Every finding on record at Milan Health Care Center

Based on interview and record review, the facility failed to ensure two residents, (Resident #7 and #10) were free from sexual abuse by one resident (Resident #11), in a review of 12 sampled residents. On 10/26/25 Resident #11 grabbed Resident #7's breasts over his/her clothing, without the resident's consent while they were outside in the courtyard. Resident #7 reported the incident to staff on 10/26/25 around 4:00 P.M. Resident #7 was tearful when recounting the abuse and reported he/she had never been grabbed like that before. Resident #7 feared being alone and Resident #11 coming around him/her again. Approximately four hours after the incident was reported by Resident #7, staff found Resident #10, who had impaired cognition, a diagnosis of dementia and who wandered in the facility, in Resident #11's room with Resident #11 around 8:00 P.M. Resident #11 and #10 sat next to each other on the bed and Resident #10's shirt was pulled up exposing his/her breasts. Resident #10's shoes and socks were off, and his/her pants were on inside out. After the incident, Certified Nurse Aide (CNA) H checked on Resident #10 at the nurses' station. Resident #10 was distraught and tearful. Resident #10 didn't want to go to his/her room to sleep and instead stayed the night in the common area. The facility census was 87.On 10/30/25 the administrator was notified of the Past Non-Compliance which occurred on 10/26/25. On 10/26/25 facility staff became aware Resident #11 had sexually abused Resident #7 and Resident #10. Following the second incident, staff placed Resident #11 on one-on-one monitoring to ensure residents were protected. Staff will continue to monitor Resident #11 while he/she is in the facility. On 10/27/25 the facility began in-servicing staff, prior to the start of their next shift, on the facility's abuse policy, specifically sexual abuse. The facility interviewed and assessed other residents to ensure no other residents were affected. The deficiency was corrected on 10/27/25. Review of the facility's Sexual Activity/Abuse and Neglect policy, revised 9/29/25, showed the following:-Residents that are wishing to engage in sexual activity/intercourse will be allowed to participate in these activities as long as both parties consent and have the ability to consent;-Non-consensual acts are not permitted;-If non-consensual sexual activity occurs, the abuse and neglect policy will be followed. Review of the facility's Abuse and Neglect Policy, revised on 6/12/24, showed the following:-Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area and coerced nudity;-This also includes failure to intervene or attempt to stop or prevent non-consensual sexual activity or performance between residents;-The facility will protect residents from harm during an investigation;-The facility will take steps to prevent mistreatment while the investigation is underway. 1. Review of Resident #7's face sheet, showed the following:-The resident admitted on [DATE];-He/She had a guardian;-Diagnoses included bipolar disorder (mental health condition characterized by extreme mood swings, alternating between periods of elevated mood and depression), anxiety disorder (mental health condition characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), and major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument dated 10/5/25, showed the following:-The resident was cognitively intact;-Independent with staff supervision with transfers and ambulation.-Presented with no behaviors. Review of the resident's care plan, revised 7/30/25, showed the following:-He/She was independent with activities of daily living (ADLs) with supervision;-Caregivers to provide opportunity for positive interaction, attention,, and stop and talk with the resident when passing by;-The resident had a communication problem related to inattention and disorganized thinking at times related to bipolar disorder. 2. Review of Resident #11's face sheet, showed the following:-The resident admitted on [DATE];-The resident was his/her own responsible party;-Diagnoses included stroke. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 9/18/25, showed the following:-The resident had moderately impaired cognition;-No functional limitation with range of motion in upper or lower extremities;-Independent with supervision to transfer from bed to wheelchair and back;-Unable to ambulate, so locomotion was via electric wheelchair;-No behaviors directed towards others. Review of the resident's care plan, dated 9/26/25, showed the following:-Provide protective oversight and assist where needed;-The care plan did not address resident behaviors. 3.Review of Resident #7's nurse note, dated 10/26/25 at 4:10 P.M., showed the following:-The resident told the charge nurse Resident #11 touched his/her breast in the courtyard before smoke break time;-Resident #11 asked Resident #7 to date him/her despite Resident #7 saying no and the guardian would not allow it;-Resident #7 felt Resident #11 saw him/her alone outside and again asked him/her to date when another resident (Resident #9) wheeled up to them via wheelchair;-Resident #11 reached over and grabbed Resident #7's breast and said, looks good enough to me;-Resident #7 told Resident #11 to stop, then Housekeeper D was right there, and Resident #11 backed off;-Both medical and psychiatric providers were made aware;-Capacity to consent assessment completed on both residents. Review of Resident #7's capacity to consent assessment, dated 10/27/25, showed the resident did not have the capacity to consent to sexual activity. Review of Resident #7's nurse's note, dated 10/27/25 at 10:38 A.M., showed the resident said as long as Resident #11 was on the one-on-one supervision he/she felt safe. After the incident she felt uncomfortable. During an interview on 10/30/25 at 11:02 A.M., Resident #7 said the following:-Resident #11 started acting inappropriately a couple days before the incident of grabbing his/her breast in the courtyard;-Three days prior to the incident, Resident #11 asked Resident #7 if he/she wanted to be in a relationship with him/her. Resident #7 said no, then Resident #11 stopped and went away;-Two days before the incident, Resident #11 again asked if Resident #7 wanted to be in a relationship, Resident #7 said, no again; however, this time Resident #11 didn't leave and talked about how the facility wouldn't allow him/her to watch his/her sexually explicit adult videos, Resident #11 asked Resident #7 if /he/she wanted to watch them with him/her and Resident #7 said, no; -The day of the incident, Resident #11 asked Resident #7 again if he/she wanted to be in a relationship, Resident #7 again said, no; this time Resident #11 told Resident #7 he/she better hurry up because Resident #11 had a [AGE] year old who wanted to be with him/her and Resident #7 again said no;-In front of Resident #9, Resident #11 grabbed Resident #7's breast and said it was good enough for him/her;-Housekeeper D was bringing another resident outside for smoke break and at that time Resident #11 moved away from him/her;-Resident #7 began crying during the interview and said he/she had never been grabbed like that before;-He/She didn't report it immediately, because he/she was not the type of person to tell on people;-Resident #5 and Resident #7 talked about what happened to him/her prior to the 11:00 A.M. smoke break. He/She then reported the incident to staff the same day it happened at approximately 4:00 P.M. -Resident #7 spoke with Resident #5 about what happened, and they decided when they were going outside in the courtyard they would go together in the hope Resident #11 wouldn't try anything;-Resident #7 feared being alone and Resident #11 coming around him/her;-Resident #7 was glad Resident #11 was on staff one on one supervision because it made him/her feel safer;-He/She did not tell the staff about any of the times Resident #11 asked him/her to be in a relationship and after talking to Resident #5, he/she decided to report that Resident #11 had touched his/her breast earlier in the day. During an interview on 10/30/25 at 11:10 A.M., Resident #5 said the following:-Resident #7 told Resident #5 about Resident #11 grabbing his/her breast;-Resident #7 said he/she was scared of Resident #11 and cried;-Resident #11 made him/her feel uncomfortable, because Resident #11 was creepy;-Resident #11 came around him/her frequently and talked about how the facility wouldn't allow Resident #11 to watch his/her favorite videos. Resident #11 liked sexually explicit adult videos and wanted someone to watch them with him/her. Resident #11 told Resident #5 he/she had a nice body;-Resident #5 said he/she didn't feel it was safe to have Resident #11 around;-Resident #5 didn't tell staff what happened until the staff asked him/her about Resident #11 touching Resident #7. Review of the facility's investigation, dated 10/27/25 at 8:46 A.M., showed the following:-The incident of alleged sexual conduct between Resident #7 and Resident #11 occurred on 10/26/25 at approximately 4:00 P.M.;-Resident #11 had been asking Resident #7 to date despite that Resident #7 had told Resident #11, no and the guardian would not allow it;-Resident #7 felt Resident #11 saw him/her alone outside and again asked to date when Resident #9 wheeled up to both residents via wheelchair;-Resident #11 reached over and grabbed Resident #7's breast and said, looks good enough to him/her, then Resident #7 said he/she better quit it;-Then Housekeeper D was there, and Resident #11 backed off;-Resident #11 said nothing inappropriate occurred and he/she never touched other residents, and he/she ran around with all the residents of the opposite gender in the facility. 4. Review of Resident #10's face sheet, showed the following:-He/She admitted on [DATE];-He/She had a durable power of attorney (DPOA);-Diagnosis of dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change). Review of the resident's admission MDS, dated [DATE], showed the following:-He/She had moderately impaired cognition;-No behaviors towards others and no wandering;-Required maximal assistance with toileting hygiene, lower body dressing, and ambulation;-Required moderate assistance with transfers and upper body dressing; Review of the resident's care plan, dated 9/15/25, showed the following:-The resident had an activities of daily living (ADLs) self-care performance deficit related to musculoskeletal impairment;-Required moderate assistance by staff to dress himself/herself;-Required moderate assistance by staff to move between surfaces;-Impaired cognitive function/dementia or impaired though process related to dementia;-Ask the resident simple question and clear statements;-Ask yes/no questions to determine the resident's needs;-No behaviors documented. Review of the resident's nurse's note, dated 10/26/25 at 8:16 P.M., showed the following:-Certified Medication Technician (CMT) F reported to the charge nurse on duty the resident sat on the edge of Resident #11's bed;-Resident #11 said nothing happened and he/she didn't know he/she was not allowed to have other residents of the opposite gender in his/her room, and they were just talking;-When the nurse asked Resident #11 about Resident #10's clothes he/she said it was not his/her problem that Resident #10's clothes were off;-Resident #11 said he/she would call 18 lawyers and discharge from the facility in the morning;-The nurse contacted both medical providers and psychiatric providers regarding the incident;-Capacity to consent assessment completed for both residents. During an interview on 10/30/25 at 1:50 P.M., CMT F said the following:-He/She saw Resident #10 in the common area on 10/26/25, fifteen minutes prior to getting a snack at approximately 7:30 P.M.; -Resident #10's pants were not on inside side out, his/her pants were on correctly;-At approximately 8:00 P.M., CNA F was administering medications and saw the door to Resident #11's room was closed. When CMT F opened the door, the privacy curtain was pulled all the way around Resident #11's bed; -CMT F pulled the curtain open and found Resident #11 and Resident #10 sitting next to each other on Resident #11's bed, then Resident #10 started crying; -Resident #10 had his/her shirt pulled up under the arms, exposing his/her breasts; -CMT F immediately took Resident #10 down to the nurses' station and reported what he/she saw to the charge nurse;-Resident #10's pants were on inside out and it was obvious, because the pockets were sticking out from under the resident's shirt;-Resident #10 was upset and cried. During an interview on 10/30/25 at 2:08 P.M., CNA H said the following:-When he/she came on shift on 10/26/25, the off going shift said Resident #10 needed assistance going to the bathroom;-At approximately 6:30 P.M., CNA H took Resident #10 to the toilet and after the resident was finished, CNA H put a clean disposable brief and pajama bottoms on the resident that were right side out;-He/She remembered seeing Resident #10 before the incident, but couldn't remember the time; however, he/she remembered Resident #10's pants were on right side out;-Resident #10 wandered. Resident #10 went down to the door leading out into the courtyard, but never attempted to open it;-After the incident, CNA H checked on Resident #10 at the nurses' station because he/she was told about the incident;Resident #10 was distraught and buried his/her face into CNA H's shoulder and cried;-Resident #10 didn't want to go to his/her room to sleep instead he/she stayed in the common area. Review of Resident #10's nurse's note, dated 10/27/25 at 1:11 P.M., showed the following:-The staff asked the nurse to go into the nurses' station with CMT F and the resident;-The resident was not wearing shoes or socks, and his/her pants were inside out;-CMT F said he/she found the resident in another resident's room with his/her shoes and socks off, pants on inside out and pulling his/her shirt down, while he/she sat on the side of the other resident's bed upon CMT F's entrance;-Resident #10 said someone touched him/her all over, he/she could have been a lot worse, and Resident #11 loved his/her beautiful chest;-The nurse performed a head to toe skin assessment on the resident and no abnormal findings were found;-The staff placed Resident #11 on one on one supervision;-The staff assured Resident #10 that he/she was in a safe place, then the resident rested on the couch with his/her eyes closed;-The nurse notified the resident's family, nurse practitioner and Director of Nursing. During an interview on 10/30/25 at 11:25 A.M., Certified Nurse Aide (CNA) A said the following:-He/She worked with Resident #10 for a long time;-Since the incident between Resident #10 and Resident #11, CNA A noticed a change in Resident #10's behavior of appearing upset, like something was bothering Resident #10;-At breakfast, the resident said a couple times, he/she was scared of him/her, while looking out in the dining room; -CNA A assumed Resident #10 referred to Resident #11 because of the previous incident between the two residents. During an interview on 10/30/25 at 11:40 A.M., Nurse Aide (NA) B said he/she heard Resident #11 tell other residents several times that he/she tried to have sex with Resident #10 while NA B provided one-on-one supervision of Resident #11. Review of the facility's investigation, dated 10/27/25 at 10:29 A.M., showed the following:-The incident of alleged sexual conduct between Resident #10 and Resident #11 occurred on 10/26/25 at approximately 8:00 P.M.;-Resident #11 said they were just talking, and it was Resident #10's problem that his/her clothes were off;-CMT F said he/she found Resident #10 in Resident #11's room with his/her shoes and socks off and pants on inside out, sitting on the side of Resident #11's bed upon entrance. Review of Resident #10's capacity to consent assessment, dated 10/27/25, showed the resident did not have the capacity to consent to sexual activity. During an interview on 10/30/25 at 9:42 A.M., Resident #10's guardian said the resident would not normally go into a resident of the opposite gender's room, especially one he/she did not know or engage in anything sexual. 5. During an interview on 10/30/25 at 9:10 A.M. and 12:30 P.M., the DON said the following:-The incident between Resident #11 and Resident #7 was in the outdoor courtyard, during a smoke break;-Resident #7 was alert and oriented times three and could remember the incident;-Immediately after Resident #7 said Resident #11 touch his/her breast, staff placed Resident #11 on supervision when Resident #11 was out of his/her room for mealtimes and smoke breaks;-Resident #11 spent most of the day in his/her room;-After Resident #10 was found in Resident #11's room, the staff placed Resident #11 on one-on-one supervision. During an interview on 10/30/25 at 2:25 P.M., the Administrator and Director of Nursing said the following:-There were no witnesses who saw Resident #11 grab Resident #7's breast;-There were no witnesses who saw Resident #11 and Resident #10 do anything or even witness Resident #11 touch Resident #10 inappropriately;-No one reported any changes in Resident #10's behavior or mood;-Resident #10 was able to take his/her own pants off but sometimes needed cues to put pants on correctly;-Resident #10 made comments in the past about worrying about being raped;-Resident #10 went into Resident #11's room after the allegation of Resident #11 touching Resident #7's breast;-The staff's focus was to watch Resident #11 when he/she was out of the room;-The staff were not monitoring Resident #10, because he/she was not known to go into other resident rooms. 2653242

Based on interview and record review, the facility failed to provide a full time Director of Nursing (DON), who did not serve as a charge nurse, when the facility had a census over 60. The facility census was 86.Based on interview and record review, the facility failed to provide a full time Director of Nursing (DON), who did not serve as a charge nurse, when the facility had a census over 60. The facility census was 86. Review of the facility Registered Nurse (RN) Policy, revised 04/30/24, showed the facility will designate a Registered Nurse to serve as the Director of Nursing on a full-time basis. Review of the facility's staffing sheets showed the facility did not have DON coverage on the following dates: -06/16/25, facility census 86;-06/17/25, facility census 86; -06/19/25, facility census 86; -06/23/25, facility census 86;-06/24/25, facility census 86;-06/25/25, facility census 86;-06/27/25, facility census 87. During an interview on 07/09/25 at 4:15 P.M., the DON said the following:-She had previously served as the DON, but during the month of May and June 2025, worked as a charge nurse because the facility was short-staffed; -The current (interim) administrator had been the DON during this time, but had been pulled to other facilities for a couple of weeks in June, so there were several days when there was no DON in the facility; -She reassumed the DON position full-time on or about 07/02/25. During an interview on 07/10/25 at 2:00 P.M., the administrator said the following: -She was previously the acting DON for the facility, as the former DON was pulled back to a charge nurse position due to staffing issues; -There were several days in June that she was away from the facility, so there was no DON coverage on those dates. 1539073

Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for three residents (Resident #6, #7 and #8), in a review of eight sampled residents, when staff failed to answer the resident's call light in a timely manner, resulting in the residents' toileting needs not being met, episodes of bladder incontinence (loss of bladder control), and prolonged time the resident remained in a soiled incontinence brief. The facility census was 86.Based on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for three residents (Resident #6, #7 and #8), in a review of eight sampled residents, when staff failed to call lights in a timely manner, resulting in the residents' toileting needs not being met, episodes of bladder incontinence (loss of bladder control), and prolonged time the resident remained in a soiled incontinence brief. The facility census was 86. 1. Review of the Facility Assessment, dated 03/03/25, showed the following:-The facility assessment will be used to inform staffing decisions to ensure a sufficient number of staff with the appropriate competencies and skill sets necessary to care for residents' needs as identified through resident assessments and plans of care; -Consider specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to its resident population; -The average daily census was 93 residents; -The residents were either disabled or incapacitated; -This staffing plan is based on the facility assessment, along with facility-based and community-based risk assessments to inform staffing decisions to ensure that there are a sufficient number of staff to care for the residents' needs;-This document is updated and adjusted as necessary based on changes to the resident population;-Staffing needs as per resident unit included four to six Certified Nurse Assistants (CNAs) for day shift, and three to four CNAs for night shift. 2. Review of the facility's staffing sheets, of the staff who worked, showed the following: -06/11/25: three CNAs scheduled for the day shift (which is less than the four to six CNAs needed for day shift as indicated by the facility staffing assessment); -06/12/25: three CNAs scheduled for the day shift (which is less than the four to six CNAs needed for day shift as indicated by the facility staffing assessment); -06/17/25: three CNAs scheduled for the day shift (which is less than the four to six CNAs needed for day shift as indicated by the facility staffing assessment);-06/24/25: three CNAs scheduled for the day shift (which is less than the four to six CNAs needed for day shift as indicated by the facility staffing assessment); -06/27/25: three CNAs scheduled for the day shift (which is less than the four to six CNAs needed for day shift as indicated by the facility staffing assessment);-07/07/25: three CNAs scheduled for the day shift (which is less than the four to six CNAs needed for day shift as indicated by the facility staffing assessment). 3. Review of Resident #6's care plan, last revised 05/08/24, showed the following: -Resident had an Activity of Daily Living (ADL) self-care performance deficit related to activity intolerance and impaired balance; -Resident required extensive assistance by one staff for toileting. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff on 05/15/25, showed the following: -Makes self understood; -Understands others; -Cognitively intact; -No rejection of cares; -Dependent for toileting;-Had a colostomy and was always incontinent of bladder. During an interview on 07/09/25 at 1:40 P.M., the resident said the following: -The facility did not have enough staff; there were four halls and when there were only three CNAs, it made it rough for staff to help everyone; -He/She required a mechanical lift for transfers and that took two staff to operate; sometimes he/she would have to wait for a while until staff could help him/her; -A couple of weeks ago, he/she had to wait over 30 minutes for his/her call light to be answered; he/she had wet (had been incontinent of urine) the bed; -He/She was uncomfortable in the wet bed and embarrassed. 4. Review of Resident #7's care plan, last revised 06/09/22, showed the following: -Resident had bladder incontinence related to limited range of motion (ROM), and gait imbalance; -Resident used disposable (incontinence) briefs, check and change every two hours and as needed, change clothing as needed after incontinence episodes. Review of the resident's annual MDS, dated [DATE], showed the following: -Makes self understood; -Understands others; -No rejection of cares; -Partial to moderate assistance for toileting;-Always incontinent of bowel and bladder. During an interview on 07/09/25 at 10:27 A.M., the resident said the following: -He/She needed help to go to the bathroom; -He/She wore incontinence briefs; -His/Her incontinence brief was currently wet; -Sometimes staff did not answer the call light right away and he/she would urinate in the brief. Observation on 07/09/25 at 10:27 A.M. showed the following: -The resident sat in a wheelchair in his/her room; -There was a strong smell of urine in the resident's room; -The front of the resident's pants was wet; -The resident pushed his/her call light to get staff assistance;-The call light emitted a loud sound, and a light came on outside and above the resident's door;-CNA A entered the resident's room [ROOM NUMBER] minutes later, at 10:45 A.M., spoke with the resident, turned the call light off and left. During an interview on 07/09/25 at 10:45 A.M., the resident said the following; -CNA A came in and asked what he/she needed, the resident told staff he/she was wet and needed to be changed; -Staff said they were running behind and needed help but would be back in a little bit to change the resident. Observation on 07/09/25 at 11:00 showed the resident in his/her room sitting in a wheelchair. The resident's pants remained wet, and a strong urine smell persisted in the room. 5. Review of Resident #8's care plan, last revised on 08/23/24, showed the following: -Resident had an ADL self-care performance deficit related to fatigue and impaired balance; -Resident required limited assistance of one staff for toileting; -Resident was at risk for impaired skin integrity related to urinary incontinence, chronic rash and need for assistance; -Evaluate for urinary incontinence; -Provide skin care per facility guidelines and as needed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Makes self understood; -Understands others; -No rejection of cares; -Substantial to maximum assistance for toileting;-Frequently incontinent of bowel and bladder. During an interview on 07/09/25 at 2:45 P.M., the resident said the following: -He/She needed help to go to the bathroom; -He/She had a history of sensitive skin and broke out easily when he/she was wet (incontinent); -About one month ago, staff did not answer his/her call light for over an hour, and he/she needed to go to the bathroom; -He/She wet the bed because staff did not answer the call light; -He/She felt terrible when he/she wet the bed and staff had to clean him/her up; -The facility did not have enough help; they often did not answer the call light when he/she needed something. 6. During an interview on 07/10/25 at 11:10 A.M., CNA A said the following: -The facility did not have enough staff; call lights were hard to get to when the facility was short-staffed; -There were seven residents on one hall that needed a mechanical lift for transfers, and eight on another hall;-Mechanical lifts required two staff to operate; there had been times when he/she would use the lift by himself/herself because there was not enough staff to help. During an interview on 07/09/25 at 4:15 P.M. and 07/10/25 at 1:20 P.M., the Director of Nurses (DON) said the following: -She was familiar with the facility assessment but was not sure what the actual staffing needs per resident unit included;-Four (or less) CNAs on day shift for the four facility halls, with an average daily census of 90, was not enough staff to provide appropriate resident care. During an interview on 07/10/25 at 2:00 P.M., the Administrator said the following: -She was familiar with the facility assessment and what the staffing needs per resident unit included; -Three CNAs on day shift was not enough staff to provide care to residents based on the facility assessment. 1539071

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of seven sampled residents, was free from physical abuse by Resident #2 when Resident #2 hit Resident #1 in the face with a fist multiple times. The facility census was 91. Review of the facility's Abuse and Neglect Policy, revised 6/12/24, showed the following: -Abuse is the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations; -Physical abuse is the purposeful beating, striking, wounding, or injury of any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane manner. Physical abuse includes, hitting, slapping, punching, biting, and kicking; -The facility will identify and correct by providing interventions in which abuse is more likely to occur, such as more secluded areas in the facility and ensuring the staff are knowledgeable of resident care needs. Prevention will also include assessment, care planning and monitoring of residents with needs or behaviors which may lead to conflict; -As part of the resident social history assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. 1. Review of Resident #1's undated face sheet showed the following: -The resident admitted on [DATE]; -Diagnoses included encephalopathy (any disorder or disease of the brain, especially chronic degenerative conditions), bipolar II disorder (condition that causes unusual shifts in mood, energy, activity levels and the ability to carry out day-to-day tasks), schizoaffective disorder (chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), and anxiety disorder (mental health condition characterized by excessive and persistent fear or anxiety that interferes with daily life, causing significant distress). Review of the resident's Care Plan, dated 5/28/24, showed the following: -The resident was at risk for aggression and other personality change related to diagnosis of traumatic brain injury; -Avoid confrontation; -Do not argue or get defensive with the resident; -The resident had behavioral symptoms related to his/her mental illness, wandered around the facility at times and was easily anxious; -Intervene as necessary to protect the rights and safety of others, remove from situation and take to alternate location as needed. Review of the resident's Care Plan, updated 6/21/24, showed the following: -The resident could be verbally aggressive and intrusive related to ineffective coping skills, mental/emotional illness, poor impulse control; -When the resident became agitated, intervene before agitation escalated, guide away from source of distress, engage calmly in conversation. Review of the resident's significant change MDS, dated [DATE], showed the following: -The resident had mild cognitive impairment; -He/She experienced verbal behaviors towards others and other behavioral symptoms not directed towards others that occurred 1-3 days out of seven days of the assessment; -The behaviors put the resident at significant risk for physical illness or injury; -He/She wandered 1-3 days out of seven days of the assessment; -He/She needed supervision with ambulation. Review of the resident's nurse note, dated 5/16/25 at 5:14 P.M., showed the following: -Peers of the resident came to tell staff that another peer was hitting the resident; -Peers said the resident walked down the sidewalk toward the carport and the other peer started yelling at the resident to get back over to the supervised smoking area; -The other peer went over to the resident and punched him/her multiple times in the face; -The staff sent the resident to the emergency department via ambulance for evaluation; -The psych physician, primary care physician, guardian, administrator, and management were notified. During an interview on 5/23/25 at 1:30 P.M., Resident #1 said the following: -Resident #2 hit him/her on the chin; -The altercation made him/her mad; -He/She felt safe now because Resident #2 was gone. 2. Review of Resident #2's undated face sheet showed the following: -The resident admitted on [DATE]; -Diagnoses included generalized anxiety disorder, major depressive disorder (mental health condition characterized by persistent feelings of sadness, emptiness, and a loss of interest or pleasure in daily activities), and dementia (general term for a group of symptoms that affect memory, thinking, and other cognitive abilities). Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/She required supervision for ambulation. Review of the resident's care plan, dated 2/21/25, showed the resident had impaired thought processes related to dementia and often had mood disturbances with agitation. Review of the resident's care plan, updated on 4/16/25, showed the following: -Begin behavior monitoring; -Skilled nursing to increase frequency of assessment of behavior monitoring (aggressive/hostile behavior). Behavior monitoring will increase with frequency during the skilled timeframe; -Increase detection and assessment of triggers and identify alternate approaches. Review of the resident's nurse note, dated 4/18/25 at 11:58 A.M., showed the following: -The resident sat in the town square of the facility with peers on couches and the nurse overheard the resident yell loudly and scream profanity; -The resident was upset about another resident that wanted to sit on the couch and he/she did not want the peer to sit on the couch; -The nurse explained to the resident, screaming foul words in front of other residents and staff who may find this offensive, the area he/she displayed behavior was not appropriate as it was a community environment, and if the resident wanted to continue discussing things in that manner, he/she could go to a private area; -The resident declined and continued to raise his/her voice and said more profanities. The resident said he/she would continue to act this way and the nurse could try and put his/her hands on the resident and see what happens; -Staff present during behavior crisis with no redirection effective; -The nurse contacted the police. Review of the resident's nurse note, dated 5/16/25 at 4:24 P.M., showed the following: -The resident's peer went inside the facility to tell staff that there was a resident altercation; -The staff went outside to separate the residents and bring them back inside the facility; -The resident said, he/she hit Resident #1; -The Administrator advised the resident, his/her actions were not appropriate; -The resident said Resident #1 should have stayed away from him/her; -A police officer responded to the facility and spoke with the resident, who admitted he/she hit Resident #1. During an interview on 5/23/25 at 11:53 A.M., Resident #2 said the following: -The staff changed his/her status from supervised smoker to unsupervised smoker to get Resident #1 away from him/her; -On the day of the altercation, Resident #1 went over to the unsupervised smoking area; -He/She told Resident #1 to go back to the other area; -Resident #1 started in on him/her and he/she hit Resident #1. 3. During an interview on 5/23/25 at 10:45 A.M., Resident #4 said the following: -Resident #2 was a bully that didn't like weak residents with mental illness; -He/She witnessed the resident yell at other residents and threatened to kick their ass; -Resident #1 went out the supervised smoking area door early to wait to smoke; -Resident #2 went out the unsupervised smoking area door and saw Resident #1, then told Resident #1 to go back to the other area; -Resident #1 did not comply, Resident #2 started hitting Resident #1 in the face; -The altercation occurred on the sidewalk between the supervised and unsupervised smoking area. During an interview on 5/23/25 at 1:15 P.M., Licensed Practical Nurse (LPN) A said the following: -Resident #2 had a temper; -Resident #1 was annoying at times to the other residents and Resident #2 did not like it; -There was an incident that occurred prior to this altercation where Resident #1 pushed another resident in a wheelchair down the 100 Hall. Resident #2 saw it from the common area and yelled at Resident #1 to stop pushing the other resident, Resident #1 yelled back, he/she was not doing anything wrong. Resident #2 charged down the 100 Hall towards Resident #1, and the staff intervened before anything happened; -Resident #2 had a target on Resident #1. During an interview on 5/23/25 at 2:01 P.M., and 5/28/25 at 3:42 P,M. the Administrator said the following: -Resident #2 did not have any issues with other residents prior to the altercation; -The resident never mentioned to the DON or herself that he/she had any issues with Resident #1 and the Administrator never expected the altercation to happen; -She did not consider the altercation as being abuse, nor preventable. MO254376

