Every finding on record at NHC Healthcare, St Charles

Based on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, and bed rails, as part of a regular maintenance program to identify areas of possible entrapment for three residents (Resident #3, #7, #36 ), who used bed rails/assist bars, in a review of 21 sampled residents. The facility census was 89. Review of the undated facility policy, Bed Rails Safety Check, showed the following: -When using bed rails, close attention must be given to the design of the rail and the relationship between rails and other parts of the bed. The seven areas in the bed system that have the potential for entrapment include; 1. Within the rail; 2. Under rail, between rail supports; 3. Between rail and mattress; 4. Under rail, and ends of rail; 5. Between split bed rails; 6. Between end of rail and side edge of head or foot board; 7. Between head or foot board and mattress end; -Entrapment may occur in flat or raised bed positions, with the rails fully or partially raised; -Regularly inspect each of the seven areas on each bed; -The mattress to bed rail interface should prevent an individual from falling between the mattress and bed rails and possibly smothering; -Check for compression of the mattress's outside perimeter. Easily compressed perimeters can increase the gaps between the mattress and the bed rail; -Ensure that the mattress is appropriately sized for the bed frame. Not all beds and mattresses are interchangeable; -The space between the bed rails and the mattress and the headboard and the mattress should be filled by the mattress or by an added firm inlay. This creates an interface with the bed rail that prevents an individual from falling between the mattress and bed rails; -Bed rails with tapered or winged ends should not be used for residents at risk of entrapment; -Maintenance and monitoring of the bed, mattress, and accessories should be ongoing; -Summary of Federal Drug Administration (FDA) potential zones of entrapment with FDA dimension recommendations; 1. Zone 1: Within the rail, FDA recommended space is: less than 4 3/4 inches; 2. Zone 2: Under the rail between rail supports or next single rail support, FDA recommended is less than 4 3/4 inches; 3. Zone 3: Between the rail and the mattress, FDA recommended space is less than 4 3/4 inches; 4. Zone 4: Under the rail at the ends of the rail, FDA recommended space is less than 2 3/8 inches and greater than 60-degree angle. 1. Review of Resident #3's physician order sheet (POS), dated June 2024, showed an open-ended order for quarter side rails for positioning and bed mobility (original order dated 10/11/23). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility, dated 6/4/24, showed the following: -The resident had moderately impaired cognition; -He/She had impairment with range of motion (ROM) with one side of both upper and lower extremities; -He/She was independent with rolling right and left in bed; -He/She was independent with lying to sitting on the side of bed. Review of the resident's quarterly bed rail assessment, dated 6/4/24, showed the following: -Type of rail used: right side bed cane; -He/She demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed; -There was no documentation of entrapment zone measurements. Review of the resident's care plan, last reviewed/updated 6/5/24, showed the following: -Left side cane rail (assist rail) to assist with transfers; -Assist of one staff for transfers; -Independent with bed mobility. Observation on 06/18/24 at 2:48 P.M., showed the following: -The resident lay in his/her bed with his/her feet hanging off the right side of the bed; -An assist rail was attached to the right side of the resident's bed and was in the raised position; -The mattress did not fit appropriately and there was a gap between the mattress and the assist rail, exposing the metal bed frame. Observation on 06/19/24 at 5:45 A.M., showed the following: -The resident lay in his/her bed; -An assist rail was attached to the right side of the bed in the raised position; -The mattress did not fit appropriately and there was a gap between the mattress and the assist rail exposing the metal bed frame. Review of the resident's electronic medical record showed no evidence staff conducted a current inspection of the resident's bed frame, mattress or assist rails to identify areas of possible entrapment. 2. Review of Resident #36's quarterly MDS, dated [DATE], showed the following: -The resident had moderately impaired cognition; -He/She had impaired ROM in both lower extremities; -He/She required substantial/maximum assistance with rolling right and left in bed; -He/She was independent with lying to sitting on the side of bed. Review of the resident's quarterly bed rail assessment, dated 5/23/24, showed the following: -Quarter sized bed rails were used on both sides of the bed; -He/She demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed; -There was no documentation of entrapment zone measurements. Review of the resident's care plan, last reviewed/updated on 5/28/24, showed the following: -The resident used bilateral bed rails to increase independence with bed mobility and activities of daily living (ADLs); -He/She was dependent on staff for bed mobility; -He/She required the use of a mechanical lift for transfers. Observation on 6/17/24 at 1:49 P.M. showed the resident lay in his/her bed on a low air loss mattress (a type of mattress system that floats the resident on air-filled cells while circulating air across the skin). The resident's bed had half bed rails on both sides of the bed. The bed rails were in the raised position. Review of the resident's low air loss mattress's manufacturer guidelines showed no directions for bed rail use. Review of the resident's electronic medical record showed no evidence staff conducted an inspection of the resident's bed frame, low air loss mattress or assist rails to identify areas of possible entrapment. 