He/she hit Resident #2 in the back of the head with an open hand, like a slap. -He/she had a temper. During an interview on 10/21/25 at 10:21 A.M. the facility's receptionist said:-Resident #2 did call Resident #1 a bitch three times.-He/She had de-escalated the situation by trying to separate the residents. -Resident #2 kept rumbling and rumbling on. -He/She did not hear Resident #1 say that he/she would hit Resident #2 if he/she called Resident #1 a bitch one more time.-The Administrator was aware of the first incident.During an interview on 10/21/25 at 11:04 A.M. the Administrator said:-To his/her own knowledge Resident #1 and Resident #2 had never been involved in an altercation before.-He/She was unaware that Resident #1 had threatened to hit Resident #2 the day before the incident.-He/She was aware that Resident #1 and Resident #2 had been involved in a verbal altercation the day before the incident and educated both residents on therapeutic communication and calling for staff if needed.During an interview on 10/21/25 at 1:58 P.M. Resident #2 said:-Around 1:00 P.M. today, Resident #1 came and sat in front of his/her door. -He/she didn't do anything but was just sitting there. -He/She told Resident #1 something along the lines of go away you witch and then Resident #1 left. -He/She just wanted Resident #1 to leave him/her alone.During an interview on 10/21/25 at 3:26 P.M. Resident #1 said:-He/She was passing Resident #2's room earlier on his/her way to speak with a nurse.-When he/she passed Resident #2's room, Resident #2 told him/her to go away witch. -He/She didn't stop at Resident #2's room; he/she just ignored it and minded his/her own business. During an interview on 10/23/25 at 8:58 A.M. Dietary Aide A said:-Both Resident #1 and Resident #2 were prone to name calling.-Resident #1 and Resident #2 had no history of physical altercations with each other or other residents.During an interview on 10/23/25 at 9:49 A.M. Facility Physician A said:-He/She did not think Resident #1 had a history of physical altercations with Resident #2 or any other residents.-He/She thought Resident #2 had been in verbal altercations with previous roommates, but not with Resident #1.-He/She did not believe that the incident was preventable.-Resident #2's cognition was worsening and seemed more paranoid recently.During an interview on 10/23/25 at 10:36 A.M. the Activities Assistant said he/she had worked with Resident #1 before, and he/she could be snappy at times but had never gotten into a physical altercation before.During an interview on 10/23/25 at 10:54 A.M. the Director of Nursing (DON) said:-He/She was unaware of the verbal altercation that Resident #1 and Resident #2 had the day prior to the incident. -Abuse occurred when Resident #1 hit Resident #2 in the back of the head.-Resident #2 had behaviors of just being playful at times, and sometimes he/she would make a joke, and no one would find it funny. -He/She had aphasia (a language disorder that affects a person's ability to communicate) and sometimes couldn't get the words that he/she wanted out.-Resident #2 had gotten into verbal altercations with staff before, like cussing, he/she hasn't had any with other residents until the incident with Resident #1. -Resident#1 had been called names by Resident #2 before. -Resident #1 was just tired of Resident #2 calling him/her that word. -Resident #2 could have said witch but with his/her aphasia it might have sounded like bitch. -Resident #1 could make sound decisions and was just tired of being called names. -He/She would have expected Resident #1 to roll away and try to ignore it.-If he/she had known about the verbal altercation the day prior the situation could have been addressed differently, and interventions may have already been put into place to prevent the physical altercation.2. Review of Resident #3's admission Record showed he/she was admitted to the facility with the following diagnoses:-Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses), Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.-Anxiety Disorder, Unspecified.-Depression, Unspecified.Review of Resident #3's undated care plan showed Resident #3 had a psychosocial well-being problem r/t ineffective coping after the sudden death of his/her brother, lack of acceptance to current condition, depressed over being here in nursing home.Review of Resident #3's Quarterly MDS dated [DATE] showed:-The resident had moderately impaired cognition.-The resident had not exhibited any behaviors within the look back period.Review of Resident #4's admission Record showed he/she was admitted to the facility with a diagnosis of Anxiety Disorder, Unspecified.Review of Resident #4's undated care plan showed he/she had the potential to be verbally aggressive related to ineffective coping skills and poor impulse control.Review of Resident #4's Quarterly MDS dated [DATE] showed:-The resident was cognitively intact.-The resident did not exhibit any type of behaviors within the look back period.Review of Resident #5's admission Record showed he/she was admitted to the facility with the following diagnoses:-Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation).-Cognitive Communication Deficit (an impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).Review of Resident #5's undated care plan showed the resident had a behavior problem related to making false and/or fabricating accusations towards staff and residents.Review of Resident #5's Quarterly MDS dated [DATE] showed:-The resident was cognitively intact.-The resident had not exhibited any type of behaviors within the look back period.Review of the facility's investigation summary dated 10/17/25 showed:-On 10/16/25 the Administrator/Executive Director (ED) was notified that Resident #3 and Resident #4 were involved in physical aggression toward each other. -Resident #5 stated that Resident #4 was at his/her lunch table and that Resident #4 told Resident #5 that it was his/her lunch table and Resident #5 needed to move.-Resident #4 grabbed Resident #5's arm and his/her shirt; Resident #3 came over to the table to intervene. -Resident #3 was just trying to help Resident #5. -No evidence of contact was found on Resident #5. Resident #4 stated that he/she did not touch Resident #5. -Resident #4 was only eating lunch and did not do anything to Resident #5. -Resident #4 stated that he/she struck Resident #3 but could not remember if it was before or after he/she was struck by Resident #3. -Resident #4 had an abrasion under his/her right eye and left side back of his/her head.-Resident #3 stated that Resident #4 was being rude to Resident #5 and went over to speak with Resident #4.-He/She bent over to get eye level with Resident #4 while speaking to him/her, then Resident #4 grabbed his/her shirt and pulled him/her forward.-Resident #4 then pushed Resident #3 back and then started to swing at Resident #4. -Staff immediately separated the residents.-Resident #3 was then placed on one-to-one (1:1) monitoring (a term used by healthcare support workers whose role is to provide one-to-one nursing or observation care to an individual patient/resident for a period of time). -The Administrator spoke with multiple residents that were present in the dining room at the time of the incident. -Some resident accounts state that Resident #5 called Resident #3 over to the table and that Resident #4 did not hit or grab Resident #5's clothing. -They heard Resident #5 call Resident #3 over to the table and Resident #3 started to speak with Resident #4. -Resident #4 grabbed Resident #3's shirt and physical aggression occurred. -Some residents have stated that Resident #4 pulled at Resident #5's clothing which prompted Resident #3 to go over to the table. -Resident #3 then started to speak with Resident #4 and then Resident #4 struck Resident #3 and then Resident #3 struck Resident #4. -Resident #3 remained on 1:1 observation until 10/20/25. -A medication review was also completed, and it was found [NAME] Resident #3 had a Gradual Dose Reduction (GDR- the stepwise process of decreasing the dosage of medication over s specific period of time) completed of his/her Buspar (Buspirone- used to treat Anxiety) on 8/12/25 in which his/her Buspar was discontinued at that time. -There was no physical aggression noted prior to altercation and when GDR was completed.During an interview on 10/21/25 at 12:25 P.M. Resident #5 said:-Resident #4 told him/her to get up from the table. -Resident #4 reached over grabbed his/her shirt and arm. -Resident #4 slapped him/her in the face. Resident #3 then came over to the table.-Resident #3 was just protecting him/her.-He/She didn't want to further discuss the incident.During an interview on 10/21/25 at 12:29 P.M. Resident #3 said:-He/She was just sitting in the dining room. -He/She saw Resident #4 and Resident #5 and heard Resident #5 saying to Resident #4 leave me alone. -He/She then went over to the table. -He/She asked Resident #4 what was wrong. -Resident #4 ignored him/her at first. -He/She told Resident #4 to not mess with Resident #5. -He/She then turned to Resident #5 to make sure he/she was okay. -That was when Resident #3 was punched in the chest by Resident #4. -He/She then proceeded to punch Resident #4 in the face and then he/she was punched in the face by Resident #4. -Staff separated them after that. -He/She was not injured during the altercation.During an interview on 10/21/25 at 1:39 P.M. Resident #8 said:-Resident #3 went over to Resident #5's table. -Resident #3 didn't go over there for any particular reason. -Resident #3 hit Resident #4 and then Resident #4 hit back. -The staff separated them after that and nothing else happened.NOTE: Review of the resident's Quarterly MDS dated [DATE] showed the resident had moderately impaired cognition.During an interview on 10/21/25 at 1:46 P.M. Resident #10 said:-Resident #3 was whispering in Resident #4's ear. -All of the sudden Resident #4 started hitting Resident #3. -Resident #4 hit Resident #3 in the face. -Resident #3 then slammed Resident #4 to the ground. -Resident #5 was not involved in the incident.During an interview on 10/21/25 at 1:53 P.M. Resident #9 said: -He/She only saw the end of it. -He/She saw Resident #4 on the ground and Resident #3 was standing over Resident #4.-He/She didn't see them hitting each other. -Resident #3 went over to the table because Resident #4 was terrorizing Resident #5.-Staff separated the residents after that.-Nothing happened afterwards.NOTE: Review of Resident #9's Significant Change MDS dated [DATE] showed the resident was cognitively intact.Review of a witness statement dated 10/16/25 completed by Licensed Practical Nurse (LPN) A showed:-Certified Medication Technician (CMT) A had told him/her that Resident #5 did not Resident #4 to sit at his/her table.-LPN A then went to the dining room and observed Resident #4 eating lunch and Resident #5 was sitting in his/her wheelchair with his/her back towards Resident #4.-LPN A was going to move Resident #4 to a different table but Resident #5 stated that Resident #4 could sit at his/her table.-LPN A then left the dining room to assist a different resident.During an interview on 10/21/25 at 2:16 P.M. LPN A said:-Resident #5 was in the dining room eating. -CMT A came and told him/her to check on Resident #5. -Resident #5 didn't want Resident #4 to sit with him/her. -He/She was really only there for the beginning part because he/she was pulled to a different dining room to check on a different resident. -When he/she was with the other resident a staff member had told him/her that something was going on in the dining room. -A nurse and CMT A were in the dining room already, so he/she didn't go back.Observation and interview on 10/21/25 at 3:06 P.M. Resident #4 showed:-A yellowing bruise and scabbed cut near his/her right eyebrow. -On the back of Resident #4's head, he/she has a grouping of scabs about the size of a tennis ball-He/She did not remember getting into a fight with Resident #3 in the dining room. -He/She had no idea how he got the marks on his/her face or the back of his/her head. During an interview on 10/21/25 at 3:26 P.M. Resident #1 said:-Resident #5 and Resident #4 were arguing at the table. -Resident #5 called Resident #3 over to the table because Resident #4 wouldn't leave the table. -He/She heard something along the lines of get away from the motherfucking table.-Resident #3 went over to the table to talk to Resident #4. -Resident #4 grabbed Resident #3's shirt when he got to the table. -He/She didn't see anything after that.During an interview on 10/23/25 at 9:32 A.M. Resident #6 said:-He/She mainly just saw Resident #3 hitting Resident #4. -He/She wasn't really sure what was going on. -Physical contact was made between both of them. -They hadn't been physical with each other before.NOTE: Review of Resident #6's Quarterly MDS dated [DATE] showed the resident was cognitively intact.During an interview on 10/21/25 at 2:31 P.M. the Maintenance Assistant said:-He/She was walking through the dining room. -Resident #3 was standing over Resident #4 when he/she was walking through. -He/She now assumed that Resident #4 was probably getting smart with Resident #5 and that was why Resident #3 was standing over Resident #4. -It seemed like they were just whispering to each other. -He/She was told afterwards that Resident #4 told Resident #5 to move because Resident #5 was sitting at Resident #4's table. -He/She had stopped by the break room because he/she saw cake and then he/she heard Dietary Aide A yell for help. He/She looked back into the dining room and saw Resident #4's wheelchair pushed over with Resident #4 still sitting in it and Resident #3 was punching Resident #4. -He/She pulled Resident #3 away from Resident #4 and then more staff arrived. -Resident #4 had bruises to his/her upper right eye/forehead area and some bruising to the back of his/her head. -Resident #3 was normally very quiet. Resident #3 and Resident #4 had never had any issues before that day. During an interview on 10/21/25 at 2:50 P.M. Certified Nursing Assistant (CNA) B said:-He/She heard someone calling for help and responded. -Once he/she was in the dining room Resident #3 and Resident #4 were already separated. -Resident #4 was on the ground still. -He/She was the one who brought Resident #4 to the nurse's station. -Resident #4 had a cut to his/her right eyebrow and some marks on the back of his/her head.During an interview on 10/23/25 at 8:58 A.M. Dietary Aide A said:-He/She had finished passing out trays and saw Resident #3 and Resident #4 talking. -Their tones weren't elevated. -He/She didn't see anything alarming at first. -Then he/she turned around and saw Resident #3 on top of Resident #4 and Resident #4's wheelchair was on the floor. -Resident #3 was punching Resident #4. -He/She assumed Resident #4 was getting hit in the face. -He/She was not sure if Resident #4 hit Resident #3 at all. -Staff responded after calling for help and the Maintenance Assistant separated Resident #3 from Resident #4. -He/She was not involved in the aftermath. -Resident #3 and Resident #4 had gotten into it with each other before, but it has been months ago. -Resident #3 and Resident #4 never escalated to physical aggression though. -Both Resident #3 and Resident #4 were prone to name calling but had no physical aggression history to his/her knowledge.During an interview on 10/23/25 at 9:14 A.M. Nurse Practitioner (NP) A said:-Resident #4 does have a behavioral history but was not sure of specifics because he/she didn't have the resident's chart in front of him/her. -He/She did not think that there has been any physical aggression in Resident #4's past.-The facility had a standing order to send out residents after altercations, so the facility's interventions were appropriate.During an interview on 10/23/25 at 9:49 A.M. Facility Physician A said:-He/She was unsure of the specifics of any behaviors. -He/She hadn't had to interact with Resident #3 much recently and had not seen him/her post incident yet. -He/She understood that NP B put him/her back on the Buspar as the main intervention. -The medication change wouldn't be enough time since the incident to know if it had been effective yet. -There were no known previous altercations between Resident #3 and Resident #4 or other residents to his/her knowledge.-Resident #3 probably didn't need to be sent out because the emergency rooms typically send residents right back for that kind of situation. -To his/her knowledge staff have done everything post-incident correctly. -He/She did not think the altercation could have been prevented.During an interview on 10/23/25 at 10:36 A.M. the Activities Assistant said:-He/She was in his/her office. -He/She heard a boom and residents yelling. -He/She initially thought someone fell. -He/She ran into the dining room. -He/She saw Resident #4's wheelchair was tipped over. -Resident #3 was punching Resident #4's face. -He/she was yelling at them to stop and then tried to grab Resident #3. -He/She was not strong enough, so the Maintenance Assistant ended up separating them.-Resident #4 appeared very scared and had a cut on his/her eyebrow bruising was already forming. -He/She helped Resident #4 up with another staff person. -Resident #3 and Resident #4 had no history of altercations with each other.During an interview on 10/23/25 at 11:03 A.M. the DON said:-The altercation that occurred counted as abuse.-He/She was told that Resident #4 was sitting next to Resident #5. -No staff member or resident could confirm what was said outside of a conversation happening. -Resident #5 looked like he/she was in distress and Resident #3 went to help. -When Resident #3 arrived at the table he/she asked Resident #5 what happened, and Resident #5 said that Resident #4 was bothering him/her. -Resident #3 told the DON that he/she was standing in front of Resident #4. Resident #3 bent over to be eye level with Resident #4. -Resident #3 told Resident #4 that Resident #4 needed to pick on someone his/her own size. -Resident #4 then grabbed Resident #3's shirt, pulled Resident #3 forward, and chest bumped Resident #3 with his/her fist. -Resident #3 took that as a threat and proceeded to strike Resident #4. -Resident #3 hit Resident #4 three to four times. -Resident #4 did end up on the floor. -Staff then separated the residents. -He/She made it down to the dining room and took Resident #3 back to his room. -He/She did 1:1 monitoring until EMS arrived. -He/She also got Resident #3's statement and performed an assessment. -Resident #3 voiced that he/she was doing his/her appropriate duties. -Resident #3 understood that he/she could have responded differently.