Based on observation, interview and record review, the facility failed to provide a full time Director of Nursing (DON), who did not serve as a charge nurse, when the facility had a census over 60. Further review showed the facility did not have eight consecutive hours of Registered Nurse staffing daily for two days. The facility census was 98. Review of the facility Registered Nurse (RN) Policy, revised 04/30/24, showed the following: -It is the intent of the facility to comply with Registered Nurse staffing requirements; -Full-time is defined as working 40 or more hours a week; -Charge Nurse is a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care; -The facility will utilize the services of a Registered Nurse for at least eight consecutive hours per day, seven days per week; -The facility will designate a Registered Nurse to serve as the Director of Nursing on a full time basis; -The Director of Nursing may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents. 1. Review of the Facility Assessment, dated 08/04/24, showed the following: -Federal regulations will require that facilities must provide 3.48 hours per resident day (HPRD) of direct care with 0.55 HPRD from registered nurses (RNs); -The remaining 0.48 HPRD can be a combination of nurse staff, including RNs. The facility assessment did not list number of staff by discipline/shift/day. 2. Review of the facility's staffing sheets, dated 01/01/25 through 01/31/25, showed the following: -01/01/25 charge nurse for the 300/400 hall was the DON from 6:00 A.M. to 12:00 noon, facility census 90; -01/05/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 91; -01/10/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 91; -01/11/25 one charge nurse (LPN) listed for day shift, and no RN listed on the staffing sheet, facility census 91 (there was not eight consecutive hours of RN coverage); -01/12/25 no RN listed on the staffing sheet, facility census 90 (there was not eight consecutive hours of RN coverage); -01/17/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 92; -01/22/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 90; -01/25/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 90; -01/27/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 94; -01/28/25 charge nurse for the 300/400 hall was the DON (half the shift) 12:00 Noon to 6:00 P.M., facility census 93; -01/30/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 92. Review of the facility's staffing sheets, dated 02/01/25 through 02/28/25, showed the following: -02/01/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 93; -02/02/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 92; -02/04/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 92; -02/05/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 91; -02/07/25 one charge nurse, the DON, listed for day shift 6:00 A.M. to 6:00 P.M., facility census 91; -02/08/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 91; -02/10/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 91; -02/11/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 92; -02/12/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 92; -02/14/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 93; -02/15/25 charge nurse for the 300/400 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 92; -02/16/25 charge nurse for the 300/400 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 93; -02/17/25 charge nurse for the 300/400 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 94; -02/18/25 charge nurse for the 300/400 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 94; -02/20/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 94; -02/21/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 96; -02/22/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 96; -02/24/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 95; -02/26/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., the DON was also listed for the Certified Medication Technician (CMT) role passing medications on the 300/400 hall for 6:00 A.M. to 6:00 P.M., facility census 96; -02/28/25 charge nurse for the 100/200 hall was the DON from 6:00 A.M. to 6:00 P.M., facility census 98. Review of the facility's staffing sheets, dated 03/01/25, showed one charge nurse, the DON, listed from 6:00 A.M. to 6:00 P.M.; the facility census was 98. 3. Review of the staffing sheets, dated 03/04/25, showed the charge nurse for the 100/200 hall was the DON from 6:00 P.M. to 6:00 A.M.; the facility census was 98. Observation on 03/04/25 at 6:00 P.M., during the survey process, showed the DON worked as the charge nurse for the 100/200 hall. 4. Review of the staffing sheets, dated 03/05/25, showed the charge nurse for the 100/200 hall was the DON from 6:00 P.M. to 6:00 A.M.; the facility census was 98. Observation on 03/05/25 at 6:00 P.M., during the survey process, showed the DON worked as the charge nurse for the 100/200 hall. During an interview on 03/05/25 at 11:41 A.M., the DON said the following: -Nursing administration covered charge nurse and floor roles daily and other department heads have had to assist; -The facility had used agency staff to fill charge nurse roles prior to January 1st 2025; -The facility had relied on agency staffing for licensed staffing, but that had stopped January 1st (2025); -She had worked almost every day as a charge nurse; she had been working an eight to thirteen day stretch with one day off the month of February; -The month of March, she was scheduled to be on nights full time; -In February, she only worked as the DON for eight hours; -She had not been able to keep up with education or other tasks that needed to be done; -When she was the charge nurse on the floor, she could not get interviews and new hire paper work completed; -If the facility did not have enough nurses, she had been on the floor working or helping. During an interview on 03/02/25 at 4:21 P.M., the administrator said the following: -The DON had worked the floor most of the month of February as a charge nurse; -The DON was only able to work in the DON role two days in February; -The facility did not have enough licensed nursing staff; -Agency staff had been utilized prior to 01/01/25 but the facility was not allowed to use agency staffing at this time. During an interview on 03/03/25 at 1:18 P.M., the Regional Director of Operations said the DON has been working the floor a lot. The company may have to bring agency staffing back in the building. The agency contract ended on 01/01/25.

Based on observation, interview, and record review, the facility failed to ensure ceilings in the dishwasher room, dry food storage room, and above food preparation and serving areas were clean and maintained in good condition to ensure food items were not subject to potential contamination. The facility failed to maintain a drain air gap between the ice machine and the floor drain. The facility census was 98. Review of the facility's policy, Dietary Equipment Operations, Infection Control, and Sanitation, last revised 02/02/24, showed the following: -Ceilings must be free of chipped and/or peeling paint; -Ceilings must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently and as required. It is important to repair peeling paint areas as soon as they appear. 1. Observation on 3/2/25 between 2:50 P.M. and 9:00 P.M., showed the following: -A ceiling area approximately 2 feet wide by 8 feet long above the door inside the dry food storage room had moisture damage and dark stains; -The ceiling in the dishwasher room had cracked, chipped, and flaking paint above the dirty and clean ends of the dishwashing area and above the clean item racks; -Above the steam table, two ceiling vents and the areas on the ceilings around each vent had a buildup of dust and debris. During an interview on 3/3/25 at 10:30 A.M., the Dietary Manager said the following: -She had not really noticed the identified areas on the ceilings. The maintenance department would be responsible for making ceiling repairs and cleaning the ceiling vents; -The maintenance department usually checked and cleaned vents monthly. During an interview on 3/5/25 at 8:40 A.M., the Maintenance Director said the following: -He was aware of the identified ceiling areas; -The maintenance department was responsible for repairing/maintaining the ceilings in the kitchen, and cleaned the ceiling vents quarterly and as needed; -He expected the identified areas on the ceilings in the kitchen to be clean and maintained. 2. Observation on 3/3/25 at 12:59 P.M., of the ice machine, located in the dining room, showed two 1-inch drain pipes exited the ice machine into a 3-inch flanged drain pipe at the floor. The two 1-inch drain pipes extended approximately 0.5-inches below the flood rim level of the 3-inch flanged drain pipe and did not contain an air gap. During an interview on 3/3/25 at 1:00 P.M., the Maintenance Supervisor said he was unaware the ice machine drain did not contain a sufficient air gap. During an interview on 3/5/25 at 9:00 A.M., the Administrator said she expected the ice machine drain to have an air gap, and expected the ceilings in the kitchen to be free of dust and debris and maintained in good repair.

Based on interview and record review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool required to be completed by facility staff, for four residents (Resident #18, #36, #59, and #79) in a review of 24 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (a decline or improvement in two or more assessed areas of resident status) in the resident's physical or mental condition which had an impact on more that one area of the resident's health status, or was placed under hospice care, and required interdisciplinary review and/or revisions of the care plan. The facility census was 98. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, Chapter 2, revised October 2023, showed the following: -The significant change in status assessment (SCSA) is a comprehensive MDS assessment for a resident that must be completed when the Interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an Admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change; -A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan; - When a resident's status changes and it is not clear whether the resident meets the SCSA guidelines, the nursing home may take up to 14 days to determine whether the criteria are met; -After the IDT has determined that a resident meets the significant change guidelines, the nursing home should document the initial identification of a significant change in the resident's status in the clinical record; -An SCSA is appropriate when: 1. There is a determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments and the resident's condition is not expected to return to baseline within two weeks; 2. An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. -The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than); -An SCSA must be performed regardless of whether an assessment was recently conducted on the resident; -This is to ensure a coordinated plan of care between the hospice and nursing home is in place. Review of the facility policy, Significant Change, revised on 11/06/23, showed the following: -The facility will identify within 14 days of a significant change in two or more areas of decline or improvement in the resident's physical or mental condition; -If the resident shows a decline or improvement in two or more areas, a significant change assessment will be completed within 14 days; -A significant change will be defined as a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan or both. -The following are the criteria for a significant change: a. Is not self limiting; b. Impacts one or more of the resident's health status; c. Being placed on hospice or discharged off of hospice care; d. Requires an inter-disciplinary review of the care plan or MDS within 14 days of the significant change; e. A significant change assessment is indicated if decline or improvement is consistently noted in two or more areas of decline or two or more areas of improvement; -If the resident experiences a significant change in status, the next annual assessment is not due until 366 days after the significant change assessment has been completed; -The MDS/Care Plan Coordinator will complete a significant change assessment when the resident meets the criteria as defined by a significant change; -The Physician, Family Member/Legal Guardian/Responsible Party and Interdisciplinary Team will be informed of any significant changes and changes in interventions included in the plan of care. 1. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 06/10/24, showed the following: -Cognitively intact; -Diagnosis of dementia, diabetes mellitus (inability to control blood sugar), bipolar (a mental health condition that causes extreme mood swings emotional highs(mania) and lows (depression)), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), extrapyramidal (describes involuntary movements that you cannot control cause by antipsychotic medications) and movement disorders; -Independent with eating, rolling left and right and propelling wheelchair 150 feet; -Set up or clean up assistance from staff for oral hygiene; -Requires supervision/touching assistance from staff members for toilet hygiene, upper body dressing, put on/take off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer and toilet transfers; -Requires partial/moderate assistance from staff for lower body dressing and tub/shower transfers; -Requires substantial/maximal assistance from staff to shower/bathe; -Scheduled pain medications, with the resident saying no pain present during assessment. Review of the resident's quarterly MDS, dated [DATE], showed the following -Severe cognitive impairment (previous assessment cognitively intact); -New diagnosis of pneumonia, and new pressure ulcer that is Stage III (Wound with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling); -New indwelling urinary catheter (tube inserted in bladder to drain urine); -Set up or clean up assistance from staff for eating (was independent previously); -Requires substantial/maximal assistance from staff for oral hygiene (was set up), upper body dressing (was supervision/touching), lower body dressing (was partial/moderate), personal hygiene (was supervision/touching), rolling left and right (was independent), and sit to lying (was supervision/touching); -Dependent on staff for toilet hygiene (was supervision/touching), shower/bathe (was substantial/maximal), put on/take off footwear (was supervision/touching), chair/bed-to-chair transfer (was supervision/touching), tub/shower transfer (was partial/moderate) and propelling wheelchair (was independent); -Not attempted during this assessment: lying to sitting on the side of the bed, sit to stand, and toilet transfer; -New mechanical soft diet; -New Stage III pressure ulcer present. A SCSA was not completed after the resident had a decline in cognition, new diagnosis that could change the resident's care plan, new urinary catheter, decline in several activities of daily living (ADL's), new diet and new Stage III pressure ulcer. 2. Review of Resident #36's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis include: dementia (15/15 on cognitive test), Parkinson's (a movement disorder of the nervous system), Traumatic brain injury (TBI-an injury to the brain caused by an external force, such as a blow, bump, jolt or penetration to the head. It can result in temporary or permanent damage to the brain, affecting cognitive, physical and emotional functions), anxiety, depression, Lewy body dementia (progressive brain disorder characterized by abnormal protein deposits called Lewy bodies in the brain); -Independent with all ADL's and walks without devices; -Occasionally incontinent of bowel and bladder; -No shortness of breath when lying flat; -Weight 181 pounds (lbs); -No falls. Review of the resident's quarterly MDS, dated [DATE], showed the following: -New delusions (a false belief or judgment about external reality, held despite incontrovertible evidence to the contrary) present; -New diagnosis of bipolar disorder; -New wheelchair use; -Independent with propelling wheelchair 50 feet and wheel wheelchair 150 feet (did not use devices on last assessment); -Requires supervision/touching assistance from staff members for eating, oral hygiene, sit to lying (was independent with these ADL's); -Requires partial/moderate assistance from staff for toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfers (was independent with these ADL's); -Requires substantial/maximal assistance from staff to shower/bathe (was independent with these ADL's); -Did not attempt walking due to medical condition (ambulated independently without devices prior assessment); -Frequently incontinent of bowel and bladder (previous assessment occasionally incontinent); -New shortness of breath when lying flat; -Two or more non injury falls, and two or more injury falls; -Weight 160 lbs.; significant weight loss (11.6 percent (%) weight loss since 07/19/24), not on a physician prescribed plan; -New intravenous (IV) access. The facility failed to complete a SCSA when the resident had many changes including new delusions, diagnosis of bipolar disorder, new wheelchair use, decline in all ADL's, increased incontinence, new shortness of breath when lying flat, four or more falls, significant weight loss and new IV access. 3. Review of Resident #59's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis: Diabetes mellitus (DM inability to regulate blood sugar), thyroid disorder, depression, respiratory failure, acute and chronic respiratory failure with hypoxia (lack of oxygen to the brain), fluid overload, stage 3 kidney disease, chronic obstructive pulmonary (respiratory) disease and chronic pain; -Moderate signs and symptoms of depression; -Rejection of care; -Independent with wheelchair propelling 50 feet and 150 feet; -Requires partial/moderate assistance from staff for upper body dressing, personal hygiene, rolling left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer and tub/shower transfer; -Requires substantial/maximal assistance from staff for toileting hygiene, shower/bathe, lower body dressing, putting on/taking off footwear and sit to lying; -Frequently incontinent; -Scheduled pain medications; -Occasionally has pain, rates pain six on one to ten scale; -Weight 258 lbs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -New diagnosis of pneumonia; -Moderate cognitive impairment (decline in cognitive abilities); -Requires substantial/maximal assistance from staff for upper body dressing, personal hygiene, rolling left and right (previous assessment required partial/moderate assistance); -Dependent on staff for toileting hygiene (previous assessment required partial/moderate assistance), shower/bathe (previous assessment required partial/moderate assistance), lower body dressing (previous assessment required partial/moderate assistance), putting on/taking off footwear (previous assessment required substantial/maximal assistance), chair/bed-to-chair transfer(previous assessment required partial/moderate assistance), tub/shower transfer (previous assessment required partial/moderate assistance), wheel 50 feet (the resident was independent on the previous assessment), wheel 150 feet (the resident was independent on the previous assessment); -Not attempted due to medical or safety concerns for sit to lying, lying to sitting on side of bed, sit to stand and toilet transfer; -Always incontinent (decline from previous assessment); -Frequent pain, occasionally effects sleep, rates a five on a one to ten scale (pain increased in frequency and now effects the resident's sleep); -New shortness of breath when laying flat; -Weigh 237 lbs, significant weight loss not on a plan; -New anticoagulant medication. A SCSA was not completed by staff when the resident had multiple changes on the 01/16/25 MDS including a new diagnosis of pneumonia, decline in cognition, decline in ADL's, increase in incontinence, increase in effects from pain, new shortness of breath, a significant weight loss and new anticoagulant medication. Review of the resident's undated census sheet showed the resident started on hospice services 01/28/25. Review of the resident's electronic medical record showed a SCSA open with an assessment reference date (ARD) of 03/09/25, the assessment had not been started or completed within 14 days of beginning hospice services (the SCSA ARD was required to be schedule on or before 02/10/25), the assessment was approximately a month late from when hospice began. During an interview on 03/04/25 at 1:36 P.M., the resident's durable power of attorney said the resident has declined physically and medically. 4. Review of Resident #79's face sheet showed the following: -The resident had a guardian; -Diagnoses include vascular dementia (brain damage caused by multiple strokes that can cause memory loss in older adults) , anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily life) and unspecified psychosis (a term used when a person experiences symptoms of psychosis that do not meet the full criteria for a specific psychotic disorder, such as schizophrenia or schizoaffective disorder) not due to a substance or known physiological condition. Review of the resident's March 2025 Physician Order Sheet (POS) showed local hospice group to evaluate and treat with an order start date of 02/07/25. Review of the resident's undated census sheet showed hospice Medicaid as primary payer with an effective date of 02/08/25. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Hospice care. Review of the resident's care plan, revised on 03/02/25, showed the resident admitted to a local hospice group for end of life care on 02/28/25. Record review showed no SCSA MDS completed within 14 days of the resident starting hospice care on 02/08/25; the SCSA MDS should have been completed by 02/22/25. During an interview on 03/05/25 at 1:36 P.M., the MDS Coordinator said the following: -She followed the RAI manual to complete an MDS; -She has been the MDS coordinator at the facility for the last few months but had been an MDS coordinator at the facility in the past and has not attended any formal MDS/RAI training; -A SCSA should be done within two weeks of the resident's changes, decline or improvement in two or more areas, or if a resident is admitted to hospice care; -It was not communicated to her when Resident #79 started hospice and she noticed the SCSA had not been opened within 14 days of the resident being placed on hospice; -Since the Director of Nursing (DON) and administrator had been working the floor as charge nurses so many shifts, the daily nursing meetings were not occurring; -Resident status changes are discussed in the daily nursing meetings, and since they were not occurring, she felt like that was why she missed the communication of resident's going on hospice care; -She currently was the MDS coordinator at this facility and a sister facility. During an interview on 03/05/25 at 8:19 P.M., the DON said the following: -The MDS Coordinator had been at the facility for a few months, and had been in that same position in the past; -The MDS Coordinator was completing the MDS information for this facility and also goes to a sister facility one day a week; -She would expect the MDS Coordinator to follow the RAI manual for MDS completions; -A SCSA needs to be completed if there is a decline or improvement in two or more areas in the MDS. During an interview on 03/05/25 at 7:51 P.M., the administrator said the following: -The MDS Coordinator completed the MDS's for this facility and one day a week at a sister facility; -She would expect the MDS Coordinator to follow the RAI manual for MDS completion. 42592

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for four sampled residents (Resident #30 #33, #36 and #71), in a review of 24 sampled residents. The facility census was 98. Review of the Resident Assessment Instrument (RAI) Manual, version 1.18.11, dated October 2023, showed the following: -Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status; -The RAI process has multiple regulatory requirements. Federal regulations require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts; -It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the Interdisciplinary Team (IDT) completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment; -Cognitive patterns: The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information and whether the resident has signs and symptoms of delirium. These items are crucial factors in many care-planning decisions; -Preferences for customary and routine activities: The intent of items in this section is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. The information obtained during this interview is just a portion of the assessment. Nursing homes should use this as a guide to create an individualized plan based on the resident's preferences and is not meant to be all-inclusive. Review of the facility policy, MDS 3.0, Care Assessment Summary and Individualized Care Plans, revised on 11/06/23, showed the following: -The MDS 3.0 with the Care Area Assessment (CAA) summaries is a much more user-friendly assessment tool that addresses the holistic person, including functional status, quality of life and individual plan of care to address and meet the needs of the individual resident; -Section C is to be completed by Social Service Director (SSD). These involve cognition, orientation and ability to recall short and long-term situations; -Section F is to be completed by Activity Director (AD) which allows the resident to determine his or her own preferences for daily activities. Patient Health Questionnaire is used here; -MDS's must be kept current and up to date. 1. Review of Resident #30's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/03/24, showed the following: -Cognitively intact; -Diagnosis of paraplegia (paralysis of the legs and lower body); -Section F Preferences for Daily Routine, for all preference: choosing what clothing to wear, take care of personal belongings or things, choose type of bathing, snacks between meals, choose own bedtime, have family involved in discussions about your care, using the phone in private and having a place to lock your things and keep them safe; are all marked somewhat important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response); -Section F Activity Preferences, for all activities: having things to read, listen to music you like, be around animals such as pets, keep up with the news, doing things with groups of people, doing favorite activities, going outside when the weather is good and participate in religious activities/practices; are all marked somewhat important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response). -The resident was the primary respondent for Section F. All interviews were conducted for this MDS. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Section B staff documented the resident is understood and understands with clear speech; -Brief interview for mental status should not be conducted because the resident is rarely/never understood; -Short and long term memory is ok; -Resident knows current season, location of own room, staff names and faces and that he/she is in a nursing home; -The resident is modified independent for cognitive skills for daily decision making; -Section D mood is marked the interview should not be conducted because the resident is rarely/never understood; -Section J pain interview was conducted and the resident said he/she has pain frequently and rates the his/her pain as a four; -Interviews were not conducted for Section B and D and resident marked as able to understand and understood in Section A and J, but marked as not able to understand or understood on Section B and D. On the 11/27/24 staff marked the resident as rarely/never understood for the cognitive, and mood interviews (Section C and D) but interview was conducted for section J. During an interview on 03/05/25 at 2:17 P.M., the resident was alert and oriented and could be understood. (most recent MDS showed the resident was rarely/never understood). 2. Review of Resident #33's face sheet showed the following: -The resident had a guardian; -Diagnoses include unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, delusional disorders, paranoid schizophrenia , mild neurocognitive disorder due to known physiological condition with behavior disturbance and major depressive disorder. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment (the last four assessments showed the same with the last assessment showing more than severed cognitive impairment in 2022); -Unclear speech or mumbles; -Sometimes able to make self understood; -Sometimes understands others; -Section F, each question answered as somewhat important with questions indicated as answered by the resident. During an interview on 03/02/25 at 7:59 P.M. and 03/05/25 at 11:58 A.M. the resident was unable to consistently answer any questions presented by the surveyor with a routine response of yep or ok. During an interview on 03/18/25, at 2:55 P.M., the Activity Director said the following: -Resident #33 was comfortable talking to her and will have a conversation and answer yes/no questions when presented; -For the annual activity questionnaire, Section F, of the MDS she presented each question to the resident as, Is this really important and the resident would answer yes or no; if no, she would ask the resident if the specific question was kinda important and the resident answered yes to each question resulting in the 2, or somewhat important value, for the MDS assessment. 3. Review of Resident #36's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis include: dementia (15/15 on cognitive test), Parkinson's (a movement disorder of the nervous system), Traumatic brain injury (TBI-an injury to the brain caused by an external force, such as a blow, bump, jolt or penetration to the head. It can result in temporary or permanent damage to the brain, affecting cognitive, physical and emotional functions), anxiety, depression, Lewy body dementia (progressive brain disorder characterized by abnormal protein deposits called Lewy bodies in the brain); -Section F Activity Preferences, for all activities: having things to read, listen to music you like, be around animals such as pets, keep up with the news, doing things with groups of people, doing favorite activities, going outside when the weather is good and participate in religious activities/practices; are all marked somewhat important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response); -The resident was the primary respondent. During an interview on 03/04/25 at 3:32 P.M., the resident was alert and oriented. He/She was able to express his/her needs and interests. Resident said there were some activities he/she enjoyed more than others. 4. Review of Resident #71's electronic medical record census showed the resident began hospice services on 04/30/24. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included diabetes mellitus, stroke with hemiplegia (paralysis affecting left dominant side), Schizophrenia (mental illness), Dysphagia, traumatic brain injury, impulse disorder, extrapyramidal and movement disorder (movement disorder caused by medications); -Section F Preferences for Daily Routine, for all preferences: choosing what clothing to wear, take care of personal belongings or things, choose type of bathing, snacks between meals, choose own bedtime, have family involved in discussions about your care, using the phone in private and having a place to lock your things and keep them safe; are all marked somewhat important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response); -Section F Activity Preferences, for all activities: having things to read, listen to music you like, be around animals such as pets, keep up with the news, doing things with groups of people, doing favorite activities, going outside when the weather is good and participate in religious activities/practices; are all marked somewhat important (choices are very important, somewhat important, not important at all, important but can't do or no choice, or no response); -Functional limitation in ROM one upper and one lower extremity; -Wheelchair use; -Hospice. Review of the resident's care plan, last revised on 05/08/24, showed the resident has an Activity of daily living (ADL) self-care performance deficit related to confusion, spastic hemiplegia affecting the resident's left dominate side with limited ROM and extrapyramidal and movement disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Functional limitations in ROM in both upper and both lower extremity; -No wheelchair or mobility device (no documentation to show the resident had had a significant change and no longer needed a wheelchair or mobility device); -Hospice. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No limitations in functional ROM (no documentation to show the resident had had a significant change and now had no limitations); -Wheelchair use; -Resident is not receiving hospice. Review of the resident's electronic medical record census showed the resident had not been discharged from hospice since he/she was admitted to hospice services. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No limits in functional ROM (no documentation to show the resident had had a significant change and now had no limitations); -Wheelchair use; -Hospice . Observation on 03/03/25 at 12:31 P.M., showed the resident in a broda style chair (reclining chair on wheels). The resident had a mechanical lift sling under him/her, was not able to use the left side of his/her body and had visible limits to range of motion on the left side of his/her body. 5. During an interview on 03/19/25 at 8:17 A.M., the Activity Director said the following: -She has been in this position for three years; -She does resident interviews for the MDS section F for comprehensive assessments; -There have been several MDS coordinators in the last year and sometimes MDS's were opened and completed and she didn't know they were scheduled; -She was doing her interviews in her section and thought they would pull over to the MDS but then found out they were not pulling over like she thought they were; -Resident' #30 and #36 are very alert and oriented and have differing preferences on what they like to do and do not like to do, she was not sure why the section F preferences and activities were all marked somewhat important. During an interview on 03/05/25 at 1:36 P.M., the MDS/Care Plan Coordinator said the following: -She has been the MDS Coordinator since January 3, 2025; -She had noticed a lot of changes on the MDS's when reviewing past MDS's; -She said some items were not coded correctly prior to her employment; she does not have time to figure out the old MDS issues so she was focusing on completing current MDS's; -There were several MDS Coordinators in the last year and corporate helped offsite at some point; -She does MDS's for this facility four days a week and for another facility one day per week; -She follows the RAI manual the best she can; -She has not had formal MDS training; -Communications about changes with the residents has been difficult since the Director of Nursing (DON) had been working the floor frequently as a charge nurse; -She was responsible for all of the sections except sections completed by other departments; -She does the nursing sections of the MDS, each discipline does their own sections; -Residents who can communicate would not be marked as unable to understand or not understood. During an interview on 03/05/25 at 8:00 P.M., the Administrator said the following: -She expected the MDS to reflect the resident and the care they needed accurately; -Staff are expected to complete the MDS accurately according to the RAI manual; -She expected staff completing MDS interviews to leave their office and go talk to the residents.

