Every finding on record at Magnolia Wellness Center

Based on observation, interview and record review, the facility failed to ensure resident safety and protective oversight. During a staff-assisted transfer from a wheelchair to a bed, one resident's (Resident #16) foot became entangled in the wheelchair wheel, resulting in a femur fracture requiring hospitalization and surgical repair. In addition, the facility failed to follow its mechanical lift policy during a resident transfer (Resident #69) and failed to ensure safe smoking practices for residents who smoked (Residents #32, #66 and #71) and follow the smoking policy and schedule. The sample size was 21. The census was 74. Review of the gait belt policy, revised 6/2020, showed:-Purpose: To provide assistance to clinical staff when moving a resident from one place to another and to increase the safety of residents by allowing clinical staff members to grip it and keep the resident from falling.-Policy: A gait belt may be used for residents who are too weak to walk or stand alone, or required assistance during transfers;-Procedure:--Explain the purpose and procedure to the resident;--Place the gait belt around the resident's waist over the clothing with the buckle in front;--Secure the belt according to manufacturer's directions;--Ensure that the belt is snug, but allows for enough room to get two fingers between the belt and the resident;--If the resident begins to fall, pull the resident close and slowly lower the resident to the floor if unable to stabilize and call for assistance. Review of the total mechanical lift policy, revised 6/2020, showed:-Purpose: The mechanical lift is used appropriately to facilitate transfers of residents;-Policy:--Nursing staff will be trained to use the mechanical lift;--The resident will have a physician order for the use of a mechanical lift;--At least two people are present while resident is being transferred with the mechanical lift;-Procedure:--Place the sling under the resident, arrange the resident's arms so they are flat next to the body;--Position the lift under the resident's bed or around the chair;--Set base legs to the widest position under the resident and lock the wheels;--Lower the boom bar, and lower enough that the sling loops will reach the hooks;--Hook the loops on the side of the sling, and attach the sling to the correct hook on the bar;--Raise the boom bar on the lift;--Keep the resident centered between legs of the base and facing the person who is operating the lift;--Move the resident to the destination and lower into position. Review of the facility's Smoking by Residents policy, revised November 2023, showed:-Purpose: To respect resident choice to smoke and to maintain a safe and healthy environment for both smokers and non-smokers;-Policy: Smoking is no allowed anywhere inside the facility; The facility only permits smoking only in the area designated by the facility's safety committee; Resident who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas; Residents who are not able to smoke independently and safely will be accompanied by facility staff while smoking; all smoking sessions will be supervised by the facility staff members; All smoking materials will be stored in a secure area to ensure they are kept safe; Residents are strongly encouraged not to share their smoking materials with any other residents, Smoking sessions are limited to 15 minutes. Review of the facility's Smoking Violation policy, undated, showed:-Smoking tobacco, matches, lighters, or other smoking paraphernalia cannot be kept by residents or stored in their rooms; Smoking by resident is only permitted in designated facility areas at designated times regulated by the facility; Smoking by resident will occur under the direct supervision of staff; Smoking assessments will be completed on admission, quarterly, and as needed only on residents who use tobacco products. 1. Review of Resident #16's medical record, showed:-re-admitted : 11/1/25;-Diagnoses included lung disease, disorientation, altered mental status, altered mental status, schizophrenia (a brain disorder that impairs the ability to think rationally, causing hallucinations, delusions and disorganized thinking), diabetes, depression, anxiety, fall history and asthma. Review of the resident's quarterly Minimum Data Set (MDS) a federally required assessment instrument completed by facility staff, dated 3/22/26, showed:-Severe cognitive impairment;-Used a wheelchair for mobility;-Dependent on staff for toileting and bathing;-Assist of one staff needed for dressing, bed mobility, and transfers;-No therapies received. Review of the resident's care plan, revised on 4/9/26, showed:-Focus: the resident has a self-care deficit due to disease process;-Goal: maintain current level of function in transfers, bed mobility, dressing and personal hygiene;-Interventions: transfer: the resident requires one staff participation with transfers. Review of the resident's electronic physician order sheet (ePOS), showed no transfer orders. Review of the resident's progress notes, showed:-On 6/10/26 at 11:10 P.M., a general progress note: the resident noted with deformed left leg and laceration to the right elbow. Notified by the certified nurse aide (CNA). The resident was sent to emergency room (ER) for evaluation and assessment;-On 6/11/26 at 1:55 A.M., diagnosis is a left femur fracture per hospital staff. Review of the resident's hospital history and physical, dated 6/11/26 at 5:11 A.M., showed:-Complaint: left leg problem;-History of present illness: the patient presents to the hospital with a left leg problem. Per emergency medical services (EMS), patient is alert and oriented x one (self) at baseline. Per previous notes, the aide at the care facility transferred the patient from the wheelchair to the bed. The patient's leg was stuck in the wheelchair and the left femur snapped. Per EMS, witness denies the patient fell. At the time of the interview, the patient said he/she fell, and his/her leg hurt. Per review of the notes, the orthopedic department pinned the bone in the ED, the head laceration also repaired;-Unable to review symptoms due to dementia;-Physical exam:--Appearance: ill appearing;--Head, ears, nose and throat (HENT): abrasion present;--Musculoskeletal:---Right lower leg: no edema (swelling);---Left lower leg: tenderness and bony tenderness present, no edema;---Skin: abrasion and signs of injury present;---Cognition: cognition is impaired;-Assessment and plan:--Fall: initial encounter, present on admission, not yet determined;--Closed fracture of left femur fracture: present on admission;-Computed tomography (CT, imagining used to create detailed imaging) lower left extremity, showed an acute displaced fracture of the femoral (long thigh bone) shaft. Osteopenia. Acute mildly displaced fracture of the femoral shaft with at least 12 centimeters overriding (a severe, high-energy injury characterized by massive muscle contracture and extreme leg-length discrepancy. Requiring immediate emergency stabilization with surgery). Post surgical changes of internal fixation are seen within the proximal femur;-Plan: orthopedics aware and planned surgery;-discharge: approximately 6/14/26 to a different facility with a wound vac in place, physical and occupational therapy orders. During an interview on 6/11/26 at 8:12 A.M., registered nurse (RN) R said he/she was the charge nurse on the evening of 6/10/26 and last saw the resident at approximately 8:50 P.M. and administered ordered medications. The resident was lying in his/her bed at that time. At approximately 11:05 P.M., to 11:10 P.M., the aide notified him/her the resident's leg was messed up. RN R said upon assessment the resident was in bed, his/her head faced the window. The resident's left leg was obviously deformed. RN R said he/she knew the resident's leg was broken by just looking at it. The resident experienced pain when he/she attempted to move the leg. The resident also had a fresh laceration above the right eyebrow. The certified nurse aide (CNA) B, who put the resident in bed, reported to RN R that when he/she transferred the resident into bed, the resident's left foot became entangled in the front wheelchair wheel, and the CNA completed the resident's transfer into bed. CNA B also told RN R he/she turned the resident in bed to provide care, and during the turning in bed, the resident struck his/her head on the wheelchair next to the bed. RN R said he/she immediately called emergency services for the resident to obtain treatment. During an interview on 6/11/26 at 10:30 A.M., CNA B said he/she had worked at the facility for five years and worked the evening shift on 6/10/26. He/She was scheduled to leave at 11:00 P.M. that evening and he/she had to ensure Resident #16 to bed before he/she left the shift. At approximately 10:55 P.M., CNA B entered the resident's room on 6/10/26 to put the resident to bed. The resident sat in his/her wheelchair. CNA B positioned the resident's wheelchair next to the bed. He/She applied the gait belt around the resident's waist and secured the gait belt. As he/she lifted the resident, and pivoted to the bed, the resident's foot got entangled in the front wheel of the wheelchair. He/She and the resident fell sideways into the bed and the resident yelled out and then quieted. CNA B said he/she did not want the resident to slide off the bed and he/she straightened the resident in bed onto his/her back. CNA B unfasted the resident's brief, turned the resident on his/her side and provided care. As he/she turned the resident onto his/her back, the resident yelled out. As the resident lay on his/her back, CNA B said, it looked like the leg was out of socket. CNA B left the room and got RN R, told the nurse the resident's leg did not look right. CNA B said he/she needed to get the resident to bed before the end of his/her shift. He/She could not recall how the resident received a cut above the eye and said the resident could have hit his/her head on the wheelchair. He/She wrote a statement before he/she left the shift. He/She had been suspended, so the facility could investigate. During an interview on 6/12/25 at 2:05 P.M., the Administrator and Director of Nursing (DON), said Resident #16 was a gait belt pivot transfer. The resident resisted care at times. The facility has begun in servicing regarding transfers and reporting. Staff should have stopped the transfer any time the resident expressed discomfort. 2. Review of Resident #69's medical record, showed:-re-admitted : 2/14/26;-Diagnoses included seizures, stroke, sepsis (blood infection), muscle weakness, right knee contracture, difficulty swallowing, and right sided paralysis. Review of the resident's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Functional impairment upper and lower extremity to one side;-Used a wheelchair for locomotion;-Dependent on staff for transfers, mobility, hygiene and toileting;-Used a mechanical lift for transfers. Review of the resident's care plan, in use during the survey, showed:-Focus: The resident has decreased mobility and need of two staff assistance and a Hoyer lift (a mechanical list used to transfer non weight bearing patients) for safe transfers;-Goal: Safety measures will be taken when transferring the resident;-Interventions: Ensure two staff members are present when using Hoyer lift for safety measures. Observation and interview on 6/8/26 at 6:10 A.M., showed Certified Nurse Aide (CNA) B entered the resident's room with the Hoyer lift. Licensed Practical Nurse (LPN) S entered the room. Both staff applied the Hoyer sling under the resident and applied the sling to the lift arms. CNA B used the remote and lifted the resident off the bed and pulled the lift away from the bed. LPN S spun the resident in the lift to face CNA B. The resident swung freely over the floor as CNA B pushed the lift approximately four feet to the wheelchair. LPN S stood behind the wheelchair as CNA B pushed the resident over the wheelchair. LPN S pulled on the back of the sling, as CNA B lowered the resident into the wheelchair. CNA B said he/she should have asked LPN S to retain a hand on the resident during the positioning of the lift. The resident swung over the floor during the transfer. LPN S said he/she forgot to keep a hand on the resident during the transfer. Keeping hands on the resident ensured comfort and safety during the transfer. During an interview on 6/12/26 at 2:05 P.M., the DON said when staff used a mechanical lift, the staff who were not operating the lift should keep hands on the resident during the transfer. Residents should not freely swing over the floor while in the lift. 3. Review of the facility's smoking schedule, undated, showed smoking times:-7:30 A.M., 10:00 A.M., 1:30 P.M., 4:00 P.M., and 7:00 P.M. 4. Review of Resident #32's quarterly MDS, dated [DATE], showed;-Moderate cognitive impairment;-Diagnosis includes high blood pressure, kidney disease, stroke, and chronic (long term) lung disease. Review of the residents' care plan, in use at the time of survey, showed:-Focus: The resident smokes and has been advised of the facility smoking policy and requires supervision with smoking;-Interventions: Observe the resident during smoking for unsafe smoking (dropping cigarette, holding the cigarette close to the body) and report to nurse. Reassess resident smoking ability quarterly and after reports of unsafe practices. Remind resident and family member that the designated smoking areas are the only area to smoke. Remind the resident and family that all cigarettes, lighter, matchers and smoking paraphernalia must be kept at the nurses' station. Review of the resident's safe smoking evaluation dated, 4/24/26, showed:-Does the resident smoke?: Yes;-Does the resident know the location of the designated areas of smoking? No;-When observed, can the resident independent light smoking materials safely? No;-Can the resident extinguish smoking materials completely in an appropriate receptacle? No;-Can the resident dispose of ashes or other tobacco-related residue appropriately? No;-If no to any of the above, explain: Blank;-The resident is safe to smoke with minimal supervision. Observation on 6/9/26 at approximately 6:30 A.M., showed the resident outside of the facility walking up and down the sidewalk in front of the facility smoking a cigarette. No staff member was present supervising the resident. During an interview on 6/12/26 at 1:11 P.M., the resident said he/she would let the staff know when he/she went out to smoke and they would let him/her out to smoke. That included smoking in the front of the facility on the sidewalk. 5. Review of Resident #66's quarterly MDS dated , 3/2/26, showed:-Cognitively intact;-Diagnoses included malnutrition (poor nutrition) and chronic lung disease. Review of the resident's care plan, in use at the time of survey, showed:-Focus: The resident smokes and has been advised of the facility smoking policy; The resident requires supervision with smoking;-Interventions: Observe the resident during smoking for unsafe smoking (dropping cigarette, holding cigarette close to body). Provide assistance as need to assist resident to and from smoking areas. Reassess the resident 'smoking ability quarterly and after reports of unsafe practices. Review of the resident safe smoking evaluation dated, 4/27/27, showed:-Does the resident smoke?: Yes;-Does the resident know the location of the designated areas of smoking? Yes;-When observed, can the resident independent light smoking materials safely? Yes;-Can the resident extinguish smoking materials completely in an appropriate receptacle? Yes;-Can the resident dispose of ashes or other tobacco-related residue appropriately? Yes;-The resident is safe to smoke with minimal supervision. Observation on 6/9/26 at 7:15 A.M., showed the resident propelled him/herself in the wheelchair out the designated smoking area on the first floor. The resident removed a pack of cigarettes and a lighter from the back pocket of his/her wheelchair. Ther resident lit and smoked his/her cigarette. When the resident was done smoking his/her cigarette, the resident placed his/her cigarettes and lighter back into the pocket on his/her wheelchair and propelled back into the facility. The Housekeeping Supervisor and CNA A were outside supervising the residents that were smoking. 6. Review of Resident #71's quarterly MDS, dated [DATE], showed:-Severe Cognitive Impairment;-Diagnoses included hypertension (high blood pressure), asthma (a chronic (long-lasting) inflammatory disease of the airways that causes the airways to spam and as well periodically so that the airways narrow), and stroke. Review of the resident's undated care plan, in use during the survey, showed:-Focus: The Resident is a smoker and has been advised of the facility smoking policy. The resident requires supervision with smoking. Resident offered Nicotine patch for smoking cessation due to inability to smoke at this time. Resident declined;-Goal: He/She will be compliant with facility smoking policy through review date;-Interventions: Observe Resident during smoking for unsafe smoking (dropping cigarette, hold to close to body etc.) and report to nurse. Offer and encourage use of Safety Devices (Smoking apron, holder) when smoking. Provide assistance as needed to assist resident to and from smoking area. Reassess resident smoking ability quarterly and after reports of unsafe practices. Remind family of need for Smoking apron for unsafe residents and that they must remain with the resident when smoking. Remind resident and family member that the designated smoking area is the only area to smoke in. Remind resident and family that all cigarettes, lighter, matches and smoking paraphernalia must be kept at nursing station. Review of the Resident's ePOS, showed no physician orders for smoking evaluations and/or assessments. Review of the Resident's medical showed:-On 4/9/26, a safe smoking evaluation completed:-Evaluation: Does the resident smoke: Yes marked;-Summary:--This resident is safe to smoke with minimum supervision: Not marked;--All smoking materials will be kept at the nurse's station: Not marked;--Additional information: No interventions needed at this time. Observations of the resident on 6/8/26, showed: `-At 6:06 A.M., he/she self-propelled him/herself down the hallway on the ground floor of the facility with a cigarette and a lighter in his/her hand. The Resident rolled past the conference room and went up the keypad located at the back exit door. He/She punched the code into the keypad and opened the door and exited out of the building. The resident positioned his/her wheelchair up against the building to the right side of the door and lit and then smoked his/her cigarette;-At approximately 6:20 A.M.; the Resident re-entered the building. He/she said he/she had no idea when the smoke times where. He/She smoked outside that exit door or on the first-floor patio. Staff took some of the residents out to smoke at that exit door sometimes. He/She smoked him/herself. He/She knew the code to the door and let him/herself out that door to smoke. He didn't remember how he/she had gotten the code, but just about everyone had the code to the door. 7. Observation on 6/10/26 at 4:52 P.M., showed multiple residents were observed punching in the code to the door alarm to go outside to the smoking area. Several staff members watched the residents exit onto the smoking patio. Observation on 6/12/26 at 9:45 A.M., showed a sign posted on the exit door to the smoking area showing smoking times: 7:00 A.M., 9:00 A.M., 11:00 A.M., 1:00P.M., 3:00 P.M., 5:00 P.M., 7:00 P.M., 9:00 P.M., 11:00 P.M. Four residents were observed in the outside smoking area with cigarettes and lighters. Residents were lighting each other's cigarettes. No staff were present supervision the residents smoking. During an interview on 6/12/26 at 9:00A.M., LPN C said residents were not to have cigarettes and lighters in their possession. The nurses or management were responsible for asking the resident to surrender the smoking items. A smoking assessment was completed quarterly. The residents had the code and let themselves out to the smoking area. Some of the residents signed out in the book and would go to the park or the front of the building and smoke. It was a work in progress, and the staff had been trying to enforce the smoking times, but it was hard when the residents had the code. During an interview on 6/12/26 at 9:20 A.M., CNA D said the residents had the code and let themselves out to the smoking area whenever they wanted. The residents had their own cigarettes and lighters. Management was aware residents knew the code and the residents had cigarettes and lighters, but they did not do anything about it. During an interview on 6/12/26 at 9:26 A.M., CNA E said the residents were not supposed to have cigarettes and lighters, but they had them anyway. CNA E said he/she notified management when the residents had smoking items in their possession. During an interview on 6/12/26 at 2:06 P.M., the Administrator and the DON said they would expect the smoking assessments to be completed quarterly. The residents were not allowed to have cigarettes or lighters in their possession. A meeting was held with the residents that smoked, and they were instructed not to use the door code. The residents were to follow the new smoking times that were recently put in place. Residents were expected to smoke in the designated smoking area and not in front of the building or in the park. All residents that smoke were supervised by staff at the designated smoking times. 3040593, 3040603, 3040173

Based on observation, interview and record review, the facility failed to provide adequate treatment and services for two residents with pressure ulcers (wounds related to prolonged pressure on bony prominences) (Resident #1 and #5) and interventions to prevent pressure ulcers for one resident (Resident #1). The facility failed to provide treatments as ordered and change dressings when saturated, (Residents #1 and #5). The facility also failed to provide Residents #1 with a low air loss mattress (LAL, special mattress that reduces pressure and moisture to prevent wounds) set to the correct settings and pressure-reducing devices, per the care plan. Staff did not lay Resident #5 in bed between meals, as recommended by the Wound Physician and Director of Nursing. Resident #1 and Resident #5 both experienced worsening pressure ulcers. The sample size was 21. The census was 74. Review of the facility's Wound Management policy, dated 06/2020, showed: - To provide a system for the treatment and management of residents with wounds including pressure and non-pressure injury;- Pressure injury/pressure ulcer (PI/PU)- any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shear are not primary causes of pressure injury, friction and shear are important contributing factors to the development of pressure injuries. Pressure injuries usually occur over bony prominences (elbows, heels, hips, sacrum (middle portion of the lower back)/coccyx (tailbone)) and are graded or staged to classify the degree of tissue damage observed;-The Attending Physician will be notified to advise on appropriate treatment promptly;-The Licensed Nurse (Licensed Practical Nursing (LPN), Registered Nurse (RN), Assistant/Director of Nursing (ADON/DON) will notify the party responsible of the presence of a pressure injury;- Per Attending Physician order, the Nursing Staff will initiate treatment and utilize interventions for pressure redistribution and wound management;- Update the resident's care plan as necessary. 1.Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/08/26, showed:-Severely impaired cognition;-Resident's weight was 136 pounds (lbs.);-Fully dependent on two-person assistance for activities of daily living (ADLs), personal hygiene and mobility.;Diagnoses: Hepatitis C (bloodborne pathogen that affects the liver inflammation (swelling), sepsis (bacterial infection in the blood), Stage 4 pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle), lack of coordination and severe protein-calorie malnutrition (inability to keep nutritional balance);-Frequently incontinent of bowel and bladder;-Number of stage 3 PU/PI (full-thickness skin loss with visible fat but no bone/tendon exposure) total of two;-Number of stage 4 PU/PI, total of one;-Number of stage unstageable PU/PI (wound covered by slough/eschar so depth cannot be determined) total of one.-Pressure reducing device for chair/bed;-Pressure ulcer/injury care. Review of the resident's care plan, last updated 03/17/26, showed:-Focus: Has a pressure ulcer to his/her sacrum and bilateral lower legs;Desired outcome: Will have no complications related to pressures ulcer to sacrum;Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury, encourage nutrition and hydration, follow facility protocols and treatments (Txs) intravenous (IV) infusions to promote wound and hydration, keep skin clean and dry, resident needs pressure relieving/reducing mattress to protect the skin while in bed, monitor/document location, size and Txs of skin injury, report abnormalities failure to heal, signs and symptoms (s/sx) of infection, maceration (soft tissue breaks down after prolonged exposure to moisture) to medical doctor (MD);-Focus: Resident has open area to his/her left knee and sacral area upon admission. On 10/03/25, open area to left lateral ankle;-Goal: Wound will be free of s/sx of infection(s);-Interventions: Apply low air loss mattress, monitor mattress for right settings, apply orthotic suspension boots (green protective boots elevates the heels off the mattress), educate staff on LAL mattress settings, provide wound care per Tx orders;-Focus: Has ADL self-care performance deficits related to mobility, stroke;-Desired outcome: Will maintain current level of function;-Interventions: The resident is bedfast most of the time, two-person assist with transfers, repositioning and turning. Resident requires skin inspections daily. Review of the electronic physician's order sheet (ePOS), dated 4/20/2026, showed: -An order, dated 06/04/26, showed: May use low air loss mattress. Check setting every shift to ensure setting are within therapeutic range;-LAL mattress orders did not specify a therapeutic range which would be set to the resident's weight; -An order, dated 06/04/26, showed: Right buttocks-clean with normal saline (NS) (sterile water), apply Dakins 0.125% (antiseptic solution used to treat infected wounds) moistened gauze, and cover with bordered foam dressing (drsg), change daily and as needed (PRN),-An order date 06/04/26, showed: Right Anterior (front) Knee- Clean with NS, apply calcium alginate (CA+ Ag) (seaweed-based dressing for moderate-to-heavy wound drainage) and dry dressing (DD) daily and as needed (PRN); -An order, dated 06/04/26, showed: Left Lateral Hip- Clean with normal saline, apply calcium alginate, cover with bordered foam dressing (drsg). Change daily and PRN;-An order, dated 06/05/26, showed: Left lateral 5th toe wound- Clean with normal saline, apply calcium alginate, daily and PRN. Change daily and PRN;-An order date 06/05/26, showed: Right Thumb wound- Clean with normal saline, apply calcium alginate, cover with dry drsg. Review of the Vendor 1's operations manual for the LAL system, undated, showed:-Indications: Pump and mattress system, is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. It can be used in a hospital, homecare, or other healthcare environment;-Operating instructions: Determine the patient's weight and set the control knob to that weight setting on the control unit. Review of the Wound Doctor's progress note, dated 01/08/26, showed a midline sacrum wound measured 11.0 centimeters (cm) in length (L) by 9.0 cm width (W) by 2.50 cm depth (D), Stage 4 PI/PU with undermining (tunneling pocket created under the skin) from 3 o'clock to 6 o'clock (location of the tunneling). Wound noted as improved. Review of the Wound Doctors progress note, dated 02/26/26, showed:-Left lateral hip PI/PU unstageable measurements; Length was 4.0 cm by width 8.0 cm. by depth 0.10 cm, total area 32.00 cm.;-Midline sacrum stage 4 PI/PU measured L 7.0 cm. by W 10.0 cm. by 2.50 cm, total area 70.00 cm. Tunneling from 1 o'clock to 6 o'clock, 5 cm., wound status stable. Review of the Wound Doctor's progress note, dated 03/26/26, showed:-Left lateral hip PI/PU Stage 3 measurements Length was 3.0 cm by width 8.0 cm. by depth 0.10, total area 24.00 cm. subsequent - improved, no drainage;-Midline sacrum stage 4 PI/PU measured L 10.0 cm. by W 11.50 cm. by 2.00 cm area 115.00 cm. tunneling from 11 o'clock to 6 o'clock, 5 cm., wound status stable, moderate drainage. Review of a nurse's progress note, dated 03/31/26 at 8:54 A.M., will continue to cleanse sacrum with wound cleanser/normal saline, apply Vashe (wound cleansing solution) soaked gauze, wet to dry dressing daily, until wound vac (applies controlled suction to a wound to accelerate healing) arrives, daily and PRN, every day shift until wound vac in place. Review of the Wound Doctor's progress note, dated 04/09/26, showed:-Midline sacrum stage 4 PI/PU measured L 12.0 cm. by W 13.00 cm. by 2.00 cm, total area 156.00 cm. Tunneling from 11 o'clock to 6 o'clock, 5 cm., wound status worsened. Moderate drainage;-Left lateral hip PI/PU stage 3 measurements Length was 3.0 cm by width 8.0 cm. by depth 0.10, total area 24.00 cm., stable;-New wound: Right knee abrasion (scrape, non PI/PU) stage 4, measurements L 1.00 cm by W 2.00 cm by D 0.10 cm, total area 2.00 cm., worsened. Review of the Wound Doctor's progress note, dated 04/09/26, showed:-Stage 3 PI/PU, right thumb, measured L 4.0 cm by W 5.0 cm D 0.10 cm, total area 20.0 cm, reopened; -Left lateral hip PI/PU stage 3 measurements, Length was 4.0 cm by width 8.0 cm. by depth 0.10, total area 28.00 cm., stable;-New wound: Right upper back PI/PU unstageable, measurements L 1.50 cm by W 2.50 cm by D 0.10 cm, total area 3.75 cm.; -New wound: Right buttock PI/PU unstageable, L 2.00 cm by 3.50 cm by D 0.10, total area 7.0 cm;-Midline sacrum, Stage 4 PI/PU, measured L 10.0 cm. by W 11.50 cm. by 2.00 cm, total area 115.00 cm. Tunneling from 11 o'clock to 6 o'clock, 5 cm., wound status stable, moderate drainage;-Right knee PI/PU Stage 4, measurements L 1.50 cm by W 2.00 cm by D 0.10 cm, total area 3.00 cm., worsened. Review of the Wound Doctor's progress note dated 05/11/2026 at 08:11 A.M., showed:-On 01/29/26: Wound stable, still need to work on optimizing offloading;-On 02/26/26: new left hip wound, possible from resident laid on tube feeding (TF) tube;-On 03/26/26: Wounds overall stable. Will reattempt wound vac on sacrum;-On4/9/26: Wound vac seems to be working well. Patient with several new wounds today, will address with DON; -On 4/16/26: Delay in wound vac supplies, will cover with moistened Dakin's gauze right now;-On 4/30/26: For unclear reasons, a wound vac has not appeared. Today there appears to be a continued decline in overall patient status, with most wounds worsened. This likely represents a deterioration of patient status. Based on the appearance of the sacral wound, which was not debrided (removal of dead tissue from a wound) as the extent exceeds what is capable at the bedside, the wound physician recommend transfer to the Emergency department (ED) for initiation of IV antibiotics, operative surgical debridement, and further assessment for this decline in patient. Family may also want to revisit hospice care; -On 05/07/26: Pt has returned from the hospital. Wounds stable to improved. Review of the hospital discharge after visit summary (AVS) dated 05/05/26 at 03:02 P.M., showed (page 9), wound care instruction: -Right ischium (lower and back part of the hip bone), right upper back, right knee, left hip: Wash wound with soap and water. Pat dry, apply silver stat gel (used for wound healing) to wound bed and top with foam dressing. Change Mondays, Wednewdays, Fridays;-Sacrum: Wash wound with Vashe Cleanse (directions below). Lightly pack Vashe soaked wet to moist kerlix (type of gauze) into wound bed, top with ABD (highly absorbent) bandage, and secure with Medipore tape (breathable, surgical tape). Change twice daily (BID);-Left Ischium: Wash wound with Vashe cleanse. Lightly pack Vashe soaked wet to moist kerlix into wound bed and top with foam dressing. Change BID;-Reduce friction/shear- lift patient in bed with sheets or pad. Do Not Pull or Drag, Single layer flat sheet for turning/microturns if glide sheet is not available. Review of the resident's Medications/Treatment Administration Record (MAR/TAR) dated May 2026 showed:-An order date of 05/06/2026-05/08/2026, cleanse sacrum with Vashe cleanser, lightly pack Vashe soaked gauze/kerlix into wound bed, top with ABD pad and secure with medipore tape change BID at 08:00 and 04:00 P.M.;-Treatments missed three out of six opportunities; -An order dated 05/06/2026 through 05/11/2026, showed Left ischium: Wash wound with Vashe cleanser. Lightly pack Vashe soaked wet to moist kerlix into wound bed and top with foam dressing. Change BID at 08:00 A.M., and 4 P.M.;-Treatments missed two out of 21 opportunities. Review of the Wound Doctor's progress note dated 05/28/2026 at 12:54 P.M., showed:-On 5/14/26: Right buttock wound unroofed (surgically removing the top) today and extensively debrided, now a stage 3 pressure wound. Worrisome for potential progression to communicate with sacral wound. Will ask facility to evaluate nutrition status, and would recommend continued antibiotic coverage at this time;-On 5/28/26: Extensive debridement undertaken again today of right buttock wound. Culture obtained. Wound has precipitously worsened, and per staff, resident's human immunodeficiency virus (HIV) medication has been changed. His/Her current immune status is unclear, and he/she is either on or just completed prolonged antibiotic therapy. Will also check albumin (lab draw to check protein levels). Encourage family to consider hospice in the setting of our current decline. Review of the hospital discharge AVS dated 06/04/26 at 12:09 P.M., showed page 9, wound care instruction: -Left hip, right buttock and sacral wound dressings - 1/4 strength Dakin's (antiseptic wound cleanser) moist kerlix gauze placed inside the wounds, cover with ABD, secure. Change BID and PRN when soiled;-Feet, right back and knee wounds - clean with NS, dry, apply Mepilex foam (dressing that creates a moist, healing environment), change on Tuesday and Friday and PRN when soiled. Observation of the resident on 06/08/26 at 5:54 A.M., showed no green protective boots on his/her bilateral (both sides) extremities. Observation on 06/08/26 at 10:22 A.M., showed the dressing on the resident's right (R) knee, dated 6/7/26, was soiled with drainage on the back side of bandage. The dressing on the resident's left (L) iliac crest (hip bone) had pink drainage that bled through the bandage. During an interview on 06/08/26 at 10:22 A.M., LPN T said he/she could not read or find the date that the iliac crest dressing was last changed. Observation on 06/08/26 at 10:37 A.M., showed the resident lay on a folded blanket, a linen pad (absorbent pad) and a depends (brief, an adult absorbent garment). Certified Nurse Assistant (CNA) G lifted the gown and the gauze around the g-tube (a surgical site used for tube feeding/nutrients) site had the right top corner folded in on itself and stuck to the resident's gown. The LAL mattress pressure was set on 120 lbs. Observation on 06/08/26 at 10:50 A.M., showed on the resident's R knee non-PI/PU, the Wound Nurse used wound cleanser (antiseptic spray), patted the site dry, changed gloves and used Ca+ Ag, dug into the closet and then applied pink border drsg with the same gloves. For the resident's right thumb, the Wound Nurse applied CA+ Ag without (w/o) a bandage, however the site was covered with white gauze dressing. The wound bed was macerated with a pink bed and no drainage noted. The resident's left hip had a dressing with an illegible date. There was serosanguinous (combination of clear and bloody fluid) drainage at 12 o'clock to about 1' o'clock, approximately 1-inch (in) long, and the wound bed was oval in shape. The Wound Nurse used wound cleanser, packed the wound with Ca+ Ag and covered it with an Island (sterile long bandage) drsg. On the left outer lateral side below the smallest toe, the bandage was dated 6/7 and had no drainage. Between 5 o'clock and 7 o'clock there was necrotic (dead, non-viable tissue) or deep tissue injury (DTI) (bruised tissue unable to determine the underlying damage) which was discolored from the normal pigmentation of the resident. The wound was covered with Ca+ Ag and from 9 o'clock to 1 o'clock, there were small amounts of sanguineous (fresh blood) drainage. On the resident's right hip, the current bandage from 9 o'clock to 11 o'clock, showed drainage throughout the bandage. The Wound Nurse used Dakins solution and a mepilex drsg. The last wound was on his/her posterior (back) lateral right side and had a drsg dated 6/7. At the 12 o'clock area on the wound, on the outside of the dressing, there was noticeable serosanguineous drainage on oval shaped wound. The Wound Nurse and CNA G rolled the resident on a folded blanket, linen pad and brief. Staff turned the resident on his/her left side supine (back flat) and knee turned to the left side. The resident's g-tube dressing was not changed. During an interview on 06/08/26 at 10:50 A.M., the Wound Nurse said all of the resident's wounds were related to pressure, aside from the right thumb that was non-pressure. The Wound Nurse said the resident's right thumb should have bandage around the wound; however, she only uses a gauze to wrap it. Observation on 06/09/26 06:37 A.M., showed the LAL mattress was set at 120 lbs. The resident had a folded blanket, linen pad and brief under him/her. On resident's right hip, there was a bandage, covered in drainage, dated 6/8, by the Wound Nurse. Observation on 06/09/26 6:47 A.M., showed the resident lay in bed and had one green protective boot on. The other boot lay on the floor next to the window. The LAL bed set was set at 130 lbs. Observation on 06/09/26 11:58 A.M., the resident had one green protective boot on the foot and the other boot was on the floor. The resident lay on his/her right side, knees facing the wall/window, with a folded blanket, linen pad and brief directly under the resident. The resident's left lateral foot wound drsg was dated 6/9. Observation on 06/11/26 10:37 A.M., showed the resident had one green protective boot on and the other boot was on the floor. The LAL setting was set at 160 lbs. The resident lay on a folded blanket, chux pad (disposable underpad) and brief in bed. Observation on 06/12/26 8:55 A.M., showed the resident in bed with the LAL mattress set at 160 lbs. The resident's right knee had an island drsg with brownish-red drainage at the top right corner. During an interview on 06/08/26 at 2:26 P.M., CNA Q said offloading meant to reposition the resident every (q) two hours (hrs) with the following equipment that can be found in house: Wedges (a foam triangle that keeps the resident on their side), green protective boot, pillows. These were all in house, and the resident needed to have an order. CNA Q said the setting on the LAL mattress meant air went into the mattress, however, he/she did not know the appropriate setting for this particular resident. Every resident was different. An example was given of, if a resident was 200 lbs and the setting was set at 150 lbs or 350 lbs, how would you know if these settings were appropriate/inappropriate? CNA Q said he/she would need to ask the nurse. CNA Q said their common practice was to place a folded blanket, linen pad and a brief on residents. Some places allow the resident to have a brief on residents with wounds and LAL mattresses, and we follow facility policies. During an interview on 06/08/26 at 4:18 P.M., LPN C said the resident always had one wound on his/her sacrum/coccyx but somewhere between February and April of this year, he/she started to develop more. The resident used to be on a wound vac, but the resident moved, which cause the wound vac to malfunction. There were no concerns he/she knew of related to supplies from the wound vac being delayed or not available. LPN C said offloading meant to move the resident off the side that has pressure by pillows, wedges or green protective boots. LPN C was not sure of what the LAL setting should be on, but the setting makes the mattress firmer or softer. LPN C was not familiar with the current settings or what they meant. It is standard practice for a folded blanket, linen/chuck pad and brief to be under the resident. The facility protocol prefers briefs worn. If there was drainage coming through the bandage, he/she would notify the provider, which is the Wound Doctor and change the dressing as much as possible, if the bandage is soiled. During an interview on 06/11/26 at 10:37 A.M., LPN B said the resident should have bilateral boots on, especially since the left foot has pressure on it from being turned to his/her left side. During an interview on 06/08/26 at 4:38 P.M., the Wound Nurse said there was a single wound in/around January of this year, then more wounds started to develop. The wound vac started to detach from the site because the resident had liquid bowel movement (BMs) that loosened up the seal around the wound. The Wound Nurse did not recall what interventions were established or if the facility attempted a fecal matter system (FMS) (a temporary tube in the rectum to catch liquid stool) and medications to harden the BMs. The second time the facility attempted to use a wound vac was in April. The Wound Nurse was not aware of delays in supplies for the wound vac. The second time the wound vac was used, the original delivery did not come with enough supplies to maintain the wound changes because the wound vac did not have a good enough seal. At one point, the wounds had improved then rapidly deteriorated. After the second failure of the wound vac, the new orders were to use Dakin's solution. The Wound Nurse said offloading meant keeping the resident off the pressure areas - wedges, pillows, protective boots, hand-splints, washcloth for the hand. An LAL mattress helps with firmness. We had to reeducate CNAs to keep it at the right setting, because it helps regulate pressure on those areas, and settings are based on the resident's weight. It is not common practice to use the fold blanket, linen/chuck or brief. The Wound Nurse thought staff should use just a sheet and chuck or brief. A brief is a counterindication when you have a wound on the sacrum/coccyx because human waste breaks the skin down more and can infect the wound. When a resident returns from the hospital, the nurse contacts the MD and reads the orders, then the MD will enter the order if the MD agrees or continues with same tx before the hospital. The Wound Nurse reviewed the patient's discharged hospital records from 05/31/26-06/04/26 on page 9 and said these are definitely orders. The nurse who accepted the resident should review the paperwork to put the orders in, then wound nurse or DON would look over the paperwork. During an interview on 06/11/26 at 11:27 A.M., the Wound Doctor said offloading meant to elevate the patient to a 30-degree side-lying position with right/left side rotation, without continuous pressure where wounds are located. He would expect pillows, wedges and boot protectors to be used. He would expect a boot on the left foot of the resident if laying on the left side. setting is based on weight. The Wound Doctor was not sure how LAL orders work, but the setting is based on the resident's weight. He normally does not add a numeric number for the setting, however, he could modify that order. The LAL purpose was to alternate the pressure when lying down, evenly when static position. The Wound Doctor said he expected a sheet and chuck and brief to be on the bed to eliminate pressure on the resident. He was not sure if there was ordering and supply issues in April, and he was not sure why the wound fact failed. They could not get a great seal. Wound Doctor would not expect staff to reach out to the medical doctor/house doctor for new interventions, but it made reasonable sense new interventions could be in place. Wound Doctor was not made aware of any new recommendations from the hospital related to the resident's stay between 05/31/26 and 06/04/2026. Wound Doctor would expect staff to contact him within 48 hours to discuss new orders. He expected wound dressings to be changed when the dressing was soiled, or when the drainage leaked through the dressing. Even if the dressing was just changed, the purpose of the PRN order was to keep wound dry and clean. During an interview on 06/12/26 at 02:01 P.M., the DON said she would expect nurses to put in a note related to the wounds anytime a change is noted. The DON expected nurses to contact the wound doctor about any recommendations and execute those orders. It is expected that staff turn the residents frequently. DON said offloading meant to turn frequently and to keep the resident from continuous pressure, which can be done by turning to side and back with pillows, wedges, and boots for heel protection. She would expect staff to check LAL for the correct weight setting; settings should always reflect the current weight of the resident. She expected the current weight to match the setting. The Wound Nurse educates the staff. Residents should not have a sheet; there should only be a pad, although it is based on patient preference. The resident can have a brief on. The blanket is used as a draw sheet because you need some leverage to pull the patient up or for turns. The resident had a higher risk for breakdown. If a resident lays on a medical device like his/her TF tube, it can cause skin break down, and staff should monitor for that. 2.Review of Resident #5's medical record, showed:-re-admitted [DATE];-Diagnoses included dementia, high blood pressure, dysphagia (difficulty swallowing), diabetes and wounds. Review of the ePOS, showed:-An order, dated: 04/07/26: May use low air loss mattress, check settings every shift to ensure settings are within therapeutic range. Review of the physician wound visit notes, dated 4/9/26, showed:-A visit note, dated 04/09/26: -Wound 3: Bilateral midline sacrum; -Severity: Stage III; -Status: Worsening; -Size: 2.5 cm x 1.2 cm x 0.1 cm; -Wound base: 50% granulation and 50% dermis; -Periwound (area around the wound): Intact; -Exudate (drainage): Moderate; -Plan: Clean with NS, apply Calcium Alginate and bordered foam dressing. Change daily and PRN for dislodgement, saturation or soiling;-A visit note, dated 04/16/26: -Wound 3: Bilateral midline sacrum; -Severity: Stage III; -Status: Stable; -Size: 2.5 cm x 1.2 cm x 0.1 cm; -Wound base: 50% granulation and 50% dermis; -Periwound: Intact; -Exudate: Moderate; -Plan: Clean with NS, apply calcium alginate and bordered foam dressing, change daily and PRN if dislodged, saturated or soiled;-A visit note, dated 04/23/26: - Wound 3: Bilateral midline sacrum; -Severity: Stage III; -Status: Worsening; -Size: 5 cm x 2.5 cm x 0.1 cm; -Wound base: 50% granulation (healing tissue) and 50% slough (dead tissue); -Periwound: intact; -Exudate: Moderate -Procedure: debridement, new measurements: 5.0 cm x 2.5 cm x 0.2 cm; -Plan: clean NS, apply calcium alginate and bordered foam dressing, change daily and PRN if dislodged, saturated or soiled;-A wound visit note, dated 04/23/26: -Wound 3: bilateral midline sacrum; -Severity: Stage III; -Status: worsening; -Size: 5.0 cm x 2.5 cm x 0.1 cm; -Wound base: 50% granulation and 50% slough; -Periwound: Intact; -Exudate: Moderate; -Treatment: Clean with NS, apply calcium alginate and bordered foam dressing, change daily . Review of the quarterly MDS, dated [DATE], showed:-Unable to make needs and wants known;-Required full staff assistance for care and mobility;-Incontinent of bowel and bladder;-At risk to develop pressure injury;-Had two stage III pressure ulcers;-Pressure reducing device for chair and bed;-Received nutrition and hydration care for wounds;-Received ointments and medications other than to the feet. Review of the interdisciplinary team (IDT) wound review note, dated 04/29/26, showed:-Reviewed by the IDT for wound care management. Wounds noted to left hip and bilateral midline sacrum. The resident is total assist with all care, transfers and required full staff support for positioning and care. The resident speaks minimally and limited in voicing needs. The resident is seen by the wound care physician. Review of the progress note, showed a nurse's note, dated 05/04/26 at 9:42 A.M.: The resident's wounds noted to worsen related to comorbidities. He/She experienced malnutrition and preferred to lie on his/her left side. Review of the IDT nutritional progress note, dated 05/07/26, showed the resident received a regular diet with bite sized pieces. Supplements included house shake supplements, and vitamins. Staff provide feeding assistance and he/she eats in the dining room. The resident consumes 50-75 percent (%) of meals. Registered Dietician (RD) agreed interventions in place were appropriate. Review of the ePOS, showed:-An order, dated 05/07/26: House supplement four times a day for weight loss. -Review of the wound visit notes, showed:-On 05/07/26: -Prior note from 04/30/26: Continued deterioration, stressed the need to offload, but this is difficult due to patient inability to comply; -Wound 3: Bilateral midline sacrum; -Severity: Stage III; -Status: Stable; -Size: 5.0 cm x 2.7 cm x 0.1 cm; -Wound base: 85% dermis and 15% slough; -Periwound: Intact; -Exudate: Moderate; -Procedure: Wound debridement and post measurement: 5 cm x 2.7 cm x 0.2 cm. -Treatment: Clean with NS, apply calcium alginate and bordered foam dressing, change daily and PRN if dressing becomes soiled, dislodged or saturated;-On 05/14/26: -Wound 3: Bilateral midline sacrum; -Severity: Stage III; -Status: Stable; -Size: 5 cm x 2.7 cm x 0.1 cm; -Wound base: 15% slough, 85% dermis; -Periwound: Intact; -Exudate: Moderate; -Procedure: Wound debridement and following wound measurement: 5 cm x 2.7 cm x 0.2 cm; -Treatment: Clean with NS, apply calcium alginate and bordered foam dressing, change daily and PRN if dressing becomes soiled, dislodged or saturated. Review of the progress notes, showed:-On 05/15/26 at 1:35 P.M., an IDT wound note: Reviewed for wound care management. The resident noted to have wounds to the left hip and bilateral midline sacrum. The resident is total assist with all care, transfers and required extensive staff assistance for positioning and care. Wounds are being monitored and treated per physician orders, wound care round weekly with the wound care physician, RD and wound care protocol. Sacral wound progressing. Interventions included low air loss mattress, skin assessments, dietary supplements to aide with wound healing, and wound dressings as ordered. Nursing to monitor for signs and symptoms of infection, delayed healing and overall decline. Review of the ePOS, showed:-An order, dated 05/19/26: clean left hip with wound cleanser (WC), cover with calcium alginate and dry dressing. Change daily until healed;-An order, dated 05/19/26: clean sacrum with WC, apply xerofoam (gauze dressing used to keep the wound moist) and cover with a dry dressing. Change daily until healed. Review of the Wound Physician notes, showed:-On 5/28/26: -Wound 3: Bilateral midline sacrum; -Severity: Stage III; -Status: Stable; -Size: 5 cm x 2.8 cm x 0.1 cm; -Wound base: 80% granulation, 20% slough; -Periwound: Intact; -Exudate: Moderate; -Procedure: Wound debridement and following wound measurement: 5 cm x 2.8 cm x 0.2 cm; -Treatment: Clean with NS, apply Triad cream (zinc oxide-based, moisture-absorbing paste primarily used for managing wounds with light to moderate drainage) and leave open to air. Change daily and PRN if dressing becomes soiled, dislodged or saturated;-On 06/02/26: - Wound 3: Bilateral midline sacrum; -Severity: Stage III; -Status: Stable; -Size: 5 cm x 3 cm x 0.1 cm; -Wound base: 80% granulation, 20% slough; -Periwound: Intact; -Exudate: Moderate; -Procedure: Wound debridement and following wound measurement: 5 cm x 2.8 cm x 0.2 cm; -Treatment: clean with NS, apply Triad and leave open to air. Change daily and PRN if dressing becomes soiled, dislodged or saturated. Review of the care plan, revised 06/08/26, showed:-Focus: Wound care needs related to pressure injuries to the left hip and sacrum;-Goal: Wounds will show signs of healing;-Interventions: Staff identify causative factors and eliminate, resolve when possible, inform staff of causative factors and measures to prevent skin breakdown, low air loss mattress and monitor/document the location, size and treatment of pressure injuries. Report abnormalities, failure to heal and signs of infection to the physician. Observation and interview on 06/08/26 at 6:09 A.M., during a skin assessment, showed the resident's left hip with a bordered, undated treatment. CNA V rolled the resident onto his/her left side and exposed the coccyx. The resident's brief noted to have yellow with light green drainage from the sacral wound. The wound was uncovered and approximately 3cm in area. There was necrotic tissue in 75% of the wound bed, and the tissue around the wound was red and inflamed. CNA V said he/she changed the resident once during the night shift and the sacral wound was uncovered. The resident is very thin. The resident has wounds to his/her left hip and his/her sacrum, and both should be covered. Observation and interview on 06/09