3. Review of Resident #7's physician's orders, dated 3/20/24, showed an order for a low air loss mattress. Review of the resident's significant change MDS, dated [DATE], showed the following: -The resident had moderately impaired cognition; -He/She had impaired ROM of bilateral lower extremities; -He/She required substantial/maximum assistance with rolling right and left in bed; -He/She was dependent with sitting to lying flat on the bed; -He/She was dependent with lying to sitting on the edge of the bed. Review of resident's quarterly bed rail assessment, dated 04/05/24, showed the following: -Bilateral U-bar/cane assist rails; -No documentation of entrapment zone measurements. Observation on 06/17/24 at 12:53 P.M. showed the resident lay in bed on a low air loss mattress. Assist bars were in the raised position on both sides of the resident's bed. Review of the resident's low air loss mattress's manufacturer guidelines showed no directions for bed rail use. Review of the resident's electronic medical record showed no evidence staff conducted an inspection of the resident's bed frame, low air loss mattress or assist rails to identify areas of possible entrapment. 4. During an interview on 06/20/24 at 11:15 A.M., the Maintenance Director said the following: -Entrapment zone measurements were completed when bed rails were installed to see if rails were safe for use; -It was a group effort between therapy, nursing, and the maintenance department to ensure the bed rails were safe for resident use; -He thought the bed rail entrapment zones were supposed to be assessed monthly, but could not provide documentation that this was completed; -Resident #3's mattress did not fit appropriately. The resident had hyperactivity, but the mattress should not move, and the bed frame should not show. The mattress would need to be replaced with one that fit the bed frame for the resident's safety. He was not aware the mattress moved like that. During an interview on 6/20/24 at 3:20 P.M., the Administrator said he thought the entrapment zone measurements were completed when the resident had a change in status. 50189

Based on observation, interview and record review, the facility failed to ensure nursing staff performed appropriate hand hygiene and changed gloves during personal care of two residents (Residents #21 and #55), in a review of 21 sampled residents. The facility census was 89. Review of the facility's policy, Hand Hygiene, dated April 2024, showed the following: -Hand hygiene includes both handwashing with plain or antiseptic containing soap and water or the use of alcohol-based products that do not require the use of water for the following situations: -Before and after contact with each resident; -Before donning gloves; -After removing gloves. Review of the facility's policy, Glove Technique, dated April 2024, showed gloves are used to prevent contamination of healthcare personnel hands in the following situations: -Anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material; -Having direct contact with residents who are colonized or infected with pathogens transmitted by the contact route; -Handling or touching visibly or potentially contaminated resident care equipment and environmental surfaces. 1. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/31/24, showed the following: -Dependent on staff for toilet hygiene and transfers; -Always incontinent of bowel and bladder. Observation on 6/17/24 at 1:30 P.M. showed the following: -Certified Nurse Assistant (CNA) G entered the resident's room, and without washing his/her hands, put on gloves; -CNA G assisted the resident to the bathroom with the sit-to-stand lift; -CNA G removed the resident's soiled incontinence brief and assisted the resident to sit on the toilet; -CNA G removed his/her gloves, did not wash his/her hands, and put on new gloves. He/She went to the resident's roommate's closet to get out clothes for the roommate's shower to be done after this resident was done toileting; -CNA G returned to the bathroom and removed the resident's soiled pants, and while wearing the same gloves, he/she put clean pants and a clean incontinence brief on the resident, raised the resident off the toilet with the sit-to-stand lift and used incontinence wipes to provide incontinence care. He/She grabbed more wipes with the same gloved hand as he/she had provided incontinence care; -Without changing his/her gloves after providing incontinence care, CNA G pulled up resident's incontinence brief and pants and lowered the resident into a wheelchair; -CNA G wiped fecal matter off the toilet, removed one glove, picked up the trash with the other gloved hand, and left the resident's room and take the trash to the trash bin in the closet on the hall. Observation on 6/19/24 at 7:04 A.M. showed the following: -CNA G entered the resident's room, and without washing his/her hands, put on gloves; -The resident lay in bed and his/her incontinence brief was soiled with urine; -CNA G attached the sling for the sit-to-stand lift, raised the resident to a standing position, removed the wet incontinence brief and cleaned the resident's peri area with incontinence wipes; -Without removing his/her gloves, CNA G pulled up the resident's clean incontinence brief and pants, lowered the resident into a wheelchair with the sit-to-stand lift, removed the sling for the sit-to-stand lift from around the resident, assisted the resident to put on his/her shirt, and gave the resident a wet washcloth to wash his/her face; -CNA G stripped the linens off the bed, removed the trash and took it to the utility room closet on the resident's hall; -CNA G then removed his/her soiled gloves and used hand sanitizer. During an interview on 6/19/24 at 10:15 A.M., CNA G said he/she should change his/her gloves between dirty and clean cares. 