Every finding on record at Meadow View Health & Rehabilitation

Based on observation, interview, and record review, the facility failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to ensure utensils, beverage dispensers, and food preparation items/equipment were kept in a sanitary condition; failed to maintain plastic and/or rubber cutting boards, plate covers, room trays, and utensils in good condition to avoid food safety hazards (cross-contamination); failed to separate damaged foodstuffs, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 87 residents with a licensed capacity for 120 residents at the time of the survey. Review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed:-Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.-Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized or discarded if they are not capable of being resurfaced.Review of facility policy Food Safety-Director of Food and Nutrition Services' Responsibilities dated 2021 showed:-The director of food and nutrition services would have assured:--Sanitary conditions would be maintained in the food storage, preparation and serving areas.--The director of food and nutrition services or designee would conduct regular inspections to assure proper food handling. -Followed all federal, state, and local requirements.1. Observation on 2/17/26 at 10:59 A.M. and 11:30 A.M., during a kitchen sanitation inspection showed the following:-Refrigeration units A, B, and C had no thermometers inside each unit to verify the temperature reading inside the unit with the thermometers on the outside of the unit that ensured the food inside was being kept at safe temperature for the storage of food. -The red, white, and green cutting boards on a bottom shelf of a shelving unit at the north wall were heavily scored.-There was a 6 pound (lb.) 14 ounce (oz.) can of garbanzo beans dented on the bottom rim and on the other side just above the bottom rim on a large can dispenser rack in the Dry Storage (DS) room.-There was a 50 oz. can of Cream of Mushroom soup that was dented on one side just above the bottom rim on the same dispenser rack in the DS room.-There was a 48 oz can of Chicken and Dumplings that was dented on one side just above its rim on the same dispenser rack in the DS room. -The manual can opener across from the 3-sink area had excessive greasy build-up of unknown debris and paper.During an interview on 2/17/2026 at 11:04 A.M., the [NAME] said:-Temperatures were checked by reading the thermometer on the outside of the refrigeration units.-The staff did not verify temperatures with a thermometer that was inside the unit.Observation on 2/17/26 between 2:13 P.M. and 2:47 P.M. during the kitchen sanitation inspection showed the following: -Refrigeration units A, B, and C had no thermometers inside each unit to verify the temperature reading inside the unit with the thermometers on the outside of the unit that ensured the food inside was being kept at safe temperature for the storage of food. -The red, white, and green cutting boards on a bottom shelf of a shelving unit at the north wall were heavily scored.-There was a 6 lb. 14 oz. can of garbanzo beans dented on the bottom rim and on the other side just above the bottom rim on a large can dispenser rack in the DS room.-There was a 50 oz. can of Cream of Mushroom soup that was dented on one side just above the bottom rim on the same dispenser rack in the DS room.-There was a 48 oz can of Chicken and Dumplings that was dented on one side just above its rim on the same dispenser rack in the DS room. -The manual can opener across from the 3-sink area had excessive greasy build-up of unknown debris and paper.During an interview on 2/19/26 at 12:46 P.M. the Dietary Manager said the following:-Damaged foodstuffs were to be separated out and returned to their food vendor for a credit or replacement.-The damaged cutting boards should have been replaced with new cutting boards. -Cutting boards should have been replaced when heavily scored. -Damaged food preparation items were to be discarded and replaced.-He/She would expect food to be free of foreign substances.-He/She expected the can opener to be cleaned in the dishwasher after each meal.

Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) that included specific assessments and contents, in accordance with State of Missouri rules and Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) standards and guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility, and the facility failed to ensure appropriate hand hygiene was completed during medication pass for four supplemental residents (Resident #30, #21, #45, and #76) out of seven supplemental residents. The facility census was 87 residents with a licensed capacity for 120 residents at the time of the survey. Review of the facility's water-borne pathogen prevention program paperwork from a contracted source, in a binder entitled Legionella - Water Tracking for the Facility, last dated 12/12/25 and provided by the Administrator, showed the following:-There were 10 numbered tabs, unlabeled and not referenced, and no table of contents page.-Tab #4 had nothing there.-Tab #7 had a PowerPoint that was missing the first 14 slides.-There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed CDC Legionella Environmental Assessment Form.-A facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens was not included. Review of the facility's undated policy titled Handwashing/Hand Hygiene showed:-An alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap and water for the following situations:--Before preparing and handling medications.--Before and after direct contact with residents.--After contact with resident's intact skin.--After removing gloves.-The use of gloves did not replace hand washing/hand hygiene.-Integration of glove use along with routine hand hygiene was recognized as the best practice for preventing healthcare-associated infections. 1. Observation on 2/17/26 between 2:13 P.M. and 2:47 P.M. during the initial Life Safety Code (LSC) kitchen inspection showed there was a sanitizing three-sink area, a chemical dish-washing machine, a hand-washing sink, and a steam table (also referred to as a hot food table, is specifically designed to hold food at steady, safe serving temperatures, and not designed to cook or warm foods from a raw state). Observation on 2/18/26 at 11:58 A.M. and 12:23 P.M. during a facility LSC walk-through inspection with the Director of Maintenance (DOM) and Corporate Maintenance Consultant (CMC) showed the following:-The city municipal water supply entered the facility through two separate main pipes in the basement fire sprinkler riser room (a dedicated space for fire protection equipment), one for their sprinkler system and the second for all other remaining water usage.-The building was equipped with a complete fire sprinkler system with sprinkler heads located throughout the facility.-Two public restrooms were located by the front reception office hall. -A medication room with sink was located behind each of the two separate main nurse's desks.-There were at least 55 resident rooms with private and/or shared bathrooms and sinks throughout the six resident hallways.-There were housekeeping closets with floor mop sinks or ceramic service sinks (mop/service sinks are used in janitorial and maintenance areas to fill and empty mop buckets, clean mops, and dispose of dirty water), boilers, and hot/cold water piping throughout the facility.-There were two commercial clothes washers in the basement laundry area.-There were three Bathhouses with showers in the facility. -There was a Beauty Shop with a sink on the 100 Hall. During an interview on 2/23/26 at 10:02 A.M. the DOM said the following:-The program already existed when he/she was hired.-He/She added the monthly testing to it.-Empty rooms were also checked weekly and faucets ran for a while, though undocumented. During an interview on 2/23/26 at 10:43 A.M. the Administrator said he/she had been educated on Legionella prevention requirements administrator trainings, studying for exams, and by a preceptor that further educated them. 2. Review of Resident #30's admission Record showed he/she admitted to the facility with a diagnosis of Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's Order Summary Report dated February 2026 showed:-An order for Voltaren Gel (a topical ointment used to treat pain) one %, apply to both hips topically two times a day.-An order for Cetirizine HCl (used to treat allergy symptoms) 10 milligrams (mg), give one tablet one time a day.-An order for Vitamin D3 (a supplement) Tablet 1000 unit, give three tablets by mouth one time a day.-An order for Celebrex (used to reduce pain, inflammation, swelling, and stiffness) oral capsule 200 mg, take one capsule by mouth one time a day.-An order for Gabapentin (used to treat nerve pain) oral capsule 300 mg, take one capsule by mouth two times a day.-An order for Lisinopril (used to treat high blood pressure) tablet 10 mg, take one tablet by mouth one time a day.-An order for Hydrocodone-Acetaminophen tablet 5-325 mg (used to treat moderate to severe pain), give one tablet by mouth three times a day. Observation on 2/19/26 at 9:42 A.M. of the resident's medication administration completed by Licensed Practical Nurse (LPN) B showed:-He/She did not wash or sanitize his/her hands before starting the task.-Once he/she finished the preparation of the medications, he/she put on gloves.-He/She picked up the resident's medication and walked into the resident's room.-He/She put the Voltaren Gel on the resident's hips and removed his/her gloves.-He/She gave the resident his/her oral medication without washing or sanitizing his/her hands.-He/She exited the resident's room without washing or sanitizing his/her hands. 3. Review of Resident #21's admission Record showed he/she admitted to the facility with a diagnosis of Huntington's Disease (a disorder that causes the progressive breakdown of nerve cells in the brain). Review of the resident's Order Summary Report dated February 2026 showed an order for Acetaminophen (Tylenol- a fever and pain reducer) Extra Strength tablet 500 mg, give one tablet by mouth every six hours as needed for pain. Observation on 2/19/26 at 9:58 A.M. of the resident's medication administration completed by LPN B showed:-He/She did not wash or sanitize his/her hands before starting the task.-He/She prepared the medication and handed it to the resident.-He/She did not wash or sanitize his/her hands after giving the medication to the resident. 4. Review of Resident #45's admission Record showed he/she admitted to the facility with the following diagnoses:-Chronic Obstructive Pulmonary Disease (COPD- a disease process tat decreases the ability of the lungs to perform ventilation).-Parkinson's Disease (a chronic, progressive disorder that impairs movement and motor control) Review of the resident's Order Summary Report dated February 2026 showed:-An order for Aspirin (commonly used to treat pain or fever) 81 mg, give one tablet by mouth one time a day for heart health.-An order for Cranberry oral tablet (a supplement) 450 mg, give one tablet two times a day.-An order for Amiodarone Hydrochloride (HCl) (used to treat abnormal heart rhythms) oral tablet 100 mg, give one tablet by mouth one time a day.-An order for Carbidopa-Levodopa (used to treat Parkinson's Disease) oral tablet 25-100 mg, give one tablet by mouth three times a day.-An order for Clopidogrel Bisulfate (used to prevent blood clots) tablet, give one tablet one time a day.-An order for Levetiracetam (used to control seizures) oral tablet 750 mg, give one tablet by mouth three times a day.-An order for Metoprolol Succinate Extended Release (ER) (used to treat high blood pressure) 25 mg, give 0.5 tablet by mouth one time a day.-An order for Oxybutynin Chloride ER (primarily used to treat overactive bladder) oral tablet 15 mg, take one tablet by mouth one time a day.-An order for Sertraline (used to treat depression) oral Ttablet 50 mg, give one tablet by mouth one time a day.-An order for Lacosamide (used to treat seizure disorders) tablet 200 mg, give one tablet two times a day. Observation on 2/19/26 at 10:01 A.M. of the resident's medication administration completed by LPN B showed:-He/She did not wash or sanitize his/her hands before starting the task.-He/She prepared all the resident's medications except for the Metoprolol Succinate ER.-He/She walked into the resident's room without washing or sanitizing his/her hands.-He/She checked the resident's blood pressure.-He/She then walked out of the resident's room without washing or sanitizing his/her hands.-He/She went back to the medication cart and placed the resident's Metoprolol Succinate ER into the medication cup with the rest of the resident's medications without washing or sanitizing his/her hands.-He/She walked back into the resident's room without washing or sanitizing his/her hands.-He/She gave the resident his/her medications and walked out of the resident's room without washing or sanitizing his/her hands. During an interview on 2/19/26 at 10:05 A.M. LPN B said:-He/She would not have done anything differently.-When asked about hand hygiene, he/she realized that he/she had missed some opportunities for hand hygiene.-He/She would normally sanitize his/her hands during medication administration:--When entering and exiting resident rooms.--Before and after each resident.--After each separate route of medication. 5. Review of Resident #76's admission Record showed he/she admitted to the facility with a diagnosis of DM II. Review of the resident's Order Summary Report dated February 2026 showed:-An order for staff to check the resident's blood glucose (sugar) level as needed.-An order for Lyumjev Kwikpen Subcutaneuos Solution Pen Injector 100 unit/milliliter (ml), inject 18 units subcutaneously before meals and at bedtime for DM II. Observation on 2/20/26 at 11:14 A.M. of the resident's blood sugar check and insulin (a vial hormone produced by the pancreas that regulates blood sugar) administration completed by Registered Nurse (RN) A showed:-He/She had all the supplies prepared and had gloves on when entering the resident's room.-He/She held the supplies in his/her hands as he/she checked the resident's blood sugar level.-Once he/she completed checking the resident's blood sugar he/she set the glucometer (a compact, portable medical device used to measure the amount of sugar in the blood) on the resident's bedside table.-He/She then dug around in his/her pocket with the same gloved hands.-He/She then administered the resident's insulin with the same gloved hands. During an interview on 2/20/26 at 2:02 P.M. RN A said:-He/She would not have done anything differently.-He/She usually wore gloves into resident rooms.-Hand hygiene needed to be completed before and after each resident during medication administration. 6. During an interview on 2/23/26 at 10:12 A.M. Certified Medication Technician (CMT) A said:-Hand hygiene needed to be performed before and after each resident during medication administration.-Hand hygiene needed to be performed in between different routes of medication administration.-Gloves should not be worn into resident rooms.-When gloves were worn into resident rooms, it caused cross contamination and the gloves were no longer clean.-LPN B did not perform hand hygiene appropriately during Resident #30's, Resident #21's, and Resident #45's medication administration.-LPN B should have washed or sanitized his/her hands before starting Resident #30's, Resident #21's, and Resident #45's medication administration.-LPN B should not have worn gloves into Resident #30's room.-LPN B should have washed or sanitized his/her hands after administering Resident #30's Voltaren Gel.-LPN B should have washed or sanitized his/her hands after exiting Resident #30's room.-LPN B should have washed or sanitized his/her hands after completing Resident #21's medication administration.-LPN B should have checked Resident #45's blood pressure first before preparing the medications, so that way he/she didn't have to re-enter and re-exit the room.-LPN B should have washed or sanitized his/her hands before entering Resident #45's room.-LPN B should have washed or sanitized his/her hands after exiting Resident #45's room.-RN A did not perform hand hygiene appropriately during Resident #76's blood sugar check and insulin administration.-RN A should not have worn gloves into Resident #76's room.-RN A should have removed his/her gloves, washed or sanitized his/her hands, and put on new gloves after completing Resident #76's blood sugar check.-RN A should not have continued to wear the same gloves after putting his/her gloved hands in his/her pocket. During an interview on 2/23/26 at 10:34 A.M. LPN C said:-Hand hygiene needed to be performed before and after each resident during medication administration.-Hand hygiene needed to be performed in between different routes of medication administration.-Gloves should not be worn into resident rooms.-When gloves were worn into resident rooms, it caused cross contamination and the gloves were no longer clean.-LPN B did not perform hand hygiene appropriately during Resident #30's, Resident #21's, and Resident #45's medication administration.-LPN B should have washed or sanitized his/her hands before starting Resident #30's, Resident #21's, and Resident #45's medication administration.-LPN B should not have worn gloves into Resident #30's room.-LPN B should have washed or sanitized his/her hands after administering Resident #30's Voltaren Gel.-LPN B should have washed or sanitized his/her hands after exiting Resident #30's room.-LPN B should have washed or sanitized his/her hands after completing Resident #21's medication administration.-LPN B should have checked Resident #45's blood pressure first before preparing the medications, so that way he/she didn't have to re-enter and re-exit the room.-LPN B should have washed or sanitized his/her hands before entering Resident #45's room.-LPN B should have washed or sanitized his/her hands after exiting Resident #45's room.-RN A did not perform hand hygiene appropriately during Resident #76's blood sugar check and insulin administration.-RN A should not have worn gloves into Resident #76's room.-RN A should have removed his/her gloves, washed or sanitized his/her hands, and put on new gloves after completing Resident #76's blood sugar check.-RN A should not have continued to wear the same gloves after putting his/her gloved hands in his/her pocket. During an interview on 2/23/26 at 12:39 P.M. the Director of Nursing (DON) said:-Hand hygiene needed to be performed before and after each resident during medication administration.-Hand hygiene needed to be performed in between different routes of medication administration.-Gloves should not be worn into resident rooms.-When gloves were worn into resident rooms, it caused cross contamination and the gloves were no longer clean.-LPN B did not perform hand hygiene appropriately during Resident #30's, Resident #21's, and Resident #45's medication administration.-LPN B should have washed or sanitized his/her hands before starting Resident #30's, Resident #21's, and Resident #45's medication administration.-LPN B should not have worn gloves into Resident #30's room.-LPN B should have washed or sanitized his/her hands after administering Resident #30's Voltaren Gel.-LPN B should have washed or sanitized his/her hands after exiting Resident #30's room.-LPN B should have washed or sanitized his/her hands after completing Resident #21's medication administration.-LPN B should have checked Resident #45's blood pressure first before preparing the medications, so that way he/she didn't have to re-enter and re-exit the room.-LPN B should have washed or sanitized his/her hands before entering Resident #45's room.-LPN B should have washed or sanitized his/her hands after exiting Resident #45's room.-RN A did not perform hand hygiene appropriately during Resident #76's blood sugar check and insulin administration.-RN A should not have worn gloves into Resident #76's room.-RN A should have removed his/her gloves, washed or sanitized his/her hands, and put on new gloves after completing Resident #76's blood sugar check.-RN A should not have continued to wear the same gloves after putting his/her gloved hands in his/her pocket.

Based on observation, interview, and record review, the facility failed to ensure appropriate medication and medical equipment storage in two out of five medication carts and in one out of two medication storage rooms. The facility census was 87 residents. Review of the facility's undated policy titled Storage pf Medications showed:-Drugs and biologicals were stored in the packaging, containers or other dispensing systems in which they are received. -Only the issuing pharmacy was authorized to transfer medications between containers.-Drug containers that had missing, incomplete, improper, or incorrect labels were returned to the pharmacy for proper labeling before storage. -Discontinued, outdated, or deteriorated drugs or biologicals were returned to the dispensing pharmacy or destroyed.Review of the facility's undated policy titled Labeling of Medication Containers showed:-Labels for stock medications included all necessary information such as:--The name and strength of the drug.--The lot and control number.--The expiration date when applicable.--Appropriate accessory and cautionary statements.--Directions for use.-Labels for over-the-counter drugs included all necessary information, such as:--The original label indicating the name, strength and quantity of the medication.--The expiration date when applicable.--Directions for use and appropriate accessory/cautionary statements.-Medications could not be transferred between containers.Review of the facility's undated policy titled Receipt and Storage of Supplies and Equipment showed:-All supplies and equipment must be stored in accordance with the manufacturer's recommendations.-It was the purchasing agent's responsibility to assure that proper storage procedures were maintained.1. Observation on 2/20/26 at 9:46 A.M. of the 400/500 hall nurse cart showed:-12 hemorrhoidal suppositories (a small, bullet-shaped medication designed for insertion into the rectum to treat internal hemorrhoids (a swollen vein or group of veins in the region of the anus) that expired in September 2025.-Seven hemorrhoidal suppositories that expired in December 2025.-One 100 milliliter (ml) bottle of sterile (free from bacteria or other living microorganisms) 0.9 percent (%) normal saline (a salt and water mixture used for many medical purposes) that expired on 1/1/26.-Two wound dressings that expired on 7/24/25.-One wound dressing that expired in May 2022.2. Observation on 2/20/26 at 10:17 A.M. of the 200-hall nurse cart showed:-Three hemorrhoidal suppositories that expired in September 2025.-One Epinephrine pen (Epi Pen- a portable, pre-filled auto-injector used for emergency treatment of severe, life-threatening allergic reactions) that was not stored in its original container with no label on the pen and no expiration date could be found on the pen.-One decannulation plug (a medical device designed to seal or cap the end of a tracheostomy (a surgically created opening (stoma) in the neck leading directly to the windpipe (trachea) to help a person breathe) tube) that expired on 11/20/25.-One bottle of vitamin supplements that expired in July 2025.-One opened spray bottle of hydrogen peroxide topical solution (commonly used as an over the counter (OTC) antiseptic for treating minor cuts, scrapes, and burns preventing infection) with no expiration date.-One urinary drainage bag that was opened and sitting at the bottom of the medication cart, no expiration date could be found, and it was missing a cap.-One tracheostomy inner cannula 5.0 millimeters (mm) with a use by date of 12/16/25.-One enteral (the administration of nutrients or medication directly into the gastrointestinal (GI) tract) funnel transition connector that expired on 7/26/25.3. Observation on 2/20/26 at 10:57 A.M. of the west side medication room showed one bottle of supplements that had a cracked and broken lid.4. During an interview on 2/23/26 at 10:07 A.M. Certified Medication Technician (CMT) A said:-Medication carts were checked once a week.-A pharmacist came to the facility once a month and checked medication carts for expired medications.-Expired medications should not be stored in the medication carts.-Expired supplies should not be stored in the medication carts.-Medications with broken seals or caps needed to be disposed of appropriately.-If he/she were to find expired or mislabeled medication in the medication cart, he/she would dispose of the medication and replace the medication.-If he/she were to find expired medical supplies on the medication cart, he/she would dispose of the supplies and tell the nurse.-All medications needed to be stored in their original container or packaging.-There should have only been one Epi Pen stored in the box and the other pen without a label should have been disposed of.During an interview on 2/23/26 at 10:28 A.M. Licensed Practical Nurse (LPN) C said:-He/She checked his/her medication carts daily to ensure appropriate storage of medications and supplies.-Nurse management did not check the carts regularly.-A pharmacist came to the facility once a month and would inform the Director of Nursing (DON) of all recommendations.-Expired medications should not be stored in the medication carts.-Expired supplies should not be stored in the medication carts.-Medications with broken seals or caps needed to be disposed of appropriately.-If he/she were to find expired or mislabeled medication in the medication cart, he/she would dispose of the medication and replace the medication.-If he/she were to find expired medical supplies on the medication cart, he/she would dispose of the supplies and tell the nurse.-All medications needed to be stored in their original container or packaging.-There should have only been one Epi Pen stored in the box and the other pen without a label should have been disposed of.During an interview on 2/23/26 at 12:32 P.M. the DON said:-A pharmacist came to the facility once a month to check the medication carts.-Nurse management also checked the carts once a month.-When the pharmacist came to the facility, they would only check a couple of carts and not all the carts in the facility.-There was not a check-off list or sheet that would be completed when the medication carts were checked.-Expired medication should not be stored in the medication carts.-Expired medical supplies should not be stored in the medication carts.-He/She expected certified staff to remove and dispose of any expired medication or supplies from the medication carts immediately once they were found.-All expired medications and medical supplies needed to be disposed of appropriately.-All medications need to be stored in their original container.-If certified staff found mislabeled or improperly stored medications in the medication carts, then he/she expected the staff to dispose of the medication.

Based on observation, interview, and record review, the facility failed to ensure orders were in place for self-administration of medication for one sampled resident (Resident #81) and one supplemental resident (Resident #47); and failed to ensure an assessment for self-administration of medication was in place for one supplemental resident (Resident #47) out of 18 sampled residents and seven supplemental residents. The facility census was 87 residents. Review of the facility's policy titled Medication and Treatment Orders dated July 2016 showed:-Orders for medications and treatments would be consistent with principles of safe and effective order writing.-Medications should be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.-Drug and biological orders were to be recorded on the physician's order sheet in the resident's chart.-Orders for medications must include:--Name and strength of the drug.--Number of doses, start and stop date, and/or specific duration of therapy.--Dosage and frequency of administration.--Route of administration.--Clinical condition or symptoms for which the medication was prescribed.--Any interim follow-up requirements.Review of the facility's policy titled Self-Administration of Medications dated March 2025 showed:-As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assessed each resident's cognitive and physical abilities to determine whether self-administering medications was safe and clinically appropriate for the resident.-The IDT considered the following factors when determining whether self-administration of medications was safe and appropriate for the resident:--The mediation was appropriate for self-administration.--The resident was able to read and understand medication labels.--The resident could follow directions and tell time to know when to take the medication.--The resident comprehended the medication's purpose, proper dosage, timing, signs of side effects, and when to report these to staff.--The resident has the physical capacity to open medication bottles, remove medications from a container, and to ingest and swallow (or otherwise administer) the medication.--The resident was able to safely and securely store the medication.-If it was deemed safe and appropriate for the resident to self-administer medications, it would be documented in the medical record and the care plan.-The decision that a resident could safely self-administer medications would be re-assessed periodically based on the changes in the resident's medical and/or decision-making status.-For self-administering residents, the nursing staff would determine who was responsible (the resident or the nursing staff) for documenting that medications were taken.-Self-administered medications were stored in safe and secure place, which was not accessible by other residents.-Any medications found at the bedside that were not authorized for self-administration were turned over to the nurse in charge for return to the family or responsible party.1. Review of Resident 47's admission Record showed the resident admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disorder (COPD-a disease process that decreases the ability of the lungs to perform ventilation).Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment completed by facility staff for care planning) dated 11/17/25 showed the resident was cognitively intact.Review of the resident's Order Summary Report dated February 2026 showed:-An order for Symbicort Inhalation Aerosol (a prescription combination inhaler used for the long-term daily maintenance treatment of COPD) 80-4.5 micrograms per actuation (mcg/act), inhale two puffs orally two times a day and rinse mouth after use.-An order related to the self-administration of his/her inhaler was not found.Observation on 2/19/26 at 9:16 A.M. of the resident's medication pass showed:-Licensed Practical Nurse (LPN) B handed the resident his/her Symbicort inhaler.-The resident attempted to inhale the medication but administered the medication incorrectly.-The resident did not rinse his/her mouth after attempting to administer the medication.During an interview on 2/19/26 at 12:15 P.M. the resident said:-He/She was normally given the inhaler to administer the medication himself/herself.-He/She had never been assessed to be able to self-administer his/her inhaler.-He/She never rinsed his/her mouth after giving himself/herself the inhaler.Review of the resident's care plan on 2/19/26 showed no focus or intervention related to the self-administration of medications.Review of the resident's Electronic Medical Record (EMR) on 2/19/26 showed no self-administration assessment had been completed or uploaded.2. Review of Resident #81's admission Record showed he/she admitted to the facility with a diagnosis of Fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues).Review of the resident's quarterly MDS dated [DATE] showed the resident was cognitively intact.Review of the resident's Order Summary Report dated February 2026 showed:-An order for Albuterol Sulfate HFA Inhalation Aerosol Solution (used to treat and prevent breathing problems such as wheezing, coughing, or shortness of breath) 90 mcg/act, inhale two puffs orally every six hours pro re nata (PRN- as needed) for shortness of breath or wheezing.-There was no order for Refresh Relieva (a lubricating eye drop designed to relieve burning, irritation, and discomfort due to dry eyes) eye drops.-There was no order for Refresh Mega-3 (a preservative-free, lubricating eye drop designed to treat moderate-to-severe dry eye symptoms) eye drops.-There was no order in place for the self-administration of eye drops or inhalers.Observation on 2/17/26 at 10:32 A.M. of the resident's room showed:-A box containing Refresh Relieva eye drops on the resident's bedside table.-A box containing Refresh Mega-3 eye drops on the resident's bedside table.Observation on 2/18/26 at 9:32 A.M. of the resident's room showed:-A box containing Refresh Relieva eye drops on the resident's bedside table.-A box containing Refresh Mega-3 eye drops on the resident's bedside table.-An Albuterol-Sulfate inhaler, not in a box or container.Observation on 2/19/26 at 10:20 A.M. of the resident's room showed:-A box containing Refresh Relieva eye drops on the resident's bedside table.-A box containing Refresh Mega-3 eye drops on the resident's bedside table.-An Albuterol-Sulfate inhaler, not in a box or container.Review of the resident's care plan on 2/19/26 showed no focus or intervention related to the self-administration of medications.During an interview on 2/19/26 at 12:03 P.M. the resident said:-He/She had recently been to the eye doctor and the doctor's office had given him/her the eye drops.-He/She had been using both eye drops two times a day.-He/She had recently been to the hospital and had an upper respiratory infection.-He/She had been given the inhaler on 2/17/26 to use as needed.-He/She had been taking the inhaler three to four times a day.-He/She could not remember if he/she had ever been assessed to be able to self-administer eye drops or inhalers.-He/She had not been telling staff when he/she was self-administering the eye drops or inhaler.-He/She did not know that he/she needed to inform staff whenever he/she self-administered any medication.Review of the resident's Medication Administration Record (MAR) dated February 2026 showed no documentation related to the administration of his/her albuterol inhaler.3. During an interview on 2/19/26 at 10:10 A.M. LPN B said:-Resident #47 had not taken his/her inhaler correctly.-Resident #47 did not rinse out his/her mouth before smoking.-Resident #47 was not a good candidate to self-administer his/her medication.-An assessment needed to be completed for residents to be able to self-administer medications.-An order needed to be in place for each medication that any resident self-administered.During an interview on 2/23/26 at 9:58 A.M. Certified Medication Technician (CMT) A said:-All medications should have orders, including over the counter (OTC) medications.-If a resident expressed that he/she wanted to self-administer a medication then an assessment needed to be completed by a nurse. -Once the assessment was completed an order needed to be placed in the resident's chart to be able to self-administer the medication.-Each medication that a resident self-administered needed an order for the self-administration.-When a resident self-administered a medication that was kept at the resident's bedside, it was the resident's responsibility to inform the certified staff that he/she had taken the medication.-When a resident informed certified staff that he/she had self-administered their medication, the staff person needed to document the administration in the resident's EMR within 30 minutes.-He/She thought Resident #81 may have gone to the local dollar store to get the eye drops that were not ordered.-Resident #81 should have had an order for the Refresh Relieva and Refresh Mega-3 eye drops.-Resident #47 used to be able to administer his/her inhaler without issue.-He/She was unsure if Resident #47 had an assessment or order to be able to self-administer medication.-If Resident #47 did not have an assessment or order then they would need to be completed.During an interview on 2/23/26 at 10:20 A.M. Licensed Practical Nurse (LPN) C said:-All medications should have orders, including OTC medications.-If a resident expressed that he/she wanted to self-administer a medication then an assessment needed to be completed.-Once the assessment was completed an order needed to be placed in the resident's chart to be able to self-administer the medication.-The assessment would also determine if the resident could keep the medication at the bedside or if the medication needed to be kept in the medication cart.-Each medication that a resident self-administered needed an order for the self-administration.-All residents who could self-administer medication were usually pretty good about telling him/her when they administered the medication.-If the medication was scheduled, then the staff would need to ask the resident if they had taken the medication.-He/She was unsure if Resident #81 had orders for his/her eye drops that were at his/her bedside.-If Resident #81 did not have an order, then an order for the eye drops needed to be in place for the resident to be able to use the eye drops.During an interview on 2/23/26 at 12:25 P.M. the Director of Nursing (DON) said:-All medications should have orders, including OTC medications.-If a resident expressed that he/she wanted to self-administer a medication then an assessment needed to be completed.-Once the assessment was completed an order needed to be placed in the resident's chart to be able to self-administer the medication.-It was the resident's responsibility to tell staff when they self-administered medication.-It was the staff's responsibility to ensure the resident had the supply of the medication and to re-order the medication when needed.-Resident #81 had been educated in the past about telling staff when he/she self-administered medication.-Resident #81 should have orders for all his/her medications.-He/She did not think Resident #81 had a known issue of getting OTC medications at the local stores.-He/She was unsure if the staff were documenting Resident #81's inhaler usage.-He/She was unaware that Resident #81 had not been informing staff when he/she was administering his/her inhaler.-When any medication was administered by staff or self-administered it needed to be documented.-He/She was unaware that Resident #81 had eye drops at his/her bedside that were not currently ordered for the resident.-Resident #47 did not have an assessment or order in place to be able to self-administer the inhaler.-Resident #47 should have had an assessment in place, but he/she did not think the resident was a good candidate to self-administer medication.