Based on observation, interview, and record review, the facility failed to provide a homelike environment by not providing an adequate supply of linens for resident care. In addition, the first-floor dining room had areas with baseboards missing, creating holes in the wall. The census was 74.Review of the facility's Residents Rights policy last revised August 2020, showed, the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life. 1. Observation on 6/8/26 at 5:30 A.M., of the second-floor linen room showed two blankets and no other linen. The linen cart had one fitted bed sheet and two towels. Observation on 6/12/26 at 7:28 A.M., showed:-The first-floor linen room had 7 washcloths, 4 bath towels and no bed linens;-The first-floor linen cart on the had no washcloths, towels or bed linens;-The second-floor linen room had no washcloths, 4 bath towels, and no bed linens;-The second-floor linen cart had two fitted bed sheets. During an interview on 6/11/26 at 1:30 P.M., Laundry Aide (LA) J said he/she washes the laundry as they come down the laundry chute and then restock the linen closets. There is no extra linen in the laundry room. Everything is sent to the floor when it is washed. The staff will sometimes come down and look for linens, but it is still in the washer or dryer. Observation at this time showed the laundry room had linens in the dryer and no linens on any shelving storage units or tables in the laundry room. During an interview on 6/8/26 at 5:35 A.M., Certified Nursing Assistant (CNA) I said there are never enough linen to provide care to the residents. CNA I cannot provide proper personal care when there are no towels or washcloths. The resident bed sheets do not get changed due to the lack of bed linens. The lack of linens has been going on for several months. During an interview on 6/8/26 at 6:05 A.M., CNA H said on a Monday after the weekend there were no supplies which included incontinent pads for the beds. CNA H had to lay down towels on the bed instead of incontinent pads. CNA H could not perform personal care the correct way without the proper linens. CNA H only had one towel available for personal care. During an interview on 6/11/26 at 1:55 P.M., the Housekeeping Supervisor said she orders linens but believes that staff throw the linens away. There is no extra supply of linens in the laundry room for the staff to take if they run out of linen on the hall. During an interview on 6/12/26 at 2:06 P.M., the Administrator said he approves any linens that are ordered and was not aware that staff were having issues with not having enough linen to provide care. He would expect staff to have enough lines to provide care to the residents. 2. Observation of the first-floor main dining room, on all the days of survey from 6/8/26 through 6/12/26, showed the baseboard missing from various sections of the wall. Holes in the wall visible in the areas with missing baseboards. During an interview on 6/11/26 at 2:08 P.M., Licensed Practical Nurse (LPN) C said the contractors removed the baseboards a few weeks ago. The facility is in different stages of updating. Several residents eat in the dining room for meals. During an interview on 6/12/26 at 8:35 A.M., Resident #40 said workers removed the dining room baseboards a few weeks ago. The walls appeared rough and the holes behind the baseboards appeared dirty. He/She hoped the dining room would look better soon. He/She ate all meals in the dining room. During an interview on 6/12/26 at 2:05 P.M., the Administrator said the first-floor main dining room baseboards were removed a week ago. He did not know when the baseboards would be replaced. The dining room did not appear homelike, and the facility was in various stages of remodeling and repair. He communicates weekly with corporate management regarding the facility remodeling. 2717445

Based on interview and record review, the facility failed to ensure a resident (Resident #12) received adequate supervision and interventions to ensure his/her safety while on Leave of Absence (LOA). Resident #12 admitted to consuming alcohol while on LOA and returned to the facility twice, with injuries from reported altercations while on LOA. The facility did not develop interventions and revise the resident's care plan regarding the frequent LOAs, the medications that were not received while on LOA, and the safety concerns for the resident while he/she was on LOA. The sample was 11. The census was 76.Review of the facility's Out on Pass policy, revised August 2020, showed:-It was the policy of the facility to meet resident's physical and psychosocial needs to go out on pass. The facility will make reasonable efforts to ensure the resident's safety and uphold residents rights;-When a resident requests to go out on pass, the interdisciplinary team (IDT) will assess the resident's ability to participate in activities outside the facility, taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications without supervision;-The IDT assessment will be documented in the IDT notes;-When a resident requests to go out on pass without supervision, nursing staff will notify the attending physician and psychiatrist (if applicable) of the need to review the resident's status prior to allowing the resident to leave the facility;- If the resident's use of the out on pass order conflicts with the resident's plan of care or jeopardizes the resident's safety, the nursing staff will notify the attending physician and psychiatrist (if applicable) of the need to review the resident's status prior to allowing the resident to leave the facility;-The order for a pass out may be discontinued by the attending physician or psychiatrist (if applicable) at any time;-Prior to the resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status and ensure:-The resident has a supply of medications for the length of the pass per attending physician order;-The resident and responsible person (if applicable) were instructed of any special needs of the resident during the pass as applicable (e.g. special diet, medications);-A licensed nurse will document the medication provided to the resident for use while out on pass (if applicable), the time the resident left the facility, and the name of the accompanying responsible person;-When the resident returns to the facility, a licensed nurse will re-assess the resident to determine the resident's condition and any medication returned after going out on pass, if applicable;-The resident/responsible person will verbally notify a licensed nurse prior to going out on pass and will sign out and back in on the Resident Out On Pass Log;-The resident/responsible person will return to the facility at the agreed-upon time or notify the facility of any unexpected delay in their return.Review of Resident #12's progress notes, dated 01/07/26 at 7:05 A.M., showed the resident had a scabbed abrasion to his/her right arm. He/She said he/she sustained the abrasion when he/she got into an altercation while on LOA a few days ago. The physician and Director of Nursing (DON) were notified.Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/26/26, showed:-Cognitively intact;-No behaviors exhibited;-Diagnoses included epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures), major depressive disorder severe with psychotic symptoms, alcoholic cirrhosis of liver with ascites (end-stage liver disease caused by chronic alcohol misuse, where severe scarring (cirrhosis) disrupts liver function, causing high pressure in the liver's blood vessels and fluid accumulation in the abdomen), hepatic encephalopathy (a reversible decline in brain function caused by severe liver disease such as cirrhosis), secondary esophageal varices without bleeding (dilated, high-risk veins in the lower esophagus), esophageal varices with bleeding (abnormally swollen, thin-walled veins in the lower esophagus that have ruptured and are bleeding, typically due to high pressure from liver cirrhosis. This is a medical emergency characterized by vomiting blood, black stools, and potential shock).Review of the resident's physician's orders (PO), dated February 2026, showed:-Anti-anxiety medication used. Observe resident closely for significant behaviors every shift;-Monitor for seizures every shift;-Abilify oral tablet five milligrams (mg). Give one tablet by mouth once daily at 8:00 A.M., related to major depressive disorder;-Cyanocobalamin (used to treat or prevent deficiency, which can cause anemia, nerve damage, and fatigue. It is essential for producing red blood cells, and nervous system function) oral tablet 1000 micrograms (mcg). Give one tablet by mouth, once daily at 8:00 A.M., for supplement;-Folic acid (vital for producing red blood cells) oral tablet one mg. Give one tablet by mouth, once daily at 8:00 A.M. for vitamin;-Magnesium oxide supplement (used as a dietary supplement, antacid to relieve heartburn, and a laxative for constipation) oral tablet 400 (240 mg). Give one tablet by mouth, once daily at 8:00 A.M., for low magnesium levels;-Multivitamin oral tablet. Give one tablet by mouth, once daily at 8:00 A.M. for supplement;-Spironolactone (used to treat high blood pressure, fluid retention (edema), and heart failure) oral tablet 50 mg. Give three oral tablets by mouth, once daily at 8:00 A.M., for diuretic;-Thiamine (maintains nervous system health, and supports heart function) oral tablet 100 mg. Give one tablet by mouth, once daily at 8:00 A.M. for vitamin supplement;-Vitamin D3 (essential for bone health, immune function, and calcium absorption) oral capsule 125 mcg (5000 units). Give one capsule by mouth, once daily at 9:00 A.M. for vitamin supplement;-Levetiracetam (anti-epileptic medication treats various seizure types) oral tablet 500 mg. Give one tablet by mouth twice daily, at 8:00 A.M. and 6:00 P.M. for seizures;-Omeprazole (used to treat acid reflux) oral capsule 40 mg. Give one capsule by mouth twice daily at 8:00 A.M. and 4:00 P.M. for acid reflux;-Lactulose (used to treat chronic constipation and to reduce blood ammonia levels in liver disease patients) oral solution 10 grams (gm)/15 milliliters (ml). Give 30 ml by mouth three times daily at 8:00 A.M., 12:00 P.M. and 4:00 P.M.;-Midodrine (used to treat sudden blood pressure drop) oral tablet five mg. Give three tablets by mouth before meals at 7:00 A.M., 12:00 P.M., and 5:00 P.M. for decreased blood pressure.Review of the resident's care plan in use during the survey, showed:-Focus: The resident was at increased risk for falls or injury due to uncontrolled seizure disorder (initiated 04/29/25);-Interventions: Staff encouraged the resident to take his/her medications as prescribed by his/her physician and encouraged the resident to complete the full course of medication unless otherwise contraindicated (initiated: 07/28/2025).Review of the resident's progress notes, showed:-On 02/03/26 at 9:46 A.M. and 7:32 P.M., the resident was on LOA from facility. No medications were administered this date;-On 02/06/26 at 6:04 A.M., the resident was on LOA to his/her cousin's house. At 3:47 P.M. and 6:06 P.M., the resident was on LOA from the facility. No medications were administered on this date;-On 02/07/26 at 10:43 A.M., the resident was on a LOA from the facility. No medications were administered on this date;-On 02/08/26 at 7:00 A.M., 5:50 P.M., and 6:21 P.M., the resident was on LOA from the facility. No medications were administered on this date;-On 02/10/26 at 7:33 A.M. and 6:57 P.M., the resident was on LOA from the facility. The resident was away from the facility during medication administration;-On 02/11/26 at 2:16 P.M. and 6:21 P.M, the resident was on LOA from the facility. No medications were administered on this date;-On 02/12/26 at 7:51 A.M., 3:15 P.M., and 6:52 P.M., the resident was on LOA from the facility. No medications were administered on this date;-On 02/16/26 at 8:00 A.M., the resident was on a LOA from the facility. No morning and afternoon medications were administered;-On 02/17/26 at 8:19 A.M. and 9:26 A.M., the resident was on LOA. He/She did not take his/her morning medications. The medications were found by housekeeping in his/her trash can. The physician was notified. No afternoon medications were administered, and evening medications were held because the resident was on LOA;-On 02/20/26 at 8:25 A.M., the night shift nurse said the resident left LOA in stable condition. At 8:32 A.M., psychiatric consult with psychiatric doctor once daily for agitation. Discontinue after completion. The resident was LOA from facility. No morning or afternoon medications administered;-On 02/21/26 at 10:21 A.M., the resident was on a LOA from the facility. No morning or afternoon medications were administered.Review of the resident's February medication administration (MAR) showed the resident was in the hospital on [DATE] during morning, afternoon and evening medication passes.Review of the resident's progress notes, showed:-On 02/22/26 at 6:03 P.M., the resident called the Administrator and said he/she was staying on LOA with his/her cousin;-On 02/23/26 at 11:27 P.M., the resident arrived at the facility. No morning, afternoon or evening medications were administered;-On 02/24/26 at 12:24 A.M., the resident returned to the facility. At 6:44 A.M., the resident was on a LOA from the facility. At 7:58 A.M., the resident was hospitalized . At 9:10 A.M., the social worker documented he/she completed a social determinants of health assessment with the resident. At 10:57 A.M., the Director of Nursing (DON) noted she called the resident's friend. The resident said he/she was at his/her friend's house. He/She did not sign out when he/she left the facility in the early morning. The resident was reminded to sign out when he/she left the facility. The resident said he/she would return between 4:00 P.M. and 5:00 P.M. The resident was away from the facility during morning and afternoon medication passes.-On 02/25/26 at 7:27 A.M., the resident was on a LOA from the facility. He/She was away from the facility during morning and afternoon medication passes;-On 02/26/26 at 6:10 A.M., the resident was on a LOA from the facility. At 8:38 A.M. the resident was on LOA. At 12:20 P.M. the physician was notified resident was on a LOA without medications. No new orders were given. At 7:00 P.M., the resident remained on LOA. The nurse did not complete a skilled note due to the resident being on LOA from 7:00 A.M. to 7:00 P.M. The resident continued to be on LOA without medications. At 10:52 P.M., the resident returned from LOA;-On 02/27/26 at 7:16 A.M., the resident was on LOA from the facility. The resident was away from the facility during morning and afternoon medication passes;-On 02/28/26 at 9:54 A.M., the resident was on LOA from the facility. No medications were administered;-On 03/01/26 at 7:46 A.M. and 9:33 A.M., the resident was on LOA from the facility. The resident's morning and afternoon medications were not administered;-On 03/02/26 at 5:27 P.M., the resident returned to the facility. The resident was away from the building during morning and afternoon medication passes;-On 03/03/26 at 6:55 P.M., the resident returned to the facility. The resident was away from the facility during morning, afternoon and evening medication passes.-On 03/04/26 at 7:30 P.M., the resident was on LOA from the facility. At 11:00 P.M., the paramedics dropped the resident off at the facility after picking him/her up at an unknown location. RN G said the paramedics dropped the resident off at the door and did not enter the facility. The staff did not feel the need to investigate. The resident's speech was slurred. He/She had poor coordination, eyes were unfocused, face was flushed, and he/she was loud. Staff assisted the resident into a wheelchair and transported him/her to his/her room. He/She was assisted to bed by two staff members. The nurse noticed a large amount of blood on the resident's pillow. The nurse assessed the resident. He/She had a large hematoma on the back of his/her head. The gash was 1 centimeter (cm) by 1 cm. Pressure was applied to the area. He/She had bruising on his/her body and scratches on his/he back. The nurse called 911. The resident said he/she was beaten with a bat while helping a woman. The resident was obnoxious. The paramedics transported the resident to the emergency room (ER). The physician, DON and resident's family were notified;-On 03/05/26 at 1:46 P.M., the resident returned from the hospital with a diagnoses of a laceration to the scalp. He/She had 13 dissolvable stitches to the back of his/her head. He/She had bruising on the front of both knees, left and right arms, bridge of nose and left eye. The physician was notified of the resident's return.Review of the resident's hospital Discharge summary, dated [DATE], showed:-The resident arrived at the ER at 12:27 A.M.;-The resident said he/she got into an altercation with an unknown male. The male hit him/her in the head twice with a bat. The resident's speech was slurred, and he/she admitted to drinking alcohol. He/She had abrasions, a nose bleed, and a contusion to his/her head. He/She complained of left shoulder pain. The laceration was triangular shaped and measured 6 cm by 4 cm by 3 cm;-discharged back to the facility on [DATE].Review of the resident's progress notes, showed:-On 03/06/26 at 8:20 A.M., the nurse observed the resident at the elevator. The resident declined vital signs. The nurse asked the resident if he/she had signed out. He/She said yes. The nurse said the resident did not sign out. He/She left the facility and did not sign out. The resident was away from the building during morning, afternoon and evening medication passes;-On 03/07/26 at 12:38 P.M., the resident returned from LOA. The resident was away from the facility during morning and afternoon medication passes. At 2:20 P.M., the nurse attempted to assess the resident's stitches. The nurse could not determine the number of stitches. The resident's hair was dirty. He/She refused a shower. His/Her upper/lower arms and legs had faded bruises. He/She had small scabs on his/he lower arm and heel of foot. He/She had faded bruises under his/her left eye. The resident said he/she had a fight four days ago;-On 03/08/26 at 9:59 A.M., the resident remained on behavior observation (It is unknown when the behavior observation was started and how long it was supposed to last). At 5:23 P.M., the resident told the nurse he/she was cold and had the shakes. He/She said there was blood in his/her vomit and mucus when he/she blew his/her nose. He/She said he/she vomited four times. The physician was notified. The physician gave a new order for Ativan (used for the short-term treatment of anxiety disorders) 0.5 mg every eight hours as needed for seven days and Zofran (used to prevent nausea and vomiting) for seven days and a complete blood count (CBC) on 03/09/26.Review of the resident's labs, dated 03/10/26,showed:-Collected on 03/10/2026 2:08 A.M.;-Received on 03/10/2026 7:07 P.M.;-Reported on 03/10/2026 11:35 P.M.; Critical results:-Red blood cells (RBC) 2.95. Normal range was 4.40-5.80. Low RBC (Anemia) causes included iron/vitamin deficiencies, chronic disease, bone marrow issues, or bleeding;-Hemoglobin (HGB) 9.4. Normal range was 1.8-17.2. Low HGB causes included iron deficiency, blood loss, chronic diseases, or bone marrow issues;-Hematocrit (HCT) 28. Normal range was 41-50. Low HCT indicated an insufficient amount of red blood cells to transport oxygen, leading to fatigue and weakness; Red Cell Distribution Width (RDW) 17.3. Normal range was 11.5-14.0. High RDW indicated early-stage nutrient deficiency, liver disease, or anemia of chronic disease;-Platelet count (PLT) 60. Normal range was 130-400. Low PLT caused bruising, nosebleeds, and fatigue;-Lymphocyte percentage (LY%) (measured percentage of white blood cells) 16.1. Normal range was 20-55. Low LY% could result from infections, severe stress and malnutrition;Lymphocyte blood test ([NAME]) (evaluated immune system function) 0.6. Normal range was 1.0-4.8. Low [NAME] result meant the body had a reduced ability to fight infection;Monocyte percentage (MO%) (attacks infections, removes dead cells and fights inflammation) 22.6. Normal range was 2.5-10. High MO% indicated chronic infections, autoimmune diseases or blood disorders;Absolute monocyte count (MO#) 0.9. Normal range was 0.0-0.8. Elevated MO# results indicated infection or inflammation.Review of the resident's medical record showed no documentation the Physician or Nurse discussed the lab results with the resident. No new orders were given.Review of the resident's progress notes, showed:-On 03/10/26 at 7:55 A.M., the resident was on LOA;-On 03/11/26 at 9:22 A.M., the resident was on LOA;-On 03/12/26 at 9:08 A.M., the resident was on LOA. At 5:32 P.M., the resident was in his/her room. At 5:47 P.M., the resident was on LOA.Review of the resident's hospital Discharge summary, dated [DATE], showed:-admitted [DATE] at 8:12 P.M. while the resident was on a LOA;-Chief complaint: [NAME] (the passage of black, tarry, foul-smelling stools, usually indicating bleeding in the upper gastrointestinal (GI) tract) and hematemesis (vomiting blood or material resembling coffee grounds, indicating upper GI bleeding);-The resident was ill-appearing. His/Her eyes and skin were jaundiced (yellow). His/Her heart beat was abnormally fast. His/Her stomach was distended (swollen, expanded, or stretched outward, often due to internal pressure). Edema was present in his/her lower legs;-The resident said he/she woke up, drenched in sweat and had difficulty breathing. He/She had a wet cough with white mucus. He/She denied chills. He/She said the foul stools started on 03/05/26 and was intermittent. A couple of days ago, he/she sneezed out huge blood clots. Then he/she vomited a couple of times. He/She was dizzy upon standing. This was a new symptom. He/She described his/her stools as motor oil. He/She feared he/she was bleeding again. He/She continued to drink alcohol. He/She did not plan to stop drinking alcohol. He/She drank alcohol 30 minutes before he/she arrived at the hospital. He/She said he/she took 32 medications at home. He/She could not recall the names of the medications. He/She said he/she took the medications religiously. It was unclear what medications the resident was taking. He/She said the medications were prescribed through the hospital.Hospital pharmacy reports showed he/she had not picked up meds since 02/2025;-discharged back to facility on 03/13/26.Review of the resident's progress notes, showed:-On 03/13/26 at 3:35 A.M., the resident was on a LOA from the facility. At 11:55 P.M., the resident arrived at the facility from the hospital, on a stretcher with two paramedics. The resident was assessed. No bleeding was noted. Vitals were within normal limits. The physician was notified of resident's return and medication changes;-On 03/14/26 at 6:22 P.M., the resident remained in facility throughout the day. Resident ate 100 percent of meals;-On 03/15/26 at 6:00 A.M., the resident was in the facility all day. No bleeding noted.Review of the resident's care plan in use during the survey, showed:-No documentation of the resident's LOA from the facility every day, not taking medications, and what staff were supposed to do;-No documentation of the resident being assaulted while on LOA and what staff were supposed to do when he/she returned to the facility with injuries.During an interview on 03/16/26 at 10:52 A.M., the resident said he/she threw up blood and was sent to the hospital. He/She thought the vomiting was due to withdrawals from alcohol. The hospital put a thing down his/her throat. They snatched his/her appendix. He/She hustled with his/her cousin on LOA. His/Her last drink was two weeks ago. The hospital told him/her that he/she was drinking. The hospital tested his/her blood. He/She did not take his/her medications before going on LOA. He/She attended alcoholics anonymous (AA) meeting in the past. He/She was supposed to start AA meetings in April. If it was not cold outside, he/she would not have been in the building today.During an interview on 03/16/26 at 12:21 P.M., Licensed Vocational Nurse (LVN) D said the resident was on LOA frequently. LVN D did not know where the resident was when he/she left the facility. He/She wore a work jump suit. He/She said he/she did odd jobs.During an interview on 03/20/26 at 8:52 A.M., Registered Nurse (RN) G said on 03/08/26 paramedics dropped the resident off at the facility. The paramedics did not come inside. The resident was intoxicated. He/She could not stand up. Staff put him/her in a wheelchair. His/Her clothes were soaked. He/She was belligerent. He/She was always belligerent when drunk. RN G propelled the resident to his/her room. An unknown male aide helped RN G transfer the resident to his/her bed. RN G noticed blood on the resident's pillow. RN G assessed the resident. He/She had a hematoma on the back of his/her head. RN G did not see the blood before the resident laid down. The resident said he/she was hit in the head with a bat on LOA. He/She had bruising all over his/her body. It looked like he/she fell. RN G called 911. RN G told the operator he/she did not know which paramedics dropped the resident off. The paramedics arrived and said they dropped the resident off. The paramedics said they did not notice the injury when theydropped him/her off at the facility. The resident often returned to the facility intoxicated. He/She was on LOA every day. He/She did not receive his/her medications. If he/she took the medications with him/her, it would have been documented. RN G was not sure if the resident worked. He/She did not tell staff where he/she was going. He/She did not let people in his/her business. Staff were not signing residents back in. He/She signed him/herself back in. Staff were in-serviced on the out-pass policy on 03/15/26 or 03/16/26. Now staff are supposed to sign residents back in. Staff were supposed to assess residents before and after LOA. The resident was confused when he/she was intoxicated and alert when sober. RN G believed the resident was safe to go out on LOA. During an interview on 03/16/26 at 2:26 P.M., the Social Worker said the resident left on LOA and returned intoxicated. When the resident returned to the facility injured, she encouraged him/her not to go out as often. It did not go well. The resident said he/she had a job. She was not sure if it was true.During an interview on 03/16/26 at 3:17 P.M., the Administrator and DON said they did not know where the resident went on LOA. He/She said he/she went to his/her cousin's house. The DON spoke to the resident's cousin. The resident was confused most of the time. He/She had alcohol dementia. Regarding the incident on 03/04/26, the nurse said the resident was dropped off by paramedics. The resident said he/she had an altercation. We took his/her word for what happened. An investigation was not needed. The resident was sent to the hospital. Sometimes the resident received medications and sometimes he/she did not. Not taking medication could affect his/her health negatively. They could not stop the resident from leaving the facility. He/She had rights. If you tell him/her he/she could not leave, he/she still left.During an interview on 03/16/26 at 11:06 A.M., the physician said the resident said he/she worked and helped people. The physician was aware the resident was not taking his/her medication. The physician did not know what to do with the resident. The resident was very non-compliant. The facility was in a hard position.2798654

Based on observation, interview and record review, the facility failed to provide necessary behavioral health care services for four residents' psychosocial well-being when staff did not address the resident's behaviors, which included repeatedly violating the Drug and Alcohol Abuse, Out on Pass, Visiting and Contraband policies and demonstrating physical and verbal aggression toward other residents and staff (Residents #4, #1, #7 and #5). The sample was 11. The census was 80. Review of the facility's behavior management policy, revised June 2020, showed:-Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. To ensure facility staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions before and after the resident begins taking psychotherapeutic medications. The facility is responsible for providing behavioral health care and services which create an environment to promote emotional and psychosocial well-being, meet each resident's needs and include individualized approaches to care;-Upon observing the adverse behavioral symptom, staff will do the following as indicated: -Ensure the safety of the resident as well as all other residents; -Document the incident on the 24-hour report.-The Charge Nurse will assign a staff member(s) to monitor/shadow the resident as needed;-Such monitoring is for the protection of the resident as well as all others, and is not meant to restrict their movement or mobility;-Nursing Staff will continue to monitor the resident's behavior to determine what event(s), if any, precipitated the behavior and document the following information as indicated:-Date and time of behavior;-Location of resident when the behavior occurred;-Description of the behavior (e.g., what the resident said or did and if the behavior intensified);-Non-verbal cues;-What seemed to cause the behavior; and -Any interventions used and their effect.-In assessing the resident for potential causal factors, licensed nursing staff will consider the following factors and document their findings in the medical record:-Physical conditions (e.g., pain or discomfort, hunger or thirst, fatigue, toileting needs, incontinence);-Environmental conditions;-Psychosocial or emotional stressors (e.g., change in resident's customary routine, loneliness, frustration, fear of the unknown, possible abuse by staff or other residents, incompatibility with roommate, inability to communicate needs, lack of support system, loss of control due to changes in physical condition);-Medical conditions that require treatment; -Mental health conditions, which may contribute to resident's behavior;-It is also important for the facility to use an interdisciplinary team (IDT) approach which includes the resident, their family, or resident representative. Review of the facility's Out on Pass policy, revised August 2020, showed:-It is the policy of the facility to meet resident's physical and psychosocial needs to go out on pass. The facility will make reasonable efforts to ensure the resident's safety and uphold residents rights;-When a resident requests to go out on pass, the IDT will assess the resident's ability to participate in activities outside the facility, taking into consideration the resident's decision-making capacity, physical disabilities, and ability to take medications without supervision;-The IDT assessment will be documented in the IDT notes;-When a resident requests to go out on pass without supervision, nursing staff will notify the attending physician and psychiatrist (if applicable) of the need to review the resident's status prior to allowing the resident to leave the facility;- If the resident's use of the out on pass order conflicts with the resident's plan of care or jeopardizes the resident's safety, the nursing staff will notify the attending physician and psychiatrist (if applicable) of the need to review the resident's status prior to allowing the resident to leave the facility;-The order for a pass out may be discontinued by the attending physician or psychiatrist (if applicable) at any time;-Prior to the resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status and ensure:-The resident has a supply of medications for the length of the pass per attending physician order;-The resident and responsible person (if applicable) were instructed of any special needs of the resident during the pass as applicable (e.g. special diet, medications); -A licensed nurse will document the medication provided to the resident for use while out on pass (if applicable), the time the resident left the facility, and the name of the accompanying responsible person;-When the resident returns to the facility, a licensed nurse will re-assess the resident to determine the resident's condition and any medication returned after going out on pass, if applicable;-The resident/responsible person will verbally notify a licensed nurse prior to going out on pass and will sign out and back in on the Resident Out On Pass Log;-The resident/responsible person will return to the facility at the agreed-upon time or notify the facility of any unexpected delay in their return. Review of the facility's Drug and Alcohol Abuse policy, revised 10/24/22, showed:-Purpose: To provide a safe and drug-free environment for residents while at the facility;-The facility will not admit a resident with a primary diagnosis of drug or alcohol addiction or abuse;-The facility may admit a resident who has a history of drug and alcohol abuse if their primary diagnosis is suitable for skilled care;-The facility has a zero-tolerance policy for the use or possession of illegal drugs or any type of drug paraphernalia in the facility or on the grounds of the facility;-All illegal drugs and/or drug paraphernalia will be confiscated from the resident and/or their room;-For the purpose of this policy, alcohol is not considered to be an illegal drug;- The facility has a zero-tolerance policy for the use of alcohol in the facility or on the grounds of the facility without a physician order;-The only drugs permissible at the facility and/or on facility grounds are those for which there is an attending physician order;-Any resident found in violation of this policy will be discharged to a more appropriate setting for care;-Social Services may provide residents with this policy in the following circumstances:-In the facility specific information provided to residents upon admission; -If the resident has a history of substance abuse:a. alcohol;b. narcotics; orc. other substances; -If the resident is at risk for post-acute withdrawal symptoms; -If the resident is at risk for behavior disturbance;-If the resident has a substance abuse care plan;-If the resident has brought illegal drugs or alcohol into the facility; -If IDT feels it is appropriate to provide the resident with the policy;-After the Social Worker provides the resident with the policy, the resident will be asked to sign the Resident Drug and Alcohol Abuse Policy Acknowledgement Form, stating they are aware of the facility's zero tolerance policy on the use or possession of illegal drugs and its policy on alcohol abuse;-The facility will use its best efforts to obtain the resident's medical records if the resident has a history of drug or alcohol abuse, or use of illegal drugs;-Residents whose medical record provides a history of drug or alcohol abuse may be seen by a psychologist who will address current behavioral management issues for the resident as part of their care plan;-The care plan will be communicated to the attending physician and facility staff to specifically address the resident's behavioral problems;-The IDT will review the care plan after it is developed, and as needed thereafter;-The facility will provide residents who have a history of drug and alcohol abuse with information on local services and resources that can assist with treating drug or alcohol abuse;-Residents who wish to attend meetings such as Alcoholics Anonymous or Narcotics Anonymous, the facility will provide transport assistance to and from the meetings;-The IDT will determine whether the resident needs to be accompanied by a staff member;-Any resident found to be in violation of this policy will be asked to sign the Statement of Acknowledgement consenting to a search of their person and belongings for illegal drugs or alcohol;-The resident's person or belongings will not be searched without the resident or resident representative's consent;-If the resident or resident representative does not consent to the search, the facility will refer the matter to law enforcement;-If the resident or resident representative consents to the search and drugs, drug paraphernalia, or alcohol are found, the facility will confiscate such items;-Any drugs, drug paraphernalia, or alcohol will be destroyed or handed over to the authorities as required;-If a resident violates this policy, the resident will also be subject to drug screening to test for the presence of any illegal substances in their body;-If the drug screening is positive, the resident will be discharged according to facility discharge procedures;-If the resident refuses the drug screening, they could be discharged according to the facility discharge procedures. Review of the facility's Smoking by Residents policy, revision date November 2023, included the following:-Smoking is not allowed anywhere inside the facility;-Residents will be allowed to smoke in designated smoking area(s) only;-Location of the smoking area(s) may depend upon local and/or state smoking laws.-All designated smoking locations will display appropriate signage.-Outdoor smoking areas will have accommodations for inclement weather.-All smoking materials will be stored in a secure area to ensure they are kept safe;-Examples of secure areas include but are not necessarily limited to:--Labeled box in a locked medication room and clearly identified with the resident's name and room number.Response to resident non-compliance with smoking rules include:A. First offense: A written letter issued to the resident and/or family regarding non-compliance.B. Second offense: A written letter issued to the resident and/or family referencing the first offense letter and advising that a third offense results in the loss of smoking privileges.C. Third offense: A written letter issued to the resident and/or family outlining the non-compliant behavior. At this time the resident loses their smoking privileges.D. Residents observed smoking following revocation of smoking privileges is issued a 30-day notice of discharge if their non-compliant behavior endangers other individuals (e.g. continuing to smoke in areas where oxygen is in use). The clinical/behavioral status of the resident endangering other individuals at the Facility will be documented by an associated physician in accordance with Policy Transfer and Discharge. 1. Review of Resident #4's medical record, showed:-admitted on [DATE] from hospital following opioid overdose;-Diagnoses included: Opioid dependence, other psychoactive substance abuse, acute and subacute ineffective endocarditis (inflammation of the heart's inner lining). Review of the resident's 12/25 electronic physician order sheet (ePOS), showed:-An order dated 8/31/25 for psychiatry (psych) to evaluate and treat;-An order dated 8/18/25 for Buprenorphine HCL-Naloxone HCL tablet (suboxone, used to treat opioid use disorder (OUD)), sublingual (under the tongue) 8-2 milligrams (mg), give one tablet sublingually three times a day for opioid dependence.` Review of the resident's care plan dated 12/9/25, showed: -Focus: Resident has a history of trauma;-Interventions/Tasks: Refer for behavioral health services in order to provide appropriate assessment and treatment;-Focus: Resident has potential to demonstrate verbally abusive behaviors related to ineffective coping skills, poor impulse control;-Interventions/Tasks: Document observed behavior and attempted interventions in behavior log. Psychiatric/Psychogeriatric consult as indicated;-Focus: Resident has potential to demonstrate physical behaviors. Poor impulse control. Resident put a hole in the wall after getting upset with friend;-Interventions/Tasks: Document observed behavior and attempted interventions in behavior log. Psychiatric/Psychogeriatric consult as indicated;-Focus: Resident has a previous history of substance abuse and is on suboxone maintenance;-Interventions/Tasks: Attempt to address any concerns that the resident may have and encourage compliance with treatment regimen as indicated. Review of the resident's progress notes, showed:-On 9/9/25 at 7:00 A.M., the resident had a guest sleeping in his/her bed. The resident was made aware that overnight guests are not allowed to sleep in the bed. The resident became very upset and yelled at the Nurse. The guest still lay in the bed with his/her eyes closed with no intentions of getting up. The resident told him/her to lay back down. The Director of Nursing (DON) was made aware. At 8:55 A.M., the Administrator met with the resident regarding reports the resident had an overnight visitor. The resident objected strongly to the discussion and claimed it was not intentional, and they only fell asleep. The resident expressed understanding. At 10:36 A.M., an administrative note showed the resident had a guest in his/her room this morning. The resident became defensive stating his/her guest had no ride last evening. Resident advised it is his/her right to have a guest, but they are not allowed after 9:00 P.M. At 9:00 P.M., the resident and his/her guest left the facility;-On 9/10/25 at 12:58 A.M., the resident returned from leave of absence (LOA). At 3:46 P.M., the resident signed him/herself out and stated he/she will be back around 10:00 P.M.;-On 9/15/25 at 2:16 P.M., the resident signed him/herself out and stated he/she would be back around 10:00 P.M.;-On 9/20/25 at 11:12 P.M., the resident signed him/herself out of the facility. He/She stated he/she is going fishing and will be back around 8:00 P.M.;-On 9/29/25 at 7:37 A.M., resident on LOA. At 8:49 A.M., a medication administration note, medication not administered due to resident on LOA. At 12:47 P.M., the resident on LOA. At 12:48 P.M., the resident's Physician made aware the resident was currently LOA and staff were unable to administer his/her Buprenorphine HCL-Naloxone HCL 8-2 mg. At 3:41 P.M., the resident's Physician made aware the resident was currently LOA and staff were unable to administer his/her Buprenorphine HCL-Naloxone HCL 8-2 mg. At 8:02 P.M., the resident LOA;-On 9/30/25 at 9:04 A.M., the resident LOA. At 12:45 P.M., the resident was back in the building;-On 10/1/25 at 3:39 A.M., the resident was LOA. At 1:07 P.M., the resident was LOA. At 6:15 P.M., the resident was LOA. At 8:35 P.M., the resident was LOA. At 11:08 P.M., the resident returned from LOA and was administered his/her suboxone;-On 10/2/25 at 6:52 A.M., the resident stated he/she was not leaving but just going downstairs to visit his/her fiance. The resident never came back to the floor. The resident did not sign out;-On 10/3/25 at 1:39 A.M., the resident was on LOA to the park with a friend. At 5:41 A.M., the resident was back in the building. At 12:57 P.M., the resident was on LOA with his/her 4:00 P.M. dose of suboxone. Per the resident, he/she will return around 10:00 P.M. tonight;-On 10/4/25 at 2:30 P.M., the resident LOA at 11:45 A.M. Will be back around 10:00 P.M. At 5:28 P.M., the resident's Physician aware the resident's Buprenorphine HCL-Naloxone that was due at 4:00 P.M. today not administered due to the resident's leave of absence from the building and did not make the Nurse aware he/she was leaving. Resident did not sign out of sign out book. At 6:46 P.M., the resident back in the building;-On 10/5/25 at 5:48 P.M., the resident on leave of absence. Per the resident, he/she is going with friends. Per the resident, he/she will return around 10:00 P.M. tonight;-On 10/7/25 at 10:28 A.M., the resident signed out and stated he/she will be back at 7:00 P.M. The nurse gave him/her the next dose of Methadone to take with him/her and the Certified Medication Technician (CMT) gave him/her medications that were due before 7:00 P.M.;-On 10/8/25 at 12:02 A.M., the resident was still on LOA. At 12:30 A.M., the resident returned and asked for his/her suboxone dose and left again saying he/she was going outside. The resident then came back again and left an hour later. At 7:35 A.M., the resident walked back in. He/She did not sign out or back in. At 2:43 P.M., the resident on LOA with his/her suboxone. Per the resident, he/she will return around 10:00 P.M.;-On 10/9/25 at 10:21 A.M., the resident was not in the building when the Nurse arrived. The resident did not get his/her suboxone at 8:00 A.M. The resident's Physician is aware. At 1:07 P.M., the resident was LOA. At 4:40 P.M., the resident was back in the building. At 5:45 P.M., the resident LOA to go to work. Per the resident, he/she will return around 9:00 P.M. At 10:18 P.M., a medication administration note the resident's Buprenorphine HCL-Naloxone HCL not administered because the resident was LOA;-On 10/10/25 at 9:25 A.M., the resident was not in the facility. At 11:06 A.M., the resident returned to the facility. At 1:57 P.M., the resident was LOA. At 3:04 P.M., the Administrator and Business Office Manager met with the resident and discussed managing the LOA privilege with the resident. The resident expressed understanding. At 4:07 P.M., the resident was LOA from the facility with his/her medication. At 8:44 P.M., the resident was LOA at the change of shift;-On 10/11/25 at 11:12 P.M., the resident was still LOA;-On 10/12/25 at 8:00 A.M., the resident returned to the facility. At 3:30 P.M., the resident was LOA from the facility. At 7:44 P.M., the resident was away. At 7:57 P.M., the resident away from the facility. At 10:29 A.M., the resident still LOA;-On 10/13/25 at 4:14 A.M., the resident returned to the facility for 30 minutes and left again. At 1:44 P.M., the resident LOA. Resident stated he/she would return around 10:00 P.M. Suboxone sent with resident. At 5:45 P.M., the Administrator educated the resident on his/her LOA days. He/She expressed understanding;-On 10/15/25 at 4:30 P.M., the resident LOA from facility. Resident stated he/she was going to visit his wife in the hospital;-On 10/18/25 at 5:00 P.M., the resident on LOA and would not say where he/she was going. Per the resident, he/she would return around 10:00 P.M.;-On 10/19/25 at 12:15 P.M., the resident LOA to see his/her friends. 4:00 P.M., suboxone sent with resident per his/her request;-On 10/20/25 at 6:23 P.M., the resident went LOA stating to nurse he/she wanted his/her next two doses of suboxone. The nurse attempted to confirm if this was okay, and the resident told the DON who told the Nurse he/she needed to give the resident what he/she requested because he/she would be out of the facility at 9:00 P.M. The Nurse did as the DON instructed and gave the resident his/her 4:00 P.M., dose as well as his 9:00 P.M. dose. The resident left the facility and then came right back in walking throughout the facility;-On 10/21/25 at 1:09 P.M., the resident LOA;-On 10/22/25 at 7:30 A.M., the resident returned to the facility;-On 10/24/25 at 2:04 P.M., the resident LOA with his/her family. Per the resident will return around 10:00 P.M. tonight. Buprenorphine HCL-Naloxone HCL 4:00 P.M. and 8:00 P.M. dose sent with resident;-On 10/25/25 at 8:38 A.M., when staff went to check on the resident to see if he/she wanted to have his/her medication after breakfast, he/she stated he/she came back to the facility on [DATE] at 11:00 P.M. At 11:42 A.M., the resident refused his/her medications. At 6:35 P.M., the resident refused his/her medications. At 6:47 P.M., the resident signed out LOA at 4:30 P.M. and did not want any of his/her medications. The resident's Physician notified;-On 10/26/25 at 11:53 A.M., the resident away with meds. At 3:18 P.M., the resident left LOA and was given all his/her medications until after 8:00 P.M.;-On 10/28/25 at 10:30 A.M., the resident returned from LOA with significant other;-On 10/31/25 at 10:45 A.M., the resident left LOA with his/her 4:00 P.M. dose of Buprenorphine HCL-Naloxone. Resident reported time of return around 8:00 P.M. today;-On 11/3/25 at 10:34 A.M., the resident's overnight guest remained in his/her room. The resident was educated on the guest leaving each evening. Administrative staff aware that the guest spent the night;-On 11/4/25 at 5:35 P.M., the Nurse noted the resident limping briskly to his/her room. When asked what was wrong, the resident replied, Someone ran over my foot with a wheelchair. The resident refused to have his/her foot assessed and left the facility again. At 8:28 P.M., the resident was LOA at change of shift;-On 11/5/25 at 12:22 A.M., the resident returned to the facility. At 10:45 A.M., the resident was not present. At 3:34 P.M., the resident LOA. He/She administered 4:00 P.M., dose of Buprenorphine HCL-Naloxone and staff sent 8:00 P.M., dose with the resident;-On 11/6/25 at 9:54 A.M., the resident left the facility LOA but did not return until after midnight. Due to the resident not returning n a timely manner, per protocol the resident was re-admitted to the facility. At 1:05 P.M., resident LOA with meds;-On 11/7/25 at 6:22 A.M., the Nurse was notified at 6:00 A.M. by housekeeping staff, the resident was found on the basement floor in the conference room with his/her boy/girlfriend. The resident was supposed to be LOA at the time. The resident is currently out of the building. The DON was notified-On 11/10/25 at 4:40 A.M., the resident left LOA. At 2:53 P.M., the resident requested his/her 4:00 P.M. and 8:00 P.M., suboxone stating he/she was going LOA and was not sure if he/she would return so he/she wanted both doses. After the Nurse gave the resident his/her medication, he/she went back to his/her room. At 9:45 P.M., resident LOA. At 11:17 P.M., the resident was in his/her room at change of shift. The resident stated he returned around 8:00 P.M.;-On 11/11/25 at 1:35 P.M., the Administrator met with the resident to discuss his/her discharge plans and provided a 30-day letter. The resident expressed understanding;-On 11/14/25 at 1:40 P.M., the resident having behavior. He/She threw an ink pen at a staff member. The resident stormed out upset. The staff were concerned the resident might try to use something against them. They checked the resident's room and found a box cutter. The DON and administrator were made aware. At 6:34 P.M., the resident LOA;-On 11/15/25 at 6:57 P.M., the resident was back in the building;-On 11/16/25 at 4:29 P.M., the resident was LOA from the building with medication. At 7:04 P.M., the resident was back at the building with male/female company;-On 11/19/25 at 9:43 P.M., the resident LOA. Buprenorphine HCL-Naloxone not given. At 10:27, resident LOA;-On 11/21/25 at 3:15 P.M., the resident LOA from facility;-On 11/22/25 at 4:26 P.M., the resident had an overnight visitor in his/her room despite being aware of the facility policy. The resident came to the nursing station and demanded two doses of his suboxone stating he/she was leaving the facility. The Nurse made the resident's physician aware and was instructed to give one dose and notify the Administrator and DON. The resident became irate, yelling at the Nurse in a foreign language with some English words. The Nurse heard him/her say bomb and it's too late. The resident and his/her overnight guest left. At 7:26 P.M., the resident LOA. At 9:13 P.M., a medication note Buprenorphine HCL-Naloxone not administered due to the resident being LOA;-On 11/23/25 at 7:50 A.M., the resident LOA. At 10:36 A.M., resident away from facility. At 4:12 P.M., resident away from facility. At 6:36 P.M., the resident returned from LOA carrying a 5-gallon bucket filled with black wires. He/She was followed by a male/female partner in a wheelchair;-On 11/24/25 at 7:22 A.M., resident LOA. At 9:25 A.M., resident back in the building. At 3:32 P.M., the Nurse called the resident's Physician to make him aware the resident was leaving LOA and wanted to take his/her 4:00/8:00 P.M., suboxone with him/her. Per the notes over the weekend, the resident did gain both doses and did not leave LOA and went to his/her room after the Nurse called the Physician to get the order to release the narcotic to him/her. The Nurse told the resident with the Physician on the phone, he/she had to take the 4:00 P.M., dose now in front of him/her. The resident was very irritated before taking the medication due to not understanding the reason why he/she could not take the medication with him/her. The resident took the medication but continued to talk under his/her breath. He/She left on the elevator LOA;-On 12/2/25 at 7:54 P.M., the resident told the nurse to Suck his dick stating the nurse was afraid when he/she darted behind the nurse's station;-On 12/3/25 at 7:24 P.M., the resident LOA from facility. At 9:03 P.M., LOA;-On 12/4/25 at 5:28 A.M., the resident outside of building smoking with peer from facility;-On 12/6/25 at 1:30 P.M., the resident requested 4:00 P.M., dose stating he/she was leaving facility and would not be back before 4:00 P.M. The Nurse gave the resident the medication, he/she got on the elevator with his/her significant other and returned to his/her room alone 10 minutes later. Review of the resident's care plan, dated 12/9/25, showed:-No documentation of the resident bringing his/her friend into the facility all hours of the day and interventions staff should provide if he/she refused to leave;-No documentation of the resident leaving the facility throughout the day without signing in or out and what interventions staff should provide if the resident did not return to the facility when expected;-No documentation of the resident bringing contraband into the building and what interventions staff should provide to prevent this to ensue the safety of residents who might wander into the resident's room;-No documentation of behavioral interventions put in place to deal with the resident's refusal to follow facility policies. Observation and interview on 12/10/25 at 11:00 A.M., showed Licensed Practical Nurse (LPN) C knocked on the resident's door and asked to enter the room. The resident opened the door and immediately reached over and shut the bathroom door. The resident said his/her friend was in the bathroom. The resident said the friend was his/her boy/girlfriend and he/she only visited during the day. When asked if the Nurse and the surveyor could meet the friend, the resident went into the bathroom and shut the door. While standing in the resident's room waiting for him/her to come out of the bathroom with his/her guest, observations were made of the room. In the corner of the room, sat a large white 5-gallon bucket of black wires. On the resident's bed were two lighters and a small metal tube. On the resident's bedside table sat a plastic package of long thin utility blades. In the resident's open drawer were two box cutters with blades in them, a set of metal pliers and a full pack of cigarettes. During interviews on 10/10/25 at 10:30 A.M. and 11:30 A.M., LPN C said when the resident first admitted , he/she pretty much kept to him/herself. Then he/she started bringing the guest in overnight. The friend was staying in the facility pretty much all the time and the resident would hide him/her in the bathroom if staff knocked on the door. The resident got hostile if anyone said anything to him/her about the guest and denied having him/her in the room. The resident would ask for two doses of his/her suboxone at once saying he/she was going to be leaving the facility but would then not leave. If the LPN refused or said he/she was going to call the resident's Physician, the resident would make threats to him/her. The staff do not know if he/she is taking the medication or if he/she is giving it to his/her friend. The LPN reported this to the DON but was told the resident is his/her own responsible party, so they are to give him/her the medication if he/she requests it and says he/she is leaving the building. The LPN tried calling the resident's Physician a couple of times, but the DON told him/her the resident had an order to take his/her medications out on pass, so the Physician did not need to be called each time. The resident leaves out at all hours of the day, and when he/she returned, sometimes he/she acted strangely and more aggressive. The LPN could not assess the resident because he/she would not let the nurse in his/her room and would become threatening if he/she tried to talk to him/her. The DON notified all of the staff that they were not supposed to go back and forth with the resident. They just stayed out of his/her room and left him/her alone. The staff knew the resident brought items in from the community like the wires and the boxcutter. The Administrator would remove them, but then the resident would go right out and get more. The Nurse was not given any instructions on what to do when administration was not in the building and the resident got aggressive. He/She worried for the safety of the residents and staff. During an interview on 12/12/25 at 12:40 P.M., Certified Nurse's Aide (CNA) B said there have been issues with the resident because he/she sneaks the guest into the building at night when all the bosses are gone. The staff do not confront him/her because he/she is aggressive. The CNA knew he/she brought in scraps and junk from outside the facility like the boxcutter and the staff would remove it if they saw it, but the resident did not want staff going in his/her room. During an interview on 12/12/25 at 12:15 P.M., CMT E said the resident brings his/her guest into the facility after hours when administration is gone. The staff had been told the guest had to leave by 10:00 P.M. or they should call the police if he/she did not leave. The CMT did not work evenings, so he/she had not had to ask the guest to leave. He/She knew the resident brought a boxcutter into the facility. The resident was always bringing stuff into the facility. He/She did not know who was supposed to monitor the room for contraband. He/She thought it would be housekeeping since they would have access to the resident's room. He/She had been told they could not search a resident's room unless they had permission. During an interview on 12/12/25 at 9:10 A.M., the Social Worker said the resident's behavior is sneaky. He/She goes out in the community and brings multiple things back into the facility and hoards them in his/her room. She knew the resident had a guest that stayed in the room sometimes. Administration had gone in there and talked to him/her about it and told the resident it was okay if the guest stayed longer if the resident let the Administrator know when it was going to happen. Then it became a problem. She knew the resident was leaving the facility at all hours of the day and night, but a person was going to do what they were going to do. She had offered a drug rehabilitation program to the resident, but he/she had declined it. The psychiatrist came to the facility once a month and saw residents, but this resident was never in the building when they came. She did not know there was a problem with the resident bringing contraband into the facility. The resident was not on a behavior contract because he/she was not displaying any behaviors. When he/she was in the facility, he/she stayed in his/her room. She knew the facility had issued a 30-day discharge to the resident and thought it was due to his/her not following the facility rules. She did not believe they could meet the resident's needs, as he/she was non-compliant with the facility's policies. During an interview on 12/12/25 at 1:00 P.M., the DON said the resident is volatile. The Administrator had talked to him/her numerous times about the rules and had removed several items out of his/her room. Staff do not go in his/her room because of his/her demeanor. He/She would put you out of the room and[TRUNCATED]