2. Review of Resident #55's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -He/She required maximum assistance with toileting; -He/She was always incontinent of bowel and bladder. Review of the resident's care plan, updated 4/15/24, showed the following: -He/She needed assistance in performing, improving and maintaining some activities of daily living (ADLs); -He/She was incontinent of bowel and bladder. Observation on 6/19/24 at 10:53 P.M. showed the following: -CNA C wore gloves and removed the resident's urine-soiled incontinence brief; -Without removing his/her gloves, CNA C assisted the resident to put on clothing, rolled the resident to his/her side and wiped the resident's back and buttock; -CNA C did not remove his/her gloves, put the mechanical lift pad and a clean incontinence brief under the resident, rolled the resident to his/her back and provided incontinence care; -CNA C did not remove his/her gloves after providing incontinence care and finished dressing the resident; -CNA C removed his/her gloves and did not wash hands; -CNA C and Certified Occupational Therapist Assistant (COTA) used the mechanical lift to transfer the resident from the bed to the chair; -CNA C took the resident in his/her chair into the hall, brushed the resident's hair, put glasses on the resident's face, and put shoes on the resident's feet. During an interview on 6/19/24 at 2:18 P.M., CNA C said the following: -He/She should change his/her gloves after providing peri-care; -He/She should wash his/her hands after taking dirty gloves off and putting on clean gloves; -He/She should change his/her gloves when going from a dirty area to a clean area; -He/She was in a hurry when performing the resident's care and that was why he/she did not change his/her gloves. During an interview on 6/20/24 at 2:32 P.M., the Director of Nursing (DON) said the following; -Staff should perform hand hygiene after removing dirty gloves and before putting on clean gloves; -When performing incontinence care, staff were to change their gloves between dirty and clean areas; -Staff should wash their hands or use hand sanitizer after removing dirty gloves and before putting on clean gloves; -If gloves were soiled, the staff should not touch anything and wash hands after removing gloves; -Staff should not touch any clean items with contaminated gloves and/or hands. 50189 50851

Based on observation, interview, and record review, the facility failed to safely transfer one resident (Resident #36), in a review of 21 sampled residents, during a mechanical lift transfer when staff failed to maintain control of the resident during the transfer, causing the resident to hit his/her head and foot on the lift. The facility census was 89. 1. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 5/23/24, showed the following: -His/Her cognition was moderately impaired; -Dependent on staff for bed to chair transfers and chair to bed transfers. Review of the resident's care plan, last reviewed/updated on 5/28/24, showed he/she required the use of a mechanical lift for all transfers. Review of the certified nurse assistant (CNA) care reference book, located at the nurse's desk, showed the resident required two persons assist with the mechanical lift. Observation on 6/19/24 at 10:42 A.M. showed the following: -The resident lay in his/her bed; -CNA A and CNA B placed a lift pad under the resident to transfer him/her from the bed to the shower gurney; -CNA B operated the lift moving the resident from the bed to the shower gurney; the sides of the shower gurney were in the raised position and CNA A and CNA B were not able to get the resident on the gurney; -CNA C did not to keep his/her hands on the resident as the resident swung in mid air; -As the resident was next to the gurney, CNA C placed his/her hands on the resident to move the resident away from the gurney to lower the side rail on the gurney. When the CNA moved the resident away from the gurney, the resident hit the back of his/her head on the lift. The resident said, ouch. Observation on 6/19/24 at 11:45 A.M. showed the following: -The resident returned to his/her room from the shower via a shower gurney; -CNA B and CNA C placed the lift pad under the resident to transfer him/her from the shower gurney to his/her wheelchair; -CNA C operated the lift while CNA B prepared the wheelchair; -CNA C used the mechanical lift to raise the resident from the shower gurney and pushed the lift with the resident swinging in mid air from the gurney to the wheelchair. No staff guided the resident while he/she was in the lift. -While the resident swung in midair, he/she spun around and hit his/her right foot on the lift. The resident said, ouch. During an interview on 6/19/24 at 1:45 P.M., the resident said the following: -Sometimes the staff rush and the mechanical lift transfers were kind of rough; -He/She hit his/her head and foot on the lift today when the staff were getting him/her up. During an interview on 6/19/24 at 2:10 P.M., CNA B said the following: -Mechanical lift transfers required two staff; -One staff should always hold and maintain control of the resident; -Residents should not be left hanging in midair; -They did not have control of the resident, and the resident hit his/her head and foot on the lift during the transfer; -There were only two staff on the very heavy hall (residents who resided on the call required a lot of care) and they were rushed to get the transfer done; -The resident should not have hit his/her head and foot on the lift. During an interview on 6/19/24 at 2:30 P.M., CNA C said the following: -Mechanical lift transfers required two staff; -One staff should always hold and maintain control of the resident; -Residents should not be left hanging in midair; -They did not have control of the resident and the resident hit his/her head and foot on the lift during the transfer; -There were only two staff on the very heavy hall and they were rushed to get the transfer done. During an interview on 6/20/24 at 2:32 P.M., the Director of Nursing said she expected staff to maintain control of a resident during a mechanical lift transfer. A resident should not have been left hanging in midair without staff maintaining control. The resident should not have hit their head and/or foot on the lift.