Based on observation, interview and record review, the facility failed to update and revise problems and interventions in resident care plans to reflect current care needs for four residents (Resident #18, #25, #33 and #54) in a sample of 24 residents. The facility census was 98. Review of the facility policy Comprehensive Care Plans, last revised 10/31/24 showed the following: -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment; -The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed; -The Individualized Care Service Plan (ICSP), (also called the bedside care plan) will be updated with pertinent information needed for nursing staff on the floor to provide the needed care for residents. The ICSP is located in Point Click Care under the Point Of Care tab. 1. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 06/10/24, showed the following: -Cognitively intact; -Diagnosis of dementia, diabetes mellitus (inability to control blood sugar), bipolar (a mental health condition that causes extreme mood swings emotional highs(mania) and lows (depression)), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), extrapyramidal (describes involuntary movements that you cannot control cause by antipsychotic medications) and movement disorders; -Independent with eating, rolling left and right and propelling wheelchair 150 feet; -Set up or clean up assistance from staff for oral hygiene; -Requires supervision/touching assistance from staff members for toilet hygiene, upper body dressing, put on/take off footwear, personal hygiene, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer and toilet transfers; -Requires partial/moderate assistance from staff for lower body dressing and tub/shower transfers; -Requires substantial/maximal assistance from staff to shower/bathe. Review of the resident's care plan, last revised 06/17/24, showed the following: -Activities of Daily Living (ADL) deficit related to dementia, limited mobility and poor safety awareness; -Requires supervision to limited assist of one staff member to move between surfaces (transfers), to dress, personal hygiene, and toilet use; -Resident requires extensive assist of one staff member for bathing/showering; -Resident requires encouragement and/or assist of one staff member for bed mobility related to turning and repositioning every two hours. Review of the resident's quarterly MDS, dated [DATE], showed the following -Severe cognitive impairment (previous assessment cognitively intact); -New diagnosis of pneumonia and new pressure ulcer that is Stage III (Wound with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling); -New indwelling urinary catheter (tube inserted in bladder to drain urine); -Set up or clean up assistance from staff for eating (was independent previously); -Requires substantial/maximal assistance from staff for oral hygiene (was set up), upper body dressing (was supervision/touching), lower body dressing (was partial/moderate), personal hygiene (was supervision/touching), rolling left and right (was independent), and sit to lying (was supervision/touching); -Dependent on staff for toilet hygiene (was supervision/touching), shower/bathe (was substantial/maximal), put on/take off footwear (was supervision/touching), chair/bed-to-chair transfer (was supervision/touching), tub/shower transfer (was partial/moderate) and propelling wheelchair (was independent); -Not attempted during this assessment: lying to sitting on the side of the bed, sit to stand, and toilet transfer; -New Stage III pressure ulcer present. The resident's care plan did not show revision to reflect the resident's current condition after the resident had a new urinary catheter, decline in several activities of daily living (ADL's), and a new Stage III pressure ulcer. Review of the resident's census record showed the resident discharged to the hospital 10/11/24 and readmitted to the facility on [DATE]. Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Usually understood, usually understands (new); -Functional limitation in range of motion in both upper and both lower extremities (new); -Requires partial/moderate assistance from staff for sit to lying; -Requires substantial/maximal assistance from staff for oral hygiene, upper body dressing, personal hygiene, rolling left and right, lying to sitting on the side of the bed, -Dependent on staff for toilet hygiene, shower/bathe, lower body dressing, put on/take off footwear, chair/bed-to-chair transfer, and to wheel wheelchair; -The resident was not able to perform sit to stand, tub/shower transfer, and toilet transfer; -Indwelling urinary catheter; -New ostomy (colostomy (a surgical procedure that creates an opening in the abdominal wall to divert feces from the colon to an external collection bag) new since hospitalization ); -New surgical wound. The resident's care plan did not show revision to reflect the resident's current conditions and care requirements after the resident had a new urinary catheter, new colostomy, new limits to functional range of motion, decline in several ADL's and the pressure ulcer changed to a surgical wound. Observation on 03/02/25 at 6:35 P.M., showed the following: -The resident sat in a reclined wheelchair in his/her room; -The resident had a mechanical lift sling under him/her; -The resident did not have a catheter, but had a urinal present; -The resident had a colostomy bag; -The resident was unable to communicate verbally but could nod head up and down (yes and no) and would point at what he/she was trying to convey. During an interview on 03/04/25 at 10:54 P.M., Registered Nurse (RN) B said the following: -The resident was very sick and in the hospital for an extended time; -The resident's wound originally looked like a pressure ulcer; -While in the hospital it was found that the resident had a fistula from his/her bowel that was causing the wound and it was surgically cleaned, so now the wound was coded as surgical; -The resident was now a mechanical lift transfer because of his/her extensive physical decline and the resident now had a colostomy; -The resident had a catheter but it was removed and the resident was able to use the urinal. Review of the resident's care plan did not include evidence the care plan was revised after the resident had a decline in several ADL's before and after a long hospitalization which now required him/her to be a mechanical transfer and dependent in several areas he/she had previously only needed supervision or limited assistance with, a urinary catheter inserted then later removed, a new colostomy, a change to his/her communication abilities and a pressure ulcer that was later discovered to be a fistula with surgical intervention. 2. Review of Resident #25's care plan, last revised 12/29/24, showed it did not address the presence, the use, or the care of a peripherally inserted central catheter (PICC) line (a form of intravenous ((IV) - in the vein) access that can be used for a prolonged period of time by the insertion of a catheter entering the body through the skin and stays in place for days, weeks or even months for administration of treatment substances). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/24/25, showed the following: -Cognitively intact; -One unstageable (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined) deep tissue (purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) -One surgical wound; -Intravenous access while a resident; -IV medications while a resident. Review of the resident's physician order sheet (POS), dated 03/2025, showed the following: -Diagnoses included unstageable pressure ulcer, sacral area (referring to the lower back region, specifically the triangular-shaped bone called the sacrum) and osteomyelitis (inflammation /infection of the bone); -Change PICC line dressing and needle hub connector (device that connects to the end of the PICC catheter) to right upper extremity (RUE) via sterile technique. Review of the resident's treatment medication record (TAR), dated 3/2025 showed the following: -Change PICC line dressing and needle hub connectors to right upper extremity via sterile technique on day shift every seven days (order date of 01/31/25); -Meropenem (antibiotic) IV solution reconstituted one gram: Use one gram intravenously in the evening for surgical care of right buttock pressure ulcer times 14 days (order date of 02/28/25); -Normal saline flush intravenous solution 0.9 percent (%) use 10 milliliters (ml's) intravenously in the morning for antibiotic use for 13 days. Ten ml's per lumen (the PICC line outer tube that allows fluid and medications to be administered into the body), pre and post IV antibiotic(order date of 02/15/25). Observation of the resident, on 03/02/25 at 5:15 P.M., showed the resident in his/her bed. An occlusive (a waterproof, airtight bandage that covers and seals what is below)dressing covered a PICC line located on the resident's right upper arm. During an interview on 03/02/25 at 5:20 P.M., the resident said he/she received antibiotics for a wound through his/her PICC line. 3. Review of Resident #33's face sheet showed the following: -The resident had a guardian; -Diagnoses include unspecified dementia without behavioral disturbance (symptoms of dementia but with specific underlying cause without behaviors), psychotic disturbance (a mental health condition characterized by a loss of touch with reality), mood disturbance (a group of psychiatric conditions that can cause intense and persistent changes in mood, energy and behavior), delusional disorders (a serious mental illness that causes people to have unshakeable false beliefs for at least a month), paranoid schizophrenia (a subtype of schizophrenia characterized by persistent delusions and hallucinations, often with a paranoid theme) and major depressive disorder (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities that were once enjoyable). Review of the resident's care plan, revised on 01/12/2025, showed the following: -Documented safety concerns, encourage use of assistive devices; -The resident has an activity of daily living (ADL) self-care performance deficit related to dementia and often needs staff to cue and assist to ensure he/she is getting the assistance needed; -Bathing/showering: required limited assistance of one staff for showers twice a week and as necessary; -Allow sufficient time for dressing and undressing, assist the resident to choose simple comfortable clothing that enhances his/her ability to dress self; -Need for assistance with dressing fluctuates but often needs limited assist of one staff to dress; -Personal hygiene: requires oversight or limited assist of one staff with personal hygiene and oral care to ensure it is being done, needs assistance shaving; -The resident has impaired cognitive function/dementia or impaired thought processes related to dementia, speech is clear, hearing is adequate, has trouble at times understanding what is being said or making self understood due to cognition. He/She will answer yes or no questions and speaks softly; -Ask yes/no questions in order to determine the resident's needs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Unclear speech or mumbles (a change from clear speech); -Sometimes able to make self understood (a change from trouble making self understood); -Usually understands others (a change from has trouble at times understanding what is being said); -Other behavior symptoms not directed toward others one to three days during observation period (new documentation of behaviors towards others); -Independently ambulatory with no range of motion limitations (ambulatory status not addressed on previous care plan); -Partial to moderate staff assistance for dressing, oral hygiene, upper and lower body dressing and putting on/taking off footwear (change limited assistance); -Substantial to maximum staff assistance for personal hygiene, toileting hygiene, and bathing (change from oversight or limited assistance). Observation on 03/02/25 at 7:59 P.M., showed the following: -The resident walked down the hall with staff; -Hair was disheveled and noted to have approximately 1/2 inches of whisker growth on face; -Sweatpants front and back and hem of shirt noted to be wet and had a moderate urine smell; -Certified Nursing Assistant (CNA) K and Nursing Assistant (NA) L led the resident to his/her room with gloved hands; -Noted to be wearing a pull up incontinence product as well as an adult brief, both noted to be saturated with urine and had a strong odor of urine when removed; -CNA K sat the resident on the toilet and removed his/her wet pants; -After the resident was toileted CNA K wiped the resident's upper thighs and groin with toilet paper and applied a new adult brief; -CNA K assisted the resident to bed. Observation on 03/03/25 at 11:36 A.M., showed the resident walking down the hall. The resident had an approximate 1/2 inch of whisker/beard growth on his/her face and disheveled hair. Observation on 03/04/25 at 9:56 A.M., showed the resident sat in the downtown common area and had a 1/2 inch growth of whiskers on his/her face with disheveled hair. Observation on 03/04/25 at 10:31 A.M., showed the resident with wet spots in the groin area and back of his/her pants. Observation on 03/04/25 at 11:00 A.M., showed the resident continued to have wet pants and had a slight smell of urine. Observation on 03/04/25 at 11:58 A.M., showed the following: -Dietary staff took to resident to his/her room and CNA M assisted the resident to the bathroom; -The resident had been incontinent of urine; -CNA M performed peri-care; -CNA M applied a new incontinent product and dry clothes. Review of the resident's care plan showed no evidence the plan had been updated based on the most up to date MDS assessment. 4. Review of Resident #54's face sheet showed his/her diagnoses include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure with hypoxia (a condition where the lungs struggle to deliver enough oxygen to the blood, leading to low blood oxygen levels and potentially requiring long-term oxygen therapy), major depressive disorder, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die). Review of the resident's care plan, updated 02/25/25, showed the following: -The resident was independent in ADL's; -He/She will have no decline in ADL performance through the next review; -Provide protective oversight and assist where needed; -Oxygen setting: continuous humidified oxygen via nasal cannula (prongs in the nares that deliver oxygen) at three liters; -The resident is on enhanced barrier precautions (EBP - infection control strategy that expands the use of personal protective equipment (PPE) during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs) in addition to universal precautions (a set of infection control measures designed to prevent the transmission of bloodborne pathogens from one person to another) related to wounds requiring dressings. Review of the resident's annual MDS, dated [DATE], showed the following: -Supervision by staff for transfers, personal and toileting hygiene and dressing (a change from the resident being independent with ADL's noted on the care plan); -Substantial to maximum assist for bathing (a change from the resident being independent with ADL's);; -No skin issues (a change from the resident having wounds). -Uses oxygen therapy. Review of the resident's March 2025 Physician Order Sheet (POS) showed the following: -Elevate head of bed due to shortness of air while lying flat; -Oxygen at two liters via nasal cannula continuously when not wearing Bilevel Positive Airway Pressure (BiPaP - a non-invasive ventilation technique that helps individuals with breathing difficulties); -No current wound dressing orders. Observation on 03/03/25 at 11:18 A.M., showed the resident sat in his/her recliner in his/her room with oxygen via nasal cannula in use. No observation or need for EBP noted. Observation on 03/04/25 at 9:44 A.M., showed the resident lay awake in his/her bed with pajamas on and head of bed elevated with oxygen via nasal cannula being used. Hair was slightly oily appearance. No observation or need for EBP noted. Observation on 03/05/25 at 10:50 A.M., showed the resident sat in his/her recliner in his/her room with oxygen via nasal cannula being used. Hair was pulled slightly oily appearance. No observation or need for EBP noted. During an interview on 03/05/25 at 10:50 A.M., the resident said since he/she had been in the hospital he/she needs more help in the shower. He/She used oxygen all of the time and carting around the oxygen tank in the holder on wheels was difficult for him/her. Review of the resident's care plan showed no evidence the plan had been updated based on the most up to date MDS assessment. The plan indicated an incorrect amount of oxygen ordered for the resident and also did not address the resident's head of the bed was to be elevated when in bed or that he/she utilized a BiPaP. 5. During an interview on 03/05/25 at 1:36 P.M., the Care Plan Coordinator said the following: -She has been the MDS Coordinator and has been responsible for updating the resident care plans since January 2025; -Department heads were also responsible for updating care plans; -She normally received information to update care plans during the daily nursing meetings, but the meetings have not been occurring regularly since the Director of Nursing (DON) had been working the floor frequently as a charge nurse. During an interview on 03/05/25 at 8:10 P.M., the DON said the following: -She had not been having the daily nursing meetings due to frequently working the floor as a charge nurse; -Not having the nursing meeting affected the communication between the departments for care plan updates; -She would expect care plans to be up-to-date to reflect the most current care necessary for the resident; -Any member of the Interdisciplinary Team (IDT) can update the care plan; -The MDS Coordinator also updates the resident care plans. During an interview on 3/5/25 at 7:51 P.M., the Administrator said the following: -She would expect care plans to be up-to-date and reflect the most current level of care for the residents; -All department heads are responsible for updating care plans; -The nursing department was responsible for updating care plans for medical issues, the activity director for activities and dietary for nutrition. 38016 42592

Based on observation, interview and record review, the facility failed to ensure facility staff provided six residents (Resident #3, #11, #30, #33, #54 and #79), of 24 sampled residents that were unable to perform their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene and prevent body odor. The facility census was 98. Review of the facility's policy for ADLs, revised on 05/18/24, showed the following: -The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. -Care and services will be provided for bathing, dressing, grooming, toileting and oral care; -A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the facility's policy for Peri-Care, revised on 06/29/23, showed the following: -The purpose of this policy is to ensure that the resident's genital area is kept clean and proper techniques are used to prevent skin break down, infections or any other impairments that can be caused from not using proper aseptic technique; -Perineal care is usually called peri care. It means washing the genitals and anal area. Peri care can be done during a bath or as a separate procedure. Peri-care prevents skin breakdown of perineal area, itching, burning, odor and infections. Perineal care is very important in maintaining the residents' comfort. More frequent care is required for residents who are incontinent or for those who have an indwelling catheter. Make every effort to respect the modesty of residents and be gentle when cleansing this sensitive area; -Other than soap and water, different products may be used when giving peri care. A non-rinse peri-wash, a peri-wash that requires rinsing, skin-barrier creams, or pre-moistened wipes are also acceptable. Use peri-care products according to the service plan and follow the manufacturer's directions for use. Review of the facility's policy for Resident Showers, revised on 06/26/24, showed the following: -It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice; -Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety; -Partial baths may be given between regular shower schedules as per facility policy. 1. Review of Resident #3's care plan, last revised 01/26/25, showed the following: -Incontinent of bladder and bowel; -Resident will remain free from skin breakdown due to incontinence; -Clean peri-area with each incontinence episodes. Wash, rinse and dry perineum. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment, completed by facility staff, dated 02/16/25, showed the following: -No rejection of care; -Independent for transfers; -Used a wheelchair; -Frequently incontinent of bladder and bowel; -Partial to moderate assist with toileting. Observation on 03/02/25 at 6:08 P.M. showed the following: -The resident ambulated to the bathroom while pulling his/her pants and feces/urine soiled incontinent pull up down and then sat on the toilet; -Nurse Aide (NA) J donned gloves, removed the soiled pull up and placed it in the trash; -NA J cleaned the resident's rectal area and buttocks with perineal wipes; -NA J did not clean the resident's front peri-area. During an interview on 03/18/25 at 10:40 A.M. NA J said that the front perineal area, as well as the back should be cleaned when performing incontinent care on a resident. 2. Review of Resident #11's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent for transfers and bathing; -Diagnoses included multiple sclerosis (MS-nerve damage disrupting communication between the brain and the body); -No rejection of care. Review of the resident's care plan, last revised 02/13/25, showed the following: -Self-care performance deficit; -Totally dependent on one to two staff for bathing twice weekly and as needed. Review of the resident's shower/bath documentation for 02/09/25 to 03/05/25, showed the following: -Resident preferred day showers; -Showers were scheduled for Tuesdays and Thursdays; -Documentation for the week of 02/09/25 through 02/15/25 showed the resident received a shower on 02/11/25 (five days from his/her previous documented shower); -There was no documentation to show the resident had been offered or refused a second shower for this week; -Documentation for the week of 02/16/25 through 02/22/25 showed no documentation the resident had been offered or refused two showers for the week; -Documentation for the week of 02/23/25 through 03/01/25 showed Certified Nurse Aide (CNA) O and NA D documented not applicable (NA) on 02/25/25; -There was no documentation to show the resident had been offered or refused a second shower for this week; -Documentation for the week of 03/02/25 through the review period of 03/05/25 showed the resident received a shower on 03/04/25 (21 days from his/her previous documented shower); -The resident was to have received seven showers for this time period but had only received two. Review of the resident's facility census showed the resident had not had a leave of abscessed or hospital stay from 02/01/25 through 03/05/25. During an interview on 03/04/25 at 11:45 A.M. the resident said he/she did not receive showers on a regular basis and definitely not two times weekly. Residents were lucky to get one shower a week. 3. Review of Resident #30's face sheet, showed the resident was his/her own responsible party. Review of the resident's care plan, last revised 01/05/25, showed the following: -Resident has an ADL self-care performance deficit related to paraplegia (paralysis of legs); -Resident is alert and oriented; -Resident is totally dependent on one staff to shower twice weekly and as necessary; -Resident refuses showers frequently if he/she feels they are too close to smoke break. Review of he resident's shower record, dated 02/02/25-03/05/25, showed the following: -The resident's shower days were to be Tuesdays and Thursdays; -Documentation for the week of 02/02/25 through 02/08/25 showed no documentation the resident was offered or refused a shower twice that week; -Documentation for the week of 02/09/25 through 02/15/25 showed staff documented giving the resident a shower on 02/13/25; -There was no documentation the resident had been offered or refused a second shower for the week; -Documentation for the week of 02/16/25 through 02/22/25 showed staff documented giving the resident a shower on 02/20/25; -There was no documentation the resident had been offered or refused a second shower for the week; -Documentation for the week of 02/23/25 through 03/01/25 showed no documentation the resident was offered or refused a shower twice that week; -Documentation for the week of 03/01/25 through the review period of 03/05/25 showed no documentation the resident was offered or refused a shower twice that week; it had been 13 days since the resident's last shower. Review of the resident's facility census showed the resident had not had a leave of absence or hospital stay from 02/05/25 through 03/05/25. Observation on 03/02/25 at 5:54 P.M., showed the resident in his/her room. The resident's hair was greasy and he/she had dry flaky skin. Observation on 03/04/25 at 11:10 A.M., showed the resident had greasy, disheveled hair and flaky skin visible on his/her arms. During an interview on 03/04/25 at 11:10 A.M., the resident said the shower aide was not always able to get to him/her. He/She gets frustrated because the shower aide has time constraints and he/she could not get a shower when he/she wanted one. At minimum, the resident would like one good shower a week (Thursdays), but really wanted two showers a week. The staff only had time to do one shower a week, so if you were busy or not feeling great that day, you were out of luck. He/She should not have to miss smoke break or an activity to take his/her shower. He/She felt like he/she had no control of his/her life sometimes even though he/she was his/her own person. 4. Review of Resident #33's face sheet showed diagnoses include unspecified dementia without behavioral disturbance (symptoms of dementia but with specific underlying cause without behaviors). Review of the resident's care plan, revised on 01/12/2025, showed the following: -The resident wandered throughout the facility; -Implement a scheduled toileting program; -The resident had an ADL self-care performance deficit related to dementia and often needs staff to cue and assist to ensure he/she is getting the assistance needed; -The resident needed to be shown where his/her bathroom was; -Required limited assistance of one staff for showers twice a week and as necessary; -Required oversight or limited assist of one staff with personal hygiene and needs assistance shaving; -Toilet use need for assistance fluctuates, he/she takes self to the bathroom at times, but needs assistance when incontinent of bowel and bladder to ensure he/she was clean and changed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No rejection of cares; -Substantial to maximum staff assistance for personal hygiene, toileting hygiene, and bathing; -Always incontinent of urine and frequently incontinent of bowel. Review of the resident's electronic health record, shower/bath documentation, for 02/05/25 to 03/05/25, showed the following: -Resident prefers day showers; -Schedule bath/shower days are Monday and Thursday; -Documentation for the week of 02/05/25 through 02/08/25 showed no documentation staff offered or the resident refused the scheduled shower for 02/06/25; -Documentation for the week of 02/16/25 through 02/22/25 showed showed no documentation the staff offered or the resident refused two showers for this week; -Documentation for the week of 02/23/25 through 03/01/25 showed showed no documentation staff offered or the resident refused two showers for this week; -Documentation for the week of 03/02/25 through end of review period 03/05/25 showed no documentation of the scheduled shower on Monday, 03/03/25; -The resident was to have eight showers for this time period but had only received two, with no documentation of refusal of showers. His/Her last shower was on 02/13/25, 20 days prior to 03/05/25. Review of the resident's facility census showed the resident had not had a leave of absence or hospital stay from 02/05/25 through 03/05/25. Observation on 03/02/25 at 7:59 P.M., showed the following: -The resident's hair was disheveled and he/she had approximately 1/2 inch whisker growth on his/her face; -The front and back of the resident's sweat pants and hem of his/her shirt were wet and had a urine smell; -Certified Nursing Assistant (CNA) K and NA L led the resident to his/her room; -CNA K assisted the resident in pulling his/her sweat pants down, the resident wore a pull up incontinent product as well as an adult brief; both were saturated with urine and a strong urine odor was noted when removed; -CNA K sat the resident on the toilet and removed his/her wet pants; -After the resident toileted, CNA K wiped the resident's upper thighs and groin with toilet paper and applied a new adult brief; -CNA K nor NA L performed peri care with the use of soap and water, peri-wash or pre-moistened wipes per the facility policy. Observation on 03/03/25 at 11:36 A.M., showed the resident walking down the hall. The resident had approximately 1/2 inch whisker/beard growth on his/her face and disheveled hair. Observation on 03/04/25 at 9:56 A.M., showed the resident sat in the downtown common area. The resident had approximately 1/2 inch whiskers on his/her face and disheveled hair. Observation of the resident on 03/04/25 showed the following: -At 10:31 A.M., the resident had wet spots, approximately the size of a baseball, in the groin area and back of his/her pants and sat down in a chair in the downtown common area; -At 11:00 A.M., the resident continued to sit with wet pants and had a slight smell of urine; -At 11:53 A.M., dietary staff assisted the resident to a standing position and took him/her toward the dining room; -At 11:58 A.M., dietary staff took the resident to his/her room and CNA M assisted the resident to toilet; the resident's adult incontinent product was saturated with urine; -CNA M performed peri-care and the resident said ouch when CNA M cleansed his/her bilateral groin areas; -The resident's bilateral groin was slightly dark pink in color; -CNA M applied a new incontinent product and dry clothes. During an interview on 03/05/25 at 1:15 P.M., the resident's guardian said the following: -He/She would want the resident to be neat and clean; -He/She would want the resident to be clean shaven if that is what the resident wanted on that day; -He/She would want the resident to receive his/her showers as scheduled; -He/She would expect staff to check the resident frequently for incontinence and staff change the resident in a timely manor. The resident should not walk around in soiled clothes. During an interview on 03/04/25 at 12:05 P.M., CNA M said the following: -He/She was assigned the 400 hall residents to care for but helped on 300 hall (the hall that Resident #33 resided on) when needed; -If there was not enough staff for each hall to have a CNA, the charge nurse and department heads were to help and cover the unassigned hall; -Charge nurse and department heads were helping on the 300 hall at this time; -Residents should be checked and changed at a minimum of every two hours; -He/She tries to keep extra clothes for Resident #33 on the hall he/she was working and would sometimes just take the resident into the bathroom on his/her hall and provide incontinence care for the resident since he/she wanders up and down the halls quite a bit; -Showers are supposed to be given twice a week, but when short handed, he/she was not sure if they were being given or not. During an interview 03/12/25 at 4:05 P.M., NA L said the following: -He/She assisted CNA K in providing care for the resident on 03/02/25; -The resident was noted to be wet and had two incontinent products on and his/her pants were wet; -He/She was not scheduled to work on the resident's hall that night but was helping catch up and get resident's ready for bed; -He/She had just started his/her shift at 6:00 P.M. on 03/02/25 and had not performed a check until he/she assisted CNA K; -He/She was unsure who was responsible for the resident's care prior and was unsure when he/she had been checked last as this was the resident's first check since he/she had been on shift; -Residents should not be double briefed at any time and is not sure why that occurred or who did the double briefing; -Peri-care should be performed every time a resident is incontinent; -Peri-care should not be performed only using toilet paper; -Residents should be checked for incontinence at least every two hours; -He/She thinks the residents are given showers a couple of times a week and as needed, but does not work the day shift when the scheduled showers are given. During an interview on 03/12/25 at 4:20 P.M., CNA K said the following: -He/She assisted NA L in providing care for the resident on 03/02/25; -The resident was noted to be wet and had two incontinent products on and his/her pants were wet; -He/She was surprised two incontinent products were on the resident as that was not a normal practice; -He/She was unsure who put two incontinent products on the resident or why that would have occurred; -He/She had just started his/her shift at 6:00 P.M. on 03/02/25 and had not performed a check until he/she assisted NA L; -He/She was unsure who was responsible for the resident's care prior and was unsure when he/she had been checked last as this was the resident's first check since he/she had been on shift; -Peri-care should not be performed with only toilet paper, but at the moment care was provided for the resident, there were no clean wash cloths to use; (meaning none available; none on the linen cart); -He/She could have used a large towel, but was frustrated that the necessary supplies were not available to use, such as the wash cloths; -Showers should be given twice a week and as needed. 5. Review of Resident #54's face sheet showed his/her diagnoses include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), chronic respiratory failure with hypoxia (a condition where the lungs struggle to deliver enough oxygen to the blood, leading to low blood oxygen levels and potentially requiring long-term oxygen therapy), major depressive disorder, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die). Review of the resident's electronic health record, shower/bath documentation, for 02/23/25 to 03/05/25, showed the following: -Resident prefers day shower; -Scheduled bath/shower days were Sunday and Thursday; 2/20 -Documentation for the week of 02/23/25 through 03/01/25 showed one scheduled shower on 02/23/25 documented as not applicable with no documentation to show the resident refused the shower or was out of the building; no documentation to show a second shower was offered/refused for this week; -Documentation for the week of 03/02/25 through review period of 03/05/25 showed no documentation the resident had been offered or refused a shower; -The resident was to have received three showers in this time period and had only received one and the resident had not received a shower for 13 days. Review of the resident's care plan, updated 2/25/25, showed the following: -The resident was independent in ADL's; -He/She will have no decline in ADL performance through the next review; -Provide protective oversight and assist where needed. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Able to make needs known, makes self understood and understands others; -No behaviors or rejection of cares; -Supervision by staff for personal hygiene; -Substantial to maximum assist for bathing; -Occasionally incontinent of urine, continent of bowel; -Uses oxygen therapy. During an interview on 03/02/25, at 6:19 P.M., the resident said the following: -He/She was supposed to get a shower two times a week, on Sunday or Tuesday and Thursday; -He/She preferred at least one weekly, usually on Thursday, on day shift; -He/She preferred to take a shower between 10:00 A.M. and 12:00 P.M. because that was when he/she felt the best due to breathing issues; -He/She had not had a shower for ten days. Observation on 03/03/25 at 11:18 A.M., showed the resident sat in his/her recliner in his/her room. His/Her hair was pulled back and had an oily appearance. During an interview on 03/03/25 at 11:18 A.M. the resident said he/she did not get a shower on 03/02/25 and would like one. Observation on 03/04/25 at 9:44 A.M., showed the resident lay awake in his/her bed. His/Her hair was pulled back and had an oily appearance. During an interview on 03/04/25 at 9:44 A.M., the resident said he/she did not receive a shower yesterday and would like one, it had been almost two weeks since his/her last shower. Observation on 03/05/25 at 10:50 A.M., showed the resident sat in his/her recliner in his/her room. His/Her hair was pulled back and had an oily appearance. During an interview on 03/05/25 at 10:50 A.M., the resident said the following: -He/She still has not received a shower this week; -He/She did not get a shower last week and so far, none this week. 6. Review of Resident #59's care plan, dated 04/05/24, showed the following: -Resident is able feed himself/herself with set up assistance at times to cut meats and open cartons; -Resident requires extensive assist of one to two staff to move between surfaces as necessary. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnoses included diabetes mellitus (DM), respiratory failure, fluid overload, chronic obstructive pulmonary (respiratory) disease COPD, and chronic pain; -Functional limits in ROM both upper and lower extremities; -Required supervision/touching assistance from staff members for eating; -Required substantial/maximal assistance from staff to roll left and right; -Dependent on staff for chair/bed-to-chair transfer; -Significant weight loss not on a plan (9.5% since 7/16/24). Observation and interview on 03/02/25 at 6:15 P.M., showed the following: -NA L brought the resident's supper tray into his/her room and sat the tray on the bedside table, approximately one foot from the resident's bed; he/she took the cover off the resident's plate and left the room; -The resident lay in bed on his/her back and the resident's head was approximately two feet from the top of the bed and his/her feet were next to the footboard; -The resident tried to adjust his/her bed with the remote, but the resident's head did not rise with the bed (because of his/her placement on the bed); -The resident said he/she could not reach his/her food; -The resident said it was hard to eat in bed, especially when he/she could not reach his/her tray; -The resident said it would be easier to eat if he/she was sitting up in a chair; -He/She had a stroke and had a hard time eating; -He/She would go to the dining room, but they said he/she was not supposed to. Observation and interview on 03/02/25 at 6:45 P.M., showed the following: -The resident remained in the same position as the 6:15 P.M. observation, and his/her bedside table with supper tray sat approximately one foot from the bed; -The resident had consumed a small amount of food located at the edge of his/her plate but less than 10 percent (%) had been consumed. Review of the resident's medical record did not show any orders the resident could not get up or go to the dining room. During an interview on 03/02/25 at 6:50 P.M., NA L said the following: -He/She has been employed by the facility for two weeks; -He/She was not sure how much assistance Resident #59 needed. During an interview on 03/05/25, at 8:05 P.M., the Director of Nursing said the following: -Staff are expected to sit a resident upright and get their tray set up where everything was easily accessible to the resident; -Staff are expected to offer to get all residents up for meals and assist them during a meal; -There was no order that the resident could not get up to his/her wheelchair, so it was up to the resident. Staff are expected to offer and encourage the resident to get up. 7. Review of Resident #79's face sheet showed the following: -The resident had a guardian; -Diagnoses include vascular dementia (brain damage caused by multiple strokes), anxiety disorder and unspecified psychosis not due to a substance or known physiological condition (a term used when a person experiences symptoms of psychosis that do not meet the full criteria for a specific psychotic disorder). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No behaviors or rejection of cares; -Partial to moderate staff assistance for upper and lower body dressing; -Substantial to maximum staff assistance for bathing, toileting hygiene and personal hygiene; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, revised on 03/02/25, showed the following: -Needs one assist with showers; -Please ask the resident if he/she needs to use the restroom and show the resident where the bathroom was located every two hours and as needed; -Provide protective oversight and assist where needed; -The resident has bowel and bladder incontinence at times related to confusion and dementia and required one assist at times of incontinence; -Clean peri-area with each incontinence episode; -Check every two hours and as required for incontinence, wash, rinse and dry perineum; -Change clothing as needed after incontinence episodes; -Staff to direct to the bathroom every two hours while awake, due to confusion need to show the resident where bathroom was located and assist with toileting if needed. Review of the resident's electronic health record, shower/bath documentation, for 02/05/25 to 03/05/25, showed the following: -Resident prefers day showers; -Schedule bath/shower days were Monday and Thursday; -Documentation for the week of 02/05/25 through 02/08/25 showed staff documented not applicable on 02/07/25 with no documentation to show the resident refused the shower or was out of the building; -Documentation for the week of 02/09/25 through 02/15/25 showed staff documented not applicable on 02/14/25 with no documentation to show the resident refused the shower or was out of the building; no documentation to show a second shower was offered/refused for this week; -Documentation for the week of 02/16/25 through 02/22/25 showed showed no documentation the resident had been offered or refused two showers for this week; -Documentation for the week of 02/23/25 through 03/01/25 showed the resident received one of his/her scheduled showers on 02/27/25 (Thursday); -Documentation for the week of 03/02/25 through end of review period 03/05/25 showed no documentation of the scheduled shower on 03/03/25; -The resident was to have nine showers for this time period but had only received one with no documentation of refusal of showers. The resident's last shower was five days prior. Observation on 03/02/25 at 8:10 P.M., showed the following: -CNA K and NA L assisted the resident to the bathroom; -The resident wore two incontinent products, one pull-up type and one brief, tab type under his/her sweat pants; -The outer incontinence product was noted to be dry; -The pull-up incontinent product was wet with a slight urine odor; -CNA K removed both incontinent products and placed a clean incontinent brief on the resident; -CNA K completed no peri-care and assisted the resident to bed. Observation on 03/04/25 at 9:00 A.M., showed the following: -The resident sat in a chair in the downtown common area; -His/Her sweat pants were wet in the front; -Multiple staff members were in an around the area with no staff assisting the resident. Observation at 03/04/25 at 9:55 A.M., showed the following: -The resident sat in the same location in the downtown common area; -His/Her sweat pants remained wet in the front. Observation on 03/04/25 at 10:56 A.M., showed the following: -The resident in the same location with wet pants; -Hospice staff took the resident to shower and change clothes. During an interview 03/12/25, at 4:05 P.M., NA L said the following: -He/She assisted CNA K in providing care for the resident on 03/02/25; -The resident was noted to be wet and had two incontinent products on; -He/She was not scheduled to work on the resident's hall that night but was helping catch up and get resident's ready for bed; -Resident's should not be double briefed at any time. During an interview on 03/12/25, at 4:20 P.M., CNA K said the following: -He/She assisted NA L in providing care for the resident on 03/02/25; -The resident had been incontinent of urine and had two incontinent products on with only the inner incontinent product slightly wet; -He/She was surprised that two incontinent products were on the resident as that was not a normal practice; -He/She was unsure who put two incontinent products on the resident or why that would have occurred. -He/She had not performed peri care because the resident was not incontinent. 8. During an interview on 03/03/25 at 1:29 P.M. NA D said he/she was the shower aide for 200 and 400 halls. He/She would have to do 20 showers per day for all of the residents to get two showers a week, and that doesn't happen because there was not enough time. He/She tried to make sure all the residents gets one shower a week. If a resident wants more showers, it probably would not happen unless another aide had time. During an interview on 03/18/25 at 10:51 A.M., NA J said the following: -He/She normally worked the 200 hall; -Department heads do not give showers; -He/She thought the resident's on 100 hall (Resident #54) did their own showers. During an interview on 03/05/25 at 8:10 P.M., the Director of Nursing (DON) said the following: -She would expect peri-care to be done with each incontinent episode using soap and water or peri-care spray, and not done only using toilet paper; -Residents should not be wearing two incontinence briefs; -Every area that was exposed to urine or feces should be completely cleaned during cares; -Residents should be checked and changed at a minimum of every two hours; -She would expect a resident to be offered a shower on scheduled shower days two times a week; -If a shower was not able to be performed on the scheduled shower day it should be offered the next day; -She would expect staff to change a resident who is soiled as soon as possible; -She thought the showers were getting completed two times a week but reviewing requested shower documentation showed this was not done. During an interview on 03/05/25 at 7:51 P.M., the Administrator said the following: -If there was no specific staff member assigned to the 300 hall, the 400 hall CNA was to help those residents along with the charge nurse and any department head that was qualified to provide care; -She expected incontinent residents to be checked and changed every two hours and as needed; -She expected showers to be given two times a week; -If a resident wanted a shower at a specific time that request should be honored; -Recently there had not been enough staff to complete all of the showers. 38016 42592