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. Staff failed to accurately and thoroughly document the controlled substance shift change inventory tracker sheets, for one of the two facility floors. The census was 80.Review of the facility's Controlled Substance Prescriptions policy, revised August 2020, showed the following:-Policy: -Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations;-The Director of Nursing and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized, licensed nursing and pharmacy personnel have access to controlled medications;-Documentation of a Controlled Substance Prescription: --Each controlled substance prescription is documented in the resident's medical record with the date and time of receipt and the signature of the person receiving the prescription. The prescription is recorded on the physician order sheet or telephone order sheet or posted elsewhere in the record and recorded on the Medication Administration Record (MAR); --Each prescription is recorded in the patient's health record in accordance with facility policy;-Security and Recordkeeping: --Controlled substances are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents. The pharmacy will include an individual resident-controlled drug record (count sheet) for each controlled substance medication container dispensed to a resident unless directed otherwise by the facility; --Controlled substance medications are stored at the facility under double lock or as required by state regulations, separate from all other medications and counted at each change of custody or in accordance with facility policy. The access key to controlled medications is not the same key that allows access to other medications. The medication nurse on duty maintains possession of a key to controlled medications. Back up keys to all medication carts may be obtained from the provider pharmacy. Review of the facility's Shift Change Controlled Substance Inventory Count Sheet on 12/12/25, showed:-Nurse coming on to shift must verify count of all controlled substances with nurse coming off shift or any time the medication cart keys are exchanged;-Nurses must count total number of cards/containers and total number of count sheets, both for individual residents and applicable contingency supplies with controlled drugs;-Nurses must verify actual drug counts (#tabs, caps, patches, vials etc.) against each individual resident count sheet;-Any discrepancies must be reported immediately to director of nursing or nursing supervisor;-Every controlled substance medication and count sheet added or removed from the medication cart must be documented below;-There were areas to document the date, shift/time, nurse signatures, total number of cards/containers, total number of count sheets, medication and count sheets added (with space for the resident's name, medication and strength, and number of cards and count sheets) and medications and count sheets removed (with resident's name and medications). Review of the first floor Shift Change Controlled Substance Inventory sheets for 11/1 through 11/30, showed:-On 11/2/25, one nurse signature for the morning shift change and one nurse signature for the evening shift change;-On 11/3/25, one nurse signature for the morning shift change;-On 11/4/25, one nurse signature for the evening shift change;-On 11/6/25, one nurse signature for the morning shift change and one nurse signature for the evening shift change;-On 11/7/25, one nurse signature for the morning shift change and one nurse signatures for the evening shift change;-On 11/8/25, one nurse signature for the evening shift change;-On 11/9/25, one nurse signature for the morning shift change and nurse signature for the evening shift change;-On 11/11/25, one nurse signature for the morning shift change;-On 11/12/25, no documentation of any nurse signatures for the evening shift change;-On 11/17/25, one nurse signature for the morning shift change. No documentation of any nurse signatures for the evening shift change;-On 11/19/25, one nurse signature for the morning shift change;-On 11/20/25, no documentation of nurse signatures for the morning shift change and no nurse signature for the evening shift change;-On 11/21/25, one nurse signature for the morning shift change and one nurse signature for the evening shift change;-On 11/23/25, one nurse signature for the evening shift change;-On 11/24/25, one nurse signature for the evening shift change;-On 11/25/25, one nurse signature for the evening shift change;-On 11/26/25, one nurse signature for the morning shift change. Staff documented the total number of cards at 24 for the morning shift and 25 for the evening shift, with no documentation of a resident's medication added;-On 11/27/25, one nurse signature for the evening shift change. Review of the first floor Shift Change Controlled Substance Inventory Sheets for 12/1 through 12/12/25, showed:-On 12/3/25, no documentation of any nurse signature for the evening shift change;-On 12/4/25, one nurse signature for the evening shift change;-On 12/5/25, one nurse signature for the morning shift change and one nurse signature for the evening shift change;-On 12/7/25, one nurse signature for the morning shift change and one nurse signature for the evening shift change;-On 12/9/25, one nurse signature for the evening shift change;-On 12/10/25, no documentation of total number of cards for the evening shift. During an interview on 12/12/25 at 11:05 A.M., Licensed Practical Nurse D said he/she is supposed to count the narcotics on his/her floor at the beginning of his/her shift and at the end of his/her shift with another nurse. They are both supposed to sign off on the narcotic inventory tracker sheet. He/She always does this when he/she works. He/She never counts the narcotics by him/herself. If there was a signature missing when he/she worked, then the other staff member who was supposed to sign off with him/her must have forgotten to sign the sheet. During an interview on 12/12/25 at 1:20 P.M., the Director of Nursing said she expected staff to count the narcotics and sign off on the controlled substance inventory tracker. She expected this to be done at the beginning of each shift and when they opened the narcotic box for any reason. This documentation would be signed off by two nurses. During an interview on 12/12/25 at 2:10 P.M., Administrator B said he expected the nursing staff to count the narcotics and sign off on the controlled substance inventory tracker before they accepted the keys from outgoing staff. This should also be done if staff opened the narcotic box for any reason during the shift. He would have expected two nursing staff members to sign off on every entry.

Based on interview and record review, the facility failed to follow the abuse prevention policy and complete a thorough investigation related to an injury of unknown origin for one resident (Resident #16), when the facility identified healed right rib fractures from an unknown cause. The census was 76.Review of the Abuse Prevention and Prohibition Program, revised October 24, 2022, showed:-Purpose: To ensure the facility establishes, operationalizes and maintains an abuse prevention and prohibition program designated to screen and train employees, protect the residents, and to ensure a standardized methodology for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements;Policy:-Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual or physical abuse, neglect, mistreatment, or misappropriation of resident property;-The facility is committed to protecting residents from abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, staff from other agencies serving residents. The policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing;-The administrator is responsible for coordinating and implementing the abuse prevention policies, procedures, training programs and systems;Procedure:-The administrator may delegate coordination and implementation of components of the abuse prevention program to other staff within the facility;-Identification: The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect:-Fractures, dislocation or sprains of questionable origin;Investigation:-The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts;-If the administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the administrator or designee, may appoint a member of the facility management team to investigate the alleged incident;-If the investigation is delegated, the administrator provides the investigator with any supporting documents related to the alleged incident;-The investigator may take some or all of the following steps:-Reviews all the relevant documentation;-Reviews the resident's medical record to determine events preceding the alleged incident;-Interviews the persons making the incident report;-Interviews any witnesses to the alleged incident;-Interviews with the resident (as medically appropriate);-Interviews with the resident's medical physician as needed to determine the resident's current level of cognitive function and medical condition;-Interviews with staff members who have had contact with the resident during the period of the alleged incident;-Interviews the resident's roommate, family members and visitors;-Interviews other residents to whom the accused employee provides care or services;-Reviews of all events leading up to the alleged incident;-Prepares an investigation report documenting findings of the investigation;-Special considerations for investigation of injuries of unknown origin (unexplained injuries):-Unexplained injuries are promptly and thoroughly investigated by the Director of Nursing (DON) and/or other staff person designated by the administrator, to ensure that resident safety is not compromised and action is taken whenever possible, to avoid future occurrences;-If a resident is observed with unexplained injuries, the nurse on duty will complete an incident and accident report form or a substantively similar form, and record such information into the medical record;-Documentation must include information relevant to risk factors and conditions that cause or predisposes someone to similar signs and symptoms;-Nursing staff will discuss the situation with the physician to consider whether medical conditions or other risk factors could account for the findings;-The physician is responsible for reviewing and verifying conclusions about the possibility of a medical or other similar cause of the findings;-Based on the determination of the nursing staff, the physician, and medical director, the administrator decides whether to undertake an investigation of the injury;-If the administrator determines the injury should be investigated, he/she may designated a member of the facility management team to serve as the incident investigator.Review of Resident #16's medical record, showed diagnoses including lung disease, Alzheimer's disease, heart failure, and fall history. Review of the resident's Annual Minimum Data Set (MDS) a federally required assessment instrument, completed by facility staff, dated 02/13/26, showed:-Severe cognitive impairment;-Full staff assistance needed for hygiene, toileting, transfers, dressing, and bed mobility.Review of the progress notes, showed:-On 03/03/26 at 12:15 P.M., a nurse's note showed the resident noted coughing and wheezing. Physician notified and new orders received for a chest x-ray and breathing treatments.-On 03/04/26 at 6:36 P.M., a nurse's note showed a chest x-ray completed related to wheezing and nonproductive cough.Review of the radiology chest x-ray report dated 03/04/26, showed the lungs clear. Multiple chronic right-sided rib fractures.Review of the progress note dated 03/05/26 at 8:12 A.M., showed the chest x-ray report provided to the physician. No new orders at this time. The resident continued on breathing treatments.Review of the facility investigation, showed:-On 03/04/26 two staff were interviewed regarding the resident's pain and said the resident had not shown signs or symptoms of pain.-A safe survey resident interview completed by staff for five residents, on 03/06/26, showed the residents said they felt safe.-One staff interviewed on dated 03/07/26 and said the resident had not shown signs or symptoms of pain.Record review of the investigation showed it did not contain:-Additional staff interviews, from various shifts and positions, regarding the findings of chronic rib fractures;-An interview with the physician;-No investigation summary.During an interview on 03/16/26 at 11:17 A.M., the resident's physician said he ordered a chest x-ray related to an ongoing cough and to rule out pneumonia. The chest x-ray showed healed rib fractures. The resident is in poor physical health and unable to clearly communicate. He/She experienced a fall in December 2025, which resulted in a left arm fracture. No surgery was required and the arm healed with sling support. He discussed the chest x-ray results with the DON and determined the healed fractures were likely as a result from the fall and the resident's poor medical condition. No new orders were needed. He expected the facility to follow the policy for investigations.During an interview on 03/16/25 at 12:33 P.M., Licensed Vocational Nurse (LVN) D said he/she had cared for the resident multiple times. The resident is full care and unable to make needs or wants clearly known. The resident experienced a fall in December 2025 that resulted in an arm fracture. No surgery was needed, and he/she wore a sling. The arm has healed. The resident had an increased cough and a chest x-ray was obtained, that showed healed rib fractures. The nurses monitored for pain. She said the resident had not shown signs or symptoms of pain.During an interview on 03/16/26 at 2:48 P.M., the DON said the investigation did not contain the staff interviews until 03/16/26. The staff interviews showed the resident had not been in pain. She discussed the x-ray results with the resident's physician and determined the fractures had healed and due to the resident's health and prior fall, the fractures likely occurred from the fall. The resident had no increase in pain after the discovery of the healed fractures. The facility investigation did not contain statements from the resident's Physician with his/her findings.During an interview on 03/16/26 at 3:16 P.M., the Administrator said the DON will manage any investigations related to injuries of unknown origin. He expected the investigation to be complete and contain the required documentation and interviews. The DON reported the findings to him. The resident's Physician was involved in the investigation and determined as a result of the resident's medical condition; the rib fractures were not a result of abuse or neglect.2796586

Based on interview and record review, the facility failed to ensure staff provided adequate assistance to prevent accidents for one of four sampled residents (Resident #1) when Certified Nursing Assistant (CNA) B and CNA C used a Hoyer lift (full body lift, used for residents who are unable to move themselves), to transfer the resident but did not use the correct size sling. While the resident was suspended in mid-air, the sling straps broke, and the resident fell to the ground and hit his/her head. This caused a laceration (cut) to the posterior side (back side) of the resident's head. The resident was sent to the hospital and required sutures. The sample size was 4. The census was 92. The facility was notified of the past non-compliance on 10/24/25. The facility initiated their investigation and suspended both CNAs pending investigation. All staff were in-serviced. The staff demonstrated followed their policy following the incident. The two CNAs alleged to be in the room when the incident occurred had scheduled 1-1 in-service and training prior to returning to the facility. Maintenance completed an audit on all the mechanical lifts for proper function. Audits were also completed on all Hoyer pads. This deficiency was corrected on 10/10/25. Review of the facility's Total Mechanical Lift Policy, revised 6/20, showed:-Purpose: A mechanical lift is used appropriately to facilitate transfer of residents.-Policy: Nursing staff will be trained to use the mechanical lift. The resident will have a physician's order for the use of a mechanical lift, and at least two people are present while resident is being transferred with the mechanical lift. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/22/25, showed:-Severe cognitive impairment;-Dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for chair/bed-to-chair transfer, sit to stand transfer, and upper and lower body dressing;-Diagnoses included stroke, right side hemiplegia (weakness on one side of the body), seizures, non-Alzheimer's dementia and malnutrition. Review of the resident's care plan, revised 9/19/23, included:-Focus: Resident has decreased mobility and needs assistance of two staff members to transfer safely with Hoyer lift;-Goal: Additional safety measures will be taken when transferring resident;-Interventions/Tasks: Ensure two staff members are present when using Hoyer lift for safety measures, ensure chair wheels are locked for repositioning and transfers, complete transfer evaluation on admission and as needed. Review of the resident's medical record, showed:-An undated order, may use mechanical lift (Hoyer) for transfer. Large sling.-A progress noted, dated 10/9/25 at 6:00 A.M., nurse aide (NA) reports resident on floor, CNA caring for resident reports them and another CNA was transferring resident to his/her wheelchair in Hoyer when Hoyer straps broke and resident fell to floor. Upon assessment resident was lying on floor on back. Resident noted with laceration to posterior scalp with slow trickle of blood noted. Resident alert and responding with yes and no answers. Unable to verbalize what happened. Director of Nursing (DON) made aware, reports she will inform Administrator. Resident denies pain. CNA instructed to remain with resident until Emergency Medical Service (EMS) arrives. 911 called.-Resident lifted off the floor onto stretcher with two EMS caregivers. Resident denies pain and remains alert and responding to questions with yes and no answers. Resident's family made aware.-A progress note, dated 10/9/25 at 11:15 P.M., Resident readmitted to facility per EMS, alert and oriented to self. Medical director made aware, orders verified. No distress noted.-A progress note, dated 10/13/25 at 10:00 P.M., resident resting quietly in bed, no distress noted. laceration 4.0 centimeters (cm) remains well approximated, no bleeding noted. Will continue to monitor. Review of the facility's investigation, showed:-It was reported by the nurse that resident fell from the Hoyer lift. The CNAs in the room claimed the Hoyer strap broke. The resident was on the floor, assessed by nurse and sent out for evaluation.-Findings: Upon interview, resident was unable to verbalize details. Immediately following the fall, Resident assessed for visible injuries, laceration covered with dry dressing. Resident lifted off floor onto stretcher with two EMS providers. Resident denied pain. No further bleeding noted on dressing. Only minor injury, small laceration on head measuring 4four cm in length and shallow, slow trickle of blood which stopped shortly after dressing applied. The incident occurred at end of shift. The staff involved in the incident were placed on suspension pending investigation.-Staff reported that the resident was being transferred from the bed when the straps (two) broke and the resident fell. The staff said they used the black Hoyer pad. The staff saved the straps, and CNAs were told to save the Hoyer pad. However, CNA D reported that CNA B threw the Hoyer pad away in the trash. According to CNA B, he/she was lifting the resident off the bed, while CNA D was spotting and watching over the resident when the resident fell. CNA C stated he/she saw the two straps hanging without the pad attached to one side. Two of the straps were still hanging on the Hoyer. This matches the witness of the nurse who saw the strap hanging apart from the Hoyer pad.-Summary of Investigation: The evidence strongly suggests that the pad used was a slide Transfer Pad which resembles a Hoyer pad. The description of the Hoyer pad was black and the black slide pad is the only pad missing. The facility does not utilize black Hoyer pads.-Conclusion: Neglect is not substantiated. The evidence from the investigation and description of the Hoyer pad provided by staff strongly suggests that the staff utilized the incorrect pad, two of the straps then failed and the resident had a fall with injury of a minor laceration.-Recommendation: The Inter-Disciplinary Team (IDT) will continue to review the implementation of safety efforts to ensure successful resident transfers.-Education on Hoyer use and working with lift pads by nursing management and therapy director.Staff responsible for utilizing the incorrect pad, CNA B and CNA D will be provided a final written notice with in-person education and demonstration prior to return to the floor.-Hoyer lifts and Hoyer pads were immediately assessed for safety. Completed 10/9/25.-All transfer pads, like pad used, have been removed from the facility. Review of the handwritten signed statements provided with the investigation, showed:-Registered Nurse (RN) A, dated 10/9/25: Approximately 6:00 A.M., he/she was called to Resident #1's room by CNA D. He/She was coming back to the nurse's station from East hall when CNA was standing in the hall. He/She asked what was wrong and CNA D said the Hoyer strap completely broke when they were transferring the resident. Resident alert, bleeding noted to posterior scalp, range of motion consistent with baseline, covered with dry dressing. He/She asked who was present when the resident fell. CNA D and CNA B said they were both with the resident. CNA C said he/she came after the resident fell. CNA instructed to keep Hoyer pad. 911 called, family called, Report to ER nurse.-CNA D, dated 10/9/25: He/She went into Resident #1's room at 6:00 A.M. after he/she heard a loud bump. The resident was on the floor, and the aide said the pad was broke. He/She called the nurse to the room, and he/she dialed 911. He/She offered to help get him/her up, but the nurse refused. He/She left the room to wait for EMS. He/She did not see the resident fall or hit his/her head. He/She was not in the room when it happened.-CNA C, undated: On 10/9/25, around 6ish A.M., he/she was sitting outside of the resident's room. He/She heard a noise, a few minutes later CNA B came out and yelled for help. He/She went to see what was going on and saw the resident lying on floor, blood coming out the back of his/her head. CNA D was kneeling beside him/her putting towels under his/her head. He/She asked what happened. CNA B said the Hoyer pad broke in half. He/She looked at the lift and saw only two straps connected to the hooks on the Hoyer. He/She did remember seeing the straps still attached. When the charge nurse came, he/she went to laundry to get another Hoyer pad, so myself, CNA D, and CNA B could get the resident up, but the charge nurse told us to have him/her lying there until EMS got here. He/She left and went to start getting his/her other residents up.-CNA B, undated: He/She started his/her morning rounds at 5:30 A.M. and walk into the resident rooms and got his/her get ups ready and then called CNA D to help, and as we were getting the resident together, we were putting him/her to the chair, the Hoyer pad broke. He/She called the nurse, did vital signs, made sure resident was ok, and sent the resident to the hospital.-CNA C, dated 10/9/25: He/She only went into the resident room to assist when he/she heard CNAs call out for help. He/She did not witness the fall. During an interview on 10/24/25 at 1:30 P.M., the Administrator said he talked to the family on the phone Monday and in person and told him/her the wrong pad was used. It was a black pad, so they got rid of all of those and maintenance did an audit. More Hoyer pads were ordered. During an interview on 10/24/25 at 2:05 P.M., CNA B said he/she was assisting the morning of the incident. He/She put the resident on the Hoyer and did not think there was a problem. That was the first time it had ever broken. Staff were transferring the resident, using their normal routine, and the resident fell. CNA B said CNA D was in the room. The Hoyer pad that was used came out of the closet on the first floor. He/She grabbed what was available. The resident hit his/her head on the chair when he/she fell. He/She was almost on the chair. It was a low fall and close to chair height. The pad was dark blue and had the different colored straps but did not have holes in it between the straps and pad like the shower ones do. During an interview on 10/24/25 at 4:10 P.M., CNA D said he/she was not in the room when the fall occurred. He/She was on one end of the hallway and CNA C was on the opposite end. CNA D was in the hallway when he/she heard the boom and came into the room. CNA D believed the Hoyer pad broke. It was blue. Both aides (CNA C and CNA B) said he/she was in the room, but he/she never said it. Once it broke, CNA B looked at the pad and it said small. The resident uses a large. He/She would not have put the resident in a small sling, he/she knows better. He/She got suspended because they said he/she was in the room, but he/she did not have nothing to do with anything. He/She saw the pad was blue and three of four straps ripped from pole. The straps were still attached to the Hoyer. During an interview on 10/24/25 at 4:37 P.M., the Administrator said they asked CNA D directly if he/she was in there so they do not know why he/she changed their story. During an interview on 10/25/25 at 3:47 P.M., the Administrator said he wanted to clarify the interviews that were conducted with the CNAs and provided the following information. He had a couple interview notes to add regarding CNA D's involvement in the fall. When he originally interviewed CNA B, he/she said CNA D left the room and came back in. He had to ask some clarifying questions and concluded that CNA D left to get help and then came back into the room. CNA D leaving and coming back all occurred after the resident had fallen. This part is at least partly confirmed by RN A's testimony that CNA D informed him/her of the fall. CNA C said CNA D was in the room with CNA B. During an interview on 10/27/25 at 11:44 A.M., RN A said he/she was finishing up the morning medication pass when he/she saw CNA D in the hall. CNA D said they were trying to get the resident up and he/she fell. The resident was on the floor on his/her back. He/She checked on the resident first and then asked what happened. CNA B and CNA D said they were trying to get him/her up and the straps broke. RN A was on the phone with the DON and asked who was in room. CNA D said him/herself and CNA B because it was CNA B's assignment. CNA C was in the room after the fall and said he/she was not there. He/She was shocked when CNA D changed his/her story because RN A was on phone with the DON when CNA D said he/she was in the room. CNA D wrote he/she was not in there. Maybe he/she was scared. RN A did not see the Hoyer pad, just where the straps broke. During an interview on 10/27/25 at 1:15 P.M., the DON said that morning, RN A called and said the resident fell out of the Hoyer, onto the floor. She asked how many people were in the room when it happened. She was told by RN A two were in there. Then the DON asked what type of injury, and it was reported there was bleeding from his/her head. She told them to call the doctor and 911. They transported the resident to the hospital. The hospital did a CT scan, and it revealed laceration to head. CNA D said he/she witnessed the incident and then recanted that. The CNA changed his/her story. She thinks it may have been the wrong kind of pad that caused the fall. During an interview on 10/28/25 at 8:35 A.M., CNA C said he/she saw CNA B and CNA D in the resident's room when he/she went down to check. CNA D was bent down by the resident putting a towel under his/her head. CNA B went out of room to get the nurse. CNA C remembered the pad was blue with different colored straps. CNA C does not know if CNA D was in the room before the fall. During an interview on 10/24/25 at approximately 5:00 P.M., the Medical Director said he expected staff to follow the facility policy. 2648788

Based on interview and record review, the facility failed to ensure two residents' right to be free from abuse was not violated, when a staff member threatened a resident, using profanity and was held back by other staff (Resident #6). In addition, Residents #1 and #2 were involved in a physical resident to resident altercation. Resident #2 flipped Resident #1's mattress over, which caused Resident #1 to fall and hit the floor. The sample was 9. The census was 85. The Administrator was notified on 8/15/25 at 9:56 A.M. of the past non-compliance, which began on 7/13/25. The facility immediately separated Resident #6 and the employee, who threatened the resident. The employee was suspended pending investigation and later terminated. Staff determined there was no physical injury to the resident. The resident's care plan was updated and social services followed up with the resident. In addition, the facility provided education for staff on de-escalation. In addition, the Administrator was notified on 8/15/25 at 9:56 A.M. of the past non-compliance, which began on 7/26/25. The facility immediately separated both residents and performed head to toe skin assessments. Resident #1 reported he/she felt safe at the facility, and he/she was fine. The police were contacted, and Resident #2 was issued a citation for peace disturbance. Resident #2 was immediately sent out to the area's local hospital for an evaluation, treatment, and monitoring. No new orders were given. Upon his/her return to the facility, Resident #2 was placed on a different floor. In addition, he/she was being followed Psychiatrist G and was placed on 72 hours (1:1) behavior monitoring. The facility also started working on alcohol abuse resources/referrals for Resident #2 to include Alcohol Anonymous (AA) classes in which the resident agreed to attend. The facility immediately conducted their investigation, whereas several residents along with staff were interviewed. An all-staff education was immediately started on abuse, neglect, and exploitation with emphasis on identifying and reporting abuse and neglect. The noncompliance was corrected on 7/28/25. Review of the facility's Abuse Prevention and Prohibition Program policy, revised 8/22, showed:-Purpose: To ensure the facility establishes, operationalizes, and maintains an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements;-Policy: --Each resident has the right to be free from mistreatment, neglect, abuse, and voluntary seclusion and misappropriation of property the facility has zero tolerance for abuse, neglect, mistreatment and or misappropriation of resident property staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect mistreatment or misappropriation of property;--The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental or psychosocial well-being;--The Administrator is responsible for coordinating and implementing the facilities abuse prevention policies, procedures, training programs, and systems. 1.Review of Resident #6's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/17/25, showed:-Cognitively intact;-No behaviors;-Independent with Activities of Daily Living (ADL, essential and routine self-care tasks that most healthy individuals can perform without assistance);-Diagnoses included asthma and other abnormalities of breathing. Review of the resident's care plan, updated 4/3/25, showed:-Focus: The resident has impaired cognitive function or impaired thought processes;-Goal: The resident will maintain current level of cognitive function through the review date;-Interventions: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues. Stop and return if agitated;-Focus: The resident has potential to demonstrate verbally abusive behaviors toward other residents and staff;-Goal: The resident will verbalize understanding of need to control verbally abusive behavior through the review date;-Interventions: --Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation;--Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document;--Document observed behavior and attempted interventions in behavior log. Review of the facility's investigation, dated 7/14/25, showed:-Description: Resident #6 was in an angry mood and cussing at Certified Nurse Aide (CNA) A. Resident #6 was rude to another resident. CNA A allegedly attempted to correct Resident #1 and tried to dissuade him/her from his/her behavior. Resident #6 called CNA A a b***h and walked over to him/her in an aggressive manner. CNA A responded and said something back to Resident #6. CNA A allegedly said, your mom's a b***h and allegedly said that he/she was going to f*** (him/her) up. There was another CNA and nurse who intervened and stood between CNA A and Resident #6. Resident #6 tried to get to CNA A, but the two were kept separated. The incident occurred in the second floor dining room;-Findings: Resident #6 had a Brief Interview for Mental Status (BIMS, a screening tool used to determine cognitive impairment. A score of 13 to 15 suggests the patient is cognitively intact) of 15 and medical diagnosis of asthma, abnormalities of breathing, and psycho-active substance use;--CNA witnessed aggressive behavior;--Resident #6 was verbally aggressive with Resident #4 briefly and the staff member intervened;--Resident #6 has a history of verbal aggression. He/She is fully ambulatory, and has some history of physical aggression but with no contact;--Resident #6 is his/her own responsible party. Resident #6's physician was notified. The Administrator and Director of Nursing (DON) were also notified;-During the interview, the resident stated Resident #4 stopped and blew his/her nose right by him/her. Resident #4 is always doing this kind of stuff. He/She claimed that he/she only turned to him/her and said come on [NAME] what are you doing?;--Resident #6 said CNA A became mad at him/her for it and would not stop.--Resident #6 stated CNA A said something about his/her mother, called him/her a crack head, and threatened to do something to him/her if CNA A saw him/her outside;--Resident #6 interview with the Director of Nurses (DON): After CNA A intervened, the resident told the CNA you look like you crawled out of a bad dog food bag. The CNA responded by calling Resident #6 out and talking about his/her mother. The resident stated he/she was sorry for his/her response to the CNA because that was rude of him/her. He/She stated that he/she doesn't feel he/she is in any danger and that he/she feels safe in the facility;-Safe surveys were completed with Resident #6;--Resident #6 stated that he/she felt safe except when CNA A was in the building on 7/13/25;--On 7/14/25, Resident #6 said he/she felt safe and said he/she wanted to apologize to CNA A;-Upon interview with the Administrator, Resident #6 stated that CNA A kinda hurt his/her feelings a bit by saying something about his/her mother;-The police were notified immediately, and arrived on scene at 4:37 P.M., the officer did not take a report;-The residents in the facility were protected from any potential harm. CNA A was removed from the area of the incident immediately, asked to make a statement and suspended pending investigation;-Interviews with staff were completed and statements obtained;-Interviews with staff and statements noted the following:--Resident #6 reacted to Resident #4, who had stopped close to him/her and blew his/her nose. Resident #6 said what the f*** is wrong with you?. CNA A reported Resident #6 said to Resident #4, why the f*** would you blow your nose so close to me. At that point, CNA A corrected him/her and said Resident #4 doesn't know what (he/she) is doing, you don't have to be so mean to (him/her). Resident #6 and CNA A exchanged words, with Resident #6 repeatedly telling CNA A to mind (his/her) own business. CNA A argued back saying that it is (his/her) business, because (Resident #4) is a resident in the facility.;-The above details are the start of the encounter, and was noted by CNA B and dietary aide (DA) D. Both corroborated the incident, in particular, DA D noted Resident #6 told CNA A to mind (his/her) own damn business;--Resident #6 then got up and moved towards CNA A in an aggressive manner;--Resident #6 called CNA A a b***h, and CNA A responded by calling Resident #6's mother a b***h. CNA B intervened and kept CNA A and Resident #6 separated. It was reported by Licensed Practical Nurse (LPN) C that CNA A said I'm gonna f*** you up, you can't keep talking to me. During this time, Resident #6 continued to insult CNA A;--LPN C intervened helping CNA B with the Resident #6 and CNA A. They kept the staff and residents separated;-Resident #6 and LPN C said CNA A called Resident #6's mother a b***h;-Resident #6 and LPN C both said CNA A threatened Resident #6. CNA A reported he/she was defending himself/herself;-Residents were interviewed; --The residents did not report much detail about the incident; --The residents in the dining room at that time reported that they felt safe;-Conclusion: CNA A responded to an aggressive resident by making comments which have been corroborated by the investigation. The comments included an insult about the resident's mother and a threat towards Resident #6;-Recommendation:--The Interdisciplinary team will continue to review and monitor the behavior of Resident #6 for interventions;--Resident #6 has been on 30 minute checks to identify mood and behavior;--Education provided on abuse and neglect, resident rights and resident incidents with staff;--Onsite education for staff on de-escalation;--Social Services will follow Resident #6 and make recommendations for mental health assessments and counseling in the facility and outside the facility when discharging;--After review, the decision has been made to terminate CNA A. During an interview on 7/18/25 at 1:14 P.M., Resident #4 said he/she did not remember the incident. He/She felt safe in the facility and had no issues with any other residents or staff. During an interview on 7/18/25 at 1:52 P.M., CNA B said there is a resident (Resident #4) upstairs in his/her early stages of dementia and he/she doesn't really understand what's going on and other residents pick on him/her. Resident #4 was sitting at a table behind Resident #6, he/she was trying to leave his/her table to blow his/her nose. He/She moved approximately two to three feet behind Resident #6 and blew his/her nose. Resident #6 got aggressive and he/she turned around and said Damn, I'm eating. Like what the f***, why would you come over here and blow your freaking nose? What the heck is wrong with you? Wow! CNA A overheard it and told Resident #6 that Resident #4 doesn't understand what's going on, you know you don't have to talk to (him/her) like that. Resident #6 said oh shut up I'm not talking to you, I'm talking to (Resident #4). This is between me and (Resident #4). CNA A said you know who you talking to like that? I'm not these other people, you got me messed up or whatever, you don't talk to me like that. CNA B intervened and tried to calm CNA A down and told him/her not to engage or argue with the resident. CNA B couldn't tell Resident #6 to stop because if he/she would have, he/she would have turned on me. So, CNA B was trying to stop CNA A and told him/her he/she could lose his/her job. CNA A said, I don't care. CNA B tried to hold CNA A back. CNA B couldn't stand there and let CNA A hit a resident. Resident #6 started picking on CNA A's mom (who works as a CNA on night shift). CNA B did not actually hear what CNA A said to Resident #6 because he/she was talking over CNA A, trying to get him/her to be quiet. Resident #6 then said CNA A's mom was a crackhead and got up and took a few steps forward. CNA B had to physically hold CNA A back because he/she started stepping forwards toward Resident #6. The nurse also got between the CNA and the resident. CNA B never witnessed CNA A ever become aggressive with Resident #6 or any other resident prior to this incident. After the incident, the administrator got his/her statement and he/she received education on resident abuse and de-escalation tactics. During an interview on 7/18/25 at 2:23 P.M., CNA A said it started when they were passing lunch. One of the other residents, who is not in his/her right mind, got up and he/she blew his/her nose by Resident #6. He/She got angry and was yelling at the other resident so CNA A intervened. Resident #6 told CNA A to mind my f***ing business, and this was his/her business. CNA A told Resident #6 it was his/her business and Resident #4 couldn't defend himself/herself because he/she was not in his/her right state of mind and really doesn't know what he's/she's doing. Resident #6 got up and was walking around and continued to be disrespectful. CNA A told Resident #6 he/she could just go to his/her room because he/she was being disruptive. That's when he/she sat down and then got back up. Resident #6 came towards CNA A like he/she was going to hit him/her. CNA A told Resident #6 he/she was not that f***ing person, that he/she was not that b***h, because he/she had been calling CNA A a b***h prior to this. This was when the nurse and CNA B both intervened and told CNA A to just go outside and calm down because he/she was getting loud. He/She was down to go outside and calm down. CNA A went outside and called the Staffing Coordinator and told him/her what had happened. When he/she calmed down and went back inside, LPN C told him/her that he/she had to go home. CNA A wrote a statement and left, and has not been back to the facility since. CNA A did not threaten the resident or tell him/her that he/she was going to f*** (him/her) up. Resident #6 told CNA A that when he/she was walking towards him/her, trying to hit him/her. CNA A did not tell Resident #6 his/her mother was a b***h, he/she called CNA A's mom that. Resident #6 kept telling him/her him/her and his/her mother were both crackheads and saying look at that ugly b***h. Resident #6 had never been that way towards him/her before the incident. Resident #6 has been in multiple altercations around the facility. During an interview on 7/18/25 at 3:00 P.M. Resident #11 said it was really a misunderstanding at first. Resident #4 came next to him, he/she is a really nice person, and he/she was blowing his/her nose, like rigorously blow his/her nose. Resident #6 said, you're killing me [NAME] and was kind of laughing. One of the nurses heard that. That CNA was locked and loaded and he/she started yelling at him/her, saying you're a crackhead and he/she threatened the resident physically. It was really like he/she had it in his/her mind that he/she was doing this terrible atrocity. They were holding the CNA back and he/she was yelling at and threatening him/her. The resident feels safe in the facility. The resident was not fearful but definitely hurt by those accusations. The CNA called his/her mom a name, and his/her mom died unfortunately in 2015. When he/she was in the facility on Sunday, he/she didn't really feel safe, but other than that he/she does. There's a lot of really good people here. The facility addressed the issue and removed CNA A that day. They were pretty thorough about that. During an interview on 7/18/25 at 3:44 P.M., LPN C said he/she was down the hall and heard some something, something with yelling. He/She jumped up and walked over to the dining room because he/she knew it was coming from that way. He/She heard, he/she wants to say Resident #6, say b**ch or something like that and CNA A said your momma don't come visit you or something like that. He/She had a CNA standing in front of CNA A and he/she was standing behind the CNA. LPN C was looking at the front of Resident #6 so they had two people in front of both of them. The two of them, the CNA and himself/herself, sandwiched in the middle. Resident #6 was on the outside of him/her and CNA A was on the outside of the other CNA. Resident #6 was trying to walk around the staff to yell at CNA A or get to him/her. LPN C heard CNA A say I'm gonna f*** you up or something about I'm gonna f*** you up. LPN C saw CNA A pointing, and he/she saw CNA A bobbing around the other CNAs head talking. He/She asked CNA A like 3 times to please leave this dining room. As soon as CNA A calmed down, he/she told CNA A he/she was going to have to leave the building and he/she did without any problems whatsoever. CNA A did come back up and grabbed a pen and paper and said that someone told him/her to write his/her statement. He/She said OK, but CNA A had to leave out of the building as soon as he/she was done. CNA A was never around the resident again after that one time. He/She was very shocked. He/She walked CNA A to the elevator and that was that. The facility provided in-servicing on verbal abuse and abuse in general. It defined the residents' rights and exactly what staff are to do, or try to do, you know steps to take to try to deescalate the situation, the DON and Administrator notified of the incident within one minute of walking away after it happened because LPN C walked him/ her to the elevator and watched him/her get on. The second he/she got on the elevator, LPN C started calling administration. The police were not called because he/she felt like they had it under control at that point. Resident #11 was asked if he/she was scared, or if he/she felt threatened at that time. Resident #6 said no. There was no injury to Resident #6. During an interview on 7/18/25 at 3:56 P.M., the DON said that during the investigation, he/she interviewed Resident #6. The resident said Resident #4 sneezed and he/she told Resident #4 [NAME], I know you didn't do that. Resident #6 said when he/she approached Resident #4, the CNA began to say don't treat (him/her) like that, you know (he/she) is not aware of what (he/she) is doing . Resident #6 then said he/she began to tell CNA A it was not his/her business, they began to go back and forth. The resident cursed CNA A and CNA A said some words to the resident. Resident #6 said he/she was sorry for what he/she said to CNA A. Resident #6 said it was too late to take it back, because those words were very hurtful that he/she said to him/her. Resident #6 was educated that he/she should have backed away from it. The employee should not have gone back and forth with the resident. Resident #6 said he/she felt safe in the facility and he/she didn't feel CNA A was a threat or anything of that nature so he/she did feel safe and was not in any danger in the facility. CNA A is still on suspension. The Administrator called the DON on 7/17/25 and said he would be terminating CNA A. During an interview on 7/18/25 at 4:59 P.M., the Administrator said that he was able to corroborate the threatening statement was made by CNA A. Resident #6 said that it was insulting to him/her and his/her mother. His expectations are for staff to get the potential victim away from the aggressive resident, get out of the way and try to de-escalate the situation. It was not appropriate of acceptable for CNA A to curse at or threaten Resident #6. Staff was in-serviced to de-escalate, protect the other resident and don't go in with an aggressive manner. 2. Review of the undated facility's investigation summary provided by the Regional Nurse, showed:-Summary of Investigation: Abuse Allegation Investigation;-Report completed by the Administrator;-Precipitating Incident: On 7/26/25 at approximately 7:10 A.M., it was reported by CNA E, that Resident #2 attempted to hit his/her roommate Resident #1. Per first interview with Resident #1, Resident #2 missed when he/she swung at Resident #1, but then pushed Resident #1 to the ground. CNA E walked in and separated the two residents. The residents were separated immediately;-Key Witnesses: CNA E and LPN C;-Findings: CNA E witnessed the end of the altercation. Resident #2 had become aggressive with Resident #1 because he/she was making noise too early in the morning. LPN C and CNA E noted the smell of alcohol on Resident #2's breath. Resident #2 acknowledged that he/she had been drinking: Resident #2 was sent to the ER for an assessment. The urine screen was requested but the hospital records did not show high ammonia levels or make any note of alcohol. Resident #2 is his/her own responsible party. The Physician, Administrator, and the DON was notified. Resident #2 is being followed by a psychiatrist and was on behavior monitoring. During an interview, Resident #2 stated his/her roommate was moving around every morning while he/she was trying to sleep, and he/she was sick of it. LPN C had asked Resident #2 if he/she had had drank liquor and he/she said yes, but he/she was not sure of how much he/she had. Social Services met with the resident regarding behavior agreement. On July 8, 2025, Resident #2 signed a behavior agreement expressing an agreement to not drink. The policy on alcohol use was reviewed with him/her at the time. Resident #2 met with Social Services to discuss alcohol abuse treatment. Resident #2 had agreed to attend AA meetings and participate in the program. Upon interview Resident #1 said he/she felt safe in the facility and that he/she was fine. Resident#1 said his/her roommate started yelling at him/her, telling him/her that he/she was always making noises and waking him/her up then pushed him/her to the floor and swung on him/her with his/her fist but stumbled and missed then went to swing on Resident #1 again and the door opened, and it was the girls (staff). LPN C took Resident #1's vitals. He/She asked the resident if he/she was ok or was he/hurt in anyway and the resident responded no that he/she was fine. LPN C asked Resident #1 if he needed medical help and he/she said, no, he/she only pushed him/her down. No injury noted. Resident #1 did not have a history of behaviors or altercations. A Trauma Informed Care assessment had been completed and Social Services was following the resident. The Police were notified immediately and arrived on scene at 10:00 A.M. Upon interview with the Police, Resident #1 said the incident was a first, he/she and his/her roommate have not had problems before. Upon exit the Police stated they would issue a ticket and summons for Peace Disturbance. The residents in the facility were protected from any potential harm. Interviews and Staff were interviewed and statements obtained; -CNA E wrote: He/She was walking down East hall, and he/she heard a lot of noises like someone was falling. Once he/she heard a vase fall, he/she opened the door and he/she noticed Resident #2 was standing over Resident #1 who was down on the ground between the bed and the night stand and CNA E yelled for assistance;-LPN C: He/She was called down to the residents' room by two CNAs who said Resident #2 was hitting Resident #1. LPN C went to the residents' room and observed Resident #2 was standing Resident #1, while Resident #1 was on the floor next to his/her own bed. Resident #2 was yelling that he/she was tired of Resident #1 making noises over there. LPN C immediately smelled liquor on Resident #2's breath;-Safe surveys were completed. Residents on the hall and in the dining room were interviewed and stated they felt safe. Upon return from the hospital Resident #2 was placed on 1 to 1 and residents were kept safe;-The incident was reviewed in QAPI on July 28, 2025, the first business day after the incident;-Conclusion: Resident #2 was under the influence of alcohol, an unspecified amount, became angry and pushed Resident #1 to the floor. Resident#1 had no injuries and felt safe in the facility;-Recommendation: The IDT was to continue to review and monitor the behavior of Resident #2. Social Services was to work with Resident #2 on treatment and management of his/her alcohol abuse. -Education on Abuse Neglect, resident to resident incidents with staff. Social Services was to follow Resident #2. Review of Resident #1's quarterly MDS, dated [DATE], showed:-Severe cognitive impairment;-Mobility devices: None used;Diagnoses included hypertension (high blood pressure) and hyperlipidemia (high cholesterol) Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: Resident was involved in an altercation with his/her roommate;-Goal: Resident will have his/her needs met by the interdisciplinary team (IDT) and not fear staff or residents through the next review period;-Interventions: Assess for signs of being afraid or skittish around residents or staff. Involve family for support and redirection activities. Refer to psych services as needed for support. Review of the resident's progress notes, dated 7/26/2025, showed:-At 7:10 A.M., LPN C was called to residents' room by two CNAs. They said Resident #2 was hitting Resident #1. LPN C went to the resident's room and observed the resident on his/her buttocks next to his/her bed with his/her roommate, Resident #2 standing over him/her and was yelling at him/her. LPN C removed Resident #2 from the room immediately. Action: Resident #1 said Resident #2 started yelling at him/her that he/she was always making noises over there and waking Resident #2 up. Then Resident #2 pushed the resident to the floor and swung on the resident with his/her fist but stumbled and missed. Then Resident #2 swung on the resident again, but the door opened, and it was the girls (staff). Resident #2 removed from room asap. The resident stood up by himself/herself from floor and sat in a chair. LPN C assessed the resident. The resident denied pain before, during and after skin assessment completed. Vitals (VS): blood pressure (B/P) 136/74, pulse (P) 80 reg, respirations (resp) 20 even unlabored, temperature (T) 98.1. LPN C asked the resident if he/she was ok or was he/she hurt in any way. The resident said no, he/she was fine. LPN C asked the resident did he/she need medical help and he/she said no, Resident #2 only pushed him/her down. No injury noted. Physician C made aware, no new orders. Director of Nursing (DON) and Administrator aware of situation. LPN C asked the resident if he/she need assistance getting ready and he/she said, no. Per the resident, all needs and wants met prior to the time LPN C exited the room;-12:27 P.M., LPN C spoke with the resident's family member that morning regarding the altercation between him/her and his/her roommate. The resident said he/she was okay and felt fine. He/She also said that if his/her vision was better, that he/she could have handled himself/herself a bit better during the altercation. The resident's family member only mentioned his/her roommate being moved and stated that he/she was glad that the resident was okay. Through observation, the resident appeared to be in good spirits and wasn't in any pain from the altercation. During an interview on 8/4/25 at 3:12 P.M., the resident said he/she didn't know how long he/she had been at the facility. Someone had hit him/her but it wasn't a big thing. The other person was a resident like he/she was. He/She didn't know the other resident's name. Then the resident said it was his/her roommate, Resident #2. They had been roommates for maybe a year. Resident #2 did not hit him/her, but Resident #2 had flipped his/her mattress over off the bed and the resident fell and hit the floor. His/Her right hip had hurt then but now it was sore once in a while. He/She didn't know if staff were around at that time or not. He/She had had covid at one time so he/she couldn't see anything. Resident #2 was never on top of him/her trying to hit him/her. Some of the staff came in when they were tussling and one staff got the resident and put him/her in one place and another staff person got Resident #2 and put him/her in another place. He/She was not sent to the hospital. He/She didn't know what staff intervened or their names, but they separated them. He/She didn't know why Resident #2 did that to him/her. He/She never found out the reason why. The resident was awake when he/she was flipped over. He/She was not asleep. He/She had not been hit in the face or eyes, nor did the resident hit his/her face or eyes when he/she fell to the floor. He/She wasn't aware if Resident #2 had gone to the emergency room or not. Review of Resident #2's annual MDS, dated [DATE], showed:-No cognitive impairment;-No behaviors;-Mobility devices: None;-Diagnoses included stroke and depression. Review of the resident's medical record, showed an additional diagnosis included alcohol abuse. Review of the resident's care plan, in use at the time of the investigation, showed:-Focus: The resident has potential to be to demonstrate physical behaviors related to poor impulse control;-Goal: Resident will verbalize understanding of need to control physically aggressive behavior through the review date;-Interventions/Tasks: Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's need: food, thirst, toileting needs, comfort level, body positioning, pain, etc.;-Focus: The resident had been advised of the facility alcohol policy;-Goal: The resident will be compliant with the facility alcohol policy through review date;-Interventions/Tasks: Educate Resident on the importance of not drinking alcohol related to his/her medications and diagnoses. Remind family of the facility's alcohol policy. Remind the resident that it was not within the facility's policy for him/her to purchase alcohol and take it into the facility;-Focus: The resident was resistive to care of the facility by consuming alcoholic beverages and therefore he/she was issued a behavior agreement to become more compliant with facility rules and regulations;-Goal: The resident will comply with care by not consuming alcohol policy through the next review date;-Interventions/Tasks: Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Offer resident AA services/counseling for his/her addiction through outside source. Resident's room was to be checked if any suspicion of resident having alcohol in his/her room with resident's permission. Review of the resident's Residents Behavior Agreement, dated 7/8/25, showed:-He/She promised to refrain from loud verbal confrontation and physical aggression with other residents. He/She would treat fellow residents with kindness and in a dignified manner;-He/she was to refrain from using alcohol or other drugs unless prescribed by physician and provided by nursing;-He/she promised to avoid the use of alcohol or drugs while out on leave of absence (LOA). He/She further promised to check in with the nurse for assessment upon return from LOA;-He/She was to work with Social Services on outpatient referral for substance abuse treatment. Review of the resident's progress notes, dated 7/26/25, showed:-At 7:10 A.M.; LPN C was called down to residents' room by two CNAs who stated the resident was hitting Resident #1. LPN C went to the residents' room and observed the resident standing over Resident #1, while Resident #1 was on the floor next to his/her own bed. The resident was standing over Resident #1 screaming he/she was tired of Resident #1 making noises over here. LPN C did smell liquor on the resident's breath. LPN C immediately removed the resident from room. LPN C spoke with the resident one on one in the[TRUNCATED]