-Resident #3 did show remorse after incident.-Resident #4 claimed that he didn't know anything. -Staff did not respond appropriately to the situation. -He/She would have expected staff to stay in dining room during the whole meal and jumped in sooner. During an interview on 10/24/25 at 12:29 P.M. CNA A said: -Resident #3 and Resident #4 had been separated in the past because Resident #4 threatened Resident #3. -Resident #3 liked helping the women in the facility and would go out of his/her way to do so which was the reason Resident #3 was involved in the first incident.3. Review of Resident #11's admission Record showed that he/she was admitted to the facility with a diagnosis of Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.Review of the resident's Annual MDS dated [DATE] showed the resident had severely impaired cognition.Review of the facility's initial self-report on 10/24/25 showed:-On 10/23/25 at approximately 1:00 P.M. a staff member heard Resident #3 with a raised voice. -Upon turning around to see what was going on, the staff member noted Resident #11 with hot sauce on his/her face. -Resident #3 refused to give complete statement. -Resident #3 stated you just going to be blame me anyway. -Resident #3 was immediately placed on 1:1 monitoring. -Resident #11 stated that Resident #3 threw the hot sauce at him/her. -Upon investigation, Resident #3 and Resident #11 were at the table in the dining room speaking to each other. -Resident #3 said they were joking with each other and then Resident #3 told Resident #11 if he/she were to throw at himself/herself, then he/she was going to throw it back at Resident #11. -Resident #11 threw juice at Resident #3 and Resident #3 threw hot sauce at Resident #11. -Hot sauce got on Resident #11's face. -Staff immediately separated the residents. -Resident #11's eyes were washed out with no injury noted. -Resident #3 continued to have aggressive behaviors which included yelling at staff and stomping in hallways. -Orders were received to send resident to the emergency room for eval due to his/her behavior. -EMS and police on site, as resident was going with EMS, he/she stated to the Administrator, you started so I am going to finish it!During an interview on 10/24/25 at the local hospital at 8:45 A.M. Resident #3 said:-He/She felt that they just want him out of the facility.-They are treating him/her like he/she was the bad guy in this situation. -He/She was always joking around with Resident #11. They are pretty close to each other. -He/She was just trying to be funny and went overboard. -Resident #11 was always playfully hitting, kicking, and throwing water at him/her.-Normally everything was fine, and he/she didn't realize that he/she wasn't in the mood yesterday for joking around.During an interview on 10/24/25 at 10:08 A.M. Resident #12 said:-Resident #3 and Resident #11 were always joking with each other. -Resident #3 told Resident #11 to throw the coffee at Resident #3 and Resident #3 did.-He/She was not sure if coffee was hot. -Resident #3 knew better, but Resident #11 did not know any better. -He/She thought it was coffee that was thrown on Resident #3. -He/She is a dining room table mate of Resident #3 and Resident #11. -Resident #11 must not have been in a good mood. NOTE: Review of the resident's Quarterly MDS dated [DATE] showed the resident had severely impaired cognition.During an interview on 10/24/25 at 10:16 A.M. Resident #6 said:-Resident #3 threw hot sauce at Resident #11's face. -They were just playing at first and then it got serious. -Usually, they play around with each other. -Resident #3 had been out of control lately. -Resident #3 needed to work on his behavior.During an interview on 10/24/25 at 10:20 A.M. the facility's van driver said:-Resident #3 and Resident #11 were usually friendly teasing each other. -Sometimes Resident #11 was not up to it.-Resident #3 was normally really mellow. -Resident #3 did not have behaviors normally.Observation and interview on 10/24/25 at 11:25 A.M. Resident #11 showed:-His/her eyes were free from injury, and no redness was noted.-He/She thought she remembered the incident, but when SA started questioning him/her about it he/she had not remembered. -He/She thought he/she normally got along well with Resident #3. -He/She could not confirm that they always were playing around with each other. -He/She was worried that Resident #3 had done it on purpose. During an interview on 10/24/25 at 11:42 A.M. the Social Services Designee said:-A staff member informed him/her that Resident #3 threw hot sauce in Resident #11's face. -He/She went with the Administrator to Resident #3's room. -They asked Resident #3 how he/she was doing. -Resident #3 responded poorly, he/she started pacing and saying that they wouldn't believe him/her anyway. -When asked when they could come back to chat and Resident #3 said, try two fucking days. -Then they went to check on Resident #11.During an interview on 10/24/25 at 12:55 P.M. LPN C said: -Resident #3 was very protective of Resident #11.-To his/her knowledge Resident #3 did not have any known triggers that would have caused the altercations.During an interview on 10/24/25 at 2:48 P.M. LPN D said:-Resident #3 and Resident #11 were sitting in the dining room.-He/She heard a noise and came over to the table that Resident #3 and Resident #11 were sitting at. -The table had juice and hot sauce all over it. -Resident #3 looked like he/she was going to hit Resident #11, but staff intervened in time and separated the residents. -When he/she looked at Resident #3, he/she had hot sauce all over his/her face and was afraid that it was in his/her eyes.-Resident #11 and Resident #3 normally got along just fine, but he/she never noticed them playing around or teasing each other.During an interview on 10/27/25 at 10:47 A.M. the DON said:-He/She was not at the facility during the altercation. -It was playful teasing until it wasn't. -Resident #3 and Resident #11 were tablemates in the dining room and had no issues with each other prior to the incident.-He/She would consider the situation abuse because Resident #3 showed intent to harm Resident #11. -The altercation could not have been prevented. 2645298, 2640530, and 2551465

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #3) was allowed back to the facility when the facility completed an Immediate Notice of Involuntary Discharge when they sent the resident to a local hospital on [DATE] out of 13 sampled residents. The facility census was 106 residents.Review of the facility's policy titled Notices of Transfers and Discharges dated 8/5/25 showed no policy related to immediate notice of involuntary discharges.1. Review of Resident #3's admission Record showed that he/she was admitted to the facility with a diagnosis of Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin).Review of the resident's Quarterly Minimum Data Set (MDS)(a federally mandated assessment instrument completed by facility staff) dated 8/7/25 showed:-The resident had moderately impaired cognition.-The resident had not exhibited any behaviors within the look back period.Review of the resident's Immediate Notice of Involuntary discharge date d 10/23/25 showed:-The resident would be forced to discharge from the facility.-The resident was being sent to a local hospital.-The safety of individuals in the facility was endangered.-The health of individuals in the facility would be otherwise endangered.-The resident was involved in a resident-to-resident altercation on 10/16/25.-The resident was involved in a resident-to-resident altercation on 10/23/25.-The resident was threatening residents and staff.Review of an emergency room Note dated 10/23/25 showed the resident was being admitted to the hospital with a primary diagnosis of Social admission Secondary to Facility Refusal for Taking Patient Back.During an interview on 10/24/25 at 8:45 A.M. the resident said:-He/She didn't know what is going on. -No one has updated him/her on anything. -He/She felt that the Administrator just want him/her out of the facility. -He/She was really upset because he/she wanted to go back to the facility because that was his/her home.During an interview on 10/24/25 at 11:04 A.M. the Administrator said:-The resident would not be allowed back to the facility.-He/She did not feel the facility was adequately equipped to take care of the resident.During an interview of 10/24/25 at 11:42 A.M. the Social Services Designee (SSD) said:-He/She had sent multiple referrals to other facilities in the area after the second resident-to-resident altercation that the resident was involved in. -The facility was not equipped to handle the resident's behaviors.-He/She had sent the Ombudsman (resident advocate) the Immediate Notice of Involuntary Discharge letter on 10/23/25.During an interview on 10/27/25 at 10:35 A.M. the Director of Nursing (DON) said:-The resident had to go. -He/She was sent to the hospital for increased behaviors and now couldn't come back to the facility. -He/She understood that the facility was not meeting regulation by not accepting the resident back, and by not providing a reevaluation after he/she received the necessary treatment. 2651315

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free of significant medication error when on 9/14/24 he/she did not receive an ordered dose of his/her seizure medication Lamotrigine Extended Release (ER) 24 hour 200 milligram (mg), 2 tablets by mouth at bedtime for seizures and on 9/16/24 and 9/17/24 he/she received incorrect doses of this medication out of four sampled residents. The facility census was 104 residents. The Administrator was notified on 9/25/24 of Past Non-Compliance which occurred on 9/14/24, 9/16/24 and 9/17/24. An all nursing staff in-service was completed on medication administration and medication administration observations were completed by 9/19/24. The deficiency was corrected 9/19/24. Review of the facility policy on medication administration revised 1/1/22 showed: -Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record (MAR). -Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in the facility's medication administration schedule. -Facility staff should confirm that the MAR reflected the most recent medication order. 1. Review of Resident #1's Admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Epilepsy (a nervous system disorder that can cause unprovoked, recurrent seizures which are sudden, uncontrolled electrical disturbances in the brain). -History of falling. Review of the resident's undated Care Plan showed he/she had a seizure disorder and interventions included giving medications as ordered. Review of the resident's hospital Discharge Summary for Facility Orders dated 9/14/24 showed: -The resident's discharge date from the hospital was 9/14/24. -He/She had a history of seizure disorder and was followed by neurology. -He/She was to continue his/her medications. -His/Her discharge order showed a physican order for Lamotrigine Extended Release (ER) 24 Hour 200 mg by mouth, 400 mg were to be given at bedtime for seizures. Review of the resident's physician's Order Summary Report showed he/she had an order for Lamotrigine Extended Release (ER) 24 Hour 200 mg. Two tablets by mouth were to be given at bedtime for seizures. The order was dated 9/14/24 with a start date of 9/15/24 and an end date of 9/20/24. Review of the resident's MAR for 9/24 showed: -He/She did not receive the Lamotrigine on 9/14/24. -He/She had an order for Lamotrigine Extended Release (ER) 24 Hour 200 mg. Two tablets by mouth were to be given at bedtime for seizures. The order was dated 9/14/24 with a start date of 9/15/24 and an end date of 9/20/24. -There was no note as to why the medication was not administered. Review of the facility investigation on 9/14/24 with hospital discharge order, timeline showed: -The resident was admitted to the facility from the hospital on 9/14/24. -He/She had an order for Lamotrigine 200 mg, 2 tablets at bedtime. -On 9/14/24 the dose of Lamotrigine was not administered related to new admission and the medication did not arrive from the pharmacy. -On 9/16/24 the resident was transferred to the hospital for seizure-like activity. -Observation of the Lamotrigine medication card revealed the pharmacy delivered 100 mg tablets, 4 tablets to be given at bedtime until the 200 mg tablets were available. Staff did not give 4 tablets at bedtime. Observation of the resident's medication card for Lamotrigine Extended Release (ER) 24 Hour 100 mg. tablets, showed 4 tablets to be taken by mouth at bedtime for 3 days until the 200 mg strength was available and 5 pills were taken from the card. Observation of the resident's medication card for Lamotrigine Extended Release (ER) 24 Hour 200 mg. tablets, 2 tablets to be taken by mouth at bedtime, showed: -An incorrect deliver date of 9/14/24 was printed on the card. -One pill had been taken from the card. During an interview on 9/25/24 at 12:40 P.M., the resident said: -He/She had not had a seizure in [AGE] years. -He/She had pneumonia and believed stress threw him/her into a seizure. -The staff may have messed up his/her medications. -He/She was back to normal now. During an interview on 9/25/224 at 1:25 P.M., Licensed Practical Nurse (LPN) E said: -He/She would help the nurses by putting orders in the computer. -The hospital would send orders to the facility computer and they would download them. -The orders the hospital sent might not be the orders that the resident arrived with. -When the resident arrived, the nurses would make sure the orders they came with matched the orders on the computer. -They would do chart checks in the mornings to make sure the orders were correct in the computer, and that care plans and assessments were done. -This was how they caught the resident's medication error. -If a medication was not available or pharmacy didn't send it, they could get a medication from the Omnicell. -If the dose in the Omnicell (an automated medication dispensing cabinet) was not correct either they give the correct dose or call the physician. -If a medication was not available, they should let the physician know. -All of the nursing staff were aware of the Omnicell. During an interview on 9/25/24 at 1:40 P.M., LPN F said; -The managers would try to put the orders in the computer before a resident arrived. -The admitting nurse should double check the orders. -If there were discrepancies, they call the physician to clarify any questions. -All of the orders were supposed to be verified by the physicians. -The next morning, the managers would collect the charts and take them to the morning clinical meeting (or Monday if a resident were admitted on a weekend) and would go through and audit the orders. -If the pharmacy did not send the medication, it could be pulled from the Omnicell. -If the medication was not in the Omnicell, the should notify the physician and get an alternative. -He/She had been trained about this prior to the incident. During an interview on 9/25/224 at 2:25 P.M., LPN B said: -He/She only worked with the resident one time; this was the first time he/she worked with him/her. He/She did not admit him/her. -He/She would check the MAR and orders before giving medications. -He/She would check the MAR and the medication cards together. -The resident had two medication cards with different doses of the medication. -He/She pulled the card that matched the MAR. -He/She gave the lower dose of the medication. -He/She did not notify anyone about the other card. During an interview on 9/25/24 at 2:15 P.M., the Director of Nursing (DON) said: -The resident arrived at the facility on 9/14/24 from the hospital. This was a Saturday. -When he/she arrived, the pharmacy did not sent his/her seizure medication, however, it was available in the Omnicell. -The resident did not get the medication on the date of his/her admission. -Two doses were given incorrectly. -There was no policy or process to determine how many tablets were removed from each medication card by each staff person. -The charge nurse was responsible to enter orders in the computer and sent paper prescriptions to the pharmacy. -LPN A was in charge when the resident was admitted . He/She had been educated on the admission orders procedure before. He/She did not give an explanation for why he/she did not give the medication. -The breakdown occurred when the medication was not pulled from the Omnicell since it was available. -The pharmacy sent incorrect cards because the correct dose was not available, and then sent the correct dose. -He/She felt LPN C gave the dose correctly and LPN B and LPN D gave the lower dose, which was not enough. -When he/she interviewed the LPNs, LPN C was able to verbalize everything that was in the orders and was very clear about giving the 400 mg and that he/she double checked the orders without being prompted. LPN B and LPN D were not able to relay the orders and they had not taken anything out of the Omnicell. -The resident had a history of seizures, but when he/she was sent out to the hospital, it was not like a typical seizure; they were tremors. -The hospital kept the resident for pneumonia. -When the resident went back to the hospital, the facility did a root cause analysis and found the medication errors. -The expectation was when a resident was admitted , the nurse would enter all orders in the computer and fax any prescriptions to the pharmacy as soon as possible, so that medication could be received in a timely manner. -He/She would expect the physician would be called if order clarification was needed or if a medication was needed that the resident was not admitted with. -For any medications that were not available prior to pharmacy delivery, they could be pulled from the Omnicell. -Medications should be administered according to policy using the five rights. -Pharmacy did not notify him/her that the medication had been filled with a different dose. -If a wrong dosage or medication were sent, he/she would expect the pharmacy to be contacted to notify them and have the correct medication or dosage sent. -The admitting nurse did not call the physician for clarification of whether the dose ordered from the hospital should be given or notified that the pharmacy had sent an alternative dosage. -He/She would expect that the medication cards would be checked against the orders. During an interview on 9/25/24 at 2:45 P.M., the Administrator said: -The nurses were expected to follow policy and double check a resident's orders to make sure they were in the system and to make sure they matched the medication that came from the pharmacy. -The nurses were expected to make sure that a prescription was filled quickly and if there was a delay to reach out to the DON and the physician. During an interview on 10/3/24 at 11:45 A.M., LPN C said: -He/She gave the resident all four 100 mg tablets of Lamotrigine. -He/She checked the order before he/she gave them, because he/she felt like it was a large dose. -The medication came from pharmacy between 9:00 P.M. and 9:30 P.M. -When he/she gave the medication, the 200 mgs tablets were not yet available. -When a nurse would admit a resident to the facility, the orders should be double checked to make sure they were the most recent orders. -If the pharmacy did not send a medication, the Omnicell should be checked to see if they could be taken from it. -If the medication was not available, the nurse should notify the physician to see if an alternative could be ordered and the pharmacy to see when the medication could be sent. -The nursing staff were trained to know to do these things. During an interview on 10/6/24 at 12:00 P.M., LPN D said: -He/She thought when he/she cared for the resident, they had received the 200 mg tablets. -He/She would have administered two 200 mg tablets. -He/She would pull up the physician's orders and check the medication cards against them before administering the medication. -If he/she did not have the correct dose available, he/she would notify the DON, notify the pharmacy and notify the physician. MO00242293