Based on observation, interview, and record review, the facility failed to store a Bilevel Positive Airway Pressure (BiPAP a machine that helps you breathe) mask and a nasal cannula (NC a device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through your nose) in a plastic bag for one sampled resident (Resident #25) out of 18 sampled residents. The facility census was 87 residents. A policy was requested on BiPAP mask storage and NC storage and was not received by the time of exit. 1. Review of Resident #25's admission Record showed he/she was admitted to the facility with the following diagnosis: -Chronic Obstructive Pulmonary Disease (COPD an ongoing lung condition caused by damage to the lungs, and the damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs).-Acute and chronic respiratory failure with hypoxia (low oxygen).-Acute and chronic respiratory failure with hypercapnia (elevated carbon dioxide).Review of the resident's Order Summary Report (OSR) dated 9/23/25 showed:-BiPAP was to be placed on at night.-Oxygen at 2 liters per NC continuous and may titrate to keep oxygen saturation levels greater than 89 percent. Review of the resident's care plan dated 10/3/25 showed:-The resident was on continuous oxygen therapy related to ineffective gas exchange and required continuous oxygen therapy.--Storage of the NC was not addressed. -The resident used a BiPAP related to COPD and chronic respiratory failure. --Storage of the BiPAP mask was not addressed. -Resident noncompliance was not addressed. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 1/7/26 showed:-The resident was cognitively intact. -Oxygen therapy was not indicated on the assessment. -BiPAP therapy was not indicated on the assessment. Observation on 2/17/26 at 10:05 A.M. of the resident's room showed:-The BiPAP mask was laying on a pile of clothing not stored in plastic bag.-There was no plastic bag on the oxygen concentrator for NC storage. Observation on 2/17/26 at 1:27 P.M. of the resident's room showed:-The BiPAP mask was laying on a pile of clothing not stored in plastic bag.-NC was wrapped around the handles of the resident's wheelchair. -There was no plastic bag on the oxygen concentrator for NC storage. Observation on 2/18/26 at 8:49 A.M. of the resident's room showed:-The BiPAP mask was laying on a pile of clothing not stored in plastic bag.-The NC was wrapped around the handles of the resident's wheelchair. -There was no plastic bag on the oxygen concentrator for NC storage. 2. During an interview on 2/20/26 at 12:01 P.M., Certified Medication Technician (CMT) A said: -BiPAP masks and NC were to be stored in a dated plastic bag when not in use. -The plastic bag would be dated and changed out weekly. -When a NC was found not in a plastic bag the NC would be replaced and placed in the plastic storage bag. -When a BiPAP mask was found not stored in a plastic bag the nurse would be notified because the BiPAP mask would need to be cleaned and dried prior to placing in a plastic bag.-Wrapping the NC around the handles of a wheelchair and laying the BiPAP mask on a pile of clothes was not appropriate. -The resident was noncompliant with storage of the NC and BiPAP mask and put them where he/she wanted. -When a resident was not complaint with the storage of the respiratory item the resident would be educated about the importance of it, and the nurse would be notified so the care plan could then be updated. During an interview on 2/20/26 at 12:14 P.M., Registered Nurse (RN) B said:-The NC and BiPAP masks were to be stored in a dated plastic bag when not in use.-When the NC was not stored in the plastic bag, he/she would get a new nasal canula and place it in the plastic bag. -When the BiPAP mask was found not stored correctly it would be cleaned allowed to dry and placed in a plastic bag for storage. -The Director of Nursing (DON) would be informed that resident was noncompliant on the storage of NC and BiPAP masks, so the care plan could be updated for education and noncompliance. -When a resident was not complaint with the storage of the respiratory item the resident would be educated about the importance of it.-The MDS Coordinator updated the care plan. -Wrapping the NC around the handles of a wheelchair and laying the BiPAP mask on a pile of clothes was not appropriate. During an interview on 2/23/2026 at 12:19 P.M., the DON said:-It was his/her expectation that NC and BiPAP masks were stored in dated plastic bags when not being used.-It was his/her expectation that staff would have educated the resident on the importance of storing nasal cannulas and BiPAP masks in plastic bags when not in use.-When a resident was noncompliant with the storage of respiratory items, he/she would be notified so the MDS Coordinator could have updated the care plan. -Wrapping the NC around the handles of a wheelchair and laying the BiPAP mask on a pile of clothes was not appropriate.

Based on interview and record review, the facility failed to identify, assess and provide supportive interventions for one sampled residents (Resident #59) with a diagnosis of Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event - either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), and one sampled resident (Resident #66) who had a positive finding on the trauma/abuse/neglect screening out of 18 sampled residents. The facility census was 87 residents. Review of Trauma-Informed Care Implementation Center (https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/) copyright 2021 showed:-Trauma-informed care shifts the focus from What's wrong with you? to What happened to you?-A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient's life situation - past and present - to provide effective health care services with a healing orientation.-Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as provider and staff wellness. It can also help reduce avoidable care and excess costs for both the health care and social service sectors.-Trauma-informed care seeks to:--Realize the widespread impact of trauma and understand paths for recovery.--Recognize the signs and symptoms of trauma in patients, families, and staff.--Integrate knowledge about trauma into policies, procedures, and practices; and--Actively avoid re-traumatization.Review of facility policy titled Trauma Informed Care reviewed April 2025, showed:-To guide staff in appropriate and compassionate care specific to individuals who have had experienced trauma. -Nursing staff were trained on screening tools, trauma assessment and how to identify triggers associated with re-traumatization.-All Staff were guided in evidence-based organizational and interpersonal strategies that supported trauma informed care. -Trauma-informed care was culturally sensitive and person-centered. -Caregivers were taught strategies to help eliminate, mitigate of sensitively, and addressed a resident's triggers. -As part of the comprehensive assessment, identified history of trauma or interpersonal violence when possible.-Identified past trauma of adverse experiences might have involved record review of the used screening tools. 1. Review of Resident #59's admission Record showed the resident admitted to the facility with a diagnosis of PTSD.Review of the resident's Trauma/Abuse/Neglect Screening dated 7/11/25 showed the resident had yes answers to the following:-The resident had a history of abuse and/or neglect.-The resident reported:--Repeated disturbing memories, thoughts, or images of a stressful experience from the past.--Felt very upset when something reminded him/her of a stressful experience from the past.--Avoided activities or situations because they reminded him/her of a stressful experience from the past.--Felt distant or cut off from other people.--Felt irritable or had angry outbursts.-Had factors that increased the resident's vulnerability.-Psychiatric history and/or present mental health diagnosis. -Denial and/or evasiveness. -Depressive illness and/or signs/symptoms of depression/mood distress. -The screening showed a score of six which meant that the resident had trauma-related symptomology.Review of the resident's Trauma/Abuse/Neglect Screening dated 10/10/25 showed the resident had yes answers to the following:-The resident had a history of abuse and/or neglect.-The resident reported:--Repeated disturbing memories, thoughts, or images of a stressful experience from the past.--Felt very upset when something reminded him/her of a stressful experience from the past.--Avoided activities or situations because they reminded him/her of a stressful experience from the past.--Felt distant or cut off from other people.--Felt irritable or had angry outbursts.-Had factors that increased the resident's vulnerability.-Psychiatric history and/or present mental health diagnosis. -Denial and/or evasiveness. -Depressive illness and/or signs/symptoms of depression/mood distress.-The screening showed a score of six which meant that the resident had trauma-related symptomology.Review of the resident's care plan revised on 1/5/26 showed:-He/She had a diagnosis of PTSD.-PTSD was not addressed in the care plan.-The resident's triggers were not addressed.-The resident's interventions were not addressed.Review of the resident's Trauma/Abuse/Neglect Screening dated 1/12/26 showed the resident had yes answers to the following:-The resident had a history of abuse and/or neglect.-The resident reported:--Repeated disturbing memories, thoughts, or images of a stressful experience from the past.--Felt very upset when something reminded him/her of a stressful experience from the past.--Avoided activities or situations because they reminded him/her of a stressful experience from the past.--Felt distant or cut off from other people.--Felt irritable or had angry outbursts.-Had factors that increased the resident's vulnerability.-Psychiatric history and/or present mental health diagnosis. -Denial and/or evasiveness. -Depressive illness and/or signs/symptoms of depression/mood distress. -The screening showed a score of six which meant that the resident had trauma-related symptomology.Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 1/21/26 showed:-The resident was cognitively intact. -Had PTSD.During an interview on 2/17/26 at 2:10 P.M. the resident said:-He/she had a diagnosis of PTSD.-No staff had asked about what made his/her PTSD worse or better. -He/She did not want to talk about his/her PTSD.2. Review of Resident #66's admission Record showed the resident admitted to the facility with a diagnosis of adult physical abuse suspected and adult sexual abuse suspected.Review of the resident's Trauma/Abuse/Neglect Screening dated 8/13/25 showed the resident had yes answers to the following:-The resident had a history of abuse and/or neglect.-Exposure to any form of trauma. -The resident reported:--Repeated disturbing memories, thoughts, or images of a stressful experience from the past.--Felt very upset when something reminded him/her of a stressful experience from the past.--Avoided activities or situations because they reminded him/her of a stressful experience from the past.--Felt distant or cut off from other people.--Felt irritable or had angry outbursts.-Had factors that increased the resident's vulnerability.-History of substance use/abuse.-Depressive illness and/or signs/symptoms of depression/mood distress. -The screening showed a score of six which meant that the resident had trauma-related symptomology.Review of the resident's Trauma/Abuse/Neglect Screening dated 11/13/25 showed the resident had yes answers to the following:-The resident had a history of abuse and/or neglect.-Exposure to any form of trauma. -The resident reported:--Repeated disturbing memories, thoughts, or images of a stressful experience from the past.--Felt very upset when something reminded him/her of a stressful experience from the past.--Avoided activities or situations because they reminded him/her of a stressful experience from the past.--Felt distant or cut off from other people.--Felt irritable or had angry outbursts.-Had factors that increased the resident's vulnerability.-History of substance use/abuse.-Depressive illness and/or signs/symptoms of depression/mood distress. -The screening showed a score of six which meant that the resident had trauma-related symptomology.Review of the resident's care plan revised on 1/9/26 showed:-He/She had prior trauma related to abuse from men in his/her life. -Recent possible physical abuse from someone in his/her residence, prior to admission. -admitted to hospital with many physical injuries. Resident had admitted tophysical abuse causing injuries, but resident had also given different stories as a reason for injuries that were not abuse related. -The resident's triggers were not addressed.-The resident's interventions were not addressed.Review of the resident's Trauma/Abuse/Neglect Screening dated 2/13/26 showed the resident had yes answers to the following:-The resident had a history of abuse and/or neglect.-Exposure to any form of trauma. -The resident reported:--Repeated disturbing memories, thoughts, or images of a stressful experience from the past.--Felt very upset when something reminded him/her of a stressful experience from the past.--Avoided activities or situations because they reminded him/her of a stressful experience from the past.--Felt distant or cut off from other people.--Felt irritable or had angry outbursts.-Had factors that increased the resident's vulnerability.-History of substance use/abuse.-Depressive illness and/or signs/symptoms of depression/mood distress. -The screening showed a score of six which meant that the resident had trauma-related symptomology.During an interview on 2/17/2026 at 12:46 P.M. the resident said:-He/she had a history of trauma. -Unsure if he/she had a diagnosis of PTSD.-He/She got anxious when unknown males came around. -He/She preferred to stay in his/her room and avoid crowds. Review of the resident's Quarterly MDS dated [DATE] showed:-The resident was cognitively intact. -No diagnosis of PTSD.3. During an interview on 2/20/26 at 12:01 P.M., Certified Medication Technician (CMT) A said: -He/She was familiar with Resident #59 and Resident #66.-He/She was unsure if either resident had PTSD or past trauma.-He/She did not know what either of the resident's triggers or inventions were.-Neither resident had any behaviors.-He/She would look on the care plan for the triggers and interventions. -He/She would have expected triggers and interventions to be on the care plan.-If the interventions and triggers were not in the care plan, he/she would have informed the nurse. During an interview on 2/20/26 at 12:14 P.M., Registered Nurse (RN) B said:-He/She was familiar with Resident #59 and Resident #66.-Neither resident had any behaviors.-Was unfamiliar with either of the residents' triggers or interventions.-He/She did not know if either resident had a diagnosis of PTSD or had experienced trauma in the past.-Triggers and interventions would be listed in the care plan.-The MDS Coordinator was responsible for care plans. -He/She had not noticed there were no triggers or interventions in either resident's care plan. During an interview on 2/20/26 at 12:30 P.M., the MDS Coordinator said:-He/She knew Resident #59 had a diagnosis of PTSD.-He/She did not know if Resident #66 had a positive trauma/abuse/neglect screening.-Since Resident #59 kept changing his/her story of the PTSD event, he/she was unsure whether to include PTSD in the care plan. -He/She did not know that a PTSD care plan needed to be done for a resident that had a positive trauma/abuse/neglect screening. During an interview on 2/23/2026 at 12:19 P.M., the Director of Nursing (DON) said:-The MDS Coordinator was responsible for the care plan for a resident with PTSD or if a resident had a positive trauma finding.-He/She did not know if Resident #59 had a diagnosis of PTSD.-He/She did not know if Resident #66 had a positive finding on the trauma/abuse/neglect screening. -When a resident had a diagnosis of PTSD there should be triggers and interventions listed in the care plan.-When a resident had a positive finding on the trauma/abuse/neglect screening, there should be a trauma care plan developed with triggers and interventions.-He/She did not know Resident #59's or Resident #66's triggers or interventions. -The information of the resident's triggers and interventions should have been in the care plan. -Care plans were audited by the MDS Coordinator.

Based on observation and interview, the facility failed to ensure resident shower rooms were kept clean, maintained and free from build-up of black mold like/grime on the lower corner of the shower wall and shower floor tile located on 200 hallway; failed to ensure shower room was maintained and showed missing base board shower tiles and missing tile on memory care floor of the shower room and missing tile in the shower itself. This practice potentially affected all resident residents who used those shower rooms. The facility census was 82 residents. Review of the facility's undated Daily Cleaning of Guidelines showed: -The facility were complete regular inspect the shower room for signs of mold (often appearing as black, brown, or green stains), mildew and clogs. -If mold or mildew return after cleaning report to maintenance immediately. Review of copy Infection Prevention Rounds Maintenance Department check list dated 12/2021 showed: -Insure integrity of caulking and tiles in shower stall is maintained as evidence by: in good repair, clean, no evidence of mold or mildew. 1. Observation on 5/29/25 at 9:40 A.M. of 200-hallways showed an unknown resident being escorted into the shower room by facility care staff. Observation on 5/29/25 at 10:36 A.M. of the memory care shower room showed: -An unknown resident was just escorted out the shower room. -The room had large section of missing floor tile. -Had build up grim in the corners shower room and shower stale. Observation on 5/29/25 at 10:50 A.M. of the shower room [ROOM NUMBER] hallway showed: The shower in the right side lower right corner, had exposed building stud and with missing tile or baseboard. -The back right lower corner floor tile and wall tile had black like mold substance build up noted. -Slight musty smell to the room. -The resident toilet was not clean old brown substance splatter on inside of the toilet bowl. During an interview on 5/29/25 at 10:30 A.M. Shower Aide B said: -He/she cleans and disinfects the shower after each resident use. -Housekeeping would be responsible for deep cleaning of the shower rooms. -He/she not aware any black mold like or grim buildup in 500 hallway showers room. During an interview on 5/29/25 at 10:36 A.M. Certified Medication Technician (CMT) B said: -He/she was not aware any mold like substance in the 500-hallway shower room. -He/she thought mold had been reported in the 200-hallway shower room. During an interview on 5/29/25 at 11:00 A.M. Housekeeper B said: -He/she was aware of possible black like mold build up in some of the resident's showers and in one resident room shower noted under shower mat. -He/she has not been instructed to clean deep clean the shower rooms. During an interview on 5/29/25 at 2:50 P.M. Registered Nurse (RN ) A said: -He/she was aware of the black mold like substance/ grim in the 200-hallway shower room. -The room had a musty odor noted. -He/she had not reported the concern to housekeeping or maintenance. During interview on 5/29/25 at 4:00 P.M. Maintenance Director said: He/she was not aware of missing tile or expose wall materials in the shower rooms. -Housekeeping would be responsible for the daily deep cleaning of the shower rooms and inspection for any mold or grim build up in the that room. -Facility staff would be responsible for reporting any missing tile or shower room maintenance needed to the maintenance team. -He/she would be responsible for checking the building eye wash station for any issue. -He/she had just been notified of resident's room [ROOM NUMBER], shower floor having black grim mold buildup under a shower mat. During an interview on 5/29/25 at 4:40 P.M. Administrator said: -He/she would expect the nursing, bath aids, CNA's and housekeeping to notify administration staff of any mold, missing tiles or repairs need in shower rooms or any resident living area. -He/she would expect housekeeping staff and maintenance staff to ensure the shower rooms are monitored and maintained for cleanness and in good repair. Complaint # MO 00253529

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) with limited range of motion (ROM) received restorative therapy services to prevent further decrease in his/her ROM out of 10 sampled residents. The facility census was 91 residents. Review of the facility's policy titled Restorative Nursing Services dated July 2017 showed: -Residents would receive restorative nursing care as needed to promote optimal safety and independence. -Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitative services. -Residents may be stared on restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care. -A restorative goal may have included maintaining his/her dignity and self-esteem. 1. Review of Resident #1's face sheet showed he/she admitted to the facility with the following diagnoses: -Person injured in unspecified motor vehicle accident. -Fusion of the spine (a surgery performed that joins two or more vertebra (any of the bony or cartilaginous segments that make up the spinal column) together), cervical region (the neck region of the spine). -Unspecified displaced fracture (when the pieces of the bone move so much a gap forms around the fracture) of sixth cervical vertebra. -Unspecified displaced fracture of seventh cervical vertebra. -Unspecified fracture of the thoracic (T- middle section of spine)7-T8 vertebra. Review of the resident's Restorative Nursing Instruction Form dated 6/11/24 showed: -The resident was to receive restorative nursing three times a week. -The resident was to receive active assisted range of motion (AAROM- performed when the patient/resident needs assistance with movement from an external force because of weakness, pain, or changes in muscle tone) to his/her lower extremities. -The goals of the program were: --Improve sitting tolerance and balance. --Maintain functional level. Review of the resident's Annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 8/17/24 showed: -The resident was cognitively intact. -The resident had full functional range to his/her upper extremities. -The resident had full functional range to his/her lower extremities in ROM. -The resident was fully dependent (helper does all of the effort, resident does none of the effort to complete the activity) for the following: --Eating. --Oral hygiene. --Toileting hygiene. --Showering/bathing. --Upper body dressing. --Lower body dressing. --Putting on/off footwear. --Personal hygiene. --Rolling left and right. --Going from a sitting to lying position. --Going from a lying position to sitting on the side of the bed. --Chair to bed transferring. --Tub/Shower transferring. -The resident had zero days of restorative nursing in which active ROM (the ROM that can be achieved when opposing muscles contract and relax, resulting in joint movement) or passive ROM (ROM that is achieved when an outside source exclusively causes movement of a joint and is usually the maximum ROM that a joint can move) in the seven days look back period. Review of the resident's care plan dated 9/4/24 showed: -The resident had an Activities of Daily Living (ADLs) self-care performance deficit related to limited mobility due to quadriplegia (paralysis that affects all a person's limbs and body from the neck down). -The resident had quadriplegia related to his/her spinal injury with a goal for the resident to maintain optimal status and quality of life within limitations. Review of the resident's response history for the task Restorative Program dated 8/13/24 through 9/5/24 showed: -The resident only received ten minutes of restorative therapy during that time period. -The task had been documented as not applicable (N/A) 10 times out of 12 opportunities. During an interview on 9/9/24 at 10:54 A.M. the resident said: -He/She was supposed to get ROM exercises from the facility's Restorative Aide. -He/She had not received any restorative therapy in the last three months. -He/She thought the reason why he/she was not receiving his/her restorative therapy was due to staffing issues. -He/She had benefited from the restorative therapy. During an interview on 9/9/24 at 1:23 P.M. Certified Medication Technician (CMT) A said he/she was unsure of what therapy services the resident was supposed to receive. During an interview on 9/9/24 at 1:50 P.M. Licensed Practical Nurse (LPN) A said: -The resident used to receive restorative therapy. -He/She thought there might have been an insurance problem and that was why the resident was no longer on restorative therapy services. During an interview on 9/9/24 at 2:00 P.M. the Director of Nursing (DON) and Administrator said: -There was a binder that held the orders for all residents currently on a restorative program. -The Administrator thought that residents were re-evaluated for restorative therapy monthly. -He/She thought the resident did not have an active order for restorative therapy. During an interview on 9/9/24 at 2:08 P.M. Certified Occupational Therapist Assistant (COTA) A said: -The Restorative Nursing Instruction Form indicated the resident had an active order for restorative therapy. -The facility had just hired a new Restorative Aide. -The therapy department was responsible for recommending restorative therapy services. -Restorative therapy was still beneficial to the resident. -Residents were re-evaluated for restorative therapy every three months. -The resident would be re-evaluated for restorative therapy on 9/11/24. During an interview on 9/9/24 at 2:15 P.M. CMT A said: -He/She had not been trained on performing restorative therapy. -He/She had charted not applicable (NA) on the restorative program task because the task was not applicable to him/her. -He/She was unsure how long the facility had been without a Restorative Aide. During an interview on 9/9/24 at 2:21 P.M. LPN A said he/she thought the facility had been without a Restorative Aide for a couple months. During an interview on 9/9/24 at 2:24 P.M. the Assistant Director of Nursing (ADON) said: -The facility had been without a Restorative Aide for a month. -He/She was unsure of who would be responsible for completing the restorative therapy during the absence of a Restorative Aide. -When N/A was documented on a task that indicated the task was not completed. -He/She was unsure of who was responsible for ensuring the restorative therapy was being completed. During an interview on 9/9/24 at 2:33 P.M. the DON and Administrator said: -The facility had been without a Restorative Aide since July or August. -A Certified Nursing Assistant (CNA)/CMT could perform restorative therapy. -The ADON was responsible for over-seeing the documentation and completion of the restorative therapy. NOTE: After the interview was conducted it was clarified that the facility had been without a Restorative Aide from 7/10/24 until the present. MO00241400