Based on observation, interview and record review, the facility failed to ensure five residents (Resident #1, #2, #3, #4, and #6) in a review of 16 sampled residents, were free from misappropriation of property when Licensed Practical Nurse (LPN) A misappropriated the residents' medications. The facility census was 86. On [DATE] at 9:57 A.M., the administrator was notified of the past noncompliance which occurred on [DATE]. On [DATE] the Director of Nurses (DON) identified Licensed Practical Nurse (LPN) A misappropriated Resident #1's antianxiety medication (Xanax). Upon discovery, staff sent LPN A home, conducted an investigation which showed additional misappropriation and inconsistencies, followed the facility policy and notified appropriate parties, including local law enforcement. Staff reviewed the abuse and neglect policies on [DATE], [DATE] and [DATE] which included abuse and neglect and the destruction of discontinued medications. LPN A was listed as do not return and the deficiency was corrected on [DATE]. Review of the facility policy, Controlled Substance Storage: Discrepancies, Loss and/or Diversion of Medications, dated [DATE], showed the following: -Schedule II medications are stored in an affixed, double-locked compartment separate from all other non-controlled medications or per state regulation. The access system to Schedule II controlled medications is not the same as the system giving access to other medications (the key that opens the compartment is different from the key that opens the medication cart.) If a key system is used, the medication nurse on duty maintains possession of the key to controlled substance storage areas. Back-up keys to all medication storage areas, including those for controlled substances, are kept by the DON; -A controlled substance accountability record is prepared by the pharmacy for all Schedule II, III, IV, and V medications, including those in the emergency supply. The following information is completed on the accountability form upon removing a controlled substance: 1) Name of the resident; 2) Name, strength, and dosage form of medication; 3) Date removed; 4) Quantity removed; -At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses, or medication technicians in states where allowed by law, and is documented; -Controlled Substance Disposal: -When controlled drugs are expired, discontinued from use or the patient for whom they are ordered is no longer a patient, the medication shall be removed from the active stock immediately and inventoried and verified by two people who shall be licensed either as a nurse or a pharmacist. The completed inventory record shall be signed and dated by those two individuals. The inventory record should include: 1) Date of discontinuance or inventory date; 2) Name of the patient; 3) Name and strength of the drug; 4) Quantities of drugs in containers when inventoried; 5) Signatures of the two persons verifying; -After being removed from active stock, inventoried controlled substances to be destroyed must be placed in a secure cabinet or area as identified by the consultant pharmacist and DON; -Discrepancies, Loss and/or Diversion of Medications: -All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed. Review of the facility's policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, last revised [DATE], showed the following: -Abuse, neglect, misappropriation of patient property and exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual in the center. The patient has the right to be free from abuse, neglect, misappropriation of patient property and exploitation; -The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect, holds the highest priority; -Misappropriation of Patient Property: the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money with the patient's consent; -The center will train all partners, through orientation and ongoing in-services, on the prevention, identification, investigation and reporting of abuse, neglect, misappropriation of patient property and exploitation. 1. Review of the facility's abuse investigation report, completed by the Director of Nursing (DON), dated [DATE], showed the following: -The staffing coordinator alerted the DON on [DATE] at 6:56 P.M. that Licensed Practical Nurse (LPN) A was sitting at the end of the hall with the medication cart. DON reviewed the surveillance footage and noted LPN A sat in a chair at the end of the hall behind the medication cart and was unable to view him/her. Due to this, the DON viewed previous footage and noted LPN A had not signed into the electronic medication administration record (EMAR), pulled up medications and threw some medications straight into the trash can; -At 7:00 P.M., LPN A was scheduled to have a staff CMT pass bedtime medications for him/her. When the CMT came down the hall to count and take over, LPN A said, I have already given everyone their medication. I only have a couple left. LPN A then told the CMT to go to B hall and help the other nurse. When