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity when an employee did not accommodate one resident's request for condiments during meal service, and engaged in an argument with the resident (Resident #3). The sample was seven. The census was 86. The Administrator was notified on 6/25/25 at 3:53 P.M., of the past non-compliance, which occurred on 6/15/25. The facility provided in-servicing for staff regarding interventions to deescalate when a resident becomes agitated. The deficiency was corrected on 6/23/25. Review of the facility's Privacy and Dignity policy, revised June 2020, showed: -Purpose: To ensure that care and services provide by the facility promote and/or enhance privacy, dignity and overall quality of life; -Policy: The facility promotes resident care in a manner and an environment that maintains or enhances dignity and respect, in full recognition of each resident's individuality; -Procedure: -Staff assists the residents in maintaining self-esteem and self-worth; -The facility promotes independence and dignity in dining; -Staff treat residents with respect including respecting their social status, speaking respectfully, listening carefully. Review of the facility's Customer Service document, provided to staff during orientation, undated, showed: -Customer service is the cornerstone of every business. The concept of excellent customer service is used in many brand taglines to assure customers that their wellbeing is the most important aspect of the customer-business relationship. This section outlines the five elements that will strengthen and drive our customer service program: -Service: In the profession of care giving, serving the client is the one thing that drives the program. Employees who select caregiving as a profession must put others before themselves every hour of every day. A resident who has immediate needs, whether great or small, requires staff to be servants to their needs without regard to their own personal needs. Caring for the elderly means nothing is more important than prompt, polite and friendly responses. Service for residents, families and coworkers is the obligation of caregiving; -Attitude: Attitude is conveyed by body language, words, and eye contact. A change in attitude by itself can positively affect the way someone is perceived. Every day, every conversation and every encounter can be controlled in a positive way by choosing the right body language, tone of voice, facial expressions, and words. Attitudes are contagious. Caregivers cannot afford to convey an image of a bad attitude - because the collective actions of staff convey the attitude of the entire facility; -Respect; -Applying Customer Services Skills: -Be pleasant and polite with our community. -Understand their request; -Be patient; -Use positive language and remove negative words; -Remember you are in someone's home. Review of the Dietary Aide (DA) position description, revised December 2023, showed: -Meal Service Responsibilities: -Dietary services must be provided to residents according to their individual needs, as determined by assessments and care plans; -Promotes customer service and resident enjoyment of meals and dining; -Customer Service Responsibilities: -Models customer service principles throughout the center and promotes appreciation of our customer's needs; -Treats residents, residents' family members, visitors and fellow employees with courtesy, respect, and dignity; -Resident Rights: -Understands, upholds, and promotes the rights of the residents; -Ensures resident concerns/complaints are responded to with tact and urgency. Review of DA A's employee file, showed a Documentation Checklist for General Orientation Information, signed by the employee on 2/6/25. The checklist showed the employee confirmed by signing that he/she received information and reviewed the material regarding the identified items on the checklist, which included Customer Service. Review of Resident #3's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/27/25, showed: -Cognitively intact; -Verbal and physical behavior not exhibited; -Diagnoses included depression and unspecified mood disorder. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident has potential to demonstrate physical behaviors related to anger. Poor impulse control toward staff and other residents; -Focus: Resident has potential to become verbally abusive related to ineffective coping skills, poor impulse control; -Interventions/tasks included: -Assess and anticipate the resident's needs; -Provide physical and verbal cues to alleviate anxiety; -Give the resident choices about care and activities to help de-escalate the situation; -When the resident becomes agitated, intervene before agitation escalates. Guide away from source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later; -Assess resident's coping skills and support system; -Assess resident's understanding of the situation. Allow time for the resident to express self and feelings toward the situation; -Provide positive feedback for good behavior; -Focus: Resident has experienced verbal abuse by one staff member evidenced by an incident that occurred on 6/15/25; -Interventions/tasks included during a verbal or physical aggression, staff will intervene and separate all parties. Review of the resident's general progress note, dated 6/15/25 at 8:30 A.M., showed Licensed Vocational Nurse (LVN) D documented resident complained of not receiving condiments from dietary. Resident upset and complained to dietary. DA arguing with resident. This nurse redirected resident several times. This nurse asked DA to stop arguing with resident. DA refused and continued to argue. Housekeeping Supervisor notified to diffuse the situation. Housekeeping Supervisor separated staff from resident. During an interview on 6/25/25 at 9:43 A.M., the resident said during breakfast in the first-floor dining room, he/she asked DA A for salt and pepper. DA A said there weren't any salt and pepper, and the resident went to the second floor and got some salt and pepper. When he/she returned to the first-floor dining room, DA A laughed at the resident and said, Haha, that's why you ain't got no salt and pepper, in a taunting manner. DA A called the resident skinny, old, bald-headed, and told the resident to get some hair weave. DA A was disrespectful. The resident needs good service and is supposed to be accommodated. During an interview on 6/25/25 at 9:50 A.M., Certified Nurse Aide (CNA) B said he/she was helping serve breakfast in the first-floor dining room when the resident and DA A got into an argument. The resident wanted salt, pepper, sugar, and milk, and dietary had none of these items. Dietary is supposed to have these items available for residents during meals. The resident went upstairs to the second floor to get the items he/she wanted. When he/she came back to the first-floor dining room, DA A could not control him/herself and laughed at the resident. The resident asked what he/she was laughing at, and DA A kept laughing and began exchanging words with the resident. DA A taunted the resident and called the resident skinny and bald-headed. DA A was rude, inappropriate, and unprofessional. He/She argued with the resident for several minutes. When the resident asked for condiments, DA A should have gotten the resident what he/she wanted. During an interview on 6/25/25 at 11:10 A.M., LVN D said he/she was at the nurse's station next to the first-floor dining room when the resident came back from the second floor with some condiments. DA A said he/she did not care that the resident didn't have his/her condiments, and this upset the resident. The resident and DA A started arguing. LVN D told DA A to stop arguing and to step away, but DA A stayed and kept going. DA A called the resident skinny and bald-headed. He/She was inappropriate, cussing and calling names while arguing with the resident. The resident said he/she would spit on DA A, and DA A said if that happened, he/she would spit on the resident. The exchange between the resident and DA A lasted for five minutes. DA A would have gotten a better response from the resident if he/she had just gotten the items the resident requested. During an interview on 6/25/25 at 2:17 P.M., DA C said he/she was on the second floor serving breakfast and could hear DA A yelling with someone else downstairs. DA C went to the first floor and saw the resident and DA A yelling back and forth in the dining room. DA A was cussing at the resident. The resident said he/she would spit on DA A and DA A told the resident to do it and laughed at him/her. The way DA A acted toward the resident was disrespectful. During an interview on 6/25/25 at 11:32 A.M., the Housekeeping Supervisor said during breakfast, she was getting off the elevator on the first floor when she heard commotion in the dining room. She saw the resident and DA A standing at the steam table, going back and forth. DA A taunted the resident and said fuck you to him/her. The Housekeeping Supervisor escorted DA A out of the dining room and had him/her clock out and go home. The situation could have been avoided if DA A had just gotten the salt and pepper the resident requested. During an interview on 6/25/25 at 1:32 P.M., DA A said during breakfast, he/she was preparing plates at the steam table with another dietary aide. The resident came up to the steam table and asked for salt and pepper. There was no salt and pepper on the dietary cart. DA A could not get the items requested because he/she was busy preparing plates and this task requires two staff. The resident cussed at DA A, then went to another floor to get the salt and pepper. When the resident came back to the dining room, another employee asked DA A for milk. DA A left the dining room to get the milk and when he/she returned, the resident called him/her a name and made a comment about how the DA A could leave to get milk, but not salt and pepper. DA A said, You're too rude, that's why I didn't break my neck getting it for you. He/She went back and forth with the resident and called him/her skinny. When the resident said he/she would spit on DA A, DA A said, Y'all play crazy but you're not crazy enough to spit on me. When asked why DA A chose to go back and forth with the resident, he/she said the resident was starting to irritate him/her. He/She could have just not said anything, but the resident was right in front of him/her, so DA A said something bad. Looking back on the situation, he/she probably wouldn't have gone back and forth with the resident, but he/she would still make the comment about the resident not being crazy enough to spit on him/her. Review of the facility's investigation summary, undated, showed: -Interviews with staff noted the resident and DA A had a back and forth exchange. Resident was loud and aggressive at the steam table with the dietary staff. DA A went back and forth with the resident about the salt and pepper, did not honor the resident's request, and kept responding in an argumentative manner to the resident's comments; -Recommendation: The staff member, DA A, will be terminated. Education with staff. Review of DA A's Corrective Action Memo, dated 6/25/25, showed: -Type of Violation: Violation of policy or procedure and unsatisfactory customer service; -Employer Statement: Unsatisfactory customer service and approach to the residents; -Objectives/Solution: Termination. During an interview on 6/25/25 at 3:53 P.M., the Administrator said the interaction between the resident and DA A is considered a customer service and dignity issue. DA A should have given the resident what he/she wanted and stepped away from the situation. DA A was terminated based on his/her approach and arguing back with the resident. Approach is critical in these situations. Staff have been educated to never argue back with residents and to deescalate when a resident is aggressive. MO00255863

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 34 opportunities observed, nine errors occurred resulting in a 26.47% error rate (Residents #11, #7, #12 and #4). In addition, Resident #1, Resident #4, and residents attending the 3/3/25 Resident Council meeting complained about receiving medications late. The census was 86. Review of the facility Medication-Administration policy, dated 5/2017, showed: -Policy: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations; -Procedure: -Medications are prepared, administered, and recorded only by licensed nursing, Certified Medications Technicians (CMTs), medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications; -Current medications and dosage schedules are listed on the resident's Medication Administration Record (MAR); -Medications are administered within 60 minutes of scheduled time (60 minutes before or after the scheduled time); -If a dose of regularly scheduled medication is withheld or refused, the space provided on the front of the MAR for that dosage administration is initialed and circled; -Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. 1. Review of the facility 3/24/25, resident census report showed 39 residents resided on the 100 hall. During an interview on 3/24/25 at 10:05 A.M., CMT I, who was on the floor passing the morning medications said he/she is the only CMT who passes medications on the 100 hall on day shift. He/She arrived at work at 7:00 A.M., and started the med pass around 7:30 A.M. He/She has about 40 residents to pass medications to. He/She just finished passing medications to the 153-168 hall and some residents while they were in the dining room. He/She still had about 9 residents left to pass medications to in the 112-127 hall. By the time he/she finished the morning medication pass, it was about time to begin the noon medication pass. The facility really needs a second person to help pass the morning medications. Observation at 11:10 A.M., showed the CMT finished his/her morning medication pass. 2. Observation on 3/25/25 at 10:00 A.M., showed CMT I prepared Resident #11's morning medications which included baclofen (muscle relaxant) 10 milligrams (mg) two times a day at 8:00 A.M. and 8:00 P.M. At 10:09 A.M. The CMT administered the medications to the resident at 10:09 A.M. 3. Observation on 3/25/25 at 10:11 A.M., showed CMT I prepared Resident #7's morning medication, levetiracetam (anti seizure medication) 1000 mg every 12 hours at 8:00 A.M. and 8:00 P.M. The CMT administered the medication to the resident at 10:12 A.M. 4. Observation on 3/25/25 at 10:13 A.M., showed CMT I prepared Resident #12's morning medications which included gabapentin (used to treat nerve pain) 400 mg three times a day at 8:00 A.M., 12:00 P.M., and 4:00 P.M. Pentoxifylline (improves blood flow) 400 mg three times a day at 9:00 A.M., 1:00 P.M., and 5:00 P.M. Risperidone (antipsychotic) 0.5 mg two times a day at 8:00 A.M., and 5:00 P.M. Oxycarbazepine (anti seizure medication) 300 mg twice a day at 8:00 A.M., and 5:00 P.M. The CMT administered the medication to the resident at 10:26 A.M. 5. Observation on 3/25/25 at 10:28 A.M., showed CMT I prepared Resident #4's morning mediations which included Oyster Shell Calcium (used to prevent calcium deficiency) 250 mg twice a day at 8:00 A.M. and 4:00 P.M., and Eliquis (used to prevent blood clots and lower the risk of stroke) 5 mg twice a day at 8:00 A.M. and 4:00 P.M. The CMT administered the medication to the resident at 10:36 A.M. During an interview on 3/24/25 at 7:30 A.M., Resident #4 said he/she gets his/her morning medications late all the time. Sometimes not until 11:00 A.M. or 12:00 P.M. 6. During an interview on 3/25/25 at 10:36 A.M., CMT I said medications should be administered one hour prior to, or one hour after the medication administration time. He/She had four more residents to administer medications to before the morning medication pass was finished. 7. Review of the Resident Council minutes, dated 3/3/25 at 11:12 A.M. - 11:35 A.M.,, attended by 14 residents, showed residents raised concerns about not getting their medications on time. 8. During an interview on 3/25/25 at 12:27 P.M., Resident #1 said when they start passing medications on his/her hall he/she gets his/her medications on time. When they start passing on the other hall first it can be close to noon before he/she gets his/her 8:00 A.M. medication. 9. During an interview on 3/25/25 at 8:44 A.M., the Director of Nurses said the residents are supposed to be on a liberalized med pass (flexible med pass times such as A.M. (7 A.M. to 11:00 A.M.)). She did not know the meds were still being passed on traditional set times. In that case, an 8:00 A.M. med can be passed from one hour before (7:00 A.M. to one hour after (9:00 A.M.)). Anything out of that range would be considered a medication error. 10. During an interview on 3/25/25 at 12:52 A.M., the Administrator said he thought the medication pass was liberalized. He did not know the residents had specific times scheduled. If there are specific times scheduled, the medication should be received one hour prior to the time scheduled or up to one hour after the time scheduled. Anything out of those time parameters would be considered a medication error. MO00246938 MO00248935 MO00250663

Based on observation, interview and record review, the facility failed to ensure residents who required enhanced barrier precautions (EBP) for infection control interventions had a sign on their door or wall next to the room entrance instructing staff to use EBPs while providing personal care. In addition, the facility failed to ensure personal protective equipment (PPE, gloves, gowns, masks and goggles/face shields) were readily accessible for residents requiring EBP, and staff were inserviced on EBP and which residents required EBPs. The facility identified 18 residents who required EBPs, and this had the potential to affect all residents (Residents #5, #6 and #3). The census was 86. Review of the facility's Standard and Enhanced Precautions policy, dated 4/1/24, showed: -Purpose: To ensure the use of appropriate personal protective equipment to improve infection control as required in the care of residents; -Policy: The facility will utilize current guidelines from the Centers for Disease Control (CDC) and the Censers for Medicare & Medicaid Services (CMS) to determine the appropriate PPE to be utilized during the care of residents to minimize the risk of infection or spread of infection; -Definitions: Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters and wound or unhealed pressure ulcers; -For residents whom EBP are indicated, EBP should be used when performing the following high-contact resident care activities: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care use such as feeding tubes, and wound care for any skin opening requiring a dressing; -EBP are intended to be in place for the duration of a resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that placed them at high risk; -The Infection Preventionist will follow the guidelines for Enhanced Standard Precautions for Long-Term Care Facilities for residents at high risk for MDRO colonization and transmission. Review of the facility's Enhanced Barrier Precaution signage (to be placed on the door or wall next to the door of residents that meet EBP requirements), showed: -EBP Everyone Must: -Clean their hands, including before entering and when leaving the room; -Providers and Staff Must Also: -Wear gloves and a gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting toileting. Device care or use: central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 2/24/25, showed: -Diagnoses of stroke and malnutrition; -Feeding Tube: Gastrostomy tube feeding (g-tube, inserted into the stomach through a surgical opening on the abdomen to provide nutrition, hydration and medicine); -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcers: Yes; -One Stage 3 pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles not exposed. Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling); -One Stage 4 pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin). Review of the resident's care plan, located in the electronic medical record (EMR), showed: -10/23/24: Focus: Activity of daily living self care performance deficit. Goal: Will maintain current level of function. Interventions/Tasks: Bedfast most of the time. Requires two staff with transfers and bed mobility. Requires a skin inspection every shift; -11/19/25: Focus: Potential nutritional problem, receives tube feeding. Goal: Will have stable weight. Interventions/Tasks: -12/31/24: Focus: resident has a Stage 4 pressure ulcer (injury) to his/her sacrum (a large, triangular bone at the base of the spine). Goal: Will have no complications related to pressure ulcer. Interventions/Tasks: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Follow facility protocols to treatment of injury; -No documentation about staff using EBP during care. Review of the facility's weekly Pressure Injury Trending Report for the third week of March, 2025, showed: -Midline sacrum Stage 4 pressure injury measuring 8.0 centimeters (cm) length by 7.5 cm width by 2.5 cm depth. Observation on 3/24/25 at 8:00 A.M., showed the resident lay in bed. There was no EBP sign on the door and no PPE supplies outside or inside the room, except gloves. Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) B entered the room to complete a skin assessment. Both the LPN and CNA donned gloves, but did not don a gown. The LPN placed the resident's g-tube feeding on hold, lowered the head of the bed, removed the resident's covers and turned the resident onto his/her right side revealing a pressure ulcer on the sacrum with no dressing covering it. The CNA lifted the corner of the dressing on the feeding tube stoma (surgical opening) for observation. The LPN applied a new dressing to the resident's sacrum wearing gloves but no gown. 2. Review of Resident #6's quarterly MDS, dated [DATE], showed: -Diagnoses of seizure disorder and malnutrition; -Feeding tube. Review of Resident #6's care plan located in the EMR, showed: -2/3/25: Focus: Tube feeding. Goal: Will remain free of side effects or complications related to tube feeding. Interventions/Tasks: Clean insertion site daily as ordered; -No documentation about staff using EBP during care. Observation on 3/24/25 at 8:21 A.M., showed the resident lay in bed. There was no EBP sign on the door and no PPE supplies outside or inside the room, except gloves. LPN A entered the room to complete a skin assessment. The LPN donned a pair of gloves, but no gown. The resident's tube feeding was off and disconnected. The LPN lowered the head of the bed, removed the covers and turned the resident from side to side, and lifted up the resident's tube feeding dressing covering the feeding tube stoma site for observation. 3. Review of Resident #3's admission MDS, dated [DATE], showed: -Diagnoses of diabetes mellitus (DM, high/low blood sugar), dementia and malnutrition; -Feeding Tube; -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcers: No; -Number of Venous and Arterial Ulcers: 0. Review of the resident's care plan located in the EMR, showed: -2/25/25: Focus: Diabetes mellitus. Goal: Will be free from signs/symptoms of hyperglycemia and hypoglycemia. Interventions/Tasks: Check all of body for breaks in skin and treat promptly as ordered by physician. Diabetes medication as ordered. Inspect feet daily for open areas, sores, pressure areas, blisters, swelling or redness. Monitor/document/report to physician signs/symptoms of hypoglycemia and hyperglycemia; -2/25/25: Focus: Requires a tube feeding due to dysphagia (difficult swallowing). Goal: Will be free of aspiration (food/fluids enters the lungs). Interventions/Tasks: Monitor and report any signs of aspiration; -No focus area for pressure injuries or wounds; -No documentation about staff using EBP during care. Observation on 3/24/25 at 8:45 A.M., showed the resident lay in bed. There was no EBP sign on the door and no PPE supplies outside or inside the room, except gloves. LPN H entered the room to complete a skin assessment. The LPN donned a pair of gloves but no gown. The resident's tube feeding was off and disconnected. The LPN lowered the head of the resident's bed, removed the covers and turned the resident from side to side. The LPN peeled back the dressings on the resident's feet and the tube feeding stoma for observation. 4. Observation of the 100 and 200 halls on 3/24/25 from 9:00 A.M. until 9:20 A.M., showed no EBP signs on any resident room doors, and no PPE supplies in the halls with the exception of room [ROOM NUMBER] that had a contact precaution sign on the door. 5. During an interview on 3/24/25 at 9:25 A.M., CNA C said to his/her knowledge, the only resident who required EBP is the resident in room [ROOM NUMBER]. No other residents require EBP when providing care. He/She was not aware he/she should wear a gown in addition to gloves while providing personal care to residents with urinary catheters, wounds or feeding tubes. 6. During an interview on 3/24/25 at 10:00 A.M., CNA D said he/she just started today and does not know which residents require EBP supplies when providing care. So far today, he/she had only worn gloves while providing personal care. 7. During an interview on 3/24/25 at 10:10 A.M., CNA E said he/she uses gloves when providing care to residents with g-tubes, urinary catheters and wounds. He/She had not been told to wear a gown in addition to gloves while providing personal care to those residents. 8. During an interview on 3/24/25 at 10:13 A.M., LPN A said he/she had not seen the facility's EBP policy, but was aware gloves and gowns should be worn while providing care to residents with pressure injuries, wounds, feeding tubes and intravenous (IVs). He/She should have worn a gown today, when he/she did Resident #5's treatment and Resident #6's skin assessment. There should be signs on the doors for those residents requiring EBP and there should be PPE supplies outside those residents' rooms. 9. During an interview on 3/24/25 at 10:20 A.M., LPN F (agency staff) said he/she was aware gloves and gowns should be used when providing care to residents with tube feeding, wounds, and IVs. He/She had not been wearing the gowns because they are not available. He/She would wear them if available. 10. During an interview on 3/24/25 at 10:31 A.M., CNA G said he/she had never seen any EBP signs on the resident doors. He/She wears gloves when providing care to all residents, but does not wear gowns. No one told him/her to wear the gowns. 11. During an interview on 3/25/25 at 8:44 A.M., the Director of Nurses (DON) said she was aware of the EBP requirements. The facility has the EBP signs but have not put them on the doors of residents requiring EBP supplies. Last week or the week before, the facility ordered containers to hold the EBP supplies, but they have not come in yet, She was going to have the signs put on the residents' doors when the containers came in. They should have put the signs up even if they did not have the containers. The facility has the necessary EBP supplies on hand. 12. Review of the facility list of residents who meet the EBP requirements received from the DON on 3/25/25 at 12:00 P.M., showed 18 of 86 residents, including Resident #5, Resident #6 and Resident #3 should have EBP signs posted on their doors with PPE supplies readily available for staff use. 13. During an interview on 3/26/25 at 8:43 A.M., the ADON/Infection Preventionist said she had been at the facility for about two weeks. The facility had EBP signs and supplies but they had not put them up on the doors of residents requiring EBPs. They were waiting on the container to hold the EBP supplies which should be in any day.

Based on observation, interview and record review, the facility failed to ensure Resident #3's physician was notified and monitoring was started after staff documented on shower review forms the resident had blisters on his/her bilateral feet. In addition, the facility failed to ensure staff initialed treatments had been completed and failed to ensure the resident wore his/her protective boots. Three residents were sampled and problems were found with one. The census was 86. Review of the facility Wound Management policy, dated 06/2020, showed: -Purpose: To provide a system for the treatment and management of residents wit wounds including pressure and non-pressure injury; -Policy: A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing; -Definitions: -Diabetic Neuropathic Ulcer: requires that the resident be diagnosed with diabetes mellitus (DM, high/low blood sugar) and peripheral neuropathy (damage or disease affecting the nerves). The diabetic ulcer characteristically occurs on the foot; -Assessment: -A licensed Nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident; -Upon identification of a new wound the Licensed Nurse will: measure the wound (length, width, depth). Initiate a Wound Monitoring Record sheet. A wound Monitoring Record will be completed for each wound. If the Wound Monitoring Record is not used, documentation will be recorded within the medical record which may include nurse's notes, treatment records or care plans. Implement a wound treatment per physician's order;; -An assessment of care needs for wound management will be made with emphasis on, but not limited to: identifying Risk factors. Treatment. Mechanical offloading and pressure reducing devices. Reducing skin friction, sheer, and moisture; -Wound Management: -The Attending Physician will be notified to advise on appropriate treatment promptly; -A Licensed Nurse will develop a care plan for the resident based on recommendations from Dietary, Rehabilitation and the Attending Physician; -Documentation: -New wounds will be documented on the 24 hour log; -Documentation will include: Location of wound. Length, width, and depth measurements recorded in centimeters (cm). Appearance of the wound base. Drainage amount and characteristics including color, consistency, and odor. Appearance of wound edges. Description of the peri-wound (the area that surrounds the wound) or evaluation of the skin adjacent to the wound; -Licensed Nurses will document effectiveness of current treatment in the resident's medical record on a weekly basis; -Document notifications following a change in the resident's skin; -Update the resident's care plan as necessary. Review of the facility's Showering a Resident policy, undated, showed: Report any broken skin, bruises, rashes, cuts, skin discoloration or reddened areas to the Charge Nurse. Review of Resident #3's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/1/25, showed: -Makes Self Understood: Usually understands; -Ability to Understand Others: Sometimes understands - responds adequately to simple, direct communication only; -Short and long term memory problem; -Functional limitations of both upper extremities and one lower extremity; -Dependent on staff for shower/bathing, roll left and roll right, lying to sitting on the side of the bed, chair/bed to chair transfer; -Diagnoses of DM, dementia and malnutrition; -Feeding Tube: Gastrostomy tube feeding (g-tube, a tube inserted into the stomach through the abdomen to provide nutrition, hydration and medicine); -Number of Venous and Arterial Ulcers: 0. Review of the resident's care plan, located in the electronic medical record (EMR), showed: 2/25/25: Focus: Diabetes Mellitus. Goal: Will be free from any signs/symptoms of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). Interventions/Tasks: Check all of body for breaks in skin and treat promptly as ordered by physician. Inspect feet daily for open sores, pressure areas, blisters, edema (swelling) or redness; -No focus/goal/interventions/tasks documented regarding actual/current wound on the resident's feet. Review of the resident's Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review forms (completed on scheduled shower days by a CNA and co-signed by a Licensed Nurse) showed: -2/26/25, the anatomical figure on the form had both feet circled and blisters documented. Charge Nurse Assessment: under wound care. Interventions: pressure relief boots. Forwarded to Director of Nurses (DON): blank. The shower form was signed by the CNA and co-signed by the Assistant Director of Nurses (ADON); -3/3/25, an anatomical figure on the form that showed both feet circled and blisters documented. Charge Nurse Assessment: under wound care. Interventions: pressure relief boots. Forwarded to DON: blank. The shower form was signed by the CNA and co-signed by the ADON. Review of the Weekly Skin Check (completed by a Licensed Nurse) dated 3/5/25 (the last skin assessment prior to the resident being sent to the hospital on 3/14/25), showed: does the resident have any skin impairments? Yes. Description: Abdomen - g-tuber. Right and left hand - edema. Right toes - edema. Left toes - edema. No documentation about blisters or open areas on the feet. Review of the resident's physician's order sheet (POS) located in the EMR, showed no order from 2/26/25 through 3/13/25, for the blisters/open areas on the resident's feet. Review of the resident's progress note, from 2/26/25 through 3/14/25, showed no documentation if the physician had been notified about the blisters or open areas on the resident's feet. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review form, dated 3/13/25, showed the anatomical figure on the form had both feet circled and blister treatment bandage documented. Charge Nurse Assessment: blisters and open area to left foot dressings in place. Intervention: under wound care physician and treatment nurse in house. Review of the resident's POS, showed: -3/14/25: wound care for bilateral lower extremity. Apply calcium alginate (an absorbent wound dressing) and dry dressing daily. The treatment order did not show how many wounds were on each foot. Review of the resident's Treatment Administration Record (TAR), showed an order dated 3/14/25, for wound care to the bilateral lower extremities. Apply calcium alginate and dry dressing daily. Staff initiated the treatment had been completed on 3/14/25. Review of the resident's progress notes, showed: -3/13 and 3/14/25: No documentation about the wounds on the resident's feet; -3/14/25 at 2:22 P.M.: Resident has an abnormal lab glucose level of 521. Resident's physician was notified; -3/14/25 at 2:45 P.M.: Talked to physician and was advised to send resident to emergency room. Review of the hospital report, dated 3/15/25 at 2:09 P.M., showed the resident came to the emergency room on 3/14/25 around 3:40 P.M. Resident arrived with wounds on the outside edge of left foot (is the worst), and right and left heel. Review of the resident's progress note, dated 3/19/25 4:10 P.M., showed the resident arrived at the facility via Emergency Medical Services (EMS) stretcher. Wound to left foot medial (middle) anterior (front) side and two open blisters on the right posterior heel. Review of the resident's TAR, showed an order dated 3/19/25, for calcium alginate to the bilateral feet daily and as necessary (PRN). Staff did not initial the treatment was completed on 3/19 and 3/20/25. Staff initialed the treatment as completed on 3/22, 3/23 and 3/24/25. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review form, dated 3/22/25, showed blisters, open area documented. Charge Nurse Assessment: wound care treatment. Interventions: heel protectors. Forwarded to DON: blank. Observation on 3/24/25 at 8:45 A.M., showed the resident lay in bed. CNA L said Resident #3 was the only resident residing in the room. The resident did not currently have a roommate. Licensed Practical Nurse (LPN) H entered the resident's room and removed the resident's covers to complete a skin assessment. The resident had a pillow between his/her knees, but no pressure relieving boots. Observation showed two green pressure relieving boots on the second bed at that time. The resident had undated dressings on both feet. The LPN lifted the dressing, showing an open area on the left lateral heel with a moderate amount of slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) and drainage, an open area on the left medial foot with a moderate amount of slough and drainage, an open area on the right small toe with a scant amount of slough and drainage, and an red beefy colored open area on the right heel. The LPN confirmed there were no dates on the dressings. He/She said he/she did not work the past weekend and did not know when the dressings had been applied. After the skin assessment, the LPN covered the resident and left the room. The green protective boots remained on top of the second bed in the room. Observation at 1:13 P.M., showed no protective boots on the resident's feet and the green protective boots remained on the second bed in the resident's room. During an interview on 3/26/25 at 8:20 A.M., Registered Nurse K and LPN J said CNAs give them the shower sheet after the shower is completed. If the CNA identifies anything abnormal, they are responsible to assess the resident's skin. If there is not a current treatment order in place, they are responsible to call the physician for a treatment order. They are responsible to put the new order on the POS and TAR and document in the resident's progress notes. They would notify the facility Wound Nurse. During an interview on 3/26/25 at 8:43 A.M., the ADON reviewed the shower sheets dated 2/26 and 3/3, and confirmed she signed them. Although she did assess the resident's feet, she never notified the physician because she assumed the facility Wound Nurse was already aware and had updated the physician. She never documented her assessments in the progress notes. She did not look at the POS or TAR to see if orders were in place and she never discussed the blisters and open areas with the facility Wound Nurse. During an interview on 3/26/25 at 9:25 A.M., the facility Wound Nurse reviewed the 2/26 and 3/3 shower sheets and said she was not notified by the ADON or anyone about the blisters or open areas. Had she been notified, she would have contacted the physician for treatment orders. She was not aware until 3/13 or 3/14, when the first treatment order was obtained and started. The resident should be wearing the protective boots. Review of the Wound Care Company physician's progress note, dated 3/26/25, no time documented, showed: -Location: left lower lateral (to the side) heel; -Measurements: 3.0 cm by 2.0 cm by 0.3 cm; -Etiology: diabetic ulcer; -Granulation (pink or red tissue with shiny, moist, granular appearance): 40%, and 60% slough; -Periwound: intact; -Exudate (drainage): moderate. Exudate appearance: serous (clear to yellow fluid that leaks from a wound); -Treatment: calcium alginate and cover with a dry dressing; -Location: left lower, medial (middle) foot; -Measurements: 3.0 cm by 2.0 cm by 0.3 cm; -Etiology: diabetic ulcer; -Granulation: 40% and 60% slough; -Periwound: intact; -Exudate: moderate; -Treatment: calcium alginate and cover with a dry dressing; -Location: right lateral 5th toe; -Measurements: 0.5 cm by 0.8 cm by 0.2 cm; -Etiology: diabetic ulcer; -Granulation: 80% and 20% slough: -Periwound: intact; -Exudate: light; -Treatment: calcium alginate and cover with a dry dressing; -Location: right medial heel; -Measurements: 2.0 cm by 23.0 cm by 0.10 cm; -Etiology: diabetic ulcer; -Epithelial (thin tissue that covers the exposed surfaces of the body): 100%; -Periwound: intact; -Exudate: none; -Treatment: Skin Prep (a liquid that when applied to the skin forms a protective film or barrier). During an interview on 3/25/25 at 8:44 A.M., the DON said she expected staff to write the date and their initials on dressings after they are completed. If there are blanks on the TAR, then she would have to assume the treatment had not been completed as ordered. At 1:26 P.M., the DON said the CNA fills out the shower sheet after every shower and gives it to the Licensed Nurse. If the CNA had documented anything abnormal about the skin, the Licensed Nurse has to assess the area(s) and if the area is new, they must call the physician and get a treatment. The new treatment should be documented on the POS and TAR. The Licensed Nurse should also document the assessment of the wound in the progress notes, including the measurement and description of the wound. She and the facility Wound Nurse should be notified. MO00251124

Based on observation, interview and record review, the facility failed to ensure staff consistently notified physicians when residents' high blood glucose levels exceeded the ordered parameters. The facility identified 10 residents with orders for routine blood glucose level checks, four were sampled and problems were found with two (Residents #13 and #3). The census was 86. Review of the facility Change of Condition - Observing, Reporting and Recording policy, dated 5/17, showed: -Policy: It is the policy of this home to inform the resident, the resident's physician and if indicated the resident's responsible party of the following: -A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications; -A need to alter treatment significantly; -The attending physician should be notified as soon as possible when immediate attention is required; -Documentation: -Date, time condition change was identified. Pertinent assessment findings. Who was notified and when. Disposition of resident. 1. Review of Resident #13's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/24/25, showed: -Makes Self Understood: Understood; -Ability To Understand Others: Usually understands; -Moderately impaired cognition; -Diagnoses of diabetes mellitus (DM, high/low blood sugar), high blood pressure and dementia. Review of the resident's care plan, located in the electronic medical record (EMR), showed: -5/9/23: Focus: diabetes mellitus requiring insulin and accu-checks (blood glucose monitoring). Goal: Will have no complications related to DM. Interventions/Tasks: diabetes medication as ordered. Monitor/document/report as necessary (PRN) any signs/symptoms of hyperglycemia (high blood glucose level) and hypoglycemia (low blood glucose level). Review of the resident's Physician's Order Sheet (POS), located in the EMR, showed: -9/14/23: Basaglar KwikPen (long-acting insulin) inject 25 units (u) one time a day for DM; -3/22/24: metformin HCI (DM oral medication) 1000 milligrams (mg) twice a day; -3/23/24: glipizide ER (DM oral medication) tablet 10 mg) daily; -5/6/24: blood sugar (glucose) every A.M. and P.M. Call physician if blood sugar is below 59 or 250 or above. Review of the resident's blood glucose levels located on the Medication Administration Record (MAR), showed: -2/1/25 through 2/28/25: 2/4 - 301, and 2/25 - 272; -3/1/25 through 2/25/25: 3/3 - 274, 3/21 - 285, and 3/22 - 401; -Review of the February and March MARs, showed no documentation the resident's physician was notified when the resident's blood glucose levels exceeded the ordered parameters of 250. Review of the resident's progress notes, dated 2/1/25 through 3/26/25, showed no documentation the resident's physician was notified when the resident's blood glucose level exceeded the ordered parameters of 250. During an interview on 3/25/25 at 1:26 P.M., the Director of Nurses (DON) said she did not find documentation staff updated the resident's physician on 2/4, 2/25, 3/3, 3/21, or 3/22 regarding the resident's blood glucose levels that exceeded the ordered parameters. Review of the resident's progress note, dated 3/25/25 at 11:48 A.M., showed the DON contacted the resident's physician regarding the blood glucose levels. The physician gave an order to increase the resident's basaglar insulin to 30 u every A.M., continue the blood glucose monitoring, update him in three days with the blood glucose level results and obtain a hemoglobin A1C (a lab that measures the average blood glucose level over the past two to three months). 2. Review of Resident #3's admission MDS, dated [DATE], showed: -Makes Self Understood: Usually understands; -Ability to Understand Others: Sometimes understands - responds adequately to simple, direct communication only; -Diagnoses of diabetes mellitus, dementia and malnutrition. Review of the resident's care plan, showed: -2/25/25: Focus: Diabetes Mellitus. Goal: Will be free from any signs/symptoms of hyperglycemia/hypoglycemia. Interventions/Tasks: Diabetes medication as ordered by the physician. Monitor/document/report to physician any signs/symptoms of hyperglycemia/hypoglycemia. Review of the resident's POS, showed: -3/20/25: Oolong (fast-acting insulin) FlexPen. Inject per sliding scale (the glucose level determines the amount of insulin that is administered) three times a day. Call physician if blood glucose level is less than 60 or greater than 400; -3/20/25: Lantus (long-acting insulin) SoloStar 10 u one time daily. Review of the resident's MAR, dated 3/1/25 through 3/31/25, showed a glucose level on 3/7 of 540 with no documentation staff contacted the resident's physician. Review of the resident's progress notes, showed no documentation staff contacted the resident's physician on 3/7/25, regarding the blood glucose level of 540. During an interview on 3/25/25 at 1:26 P.M., the DON said she did not find documentation staff updated the resident's physician on 3/7/25 about the resident's glucose level of 540. 3. During an interview on 3/25/25 at 7:20 A.M., Licensed Practical Nurse (LPN) J said if a resident's blood sugar exceeds the parameters the physician orders, he/she would contact the physician with the blood glucose results and document it in the progress notes along with any new order given by the physician. 4. During an interview on 3/25/25 at 7:24 A.M., LPN O said if a resident's blood sugar exceeds the parameters the physician orders, he/she would contact the physician with the blood glucose results and document it in the progress notes along with any new order given by the physician. 5. During an interview on 3/25/25 at 8:44 A.M., the DON said if a resident's blood glucose level exceeds the the physician's parameters for low or high blood glucose levels, she expected staff to contact the physician. Staff should document contacting the physician along with any new orders in the resident's progress notes. MO00251124

Based on interview and record review, the facility failed to provide services and/or treatment to increase or prevent reduction of range of motion. The facility failed to maintain a measurable, goal oriented restorative nursing program, and/or exercise program, to ensure residents requiring physical assistance were assisted by staff to maintain or improve their physical abilities, per facility policy. The facility provided a list of 11 current residents who had been discharged from skilled therapy services. Of those 11, two were identified with concerns of not getting recommended restorative therapy (Residents #21 and #19). The census was 87. Review of the facility Restorative Nursing Program Guidelines, dated 6/20, showed the following: -Purpose: The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This program actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning; -Policy: -I. A resident may be started on a Restorative Nursing Program: -A. Upon admission to the Facility with restorative needs, but is not a candidate for formalized rehabilitation therapy; -B. When restorative needs arise during the course of a longer-term stay; -C. In conjunction with formalized rehabilitation therapy; or -D. When a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy. -II. The Director of Nursing Services (DNS), or their designee, manages and directs the Restorative Nursing Program. Licensed rehabilitation professionals, (physical therapists, occupational therapists, and speech therapists) provide ongoing consultation and education for the Restorative Nursing Program; -A. General restorative nursing care is that which does not require the use of a qualified professional therapist to render such care. The basic restorative nursing categories include: -i. Active range of motion (AROM); -ii. Passive range of motion (PROM); -iii. Splinting or bracing; -iv. Amputation/Prosthesis management; -v. Bladder training or bowel training; -vi. Bed mobility; -vii. Transfer training; -viii. Dressing or grooming; -ix. Walking; -x. Eating or swallowing; -xi. Communication. -Procedure: -I. Residents will be reviewed by the Interdisciplinary Team (IDT) upon admission, readmission, quarterly, and as needed to identify any decline in activity of daily living (ADL) function. If a decline is identified, the IDT will evaluate whether the resident is an appropriate candidate for restorative services; -II. The Attending Physician, Licensed Nurse or Therapist may refer the resident to the rehabilitation department for rehabilitative screening; -III. The Licensed Therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy (e.g. restorative nursing services that can be provided by caregivers); -IV. In conjunction with the Attending Physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency and duration of interventions to help achieve anticipated goals and expected outcomes; -V. If a potential to benefit from rehabilitation therapies or restorative therapy (either skilled or unskilled) is identified, the Attending Physician will order a relevant therapy evaluation; -VI. An order will be obtained from the Attending Physician as indicated for participation in the Restorative Nursing program or for skilled rehabilitation services (e.g. physical, occupational, or speech therapy). -Documentation: -A. Restorative programs developed by therapy will be completed on paper and the facility will enter Restorative Nursing Program (RNP) in Point Click Care (PCC, electronic medical record) as appropriate; -B. The documentation will be done in PCC; -C. The care plan will reflect the restorative needs of each resident including problems/needs, measurable goals and individualized approaches; -i. The care plan for each resident will be reviewed quarterly or as needed by the IDT; -ii. The Restorative Nurse's Aide (RNA) carries out the restorative program according to the care plan and documents daily. In addition, the RNA completes a written weekly summary for residents on a Restorative Nursing Program; -C. The Restorative Nursing Program Coordinator (or designee) reviews RNA weekly summary notes on a regular basis; -D. Licensed Nurses reflect participation in and progress of residents in the Restorative Nursing Program in their weekly/monthly summaries; -E. The following criteria must be met in order to code 00500 in the Minimum Data Set (MDS); -i. Measurable objectives and interventions must be documented in the care plan and in the medical record; -ii. Evidence of periodic evaluation by the Licensed Nurse must be present in the resident's medical record; -a. When not contraindicated by state practice act provisions, a progress note written by the restorative aide and countersigned by a Licensed Nurse is sufficient to document the Restorative Nursing Program once the purpose and objectives of treatment have been established; -iii. Nursing assistants/aides are trained in the techniques that promote resident involvement in the activity; -iv. A Licensed Nurse must supervise the activities in the Restorative Nursing Program. 1. Review of Resident #19's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/24/25, showed the following: -Severe cognitive impairment; -No behaviors; -Impairment on one side for an upper and lower extremity; -Required partial to moderate assistance with ADLs; -Wheelchair mobility (manual or electric); -Diagnoses of high blood pressure, diabetes, and stroke; -Zero days of restorative therapy. Review of the resident's occupational therapy (OT) Discharge summary, dated [DATE], showed Discharge Recommendation: Restorative Program Established/Trained-Restorative Dining Swallowing Program, Restorative Range of Motion Program. Review of the resident's medical record, showed no documentation the resident's physician was notified regarding the restorative therapy recommendation. Review of the resident's care plan, dated 10/5/24, showed the following: -Focus: The resident has an ADL self care performance deficit related to stroke; -Interventions: Eating: The resident is able to hold cup, feed him/herself and eat finger foods independently. -No documentation regarding ROM; -No interventions regarding restorative therapy. Review of the resident's Range of Motion-Indicate Passive or Active ROM form, dated 4/25/25, showed the following: -Goal: To maintain full ROM; -Training Approaches: Bilateral Upper Extremity (BUE); -No documentation of frequency. Review of the resident Eating form, dated 4/25/25, showed the following: -Goal: To maintain minimum of self feeding: -Training Approaches: Position at table with assistance with scooping hand to mouth as needed; -No documentation of frequency. During an interview on 4/30/25 at 7:43 A.M., the resident said he/she has not received any restorative therapy. He/she did not know how long it had been since he/she was evaluated. The resident said restorative therapy is important to him/her because he/she would like to get out of his/her wheelchair at some point. 2. Review of Resident #21's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Wheelchair for mobility (manual or electric); -Dependent with ADLs; -Diagnoses of anemia (a condition where the blood doesn't have enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), congestive heart failure, and high blood pressure; -Zero days for restorative therapy. Review of the resident's medical record, showed an order dated 3/4/25, for an OT evaluation and treatment as indicated. Review of the resident's medical record, showed OT evaluation completed as ordered. Review of the resident's OT Discharge summary, dated [DATE] through 4/9/25, showed the following: -Discharge Recommendation and Status: -Discharge Recommendation: Potential need for scoop bowl for increased independence with feeding; -Restorative Programs: Restorative Program Established/Trained=Restorative Dining/Swallowing Program. Dining/Swallowing Program Established/Trained: Resident has difficulty obtaining items due to decreased coordination as well as attention to continue to self-feed. Resident to increase ability to self feed with appropriate adaptations like scoop bowl as needed and attention to meal. Review of the resident's medical record, showed no documentation the resident's physician was notified regarding the restorative therapy recommendation. Review of the resident's care plan, dated 10/5/24, showed the following: -Focus: Resident has an ADL self care performance deficit related to dementia; -Intervention: The resident is able to a hold cup, feed him/her self and eat finger foods independently. -The care plan did not identify OT recommendations or use of a scoop bowl; -No interventions regarding restorative therapy. Review of the resident's Eating Form, dated 4/9/25, showed the following: -Goals: Increase attention and ability to self feed; -Training Approaches: Blank. 3. During an interview on 4/29/25 at 9:33 A.M., the Restorative Aide (RTA) said he/she had not done any restorative exercises for any of the residents. The RTA said he/she has been busy taking his/her Certified Medication Technician classes. During an interview on 4/30/25 at 9:52 A.M., the Area Director of Rehabilitation said the purpose of restorative therapy program is to prevent decline in the resident's achievement from skilled therapy. A protocol of exercises will be given to the RTA regarding each resident and kept in a book. The Director of Nursing (DON) will oversee the RTA and the duties. The Area Director of Rehabilitation said she was aware the restorative program was not active due to the RTA being in another school. During an interview on 4/30/25 at 12:33 P.M., the MDS Coordinator said the therapy department will send over the restorative orders via email. He/She did not know what to do with the tasks. He/She has spoken with the DON on what to do, but was not given any clear guidance. The MDS Coordinator said a Registered Nurse (RN) should oversee the restorative aide and he/she is not an RN. During an interview on 4/30/25 at 12:07 P.M., the DON said the purpose of restorative therapy is to prevent decline after skilled therapy. The DON said the Director of Rehabilitation (DOR) will send the recommendations to the MDS Coordinator. He/She will call the doctor for orders for restorative therapy. Once the order is obtained, the orders are given to the RTA to follow through. The DOR will oversee the RTA for the duties. The DON should be kept updated. The facility has an active RTA, but he/she did not feel comfortable doing the tasks. At that time, the Administrator said he agreed with the DON's statements about who should monitor the RTA and the tasks for the RTA. MO00253381

Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when residents were involved in physical resident to resident altercations. Staff witnessed Resident #6 engage in a verbal altercation with Resident #5. Resident #5 then choked the neck of Resident #6, which caused bruising to the resident's neck and a sore throat. The sample was 8. The census was 87. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed: -Purpose: To ensure the facility establishes, operationalizes, and maintains an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors; -The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems; -Procedure: The Administrator may delegate coordination and implementation of components of the abuse prevention program to other staff within the facility; -Prevention: Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation; -Identification: The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect: Physical Abuse: Welts or bruises; -Investigation: The facility promptly and thoroughly investigates reports of resident abuse. The investigation may take some or all of the following steps: An employee who knowingly makes a false report may be subject to disciplinary action, up to and including termination; -Protection: Resident-resident altercations will only be investigated as an incident of abuse if the incident meets the criteria of the definition of abuse (no definition provided); -Residents and facility staff will not be retaliated against for reporting abuse. Review of the Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/2/24, showed: -Cognitively intact; -No impairment upper or lower extremity; -Walker; -Depression (other than bipolar disorder). Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: Resident has the potential to demonstrate physical behaviors related to anger and poor impulse control toward staff and other residents; -Goal: Resident will verbalize understanding of need to control physically aggressive behavior; -Interventions: - Analyze key times, places, circumstances, triggers and what de-escalate behavior and document; -Provide physical and verbal cues to alleviate anxiety, positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; -Give the resident choices about care and activities to help de-escalate the situation; -When the resident becomes agitated, intervene before agitation escalates. Guide away from the source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later; -Focus: Resident has potential to demonstrate verbally abusive behaviors related to ineffective coping skills and poor impulse control; -Goal: Resident will verbalize understanding of need to control verbally abusive behavior; -Interventions included: -Assess resident's understanding of the situation. Allow time for the resident to express self and feelings toward the situation; -Give choices of care and activities to de-escalate the situation; -When the resident becomes agitated, intervene before agitation escalates. Guide away from the source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. Review of Resident #8's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abuses others, sexually): Behavior of this type occurs daily; -Wheelchair; -Diagnoses included stroke. Review of the resident's care plan in use at the time of the investigation, showed: -Focus: Resident has potential to be physically aggressive related to poor impulse control, throwing things at staff and attempting to trip staff and other residents by putting his/her feet out; -Goal: Resident will verbalize understanding of need to control physically aggressive behavior through the review date; -Interventions/Tasks: Maintain and keep resident safe and prevent harm to other residents. Monitor and document observed behavior and attempted interventions in behavior log. Monitor/document/report as need any signs/symptoms of resident posing danger to self and others. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abuses others, sexually): Behavior not exhibited; -No impairments upper/lower extremity; -Walker; -Diagnoses included: Hypertension and Alzheimer's Disease. Review of the resident's care plan in use at the time of the investigation, showed: -Focus: The resident has potential to demonstrate physical behaviors related to Dementia; -Goal: The resident will verbalize understanding of need to control physically aggressive behavior through the review date; -Interventions included: -Analyze of key times, places, circumstances, triggers, and what de-escalated behavior and document; -Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; -When the resident becomes agitated: Intervene before agitation escalates; Guide away from the source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later. Review of Resident #6's alert note, showed: -2/25/25 at 12:59 P.M., the resident was yelling at everyone about the food issues but he/she was not combative at that moment. Staff stated the resident walked up to another resident (Resident #8) and made contact with his/her leg. This nurse call 911 and paramedics to assist with calming resident down and to prevent him/her from fighting other residents. Police arrived, stated that they could not take him/her since he/she had calmed and refused to go; -2/25/25 at 2:26 P.M., resident placed on 1:1 immediately after for his/her and other residents safety. Review of the facility's investigation summary, dated 2/25/25, signed by Regional Nurse Consultant (RNC), showed: Resident # 8 and Resident #6; -Incident description: During breakfast on 2/25/25, Resident #6 expressed his/her discontent about the meal and stood up, gesturing with his/her arms. In doing so, he/she inadvertently made contact with Resident #8's anterior (outer) thigh; -Immediate actions taken: -Staff promptly intervened and separated the two residents to ensure their safety; -Both residents were assessed for injuries by a licensed nurse (none noted); -Notifications were made to the Administrator, Director of Nursing (DON), RNC, Regional Director of Operations (RDO), PCP, Responsible party (RPs); -Interviews were conducted with both residents and staff; -Trauma-informed screenings were performed for Resident #8, Resident #6, and all other residents in the dining room; -Safe surveys were conducted with all residents on the unit with a Brief Interview for Mental Status (BIMS ) score above 8 (moderate cognitive impairment); -Both residents' plan of care, care plans and progress notes were reviewed; -Both residents' PCPs were seen onsite, and orders were obtained; -Both residents were placed under direct close supervision; -Follow-up action: On 2/25/25, the DON and Administrator interviewed both residents. Resident #8 could not recall the event. Resident #6 adamantly denied any willful intent to strike Resident #8, explaining that he/she was merely expressing his/her discontent with the meal and accidentally made contact while gesturing. He/She emphasized that he/she did not intend to cause any harm, injury, or pain to Resident #8. Resident #8 was unable to recall the event. Resident #6 remained 1:1 supervision, but it was lowered at this time due to the investigation deeming it was not abuse. However, he/she continued to be monitored to ensure safety. During a telephone interview on 3/3/25 at 12:36 P.M., the Social Worker Manager said she didn't hear about the event between Resident #8 and Resident #6 until after the incident between Resident #6 and Resident #5. She asked nursing staff who were present what happened. She was told Resident #6 kicked Resident #8's wheelchair, not the resident. She wasn't there. She was dependent upon information given to her by the staff. It was difficult to ask Resident #8 questions. He/She may understand most of the questions, but he/she could be aggressive too. Staff stopped Resident #6 from making things worse. She would consider the ideal thing to do was to keep Resident #6 away from Resident #8, so that's what happened. She expected staff to be proactive. If staff saw Resident #6 was screaming, agitated, acting erratic, the staff should intervene then. She said the staff actions/interventions with Resident #6 should have happened prior to the altercation with Resident #8. Review of Resident #6's alert note on 2/25/25 at 12:59 P.M., written by the ADON, showed the resident was yelling at everyone about the food issues, but he/she was not combative at that moment. He/She went outside, exchanged words with another resident (Resident #5), who then wrapped his/her hands around the resident's neck and choked him/her, leaving visible marks. Review of Resident #6's general progress note, effective on 2/25/25 at 8:45 P.M. and created on 2/26/25 at 7:58 P.M. by Registered Nurse (RN) K, showed resident agreed to go to hospital for psych evaluation. Resident alert and oriented times four. Respirations even and nonlabored. No complaints of pain. [NAME] noted to neck area. Review of resident's Resident #6's social service note dated 2/25/25 at 3:00 P.M., showed at 10:00 A.M., the resident appeared agitated and displayed signs of distress, leading to a verbal altercation with another resident. Nursing staff and aides promptly intervened to de-escalated the situation, providing verbal redirection and emotional support. The resident was encouraged to take deep breaths and step away from the situation to regain composure. Review of Resident #5's alert note, showed on 2/25/25 at 2:27 P.M., the resident was placed on 1:1 for choking another resident (Resident #6). Review of Resident #5's social service note, showed on 2/25/25 at 4:23 P.M., at 10 A.M., Resident #5 was engaged in an altercation with another resident. Nursing staff and aides promptly intervened to de-escalate the situation, providing verbal redirection and emotional support. This afternoon, the Social Worker met with the resident to discuss the physical altercation that occurred earlier on 2/25/25. The resident was given the opportunity to share his/her perspective on the incident. The Social Worker reviewed the importance of personal boundaries and discussed the impact of physical aggression on others and the overall community. He/She was encouraged to seek staff assistance or remove himself/herself from escalating situations to prevent further conflicts. The Social Worker provided education on the facility's behavioral expectations and the consequences of physical aggression. Review of Resident #5's general progress note, showed on 2/25/25 at 4:28 P.M., PCP on rounds and resident assessed. New orders received for psychiatric evaluation for patient-to-patient altercation for safety evaluation. Review of the facility's investigation summary provided by RNC, dated 2/26/25, showed: -It was alleged that during a smoke break on 2/25/25, Resident #6 and Resident #5, who know each other well from the facility and are friends, were conversing. Suddenly, without provocation, Resident #5, who was sitting across from Resident #6, extended his/her arms and placed his/her hands around Resident #6's neck. Staff immediately took the following actions: -Staff immediately intervened and separated the two residents to ensure safety; -A licensed nurse assessed both residents, and no injuries were noted; -Resident #6 stated he/she was unsure what provoked this behavior, as they are friends and it happened without apparent cause; -When interviewing Resident #5, he/she did not recall what occurred; -Resident #5 is cognitively intact. During an interview on 2/26/25 at 11:23 A.M., Resident #5 said he/she knew Resident #6 and they were friends. He/She said Resident #6 cussed him/her out yesterday. He/She said Resident #6 came into his/her room and started cussing him/her out. Resident #6 wanted everything his/her way. He/She didn't get hurt but did push Resident #6 back because he/she was in his/her face talking about people's mama and stuff. Resident #6 cussed people out bad and staff let him/her get away with a lot of stuff. He/She said Resident #6 thinks he/she can say anything to people. During an interview on 3/4/25 at 9:53 A.M., Resident #6 said Resident #5 liked him/her but they were just friends. He/She wanted to stay just friends, nothing else. Resident #5 saw him/her talking to a new resident. He/She said Resident #5 called the new resident a honky. He/She said Resident #5 choked him/her because Resident #5 was jealous. That was the only time Resident #5 choked him/her. Resident #6 and Resident #5 were arguing in the hallway as he/she was going outside to smoke a cigarette. He/She said Resident #5 didn't choke him/her until they got outside. There were aides in the hallway when they were arguing but only one of them said hey hey, what's the arguing about? No one came over to where he/she and Resident #5 were. He/She said Resident #5 told him/her to keep talking smart and if talking smart when they got outside, See what happens. He/She told Resident #5 he/she was going outside to smoke. He/She said there was bruising on his/her neck and his/her throat was sore after Resident #5 choked him/her. He/She demonstrated the choking by placing his/her thumb on one side of his/her neck, near his/her throat and his/her fingers around the neck on the other side. He/She said some residents and staff pushed Resident #5 off him/her. He/She left the patio and went to his/her room. Staff said he/she had to go to the hospital. He/She told staff Resident #5 choked him/her so why did he/she have to go? He/She said staff told him/her that was protocol. The aides kept asking him/her if he/she was ok. He/She thought there was only one other resident outside when Resident #5 choked him/her, but staff ran outside to help get Resident #5 off him/her. He/She saw the doctor at the facility. He asked if he/she was ok and didn't say anything else. He/She went to the hospital. The resident felt safe because they moved Resident #5 farther down the hall. He/She was not worried about Resident #5. He/She kept his/her distance from Resident #5 and Resident #5 has kept his/her distance from him/her. He/She said Resident #5 was his/her friend, but not now. He/She doesn't look Resident # 5's way and doesn't talk to him/her anymore. He/She doesn't trust Resident #5 anymore because he/she did him/her like that, grabbing him/her by his/her throat. He/She said Resident #5 grabbed him/her like he/she was trying to kill him/her or something. He/She said as little as he/she was, Resident #5 would grab him/her by the throat. That let him/her know where he/she was coming from. He/She said their friendship was a done deal (not friends). He/She was friendly. It made him/her upset when people got up in his/her face. Resident #6 left with his/her family because that's how upset he/she was. He/She couldn't fight. He/She was too old for that. He/She couldn't tussle and Resident #5 was big compared to him/her. During an interview on 2/25/25 at 2:15 P.M., the Social Service Manager said Resident #6 and Resident #5 didn't have a history of resident-to-resident abuse with each other or other residents. She said the residents had arguments with each other before but nothing like this. During an interview on 2/26/25 at 1:09 P.M., the Social Service Manager said she had just learned of the information about yesterday when she took Resident #6 to his/her room. The resident said Resident #5 put his/her hands on him/her. She talked with Resident #5 in his/her room. She said Resident #5 said he/she never touched Resident #6. The information Resident #5 told her was different than what everyone else said. Resident #5 told her he/she just pushed Resident #6 but didn't touch his/her neck. She informed the Administrator. During an interview on 2/26/25 at 11:59 A.M., Nursing Assistant (NA) C said he/she was at work yesterday and was assigned to Resident #6. Resident #5 lived on the same hall . The Resident #6 was outside on the patio. He/She started cussing and swung on Resident #5. Resident #5 tried to stop the resident from hitting him/her. NA C and another staff separated Resident #6 and Resident #5. They told the DON what happened and wrote statements. Resident #6 was fussing at Resident #5 and getting all up in his/her face. Then, the resident Resident #6 hit Resident #5. Resident #5 put his/her hands up. It looked like he/she hit the resident Resident #6. Resident #5 put his/her hands up to stop Resident #6 from hitting him/her. It wasn't a fight or anything like that. During an interview on 3/4/25 at 11:30 A.M., NA C said he/she didn't hear any argument between Resident #6 and Resident #5. Resident #6 was out on the patio first, then Resident #5 came out. Both were smoking. He/She didn't think there were other residents out there besides those two residents, but there could have been one other resident. He/She wasn't sure. He/She didn't know Resident #6 and Resident #5 were coupled up or dating. He/She just knew they were friends. He/She saw Resident #5 hit Resident #6 but not choke. At first, they were arguing outside. Then it escalated. Resident #6 hit Resident #5, then Resident #5 hit Resident #6 back. Resident #5 told Resident #6, you suck other people's dick. Resident #5 said other things to Resident #6 but he/she didn't hear it all. He/She just tried to keep them separated. He/She didn't know anything about Resident #6 and Resident #8's altercation. During a telephone interview on 3/3/25 at 12:36 P.M., the Social Worker Manager thought nursing staff took Resident #6 to the patio to calm down and that's where the altercation with Resident #5 happened. Resident #6 and staff told her the altercation happened on the patio but Resident #5 said it happened in his/her room. She wasn't completely dependent upon what Resident #5 said but it was false based on what everyone else said. Based on what she saw, there were two staff with Resident #6 and Resident #5 was taken back to his/her room. The door was closed. She said Resident #5 said Resident #6 tried to ask him/her for money and he/she said no. Resident #6 said he/she and Resident #5 were friends, but he/she didn't want it to be more than that. From what she understands, Resident #6 was in a heightened state that morning due to something else. She thinks the staff did their job related to the incident between Resident #6 and Resident #8. She didn't think the staff thought Resident #6 would escalate so fast. What happened that day, she didn't think anybody was used to Resident #6 getting escalated to that point. She said the resident was a calm, strict, and firm person. During a telephone interview on 3/3/25 at 3:39 P.M., the PCP said he was aware of the choking incident between Resident #5 and Resident #6. He was told the residents were girlfriend/boyfriend but he wasn't sure. During an interview on 3/4/25 at 11:53 A.M., the ADON said the Resident #6 had bruises on his/her neck. Resident #5 snatched (grabbing someone fast and with force) him/her up. He/She said Resident #6 was already upset from the night before. He/She said the resident said he/she had been upset all night and woke up this morning still upset. Resident #6 went out on the patio. He/She was cussing at Resident #5. Resident #5 picked Resident #6 up by the neck. The ADON said you can't agitate these residents because it takes a long time to calm them down. During a telephone interview on 3/3/25 at 1:45 P.M., the DON said staff could have not let Resident #5 and Resident #6 go out on the patio to smoke at the same time, if Resident #6 was still upset. She didn't think Resident #6 was still upset with Resident #5. There was nothing to indicate Resident #5 would have choked Resident #6. No words were passed between them. She said no one saw that coming because of their friendship. It happened so fast. Staff separated them immediately.

Based on interview and record review, the facility failed to provide the necessary behavioral health care services when staff did not intervene during a resident's agitated and heightened state (Resident #6) who then kicked another resident (Resident #8). The facility also failed to intervene when Residents #6 and #5 were involved in a verbal altercation that led to Resident #5 reaching out and wrapping his/her hands around Resident #6's neck. Resident #6 complained of bruising to his/her neck and a sore throat. The sample was 8. The census was 87. Review of the facility's Behavior Management policy, revised 06/2020, showed: -Purpose: To implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the resident's quality of life; -The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being meet each resident's needs and include individualized approaches to care; -Policy: The concept of behavior management is an interdisciplinary process. The key components of this process are: -Identifying residents whose behaviors may pose a risk to self or others; -Developing individual and practical care strategies based on assessed needs; -Implementing the behavior management program; -Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program; -The goal of any behavior management process is to maintain function and improve quality of life. The goal of the interdisciplinary team is to promptly identify behavior management issues and develop an effective management program; -The charge nurse will assign a staff member(s) to monitor/shadow the resident as needed. Review of the Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/2/24, showed: -Cognitively intact; -No impairment upper or lower extremity; -Walker; and -Depression (other than bipolar disorder). Review of the resident's care plan in use at the time of the investigation, showed: -Focus: Resident has the potential to demonstrate physical behaviors related to anger and poor impulse control toward staff and other residents; -Goal: Resident will verbalize understanding of need to control physically aggressive behavior; -Interventions/Tasks: Analyze of key times, places, circumstances, triggers, and what de-escalate behavior and document; -Provide physical and verbal cues to alleviate anxiety, positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; -Give the resident choices about care and activities to help de-escalate the situation; -When the resident becomes agitated, intervene before agitation escalates. Guide away from the source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later; -Focus: Resident has potential to demonstrate verbally abusive behaviors related to ineffective coping skills and poor impulse control; -Goal: Resident will verbalize understanding of need to control verbally abusive behavior; -Interventions included: -Assess and anticipate resident's needs; -Assess resident's coping skills and support system; -Assess resident's understanding of the situation. Allow time for the resident to express self and feelings toward the situation; -Give choices of care and activities to de-escalate the situation; -Provide positive feedback for good behavior and emphasize the positive aspects of compliance; -When the resident becomes agitated, intervene before agitation escalates. Guide away from the source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. Review of Resident #8's admission MDS, dated [DATE], showed: -Severely impaired; -Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abuses others, sexually): Behavior of this type occurs daily; -Wheelchair; -Diagnoses included stroke. Review of the resident's care plan in use at the time of the investigation, showed: -Focus: Resident has potential to be physically aggressive related to poor impulse control, throwing things at staff and attempting to trip staff and other residents by putting his/her feet out; -Goal: Resident will verbalize understanding of need to control physically aggressive behavior through the review date; -Interventions/Tasks: Maintain and keep resident safe and prevent harm to other residents. Monitor and document observed behavior and attempted interventions in behavior log. Monitor/document/report as need any signs/symptoms of resident posing danger to self and others. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abuses others, sexually): Behavior not exhibited; -No impairments upper/lower extremity; -Walker; -Diagnoses included: Hypertension and Alzheimer's Disease. Review of the resident's care plan in use at the time of the investigation, showed: -Focus: The resident has potential to demonstrate physical behaviors related to Dementia; -Goal: The resident will verbalize understanding of need to control physically aggressive behavior through the review date; -Interventions included: -Analyze of key times, places, circumstances, triggers, and what de-escalated behavior and document; -Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; -Monitor. Document observed behavior and attempted interventions in behavior log; -When the resident becomes agitated: Intervene before agitation escalates; Guide away from the source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later. Review of Resident #6's mood/behavior note, showed: - On 1/1/25 at 11:58 A.M., today this resident was complaining of having his/her gold chain stolen. He/She came out in the hall and said his/her chain was stolen and muthafuckers are going to find his/her shit! He/She then went to a resident that was sitting in the hall and said to him/her, I know you took my shit because yo sneaky ass always by my door! If my shit don't come up, it's gone be a problem! Resident then went to three other resident's doors and stated, come the fuck out here and find my shit! Other residents were saying they did not have the chain for the resident to go back into his/her room and look for it. He/She was calling staff out of their names, stating staff don't do anything for him/her at all. The resident went back into his/her room and found the box with his/her gold chain in the closet in one of his/her jacket pockets. He/She then came out and stated he/she was sorry everyone, he/she found the gold chain. This nurse reached out to administration who came to assist with the situation. Also called 911 for assistance with the resident and calming down the situation. The resident left the facility for two nights to go with his/her family; -On 1/18/25 at 11:18 A.M., during this shift, resident yelling at this nurse, cursing, and displaying erratic behavior. Resident appeared to be upset due to him/her having to wait for this nurse to complete his/her treatment. The other nurse that was present notified resident that this nurse would be doing his/her treatment. He/She then appeared to be agitated and visibly upset. This nurse informed the resident his/her treatment would be started as soon as this nurse took his/her personal items away. He/She then started saying that he/she was ready and that the nurse needed to be ready. The resident then proceeded to walk towards this nurse yelling and cursing, calling the nurse a fake bitch and also said the nurse thought the resident was cute. The resident yelled at this nurse saying, with all the at fake shit. At this time, this nurse feels unsafe working with this resident. The resident has created a hostile work environment. Review of Resident #6's alert note, showed: -2/25/25 at 12:59 P.M., the resident was upset this a.m. The resident stated he/she spent the entire night upset. The resident yelling at everyone but he/she was not combative at that moment. Staff stated the resident walked up to another resident (Resident #8) and kicked that resident's leg. This nurse called 911 and paramedics to assist with calming resident down to prevent him/her from fighting other residents. Police arrived and stated they could not take him/her since he/she had calmed and refused to go. The police stated it would be involuntary due to him/her being his/her own responsible party. The resident went outside, exchanged words with another resident, who then wrapped his/her hands around the resident's neck and choked him/her, leaving visible marks. Resident stated he/she was not going to the hospital under no circumstances. He/She refused vital signs and stated he/she wanted to speak with the Social Worker only. The Social Worker arrived, and the resident went to his/her room with the Social Worker; -2/25/25 at 2:26 P.M., resident placed on 1:1 immediately after for his/her and other residents safety. Review of Resident #8's alert note, showed on 2/25/25 at 5:39 P.M., resident kicked by another resident in his/her leg, per staff. Primary Care Physician (PCP) assessed resident and stated he/she had no injuries. No bruising noted. Resident has no complaints of pain or discomfort. Resident unable to tell this nurse what happened and why he/she was kicked. Guardian made aware via phone. Review of the facility's investigation summary, dated 2/25/25, signed by Regional Nurse Consultant (RNC), showed: -Incident description: During breakfast on 2/25/25, Resident #6 expressed his/her discontent about the meal and stood up, gesturing with his/her arms. In doing so, he/she inadvertently made contact with Resident #8's anterior (outer) thigh; -Immediate actions taken: -Staff promptly intervened and separated the two residents to ensure their safety; -Both residents were assessed for injuries by a licensed nurse (none noted); -Notifications were made to the Administrator, Director of Nursing (DON), Regional RNC, Regional Director of Operations (RDO), PCP, Responsible party (RPs), Department of Health and Senior Services, and Police Department; -Interviews were conducted with both residents and staff; -Trauma-informed screenings were performed for Resident #8, Resident #6, and all other residents in the dining room; -Safe surveys were conducted with all residents on the unit with a Brief Interview for Mental Status (BIMS) score above 8; -Both residents' plan of care, care plans, and progress notes were reviewed; -Both residents' PCPs were seen onsite, and orders were obtained; -Both residents' were placed under direct close supervision; -Follow-up action: On 2/25/25, the DON and Administrator interviewed both residents. Resident #8 could not recall the event. Resident #6 adamantly denied any willful intent to strike Resident #8, explaining that he/she was merely expressing his/her discontent with the meal and accidentally made contact while gesturing. He/She emphasized that he/she did not intend to cause any harm, injury, or pain to Resident #8. Resident #8 was unable to recall the event. Resident #6 remained on 1:1 supervision, but it was lowered at this time due to the investigation deeming it was not abuse. However, he/she continued to be monitored to ensure safety. Review of the resident's alert note, dated 2/25/25 at 2:26 P.M., showed: -Patient placed on 1:1 immediately after for his/her and other residents safety; -No other documented interventions during the residents agitated state and/or prior to the altercation. Review of the resident's social service note, dated 2/25/25 at 3:00 P.M., showed at 10:00 A.M. in the morning, the resident (Resident #6) appeared agitated and displayed signs of distress, leading to a verbal altercation with another resident. During an interview on 3/3/25 at 12:36, the Social Worker said nursing staff and aides promptly intervened to de-escalate the situation, providing verbal redirection and emotional support. Staff stopped Resident #6 from making things worse. She would consider the ideal thing to do was to keep Resident #6 away from Resident #8 and that's what happened. She expected staff to be proactive. If staff saw Resident #6 was screaming, agitated, and/or acting erratic, the staff should have intervened then. She said the staff actions with Resident #6 should have happened prior to the altercation with Resident #8. During a telephone interview on 3/3/25 at 3:39 P.M., the facility physician said he was notified Resident #8 had been kicked in the leg. He assessed the resident, and he/she had no bruising to the leg. During an interview on 3/4/25 at 11:53 A.M., the ADON said Resident #6 kicked Resident #8 in the leg. He/She was standing in the doorway behind nurse's station when he/she heard staff asking Resident #6 why he/she kicked Resident #8. Review of Resident #6's alert note, showed on 2/25/25 at 12:59 P.M., the resident was yelling at everyone about the food issues, but he/she was not combative at that moment. He/She went outside, exchanged words with another resident (Resident #5), who then wrapped his/her hands around the resident's neck and choked him/her, leaving visible marks. Review of the Resident #6's social service note, showed 2/25/25 at 3 P.M., at 10 A.M., in the morning, the resident appeared agitated and displayed signs of distress, leading to a verbal altercation with another resident. Nursing staff and aides promptly intervened to de-escalate the situation, providing verbal redirection and emotional support. The resident was encouraged to take deep breaths and step away from the situation to regain composure. Review of the Resident #6's general progress note, dated 2/25/25 at 8:45 P.M., showed the resident agreed to go to the hospital for psychiatric evaluation. [NAME] noted to neck area. Review of Resident #5's alert note, showed on 2/25/25 at 2:27 P.M., resident placed on 1:1 for choking another resident (Resident #6). Review of Resident #5's social service note, dated 2/25/25 at 4:23 P.M., showed at 10:00 A.M., the resident was engaged in an altercation with another resident (Resident #6). Nursing staff and aides promptly intervened to de-escalate the situation, providing verbal redirection and emotional support. This afternoon, the social worker met with the resident to discuss the physical altercation that occurred earlier on 2/25/25. The resident was given the opportunity to share his/her perspective on the incident. The social worked reviewed the importance of personal boundaries and discussed the impact of physical aggression on others and the overall community. He/She was encouraged to seek staff assistance or remove himself/herself from escalating situations to prevent further conflicts. The social worker provided education on the facility's behavioral expectations and the consequences of physical aggression. Review of the Resident #5's general progress note, showed on 2/25/25 at 4:28 P.M., PCP on rounds and resident assessed. New orders received for psychiatric evaluation for patient-to-patient altercation for safety evaluation. Review of the facility's investigation summary provided by RNC, dated 2/26/25, showed: -It was alleged that during a smoke break on 2/25/25, Resident #6 and Resident #5, who know each other well from the facility and are friends, were conversing. Suddenly, without provocation, Resident #5, who was sitting across from Resident #6, extended his/her arms and placed his/her hands around Resident #6's neck. Staff immediately took the following actions: -Staff immediately intervened and separated the two residents to ensure safety; -A licensed nurse assessed both residents, and no injuries were noted; -Resident #6 stated he/she was unsure what provoked this behavior, as they are friends and it happened without apparent cause; -When interviewing Resident #5, he/she did not recall what occurred; -Resident #5's BIMS score of 14 and is cognitively intact. During an interview on 2/26/25 at 11:23 A.M., Resident #5 said he/she knew Resident #6 and they were friends. He/She said Resident #6 cussed him/her out on yesterday. He/She said Resident #6 came into his/her room and started cussing him/her out. Resident #6 wanted everything his/her way. He/She didn't get hurt but did push the resident back because Resident #6 was in his/her face talking about people's mama and stuff. Resident #6 cussed people out bad and staff let him/her get away with a lot of stuff. He/She said Resident #6 thinks he/she can say anything to people. During an interview on 3/4/25 at 9:53 A.M., Resident #6 said Resident #5 said he/she liked Resident #6, but they were just friends. He/She wanted to stay just friends, nothing else. Resident #5 saw him/her talking to a new resident. He/She said Resident #5 called the new resident a honky. Resident #5 choked him/her because he/she was jealous. That was the only time he/she choked him/her. The two residents were arguing in the hallway as he/she was going outside to smoke a cigarette. Resident #5 didn't choke him/her until they got outside. There were aides in the hallway when they were arguing but only one of them said hey hey, what's the arguing about? No one came over to where he/she and Resident #5 were. Resident #5 told him/her to keep talking smart and if he/she talked smart when they got outside, See what happens. He/She told Resident #5 he/she was going outside to smoke. There was bruising on his/her neck and his/her throat was sore after Resident #5 choked him/her. He/She demonstrated the choking by placing his/her thumb on one side of his/her neck, near his/her throat and the rest of his/her fingers around the neck on the other side. He/She said some residents and staff pushed Resident #5 off him/her. He/She left the patio and went to his/her room. Staff said he/she had to go to the hospital. He/She told staff Resident #5 choked him/her so why did he/she have to go? Staff said it was protocol. The aides kept asking if he/she was ok? He/She thought there was only one other resident outside when Resident #5 choked him/her, but staff ran outside to help get Resident #5 off him/her. He/She saw the doctor at the facility. He asked if he/she was ok and didn't say anything else. He/She went to the hospital. He/She felt safe because they moved Resident #5 farther down the hall. He/She was not worried about him/her. He/She kept his/her distance from Resident #5 and Resident #5 has kept his/her distance from Resident #6. Resident #5 was a friend, but not now. He/She didn't look Resident #5's way and didn't talk to him/her anymore. He/She doesn't trust Resident #5 anymore because he/she grabbed him/her by the throat. Resident #5 grabbed like he/she was trying to kill him/her or something. He/She said as little as he/she was, Resident #5 would grab him/her by the throat. That let him/her know where Resident #5 was coming from. He/She said their friendship had ended. Resident #6 was friendly. It made him/her upset when people get up in his/her face. He/She left with his/her family because that's how upset he/she was. Resident #6 said he/she couldn't fight or tussle. He/She was too old for that. Resident #5 was big compared to him/her. During an interview on 2/25/25 at 2:15 P.M., the Social Service Manager said Resident #6 and Resident #5 didn't have a history of resident-to-resident abuse with each other or other residents. She said the residents had arguments with each other before but nothing like this. During an interview on 2/26/25 at 11:59 A.M., Nursing Assistant (NA) C said he/she was at work yesterday and was assigned to the resident's hall. The resident was outside on the patio. He/She started cussing and swung on Resident #5. Resident #5 tried to stop the resident from hitting him/her. NA C and another staff separated the two residents. They told the DON what happened and wrote statements. The resident was fussing at Resident #5 and getting all up in his/her face. Then, the resident hit Resident #5. Resident #5 put his/her hands up. It looked like he/she hit the resident (Resident #6). Resident #5 put his/her hands up to stop the resident (Resident #6) from hitting him/her. It wasn't a fight or anything like that. During an interview on 2/26/25 at 1:09 P.M., the Social Service Manager said she had just learned of the information about yesterday when she took the resident to his/her room. The resident (Resident #6) said Resident #5 put his/her hands on his/her. She talked with Resident #5 in his/her room. She said Resident #5 said he/she never touched Resident #6. The information Resident #5 told her was different than what everyone else said. Resident #5 told her he/she just pushed Resident #6 but didn't touch his/her neck. She informed the administrator. During an interview on 2/26/25 at 2:41 P.M., Certified Nursing Assistant/Certified Medication Technician (CNA/CMT) D said he/she never had a problem with the resident. He/She didn't know what the resident's interventions were and the resident had not had any outburst since he/she had been there. During an interview on 2/26/25 at 4:23 P.M., CMT A said he/she was fairly new to the floor and was not very familiar with the resident. CMT A said he/she got a walk through and was given paperwork during orientation about the residents. She didn't know of any interventions for the resident but said she would ask a nurse and use whatever resources that were available. CMT A said he/she would be responsible to intervene if the resident became agitated and escalated, even though he/she was fairly new. CMT A said it depended on the situation, but he/she would separate and make the resident 1:1. CMT A said he/she would use common sense but he/she should know what the resident's interventions were. He/She said he/she was sure there were interventions listed but he/she didn't know what they were. During an interview on 2/26/25 at 4:25 P.M., CNA B said he/she knew the resident and he/she did pretty much for himself/herself. CNA B reported the resident's concerns and encouraged him/her to do the same. He/She walked the resident to his/her room to calm him/her down. Sometimes that worked and sometimes it didn't. CNA B said he/she tried to separate the resident from the situation. That was the only intervention he/she was aware of. He/She wasn't aware of all the resident's other interventions but said he/she would ask the nurse, peers, or look in the resident's care plan. During an interview on 2/27/25 at 10:32 A.M., the DON said staff knew what the resident's interventions were because the facility in-serviced staff after the first resident-to-resident altercation. She said the resident was never 1:1 and the documentation in the resident's progress note was not accurate. She said the documentation in the resident's progress note related to kicking the first resident-to-resident altercation was not accurate. She would have both documentations removed from the resident's record. The facility had an immediate huddle and in-service the same day related to the resident's interventions after the first altercation. She and other presenters read the resident's interventions verbatim. They will have to re-in-service staff again on the resident's interventions. The facility gave monthly de-escalation in-services. The resident went out for psychiatric evaluation. She was told the resident was not a threat to self or others. She expected staff to know how to intervene when the resident displayed verbal/physical agitation and expected staff to intervene before the resident's behavior escalated. During an interview on 2/27/25 at 10:41 A.M., the Administrator said he expected the staff to follow the resident's interventions. He expected staff to know what to do before the residents behavior escalated. During a telephone interview on 3/3/25 at 12:36 P.M., the Social Worker Manager thought nursing staff took Resident #6 to the patio to calm down and that's where the altercation with Resident #5 happened. Resident #6 and staff told her the altercation happened on the patio but Resident #5 said it happened in his/her room. She wasn't completely dependent upon what Resident #5 said but it was false based on what everyone else said. Based on what she saw, there were two staff with Resident #6 and Resident #5 was taken back to his/her room. The door was closed. She said Resident #5 said Resident #6 tried to ask him/her for money and he/she said no. Resident #6 said he/she and Resident #5 were friends, but he/she didn't want it to be more than that. From what she understands, Resident #6 was in a heightened state that morning due to something. She thinks the staff did their job related to the incident between Resident #6 and Resident #8. She didn't think the staff thought Resident #6 would escalate so fast. What happened that day, she didn't think anybody was used to Resident #6 getting escalated to that point. She said the resident was a calm person, strict, and firm person. During a telephone interview on 3/3/25 at 1:45 P.M., the DON said staff could have not let Resident #5 and Resident #6 go out on the patio to smoke at the same time, if Resident #6 was still upset. She didn't think the resident was still upset with Resident #5. There was nothing to indicate Resident #5 would have choked Resident #6. No words were passed between them. She said no one saw that coming because of their friendship. It happened so fast. Staff separated them immediately.

Based on observation, interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when residents were involved in physical resident to resident altercation, in which one resident placed their hands around another resident's neck (Residents #1 and #2). The sample was 32. The facility census was 74. The facility was notified of past non-compliance on 7/2/24. Facility staff immediately intervened, notified administration, separated the residents, and provided assessment and services to the involved residents. Staff were in-serviced on abuse and neglect prevention. The deficiency was corrected on 6/29/24. Review of the facility's Abuse Prevention and Prohibition Program policy, dated 10/24/22, showed: -Purpose: To ensure the Facility establishes, operationalizes, and maintains an Abuse Prevention and Prohibition Program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: The Facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. This policy statement also includes deprivation by any individual, including a caretaker, of goods, services or rights that are necessary for a resident to attain or maintain physical, mental, and psychosocial wellbeing. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 5/26/24, showed: -Diagnoses included anemia, atrial fibrillation (irregular heartbeat), coronary artery disease (heart disease), hypertension (high blood pressure), acid reflux, diabetes, kidney failure, arthritis, depression, schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), asthma, and respiratory failure; -No cognitive impairment; -No behaviors. Review of the Resident #1's progress notes, showed: -On 6/26/24 at 4:28 P.M., this nurse heard screaming down the east hallway. This patient was seen being strangled by another patient around his/her neck. This nurse quickly went down the hall to separate the two patients with another staff member. Patient assessed after situation, redness noted under neck. Patient stated he/she was wiping under neck with a cloth. This nurse asked patient was happened, he/she stated the other patient attempted to go inside his/her room. He/She told him/her don't go in my room and he/she began to choke him/her. Patient stated although he/her choked him/her, he/she did not have any pain and it did not hurt. All parties notified of the situation; -At 4:49 P.M., Charge Nurse notified Assistant Director of Nursing (ADON) and this writer that resident was choked by another resident. Nurse, ADON, and this writer went to resident's room and asked resident what happened. He/She stated that he/she believes that other resident came into his/her room earlier and slobbered on his/her mints. He/She saw other resident going towards his/her room so he/she passed him/her and went in his/her door way other resident walked by and he/she told other resident not to come into his/her room. He/She came towards him/her and grabbed his/her neck. When asked if he/she was hurt, he/she stated no it just scared me. Administrator and social services updated; -At 4:51 P.M., Charge nurse notified this reporting nurse and Director of Nursing (DON) that resident was choked by another resident. When this reporting nurse, DON and charge nurse entered residents room to do an assessment. Resident seemed to be calm, no signs or symptoms of distress or pain. When asked if resident was hurt, he/she stated no. Resident stated that earlier that resident had came into his/her room and slobbered all over his/her candy. Resident was in the door way of his/her room so resident could not come inside again and that is when he/she put his/her hands on his/her neck. Again resident stated that he/she is not hurt but it just scared him/her. Administrator and Social services have been updated; -At 4:53 P.M., Social Worker met with Resident #1 in regard to an incident reported with Resident #2. Social Worker informed Resident #1 that they are trying to get the full picture of the situation to help with an intervention. Resident #1 stated that earlier that morning Resident #2 had entered his/her room. There was a bag of candy on his/her table and Resident #2 proceeded to try and take a piece. Resident #1 informed Resident #2 that that was his/her candy and asked the resident to leave. Resident #2 left the room. Resident #1 later came back to the room to find the bag of candy to be wet. Resident #1 is not sure who was in his/her room but believes it was Resident #2. Later on Resident #1 was headed to his/her room and noticed Resident 2 walking in the direction of his/her room. Resident 1 got ahead of Resident #2 and blocked the door. Resident #1 informed Resident #2 not to enter his/her room. Resident #2 proceeded to come towards Resident #1 waving his/her arms and making noises. Resident #1 stated that Resident #2 ran into his/her foot pedals and put his/her arms around his/her neck. Resident #1 then shouted for help and staff intervened. Resident #1 was asked if Resident #2 was choking him/her. Resident #1 stated no that all he/her did was get slobber around his/her neck. Resident #1 was asked if there were any other incidents and if he/she felt safe. Resident #1 stated this is the only time Resident #2 had done this and that he/she felt safe. Resident #1 was given an option of a room on another floor but declined. Resident #1 was asked again if she felt safe and asked for a way to keep resident 2 out of his/her room. Social worker asked Resident #1 about his/her thoughts on a keypad entry for her room that only herself and staff have the pin for. Resident #1 liked this idea. Social worker informed Resident #1 that he/she would speak with the Administrator to see about having a keypad entry installed on her door. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Diagnoses included hypertension, hyperlipidemia (high lipids in the blood), stroke, dementia, anxiety, and depression; -Severe cognitive impairment; -Daily wandering behavior. Review of Resident #2's care plan, in use during survey, showed: -Problem: Resident has been physically aggressive with staff related to dementia; -Goal: He/She will not harm self or others; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; Monitor/document/report as needed (PRN) any signs or symptoms of resident posing danger to self and others; Psychiatric/Psychogeriatric consult as indicated; When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later; -Problem: Resident is a wanderer disoriented to place, impaired safety awareness and resident wanders aimlessly significantly intrudes on the privacy of the other resident; -Goal: Resident's safety will be maintained; -Interventions: Assess for fall risk; Check Wander Guard placement every shift; Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes; Redirect resident when wandering in hall to structured activities; -Problem: Resident has a behavior problem related to walking up on other residents trying to scare them; -Goal: Resident will have no evidence of behavior problems; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; Anticipate and meet the resident's needs; Assist the resident to develop more appropriate methods of coping and interacting with other residents. Encourage the resident to express feelings appropriately; Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of the resident's progress notes, showed: -On 6/26/24 at 3:36 P.M., this nurse heard screaming down the east hallway, this patient was seen choking another patient around his/her neck. This nurse quickly went down the hall to separate the two patients with another staff member. Patient was escorted down the hall away from the patient who was harmed. DON and ADON notified of the situation. Call placed to physician waiting on call back; -At 3:54 P.M., Orders received to send patient out for evaluation; -On 6/27/24 at 12:00 A.M., resident returned from hospital. No new orders received. Alert and oriented x 1-2. No complaints of pain. No aggression noted; -On 6/28/24 at 2:54 P.M., Resident remains on intervention follow up (IFU) after physical altercation with another resident. Resident calm and corporative with care. Pacing up and down each hallway. Easy to redirect. No aggressive behavior observed. Resident smiling this morning with nursing staff. No signs and symptoms of distress noted. Resident denies pain/discomfort. no face grimacing or moaning noted. Resident in activities having cake and ice cream as activities celebrates the monthly birthdays; -On 6/29/24 at 11:46 A.M., Resident remains on IFU after physical altercation with another resident. Resident calm and corporative with care. Pacing up and down each hallway. Easy to redirect. Resident denies pain/discomfort. No face grimacing or moaning noted. Review of the facility's investigation, dated 6/26/24, showed: -Date and time of incident: 6/26/24 at 4:30 P.M.; -Date and time of discovery: 6/26/24 at 4:30 P.M.; -Date and time incident reported to supervisory staff: 6/26/24 at 4:30 P.M.; -Charge nurse heard screaming down the hall and went down the hall to find Resident #2 with his/her hands on Resident's #1's neck. Nurse immediately intervened and separated residents. Resident #1 states that he/she was not hurt and just had slobber on his/her neck from the other resident's hands. Resident #1 had red marks on his/her neck but states that it was from rubbing his/her neck with a towel; -Resident #2 was sent to the emergency room for an evaluation and returned. He/She was on 1:1 monitoring x 24 hours with no issues, decreased to checks every 15 minutes x 24 hours with no issues, decreased to checks every 30 minutes x 24 hours, decreased to checks hourly with no issues. Resident #2 is now on two hour checks and no further issues have been observed; -Resident #1 was initially offered to move rooms down to the first floor as it is not an option for Resident #2 to move due to his/her wandering tendencies. Resident #1 refused and agreed to a keypad lock on his/her door and staff having the knowledge of the code. Resident #1 later declined the lock and has now agreed to move to the first floor. No further issues have been noted; -It is the conclusion of facility that the facility acted appropriately, staff immediately intervened in the situation and separated the residents. Staff stayed with Resident #2 until he/she was sent out with emergency medical technicians (EMTs) for evaluation. Upon return Resident #2 was closely monitored and no further issues have been observed. Resident #1 states nothing like this has happened before. He/She states that he/she feels safe in his/her room and does not have fear in his/her current environment. Review of Licensed Practical Nurse (LPN) A's written statement, dated 6/26/24, showed this nurse heard screaming down the hall. This nurse seen patient choking another patient. This nurse quickly went down the hall to separate the two individuals this nurse and another staff member escorted patient to room. During an interview on 7/2/24 at 10:30 A.M., LPN A said the incident occurred right before dinner. Resident #1 screamed and LPN A and Certified Medication Technician (CMT) B ran to the resident. Resident #1 and #2 were seen in the hall in front of Resident #1's doorway. Resident #2's hands were around Resident #1's neck. Resident #2 was physically escorted away by LPN A and CMT B. This was the first time LPN A witnessed aggressive behavior from Resident #2. He/She may jump out at someone in a playful way. If Resident #2 knows if the person is frightened, he/she may continue to do it. LPN A never saw Resident #2 physically touch another resident. He/She is unable to speak, but he/she can shake their head yes and no. Resident #1 was assessed by staff and he/she had redness on his/her neck. At the time, Resident #1 started wiping his/her neck with a washcloth because he/she said Resident #2 had drool on his/her hands. Resident #1 said the redness resulted from him/her wiping his/her neck with the cloth. There were no complaints of pain and to his/her knowledge Resident #1 did not hit Resident #2 during the altercation. Resident #2 wanders into other resident's rooms, but he/she was never aggressive. Resident #1 did not have a history of behaviors. He/She yelled for staff and for the resident to get out of his/her room. Review of CMT B's written statement, dated 6/26/24, showed CMT B witnessed Resident #2 choke Resident #1. During an interview on 7/2/24 at 10:58 A.M., CMT B said he/she was at the nurse's station with the medication card. He/She heard a scream, turned around, and ran down the hall with LPN A. Resident #2's hands were around Resident #1's neck. Resident #1 was blocking Resident #2 from going into his/her room. Resident #1 was in his/her wheelchair and Resident #2 leaned over him/her. Resident #1 grabbed Resident #2's hands to try to pull him/her off. LPN A and CMT B had to physically remove Resident #2's hands from Resident #1. LPN A and CMT B escorted Resident #2 back to his/her room. Resident #2 did not have any injuries. Resident #1 was assessed by another nurse. Resident #2 went to the hospital. CMT B never witnessed aggressive behavior from Resident #2. He/She wanders and has a wander guard. He/She jumps at someone, but his/her expression is blank, so CMT B did not know if he/she is joking around. During an interview on 7/2/24 at 9:12 A.M., LPN C said Resident #2 is a wanderer. He/She walks around and enters other resident rooms. It does not happen often. Staff re-direct the resident. He/She usually finds an empty bed and sleeps in the room. LPN C heard about the incident that occurred between Resident #1 and #2 and he/she was surprised. LPN C never witnessed aggressive behavior or hostile behavior. He/She does not speak. He/She jumps at people and he/she jokes around because he/she will start to smile. During an interview on 7/2/24 at 11:20 A.M., Resident #1 said Resident #2 was in his/her room earlier that day. He/She had a bag of candy in the room the resident went for. There was drool all over the bag, so the nurse told him/her to throw it away. Resident #1 did not want Resident #2 in his/her room. He/She saw Resident #2 wandering again, so he/she met Resident #2 at the doorway of his/her room. Resident #1 said, do not go in my room. Resident #2 started to choke Resident #1. His/her hands were around Resident #1's neck. Resident #1 said he/she did not lose consciousness, did not cough or choke, but there was pressure from his/her hands. It happened so fast. He/She believed he/she grabbed Resident #2's hands. He/She yelled out and staff immediately came and separated them. Resident #1 said his/her neck was red, but it was from wiping the drool off that was on Resident #2's hands. He/She did not have any pain. He/She was asked if he/she wanted to move to another room, but he/she said no. Resident #1 later thought about it and agreed to move to another room. He/She feels safe and happy with his/her room. Observation and interview 7/2/24 at 9:13 A.M., showed Resident #2 in his/her room. He/She was alert and oriented to self. The resident was asked questions and was not able to verbally communicate. He/She was asked yes or no questions. The resident was asked if he/she ate breakfast. He/she shook his/her head yes. The resident had a breakfast tray on the bedside table. He/She was served scrambled eggs, sausage, toast, and oatmeal. The food appeared to not have been touched or eaten. Surveyor continued to attempt to interview, but resident lay back in bed. Observation and interview on 7/3/24 at 11:48 A.M., showed Resident #2 sat in the TV room. He/she was alert and oriented to self. The resident was unable to shake his/her head yes or no to questions. The resident did not maintain eye contact. He/She had drool, approximately 12 inches long, that started from his/her bottom lip that landed on his/her shirt. The resident's shirt was wet from the drool landing on the shirt. During an interview on 7/2/24 at 1:30 P.M., Corporate Nurse D/Interim Administrator said she would expect for staff to continue to follow the abuse and neglect policy. She would expect staff to continue to follow up with Resident #2's behaviors, document them, and report any aggressive behavior.