Based on interview and record review, the facility failed to ensure sufficient staffing numbers to consistently provide timely Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) assistance for two sampled residents (Resident #77 and Resident #69) out of 18 sampled residents and ADL-dependent residents on the [NAME] Side of the building and to ensure adequate weekend staffing as reflected on the Payroll Based Journal data (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for the fourth quarter of 2023 (July 1 - September 30, 2023) and first quarter of 2024 (October 1 - December 31, 2023) which had the potential to affect all residents. The census was 88 residents. Review of the facility's Staffing policy, revised October, 2017 showed: -The facility provided sufficient numbers of staff with the skills and competencies necessary to provide care and services for all residents according to identified resident care needs and facility assessments. -Daily direct care staffing information was submitted to the Centers for Medicare and Medicaid Services (CMS) PBJ system on the schedule specified by CMS but no less than quarterly. -Concerns relative to facility staffing should be directed to the Administrator or his/her designee. Review of the facility's Hospitality Assistant (HA) Job Description, undated showed: -The HA was responsible for providing non-nursing, non-direct care, and ancillary services under the direction of the nurse supervisor. -Has assisted nursing staff by making beds, passing ice and water, passing linens, answering call lights, passing meal trays, distributing laundry, cleaning and organizing equipment, reporting resident and family concerns to the supervisor, stocking rooms with health care items, and non-hands-on care to residents. 1. Review of the facility's PBJ Staffing Data Report for Fiscal Year (FY) Quarter Four 2023 (July 1 - September 30, 2023) showed excessively low weekend staffing for the quarter. Review of the facility's PBJ Staffing Data Report for FY Quarter One 2024 (October 1 - December 31, 2023) showed excessively low weekend staffing for the quarter. 2. Review of the Facility Assessment Tool, dated 5/2/24, showed: -An average daily census of 95 residents. -Seventy residents required some to total assistance from staff for dressing. -Seventy residents required some to total assistance from staff for bathing. -Seventy residents required some to total assistance from staff for toileting. -Seventy residents required some to total assistance from staff for transferring. -Sixty residents required some to total assistance from staff for eating. 3. Review of the working staff schedules, dated 5/15/24 through 5/21/24 showed: -The facility had three distinct staffing areas. The [NAME] Side consisted of three halls. The East Side consisted of two halls and there was a Special Care Unit (SCU - locked unit for residents with cognitive impairments who were at risk for wandering and/or needed dementia-specific cares). -There were twelve, eight, and four-hour shifts shown on the schedule. -The following nurse aide staffing was documented on the [NAME] Side: --On 5/15/24 two Certified Nurse Assistants (CNAs) worked four hours each covering one Night shift from 10:30 P.M. to 6:30 A.M. Two HAs, were scheduled four hours each to cover the Night shift, but could not provide resident cares. There was not a second CNA scheduled for the Night shift. --On 5/16/24 one CNA worked from 10:30 P.M. to 6:30 A.M. An HA was scheduled, but could not provide resident cares. There was not a second CNA scheduled for the Night shift hours. --On 5/17/24 there was not a third CNA scheduled for the Day Shift. No staff was assigned bathing/showering responsibilities. On the Evening shift from 4:30 P.M. to 6:30 P.M. there was only one CNA scheduled. --On 5/18/24 there was not a third CNA scheduled for the Day shift. --On 5/19/24 there was not a third CNA scheduled for the Day shift. --On 5/21/24 there was only one CNA scheduled from 7:30 P.M. to 10:30 P.M. Two other CNAs left at 7:30 P.M. An HA was scheduled from 6:30 P.M. to 10:30 P.M., but could not provide resident cares. 4. Review of Resident #77's Significant Change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 5/20/24, showed the resident was: -diagnosed with Alzheimer's disease (a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception). -Severely cognitively impaired. -Dependent upon staff for eating, toilet hygiene, bathing, dressing, and transfers. Observation on the SCU on 5/19/24 starting at 9:46 A.M. showed: -Three residents were sitting in the common area/dining room. There was no staff in the area. -A few minutes later Certified Medication Technician (CMT) A came out of a resident's room. -At 9:55 A.M. Resident #77 was observed lying in bed. During an interview on 5/19/24 at 10:15 A.M. CMT A said: -He/She had been the only staff on the SCU since 7:00 A.M. -The East Side nurse could help as needed for medical cares. -There should always be two people on the SCU on the Day shift, but someone called in and he/she was by himself/herself. -He/She thought an HA was coming in. The HA could help pass trays and restock linens and gloves, but couldn't do hands on cares with residents like feeding, transferring, or changing anyone who was incontinent, so he/she would need to do all the resident cares. -There were 17 residents on the unit. Seven were incontinent and also needed help getting dressed. Two residents required cuing to toilet and two others required one-person staff assistance for transfers. -Resident #77 transferred with a two-person mechanical lift. The resident hadn't gotten out of bed since there was nobody on the unit to help get him/her up. The resident also needed help repositioning in bed. -Resident #77 needed to be fed so he/she raised the head of the bed to feed him/her breakfast. Two other residents needed cueing during meals, so he/she had to feed Resident #77 at a separate time. Observation on 5/19/24 starting at 11:16 A.M. showed the Marketing Director entered the unit. During an interview on 5/19/24 at 11:20 A.M. the Marketing Coordinator said: -He/She came in on a Sunday because there was a new admission. -He/She had current nurse aide certification and would be assisting on the SCU for as long as was needed. Observation on 5/19/24 starting at 11:46 A.M. showed: -CMT A and the Marketing Coordinator went into Resident #77's room. -They were observed using the mechanical lift to get the resident out of bed. Note: Review of the working staff scheduled showed a Certified Medication Technicians (CMT) and a CNA were scheduled to work the entire 6:30 A.M. to 2:30 P.M. shift. The schedule was not adjusted to show only one staff had provided resident cares from 7:00 A.M. to 11:15 A.M. 5. Review of Resident #69's quarterly MDS, dated [DATE], showed the resident: -Had previously had a stroke. -Had an upper body impairment on one side. -Was cognitively intact. -Required maximal assistance (staff does over half the effort) for showering and required moderate assistance to transferring into the shower or tub. -Required cueing and/or steadying for toilet transfers. During an interview on 5/20/24 at 9:44 A.M. Resident # 69 said: -He/She needed help with transfers on and off the toilet. -He/She had been left on the toilet for 25 minutes during the night shift. -There wasn't any staff responding to the bathroom call light. 6. During an interview on 5/22/24 at 5:20 A.M. CMT D said: -On the SCU a CMT and either an HA or CNA was usually scheduled during the Evening shift and a CMT or CNA was scheduled on the Night shift. -An HA was sometimes left with the residents when he/she took a break. When residents got up during the night the HA was unable to toilet them or change them. If anyone needed any resident cares while the HA was alone on the SCU the East Side nurse had to leave that area unattended and provide the cares because the nurse was the only staff person scheduled on the East Side at night. During an interview on 5/22/24 at 6:10 A.M. CNA H said: -Several times there had just been a nurse, himself/herself, and one HA working the three [NAME] Side halls at night. The nurse had to pass medications as needed during the night. The HA wasn't supposed to help with incontinent cares, transfers, and dressing. There were times only he/she and a nurse worked the three halls. -The 300 hall had 10 incontinent residents and another resident needed to be taken to the toilet during the night. -Nine residents on the 200 hall were incontinent and one had to be taken to the toilet. -On the 100 hall there were two incontinent residents. -When he/she was the only CNA working he/she was unable to keep up with all the cares the residents needed during the night. He/She just did the best he/she could. During an interview on 5/22/24 at 6:33 A.M. CNA B said: -He/She sometimes worked the 6:30 P.M. to 11:00 P.M. hours if the facility was short staffed. There were times between those hours that he/she and the nurse were the only two staff. -Thirteen residents on the 300 hall were sometimes or always incontinent and one resident needed to be taken to the toilet. -Three residents on the 200 hall were always incontinent and one needed to be taken to the toilet. -Two residents on the 100 hall were incontinent and one needed help getting off the toilet. -Many times he/she had worked the 6:30 A.M. to 6:30 P.M. hours with only a nurse and two CMTs. -Before meals the nurse was always busy getting the diabetics' blood sugar levels and giving insulin and the two CMTs were busy passing medications. -The facility needed at least three CNAs on the [NAME] Side to do the three halls. It was too much for one CNA to get residents out of bed, changed if wet, and dressed for breakfast. The [NAME] Side was busy before the lunch and supper meal as well with only one CNA. During an interview on 5/22/24 at 6:56 A.M. CNA D said: -He/She did the [NAME] Side halls by himself/herself the previous night from 6:30 P.M. to 11:00 P.M. A nurse was also on the unit but had to pass medications leaving just him/her to do the cares part of the time. -Some of the 100 hall residents could put on their call lights to let him/her know if they were wet. -There were at least five residents on the 100 hall and at least five on the 200 hall who were incontinent and couldn't use their call lights or tell him/her if they were wet, so he/she had to check on them frequently. During an interview on 5/23/24 at 9:23 A.M., CNA A said: -Residents were supposed to gets showers or baths two times a week. -Realistically the residents rarely got them twice a week. -Residents would hopefully get a shower or bath at least every two weeks to a month. -The lack of showers was due to a lack of staff. Often there were only two CNAs assigned for the three [NAME] Side halls. During an interview on 5/23/24 at 9:28 A.M., CNA B said: -Residents were supposed to get two showers/baths twice a week, but it would usually be two to three weeks with no baths for the residents. -There was usually not enough staff to do showers twice a week. During an interview on 5/23/24 on 9:34 A.M., CNA C said: -Residents would get showered/bathed depending on staffing coverage. -Residents were showered/bathed at least once every week to two weeks. -The facility had no shower/bath aide full time. -Two CNAs couldn't provide cares, answer call lights, and give baths on the three [NAME] Side halls. During an interview on 5/23/24 at 9:40 A.M., Registered Nurse (RN) A said: -Residents were to be showered/bathed two-three times a week. -He/She was unsure how often residents were showered/bathed, but thought it was maybe once a week. During an interview on 5/23/24 at 10:30 A.M. the Assistant Director of Nursing (ADON) said: -He/She was responsible for the staffing assignment sheets which should accurately reflect the various nursing staff working on any given shift. -Shifts were 6:30 A.M. to 2:30 P.M., 2:30 P.M. to 10:30 P.M. and 10:30 P.M. to 6:30 A.M. -Minimum staffing on the [NAME] Side was: --On the Day shift there should be one nurse, two Certified Medication Technicians (CMTs), and at least three Certified Nurse Assistants (CNAs), one of which was responsible for resident showers and the other two CNAs were responsible for care on the three resident halls. --On the Evening shift there should be at least one nurse, two CMTs and two CNAs. --On the Night shift there should be at least one nurse and two CNAs. -Staffing on the two East Side halls should be: --At least one nurse and one CMT or CNA on the Day shift. --One nurse and one CMT on the Evening shift. --One nurse on the Night shift. -Minimal staffing on the SCU was: --One nurse and two CNAs on the Day shift. --One nurse or CMT and a CNA on the Evening shift. --One CMT or CNA on the Night shift. If a CNA was working the hall the nurse from the East Side would assist with medications and medical needs. -Weekends should be staffed the same as the weekdays on all shifts and all living areas, and as far as he/she knew they were. -HAs were not allowed to do any resident cares such as transfers, incontinence cares, or feeding. They could make beds, keep the linen cart tidy, answer call lights and relay messages to the nurse or CNA, get ice for residents, wash wheelchairs and wipe trash bins. During an interview on 5/28/24 at 3:56 P.M., the Administrator said: -He/she was not aware that the facility triggered for low weekend staffing on the PBJ Staffing Data Report for two quarters. -The facility used a third-party vendor for payroll who sent a summation with hours worked for each nursing category which was used for submitting PBJ data. -He/She and the DON and ADON were responsible for addressing any known low nursing staff numbers. MO00236223

Based on observation and interview, the facility failed to maintain the floor under the refrigerator in the storage room, free of heavy dust buildup; failed maintain the sprinkler heads over the handwashing sink and the food preparation, free of dust buildup on the sprinkler heads; failed to remove a buildup of grime from under the deep fat fryer; failed to maintain the gaskets (a mechanical seal which fills the space between two or more mating surfaces, generally to prevent leakage from or into the joined objects) of the walk-in freezer and the reach-in refrigerator across from the food preparation table in good repair; failed to maintain the ceiling vents in the kitchen free of a heavy buildup of dust; failed to maintain the handles of the food spatula in good repair; failed to maintain the nozzle of the upper spray wand of the dishwasher; failed to have a trash container dietary staff did not have to use their hands to open the lid every time they placed trash in the trash container; failed to maintain the bottled milk in the dining room at or close to a temperature of 41 F (degrees Fahrenheit); and failed to have enough spatulas available for use. This practice potentially affected 87 residents who ate food from the kitchen. The facility census was 88 residents. 1. Observations on 5/19/24 from 9:49 A.M. through 1:40 P.M., during the lunch meal preparation, showed: - A buildup of dust and debris under the refrigerator in the storage room. - The presence of dust on the sprinkler heads over the handwashing station and the food preparation table. - A buildup of greasy grime under the deep fat fryer. - A 24.5-inch (in.) section of the gasket of the reach-in refrigerator next to the food preparation table was held to the refrigerator door frame with black tape. - A buildup of dust on the ceiling vent over the clean side of the automated dishwasher. - A buildup of dust on the sprinkler head between the food preparation table and handwashing sink. -A buildup of grime under the deep fat fryer. The presence of food debris on the blade of the tabletop can opener. - The handle of a spatula with melted areas which were not easily cleanable. - An 18.5 in. section of gasket of the walk-in freezer was in disrepair. - The presence of debris in the nozzle of the upper spray wand. - Dietary staff had to use their hands to lift the lid of trash container and wash their hands every single time. - Dietary [NAME] (DC) A pulled two hamburgers from a frying pan and placed into a pan to place on the steam table without checking the temperature of the burgers. - The DD said the kitchen ran out of spatulas while he/she looked for a spatula to use when another one was being used for another process. - A temperature check was conducted of the milk that served in the dining room by pouring a sample of milk into a glass and the temperature of the milk was 50 F. During interviews on 5/19/24, the Dietary Director (DD) said the following: - At 10:59 A.M., he/she said the gasket of the refrigerator across from the food preparation table was held together tape before he/she started employment in 11/2023. - At 11:01 A.M., he/she said the freezer did not close properly because of the damaged gasket and the lever at the top did not operate the way it should. - At 1:46 P.M., the DD said he/she had not checked the temperature of the milk in the bins in the different dining rooms and may have to use a different method keeping the milk at a cool temperature. - At 2:24 P.M., the DD said he/she expected facility staff to sweep under the refrigerator in the storage room nightly. - At 2:26 P.M. he/she expected dietary staff to scrub clean under the deep fat fryer weekly and to sweep and mop nightly. - At 2:29 P.M., DD said it was his/her job to check on the spatula handles to ensure they were easily cleanable. He/she knew about the white handled one but not the black handled spatula. - At 2:36 P.M., the DM said the dietary staff needed another trash container with a foot operated lid. During an interview on 5/22/24 at 1:20 P.M., the DM said he/she expected the dietary cooks to check temps of potentially hazardous foods.

Based on observation, interview and record review, the facility failed to maintain the floors free from a heavy buildup of dust and debris in the following resident rooms 208, 207, 302, 300, 601, 510, 500 Hall shower room, 607, 405, 410, 409, 407, 401; failed to maintain the fans free of a heavy buildup of dust in the following resident rooms 302, 301; and failed to maintain ceiling vents free of a heavy buildup of dust in the following resident rooms 405 and the 500 Hall shower room . This practice potentially affected at least 30 residents who resided in or used those areas. The facility census was 88 residents. 1. Review of the undated Housekeeping Route sheet (a sheet which showed the steps to clean the resident rooms), showed: 7-Step room cleaning: 1. Pull Trash. 2. Dust horizontal surfaces. 3. Sanitize high traffic areas. 4. Spot clean walls. 5. Sweep floors under and behind furniture and beds. 6. Damp mop floors under and behind furniture and beds. 7. Wipe down beds. 8. Sanitize high touch areas such as call lights, bed remotes light switches etcetera (etc.) 2. Observations with the Maintenance Director (MD) and the Regional Maintenance Person on 5/21/24, showed: - At 10:15 A.M., there was a heavy buildup of dust on the floor of resident room [ROOM NUMBER]. - At 10:17 A.M., there was a heavy buildup of dust on the floor of resident room [ROOM NUMBER]. - At 10:37 A.M., there was a crack in the shower chair in the 200 Hall shower room. - At 10:51 A.M., there was a buildup of debris on the floor and the there was a buildup of dust on the fan blades in resident room [ROOM NUMBER]. - At 10:52 A.M. there was a buildup of grime on the floor in resident room [ROOM NUMBER]. - At 10:53 A.M., there was a buildup of grime on the floors in resident room [ROOM NUMBER]. - At 11:00 A.M., there was a buildup of dust and hair between the bed and the wall in resident room [ROOM NUMBER]. - At 11:05 A.M., there was a buildup of dust on the fan in resident room [ROOM NUMBER]. - At 12:44 P.M., there was a buildup of grime on the floor next to the bed in resident room [ROOM NUMBER]. - At 1:05 P.M., there was a buildup of debris on the floor behind the nightstand in resident room [ROOM NUMBER]. - At 1:09 P.M., there were many sugar packets, food crumbs and empty coffee creamer containers on the floor behind the 600 Hall nurse's station. - At 1:18 P.M., there was a buildup of crumbs on the floor in resident room [ROOM NUMBER]. - At 1:37 P.M., there was a buildup of dust on the ceiling vent in the restroom of Resident room [ROOM NUMBER]. - At 1:39 P.M., there was a buildup of grime and debris in under the bed and next to the bed in resident room [ROOM NUMBER]. - At 1:42 P.M., there was a buildup of grime between the bed and wall in resident room [ROOM NUMBER]. - At 1:51 P.M., there was a buildup of food debris under the bed in resident room [ROOM NUMBER]. - At 1:53 P.M., there was a layer of dust between the bed and the wall in resident room [ROOM NUMBER]. - At 1:56 P.M., there was a buildup of dust ad debris on the floor in resident room [ROOM NUMBER]. 3. Review of Resident #47's quarterly Minimum Date Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 3/22/24, showed the resident was cognitively intact. During an interview on 5/21/24 at 11:02 A.M., the resident said the housekeepers do not get behind his/her bed as he/she noticed a lot of debris between his/her bed and the wall in his/her room. 4. Review of Resident #5's quarterly MDS dated [DATE], identified the resident as cognitively intact. During an interview on 5/21/24 at 1:54 P.M., the resident said the housekeeping department did not have enough staff to clean his/her room regularly. 5. Observation on 5/22/24 at 12:37 P.M., with the Housekeeping Supervisor showed a buildup of grime and hair along the wall in room [ROOM NUMBER]. During an interview on 5/21/24 at 12:47 P.M., the Housekeeping Supervisor said there were only three housekeepers at that time and the housekeepers felt rushed to get to every room. During an interview on 5/21/24 at 1:10 P.M., Certified Medication Technician (CMT) B said the housekeepers do not get a chance to clean behind the nurse's station very often. During an interview on 5/22/24 at 12:39 P.M. the Housekeeping Supervisor said the dust and debris were present on the floor of resident room [ROOM NUMBER], because there were only three housekeepers on staff and they feel rushed to get to every room and may not do as thorough as a job in cleaning each room. During an interview on 5/23/24 at 1:04 P.M., Housekeeper A said: - He/she did not have enough time to clean the resident rooms because they were short staffed. - The housekeepers do their best to clean all the rooms. - He/she did not have enough time to move the beds and he/she can get under the beds as best he/she can, when the residents do not have a lot of stuff under the beds. 6. Observations with the MD and the corporate Maintenance Person on 5/21/24, showed: -At 1:34 P.M., there was a buildup of dust on the ceiling vent in the 500 Hall shower room. -At 1:37 P.M., there was a buildup of dust on the ceiling vent in the restroom of Resident room [ROOM NUMBER]. During an interview on 5/21/24 at 1:35 P.M., the MD said he/she did not know how long the ceiling vent in the shower room had dust inside of it.