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for five residents (Resident #33, #54, #29, #11 and #30) in a review of 24 sampled residents. Staff failed to provide routine showers to ensure good personal hygiene, failed to provide restorative nursing to prevent decline in Activities of Daily Living (ADL's) and new or worsening contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The facility census was 98. Review of the Facility Assessment, dated 08/04/24, showed the following: -Federal regulations will require that facilities must provide 3.48 hours per resident day (HPRD) of direct care with 0.55 HPRD from registered nurses (RNs) and 2.45 HPRD from nurse aides (Certified Nurse Assistants (CNAs), Nurse Aides (NAs), or medication technicians/aides); -The remaining 0.48 HPRD can be a combination of nurse staff (RNs, Licensed Practical Nurses (LPNs)/Licensed Vocational Nurses (LVNs) or nurse aides) to comply with the minimum; -Listed below are some tables the facility can utilize to help determine their staffing needs based on the Federal minimum staffing standards, however, if State regulations require a higher standard, then the higher standard should be met; -The minimum staffing standard is considered the floor of the standard. Facilities with higher resident acuities and needs may need to adjust their staffing numbers higher than the minimum standard; -This staffing plan is based on the facility assessment, along with facility-based and community-based risk assessments to inform staffing decisions to ensure that there are a sufficient number of staff to care for the residents' needs; -This document is updated and adjusted as necessary based on changes to the resident population; -Additionally, this plan includes plans to maximize recruitment and retention of direct care staff along with contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care; -This can include, but is not limited to, the availability of direct care nurse staffing or other resources needed for resident care. The facility assessment did not list number of staff by discipline/shift/day. 1. Review Resident #30's care plan, last revised 01/05/25, showed the following: -Resident has an ADL self-care performance deficit related to paraplegia (paralysis of legs); -Resident was totally dependent on one staff to shower twice weekly and as necessary. Review of the resident's shower record, dated February 2025, showed the following: -The resident's shower days were to be Tuesdays and Thursdays; -The resident only received a shower on 02/13/25 and 02/20/25; (Review showed no documentation the resident refused a shower during February.) Review of the resident's shower record for 03/01/25 through 03/05/25 showed no documentation the resident received or refused a shower. Observation on 03/02/25 at 5:54 P.M., showed the resident in his/her room. The resident's hair was greasy and he/she had dry flaky skin. Observation on 03/04/25 at 11:10 A.M., showed the resident had greasy, disheveled hair and flaky skin visible on his/her arms. During an interview on 03/04/25 at 11:10 A.M., the resident said the shower aide was not always able to get to him/her. He/She gets frustrated because the shower aide has time constraints and he/she could not get a shower when he/she wanted one. At minimum, the resident would like one good shower a week (Thursdays), but really wanted two showers a week. The staff only had time to do one shower a week, so if you were busy or not feeling great that day, you were out of luck. He/She should not have to miss smoke break or an activity to take his/her shower. He/She felt like he/she had no control of his/her life sometimes even though he/she was his/her own person. 2. Review of Resident #33's care plan, revised on 01/12/25, showed the following: -The resident had an ADL self-care performance deficit related to dementia and often needs staff to cue and assist to ensure he/she is getting the assistance needed; -Required limited assistance of one staff for showers twice a week and as necessary; -Required oversight or limited assist of one staff with personal hygiene and needs assistance shaving. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No rejection of cares; -Substantial to maximum staff assistance for personal hygiene and bathing. Review of the resident's electronic health record, shower/bath documentation, for 02/05/25 to 03/05/25, showed the following: -Schedule bath/shower days are Monday and Thursday; -Documentation for the week of 02/05/25 through 02/08/25 showed no documentation staff offered or the resident refused the scheduled shower for 02/06/25; -Documentation for the week of 02/16/25 through 02/22/25 showed showed no documentation the staff offered or the resident refused two showers for this week; -Documentation for the week of 02/23/25 through 03/01/25 showed showed no documentation staff offered or the resident refused two showers for this week; -Documentation for the week of 03/02/25 through end of review period 03/05/25 showed no documentation of the scheduled shower on Monday, 03/03/25; -The resident was to have eight showers for this time period but had only received two, with no documentation of refusal of showers. His/Her last shower was on 02/13/25, 20 days prior to 03/05/25. During an interview on 03/05/25 at 1:15 P.M., the resident's guardian said the following: -He/She would want the resident to be neat and clean; -He/She would want the resident to be clean shaven if that is what the resident wanted on that day; -He/She would want the resident to receive his/her showers as scheduled. During an interview on 03/04/25 at 12:05 P.M., Certified Nurse Aide (CNA) M said the following: -He/She was assigned the 400 hall residents to care for but helped on 300 hall (the hall that Resident #33 resided on) when needed; -If there was not enough staff for each hall to have a CNA, the charge nurse and department heads were to help and cover the unassigned hall; -The charge nurse and department heads were helping on the 300 hall at this time; -Showers were supposed to be given twice a week, but when short handed, he/she was not sure if they were being given or not. 3. Review of Resident #54's electronic health record, shower/bath documentation, for 02/23/25 to 03/05/25, showed the following: -Resident prefers day shower; -Scheduled bath/shower days were Sunday and Thursday; -Documentation for the week of 02/23/25 through 03/01/25 showed one scheduled shower on 02/23/25 documented as not applicable with no documentation to show the resident refused the shower or was out of the building; no documentation to show a second shower was offered/refused for this week; -Documentation for the week of 03/02/25 through review period of 03/05/25 showed no documentation the resident had been offered or refused a shower; -The resident was to have received three showers in this time period and had only received one and the resident had not received a shower for 13 days. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors or rejection of cares; -Substantial to maximum assist for bathing. During an interview on 03/02/25, at 6:19 P.M., the resident said the following: -He/She was supposed to get a shower two times a week, on Sunday or Tuesday and Thursday; -He/She preferred at least one weekly, usually on Thursday, on day shift; -He/She had not had a shower for ten days. Observation on 03/03/25 at 11:18 A.M., showed the resident's hair had an oily appearance. During an interview on 03/03/25 at 11:18 A.M., the resident said he/she did not get a shower on 03/02/25 and would like one. Observation on 03/04/25 at 9:44 A.M., showed the resident's hair had an oily appearance. During an interview on 03/04/25 at 9:44 A.M., the resident said he/she did not receive a shower yesterday and would like one, it had been almost two weeks since his/her last shower. Observation on 03/05/25 at 10:50 A.M., showed the resident's hair had an oily appearance. During an interview on 03/05/25 at 10:50 A.M., the resident said the following: -He/She still has not received a shower this week; -He/She did not get a shower last week and so far, none this week. 4. Review of Resident #11's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Dependent for bathing; -No rejection of care. Review of the resident's care plan, last revised 02/13/25, showed the following: -Self-care performance deficit; -Totally dependent on one to two staff for bathing twice weekly and as needed. Review of the resident's shower/bath documentation for 02/09/25 to 03/05/25, showed the following: -Showers were scheduled for Tuesdays and Thursdays; -Documentation for the week of 02/09/25 through 02/15/25 showed the resident received a shower on 02/11/25 (five days from his/her previous documented shower); -There was no documentation to show the resident had been offered or refused a second shower for this week; -Documentation for the week of 02/16/25 through 02/22/25 showed no documentation the resident had been offered or refused two showers for the week; -Documentation for the week of 02/23/25 through 03/01/25 showed Certified Nurse Aide (CNA) O and NA D documented not applicable (NA) on 02/25/25; -There was no documentation to show the resident had been offered or refused a second shower for this week; -Documentation for the week of 03/02/25 through the review period of 03/05/25 showed the resident received a shower on 03/04/25 (21 days from his/her previous documented shower); -The resident was to have received seven showers for this time period but had only received two. During an interview on 03/04/25 at 11:45 A.M., the resident said he/she did not receive showers on a regular basis and definitely not two times weekly. Residents were lucky to get one shower a week. During an interview on 03/03/25, at 1:29 P.M., Nurse Aide (NA) D said he/she was the shower aide for 200 and 400 hall. He/She would have to do 20 showers per day for all of the residents to get two showers a week, and that doesn't happen because there was not enough time. He/She tried to make sure all the residents get one shower a week. If a resident wants more showers, it probably would not happen. 5. Review of Resident #30's care plan, last revised 04/17/24, showed the following: -Resident has chronic pain related to chronic physical disability which is paraplegia (paralysis of legs); -Resident will remain free of complications related to immobility, including contractures; -Observe and report decrease in functional abilities, decrease Range of Motion (ROM), and withdrawal or resistance to care; -Monitor/document/report contractures forming or worsening; -Provide gentle range of motion as tolerated with daily care. Review of the resident's Physician's Orders Sheet (POS), dated 06/07/24 (and still active), showed the resident was to receive restorative nursing for passive PROM. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/03/24, showed the following: -Cognitively intact; -Diagnosis of paraplegia (paralysis of the legs and lower body); -Impairment to functional ROM to both lower extremities; -No documentation of restorative nursing minutes and no therapy services. Review of the resident's quarterly MDS, dated [DATE], showed no restorative nursing minutes, and not receiving therapy services. Review of the resident's electronic medical record showed no evidence the resident's order for RN and PROM had been discontinued. Review of the resident's restorative log, for January 2025, showed staff documented completing the following: -01/02/25, 10 minutes of passive ROM; -01/08/25, 10 minutes of passive ROM; -01/09/25, 12 minutes of passive ROM; -01/17/25, 10 minutes of passive ROM; -01/21/25, 10 minutes of passive ROM; -No documentation to show the resident ever refused PROM. Review of the resident's restorative log, for February 2025, showed staff documented the following: -02/07/25, 10 minutes of passive ROM; -02/17/25, 10 minutes of passive ROM; -02/18/25, 10 minutes of passive ROM; -02/21/25, 10 minutes of passive ROM; -02/25/25, 8 minutes of passive ROM; -02/27/25, 10 minutes of passive ROM; -No documentation to show the resident ever refused PROM. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis of paraplegia; -Impairment to functional ROM to both lower extremities; -No restorative nursing and no therapy. Review of the resident's electronic medical record showed no documentation of restorative minutes on 02/27/25 or 02/28/25, including refusals of PROM by the resident. Review of the resident's facility electronic medical record showed no documentation of restorative minutes on 03/01/25 through the review period of 03/03/25, including refusals of PROM by the resident. Review of the resident's restorative log, for 03/01/25 through 03/04/25, showed the resident received 10 minutes of passive ROM on 03/04/25. Observation on 03/02/25 at 5:54 P.M., showed the resident in his/her room in a reclining chair on wheels (gerichair). The resident's lower extremities were paralyzed and contracted. During an interview on 03/05/25 at 2:17 P.M., the resident said the following: -He/She was paraplegic and unable to move his/her legs; -He/She has contractures and was supposed to have restorative services three times per week; -The Restorative Aide (RA) says he/she was pulled to the floor and doesn't have time to complete his/her restorative program; -He/She may have one day of restorative and then go without any restorative nursing for two to three weeks; -He/She was having more spasms in his/her legs and they hurt; -He/She felt like his/her contractures were getting worse; he/she needed to have aggressive stretching to prevent worsening of contractures and to help his/her spasms. 6. Review of Resident #55's facility document, Point of Care Restorative Tasks, showed the following: -Date initiated: 02/14/2022; -Last revision: 08/28/24; -Task: Restorative: PROM; -Description: daily; -Instruction: [NAME] resting hand splint to contracture two to four hours after completion of ROM; -Frequency: Monday, Tuesday, Wednesday, Thursday and Friday, every shift, days 6:00 A.M. to 6:00 P.M. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis: stroke, hemiplegia (paralysis of one side of the body), seizure disorder and depression; -Functional limitation in ROM both upper and lower extremities; -Dependent all ADL's; -No documentation of therapy and no restorative nursing. Review of the resident's Physician's Order Sheet, dated January 2025 (and still active) showed an order for passive ROM. Review of the resident's restorative log, for January 2025, showed staff documented completing the following: -Resident is scheduled for passive ROM daily: -01/01/25, 10 minutes of passive ROM; -01/02/25, 10 minutes of passive ROM; -01/03/25, 12 minutes of passive ROM; -No documentation of restorative nursing documented 01/04/25 through 01/06/25; no documentation the resident refused; -01/07/25, 10 minutes of passive ROM; -01/08/25, 10 minutes of passive ROM; -01/09/25, eight minutes of passive ROM; -01/10/25, 12 minutes of passive ROM; -No documentation of restorative nursing documented 01/11/25 through 01/13/25; no documentation the resident refused; -01/14/25, 10 minutes of passive ROM; -01/15/25, seven minutes of passive ROM; -01/16/25, seven minutes of passive ROM; -01/17/25, 12 minutes of passive ROM; -No documentation of restorative nursing documented 01/18/25 or 01/19/25; no documentation the resident refused; -01/20/25, 10 minutes of passive ROM; -01/21/25, 10 minutes of passive ROM; -01/22/25, 10 minutes of passive ROM; -01/24/25, 10 minutes of passive ROM; -No restorative nursing minutes documented between 01/25/25 and 01/31/25; no documentation the resident refused. Review of the resident's restorative log, for February 2025, showed the following: -Passive ROM scheduled daily; -No documentation of restorative nursing documented for 02/01/25 or 02/02/25; no documentation the resident refused; -02/03/25, eight minutes of passive ROM; -No documentation of restorative nursing documented for 02/04/25 through 02/12/25; no documentation the resident refused; -02/13/25, 10 minutes of passive ROM; -No documentation of restorative nursing documented for 02/14/25 through 02/16/25; no documentation the resident refused; -02/17/25, 10 minutes of passive ROM; -No documentation of restorative nursing documented for 02/18/25 or 02/19/25; no documentation the resident refused; -02/20/25, 14 minutes of passive ROM; -02/21/25, 15 minutes of passive ROM; -No documentation of restorative nursing documented for 02/22/25 through 02/23/25; no documentation the resident refused; -02/24/25, 10 minutes of passive ROM. -02/25/25, 12 minutes of passive ROM; -02/26/25, 10 minutes of passive ROM; -02/27/25, 12 minutes of passive ROM; -02/28/25, 15 minutes of passive ROM. Review of the resident's facility electronic medical record showed no documentation of a restorative plan of care to include: restorative plans with the problem, needs/strengths, measurable goals with a target date, specific interventions/task to be provided, frequency and duration of interventions/task, such as number of repetitions, length of time, or direction to staff to meet resident needs. The electronic medical record also showed no documentation of the Restorative Nurse, or designated licensed nurse, documenting a weekly review or evaluation of the effectiveness of the plan monthly. During an interview on 03/03/25 at 2:30 P.M., CNA O said the following: -He/She was the restorative aide (RA); -He/She was pulled to the floor a lot and was unable to fulfill the RNP or resident PROM duties; -There have been weeks when she was not able to do restorative nursing at all because of staffing, the Director of Nursing tried not to pull him/her but sometimes there was no choice. 7. During an interview on 03/05/25 at 11:41 A.M. and 8:10 P.M., the DON said the following: -The facility identified the following staffing was required to meet the needs of the residents: -Day shift: Two charge nurses (12 hour shifts), two CMTs (eight hour shifts on days) and six CNAs (12 hour shifts); -Night shift: Two charge nurses (12 hour shifts), two CMTs (eight hour shifts on evenings) and four to five CNAs; -She has not been able to maintain staffing at the levels to meet all the residents' needs; -Nursing administration was covering charge nurse and floor roles daily and other department heads have had to assist; -At times, the facility has had other departments assist with nursing tasks they can do like pass ice, make beds and washing equipment, so nursing staff can focus on care; -Agency staff stopped January 1st; that decision was not made at the facility level. Review of the facility's staffing sheets, dated 02/01/25 through 02/28/25, showed the following: -02/01/25: 6:00 A.M. to 6:00 P.M., one CNA and two NAs (department heads was written in for one of the CNA spots). (Three CNAs/NAs worked instead of the six the DON said it would require to meet residents' needs.) 6:00 P.M. to 6:00 A.M., there were three CNAs. (The DON said four to five CNAs would be required to meet the residents' needs). The facility census was 93; -02/02/25: 6:00 A.M. to 6:00 P.M., one CNA and one NA (department heads was written in for one of the CNA spots) (Two CNAs/NAs worked instead of the six the DON said it would require to meet residents' needs.) 6:00 P.M. to 6:00 A.M., there were three CNAs. (The DON said four to five CNAs would be required to meet the residents' needs). The facility census was 92; -02/03/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON), three CNAs and one NA. (Four CNAs/NAs worked this shift. One of the CNAs was the restorative aide who was scheduled with a floor assignment.) 6:00 P.M. to 6:00 A.M., there were only two CNAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 92; -02/04/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON), four CNAs and one NA. (Five CNAs/NAs worked this shift. One of the CNAs was the restorative aide who was scheduled with a floor assignment.) 6:00 P.M. to 6:00 A.M., there was only one CNA (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 92; -02/05/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON), three CNAs and one NA. (Four CNAs/NAs worked this shift. One of the CNAs was the restorative aide who was scheduled with a floor assignment.) The facility census was 91; -02/06/25: 6:00 A.M. to 6:00 P.M., there were three CNAs and one NA. (Four CNAs/NAs worked this shift. One of the CNAs was the restorative aide who was scheduled with a floor assignment.) 6:00 P.M. to 6:00 A.M., there were two CNAs and one NA (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 91; -02/07/25: 6:00 A.M. to 6:00 P.M., the DON as the only charge nurse. 6:00 P.M. to 6:00 A.M., there was one CNA and one NA (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 91; -02/08/25: 6:00 A.M. to 6:00 P.M., there were five CNAs (no RA or shower aide was scheduled). 6:00 P.M. to 6:00 A.M., there was one CNA and two NAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 91; -02/09/25: 6:00 A.M. to 6:00 P.M., there were four CNAs (four out of six needed CNAs, and no RA or shower aide was scheduled); 6:00 A.M.-2:00 P.M., there was one CMT (one CMT out of two needed CMT's), 2:00 P.M.-10:00 P.M., one CMT (one CMT out of two needed CMT's); The facility census was 91; -02/10/25: 6:00 A.M. to 6:00 P.M., the DON and the administrative were the charge nurses, three CNAs and two NAs (five out of six needed CNAs; one of the CNAs was the restorative aide who was scheduled with a floor assignment); 6:00 P.M. to 6:00 A.M., two CNAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 91; -02/11/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON), four CNAs and one NA (five out of six needed CNAs, and no RA was scheduled); 6:00 P.M. to 6:00 A.M., there were two CNAs and one NA (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 92; -02/12/25: 6:00 A.M. to 6:00 P.M., there were two charge nurses (one was the DON) and three CNAs (department heads was written in with no specific assignments or job titles) (three out of six needed CNAs, and no RA or shower aide was scheduled); 6:00 P.M. to 6:00 A.M., there was one CNA and two NAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 92; -02/13/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the administrator), four CNAs and one NA (five out of six needed CNAs, and no RA was scheduled); 6:00 P.M. to 6:00 A.M., one CNA and two NAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 93; -02/14/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON); 6:00 P.M. to 6:00 A.M., one CNA and two NAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 93; -02/15/25: 6:00 A.M. to 6:00 P.M., the DON and the administrator were the charge nurses, two CNAs and two NAs (four out of six needed CNAs, and no RA or shower aide was scheduled). The facility census was 92; -02/16/25: 6:00 A.M. to 6:00 P.M., two CNAs and two NAs (four out of six needed CNAs, and no RA or shower aide was scheduled). The facility census was 93; -02/17/25: 6:00 A.M. to 6:00 P.M., the DON and the administrator were the charge nurses, three CNAs and one NA (four out of six needed CNAs, and no RA was scheduled). 6:00 A. M-2:00 P.M., there was one CMT (one of two needed CMT's). 6:00 P.M. to 6:00 A.M., two CNAs and one NA (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 94; -02/18/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON). 6:00 P.M. to 6:00 A.M., one CNA and two NAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 94; -02/19/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the administrator), two CNAs and two NAs (four out of six needed CNAs. One of the CNAs was the restorative aide who was scheduled with a floor assignment.) 2:00 P.M.-10:00 P.M., there was one CMT (out of two needed CMT's). 6:00 P.M. to 6:00 A.M., two CNAs and one NA (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 94; -02/20/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON). 6:00 A.M.-2:00 P.M., one CMT (out of two needed CMT's). The facility census was 94; -02/21/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON), one CNA and three NAs (four out of six needed CNAs, with the RA being one of the CNAs on the floor assignment). 2:00 P.M.-10:00 P.M., one CMT (out of two needed CMTs). The facility census was 96; -02/22/25: 6:00 P.M. to 6:00 A.M., two CNAs and one NA (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 96; -02/23/25: 6:00 A.M. to 6:00 P.M., four CNAs and one NA (five out of six needed CNAs, and no RA or shower aide was scheduled). 6:00 P.M. to 6:00 A.M., one CNA and two NAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 95; -02/24/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON). 2:00 P.M.-10:00 P.M., one CMT (one of two needed CMTs). The facility census was 95; -02/25/25: 6:00 P.M. to 6:00 A.M., two CNAs and one NA (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 96; -02/26/25: 6:00 A.M. to 6:00 P.M., the DON and the administrator were the charge nurses. 6:00 A.M.-2:00 P.M., one CMT (one out of two needed). 6:00 P.M. to 6:00 A.M., two CNAs and one NA (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 96; -02/27/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the administrator). 6:00 P.M. to 6:00 A.M., the DON was the only charge nurse (out of two charge nurses needed), one CNA and two NAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 98; -02/28/25: 6:00 A.M. to 6:00 P.M., two charge nurses (one was the DON). 6:00 P.M. to 6:00 A.M., one CNA and two NAs (instead of four to five CNAs the DON said was needed to meet the residents' needs). The facility census was 98. During an interview on 03/02/25 at 4:21 P.M., the administrator said the facility did not have enough licensed nursing staff, have had vacancies, and have several NAs (uncertified aides); -Agency staff were utilized prior to 01/01/25 but the facility was not allowed to use agency staffing at this time. During an interview on 03/03/25 at 1:18 P.M., the Regional Director of Operations said the facility has had staffing challenges. The company may have to bring agency staffing back in the building. The agency contract ended on 01/01/25.