Based on interview and record review, the facility failed to provide acceptable nursing services by not directly and continuously monitoring and intervening for one resident who was in respiratory distress (Resident #1). Two therapy staff found the resident difficult to wake, breathing heavily, and would groan and open and then close his/her eyes when his/her name was called. The resident was identified not connected to the oxygen concentrator and the resident did not have his/her BiPap on. The concentrator was broken. When staff attempted to use the emergency oxygen tank (e-tank) on the back of the resident's wheelchair, it was found empty, further delaying treatment while staff went to retrieve a full e-tank. Staff applied the nasal cannula with oxygen at 4 liters from the e-tank. The resident had an order for a BiPap which was not applied when the resident was noted to be in distress. The resident's oxygen saturation level was 68%. When Emergency Medical Services (EMS) arrived at the resident's bedside, the resident was unattended, prone (chest down) on a flat bed, with his/her head to the side. The resident had audible rales (crackling noises), thick white sputum, peripheral cyanosis (bluish-purple color) of the fingers and lips, an oxygen saturation level of 57%, and was hot and diaphoretic (sweating). EMS placed the resident on a nonrebreather mask (fits over mouth and nose) at 15 liters. His/Her breathing rate was 40 and shallow. The resident was transferred to the hospital, where he/she expired a short time later. The census was 71. The Administrator was notified on [DATE] at 4:58 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect - Clinical Protocol Policy, revised ,d+[DATE], showed: -Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.; -Assessment and Recognition: -l. The nurse will assess the individual and document related findings. Assessment data will include: -e. All current medications; -g. Vital signs; -j. All active diagnoses; -k. Any recent labs; -2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear; -4. The physician and staff will help identify risk factors for abuse within the facility; for example, significant numbers of residents/patients with unmanaged problematic behavior, significant injuries in physically dependent individuals; problematic family issues; deficiencies in the physical environment; problems related to adequate staffing, staff burnout, poor preparation, and training; and lack of knowledge, skills, or performance that might affect how the residents/patients are being cared for; -Treatment/Management: -1. The facility management and staff will institute measures to address the needs of residents/patients and minimize the possibility of abuse and neglect. -Monitoring and Follow-Up: -2. The medical director will advise facility management and staff about systems to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately; -3. The medical director will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process. Review of the facility's Pulse Oximetry (Assessing Oxygen Saturation) Policy, revised ,d+[DATE], showed: -Purpose: The purpose of this procedure is to monitor arterial blood oxygen saturation (SaO2) without the use of invasive devices; -Preparation: -1. Review the physician's orders or facility protocol for pulse oximetry; -2. Review the resident's care plan to assess for any special needs of the resident; -General Guidelines: -1. The pulse oximeter is a probe with light emitting diodes (LEDs) connected to an oximeter. The LED emits light waves that are absorbed by oxygenated and deoxygenated hemoglobin molecules. The oximeter measures the light reflected by these molecules and calculates the pulse oxygen saturation (SpO2) which is a reliable measure of SaO2; -2. Normally SpO2 is between 90 and 100 percent; SpO2 below 70 percent is life threatening; -Assessment; -1. Assess the resident for the following signs and symptoms of impaired oxygen saturation: -a. Altered respirations, difficulty breathing, abnormal breath sounds; -b. Cyanotic appearance of nail beds, lips, skin, mucous membranes, skin; -c. Restlessness, irritability; and/or; -d. Confusion, loss of consciousness; -11. If SpO2 is less that 90 percent: -a. Reposition the probe and re-evaluate readings; -b. If SpO2 is less than acceptable level for resident's condition, notify the physician; -c. Position the resident in semi-Fowler's (position in which the individual lies on their back on a bed with the head of the bed elevated at 30 to 45 degrees) or high-Fowler's (position in which the individual lies on their back on a bed with the head of the bed elevated between 60 and 90 degrees) position; -Documentation: The SpO2 flow sheet should be placed in the medical record. In addition, the following information should be recorded in the resident's medical record: -1. The date and time the procedure was performed; -2. The type of probe and location of placement; -3. The assessment data gathered prior to the procedure; -4. The resident's response to the procedure; -5. Any unusual findings and action taken; -Reporting: -2. Report other information in accordance with facility policy and professional standards of practice. Review of the facility's Oxygen Administration Policy, revised ,d+[DATE], showed: -Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration; -Preparation: -1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration; -2. Review the resident's care plan to assess for any special needs of the resident; -General Guidelines: -1. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter; -a. The oxygen mask is a device that fits over the resident's nose and mouth. It is held in place by an elastic band placed around the resident's head; -b. The nasal cannula is a tube that is placed approximately one-half inch into the resident's nose. It is held in place by an elastic band placed around the resident's head; -Assessment: -Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: -1. Signs or symptoms of cyanosis (blue tone to the skin and mucous membranes); -2. Signs or symptoms of hypoxia (rapid breathing, rapid pulse rate, restlessness, confusion); -3. Signs or symptoms of oxygen toxicity (tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); -4. Vital signs; -5. Lung sounds; -Steps in the procedure: -13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated (see Assessment); -Documentation: -After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: -1. The date and time that the procedure was performed; -2. The name and title of the individual who performed the procedure; -3. The rate of oxygen flow, route, and rationale; -4. The frequency and duration of the treatment: -5. The reason for as needed (PRN) administration: -6. All assessment data obtained before, during, and after the procedure; -7. How the resident tolerated the procedure; -Reporting: -2. Report other information in accordance with facility policy and professional standards of practice. Review of the facility's Acute Condition Changes, Clinical Protocol Policy, revised ,d+[DATE], showed: -Assessment and Recognition: -1. During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay; -2. In addition, the nurse shall assess and document/report the following baseline information: -a. Vital signs; -b. Neurological status: -c. Current level of pain, and any recent changes in pain level; -d. Level of consciousness; -e. Cognitive and emotional status; -f. Resident's age and sex; -g. Onset, duration, severity; -h. Recent labs; -i. History of psychiatric disturbances, mental illness, depression, etc.; -j. All active diagnoses; -k. All current medications; -3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse; -6. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; for example, history of present illness and previous and recent test results for comparison; -a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status; -b. Nurses are encouraged to use the situation, background, assessment, and recommendation (SBAR) communication form and progress note as a tool to help gather and organize information before notifying the Physician; -7. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less); -8. The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status; -a. The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. The Physician should ask questions to clarify the situation; for example, vital signs, physical findings, and description of symptoms; -9. The Nurse and Physician will discuss and evaluate the situation; -a. The Physician should ask questions to clarify the situation; for example, vital signs, physical findings, and description of symptoms; -Treatment/Management: -2. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting; -Monitoring and Follow-Up: -1. The staff will monitor and document the resident's progress and responses to treatment, and the Physician will adjust treatment accordingly; -2. The Physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. -The facility policy did not address emergency situations such as when a resident is in acute distress (such as respiratory distress), if the staff should call for assistance, and how the staff should care for the resident. Review of the facility's Change in a Resident's Condition or Status, revised ,d+[DATE], showed: -Policy Statement: -Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status; -Policy Interpretation and Implementation: -1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): -d. Significant change in the resident's physical/emotional/mental condition; -g. Need to transfer the resident to a hospital/treatment center; -i. Specific instruction to notify the Physician of changes in the resident's condition; -2. A significant change of condition is a major decline or improvement in the resident's status that: -a. Will not normally resolve itself without intervention by staff or by implementing standard disease- related clinical interventions (is not self-limiting); -3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form. -The facility policy did not address emergency situations such as when a resident is in acute distress (such as respiratory distress). If the staff should call for assistance and how the staff should care for the resident. Review of the facility's Emergency Procedure for Critically Low Oxygen Level, dated [DATE], showed: -In the event that a resident has critically low oxygen level and you are unable to immediately reach the resident's PCP the following procedures should be followed: -Start the resident on oxygen at 2L (liters) per nasal cannula or mask and titrate up to 10L until SpO2's reach 90%; -Continue to attempt to reach PCP and call EMS to transport the resident to the ER for emergency care. Review of Resident #1's hospital discharge orders, dated [DATE], showed, bilevel positive airway pressure (BiPap, machine that helps with breathing when the patient is unable to get enough oxygen or unable to get rid of carbon dioxide) to be used with sleep and as needed during the daytime, use nightly. Review of Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -Rejection of care not exhibited; -Independent with eating, oral hygiene, upper body dressing, and putting on or taking off footwear; -Required supervision or touching assistance with toileting, bathing, sit to stand, transfers, and walking 10 feet, and walking 10 feet on uneven surface; -Required set up or clean up assistance with lower body dressing, roll left and right, sit to lying, lying to sitting; -Shortness of breath with exertion walking, bathing, transferring, none; -Shortness of breath or trouble breathing when sitting at rest, none; -Shortness of breath or trouble breathing when lying flat, none; -Received continuous oxygen therapy on admission and while a resident; -Used noninvasive positive pressure ventilation (NPPV, ventilatory assistance without an invasive artificial airway. It is delivered to a spontaneously breathing patient via a tight-fitting mask that covers the nose or both the nose and mouth), BiPap; -Diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), obstructive sleep apnea (intermittent airflow blockage during sleep), narcolepsy, congestive heart failure (CHF, a weakened heart condition that causes fluid buildup), Covid 19, respiratory failure, and obesity. Review of the resident's care plan, in use during the survey, showed: -Problem: Resident has COPD; -Goals: Resident will display optimal breathing patterns and will be free of signs and symptoms of respiratory infections through the review date; -Interventions: -Give aerosol (fine mist inhaler, used to treat breathing disorders) or bronchodilators (inhaler used to treat breathing disorders) as ordered. Monitor and document any side effects and effectiveness; -Head of bed (HOB) elevated to 45 degrees if tolerated or out of bed upright in a chair during episodes of difficulty breathing; -Monitor for difficulty breathing on exertion. Remind resident not to push beyond endurance; -Monitor for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath (SOB) at rest, cyanosis, somnolence (lethargy); -Monitor, document, report PRN any signs and symptoms of respiratory infection: fever, chills, increase in sputum (document amount, color, and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing; -Problem: Resident has oxygen therapy related to CHF, ineffective gas exchange at 3L/NC and use BiPap with the following settings: NPPV settings: titrate to keep SpO2 greater than or equal to 90%, FiO2 (fraction of inspired oxygen, an estimation of the oxygen content a person inhales) 40%, set respiratory rate to 20; -Goals: Resident will have no signs or symptoms of poor oxygen absorption through the review date; -Interventions: -Monitor for signs and symptoms of respiratory distress and report to physician PRN: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis (partial or complete collapse of the lung), hemoptysis (coughing up blood), cough, pleuritic pain (inflammation of the lining of the lungs that causes sharp chest pains), accessory (muscles of the shoulder and chest wall that are utilized during respiratory distress to help the flow of air in and out of the lungs) muscle usage, skin color; -Oxygen settings: oxygen via nasal cannula at 3L and BiPap: NPPV settings: titrate to keep oxygen greater than or equal to 90%, Fio2: 40%, set respiratory rate to 20; -Promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, HOB elevated to 45 degrees. Review of the resident's electronic physician order summary (ePOS), showed: -Order date, [DATE], Full code (when vital signs are not present, basic cardiopulmonary resuscitation (CPR) will be initiated and 911 will be called); -Order date, [DATE], listed under other (orders listed under other do not show up on the electronic medication administration (eMAR) or electronic treatment administration (eTAR)), oxygen 3 L per minute continuous via nasal cannula (NC); -Order date, [DATE], listed under other, NPPV Settings: titrate (adjust) to keep oxygen saturations greater than or equal to 90%, FiO2 40%, set respiratory rate 20; -Order does not specify when to use BiPap. Review of the resident's vital signs summary, dated [DATE] through [DATE], showed: -[DATE] at 6:25 P.M.: -SpO2, 92% via 3L/NC (normal range 95% - 100%); -Respiratory rate (RR, breaths per minute, normal range is ,d+[DATE]) 18; -Pulse rate, (PR, heart beats per minute (BPM), normal range 60 - 100) 98; -Blood pressure, (BP, normal ,d+[DATE]) ,d+[DATE]; -Temperature, (T, normal 98.6 degrees Fahrenheit (F)) 98.3 F; -[DATE] at 12:51 A.M.: -SpO2, 98% via 4L/NC; -RR, 18; -PR, 70; -BP, ,d+[DATE]; -T, 98.6 F; -[DATE] at 12:56 A.M.: -SpO2, no value recorded; -RR, 18; -PR, 72; -BP, ,d+[DATE]; -T, 98.2 F; -[DATE] at 12:42 P.M.: -SpO2, 98% via 4L/NC; -RR, 16; -PR, 120; -BP, ,d+[DATE]; -T, 96.6 F. Review of the resident's progress notes, dated [DATE], showed: -At 7:39 A.M., resident was up in wheelchair watching TV. Resident slept well through the night. Resident denied pain until he/she went to the bathroom with staff assistance. PRN pain medication was administered as ordered and pain medication was effective; -At 12:31 P.M., nurse was called to resident's room to check oxygen concentrator. Resident's oxygen concentrator was found to be broken and portable e-tank was obtained, and oxygen was administered at 4L per nasal cannula. Resident's SpO2 started out at 61% when oxygen was first applied. Resident's SpO2 increased to 76% on 4L, resident is lethargic, and only answered to name. Primary Care Physician (PCP) called and orders given to send to ER. Report called to ER, ambulance arrived and transported resident to ER. Review of the Emergency Medical Services (EMS) Care Report, dated [DATE], showed: -Nature of call: Breathing problem; -Response mode to scene: Emergent; -Timeline of EMS services: -Public-safety answering point (PSAP, call center) call at 12:46 P.M.; -Unit arrived on scene at 12:56 P.M.; -Arrived at patient at 1:02 P.M.; -Unit left scene at 1:56 P.M.; -Destination patient transfer of care 2:16 P.M.; -Primary impression: Respiratory failure; -Initial patient acuity: critical; -Assessment summary: -Skin: diaphoretic, hot, cyanotic; -Mental status: somnolent; -Eyes: left reactive, right reactive; -Findings: -Responded on 911 to call out of facility, arrived on scene to find nurse at nurse's station. Nurse stated the resident was off oxygen for an unknown amount of time due to his/her oxygen tank not working. Nurse stated the resident is now lethargic and has low SpO2 saturations and the resident is on 4L at baseline. EMS crew made patient contact. The resident was found prone on his/her bed with his/her head to the side. Resident was on 4L via nasal cannula. Resident's skin was diaphoretic and hot. Resident had audible rales and white thick sputum. Resident was alert to painful stimuli (assessing the consciousness level of a person. The patient may move, moan, or cry out directly but only in the response to the application of painful stimuli). Resident had peripheral cyanosis of the fingers and lips. Resident was unable to be repositioned due to furniture and other resident belongings in the way. Resident was placed on nonrebreather (NRB, mask that allows person to only breathe in pure oxygen) at 15L and crew removed objects and furniture to better gain access to the resident and treat the resident. Resident was rolled supine (chest up) in his/her bed and was transferred to the stretcher. Resident was breathing 40 RR and shallow. The resident's SpO2 saturation was steadily improving, but respiratory effort was not. Second Advanced Life Support (ALS/EMS) crew for lift assist arrived on scene as crew reached the ambulance. Resident's SpO2 saturation raised above 90% and peripheral cyanosis improved. Resident's respiratory effort did not improve. Crew placed intraosseous (IO, placement of a specialized hollow bore needle through bone for fast and reliable route to give medications and infusions) in the resident's right tibia (the shinbone). The resident was placed on 1L of normal saline (IV fluids) infusion via pressure bag (used when a critically ill or injured patient requires a rapid administration of fluids). Crew prepared for sedative assisted intubation (tube inserted through the mouth to maintain an open airway to assist with breathing). Resident had intact gag reflex and was alert to pain. I-gel (used in securing and maintaining an airway in emergency situations) was placed and crew began to ventilate (to force air in and out of the lungs of a person who cannot breathe on their own) with bag-valve-mask (BVM, the standard method for rapidly providing rescue ventilation). Resident capnography (measurement of the partial pressure of carbon dioxide (CO2)) read high. Resident was given a breath every 5 seconds. Resident was transported to ER. Resident remained unconscious without gag reflex. Crew maintained SpO2 in the high 90's for duration of transport. Resident was taken intoER on the stretcher; -Vital signs: -At 1:06 P.M.: -SpO2, 57%; -RR, no value recorded; -PR, 134; -BP, no value recorded; -At 1:11 P.M.: -SpO2, 88%; -RR, 42, shallow; -PR, 126; -BP, ,d+[DATE]; -At 1:13 P.M.: -SpO2, 89%; -RR, 40, normal; -PR, 127; -BP, ,d+[DATE]; -At 1:18 P.M.: -SpO2, 92%; -RR, 40, shallow; -PR, 128; -BP, ,d+[DATE]; -At 1:28 P.M.: -SpO2, 95%; -RR, no value recorded; -PR, 48; -BP, ,d+[DATE]; -At 1:38 P.M.: -SpO2, 48%; -RR, 21, mechanically assisted with BVM; -PR, 107; -BP, ,d+[DATE]; -At 1:43 P.M.: -SpO2, 94%; -RR, 12, mechanically assisted with BVM; -PR, 118; -BP, ,d+[DATE]; -At 1:48 P.M.: -SpO2, 90%; -RR, 10, mechanically assisted with BVM; -PR, 116; -BP, ,d+[DATE]; Review of the resident's Emergency Department (ED) record, dated [DATE], showed: -At 1:54 P.M. resident arrived in ED, resident was in respiratory distress and unresponsive; -At 2:01 P.M. vital signs: -SpO2, 100%; -RR, 16; -PR, 115; -BP, ,d+[DATE]; -At 2:13 P.M., CPR started; -At 2:33 P.M., time of death was called. During an interview on [DATE] at 8:55 A.M., Certified Medication Technician (CMT) D said the last time he/she worked with the resident was on Thursday [DATE]. CMT D said the resident wore his/her oxygen and thought he/she was on 3L via nasal cannula. CMT D said the resident did not refuse to wear his/her oxygen. CMT D said the resident did not voice any complaints of not feeling well on Thursday. He/She monitors if a resident is wearing oxygen when he/she passes medication to the resident. CMT D said he/she does not document the monitoring that the nurse is responsible for that documentation. CMT D said if a resident had a change in condition, he/she would take the resident's vitals and ask the resident how they are feeling and then report the information to the nurse. Vitals would be documented in the electronic medical record (EMR) in the vitals section. During an interview on [DATE] at 9:05 A.M., Licensed Practical Nurse (LPN) E said the last time he/she worked with the resident was on Thursday [DATE]. LPN E said the resident wore oxygen and did not refuse care. LPN E said the resident would use his/her call light to request assistance as needed. LPN E said he/she would know a resident receives oxygen by looking at the orders in the EMR. LPN E said if a resident wore oxygen, it would be monitored on rounds and when medication is administered. Certified Nurse Aides (CNAs) check to make sure residents are wearing the oxygen and the head of the bed is elevated. LPN E said the oxygen monitoring would be documented in the progress note if the resident wore the oxygen as ordered or if the resident refused. If a resident had a change in condition, he/she would assess the resident including taking vitals and call the PCP with the assessment and follow the PCP orders. If a resident was in respiratory distress, 911 would be called. The change of condition would be documented in PCC under progress notes along with any other interventions completed for the resident including notifications to PCP and responsible party. During an interview on [DATE] at 12:45 P.M., LPN F said he/she worked with the resident on the night shift Thursday [DATE]. LPN F said the resident wore his/her BiPap during the night shift and only removed it when she got up that morning to go to the bathroom. The resident wore his/her oxygen after removing the BiPap. The resident required assistance with transfers. The resident never had any respiratory distress while LPN F was caring for the resident. LPN F said the resident did not have any respiratory problems when he/she assisted the resident with transfers. The resident did not breath heavily on his/her shift, did not have cold skin and was not sweating. LPN F said that would not be normal for the resident. The resident wheeled himself/herself outside and back inside on Thursday and the resident did not sweat then. The resident did not report any concerns of not feeling well to LPN F on Thursday or Friday morning [DATE]. There were no problems with the oxygen concentrator during LPN F's shift. When LPN F left Friday morning, the resident was sitting up in his/her wheelchair and was A&O X 4. During an interview on [DATE] at 9:49 A.M., CNA G said he/she was familiar with the resident. CNA G said the resident always wore his/her oxygen. The resident was independent except he/she required assistance with transfers. CNA G said the resident wore oxygen on Friday [DATE]. CNA G did not notice any problems with the resident on Friday. He/She delivered the breakfast tray to the resident in his/her room. When CNA G delivered the breakfast tray, the resident had his/her eyes closed and he/she opened and then closed them CNA G said he/she would know a resident uses oxygen by the nurse informing him/her in report. CNA G said he/she would ask the nurse to find out how many liters the resident is supposed to be receiving. CNA G said residents who wear oxygen are monitored when they complete rounds, they visually check to see if the residents are wearing oxygen. Monitoring the oxygen is not documented by the CNA. If a resident was noticed not wearing oxygen and they were supposed to, CNA G would report it to the nurse. If a resident had a change in condition, CNA G would take the resident's vitals and report the change and vitals to the nurse. During an interview on [DATE] at 10:41 A.M., CNA B said he/she worked with the resident on Friday [DATE]. CNA B said when he/she came in and was making rounds, the resident was up in his/her wheelchair and he/she wore oxygen. CNA B said the resident requested assistance with getting into bed and CNA B assisted the resident from his/her wheelchair into bed. CNA B said he/she asked the resident if he/she was going to eat breakfast and the resident said no. CNA B said he/she went to check on the resident after breakfast between 9:00 A.M. and 10:00 A.M. CNA B said the resident had his/her oxygen on at that time. CNA B said he/she went into the resident's room around 11:00 A.M. to take this/her vitals because LPN A asked him/her to. CNA B said when he/she went into the resident's room, he/she lay on his/her side on the bed. CNA B said it looked like the resident was breathing harder than he/she was earlier. The resident did not open his/her eyes or respond to CNA B when he/she spoke to him/her when CNA B went to get the resident's vitals. CNA B said the resident's fingers were purple, the resident was cold to touch and his/her head was sweaty. CNA B took the resident's vitals and wrote them down on a piece of paper and gave them to the nurse. CNA B did not document the vitals in the EMR. CNA B said He/She did not recall what the vitals were or if they were abnormal. CNA B told LPN A he/she did not think the resident was alright because the resident was breathing harder and not responding when CNA B spoke to him/her or when CNA B took the resident's vitals. CNA B also reported the resident was cold to touch, his/her head was sweaty and his/her three fingers (index, middle, and ring finger) on his/her the right hand were purple. LPN A said the resident is always like that, cold and sweaty. CNA B did not remember what LPN A did after reporting the change in condition. CNA B did not go back into the resident's room, because it was lunch time and he/she started assisting other residents into the dining room. CNA B said EMS arrived approximately 10 minutes later. During an interview on [DATE] at 7:09 A.M., CMT C said Friday [DATE] was the first time he/she had worked with the resident. CMT C went in to administer medications to the resident between 10:20 A.M. and 11:00 A.M. CMT C said the first time he/she saw the resident, the resident breathed funny. The resident would take deep breaths, like he/she was breathing heavy. CMT C asked the resident about his/her breathing and the resident told CMT C he/she had COPD and said he/she was fine, that was just how he/she breathes. CMT C said the resident laid in bed on his/her right side. The resident propped himself/herself up a little on his/her right elbow so CMT C could give the resident's medication. CMT C also administered inhalers to the resident. The resident took his/her medication and inhaler fine and then laid back down in bed. CMT C asked the resident if he/she wanted a BiPap treatment because the machine was right there. The resident told CMT C he/she just had a BiPap treatment. CMT C said he/she was unsure who administered the treatment, maybe the night nurse, but the resident did not want a BiPap treatment whi

Based on interviews, record reviews, personnel file review, and review of the facility's policy, the facility failed to have two staff available during the mechanical lift transfer of one resident (Resident (R) 73). Staff failed to ensure the mechanical lift device was in working order and inspection of the device showed it had missing bolts. During the transfer, the lift collapsed. The resident was later transferred to the hospital, diagnosed with a brain bleed, underwent surgery, and expired. This had the likelihood to cause serious injury, harm or death for any of the 76 residents that could be transferred by untrained personnel. An Immediate Jeopardy was identified on [DATE] and was determined to exist starting on [DATE]. The Administrator and Director of Nursing were notified on [DATE] at 9:24 PM. The facility was notified that an acceptable plan of removal had been accepted and verified as implemented on [DATE]. Findings include: Review of the facility's policy titled, Lifting Machine, Using a Mechanical, revised [DATE], showed: General Guidelines- 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Review of R73's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE] of with medical diagnoses that included hemiplegia and hemiparesis (paralysis and weakness) following a nontraumatic intracerebral hemorrhage (stroke) affecting the left non-dominant side, muscle weakness, abnormal posture, dementia, and cognitive communication deficit. A quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE] showed R73 had a Brief Interview for Mental Status (BIMS) score of six of a possible 15, indicative of severe cognitive impairment. Review of R73's Care Plan, initiated on [DATE], from the EMR Care Plan tab revealed she had an Activities of Daily Living (ADL) self-care performance deficit and required the use of a full body mechanical lift with the assistance of two staff for transfers. The care plan also showed R73 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to self-care deficit, alert and oriented to self, confusion and a diagnosis of cognitive communication deficit. Review of the Progress Note from the EMR Progress Note tab, dated [DATE] at 6:12 AM showed, [CNA4's name] was opening the arms of mechanical lift once up in the air, the right arm folded in instead of opening up. Resident went straight down to floor on her back. Couldn't tell if she hit head but initiated Neuros regardless. VSS [Vital Signs Stable] ,d+[DATE], 70, 18.perrla [pupils are equal round and reactive to light and accommodation] Call placed to pcp [primary care provider] to get order for R [right] hip x-ray, and to update on fall. Awaiting response. Review of the undated Facility Reported Investigation, provided by the facility, indicated, an agency Certified Nurse Aide (CNA) 4 (contracted [DATE]) was performing a transfer with R73 with a manual mechanical lift on [DATE] at approximately 5:45 AM. CNA4's statement showed she had never used the lift previously. R73 was in the mechanical lift sling over the bed when the lift had a mechanical failure, and the leg collapsed into the other leg instead of opening up, causing the lift to fall, and R73 hit the floor as the lift started going back down by itself. Neuro checks were instituted and were within normal limits until the two one-hour checks at 8:45 AM and 9:45 AM when it was documented the resident refused. R73 was taken to breakfast and then placed in a chair. There was no documentation for the hours between breakfast and 11:20 AM. At 11:20 AM, R73 vomited and was unresponsive to sternal rubs. R73 was transferred to the hospital. The resident underwent surgery for a brain bleed and passed away. CNA4 was the only nursing staff in the room when the lift fell over. The nurse was in the common area just outside of R73's room. According to facility policy, another staff member should have been in the room during the transfer. During a telephone interview on [DATE] at 4:35 PM CNA4 stated she was getting ready to do last rounds and R73 wasn't feeling good that morning. CNA4 stated she had asked for help from another aide that worked overnight - but the aide didn't come. R73 was connected with the [mechanical lift brand commonly used to signify a total body lift], I've never worked with this type lift before it was a crank and [R73's] wouldn't stop moving, I'd tell her to be still but it kept going up and down. The Charge Nurse was at the end of the hall and as I was ready to ask for help when the whole machine fell inwards, the whole thing just collapsed. It was a crank and she couldn't be still. It happened so fast she wouldn't be still. She [R73] was moving all the time. It just lifted up and toppled over collapsed on itself. It was still under the bed and she was over the bed. When queried if CNA4 had received training on the lifts available for use in the facility, CNA4 responded, No I didn't have no [sic] orientation. They did a walk through with me to know the people [residents] I will be working with. During an interview with the Director of Nursing (DON) on [DATE] at 5:09 PM, the DON stated the incident was not an injury of unknown origin, so no report was sent to state and an internal investigation led to the conclusion that the equipment malfunctioned. The lift has been taken out of service. Maintenance records show that monthly inspections were completed on the lifts; however, the records do not indicate which lifts were inspected. Inspection of the involved lift after the incident showed bolts were missing. Competency checks have been requested for facility and agency staff members. R73 went to the hospital and, according to a family interview on [DATE] at 10:42 AM, was diagnosed with a brain bleed, underwent surgery, and expired. A training regarding the requirement for two nursing staff to be present before a resident is attached to a mechanical lift was completed on [DATE]. Twenty staff signed the Staff to Inservice sign-in sheet. A staff list provided [DATE] showed there are 45 facility & agency employees, which leaves 25 current staff members not in-serviced on the requirement for the presence of two nursing staff when the mechanical lift is used. Note: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective actions to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of the exit, the deficiency was lowered to the D level. This statement does not denote the facility has complied with state law (section 198.026.1 RSMO) requiring that prompt remedial action to be taken to address Class I violation(s). MO00230310

Based on observation, interview and record review, the facility failed to ensure there were a sufficient number of skilled licensed nurses and other nursing personnel to provide care and respond to each resident's need. The facility also failed to ensure licensed nurse coverage 24 hours a day when a nurse, scheduled to work the evening shift on 1/7/22, failed to report for duty. The facility did not have a system in place to ensure the required coverage was provided. Licensed Practical Nurse (LPN) T, who worked the day shift on 1/7/22, left the facility at approximately 5:00 P.M., with only one certified nursing assistant (CNA) on duty. When the night shift staff arrived, only two CNAs were on duty. As a result, Resident #34 was not evaluated by a licensed nurse when he/she experienced respiratory distress and an elevated blood pressure and complained of severe pain throughout the night without receiving his/her ordered pain medication. A licensed nurse was not on duty to assess Resident #401 after a fall, . The facility had no licensed nurse and no staff qualified to administer medications, perform treatments for two shifts resulting in seven residents (Residents #245, #18, #39, #402, #25, #8, #403) who did not receive medications as ordered and did not replace a dressing on a stage IV pressure ulcer when the dressing became soiled for Resident #32. Resident #11 reported having loose stools but there was no licensed nurse to assess the resident. As a result the resident reported discomfort and skin irritation. In addition, the facility had six residents positive for COVID-19 who did not receive the oversight of a licensed nurse. Two of the COVID-19 residents were included in the sample (Residents #400 and #41), in addition to four expanded sampled residents, all who required prescribed medication for medical conditions and did not receive those medications (Residents #402, #25, #8 and #403). In addition, the facility failed to ensure staff in sufficient numbers to meet the needs of the residents when only one nurse was scheduled to work on 1/2/22. The facility had residents who required assistance of two staff for care. These failures had the potential to affect all residents who resided in the facility. The sample was 13. The facility census was 42. The administrator was notified on 1/10/22 at 10:52 A.M. of an Immediate Jeopardy (IJ) which began on 1/7/22. The IJ was removed on 1/12/22, as confirmed by surveyor onsite verification. 1. Review of the facility's Facility Assessment Tool, last reviewed on 6/30/21, showed: -Average daily census: 40-50; -Staff type, included: Administrator, Director of Nursing (DON), unit managers, registered nurse (RN), LPNs, certified medication technicians (CMTs) and CNAs; -Staffing plan: Total number needed, average, or range: -Licensed nurses providing direct care: 10 (agency also used); -Other nursing personnel (e.g., those with administrative duties): five; -This facility reviews and updates job descriptions annually. The facility administration also reviews the staffing needs and the needs of the residents on an ongoing basis. The facility works on recruitment and retention continually offering bonus programs for new hires, retention bonus programs for those who currently work in the community, performing market analysis to assure that our wages remain above competitive to draw the best staff. During an interview on 1/10/22 at 12:40 P.M., the administrator and consultant administrator said the facility assessment provided is the facility assessment currently in use at the facility. 2. Review of the facility's undated Following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Purpose of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Classification of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Medication orders: These orders cover all the medications that may be prescribed for a resident by several different routes of administration. There may also be different indications as to when and how a medication is to be given, such as before meals or with food; -Treatment orders: These orders cover various treatments a resident receives and may vary from a preventative dressing to a dressing for a wound with multiple different ointments; -Importance of following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Medication must be administered in such a way that the balance of absorption and metabolism maintains a specific level in the blood. For each medication, scientists have determined the optimal dose and frequency of dosing to maintain concentrations in the blood that are high enough to maximize beneficial effects but low enough to avoid toxic side effects. If the doses are too low or are taken too infrequently, the medication may not be effective; -Although the timing of medication is often dictated by the need to maximize benefits and limit side effects, a physician might also specify particular timing of doses and length of treatment in order to avoid interactions with other medications. In addition, certain procedures or tests may require special timing of the prescribed medicines. Finally, physicians may recommend that a medication be discontinued because it may interfere with certain procedures or tests. Not following a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -The bottom line is that to obtain the maximum benefit from medications, ointments, treatments, etc. and to minimize the potential for side effects for our residents, a charge nurse must always follow exactly the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. During an interview on 1/9/22 at 10:20 A.M., the CNA/staffing coordinator said WNBI stands for will not be in and indicates a scheduled staff person will not be reporting to work. Review of the facility's Daily Staffing Sheet, dated 1/7/22, showed: -Day shift 6:30 A.M. through 3:00 P.M.: One nurse and two CNAs scheduled; -Evening shift 2:30 P.M. through 11:00 P.M.: -One nurse scheduled with WNBI hand written next to the name; -One CNA scheduled with WNBI hand written next to the name; -A third name scratched through and illegible; -Night shift 10:30 P.M. through 7:00 A.M.: -One nurse scheduled with WNBI hand written next to the name; -CNA W and CNA X scheduled; -Two names scratched through and illegible. Review of LPN T's time card, showed: -On 1/7/22, he/she clocked in at 6:45 A.M. and clocked out at 5:07 P.M.; -On 1/8/22, he/she clocked in at 6:45 A.M. During an interview on 1/8/22 at 1:30 P.M., LPN T said he/she works for the facility. He/she is the only nurse currently on duty. His/her shift started at 7:00 A.M. There was no nurse on duty to give him/her report from night shift. At 2:45 P.M., LPN T said yesterday (1/7/22), his/her shift ended at 3:00 P.M., but he/she left about 5:00 P.M. When he/she left, the CNA/staffing coordinator was the only staff on duty. She took over for him/her. He/she did not report off to a nurse. There was no CMT either. He/she did not personally notify management, but he/she knew the CNA/staffing coordinator took care of it. Today, he/she is the only nurse with two CNAs. There is no CMT to pass medications. He/she does not have enough staff to get his/her duties done appropriately in a day. At 4:10 P.M., LPN T said when he/she left the faciity on [DATE] in the hands of the CNA/staffing coordinator, he/she left the medication keys in the drawer at the nurse's station in the control of the CNA/staffing coordinator. He/she believed the CNA/staffing coordinator was responsible enough to keep control of the keys. She returned them to him/her this morning when he/she returned to the facility. On 1/9/22 at 10:37 A.M., LPN T said he/she had never been given guidance on what to do if the staff from the next shift do not show up. On 1/7/22, it was the CNA/staffing coordinator who relieved him/her, and she handles the staffing issues. At 12:16 P.M., LPN T said when he/she returned to the facility on [DATE], the night shift had already left and the CNA/staffing coordinator had returned to the facility and was the only staff there. During a telephone interview on 1/8/21 at 5:36 P.M., with the administrator and consultant administrator, the administrator said she knew there was no nurse last night. She was called and informed. The facility's nurse staffing agencies were contacted. The facility has contracts with three staffing agencies. They reached out to sister facilities, but they had no staff to provide. The consultant administrator said she was not aware there was no nurse last night until 1/8/22 at 5:30 A.M. She could have come in and worked if she had been made aware they had no nurse, but by the time she knew, it was too late. She has a 3 hour drive to the facility. The administrator said the CNA/staffing coordinator said she was staying over on the evening shift to help and she was putting calls out to the nurse staffing agencies. She found out in the middle of the night, at the start of night shift, that no nurse ever came in, but there was nothing else she could do. During an interview on 1/8/22 at 11:00 P.M., CNA X said the night of 1/7/22 was the first time he/she ever worked at the facility. He/she arrived at approximately 10:30 P.M. and worked until 7:00 A.M. There was no nurse on duty at any time. All the residents were asking for medications, but no one got any. There were residents asking for anything from Tylenol, to blood pressure medications, or really anything. They needed a nurse. During an interview on 1/8/22 at 11:10 P.M., CNA W said he/she had never worked at the facility prior to the night of 1/7/22. He/she was scheduled to work from 10:30 P.M. through 7:00 A.M. There was no nurse on duty. The only other staff in the building was another CNA. Residents needed their medications and he/she was not able to do that for them. He/she and CNA X did not know what to do, they were just told they were the only staff there. During an interview on 1/9/22 at 10:20 A.M., the CNA/staffing coordinator said on 1/7/22, after the day shift nurse left, it was just her at the facility. She reached out to one of the staffing agencies by texting them and reached out to the administrator, so she could reach out to the other two agencies. She was not scheduled to work, but came in because of the staffing issues. She informed the administrator later that night, before she left for the night, that no nurse had shown up from any of the agencies. Her shift ended after the two night shift CNAs came in, around 11:00 P.M. There was no one at the facility who was able to administer medications. During her shift, residents were needing their medications. She gave the two oncoming CNAs a rundown of the circumstances before leaving at 11:00 P.M. She returned to the facility the next day at 6:30 A.M., to relieve the night shift CNAs. The day shift nurse arrived around 7:00 A.M. or 7:15 A.M. Before the two night shift CNAs left, they reported that Resident #401 had a fall and that Resident #34 wanted his/her blood pressure medications because he/she was having high blood pressures. On 1/10/22 at 12:23 P.M., the CNA/staffing coordinator said the facility has not had a DON for a while, today was the first day the DON arrived to the facility. CNAs do not have access to the electronic medical record, so they have no way to document. They usually report concerns to the nurse, who then documents it. The facility does have residents who require the use of a Hoyer lift (mechanical lift that requires two staff to use), as well as residents who require assistance of two for care. During an interview on 1/9/22 at 12:40 P.M., with the administrator and consultant administrator, the administrator said the CNA/staffing coordinator said she was staying over to make sure everyone had coverage as we had found out earlier that day the scheduled nurse for evening and night shift was accidentally told he/she was not needed. When she contacted the nurse back, it was already too late as he/she had picked up a shift somewhere else. It was in the morning that she placed the request for a nurse from the staffing agencies. The administrator said she spoke with the consultant administrator earlier in the day and their facility had no nurses available. Facility staff were also called to work, but no one was able to. She never heard back from the staffing agencies. It is not acceptable for a nurse on duty to abandon their shift without passing off responsibility to a licensed nurse. LPN T should have stayed until someone showed up. He/she could have called the administrator and reaffirmed that no licensed staff was there so she could guide him/her, but he/she did not. LPN T should have contacted the administrator before he/she left. 4. Review of the facility's undated Change in Resident's Condition or Status policy, showed: -Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status; -The nurse will notify the resident's physician or physician on call when there has been an: -Accident or incident involving the resident; -Significant change in resident's physical/emotional/mental condition; -Need to alter the resident's medical treatment significantly; -Need to transfer the resident to a hospital/treatment center; -Specific instructions to notify the physician of changes in the resident's condition; -A significant change of condition is a major decline or improvement in the resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions; -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision to the care plan; -Ultimately is based on the judgement of the clinical staff and the guidelines outlined in the resident assessment instrument; -Regardless of the resident's current mental or physical conditions, a nurse or healthcare provider will verbally inform the resident/representative of any changes in his/her medical care of nursing treatments; -The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 5. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/6/21, showed: -Clear speech, understood, understands, clear comprehension; -Moderately impaired cognition; -No behaviors; -Total dependence on two plus staff for bed mobility and transfers; -Total dependence on one staff required for toilet use; -Functional limitation in range of motion to the lower extremities on both sides; -Always incontinent of bowel and bladder; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Pain management: -Resident is on a scheduled pain medication regimen and received as needed pain medications; -Pain frequency: Occasionally; -Has pain made it hard for you to sleep at night: Yes; -Received oxygen therapy. Review of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, in use at the time of the survey, showed: -The resident has impaired physical mobility related to weakness and requires the use of a Hoyer lift: -Goal: Will remain free of complications related to immobility; -Interventions: The resident will be educated on the safe use of the Hoyer lift for transfer from bed to chair; -The resident has high blood pressure and takes [MEDICATION(S)] (medication use to treat high blood pressure): -Goal: The resident will remain free from signs and symptoms of high blood pressure; -Interventions: Give anti-hypertensive medications as ordered. Assigned to the LPN and RN; -The residents lung disease, oxygen therapy or pain that required routine and as needed pain medication, were not included in the care plan. Review of the resident's electronic physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated 7/24/21, for [MEDICATION(S)] (used to treat high blood pressure) 5 milligram (mg) at bedtime for high blood pressure: -Not documented as administered on 1/7/22; -An order dated 7/24/21, for [MEDICATION(S)] (topical patch used to treat pain) 5%. Apply to affected area topically. Apply in A.M. and remove at hour of sleep: -Scheduled to be removed at 4:00 P.M.; -No documentation the patch was removed on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] Diskus (used to treat [CONDITION(S)]) 100-50 micrograms (mcg)/dose. One inhalation two times a day for shortness of breath: -Scheduled administration time 9:00 A.M. and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] solution (a medication used to open up the airways) 0.03%, two sprays in both nostrils three times a day for difficulty breathing: -Scheduled administration times of 9:00 A.M., 1:00 P.M., and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] (generic for [MEDICATION(S)], used to treat nerve pain) 75 mg. Give one capsule by mouth three times a day for low back pain: -Scheduled administration times of 9:00 A.M., 2:00 P.M., and 9:00 P.M.; -Not documented as administered for the 9:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for econaxole [MEDICATION(S)] cream (used to treat fungal infections) 1%. Apply to affected area topically two times a day for fungal rash: -Scheduled administration times of 9:00 A.M. and 6:00 P.M.; -Not documented as administered for the 6:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] (used to prevent seizures) 500 mg. One tablet two times daily for seizures: -Scheduled administration time 9:00 A.M. and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] sodium gel (topical non-steroidal anti-[CONDITION(S)]) 1%. Apply to affected area topically four times a day for pain: -Scheduled pain assessment and administration at 9:00 A.M., 12:00 P.M., 5:00 P.M. and 9:00 P.M.; -Pain assessment not documented as completed and medication not documented as administered for the 5:00 P.M. and 9:00 P.M. doses on 1/7/22; -An order dated 9/17/21, for Tylenol extra strength tablet 500 mg. Give one tablet every night shift before midnight, daily: -Pain level not assessed on 1/7/22; -Not documented as administered on 1/7/22; -An order dated 10/14/21, to check blood pressure daily in the morning: -Not transcribed onto the eMAR or eTAR; -Not documented as completed in January 2022; -An order dated 12/8/21, for [MEDICATION(S)] (skin protectant) paste. Apply to buttocks topically every shift: -Not documented as administered on the evening or night shift on 1/7/22. During an interview on 1/8/22 at 2:28 P.M., the resident said last night and yesterday evening, he/she was not able to get his/her medications. He/she did not get any medications until mid-day today. His/her blood pressure last night was very high, it measured 175/65 (normal 90/60 through 120/80). It has been better today after he/she received his/her medications. He/she was in pain overnight and that makes his/her blood pressure go up. Last night he/she was having severe pain in his/her back and cervical spine area. Normally, he/she takes [MEDICATION(S)] (narcotic pain medication) and [MEDICATION(S)] (medication used to treat nerve pain), but last night he/she could not get any of his/her medication and the pain was unbearable. No one at the facility could give his/her medications to him/her. The pain has gotten a little better today, now that he/she had received his/her medication. He/she has a history of seizures and did not get any of those medications either. In addition, last night his/her oxygen concentrator broke. Water started coming out of the humidity bottle and poured through the nasal cannula into his/her nose. He/she could not breathe. The staff working on night shift did not know anything about the oxygen concentrator and did not know what to do. He/she did not get his/her oxygen and had severe shortness of breath. The nurse on day shift today was able to do something with it to fix it. He/she had no oxygen last night. Observation on 1/8/22 at 2:28 P.M., showed the resident lay in bed on his/her back. An oxygen concentrator on at 5 liters per nasal cannula. During an interview on 1/8/22 at 11:00 P.M., CNA X said the resident's blood pressure was up and he/she could not breathe. The oxygen machine was not working and he/she did not know what to do. The resident was in a lot of distress. There was no nurse in the facility. Review of the resident's progress notes, showed: -On 1/6/22 at 9:12 P.M., the resident's spouse asked about the oxygen machine and when observed, it was turned off and on and was not alarming. The resident's oxygen level was 95% (normal 95% through 100%). When the machine alarm went off again, they insisted that it was an emergency and the administrator needed to be called. The resident's oxygen level was still at 95%, but his/her spouse still insisted, even after it was explained that the concentrator cannot be replaced tonight and we just need to turn it off. The administrator was called and she stated there were oxygen tanks to use in the meantime and that was given to the resident and they were able to be calmed thereafter, but still stated I don't want to die in the middle of the night.; -Further review of the progress notes, showed no documentation if the oxygen concentrator was changed out and no documentation of the oxygen concentrator not working on the night shift on 1/7/22, the resident's shortness of breath, elevated blood pressure or pain. Review of the resident's medical record, reviewed on 1/8/22 at 3:01 P.M., showed no documentation of the resident's blood pressure measured daily in the morning and no documentation of the resident's pain, elevated blood pressure and shortness of breath experienced on the night shift on 1/7/22. During an interview on 1/9/22 at 12:16 P.M., LPN T said when he/she arrived to work on the morning of 1/8/22, the night shift CNAs were gone, but the CNA/staffing coordinator had come in. The CNA/staffing coordinator reported that the resident had issues with his/her blood pressure and oxygen overnight. During an interview on 1/9/22 at 11:00 A.M., the medical director said he was not made aware that the resident had shortness of breath and an elevated blood pressure on the night shift of 1/7/22. If those conditions existed, staff should have notified him. During an interview on 1/9/22 at 12:40 P.M., the administrator said the resident has had some issues with the oxygen machine. She told staff to get him/her a new oxygen concentrator. She was not aware it was still an issue. 6. Review of the facility's Fall- Clinical Protocol, revised September 2012, showed: -As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling; -The staff will document risk factors for falling in the resident's record, and discuss the resident's fall risk; -The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the event, etc.; -Falls should be categorized as: -Those that occur while trying to rise from a sitting or lying to an upright position; -Those that occur while upright and attempting to ambulate; and -Other circumstances such as sliding out of a chair or rolling from a low bed to the floor; -Falls should also be identified as witnessed or unwitnessed events; -The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved; -Delayed complications, such as late fractures and major bruising, may occur hours or several days after a fall, while signs of subdural hematoma (bleeding on the brain) or other intracranial bleeding could occur up to several weeks after a fall; -The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling; -Frail elderly individuals are often at greater risk for serious adverse consequences of falls; -Risk of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. Review of Resident #401's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Independent with transfers, walking in room and walking in corridor; -Mobility devices: Walker; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Has the resident had any falls since admission or prior assessment: Yes; -Number of falls with no injury: Two; -Received antipsychotic and antidepressant medications seven of seven days. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for upper respiratory infection/COVID-19 virus: -Goal: Resident will show no signs/symptoms of infection; -Interventions: Administer antibiotic therapy as prescribed, evaluate lung sounds, evaluate shortness of breath, evaluate heart rate, and evaluate lung sounds. Assigned to the LPN and RN. Initiate isolation precautions per order, monitor for signs/symptoms of infection; -Resident has a communication problem related to [CONDITION(S)] disorder. Resident stutters sometimes and can be difficult to understand. Remind resident to slow down: -Goal: Be able to make basic needs known by speaking slowly on a daily basis; -Interventions: Monitor/document/report as needed any changes in ability to communicate, potential for contributing factors for communication problems. Potential for improvement; -Impaired cognitive function/dementia or impaired thought process related to [CONDITION(S)] disorder: -Goal: Maintain current level of cognitive function; -Administer medications as ordered. Monitor/document for side effects and effectiveness. Assigned to the LPN and RN; -The resident has high blood pressure: -Goal: Be free of complications related high blood pressure: -Interventions: Give blood pressure medications as ordered. Monitor for side effects such as [CONDITION(S)] and increased heart rate. Monitor and document any [CONDITION(S)] (swelling). Monitor/record use/side effects of medication. Report to physician as necessary. Assigned to the LPN and RN; -Resident has diabetes: -Goal: Have no complications related to diabetes; -Interventions: Diabetic medications as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report as needed any signs or symptoms of low blood sugar, sweating, tremor, increased heart rate, nervousness, confusion, slurred speech, lack of coordination, and staggered gate. Assigned to the LPN and RN; -At moderate risk for falls related to balance issues. Resident walks fast and does not look where he/she is going. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Goal: Be free of falls; -Interventions: [CONDITION(S)] disease medication as ordered. Assigned to the LPN and RN. Remind the resident to slow down when he/she is walking and to look when walking; -On 1/3/22, the resident has tested positive for COVID-19, remains on quarantine: -Goal: Be free form signs and symptoms of infection; -Interventions: Educate resident on infection control practices, evaluate temperature, initiate proper isolation precautions per order, and monitor laboratory results. Assigned to the LPN and RN; -The resident uses [CONDITION(S)] medications, antidepressant and antipsychotic medications for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Goal: The resident will be/remain free of [CONDITION(S)] drug related complications, including movement disorder, discomfort, low blood pressure, gait disturbances or cognitive/behavioral impairment; -Interventions: Administer [CONDITION(S)] medications as ordered by the physician, monitor for side effects and effectiveness every shift. Assigned to the LPN and RN; -The resident has a [CONDITION(S)] disorder related to Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Goal: Remain free from injury related to [CONDITION(S)] activity; -Interventions: Give medications as ordered. Monitor/document for effectiveness and side effects. Give [CONDITION(S)] medication as ordered by the doctor. Monitor labs and report any sub-therapeutic or toxic results to the physician. Assigned to the LPN and RN. Review of the resident's ePOS, eMAR and eTAR, for January 2022, showed: -An order dated 6/5/18, for [MEDICATION(S)] (medication used to treat Alzheimer's disease) 10 mg. One tablet at bedtime related to dementia: -Scheduled administration time 9:00 P.M.; -Not documented as administered on 1/7/22; -An order dated 6/5/18, for [MEDICATION(S)]/[MEDICATION(S)] (medication used to treat [CONDITION(S)] disease) 25-100 mg. One tablet three times a day: -Scheduled administration times of 9:00 A.M., 1:00 P.M. and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 1/30/20, for [MEDICATION(S)] (antipsychotic mediation) 200 mg and 50 mg tablets at bedtime related to [CONDITION(S)] disorder: -Scheduled administration time 9:00 P.M.; -Not documented as administered on 1/7/22; -An order dated 4/7/20, take temperature twice a day, monitor for signs of respiratory infection, notify physician if indicated: -Scheduled at 9:00 A.M. and 6:00 P.M.; -Not documented as completed for the 6:00 P.M. scheduled time on 1/7/22; -An order dated 10/8/20, for [MEDICATION(S)] (used to treat high cholesterol) 20 mg. One tablet at bedtime related to high cholesterol: -Not documented as administered on 1/7/22. During an interview on 1/8/22 at 11:00 P.M., CNA X said on the night shift of 1/7/22, there was no nurse at the facility. The resident resided on the COVID-19 unit and fell on the floor. He/she and the other CNA assisted to get the resident up and back to bed. He/she did not have any visible injuries. The resident said he/she was fine. During an interview on 1/8/22 at 11:10 P.M., CNA W said on the night shift on 1/7/22, many things happened that would have required a nurse. There was no nurse at the facility. The resident fell and needed a nurse to assess him/her, but no one was there. CNAs cannot assess residents after a fall correctly. Review of the resident's progress notes, showed: -On 1/5/22 at 2:27 P.M., resident tested positive for COVID-19, resident placed under quarantine in room; -On 1/8/22 at 9:52 P.M., resident remains on follow up for a fall. No apparent injuries noted. Will continue to monitor; -No documentation of the resident's fall on 1/7/22 night shift, the circumstances surrounding the fall, assessment completed or interventions to prevent further falls. During