Based on observation, interview and record review, the facility failed to ensure a system in place for monitoring shower/bathing related to Activities of Daily Living (ADL's- grooming, bathing, hygiene), and to ensure baths or showers were provided at as scheduled for five sampled residents (Resident #6, #32, #58, #76, and #85) out of 18 sampled residents. The facility census was 88 residents. Review of undated facility policy entitled Bath, Shower/tub showed: -The purpose was to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. -Complete bathing per residence preference (shower or bath). -Document the time the shower/tub bath was performed. -Document the name and title of the individual(s) who assisted the resident with shower/tub bath. -Document all assessment data. -Document how the resident tolerated the shower /tub bath. -Document if the resident refused shower/tub bath, the reason(s) why and the interventions taken. -Document the signature and title of the person who recorded the data. -Notify the supervisor if the resident refused the shower/tub bath. -Report other information in accordance with facility policy and professional standards of practice. 1. Review of Resident #32's Admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of Cerebral Palsy (a congenital disorder of movement, muscle tone, or posture). Review of the resident's bathing documentation from the Electronic Medical Record (EMR) dated 3/2024 showed: -The resident received a shower on 3/8/24, 3/11/24 and 3/12/24 and was totally dependent on staff. -The resident received a bed/towel bath on 3/21/24 and was totally dependent on staff. -The resident was scheduled for a shower/bath twice a week and received four baths out of eight opportunities. Review of the resident's bathing documentation from the EMR dated 4/2024 showed: -The resident received a shower on 4/2/24, 4/12/24, 4/18/24 and was totally dependent. -The resident was scheduled for a shower/bath twice a week and received three shower/baths out of nine opportunities. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/20/24 showed the resident: -Had severe cognitive impairment. -Required staff to perform all the activities for bathing and showering. Review of the resident's bathing documentation from the EMR from 5/1/24 through 5/21/24 showed: -The resident received a shower on 5/14/24 and was totally dependent. -The resident was scheduled for a shower/bath twice a week and received one shower/bath out of six opportunities. Review of the resident's Skin Monitoring Comprehensive Shower Review sheets 5/1/24-5/21/24 showed: -A signed shower sheet for 5/14/24 and 5/17/24 that did not show if a bath or shower was given was not signed by the Certified Nurse's Aide (CNA) just signed by the charge nurse. -A signed shower sheet for 5/21/24 that does not show if a bath or shower was given and was signed by the CNA, but not signed by the charge nurse. -The resident was scheduled for a shower/bath twice a week and received three shower/baths out of five opportunities. -No other shower sheets were received. Review of the resident's care plan revised on 5/2/24 showed the resident required total assistance for bathing/showering. Observation on 5/20/24 at 10:18 A.M. showed the resident had greasy hair that was combed. 2. Review of Resident #58's Admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis of all four limbs). Review of the resident's bathing documentation from the EMR dated 3/2024 showed: -The resident received a shower on 3/7/24, 3/14/24, 3/18/24, 3/21/24, and 3/25/24 and was totally dependent on staff. -The resident was scheduled for a shower/bath twice a week and received five shower/baths out of eight opportunities. Review of the resident's bathing documentation from the EMR dated 4/2024 showed: -The resident received a shower on 4/11/24, 4/15/24, and 4/22/24 and was totally dependent. -The resident was scheduled for a shower/bath twice a week and received three shower/baths out of nine opportunities. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Required staff to perform all the activities for bathing and showering. Review of the resident's care plan revised on 4/16/24 showed: -The resident required total assistance for bathing/showering. -The resident's family preferred to do to the resident bed baths. -The care plan did not state when staff were supposed to give baths. Review of bathing documentation from the EMR from 5/1/24 through 5/21/24 showed no baths/showers were given. Review of the resident's Skin Monitoring Comprehensive Shower Review sheets dated 5/2024 showed: -The resident's family member gave the resident a bath on 5/11/24 and 5/20/24 signed by the charge nurse. -The resident was scheduled for a shower/bath twice a week and received two shower/baths out of six opportunities. During and interview on 5/20/24 at 9:30 A.M., the resident's family member said: -He/She preferred the resident to have a bed bath instead of a shower. -He/She preferred to do the bathing, but expected the facility to do the bathing when he/she could not. 3. Review of Resident #76's Admission record showed the resident was admitted to the facility on [DATE] with a diagnosis of quadriplegia. Review of the resident's admission MDS dated [DATE] showed the resident: -Was cognitively intact. -Required staff to perform all the activities for bathing and showering. Review of the resident's bathing documentation from the EMR dated 4/2024 showed: -The resident received a shower on 4/22/24 and was totally dependent on staff. -The resident was scheduled for a shower/bath twice a week and received one shower/baths out of five opportunities. Review of the resident's Skin Monitoring Comprehensive Shower Review sheet for 4/2024 showed: -The resident received a bath/shower on 4/23/24 signed by the CNA, but the form did not show if the resident received a shower or bath and was not signed by the charge nurse. -This was the only shower sheet provided by the facility. Review of the resident's care plan dated 5/1/24 showed the resident was totally dependent on staff to provide a bed bath/shower twice weekly and as necessary. Review of bathing documentation from the EMR from 5/1/24 through 5/21/24 showed: -The resident received a shower on 5/2/24 and was totally dependent. -The resident was scheduled for a shower/bath twice a week and received one shower/baths out of five opportunities. During an interview on 5/19/24 at 12:08 P.M. the resident said that no baths had be given to him/her in over 20 days. Review of the resident's Skin Monitoring Comprehensive Shower Review sheet for 5/2024 showed: -The resident received a bath/shower on 5/21/24 signed by the CNA, but the form did not show if the resident received a shower or bath and was not signed by the charge nurse. -This was the only shower sheet provided by the facility. 19016 4. Review of Resident #85's Admission Face Sheet showed the resident was admitted to the facility on [DATE] with diagnosis of traumatic brain injury (TBI - damage to the brain resulting from external mechanical force). Review of the resident's ADL Care Plan dated 12/21/23 showed the resident required extensive assistance by one staff with showering twice weekly as necessary. Review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Required substantial/maximal assistance of facility staff for bathing and showers. -Was frequently incontinent of urine and occasionally incontinent of bowel. Review of the resident's undated shower schedule showed the resident was scheduled for showers on Tuesdays and Fridays. Review of the resident's electronic CNA Bathing Task dated 3/2024 showed: -The resident received showers on 3/1/24, 3/15/24, 3/21/24 and 3/26/24. -On 3/5/24, 3/12/24, and 3/29/24 the resident did not receive a shower or bath. There was no documentation why these showers were missed. -The resident received four out of nine showers. Review of the resident's electronic CNA Bathing Task dated 4/2024 showed: -The resident showered on 4/2/24, 4/5/24 and 4/17/24. -There was no shower as scheduled on 4/9/24, 4/12/24, 4/19/24, and 4/30/24. There was no documentation why he/she did not receive a shower. -The resident received five out of nine showers. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review Sheets for 4/2024 showed: -He/she showered on 4/22/24, and 4/25/24. He/She refused a shower on 4/29/24, but there was no documentation why or if the resident had an opportunity to make up the shower. The resident did not sign the shower sheet acknowledging he/she refused the shower. -The resident received five out of nine showers. Review of the resident's Skin Monitoring Comprehensive CNA Shower Review sheets for 5/1/24 through 5/21/24 showed: -The resident had a shower on 5/9/24. No other showers were given. -The resident received one out of six showers scheduled for the three week period. During an interview on 5/20/24 at 12:22 P.M., the resident said: -He/She was not getting showers twice weekly as scheduled and had gone as long as two or three weeks before getting them. -He/She had accidents and sometimes urinated before staff could get him/her to the toilet. The accidents made him/her smell. -He/She needed help getting onto a shower chair and taking a shower. It was hard to get staff help for showers and staff never offered him/her a shower for any that were missed. During an interview on 5/22/24 at 10:10 A.M. the resident's responsible party said: -The resident sometimes urinated on himself/herself. -The resident required staff assistance with ADLs. During an interview on 5/22/24 at 11:08 A.M. Certified Medication Technician (CMT) A said the resident was incontinent every day. The resident just couldn't hold his/her urine and staff couldn't always toilet him/her in time. During an interview on 5/23/24 at 3:16 P.M. CMT C said: -All residents were scheduled to be showered twice weekly. The shower schedule was located at the nurses' desk and was available to all nursing staff. -If a resident refused his/her shower staff were supposed to tell the charge nurse and the Director of Nursing (DON). -The resident was partly incontinent, so showers for him/her were important. -Staff used to document showers on the residents' electronic CNA Bathing Task form, but some staff weren't filling it out like they were supposed to. -Staff were recently asked to do shower documentation on the shower (Skin Monitoring: Comprehensive CNA Shower Review) sheets. -Shower sheets should be completed for every shower given or refused. -Showers should be given as scheduled. -The resident sometimes refused to shower and staff had to sweet talk him/her into taking a shower. -He/She didn't know why there was missing documentation of all the resident's scheduled showers, but there should be documentation showing all the resident's showers. 33409 6. Review of Resident #6's Admission Face Sheet showed the resident admitted to the facility with diagnosis of quadriplegia. Review of the resident's Care Plan 6/29/21 showed: -The resident has an ADL self-care performance deficit related to quadriplegia. -During resident showers/bathing care staff were to check nail length, trim and clean on bath day and as necessary. Report any changes to the nurse. -The resident requires total assistance from care staff for bathing/showers. Review of the resident's Quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -Required total assistance of facility staff for bathing and showers. -He/she had impairment of both upper and lower extremities. Review of the resident's electronic CNA Bathing Task dated 4/2024 showed the resident had documentation that he/she was given a shower 7 out 10 opportunities. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheet for 4/1/24 to 4/30/24 showed. -Had no documentation of nail care was provided. -The resident had documented on shower sheet showed he/she was given eight showers out of 10 opportunities. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheet for 5/1/24 to 5/23/24 showed: -Had documentation of a shower given on 5/1/24. -Had no written Skin Monitoring: CNA shower sheet were completed from 5/8/24 to 5/20/24. -The resident had documented on a shower sheet showed he/she was given one shower out seven opportunities. Review of the resident's electronic CNA task report for 5/2024 showed the resident: -Documented had been given a shower on 5/13/24 and 5/15/24. -The resident had bathing documented showed he/she was given a shower two out seven opportunities. Observation and interview on 5/19/24 at 11:30 A.M., the resident said: -The CNAs were not clipping the resident's fingernails and toe nails. -Observation of the resident's fingernails were slightly long. During an interview on 5/20/24 at 10:45 A.M. the resident said: -He/she was supposed get showers on Monday and Thursday and was not receiving showers. -He/she had not received a shower that morning. -He/she had refused a shower one time when care staff came in at 6:00 A.M. to take him/her to shower room. -He/she washed his/her own hair in the morning at his/her bedside. During an interview on 5/20/24 at 10:54 A.M., CNA D said: -He/she was only working until 2:30 P.M. that day. -He/she was not sure what residents were scheduled for shower/baths that day. -Observation showed the CNA D went into the shower room and obtain the resident's shower schedule. -Resident #6 was listed under Monday and Thursday as his/her shower days. During interview 5/22/24 at 5:28 A.M., CNA E said: -Resident # 6 requires total assistance with cares from facility staff. -The resident had made complaints to staff related not getting baths as schedule. -He/she had seen the resident not well groomed upon coming on for shift. -The resident would request bucket of water to be able to wash his/her hair while in bed. The CNA would assist the resident at that time. -He/she had notified the day shift care staff that the resident was requesting a shower. During an interview on 5/22/24 at 6:50 A.M., CNA B said: -He/she would complete a Skin Monitoring Comprehensive CNA Shower sheet for resident had received a shower and if refused would write resident refused and number of times offered shower that day. -He/she would document on CNA shower sheet care provided to include hair washed and nails clipped. -The electronic record under Task the CNA would document bath given or refused. -He/she would normally complete the Skin Monitoring: shower sheet form, which would include skin monitoring section. -If resident refused a shower, he/she would document on shower sheet and have the resident signed the shower sheet form. During an interview on 5/22/24 at 7:07 A.M., with CNA F said: -Each CNA for that hall would complete the resident's shower assigned to the CNA that day. -He/she would complete the skin/shower sheet and give to the nurse for review. -He/she would notify the nurse if resident the refused showers or if found any skin issue during showers. -He/she would have the resident sign shower sheet showing the resident had refused the shower. -He/she would inform the charge nurse of resident refusal of care or new skin issue. -The DON would review the resident shower sheets. During an interview on 5/22/24 at 10:47 A.M., CNA D said: -He/she would complete handwritten shower sheets and document the shower in the resident's EMR. -He/she was not aware of any resident left alone shower room. -Staff were stay with the resident while in shower for safety issue. During an interview on 5/23/24 at 12:13 P.M., Registered Nurse (RN) A said: -CNA would verbally inform him/her any skin changes or if resident had refused a shower or care. -He/she was not aware who assigned the resident shower or were CNA were to document showers given. -He/she had not received or reviewed resident shower sheets. -He/she not aware of Resident #6 complaint of not getting showers. 7. During an interview on 5/23/24 at 9:23 A.M., CNA A said: -Residents were supposed to get showers/baths two times a week. -Realistically the residents rarely get bathed twice a week. -Residents would hopefully get a shower/bath at least every two weeks to a month. -The lack of showers was due to lack of staff. There were only two CNAs assigned for the three halls. -When a resident refused a shower or bath, he/she would tell the charge nurse after trying to reeducate the resident on the importance of the shower/bath if the resident still refused. -The bathing charting used to be done on the computer, but now on shower sheets were started about two weeks ago. During an interview on 5/23/24 at 9:28 A.M., CNA B said: -When a resident refused showers/baths he/she would try to reeducate the resident on the importance and chart the refusal in the computer or on a shower sheet and inform the charge nurse. -Residents were supposed to get a shower/bath twice a week, but it would usually be one bath every two to three weeks for the residents. -There was usually not enough staff to do showers twice a week in his/her opinion. -There was usually only two CNA's for the three halls no bath aide. During an interview on 5/23/24 on 9:34 A.M., CNA C said: -Residents would get showered/bathed depending on the staffing schedule. - Residents were showered/bathed at least once every week to every two weeks. -The facility had no shower/bath aid full time. -Two CNAs cannot work the hall provide cares, answer call lights and give baths. -The shower/bath charting used to be done in the EMR but now was done on paper charting. -When a resident refused a shower/bath he/she would inform the charge nurse. During an interview on 5/23/24 at 9:40 A.M., RN A said: -Residents were to be shower/bathed two to three times a week. -Residents were being showered/bathed maybe once a week. -He/she was unsure why, but felt it was because the facility did not have a full time bath aide. -When a resident refused a shower/bath and was told this by the CNA he/she would find out why and the reason and then educate. - When resident still refused a shower/bath he/she would chart the refusal and education that was given in the chart. -He/She might not chart first refusal but defiantly the second and consecutive refusals. -When the resident's preferences were identified he/she would put this information in the residents care plan. -The shower/bath charting was done in the EMR as a task but now it was done on paper. During an interview on 5/23/24 at 2:50 P.M., Assistant Director of Nursing (ADON) said: -Shower/Bathing was discovered to be an problem and a performance improvement plan (PIP) was started in March. -Documentation for shower and baths was done in the computer, but there was an issue with the computer, so it was changed to a paper process then. -The charge nurse was to ensure the bathing sheets were being done. -The charge nurse reviewed bath sheets and then signed them. -The charge nurses would give the signed shower sheets to the ADON who reviewed them for skin issues. -When a resident refused a shower. A shower sheet was still filled out with refusal written on it. -The resident was supposed to sign the refusal shower/bath sheet if the resident was able. -When a resident had multiple refusals the ADON would talk with resident and find out why and see if a compromise could made to make the resident willing to get the shower/bath. -It was easier to track refusals and when multiple refusals happen with the shower/bath sheets versus the computer. -Prior to the PIP there was no system in place to track showers/baths. -The expectation was for residents to get showers/baths was minimal shower/bath twice a week. -He/she felt that if had been more than three weeks since a resident had a shower/bath it was an issue. -The computer charting system did not flag if showers/baths were not done there was no report the system could generate. -This was why it was decided to go back to the shower/bath sheets so the showers/baths would be tracked. -The process for a refusal was when a resident refused a bath/shower the CNA reported this to the charge nurse then the charge nurse would approach and try to reschedule the shower/bath. -The charge nurse would then sign the shower sheet and follow up on the bath/shower. -There had been a lot of change in staff so tracking of the showers/baths had not been consistent. -The facility had a bath aide and he/she used to track and reschedule residents for showers/baths he/she was then making up for missed showers/baths. -He/She had left the facility about a month ago and the facility has not been able to hire a new bath aide. -When a shower/bath was missed it should be charted in the progress notes and the reason why it was and the education provided. -Residents should have received showers/baths at least twice weekly. MO00236026, MO00235049 and MO00236223

Based on observation, interview and record review, the facility failed to cook broccoli florets so they would not be mushy; failed to follow the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) broccoli, so the broccoli would be palatable; and failed to maintain room trays at the 600 Hall and the 300 Hall at or close to 120 F (degrees Fahrenheit) at the time of service. This practice potentially affected at least 13 residents. The facility census was 88 residents. 1. Review of the recipe for pureed broccoli florets, dated 9/1/15, showed: - Steam broccoli 15-25 minutes until tender. - Drain broccoli, in large mixing bowl, and toss broccoli with margarine and season with salt and pepper. - Transfer to service pans and hold at a temperature of 135 F or greater. - Puree step: Remove desired number of servings and add nutritive liquid such as milk or broth. Blend until desired consistency. - Add approved thickener to achieve desired consistency if needed. Observation during a taste test on 5/19/24 at 10:33 A.M., showed the broccoli had a mushy and overcooked texture. Observation on 5/19/24 at 12:00 P.M., showed the following: - Dietary [NAME] (DC) A made pureed broccoli. - DC A added water to the mixture. - DC A had no recipe book open. During a taste test on 5/19/24 at 12:05 P.M., the pureed broccoli tasted bland. During an interview on 5/19/24 at 12:07 P.M., DC A said the pureed broccoli was more bland, after he/she tasted the pureed broccoli. Review of the recipe with DC A showed that he/she should have added broth to the pureed mixture instead of just water. During an interview on 5/19/24 at 2:33 P.M., the Dietary Director (DD) said: -DC A had been training for only a couple of weeks. -He/she expected the dietary staff to taste the pureed food for temperature and taste. -He/she expected facility staff to use the recipe book when making pureed recipes. During an interview on 5/19/24 at 2:36 P.M., DC A said: - He/she thought he/she was trained. - The other cook (DC B) he/she did not tell him/her about using the broth instead of water for the pureed broccoli. 2. Observation on 5/19/24 from 1:05 P.M. through 1:34 P.M., showed the following: - At 1:05 P.M., the food cart arrived at the 600 Hall. - There were 12 residents in the 600 Hall dining room. - None of the food trays inside the cart, had covers on them. - Certified Medication technician (CMT A) and the Marketing director started serving the residents. - With 5 more trays in the cart, the state surveyor checked the temperature of the test tray and the following temperatures were recorded: -Sliced turkey was 95.2 F, the mashed sweet potatoes were 93.3 F and the broccoli was 93.7 F. During an interview on 5/19/24 at 1:34 P.M., CMT A said no one from the dietary department had come to the 600 Hall to check temperatures of the room trays. 3. Observation on 5/19/24 at 2:19 P.M. showed the following temperatures of a tray that was served on the 300 Hall with two residents left to serve showed the following temperatures: Sliced turkey was 93.9 F, the mashed sweet potatoes were 97.4 F and the broccoli was 95.5 F. Record review of Resident #39's annual Minimum Date Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 5/12//24 showed the resident was cognitively intact. During an interview on 5/22/24 at 12:51 P.M., Resident #39 said: - At almost every meal, the food was cold. - About two out of every three days, the meals were cold. - People who eat in the dining room get their meals delivered to them hot. - It makes him feel like less of a person because the residents who ate in the dining room get hot food. Record review of Resident #3's significant change MDS dated ,d+[DATE]//24, identified the resident as cognitively intact. During an interview on 5/22/24 at 12:56 P.M, Resident #3 said: - The food was cold at times when it was delivered to his/her room. - Turkey was offered on one day and the flavor was OK, but the food temperature was cold, so he/she did not like it. Record review of Resident #83's quarterly MDS dated [DATE], identified the resident as cognitively intact. During an interview on 5/22/224 at 1:03 P.M., Resident #83 said: -The room trays were cold every day said the room trays are cold every day. -On 5/22/24, the food was served warm, but usually it was cold. - During breakfast meals, the eggs were usually cold. - He/she has received warm milk in the past if the food the food was late. During a phone interview on 5/28/24 at 2:11 P.M., the Dietary Director said: - He/she was working on temperature logs. - He/she liked the facility staff to measure the temperatures of the foods when they cook the foods, again about halfway through the service and close to the end of service. - He/she did not have any processes for checking temperatures of meals when those meals got to a resident or a certain hall. - He/she only knew of a few complaints from residents about the food being cold.

Based on observation and interview, the facility failed to ensure there was negative airflow in the restrooms of the following resident rooms: 106, 102, 210, 209, 206/204, 205, 311/309, and 302/304. This practice potentially affected at least 20 residents who resided in those rooms. The facility census was 88 residents. **Note: Air flow was tested by holding one piece of tissue paper to the ceiling vent. If the paper was drawn up then negative air flow was present; if the paper was not drawn to the ceiling vent, then negative airflow was absent. 1. Observations with the Maintenance Director and the Regional Maintenance Person on 5/21/24, showed: -At 9:52 A.M., there was not any negative airflow from the restroom vent of resident room [ROOM NUMBER]. -At 9:57 A.M., there was not any negative airflow from the restroom vent of resident room [ROOM NUMBER]. -At 10:04 A.M., there was not any negative airflow from the restroom of resident room [ROOM NUMBER]. -At 10:11 A.M., there was not any negative airflow from the restroom of resident room [ROOM NUMBER]. -At 10:18 A.M., there was not any negative airflow from the shared restroom of resident rooms 206/204. -At 10:21 A.M., there was not any negative airflow from the shared restroom of resident rooms 205. -At 10:39 A.M., there was not any negative airflow from the shared restroom of resident rooms 311/309. and -At 10:51 A.M., there was not any negative airflow from the shared restroom of resident rooms 302/304. During a telephone interview on 5/29/24 at 5:08 P.M., the Maintenance Director said: -When he/she investigated the issue regarding the ventilation he/she was not sure if it was something related to electrical wiring. -Some fans needed a bigger motor. -The issues which affected the fans not providing negative airflow, was a little different for each hall.

Based on observation, interview, and record review, the facility failed to obtain a physician order for the setting of the low air loss mattress (LAL - a mattress designed to distribute weight over a broad surface and help prevent skin breakdown. It has continuous air flow through tiny holes on the mattress surface) for one sampled resident (Resident #77) who had developed a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) out of 18 sampled residents. The facility resident census was 88 residents. Review of the facility's Pressure Ulcer (PU)/Skin Breakdown - Clinical Protocol policy, revised April, 2018 showed the physician will order pertinent treatments, including pressure reduction surfaces and identify medical interventions related to wound management. 1. Review of Resident #77's Admission Record showed the resident was readmitted to the facility on [DATE] with diagnoses that included dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of the physician's Orders Summary Report (OSR) showed LAL mattress on at all times. Settings at resident's comfort. Check comfort level and functioning status every shift and as needed for skin integrity, starting 3/4/24. Review of the resident's current Skin Integrity Care Plan, initiated 9/15/23 and showed: -LAL mattress as ordered, initiated 3/4/24. -An opened area was classified as pressure on 5/17/24. -There was no information on how the resident's LAL mattress was to be set. Review of the resident's Electronic Medical Record (EMR) showed the resident's most recent weight was 130.8 pounds on 5/3/24. Review of the resident's Weekly Wound Assessment, dated 5/17/24 showed: -A Stage II PU was identified on 5/17/24 on the resident's coccyx (small triangular bone at the base of the spine) measuring 1.8 centimeters (cm) long, 0.7 cm wide and 0.2 cm deep, red in color with no drainage or odors. -Turn resident every two hours, continue LAL mattress as ordered, cushion in resident's chair while up, vitamins and wound care as ordered. Physician notified. -No LAL mattress setting was specified. Review of the physician's OSR on 5/21/24 showed: -LAL mattress on at all times. Settings at resident's comfort. Check comfort level and functioning status every shift and as needed for skin integrity, starting 3/4/24. -The order had not been changed once the resident developed a PU to specify a LAL mattress setting. Review of the resident's Significant Change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 5/20/24 showed the resident: -Was severely cognitively impaired. -Was receiving hospice services (medical care focused on comfort and quality of life for a person approaching end of life). -Was at risk for PUs. -Had one Stage II PU. -Had a pressure reducing device for his/her bed and wheelchair. Observation on 5/19/24 at 11:35 A.M. showed: -The resident was lying on his/her right side in bed. -The resident appeared thin and frail. -The resident's LAL mattress was set to 200 pounds. -The LAL adjustment device had 130 pounds as one possible setting. Observation on 5/20/24 at 10:33 A.M. showed: -The resident was lying in bed. -The resident's LAL mattress was set at 200 pounds. During an interview on 5/22/24 at 11:12 A.M. Certified Medication Technician (CMT) A said: -The resident had a PU for about three weeks. He/She had a LAL mattress before acquiring the PU. -Direct care staff were responsible for repositioning the resident every two hours. -The CMTs and Certified Nurse Assistants (CNAs) didn't touch the LAL settings and he/she hadn't been trained on appropriate settings. Observation on 5/23/24 at 9:30 A.M. showed: -The resident was lying in bed. -The resident's LAL mattress was set at 200 pounds. During an interview on 5/23/24 at 11:20 A.M. the Wound Nurse said: -The physician and his/her Nurse Practitioner (NP) assessed the resident's PU and he/she did the resident's wound treatments. -He/She monitored LAL mattress settings for all residents when doing wound treatments, but he/she didn't document anywhere when settings were checked. -He/She wasn't sure if hospice checked the resident's LAL mattress settings when they visited. -The resident's physician's orders show his/her LAL mattress should be set for comfort. Once the resident developed a PU the mattress should have been set according to his/her weight. During an interview on 5/23/24 at 12:37 P.M. the Assistant Director of Nursing (ADON) said: -If a PU develops or gets worse the LAL mattress could be too hard or too soft. The LAL mattresses should be at the setting closest to the resident's weight. If a resident's weight is half-way between two settings the LAL mattress can be set up or down. -The CMT should check the settings every shift. The LAL mattress settings should be on the physician's orders and there should be an order to check the resident's LAL mattress. CMTs wouldn't necessarily know they should check the settings by weight if the order doesn't show it should be set according to weight. -The CMTs don't adjust the settings, but they should tell the charge nurse or the wound nurse when the mattress isn't set according to weight. -The resident was unable to communicate, except by grimacing, if the LAL mattress was comfortable. -The mattress should be set as close as possible to 130 pounds for the resident. During an interview on 5/23/24 at 1:01 P.M. LPN B said: - If an order showed a LAL mattress was to be set for comfort the residents could tell staff how they wanted it set. He/She asked residents if they want the mattress alternating or static. He/She had been taught if a resident had a PU staff were to set it alternating and not on static. -He/She hadn't received any training at the facility on setting LAL mattresses. -The nurse had to document on the Treatment Administration Record (TAR) that they checked the mattress. -He/She wasn't sure how staff knew how to set the LAL mattresses if the order showed it was to be set according to comfort. -If the resident weighed half-way between two weight settings staff could set the mattress to the setting up or down from their weight. Any resident who had a PU should have the LAL mattress set according to their weight.

Based on observation, interview and record review, the facility failed to ensure accurate documentation of refusal of enteral feeding via feeding tube called Percutaneous endoscopic gastrostomy (is a surgery to place a feeding tube also called a PEG or G-tube) and physician order for total amount caloric formula to be given in a 24 hour period, for one sampled resident (Resident #4) who's at risk for weight loss due to decline health, refusal of treatment and cares out of 18 sampled residents. The facility resident census of 88 residents. Review of the facility Policy for Medication Orders revised on 11/2014 showed: -Enteral feedings orders: when recording orders for enteral tube feedings, specify the type of feeding, amount, frequencies of the feeding and rationale if as needed. -The order should always specify the amount of flushing following the feeding. Review of the facility Enteral Tube feeding via a Pump revised on 11/2018 showed: -Document the average fluid intake per day. -If the resident refused procedure or enteral feeding document the reason why and intervention taken. -Report to supervisor if the resident refuses procedures. 1. Review of Resident #4's Admission Face Sheet showed the resident had diagnosis of: -Gastrostomy (is a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach.) -Protein-Calorie Malnutrition (is the state of inadequate intake of food). -Dysphagia (difficult to swallowing). -Adult Failure to thrive (is a decline in older adults that manifests as a downward spiral of health and ability). Review of the resident's Nutrition Assessment Note dated 2/13/24 showed: -Had recent new diagnosis of Protein-Calorie Malnutrition, G-tube, Dysphagia, Diabetes Mellitus, Failure to thrive. -Readmission noted, resident back on enteral feedings as he/she used to be. -Oral diet advanced to pureed but resident was not eating well and has a history of refusing pureed food. -Therapy orders noted, including speech therapy for Dysphagia. Weight down 4.8 pounds in one month, 15.5 pounds in six months, within ideal body weight. Recent weekly weights reviewed. -Blood Sugar are generally less than 200 on return. -Would change enteral regimen to Glucerna 1.2 at 80 milliliters (ml) per hour(hr) times 20 hr per day with no change to water flushes. -Will monitor weight/intake/enteral tolerance moving forward. ` Review of the resident's Care plan initiated on 2/20/24 showed: -The resident required tube feeding related to Dysphagia, failure to thrive and poor intake. -Discuss with resident/family/care givers any concerns about tube feeding. Review of the resident Quarterly MDS dated [DATE] showed: -Was severely cognitive impairment. -Required tube feeding and altered mechanical diet while a resident at the facility. -His/her weight at time of assessment was 155 pounds. -Was dependent on facility staff for all cares. Review of the resident's Nutrition Task (amount eaten) from 5/1/24 to 5/21/24 showed: -The resident had meal intake of 37 out 63 opportunities documented at 0-25% of meal eaten. -The resident had meal intake of 7 out 63 opportunities documented at 26%-50% of meal eaten. -The resident had meal intake of 3 out 63 opportunities documented at 51%-75% of meal eaten. -He/she had refused meal 13 out of 63 opportunity. Review of the resident's nursing note dated 5/16/24 at 7:36 A.M. showed: -A late entry note: dated 5/15/24 at 5:00 P.M., the resident hollering in his/her room, demanded to be unhooked from his/her PEG tube feeding stating I don't want this, get this off of me while pulling at his/her PEG tube in distress. -Resident was assisted out of bed to dining room at that time. -Notified social services of his/her distress and verbalization of not wanting his/her feeding per tube. Review of the resident's nursing note dated 5/16/24 at 12:53 P.M. showed the nurse had notified the resident's nurse practitioner, about the resident's ongoing refusal at time for tube feeding and/or medications/general decline and routine refusal to eat pureed food. Order received for hospice (end of life) to consult/notified social services. Review of the resident's nursing note dated 5/17/24 at 3:06 P.M. showed: The resident continued to refuse tube feeding to be re-administered. -He/she said, no and repeatedly says don't put nothing in there referring to his/her peg tube. -Was unable to even flush the peg tube due to resident's agitation when he/she even touched the resident's peg tube. -The resident also refused both breakfast and lunch, he/she would attempt to have the resident to eat dinner. -Was told in change of shift report the doctor was already aware and a hospice care consult was pending. Review of the resident's nursing note dated 5/18/24 at 3:09 P.M. showed: - An enteral feed order every shift for hydration and to flush the peg tube with 250 cubic centimeters (cc) water every four hours. -The resident was refusing anything to be put into peg tube including just water. Review of the resident's Treatment Administration (TAR) dated from 5/1/24 to 5/31/24, showed: -Enteral Feed every shift for nutrition Glucerna 1.2 to run at 85 ml/hr continuous time 20 hours off tube feeding from 10:00 A.M. to 2:00 P.M. (initial order was dated 4/18/24). -Enteral feed every shift for hydration, Flush tube with 250 cc's water every four hours (order dated 2/7/24). -Had documented on 5/16/24 at 6:30 A.M. code 9 and nursing initial, which meant to see progress note for tube feeding and water flushes. -Had documented 5/16/24 at 6:30 P.M. had code 2 which meant resident refused tube feeding and water flushes. -Had documented on 5/17/24, 5/18/24, had code 2 and nursing initial. Resident refused tube feeding and water flushed. -Had documented on 5/19/24 and 5/20/24 a check mark and nursing initials of the tube feeding and water flushed were given. Review of the resident's Orders - Administration Note dated 5/19/24 at 11:21 A.M. showed: -Order to shut tube feeding off one time a day for overload. -The resident was not allowing tube feeding to be infused at this time and stated don't put anything in that tube. Observation and interview on 5/20/24 at 11:00 A.M., the resident showed: -His/Her enteral feeding pump in the resident room was not running or connected to the resident. -Had no formula bottle or bag hung on tube feeding pole/pump. -The resident said he/she not getting tube feeding at this time. Review of the resident's Orders - Administration Note dated 5/20/24 at 1:39 P.M. showed: -A physician's order to shut the tube feeding off one time a day for overload. -The resident continued to refuse his/her tube feed. Review of the resident's Physician Order Sheet (POS) dated 5/21/24 showed: -Enteral Feed every shift for hydration, Flush tube with 250 cc's water every four hours (order dated 2/7/24). -On 5/21/24 an order for Enteral Feeding be placed on hold. --Enteral Feed every shift for nutrition Glucerna 1.2 to run at 85 ml/hr continuous time 20 hours. The tube feeding turned off from 10:00 A.M. to 2:00 P.M. (initial order was dated 4/18/24). -New order dated 5/21/24, nursing staff were to check feeding tube placement prior to administering medications or feeding. --1. Current measurement for resident feeding tube was one centimeter (cm) between skin & bumper. If area between skin & bumper was more than finger width wide or two inches, notify physician. --2. Residual (amount of formula left in the tube) check if 250 ml-500 ml, take measures to reduce risk of aspiration. If more than 500 ml, notify physician. Monitor residual every shift. -NOTE: There were no physician's order's for recommended amount of tube feeding formula intake in a 24 hour and order for monitoring/documentation of caloric intake. Review of resident nurse's note dated 5/21/24 at 12:40 P.M. showed: -The resident's tube feeding was placed on hold until further notice due to refusals. -Hospice was to consult. -Nursing staff will continue with meals by mouth although intake was declining. -The resident family member aware of the resident refusal. Review of the resident's Order-Administration Note dated 5/21/24 at 11:31 A.M. showed: -An order to shut off tube feeding one time a day for overload. -The resident was refusing tube feeding states If you put that in, I will pull it out. I do not want it. Review of the resident's Care plan revision on 5/21/24 showed the resident refusing to eat and refusing to allow tube feeding. Observation and interview on 5/21/24 at 1:11 P.M. showed: -The resident was in a low bed in his/her room. -No meal tray in room. -Had tube feeding pole and pump at bedside. Did not have tube feeding bottle hung or running. During an interview on 5/21/24 at 1:12 P.M., Certified Nursing Assistant (CNA) G said: -The resident was only staying up in his/her wheelchair for 30 minutes at a time. -He/she not aware if the tube feeding was running at this time. -The resident was declining in his/her health. -He/she had a meal tray for the resident, but he/she did not want to eat. -The meal tray was taken away. Observation of the resident at 05/22/24 at 8:20 A.M., showed: -The resident was in a low bed. -The tube feeding pump not running, and no formula was hung at that time. Observation and interview on 5/22/24 at 10:00 A.M., of the resident tube feeding and site showed: -Registered Nurse (RN) A enter the resident room washed hand soap and water. -The resident had agreed to have PEG tube site checked and to provide water flush through the feeding tube. -RN A check PEG tube for residual, obtained a clear thick creamy substance from tube. -He/she flushed the feeding tube with water. -The resident said he/she would agree to have formula via pump connected. -RN A said he/she needed to verify order, since tube feeding was placed on hold at that time. -The resident was able to make his/her needs and wishes known, but difficulty understand him/her at times. -RN A cleaned PEG site with Normal saline, then dried with gauze pad, then applied clean split 4 x 4. -Resident denied any pain at this time. During an interview on 5/23/24 at 9:49 A.M., with the resident said: -He/she ate breakfast that morning and was up in wheelchair in dining area. -He/she did have tube feeding per pump yesterday afternoon. 3. During an interview on 5/21/24 at 1:15 P.M., Licensed Practical Nurse (LPN) A said: -The resident had a hospice evaluation and waiting on family response for approval of services. -He/she was refusing his/her tube feeding and meals at times. -The resident had a declined in health, with a short life expected. -The resident's family members were aware of the resident's declining health, refusal of cares and meals. During an interview on 5/22/24 at 8:00 A.M., Assistant Director of Nursing (ADON) said: -Review of the resident TAR with ADON. -When the resident had refusal of tube feeding and water flushes, he/she would expect nursing staff to code as refusal and document in the resident's nursing note. -A check mark on TAR would indicate as treatment or medication were given as ordered or treatment completed. -He/she had received an order to place tube feeding on hold 5/21/24, due to the resident's refusal of tube feeding and water flushes. -On the TAR, if a check marked and nursing initial then would have meant tube feeding was given, but the resident had been refusing tube feedings and flushes. He/she and other nursing staff should had coded the resident refusal of tube feeding on the TAR and include a nursing note. -He/she would expect nursing staff to documented refusal of tube feeding accurately and correctly. -Nursing staff should report to the physician the resident refusal of tube feeding and document notification in the resident's nursing notes. -The resident's family member was aware of his/her refusal of cares, tube feeding and medication. -The facility recently obtained a physician order for hospice evaluation and care. -The facility does not document or monitor the total amount of formula that was administered each shift. During an interview on 5/22/24 at 9:42 A.M., RN A said: -The resident had been refusing tube feedings. -The resident had really did not want tube feeding since beginning, the family requested the resident be on tube feedings. -The water flushing had also been refused by the resident. During an interview on 5/23/24 at 12:13 P.M., RN A said he/she would document in the TAR if feedings were completed and if refused coded as refusal and complete a progress note for refusal and any action taken. During an interview on 5/23/24 at 2:48 P.M., Regional Nurse and ADON said: -The acting DON was out of facility for part of the survey. -He/she would expect a physician order to include recommended intake amount and recorded per shift and would expect nursing staff to document the amount formula received each shift. -He/she would expect to have accurate documentation and coding for administered and refusal for treatment/feeding in the resident TAR and progress notes. -He/she would expect nursing staff to notify the resident physician of the resident refusal tube feeding and cares, and complete progress notes of the of the notification. -He/she would expect the CNA to document in the resident oral meal intake or refusal of meals under the CNA Meal Task section.