Based on observation, interview, and record review, the facility failed to follow policy to check temperatures during the meal service and failed to serve food items in a manner to ensure the food was at a safe and appetizing temperature. The facility census was 98. Review of the facility's policy, Receiving and Storing Food and Supplies, last revised 6/30/23, showed the following: -Record reading on Food Temperature Chart form at beginning of tray line and during the tray line. If temperatures do not meet acceptable serving temperatures, reheat the product or chill the product to the proper temperature. Take the temperature of each pan of product before serving; -Acceptable serving temperatures are: casseroles (greater than 135 degrees Fahrenheit); hot pureed food (greater than 135 degrees Fahrenheit); hazardous salads and desserts (less than 41 degrees Fahrenheit). 1. During an interview on 03/02/25 at 6:05 P.M., Resident #43 said he/she sometimes ate in the dining room and sometimes ate in his/her room. The food was not very warm when served. During an interview on 03/02/25 at 6:25 P.M., Resident #44 said he/she normally ate in his/her room. The food was not always warm when served. During an interview on 03/02/25 at 6:33 P.M., Resident # 19 said he/she ate in his/her room most of the time, and his/her food was always cold. Even when he/she ate in the dining room, the food was cold. During an interview on 03/03/25 at 1:41 P.M., Resident #59 said his/her food was barely warm, it was not served hot. The food would taste better if it was hot. During an interview on 03/03/25 at 1:45 P.M., Resident # 70 said the food was warm, not hot. The food was never hot. During an interview on 03/03/25 at 2:01 P.M., Resident #30 said the food was never hot. Today's food was barely warm and that was the usual. 2. Review of the Resident Diet Type Report dated 3/2/25, showed 62 residents were on a regular diet. Review of the Diet Spreadsheet Menu for the dinner meal on 03/02/25 showed residents on a regular diet were to receive tuna noodle casserole and tossed salad/dressing. Review of the recipe for the regular tuna noodle casserole showed to maintain at 135 degrees Fahrenheit or above. Review of the recipe for the tossed salad/dressing showed to maintain at 41 degrees Fahrenheit or below. Observation on 3/2/25 at 4:45 P.M., showed staff took the final cooking temperatures of the food items (all were within acceptable parameters for temperature prior to meal service) and placed the food items on the steam table for the supper meal. Observation on 03/02/25 at 5:05 P.M., showed staff began the dinner meal service. Staff served plates from the steam table in the kitchen to residents in the main dining room. Observation on 03/02/25 at 5:43 P.M., showed staff served the last tray to residents in the dining room. Observation on 03/02/25 at 5:45 P.M., showed the following: -Staff began preparing hall trays from the steam table in the kitchen; -Staff placed the food items, including the tuna noodle casserole and the tossed salad on hot/warm plates on insulated bases, covered the plates with insulated tops, and placed them in a covered food transport rack. Observation on 3/2/25 at 6:02 P.M., showed staff prepared the last hall tray from the steam table. (Staff did not take the temperature of the food items during the meal service (per policy) to ensure the food was an appropriate temperature.) Observation on 3/2/25 at 6:32 P.M., showed staff served the last tray from the hall cart. Observation of the food temperatures for the test tray (received after the last tray was served from the hall tray cart) on 3/2/25 at 6:34 P.M., taken with a digital metal stem type thermometer, showed the following: -Tuna noodle casserole was 118.2 degrees Fahrenheit; -Tossed salad/dressing was 77.0 degrees Fahrenheit. During an interview on 3/3/25 at 10:30 A.M., the Dietary Manager said the following: -The cook did not always check the temperature of the food midway through meal service; -She expected meals to be served at safe and appetizing temperatures (hot foods hot and cold foods cold). During an interview on 3/5/25 at 11:30 A.M., the Administrator said she expected hot foods to be served hot and cold foods to be served cold. 44610

Based on observation, interview and record review, the facility failed to ensure nursing staff washed their hands after each direct resident contact and between glove changes, for three residents (Resident #3, #33, #79) of 24 sampled residents, failed to ensure soiled surfaces were sanitized appropriately, failed to ensure proper infection control was utilized for respiratory care supplies for one resident, (Resident #7), and failed to wear gloves when administering eye drops for one resident (Resident #25). The facility census was 98. Review of the facility policy, Hand Hygiene, revised on 06/26/24, showed the following: -Purpose: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility; -Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR); - Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating and after using the restroom; - The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Review of the facility policy, Glove Utilization, revised on 05/18/25, showed the following: -Purpose: The purpose of this procedure is to provide guidelines for the use of gloves. To prevent the spread of infection and disease to residents and employees; to protect wounds from contamination; to protect hands from potentially infectious material; and to prevent exposure to the HIV (AIDS) and Hepatitis B (HBV) viruses from blood or body fluids; - When gloves are indicated, disposable single-use gloves should be worn; - Non-sterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment or services to the resident and when cleaning contaminated surfaces; -Wash hands after removing gloves. (Note: gloves do not replace hand washing); - When changing dressings, after the dirty dressing is removed, gloves should be removed, hands washed and clean gloves donned before applying the clean dressing; - Gloves should be removed before removing the mask and gown and should be discarded into the designated waste receptacle inside the room; - When to use gloves: When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin. Gloves need to be used during removal of wound dressings. Gloves are to be changed and hands are washed, new gloves donned before a clean dressing is applied. When the employee's hands have any cuts, scrapes, wounds, chapped skin, dermatitis, etc. When cleaning up spills or splashes of blood or body fluids. When cleaning potentially contaminated items; -Wash hands after glove removal. 1 Review of the Resident #3's care plan, last revised 01/26/25, showed the resident was incontinent of bladder and bowel. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 02/16/25, showed the following: -Frequently incontinent of bladder and bowel; -Partial to moderate assist with toileting; -Supervision to touch assist with dressing. Observation on 03/02/25 at 6:08 P.M. showed the following: -Nurse Assistant (NA) J followed the resident to his/her room; -The resident ambulated to the bathroom in his/her room while pulling his/her pants and incontinence brief down. The brief was soiled with feces and urine. The resident sat on the toilet; -Without washing hands, NA J donned gloves, removed the soiled brief and placed it in the trash; -NA J retrieved a clean brief, without changing gloves or washing hands, and applied it over the resident's feet up to mid calf; -The resident stood and NA J cleansed the resident's buttocks and rectal area using approximately ten perineal wipes. NA J pulled the clean incontinent brief up with his/her soiled gloves; -The resident attempted to sit back on the toilet with feces noted on the toilet seat. NA J touched the resident's right arm with his/her soiled gloves and instructed the resident to not sit; -NA J wiped the feces from the seat with perineal wipes; -The resident sat back on the seat; The resident had feces on his/her socks and feces were noted on the floor; -NA J removed the resident's socks and wiped the feces from the floor with another wipe; -Without changing gloves and performing hand hygiene, NA J applied the resident's pants; -The resident stood and NA J pulled the resident's pants up; -The resident ambulated into his/her room, obtained clean socks and returned to sit on the toilet seat; -Wearing the same soiled gloves, NA J applied the clean socks; -The resident stood and ambulated back to his/her chair; -NA J picked up the bagged, soiled clothing, opened the door with his/her soiled, gloved hand, removed the soiled gloves and exited the room without washing his/her hands. During an interview on 3/18/24 at 10:40 A.M., NA J said the following: -Hands should be washed before cares, with glove changes, when they become soiled and after cares; -Clean items/areas should not be touched by soiled hands/gloves; -Gloves should be changed after becoming soiled; -He/She had only known to clean feces from surfaces with the white cloths they used for perineal care, perineal wipes or a washcloth with soap; -He/She had not been instructed or shown to use a disinfectant when cleaning feces from surfaces. 2. Review of Resident #33's care plan, revised on 01/12/25, showed the following: -The resident had an activity of daily living (ADL) self-care performance deficit related to dementia and often needed staff to cue and proved needed assistance; -Toilet use need for assistance fluctuated; the resident takes self to the bathroom at times, but needs assistance when incontinent of bowel and bladder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Substantial to maximum staff assistance for personal hygiene, toileting hygiene, and bathing; -Always incontinent of urine and frequently incontinent of bowel. Observation on 03/02/25 at 7:59 P.M., showed the following: -The resident walked down the hall with staff going to his/her room; -The front and back of the resident's sweat pants and hem of his/her shirt were wet and had a moderate urine smell; -Certified Nursing Assistant (CNA) K and NA L led the resident to his/her room with gloved hands; -CNA K assisted the resident to pull his/her sweat pants down, the resident wore a pull up incontinent product as well as an adult brief; both were saturated with urine and had a strong urine odor; -CNA K sat the resident on the toilet and removed the resident's wet pants; -After the resident used the toilet, CNA K wiped the resident's upper thighs and groin with toilet paper and applied a new adult brief. CNA K removed his/her gloves and applied a clean pair of gloves without hand hygiene prior; -NA L assisted in dressing the resident, took the trash to the soiled utility room, and removed gloves; -NA L reapplied gloves without hand hygiene between glove changes and made the resident's bed; -CNA K assisted the resident to bed, removed his/her gloves and without washing his/her hands, left the room to get a pillow for the resident. 3. Review of Resident #79's care plan, revised on 03/02/25, showed the following: -The resident has bowel and bladder incontinence related to confusion and required one assist when incontinent; -Clean peri-area with each incontinence episode; -Check every two hours and as required for incontinence, wash, rinse and dry perineum. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Partial to moderate staff assistance for upper and lower body dressing; -Substantial to maximum staff assistance for bathing, toileting hygiene and personal hygiene. Observation on 03/02/25 at 8:10 P.M., showed the following: -CNA K and NA L assisted the resident to the bathroom; -CNA K and NA L entered the resident's room with gloves on that were applied in the hallway prior to assisting the resident; -The resident's pull-up was noted to be slightly wet with a slight urine smell; -CNA K removed the incontinence product and with the same soiled gloves, he/she applied a clean brief on the resident; -CNA K noticed what appeared to be dried feces on the resident's bed sheet, removed the sheet and placed it in a bag to take to the laundry; -CNA K removed his/her gloves and without completing any hand hygiene left the room. During an interview on 03/12/25 at 4:05 P.M., NA L said the following: -Hands should be washed all of the time when providing for the residents in any way; -Hands should be washed before applying gloves, when changing gloves and after gloves are removed; -He/She did not wash his/her hands when providing care for Resident #33 or Resident #79 on 03/02/25; -He/She should have washed his/her hands between glove changes and when he/she removed gloves after providing resident cares. During an interview on 03/12/25 at 4:20 P.M., CNA K said the following: -He/She assisted NA L in providing care for the resident on 03/02/25; -The resident was incontinent of urine, had two incontinent products on, and his/her pants were wet; -Hands should be washed every step of resident care, before providing care, when soiled and when gloves are changed; -He/She did not wash his/her hands between glove changes when providing care for Resident #33 and Resident #79; -He/She should have washed his/her hands each time gloves were changed and between residents and did not. 4. Review of Resident #45's care plan, dated 5/24/23 showed the following: -Diabetes Mellitus (high blood glucose); -Diabetes medication as ordered by physician; -Resident approved to have accuchecks and insulin administered in the dining room. Review of the resident's POS, dated 3/2025 showed the following: -Humalog injection solution 100 unit/ml (Insulin Lispro-fast acting insulin used to treat diabetes) inject as per sliding scale: For blood glucose of: 0-149=0 units, 150-199=5 units , 200-250=10 units, 251-300=15 units, 301-350=20 units, 351-400=25 units, 401-500=30 units and call primary care physician if over 500 and give full dose subcutaneously three times daily for Type II diabetes. Observation on 3/4/25 showed the following: -At 11:32 A.M. Registered Nurse (RN) B performed an accucheck on the resident in the resident's room, removed gloves and without washing/sanitizing his/her hands, regloved and wrapped the glucometer in a disinfectant wipe; -At 12:35 P.M. RN B prepared to administer the resident's insulin. The resident sat in his/her wheelchair in the dining room. Without washing/sanitizing hands, he/she removed the insulin from the cart, cleaned the top of the vial with alcohol, withdrew 15 units of Lispro insulin and administered it into the resident's abdomen. He/She removed his/her gloves and did not perform hand hygiene, placed the insulin vial in the cart, documented the administration in the electronic health record, locked the medication cart and pushed the cart out of the dining room. During an interview on 3/14/25 at 3:45 P.M. RN B said the following: -Hands should be washed when physically soiled and between residents; -Staff should deglove and wash/sanitize hands after administering insulin and before touching clean surfaces; -Hands should be washed/sanitized after removing gloves. 5. Review of Resident #7's care plan, last revised 1/31/25 showed the following: -Diagnoses included obstructive sleep apnea (sleep disorder in which breathing repeatedly stops and starts) and emphysema (difficulty breathing); -BiPAP (bilevel positive airway pressure-a non-invasive ventilation therapy) with distilled, humidified water at 16/8 with two liters oxygen (O2) bleed in during hours of sleep; -Total dependence of staff for transfers, hygiene and -The care plan did not address the use of a nebulizer for inhalation therapy or how to store respiratory equipment when not in use. Review of the resident's POS, dated 3/2025, showed the following; -BiPaP with distilled, humidified water at 16/8 with two liters O2 bleed in during hours of sleep (2/1/25); -Albuterol Sulfate (bronchodilator-relaxes airway muscles) inhalation nebulization solution (2.5 milligrams (mg)/three milliliters (ml)-inhale one vial via nebulizer two times daily (2/1/25); -Review of the resident's Medication Administration Record (MAR), dated 3/2025 showed the following -Albuterol Sulfate inhalation nebulization solution (2.5 mg's/three ml's)-inhale one vial via nebulizer two times daily at 6:00 A.M. and 7:00 P.M. (2/1/25). Treatment documented as administered two times daily from 3/1/25 to 3/5/25. Review of the resident's TAR dated 3/2025 showed the following: -BiPaP with distilled, humidified water at 16/8 with two liters oxygen bleed in during hours of sleep every night shift related to obstructive sleep apnea (2/1/25). Observation showed the following: -On 3/3/25 at 11:15 A.M. the resident was up in his/her chair in his/her room. The BiPaP equipment lay unbagged, on the bedside table next to the resident's bed; -On 3/4/24 at 11:47 A.M. the resident's nebulizer equipment lay unbagged, on the bedside table. The BiPaP tubing hung from the table and the mask lay on the floor between the bed and the outside wall. During an interview on 3/4/2025 the resident said he/she had been using his/her BiPaP lately as he/she has had a cold and used the nebulizer for treatments two times daily. During an interview on 3/18/25 at 8:07 P.M. Licensed Practical Nurse P said the following: -A BiPaP/ Continuous Positive Air Pressure (CPAP) mask should not touch the floor and should be stored in a plastic bag when not in use; -If a BiPaP mask was on the floor, it should be replaced or disinfected. 6. Review of Resident #25's face sheet showed his/her diagnoses include bilateral ocular hypertension (a condition where the pressure inside both eyes is elevated above normal levels) and dry eye syndrome. Review of the resident's March 2025 Physician Order Sheet (POS) showed the following: -Artificial tears ophthalmic solution (an eye drop used to treat dry eyes), instill one drop into both eyes daily; -Timolol maleate ophthalmic solution 0.5 percent (%) (an eye drop used to treat high pressure inside the eye) instill one drop into both eyes daily. Observation on 03/04/25 at 10:28 A.M., showed the following: -Certified Medication Technician (CMT) N administered artificial tears for Resident #25 without using gloves; -CMT N used an alcohol based hand rub after exiting the resident's room. During an interview on 03/04/25 at 11:00 A.M., CMT N said he/she did not use gloves when administering eye drops to the resident and he/she should have. During an interview on 03/05/25 at 8:10 P.M., the Director of Nursing said the following: -Hands should be washed before applying gloves, when removing gloves and in between glove changes; -Gloves should be worn when providing resident care; -Gloves should be worn when instilling eye drops or with wound care; -Gloves should be changed when soiled; -Hands should be washed after performing an accucheck and upon exiting a resident's room. During an interview on 03/05/25 at 7:51 P.M., the Administrator said the following: -Hands should be washed before all cares, when hands are soiled and before and after using gloves; -Gloves should be worn when providing resident care, and should be changed when soiled; -Respiratory equipment should not touch the floor and should be stored in a plastic bag when not in use. 38016 42592

Based on observation, interview and record review, the facility failed to ensure residents had the right to be as independent as possible when one resident (Resident #30), in a review of 24 sampled residents, who required a power wheelchair to be fully independent with mobility, was denied the assistance in obtaining a power wheelchair. Resident #30 was told by the administrator she forbid power chairs at the facility because they could hurt someone and that he/she would need to move to another facility if he/she wanted a power chair. The resident felt hopeless and discriminated against. Resident #11 had a power wheelchair, but said the administrator had threatened to take it away. The administrator said the resident failed his/her driver test and she was looking to take the resident's chair as she did not want any motorized chairs in the building. The resident's medical record showed no documentation the resident had failed his/her driving test. The threat of having the chair taken away made the resident feel more depressed at the thought of having his/her independence taken away, causing him/her to be more dependent on staff for things he/she could do for him/herself if he/she was allowed to keep his/her motorized chair. The facility census was 98. Review of the facility policy, Use of Assistive Devices, last revised 05/18/24, showed the following: -The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity; -Assistive devices are tools, products, types of equipment or technology that help individuals perform tasks and activities. They may help the individual move around, see, communicate, eat or get dressed. Assistive devices included mobility aids (i.e. walker, cane, wheelchair, raised toilet seat); -The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care; -The facility will provide assistive devices for residents who need them. Nursing, dietary, social services and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement; -Facility staff will provide appropriate assistance to ensure that the resident can use the assistive devices. This may include education or therapy sessions for training on the use of the device, set up assistance, supervision or physical assistance as needed; -Direct care staff will be trained on the use of the devices as needed to carry out their roles and responsibilities regarding the devices. Training will also include when to refer to other departments for changes in condition or problems with the device; -A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modifications to the plan of care will be made as needed. Review of the facility policy, Resident Rights, dated 07/05/23, showed residents have the to right to accommodation of needs, residents have the right to reside and receive services with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. 1. Review of Resident #30's face sheet, showed the resident was his/her own responsible party. Review of the resident's care plan, last revised 04/17/24, showed the following: -Resident had chronic pain related to chronic physical disability which is paraplegia (paralysis of legs); -He/She used a geri chair (reclining chair on wheels; (this type of chair cannot be self propelled and requires staff to push for mobility); -Resident will remain free of complications related to immobility; -Resident was non-weight bearing; -Resident was dependent on staff for locomotion using gerichair; -No indication the resident must be reclined or could not sit upright. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/27/25, showed the following: -Cognitively intact; -Diagnosis of paraplegia (paralysis of the legs and lower body); -Impairment to functional range of motion (ROM) to both lower extremities, no documentation of impairment to upper extremities; -Dependent on staff for toileting hygiene, shower/bathing, lower body dressing, all transfers and wheelchair mobility. -No therapy services. Observation on 03/02/25 at 5:54 P.M., showed the resident in his/her room in a geri chair that was reclined. During an interview on 03/05/25 at 2:17 P.M., the resident said the following: -He/She was a paraplegic. He/She had his/her own power chair for years when he/she was at another facility; -While he/she was at the hospital, he/she decided to change facilities. The previous facility threw his/her motorized wheelchair in the dumpster; it had some issues and was old, but it worked fine; -He/She has been at this facility for 17 months and therapy was trying to get him/her a new power chair; -He/She had a physician's order and it was approved by Medicaid but the administrator stopped the order; -The Administrator said she forbid power chairs at the facility because they could hurt someone; -He/She has never hurt anyone and had driven safely for over [AGE] years; -He/She felt like he/she had lost his/her independence; -He/She felt hopeless and was at the mercy of everyone else; -He/She felt he/she was discriminated against because there was another resident that had and used a power chair in the facility; -The administrator said he/she could not have the power chair and would need to move to another facility if he/she wanted a power chair; -He/She felt he/she missed out on a lot and wanted to move to a facility that allowed him/her to have a power chair because he/she wanted to be independent; -He/She was depressed because he/she was stuck in a geri chair and could not be independent in areas that he/she could be independent in; -When he/she had a power chair he/she could go all over the facility and outside independently; now he/she was stuck in a gerichair and at the mercy of the staff. No one would like to have to be dependent for every aspect of their life if there was a way to have some freedom; -He/She felt he/she had no control of his/her life even though he/she was his/her own person. During an interview on 03/19/25 at 1:30 P.M., the Therapy Director said the following: -The resident wanted a motorized wheelchair; -They spoke with the physician and got the order to have the resident evaluated by the durable medical equipment company that specialized in wheelchairs and the resident was approved; -The Administrator preferred not to have power chairs at the facility because of an incident in the past when a resident in the facility was run over by a resident using a power chair; the current residents were not involved in that incident; -Therapy staff did not know of any issues with the resident utilizing a power chair; -He offered to help the resident look at a manual tilt in space chair but the resident insisted on wanting more independence that the power chair would give him/her; -He believed the resident was being discharged tomorrow to a home that would allow him/her to have a power chair. During an interview on 03/05/25 at 8:00 P.M., the Administrator said the following: -To have a motorized chair, the residents have to be safe and pass a test; -The residents go through therapy and do a testing (cognition test and abilities) and the physicians get involved; -The resident was eligible for a new chair; the chair he/she has does not fit appropriately and the wheels have fallen apart because the resident was too large for the gerichair; -The resident wanted an electric wheelchair, but the resident cannot sit upright; -The resident will not get into a regular manual wheelchair and refused the manual wheelchair; -Therapy spoke with the resident and with the wheelchair company, and they measured to see what the resident would qualify for; -She was not sure if the resident could be reclined in a motorized chair and drive it; -She told therapy not to order the motorized wheelchair for the resident and offered for him/her to go to another home. 2. Review of Resident #11's annual MDS, dated [DATE] showed the following: -Cognitively intact; -Dependent for bed mobility, transfers, dressing and bathing; -Used a motorized chair; -Functional limitation in range of motion of bilateral upper and lower extremities; -Once seated in chair, able to wheel 50 feet (ft) with two turns with no assistance from helper; -Once seated in chair, able to wheel 150 ft in corridor or similar space with no assistance from helper; -No behaviors affecting others.; -No Occupational Therapy, Physical Therapy or Restorative Nursing minutes documented. Review of the resident's Power-Mobility Indoor Driving Assessment, dated 02/06/25 showed the following: -The assessment was completed by the physical therapy department;-The resident owned his/her motorized chair; -The chair had a horn for a safety device; -The resident was able to explain or demonstrate how each accessory was used; -The resident could turn device on and off, utilize the braking system, use the speed control switch, use special features of the device and request assistance if necessary; -The resident could not transfer him/herself on and off the device; -Handwritten comments authored by the medical director, dated 2/9/25 read: I have reviewed these notes, I agree. He/She was not safe to drive based on history of running into residents repeatedly; -Score of 79% with handwritten note: Resident would benefit from mirrors to see behind/beside him/her due to impaired cervical ROM. Resident would benefit from decreased speed; -The assessment did not indicate what was a passing or failing score; -Opinion: Able to drive with some difficulty. Review of the resident's care plan, last revised 02/13/25, showed the following: -ADL self-care performance deficit related to multiple sclerosis (MS-nerve damage disrupting communication between the brain and the body) and fatigue; -Totally dependent of one to two staff for bathing, bed mobility, dressing; -Dependent on two staff and a mechanical lift for transfers; -Encourage resident to discuss feelings about self-care deficit frequently; -Encourage resident to participate to the fullest extent possible with each interaction; -Encourage use of prescribed assistive devices (12/21/23). Review of the resident's physician order sheet (POS), dated 03/2025, showed he/she had diagnoses that included MS, depression and anxiety. Review of the resident's facility electronic medical record showed no documentation the resident had run his/her motorized chair into other residents repeatedly and no documented safety concerns regarding the resident's use of his/her motorized chair. There was no documentation to show mirrors had been installed on his/her motorized wheelchair or that the speed had been decreased. During an interview on 03/02/25 at 4:52 P.M., the resident said the following: -The facility told him/her that he/she could not have his/her motorized chair and had threatened to take it away; -His/Her chair was the only way he/she had any independence and could do things for him/herself; -He/She would be mostly dependent on staff without the chair; -He/She would become more depressed without the chair; -Therapy had evaluated him/her in the chair and he/she had never hit anyone in his/her motorized chair. Observations during the survey process from 03/02/25 to 03/05/25, showed the resident up in his/her motorized chair in his/her room and in the common areas without any concerns of unsafe driving of the motorized chair or excessive speed. No mirrors were observed on the resident's motorized chair. During an interview on 03/19/25 at 1:30 P.M., the Therapy Director said the following: -The scoring of the power-mobility indoor driving assessment did not indicate a pass or fail; -The resident had not run into any residents when accompanied by therapy; -Therapy could help the resident to use the chair safely. During an interview on 03/05/25, at 8:00 P.M. and 3/19/256 at 2:19 P.M., the Administrator said the following: -Therapy evaluated the resident, and the resident failed the test; -The resident wanted to drive too fast; -The resident has not had an accident she was aware of; -She worried about the safety of others; -She knew the company which provided/attached safety devices to the motorized chairs had been in the facility a few times but they always worked on the resident's chair in his/her room; -She did not know if the company had attempted to turn the speed down or apply mirrors (per the assessment recommendations) to the resident's chair or not; -The resident failed his/her driver test and she was looking to take his/her chair as she did not want any motorized chairs in the building; -Therapy will evaluate to put him/her in a chair in which he/she could maintain level of function.