Based on observation, interview and record review, the facility failed to have a system in place to ensure there are an adequate number of staff present at all times who are properly trained and/or certified in cardiopulmonary resuscitation (CPR) for Healthcare Providers to be able to provide CPR until emergency medical services arrive. The facility failed to ensure CPR certified staff were working at the facility on [DATE] on the day and evening shift, [DATE] on the day shift, and [DATE] on the day shift. In addition, the facility failed to ensure CPR certified staff were certified in CPR for Healthcare Providers. This training includes hands-on practice and in-person skills assessment. In addition, the facility failed to ensure residents had orders for code status, code status sheets were available in the code status binder available to all staff, and that code status orders were congruent throughout the medical record for 5 of 13 sampled resident (Residents #403, #402, #25, #41, and #18). This had the potential to affect all residents in the facility who had full code status orders (all lifesaving measures desired). The census was 42. The administrator was notified on [DATE] at 3:11 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Advance Directives policy, revised [DATE], showed: -Advance directives will be respected in accordance with state law and facility policy; -Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -The attending physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan; -The resident has the right to refuse treatment, whether or not he or she has an advanced directive. A resident will not be treated against his or her own wishes. Review of the facility's Emergency Procedure- Cardiopulmonary Resuscitation policy, revised [DATE], showed: -Personnel have completed training on the initiation of CPR and basic life support (BLS), including defibrillation (stopping of fibrillation (irregular and often rapid heartrate) of the heart by administering a controlled electric shock in order to allow restoration of the normal rhythm), for victims of sudden [CONDITION(S)] (sudden loss of heart function); -Sudden [CONDITION(S)] is a loss of heart function due to abnormal heart rhythms. [CONDITION(S)] occurs soon after symptoms appear. It is a leading cause of death among adults; -A heart attack refers to impaired blood flow to the heart, which leads to damage of the heart muscle. A heart attack can cause sudden [CONDITION(S)]; -Victims of [CONDITION(S)] may initially have gasping respirations or may appear to be having a [CONDITION(S)]. Training in BLS includes recognizing presentations of sudden [CONDITION(S)]; -The chances of surviving sudden [CONDITION(S)] may be increased if CPR is initiated immediately upon collapse; -If an individual is found unresponsive and not breathing, normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR; unless: -It is known that a do not resuscitate (DNR, no life saving measures performed) order that specifically prohibits CPR exists for that individual, or; -There are obvious signs of irreversible death; -If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -If the first responder is not CPR certified, that person will call 911 and follow the 911 operator's instructions until a CPR certified staff member arrives; -Obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR for key clinical staff members who will direct resuscitative efforts including non-licensed personnel; -Select and identify a CPR team for each shift in the case of an acute [CONDITION(S)]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue efforts and directing other team members during the rescue effort; -The CPR team in the facility shall include at least one nurse and two certified nursing assistants (CNAs), all of whom have received training and certification in CPR/BLS. 1. Review of the facility's resident census report, dated [DATE], showed a census of 42. Review of the electronic medical record, for the 42 residents in the facility on [DATE], showed: -Full code: 23 residents; -No order for code status: three residents. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -The administrator worked as the nurse on the second floor; -Certified Nursing Assistant (CNA) DD, CNA GG and CNA FF worked on the second floor; -Only the administrator was CPR certified with a non-qualifying CPR certification; -On evening shift 2:30 P.M. through 11:00 P.M.: -Licensed Practical Nurse (LPN) U worked as the nurse on the second floor; -CNA FF worked on the second floor; -Only LPN U was CPR certified with a non-qualifying CPR certification; -On night shift 10:30 P.M. through 7:00 A.M.: -LPN U worked as the nurse on the second floor; -CNA HH and CNA DD worked on the second floor; -Only LPN U was CPR certified with a non-qualifying CPR certification. Review of the documentation of CPR certification, provided by the facility, showed: -The Administrator's CPR certification card, for basic first aid: -The certification was not specified for healthcare providers; -The company website, showed the course was an online only certification course. -LPN U's CPR certification card, for basic life support; -The certification was not specified for healthcare providers; -The company website, showed the course was an online only certification course. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -The administrator worked as the nurse on the second floor; -CNA DD worked on the second floor; -Only the administrator was CPR certified with a non-qualifying CPR certification; -On evening shift 2:30 P.M. through 11:00 P.M.: -LPN U worked as the nurse on the second floor; -CNA FF worked on the second floor; -Only LPN U was CPR certified with a non-qualifying CPR certification; -On night shift 10:30 P.M. through 7:00 A.M.: -LPN U worked as the nurse on the second floor; -No other staff worked the floor; -Only LPN U was CPR certified with a non-qualifying CPR certification. During an interview on [DATE] at 4:10 P.M., LPN U verified he/she worked alone on the night shift of [DATE]. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -The receptionist worked on the first floor starting at 7:15 A.M.; -LPN T worked as the nurse on the second floor; -CNA J, CNA K and CNA CC worked on the second floor; -Restorative Aide (RA) C worked on the second floor; -Only the receptionist, located on the first floor, was CPR certified with a qualifying CPR certification; -Only RA C was CPR certified on the second floor with a non-qualifying CPR certification; -On evening shift 2:30 P.M. through 11:00 P.M.: -The receptionist worked on the first floor until 4:30 P.M.; -LPN Z worked as the nurse on the second floor; -CNA BB and CNA FF worked on the second floor; -Only the receptionist, located on the first floor, was CPR certified with a qualifying CPR certification until 4:30 P.M.; -Only LPN Z was CPR certified on the second floor with a non-qualifying CPR certification; -On night shift 10:30 P.M. through 7:00 A.M.: -The administrator worked as the nurse on the second floor; -CNA II worked on the second floor; -Only the administrator was CPR certified on the second floor with a non-qualifying CPR certification. Review of the documentation of CPR certification, provided by the facility, showed: -Restorative Aide C's CPR certificate, for standard CPR and AED: -The certification was not specified for healthcare providers; -The company website, showed the course was an online only certification course. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -The receptionist worked on the first floor starting at 7:15 A.M.; -LPN T worked as the nurse on the second floor; -CNA J, CNA K, and CNA CC worked on the second floor; -RA C worked on the second floor; -Only the receptionist, located on the first floor, was CPR certified with a qualifying CPR certification; -Only RA C was CPR certified on the second floor with a non-qualifying CPR certification; -On evening shift 2:30 P.M. through 11:00 P.M.: -The receptionist worked on the first floor until 4:15 P.M.; -The administrator worked as the nurse on the second floor; -CMT V, CNA BB, the CNA/staffing coordinator, and CNA FF worked on the second floor; -Only the receptionist, located on the first floor, was CPR certified with a qualifying CPR certification until 4:15 P.M.; -Only the administrator was CPR certified on the second floor with a non-qualifying CPR certification; -On night shift 10:30 P.M. through 7:00 A.M.: -LPN B worked as the nurse on the second floor; -CNA EE worked on the second floor; -Only LPN B was CPR certified on the second floor with a non-qualifying CPR certification. Review of the documentation of CPR certification, provided by the facility, showed: -LPN B's CPR certification card, for healthcare provider CPR and automated external defibrillator (AED): -The company website, showed the course was an online only certification course. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -The administrator worked on the first floor; -Registered Nurse (RN) AA worked as the nurse on the second floor; -CNA J, CNA K, CNA CC and RA C worked on the second floor; -The administrator located, on the first floor, was CPR certified with a non-qualifying CPR certification; -Only RN AA and RA C were CPR certified on the second floor with a non-qualifying CPR certification; -On evening shift 2:30 P.M. through 11:00 P.M.: -RN JJ worked as the nurse on the second floor; -CMT V, CNA BB and CNA O worked on the second floor; -Only RN JJ was CPR certified with a qualifying CPR certification on the second floor; -On night shift 10:30 P.M. through 7:00 A.M.: -LPN B worked as the nurse on the second floor; -CNA EE worked on the second floor; -Only LPN B was CPR certified on the second floor with a non-qualifying CPR certification. Review of the documentation of CPR certification, provided by the facility, showed: -RN AA's CPR certification card, for CPR and AED: -The certification was not specified for healthcare providers; -The company website, showed the course was an online only certification course. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -The administrator worked on the first floor; -LPN T worked as the nurse on the second floor; -CNA J, CNA CC, CNA DD and RC T worked on the second floor; -The administrator, located on the first floor, was CPR certified with a non-qualifying CPR certification; -Only RA C was CPR certified on the second floor with a non-qualifying CPR certification; -On evening shift 2:30 P.M. through 11:00 P.M.: -LPN Z worked as the nurse on the second floor; -Certified Medication Technician (CMT) V, the CNA/staffing coordinator and CNA O worked on the second floor; -Only LPN Z was CPR certified with a qualifying CPR certification on the second floor; -On night shift 10:30 P.M. through 7:00 A.M.: -LPN B worked as the nurse on the second floor; -CNA EE and CNA HH worked on the second floor; -Only LPN B was CPR certified on the second floor with a non-qualifying CPR certification. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -LPN T worked as the nurse on the second floor; -CNA K and CNA DD worked on the second floor; -No CPR certified staff on duty; -On evening shift 2:30 P.M. through 11:00 P.M.: -No nurse worked in the facility; -The CNA/staffing coordinator worked on the second floor; -No CPR certified staff on duty; -On night shift 10:30 P.M. through 7:00 A.M.: -No nurse worked in the facility; -CNA W and CNA X worked on the second floor; -Only CNA X was CPR certified on the second floor with a non-qualifying CPR certification. Review of the documentation of CPR certification, provided by the facility, showed: -CNA X's CPR certification card, for healthcare provider CPR and AED: -The company website, showed the course was an online only certification course. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -LPN T worked as the nurse on the second floor; -CNA J, CNA K and CNA CC worked on the second floor; -No CPR certified staff on duty; -On evening shift 2:30 P.M. through 11:00 P.M.: -LPN U worked as the nurse on the second floor; -CNA BB and CNA O worked on the second floor; -Only LPN U was CPR certified on the second floor with a non-qualifying CPR certification; -On night shift 10:30 P.M. through 7:00 A.M.: -LPN U worked as the nurse on the second floor; -CNA EE, CNA X and CNA W worked on the second floor; -Only LPN U and CNA X were CPR certified on the second floor with non-qualifying CPR certifications. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -LPN T worked as the nurse on the second floor; -CNA J, CNA K and CNA CC worked on the second floor; -No CPR certified staff on duty; -On evening shift 2:30 P.M. through 11:00 P.M.: -LPN U worked as the nurse on the second floor; -CNA BB and CNA O worked on the second floor; -Only LPN U was CPR certified on the second floor with a non-qualifying CPR certification; -On night shift 10:30 P.M. through 7:00 A.M.: -LPN U worked as the nurse on the second floor; -CNA EE and CNA LL worked on the second floor; -Only LPN U was CPR certified on the second floor with a non-qualifying CPR certification. Review of the staffing sheet, dated [DATE], showed: -On evening shift 2:30 P.M. through 11:00 P.M.: -The receptionist worked on the first floor until 4:45 P.M., with a qualifying CPR certification; -The Director of Nursing (DON) worked as the nurse on the second floor; -The CNA/Staffing Coordinator and CNA O worked on the second floor; -Only the DON was CPR certified on the second floor with a qualifying CPR certification; -On night shift 10:30 P.M. through 7:00 A.M.: -LPN B worked as the nurse on the second floor; -CNA EE, CNA FF, CNA X and CNA HH worked on the second floor; -Only LPN B and CNA X were CPR certified on the second floor with non-qualifying CPR certifications. During an interview on [DATE] at 1:03 P.M., the administrator said the DON's first day at the facility was today. Review of the staffing sheet, dated [DATE], showed: -On day shift 6:30 A.M. through 3:00 P.M.: -The receptionist worked on the first floor, with a qualifying CPR certification; -The administrator worked on the first floor, with a non-qualifying CPR certification; -LPN T worked as the nurse on the second floor; -CMT V, CNA J and CNA CC worked on the second floor; -No CPR certified staff worked on the second floor. During an interview on [DATE] at 3:58 P.M., the CNA/staffing coordinator confirmed he/she worked alone at the facility on [DATE] evening shift and said she was not CPR certified. She said the nurses should be, but only a handful of CNAs are. They used to do classes at the facility, but they have not been doing them. During an interview on [DATE] at 8:40 A.M., the administrator said she would provide the CPR certification for LPN T. During an interview on [DATE] at 1:12 P.M., LPN T said he/she thinks he/she is CPR certified. The facility has been asking about it, but he/she cannot find his/her CPR card. The last time he/she was CPR certified, the class was at the facility, he/she does not remember when it was. It had been a while. During an interview on [DATE] at 1:16 P.M., the staffing coordinator said it had been approximately 5 years since the facility offered CPR training to staff. During an interview on [DATE] at 8:40 A.M., the administrator said she would provide the CPR certification for RN Y and CNA W. During an interview on [DATE] at 3:11 P.M., the administrator confirmed no CPR card was available for LPN T, RN Y and CNA W. During an interview on [DATE] at 10:13 A.M., the consultant administrator said she would provide CPR certification for staff who worked from the dates of [DATE] through current. Review of the documentation of CPR certification, provided by the facility, showed as of [DATE], no CPR certification was provided for: -The CNA/Staffing coordinator; -CNA CC; -CNA K; -CNA J; -CNA DD; -CNA GG; -CNA FF; -CNA HH; -CNA BB; -CNA EE; -CMT V; -CNA O. During an interview on [DATE] at 11:40 A.M., CNA CC said any staff person can administer CPR. He/she had been CPR certified in the past, but needed to be recertified. During an interview on [DATE] at 11:35 A.M., CNA K said the nurse is responsible to administer CPR. He/she had been CPR certified in the past, but needed to be recertified. During an interview on [DATE] at 1:03 P.M., the administrator said she needed to clarify the facility's policy regarding CNAs and nurses being CPR certified. The facility should follow the policy. During an interview on [DATE] at 9:10 A.M., with the administrator and consultant administrator, they said the facility does not have a staff educator at this time. Agency staff utilized by the facility should be CPR certified. The administrator said she just assumed most staff are CPR certified. The administrator is responsible to ensure someone CPR certified is working every shift. The administrator said she would expect one CPR certified staff per shift for the most part, but if not, the facility should have something in place. The facility should at least ensure staff have had CPR training at some point. The administrator said she was CPR certified. She is not sure if the facility's agreement with the staffing agencies required the agency staff to be CPR certified. During an interview on [DATE] at 12:40 P.M., the consultant administrator said she would expect the facility staffs' CPR certification to be CPR for healthcare providers. During an interview on [DATE] at 12:13 P.M., the facility's Medical Director said regarding the development of facility policies and procedures, corporate makes the policies and will sometimes ask for his input on medically related procedures. He would expect facility staff on duty to include nursing staff on each shift who are CPR certified. 2. Review of Resident #403's medical record, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -A full code status, dated [DATE], for CPR. Review of the code status binder, located at the nurses station, and reviewed on [DATE] at 12:11 P.M., showed no code status sheet located in the binder. 3. Review of Resident #402's medical record, showed: -The resident admitted on [DATE]; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -No order for code status. Review of the code status binder, located at the nurses station, and reviewed on [DATE] at 12:11 P.M., showed no signed code status sheet available to staff. During an interview on [DATE] at 3:30 P.M., the Social Service Director (SSD) said she obtained the resident's code status upon admission, but had not gotten around to putting it in the system. It was in his/her office. Review of the code status sheet, provided at this time, showed full code, dated [DATE]. 4. Review of Resident #25's medical record, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -No order for code status. Review of the code status binder, located at the nurses station, and reviewed on [DATE] at 12:11 P.M., showed a signed full code form, dated [DATE]. 5. Review of Resident #41's medical record, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -No order for code status. Review of the code status binder, located at the nurses station, and reviewed on [DATE] at 12:11 P.M., showed a signed full code form, dated [DATE]. 6. Review of Resident #18's medical record, showed: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -An ordered code status, dated [DATE], for CPR. Review of the code status binder, located at the nurses station, and reviewed on [DATE] at 12:11 P.M., showed an out of the hospital do not resuscitate order, dated [DATE] and signed by the physician on [DATE]. Further review of the resident's medical record, showed no clarification for the conflicting orders for code status. 7. During an interview on [DATE] at 11:15 A.M., CNA J said he/she was unsure about the meaning of code status, but it should be with the resident's information. During an interview on [DATE] at 3:58 P.M., the CNA/staffing coordinator said code statuses are documented in the electronic medical record. During an interview on [DATE] at 11:40 A.M., CNA CC said resident's code statuses are located in a book at the nurse's station. During an interview on [DATE] at 11:35 A.M., CNA K said resident's code statuses are located in a book at the nurse's station. During an interview on [DATE] at 9:10 A.M., with the administrator said she would expect staff to know where to look to determine a resident's code status. During an interview on [DATE] at 12:40 P.M., the consultant administrator said newly admitted residents should have a code status obtained right away. This is typically the responsibility of the Social Service Director. If the admission comes during off hours, the responsibility falls on the nurse. The code status is filled out on a paper form and the resident or resident's representative signs off on it. It is then signed by the physician and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation and the deficiency was lowered to an E at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. MO 618

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from neglect. On 1/7/22, no evening shift nurse reported for duty and the day shift nurse, Licensed Practical Nurse (LPN) T, clocked out at 5:07 P.M. and failed to notify the administrator that he/she was leaving the facility with no licensed nurse to cover the next shift. He/she left the facility with one certified nursing assistant (CNA). This resulted in having no licensed nurse on duty from 1/7/22 at 5:07 P.M. through 1/8/22 at 6:45 A.M. Not having a licensed nurse on duty resulted in one resident (Resident #34) experiencing pain throughout the night without receiving his/her ordered pain medication. In addition, this resident experienced respiratory distress and an elevated blood pressure that was not assessed or treated by a nurse One resident (Resident #401) experienced a fall and was not assessed by a nurse prior to being transferred back into bed. One resident (Resident #32) required a dressing change to a stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). One resident (Resident #245) experienced [CONDITION(S)] and stress due to fear of complications from not receiving his/her ordered medications. One resident (Resident #11) reported having loose stools, was not assessed by a nurse and the loose stools were not treated, resulting in discomfort and irritation of the skin. One resident (Resident #39) reported he/she had a headache all night and did not receive his/her ordered Tylenol. Scheduled medications, treatments and assessments were not administered or completed on the evening of 1/7/22 and night shift of 1/8/22 for 13 of 13 sampled residents (Residents #34, #401, #32, #245, #11, #39, #400, #41, #402, #25, #8, #403 and #18). In addition, on 1/11/22, no evening shift nurse reported for duty. Administration required LPN T to remain at the facility until a licensed nurse arrived to replace him/her. LPN T remained at the facility, but refused to administer medications or complete the required skilled treatments and assessments, for 13 of 13 sampled residents (Residents #34, #401, #32, #245, #11, #39, #400, #41, #402, #25, #8, #403 and #18). This affected all residents in the facility. The census was 42. Review of the facility's Abuse and Neglect- Clinical Protocol policy, revised July 2017, showed: -Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress; -Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -The physician and staff will help identify risk factors for abuse within the facility, for example: -Problems related to adequate staffing, staff burnout, poor preparation and training; -Lack of knowledge, skills or performance that might affect how the residents are being cared for; -Along with other staff and management, the physician will help identify situations that might constitute or could be construed as neglect, for example: -Inadequate prevention or care of pressure ulcers, inattention to advanced directives, inappropriate management of problematic behaviors, recurrent failure to provide incontinence care, etc.; -The staff, with the physician's input as needed, will investigate alleged occurrences of abuse and neglect, to clarify what happened and identify possible causes; -The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect; -The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations; -The medical director will advise facility management and staff about systems to ensure that basic medical, functional and psychosocial needs are being met and the potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately; -The medical director will advice the facility and help review and address abuse and neglect issues as part of the quality assurance process. 1. During an interview on 1/9/22 at 10:20 A.M., the CNA/staffing coordinator said WNBI stands for will not be in and indicates a scheduled staff person will not be reporting to work. Review of the facility's Daily Staffing Sheet, dated 1/7/22, showed: -Day shift 6:30 A.M. through 3:00 P.M.: LPN T and two CNAs scheduled; -Evening shift 2:30 P.M. through 11:00 P.M.: -One nurse scheduled with WNBI hand written next to the name; -One CNA scheduled with WNBI hand written next to the name; -A third name scratched through and illegible; -Night shift 10:30 P.M. through 7:00 A.M.: -One nurse scheduled with WNBI hand written next to the name; -CNA W and CNA X scheduled; -Two names scratched through and illegible. Review of LPN T's time card, showed: -On 1/7/22, he/she clocked in at 6:45 A.M. and clocked out at 5:07 P.M.; -On 1/8/22, he/she clocked in at 6:45 A.M. During an interview on 1/8/22 at 1:30 P.M., LPN T said he/she is the only nurse currently on duty. His/her shift started at 7:00 A.M. There was no nurse on duty to give him/her report from night shift. At 2:45 P.M., LPN T said yesterday (1/7/22), his/her shift ended at 3:00 P.M., but he/she left about 5:00 P.M. When he/she left, the CNA/staffing coordinator was the only staff on duty. He/she took over for him/her. LPN T did not report off to a nurse. There was no certified medication technician (CMT) either, just the one CNA. The LPN did not personally notify management, but he/she knew the CNA/staffing coordinator would take care of it. LPN T said when he/she left the faciity on [DATE] in the hands of the CNA/staffing coordinator, he/she left the medication keys in the drawer at the nurse's station. He/she believed the CNA/staffing coordinator was responsible enough to keep control of the keys. The CNA returned the keys to LPN T in the morning when he/she returned to the facility. During an interview on 1/9/22 at 10:37 A.M., LPN T said on 1/7/22, it was the CNA/staffing coordinator who relieved him/her, and she handled the staffing issues. At 12:16 P.M., LPN T said when he/she returned to the facility on [DATE], the night shift had already left and the CNA/staffing coordinator had returned to the facility and was the only staff there. During a telephone interview on 1/8/22 at 5:36 P.M., with the administrator and consultant administrator, the administrator said she knew there was no nurse last night. She was called and informed by the CNA Staffing Coordinator . The consultant administrator said she was not aware there was no nurse last night until 1/8/22 at 5:30 A.M. The administrator said the CNA/staffing coordinator told her she was staying over on the evening shift to help. The CNA/Staffing Coordinator said she was putting calls out to the nurse staffing agencies to find a licensed nurse to cover the evening and night shift. She found out, at the start of night shift no nurse ever came in. During an interview on 1/8/22 at 11:00 P.M., CNA X said the night of 1/7/22 was the first time he/she ever worked at the facility. He/she arrived at approximately 10:30 P.M. and worked until 7:00 A.M. There was no nurse on duty at any time. All the residents were asking for medications, but no one got any. There were residents asking for anything from Tylenol, to blood pressure medications, or really anything. They needed a nurse. During an interview on 1/8/22 at 11:10 P.M., CNA W said he/she had never worked at the facility prior to the night of 1/7/22. He/she was scheduled to work from 10:30 P.M. through 7:00 A.M. There was no nurse on duty. The only other staff in the building was CNA X. Residents needed their medications and he/she was not able to do that for them. He/she and CNA X did not know what to do, they were just told they were the only staff there. During an interview on 1/9/22 at 10:20 A.M., the CNA/staffing coordinator said on 1/7/22, after the day shift nurse left, it was just her at the facility. She was not scheduled to work, but came in because of the staffing issues. She informed the administrator later that night, before she left for the night, that no nurse had shown up from any of the agencies. Her shift ended after the two night shift CNAs came in, around 11:00 P.M. There was no one at the facility who was able to administer medications. During her shift, residents were needing their medications. She gave the two oncoming CNAs a report of the residents and a rundown of the circumstances regarding staffing before leaving at 11:00 P.M. She returned to the facility the next day at 6:30 A.M., to relieve the night shift CNAs. The day shift nurse arrived around 7:00 A.M. or 7:15 A.M. Before the two night shift CNAs left, they reported that Resident #401 had a fall and that Resident #34 wanted his/her blood pressure medications because he/she was having high blood pressures. During an interview on 1/9/22 at 12:40 P.M., with the administrator and consultant administrator, the administrator said it was not acceptable for a nurse on duty to abandon the facility and residents without passing off responsibility to a licensed nurse. LPN T should have stayed until someone showed up. He/she could have called her and reaffirmed that no one was there so she could guide him/her but he/she did not. LPN T should have contacted the administrator before he/she left. 2. Review of Resident #34's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/6/21, showed: -Clear speech, understood, understands, clear comprehension; -Moderately impaired cognition; -No behaviors; -Total dependence on two plus staff for bed mobility and transfers; -Total dependence on one staff required for toilet use; -Functional limitation in range of motion to the lower extremities on both sides; -Always incontinent of bowel and bladder; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Pain management: -Resident is on a scheduled pain medication regimen and received as needed pain medications; -Pain frequency: Occasionally; -Has pain made it hard for you to sleep at night: Yes; -Received oxygen therapy. Review of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan, in use at the time of the survey, showed: -The resident has impaired physical mobility related to weakness and requires the use of a Hoyer lift (mechanical lift): -Goal: Will remain free of complications related to immobility; -Interventions: The resident will be educated on the safe use of the Hoyer lift for transfer from bed to chair; -The resident has high blood pressure and takes [MEDICATION(S)] (medication use to treat high blood pressure: -Goal: The resident will remain free from signs and symptoms of high blood pressure; -Interventions: Give anti-hypertensive medications as ordered. Assigned to the LPN and RN; -The residents lung disease, oxygen therapy or pain that required routine and as needed pain medication, not included in the care plan. Review of the resident's electronic physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -An order dated 7/24/21, for [MEDICATION(S)] (used to treat high blood pressure) 5 milligram (mg) at bedtime for high blood pressure: -Not documented as administered on 1/7/22; -An order dated 7/24/21, for [MEDICATION(S)] (topical patch used to treat pain) 5%. Apply to affected area topically. Apply in A.M. and remove at hour of sleep: -Scheduled to be removed at 4:00 P.M.; -No documentation the patch was removed on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] Diskus (used to treat [CONDITION(S)]) 100-50 micrograms (mcg)/dose. One inhalation two times a day for shortness of breath: -Scheduled administration time 9:00 A.M. and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] solution (a medication used to open up the airways) 0.03%, two sprays in both nostrils three times a day for difficulty breathing: -Scheduled administration times of 9:00 A.M., 1:00 P.M. and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] (generic for [MEDICATION(S)], used to treat nerve pain) 75 mg. Give one capsule by mouth three times a day for low back pain: -Scheduled administration times of 9:00 A.M., 2:00 P.M. and 9:00 P.M.; -Not documented as administered for the 9:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for econaxole [MEDICATION(S)] cream (used to treat fungal infections) 1%. Apply to affected area topically two times a day for fungal rash: -Scheduled administration times of 9:00 A.M. and 6:00 P.M.; -Not documented as administered for the 6:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] (used to prevent seizures) 500 mg. One tablet two times daily for seizures: -Scheduled administration time 9:00 A.M. and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 7/25/21, for [MEDICATION(S)] sodium gel (topical non-steroidal anti-[CONDITION(S)]) 1%. Apply to affected area topically four times a day for pain: -Scheduled pain assessment and administration at 9:00 A.M., 12:00 P.M., 5:00 P.M. and 9:00 P.M.; -Pain assessment not documented as completed and medication not documented as administered for the 5:00 P.M. and 9:00 P.M. doses on 1/7/22; -An order dated 9/17/21, for Tylenol extra strength tablet 500 mg. Give one tablet every night shift before midnight, daily: -Pain level not assessed on 1/7/22; -Not documented as administered on 1/7/22; -An order dated 10/14/21, to check blood pressure daily in the morning: -Not transcribed onto the eMAR or eTAR; -Not documented as completed in January 2022; -An order dated 12/8/21, for [MEDICATION(S)] (skin protectant) paste. Apply to buttocks topically every shift: -Not documented as administered on the evening or night shift on 1/7/22. Review of the resident's progress notes, showed: -A nurses note: On 1/6/22 at 9:12 P.M., the resident's spouse asked about the oxygen machine and when observed, it was turned off and on and was not alarming. The resident's oxygen level was 95% (normal 95% through 100%). When the machine alarm went off again, they insisted that it was an emergency and the administrator needed to be called. The resident's oxygen level was still at 95%, but his/her spouse still insisted, even after it was explained that the concentrator cannot be replaced tonight and we just need to turn it off. The administrator was called and she stated there were oxygen tanks to use in the meantime, and that was given to him/her and they were able to be calmed thereafter, but still stated I don't want to die in the middle of the night.; -Further review of the progress notes, showed no documentation if the oxygen concentrator was changed out and no documentation of the oxygen concentrator not working on the night shift on 1/7/22, the resident's shortness of breath, elevated blood pressure or pain. Review of the resident's medical record, reviewed on 1/8/22 at 3:01 P.M., showed no documentation on the night shift of 1/7/22 showing the resident's blood pressure, pain level, and shortness of breath because the CNA's are unable to chart in the medical record. During an interview on 1/8/22 at 2:28 P.M., the resident said last night and yesterday evening (1/7/22), he/she was not able to get his/her medications. He/she did not get any medications until mid-day today. His/her blood pressure last night was very high, it measured 175/65 (normal 90/60 through 120/80). It has been better today after he/she received his/her medications. He/she was in pain overnight and that makes his/her blood pressure go up. Last night he/she was having severe pain in his/her back and cervical spine area. Normally, he/she takes [MEDICATION(S)] (narcotic pain medication) and [MEDICATION(S)] (medication used to treat nerve pain), but last night he/she could not get any of his/her medication and the pain was unbearable. No one at the facility could give his/her medications to him/her. The pain has gotten a little better today, now that he/she had received his/her medication. He/she has a history of seizures and did not get any of those medications either. In addition, last night his/her oxygen concentrator broke. Water started coming out of the humidity bottle and poured through the nasal cannula into his/her nose. He/she could not breathe. The staff working on night shift did not know anything about the oxygen concentrator and did not know what to do. He/she did not get his/her oxygen and had severe shortness of breath. The nurse on day shift today was able to do something with it to fix it. He/she had no oxygen last night. Observation on 1/8/22 at 2:28 P.M., showed the resident lay in bed on his/her back with an oxygen concentrator on at 5 liters per nasal cannula. During an interview on 1/8/22 at 11:00 P.M., CNA X said on the night shift of 1/7/22, he/she took the resident's blood pressure. The resident's blood pressure was up and he/she could not breathe. The oxygen machine was not working and he/she did not know what to do. The resident was in a lot of distress. There was no nurse in the facility. During an interview on 1/9/22 at 12:16 P.M., LPN T said when he/she arrived to work in the morning of 1/8/22, the night shift CNAs were gone, but the CNA/staffing coordinator had come in. The CNA/staffing coordinator did report that the resident had issues with his/her blood pressure and oxygen overnight. During an interview on 1/9/22 at 11:00 A.M., the medical director said he was not made aware that the resident had shortness of breath and an elevated blood pressure on the night shift of 1/7/22. If those conditions existed, staff should have notified him. During an interview on 1/9/22 at 12:40 P.M., the administrator said the resident has had some issues with the oxygen machine on 1/6/22. She told staff to get him/her a new oxygen concentrator. She was not aware it was still an issue on 1/7/22. 3. Review of Resident #401's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Independent with transfers, walking in room and walking in corridor; -Mobility devices: Walker; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Has the resident had any falls since admission or prior assessment: Yes; -Number of falls with no injury: Two; -Received antipsychotic and antidepressant medications seven of seven days. Review of the resident's undated care plan in use at the time of the survey, showed: -At risk for upper respiratory infection/COVID-19 virus: -Goal: Resident will show no signs/symptoms of infection; -Interventions: Administer antibiotic therapy as prescribed, evaluate lung sounds, evaluate shortness of breath, evaluate heart rate, and evaluate lung sounds. Assigned to the LPN and RN. Initiate isolation precautions per order, monitor for signs/symptoms of infection; -Resident has a communication problem related to [CONDITION(S)] disorder. Resident stutters sometimes and can be difficult to understand. Remind resident to slow down: -Goal: Be able to make basic needs known by speaking slowly on a daily basis; -Interventions: Monitor/document/report as needed any changes in ability to communicate, potential for contributing factors for communication problems. Potential for improvement; -Impaired cognitive function/dementia or impaired thought process related to [CONDITION(S)] disorder: -Goal: Maintain current level of cognitive function; -Administer medications as ordered. Monitor/document for side effects and effectiveness. Assigned to the LPN and RN; -The resident has high blood pressure: -Goal: Be free of complications related to high blood pressure: -Interventions: Give blood pressure medications as ordered. Monitor for side effects such as [CONDITION(S)] and increased heart rate. Monitor and document any [CONDITION(S)] (swelling). Monitor/record use/side effects of medication. Report to physician as necessary. Assigned to the LPN and RN; -Resident has diabetes: -Goal: Have no complications related to diabetes; -Interventions: Diabetic medications as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report as needed any signs or symptoms of low blood sugar, sweating, tremor, increased heart rate, nervousness, confusion, slurred speech, lack of coordinator, and staggered gate. Assigned to the LPN and RN; -At moderate risk for falls related to balance issues. Resident walks fast and does not look where he/she is going. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Goal: Be free of falls; -Interventions: [CONDITION(S)] disease medication as ordered. Assigned to the LPN and RN. Remind the resident to slow down when he/she is walking and to look when walking; -On 1/3/22, the resident has tested positive for COVID-19, remains on quarantine: -Goal: Be free form signs and symptoms of infection; -Interventions: Educate resident on infection control practices, evaluate temperature, initiate proper isolation precautions per order, and monitor laboratory results. Assigned to the LPN and RN; -The resident uses [CONDITION(S)] medications, antidepressant and antipsychotic medications for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Goal: The resident will be/remain free of [CONDITION(S)] drug related complications, including movement disorder, discomfort, low blood pressure, gait disturbances or cognitive/behavioral impairment; -Interventions: Administer [CONDITION(S)] medications as ordered by the physician, monitor for side effects and effectiveness every shift. Assigned to the LPN and RN; -The resident has a [CONDITION(S)] disorder related to Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Goal: Remain free from injury related to [CONDITION(S)] activity; -Interventions: Give medications as ordered. Monitor/document for effectiveness and side effects. Give [CONDITION(S)] medication as ordered by the doctor. Monitor labs and report any sub-therapeutic or toxic results to the physician. Assigned to the LPN and RN. Review of the resident's ePOS, eMAR and eTAR, for January 2022, showed: -An order dated 6/5/18, for [MEDICATION(S)] (medication used to treat Alzheimer's disease) 10 mg. One tablet at bedtime related to dementia: -Scheduled administration time 9:00 P.M.; -Not documented as administered on 1/7/22; -An order dated 6/5/18, for [MEDICATION(S)]/[MEDICATION(S)] (medication used to treat [CONDITION(S)] disease) 25-100 mg. One tablet three times a day: -Scheduled administration times of 9:00 A.M., 1:00 P.M. and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 1/30/20, for [MEDICATION(S)] (antipsychotic mediation) 200 mg and 50 mg tablets at bedtime related to [CONDITION(S)] disorder: -Scheduled administration time 9:00 P.M.; -Not documented as administered on 1/7/22; -An order dated 4/7/20, take temperature twice a day, monitor for signs of respiratory infection, notify physician if indicated: -Scheduled at 9:00 A.M. and 6:00 P.M.; -Not documented as completed for the 6:00 P.M. scheduled time on 1/7/22; -An order dated 10/8/20, for [MEDICATION(S)] (used to treat high cholesterol) 20 mg. One tablet at bedtime related to high cholesterol: -Not documented as administered on 1/7/22. Review of the resident's progress notes, showed: -On 1/8/22 at 9:52 P.M., resident remains on follow up for a fall. No apparent injuries noted. Will continue to monitor; -No documentation of the resident's fall on 1/7/22 night shift, the circumstances surrounding the fall, assessment completed or interventions to prevent further falls. During an interview on 1/8/22 at 11:00 P.M., CNA X said on the night shift of 1/7/22, there was no nurse at the facility. The resident resided on the COVID-19 unit and fell on the floor. He/she and the other CNA assisted to get the resident up and back to bed. He/she did not have any visible injuries. The resident said he/she was fine. During an interview on 1/8/22 at 11:10 P.M., CNA W said on the night shift on 1/7/22, many things happened that would have required a nurse. There was no nurse at the facility. The resident fell and needed a nurse to assess him/her, but no one was there. CNAs cannot assess residents after a fall correctly. During an interview on 1/9/22 at 12:16 P.M., LPN T said when he/she arrived to work on the day shift on 1/8/22, the night shift was already gone. The CNA/staffing coordinator had come in and she reported that the resident fell on night shift. During an interview on 1/9/22 at 11:00 A.M., the medical director said he was not informed that the resident fell on the night shift on 1/7/22. If a fall occurs, staff should notify him. During an interview on 1/9/22 at 12:40 P.M., the consultant administrator said she was notified that the resident fell . The nurse staffing agency called at 5:30 A.M. and said their CNA had called them and reported a resident fell . She called the facility and spoke with the CNA and did an assessment over the phone. The administrator said she would expect a resident who experienced a fall to be assessed by a nurse before being assisted back to bed. 4. Review of Resident #32's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Total dependence of one for bed mobility, dressing, toilet use, personal hygiene and bathing; -Total dependence of two for transfers; -Functional limitation in range of motion to the lower extremities on both sides; -Indwelling urinary catheter; -Ostomy (an artificial opening into the gastrointestinal tract to allow the removal of stool); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Unhealed pressure ulcers (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin): Yes; -Number of stage IV pressure ulcers: One; -Skin and ulcer treatments: Pressure reducing device for chair and bed, nutrition or hydration interventions, pressure ulcer care, application of nonsurgical dressings, application of ointments/medications. Review of the resident's care plan, in use at the time of the survey, showed: -Oxygen therapy continuous positive airway pressure ([CONDITION(S)], used to treat sleep apnea by delivering steady air pressure): -Goal: Have no signs or symptoms of poor oxygen absorption; -Interventions: See MAR/TAR daily for instructions. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for signs and symptoms of respiratory distress and report to the physician as needed: Respirations, pulse oximetry (percentage of oxygen in the blood), increased heart rate, restlessness, headaches, lethargy, confusion, cough, use of accessory muscles and skin color. Assigned to the LPN and RN; -Stage IV pressure ulcer to the sacrum (tailbone area), buttocks and groin area upon admission and unstageable (depth unable to be determined) area on heel and potential for pressure ulcer development related to history of ulcers and immobility: -Goal: The resident's pressure ulcer will show signs of healing and remain free from infection; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of the wound perimeter, wound bed and healing progress. Report improvement and declines to the physician. Monitor dressing during shift to ensure it is intact and adhering. Report lose dressing to treatment nurse. Assigned to the LPN and RN; -Potential for stroke related to high blood pressure: -Goal: The resident will remain free of complications related to high blood pressure; -Interventions: Give medications as ordered. Monitor for side effects such as [CONDITION(S)] and increased heart rate, and effectiveness. Monitor and document any [CONDITION(S)]. Notify physician. Assigned to the LPN and RN; -The resident has [CONDITION(S)] (high blood sugar levels) related to disease process and requires insulin therapy: -Goal: The resident will be free from any signs or symptoms of [CONDITION(S)]; -Interventions: Educate regarding medications and importance of compliance. Monitor compliance with diet and document any problems. Assigned to the LPN and RN; -The resident has diabetes: -Goal: Will have no complications related to diabetes; -Interventions: Diabetes medications as ordered by the doctor. Monitor/document for side effects and effectiveness. Monitor/document/report as needed any signs and symptoms of high blood sugar: Increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, and abdominal pain. Monitor/document/report as needed any signs or symptoms of low blood sugar: Sweating, tremor, increased heart rate, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Assigned to the LPN and RN. Review of the resident's ePOS, eMAR and eTAR, for January 2022, showed: -An order dated 10/13/20, for [MEDICATION(S)] cream (skin protectant) 24%. Apply to buttocks topically two times a day for excoriation: -Scheduled administration times of 9:00 A.M. and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 10/13/20, for a pain assessment every shift: -Not documented as assessed on the evening and night shifts on 1/7/22; -An order dated 10/13/20, for vitamin D tablet 1000 units three times a day related to pressure ulcer of left buttocks: -Scheduled administration times of 9:00 A.M., 1:00 P.M. and 5:00 P.M.; -Not documented as administered for the 5:00 P.M. dose on 1/7/22; -An order dated 10/13/20, for [MEDICATION(S)] 10 mg. One tablet at bedtime related to high blood pressure: -Scheduled administration on 1/7/22, not documented as administered; -An order dated 10/13/20, for [MEDICATION(S)] (supplement used for sleep) 5 mg at bedtime for [CONDITION(S)]: -Scheduled administration on 1/7/22, not documented as administered; -An order dated 10/14/20, to take temperature twice a day and monitor for signs and symptoms of infection. Notify physician if indicated: -Scheduled times of 9:00 A.M. and 5:00 P.M.; -Not documented as completed for the 5:00 P.M. scheduled time on 1/7/22; -An order dated 10/14/20, for [MEDICATION(S)] cream (antifungal) 100,000 unit/gram. Apply to abdominal fold topically every day and evening shift: -Not documented as administered in the evening on 1/7/22; -An order dated 4/16/21, for [MEDICATION(S)] (used to treat high blood pressure) 12.5 mg two times a day for high blood pressure: -Blood pressure and pulse scheduled to be measured at the times of s