the DON noted the CMT walking away from LPN A, the DON called the CMT and asked what LPN A had said, which was the above. This call took place at 7:46 P.M. The DON asked the CMT to go straight to the supervisor on duty, who was then updated. LPN A was then asked to count (medications) and leave the building. The count was thought to have been okay at that time because all the numbers were checked out; -At 8:58 P.M., the supervisor called the DON and said they noted clear tape on the back of a couple of cards (of medications). They went looking after finding a Tylenol getting ready to fall out of Resident #3's oxycodone/APAP ,d+[DATE] mg card. This resident is in the hospital. The supervisor and CMT found six residents' medications in the trash can, still in the packs received from pharmacy and nothing was signed off on the EMAR; -On the morning of [DATE], the investigation continued. The first thing in the morning, the number of cards was off. Resident #1's alprazolam was signed out without a date, but the medication that was missing was a card of Xanax for Resident #2 that had been discontinued. The entry that was written in (for Resident #1) has a signature that was made to look like one of the in-house staff member's signatures who did not work in the building on [DATE]. At the beginning of the day of [DATE], there were 21 cards but when the agency LPN (LPN A) left, there were 20. Review of the facility's final investigation report, undated, showed the following: -On exam, Tylenol was replaced in one of the bubbles (on Resident #3's medication card); -On further investigation, four bubbles of a Xanax card (labeled for Resident #1) were substituted with Tramadol and taped shut on the back side of card. -On further investigation, a Xanax card (labeled for Resident #4) was missing, other controlled medications were signed out that were prescribed, erroneous times were documented, and dispensing time noted when LPN A had already left and wasn't even in the building. -After viewing the surveillance footage, LPN A put narcotics into a medicine cup, dumped the cup into his/her hand, held his/her coat up while bringing his/her hand up to his/her mouth, put on his/her coat, and sipped some water. As he/she walked up the hall, he/she popped his/her head backwards; -LPN A went through the nurse's station cabinet and placed the tape dispenser on top of the control sign out book on the medication cart. He/She pushed the medication cart to the end of the hall and sat behind the medication cart but unable to see what he/she was doing. LPN A was at the end of the hall for approximately 40 minutes. Staff noted LPN A sat at the end of the hall with the medication cart and the drawers open. -On the surveillance footage, LPN A took off his/her light jacket, placed it onto the control sign out binder, which lay on top of the medication cart, then picked up both, then walked into an unoccupied room for approximately two minutes. When exiting the room, he/she put his/her jacket on the nurse's station desk, drank water and popped his/her head backwards. -LPN A placed his/her right hand onto the control medication binder (located under his/her jacket on the nurses station) while placing his/her winter coat from the chair onto the jacket that was on the nurses station. At the same time, he/she removed the control medication log binder out from underneath the jacket and placed it on the medication cart, then removed a paper from the binder, folded it and placed it at nurses station (said paper has not been found). LPN A picked up folded paper off of the nurse's station, looked at it then folded it and put it into his/her winter coat. LPN A put on his/her winter coat, grabbed his/her jacket from the on the nurses' station with his/her right hand like it had something under it and held it with his/her hand in a U position. A flat appearance with corners was observed at times with movement. LPN A placed the jacket under his/her left arm inside his/her winter coat. As he/she walked out through the front door, his/her left arm had minimal movement compared to right arm. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed the following: -Moderately impaired cognition; -Received antianxiety medication during the look back period; -Diagnoses included heart failure, high blood pressure, high cholesterol, dementia, anxiety and depression. Review of the resident's care plan, last reviewed on [DATE], showed the following: -Psychotropic drug use: anxiety and depression; -Administer medication as ordered and observe for adverse effects. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed the following: -Alprazolam (brand name Xanax; an antianxiety medication) 0.25 milligrams (mg) at 8:00 A.M. and 12:00 P.M.; -Alprazolam 0.5 mg at 8:00 P.M. (bedtime; HS).; -Vitamin D3 (vitamin) 1000 units, two capsules at HS; -Eliquis (an anticoagulant medication) 5 mg at 4:00 P.M.; -Pravastatin (a medication used to treat high cholesterol) 20 mg at HS; -Trazadone (an antidepressant medication) 50 mg at HS; -Tylenol eight-hour extended release (a arthritis pain reliever) 650 mg at HS. Review of the resident's EMAR showed staff (not LPN A) administered the resident's scheduled dose of alprazolam 0.25 mg at 8:00 A.M. and 12:00 P.M. (prior to LPN A's scheduled shift). Review of the resident's Narcotic Inventory Record (a paper document staff use to show a narcotic medication was pulled from the resident's narcotic medication card) for alprazolam 0.5 mg showed staff (unable to verify signature) signed out one tablet on [DATE] at 4:30 P.M. (This dose of the medication was scheduled to be given at 8:00 P.M.) Review of the resident's Narcotic Inventory Record for alprazolam 0.25 mg showed staff (unable to verify signature) signed out one tablet on [DATE] at 8:00 P.M. (This dose of the medication was scheduled to be given at 8:00 A.M. and 12:00 P.M. The resident had already received these scheduled doses of the medication on [DATE].) Review of the resident's Narcotic Inventory Record for alprazolam 0.5 mg showed staff (unable to verify signature) signed out one tablet on [DATE] at 10:45 P.M. (This dose of the medication was scheduled once a day at 8:00 P.M. Staff signed out this dose of the medication twice on [DATE].) During interviews on [DATE] at 11:50 A.M., the DON said LPN A would have been the only staff to have the keys to the medication cart on the A-hall (evening shift) on [DATE]. (Review of LPN A's timeclock report showed he/she clocked in at 3:03 P.M. and signed out at 8:07 P.M.) During interview on [DATE] at 3:03 P.M., CMT D (who took over the medication cart after LPN A left at 8:07 P.M. on [DATE]) verified the signature found on the narcotic inventory sheet at 10:45 P.M. was not his/her signature. Review of the resident's EMAR, dated [DATE], showed no documentation LPN A administered alprazolam, vitamin D3, Eliquis, pravastatin, Trazodone or Tylenol eight-hour extended release as ordered to the resident on [DATE]. Review of the facility's surveillance footage from [DATE], with the DON, showed LPN A opened the medication cart drawer, opened the locked narcotic box, picked up a medication card from the back of the box (Resident #1's alprazolam), popped out four tablets into a small medication cup, placed the medication card back in the narcotic box, closed the lid and sat the medication cup on top of the medication cart. Review of the resident's Alprazolam medication card showed four bubbles packs where the alprazolam had been removed and replaced with another medication. During interviews on [DATE] at 11:50 A.M. and 2:00 P.M., the DON said the following: -She saw LPN A put medications in a medication cup from a card that was located in the back of the narcotic box (belonging to Resident #1, his/her alprazolam) because that is where the resident's card was located; -The signatures on Resident #1's narcotic inventory records for [DATE] at 4:30 P.M., 8:00 P.M. and 10:45 P.M. would have been LPN A's signature because when viewing the surveillance footage, LPN A is seen picking up a card from the back of the locked narcotic box and Resident #1's card is located in the back. LPN A would have had to sign those medications out for the count to be correct; -Resident #1's medications were found in the trash. 3. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -Received scheduled and PRN pain medications for constant moderate pain that affected his/her sleep; -Received an opioid (a class of pain medication) for pain. Review of the resident's care plan, dated [DATE], showed the following: -Has complaints of chronic pain related to osteoarthritis and a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle); -Evaluate effectiveness of pain management interventions. -Offer pain medication prior to dressing change. Review of the resident's POS, dated [DATE], showed oxycodone/acetaminophen (APAP) (a narcotic pain medication) ,d+[DATE] mg one tablet by mouth at 5:00 A.M. and every four hours as needed (PRN) for pain. Review of the resident's nurses' notes, dated [DATE], showed the resident was admitted to the hospital. (The resident had not been readmitted to the facility and remained in the hospital through [DATE].) Review of the resident's Narcotic Inventory Record for oxycodone/APAP ,d+[DATE] mg showed staff (unable to verify signature) signed out one tablet at 3:00 P.M. on [DATE]. Review of the resident's Narcotic Inventory Record for oxycodone/APAP ,d+[DATE] mg showed staff (unable to verify signature) signed out one tablet at 9:00 P.M. on [DATE]. Review of the resident's EMAR, dated [DATE], showed no documentation LPN A administered any oxycodone/APAP to the resident. (The resident was in the hospital on [DATE] and was not available to receive the two tablets of oxycodone/APAP ,d+[DATE] mg staff removed from the resident's medication card.) During interview on [DATE] at 11:50 A.M. and 2:00 P.M., the DON said LPN A would have been the only staff to have the keys to the medication cart on the A-hall (evening shift) on [DATE]. She believed LPN A made the entries on the resident's narcotic inventory records on [DATE]. 