Based on observation, interview and record review, the facility failed to puree (to make food into a paste or a thick liquid suspension which is made from finely ground cooked food) turkey into a smooth texture that was not stringy. This practice potentially affected three residents with pureed diets. The facility census was 88 residents. 1. Review of the recipe for pureed turkey showed: - Place turkey roasts in oven at a temperature of 375 F (degrees Fahrenheit) and roast for 3-4 hours. [NAME] until an internal temperature of 165 F was reached. - Remove from oven and allow turkey breast to rest for 15 minutes prior to carving. - Hold at 135 F or greater, for service. - For pureed step do the following: Remove the desired number of servings and add nutritive liquid such as milk, broth etc. Blend until desired consistency. Add approved thickener to achieve desired consistency if needed. Observation on 5/19/24 from 12:57 P.M. through 1:00 P.M., showed the following: - DC A did not have the recipe book open. - Dietary [NAME] (DC) A placed 3 servings of (3-4 ounces per serving) into the food processor and added broth and he/she pureed the turkey servings and the broth together. - After pureeing the turkey servings with the broth, DC A placed the mixture into a pan and placed that pan on the steam table without tasting the mixture for texture. Observation on 5/19/24 at 1:00 P.M., during a taste test of the pureed turkey the texture of the pureed turkey did not have a smooth texture and consistency. During an interview on 5/19/24 at 1:58 P.M., the Dietary Director (DD) tasted the pureed turkey and said the pureed turkey was a bit stringy. During an interview on 5/19/24 at 2:01 P.M., the DD said he/she required the cooks to taste the pureed foods. During a phone interview on 5/29/24 at 10:58 A.M., the Consultant Registered Dietitian (RD) said: -He/she has been the Consultant RD to that facility for at least [AGE] years. -He/she expected the cooks for that meal to taste the puree food -He/she expected the cook that day to taste the pureed food 100 %. He/she usually planned in-services for the dietary staff at least quarterly, but those do not always occur, due to dietary staff turnover and scheduling issues. Realistically, in-services happen at least twice per year.

Based on interview and record review, the facility failed to promote and enhance one sampled resident's (Resident #2) feelings of self-worth and self-esteem, when Certified Nursing Assistant (CNA) A, was disrespectful and rude out of four sampled residents. The facility census was 93 residents. On 8/14/23, the Administrator was notified of the past noncompliance which occurred on 8/1/23. The facility administration was notified on the same day of the incident and the investigations were started. Facility staff were educated on Dignity, Respect, and Abuse policy, resident intervention and behaviors before the start of the next shift. Resident care plans were updated. The deficiency was corrected on 8/1/23. Review of the facility policy titled, Dignity, dated 2/2021 showed: -Each resident shall be cared for in a manner that promoted and enhanced his/her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -Resident were treated with respect at all times. -The facility culture supported dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. -Staff speak respectfully to residents at all times, including addressing the resident by his/her name of choice. -Demeaning practices and standards of care that compromise dignity are prohibited. -Staff were expected to promote dignity and assist residents; for example: --Promptly responding to a resident's request for toileting assistance. 1. Review of Resident #2's face sheet showed the resident admitted to the facility on [DATE] with diagnoses that include: -Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). -Severe Protein Calorie Malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). -Gun shot wound. -Open wound to his/her right lower leg. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 6/13/23 showed: -Brief Interview of Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. -Required one person physical assistance for transferring, personal hygiene and toileting. -Required two person physical assistance for dressing. Review of the resident's care plan dated 6/20/23 showed the resident was in the facility for short term healing from a traumatic event. Review of the facility investigation dated 8/1/23 showed: -The resident approached the Social Worker (SW). -The resident said he/she needed to speak with the SW. -The resident said he/she turned on the call light in the bathroom, CNA A walked in and he/she said he/she needed his/her behind wiped. -CNA A wiped the resident's behind and as he/she was walking out of the bathroom said, you can do everything else but wipe your self. -The resident said, excuse me, what did you say his/her insurance paid for him/her to be there. -CNA A then said, his/her taxes paid for him/her to be there. -The resident then said that he/she recorded everything, as CNA A was rude and hateful. During an interview on 8/14/23 at 11:35 A.M.,the SW said: -The resident stopped him/her in the hall and was wanting to speak with him/her in private. -The resident played a recording from his/her phone. -The recording was: --CNA A said, you can do everything else but wipe yourself. --Resident then said, excuse me, what did he/she say because his/her insurance paid for him/her to be there. --CNA A said, His/her taxes paid for him/her to be there. -The resident shared that he/she recorded the conversation as he/she knew CNA A was rude and hateful. -The resident was very angry. During an interview on 8/14/23 at 11:50 A.M.,the Director of Nursing (DON) said: -CNA A denied any wrong doing. -The resident had recorded the interaction on his/her phone. -Multiple attempts were made to obtain statements from witnesses of the situation, but the other employees are reluctant to make statements. -Verbal statement heard on the recording showed CNA A did in fact make the statements to the resident. During an interview on 8/14/23 at 12:05 P.M.,the Administrator said: -The resident was no longer at the facility. -The resident had his/her discharge planned before the incident, to a facility closer to his/her home, across the state. -He/she felt that this incident was a dignity issue. -Other staff were reluctant to give witness interviews about the incident. -When the resident played the recording from his/her phone, they felt as though this was a dignity issue. During an interview on 8/22/23 at 2:00 P.M., the resident said: -That was all behind him/her now, as he/she was in a different facility. -When CNA A said that to him/her, it really made him/her mad and he/she felt bad. -He/she had started recording CNA A because he/she knew that CNA A would be rude and hateful. -He/she was glad that he/she recorded the conversation, because that wasn't right. MO00222338

Based on observation, interview and record review, the facility failed to protect Resident #500 from misappropriation of property and exploitation when Hospitality Aide (HA) A took advantage of the resident for personal gain, through use of emotional manipulation while employed at the facility. Hospitality Aide (HA) A befriended the resident in order to gain the resident's trust, took money from the resident for personal gain, and made plans to take the resident's truck while employed at the facility. After HA A left employment and received the truck, she ended the relationship with the resident, causing him/her to feel emotional harm including feelings of being hurt, angry, and violated. This deficient practice effected one out of seven sampled residents. The facility census was 86 residents. Record review of the facility's Abuse Prevention Program, dated December 2016, showed: -Residents have the right to be free from misappropriation of resident property and exploitation. -The administration will protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Record review of the facility's Employee Handbook, dated 2021, showed: -Resident rights: --The employee has an obligation to read materials provided about resident rights, understand what they mean, and sign a written Resident Rights acknowledgement that they understand them as a condition of employment. --Resident rights include, but are not necessarily limited to: ---Freedom from abuse, neglect, exploitation, and misappropriation of property. -Code of conduct: --Provides guidance regarding required ethical and business conduct- which all employees are expected to read, be familiar with, and follow the principles, which include, but are not limited to: ---Refraining from any conduct which might violate the fraud and abuse laws. ---Avoiding questionable gifts from vendors or any gifts from residents and their families. -Employee/Resident interactions: --While giving efficient and friendly service to residents and families employees may get to know residents and there may be occasions where professional boundaries may be implicated. --An employee may be offered a gratuity (gift, money, etc.) in appreciation for something done. Employees should courteously decline any individual gift and report the offered gift to supervisor. --Employees may not solicit a gratuity under any circumstances. --Under no circumstances may an employee borrow money from, give a loan to, or accept a loan, from a resident or the resident's family member. -Termination: --Some violations of policy or standards may warrant immediate discharge, including but not limited to: ---Theft or other criminal conduct, including toward a coworker, a resident, and/or the resident's family. -Abuse and Neglect: --Residents have right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, neglect, and/or misappropriation of property. --Misappropriation means depriving, defrauding, or otherwise obtaining the real or personal property of a resident under applicable law and regulations. Record review of the Power Point slide presentation (undated) employees watch during the orientation process showed: -Code of conduct: ---Refraining from any conduct which might violate the fraud and abuse laws. ---Avoid questionable gifts from vendors or any gifts from residents and their families. -Customer service: --Be professional and courteous. -Abuse and neglect: --Misappropriation means depriving, defrauding, or otherwise obtaining the real or personal property of a resident under applicable law and regulations. 1. Record review of HA A's personnel file showed he/she hired as a HA on 12/1/22. Job duties included- assist in passing drinks, meals, answering call lights and notifying the Certified Nursing Assistant (CNA) or nurse of a resident's needs; does not perform any type of resident cares. On 12/1/22, he/she took a quiz related to abuse, which included: - It is not ok to borrow money from a resident. -Residents have the right to be free from verbal, sexual, physical, or mental abuse, neglect, corporal punishment and involuntary seclusion. - Employees cannot accept money or gifts. Record review of the facility Abuse and Neglect in-service documentation dated 1/23/23 and 2/3/23 showed HA A attended the in-services and answered questions related to content of the in-service. Record review of Resident #500's Admission Record showed the following diagnosis Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), recurrent, unspecified. Record review of phone texts between HA A and the resident showed: On 1/20/23, HA A wrote: -Awww and 3 heart emoji (An emoji is a picture or symbol embedded in text and used in electronic messages and web pages. The primary function of emoji is to fill in emotional cues otherwise missing from typed conversation) Love you [NAME] cakes. On 1/21/23, HA A wrote: -Good morning dear. Aww so sorry ur (your) world is getting turned upside down maybe not a bad thing tho (though). Mine is too as we speak. Everyone is clearing out and you are still holding strong [NAME]. I love you (heart face emoji) thanks for loving us. -Is grandpas land liveable?or what is it. Always dreamed for like a good new car. But I will have like 4k soon so hopefully find a good one with that. I still fixing home situation now. I hope. -Love you too. (Heart eyes face emoji.) -I love you too hunny. Yes too long without seeing you. I miss you. (sad face, crying emoji, and 7 heart emoji) sweet dreams dear. -Life is sure hard. I just want to live peaceful. Be happy. Calm and comfortable. Ot always worried about how I'm gonna make it or who's our (out) to hurt me. -Awww. You mean a lot to me [NAME] cakes. Yes, you can be married to someone thru God. Doesn't have to be paperwork. I have never been married. But used to call the abusive one husband. -On 1/22/23: -The resident texted: I have the cash for you! I'll try and have my friends bring up my diesel to drive until you get your money or when. It's ford 350? Crew cab so there would be plenty of room for all 4 us. It's a bug TRUCK I like big Trucks oh ya. If you think you can drive we'll make it work I'll put your name as a driver I gave permission to drive. Ins co. (insurance company) Pictures of the house in [NAME] city (resident sent two pictures of living area). I had went thru house and remodeled it I love it and I love [NAME] city hope you will. -HA A texted: -Oh yes. I love big trucks I am good driver. Always drove big cars and vans. Used to pull a 19 ft trailer. Been walking for 3 years now because when I broke those windows and went to jail they took my license. Even tho (though) I was on foot. It was wrong and I couldn't fight it because I was in jail. -I love you. Miss u (crying sad face, heart emoji). Still can't talk a whole lot at work cause they on me. But soon I will have you all to myself. -And oh good cause I had to spend some cash on my medicine. Couldn't take the stress any longer so now im short. That will replace it so I don't get in trouble. Hanging in there best I can. U give me hope. I love you (resident's name). Glad to be your soulmate wifey. -I trust you. What a wonderful man the Lord's sent for us. (heart and lip emoji) -On 1/23/23, HA A texted: -Good morning hunny (heart emoji) -Awwww hunny. Don't be depressed. I love you. Today has been rough. Looking forward to seeing ur face tomorrow. Bright eyed to see me. How wonderful. On 1/24/23: -HA A texted: I'm coming don't say nothing about money or nothing. I will get it. People everywhere. LOL it's ok hunny I got the money but left your card cause u (you) had cash u said. There was people everywhere so I just had to be quick. I am on a transport. But I'll be back (2 heart emoji) -The resident texted: The card is for you also. Pick up at your convenience please. You looked so pretty in the photo wow (emoji). No fair you get to see me but me see you no not fair!! Love you sweetheart! (2 heart emoji) -HA A texted: So what's the card for? 80? For diapers lol -The resident texted: Yes whatever you want 85 if you want just because I love you sweetheart sweet mommy (2 heart emoji) -HA A texted: lol ok (a four digit pass code) I had to leave a bit early. But will bring ur card back tomorrow and say hi again. Im very depressed but trying to snap out of it. Yep it's (a four digit pass code) I found the message; -The Resident said: I trust you. Remember I love you (2 heart emoji) -On 1/25/23 -HA A texted: Darnnit. Really want to drop this card off with so I don't have to keep it another day. Just for here tho and I am on the other side. It is hard to get to ur room without being see but I'll try. Love you hunny. (2 red hearts) frustrated a bit but hanging in there. Ahng (Hang) in there too! (prayer hands emoji) -The Resident texted: no proble (problem) with the ard (card) I could feel that you were upset, didn't risk getting in trouble (devil face emoji) I miss u but safe is better (2 heart emoji) -On 1/26/23: -HA A texted: Love u too. They moving (name of resident's roommate) out of ur room. I feel like they always watching me. Probably cause they are. Just talk work. (3 red heart emoji) -Good night, hunny. I love you. (heart emoji) -On 1/27/23: -Good morning hunny (heart emoji) just getting up (kiss face emoji) u too. Hope to see u. -Thanks so much for loving and caring about us (3 heart emoji) love you too. -Sweet dreams hunny (heart emoji); -On 1/28/23: -HA A texted: Good morning [NAME] cakes. Have a good day (heart emoji); -Good night hunny (sleeping face emoji) just been enjoying day off pretty good. (heart eyes emoji); -On 1/29/23: -The resident texted: Good morning sweetheart a big hug and kiss for you all. Was thinking about 2nd or 3rd week in February I may have to leave meadowview for a couple weeks before they operate on my shoulder if that's the case I'll drive up here so I can drive you around if you want. As soon as the house is empty you may move in, maybe you could pay me $200 a month for rent to help with expenses. Just think about it. It's the bed I could do! Wish I could do more for you. Your [NAME] cakes loves his sweet Angel Mommy very much (3 heart emojis and 4 lips emojis) -HA A texted: Good morning hunny. Yes that sounds good. Keep me informed. Home in the cold with my little men today. Cleaning and playing. (3 heart emoji) -On 1/30/23: -HA A texted: Awww thank you hunny. I just met with caseworker and she said I do need to start working on somewhere else to go cause the daycare and housing keeps turning me down. I have until [DATE] and they not kicking me out but will meet every week after that until I find something else. Gotta start calling other shelters and programs and stuff. Keep me informed on truck and the house and stuff. Don't worry it will work out. Gotta call [NAME] City today and see about license and just duties duties. -The resident texted: The truck is at the house I'll try and find out if house empty. When I find out I'll let you know. the truck is yours if you want. wound (would) $3500 work for you? If not then talk to me, love (heart emoji) sweet mommy it's [NAME] cakes. -HA A texted: Oh thank goodness. Finally got one thing of good good news. Friday 1/27 my drivers license was reinstated What kind of truck is it? Year and stuff so I can take a look. How many miles on it; -The resident texted: It is a 2003 ford f150 4.3 engine king cab, short box, has new tires brakes good all lights work. It is two tone gray 100119 . I put [NAME] flares and running boards interior is good no holes, plastic fish not cracked. -The resident texted: I need to check my text before sending I'll pay my personal tax bill I have good ins (insurance) agent, cost about $70.00 a month fyi -HA A texted: King cab means back seat space or no? I appreciate your sweet help so much [NAME] cakes little half doors with seats? Or 4 doors whole seats. Automatic transmission? No mechanical like engine transmission problems. A good truck. You would drive it to Washington?! Hahaha. Good miles too been dreaming of a car at 100K or less. Need a good ride for us so badly. And would you write gift on the title so I pay less taxes. Lol and yes. I will need to get insurance. Just regular insurance yay!! -The resident texted: Little 1/2 doors up yes automatic transmission. Yes would drive any were. Less than 100k will costs 15kto 20k yes has a back seat has chrome side rails and a headache rack behind cab -HA A texted: Yes I know it haha that's why it's always been my dream. But 100119 is good enough for me! Sounds great (thumbs up emoji) yes. I need to do that as long as it's a good running truck u believe will get me thru next 5 years or so -So it looks like this kinda. With the cab and short butt. Do you think 2 of those carseats would bit in the back row? Kids not really supposed to be in front seat. Safer (picture of a Ford F-150 truck) -The resident texted: I had new head gasket installed in May of last year I would trust as long as no drag racing. I need to get the exhaust welded at the y but I'll take of this for you yes. Last time I looked up blue book it was about $6000 -HA A texted: id the head gasket blow or you replaced it? No bent pistons and all that LOL I'm almost a mechanic myself. No cracked block or nothing. (2 lip emoji) -The resident texted: Nothing I would not do that to you!!! no my mechanic said this engine has a history of blowing gasket mine were almost blown, should be good to 600000 miles he said. Body is good no dents no accidents!! Oil filter changed every 2000 miles has up graded air filter. Has a bed liner also!! -HA A texted: Awwww yay!!! I'm very excited. Thanks so much for caring about us. -The resident texted: AC and heater work -HA A texted: I love you so much (beating heart emoji) no one has truly been there for me like this. So the back seats are the little ones that fold right? Do you think the carseats will fit in the back -The resident texted: You are the only one I would do this for!! Yes I think car seats will fit the seats don't fold a person can sit back there I keep telling you -On 1/31/23: -The resident texted: Good morning new truck owner. Ya! So glad this helps you out, all i want is to protect you and your boys and shower you with (heart emoji). I think you heal your self now with Gods help and some good loving from me! Hope to see your beautiful face today! I love you sweet mommy (3 heart emoji) -The resident texted: I got price to replace exhaust. Will get it done my cost -HA A texted: I love you sweet [NAME]. Good morning. (2 heart emoji) -Unknown Date: -The Resident texted: What did you think of your rings? -HA texted: They are really pretty. (Heart face emoji) -HA A texted: It's ok. Will get it to u. Yes Ill come to ur appointment. The card been the emergency plan until my new card gets here. Hope it hurries cause I got money like I cant spend. Lol stupid. GM. My card wont work for daycare lol ughh neither will urs. Fun. Ugh cant do nothing until my new card gets here . Okay. What time where is tomorrow. Yes Ill come visit with you (heart emoji); Struggling to stay happy or even know what to do. But trying. -On 1/31/23, HA A texted: -I love you sweet [NAME]. Good morning. (2 heart emojis); -Your looking so good and healthy [NAME] today (kissy face emoji) love you; -So excited (smiling face emoji) -I'm still here just working. Love you you look happy and good today (content smiling face and heart emoji); -Yes [NAME] cakes dollar general or work parking lot or something works just fine (3 heart emojis); yes I need to do the vehicle right away so I can get full time at work. They are thinking of renting the apt there for me for 3 months . So the truck helps me be able to do that in getting full time. Like as soon as I can drive I can get kids in daycare further with openings and work more (heart emoji and strong arm emoji) I am going to get my license valid Monday. Funds will be here soon (celebration hands emoji) -Sweet dreams hunny.(2 heart emojis); -On 2/1/23, HA A texted: -Ok yes [NAME] cakes. All is sounding good. I will give you my information and you can see how much to add me to your insurance. I do liability and usually still 100. so maybe too much if you do full coverage. I will check into a couple too just for solo insurance. Get it figured out soon. So excited! I love you. -I love you too! So much. Miss you hunny (2 heart emoji); -Aww Love you too hunny. Sweet dreams. Very thankful to have you. (3 heart emoji); -On 2/2/23, HA A texted: -Good day honey. -Trying to hang on but it comforts me knowing we have a place to go with a wonderful man that cares about us. For real. You mean a lot to me [NAME] cakes. -I love you too. -I love u too so blessed to have u in our lives. A great role model for my men. -Thanks so much. I will take a ride out if I have to and get there. Be waiting for u. Don't know what I would do without my [Resident name] cakes hehehe -Love you sweet dreams. -On 2/4/23, HA A texted: -Love you; -Good night [NAME] cakes. Love you. Record review of HA A's personnel file showed his/her last day worked was 2/3/23. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning), dated 2/4/23, showed: -He/she was cognitively intact. -His/her mood score a 7 on a scale of 7 out of 15, where 7 equaled the resident was moderately depressed. --He/she felt down, depressed, or hopeless. --He/she had difficulty in falling or staying asleep. --He/she was tired little energy. --He/she had trouble concentrating on things. --He/she moved or spoke slowly that other people noticed or was fidgety. During an observation and interview on 3/1/23 at 10:05 A.M., the resident rubbed his/her hands together and wiped a tear from his/her eyes. The resident said: -HA A worked at the facility he/she was a tremendous con artist. -HA A had went a to doctor's appointment with him/her in November 2022. -The two of them seemed to have a lot in common. -They started texting and it got interesting. -The HA told him/her about his/her children and that he/she needed to borrow money to get medicine for them. -He/She gave the HA his/her debit card and he/she pulled out $100 what was agreed on. -The HA then said he/she needed to pay to get kids into day care. -He/She agreed and let the HA have $200 which was all he had. -The HA was supposed to buy the resident's truck. -The HA was supposed to go to the town where he/she was from and get the keys to the truck from his/her landlord and the truck from his/her ex-spouse. -The HA was also supposed to get the house key from the landlord to be able to move into it when his/her ex-spouse moved out. -He/She said this was about six weeks ago. -After HA A had the truck he/she drove up to see the resident and told him/her there was some problems with the truck. -He/She told HA A he/she would knock the price down. -He/she told HA A to give him/her $3,000 and use the $5,000 he/she reduced it to, to fix the truck. -The shop the HA took the truck to wanted $3,000 to fix it. -HA A sent the resident a Dear [NAME] text on 2/28/23 saying he/she just wanted to be friends due to their age differences and he/she was done with him/her. -He/She bought HA A soulmate rings in November 2022. -He/she had also bought the staff person a promise ring. -The rings cost $50 each. During an interview on 3/1/23 at 3:21 P.M., CNA B said: -On Sunday 2/26/23, the resident had what looked like an engagement ring and a wedding ring on his/her bedside table. -He/She thought the rings belonged to the resident and spouse since he/she had mentioned several times in past they were divorcing. -The resident was crying and he/she assumed it was the resident's spouse's ring. -He/She told the resident he/she shouldn't torture his/herself like this. -He/She said something to the resident about the rings being his/her spouse's ring. -The resident said no, it was not his/her spouse's ring it was supposed to be for a friend. -The resident did not mention the friend's name. During an interview on 3/2/23 at 1:47 P.M., Certified Medication Technician (CMT) B said: -On 2/28/23, in the morning, the resident was broken hearted, disappointed, and disgruntled. During an interview on 3/2/23 at 2:45 P.M., Licensed Practical Nurse (LPN) B said: -The resident normally was alert and oriented times four, very polite and pretty much independent with his/her cares. -On 2/28/23 in the morning the resident was normal, nothing out of the ordinary. -By lunch the resident was sad, crying and upset. -He/She found the resident with his/her call light cord around his/her neck and his/her face very dark red. -Everybody had a feeling there was something between the resident and the HA, but where not sure what it was. Record review of the Social Services Designee (SSD)'s written statement, dated 2/28/23, showed: -At approximately 3:25 P.M., he/she went to the resident's room. -When he/she entered the resident's room he/she was lying on his/her right side and appeared to be sobbing. -He/she walked over to the resident and held his/her hand. -He/She told the resident it was going to be ok. -He/She sat with the resident until the police arrived. -The police were talking to the resident and he/she handed his/her phone to the police officer. -The police officer stated that it appeared that the resident was upset due to a person stating he/she wasn't in a relationship with the resident. -The police officer stated it appeared that a person had been asking for money. -The police officer asked if this person worked here. -He/She stated the person was a former employee who hadn't worked in around a month. -The police officer asked if he/she knew that the resident had given the person a truck. -He/she stated the situation was shocking as nothing had ever been said. Record review of the resident's Hospital Emergency Department Note, dated 2/28/23, showed: -Resident admitted thoughts of self-harm, had plan, acted on the plan and self-inflicted trauma. -He/she presented as crying and tearful. -The resident reported HA A had texted him/her and wanted to be only friends. He/she had given HA $700 and a truck. He/she was upset and attempted to hang him/herself with the facility call light. Record review of the facility investigation, dated 2/28/23, no time noted, showed: -HA A had: --Befriended the resident under false pretense. --Led the resident to believe they were in a relationship. --The resident had signed the title of his/her truck over to him/her. During an interview on 3/1/23 at 9:40 A.M., the Hospital Behavioral Health Facility's Program Director said: -The resident allegedly gave the staff person $700 and signed his/her truck over to the staff member. -Now the staff member just wants to be friends. During observation and interview on 3/1/23 at 10:39 A.M., the Hospital Behavioral Health Facility's Program Director said: -The resident had allowed the program director to access his/her phone and copy the text messages between him/her and the staff person from the nursing facility from January 17, 2023 at 8:12 P.M., to February 28, 2023. -The program director said: --There was talk between the HA and the resident about using his/her credit card. --A text message dated January 19, 2023 at 11:02 A.M., showed the HA left things in the resident's notebook in case he/she gets searched and that he/she needs the resident's debit card. --A text message dated January 19, 2023 at 11:37 A.M., showed the HA will have to grab the resident's debit card the next time he/she is there. During an interview on 3/2/23 at 11:51 A.M., CMT A said the resident told him/her: -A person took his/her truck. -He/She thought the person loved him/her and now he/she doesn't have a truck. -HA A was the person. -He/She said this is the first he/she had heard of this. -HA A had told him/her at one time that he/she was buying a truck, but didn't say who it was from. -HA A was staying in a homeless shelter and talked about all the improvements in his/her life and had got his/her taxes and a truck. -He/she took the resident back to his/her room. -The resident had calmed down and said he/she would be ok. -He/She went to let the Assistant Director of Nursing (ADON) know about the information the resident just told him/her about. -The ADON was on the phone, so he/she told the SSD. During an interview on 3/1/23 at 3:44 P.M., the ADON said: -On 2/28/23, the resident was crying when he/she was telling the police about the text messages on his/her phone about a person who got his truck and money. During a phone interview on 3/3/23 at 10:10 A.M., HA A said: -He/she left the faciity on his/her own and no longer worked there. -He/she quit working at the facility on either 2/6/23 or 2/7/23. -Resident #500 was a resident at the facility. -He/She was the HA and answered call lights, took drinks and meals to the residents. -He/She walked to work. -Resident #500 had a truck for sale and offered to sell it to him/her due to his/her walking to work. -The resident and his/her spouse were divorcing and both wanted to sell the truck. -He/She was going to buy the truck and did buy the truck from the resident. -Both the resident and his/her wife signed the truck over to him/her. -He/She picked the truck up from the resident's spouse's house on 2/9/23. -The resident then wanted to be together with him/her after he/she quit working at the facility. -He/She had texted the resident only about his/her surgery and about getting the truck fixed before he/she bought it. -He/She bought the truck unfixed and texted him/her about the suspension issues. -He/She was paying the resident $1200 for the truck after the repairs are done. -He/She got the keys and the truck title from the resident's spouse. -The resident put him/her on his/her truck insurance until he/she gets his/her tax returns. -Then he/she will title the truck and get insurance on it with the tax money. -The resident offered to do all of this for him/her without his/her asking for anything. -The resident was concerned about his/her struggles and his/her kids. -The resident never gave him/her $700 or any other cash. During an interview on 3/2/23 at 4:50 P.M., the Director of Nursing (DON) said it is not ok for employees to take money, gifts or have a relationship with a resident. During an interview on 3/14/23 at 1:32 P.M., the resident said: -He/she was still in the hospital. -He/she had felt hurt, angry, and violated. -On 2/28/23 after receiving HA A's text just wanted the hurt to go away. -HA A had told him/her from the beginning that no one could know they were more than employee and patient or HA A would lose HA A's job. -HA A had told him/her in the beginning he/she could be the parent HA A never had and the grandparent to HA A's children. -The relationship had begun in December 2022, HA A had sent a picture of him/herself in front of the Christmas tree. -HA A had kissed him/her on the head and on the cheek twice. HA A had hugged him/her. -HA then needed help with money and HA A told him/her, I love you. -HA A called him/her [NAME] cakes and he/she called HA A mama bug. -HA A had accepted soulmate rings from him/her. -HA said he/she would wear the rings around his/her neck. -The relationship had changed or at least he/she thought it had. -HA A would come and spend HA A's breaks when working at the facility and check in with him/her before leaving. During an interview on 3/14/23 at 4:15 P.M., the Administrator said on 2/28/23: -The resident was upset and crying. -He/She did not know anything about the relationship until the police were talking to the resident and the resident told what had gone on between him/her and the HA. During an interview on 3/15/23 at 1:01 P.M., the DON said: -Did not work on 2/28/23. -He/She didn't know about the resident giving truck to an ex-employee until the State surveyor came into the facility for investigation. -It is not ok or appropriate for staff to take, accept money, gifts or have a relationship with a resident. MO00214739 & MO00214746