Based on interview, and record review, the facility staff failed to ensure the safe storage and accountability of a resident's narcotic medication (controlled substance medications that can cause physical and mental dependence) card by failing to verify and sign for the delivery of medications to the East Nurses Station resulting in the missing of 30 tabs of Oxycodone HCL (Hydrochloride) (a narcotic pain medication) 10 milligrams (mg) for one sampled resident (Resident #500) out of three sampled residents. The facility census was 116 residents. The Administrator was notified on 6/7/24 of the past noncompliance which began on 5/11/24. The facility in-serviced all nursing staff on the facility drug diversion policy. The deficiency was corrected 5/29/24. Review of the facility's policy from the pharmacy titled Skilled Nursing Facility Pharmacy Services and Procedures Manual dated January 2022 showed: -Facility staff should sign the delivery log as proof of delivery before pharmacy delivery representative leaves facility. -Once received by facility staff, medical record documents should be separated by room number and collated according to facility room number and name. -Facility should store controlled substances in a separate compartment within the locked medication carts and should have a different key or access device. -Facility should ensure that controlled substances are only accessible to licensed nursing, pharmacy, and medical personnel designated by facility. -After receiving controlled substances and adding to inventory, facility should ensure that controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with applicable Law). 1. Review of Resident #500's Admission Record showed he/she was readmitted on [DATE] with the following diagnoses: -Acquired absence (amputation) of right leg below knee. -End stage renal disease (ESRD-The kidneys have stopped working well enough to survive without dialysis or a kidney transplant). -Dependence on renal dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). Review of the resident's Physician's Order Summary (POS) dated June 2024 showed: -Oxycodone HCL tablet 10 mg give one tablet by mouth (PO) every four hours as needed (PRN) for pain rated 4-6 related to other chronic pain dated 2/8/2024. Review of the pharmacy pink delivery manifest sheet dated 5/11/23 and signed by RN B showed: -Two narcotic medications filled from the pharmacy on 5/11/24 at 3:39 P.M. including Oxycodone Immediate Release 10 mg, 30 tabs for Resident #500. -RN B did not check mark either medication as received. Review of the facility's investigation of the drug diversion dated 5/13/24 - 5/17/24 showed: -Registered Nurse (RN) B signed for a narcotic that pharmacy reported sent and facility unable to locate on evening shift Saturday May 11, 2024. -RN B said he/she signed for a blue bag from pharmacy and did not open it and locked it in his/her cart. -A copy of the pharmacy's pink delivery receipt signed by the driver showed: --Two narcotic medications filled from the pharmacy on 5/11/24 at 3:39 P.M. including Resident #500's 30 tablets of Oxycodone 10 mg. --The pharmacy driver signed but did not date or time when delivered. -A copy of the pharmacy's pink delivery receipt signed by RN B showed: --Two narcotic medications filled from the pharmacy on 5/11/24 at 3:39 P.M. including Resident #500's 30 tablets of Oxycodone 10 mg. --RN B signed and dated as received on 5/11/24 at 9:25 P.M. --RN B did not check mark each medication to verify the delivery matched the delivery receipt and that each medication was received in the delivery. -A copy of the pharmacy's shipment summary. --Delivered to the facility on [DATE] at 9:33 P.M., and signed by RN B. -The former Director of Nursing's (DON) statement of incident dated 5/13/24 showed: --Licensed Practical Nurse (LPN) A reported a full card of Resident #500's Oxycodone Immediate Release was missing. --The former DON checked every card from pharmacy, each med room, each unit, and each shred box but was unable to locate the narcotic card. --RN B, who signed the pharmacy sheet for the medication on 5/11/24, was immediately suspended and taken off the schedule pending investigation. --He/She spoke with pharmacist who reported that the narcotic could have been delivered in a blue bag instead of red bag. --Red bags are used for narcotic delivery. --RN B reports that he/she signed for a blue bag from pharmacy Saturday evening and put it in his/her cart because he/she was busy. --Blue bag location unknown after that. -Nursing staff educated to open all packages from pharmacy to ensure no narcotics are in a blue bag and to ensure they are reading the pharmacy delivery sheet that they sign when accepting medications. -RN B's statement dated 5/13/24 no time noted showed: --It was an extremely busy evening. --He/She was trying to finish glucometer scans. --The delivery driver came up to him/her and he/she had to stop what he/she was doing. --He/She did not count the bag of meds. --He/She put them in the second drawer on the right side of the cart until he/she could get them put away. --He/She did not remember anything unusual about the evening except being so busy. Review of the in-service on signing in medications and narcotics from the pharmacy was given by the Pharmacy's General Manager on 5/29/24 showed 15 nursing staff attended. During an interview on 6/5/24 at 11:40 A.M., CMT C said: -When a new narcotic medication comes from the pharmacy, it comes with a narcotic count sheet. -The count sheet is put into the narcotic book under the resident's name. -The count sheet shows the date the medications were delivered at the top left hand. -The pharmacy delivers medications during the 3-11 evening shift. Review of resident #500's Oxycodone Immediate Release 10 mg narcotic sheets on 6/5/24 at 11:50 A.M., showed no documentation of a narcotic count sheet delivered on 5/11/24. During an interview on 6/5/24 at 11:55 A.M., LPN C said: -When pharmacy delivers medications, the person receiving verifies and signs that it is correct. -A nurse or a CMT can receive and sign for medications. -The receiving staff should open the package of medications when it comes and count with the pharmacy delivery person to be sure all medications and counts are correct. -Receiving staff should count all medications no matter what color bag they come in. -Staff put the narcotic medications in the front of medication locked box in the cart so the next shift sees they are there. -The staff receiving new narcotic medications counts them with the next on-coming staff. -Narcotics come just one card per narcotic per resident and all go into the medication cart lock box. -Put the narcotic medication cart in the medication cart lock box and put the count sheet in the narcotic book. -All narcotic medications come with a count sheet with the amount on the card. -The count sheet shows the date the medications were delivered on the top of it. During an interview on 6/5/24 at 2:11 P.M., RN B said: -He/She worked the evening shift which was 3:00 P.M. to 11:00 P.M., on the East side 200 hall. -The pharmacy delivery person walked up to him/her with a blue bag that medications come in. -He/She knew he/she didn't have time to count medications and looked down 400 hall on the other side of the nurse's station to see if that nurse was in sight to take the delivery. -He/She did not see anyone. -He/She took the bag and looked the delivery person in the eye and told him/her I'm going to have to trust you I don't have time to check them off. -The blue bag usually does not have narcotics in them. -He/She put the bag in the third drawer of the medication cart and locked it. -The delivery person handed him/her the paper to sign as to what was delivered. -He/She did not look at or read the delivery sheet, he/she just signed the paper. He/She did not verify with the pharmacy delivery person the medications that were received in the delivery bag. -He/She had never accepted any pharmacy deliveries before without opening the bag and counting to verify what was delivered before signing. -Medication deliveries were always correct in the past. -Protocol was to always count what was delivered and put medication in the med cart and the count sheet in the narcotic book. -If do not have time to put all medications away after verifying medications are correct with pharmacy, put them in the locked narcotic box until have time to put in right spot for each resident and papers in the book. -Around 11:00 P.M., he/she took the blue bag from the medication cart and put the one medication card away. -He/She did not remember what the medication was or if it had a naroctic sheet. -He/She had no idea that there was supposed to have been a narcotic card that was not there. -He/She did not verify the medication with the shipping manifest. -Counted after 11:00 P.M., with the oncoming nurse and everything was correct at that time. -The next day a CMT, believes it was CMT E, was working with him/her and went to give a resident, believes it was for resident #500, pain medication and there was no narcotic pain medication for the resident. -The CMT called the pharmacy to reorder the narcotic and the pharmacy said it had already been delivered. -The pharmacy said he/she was the person who signed for the delivery of the medications. -The former DON came in and they started looking through the medication carts, treatment carts, and everywhere and the missing medication was not found. During an interview on 6/6/24 at 9:28 A.M., the Pharmacy General Manager said: -All drug deliveries to facilities have a manifest that prints out on a pink sheet for controlled substances. -The controlled drugs go into a red sealed bag. -When the driver gets to the facility, he/she scans it by phone as delivered to the facility. -The nurse opens the sealed bag and verifies the delivered medications by checking each drug in the bag and signing the copy of the manifest in the bag. -Each drug on the manifest has a check box to be checked by receiving nurse. -The facility keeps a copy of the manifest and the driver brings the other copy back to the pharmacy. -The copy of the manifest showed no documentation that the receiving nurse checked marked any medication listed on the manifest. -Once the facility signs for each medication on the manifest and the pharmacy receives the signed copy back it is out of the pharmacy's hands. -If there is an error and a medication is not in the bag that is on the manifest the nurse receiving can call the pharmacy 24-hours a day and report what is missing. -Once the nurse signs the manifest it is expected that the facility received all that was in the bag. -The pharmacy was made aware of the missing narcotic when the facility called on 5/14/24. -He/She went to the facility and gave an in-service to the nurses on the security of controlled substances and verifying before signing. He/She could not recall the date of the in-service. During an interview on 6/6/24 at 11:27 A.M., the Administrator said: -The former DON was made aware and reported him/her on 5/13/24 that a narcotic medication card was missing when another nurse went to reorder the medication from the pharmacy and found out it had been delivered a few days earlier. -The medication was missing from the East 200/400 hall nursing medication cart. -The former DON went to the unit and went with RN B, through the medication cart, treatment cart, shred container, medication room, and anywhere he/she could think of in the facility and did not find the missing narcotic medication card. -The medication card was not visually seen or accounted for. -The pharmacy general manager came to the facility and gave an in-person in-service to all nursing staff to address future security of controlled substances, to open the delivery bag and to verify the medications before signing for them. MO00236116

Based on interview, and record review, the facility failed to ensure two sampled residents (Resident #508) were free from abuse when on 6/2/24 Resident #507 hit Resident #508 which resulted in Resident #508 having an injury to his/her bottom lip and a bruise over the left eye out of 19 sampled residents. The facility census was 115 residents. The Administrator was notified on 6/7/24 of the past noncompliance which began on 6/2/24. The facility completed education on resident abuse and interventions for all staff and residents. The deficiency was corrected on 6/4/24. Review of the facility's Abuse and Neglect policy, undated, showed: -Each resident had the right to be free from abuse, neglect, misappropriation resident property, and exploitation. -This included, but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint. -Resident's must not be subjected to abuse by anyone including other residents. 1. Review of Resident #508's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/21/24, showed the resident was severely cognitively impaired. Review of the Resident #508's face sheet, undated, showed the resident diagnoses included: -Dementia (loss of memory, language, problem-solving and other thinking abilities), cognitive communication deficit (difficulty expressing thoughts and ideas), and generalized muscle weakness. Review of Resident #508's care plan, dated 12/23/23, showed: -The resident had impaired cognitive ability and though processes related to dementia. Review of Resident #508's Preadmission Screening and Resident Review (PASRR, DA-124C - a required form to be submitted for any resident who requested admission to a Medicaid certified bed regardless of the resident payment source; this included dually certified beds both Medicare and Medicaid) dated 2/23/24, showed: -The resident was diagnosed with anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). -The resident exhibited moderate abnormal thought processes. -The resident required a secure unit for safe wandering. Review of Resident #507's quarterly MDS dated [DATE], showed: -The resident was severely cognitively impaired. -The resident was severely cognitively impaired without behaviors. Review of Resident #507's face sheet, undated, showed the resident was diagnosed with: -Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), -Cognitive communication deficit. -Generalized muscle weakness. Review of Resident #507's care plan dated 5/8/24, showed: -The resident had the potential to be physically aggressive related to dementia (loss of memory, language, problem-solving and other thinking abilities). -Interventions included: --Providing coloring sheets. --Placed on 1:1 observation. --Monitor and report any signs or symptoms of posing danger to self or others. --Take outside when possible. --Turn on music when resident was anxious. --Lab draws to rule out infection. -The resident had impaired cognitive ability/thought processes related to dementia. -Interventions included: --Administer medications as ordered. --Ask yes/no questions. --Cue, reorient and supervised as needed. Review of Resident #508's Physical Aggression Received form, dated 6/2/24, showed: -The resident was in his/her wheelchair in the dining area. -Resident #507 tried to sit on the resident. -The resident put his/her hands up to stop Resident #507 from sitting on him/her. -Resident #507 turned around and hit the resident causing a scratching on the lip which was treated with a cold wet cloth. -As a result, the resident slid out of his/her wheelchair. -The resident was transported to the emergency room for evaluation. Review of Resident #507's Physical Aggression Initiated form, dated 6/2/24, showed: -The resident was trying to sit on Resident #508. -Resident #508 told him/her no. -The resident turned around and hit Resident #508 in the face and mouth. -The resident hit Resident #508 again which caused him/her to slide out of wheelchair. -The resident was unable to give a description of why or what happened. -There were no predisposing environmental factors. -The predisposing physiological factors included confusion and impaired memory. Review of the facility's incident investigation, dated 6/2/24, showed: -On 6/2/24 at approximately 1:30 P.M. the Director of Nursing (DON) was notified of an altercation between Resident #507 and #508. -Certified Nursing Assistant (CNA) A was interviewed and reported he/she was assisting another resident and upon coming down the hall he/she saw Resident #507 attempting to sit on Resident #508's lap with Resident #508 saying 'No' and Resident #507 striking Resident #508. CNA A was unable to get to the residents quick enough to stop the incident but did remove Resident #507 from the area. -CNA C was interviewed and reported he/she was at the nurses station speaking to Certified Medication Technician (CMT) A regarding residents' medications. CNA C looked up and saw Resident #507 strike Resident #508 and saw Resident #508's wheelchair roll back, and the resident slid to the floor. He/she immediately went to intervene. -CMT A was at the nurses station documenting when he/she saw Resident #507 