Based on observation, interview and record review, the facility failed to provide restorative nursing services to assist two residents (Resident #30 and #55), in a review of 24 sampled residents, in attaining or maintaining their highest level of functioning. The facility failed to follow their policy to develop restorative plans with the problem, needs/strengths, measurable goals with a target date, specific interventions/task to be provided, frequency and duration of interventions/task, such as number of repetitions, length of time, or direction to staff to meet resident needs. The facility census was 98. Review of the facility policy, Restorative Nursing Program (RNP), dated 04/30/24, showed the following: -It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level; -Restorative nursing program refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning; -Cognitive and physical functioning of all residents will be assessed in accordance with the facility's assessment protocols; -The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment; -Nursing personnel are trained on basic, or maintenance nursing care that does not require the use of a qualified therapist or licensed nurse oversight. This training may include, but is not limited to: -Maintaining proper positioning and body alignment; -Assisting residents with range of motion exercises, performing passive range of motion for residents who lack active range of motion ability; -All residents will receive maintenance nursing services as described above, as needed, by certified nursing assistants; -The Restorative Nurse and restorative aides receive additional training on restorative nursing program activities upon hire and as needed; -Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services and may include passive or active range of motion; -Residents may receive restorative nursing services upon admission when not a candidate for specialized rehabilitation services, when restorative needs arise during the course of a longer term stay, in conjunction with specialized rehabilitation therapy, or upon discharge from therapy; -The Restorative Nurse is responsible for maintaining a current list of residents who require restorative nursing services and for ensuring that all elements of each resident's program are implemented; -A resident's Restorative Nursing plan will include: -a. The problem, need or strength the restorative tasks are to address; -b. The type of activities to be performed; -c. Frequency of activities; -d. Duration of activities; -e. Measurable goal and target date; -Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting in the Electronic Health Record; -The Restorative Nurse, or designated licensed nurse, will provide oversight of the restorative aide activities, review the documentation at least weekly and evaluate the effectiveness of the plan monthly; -The facility maintains complete, accurate and organized documentation of restorative treatments and the response to those treatments; -The need for restorative nursing services will be documented in the medical record and indicated on the resident's plan of care. Documentation shall include: -a. The problem, need or strength that is being addressed; -b. A measurable goal with target date; -c. The specific interventions/treatments to be provided; -d. The frequency and duration of interventions/treatments; -Treatment provided as part of a restorative nursing program will be documented on a daily basis by the restorative aide or other trained individual providing the treatment; -a. The treatment as described in the resident's care plan will be written on the designated restorative flowsheet; -b. The specific treatment provided will be initialed daily or as specified by the care plan; -d. If the treatment is refused or withheld, a narrative note will be written explaining why; -A weekly progress note will be written by the restorative aide and countersigned by a licensed nurse (if allowed by state practice act). The progress note shall include, but is not limited to: -a. The treatment provided (ambulation, etc.); -b. The specific distance or repetitions; -c. The use of assistive devices; -d. The endurance and tolerance level; -e. The amount of assistance needed and why; -The Restorative Nurse will document an evaluation monthly. The evaluation will include: -a. The problem, need or strength that is being addressed; -b. The resident's progress towards goals; -c. The resident's tolerance or response to the treatments; -d. Any complications or risks associated with the restorative interventions; -e. A determination regarding the need for continued restorative services or rationale for discontinuing restorative services; -The resident's plan of care will be updated at routine intervals and as indicated. 1. Review of Resident #30's care plan, last revised 04/17/24, showed the following: -Resident has chronic pain related to chronic physical disability which is paraplegia (paralysis of legs); -He/She uses a gerichair (reclining chair on wheels) pushed/propelled by staff for mobility; -Resident will remain free of complications related to immobility, including contractures; -Observe and report decrease in functional abilities, decrease Range of Motion (ROM), and withdrawal or resistance to care; -Resident is non-weight bearing; -Resident is dependent on staff for locomotion using gerichair; -Monitor/document/report contractures forming or worsening; -Provide gentle range of motion as tolerated with daily care. Review of the resident's Physician's Orders Sheet (POS), dated 06/07/24 (and still active), showed the resident was to receive restorative nursing for passive PROM. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 10/03/24, showed the following: -Cognitively intact; -Diagnosis of paraplegia (paralysis of the legs and lower body); -Impairment to functional ROM to both lower extremities; -Requires partial/moderate assistance from staff for personal hygiene and upper body dressing; -Dependent on staff for toileting hygiene, shower/bathing, lower body dressing all transfers and wheelchair mobility; -No documentation of restorative nursing minutes and no therapy services. Review of the resident's quarterly MDS, dated [DATE], showed no restorative nursing minutes, and not receiving therapy services. Review of the resident's electronic medical record showed no evidence the resident's order for RN and PROM had been discontinued. Review of the resident's restorative log, for January 2025, showed staff documented completing the following: -01/02/25, 10 minutes of passive ROM; -01/08/25, 10 minutes of passive ROM; -01/09/25, 12 minutes of passive ROM; -01/17/25, 10 minutes of passive ROM; -01/21/25, 10 minutes of passive ROM; -No documentation to show the resident ever refused PROM offered; -This documentation did not include the location PROM was to be completed for, the frequency of activities, duration of activities or the measurable goal and target date. Review of the resident's restorative log, for February 2025, showed staff documented the following: -02/07/25, 10 minutes of passive ROM; -02/17/25, 10 minutes of passive ROM; -02/18/25, 10 minutes of passive ROM; -02/21/25, 10 minutes of passive ROM; -02/25/25, 8 minutes of passive ROM; -02/27/25, 10 minutes of passive ROM; -No documentation to show the resident ever refused PROM offered; -This documentation did not include the location PROM was to be completed for, the frequency of activities, duration of activities or the measurable goal and target date. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis of paraplegia; -Impairment to functional ROM to both lower extremities; -Requires partial/moderate assistance from staff for personal hygiene and upper body dressing; -Dependent on staff for toileting hygiene, shower/bathing, lower body dressing, all transfers and wheelchair mobility; -No restorative nursing, and no therapy. Review of the resident's electronic medical record showed no documentation of restorative minutes on 02/27/25 or 02/28/25, including refusals of PROM by the resident. Review of the resident's facility electronic medical record showed no documentation of restorative minutes on 03/01/25 through the review period of 03/03/25, including refusals of PROM by the resident. Review of the resident's restorative log, for 03/01/25 through 03/04/25, showed the resident received 10 minutes of passive ROM on 03/04/25, the documentation did not show any refusals, the body location that PROM was to be performed on, frequency of activities, duration of activities or the measurable goal and target date. Review of the resident's facility electronic medical record showed no documentation of a restorative plan of care to include restorative plans with the problem, needs/strengths, measurable goals with a target date, specific interventions/task to be provided, frequency and duration of interventions/task, such as number of repetitions, length of time, or direction to staff to meet resident needs. The electronic medical record also showed no documentation of the Restorative Nurse, or designated licensed nurse, documenting a weekly review or evaluation of the effectiveness of the plan monthly. Observation on 03/02/25 at 5:54 P.M., showed the resident in his/her room in a reclining chair on wheels (gerichair); the resident's lower extremities were paralyzed and contracted. During an interview on 03/05/25 at 2:17 P.M., the resident said the following: -He/She is a paraplegic and unable to move his/her legs; -He/She has contractures and was supposed to have restorative services three times per week; -The Restorative Aide (RA) says he/she is pulled to the floor and doesn't have time to complete his/her restorative program; -He/She may have one day of restorative and then go without any restorative nursing for two to three weeks; -He/She was having more spasms in his/her legs and they hurt; -He/She felt like his/her contractures were getting worse; he/she needed to have aggressive stretching to prevent worsening of contractures and to help his/her spasms. 2. Review of Resident #55's facility document, Point of Care Restorative Tasks, showed the following: -Date initiated: 02/14/2022; -Last revision: 08/28/24; -Task: Restorative: PROM; -Description: daily; -Instruction: [NAME] resting hand splint to contracture two to four hours after completion of ROM; -Frequency: Monday, Tuesday, Wednesday, Thursday and Friday, every shift, days 6:00 A.M. to 6:00 P.M. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis: stroke, hemiplegia (paralysis of one side of the body), seizure disorder and depression; -Functional limitation in ROM both upper and lower extremities; -Wheelchair propelled by staff; -Dependent all ADL's; -No documentation of therapy and no restorative nursing. Review of the resident's Physician's Order Sheet, dated January 2025 (and still active) showed an order for passive ROM. Review of the resident's restorative log, for January 2025, showed staff documented completing the following: -Resident is scheduled for passive ROM daily: -01/01/25, 10 minutes of passive ROM; -01/02/25, 10 minutes of passive ROM; -01/03/25, 12 minutes of passive ROM; -No documentation of restorative nursing documented 01/04/25 through 01/06/25; no documentation the resident refused; -01/07/25, 10 minutes of passive ROM; -01/08/25, 10 minutes of passive ROM; -01/09/25, eight minutes of passive ROM; -01/10/25, 12 minutes of passive ROM; -No documentation of restorative nursing documented 01/11/25 through 01/13/25; no documentation the resident refused; -01/14/25, 10 minutes of passive ROM; -01/15/25, seven minutes of passive ROM; -01/16/25, seven minutes of passive ROM; -01/17/25, 12 minutes of passive ROM; -No documentation of restorative nursing documented 01/18/25 or 01/19/25; no documentation the resident refused; -01/20/25, 10 minutes of passive ROM; -01/21/25, 10 minutes of passive ROM; -01/22/25, 10 minutes of passive ROM; -01/24/25, 10 minutes of passive ROM; -No restorative nursing minutes documented between 01/25/25 and 01/31/25; no documentation the resident refused; -This documentation did not include the location PROM was to be completed for, the frequency of activities, duration of activities or the measurable goal and target date. Review of the resident's restorative log, for February 2025, showed the following: -Passive ROM scheduled daily; -No documentation of restorative nursing documented for 02/01/25 or 02/02/25; no documentation the resident refused; -02/03/25, eight minutes of passive ROM; -No documentation of restorative nursing documented for 02/04/25 through 02/12/25; no documentation the resident refused; -02/13/25, 10 minutes of passive ROM; -No documentation of restorative nursing documented for 02/14/25 through 02/16/25; no documentation the resident refused; -02/17/25, 10 minutes of passive ROM; -No documentation of restorative nursing documented for 02/18/25 or 02/19/25; no documentation the resident refused; -02/20/25, 14 minutes of passive ROM; -02/21/25, 15 minutes of passive ROM; -No documentation of restorative nursing documented for 02/22/25 through 02/23/25; no documentation the resident refused; -02/24/25, 10 minutes of passive ROM. -02/25/25, 12 minutes of passive ROM; -02/26/25, 10 minutes of passive ROM; -02/27/25, 12 minutes of passive ROM; -02/28/25, 15 minutes of passive ROM. -This documentation did not include the location PROM was to be completed for, the frequency of activities, duration of activities or the measurable goal and target date. Review of the resident's facility electronic medical record showed no documentation of a restorative plan of care to include: restorative plans with the problem, needs/strengths, measurable goals with a target date, specific interventions/task to be provided, frequency and duration of interventions/task, such as number of repetitions, length of time, or direction to staff to meet resident needs. The electronic medical record also showed no documentation of the Restorative Nurse, or designated licensed nurse, documenting a weekly review or evaluation of the effectiveness of the plan monthly. 4. During an interview on 03/03/25 at 2:30 P.M., Certified Nurse Assistant (CNA) O said the following: -He/She was the restorative aide (RA); -He/She was pulled to the floor a lot and was unable to fulfill the RNP or resident PROM duties; -There had been weeks when she was not able to do restorative nursing at all because of staffing, the Director of Nursing tried not to pull her but sometimes there is no choice; -He/She does not make a weekly or monthly note, he/she follows what tasks are in the electronic medical record. During an interview on 03/05/25 at 8:05 P.M. and 03/20/25 at 12:41 P.M., the Director of Nursing said the following: -She would like to see the Restorative Program stronger, -She tries very hard not to pull the RA to the floor, but sometimes had no choice; -She would like all residents to get restorative nursing; -Therapy recommends residents for restorative nursing; -She believed therapy recommended restorative nursing for Residents #30; -She was not sure if the facility still had the written therapy recommendations for restorative therapy because once the recommendation is entered in the computer, they do not keep the paper form; -Resident #55 should have PROM for the rest of his/her life due to being bedridden. During an interview on 03/05/25 at 8:00 P.M., the Administrator said the following: -Restorative Nursing is important to maintain the resident's abilities and prevent declines in function; -The restorative aide does get pulled to work as a CNA on the floor especially with recent staffing challenges. 38016

Based on interview and record review, the facility failed to provide protective oversight to ensure residents did not have materials to start a fire after staff identified a fire had been started in Resident #1 and Resident #2's room. On 1/12/25 at approximately 12:45 A.M., staff noted an odor coming from Resident #1 and Resident #2's room. Resident #1 said there was a small fire in the bathroom trash can that he/she extinguished with water. Staff noted a small amount of melted plastic in the bathroom trash can. Staff searched the room and found cigarettes in Resident #2's drawer, ashes in Resident #2's bed, and a cigarette butt on Resident #1's side of the room. Staff did not locate a lighter or any other lighting materials. On 1/12/25 at 1:07 A.M., the fire alarm sounded and at 1:09 A.M. staff observed Resident #1 walk up the hall. Staff noted a red glow and flames coming from the resident's room. Staff responded and found a box on fire on Resident #1's side of the room by the door. Staff extinguished the fire while other staff evacuated residents to the common area and called a Code Red (fire emergency that requires immediate attention). Resident #2 was transferred to the emergency room for evaluation as a result. A sample of ten residents was selected for review. The facility census was 92. The administrator was notified of the Immediate Jeopardy (IJ) on 1/16/25 at 3:04 P.M. which began on 1/12/25. The IJ was removed on 1/20/25 as confirmed by surveyor onsite verification. Review of the facility policy titled Smoking Contraband, reviewed 5/18/24, showed the following: -The purpose of the policy was to define what the facility classifies as smoking contraband and to provide safety and protective oversight to the residents and employees by monitoring the smoking contraband in the facility. It was the goal of the facility to provide a safe environment for all; -The facility defined contraband as cigarettes, electronic cigarettes, cigars, vaporizing electronic cigarettes, tobacco, lighters, matches, any other smoking materials (including illegal substances), and any other type of smoking device utilized to smoke; -Residents will not be allowed to carry or keep any smoking contraband on the unit or in their rooms; -Residents who have been assessed to be safe to smoke unsupervised and have purchased their own smoking contraband, will be allowed to sign out their own personal smoking contraband from the staff to utilize when they wish to smoke; -Unused personal smoking contraband must be turned back into the facility staff and signed back in when the resident returns to the unit; -Facility staff must initial and sign all smoking contraband out and back in to keep an accurate record and account of all smoking contraband on the unit; -In the event that smoking contraband was unable to be located, or was not properly turned in, the charge nurse will be notified. Assessment of independent smoking will be reassessed should smoking contraband not be turned in and was found on their person or in their possession on the unit or in their rooms. The staff will ensure the Resident Care Coordinator (RCC), Director of Nursing (DON), administrator and legal guardian (if applicable) was notified; -Further direction may be given by the facility administrator and/or the legal guardian for resident/room searches to locate the smoking contraband. 1. Review of Resident #1's smoking safety evaluation, dated 12/11/24, showed the resident used tobacco and was an unsupervised smoker. Review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 12/17/24 showed the following: -Diagnoses included depression and schizophrenia (a chronic mental illness characterized by significant disruptions in thought processes, perceptions, emotions, and behaviors); -Mild cognitive impairment; -Hallucinations (perpetual experiences in the absence of real external sensory stimuli) present; -Independent with mobility. Review of the resident's Care Plan, revised 12/29/24, showed the following: -The resident had mental illness with history of frequent psychiatric hospital admissions. Provide 1:1 interventions as needed; -The resident tended to wander and think rules do not apply to him/her. Mood was labile, elevated/expansive. The resident communicated inappropriately, had poor concentration, judgment and insight. Recommended for the resident to be in a locked facility. Staff will observe for and report behaviors and redirect the resident when negative behaviors are observed; -The resident had behavioral challenges that required protective oversight in a secure setting. The resident had diagnoses of paranoid schizophrenia (subtype of schizophrenia that's characterized by paranoia, hallucinations, and delusions), polysubstance abuse, impulse control disorder (a group of mental health conditions characterized by difficulty controlling impulsive behaviors and thoughts), psychotic disorder (a mental health condition characterized by a loss of touch with reality), borderline intellectual functioning, developmental delay and dependent personality disorder; -The resident is a smoker and required supervision while smoking. Instruct the resident on the facility smoking policy, locations, times and safety concerns. Notify the charge nurse immediately if it was suspected the resident has violated the facility smoking policy. Review of a list of residents who smoke, provided by the facility on 1/14/25, showed Resident #1 was an unsupervised smoker. 2. Review of Resident #2's undated face sheet showed the following: -Diagnoses included paranoid schizophrenia and chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it difficult to breathe. Review of the resident's Care Plan, revised 4/3/24, showed the following: -The resident is a full-time smoker and was aware of the smoke break times and the designated smoking area; -Independent with activities of daily living; -The resident was at risk for impaired respiratory status due to smoking. The resident smoked cigar type cigarettes with unsupervised smoking groups. Sometimes the resident would save cigarette butts if there were a few puffs left and put them in his/her pocket and take it to the next cigarette break, despite staff education; -The resident would attempt to hide lighters to smoke at nonsmoke break times; -Conduct a smoking safety evaluation upon admission and as needed; -Instruct the resident on the facility policy on smoking, locations, times and safety concerns; -The resident can smoke unsupervised; -The resident's smoking supplies were stored in the storage room on the unsupervised hall entrance; -Observe clothing and skin for signs of cigarette burns. Review of the resident's smoking safety evaluation, dated 6/1/24, showed the resident utilized tobacco products and was a supervised smoker. Review of the resident's Care Plan showed no update following the resident's smoking safety evaluation, dated 6/1/24, which identified the resident was a supervised smoker. Review of the resident's nurse's notes showed the following: -On 6/27/24 at 10:06 A.M., staff observed the resident in the courtyard with a lit cigarette. The resident was unable to truthfully tell staff how he/she got possession of the cigarette or the lighter. Staff reviewed the smoking contraband policy with the resident and discussed concerns of unsupervised smoking. Resident aware of changes to smoking limitations if further actions occurred. Resident verbalized understanding; -On 11/3/24 5:33 P.M., the nurse aide came to the nurse's station and asked the nurse to go down and smell the resident's room because it smelled of cigarettes. The nurse went with the aide to the resident's room and agreed the room smelled like a cigarette had been lit in the room. The nurse and aide lifted the resident's mattress and found a lighter that fell on to the floor between the bed and the nightstand. Staff confiscated the lighter. The resident returned to his/her room after seeing staff come out of the room. The resident was instantly upset and yelled at multiple staff members. The resident tried to say the lighter belonged to his/her roommate. The resident continued to be upset, yell and pointed a finger in the nurse's face. The resident's guardian was notified. The guardian said if the resident could not follow the rules or be respectful, he/she would not be allowed to smoke. The guardian instructed the resident there would be no smoking that night and the guardian would follow up with facility office staff the following day with further instructions. Review of the resident's smoking safety evaluation, dated 12/1/24, showed the following: -Supervised smoker; -Rummaged through ashtrays. Review of a list of residents who smoke, provided by the facility on 1/14/25, showed Resident #2 was a supervised smoker. Review of the resident's Care Plan showed no update to reflect the resident was a supervised smoker. 3. Review of the facility's timeline of events showed the following: -On 1/12/25 at 12:45 A.M., staff noted an odor in Resident #1 and Resident #2's shared room and a trash can with melted plastic and a melted/charred plastic bag in the sink; -Certified Nurse Aide (CNA) A reported to charge nurses Licensed Practical Nurse (LPN) B and LPN C, and all three staff investigated; -During an interview with staff, Resident #1 said he/she did not start the fire or have a lighter. Resident #1 said he/she was cupping water with his/her hands to put out the fire and said the fire was approximately the size of his/her cupped hands; -Staff asked Resident #1 to empty his/her pockets and he/she did, producing a burnt end cigarette butt with charring to the pocket of his/her jacket; -During the room search, staff found approximately six cigarettes from Resident #2's (Resident #1's roommate) possession. Resident #2 denied possession of a lighter; -On 1/12/25 at 1:07 A.M., the fire alarm company submitted first warning trigger; -On 1/12/25 at 1:09 A.M., CNA A observed flames and smoke and called a Code Red as simultaneously the fire alarm panel alarmed; -LPN C called 911; -As staff responded, Resident #1 was observed walking in the hallway, in the opposite direction of the fire towards the common area; -Staff evacuated Resident #2 from the room as well as residents in the adjoining room (connected by a bathroom); -LPN B and LPN C extinguished the fire with a fire extinguisher through the resident's doorway; -Staff checked rooms and closed doors as the location was evacuated and secured and brought other residents to the common area; -On 1/12/25 at 1:12 A.M., staff notified the DON; -On 1/12/25 at 1:13 A.M., staff notified the ADON (Assistant Director of Nurses); -On 1/12/25 at 1:30 A.M., the fire department arrived on scene with police and emergency medical services (EMS); -Staff completed room searches and utilized a fan to ventilate and removed a burned box from the scene; -On 1/12/25 at 1:31 A.M., the administrator was made aware; -Resident #2 was transferred to the emergency room and treated for COPD exacerbation. During an interview on 1/14/25 at 9:00 P.M., CNA A said he/she walked down the hall and smelled something burning which he/she reported to LPN B and LPN C. The staff searched the room and found some new cigarettes and old butts in Resident #2's dresser. One of the resident's coats was found with a burn mark and a cigarette butt in the pocket. No lighters were found. Staff left the room when the search was completed. About 20 minutes later CNA A noticed a red glow coming from the room and called a Code Red. At this time Resident #1 walked up the hallway. Another staff member got Resident #2 out of the room as other staff extinguished the fire. The fire was located in a box that was on Resident #1's side of the room by the door. The box contained a couple of coats and papers and odd and ends. Resident #1 was seated on a couch in the common area, rocking back and forth. Resident #1 appeared anxious and CNA A could tell something was off. Resident #2 had a habit of hiding lighters. It was unknown how Resident #2 acquired them. Staff are to keep all smoking materials including lighters. Staff hang their coats on the 200 hall or in the shower room as there are not enough lockers for all staff to have one. CNA A has told night shift in the past to be sure and keep their lighters on their person. During an interview on 1/14/25 at 4:50 P.M., LPN C said CNA A reported to him/her and LPN B a smell like something was burning. LPN C and LPN B went to Resident #1 and Resident #2's room. Resident #1 stood beside the bed, Resident #2 lay in his/her bed. Resident #1 said there was a little fire in the bathroom, but he/she had put it out with water. LPN C removed the melted trash can liner where the fire had been located. It was not hot. LPN B and LPN C searched the room and bathroom and found a cigarette in Resident #1's night stand drawer and ashes in Resident #2's bed and a burn mark on the inside of Resident #2's jacket pocket. LPN C and LPN B left the room and went to the desk and notified supervisors. Resident #2 went back to sleep. Approximately 10 to 15 minutes later, CNA A yelled out, Code Red!. LPN C saw flames coming from Resident #1 and #2's room. LPN C grabbed a fire extinguisher. Resident #1 walked up the hallway, away from the room and towards the common area. Resident #1 looked nervous and sat on the couch. LPN C extinguished the fire with the extinguisher. The fire department arrived and removed the box that was burned from the room. The fire department cleared residents to return to their rooms. Staff searched the room again. LPN B interviewed Resident #1 and Resident #2 about the fire. LPN C assessed the residents. Resident #2's breathing became worse and was sent to the emergency room for evaluation around 10:00 A.M. Resident #1 and Resident #2 has been known to dig through the ashtrays for cigarette butts in the past. Review of the written statement obtained by the surveyor from LPN C, dated 1/15/25, showed the following: -On 1/12/25 at 12:45 A.M., CNA A came to the nurse's station and reported there was a smell of something burning. LPN B and LPN C went down the hall and followed the smell to Resident #1 and Resident #2's room; -LPN B and LPN C entered the room and there was a strong odor of smoke; -Resident #1 sat on his/her bed and said there was a small fire in the bathroom trash can that he/she put water on; -LPN B and LPN C observed a melted trash bag in the trash can and ashes in the sink in the bathroom; -Aides searched the room for contraband as LPN B and LPN C went back to the nurse's station to notify supervisors; -Aides found contraband on both Resident #1's and Resident #2's side of the room and brought it to the nurse's station; -At 1:00 A.M., CNA A yelled Code Red and Resident #1 and 2's room number; -Staff observed flames coming from the room and Resident #1 walking away from the room towards the common area; -LPN C grabbed the fire extinguisher as CNA A woke up Resident #2 and evacuated him/her from the room; -All aides began to evacuate all residents from their rooms to the common area; -At 1:09 A.M., staff called 911; -Immediately after the fire department cleared the smoke from the hallway, fire department staff searched rooms. The fire department cleared all residents to return to their rooms, expect the four residents whose rooms were affected due to smoke and fire damage; -Staff assessed Resident #1 and Resident #2. Resident #2's assessment showed wheezes in his/her lungs and an oxygen saturation level (the percentage of oxygen molecules carried by red blood cells. Normal is between 95% and 100%) of 84%. Staff applied supplemental oxygen at 3 liters per nasal cannula and Resident #2's oxygen saturation increased to 91%; -LPN B interviewed Resident #1 and Resident #2 separately about what happened. During an interview on 1/16/25 at 12:55 P.M., CNA E said after the first fire he/she helped with the room search to try and determine what started the fire. Staff searched everything, including under Resident #1's and #2's mattresses. Staff also searched the bathroom and the adjoining room. No lighter was found. As CNA D and CNA E started the 15 minute checks for the four residents in the room and adjoining room where the first fire started, the big fire was observed. LPN C pulled the fire alarm and got the fire extinguisher and CNA A and CNA D got Resident #2 out of the room. Resident #1 was already in the common area. There was approximately 20 minutes between the fires. During an interview on 1/14/25 at 8:41 P.M., CNA D said he/she was told there had been a fire in a trash can on the 300 hall. When CNA D arrived to the room there were two other staff already searching the room. Staff found six or seven cigarettes in Resident #2's bedside table. CNA D observed ashes in Resident #2's bed around where the resident had laid, which he/she reported to LPN B and LPN C. No lighter was found. About 10 minutes later the fire alarm went off. CNA D ran back to the 300 hall which was full of smoke. Staff already had about half of the residents evacuated from the hall. After the first fire, Resident #1 was seated in the common area. At the time of the second fire, Resident #1 was no longer sitting in the common area. During an interview on 11/15/24 at 3:30 P.M. LPN B said he/she interviewed Resident #1 and Resident #2 after both fires. Neither resident admitted to having a lighter or starting the fire. After the first fire, the room was searched, including looking under their mattresses. No lighter was found. During an interview on 1/14/25 at 12:50 P.M., Resident #2 said he/she guessed Resident #1 started a fire in their room with a lighter, but he/she didn't see it because he/she was sleeping. The resident went to the hospital after the fire as he/she was not feeling well and returned to the facility from the hospital on 1/13/24. Resident #2 denied having a lighter or cigarettes or bringing cigarette butts back from smoke times. Resident #2 said he/she suspected Resident #1 brought cigarette butts back into the room, but could not prove this. During an interview on 1/16/25 at 11:41 A.M., the Assistant Director of Nursing (ADON) said the following: -After the first fire incident occurred, staff were to intensively monitor Resident #1 and keep him/her in staff's line of sight; -Intensive monitoring was defined as staff checking on residents at a frequency of less than an hour between each check and keeping the resident in line of sight; -Resident #1 was not placed on a 1:1 staff-to-resident monitoring because that was considered a within arms reach check and she and the Administrator did not feel the resident needed to be within arms length of staff, just that the resident was in the line of sight of staff; -She expected if staff saw Resident #1 enter his/her room during line of sight monitoring that staff follow him/her into his/her room; -No particular staff was assigned to monitor Resident #1, staff just made a team effort to monitor him/her. During interviews on 1/14/25 at 11:50 A.M. and 1/16/25 at 10:23 A.M., the Administrator said both Resident #1 and Resident #2 had a history of sneaking cigarette butts back into the facility after smoke times. Resident #2 was already a supervised smoker. Prior to the fires, Resident #1 was an unsupervised smoker. Staff were expected to extinguish supervised residents' cigarettes when finished. Staff were expected to empty the ashtrays after each smoke break and were expected to monitor the box of cigarettes and lighters at all times and not to leave them unattended around residents. Intensive monitoring, 15-minute checks, and staff having a resident in their line of sight were considered the same thing. After the fire incidents occurred, Resident #1 was not placed on 1:1 staff-to-resident monitoring with an assigned staff member. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s). MO247905 MO247912