4. Review of Resident #4's annual MDS, dated [DATE], showed the following: -Received scheduled and PRN pain medications; -Received an opioid during the look back period. Review of the resident's care plan, dated [DATE], showed the following: -The resident has complaints of chronic pain related to osteoporosis and leg pain; -Administer medications as ordered. Monitor and record effectiveness. Review of the resident's POS, dated [DATE], showed the following: -Tramadol (an opioid pain medication used for severe pain) 50 mg by mouth every 12 hours at 8:00 A.M. and 8:00 P.M.; -Tramadol 50 mg by mouth twice a day PRN for severe pain. Review of the resident's Narcotic Inventory Record for Tramadol 50 mg showed the following: -Staff (unable to verify signature) signed out a tablet of Tramadol 50 mg (no date or time listed). This entry was located just above the entry dated [DATE] at 8:00 P.M.; -Staff (unable to verify signature) signed out a tablet of Tramadol 50 mg on [DATE] at 8:00 P.M.; Review of the resident's second Narcotic Inventory Record for Tramadol 50 mg showed the following: -Staff (unable to verify signature) signed out one tablet of tramadol 50 mg on [DATE] at 5:00 P.M. -Staff (unable to verify signature) signed out one tablet of tramadol 50 mg on [DATE] at 8:45 P.M. During interview on [DATE] at 3:03 P.M., CMT D (who took over the medication cart after LPN A left at 8:07 P.M. on [DATE]) said he/she did not give the resident alprazolam at 8:45 P.M. on [DATE]. He/She verified the signature found on the narcotic inventory sheet at 8:45 P.M. was not his/her signature. Review of the resident's medical record showed no documentation the resident was having pain which would have required a PRN pain medication on [DATE]. Review of the resident's EMAR, dated [DATE], showed no documentation LPN A administered tramadol to the resident on [DATE] during his/her shift. (Staff signed out four tablets of tramadol on [DATE] between 5:00 P.M. and 8:45 P.M., and did not document the medication was administered to the resident.) During interview on [DATE] at 11:50 A.M., the DON said LPN A would have been the only staff to have the keys to the medication cart on the A-hall (evening shift) on [DATE]. She believed LPN A made the entries on the resident's narcotic inventory record on [DATE], including the entry with no date, because the count was correct when LPN F turned the cart over to LPN A (at the beginning of LPN A's shift). 5. Review of Resident #6's quarterly MDS, dated [DATE], showed the following: -Received antianxiety medication in the seven-day look back period; -Diagnosis included anxiety. Review of the resident's care plan, dated [DATE], showed the resident receives antianxiety medication related to generalized anxiety disorder in the past. Review of the resident's POS, dated [DATE], showed an order for alprazolam 0.25 mg by mouth three times a day at 8:00 A.M., 1:00 P.M., and 8:00 P.M. Review of the resident's Narcotic Inventory Record for alprazolam 0.25 mg showed staff (unable to verify signature) signed out two tablets on [DATE] at 8:00 P.M. (The physician's order was for one tablet at 8:00 P.M.) Review of the resident's EMAR, dated [DATE], showed no documentation LPN A administered alprazolam to the resident during his/her shift. (Staff signed out two tablets of alprazolam 0.25 mg on [DATE] at 8:00 P.M. and did not document the medication was administered to the resident. The physician's order was for one tablet at 8:00 P.M.) 6. Review of Resident #2's POS, dated [DATE], showed an order for alprazolam 0.25 mg by mouth twice a day PRN for two weeks then discontinue ([DATE]). Review of the Controlled Substance Shift Change Count Check Sheet, dated [DATE], showed the total count of narcotic/controlled medication cards on the A-hall medication cart on [DATE] at 7:00 A.M. was 21 cards. Review of the A-hall Medication Substance Inventory Record (a document listing the narcotic/controlled medication cards located in the medication cart) showed the following: -An undated entry (located underneath an entry dated [DATE]) on the 7:,d+[DATE]:00 P.M. shift, showed one card of alprazolam 0.5 mg, labeled for Resident #1, was removed from the medication cart. -Two signatures were listed verifying this entry and removal of the card from the cart; -The new count was 20 cards. During interview on [DATE] at 2:09 P.M., LPN B denied removing any alprazolam cards for Resident #1 and verified the signature associated with the undated entry on the Substance Inventory Record for Resident #1 was not his/her signature. During interview on [DATE] at 2:58 P.M., the Staffing Coordinator said LPN A called her to see about picking up an evening shift for [DATE]. LPN A asked if he/she had a CMT to pass medications. LPN A said he/she preferred to pass his/her own medications. On [DATE] around 7:00 P.M., she went to talk to LPN A. LPN A had the medication cart at the end of A-hall, and was