trying to sit on Resident #508's lap. Resident #508 said 'No' and began to stand up and Resident #507 struck Resident #508 in the face. CMT A said it happened very quickly and he/she was unable to get to the residents in time to stop the situation. -Immediate action taken: --Resident's separated. --Resident #507 was placed on 1:1 observation until sent to emergency room (ER) for evaluation. -Resident #508 was transported to the ER for evaluation of injuries. -Root cause analysis: --Resident #507 had a history and was care planned for mood problems related to heightened startled response. --Due to Resident #507 being startled when Resident #508 said 'No', Resident #507 reacted by striking Resident #508. -It was determined that Resident #507 was not attempting to hurt Resident #508 and responded only due to being startled. During an interview on 6/6/24 at 10:10 A.M., Certified Nurses Assistant (CNA) A said: -He/She was helping another resident and, on the way back down the hall he/she was coming around the nurse station and saw Resident #507 try to sit on Resident #508. -Resident #508 was sitting at the lunch table. -Resident #507 was in the dining room also. -Resident #507 approached Resident #508 and tried to sit on his/her lap, Resident #508 put his/her hands up and said No, then Resident #507 turned around and closed fist hit Resident #508. -He/She saw Resident #507 hit Resident #508 one time. -He/She dropped everything and ran over there. -He/She redirected Resident #507 and CNA C helped Resident #508. -He/She took Resident #507 to their room and asked him/her what happened and why he/she hit Resident #508 and he/she said he/she didn't know why. -Resident #508 was confused and asked what he/she did to get hit. During an interview on 6/7/24 at 8:19 A.M., CNA C said: -He/She was standing at the nurses station talking to CMT A about resident medications and scheduling dinner and showers and planning the evening. -He/She saw resident #507 moving to sit on resident #508. -He/She went to help separate them by taking resident #507 away and walked down the hall with resident #507. During an interview on 6/7/24 at 11:06 A.M., CMT A said: -He/She was sitting at the desk charting when Resident #508 and Resident #507 were in the middle of the dining room. -Resident #507 was trying to sit on Resident #508 and Resident #508 said no no no -CNA C told Resident #507 that they cannot sit on Resident #508. -Resident #507 turned around to walk away, turned back again and started hitting Resident #508 in her face. -CNA A was in the dining room and was able to intervene first. -He/She thought Resident #507 was going to hit the aide. -Resident #507 hit Resident #508 which caused Resident #508's to bleed. During an interview on 6/7/24 at 3:07 P.M., the Administrator said: -The facility investigation showed Resident #507 hit Resident #508 in the face when Resident #508 startled Resident #507. -He/She did not believe the incident was defined as abuse. MO00237042 MO00237029

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility, the facility failed to ensure proper hand hygiene was performed by staff during wound care for two sampled residents, (Resident #51 and Resident #35), failed to follow infection control practices to prevent potential cross-contamination during wound care for one sampled resident (Resident #35) and during suprapubic (s/p) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) care, including ensuring the catheter drainage bag remained off the floor for one sampled resident (Resident #52), Additionally the facility failed to initiate and perform Enhanced Barrier Protection (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for two sampled residents, (Resident #51 and #52), failed to ensure staff sanitized the rubber hub prior to accessing and administering (medication used to treat high blood sugars) for two residents (Residents #107 and #37), and the facility failed to implement appropriate infection control procedures to mitigate the communication of infectious diseases when staff failed to ensure all residents were screened for tuberculosis (TB), a potentially serious infectious bacterial disease affecting the lungs, and failed to ensure a two-step TB skin test (TST) or a chest x-ray (tests to determine if a person is infected with the TB bacteria) was completed and documented in accordance with the facility policy for four (residents #27, #61, #165, #166), out of 23 sampled residents. The facility census was 115 residents with a licensed capacity for 172 residents at the time of the survey. 1. Observations on 5/1/24 between 10:13 A.M. and 11:05 A.M. during the initial kitchen Life Safety Code (LSC) inspection showed a three-sink area, and an area with a low-heat, chemical dish-washing machine, a handwashing sink, and an ice machine. Observations on 5/6/24 between 11:11 A.M. and 2:57 P.M. during the initial facility LSC room-to-room inspections with the Maintenance Supervisor (MS) and the Administrator showed the following: -There was a facility-wide fire sprinkler system. -There was a Laundry room with clothes washers next to the kitchen. -There were rooms with hot water heaters/boilers, and six standard bathtubs. -There were at least 85 resident rooms with sinks and bathrooms, two bathhouses, four clean/soiled utility rooms with sinks, and housekeeping closets with mop hopper sinks. -There was a satellite dining room near the Rehab Gym with an ice machine. Review of the facility's 10-page water-borne pathogen prevention program entitled, Water Management Program, last revised on 4/1/24 and provided by the MS, showed the following: -In Table 2., under the heading Inventory of System Components, some of the facility's plumbing components were mentioned, and Tables 3. and 4. had a list of Potential Hazardous Events and examples of Qualitative Measures of Likelihood, respectively, but there was no diagram or flowchart that identified and indicated specific potential risk areas of growth within the building with assessments of each area's individual potential risk level. -There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -Table 7. listed possible incidents with their response procedures, but there was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens, including testing protocols and acceptable ranges for control measures with a method of monitoring them at this facility, with interventions or action plans for when control limits were not met. -Tables 9. and 10. had 15 separate building descriptions and components to be completed, yet all were answered, 'No construction at this time. -Table 12. contained 4 protocols for vacant rooms with suggested responses to each, but there was no documentation of any being performed and/or a site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. -Table 14. showed the quantities of several points of their water system throughout the building, but there was no written explanation of the water flow throughout the facility, with a schematic, diagram, or flowchart of the facility's complete water system. During an interview on 5/9/24 at 12:31 P.M., the MS said the following: -He/She had viewed educational materials on Legionella on the computer, but it really was not specific on program requirements. -He/She conducted an in-service for staff once and explained to them what Legionella was. Review of the in-service sign in sheets provided by the MS showed they were dated 3/31/23, 7/26/23, 8/31/23, 10/5/23, and 11/29/23, and consisted of the signature pages only, with no educational materials attached. During an interview on 5/9/24 at 2:32 P.M., the Administrator said that he/she had been educated on Legionella program requirements through viewing a recent PowerPoint training. 39469 2. Review of the facility's policy, Hand Hygiene, dated 6/13/23 showed: -Associates perform hand hygiene (even if gloves were used) in the following situations: --Before and after contact with the resident. --After contact with blood, body fluids, or visibly contaminated surfaces. --Before performing a procedure such as dressing care. -Ensure that supplies necessary for adherence to hand hygiene were readily accessible in all areas where patient care was being delivered. Review of the facility's Insulin policy, dated 8/30/23 did not include directions for the staff to sanitize the hub before applying the needle. Review of the facility's Policy, Enhanced Barrier Precaution, dated 3/21/24 showed: -EBP is indicated for residents with wounds and/or indwelling devices even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO). -EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities which would include wound care. -The facility may choose to post signage on the door or wall outside of the resident room indicating the resident was on EBP. -Examples of high-contact resident care activities requiring gown and gloves include device care of use, including urinary catheters, and wound care for any skin opening requiring a dressing. Review of the Mayo Clinic instructional guide, How to use an Insulin Pen, on the Mayo Clinic Website, dated 6/13/14 showed: -Remove the cap from the insulin pen. -Wipe the rubber membrane with an alcohol wipe. -Apply needle. 3. Review of Resident # 51's face sheet showed he/she was admitted on [DATE] with a diagnosis of Malignant Melanoma of the skin (a type of skin cancer - when the cells that give the skin its color grow out of control). Review of the resident's Annual Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 3/14/24 showed: -The resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating he/she was cognitively intact. -He/She had a medically complex condition. -He/She had a skin tear, abrasion (a scraping or wearing away), or laceration (a deep cut or tear in the skin or flesh). -He/She had ointment or medications applied to (places) other than the feet. Review of the resident's 3/14/24 care plan showed: -He/She had excoriation ( a conscious repetitive picking of the skin that leads to skin lesion)/Yeast (a skin condition on the skin that creates a raised, red itchy bumps on the skin) on bilateral rear thighs upon admission. -He/She was witnessed on several occasions scratching and picking at areas. -Staff was to administer treatments as ordered. -The care plan did not address placing the resident on EBP related to his/her open wounds. Review of the resident's May 2024 Physician's Order Sheet (POS) showed the following order: -Apply antifungal cream to bilateral posterior thigh every day and evening shift for dry skin and itching, dated 2/10/22. Review of the resident's Weekly Skin Integrity Data Collection sheet dated 5/1/24 showed the following alterations in skin: -The resident had friction (the resistance that one surface encounters when moving over another) or shearing (a force acting in a direction that's parallel to a surface causing pressure). Observation and interview on 5/03/24 at 11:12 A.M. during wound care with Licensed Practical Nurse (LPN) C/Wound Care Nurse showed: -The resident did not need to be on EBP as the wound was not open. -The resident would often scratch his/her thighs until he/she would bleed. -The wound would heal and then open up again. -There was no EBP sign on the door. -There was no isolation supplies in the resident's room. -The nurse entered the resident's room without a gown or gloves on. -The nurse was stopped to put on isolation Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). -The resident had a large open area on his/her inner right thigh 8 x 3 inches with bloody meaty looking opened area. -The resident had a large open area on his/her left inner thigh 8 x 2 inches with red raw looking area. -The nurse cleansed the wounds per the physician's order. -He/She took off his/her gloves cleansed his/her hands and reapplied gloves. -He/She opened two packets of antifungal (medication used to treat skin infections) cream and squirted both packets of the cream into his/her right gloved hand. -He/She applied the cream to the residents right wound. -He/She applied the cream to the resident's left side wound without changing gloves or cleansing his/her hands. -The resident had the wound when he/she came into the facility a couple of years ago. -The resident went to the dermatologist (a physician who specialized in conditions that affect the skin) twice in the last couple of months. -The dermatologist said the resident had Dermatitis (An inflammation of the skin). -He/She maybe should not have applied the medicated cream to both wounds without changing gloves. -They just started EBP at the facility in April. -The resident should have had a EBP sign on his/her door stating they had to wear PPE. -He/She did the wound care on the resident daily. -The resident scratches the areas and then the area would open up again. -He/She should have worn a gown and gloves to treat the wound per the EBP protocol. -Any time there was a opening in the resident staff should have used EBP protocol. During an interview on 5/3/24 at 11:45 A.M. the resident said: -The areas on his/her thighs often itched. -He/She had scratch his/her thighs until they bleed. -The Wound Care Nurse puts medication on his/her thighs just like he/she did today. -Staff had not been wearing a gown only gloves when doing wound cares. During an interview on 5/7/24 at 9:30 A.M. Certified Nursing Assistant (CNA) E said: -The facility had provided education on EBP more than two weeks ago. -If there were any open wounds the resident would have been on EBP. -There should have been a sign on the resident's door which showed they were on EBP. -There should have been PPE at the resident's door. -The nurse was responsible for ensuring there was a sign on the resident's door and PPE available. During an interview on 5/7/24 at 10:00 A.M. Certified Medication Technician (CMT) B said: -The facility had provided education on EBP maybe three weeks ago. -The staff was expected to wear a gown and gloves when doing cares with the resident if they had an open wound. -There should have been a EBP sign on the resident's door. -There should have been an isolation cart with PPE at the resident's door. -The nurse should have been responsible for ensuring it was done. During an interview on 5/7/24 at 10:52 A.M. Registered Nurse (RN) C said: -The facility had recently provided education on EBP. -If a resident had a wound, open area, or tube the resident should have had a sign on their door stating EBP precautions were in place. -That resident should have had EBP precautions in place. -There should have been a EBP sign on the door and PPE at the door. -The nurse or charge nurse should have ensured EBP precautions were in place. -The nurse should have changed gloves and cleansed hands before applying medication to the second wound because it would spread infection from one wound to the other. During an interview on 5/7/24 at 12:25 P.M. the Director of Nursing (DON) said: -According to the Centers for Disease Control (CDC), any direct patient care when they have a wound should have EBP in place. -The facility has provided education on what was expected for EBP. -There should have been a EBP sign on that resident's door. -There should have been PPE at the resident's door. -The nurse should have used EBP because the resident had an open wound. -Any nurse could have initiated the EBP. -The nurse should have changed gloves and cleansed his/her hands before applying medication to the second wound because it would have spread germs from one wound to the other. 4. Observation on 5/3/24 at 7:50 A.M. during a medication pass with LPN B showed: -He/She took out Resident #107's Novolog (a rapid acting insulin used to control high blood sugars) insulin pen. -He/She did not clean the rubber hub before applying the needle and administering the insulin to the resident. Observation on 5/3/24 at 7:55 A.M. during a medication pass with LPN B showed: -He/She took out Resident #37's Lantus (a long acting insulin used to control high blood sugars) insulin pen. -He/She did not clean the rubber hub before applying the needle and administering the insulin to the resident. During an interview on 5/3/24 at 8:00 A.M. LPN B said: -He/She did not clean the rubber hub on the insulin pens because he/she forgot to. -The facility had provided education on using the insulin pens. During an interview on 5/7/24 at 10:52 A.M. Registered Nurse (RN) C said: -They have had education on using Insulin pens. -The nurse should have cleaned the rubber hub with an alcohol wipe before attaching the needle and administering the insulin to the resident. -The charge nurse or DON should have been responsible for ensuring the nursing staff were giving the residents insulin correctly. During an interview on 5/7/24 at 12:25 P.M. the DON said: -The staff has had education on how to use insulin pens. -The nurse should have cleaned the rubber hub with alcohol before attaching the needle to administer insulin to the resident. 