Based on interview and record review, the facility failed to report an allegation of sexual abuse involving two residents (Resident #1 and #2), in the review of six sampled residents to the state agency. The facility census was 94. Review of the facility Abuse and Neglect policy, last revised 06/12/2024, showed the following: - It is the policy of the facility to report all allegations of abuse are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within the prescribed time frames; -Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to, the following: -Unwanted intimate touching of any kind especially of breasts or perineal area (the area of the body between the anus (rectal opening) and the external genitalia-the male or female reproductive organs); -All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; -This also includes failure to intervene or attempt to stop or prevent non-consensual sexual activity or performance between residents; -The facility will investigate all allegations and types of incidents as listed in accordance to facility accordance to facility procedure for reporting and response; -The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required; -Best practice refer to the State Operations [NAME] (SOM) for reporting and utilize the abuse-neglect reporting decisions tree to assess the incident. Should the incident be a reportable event, notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after the discovery of the incident; -Follow-up with appropriate agencies, during business hours, to confirm the report was received; -Within five working days of the incident report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified. 1. Review of Resident #1's Face Sheet, undated, showed the following: -The resident was admitted to the facility on [DATE]; -He/She had a legal guardian; -Diagnoses included unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's Care Plan dated 6/11/24, showed the following: -The resident has a communication problem related to dementia, hearing deficit, inattention and disorganized thinking -The resident had a psychosocial wellbeing problem due to distractibility and inability to concentrate. Encourage participation from the resident who depends on others to make own decisions, when conflict arises move the resident to a safe, calm environment, allow the resident to vent feelings. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/31/24, showed the resident was cognitively intact. He/She exhibited no behavioral symptoms. 2. Review of Resident #2's Face Sheet, undated, showed the following: -The resident was admitted to the facility on [DATE]; -He/She had a legal guardian -Diagnoses include early onset of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia. Review of the resident's baseline Care Plan, dated 10/3/2, showed the following: -The resident was cognitively impaired and had a diagnosis of Alzheimer's disease. The resident communicated easily with staff and understood staff; -The resident did not require staff setup or physical assistance to walk in room, corridor, or locomotion on the unit. 3. During an interview on 10/15/24 at 8:55 A.M. Nurse Aide (NA) B said on 10/6/24 at approximately 10:00 P.M., he/she entered Resident #1's room. Certified Nurse Aide (CNA) C was already in the room. Resident #2 stood beside Resident #1's bed. Resident #2 zipped up his/her pants when NA B walked in the room. Resident #2 tried to hit NA B and was agitated when staff assisted him/her out of Resident #1's room. Resident #2 was new to the facility and staff did not know a lot about him/her. During an interview on 10/15/24 at 9:30 A.M. CNA D said the following: -He/She worked the day shift on 10/7/24. Staff from the previous shift reported the two residents (Resident #1 and #2) were having sex the night before; -Resident #2 tried to go down Resident #1's hall several times throughout the day shift. CNA D thought Resident #1 was looking for Resident #2 and it worried him/her; -The charge nurse said to keep an eye on Resident #1 and to make sure he/she wasn't on Resident #2's hall. During an interview on 10/15/24 at 1:25 P.M., CNA C said the following: -On 10/6/24 at approximately 10:00 P.M., he/she answered Resident #1's roommate's call light. Resident #1's privacy curtain was pulled when he/she entered the room. CNA C left the room to get ice for the roommate; -Upon returning to the room, CNA C heard a noise on Resident #1's side of the room. CNA C pulled the privacy curtain back and observed Resident #2 standing beside Resident #1's bed (Resident #1 faced Resident #2). Resident #1 abruptly zipped up his/her pants; -Resident #2 was new to the facility. Resident #2 tensed up and pulled away from staff, when he/she was redirected out of the room. CNA A reported to Licensed Practical Nurse (LPN) A that he/she felt something sexual had occurred between the two residents. CNA C was concerned for Resident #1's safety and was also concerned it wasn't reported to the state agency. During an interview on 10/14/24 at 11:35 A.M. LPN A said the following: -On 10/6/24 at approximately 10:00 P.M.,CNA C and NA B reported Residents #1 and #2 were were having oral sex. LPN A told CNA C and CNA B he/she did not feel anything had happened. He/She thought Resident #2 just helped Resident #2 back to his/her room and the staff were being dramatic about the situation; -LPN A called the Assistant Director of Nursing (ADON) and reported what the aides said occurred. LPN A kept a close eye on Resident #2 in case what NA B reported had actually occurred. He/She didn't interview Resident #1. The ADON said he/she would look into the incident the next day. During an interview on 10/15/24 at 1:00 P.M. the ADON said the following: -LPN A called him/her on 10/6/24 at approximately 10:00 P.M. and said CNA C found Resident #2 in Resident #1's room. CNA C said he/she thought something sexual occurred or was going to occur; -The ADON thought CNA C was being dramatic and the ADON told LPN A he/she would look into it in the morning and to keep the two residents separated; -He/She did not instruct LPN A to report the incident to the state agency as he/she didn't feel it was necessary. The ADON thought what CNA C said was a gossip and the staff exaggerated; -Staff redirected Resident #2 back to his/her hall; -The following morning the ADON asked Resident #1 if he/she felt safe and he/she said yes, or if he/she had anything to report and Resident #1 said no. The ADON assumed nothing happened. During an interview on 10/17/24 at 10:20 A.M. the Director of Nursing said she would expect an allegation of sexual abuse be reported to the state agency. During an interview on 10/17/24 at 10:18 A.M. the Administrator said she would expect staff to report an allegation of sexual abuse to the state agency.

Based on interview and record review, the facility failed to complete a thorough investigation of an allegation of sexual abuse between two residents (Resident #1 and #2), of six residents sampled residents. The facility did not complete resident interviews with other residents following the incident to assess if they felt safe or had been subjected to or witnessed abuse and did not interview all staff present at the time of the alleged incident of abuse. The facility census was 94. Review of the facility Abuse and Neglect policy, last revised 06/12/2024, showed the following: -Sexual abuse is non-consensual contact of any type with a resident. Sexual abuse includes, but is not limited to, the following: -Unwanted intimate touching of any kind especially of breasts or perineal area (the area of the body between the anus (rectal opening) and the external genitalia-the male or female reproductive organs); -All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; -This also includes failure to intervene or attempt to stop or prevent non-consensual sexual activity or performance between residents; -The facility will investigate all allegations and types of incidents as listed in accordance with facility procedure for reporting and response; -When suspicion of abuse or reports of abuse occur, the licensed nurse will respond to the needs of the resident and protect him/her from further incident; -The Administrative/Designee will complete an administrative investigation to include personal statements from staff and residents involved in a situation that has any type of accusations of abuse either staff or resident abuse, or when administrative staff feel uncomfortable in any situation involving resident care or treatment; -The administrative investigation will also include a review of the resident's record to ensure that the documentation reveals that the legal guardian and/or responsible party was notified (if applicable), the physician was made aware, the resident was fully assessed, interventions and physician's orders were followed, the resident was re-evaluated, and the plan of care was updated to reflect the change in medical or behavioral status; -The facility Director of Nursing/Designee will ensure all clinical details and supportive plan of care interventions are completed for the administrative investigation. 1. Review of Resident #1's Face Sheet, undated, showed the following: -The resident was admitted to the facility on [DATE]; -He/She had a legal guardian; -Diagnoses included unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's Care Plan dated, 6/11/24, showed the following: -The resident has a communication problem related to dementia, hearing deficit, inattention and disorganized thinking -The resident had a psychosocial well-being problem due to distractibility and inability to concentrate. Encourage participation from the resident who depends on others to make decisions. When conflict arises move the resident to a safe, calm environment and allow the resident to vent feelings. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 8/31/24, showed the resident was cognitively intact. He/She exhibited no behavioral symptoms. 2. Review of Resident #2's Face Sheet, undated, showed the following: -The resident was admitted to the facility on [DATE]; -He/She had a legal guardian -Diagnoses include early onset of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and dementia. Review of the resident's baseline Care Plan, dated 10/3/24, showed the following: -The resident was cognitively impaired and had a diagnosis of Alzheimer's disease, the resident communicated easily with staff and understood staff; -The resident did not require staff setup or physical assistance to walk in room, corridor, or locomotion on the unit. 3. During an interview on 10/15/24 at 8:55 A.M., Nurse Aide (NA) B said on 10/6/24 at approximately 10:00 P.M., he/she entered Resident #1's room. Certified Nurse Aide (CNA) C was already in the room. Resident #2 stood beside Resident #1's bed. Resident #2 zipped up his/her pants when NA B walked in the room. Resident #2 tried to hit him/her (NA B) and was agitated when staff assisted him/her out of Resident #1's room. Resident #2 was new to the facility and staff did not know a lot about him/her. During an interview on 10/15/24 at 9:30 A.M. CNA D said the following: -He/She worked the day shift on 10/7/24. Staff from the previous shift reported the two residents (Resident #1 and #2) had sex the night before; -Resident #2 tried to go down Resident #1's hall several times throughout the day shift. CNA D thought Resident #1 was looking for Resident #2 and it worried CNA D; -The charge nurse said to keep an eye on Resident #1 and to make sure he/she wasn't on Resident #2's hall. During an interview on 10/15/24 at 1:25 P.M.,. CNA C said the following: -On 10/6/24 at approximately 10:00 P.M., he/she answered Resident #1's roommate's call light. Resident #1's privacy curtain was pulled when he/she entered the room. CNA C left the room to get ice for the roommate; -Upon returning to the room, CNA C heard a noise on Resident #1's side of the room, CNA C pulled the privacy curtain back and observed Resident #2 standing beside Resident #1's bed (Resident #1 faced Resident #2). Resident #1 abruptly zipped up his/her pants; -Resident #2 was new to the facility. Resident #2 tensed up and pulled away from staff when he/she was redirected out of the room. CNA C reported to Licensed Practical Nurse (LPN) A that he/she felt something sexual had occurred between the two residents. CNA C was concerned for Resident #1's safety. During an interview on 10/14/24 at 11:35 A.M. LPN A said the following: -On 10/6/24 at approximately 10:00 P.M.,CNA C and NA B reported Residents #1 and #2 were were having oral sex. LPN A told CNA C and NA B he/she did not feel anything had happened. LPN A thought Resident #2 just helped Resident #2 back to his/her room and the staff were being dramatic about the situation; -LPN A called the Assistant Director of Nursing (ADON) and reported what the aides said occurred. LPN A kept a close eye on Resident #2 in case what NA B and CNA C reported had actually occurred. LPN A didn't interview Resident #1 or anyone else. He/She didn't obtain statements from residents or the staff involved. The ADON told LPN A he/she would look into the incident the next day. During an interview on 10/15/24 at 1:00 P.M. the ADON said the following: -LPN A called him/her on 10/6/24 approximately 10:00 P.M. and said CNA C found Resident #2 in Resident #1's room. CNA C said he/she thought something sexual occurred or was going to occur; -The ADON thought CNA C was being dramatic and told LPN A he/she would look into it in the morning and to keep the two residents separated. He/She thought what CNA C said was a gossip and staff exaggerated; -Staff redirected Resident #2 back to his/her hall; -The following morning, the ADON asked Resident #1 if he/she felt safe and he/she said yes, or if he/she had anything to report and Resident #1 said no. The ADON assumed nothing happened. He/She didn't complete an investigation into the incident. During an interview on 10/17/24 at 10:20 A.M. the Director of Nursing said she thought the comments the CNAs made were poor humor. She did not feel there were any concerns at the time of the incident. She would expect an allegation of sexual abuse be investigated. During an interview on 10/17/24 at 10:18 A.M. the Administrator said she was not aware a staff member had reported an allegation of sexual abuse on 10/6/24. She would expect staff to investigate any allegation of sexual abuse brought to them by a staff member.

Based on observation, interview, and record review, the facility failed to ensure staff safely secured one resident (Resident #1), in a review of six residents, in the facility van during transport. The facility census was 93. On 10/2/24 at 11:25 A.M., the administrator was notified of the past noncompliance which occurred on 9/11/24. Upon notification of the incident, the facility completed an investigation and notified appropriate parties. The facility reeducated the transportation staff how to safely secure residents in the transport van. The deficiency was corrected on 9/11/24. During an interview on 10/1/24 at 11:15 A.M., the administrator said the facility did not have a policy for how to safely secure a resident in the transport van. 1. Review of Resident #1's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 7/24/24, showed the following: -Severely impaired cognition; -Required moderate assistance of staff for transfers; -Used a wheelchair for mobility; -Diagnosis frontotemporal neurocognitive disorder (group of brain diseases that mainly affect the frontal and temporal lobes of the brain). Review of the resident's care plan, last reviewed 8/18/24, showed the following: -Self performance fluctuates throughout the day; -Abilities range from independent to partial/moderate assistance of one staff for transfers; -Care plan does not include the use of a wheelchair for mobility. Review of the resident's late entry progress note (from an incident that occurred on 9/11/24), dated 9/12/24, showed SSD/Transporter D called the facility and reported the resident slid out of his/her wheelchair on the transportation van. The transportation van was stopped at the end of the facility driveway. Code Blue fall was called and available staff responded. When staff entered the van, the resident lay on his/her left side with his/her head against the wall of the van. His/Her legs were slightly bent, his/her left arm was bent up against the wall of the van, and his/her right arm lay on the right side of his/her body. The resident had a skin abrasion on his/her left elbow. The resident complained of neck pain saying, feels like my neck is broke. The resident said he/she just slid out of the chair. Staff called 911, and facility staff assisted ambulance staff to place the resident on a backboard and then a stretcher. Administration and the Maintenance Supervisor provided transportation education to SSD/Transporter D. During interview on 10/1/24 at 9:20 A.M. and 10/2/24 at 11:25 A.M., the Administrator said SSD/Transporter D picked up the resident from the hospital (in the facility transportation van). SSD/Transporter D pulled into the end of the facility parking lot and the resident had scooted far enough forward to tip out of the wheelchair. The resident did not have foot pedals on his/her wheelchair. SSD/Transporter D called the facility for assistance. Staff called 911 and the ambulance took the resident back to the hospital for evaluation. SSD/transporter D trained with the previous SSD about a month before he/she was on his/her own. The Maintenance Director re-educated SSD/transporter D again after this incident occurred including making sure the resident has foot pedals on the wheelchair. SSD/Transporter D had worked at the facility for one and a half months and trained with the former SSD for a month. She did not have any documentation to show when SSD/Transporter D was trained and by whom. During interview on 10/1/24 at 9:51 A.M., the Director of Nurses (DON) said the facility got a call at end of the day (between 5:30 P.M. and 6:00 P.M.) from SSD/Transporter D who said there was an emergency in the parking lot. She called a Code Blue fall and several staff responded. The responding nurses assessed the resident and she interviewed SSD/Transporter D on what had happened. The resident lay on his/her left side in the wheelchair. The back wheels of the wheelchair were still secured and the shoulder/lap belt was still secured. SSD/Transporter D told her that when the transport van turned into the driveway, the wheelchair tilted to the left enough that the resident slid out and the wheelchair folded on itself (with the resident still in the wheelchair). The resident had a skin tear on his/her left elbow and was sent back to the hospital for evaluation. The Maintenance Director looked over the transport van to see if there was anything functionally wrong that would have caused the resident to tip over in his/her wheelchair. There wasn't anything wrong with the van. The Maintenance Director re-educated the SSD/Transporter D on the correct way to secure a resident in the van for transport, including making sure the seatbelt went under the arm rests of the wheelchair instead of over the top and making sure the front wheels of the wheelchair were secured with ratchet straps. During interview on 10/1/24 at 10:19 A.M., Licensed Practical Nurse (LPN) A said he/she responded to the code blue fall in the parking lot. The resident lay on his/her left side in the wheelchair with his/her head against the wall of the van. The resident had blood on his/her elbow. The resident told him/her that he/she slid out of the wheelchair but didn't know what happened. SSD/Transporter D said, I don't know what happened. He/She just fell over. The resident said, I think my neck is broken. Staff called 911 and assisted the ambulance crew to stabilize the resident and transfer him/her to the stretcher. He/She wasn't aware of any injuries other than the skin tear to the resident's left elbow. Review of the hospital emergency room report, dated 9/11/24, showed facility staff transported the resident in the facility's van. Apparently, the resident slid out of his/her wheelchair. The resident complained of neck and pain to the back of his/her head. There was no loss of consciousness. There is no mental status change and no localizing motor or sensory deficits. CT scan (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) of cervical spine (neck area) showing moderately severe multilevel degenerative spondylosis (age-related arthritis) of the cervical spine encroaching the central canal at multiple levels. CT scan of the head with no acute pathology reported. Observation on 10/1/24 at 10:53 A.M., showed the following: -The administrator sat in a wheelchair; -Transporter C loaded the wheelchair onto the wheelchair lift on the transport van, locked the wheelchair, attached a seatbelt around the back of the wheelchair and flipped up the stopper on the bottom of the platform of the wheelchair lift (to stop anything from rolling off backwards); -Transporter C raised the wheelchair on the lift to the floor level of the van and wheeled the administrator on to the van; -Transporter C positioned the wheelchair at the back of the van, attached a ratchet strap (anchored to the floor) through the back wheel on each side and hooked them to the crossbar under the wheelchair, attached a ratchet strap (also anchored to the floor in front of the wheelchair on either side) to the bar above the front wheels on the wheelchair on both sides and secured a seatbelt run through/under the arm rests of the wheelchair so the seatbelt fit snugly against the administrator's stomach. During interview on 10/1/24 at 11:07 A.M., the Maintenance Director said he trained Transporter C and SSD/Transporter D on how to secure a resident for transport and retrained SSD/Transporter D after the resident fell in the van. SSD/Transporter D had not secured the front wheels of the wheelchair during the transport when the resident fell . During interview on 10/2/24 at 3:20 P.M., SSD/transporter D said she picked up the resident from the hospital, and when turning into the parking lot of the facility, she hit a bump. She then heard the resident yell. The hook popped off the right side of the wheelchair and the resident tipped over onto his/her left side. The resident was still in his/her wheelchair laying on his/her left side. The resident's wheelchair was locked and the back wheels were secured with hooks that went through each big wheel and attached to a bar under the wheelchair. She didn't remember being told to secure the front of the wheelchair prior to the incident. She was only trained twice with Transporter C (the main transporter). She secured the seatbelt around the front of the armrest of the wheelchair (not under the armrest). The Maintenance Director reviewed with him/her, after the resident went to the emergency room , how a resident should be secured in the van. MO242330