Based on interview and record review, the facility failed to obtain a physician's order for and the cares for, and document the care of a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine); and failed to obtain orders for and the care of and to document care of a Colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen) for one sampled resident (Resident #501) out of three sampled residents. The facility census was 86 residents. Record review of the facility's Colostomy/Ileostomy (an alternative exit from the ileum [the last part of the small intestine] to divert waste through a hole in the wall of the abdomen) Care policy dated October 2010 showed: -The purpose of care is to prevent exposure of the resident's skin to fecal matter. -The following information should be recorded in the resident's medical record: --The date and time care was provided. --The name and title of the individual(s) who provided the care. --Any breaks in the resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation (wear off) of skin. --How the resident tolerated the procedure. Record review of the facility's Foley Catheter Insertion, Female Resident policy dated October 2010 showed: -Verify that there is a physician's order for this procedure. -Document the following: --The date and time care was provided. --The name and title of the individual(s) who provided the care. --All assessment data (i.e., character, color, clarity, etc.) obtained during the procedure. --The size of the Foley catheter inserted and the amount of fluid used to inflate the balloon. --How the resident tolerated the procedure. -Notify the physician of any abnormalities (i.e., bleeding, obstruction, etc.). Record review of the facility's Catheter Care, Urinary policy dated September 2014 showed: -The purpose is to prevent catheter-associated urinary tract infections (CAUTIs). -Maintain an accurate record of the resident's daily output, per facility policy and procedure. -Check the resident frequently to be sure he/she is not lying on the catheter and to keep the catheter and tubing free of kinks. -Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended; rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. -The following information should be recorded in the resident's medical record: --The date and time care was provided. --The name and title of the individual(s) who provided the care. --All assessment data obtained when giving catheter care. Record review of the facility's Catheter-Urinary Catheter, Changing policy dated (no Month noted) 2016 showed: -Indwelling urinary catheters will be changed based on assessment of the catheter for malfunction, infection or closed system compromise and not at arbitrary intervals, due to increased risk of infection and other urinary complications. 1. Record review of Resident #501's Admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Chronic (persisting for a long time or constantly recurring) kidney disease (CKD- is a condition characterized by a gradual loss of kidney function over time) or End Stage renal Disease (ESRD-The kidneys have stopped working well enough to survive without dialysis or a kidney transplant). -Diabetes Mellitus type II (condition that affects the way the body processes blood sugar [glucose]) with diabetic nephropathy (affects the kidneys' ability of removing waste products and extra fluid from the body). -Chronic Candidiasis (infection caused by a yeast [a type of fungus]) of the genitalia. -Hydronephrosis (swelling of a kidney due to a build-up of urine) with renal (kidney) and ureteral calculous (stones that have formed in the kidney and passed front the renal collecting system into the ureter) obstruction. -Colostomy status. -Sepsis (body's extreme response to an infection), unspecified organism. Record review of the resident's Progress notes and Nurse's Notes for February 2023 showed no documentation of any cares for the resident's Foley Catheter or Colostomy. Record review of the resident's Physician's Order Summary (POS) dated 2/1/23 showed: -No order for a Foley Catheter, size of the catheter to be placed or amount of fluid to inflate the retaining balloon on the catheter. -No order for the care of a Foley Catheter. -No order for the care of a colostomy. Record review of the resident's Nurse's Note dated 2/2/23 at 3:15 A.M, showed: -The resident entered the facility by stretcher from a hospital. -Had a Foley catheter with yellow mucus looking drainage -Had a Colostomy. Record review of the resident's Baseline Care Plan (written out plan for the care of the resident) dated 2/2/23 at 9:05 P.M., showed: -Under bladder function that he/she had a catheter. -Under bowel function he/she was not continent of bowel. -Under medical conditions he/she had an ostomy. --Did not specify the type of ostomy. Record review of the resident's Skilled Note dated 2/3/23 showed the resident had a Foley catheter. Record review of the resident's Physician's Progress Note dated 2/5/23 at 1:26 P.M., showed: -Colostomy on 10/18. Record review of the resident's Nutritional assessment dated [DATE] showed the resident had a Colostomy. Record review of the resident's Progress Note dated 2/13/23 at 11:19 P.M., showed the resident was transported to the hospital for difficulty breathing. Record review of the resident's Treatment Administration Record (TAR) dated 2/1/23 -2/28/23 showed: -Change Foley catheter bag weekly on Sunday night for catheter care dated 2/12/23 and documented as completed on 2/12/23. -Change Foley catheter as needed (PRN) for catheter care when blocked or dislodged dated 2/12/23. The order did not include the size of the catheter tube or the size of the balloon. -Change catheter securement device every week, every 7 days dated 2/13/23 and documented as completed on 2/13/23 -Change catheter tubing and bag every month on the night shift dated 2/15/23 and documented as completed on 2/15/23. -Change Foley catheter every night shift every 30 days for catheter care dated 2/15/23 and documented as completed on 2/15/23. --NOTE: the resident had discharged from the facility to the hospital on 2/13/23 and had not returned to the facility as of 3/2/23. -No orders or the resident's colostomy including directing staff how and how often to provide colostomy care. -No orders for Foley catheter care including directing staff how often to cleanse the catheter insertion site. During an interview on 3/2/23 at 11:48 A.M., Certified Nursing Assistant (CNA) C said: -Cleans a Foley catheter tubing when doing peri care at least once a shift. -He/She does not document Foley catheter care since it is just part of routine cares for a resident with a Foley catheter. During an interview on 3/2/23 at 12:06 P.M., CNA A said: -Cleans a Foley catheter tubing each shift when doing peri cares. -He/She does not document Foley catheter care since it is just part of routine cares for a resident with a Foley catheter. -Does not know much about this resident. -Thinks the resident did not have much urine output he/she went to dialysis. -The resident also had a colostomy bag. -The colostomy bag sometimes would get loose on a side and have to be changed at least daily. -The resident would call the staff if colostomy bag was leaking and needed to be changed. -The CNA or nurse can change the colostomy bag. During an interview on 3/2/23 at 3:25 P.M., Licensed Practical Nurse (LPN) D said: -He/She would expect to have a doctor's order to have, and the care of a Foley catheter or a Supra pubic catheter (a hollow flexible tube that is used to drain urine from the bladder and inserted through the abdominal wall into the bladder) if a resident had one. -He/She would also expect to have a doctor's order to have and the care of a colostomy. -Orders should be on the Physician's orders and printed out on the TAR. -The nurse charts on the TAR when cares are completed. During an interview on 3/2/23 at 3:32 P.M., RN A said: -Residents should have orders on the POS sheet if have they have a catheter or colostomy. -Orders would be on the TAR for nurses to chart on. -Would expect orders to be followed. During an interview on 3/2/23 at 4:22 P.M., (LPN) D said: -He/She found no physician orders for the resident for a Foley catheter and cares or for a colostomy and cares on the electronic chart. -He/She found orders the Foley catheter and cares on the resident's electronic TAR. -He/She did not find any orders for the resident's colostomy cares on the electronic TAR. During an interview on 3/2/23 at 4:50 P.M., the Director of Nursing (DON) said: -There should be an order for a Foley Catheter including the size of the catheter and of the balloon and when to change the Foley Catheter. -There should be an order for the colostomy care. -These should be documented on the TAR. -The resident's Foley catheter and colostomy should be on his/her Care Plan. -Nursing should get orders if there were no orders for the Foley or the colostomy. -The nursing team and the Assistant Director of Nursing (ADON) should check for and be sure orders have been written. MO00214046

Based on observation, interview, and record review, the facility failed to ensure the environment remained free from accident hazards by not assessing for safe smoking practices for one sampled resident (Resident #340) out of 19 sampled residents. The facility census was 95 residents. Record review of facility's undated policy titled Smoking Policy and Acknowledgement showed: -All residents must be supervised by a facility staff member or personal family member at the designated location. -Smoke breaks were outside in a designated area. -Facility staff member would only supervise smoke breaks at the designated times. -The policy did not include a safe smoking assessment was to be performed for the resident who smoked or be assessed for any special equipment the resident needed while he/she smoked. 1. Record review of Resident #340's Admission Record showed he/she was admitted on [DATE] with the following diagnosis [CONDITION(S)] ([CONDITION(S)] - a disease process that decreases the ability of the lungs to perform ventilation). Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 9/5/22 showed he/she: -Was moderately cognitively impaired. -Smoked. Record review of residents undated care plan showed the resident: -Was dependent on tobacco. -Was educated on smoking risks and hazards. -Was instructed on the facility policy for smoking. During an interview on 9/12/22 at 2:25 P.M., the resident said he/she smoked and went out on the smoke breaks when the facility had them. Record review of the resident's medical record on 9/14/22 showed there was no documentation that a safe smoking assessment had been completed. Observation on 9/15/22 at 2:26 P.M. the resident was outside smoking with nine other residents. During an interview on 9/16/22 at 9:18 A.M., Licensed Practical Nurse (LPN) A said: -He/she was unsure how often a smoking assessment would be done. -A smoking assessment should have been performed before the resident smoked for the first the time at the facility. -He/She did not know who assessed the resident for safe smoking and filled out the assessment. During an interview on 9/15/22 at 1:00 P.M., Registered Nurse (RN) A said: -A safe smoking assessment would be completed on the resident before the resident ever smoked at the facility. -The assessment would have covered if the resident would be able to perform the actions needed to smoke in a safe manner, or if any special equipment was needed. During an interview on 9/20/22 at 12:04 P.M., the Director of Nursing (DON) said: -It was his/her expectation that a safe smoking assessment would be done upon admission if a resident smoked. -It was his/her expectation that a safe smoking assessment would be done prior to resident smoking at the facility.

Based on interview and record review, the facility failed to ensure one sampled resident (Resident #81) was free from abusive acts when one sampled resident (Resident #25) who had a known history of aggression, anger issues, yelling, hitting and kicking other residents struck the resident in his/her face causing reddened areas to his/her left cheek, nose and the left side of his/her upper lip with a small amount of blood noted out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's policy Behavioral Assessment, Intervention and Monitoring policy revised 3/2019 showed: -The facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment. -Behavioral health services would be provided by qualified staff who have the competencies and skills necessary to provide appropriate services and treatment. -The Interdisciplinary Team (IDT) would thoroughly evaluate new or changing behavioral symptoms in order to identify the underlying causes and address and modifiable behaviors. -The IDT would evaluate the behavioral symptoms of residents to determine the degree of severity, distress, and potential safety risks. -The care plan would incorporate the findings. -The interventions would be individualized and part of the overall care environment that supported physical function and psychosocial needs. Record review of the facility's policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 showed: -The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: --Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone. --Develop and implement policies and protocols to prevent and identify: ---Abuse or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] --Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. --Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems. 1. Record review of Resident #81's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) date 8/22/22 showed the resident: -Was admitted to the facility on [DATE]. -Had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . -Had no behaviors. -Required extensive to total assistance with all cares. -Used a wheelchair for mobility. 2. Record review of Resident #25's Admission Record showed he/she was admitted to the facility on [DATE] and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Traumatic brain injury (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile). -SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, [CONDITION(S)] and sensory processing problems). -[CONDITION(S)] disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems). -Restlessness and agitation. -[CONDITION(S)] (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). -Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society). -Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation). Record review of the resident's admission MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Had fluctuating inattention. -Had physical behaviors directed towards others one to three days out of seven. -Had no verbal behaviors directed towards others. -Had no other behaviors not directed towards others (e.g. hitting self, screaming). Record review of the resident's Preadmission Screening and Resident Review (PASARR) II (determines if the intellectual disability or serious mental illness of the individual can be met in a nursing facility or if the resident requires specialized services), reviewed on 6/7/22 by the Central Office Medical Review Unit (COMRU - reviews the DA 124 assessment forms for the PASARR) showed: -The resident had an Intellectual Disability ( when there are limits to a person's ability to learn at an expected level and function in daily life) and a substantiated dementia ( chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) or related condition and required nursing facility services. -Due to the resident's TBI he/she had problems with impulsive behaviors and anger control. -His/her reported moods could be labile (rapid, exaggerated changes) and he/she struggles with expressing emotions appropriately. -He/she has a guardian to assist with major life and financial decisions and requires 24 hour support. -The resident needs assessment and implementation of a behavioral support plan, monitoring of behavioral symptoms, and provision of behavioral supports. Staff should identify precipitating factors which may exacerbate his/her volatile behaviors. A structured, low-stimulation environment should be provided. He/She will require continued psychiatric follow-up and medication management and periodic review of medications. Establish consistent routine, provide daily tasks/activities and assess and plan for the level of supervision required to prevent harm to self or others. The plan should identify clear steps to manage the individual's behavior in a crisis situation, who to contact for assistance, and how staff will work together in a crisis. Record review of the resident's Potential for Physical Aggression Care Plan, updated on 6/21/22 showed: -The resident's triggers for physical aggression were paranoia that others were talking about him/her. -An intervention added on 6/21/22 showed the resident's behaviors were de-escalated by 1:1 attention and reassurance and attempts to calm him/her. -The Care Plan did not include the assessment and implementation of a behavioral support plan, monitoring of behavioral symptoms, and provision of behavioral supports. Staff should identify precipitating factors which may exacerbate his/her volatile behaviors. A structured, low-stimulation environment should be provided. He/she will require continued psychiatric follow-up and medication management and periodic review of medications. Establish consistent routine, provide daily tasks/activities and assess and plan for the level of supervision required to prevent harm to self or others. The plan should identify clear steps to manage the individual's behavior in a crisis situation, who to contact for assistance, and how staff will work together in a crisis. Record review of the resident's Behavioral Nurses' Notes for July, August, and September 2022 showed many notes were not detailed enough to help staff in fully assessing and addressing the resident's needs and behaviors. For instance many notes did not show: -What precipitating factors contributed to the resident's behaviors. -Whether or not the resident was asked what was upsetting him/her at the time of his/her agitation to help staff in identifying the resident's thought processes, or unmet emotional or physical needs that might trigger behaviors. -What non-pharmacological interventions were used to try to de-escalate behaviors and whether or not they were successful. -Whether or not the resident was able to calm down on his/her own or if interventions or cuing was needed to help the resident de-escalate. -How long the resident's behaviors lasted. Record review of the resident's electronic record (e-record) showed: -There was no comprehensive evaluation of the resident's behaviors and no detailed plan to address the behaviors which had not decreased over time. -The resident's Physical Aggression Care Plan did not show factors precipitating behaviors other than the resident thinking others were talking about him/her. The care plan did not address the resident's frustrations of being told he/she could not smoke, having to wait for food, or other observed frustrations the resident experienced and how staff were to address these. -There was no documentation that staff were educated on how to manage and work with the resident's specific behaviors. -There was no documentation showing how the facility was working with the resident's Guardian or psychiatrist to address the resident's behaviors. -There was no documentation what role various disciplines like social services, nursing and activities could play in helping to address the resident's needs. -There was no documentation the facility had evaluated trends related to the resident's behaviors such as: --The time of day or shifts most behaviors took place. --The specific employees working at the time of behaviors. --The number of staff working when most of the behaviors took place. --The most common precipitating factors triggering behaviors. --Evaluations of the most and least successful interventions implemented. --Periods of time when the resident had the fewest behaviors and circumstances surrounding those times (specific staff working, interventions being implemented, medications that were successful). 3. Record review of Resident #25's Incident Investigation, dated 9/3/22 showed: -On 9/3/22 at 12:12 P.M. the resident was witnessed hitting another resident (Resident #81) in the face. -The charge nurse notified the Director of Nursing (DON) and said the Rehabilitation Assistant (RA) was to assist the resident with lunch and when he/she didn't return quick enough the resident rolled his/her wheelchair next to the Resident #81 and hit him/her. The incident happened during lunch as the meal trays were being passed. -The responsible parties for both residents and the physician were notified. -The resident was sent to the hospital where the case manager was going to try to get him/her into a psychiatric evaluation hospital. -The resident returned from the hospital. --Staff were informed by the hospital he/she was not admitted because the resident couldn't be kept safe from other patients. -Registered Nurse (RN) A said he/she was sitting at the nurses' station as the resident sat in his/her wheelchair on the 300 hall in front of the therapy gym waiting for the RA to return and assist him/her with his/her meal. The resident self-propelled toward the nurses' station and turned down 200 hall where the Resident #81 sat in his/her geriatric chair (Geri-chair) without signs of agitation or provocation. The resident hit Resident #81 with his/her half-opened hand because he/she was tired of waiting. The RA's statement showed he/she was coming from the 200 hall toward the nurses' station when he/she saw the resident hit Resident #81 in the face and immediately moved the resident away from Resident #81 as the nurse checked him/her (Resident #81) for injuries. -The resident said Resident #81 tried to kick him/her at which time RN A told the resident that was not what happened. Then the resident said Yeah, he/she took too long referring to the RA whom he/she was waiting on for assistance with his/her meal. -Resident #81 was examined and was noted to have reddened areas to his/her left cheek, nose and the left side of his/her upper lip was slightly swollen with a small amount of blood noted. -After the physician was notified an order was received to transport the resident to the hospital for psychiatric evaluation and treatment. -Based on information gathered from interviews with staff and residents, it appeared the resident was unable to rationalize how much time it would take the RA to assist with hall trays before assisting him/her which created anxiety and frustration. As a result the resident displayed physical aggression (a behavior) to get the staff to respond to him/her. -Intervention created for the physician to see the resident regarding his/her physical aggression and recent incident. New orders on 9/7/22 to discontinue [MEDICATION(S)] and [MEDICATION(S)] (generic for [MEDICATION(S)], a benzodiazepine often used to treat depressive disorders) and start [MEDICATION(S)] (an anxiolytic used to treat anxiety and panic disorders) 0.5 milligram (mg) three times daily and to increase [MEDICATION(S)] (an antipsychotic medication which can decrease hallucinations (perceptions, such as hearing or seeing things which are not really there) and improve concentration) to 10 mg four times daily. Record review of the resident's Potential for Physical Aggression Care Plan, updated 9/3/22 showed a new intervention that staff encourage the resident to remain in his/her room when agitated. Record review of the resident's Nurses' Note dated 9/3/22 at 9:58 P.M. showed: -The Certified Medication Technician (CMT) just told this nurse that the resident was threatening to come kick their ass because they were talking about him/her. -The resident said he/she was going to kill them and [NAME] them into the ground. During an interview on 9/15/22 at 9:39 A.M. the RA said: -About 2 weeks ago he/she was mid-way down the 200 hall and saw the resident and another resident talking. The other resident said something and before he/she could reach him/her the resident had hit the other resident with his/her fist. The resident was not provoked by the other resident. -He/she wasn't sure if the resident was hit on the mouth or how hard he/she was hit. The resident had been in the midst of talking when he/she was hit. -The resident said he/she thought the other resident was talking bad about him/her. He/she assured the resident he/she wasn't. -The resident was paranoid. He/she thought others were talking about him/her or people he/she liked quite often and would get upset and would raise a fist, yell out or start muttering. -A lot of staff don't know how to handle the resident. He/she didn't tell the resident no. He/she would get the resident a soda or ask him/her to wait until later for something he/she wanted. -The resident would hit his/her wheelchair or other surfaces when told no by staff. They sometimes talked to the resident like he/she was a kid. Some staff didn't know how to deal with him/her. -The resident got upset when he/she couldn't have a cigarette or vape. His/her guardian wouldn't allow him to smoke or vape, but he/she wasn't sure why. He/she might burn himself/herself with a cigarette. The resident's right hand was shaky and he/she was inattentive. His/her left arm was contracted. He/she took the resident out when others smoke. Others tell the resident no when they take other residents out to smoke. The resident would tell him/her thanks for the smoke when he/she took him/her out even though he/she hadn't smoked. -There had been no recent education about dealing with the resident's behaviors. The facility sometimes did inservices on individual resident behaviors, but he/she couldn't remember ever receiving education on the resident in particular. -He/she heard about the resident being aggressive with others. The resident hit one of the CMT's in the head twice during one incident and he/she punched the evening night nurse and hit another resident. -When he/she was told absolutely no he/she became upset and aggressive. -That was why he/she kept the resident close to him/her during his/her shift. -A lot of incidents happen during the evening and night shifts with the resident. During an interview on 9/16/22 at 10:02 A.M. the resident said: -He/she and the other resident were enemies. -He/she didn't know how the incident started between him/her and the other resident. -He/she couldn't remember what the other resident did to make him/her mad and couldn't remember what the other resident said. -He/she didn't remember hitting the other resident. -He/she probably thought the other resident was talking about the nurses. It made him/her mad when he/she thought someone was talking badly about the nurses. -Sometimes he/she would hit the wall when he/she was upset. -He/she wanted to smoke big time, but his/her guardian didn't want him/her to smoke. -His/her guardian thought he/she owned him/her. It was because of [CONDITION(S)] (Chronic Obstructive Pulmonary Disease - a disease process that decreases the ability of the lungs to perform ventilation) that he/she couldn't smoke. His/Her guardian thought the smoking would kill him/her, but it won't. It made him/her mad when he/she couldn't smoke. -He/she thought he/she had hit one staff when they said he/she couldn't smoke and the nurse was going out to smoke. -He/she probably tried to hit another resident as well, but he/she couldn't remember. -He/she had a bad anger problem. -He/she saw a psychologist or counselor who visited the facility during the week. -When he/she was upset staff would try to get him/her in another spot where he/she could calm down which often helped, although sometimes he/she didn't want to go to another area. During an interview on 9/16/22 at 10:49 A.M. CNA B said: -The resident thought everyone was talking bad about him/her when they were talking about other things or talking bad about staff he/she liked. -Usually the resident would cuss and bang his/her elbow, hand or head against the wall. -Sometimes he/she would roll up to a person he/she was mad at. -He/she was told by another CNA one time the resident hit another resident in the face maybe two months ago -About a month ago in the dining room he/she saw the resident stick his/her foot in a resident face. It didn't touch his/her face. The resident just kind of sat there and didn't react. He/she didn't seem afraid. He/she took the resident out of the dining room and told the charge nurse about it. He/she sat with the resident near the nurse' station. -Usually staff just seat the resident near the nursing station after aggressive incidents. During an interview on 9/16/22 at 11:08 A.M. CNA C said: -He/she had seen the resident hit the wall, tables, and his/her chair when irritated. He/she wanted things right away. Any time the resident got aggravated he/she did this. Staff tried to find out what he/she was aggravated about. -He/she didn't think the resident had control of his/her aggression. -It helped the resident's behavior if staff offered to help him/her lay down in bed. He/She liked that and realized that helped him/her calm down. -The resident wanted to smoke. It made him/her upset he/she couldn't. -One time staff brought the resident outside with them when taking others outside to smoke because he/she liked to be outside. He/she was trying to rock hard to throw himself/herself out of his/her wheelchair. Staff had to bring the resident back inside. -Today the resident went out with staff when others went out to smoke and he/she was fine. It just depends. During an interview on 9/16/22 at 11:41 A.M. RN A said: -It was just he/she and the RA who saw the the resident hit another resident on 9/3/22. -The resident said the other resident made him/her mad, but never was able to explain why. -He/She was at the nurses' station around 1:00 P.M. charting and the other resident was in the hallway near the nurses' station. The resident had anger management issues partly due to his/her TBI diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident would throw a temper tantrum when not immediately getting his/her way and called staff names like [OBSCENITY] , whore, slut and says our butt stinks. He/She would swing out at and hit staff. -To his/her knowledge the resident had only made physical contact with two residents. Staff tried to keep him/her separated from other residents for that reason. -The RA would let him/her follow him/her around and would bring him/her into the physical therapy room where it was calm and quiet and keep him/her close to the nursing station. -When provided one to one attention the resident was great with no problems, but the facility didn't have staff to provide one to one staffing for him/her 24 hours a day. -On 9/3/22 the resident started down the 200 hall, He/She didn't hear anything the other resident said and the resident drew his/her arm back and hit the other resident with a closed fist on his/her lip, nose and left side of cheek. The other resident, with his/her dementia attempted to hit the resident back but he/she and the RA intervened before any other punches were thrown. The other resident had a scant amount of blood on his/her upper lip which was initially swelled that day. -The resident swung and made contact with him/her once. It didn't really hurt. He/she didn't necessarily do an incident if he/she isn't hurt. -The resident was not fully accountable due to his/her TBI. -The resident thought everyone was talking about him/her and became very upset about that. -Social Services had tried to get the resident in-patient psychiatric services and they told him/her they had no openings. After the 9/3/22 incident the facility put the resident on 15 minute checks for 72 hours. There was a 24 hour form for the 15 minute checks and the resident would have had it for 3 days. -He/she was not here when the resident hit the other resident. They tried to get the resident into an in-patient psychiatric setting then as well. The SSD said there was no bed available. -The resident would hit and punch himself/herself in the head, hit the wall and medication cart when upset. -Frequently the resident became upset when he/she saw others go out to smoke because he/she knows he/she can't smoke due to his/her [CONDITION(S)]. -The resident's psychiatrist has been changing his/her medications. During an interview on 9/19/22 at 10:30 A.M. the SSD said: -The resident's behaviors were hitting and punching the walls periodically throughout the day. -He/she was usually redirectable, but not always redirectable in the evenings. -The resident had some recent behavioral medication changes. -He/she had been in contact with the resident's guardian, but hadn't documented the calls. -Most of the time he/she, the RA, or charge nurse had the resident with them. -The resident saw psychiatrist routinely, but he/she couldn't find any of the psychiatrist's notes in his/her e-record. -He/she had tried to discharge the resident to a facility that dealt more with behaviors and to get psychological evaluations and treatment, but had been unable to find any facility who would accept the resident and didn't think the resident was appropriate for the facility's setting due to the extent of the behaviors. He/She was unable to provide documentation showing what facilities and hospitals had been contacted. -He/she had conversations with the resident about his/her behaviors, but had not documented the conversations or the resident's behavioral progress. -He/she did not schedule regular meetings with the resident to discuss his/her mood and behaviors. -No comprehensive root-cause analysis had been done related to the resident's behaviors. During an interview on 9/20/22 at 10:46 A.M. the DON said: -The resident doesn't always have control over his/her moods and would act out. -He/she was normally redirectable. -He/she didn't target any specific person. During an interview on 9/20/22 at 12:00 P.M. the DON said: -The facility had a psychiatrist who visited residents routinely. -They discussed behaviors in clinical meetings and documented behaviors in notes. -The IDT should try to determine the root cause of the resident's behaviors. -If residents had on-going behaviors there should be a detailed plan with specific interventions and all staff should know the interventions. -CNA's had access to care plans through the e-record. -CNA's were educated through shift change meetings regarding residents' behavioral interventions. MO 506