33409 5. Review of Resident #35's Admission Face Sheet showed the following diagnoses: -Pressure Ulcer (is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of his/her left hip Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). -Pressure Ulcer of Sacral (sacrum, is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) Area Stage IV. Review of the resident's Admission MDS dated [DATE] showed: -The resident had a BIMS score of 15 out of 15 indicating he/she was cognitively intact. -He/She had a two wounds upon admission and Moisture-associated skin damage (MASD, is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture). -Required total staff assistance with all cares. Review of the resident's Skin Care Plan dated 3/7/24 showed he/she had break in skin integrity, Pressure Ulcer Coccyx/Sacrum and to Left Ischium (the lower and back part of the hip). Review of the resident's Physician order Sheet May 2024 showed: -Cleanse Coccyx/Sacrum and wound with Normal Saline (NS), Apply Skin Prep (a topical barrier between skin and adhesives) to surrounding edges, then apply Collagen Prisma Wound Dressing (It is a freeze-dried product designed to kick start the healing process while providing protection from infection) and apply Aquacel AG (a surgical Hydro fiber cover dressing with Ionic Silver for your wound care needs. Is suitable for a wide range of acute and chronic wounds) then cover with bordered foam dressing (convenient adhesive border helps secure the dressing in place and provides a barrier to outside contaminants) every dayshift on Monday, Wednesday and Fridays. As needed for if soiled or dressing removed. (Ordered on 4/12/24). -Cleanse Left Ischium with Normal Saline (NS), Apply Skin Prep to surrounding edges, then apply Collagen Prisma and apply Aquacel AG, then cover with bordered foam. Change dressing every dayshift on Monday, Wednesday, Friday and as needed for if soiled or dressing removed. (Ordered on 4/11/24). Observation of the resident on 5/3/24 at 8:00 A.M., showed: -The resident was on Enhanced Barrier Precautions. -Had signage posted due to wounds and other health factors. Observation on 5/3/24 at 9:00 A.M., of the resident's wound care showed: -Wound Nurse and unknown CNA entered the resident room and washed their hands with soap water, then applied protective gown and gloves on hands. -With gloves hands the Wound Nurse had removed the three old wound dressings dated 5/1/24. -The old dressings had soiled brown substance and slight wound odor noted. -Wound nurse removed his/her gloves and without washing or sanitizing his/her hands, donned clean gloves. -He/She then cleaned the resident's coccyx wound, sacral wound, and left ischium wound with the same gloved hands without changing gloves or sanitizing his/her hands between each wound. -Wound nurse removed gloves and without washing or sanitizing his/her hands, donned clean gloves. -He/She then then Apply Skin Prep to surrounding wound edges for each of the three wounds with same the gloved hands. -Without changing his/her gloves, he/she then applied the wound treatments to each wound. He/she did not change his/her gloves or sanitize hand between each wound dressing. -Wound nurse removed soiled gloves and then sanitized his/her hands to assisted in replacement of a draw sheet under the resident. -Wound nurse and CNA removed gloves and gown, washed hands with soap and water prior to exiting the resident room. During an interview on 5/7/24 10:20 A.M., CNA C said: -Hand hygiene should be done between dirty to clean areas and with every glove change to prevent cross contamination. -The facility had just started Enhanced Barrier Precaution for those resident with catheters, wounds, other medical condition that would be potential for cross-contamination during care. During an interview on 5/7/24 at 10:32 A.M., the Wound Nurse said: -He/She would wash his/her hands upon enter of the resident room prior to wound care. -He/She should sanitize or wash his/her hand between each glove change, when soiled, and from a dirty to clean process. -For residents on EBP, hands-on care staff should wear gloves and gowns, wash their hands upon entering the room, between glove changes, and from a dirty to clean process. -He/She said thought had he/she had sanitized his/her hands between each glove change by using the hand sanitizer that was in his/her scrub top pocket. -He/she should have completed each wound care separately to include hand hygiene and glove change between each wound care treatment to prevent cross-contamination during wound care and to reduce the risk of the resident getting wound infections. During an interview on 5/7/24 at 12:23 P.M., DON, Regional Director Services, Assistant Director of Nursing (ADON) said: -He/She would expect care staff to perform hand washing or sanitize hands between each glove change and between each wound care process. -He/she would expect wound care nurse and nursing staff to complete each wound care process separately, to change gloves and perform hand hygiene prior the start on the next wound to prevent cross-contamination. -He/She would expect glove changes and hand hygiene when hands or gloves were soiled or contact body fluid and from a dirty to clean process. -If wounds were open area, staff should change gloves between each wound process. 6. Review of Resident #52's Admission Face sheet showed the following diagnoses: -History of urinary tract infection. -Neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). Review of the resident's Quarterly MDS dated [DATE] showed: -The resident had a BIMS score of 15 out of 15 indicating he/she was cognitively intact. -He/She had a diagnosis of Neurogenic Bladder. -Required a indwelling catheter. -History of antibiotic use during look back period. Review of the resident's Care Plan revised on 4/12/24 showed: -The resident had a Suprapubic Catheter (S/P) related to Neurogenic bladder. -Position catheter bag and tubing below the level of the bladder. -Catheter care every shift. Review of the resident's POS 5/2024 showed: -He/She had physician order for a Suprapubic Catheter related to Neuromuscular Dysfunction of bladder, ordered on 8/28/23. -Suprapubic catheter to be irrigated with Acetic Acid Irrigation Solution 0.25 % (Acetic Acid, irrigation solution is used to prevent infection due to placement of a catheter into the bladder), use 50 centimeters (cc) via irrigation one time a day, related to his/her personal history of UTI. Plug catheter for 30 minute then unplug, (ordered on 11/7/23). -Cleanse suprapubic site with warm soap and water and replace split sponge daily every night shift. (Ordered on 9/20/22). -Catheter care every shift with warm soap and water every shift, keep catheter bag placed below the level of the bladder at all times. (Ordered on 9/8/22). Observation on 5/1/24 at 1:59 P.M. and 3:30 P.M., showed the resident's bed was in lowest position to ground, and the catheter drainage bag laid on ground without a protective barrier. Observation on 5/2/24 at 8:58 A.M., showed: -The resident bed was in low position. -His/Her catheter drainage bag hung on bed rail touching the ground without a protective barrier for the drainage bag. Observation 5/3/24 at 7:18 A.M., showed the resident's bed in the lowest position with the catheter drainage bag touching the ground. Observation on 5/3/24 at 8:38 A.M., showed the resident's bed was in lowest position to ground, with catheter drainage bag touching the floor with no barrier under the bag. Observation on 5/3/24 at 9:45 A.M., showed: -Upon enter of the resident room noted a EBP signage posted on the open door. -LPN B was going to flush the resident's suprapubic (SP) catheter. -He/She the entered the resident room and washed his/her hands. Placed gloves on his/her hands. -He/She did not don a protective gown prior to flushing the Foley catheter -He/she removed soiled gloves and washed his/her hands with soap and water. During an interview on 5/6/24 at 1:25 P.M., CMT A said: -SP catheters drainage bag should be keep below the bladder at all times. -When resident laid in bed with bed in lowest position, he/she would place on drainage back on bed frame ensuring catheter drainage bag does not touch ground to prevention infection. Observation on 05/07/24 at 9:15 A.M. the resident Foley catheter bag on touching ground no barrier, bed in lowest position. During an interview on 5/7/24 at 10:20 A.M., CNA C said: -If resident's bed low position the catheter drainage bag should be placed in a dignity bag and never touch ground. If found on ground should notify nurse and replace the catheter drainage bag. -The catheter drainage bag and tubing should not touch round due to possible pull catheter out and the possibility of cross contamination and infections. -Hand hygiene should wash your hand or sanitize your hands between a dirty to clean process and between each glove changes to prevent cross contamination. -Enhanced barrier precaution was new at the facility. -He/she should wear gown and gloves when provided direct resident care for those resident on EBP. During an interview on 5/7/24 at 10:56 A.M., LPN B said: -He/She had recent training related to EBP, a new process the facility putting in place. -If catheter care or wound care need to be completed, he/she would expect care staff to don a gown and gloves during those care to prevent cross contamination. -He/She did not wear a gown during catheter irrigation and SP site care, he/she did not see the EBP signage posted. During interview on 5/7/24 at 12:23 P.M., DON, Regional Director Services, and the ADON said: -If the resident was in bed, the catheter drainage bag should not be touching the floor or laid on ground. -He/She would expect a barrier for the catheter drainage bag if bed lowest position and not laid on floor/ground without a barrier, to prevent the potential for infection and cross contamination. -The facility had recent training for all staff related to EBP. -The facility would determine by facility EBP policy and per CDC standard of care, that any resident with open wounds, indwelling catheter, supra pubic would be placed on EBP. This would require any direct care for the wear a gown, gloves and possible mask. -He/She would expect nursing staff to have worn a gown and gloves to prevent cross contamination from potential splatters or spills when doing a catheter flush/irrigation. 50579 7. A facility policy on resident TB screening, testing and mitigation was requested but not provided. Review of the facility Long-term Care - TB Risk Assessment, dated 2/6/24, showed: -The facility was a low-risk setting for the transmission of TB. -A two-step TST (where one antigen skin test is administered and observed for a reaction 48-72 hours later. Then, a second skin test is administered one to three weeks later and observed 48-72 hours after administration to determine if a person has antibodies for the TB bacteria) should have been completed upon resident admission. -A medical evaluation would be completed, including symptom assessment and chest x-ray is TST is positive. Review of Resident #27's medical record showed: - An admitted [DATE]. -No administration of a two-step TST upon admission. -No screening or evaluation of TB symptoms. -No documentation of a chest x-ray to rule out active TB infection. Review of Resident #61's medical record showed: -Administration of one step of a two-step TST (administered 1/18/24, evaluated 1/20/24). -No administration of a second step of the two-step TST. -No screening or evaluation of TB symptoms. -No documentation of a chest x-ray to rule out active TB infection. Review of Resident #165's medical record showed: -Administration of a two-step TST (3/11/21 and 3/21/21). -No annual screening or evaluation of TB symptoms. Review of Resident #166's medical record showed: -An admitted [DATE]. -No administration of a two-step TST upon admission. -No screening or evaluation of TB symptoms. -No documentation of a chest x-ray to rule out active TB infection. During interview on 5/07/24 at 9:22 A.M., the Assistant Director of Nursing (ADON) said Resident #166 is unable to receive a TST because they come back positive. However, the facility did not have a chest x-ray, other proof the resident did not have an active TB infection, or documentation to support inability to have a TST due to a previous positive. During interview on 5/07/24 at 9:40 A.M., the ADON said: - He/she was responsible for ensuring the completion of TB screening and skin tests. -He/She would put the orders in for resident's two-step TSTs on admission and the nurses were responsible for administering and evaluating the TST. -The nurses didn't always get the order completed or put the information into the resident's immunization record. -The residents should have an annual screening for TB in addition to their admission TST. -Any positives would need further evaluation to determine why the TST was positive. During interview on 5/7/24 at 12:24 P.M., the Director of Nursing (DON) said: - The ADON was tasked with ensuring TB screening and skin testing was completed, but the DON was ultimately responsible. -New admissions needed a two-step TST or chest x-ray on admission. -An annual evaluation needed to be completed to screen for TB. -Any readmission would need another TST if they were in the community for over 30 days. -The nurses were responsible for administering and documenting results of TSTs.

Based on interview and record review, the facility failed to provide education to the resident or the resident's representative and obtain signed consent or refusal of the pneumococcal (any infection caused by the bacteria Streptococcus pneumoniae) vaccine, for two residents (Residents #48 and #166), failed to obtain signed refusal the pneumococcal vaccine for one resident (Resident #165) and failed to administer a consented pneumococcal vaccine to one resident (Resident # 61) out of five sampled residents. The facility census was 115 residents. Review of a facility policy titled Influenza and Pneumococcal Vaccine Policy for Residents, dated 7/30/2019, showed: -The facility was to offer each resident the pneumococcal vaccine unless medically contraindicated or the resident has already been immunized. -There should have been documentation in the medical record if there was reason to believe the resident was previously given the pneumococcal vaccine. -Refusals should have been documented in the medical record and re-addressed each year. -Education should have been provided in the form of a vaccine information statement (VIS) and a consent or refusal should have been signed. 1. Review of Resident #48's medical record showed: -An admitted [DATE]. -No pneumococcal vaccination history. -No evidence of a pneumococcal vaccine being offered or administered by the facility. -No signed consent or refusal for the pneumococcal vaccine. -No evidence of pneumococcal vaccine education provided to the resident or resident's representative. 2. Review of Resident #166's medical record showed: -An admitted [DATE]. -No pneumococcal vaccination history. -No evidence of a pneumococcal vaccine being offered or administered by the facility. -No signed consent or refusal for the pneumococcal vaccine. -No evidence of pneumococcal vaccine education provided to the resident or resident's representative. 3. Review of Resident #165's medical record showed: -A current admitted [DATE], with an initial admitted [DATE]. -No pneumococcal vaccination history. -A status of Consent Refused for the pneumococcal vaccine under facility immunization tracking. -No signed refusal for the pneumococcal vaccine. 4. Review of Resident #61's medical record showed: -An admitted [DATE]. -No pneumococcal vaccination history. -A Informed Consent for Pneumococcal Vaccine verbally consented by resident's medical representative dated 9/7/23. -No evidence of pneumococcal vaccine education provided to the resident or resident's representative. -No evidence of administration of the pneumococcal vaccination. During interview on 5/07/24 at 9:40 A.M., the Assistant Director of Nursing (ADON) said: -He/She was responsible for ensuring the completion of pneumococcal vaccinations for residents. -Vaccine history was reviewed on admission, including the state vaccine registry. -The facility would offer the vaccine to residents able to consent and send letters to the medical representatives of those who were not. -The residents should have signed a form indicating a consent or refusal for the pneumococcal vaccine. -The pneumococcal vaccine administration or refusal should have been documented in the resident's medical record. During interview on 5/7/24 at 12:24 P.M., the Director of Nursing (DON) said: -The ADON was tasked with infection control, including ensuring the completion of the pneumococcal vaccinations of residents. -The DON was ultimately responsible for ensuring the resident's received education, the facility obtained a signed consent/refusal, administered the pneumococcal vaccine as appropriate and documented the resident's pneumococcal vaccination status in the medical record. -He/she would expect education, signed consents/refusals, vaccination administration information and the offering of the pneumococcal vaccination as appropriate to be done and documented by the facility.

Based on observation, interview, and record review, the facility failed to keep the Dry Storage (DS) room and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary and food preparation equipment; failed to change the deep fryer oil in a timely manner; and failed to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination), in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 115 residents with a licensed capacity for 172 residents at the time of the survey. 1. Observations on 5/1/24 between 10:32 A.M. and 11:05 A.M. during the initial kitchen inspection, showed the following: -There was a strip of plastic, a sugar packet, a half & half creamer pod, and an iodized salt packet under the racks in the DS room. -There was a small smudge of unknown residue on the blade of the manual can opener. -A white handled spatula hanging on a utensil rack by the food preparation table had chipped edges on its blade. -The light blue and red cutting boards were excessively scored to the point of plastic flaked off. -There was paper and plastic trash under the racks in the walk-in freezer. -The deep fryer oil had a multitude of crumbs floating on the top and was so black the bottom basket resting racks could not be seen. Observation on 5/3/24 at 10:11 A.M. during the follow-up kitchen inspection, showed the following: -There were pieces of plastic, paper, and a ketchup packet under the racks in the DS room. -The same bit of unknown residue was on the manual can opener blade. -The light blue, red, and yellow cutting boards were excessively scored. -Paper and plastic trash were under the racks in the walk-in freezer. During an interview on 5/3/24 at 10:13 A.M. the Dietary Services Manager (DSM) said the following: -The deep fryer was used about twice a week and the oil was changed every other week. -In the fall and winter, it was used more often so they tried to change the oil weekly then. Observations on 5/6/24 at 11:50 A.M. during the initial facility Life Safety Code (LSC) room-to-room inspections with the Maintenance Supervisor (MS) and the Administrator showed the white refrigerator in the Galley between the locked unit dining room and the rehab unit dining room did not have a thermometer in the bottom section. During an interview on 5/6/24 at 11:53 A.M. the Administrator said that all the food and beverages in that white refrigerator were for the residents. During an interview on 5/7/24 at 10:07 A.M. the DSM said the following: -The dietary aides cleaned the floors twice a week after their food deliveries. -Cooks and aides report damaged food preparation items to him/her and they are tossed out and replaced. -He/She would expect food to be free of foreign substances. -All refrigerators should have thermometers in them. Observations on 5/7/24 at 10:51 A.M. during another follow-up kitchen inspection showed the deep fryer oil had numerous crumbs floating on the top and was so black the bottom basket resting racks could not be seen.