Based on observation, interview and record review, the facility failed to ensure appropriate care and services were provided to residents with pressure ulcers (injury to the skin and underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility failed to document weekly wound assessments, failed to notify the physician of new wound development delaying the resident's treatment and failed to identify a newly acquired Deep Tissue Pressure Injury (DTPI). Facility staff also failed to consistently ensure pressure ulcer treatments and interventions were performed according to the wound specialist's recommendations or as ordered and failed to ensure prevention interventions were completed as ordered. This resulted in a delay of 11 days in obtaining orders and treating a pressure ulcer for one resident (Resident #15). When the wound was first staged, it was identified as unstageable (an ulcer that has full thickness tissue loss but is covered by extensive necrotic (dead) tissue). The facility identified three residents as having pressure ulcers. The survey team identified four residents as having pressures. Issues were found with three out of four residents sampled with pressure ulcers (Resident #15, #32 and #30). The sample was 12. The census was 44. Review of the facility's Resident Census and Condition of Residents, dated 12/2/21, showed: -Total residents 44; -Indicate the number of residents with pressure ulcers: Three; -Of the total of residents with pressure ulcers, how many residents had pressure ulcers on admission: Zero. Review of the facility's Resident Matrix Centers for Medicare and Medicaid Services (CMS) form, showed: -Resident #15 identified as having a stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough (moist dead tissue) or eschar (dry dead tissue) may be present on some parts of the wound bed) pressure ulcer; -Resident #32 identified as having a stage IV pressure ulcer; -Resident #30 not identified as having any pressure ulcers. Review of the facility's Wound Care Policy, revised October 2010, showed: -Purpose: To provide guidelines for the care of wounds to promote healing; -Procedure: Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed; -Documentation: The type of wound care given. The date and time the wound care was given. The name and title of the individual performing the wound care. Any change in the resident's conditions. All assessment data (wound bed color, size, drainage) obtained when inspection the wound. If the resident refused the treatment and the reason why; -Reporting: Report other information in accordance with facility policy and professional standards of practice. Notify the supervisor if the resident refuses the wound care. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/9/21, showed the following: -admitted [DATE]; -Severe cognitive impairment; -Dependence on staff for eating, dressing, toileting, and bed mobility; -Unable to ambulate; -One stage IV pressure ulcer; -Is resident at risk for developing pressure ulcers: Yes; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan in use at time of survey, showed; -Problem: Resident is at risk for pressure ulcers related to incontinence, immobility and right sided [CONDITION(S)]; -Interventions: Administer treatments as ordered and monitor for effectiveness. Conduct a systematic skin inspection per protocol on shower days. Pay particular attention to boney prominences. Follow facility policies and protocol for the prevention and treatment of skin breakdown. Follow treatment orders given by physician daily. Monitor dressing during care to ensure it is intact and adhering. Monitor, document and report as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size (length, width, depth), and stage. Needs assistance to turn and reposition at least every 2 hours. Report any signs of skin breakdown. Resident requires cushion in chair and pressure reliving mattress. Weekly treatment documentation to include measurement of each area of skin breakdown, width/length/depth, type of tissue and exudate (drainage). Review of the resident's skin observation tools, showed: -Dated 10/6/21, showed a new open area on coccyx (tailbone area). Treatment orders needed; -Site: Coccyx: Type: Pressure; Measurements: 1 centimeter (cm) length by 1 cm width; -Site: Right gluteal fold (buttocks); Measurements: 0.5 cm length by 0.5 cm width; -No documentation the physician was notified; -No other skin observation tools were completed in October 2021. Review of the resident's progress notes, showed: -On 10/17/21, open area noted to coccyx 1.9 cm by 0.8 cm wound bed red with macerated (soft or wet) edges, no drainage slough or odor noted. Physician notified of new area to coccyx. New order cleanse coccyx with normal saline apply foam dressing daily; -No documentation the physician was notified of the wound prior to 10/17/21. Review of the resident's electronic physician order sheet (ePOS), showed: -An order with a start date of 4/6/21, for weekly skin assessments every Tuesday; -An order dated 10/17/21, to cleanse the coccyx with normal saline, apply foam dressing daily. Discontinued 10/26/21; -No treatment order for the coccyx wound prior to 10/17/21. Review of the resident's wound provider's note dated, 10/19/21, showed: -Location: Coccyx; -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 10% granulation (new tissue growth) and 90 % necrosis and slough; -Measurements: Length 2.1 cm by width 1.4 cm, depth unable to determine (utd) cm; -Peri-wound (surrounding tissues): Normal; -Exudate: Small; -Color: Serosanguineous (clear blood tinged); -Plan: Cleanse with normal saline apply, apply nickel thick Santyl (used to remove dead tissue from wounds so they can start to heal) and cover with border gauze daily and as needed. Review of the resident's medial record, showed the resident sent to the hospital on 10/19/21 for a change in condition and returned to the facility on [DATE]. Further review of the resident's progress notes, dated 10/26/21, showed: -Multiple wounds, coccyx wound 4 cm is clean. No redness or drainage. Dry dressing intact. Three additional patches to buttock and old wounds not open 1 cm by 1 cm; -No further description of the wounds, staging, drainage, or clarification of the location of the multiple wounds. Further review of the resident's ePOS, showed: -No treatment order from 10/26/21 through 10/28/21; -An order dated 10/28/21, to cleanse the buttock and coccyx wounds with normal saline, apply nickel thick Santyl and cover with border gauze daily. Review of the resident's October 2021 electronic Treatment Administration Record (eTAR), showed: -No treatment documented as ordered or applied to the resident's coccyx from 10/26/21 through 10/28/21; -An order dated 10/28/21, to cleanse buttock and coccyx wounds with normal saline, apply nickel thick Santyl and cover with border gauze daily; -Not documented as completed on 10/28, 10/29 and 10/30/21. Review of the resident's wound provider note, dated 11/2/21, showed: -Location: Coccyx: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 10% granulation and 90% necrosis and slough; -Measurements: Length 1.8 cm by width 1.2 cm by depth utd cm; -Peri-wound: Normal; -Exudate: Small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply, apply nickel thick Santyl and cover with border gauze daily and as needed; -Location: Right buttock: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 10 % granulation and 90% necrotic and slough; -Measurements: Distal (lowest part of the wound) 1.5 cm by 0.5 cm and depth utd, Medial (middle) 4 cm by 0.5 cm; -Peri-wound: Excoriated (reddened); -Exudate: Small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply nickel thick Santyl and cover with border gauze daily and as needed. Further review of the resident's ePOS, showed: -The order to cleanse buttock and coccyx wounds with normal saline, apply nickel thick Santyl and cover with border gauze daily, discontinued on 11/2/21; -An order dated 11/3/21, for [MEDICATION(S)] Sulfate Ointment 1% (antibiotic ointment); Apply to buttocks and sacral (tailbone area) wounds once daily. Cleanse right buttock and sacral wounds with normal saline. Apply nickel thick Santyl and [MEDICATION(S)] 1% cover with border gauze and dressing daily; -An order dated 11/13/21 and discontinued 11/16/21, for Santyl ointment 250 unit/gram. Apply to right buttocks wound topically every day shift for wound care. Cleanse right buttocks with normal saline. Apply nickel thick Santyl and cover with boarder gauze daily and as needed. Review of the resident's November 2021 eTAR, showed the following: -An order dated 11/2/21, for weekly skin assessments every Tuesday; -An order dated 11/3/21, for [MEDICATION(S)] Sulfate Ointment 1%; Apply to buttocks and sacral wounds once daily. Cleanse right buttock and sacral wounds with normal saline. Apply nickel thick Santyl and [MEDICATION(S)] 1% cover with border gauze and dressing daily; -Not documented as administered on 11/3 through 11/6, 11/18 through 11/19, 11/21, 11/23, and 11/25 through 11/26/21. Review of the resident's wound provider note, dated 11/9/21, showed: -Location: Coccyx: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 20% granulation and 80 % slough; -Measurements: Length 2.5 cm by width 1.5 cm by depth utd cm; -Peri-wound: Normal; -Exudate: Small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply, apply nickel thick Santyl and cover with border gauze daily and prn; -Location: Right buttock: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 10 % granulation and 90% necrotic and slough; -Measurements: 4 cm by 0.5 and depth utd; -Peri-wound: excoriated; -Exudate: small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply nickel thick Santyl and cover with border gauze daily and prn. Further review of the resident's ePOS, showed: -An order dated 11/13/21 and discontinued 11/16/21, for Santyl ointment 250 unit/gram. Apply to right buttocks typically every day shift. Cleanse right buttocks with normal saline. Apply nickel thick Santyl and cover with border gauze daily and as needed; -No order to discontinue the [MEDICATION(S)] Sulfate. Review of the resident's wound provider's note, dated 11/16/21 showed: -Location: Coccyx: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 20% granulation and 80% slough; -Measurements: Length 2.2 cm by width 2.0 cm by depth utd cm; -Peri-wound: Normal; -Exudate: Small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply, apply nickel thick Santyl and cover with border gauze daily and as needed; -Location: Right buttock: -Type: Pressure ulcer/injury: Stage III (full thickness tissue loss, subcutaneous (under the skin) fat may be visible but the bone, tendon or muscle is not exposed); -Additional notes: Closed. Review of the resident's wound provider's note, dated 11/30/21, showed: -Location: Coccyx: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 90% slough, dark tan, malodorous (foul odor) and 10% non-granular (no granulation tissue); -Measurements: Length 3.0 cm by width 3.0 cm by depth 2.5 cm; -Undermining (when significant erosion occurs underneath the outer wound edges resulting in more extensive damage beneath the skin surface): 2.5 cm circumference; -Peri-wound: 2 cm induration (hardening of the skin due to inflammation); -Exudate: Moderate; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply, apply nickel thick Santyl and cover with border gauze daily and prn; -Additional notes: tissue culture (lab test to check for infection) ordered; -Location: Left heel: -Type: Pressure ulcer/injury, Deep tissue pressure injury (DTPI) Intact skin; -Wound bed description: 100% stable eschar; -Measurements: Length 4 cm by width 5cm, depth DTPI; -Exudate: None; -Interventions: Float heels with booties; -Plan: Cleanse with normal saline and apply skin prep (skin protectant) daily and as needed. Further review of the resident's medical record, showed no skin observation tools completed in November 2021. Further review of the resident's progress notes, showed no documentation of the resident's left heel DTPI. Observation on 12/1/21 at 12:22 P.M. showed the resident in his/her wheelchair and a foul odor noted in the room. CNA/Staffing Coordinator, Restorative Aide C and Certified Nursing Assistant (CNA) S placed the resident into his/her specialty bed per Hoyer lift and provided peri-care (cleansing of genitals and buttocks). Staff assisted the resident to his/her left side and the foul odor became stronger when the resident lay on his/her side. A dressing to the resident's coccyx saturated with brown drainage. The administrator, who was also working as the floor charge nurse, entered the room and removed the dressing to the coccyx. The coccyx wound had a large amount of brown drainage and string-like brown tissue to the wound bed. The administrator cleansed the wound with normal saline applied [MEDICATION(S)] 1% ointment onto a piece of gauze and then packed the dressing into the resident's coccyx wound. He/she then covered it with a Collagen Alginate (specialty wound dressing that contained collagen and calcium alginate) and secured it with paper tape. No border gauze used. Further review of the resident's ePOS, showed: -An order start date 12/3/21, cleanse coccyx with normal saline, apply nickel thick Santyl ointment daily; -An order start date 12/3/21, cleanse left heel with normal saline and apply skin prep daily and as needed; -No order for a Collagen Alginate dressing; -No order for heel protector booties; -No order for wound culture. Observation and interview on 12/2/21 at 7:20 A.M., showed the resident lay in bed with no protective heel booties on his/her feet. The protective heel booties observed in the corner of the room. At 7:30 A.M., CNA M provided peri-care and then turned the resident on his/her left side. No dressing to the coccyx observed. CNA M said the wound was looking very bad and probably the worse he/she had ever seen it. He/she said the odor was awful. The coccyx wound drained a large amount of brown drainage and the drainage noted on the resident's incontinence pad on the bed. The resident's left heel observed with large, intact, blackened area. CNA M left the room to tell the nurse that there was no dressing on the resident's coccyx. Licensed Practical Nurse (LPN) B entered the room, cleansed the resident's coccyx wound with normal saline, applied [MEDICATION(S)] 1% ointment to the wound base and covered it with a gauze and secured it with tape. Observation on 12/3/21 at 7:30 A.M., showed the resident's heel booties not on his/her feet. CNA M stood in the resident's room and sprayed odor [MEDICATION(S)]. During an interview on 12/8/21 at 8:20 A.M., Restorative Aide C said when the aide completes a bed bath or shower, a shower sheet is filled out to indicate a new area and the shower sheet is signed off by the charge nurse. Review of the resident's shower sheets, requested from the facility, showed one shower sheet provided, dated 12/3/21 and it did not indicate the resident's DTPI to the left heel. CNA signature and charge nurse signature observed on the sheet. During an interview on 12/7/21 at 9:44 A.M., Wound Provider Nurse R, said he/she identified the resident's left heel DTPI on 11/30/21. The facility did not. He/she verified that the orders for the resident's coccyx wound was only to be Santyl and not [MEDICATION(S)] after the 11/9/21 visit. He/she expects staff to pack the wound if there is a depth to the wound. That would be common nursing practice for wound care. The wound culture was not obtained by the facility as ordered. He/she expects the treatments to be completed as ordered. He/she expects orders to be followed through within 24 hours. 2. Review of Resident #32's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No evidence of acute change in mental status from the resident's baseline; -Total dependence in bed mobility, transfer, toilet use and dressing; -Impairment in range of motion on both lower extremities; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Has a stage IV pressure ulcer. Review of the resident's care plan, in use at the time of survey, showed: -Has a stage IV pressure ulcer to the buttock; -Administer medications as ordered; -Administer treatments as ordered and monitor effectiveness; -Follow the facility policies and protocols for the prevention and treatment of skin breakdown; -Monitor dressing during shift to ensure it is intact and adhering; -Monitor nutritional status; -Encouraged good nutrition and hydration in order to promote healthier skin. Review of the resident's wound provider's note, dated 9/21/21, showed: -Location: Left buttocks; -Type: Pressure ulcer/injury: Stage IV; -Wound bed description: 70% granulation, 10% hyper-granulation (new tissue growth that forms beyond the surface of the wound) and 10% slough; -Measurements: length 16.3 cm by width 6 cm by depth 0.1 cm; -Peri-wound: Normal; -Exudate: Moderate; -Color: Serosanguineous; -Plan: Normal Saline cleanse, apply nickel thick Santyl and cover with Silver Alginate (antimicrobial dressing) and super absorbent dressing two times a day and as needed; -Additional notes: Wound bed is improving. Review of the resident's ePOS, showed: -An order dated 9/26/21, for Santyl ointment 250 unit/gram, to be applied to the left buttock topically two times a day for wound care. Cleanse area with normal saline and cover with Silver Alginate, and super absorbent dressing. The order discontinued on 11/10/21; -An order dated 11/10/21, for Santyl ointment 250 unit/gram, to be applied to left buttock topically tow times a day and as needed for wound care. Cleanse area with normal saline and cover with Silver Alginate and super absorbent dressing. The order discontinued on 12/2/21. Review of the resident's eTAR, reviewed on 12/6/21 at 8:10 A.M., showed the following dates the wound treatments not documented as administered: -On 9/27/21, 9/29/21, and 9/30/21, both day and evening shifts; -On 9/28/21, evening shift; -On 10/1/21 through 10/4/21, 10/8/21, 10/20/21 and 10/28/21, both day and evening shifts; -On 10/5/21, 10/9/21, 10/19/21, 10/23/21 to 10/25/21, 10/27/21, 10/29/21, and 10/31/21, day shifts; -On 10/10/21, 10/13/21, 10/14/21, 10/17/21, and 10/18/21, evening shifts; -On 11/3/21, 11/5/21, 11/8/21, 11/16/21, 11/18/21, 11/20/21, 11/23/21 to 11/26/21, day shifts; -On 11/21/21 and 11/25/21, both day and evening shifts. Review of the resident's wound provider note, dated 11/30/21, showed: -Location: Left buttocks; -Type: Pressure ulcer/injury: Stage IV; -Wound bed description: 90% hyper-granulation and 10% slough; -Measurements: length 14.5 cm by width 5 cm by depth hyper-granulation friable tissue; -Peri-wound: Normal; -Exudate: Moderate; -Color: Serosanguineous and yellow/dark tan; -Plan: Normal Saline cleanse, apply nickel thick Santyl and [MEDICATION(S)] 0.1% and cover with Silver Alginate (antimicrobial dressing) and super absorbent dressing two times a day and as needed; -Additional notes: Wound culture ordered. Further review of the resident's ePOS, showed an order dated 12/2/21, for [MEDICATION(S)] Sulfate ointment 0.1% and Santyl, to be applied to left buttock topically two times a day and as needed for wound care. Cleanse area with normal saline and cover with Silver Alginate and super absorbent dressing. During an interview on 12/1/21 at 8:09 A.M., the resident said the nurses provide wound treatments sometimes only once a day, as opposed to two times a day. He/she said it may be due to the facility's shortage of staff. 3. Review of Resident #30's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Required extensive assistance from staff for mobility, dressing and personal hygiene. Total dependence on staff for showers and toileting; -Always incontinent of bowel and bladder; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -At risk for pressure ulcers; -Number of unhealed pressure ulcers: One unhealed Stage 3. Review of the resident's care plan, in use during the survey, showed staff failed to address the wound to the resident's knee or include any preventative interventions. Review of the resident's wound management provider note, dated 10/26/21, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 90% granulation and 10% slough; -Measurements: Length 2.5 cm by width 1.2 cm by depth 0.1 cm; -Exudate: None; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's ePOS, showed: -An order dated 10/27/21, for Santyl ointment 250 milligrams (mg), apply to left medial knee topically every day shift for wound care. Cleanse left medial knee with normal saline. Apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed; -An order dated 10/27/21, to place pillow/wedge between knees to off load pressure. Review of the resident's October 2021 TAR, showed: -An order dated 10/27/21, for Santyl Ointment 250 mg, apply to left medial knee topically every day shift for wound care. Cleanse left medial knee with normal saline. Apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed; -Start date: 10/28/21; -Staff documented completing the treatment for one out of four opportunities; -No other documentation; -No order for a pillow/wedge. Review of the resident's wound management provider note, dated 11/2/21, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 2 cm by width 1 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's 11/9/21 wound management provider note, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 1.8 cm by width 0.8 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's 11/16/21, wound management provider note, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 0.9 cm by width 0.6 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's 11/30/21 wound management provider note, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 1.3 cm by width 0.5 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's November 2021 eTAR, showed: -Staff documented administering the treatment 18 out of 30 opportunities; -No other documentation; -No order for a pillow/wedge. Review of the resident's 12/1/21 wound management provider note, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 1.3 cm by width 0.5 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Observation on 12/2/21 at 7:39 A.M., showed the resident lay in bed on his/her back. The resident had a treatment on his/her left knee dated 11/30/21 and signed by the wound management provider. A wedge/pillow was not in place between his/her knees. Observation on 12/3/21 at 7:30 A.M., showed the resident lay in bed on his/her back. The resident had a treatment on his/her left knee dated 12/2/21 and signed by the wound management provider. A wedge/pillow was not in place between his/her knees. Observation on 12/6/21 at 1:04 P.M., showed the resident lay in bed on his/her back. The resident had a treatment on his/her left knee dated 12/5/21 and initialed by facility staff. A wedge/pillow was not in place between his/her knees. Review of the resident's December 2021 eTAR reviewed on 12/6/21 at 5:25 P.M., showed: -Staff documented administering the treatment 5 out of 6 opportunities; -No other documentation; -No order for a pillow/wedge. During an interview on 12/8/21 at 8:19 A.M., CMT D said he/she was familiar with the resident. The resident used to have a wedge that staff placed on his/her side, but he/she was not aware of a wedge or pillow that needed to go between the resident's knees. 4. During an interview on 12/7/21 at 11:25 A.M., the administrator said she expected staff to follow physician orders. If the eTAR is blank, staff should document as to why it was not completed. If it is blank, either the treatment was not completed or staff failed to document completing it. There should be documentation the physician was notified after three missed treatments. 5. During an interview on 12/8/21 at 8:25 A.M., LPN L said once a wound is newly identified he/she will measure the wound, describe the wound bed and drainage if any is noted. The physician needs to be notified before the nurses shifts ends to obtain new orders. In the meantime, he/she would place a dry dressing over the wound until orders are received. He/she did not know when skin assessments are done because he/she was agency staff. He/she thought they would pop up on the computer to be completed and was not sure where they are documented. 6. During an interview with the administrator and the consultant administrator on 12/8/21 at 12:04 P.M., they said staff is expected to notify the physician before their shift ends if a new wound or a change in a wound status is observed to obtain orders so there is no delay in treatment. The weekly wound assessments are expected to be signed off on the eTAR and a skin observation tool is expected to be used weekly for the documentation of the specifics of the wound, such as if the wound is new, changes in the wound, measurements, location, and if drainage is noted. New orders from the wound nurse is expected to be in place within 24 hours. Staff is expected to complete treatments and assessments accurately and as ordered. MO 410

Based on interview and record review, the facility failed to protect a resident from emotional injury when the staff forced the resident to take a bath against his/her will for one of four sampled residents. (Resident #1) The resident cried and yelled and screamed he/she did not want a bath. The resident was distraught and fearful for several days after the incident occurred. The census was 90. 1. Review of Resident #1's face sheet, showed the facility admitted the resident on 12/31/09 with a [DIAGNOSES REDACTED]. Review of the facility's resident rights form dated 12/31/09, showed the resident signed the form which stated he/she understood the facility required him/her to have knowledge of his/her resident rights. The resident received a three page descriptive list of the rights and the facility encouraged the resident to report any violations of his/her rights immediately to the nurse or a department head. Review of the resident's care plan last updated 4/12/11, showed the following: -Required extensive assistance with moving to and from the lying position, turning side to side and positioning while in bed; -Required total assistance with all transfers; -Required physical help in part of bathing activity (during full body bath, sponge bath, including transferring in and out of the tub/shower); -Required total assistance with toileting; -Resident perceived that past routine was very different from prior pattern in the community. The resident's goal was to be treated as an adult with major changes in his/her life; -The resident's care plan did not address the resident did not take baths or showers. It only addressed bed baths two times per week. Review of the resident's psychiatrist progress note dated 6/28/11, showed the resident was alert and oriented to person, place and time and was "somewhat" anxious. Review of the resident's nurse's notes dated 7/19/11 through 8/9/11, showed no documentation the resident had any body odor or the resident was not clean. Review of the resident's monthly summary dated 8/10/11, showed the following: -Alert and oriented; -Friendly and cooperative; -Catheter (flexible tube inserted into the bladder through the urethra to drain the bladder of urine); -Bed bath. Review of the resident's psychologist progress note dated 8/25/11, showed the following: -Logical and coherent; -Anxious; -Fully oriented; -Cooperative, responsive and engaged. Review of the resident's psychiatrist progress note dated 8/29/11, showed the resident was alert and oriented with no psychotic symptoms and no cognitive changes. Review of the resident's nurse's notes dated 8/16/11 through 9/8/11, showed no documentation the resident had any body odor or the resident was not clean. Review of Ombudsman C's report dated 9/9/11, showed on 9/8/11, the Director of Nursing (DON) and the assistant DON (ADON) gave the resident a bath against his/her will. The two nurses went into the resident's room and said he/she was going to take a bath. The resident said "No" and the nurses said the resident did not have a choice. The resident said he/she was scared to take a bath and wanted to talk to the administrator or charge nurse B. The nurses called the administrator, but the administrator never came down to the resident's room. The administrator told the ombudsman it would have made it worse (if she had gone down to the resident's room). The resident then "closed" his/her hands around the bed rails and the nurses tried to pry the resident's fingers off. The nurses then lifted the resident one side at a time and placed the mechanical lift pad under him/her. The DON and ADON lifted the resident with the mechanical lift and pried his/her fingers from the bed rails. The resident said he/she "Feels like a piece of meat, they didn't act like he/she was crying and screaming." The resident said he/she felt like he/she had no control over his/her body. The administrator told Ombudsman C she did not feel it was abuse and she resented the fact the resident said it was. The administrator did not know about the "hand/finger prying," but would investigate it. The administrator said the resident's bath was needed because of the resident's "disturbing" feminine odor that was not addressed with a bed bath and other resident's were bothered by it. During an interview on 9/30/11 at 3:20 P.M., Ombudsman C said she saw the resident on 9/9/11 and he/she was very upset, devastated. The resident said several times, the staff treated him/her like "a piece of meat" and he/she had no control over his/her body. The ombudsman visited the resident almost weekly and the resident only had a slight urine odor which came from his/her catheter. During an interview on 9/21/11 at 8:04 A.M., the resident said on 9/8/11, the DON came into his/her room and told the resident he/she was going to take a bath. The resident said he/she was not going to because the staff clean him/her up everyday. The resident said he/she then held onto each side rail and pulled his/herself up in bed and said, "No, I'm not". The resident said when he/she first came to the facility, he/she was getting a bath and it did not go well, so he/she had been getting bed baths since that time. One time per week, the staff washed his/her hair, once he/she got up for the day. The DON was on the resident's left side and the ADON was on the right side. CNA A stood at the foot of the resident's bed and had tears in his/her eyes during the incident and did not want to be in the resident's room. The resident said he/she was getting more and more upset and held onto the side rails, but both the DON and ADON pried the resident's fingers from the side rails. "I was afraid to get a bath again and I started crying." The resident said he/she was getting hysterical and said, "I can't tell you what it did to me not having a say over my body." It was a shock because the resident received excellent care at the facility. The resident kept asking to talk to the administrator or charge nurse B, but the DON and the ADON ignored him/her like they did not hear him/her. The resident did not remember how he/she got from the bed to the wheelchair, but remembered being rolled down the hallway. The resident kept screaming he/she wanted to talk to the administrator or the nurse and it was against his/her "patient" rights (to be forced to take a bath). The resident said the DON and ADON rolled him/her down the hall, through the dining room to the shower room (located next to the dining room). There were three or four people sitting in the dining room. The resident did not remember how he/she got into the bath tub, but CNA A gave him/her the bath and washed his/her hair. The resident just sat in the tub and cried. After the bath, the staff took the resident back to his/her room and put him/her to bed. The resident said he/she was so distraught, still crying uncontrollable and screaming when staff brought him/her back to his/her room, he/she could not remember who put him/her back in bed. The resident said he/she had polio and had been in a wheelchair since he/she was [AGE] years old. He/she was going to be [AGE] years old and had never not had charge of his/her body. The resident said he/she never had any body odor and could not smell an odor coming from him/herself. The staff cleaned him/her completely front to back and used baby powder after each bed bath. The psychologist happened to come in after the incident occurred on 9/8/11, he calmed the resident down and said he was going to talk to the administrator about what happened. The resident said he/she did not get an apology from the facility or even validation that the incident had occurred. He/she said the administrator did not come down to talk to him/her until approximately one week later. On 9/16/11, the ADON apologized and said she never meant to hurt him/her. The resident asked the ADON, "Didn't you hear me screaming?" and the ADON did not say anything. The ADON then said she could lose her job and her license The resident said he/she felt like "a piece of meat, I didn't feel like a human being." For a few days after the incident, the resident said he/she did not feel safe at the facility. The resident said it was emotional abuse. During an interview on 9/21/11 at 12:35 P.M., CNA A said on 9/8/11, both him/her and charge nurse B asked the resident if he/she would take a bath. The resident said "absolutely no". The DON then came done onto the first floor and asked who was the resident's aide for that day and CNA A said he/she was. The DON told CNA A to go with her down to the resident's room and CNA A told the DON the resident was not going to take a bath. The DON replied, "Oh, yes he/she is." The DON, ADON and CNA A went to the resident's room and the resident's eyes were closed, so the DON touched the resident on the shoulder and told the resident he/she was going to take a bath. The resident said no, he/she was not and the DON said again, "Yes, you are." The resident said he/she was not and to go get the administrator. The ADON left the room approximately three different times to get the administrator, but the administrator did not come to the resident's room. The DON explained to the resident he/she needed a bath because the resident smelled. The resident began yelling he/she was not going to take a bath, he/she did not want to take a bath and it was against his/her patient rights. CNA A left the room to get supplies for the bath, when he/she returned, the DON and ADON rolled the resident from side to side and placed the mechanical lift pad under the resident. The resident was holding onto the side rails because he/she did not want to get up. The resident kept repeating no and to get the administrator or the charge nurse. The DON and ADON pried the residents hands off the side rails as they rolled the resident from side to side. The resident was sitting up and holding onto the side rails when the DON and ADON hooked the mechanical lift pad to the mechanical lift. They began to lift the resident above his/her bed, CNA A grabbed the resident's catheter bag and lowered the side rails. The resident held onto the top bar of the lift and began to shake the entire lift back and forth while yelling for the administrator and the charge nurse. CNA A told the resident he/she needed to stop shaking the lift, he/she was going to hurt him/herself. The resident stopped shaking the lift and the DON and ADON lowered the resident into a wheelchair. CNA A covered the resident with a blanket and the DON and ADON rolled the resident down the hall to the shower room. The resident cried, screamed and yelled all the way down the hall. Residents in their rooms could hear all the crying and screaming. Charge nurse B was in a care plan meeting in the basement and would not have been able to hear any of the incident. When they reached the shower room door, they stopped and the resident grabbed the wheelchair wheels to keep them from rolling him/her into the shower room. Everyone standing around was looking at the resident while the DON and ADON removed his/her hands from the wheelchair wheels. Once, inside the shower room, the resident continued crying and screaming. The resident yelled at CNA A, "You know this isn't right!" CNA A said there was nothing he/she could do because it was his/her two bosses doing it. They placed the resident in the tub and the CNA bathed the resident and the ADON washed the resident's hair. The DON stood in the room while they bathed him/her. The resident cried the entire bath. The CNA dried the resident after the bath and and all three staff took the resident back to his/her room and placed the resident back in his/her bed. The CNA said after the resident told charge nurse B he/she did not want a bath, the staff should have left the resident alone and then asked the administrator to talk to the resident. The resident should not have been forced to take a bath, it is never okay to force a resident to do something. The CNA said that is why they have steps to follow, we tell different people about a refusal and they can try to talk the resident into whatever was needed. That is what the staff normally do. The CNA said he/she thought the DON and ADON knew the CNA was uncomfortable doing this and that was why he/she did not touch the resident in the resident's room. CNA A said the DON and ADON were his/her bosses and he/she did not know what to do. The DON told the resident the administrator wanted him/her to take a bath. The resident had an incident when he/she was first admitted , so he/she was afraid to take a bath. The resident never got a bath in the tub, the staff only gave him/her bed baths. Later, the resident told CNA A, it wasn't so much the bath, but how he/she was treated and he/she had no choice. CNA A said on 9/16/11, the administrator told nurse D to tell CNA A to go talk to the resident. CNA A asked why and Nurse D said the administrator wants the resident to understand that CNA A was just as much a part of the incident as the DON and ADON were. CNA A and nurse D went to the resident's room and the resident said, "(The administrator) really pissed me off. She told me I stink, I have an odor and possibly scabies." The resident said he/she called physician E and the physician said the resident did not have scabies. Then the resident told nurse D what happened on 9/8/11. CNA A said he/she did not say anything to the administrator about the incident because it was the administrator who sent the DON and ADON in to give the resident a bath. The administrator knew the resident refused that bath, but got it anyway, the resident was crying and the administrator did not go talk to the resident. During an interview on 9/21/11 at 11:35 A.M., the ADON said she was in standup/census meeting the morning of 9/8/11 with the DON, administrator, charge nurses and department heads, when the administrator said the resident needed a bath because people could smell body odor and urine in his/her room. CNA A told her the resident did not want a bath, so the ADON went to the resident's room and smelled urine and body odor when she entered the resident's room. The ADON went back to the census meeting and told the DON and the administrator the resident did have body and urine odor and had refused the bath. The DON said the resident needed a bath because he/she had not had one in a while and the ADON and DON left the meeting and got CNA A and went to the resident's room to get the resident ready for his/her bath. The ADON said the resident started crying and repeated three or four times he/she did not want to take a bath. The resident grabbed onto both siderails when they started to lift him/her up in the mechanical lift, causing the mechanical lift to shake. The ADON said she and the DON lifted the resident's hands off of the siderail. The resident asked to see the administrator, so the ADON went down to the administrator's office, but she was on a phone call and the administrator said she would come down to see the resident later. The three staff took the resident down the hall to the shower room while the resident cried and yelled, "This is not right, I don't need a bath and you can't force me to take a bath!" There were residents sitting in the dining room listening and watching. The ADON said she should have left the resident alone, it is never okay to force a resident to do anything. The ADON said she did not know until after the incident, the resident had not had a bath in the tub in over a year, he/she only received bed baths. It would not be appropriate to put a resident in the tub if they had not had a tub bath in over a year. The ADON said she must have had "tunnel vision", she should have told the DON this was not right and they shouldn't do it. The ADON said she knows the resident rights, residents have the right to refuse anything. The ADON said when she walked in the resident's room, she could smell the body odor and the resident's hair was so unclean, she did not want the resident to be embarrassed in front of other residents. The staff were not giving the resident a thorough bed bath. The ADON apologized to the resident over and over again for making him/her feel like he/she did not have control over his/her body. During an interview on 9/21/11 at 3:00 P.M., the DON said during the standup meeting on 9/8/11, the staff discussed the resident and that he/she had been refusing to take a bath. The administrator told the DON she needed to give the resident a bath. The DON went to the resident's room with the ADON and CNA A and told the resident he/she was going to get a bath today (9/8/11). The resident started screaming he/she was not taking a bath, the resident kept screaming and yelling. The DON tried to talk to the resident about the bath, but the resident was crying it was his/her right to not take a bath. The DON said the resident grabbed onto the siderails when they suspended him/her above his/her bed with the mechanical lift. The resident was shaking the mechanical lift. The DON lifted the resident's hands from the siderails and the resident let go, but he/she was still screaming he/she wanted to see the administrator and the charge nurse. The administrator was on the phone and even if she had come to the resident's room, it would have still been the same decision (to bathe the resident). They rolled the resident down the hall to the shower room and the resident was crying and "whining". The DON said she knew the resident was upset, but she did not think she had done anything wrong. She knew the resident was mad because she made him/her take a bath. The DON said she should have stopped when the resident refused. Later, she found out the resident had an incident with the tub and the resident said he/she only got bed baths. If the staff had thoroughly given the resident bed baths this could have been avoided. The resident had a feminine odor, his/her was dirty and the catheter must have been "dribbling", because he/she had a urine odor. The DON thought the resident was "just throwing a tantrum", she was not thinking about stopping and trying later, she just wanted it to be over, so the resident could go on with the rest of his/her day. The administrator knew the resident refused the bath and that they gave it anyway. During an interview on 9/21/11 at 11:16 A.M., Resident #4 said on 9/8/11, he/she was in the dining room with his/her spouse. Resident #1 was in the shower room, off the dining room, and he/she could hear Resident #1 screaming and crying. Resident #4 could not make out the words while Resident #1 was in the shower room, then the staff brought him/her out and Resident #1 was crying and saying, "Just leave me alone." Resident #4 said the crying and screaming was really loud and it bothered him/her because the staff made Resident #1 take a bath. Resident #4 said it made him/her nervous hearing it, "It was sad for (Resident #1). Resident #1 did not want to take a bath and if the staff had treated Resident #1 right, he/she would not have cried. During an interview on 9/21/11 at 11:16 A.M., spouse F said he/she was sitting in the dining room on 9/8/11, and could hear a resident crying and screaming in the shower room. He/she saw the ADON come out of the shower room with Resident #1. Spouse F was concerned about what he/she heard that day, he/she was worried that when he/she was not at the facility, it might happen to his/her spouse. During an interview on 9/22/11 at 12:55 P.M., CNA G said on 9/8/11, he/she was in the shower room across the hall giving another resident a shower. He/she could hear Resident #1 "yelling at the top of his/her lungs", the resident was yelling uncontrollably, but CNA G could not make out what the resident was saying. It is never appropriate to make a resident do something. If a resident refuses to do something, try to convince them later and report it to the nurse. CNA G said the resident cried for week after the incident occurred. CNA G went to see the resident that day and the resident was still crying and said it was not right what "they" did to him/her. During an interview on 9/21/11 at 2:35 P.M., CNA K said he/she saw the DON, ADON and CNA A bring the resident out of the shower room on 9/8/11. The resident was sobbing, but not yelling. It is never okay to force a resident to do something, it is their right to refuse. During an interview on 9/21/11 at 12:12 P.M., housekeeper H said when he/she came back from lunch, he/she went to the resident's room to clean it. The resident was in his/her room crying loudly. Psychologist I walked in the room, so housekeeper H left. Housekeeper H said he/she had never seen the resident upset like that before and it bothered him/her the resident was crying. He/she has never seen the resident refuse to take a bath and staff are suppose to come back later and try again if a resident refuses something. It is never okay to make a resident do something they refused to do, he/she learned this in a resident rights inservice. During an interview on 9/21/11 at 12:26 P.M., CNA J said he/she has given the resident a bed bath before. The resident does not get that dirty and does not have a feminine odor. The resident's main issue is a urine odor and he/she thinks it is the resident's catheter bag that smelled. It is never okay to force a resident to do something. During an interview on 9/21/11 at 3:30 P.M., charge nurse B said he/she was in a care plan meeting when the incident occurred on 9/8/11. He/she said the resident always gets a bed bath and everybody knows that and the resident can tell you this too. The charge nurse did not know why the resident's bath preference was not on his/her care plan, but it should have been. Charge Nurse B said he/she talked to the resident after the psychologist left on 9/8/11 and the resident was still crying. Staff should have just given the resident a bed bath like they normally do, it is never okay to force a resident to do something. During an interview on 9/21/11 at 1:10 P.M., charge nurse L said he/she was in resident room [ROOM NUMBER] at the end of the hallway on 9/8/11 and heard a resident screaming. The door to room [ROOM NUMBER] was slightly open and the charge nurse heard a resident screaming, someone was really in distress. The charge nurse went down to the nurse's station and asked staff who was screaming and someone said it was Resident #1 getting a bath. By the time the charge nurse got up to the nurse's station, the resident was already in the shower room. The administrator told staff that morning in the census meeting, the resident had to get a bath and the ADON said that it would be very difficult. The administrator said it had to be done and needed to be done weekly. The charge nurse said he/she was "petrified", he/she thought someone was hurt and in a lot of distress. It bothered him/her. He/she said it was absolutely never appropriate to force a resident to do something. When a resident refused to do something, it would be abuse to force them. If a resident refused to do something, the staff should come back later or see if there was a better time for the resident. During an interview on 9/21/11 at 2:04 P.M., nurse D said he/she talked to the resident about the incident on 9/16/11. The resident said he/she was "pissed off" at what "they" did to him/her. The resident had no control over what was done to him/her, it was against his/her rights and they proceeded anyway. Nurse D felt horrible listening to the resident tell what had happened, he/she felt sorry for the resident and apologized for what happened to him/her. The administrator told the DON and ADON in the standup meeting on 9/8/11 to give the resident a bath. Normally, if a resident refused to do something, the CNA tells the nurse and the nurse talks to the resident. During an interview on 9/21/11 at 1:32 P.M., the administrator said she was not aware the resident only received bed baths; therapy gave him/her a bath this year. The administrator told the DON as "in nursing" to give the resident a bath. The ADON came to the administrator's office to get her, but the administrator was on the phone and could not get off. The administrator said she should have told the ADON to just wait for her. The resident told the administrator later, if she had come down there to talk to him/her, he/she would have taken the bath. When the staff brought the resident down to the shower room, the administrator heard the resident yelling. The administrator did not talk to the resident after his/her bath. After the bath, the DON told the administrator the resident was making a "sobbing" noise during the bath. If the resident refused the bath, the staff should have just stopped. It is never okay to force a resident to do something. After the bath, the administrator heard the resident refused. The DON and ADON said when they had the resident in the mechanical lift, the resident was shaking the lift and the DON was afraid the resident was going to hurt him/herself. The DON should have just lowered the resident back down in his/her bed. The facility's policy regarding a resident's right to refuse treatment is the actual resident rights. If a resident refuses, the staff should stop. During an interview on 9/23/11 at 1:30 P.M., psychologist I said he happened to conduct his weekly visit with the resident on 9/8/11, after the incident occurred. The resident was relatively calm, but somewhat angry and had mixed feelings about the incident. The resident felt better about having had the bath, but was fearful about being forced to do something. The resident was fearful and distraught at the time of his visit with him/her. The resident's right were not respected. It was obviously disturbing what happened to the resident. Psychologist I tried to talk to the administrator on 9/8/11 before he left, but the administrator was in a meeting. On 9/15/11, psychologist I spoke with the administrator, she was concerned and sad the incident had happened, she was disappointed with the staff who did it. During an interview on 9/21/11 at 10:45 A.M., the facility social worker said she was working on 9/8/11, but did not hear anything and no one told her about the incident that had occurred on that day. The following Friday, 9/16/11, Ombudsman C came back to the facility and told the social worker about the incident that had occurred on 9/8/11. On 9/8/11, during the census meeting, the administrator told the DON the resident was dirty, had an odor and needed a bath. The DON said the resident would get a bath today, 9/8/11. The resident had an incident with a bath when he/she first arrived at the facility and was fearful about falling. The resident is anxious and has always received a bed bath and the staff cleaned him/her up two to three times per day if he/she had a bowel movement. The resident's bed baths were never talked about in the care plan meeting. The social worker said she has never smelled the resident from outside his/her room, he/she has a catheter and you could smell urine. If a resident refused to take a bath, we talked about it in the census meeting, we would talk to the resident and family and then try to figure out why the resident was refusing. It is never appropriate to force a resident to take a bath. The administrator talked to the resident about the incident for the first time on 9/15/11. The administrator said she talked to the resident three times before that and the resident did not remember. The social worker asked the administrator why would the resident forget talking to the person he/she asked to talk to during the incident? During an interview on 9/28/11 at 1:15 P.M., Ombudsman M said she spoke with the resident on 9/14/11 and the resident was still angry and felt violated. The resident was still very clear with what had occurred. During interviews on 9/22/11 at 1:40 P.M., the psychiatrist said it was not appropriate to force the resident to bath, the staff should have utilized other resources such as a sponge bath. He would avoid this kind of situation with residents. The staff should have made him aware the incident had occurred. During an interview on 9/26/11 at 9:35 A.M., physician E said the facility did not make him aware of the incident, but the resident mentioned it to him. The resident's hygiene has been poor over the years, but it was completely inappropriate to force him/her to take a bath; there were better ways of handling this. The staff should have called him, he has known the resident for [AGE] years and he could have talked to him/her. This incident would be traumatic to the resident and he/she would be anxious about it happening again, the resident will be more suspicious. He said he was sure everyday the resident would be suspicious that something else would happen to him/her. Review of the facility's elder abuse and neglect policy, undated, showed the following: -The facility shall ensure each resident has the right to be free from mistreatment, neglect and misappropriation of property; -Each resident has the right to be free from abuse and residents must not be subjected to abuse by anyone including facility staff; -Definition of abuse included willful infliction of mental anguish; -All reports of resident abuse, neglect, misappropriation of resident property and injuries of an unknown source shall be promptly and thoroughly investigated; -Employees of the facility who have been accused of resident abuse will not return to assigned duties until the results of the investigation have been reviewed by the administrator; -The administrator will report alleged abuse to the state licensing agency. MO 028 MO 074 MO 169