Based on observation, interview and record review, the facility failed to identify, assess, monitor and treat non-pressure wounds to the right great toe, the right little toe, the right ankle, the right Achilles tendon (fibrous tissue that connects the calf muscles to the heel bone)) and multiple scabbed areas over the resident's bilateral shins resulting in the non-pressure wounds worsening over the 42 day delay before treatment started for one sampled resident (Resident #14); to ensure the charge nurse reviewed and followed up with lab results for a resident suspected of having [CONDITION(S)] (C. Diff - an infection which typically occurs after use of antibiotic medications that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon); failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #47 and Resident #68) were witnessed taking their medications out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's Wound Evaluations policy revised 9/2018 showed: -The purpose of this procedure was to provide guidelines for the evaluation of current or new wounds. -Evaluation of wounds would be performed on admission, weekly, and on discovery. -Wound assessments may be completed by a facility nurse or an outside wound company. -The wound assessment would identify the type of wound, size, wound bed, drainage, odor, infection, healing, the surrounding skin and pain. -Evaluation results were communicated to the members of the care team through documentation, care plan meetings and care planning. -Wounds would be observed during dressing changes. Record review of the Missouri Certified Medication Technician, 2008 Revision manual showed: -Hand the medication to resident with a glass of water if needed. -Remain with resident until medication is swallowed. 1. Record review of Resident #14's Admission Record showed he/she was admitted to the facility on [DATE] and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -[CONDITION(S)] ([CONDITION(S)], stroke), cerebral artery occlusion with infarct (a blockage in the one or more of the arteries supplying blood to the brain resulting in a stroke). Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated 3/24/22 showed the resident: -Was cognitively intact. -Did not have any wounds on his/her body. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Did not have any wounds on his/her body. Record review of the resident's Weekly Skin Check dated 6/30/22 showed the resident did not have any new wounds identified during this skin check. Record review of the resident's Weekly Skin Check dated 7/7/22 showed the resident did not have any new wounds identified during this skin check. Record review of the Resident's Comprehensive Certified Nurses Assistant (CNA) Shower Review Sheet dated 7/13/22 showed: -The form was used for a visual assessment of the resident's skin while showering. Report any abnormal skin to the charge nurse immediately. -There were no skin issues marked on the form for the resident's legs or feet. Record review of the resident's Weekly Skin Check dated 7/14/22 showed the resident did not have any new wounds identified during this skin check. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 7/15/22 showed there were no skin issues marked on the form for the resident's legs or feet. Record review of the resident's Weekly Skin Check dated 7/21/22 showed the resident did not have any new wounds identified during this skin check. Record review of the resident's Weekly Skin Check dated 7/28/22 showed the resident did not have any new wounds identified during this skin check. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/3/22 showed the resident: -Had scabs on the side of his/her right lower leg. -Had scabs on the top of the right side of his/her right foot. Record review of the resident's Weekly Skin Check dated 8/4/22 showed the resident: -Did not have any new wounds identified during this skin check. -NOTE: the scabs on the side of his/her right lower leg were not identified. -NOTE: the scab on the top of the right side of his/her right foot were not identified. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/4/22 showed: -There were no skin issues marked on the form for the resident's legs or feet. -NOTE: the scabs on the side of his/her right lower leg were not identified. -NOTE: the scab on the top of the right side of his/her right foot were not identified. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/8/22 showed the resident: -Had scabs on the top of the right side of his/her right foot. -NOTE: the scabs on the side of his/her right lower leg were not identified. Record review of the resident's Weekly Skin Check dated 8/11/22 showed the resident: -Did not have any new wounds identified during this skin check. -NOTE: the scabs on the side of his/her right lower leg were not identified. -NOTE: the scab on the top of the right side of his/her right foot were not identified. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/12/22 showed the resident: -Had scabs on the front of his/her right lower leg. -Had an open area behind the right ankle. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/16/22 showed: -The resident had scabs on the front of his/her right lower leg. -NOTE: the open area behind the right ankle was not identified. Record review of the resident's Weekly Skin Check dated 8/18/22 showed: -The resident did not have any new wounds identified during this skin check. -NOTE: the scabs on the front of his/her right lower leg were not identified. -NOTE: the open area behind the right ankle was not identified. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/23/22 showed the resident: -Had scabs on the front of his/her right lower leg. -Had scabs on his/her right little toe. -NOTE: the open area behind the right ankle was not identified. Record review of the resident's Weekly Skin Check dated 8/25/22 showed: -The resident did not have any new wounds identified during this skin check. -NOTE: the scabs on the front of his/her right lower leg were not identified. -NOTE: the open area behind the right ankle was not identified. -NOTE: the scabs on his/her right little toe were not identified. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/28/22 showed: -The resident had scabs on the front of his/her right lower leg and left lower leg. -NOTE: the open area behind the right ankle was not identified. -NOTE: the scabs on his/her right little toe were not identified. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 8/30/22 showed the resident: -Had scabs on the front of his/her right lower leg. -Had a scab on his/her great right toe and on the little toe. -NOTE: the open area behind the right ankle was not identified. -NOTE: the scabs on his/her left lower leg were not identified. Record review of the resident's Weekly Skin Check dated 9/1/22 showed: -The resident did not have any new wounds identified during this skin check. -NOTE: the scabs on the front of his/her right lower leg were not identified. -NOTE: the scabs on the front of his/her left lower leg were not identified. -NOTE: the scabs on his/her right great toe were not identified. -NOTE: the scabs on his/her right little toe were not identified. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 9/2/22 showed the resident: -Had scabs on the front of his/her right lower leg. -Had a scab on his/her right great toe. -NOTE: the scabs on the front of his/her left lower leg were not identified. -NOTE: the scabs on his/her right little toe were not identified. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 9/6/22 showed the resident: -Had scabs on the front of his/her right lower leg. -Had a scab on his/her right great toe. -Had scabs on his/her left knee. -NOTE: the scabs on the front of his/her left lower leg were not identified. -NOTE: the scabs on his/her right little toe were not identified. Record review of the resident's Weekly Skin Check dated 9/8/22 showed: -The resident did not have any new wounds identified during this skin check. -NOTE: the scabs on the front of his/her right lower leg were not identified. -NOTE: the scabs on the front of his/her left lower leg were not identified. -NOTE: the scabs on his/her right great toe were not identified. -NOTE: the scabs on his/her right little toe were not identified. -NOTE: the scabs on his/her left knee were not identified. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 9/9/22 showed the resident: -Had scabs on the front of his/her right lower leg. -Had a scab on his/her right great toe. -NOTE: the scabs on the front of his/her left lower leg were not identified. -NOTE: the scabs on his/her right little toe were not identified. -NOTE: the scabs on his/her left knee were not identified. Observation on 9/13/22 at 12:41 P.M. showed: -The resident was in his/her recliner with lower legs and feet exposed. -The resident had multiple scabbed areas on the front of both lower legs up to the knees. -Had wound/scabbed areas to his/her feet. -Had a quarter sized wound on the right great out toe covered in eschar (a collection of dry, dead tissue within a wound). --There was no documentation indicating eschar had been present. --The staff were preparing to take the resident to the shower including Licensed Practical Nurse (LPN) F. Record review of the Resident's Comprehensive CNA Shower Review Sheet dated 9/13/22 showed the resident: -Had scabs on the front of his/her right lower leg. -Had a scab on his/her right great toe. --There was no documentation of eschar on the wound. -Had scabs on his/her left knee. -NOTE: the scabs on the front of his/her left lower leg were not identified. -NOTE: the scabs on his/her right little toe were not identified. Record review of the resident's Weekly Wound assessment dated [DATE] at 3:37 P.M. showed: -A great right toe wound. -Date of onset of wound was 9/13/22. -The wound was facility acquired. -The wound was 2.2 centimeters (cm) in length by 1.1 cm in width. -The wound bed was eschar and deep red/black in color. -The area around the wound was red. -There was no drainage and no odor. -The wound was a trauma with no drainage noted. The area around to wound had skin texture, temperature, and moisture were within normal limits. -Apply skin prep (forms a film upon application to intact or damaged skin) and leave open to air. -There was no other documentation related to other areas of the resident's feet and legs. -There were no other wound assessments in the resident's electronic medical record. -NOTE: this wound was identified on 8/30/22 as a scab with no redness on the skin around the wound. Record review of the resident's Order Recap Report showed the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Apply A&D ointment (a protective barrier to seal out wetness) to bilateral lower extremities (lower legs) every day shift for skin integrity. -Skin prep to right great toe eschar every shift for wound care. Record review of the resident's care plan dated 9/14/22 showed: -The resident had a wound on his/her right great toe and bilateral shins. -Avoid scratching and keep hands and body parts from excessive moisture. -Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Weekly treatment documentation to include measurements of each area of the skin and any other notable changes. During an interview on 9/14/22 at 8:01 A.M. the Wound Nurse said: -He/she was notified of the resident's wound on the right great toe by LPN F on 9/13/22. -He/she was not aware of any wounds on the resident prior to 9/13/22. -He/she measured the resident's great right toe wound and assessed the wound. -He/she obtained physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The great right toe area was red so he/she put a note in for the doctor to take a look at the toe due to redness around the wound. -The toe was not warm to touch. -The resident's physician should be able to assess the wound type today. -He/she thought the wound was probably trauma because the resident moves around a lot. -He/she did not think the wound was pressure related due to the resident not wearing shoes. -The nurses were responsible for completing wound assessments weekly. -The wound should have been identified with bath sheets or on a skin assessment. -The CNAs should have reported to the nurse the resident had a wound. -The nurse was then responsible to notify him/her the resident had a wound so he/she could haven assessed and obtained treatment orders. -The wound has been there for a while and has not been assessed or treated. -The resident's wounds should have been caught and documented on a skin assessment. -It was a pretty significant wound and should have been noticed. -He/she was responsible for measuring, assessing and documenting all wound reports. -He/she was responsible for completing wound treatments. Observation and interview on 9/14/22 at 10:02 A.M. showed: -The resident's wounds were being assessed by the Wound Nurse. -The resident stated his/her toe had been hurting for two days. -The resident's right great toe wound was closed with a brown eschar over the wound bed. The wound measured 2.2 cm in length by 1.1 cm in width. The periwound (area around the wound) was slightly reddened, intact, and the redness extended down halfway down on the pad of the toe. The redness extended over the top side of the toe further than the nail bed. -The resident's right heel was red with a small scab. -The resident's right little toe had an area that was moist with yellow slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy) and eschar measuring 0.5 cm in length by 0.5 cm in width. The periwound had peeling skin. -The right outer ankle had a wound that measured 3.1 cm in length by 1.1 cm in width with 25% slough and the rest of the area was eschar. The periwound area was starting to peel around the edges. -The right heel was red in color. -The right foot area had a wound over the Achilles tendon which measured 0.4 cm in length by 0.7 cm in width covered with brown eschar. The periwound area was red. -The right ankle bone area had a wound that was 0.5 cm in length by 0.4 cm by 0.7 cm in width with 25% slough and the rest of the area was covered in eschar. -The right lower leg had multiple scabbed areas 22 cm in length by 3.5 cm in width. -The left leg had multiple scabbed areas 22 cm in length by 8.0 cm in width. -The left knee had one distinct scabbed area 3 cm in length by 1.5 cm in width. -The resident stated he/she obtained the wounds in prison from thrashing around and could not state how long the wounds had been on his/her legs. -The Wound Nurse stated he/she had only obtained physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He/she had not assessed all of the areas on the resident's legs and should have done a better job on the wound assessment. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/14/22 at 11:21 A.M. CNA C said: -If scabbed areas or wounds were seen on a resident, he/she would report this to the charge nurse immediately. -If he/she saw the wound care nurse he/she would also notify him/her. -CNA D usually completed all the baths for the residents. -When bathed, he/she documented skin issues on the bath sheet. -The bath sheets were given to the charge nurse and he/she was not sure where they go after that. -He/she put a pillow under the resident's heals today because the resident complained of pain to his/her heels. -He/she did not notice any wounds on the resident's feet or legs today. -He/she really did not look at the resident's legs or feet when he/she put the pillow under the resident's heels. -He/she had reported to LPN F and to RN B the resident's heels were hurting. During an interview on 9/14/22 at 11:31 A.M. CNA D said: -He/she was the bath aide and completed all of the residents' baths. -If he/she discovered wounds or skin issues, he/she would immediately report this to the charge nurse. -He/she documented the skin issues on the resident's bath sheet (also called Comprehensive CNA Shower Review Sheet). -He/she would document the wound/skin issues on the bath sheet and give it to a charge nurse. -The charge nurse should review and sign the bath sheet, then it goes to the Assistant Director of Nursing (ADON) B. -He/she bathed the resident twice a week. -He/she had noticed the scabs on the resident's legs and the wound on the right big toe. -He/she had been documenting the resident's wound and skin issues for weeks. -He/she put it on the bath sheets and told the charge nurse each time including LPN F and Register Nurse (RN) B. -He/she verbally told them because it was there for weeks, at least three weeks. -Whoever the nurse was on this side it was reported immediately each time. -He/she did the reporting and the nurses were responsible for following up. -He/she kept telling the nurses because nothing was being done for the resident's wound and sin issues. -He/she kept putting on bath sheet and letting the nurses know of the resident's wound and skin issues. -The nurses were responsible for signing off on the bath sheet so they do see the wound and skin issues he/she had documented on the bath sheets for the resident. During an interview on 9/14/22 at 11:32 A.M. CNA E said: -He/she saw the resident's skin on 9/12/22 and the resident's right great toe had a quarter size black area. -He/she thought the nurses were aware of the resident's wounds and skin issues. -The resident's right great toe had the black area since June 2022. -The resident scratched himself/herself. -When he/she saw the resident scratch himself/herself, he/she would tell the resident he/she needed to stop scratching himself/herself, if the resident did not stop he/she would tell the licensed nurse the resident was scratching himself/herself. -If he/she saw any new skin areas he/she had not seen before, he/she would tell the licensed nurse. During an interview on 9/14/22 at 11:50 A.M. RN B said: -If the CNAs discovered wounds, scabs, or skin issues, they were to report the issues to the charge nurse. -If wounds and skin issues were discovered during a shower, the bath aide was responsible for documenting this on the bath sheet. -Nurses were responsible for reviewing the bath sheets and sign the bath sheet when reviewed. -Nurse should go in and assess any new issues and if it needed treatment he/she would notify the wound nurse if a wound was present. -The bath sheets were then given to ADON B for review. -Skin assessments were completed by nurses. -All new skin issues and wounds should be reflected on the weekly skin check. -The resident did not have any wounds or skin issues that he/she was aware of. -The CNAs were very good at reporting new wound and skin issues. -No staff have reported any wounds to him/her by CNA or bath aide. -He/she could not recall if anyone reported wounds to feet or legs over the past weeks, not this week though. -He/she had not seen any new wounds on the resident's legs and feet on his/her skin assessments he/she completed. During an interview on 9/14/22 at 12:01 P.M. LPN F said: -If a CNA or Bath Aide discover wounds or skin issues they should report this to a charge nurse immediately. -The Bath Aide was responsible for documenting the issues on the residents' skin on the bath sheet. -He/she would review and sign the bath sheet and look to see if skin issues were present. -Skin assessments were completed by the nurses. -The nurse would document any new skin issues on the skin assessment. -He/she would notify the wound nurse of any new wounds. -The wound nurse was responsible for assessing and treating the residents' wounds. -The resident can turn himself/herself in bed. -No identification of wounds were reported to him/her by the CNAs. -The resident did pick at his/her lower legs. -He/she had noticed any other wounds or skin issues except for the resident's toe yesterday when he/she assisted transferring the resident. -He/she reported great right toe wound to the Wound Nurse. -He/she did not notice any other wounds on the resident's legs or feet but the great right toe which had a big wound on it. Observation and interview on 9/14/22 at 12:54 P.M. showed: -The resident was up in his/her wheelchair in his/her room; his/her legs, feet and toes were uncovered. -The resident's physician and the facility wound nurse were discussing the resident's right great toe. -The resident's physician told the wound nurse he would order calcium alginate (dressings used on moderate to heavily exudative wounds during the transition from debridement to repair phase of wound healing), a venous ultrasound to produce images of the veins in the body. It is commonly used to search for blood clots, especially in the veins of the leg and an arterial Doppler (an ultrasound exam of the arteries in the arms or legs that can help evaluate whether there are blockages caused by plaque in the arteries). -He/she said the resident's right great toe wound was a venous wound, not a pressure wound; all the other wound areas on the resident's legs were scratches, and the areas on the resident's right little toe and the over the resident's right Achilles tendon (fibrous tissue that connects the calf muscles to the heel bone) area were scratches. During an interview 9/19/22 at 8:41 A.M. ADON B said: -CNAs were responsible for letting the nurse know if a resident had wounds or skin issues. -CNAs were responsible for documenting any wounds or skin issues on the bath sheet and charge nurse would sign off of the bath sheet after he/she reviewed it. -The nurse was responsible for notifying the Wound Nurse of any new wounds. -The Wound Nurse was responsible for assessing and treating the residents' wound. -The Wound Nurse was responsible for obtaining physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -He/she received the bath sheets and housed them. -He/she did not review the bath sheets because the nurses already reviewed them. -Skin assessments were completed by the nurses and should be done weekly, and document any new skin or wound issues. -When the resident's wounds and skin issues were brought to his/her attention by the Wound Nurse on 9/16/22, he/she reviewed the bath sheet and found the right great toe wound went back to mid-August. -The staff had not told the wound nurse the resident had wounds. -The bath sheets and the skin assessments should match up for the resident but do not. -The wound was significant and had been on the resident for a while with no assessments, monitoring or treatments. During an interview on 9/20/22 at 11:59 A.M. the Director of Nursing (DON) said: -If a CNAs discover wounds or skin issues they were responsible for notifying the charge nurse. -CNAs were to add the wound and skin issues to bath sheet -The charge nurse was responsible for reviewing the bath sheet for wounds and skin issues and sign the bath sheet. -Skin assessments were completed weekly by the charge nurses and all new areas should be documented. -Skin assessments should match up with bath sheets with the condition of the resident's skin. -Bath sheets were then given to ADON B and/or the Wound Nurse and should be reviewed for skin issues and wounds. -The wound nurse was responsible for calling the physician to obtain orders to treat the wound. -The wound nurse was responsible for assessing the wound and trying to determine what type of wound it was. -The Wound Nurse would monitor and assess the wounds. -If needed, the wound nurse would call wound care plus. -The resident's wounds were not identified prior to 9/13/22. -The resident's wounds should have been caught on the bath sheets and skin assessments. -The nurses should have notified the wound nurse of the resident's skin condition and wounds. 2. Record review of Resident #31's Admission Record sheet showed he/she was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This can lead to muscle loss, fat loss, and your body not working as it usually would). Record review of the resident's Admission MDS, dated [DATE] showed the resident: -Was severely cognitively impaired. -Had fluctuating disorganized thinking. -Required limited assistance with most Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) and was totally dependent upon staff for toileting. -Was always incontinent of both bowel and bladder. -Had not been on an antibiotic within the past seven days. Record review of the resident's progress notes, dated 8/15/22 to 9/19/22 showed no mention of the resident having diarrhea or of staff suspecting the resident to have C. Diff. Record review of the resident's laboratory results, dated 9/8/22 showed: -A stool sample was collected 9/7/22. -Results on 9/8/22 showed the resident tested positive for C. Difficile Toxin Gene (indicates it is likely the person's diarrhea and related symptoms were due to toxin-producing C. Difficile, a bacteria present in the digestive tract) by nucleic acid amplification (a test used to detect the presence of C. Diff). During an interview on 9/14/22 at 12:17 P.M. CNA A said: -The resident was having diarrhea, usually after eating, and sometimes even after drinking. -He/she told multiple charge nurses. -The resident would cry because he/she was so sad about it. The fact he/she couldn't control the diarrhea bothered him/her. The resident said the smell bothered him/her and he/she knew it bothered others. Yesterday the resident had his/her first formed stool since he/she came to facility. -His/Her feces had [MEDICATION(S)] in it last week. -The resident was in isolation last week. Record review of the resident's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] HCI (an antibiotic used to treat C. Difficile and certain other bacterial infections) capsule 125 milligrams (mg) by mouth four times a day every 10 days for C. Diff starting 9/15/22. --NOTE: this order was written seven days after the results of the resident's stool sample were received, this was a delay in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -NOTE: the resident continued to have loose, watery stools during those seven days. Record review of the resident's Medication Administration Records (MAR) for September 2022 showed: -[MEDICATION(S)] HCI 125 mg capsule 125 mg by mouth four times a day (at 9:00 A.M., 12:00 P.M., 5:00 P.M. and 9:00 P.M.) every 10 days for C. Diff starting 9/15/22. The order was discontinued on 9/17/22. -The resident was not administered [MEDICATION(S)] HCI 125 mg on the following dates and times: --9/15/22 at 9:00 A.M. and 12:00 P.M. --9/16/22 at 9:00 A.M., 12:00 P.M. and 5:00 P.M. -[MEDICATION(S)] HCI capsule 125 mg by mouth four times a day for C. Diff for 10 days starting on 9/17/22. The resident was administered the medication on: -There were no orders for [MEDICATION(S)] shown in the September, 2022 MAR prior to 9/15/22. During an interview on 9/15/22 at 10:17 A.M. the resident said: -He/she had stomach problems starting 1 1/2 to 2 weeks ago that included lots of gas and real watery diarrhea multiple times a day. -Staff would know when it started because they help with his/her brief changes. -Staff took a stool sample to see if it was contagious and they told him/her it was not contagious. -He/she had not been put on any antibiotic. -His/Her stools were still loose. -The stomach issues were a new thing and were not typical for him/her. During an interview on 9/16/22 at 10:38 A.M. CNA B said: -Since the resident's admission he/she has had a little diarrhea off and on. -He/she told the DON the resident had diarrhea two or more weeks ago and the resident had been on isolation for about one or two weeks. During an interview on 9/19/22 at 9:04 A.M. LPN G said: -He/she wasn't sure why it would take a week to get an antibiotic medication. -Normally when someone was diagnosed with C. Diff they put them on an antibiotic right away. -Once the lab results were back the nurse should immediately phone the physician to get an order. -Depending on the time the lab results got back, the medication should be at the facility that day or at least by the time medications are delivered that night, whenever the next pharmacy delivery takes place. Normally, medications are delivered before 3:00 P.M. -If results from the lab come in later that day there was one night pharmacy delivery and the medication should come by then. It should definitely be at the facility in less than 24 hours. -He/She thought the pharmacy might even do emergency deliveries but was not sure. During an interview on 9/19/22 at 9:29 A.M. LPN B said: -The nurse should call the doctor immediately upon positive C. Diff lab results to get an order. -If the resident had tested positive for C. Diff they would likely be put on [MEDICATION(S)]. -Nurses should put the order in as soon as they get it and fax it to the pharmacy because the resident needed to start it right away. -He/she thought the facility had [MEDICATION(S)] in their emergency kit (e-kit) because most oral antibiotics were in there. (At this point LPN B checked the facility's list of medications that could be accessed from the e-kit and said [MEDICATION(S)] was not on the list). -[MEDICATION(S)] should be available on the next pharmacy delivery. They deliver in the afternoon and on the evening or night shift. -The medication should arrive within 24 hours or less. During an interview on 9/19/22 at 10:00 A.M. LPN D said: -Once lab results of positive C. Diff arrive the nurse should contact the physician immediately to get orders to start the resident on antibiotic therapy. They usually get orders for [MEDICATION(S)] for C-Diff. -The medication should be at the facility from pharmacy by early to mid-afternoon. If the lab results come back later in the day the medication should be here by the night run. -[MEDICATION(S)] was not in the facility's e-kit. -An antibiotic order wa