Based on interview and record review, the facility failed to assure one sampled resident (Resident #1) out of seven sampled residents, was free from abuse when Certified Nursing Assistant (CNA) A, grabbed the resident's left ankle and pushed him/her backwards while in bed, resulting in two skin tears and bruising to his/her lower left leg. The facility census was 120 residents. On 12/30/22 the Administrator was notified of the past noncompliance which occurred on 12/29/22. On 12/29/22 the facility administration was notified of the incident and the investigation was started. CNA A was suspended on 12/29/22 and terminated on 12/29/22. No employees were allowed to work prior to reeducation. The deficiency was corrected on 12/29/22. The undated facility policy titled, Abuse and Neglect showed: -To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. -Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. -This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. -Residents must not be subjected to abuse by anyone. -This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals. -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. -The facility should provide oversight and monitoring to ensure the implementation of the required policies and procedures. 1. Record review of Resident #1's facility face sheet, showed: -He/she was admitted to the facility on [DATE] with diagnoses that include: --Cerebral Infarction (ischemic stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). --Dementia (a group of thinking and social symptoms that interferes with daily functioning). --Chronic Kidney Disease (Longstanding disease of the kidneys leading to renal failure). --Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances in and on the artery walls). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 9/30/22 showed: -His/her Brief Interview of Mental Status (BIMS-an assessment used to assess cognitive states) score of 15 which reflects the resident is cognitively intact. -His/her functional status (bed mobility, transfer, walking, dressing, eating and personal hygiene) requires staff supervision, oversight, encouragement and/or cueing. -He/she required only set up help with bathing. Record review of the resident's care plan dated 6/22/22 showed: -Assessed location, size and treatment of skin tear and report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc., to doctor. -Encouraged good nutrition and hydration in order to promote healthier skin. -Resident was occasionally incontinent of urine. -Assisted with toileting as needed. -Encouraged resident to utilize call light for assistance. -Resident had impaired visual function related to glaucoma (a group of eye conditions that can cause blindness). -Eye examination, treatment and management by perspective vision care. Record review of the facility investigation dated 12/29/22 showed: -The resident had no short/long term memory impairment and his/her most recent BIMS was a 15. -He/she was alert and oriented to person, place, time and event. -During an interview with Resident #1, on 12/29/22, he/she said: --On 12/29/22 at approximately 5:00 A.M., CNA A was providing care for Resident #1's roommate and woke Resident #1 up with roommate and CNA making a lot of noise. --Resident #1 yelled, why don't you shut up? --CNA A stated, you can't make me shut up, while turning and walking toward Resident #1's bed. --He/she put his/her legs up toward the CNA to defend his/herself. --CNA then grabbed his/her left ankle and pushed him/her backwards towards the wall while in bed, resulting in two two skin tears to the lower left leg and bruising. --The resident went to the nurses station to Registered Nurse (RN) B, and stated the CNA really did it this time, as he/she was bleeding all over. --RN B dressed the area and resident returned to his/her room to clean him/herself up, changed his/her clothes and got back in bed. --Physician, Executive Director, Director of Nursing (DON), local law enforcement and state agency were notified. --Upon completion of the investigation the facility was able to substantiate that improper actions and unprofessional physical contact of the CNA did occur. Record review of CNA A's Witness Interview Form dated 12/29/22 showed: -He/she transferred a resident to bed and in the middle of changing the resident, Resident #1 in the other bed yelled at him/her to shut up. -Resident #1 was so angry and he/she stood up and walked towards him/her. -Resident #1 tried to kick him/her when he/she grabbed the resident's leg. -Afterward, the nurse looked at Resident #1 and cleaned up his/her leg and wrapped it up. Record review of the resident's Wound Observation Tool dated 12/29/22 showed: -His/her left lower leg skin tears measurement: --Left lower leg anterior (front) with black/purple bruising, 8.5 centimeters (cm) length. --7.0 cm width. --0.2 cm depth and --Left lower leg posterior (back) with black/purple bruising, 4.5cm length. --3.0 cm width. --0.3 cm depth. Record review of the resident Pain Evaluation Tool dated 12/29/22 showed: -Resident rated pain from skin tears at a 5 on a 1-10 scale, with 10 being worst pain ever experienced. -Resident had refuse pain medications. -Resident was to elevate his/her left leg. During an interview on 12/30/22 at 9:10 A.M., the DON said: -As soon as they were aware of the incident CNA A and RN B were suspended immediately 12/29/22 at 10:00 AM. -The incident happened at 5:00 A.M., on 12/29/22 and RN B notified administration at 10:00 A.M. -CNA A was terminated during the course of the investigation on 12/29/22. -RN B admitted he/she was to notify administration immediately, and just did not in error. During an interview on 12/30/22 at 10:00 A.M., the Administrator said: -The incident was handled appropriately from the point in time he/she was made aware of the incident. -He/she understood the DON has completed all education to the staff. -CNA A had been terminated and RN B had been re-educated and suspended until the investigation is completed. During an interview on 12/30/22 at 10:15 A.M., Resident #1 said: -It shouldn't have happened if people were doing their job. -His/her roommate always kept him/her awake. -CNA A was in caring for his/her roommate, and he/she had just had it. -The roommate called on his/her call light and talks all the time at night. -He/she said to CNA A will you all shut up and go to sleep! -CNA A said, you shut up. -He/she would have usually just ignored the comment. -It was just very unfortunate. -He/she did put his/her legs up defensively. -The CNA A grabbed a hold of his/her legs and wrenched him/her backwards. -He/she usually does not have much pain but it hurt like a son of a bitch. -He/she felt as though he/she was coming out the loser here. During an interview on 12/30/22 at 11:48 A.M., RN B said: -The resident came out to the nurses station where he/she was, and had blood all over him/herself. -He/she cleansed the area and bandaged the resident's skin tears on his/her legs, which he/she actually thought were blood blisters initially. -Then the resident told him/her that he/she had put his/her legs up to defend him/herself and CNA A had pushed them down. -CNA A came out of the room and said that Resident #1 had tried to kick him/her and got a skin tear. During an interview on 12/30/22 at 12:10 P.M., Nurse Practitioner C said he/she would expect that the CNA should have simply walked away from the situation. An attempt to interview CNA A was made on 12/30/22 with three phone calls placed and again on 12/31/22 with one phone call placed and no response. A letter was sent to CNA A on 12/30/22 for contact. MO00211852

Based on observation, interview and record review, the facility failed to implement interventions to prevent or attempt to prevent the development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear) and/or abrasions (a wound consisting of superficial damage to the skin, such as a scrape that generally does not scar or bleed) and/or blisters or other skin alterations caused by the residents' brace/splint/cast for two sampled residents (Residents #34 and #28); failed to ensure that skin remained intact for one sampled resident (Resident #34) by the resident developing four Stage 3 pressure ulcers (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed) to his/her coccyx area, Deep Tissue Pressure Injuries (DTPI-may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to his/her right upper thigh, caused by the ace wrap being wrapped tightly around his/her thigh after he/she had destroyed the plaster cast/long leg splint that was applied to his/her right leg; failed to ensure the resident's [DEVICE] (machine that applies negative pressure to an area to promote healing in acute or chronic wounds) dressing was maintaining an airtight seal, and did not address the loud noise that the [DEVICE] machine was making to ensure it was functioning properly for one sampled resident (Resident #17); and failed to do pressure ulcer dressing changes and [DEVICE] dressing changes for one sampled resident (Resident #115) out of 23 sampled residents. The facility census was 114 residents. Record review of the facility's treatment of [REDACTED]. -Care of wounds involve the cleansing and application of dressings and possible adjuvant therapies (i.e., electrical stimulation) as appropriate. -Dressings are chosen based upon: --The presentation of the wound. --The desired dressing function. --The patient's medical condition. --The cardinal rule is to keep the ulcer moist and the surrounding skin dry and intact. -Adjuvant therapies may be considered when wounds have proven unresponsive to conventional therapy and in keeping with patient goal and medical condition. Record review of the facility's Pressure Ulcer/Injury Prevention policy dated as revised (MONTH) (YEAR) showed: -A comprehensive skin assessment should be completed on admission and re-admission; -A weekly skin assessment should be conducted; -A plan should be developed to maintain and improve the resident's skin integrity such as skin inspections and encouraging food and fluid intake; -Measures should be put in place to protect the resident's skin integrity such as repositioning at least every two to four hours, utilizing positioning devices, ensure proper body alignment, maintain the head of the bed at the lowest degree of elevation, pressure reduction mattresses and proper wheelchair positioning and -Develop a change in the care plan when skin breakdown does occur. Record review of the facility's policy dated 12/29/14 Negative Pressure Wound Therapy ([DEVICE]), said: -The wound must be surrounded by enough intact periwound skin (tissue surrounding a wound) to ensure an airtight seal of the occulsive dressing; -The nurse should check that the dressing is fully sealed at the beginning of each shift and every four hours after; -To be effective, the machine must be on at least 22 hours per day; -The nurse must check and document that the clamps are open; -The dressing is fully contracted at the beginning of each shift and every four hours thereafter; and -The policy does not instruct the staff to check the machine to see if it is working correctly. 1. Record review of Resident #34's care plan dated 4/21/16 showed: -The resident was at risk for developing a pressure ulcer and -The care plan was not updated for the resident's tibia (shin bone) and fibula (calf bone) fracture on 9/7/18. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/10/18 showed the following staff assessment of the resident: -Was severely cognitively impaired; -Required extensive assistance with bed mobility, transferring from one surface to another, locomotion on the unit, dressing and hygiene; -Did not walk; -Used a wheelchair; -Had [DIAGNOSES REDACTED]. -Did not have any pressure ulcers. Record review of the resident's most recent bath sheet provided dated 8/21/18 showed the resident had a brace on his/her leg and there were scratches on his/her right inner thigh. Record review of the resident's weekly skin integrity data collection sheet dated 9/6/18, 9/13/18 and 9/20/18 show the resident's skin was intact. Record review of the resident's nurse's note dated 9/7/18 at 11:12 P.M., showed: -The resident's family member reported to the nurse that the resident's right knee looked swollen and the resident was in pain; -The nurse assessed the resident's right knee and it was swollen and -The resident was sent to the emergency room . Record review of the resident's nurse's note dated 9/8/18 at 8:03 A.M., showed: -The resident was sent out to the hospital by the evening shift the prior evening due to a tibia and fibula fracture and -The resident returned from the hospital at 6:00 A.M. Record review of the resident's nurse's note dated 9/8/18 at 5:24 P.M., showed the resident was in bed with his/her right leg elevated on a pillow and had a splint on his/her right leg. Record review of the resident's nurse's note dated 9/8/18 at 11:47 P.M. showed the resident was in bed and had a splint on his/her right leg. Record review of the resident's nurse's note dated 9/10/18 at 5:17 P.M. showed the resident had a splint on his/her right leg. Record review of the resident's nurse's note dated 9/11/18 showed a follow-up appointment was scheduled with the resident's orthopedic physician for 9/21/18. Record review of the resident's physician's progress note dated 9/11/18 showed: -The resident had a recent right leg fracture which is currently wrapped with ace wrap and has a soft cast. The resident constantly pulls at the ace wrap and it gets very tangled and pulled off; -The resident has an appointment with an orthopedist this week to have the soft cast removed and a hard cast placed and -The plan was to re-wrap the resident's right leg. Record review of the resident's nurse's note dated 9/13/18 at 11:57 P.M. showed the resident's family member requested the resident be out of bed and up in his/her wheelchair daily. Record review of the resident's nurse's note dated 9/16/18 at 9:52 A.M., showed: -The resident took apart his/her cast on his/her right leg; -The resident took the soft fluffy material out of upper part of his/her cast, unwrapped the ace bandage and snapped apart the plaster splinted areas and -A family member reported that the resident says the cast itches and he/she wants it off. Record review of the resident's nurse's note dated 9/17/18 at 8:00 P.M. showed the resident's splint on his/her right leg was intact. Observation on 9/18/18 at 10:00 A.M., showed the resident was asleep in bed. Observation on 9/18/18 at 1:28 P.M., showed the resident was in his/her wheelchair in his/her room. There was an ace wrap and a soft-cast on the resident's right leg. Observation on 9/20/18 at 11:45 A.M., showed the resident was in his/her room sitting in his/her wheelchair. The resident's position in the wheelchair was: the resident was sitting at the very edge of the wheelchair seat. The resident's left leg was bent with his/her left heel resting against the footrest. The resident's right mid-calf was resting against the front part of the footrest. Record review of the resident's nurse's note dated 9/21/18 at 3:12 P.M. showed: -Staff reported to the nurse that the resident's eyes appeared to rolled back and he/she was not responding; -The resident's blood pressure was low at 85/44 and -The nurse practitioner was at the facility and gave an order to send the resident to the emergency room . Record review of the resident's hospital orthopedic consult dated 9/21/18 at 7:14 P.M. showed: -The resident's right leg was in a long-leg splint. -The lateral (away from the midline of the body) portion of the plaster was broken at the level of the proximal (near the center) tibia and the ace bandages were tightly wrapped around the right thigh. There were ecchymoses (discoloration of the skin that occurs when blood leaks from a broken capillary into surrounding tissue under the skin) and blisters about the right mid-thigh as well as the right lateral shin in the region where the plaster was broken. There was exposed plaster over the medial (toward the middle) and lateral aspects of the right knee, as the padding was removed at those sights. The right knee was swollen as it was the only portion of the right leg that was not wrapped with ace bandage. Record review of the resident's hospital wound notes dated 9/21/18 showed: -The resident had a Stage 3 pressure ulcer on his/her sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) that was present upon admission; -The resident had a DTPI on below his/her right, distal (away from the point of attachment or origin) knee that was present upon admission and -The resident had DTPI on both heels. Record review of the hand-written report called from the hospital note dated 9/26/18 showed the following: -The resident was returning to the facility with Hospice services (end of life care); -Instructions to turn the resident right to left every two hours and do not lay the resident on his/her back; -The resident had a Stage 3 pressure ulcer on his/her sacrum; -The resident had DTPIs from his/her cast and -The resident had wounds on his/her right and left heels and right ankle. Record review of the resident's baseline care plan dated 9/26/18 showed: -The resident had a break in skin integrity and -Instructions for staff to reposition the resident every two hours. Record review of the resident's weekly skin integrity data collection dated 9/26/18 showed the resident had boggy (spongy) heels, blisters on his/her right upper thigh, bruising on his/her ankle and an open area on his/her sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity). Record review of the resident's Braden Scale for predicting pressure ulcer risk dated 9/26/18 showed the resident was at high risk. Record review of the resident's physician's orders [REDACTED].