Based on interview and record review, the facility failed to protect two residents' (Resident #1 and #2's) of six sampled residents, right to be free from sexual abuse. The facility had not assessed either resident for capacity to consent to sexual contact when staff observed the residents touching, kissing and fondling each other. Resident #2 had a history of hypersexual behavior, was under guardianship and cognitively impaired. Resident #1 was under guardianship and had severely impaired cognition. On 4/28/24, staff found the residents without clothing and in bed together with physical indications the residents had been sexually intimate. The facility census was 89. Review of the facility policy and procedure, Sexual Activity/Abuse and Neglect, dated (origination) 4/6/2017, and last reviewed/revised 4/18/22, showed the following: -The purpose of this policy is to ensure that the facility provides protective oversight and care for all residents requesting to engage in sexual activity/intercourse while at the same time protecting their rights; -Residents that are wishing to engage in sexual activity/intercourse will be allowed to participate in these activities as long as both parties consent and have the ability to consent; -Determination of ability to consent: -a. If the resident has a guardian or a physical and/or cognitive impairment, an assessment should be completed to determine the resident's ability to consent. This assessment will be completed by the Interdisciplinary Care Team (ICT), with the assistance of the resident's physician and/or psychiatrist as needed. The assessment shall include the following: -i. Awareness of the relationship including awareness of who is initiating the relationship, identify of the other person, and comfort level with sexual intimacy; -ii. Ability to avoid exploitation including the resident's values and ability to refuse unwanted advances; -iii. Awareness of potential risk associated with the relationship, including sexually transmitted diseases or pregnancy, if applicable, or reaction if the relationship ends; -The resident's guardian (if applicable) will be invited to provide their guidance/opinion to the ICT. Family members may be involved in the assessment as appropriate; -b. All documentation regarding the resident's ability to consent shall be maintained in the resident's medical file, and if appropriate, in the resident's care plan; - If a resident has been deemed to be unable to consent to sexual activity, the resident will be told that they are not permitted to engage in sexual activity; -If non-consensual sexual activity occurs, the abuse and neglect policy will be followed. 1. Review of Resident #1's face sheet showed the following: -He/She was admitted on [DATE]; -He/She had a durable power of attorney (DPOA)/legal guardian; -Medical diagnoses included unspecified dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), unspecified severity, with agitation and vascular dementia (changes in memory, thinking and behavior resulting from conditions that affect the blood vessels in the brain, such as strokes). Review of the resident's admission history and physical, dated 05/04/23, showed the following: -The resident had a history of wandering; -The resident had a history of incarceration related to sexual behaviors. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 02/08/24, showed staff assessed the resident as: -Cognition is severely impaired; resident is rarely/never understood; -Had behavioral symptoms not directed towards others that occurred one to three days during the look-back period; -No rejection of cares; -Independent with transfers and mobility. Review of the resident's nursing progress notes showed staff documented the following: -On 4/27/24 at 10:01 P.M., staff observed the resident wandering into other residents' rooms, resident redirected easily; -On 4/28/24 at 2:29 P.M., staff saw the resident multiple times with Resident #2 going into other residents' rooms, resident continues to be inappropriate with Resident #2, redirected as ordered; -On 4/28/24 at 3:03 P.M., staff observed the resident and Resident #2 walking throughout the halls today and looking in other rooms, resident asked to allow privacy of others and redirected without concern; -On 4/28/24 at 8:30 P.M., staff found the resident with Resident #2, a resident of the opposite sex, in his/her bed naked and on top of each other. After separation, the residents were assessed. Guardian notified, assistant director of nurses (ADON) notified; -On 4/28/24 at 10:52 P.M., the resident's nurse practitioner (NP) was notified of the incident, initiation of 15-minutes checks completed, capacity to consent completed with resident and discussed with DPOA (following the incident). Review of the resident's care plan, revised 04/29/24, showed the following: -The resident grasped staff inappropriately while staff was assisting with a shower; -Staff of the same sex to shower the resident if he/she becomes sexually inappropriate; -Provide protective oversight and assist where needed; -The resident is an elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended, impaired safety awareness, significantly intrudes on the privacy or activities of others. The resident wanders into other peer's rooms; -Identify pattern of wandering, is the wandering purposeful, aimless, or escapist? Is the resident looking for something; -Monitor location every 30 minutes; -The resident has participated in consensual activities per his/her report with a resident of the opposite sex related to his/her request to engage, and delusional belief that the resident was his/her spouse; -Interventions: -4/28/24: 15-minute face checks scheduled in electronic medical record; -4/28/24: Completion of capacity to consent to sexual activity; -Psych consult for medication adjustments as needed/ordered; -5/1/24-Acute psych visit with medication change and diagnosis of vascular dementia moderate with mood disturbance; -New order, Rexulti (an antipsychotic medication used to treat major depressive disorder), schizophrenia (a mental disorder characterized by disruption in thought processes, perceptions, emotional responsiveness and social interactions) and agitation associated with dementia due to Alzheimer's disease-a progressive disease that destroys memory and other important mental functions) related to sexual behavior symptoms secondary to dementia. During an interview on 05/07/24 at 10:00 A.M., the resident's legal guardian said the following: -Resident #1 had had a stroke in the past that affected his/her ability to speak and think; -He/She was notified by facility staff that Resident #1 and Resident #2 had been found in Resident #1's bed naked together. 2. Review of Resident #2's preadmission screening and resident review (PASARR), a federally mandated screening process for individuals with serious mental illness, dated 11/17/23, showed per previous evaluation, historical symptoms have included periods of mania (abnormally elevated, extreme changes in mood, emotions, energy or activity level), decreased sleep, loud, intrusive behaviors, disrobing, risk-taking behaviors, paranoia, hallucinations and delusions. Review of the resident's face sheet showed the following: -He/She was admitted on [DATE]; -He/She had a legal guardian; -Medical diagnoses included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), vascular dementia and high-risk heterosexual behavior. Review of the resident's psychiatric telemedicine visit, dated 12/05/23, showed the following: -The resident had been delusional believing he/she and a member of the opposite sex were in love with each other and had sexual intercourse and they were going to fight in Armageddon together; -Had run down the hall naked on several occasions. Review of the resident's hospital history and physical, dated 12/11/23, showed the following: -The resident's legal guardian said the resident had struggled in the past with his/her mental health; -He/She goes through spells when he/she is off and he/she gets hypersexual, stops taking care of himself/herself. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognition moderately impaired; -Independent with transfers and mobility. Review of the resident's nursing progress notes showed staff documented the following: -On 04/25/24 at 9:38 A.M., communication with the guardian by Social Services Director (SSD): SSD called guardian's office today to discuss Resident #2's attention seeking behaviors (sitting close to Resident #1 and holding hands); guardian and deputy guardian are going to collaborate next week and get back with (the SSD) about solutions to this; -On 4/27/24 at 12:12 P.M. spoke with resident with Certified Medication Technician (CMT) and activity aide present. Spoke with resident at length regarding his/her opposite-sex attention seeking behavior with Resident #1, who has limitations with his/her guardian, (no capacity to consent to sexual activity evaluation completed at that time). Resident verbalized understanding of limitations and requested a meeting with guardians and administration regarding limitations. Resident verbalized he/she would keep to him/herself until meeting could be organized. Review of the resident's care plan, dated 4/29/24, showed the following: -Problem: the resident has participated in consensual activities per his/her report with Resident #1, a resident of the opposite sex, related to high-risk heterosexual diagnosis; -Interventions: 4/28/24 completion of capacity to consent to sexual activity and psychosocial post incident assessment; -4/28/24, 15-minute face checks scheduled in electronic medical record (EMR); -Intervene as necessary to protect the rights and safety of others. Review of Resident #2's nursing progress notes, dated 04/30/24 at 11:31 A.M., showed the DON documented the following: -Communication email sent to guardian requesting thoughts and insight on 15-minute face checks, inpatient psych evaluation, facility implemented interventions. Return call from legal guardian. Presented this nurse with history of residing at other facilities and hypersexual behavior. Resident would disrobe, wander halls undressed, attempted to leave with residents of the opposite sex who he/she thought he/she was in love with, promiscuous and provocative behavior. During an interview on 05/07/24 at 1:12 P.M., Resident #2's deputy legal guardian said the following: -Resident #2 had a history of trying to hook up with a member of the opposite sex at previous facilities; -The facility sent a capacity to consent to sexual activity after Residents #1 and #2 were found in bed together naked, but the Public Administrator declined on behalf of Resident #2. Review of an electronic mail (email) correspondence on 4/29/24 at 5:21 P.M., in response to the Facility DON's request for the capacity to consent to sexual activity form, Resident #2's legal guardian declined to sign the document at this time and said she believed that Resident #2 did not have the capacity to understand and/or consent currently as he/she is currently being treated for a urinary tract infection (UTI, an infection of the bladder). Hypersexuality had been a part of his/her mental illness for many years and typically manifested when his/her mental health declined. 3. During an interview on 05/21/24 at 9:15 A.M., LPN C said the following: -Resident #1 and Resident #2 just started to seek each other out about three to four days before they were found naked in bed together on the evening of 4/28/24; -On 4/28/24 in the afternoon, in about one hour's time, he/she pulled the residents' out of empty rooms at least three times; -On 04/28/24 at 2:29 P.M., he/she saw both residents come out of an empty resident room and both residents had red faces, and Resident #2's clothing was disheveled; -He/She did not ask the residents at that time what, if anything, had occurred; -He/She saw Resident #1 put his/her hand inside Resident #2's clothing on several occasions; -Administration was aware of these behaviors, staff were told through the grapevine (to mean staff had talked amongst themselves) to keep an eye on both residents and separate them or redirect them when/as needed. During an interview on 05/21/24 at 9:38 A.M., LPN D said the following: -Resident #1 and Resident #2 just started to seek each other out randomly about one week prior to the incident on the evening of 4/28/24; -The residents would walk hand in hand down the hall and would kiss in plain sight; -Their behaviors seemed innocent enough and did not seem like any type of abuse; -He/She saw Resident #1 put his/her hands inside Resident #2's clothing several times; -Resident #2 started wearing (looser) clothing to allow Resident #1 easier access, staff tried to redirect Resident #2 to wear more restrictive clothing, but he/she would refuse; -Even though staff would redirect the residents, they would ultimately get back together; -Resident #1 could be redirected easily enough, Resident #2 would ask why he/she could not be with Resident #1 and would try to seek Resident #1 out if they were separated; -Administration was aware of the behaviors because that's who told the staff to keep an eye on the residents and redirect/separate them when needed; -He/She found out about the incident where the two residents were found naked in bed together from the night charge nurse's report sheet when he/she came to work the next morning; -15-minute face checks of Resident #1 and #2 were started after they were found naked in bed together on the evening of 4/28/24. During an interview on 05/07/24 at 5:05 P.M., the SSD said the following: -She and some of the staff saw Resident #1 and Resident #2 holding hands and sitting close to each other prior to the staff finding both residents naked in bed together; -She called the resident's legal guardian on the morning of 4/25/24 to discuss the resident's attention seeking behaviors towards the opposite sex and was told that the legal guardian was out of the office and the deputy (legal guardian) would discuss it with him/her and call the facility back the following week; -She did not notify Resident #1's legal guardian about his/her behaviors at that time; -The DON reached out to Resident #1 and Resident #2's legal guardians about the capacity to consent to sexual activity following the incident on the evening of 4/28/24. During an interview on 05/07/24 at 5:05 P.M. the DON said the following: -Resident #2 started having some affectionate behavior towards Resident #1 on 04/22/24, not hypersexual, just hand holding at times and sitting on the couch together; -Facility staff told her the behavior of both Resident #1 and #2 seemed to escalate, they would look for empty rooms, but no specific interventions were put in place for this at that time; -She was aware that Resident #1 had a history of being a sex offender, but there had been no further information regarding that history when he/she was admitted to the facility; -She was not aware that Resident #2 had a history of hypersexual behavior until after Resident #1 and Resident #2 were found naked in bed together on the evening of 4/28/24; -She came into the facility to investigate the report of the residents being naked in bed together on the evening of 4/28/24 and interviewed both residents involved; -She instructed LPN A to tell the oncoming shift then to continue every 15-minute checks on both residents and document those, as well as to continue to keep the residents separated; -She emailed the legal guardian of Resident #2 on 4/29/24 at 10:57 A.M. to obtain a capacity to consent to sexual activity document, and that's when she learned of Resident #2's past hypersexual behavior; -Resident #2's legal guardian declined to agree to the capacity to consent to sexual activity on 4/29/24; -Resident #1's legal guardian signed and approved his/her capacity to consent to sexual activity on 4/28/24 after the incident occurred. MO235367

Based on interview and record review, the facility failed to ensure three residents with mental illness, one resident (Resident #2 with a prior history of childhood abuse including sexual, physical and emotional abuse (Resident #1, #2 and #4), remained free from verbal abuse by NA (Nurse Aide) A in a review of seven sampled residents when NA A cursed the residents and used derogatory names. The abuse upset and angered Resident #1, hurt Resident #4's feelings, and caused Resident #2 to be anxious and start to experience a panic attack. The facility census was 94. Record review of the facility's policy Abuse and Neglect Policy, revised 9/17/21, showed the following: -Purpose: To outline procedures for reporting and investigating complaints of abuse neglect and misuse of funds/property and to define terms of types of abuse/neglect and misappropriation of funds and property; -To ensure immediate reporting of all abuse allegations to the administrator or designee and the director of nursing or designee and outside persons or agencies, to establish actions related to the alleged perpetrator and to ensure investigation and assessment of all residents involved is completed; -Verbal abuse: Using profanity or speaking in a demeaning non therapeutic, undignified, or threatening, or derogatory manner in a resident's presence, . Examples include harassing a resident, mocking, insulting ridiculing; yelling at a resident, with the intent to intimidate; threatening residents, including to but not limited to, depriving a resident of care or withholding a resident from contact with family and friends, and insulting a resident from social interaction or activities; -Report to state, law enforcement, and others: The facility must ensure that alleged violations involving abuse, neglect, exploitation, mistreatment or sexual assault including injuries of unknown source and misappropriation of resident property are reported immediately but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse and do not result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the state survey agency; -If the abuse involves the suspicion of crime, it must also be reported to local law enforcement within those time frames; -A final report of the investigation will be sent to the Department of Public Health/Department of Health and Senior Services no later than five days following the initial complaint or incident. All investigation results will be made available as required by law. 1. Record review of Resident #1's quarterly Minimum Date Set (MDS), a federally mandated assessment instrument assessment completed by facility staff, dated 12/30/21 showed the following: -Cognition intact; -No delusions or hallucinations exhibited; -Physical, verbal and other behavioral (such as physical symptoms such as hitting or scratching self, pacing or rummaging symptoms occurred one to three days, verbal/vocal sounds such as screaming or disruptive sounds); -Requires supervision of one staff member with transfers; -Independent with walking in room, corridor and in the unit; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan revised on 1/14/22 showed the following: -This resident was at risk for behavior problem related to paranoid [CONDITION(S)]; -The resident also tends to fabricate truths; -Administer medications as ordered; -Assist the resident to develop more appropriate methods of coping an interacting strategies; -If reasonable discuss the resident's behavior, explain and reinforce why the resident's behavior is inappropriate and/or unacceptable to the resident; -Intervene as necessary to protect the resident's rights and safety of others. Approach and speak in a calm manner, divert attention. Remove from situation and take to alternate location as needed; -Minimize potential for disruptive behaviors by offering tasks to divert attention; -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations, document behavior and potential causes; -Praise any indication of the resident progress/improvement to behavior. During an interview on 1/18/22 at 9:35 A.M., the resident said the following: -He/She told the Assistant Director of Nursing (ADON) after supper on 1/12/22 that he/she got into it with NA A over smoke break; -He/She told the ADON how NA A cussed at him/her; -NA A used the [OBSCENITY] word to his/her face; -NA A was throwing dishes and swearing; -NA A was mad that day and had an attitude; -NA A said every time he/she worked on Resident #1's hall he/she had to call code greens (a behavioral emergency code announced overhead where facility staff respond to assist); -The way NA A talked to him/her (Resident #1) made him/her upset and angry. 2. Record review of Resident #2 quarterly MDS dated [DATE] showed the following: -Cognition intact; -Independent with transfers, walking in room, corridor and on the unit; -No delusions or hallucinations exhibited; -No Physical or behavioral symptoms; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan last revised 1/14/22 showed the following: -The resident has a long history of mental illness as he/she has experienced sexual, physical, emotional abuse as a child as well as disruptive childhood; -Memories of traumatic events self-claim for abuse; diminished interest activities, angry outbursts, very reckless and self-destructive behaviors, sleep disturbances, frequently, [CONDITION(S)], [CONDITION(S)] disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, psychotic disorder (a mental disorder characterized by a disconnection from reality), eating disorder, antisocial personality disorder (a mental disorder characterized by disregard for other people); -He/She is alert and oriented to person place and time, hears voices, and history of suicide ideation with attempt at overdose and substance abuse, attention seeking behavior poor impulse control cruelty to animals, starting fires as child, and he/she fabricates the truth; -Interventions: CALM technique (Crisis Alleviation Lessons and Methods) (self protection technique) if needed, interdisciplinary team (IDT) and guardian involvement as necessary, long term psych management and counseling if needed, pharmaceutical interventions as needed. During an interview on 1/14/22 at 12:35 P.M. the resident said the following: -On 1/12/22 after supper he/she asked NA A if he/she could get his/her smoke break; -NA A said can't you give me a [OBSCENITY] ing minute; -He/She did not know why NA was so hateful to him/her; -He/She went back to his/her room and was crying into his/her pillow; -He/She felt anxious and started having a panic attack. 3. Record review of Resident #4's care plan last revised on 12/15/21 showed the following: -The resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Intervention: Monitor signs and symptoms daily and report to charge nurse if any changes with diagnosis, the resident to remain in locked unit; -The resident has a history of behavioral challenges that required protective oversight in a secure setting; -The resident likes to fabricate stories about staff and residents to get them in trouble and seek the attention; -Interventions: CALM technique if needed. Record review of the resident's quarterly MDS dated [DATE] showed the following: -Cognition intact; -Exhibits no delusions and hallucinations; -No verbal and physical behavioral symptoms; -Independent with activities of daily living (ADLs); -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/14/22 at 12:30 P.M., the resident said the following: -Wednesday (1/12/22) when he/she was on smoke break NA A said let that [OBSCENITY] (referring to Resident #4) light that nigger's (referring to Resident #1's) cigarette; -The resident said NA A uses cuss words a lot and it hurts Resident #4's feelings. 4. Record review of the Resident #5's quarterly MDS dated [DATE] showed the following: -Cognition intact; -No delusions or hallucinations; -No physical or verbal behavioral symptoms; -Other behavioral symptoms (such as physical symptoms such as hitting or scratching self, pacing or rummaging symptoms, verbal/vocal sounds such as screaming or disruptive sounds) not directed towards others occurred one to three days; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/14/22 at 12:15 P.M., the resident said the following: -He/She was finishing up with supper on 1/12/22 and NA A was cussing and yelling at Resident #1; -NA A was using the word [OBSCENITY] . 5. Record review of the Resident #3's quarterly MDS dated [DATE] showed the following: -Cognition intact; -No delusions or hallucinations; -No physical or verbal behavioral symptoms; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 1/18/22 at 2:00 P.M., the resident said the following: -On Wednesday night (1/12/22) NA A was mad and yelling; -NA A was having a bad night; -NA A was using the word [OBSCENITY] a lot and called Resident #1 a nigger under his/her breath in the hall. During an interview on 1/14/22 at 12:40 P.M., NA A said the following: -On 1/12/22 after supper, Resident #1 wanted to hurry and go to smoke break; -He/She told Resident #1 they could not smoke until all the silverware was accounted for; -He/She did speak to Resident #1 in a stern voice and Resident #1 got mad and upset; -He/She was flustered and went to the ADON to report the issue; -He/She reported to the ADON that Resident #1 had a bad attitude; -He/She asked Resident #2 what was wrong as Resident #2 was screaming into his/her pillow. During an interview on 1/14/22 at 11:20 P.M., CNA (Certified Nurse Aide) B said the following: -On the evening of 1/13/22 he/she walked in on a conversation where the residents were talking about NA A; -Resident #1 said NA A used profanity towards him/her just before smoke break on 1/12/22 around 5:30 P.M.; -Resident #4 said that NA A called Resident #1 a nigger during smoke break on the evening of 1/12/22; -The residents said they had reported issues they were having with NA A to the ADON and nothing was done to address the issue; -CNA B gave the residents the hotline number to call state. During an interview on 1/14/22 at 11:40 A.M., the ADON said the following: -On 1/12/22 around 6:00 P.M. NA A came to him/her and said Resident #1 was upset and rude because Resident #1 wanted to smoke and NA A tried to explain to Resident #1 he/she would need to wait till everyone was done eating before going out for smoke break; -NA A said Resident #1 continued to be impatient and started to yell and curse at him/her (NA A); -NA A said he/she had to yell back at Resident #1 to talk over him/her, and asked him/her (Resident #1) to be patient, but Resident #1 continued to be upset and yell; -The ADON brought Resident #1 into his/her office on the evening of 1/12/22 after speaking to NA A; -Resident #1 reported everything NA A had reported, but from Resident #1's point of view; -Resident #1 said NA A was yelling and cursing at him/her. During an interview on 1/14/22 at 11:28 A.M. and 12:00 P.M., the administrator said the following: -She was not aware of the allegation of verbal abuse made by Resident #1 against NA A on the evening of 1/12/22; -She would expect the ADON to notify her immediately of the allegation of abuse on 1/12/22 so it could be investigated; -She was not aware of the allegations of abuse made by Resident #1, #2 or #3 until she arrived to work around 9:00 A.M. this morning; -She felt allegations made by the residents were considered allegations of abuse and she would have expected them to have been investigated; -She would expect the ADON and CNA B to report the allegations of abuse to her; -NA A had been educated in the past for using the word nigger while talking on the phone at the facility. MO 4

Based on interview and record review, the facility staff failed to develop policies and procedures for immunization of residents against pneumococcal disease as required. The facility failed to assess and vaccinate eligible residents with the pneumococcal vaccine as indicated by the current CDC guidelines, unless the resident had previously received the vaccine, refused, or had a medical contraindication present for ten residents (Residents #42, #54, #48, #16, #74, #56, #92, #67 and #93), in a review of 19 sampled residents. One resident (Residents #89) developed pneumonia while a resident at the facility. The facility census was 94. 1. Review of the facility policy and procedure Influenza and Pneumococcal Immunizations, last revised 12/12/17, showed the following: -The purpose of this policy is to ensure all residents residing in the facility are offered influenza and pneumococcal immunizations to prevent infection and the spread of communicable disease; -As part of the admission process, the resident or the resident's legal representative will be provided education on the benefits and potential side effects for both the influenza and pneumococcal immunization; -The resident or the legal representative will be told the influenza immunizations are provided yearly (between (MONTH) 1 and (MONTH) 31) unless the immunization is medically contraindicated, the facility has evidence that the resident has already been immunized during this time period, or the resident or the legal representative has refused the immunization; -The resident or legal representative will be told the pneumococcal immunization will be offered upon admission and a second pneumococcal immunization will be recommended after five years from the first immunization. The pneumococcal immunization will not be given if the immunization is medically contraindicated, the facility has evidence to support the resident received the immunization, or the resident or their representative has refused the immunization; The resident or their legal representative will be asked to sign the revolving consent form attached to this policy; -Any resident who has not been offered a revolving consent form will have the revolving consent form offered to the resident or their legal representative following the procedure listed above for At admission; -If a resident or their legal representative chooses not to sign a revolving consent form, an annual consent may be obtained; -The resident or their legal representative will be provided education on the benefits and potential side effects of the immunizations; -On admission and yearly, the resident or their legal representative will sign a form showing the resident or legal representative has been educated on and is aware of the benefits and potential side effects of receiving the immunizations; -The pneumococcal immunization will be offered upon admission and a second pneumococcal immunization may be recommended after five year from the first immunization. The pneumococcal immunization will be given unless the immunization is medically contraindicated, the facility has evidence the resident has already been immunized during this time period, or their legal representative has refused the immunization. 2. Review of the Vaccine Information Statement: Pneumococcal Vaccine, dated 11/5/15, provided by the facility as the educational material provided to residents and/or representatives, showed education regarding the risks and potential side effects of the PCV13 and PPCV23 vaccinations. 3. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Time for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR 13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23): -One dose of PCV13 was recommended for adults [AGE] years or older who had not previously received PCV13; -One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered; -For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history, administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions; -For those age [AGE] years or older who previously received one dose of PPSV23 and no doses of PCV13, administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions; -For residents age 19-[AGE] years, administer one dose of PPSV23 at 19 through [AGE] years. This includes adults with chronic heart or lung disease, diabetes mellitus, alcoholism, chronic liver disease and adults who smoke; -For residents age 19-[AGE] years, administer one dose of PCV13 then administer PPSV23 at least eight weeks apart from the PCV13 (at 19-[AGE] years). Administer another PPSV23 at least five years after the first dose of PPSV23(at 19-[AGE] years). 4. Review of Resident #89's face sheet showed the resident's original admitted was 10/20/11. The resident was under [AGE] years of age. Further review of the resident's Vaccinations/PPD ([MEDICAL CONDITION]) Record, undated, showed the resident received a second pneumonia vaccine on 12/4/12. The record did not specify which vaccination the resident received. Review of the resident's vaccination records showed no evidence of the first pneumonia vaccination being given or what type of vaccination was given. Review of the resident's Immunization Acknowledgement and Consent Form, dated 10/14/16, showed the following: -I agree to receive the Pneumococcal Immunization, marked with an X; -The resident signed the consent form. Review of the resident's vaccination record showed no evidence the resident received a pneumococcal immunization after signing the consent form on 10/14/16. Review of the resident's hospital admission note, dated 6/26/18, showed an admitting [DIAGNOSES REDACTED]. Review of the resident's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 7/10/18, showed the following: -Cognitively intact; -Pneumococcal vaccine was up to date. 5. Review of Resident #53's face sheet showed the resident was admitted on [DATE]. The resident was under [AGE] years of age. Further review of the resident's Vaccinations/PPD Record, dated 7/22/16, showed the pneumonia vaccine section was left blank. Review of the resident's Immunization Acknowledgement and Consent Form, dated 10/21/16, showed the following: -I agree to receive the Pneumococcal Immunization, was checked I agree to received the pneumococcal immunization; -The guardian signed the consent form. Review of the resident's vaccinations/PPD record showed no evidence the resident received the pneumococcal vaccine after signing the consent on 10/21/16. Review of the resident's Immunization Acknowledgement and Consent Form, dated 9/25/17, showed the following: -I agree to receive the Pneumococcal Immunization, was initialed by the guardian; -The guardian signed the consent form. Review of the resident's vaccinations/PPD record showed no evidence the resident received the pneumococcal vaccine after signing the consent on 9/25/17. Review of the resident's diagnostic imaging, dated 5/2/18, showed impression possible upper left lobe pneumonia. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -[DIAGNOSES REDACTED]. -Pneumococcal vaccine up to date. 6. Review of Resident #42's medical records showed a Vaccinations/PPD ([MEDICAL CONDITION]) Record, dated 6/23/15, where the resident had received a pneumonia vaccine on 10/20/13 at another facility. The record failed to specify which pneumonia vaccine the resident received. Review of the resident's face sheet showed the resident was admitted on [DATE] and re-admitted on [DATE]. The resident was under [AGE] years old. Review of the resident's Immunization Acknowledgement and Consent Form, dated 9/22/17, showed the following: -I agree to receive the Pneumococcal Immunization, marked with a handwritten check mark; -The resident signed the consent form. Review of the resident's vaccination record showed no evidence the resident received a pneumonia vaccine after signing the consent form on 9/22/17. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Pneumococcal vaccine up to date. 7. Review of Resident #48's face sheet showed the resident was admitted on [DATE]. The resident was over [AGE] years of age. Review of the resident's Vaccinations/PPD Record, dated 2/27/18, showed no evidence the resident received a pneumonia vaccine. Review of the resident's admission MDS, dated [DATE], showed the following: -Short and long term memory problems; -Pneumococcal vaccine up to date. Review of the resident's medical records showed no documentation of a consent form for the pneumonia vaccination. 8. Review of Resident #16's face sheet showed the resident was admitted on [DATE]. The resident was over [AGE] years of age. Review of the resident's medical record showed no documentation of a consent form for the pneumonia vaccination. Review of the resident's Vaccinations/PPD Record, dated 1/30/18, showed no evidence the resident received a pneumonia vaccine. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Pneumococcal vaccine up to date. 9. Review of Resident #92's face sheet showed the resident was admitted to the facility on [DATE]. The resident was over age 65. Review of the resident's Vaccinations/PPD Record showed the resident had received the pneumonia vaccine at a previous facility (no date provided) but did not specify which vaccine was received. Review of the resident's medical record from another health care facility showed the following: -The resident answered to yes to having received the pneumococcal vaccine in the last five years; -The resident was given the immunization after he/she was 65 but does not specify which vaccination the resident received. Review of the resident's immunization acknowledgement and consent form, dated 9/22/17, showed the following: -Resident educated by the facility of the benefits and potential side effects of receiving Pneumococcal Vaccination; -The resident signed the consent form to receive the pneumococcal vaccination. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Pneumococcal vaccine up to date. 10. Review of Resident #74's face sheet showed the resident was admitted to the facility on [DATE]. The resident is under the age of 65. Review of the resident's Vaccinations/PPD Record showed the resident received the pneumonia vaccine on 7/1/14, but did not specify which vaccine was received. Review of the resident's immunization acknowledgement and consent form, dated 11/14/16, showed the following: -Resident educated by the facility of the benefits and potential side effects of receiving Pneumococcal Vaccination; -The resident signed the consent form for the pneumococcal vaccination. Review of the resident's vaccination record showed no evidence the resident received a pneumonia vaccine after signing the consent form on 11/14/16. Review of the resident's immunization acknowledgement and consent form, dated 10/27/17, showed the following: -Resident educated by the facility of the benefits and potential side effects of receiving Pneumococcal Vaccination; -The resident signed the consent form for the Pneumococcal Vaccination. Review of the resident's vaccination record showed no evidence the resident received a pneumonia vaccine after signing the consent form on 10/27/17. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Pneumococcal vaccine up to date. 11. Review of Resident #56's face sheet showed the resident was admitted to the facility on [DATE]. The resident is under age 65. Review of the resident's immunization acknowledgement and consent form, dated 9/25/17, showed the following: -Resident educated by the facility of the benefits and potential side effects of receiving Pneumococcal Vaccination; -The resident signed the consent form to receive the Pneumococcal Vaccination Review of the resident's Vaccinations/PPD Record showed the resident received the pneumococcal vaccine on 10/22/17 but did not specify which vaccine was received. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Pneumococcal vaccine up to date. 12. Review of Resident #67's face sheet showed the resident was admitted on [DATE]. The resident was over the age of 65. Review of the resident's Vaccinations/PPD Record showed no evidence the resident had received the pneumococcal vaccine. Review of the resident's Immunization Acknowledgement and Consent Form, dated 11/17/16, showed the following: -I agree to receive the Pneumococcal Immunization, was marked; -Verbal consent was written in the resident/resident legal representative section. Review of the resident's vaccinations/PPD record showed no evidence the resident received the pneumococcal vaccine after signing the consent form. Review of the resident's Immunization Acknowledgement and Consent Form, dated 10/12/17, showed the consent section for pneumococcal immunization was left blank. Review of the resident's annual MDS, dated [DATE], showed the following: -Short and long-term memory problem; -Pneumococcal vaccine up to date. 13. Review of Resident #93's face sheet showed the resident was admitted on [DATE]. The resident was under the age of 65. Review of the Vaccinations/PPD record, dated 10/15/14, showed the resident received a pneumonia vaccination at another facility on 10/3/14. The form did not indicate which pneumococcal vaccination the resident received. Review of the resident's Immunization Acknowledgement and Consent Form, dated 9/17/15, showed the following: -I agree to receive the Pneumococcal Immunization, was checked; -The consent was signed by the resident's guardian. Review of the resident's vaccinations/PPD record showed no evidence the resident received the pneumococcal vaccine after signing the consent. Review of the resident's Immunization Acknowledgement and Consent Form, dated 9/28/17, showed the following: -I agree to receive the Pneumococcal Immunization, was checked; -The consent was signed by the resident's guardian. Review of the resident's vaccinations/PPD record showed no evidence the resident received the pneumococcal vaccine after signing the consent. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Pneumococcal vaccine up to date. 14. During interviews on 8/17/18 at 8:26 A.M. and 8/31/18 at 10:15 A.M., the administrator said the facility provides the Prevnar 13 vaccination but has not given the PPSV23 vaccine. The facility's policy does not meet the current CDC guidelines. Each resident and/or representative are educated on the pneumonia vaccination upon containing consent or refusal of the vaccination. The resident and/or representative are provided with a copy of the education.