Based on observation, interview and record review, the facility failed to adequately assess, monitor, document and provide treatment that includes ongoing appropriate interventions related to the resident's behaviors; to ensure monthly psychiatric visits were in the medical record and reviewed by the staff; to ensure supportive services were in place and to have an individualized care plan based on the resident's behaviors of two sampled residents (Resident #14 and #25) out of 19 sampled residents. The facility census was 95 residents. Record review of the facility's policy Behavioral Assessment, Intervention and Monitoring policy revised 3/2019 showed: -The facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment. -Behavioral health services would be provided by qualified staff who have the competencies and skills necessary to provide appropriate services and treatment. -The Interdisciplinary Team (IDT) would thoroughly evaluate new or changing behavioral symptoms in order to identify the underlying causes and address and modifiable behaviors. -The IDT would evaluate the behavioral symptoms of residents to determine the degree of severity, distress, and potential safety risks. -The care plan would incorporate the findings. -The interventions would be individualized and part of the overall care environment that supported physical function and psychosocial needs. 1. Record review of Resident #14's Admission Record showed he/she was admitted to the facility on [DATE] and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -Major depressive disorder with psychiatric symptoms (a mental disorder in which a person has depression along with loss of touch with reality). -[CONDITION(S)] (inability to sleep). Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated 3/24/22 showed the resident: -Was cognitively intact. -Did not have behaviors. Record review of the resident's Nurses Notes dated 5/20/22 showed: -The Certified Nursing Assistant (CNA) brought the resident to the nurses station. -The resident was tearful and kicking his/her feet into the floor stating he/she was having withdrawals. -The CNA reported the resident was talking to him/her and roommate stating he/she wanted to kill himself/herself. -The resident stated he/she wanted to go to the hospital or he/she was going to kill himself/herself. -The physician and family were notified. -The resident was sent to the hospital for a psychiatric (relating to mental illness or its treatment) evaluation. -The resident was sent back from the hospital saying the resident was not a harm to himself/herself and was not admitted for psychiatric services. -The resident complained he/she did not want to return to the room he/she was in and wanted a different roommate. -His/her roommate was mean to him/her. -The resident was placed in a different room. -The resident was appreciative of the room move and was resting without distress. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Did not have behaviors. Record review of the resident's Care Plan dated 7/29/22 showed the resident: -Was at risk of falls related to lowering himself/herself to the floor for attention. -Did not have a care plan that showed all the resident's behaviors, including attention seeking or making statements of harming him/herself. Record review of the resident's Behavioral Note dated 7/22/22 showed: -He/she received a call from the resident's family member stating the resident sent a text to him/her saying the resident was in pain. -He/she went to check on the resident and the resident said he/she was not in pain. Record review of the resident's Behavioral Note dated 8/2/22 showed: -The resident had been crying since the writer was on duty. -The resident wanted his/her family member to come take care of him/her. -The resident needed help with charging his/her phone and the CNA went to assist. -The resident was yelling that they were trying to poison him/her with medications and refused medications. -The resident said he/she was being held against his/her will and needed his/her family member to come and get him/her. -The resident was assisted with incontinence care, linen changes and laid down. -The resident was sleeping. Record review of the resident's Behavioral Note dated 8/7/22 showed: -The resident was very emotional and crying this morning and refused his/her medications. -The resident had called his/her family member and the family member would not answer the phone. -The resident refused evening medications and was throwing his/her belongings out into the hallway. -The staff asked the resident why he/she was throwing his/her belongings the resident said because his/her family member would not get up. -The staff explained the resident's family member was not here. Record review of the resident's Behavioral Note dated 8/10/22 showed: -The resident was crying, upset, or arguing about different things all shift. -Once the resident was afraid he/she would fall off his/her bed. -The CNA went to sit with the resident to calm him/her down and the resident became angry stating if the CNA left he/she would cry rape. -The resident was now crying and praying he/she was urinating more than usual and he/she was afraid. -The staff offered to take the resident to the bathroom and the resident declined. -The resident was not wet but was scared he/she might urinate. -The resident continued to cry and repeat he/she was scared. Record review of the resident's Behavioral Note dated 8/31/22 showed: -The resident had been crying all during the shift. -Staff had just left the room and the resident was in his/her wheelchair. -The resident put himself/herself on the floor. -The resident refused all medications this shift. -The resident was assisted to the dining room for lunch. Record review of the resident's Behavioral Note dated 8/31/22 showed: -The resident was very tearful this morning stating they are trying to kill me. -He/she offered reassurance to the resident that he/she was safe here. Record review of the resident's Behavioral Note dated 8/31/22 showed the resident: -Had been yelling since he/she came on shift. -Stated the staff were not taking care of him/her. -Wanted his/her family member to come take him/her home. -Threw his/her food all over the floor then denied doing this when a CNA witnessed this. -Threw his/her medications on the floor. Observation on 9/14/22 at 10:02 A.M. showed: -The resident was alert and laying in his/her bed. -He/she said he/she had just gotten out of prison. During an interview on 9/16/22 at 12:52 P.M. CNA B said: -The resident had behaviors and said the staff worshiped Satan. -The resident's family members did not come to see him/her often. -He/she was not aware of any behavioral interventions. -He/she believed the resident was depressed. -The resident scratched at his/her legs. -He/she would scream and yell and cry all day sometimes. Record review of the resident's electronic medical record on 9/16/22 showed no Social Services Designee (SSD) notes or psychiatric notes. Observation on 9/19/22 at 11:10 A.M. showed: -The resident was in the dining room in his/her wheelchair. -He/she was crying and speaking but could not be understood. -He/she was crying with no staff consoling him/her. -Multiple staff walked by the resident. Observation on 9/19/22 at 12:20 P.M. showed: -The resident continued sitting in his/her wheelchair in the dining room. -He/she was crying with no staff consoling him/her. -Another resident was across the room and was telling the resident to shut up and quit crying. During an interview on 9/19/22 at 12:20 P.M. the SSD said: -The resident was sometimes happy and sometimes he/she cried. -He/she had been referred to psychiatric (mental health) due to his/her crying and mood. --There were no psychiatric notes in the resident's e-chart (facility electronic medical record -EMR). -He/she had not been told about the resident picking his/her skin. -The resident's crying was constant and he/she would get upset and want to go to emergency room . -He/she had not been documenting in the resident's progress notes related to his/her behaviors. -He/she did talk to the resident but did not put notes in the resident's e-chart. -He/she would just talk to the resident and try to calm him/her down. -He/she did not do scheduled regular meetings with the resident related to his/her mood and behaviors. -The resident had said he/she felt like he/she was just left at the facility. -The resident was not that emotional when he/she first came to the facility. -He/she had not referred the resident for behavioral health services. -Psychiatric came to the facility monthly. -He/she could not find notes related to psychiatric visits in the resident's e-chart. -The resident was very easy to re-direct. -No root cause analysis had been done related to the resident's behavior. During an interview on 9/19/22 at 12:54 P.M. Licensed Practical Nurse (LPN) D said: -The resident did not have behaviors when he/she first was admitted to the facility. -He/she was not sure what happened with the resident. -The resident yelled out a lot and if he/she checked on the resident, he/she said non-sensible things. -He/she just tried to console the resident. During an interview on 9/19/20 at 1:38 P.M., the MDS Coordinator said: -The resident was admitted to the facility from a psychiatric hospital. -The resident made up stories and would sit himself/herself on the floor; facility staff had talked about that. -The resident had been seen by a psychiatrist but no notes had been given to the facility. -The resident had no behavioral health services or counseling services. -Facility staff had just talked about the resident but had not tried to determine the root cause of the resident's behaviors there had been no root cause analysis. -Staff had not looked at the root cause of the resident's behavior to try to determine a plan to address the resident's behaviors. -The SSD should have been visiting the resident to talk about the resident's mood and behavior and this should have been documented. -The resident's care plan should have been updated to reflect the resident's current behaviors and interventions. -He/she was responsible for updating the care plan. During an interview on 9/20/22 at 12:00 P.M. the Director of Nursing (DON) said: -Regarding resident behaviors, he/she expected staff, depending on the behavior to redirect the resident and provide diversion (activity that diverts the mind from concerns). -The facility could have residents with behaviors seen by psychiatric for evaluation. -The clinical team meets every morning regarding behaviors at the daily Resident Risk Meetings but the meetings were not documented. -No behavioral health services were utilized for the resident, but this would be the SSD that would assist to council the resident. 2. Record review of Resident #25's Admission Record showed he/she was admitted to the facility on [DATE] and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)] (TBI - damage to the brain resulting from external mechanical force, such as rapid acceleration or deceleration, impact, blast waves, or penetration by a projectile). -SynGap 1 related intellectual disability (a neurological disorder characterized by moderate to severe intellectual disability evident in early childhood with features of delayed speech development and motor skills and often seizures, [CONDITION(S)] and sensory processing problems). -[CONDITION(S)] disorder, depressive type (a mental condition that causes loss of contact with reality and mood problems). -Restlessness and agitation. -[CONDITION(S)] (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). -Antisocial personality disorder (condition characterized by repetitive behavioral patterns that are contrary to usual moral and ethical standards and cause a person to experience continuous conflict with society). -Intermittent Explosive Disorder (a chronic disorder involving repeated, sudden episodes of impulsive, aggressive, violent behavior and/or angry verbal outbursts in which reactions are grossly out of proportion to the situation). Record review of the resident's admission MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Had fluctuating inattention. -Had physical behaviors directed towards others one to three days out of seven. -Had no verbal behaviors directed towards others. -Had no other behaviors not directed towards others (e.g. hitting self, screaming). Record review of the resident's Preadmission Screening and Resident Review (PASARR) II (determines if the intellectual disability or serious mental illness of the individual can be met in a nursing facility or if the resident requires specialized services), reviewed on 6/7/22 by the Central Office Medical Review Unit (COMRU - reviews the DA 124 assessment forms for the PASARR) showed: -The resident had an Intellectual Disability ( when there are limits to a person's ability to learn at an expected level and function in daily life) and a substantiated dementia ( chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) or related condition and required nursing facility services. -Due to the resident's TBI he/she had problems with impulsive behaviors and anger control. -His/her reported moods could be labile (rapid, exaggerated changes) and he/she struggles with expressing emotions appropriately. -He/she has a guardian to assist with major life and financial decisions and requires 24 hour support. -The resident needed assessment and implementation of a behavioral support plan, monitoring of behavioral symptoms, and provision of behavioral supports. Staff should identify precipitating factors which may exacerbate his/her volatile behaviors. A structured, low-stimulation environment should be provided. He/She will require continued psychiatric follow-up and medication management and periodic review of medications. Establish consistent routine, provide daily tasks/activities and assess and plan for the level of supervision required to prevent harm to self or others. The plan should identify clear steps to manage the individual's behavior in a crisis situation, who to contact for assistance, and how staff will work together in a crisis. Record review of the resident's Potential for Physical Aggression Care Plan, updated on 6/21/22 showed the resident's triggers for physical aggression were paranoia that others were talking about him/her. An intervention added on 6/21/22 showed the resident's behaviors were de-escalated by 1:1 attention and reassurance and attempts to calm him/her. Record review of the resident's Nurses' Note dated 6/25/22 at 2:07 P.M. showed: -At approximately 3:00 A.M. the resident started yelling and cursing down the hall. Staff assisted the resident to go to the bathroom. -He/she was assisted to his/her wheelchair and taken to the nurses' desk at 5:00 A.M. -A few minutes later the resident started to yell again and cursing at staff calling them [OBSCENITY] es and punching anything close to him/her. -Another resident down the hall started to yell and the resident started yelling if the other resident did not stop yelling he/she would come down and beat his/her ass. The resident would only be redirected a few minutes and start again yelling at staff and other resident and threatening to beat their ass. This continued until lunchtime. -The resident was taken to the dining room to eat and started to yell to other residents and staff to shut the hell up and started to pound the table. The resident was taken out of the dining room to the therapy room to eat lunch. The resident was still unable to be redirected for more than a few minutes. -A one-time order was received from the physician for Haloperidal ([MEDICATION(S)], an antipsychotic (a psychoactive drug (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat [CONDITION(S)]) 5 milligrams (mg)/milliliter (ml) Intramuscularly (IM). -At 1:00 P.M the medication was administered in the right deltoid (upper arm). Record review of the resident's Potential for Physical Aggression Care Plan, updated on 6/27/22 showed a new intervention for staff to keep the resident away from others when agitated when he/she appears aggressive to others. Record review of the resident's Nurses' Note dated 7/8/22 at 2:30 A.M showed: -The resident began yelling at 1:15 A.M. down the hall from his/her room waking other residents. -The CNA got the resident up and dressed so he/she wouldn't wake other residents. -The nurse made and fed the resident a packet of oatmeal and one pudding cup. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Had fluctuating inattention. -Had physical behaviors directed towards others four to six days out of seven. -Had verbal behaviors directed towards others one to three days out of seven. -Had other behaviors not directed towards others one to three days out of seven. Record review of the resident's Incident Investigation, dated 7/21/22 showed: -A statement from the CNA that he/she had been at the nurses' station when he/she saw the resident hit another resident when that resident was just sitting there. He/she immediately separated the two and then the DON came into the area. -The other resident was sitting in his/her wheelchair at the nurses' station when a CNA witnessed the resident, who had been sitting next to him/her, became agitated and hit the other resident on the face/nose area with his/her right hand. -The residents were immediately separated. -The other resident said he/she didn't know why the resident hit him/her. -There were no observable injuries. -The resident said he/she was sorry and thought the other resident had been talking about him/her. -The resident was given a pro re nata (PRN - as needed) medication (the investigation did not show what medication) for agitation and placed on 15 minute checks. -The cause of the behavior was believed to be the resident's paranoia (symptoms of a chronic mental illness, characterized by persistent preoccupation with illogical delusions (false beliefs), usually of a persecutory, grandiose, or jealous nature) and not abuse. -The investigation showed a new behavioral intervention beginning 7/21/22 for the resident to not be placed within arm's length of other residents. -A Nursing Note dated 7/22/22 at 1:18 P.M. showed the resident continues on 15 minute checks and staff ensuring the resident sat away from other residents for safety. He/She was noted to have two episodes of agitation and was easily redirectable. Record review of the resident's Potential for Physical Aggression Care Plan, updated 7/21/22 showed the resident hit another resident and was immediately separated from the other resident. He/she was given a PRN for agitation and placed on 15 minute checks. A new intervention was added that staff were not to place the resident within arm's length of other residents. -Other interventions on the care plan included: --Administer medications as ordered. --Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. --Assess and anticipate the resident's needs related to food, thirst, toileting, and comfort level. --Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist the resident in verbalizing his/her source of agitation, encourage seeking out a staff member when agitated. --Psychiatric consult as indicated. --Staff to remove those the resident feels are talking about him/her out of view by closing doors. Record review of the resident's Nurses' Note dated 7/22/22 at 10:54 P.M. showed: -The resident was trying to start a fight with three different residents. -When trying to redirect the resident he/she swung at the nurse. -Nurse called the physician and got a one-time order for [MEDICATION(S)] IM. -IM medication was administered and effective. Record review of the resident's Nurses' Note dated 7/24/22 showed: -The resident was yelling and cussing at staff, accusing them of stealing his/her money. -The resident then started hitting himself/herself in the stomach with his/her hand. -No bruising at this time. -Hitting his/her head on the wall. Record review of the resident's Nurses' Note dated 7/24/22 at 5:57 P.M. showed: -The resident propelled himself/herself to the dining room and started to go after another resident, saying the other resident stole his/her money. -Staff took the resident out of the dining room and the resident was still yelling. Record review of the resident's Nurses' Note dated 7/24/22 at 6:19 P.M. showed: -The resident propelled himself/herself down the hallway while yelling, cussing and hitting his/her head, arm, and hand on the wall. -Staff were unable to talk to the resident and calm him/her down. -The resident was now sitting in the hallway eating. Record review of the resident's Nurses' Note dated 7/26/22 at 5:59 A.M. showed: -The resident was hitting himself/herself on the right upper thigh. -No bruising at this time. Record review of the resident's Nurses' Note dated 8/21/22 at 10:45 P.M. showed: -The resident was sitting in front of the nurses' station and started to lean to the right and kept leaning until he/she turned over his/her wheelchair, saying he/she meant to turn over his/her chair. -Range of Motion was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] -The resident had been hitting his/her head on the wall since the nurse came in at 6:30 P.M. -Staff were unable to distract the resident. -He/she continued to hit his/her head on the wall until he/she turned over the chair. -He/she also hit his/her right arm and watch on the bedside table. -The resident then asked if he/she broke it because he/she wanted to break it. -The resident then took off his/her glasses, threw them on the floor, picked them back up and was bending them. -This nurse asked him/her to please stop before he/she broke them and he/she said he/she wanted to break them. -The resident got the lens out of his/her glasses frames. -The resident was given [MEDICATION(S)] IM at 9:01 P.M. for behaviors. Record review of the resident's Nurses' Note dated 8/24/22 showed: -The resident was seen by several people punching a Certified Medication Technician (CMT) because he/she pushed him/her away from the door as he/she was trying to get out to smoke. -The resident wasn't allowed to smoke per his/her Guardian. -The resident pushed the CMT twice in the forehead after being pushed from the door. Record review of the resident's Nurses' Note dated 8/29/22 at 6:30 P.M. showed: -The resident was in the dining room cussing and propelling himself/herself to the hallway when the resident stopped in front of the entrance door and started to kick the door, saying he/she was leaving. -The nurse went to the door and pulled the resident backward and he/she took his/her right hand and hit the nurse in the right shoulder cussing at the nurse. -The resident went to the wall and took the fire extinguisher off the wall and dropped it to the floor. -The resident received [MEDICATION(S)] IM at this time. Record review of the resident's e-record further showed there were no social services notes or psychiatric notes. Record review of the resident's Nurses' Note dated 9/14/22 at 3:21 A.M. showed: -The resident went after another resident, but the CNA walked up before he/she punched the other resident and stopped the incident from happening. -The resident was taken to the other side of the nurses' station and within an hour the resident went to bed. -The resident woke up at 2:30 A.M. wanting to get up but was talked into staying in bed and trying to get some more rest. During an interview on 9/16/22 at 10:49 A.M. CNA B said: -The resident thought everyone was talking bad about him/her when they were talking about other things or talking bad about staff he/she liked. -Usually the resident would cuss and bang his/her elbow, hand or head against the wall. -Sometimes he/she would roll up to a person he/she was mad at. -He/She was told by another CNA one time the resident hit another resident in the face maybe two months ago. -About a month ago in the dining room he/she saw the resident stick his/her foot in a resident face. It didn't touch his/her face. The resident just kind of sat there and didn't react. He/she didn't seem afraid. He/She took the resident out of the dining room and told the charge nurse about it. He/She sat with the resident near the nurse' station. -Usually staff just put the resident near the nursing station after aggressive incidents. During an interview on 9/16/22 at 11:08 A.M. CNA C said: -He/she had seen the resident hit the wall, tables, and his/her chair when irritated. He/She wanted things right away. Any time the resident got aggravated he/she did this. Staff tried to find out what he/she was aggravated about. -He/she didn't think the resident had control of his/her aggression. -It helped the resident's behavior if staff offered to help him/her lay down in bed. He/She liked that and realized that helped him/her calm down. -The resident wanted to smoke. It made him/her upset he/she couldn't. -One time staff brought the resident outside with them when taking others outside to smoke because he/she liked to be outside. He/She was trying to rock hard to throw himself/herself out of his/her wheelchair. Staff had to bring the resident back inside. -Today the resident went out with staff when others went out to smoke and he/she was fine. It just depends. During an interview on 9/19/22 at 10:30 A.M. the SSD said: -The resident's behaviors were hitting and punching the walls periodically throughout the day. -He/she was usually redirectable, but not always redirectable in the evenings. -The resident had some recent behavioral medication changes. -He/she had been in contact with the resident's guardian, but hadn't documented the calls. -Most of the time he/she, the RA, or charge nurse had the resident with them. -The resident saw psychiatrist routinely, but he/she couldn't find any of the psychiatrist's notes in his/her e-record. -He/she had tried to discharge the resident to a facility that dealt more with behaviors and to get psychological evaluations and treatment, but had been unable to find any facility who would accept the resident and didn't think the resident was appropriate for the facility's setting due to the extent of the behaviors. He/She was unable to provide documentation showing what facilities and hospitals had been contacted. -He/she had conversations with the resident about his/her behaviors, but had not documented the conversations or the resident's behavioral progress. -He/she did not schedule regular meetings with the resident to discuss his/her mood and behaviors. -No comprehensive root-cause analysis had been done related to the resident's behaviors. Observation on 9/19/22 at 10:50 A.M. showed: -The resident was outside the SSD's office yelling and banging his/her right foot on the floor requesting change for his/her bill. -The SSD went to get the resident change from the business office and the resident calmed down. Observation on 9/20/22 at 9:20 A.M. in the therapy room showed: -The Certified Occupational Therapist Assistant (COTA) put a splint on the resident's hand and wrist. -The resident yelled out and cussed at the COTA and then calmed without further incident. During an interview on 9/20/22 at 9:39 A.M. CNA E said: -The resident's speech became rapid and excessive and he/she became fidgety when agitated. Behaviors consisted of beating his/her arms and head against the wall and purposely trying to flip his/her wheelchair backwards. -He/she had seen various residents make fun of the resident when he/she hit the wall. They would tell the resident it wasn't OK to keep hitting the wall or will tell him/her he/she will get sent out. -He/she received no training on what to do in particular for the resident's behaviors, but he/she could ask the nurse what he/she was supposed to do. -He/she just separated the resident when he/she became agitated and tried to talk with him/her. During an interview on 9/20/22 at 10:46 A.M. the DON said: -The resident doesn't always have control over his/her moods and would act out. -He/she was normally redirectable. -He/she didn't target any specific person. During an interview on 9/20/22 at 12:00 P.M. the DON said: -The facility had a psychiatrist who visited residents routinely. -They discussed behaviors in clinical meetings and documented behaviors in notes. -The IDT should try to determine the root cause of the resident's behaviors. -If residents had on-going behaviors there should be a detailed plan with specific interventions and all staff should know the interventions. -CNA's had access to care plans through the e-record. -CNA's were educated through shift change meetings regarding residents' behavioral interventions.