>-Lay down after lunch; -Cleanse Stage 3 sacral wound with normal saline, cover with Allevyn (a wound healing product that provides a moist wound environment) foam every three days until healed; -Cover right ankle with Allevyn foam every three days until healed and -Cover right upper thigh and right upper shin with Allevyn foam every three days until healed and as needed. Record review of the resident's Pressure Ulcer Status Records dated 9/27/18 showed the resident had the following pressure ulcers that were all first observed on 9/27/18: -A Stage III pressure ulcer on his/her left distal sacrum. --It measured 1.7 centimeters (cm) x 0.7 cm x 0.1 cm. --It was 100% granulation. -A Stage 3 pressure ulcer on his/her left, proximal sacrum. --It measured 2.0 cm x 0.3 cm x 0.1 cm. --It was 100% granulation. -A Stage 3 pressure ulcer on his/her right distal sacrum. --It measured 2.5 cm x 2.5 cm x 0.1 cm. --It was 50% slough and 50% granulation. -A Stage 3 pressure ulcer on his/her right proximal sacrum. Record review of the resident's non-pressure skin condition records dated 9/27/18 showed the resident had had the following what the facility called blood blisters (a blister containing blood or bloody serum usually caused by an injury) that were all first observed on 9/27/18: -Right thigh that measured 30.0 cm x 1.5 cm x unknown depth; -Right thigh that measured 1.0 cm x 8.0 cm x unknown depth; -Right thigh that measured 0.5 cm x 8.0 cm x unknown depth and -Right shin that measured 4.0 cm x 6.0 cm x unknown depth. Observation on 9/27/18 at 7:45 A.M. showed the resident: -Was on his/her back with a wedge pillow under his/her right knee in bed; -Had waffle boots (cushioned foot protector) on both feet and -Had a regular mattress (not a low air-loss mattress). During an interview on 9/27/18 at 8:15 A.M., Registered Nurse (RN) A said new admissions and residents returning from the hospital have wounds measured by the wound nurse. Continuous observation on 9/27/18 showed: -At 8:20 A.M.: --The resident was in bed and was on his/her back with a wedge pillow under his/her right knee. --The resident had waffle boots on both feet. --The resident's right leg was in a soft blue splint. -At 8:43 A.M., the resident was on his/her back. A staff member elevated the resident's head to sitting up in bed. -At 9:17 A.M., Certified Medication Technician (CMT) A removed the resident's meal tray and the resident remained on his/her back with his/her head elevated. Observation on 9/27/18 at 9:45 A.M. showed: -The resident had a linear blister across the top and around the resident's upper right thigh and had two additional blisters on his/her upper right thigh; -The resident had two blisters on his/her right shin and -The resident had multiple wounds on his/her coccyx. During an interview on 9/27/18 at 10:02 A.M., the wound nurse said he/she was not aware of the resident having any wounds prior to going out to the hospital. Observation on 9/27/18 at 9:45 A.M. showed the resident remained on his/her back with a wedge cushion by the resident's right side. Observation on 9/28/18 showed: -At 7:55 A.M., the resident was in bed, on a regular mattress, on his/her back with a wedge cushion by the resident's right side; -At 9:10 A.M., the resident was lying on his/her back with the head of his/her bed elevated; -At 9:40 A.M., the resident remained positioned on his/her back with a wedge pillow on his/her right side and the head of the bed elevated and -At 10:05 A.M., the resident was positioned on his/her back. During an interview on 9/28/18 at 8:00 A.M., CMT B said: -If a resident was supposed to be turned from side to side, the resident should not be on his/her back; -If a resident had a pressure ulcer/injury on his/her bottom, the resident should be positioned on his/her side with a pillow to support him/her on his/her side and -A resident should not be positioned on his/her back if he/she had a wound on his/her bottom. During an interview on 9/28/18 at 9:25 A.M., Certified Nursing Assistant (CNA) D said: -Residents are supposed to be turned and repositioned every two hours; -Residents who have a wound on his/her bottom should be positioned on his/her side with a pillow behind him/her to help hold them on his/her side; -If a resident had specific instructions to keep off his/her back, the resident should not be positioned on his/her back; -No one told him/her to keep the resident off of his/her back; -No one told him/her the resident had pressure ulcers on his/her bottom; -If he/she had known the resident had pressure ulcers on his/her bottom, the resident would not be positioned on his/her back but would be positioned on his/her side; -The resident is not able to re-position himself/herself and -Was not aware that the resident had pressure ulcers anywhere. During an interview on 9/28/18 at 9:50 A.M., CNA E said: -Residents are turned and repositioned every two hours; -If a resident had a wound, the resident would be positioned so the wound was not getting any pressure to it; -The nurses will report to the CNAs if there is anything going on with the residents; -Was informed of the cares of all the residents on the wing currently working.; -Was not told the resident had any wounds; -Had not performed any incontinent care to the resident since the beginning of his/her shift (7:00 A.M.); -Residents are to be changed every two hours; -The resident is currently positioned on his/her back; -The resident should have been turned side to side while in bed, but he/she had breakfast so he/she was on his/ her back; -The resident was positioned on his/her back at the beginning of his/her shift and -The resident is not able to re-position himself/herself. During an interview on 9/28/18 at 10:10 A.M. RN A said: -Residents are repositioned every two hours; -CNAs are present for morning shift report; -CNAs can get information about the resident off the assignment sheet and the resident list; -The information shared with the CNA's included any wounds residents' had and how the residents should be positioned; -The resident should be repositioned at least every two hours; -The resident should be positioned from side to side with a pillow to keep him/her on his/her side; -The resident is able to reposition himself/herself and favors his/her back; -RN A does a walk through at the beginning of his/her shift between 6:45 A.M. and 7:00 A.M; -The resident was positioned was on his/her right side during the walk through that morning; -The wedge pillow should be behind him/her by the wall; -The resident had a popped blister where the adult brief was placed and it healed quickly; -The resident had no other wounds; -RN A expected the CNA to report any skin abnormalities to him/her immediately and -RN A did not notice if the resident had any wounds and no one had reported the resident had any wounds. During an interview on 9/28/18 at 12:00 P.M. the Director of Nursing (DON) said: -He/she expected staff to turn and reposition residents every two hours at least every couple hours; -He/she expected staff to document assessments of resident's skin condition; -They document residents' skin conditions on the bath sheets; -If a resident had wounds to his/her bottom, they should get a low air loss mattress, turn and re-position the resident, check on the resident every couple of hours and as needed; -The charge nurse should be looking at wounds and documenting what the residents' wounds look like; -He/she expected the resident's skin to be assessed upon return on his/her hospital return on 9/8/18 and the assessment documented; -The resident was not able to reposition himself/herself; -The resident sometimes slid down in the bed but he/she does not consider that as repositioning and -He/she would expect the charge nurse to give a report to the CNAs. During an interview on 9/28/18 at 12:10 P.M. the resident's physician's nurse practitioner said: -Staff should have done an assessment of the resident's right lower extremity after he/she returned to the facility with the fracture. -The ace wrap was wadded up around the resident's thigh. -The wound care nurse at the facility should report wounds in the facility to him/her. MO 871 2. Record review of Resident #28's annual MDS dated [DATE] showed he/she: -Was moderately impaired cognitively; -Had two pressure ulcers; -Had a healed pressure ulcer; -Had no other skin alterations; -Was totally dependent on staff for bathing, bed mobility, personal hygiene and dressing; -Did not walk; -Used a wheelchair and -Had [DIAGNOSES REDACTED]. Record review of the resident's care plan dated 7/15/16 for pressure ulcers showed he/she had a pressure ulcer on his/her buttocks and left ankle. No other skin alterations were on the care plan. There were no care plan updates since 7/15/16. Record review of the resident's nurse's note dated 8/26/18 showed he/she returned to facility (from the hospital) with a knee splint on his/her right leg. Record review of the resident's (MONTH) (YEAR) physician's orders [REDACTED]. -There were treatment orders for the resident's left and right ischium (forms the lower and back part of the hip bone).treatment orders; -9/19/18: Right inner ankle: Clean with normal saline, apply [MEDICATION NAME] AG (a dressing that is indicated for moderate to high exuding wounds which are infected or at risk of infection), secure with bordered foam and change daily and as needed if soiled and -9/19/18: Right shin: Clean with normal saline, apply [MEDICATION NAME] AG, secure with bordered foam and change daily and as needed if soiled. Observation on 9/18/18 at 1:52 P.M. showed the resident had visible bandages on his/her left ankle and left shin. The resident said he/she did not know how he/she got them Record review of the resident's non-pressure skin condition record completed by the facility wound nurse dated 9/20/18 showed: -Site A: --Was an abrasion on the resident's left shin; --Was first observed on 9/19/18 (bandages were observed in place on 9/18/18); --The abrasion was 1.5 cm x 0.5 cm x 0.1 cm; --The tissue was 50% granulation (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) and 50% slough (dead tissue that is in the process of separating from the viable portions of the body); --Did not have any drainage and -The documentation did not specify why the wound was documented to be an abrasion and not a pressure ulcer. Record review of the resident's facility's wound nurse's note dated 9/19/18 showed: -The resident had two new wounds on his/her left leg; -The wounds corresponded with the metal on the leg brace the resident wore on his/her right leg for his/her fractured kneecap and -Treatment orders were written for wound care for the two new wounds. Record review of the resident's nurses' notes dated 9/19/18 through 9/28/18 at 9:33 A.M. showed no further documentation regarding the resident's brace or new wounds. Record review of the resident's consulting wound company's physician's assistant's wound note dated 9/20/18 at 11:20 A.M. showed: -The resident had a pressure ulcer on his/her left ischium. -The resident had a wound caused by pressure from a brace on his/her left, medial ankle that: --Was a Stage 3 pressure ulcer; --Measured 1.0 cm x 1.0 cm x 0.2 cm; --Had no drainage; and --Was 100% granulation. -There was no documentation regarding the resident's shin wound. During an interview and observation on 9/24/18 at 10:28 A.M.: -The wound nurse said: --The resident has two areas, one on his/her left shin and one on his/her left ankle that were caused by the resident's brace on his/her right leg; --The joints of the brace rub on the rsident's left leg; --The resident had a brace on his/her right leg due to a fractured kneecap; --The resident had recurring wound areas on his/her ischium; --The resident had [DIAGNOSES REDACTED] (a birth defect that occurs when the spine and spinal cord do not form properly); -The resident's legs were together with the left side of the brace on the resident's right leg being directly up against the right side of the resident's left leg; -The wound nurse had to pull the resident's legs apart to separate them; -The wound nurse removed the bandages on the resident's left leg and there were red open areas on the resident's left shin and left ankle; -When the wound nurse was asked if therapy had looked at the resident's brace, he/she said the brace was for the resident's fractured patella (kneecap); -When the wound nurse was asked if they tried to put something between the resident's legs to prevent the brace from rubbing on his/her left leg, he/she said no, that the resident was up most of the time during the day and -The resident had a dressing on his/her left ischium. Observation on 9/25/18 at 2:50 P.M. showed the resident was sitting in his/her wheelchair in his/her room. His/her right foot was on the floor. His/her left foot was partially on the foot rest. The resident's left ankle was touching the brace on the resident's right leg. During an interview on 9/26/18 at 8:30 A.M., the DON said: -They tried pillows to keep his/her legs apart and -They did not refer the resident to therapy because he/she was not able to stand on his/her right leg. During an interview on 9/28/18 at 9:42 A.M., CNA C said: -The resident's wounds on his/her left leg were from his/her brace rubbing against his/her skin and -The resident has had the same brace since he/she first broke his/her kneecap. During an interview on 9/28/18 at 9:55 A.M., Licensed Practical Nurse (LPN) D said: -The resident's wounds on his/her left leg were from the brace rubbing on it and -They tried using towels and pillow cases to position the resident's legs in the past but not specifically since he/she started wearing the brace. During an interview on 9/28/18 at 11:04 A.M., the facility's wound nurse said: -The wound on the resident's left shin was healed and -They received a physician's orders [REDACTED]. During an interview on 9/28/18 at 12:00 P.M., the DON said: -The staff should document any preventative measures they put in place for the resident's brace rubbing on his/her skin and -They did not refer the resident to therapy to evaluate the positioning of the brace. During an interview on 9/28/18 at 12:10 P.M., the resident's physician's nurse practitioner said: -The resident is constantly moving himself/herself; -The resident is in his/her wheelchair a lot; -A pillow probably would not stayed between the resident's legs and -If the resident had been referred to therapy, therapy could have looked at the resident to make sure the brace fit well, to make sure the brace was on properly and for positioning of the brace. 3. Record review of the facility's inservice sign in sheet on 6/26/18 showed LPN D had attended an inservice on the Wound Vac (vacuum). Record review of Resident 17's admission MDS dated [DATE] said the resident had the following Diagnoses: [REDACTED]. -Pressure ulcer. Record review of the resident's medical record showed he/she was admitted to the facility on [DATE] from a hospital with a Stage 4 ulcer (wound that exposes bone, muscle, or tissue). The resident was unable to make decisions for his/her self. During an observation on initial tour on 9/18/18 at 10:00 A.M. the resident was observed to have: -A [DEVICE] attached to his/her lower back; -The collection canister was half full with a yellow colored drainage; -The [DEVICE] machine was making a very loud noise indicating a malfunction; and -The seal on the dressing covering the wound and [DEVICE] was stuck to itself not flat to the skin. During an observation and interview on 9/18/18 at 10:33 A.M. with LPN D said: -The resident had a bridge in the [DEVICE] system (an extension to the system); -The nurse was able to stick his/her fingers in the dressing and said that was ok; -The noise was ok; and -According to the facility's policy it said the wound vac should be sealed to create a vacuum. During an observation on 9/18/18 at 12:44 P.M., showed: -The resident's dressing covering the wound and [DEVICE] was stuck to itself not flat to the skin; and -The [DEVICE] machine was still making a loud noise indicating it was not working properly. During an observation and interview on 09/18/18 at 02:32 P.M. with the DON and LPN D: -Turned the resident so his/her lower back wound site could be more observable; -The seal on the low back [DEVICE] dressing was stuck to itself not flat to the skin; and -LPN D said the dressing and noise from the machine were ok. During an interview on 09/18/18 at 2:45 P.M. with the DON said: -The [DEVICE] noise and the dressing was not attached correctly; and -He/she would make sure it was fixed. Record review on 09/25/18 at 2:32 P.M., showed the resident's POS dated 09/04/18 directed the staff to monitor the function of the [DEVICE] every shift. 4. Record review of Resident #115's Admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. -PU of the left hip, unspecified stage. -Unspecified open wound of the resident's left foot, sequela (a condition that is the consequence of a previous disease or injury). -Unspecified injury at T11-T12 level of [MEDICATION NAME] spinal cord, sequela. -[MEDICAL CONDITION]. -Diabetes II with diabetic peripheral angiopathy (generic term for a disease of the blood vessels, a common complication of chronic diabetes) without gangrene (dead tissue caused by an infection or lack of blood flow). Record review of Resident's POS dated 8/2/18 showed physician's orders [REDACTED].>-Change the resident's Wound Vac dressing on Monday, Wednesday, and Friday on the 7:00 A.M.-3:00 P.M. shift. -Monitor Wound Vac function every shift and as needed. Record review of the Resident's Treatment Administration Record (TAR) dated (MONTH) (YEAR) showed that the PU and wound vac dressings were not changed on the following dates: -Wednesday 8/8/18. -Monday 8/13/18. -Wednesday 8/15/18. -Wednesday 8/22/18. -Monday 8/27/18. -Friday 8/31/18. Record review of Resident's POS dated (MONTH) (YEAR) showed: -No order for a Wound Vac machine to wounds. Record review of the Resident's TAR dated (MONTH) (YEAR) showed that the PU dressings were not changed on Monday 9/3/18. Record review of the Resident's medical record showed only one entry for a missed dressing change on 9/3/18 as follows: -Dressing changes not done this shift. -Nurse told resident several times that he/she was ready to change the dressings. -The resident was either in another resident's room or outside each time the nurse went to do the dressing changes. -The on-coming nurse was informed. Record review of Resident's Care Plan (written out plan for the care of the resident) dated 9/7/18 showed: -Risk for developing a pressure ulcer, currently has PU. -Goal: will have intact skin by next review of 12/31/18. -Interventions: --Reposition/shift weight to relieve pressure. --Minimize pressure over bony prominences. --Provide pressure relieving or reduction device: ---Low air loss mattress. ---Chair cushion. ---Pressure reduction device in wheelchair. ---Reposition. Record review of Resident's medical record showed no Care Plan for the care of the Resident's wounds or the use of a Wound Vac. Record review of the Resident's Wound Rounds charting dated 8/28/18 at 1:38 P.M. showed: -Physician here for rounds. -Resident non-compliant with wound care/dressing changes. -While changing his/her dressing he/she would not roll to the right side to allow access to the wound on the left great trochanter (a part of the thigh bone). -While taping the bridge (connects two or more dressings to a wound vac) down he/she continued to state the tape was tight and to remove it. -Resident continued t

Based on observation, interview and record review, the facility failed to ensure one resident was provided sufficient nutrition, fluids and monitoring while on a diuretic (medication used to treat heart-related conditions by helping the body get rid of unneeded water and salt through increased urination which helps lower blood pressure and helps make it easier for the heart to pump), high blood pressure medications and was sent to the hospital emergency room for a very low pulse and blood pressure and for critical lab results which resulted in the resident to have poor kidney function and was placed on hospice (end of life care); and to assist the resident with his/her meals after being readmitted to the facility after a hospital stay with a significant change in condition for one sampled resident (Resident #34) out of 23 sampled residents. The facility census was 114 residents. Record review of the facility's hydration policy dated as revised 3/1/13 showed: -Instructions for staff to staff to watch for risk factors for dehydration such as insufficient fluids, loss of appetite, the use of diuretics refusal of fluids and Dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes) and -Clinical symptoms of a deficit of fluids include decreased blood pressure. 1. Record review of Resident #34's care plan dated 4/21/16 showed instructions to staff to encourage the resident to eat and drink. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/10/18 showed the following staff assessment of the resident: -Was severely cognitively impaired; -Required supervision, encouragement or cueing with eating and -Had [DIAGNOSES REDACTED]. Record review of the resident's (MONTH) (YEAR) physician's orders [REDACTED]. -A diet order of mechanical soft and discontinued on 9/21/18; -A physician's orders [REDACTED]. - A physician order [REDACTED].>-A physician orders [REDACTED]. Notify MD if any BP meds are held) and discontinued on 9/21/18; -Please encourage po fluids at all meals dated 2/28/17 and discontinued on 9/21/18; -Monitor BP and pulse weekly. Notify MD is SBP is less than 90 or above 200 or if pulse is less than 50 every day dated 7/18/17 and discontinued on 9/21/18 and -[MEDICATION NAME] 30 mg daily dated 7/3/18 (hold if SBP is below 100. Notify MD if any BP meds are held) and discontinued 9/21/18. Record review of the resident's nurse's note dated 9/8/18 at 5:24 P.M. showed he/she consumed 75% of breakfast and 50% of lunch. Record review of the resident's Nurse's Note dated 9/8/18 at 11:47 P.M. showed he/she was fed dinner by a Certified Nursing Assistant (CNA). Record review of the resident's Nurse's Note dated 9/10/18 at 5:17 P.M. showed: -The resident was fed breakfast by staff; -The resident's family member fed the resident lunch and -The resident's family member reported that the resident ate 100% of the food they brought from home. Record review of the resident's physician's progress note dated 9/11/18 showed: -The resident's heart rate was low at 47 beats per minute (normal is 60-100); -The resident was seen urgently for low heart rate and low blood pressure; -The resident has a very dry mouth; -Nursing stated the resident refuses to drink regular water and likes sweets and -The resident's family brought the resident in [MEDICATION NAME] flavored water to drink. Record review of the resident's Nurse's Note dated 9/17/18 at 12:50 P.M. showed the resident's blood pressure was low at 115/46 ( normal range is 120/80) and the resident's pulse was low 47. Observation on 9/18/18 at 10:00 A.M. showed the resident was asleep in bed. Observation on 9/18/18 at 1:28 P.M. showed the resident was in his/her wheelchair in his/her room. Record review of the resident's Nurse's Note dated 9/18/18 at 4:54 P.M. showed the resident's blood pressure medication was held due to a low blood pressure of 84/44. Record review of the resident's Nurses' Notes showed there were no nurses' notes dated 9/19/18-9/20/18. Observation on 9/20/18 at 11:45 A.M. showed the resident was in his/her room in his/her wheelchair. Record review of the resident's Nurse's Note dated 9/21/18 at 12:55 A.M. showed the resident's blood pressure medication was held due to a low blood pressure of 97/37. The physician was informed. The physician ordered a Basic Metabolic Panel (a blood test that measures sugar levels, electrolytes, fluid balance, and kidney function), Urinary Analysis and a Complete Blood Count (a test that gives information about blood cells) in the morning. Record review of the resident's lab results dated 9/21/18 at 11:38 A.M. showed: -The resident's white blood cell count was elevated at 11.0 (normal range 4.5-10.5) which can indicate an infection; -The resident's red blood cell count was low at 3.45 (normal range 3.9-5.2) which can indicate [MEDICAL CONDITION] (when one doesn't have enough healthy red blood cells to carry adequate oxygen to the body's tissues), kidney disease and other conditions; -The resident's potassium level was elevated at 5.4 (normal range 3.5-5.1) which can indicate kidney disease; -The resident's blood urea nitrogen (BUN-A measurement of the amount of nitrogen in the blood. A high BUN may indicate heart failure or dehydration) was elevated at 71 (normal range 7-25); -The resident's Creatinine (blood test is used to assess kidney function) was elevated at 3.7 (normal range 0.6-1.3) which can indicate dehydration and/or impaired kidney function; -The resident's hemoglobin level (the protein molecule in red blood cells) was low at 8.4 (normal range is 12.0-16.0) which can indicate [MEDICAL CONDITION]; -The resident's Hematocrit (a blood test that measures the percentage of red blood cells found in whole blood) was low at 27.8 (normal range is 36.0-48.0) which can indicate conditions such as [MEDICAL CONDITION] or blood loss and -The lab was dated, initialed and it was hand-written on the lab results that the resident was sent to the emergency room . Record review of the resident's Nurse's Note dated 9/21/18 at 3:12 P.M. showed: -Staff reported to the nurse that the resident's eyes appeared to roll back and he/she was not responding; -The resident's blood pressure was 85/44 and -The Nurse Practitioner was at the facility and gave an order to send the resident to the emergency room . Record review of the resident's hospital notes dated 9/21/18-9/26/18 showed the resident had [DIAGNOSES REDACTED]. Hypovolemia occurs with dehydration or bleeding). Record review of the hand-written report called from the hospital note dated 9/26/18 showed the following: -The resident was returning to the facility with hospice services and -A diet order of puree food with thin liquids. Record review of the resident's POS dated 9/26/18 showed physician orders: -[MEDICATION NAME] CD 240 mg daily dated 9/26/18 (hold if SBP is less than 90 or pulse is less than 50. Notify MD if any BP meds are held); -Please encourage po fluids at all meals dated 9/26/18; -Monitor BP and pulse weekly and notify MD if SBP is less than 90 or above 200 or pulse is less than 50 every day dated 9/26/18; -[MEDICATION NAME] 12.5 mg twice a day dated 9/26/18 and -[MEDICATION NAME] 25 mg three times a day, date 9/26/18. Record review of the resident's baseline care plan dated 9/26/18 showed: -The resident required some or total assistance to eat/drink and he/she had a chewing, swallowing or choking problem and -Instructions for staff to assist the resident with eating. Record review of the resident's initial data collection tool/nursing service dated 9/26/18 showed the resident: -Eats poorly; -Has trouble swallowing; -Has choking problems; -Accepts fluids when offered and -Had a [DIAGNOSES REDACTED]. Observation on 9/26/18 at 2:40 P.M. showed: -There were five bottles of flavored water in the resident's room. One of the bottles had been opened and about 1/4 of it was gone and -There was an insulated mug that had water in it by his/her television. During an interview on 9/26/18 at 2:45 P.M., CNA G said: -The resident's family brings bottled water; -They put the flavored water in her pitcher in the resident's room; -They give the resident flavored water at meals and -The resident's family member comes every day at lunch and gives the resident flavored water when he/she's here. Record review of the resident's POS upon return from the hospital on [DATE] showed diet orders for puree food (food that is ground and altered into a consistency of a soft, smooth, thick paste (similar to a thick pudding) that requires very little or no chewing) and to encourage beverages with all meals. Observation on 9/27/18 at 7:45 A.M. showed the resident('s): -Tongue was coated with a white substance that was cracked in appearance; -Water pitcher was on his/her bedside table; -Flavored water bottle was half full and - A sucker was on the open wrapper on the bedside table. Continuous observation on 9/27/18 showed: -At 8:20 A.M.: --The resident was in bed. --The resident's water pitcher was on his/her bedside table. --The resident's flavored water bottle was half full. --The resident's sucker was on the open wrapper on the bedside table. -At 8:24 A.M., housekeeping was cleaning the resident's room. -At 8:41 A.M., the housekeeper left the resident's room. -At 8:43 A.M., the resident was served a breakfast tray in his/her room that consisted of eggs, oatmeal, bread, 1/2 a glass of orange juice, [MEDICATION NAME] water, unopened butter and jelly. Certified Medication Technician (CMT) A elevated the resident's head to sitting up in bed. Staff did not assist the resident with his/her breakfast. The resident was not able to feed himself/herself. -At 8:54 A.M., the resident was crying out. -At 8:56 A.M., the charge nurse walked by the resident's room. -At 9:01 A.M., the resident was crying out. The resident cried out my leg. -At 9:05 A.M., the resident's breakfast tray remained untouched on a bedside tray. -At 9:15 A.M., the resident's breakfast tray remained untouched on a bedside tray. No staff entered the resident's room since his/her breakfast tray was delivered. The resident's food and drink remained untouched. -At 9:17 A.M., staff were picking up room trays. CMT A offered the resident a sip of orange juice. The resident shook his/her head no. The resident was offered flavored water. The resident took a sip of flavored water. CMT A removed the resident's meal tray. The resident was not offered any food. The resident's glass of orange juice and flavored water were left for the resident. During an interview on 9/27/18 at 10:10 A.M., the resident's family member said: -The resident's appetite declined around the same time he/she complained of knee pain on 9/7/18; -The resident began pocketing food in his/her cheeks and not eating and -He/she noticed the resident was more lethargic recently. Record review of the resident's Nurse's Note dated 9/27/18 at 3:23 P.M. showed Registered Nurse (RN) A documented: -The resident ate a few bites for breakfast; -The resident's family member brought the resident lunch and -The resident's family member reported to RN A that the resident ate two bites and refused to eat or drink. Record review of the resident's Nurse's Note dated 9/27/18 at 6:56 P.M. showed RN A documented: -CNA F reported to RN A that he/she served the resident dinner and -CNA F reported to RN A that the resident's family member asked CNA F to take away the resident's dinner as the family member was bringing the resident soup. Continuous observation on 9/28/18 showed: -At 9:10 A.M.: --The resident was in bed. --A breakfast tray was in the resident's room uncovered. It included pureed eggs, oatmeal, bread, water and orange juice. The resident was not feeding himself/herself and staff were not in the room assisting the resident. None of the food and/or drinks were consumed. -At 9:15 A.M., a housekeeper began cleaning the resident's room. -At 9:20 A.M.: --The resident had not eaten any food. --A CNA removed the resident's breakfast tray without offering the resident any food or drink. During an interview on 9/28/18 at 8:00 A.M., CMT B said: -The resident drinks flavored water when taking his/her medications; -The resident will drink orange juice when he/she is in the dining room; -The resident will eat cereal for breakfast and -The resident will feed himself/herself. During an interview on 9/28/18 at 9:25 A.M., CNA D said: -The resident was able to feed himself/herself and -He/she would encourage the resident to eat and then inform the charge nurse. During an interview on 9/28/18 at 9:50 A.M., CNA E said: -The nurses will report to the CNAs if there is anything going on with the residents; -He/she was informed of the cares of all the residents on the wing currently working; -The resident was able to feed himself/herself but required a lot of cueing and -The meal tray should be covered until the staff are sitting next to him/her and assisting/cueing him/her to eat or feeding him/her. During an interview on 9/28/18 at 10:10 A.M. RN A said: -CNAs are present for morning shift report; -CNAs can get information about the resident off the assignment sheet and the resident list; -The resident was able to feed himself/herself with verbal cueing; -The resident would eat what he/she wants to eat and if he/she doesn't want to eat it, he/she won't; -Family have been coming in and bringing food for the resident; -The resident does not drink regular water but will drink flavored water his/her family brings in; -He/she attempted to feed the resident but he/she would not eat anything; -The resident had always been a picky eater but it has been decreasing recently and -He/she would expect staff to assist the resident with meals. During an interview on 9/28/18 at 12:00 P.M. the Director of Nursing (DON) said: -He/she expected staff to assist residents with meals as needed; -He/she expected staff to feed residents when needed; -He/she did not expect staff to place a room tray in the room, uncover the meal and leave the room if the resident was unable to feed himself/herself; -The resident was able to feed himself/herself when he/she wants to eat; -The resident does need assistance with meals; -The resident would eat the dessert first; -The resident doesn't have the appetite so he/she is not eating as much as he/she was before; -The resident will only drink flavored water and will not drink orange juice and -The resident's family said the resident will eat sweets. During an interview on 9/28/18 at 12:10 P.M. the resident's physician's Nurse Practitioner said: -He/she would expect the staff to feed the resident if he/she was unable to feed himself/herself and -He/she would expect staff to notify him/her of a resident refusing to eat if the resident was refusing to eat on a regular basis. MO 871