sitting in a Broda chair (a supportive positioning wheelchair). The narcotic box was open and LPN A had the narcotic book open in his/her lap. LPN A told her he/she was counting narcotics. She reminded LPN A that he/she couldn't count the narcotics by himself/herself. LPN A replied, I know. She felt uneasy about LPN A and called the DON. During interview on [DATE] at 6:27 P.M., CMT D said he/she arrived at the facility around 7:00 P.M. on [DATE] and went to A-hall to count narcotics and found LPN A backed into a corner. LPN A told him/her that he/she didn't need a medication technician and to go help on B-hall. LPN A acted a little nervous and said, I didn't know I had a medication technician for tonight. CMT D got a call from the DON and was told to go with another nurse to A-hall and count and relieve LPN A. He/She counted narcotics with LPN A and got to Resident #3's card. He/She asked LPN A if the resident was back from the hospital. LPN A said, Oh, I made an error. He/She went back to the medication cart after LPN A left to double check medications and found a Tylenol in Resident #3's oxycodone card and found Tramadol in Resident #1's alprazolam card and those areas had been taped over. He/She reported this to Registered Nurse (RN) E and the DON. Review of RN E's written statement, dated [DATE], showed he/she was working as a charge nurse on the C-hall on the evening shift on [DATE]. At 7:45 P.M., CMT D came to him/her because the DON observed the nurse (LPN A) through the surveillance cameras and saw him/her throwing medications into the trash. The DON asked him/her and the CMT to go to A-hall and ask the nurse (LPN A) to leave. RN A asked the nurse (LPN A) to count (a check to ensure the number of medications in the medication card matched the number of medications listed on the narcotic inventory record for each narcotic medication) with the CMT on the medication cart and the medications in the medication room, then he/she needed to leave the building. The count was correct on the medication cart and in the medication room. The agency nurse (LPN A) left the building some minutes after 8:00 P.M. After he/she (LPN A) left, the CMT let RN E know that he/she and the nurse had to correct a count on a resident's card (Resident #3) who was not in the building because the nurse (LPN A) took out narcotics for this resident who was in the hospital. Because of this, staff took a closer look on the narcotics and found out that the nurse (LPN A) took out more than one pill from that resident's oxycodone card, then replaced one of those pills with a Tylenol. Then staff found one more narcotic card (that belonged to Resident #1) which was opened, four pills were taken out and replaced with different narcotics and taped back on the back of the cards. By doing this, he/she was looking up the script number for the medications involved and at that time I realized that a narcotic card was taken out from the count that day and it was signed by a nurse who did not work that day. During interview on [DATE] at 5:31 P.M., RN E said the DON told him/her that she was watching LPN A on the camera, and LPN A was throwing away unopened medications. He/She and CMT D went to LPN A and told him/her they needed to count narcotics and send him/her home. RN E told LPN A that the DON was watching him/her throw medications away, and all LPN A said was that he/she had passed his/her medications. CMT D counted the narcotics on the medication cart, and he/she counted the narcotics with LPN A in the medication room. At that point, the narcotic counts were okay. CMT D noticed that Resident #3's card had been used and asked LPN A if the resident was back from the hospital. LPN A acted surprised. After LPN A left the building, CMT D went through the medication cards again and noticed a Tylenol (used for pain or fever) tablet fell out of Resident #3's oxycodone card and Resident #1's alprazolam's card had four Tramadol in the card and had been taped over. During interview on [DATE] at 1:34 A.M., the DON said the following: -Prior to [DATE], when a narcotic card was empty, staff would slide the empty card and the corresponding narcotic sheet under her door. She would then check the card off the inventory record log (that keeps track of the number of cards on the medication cart) and would put her initials in the corner (meaning she had checked it against the record log) and then send the paper to medical records to scan into the electronic medical records (EMR). -The entry on the inventory record log showing Resident #1 had no date or time for the entry and he/she did not have any corresponding medication card or count sheet for this entry (LPN A listed Resident #1 as the owner of the card but it was actually Resident #4). She started auditing the inventory log and when looking at the additions and subtractions of cards, the last entry for Resident #1 was not correct. The missing card belonged to Resident #4; -Upon review of the inventory record log for A-hall, it looked like LPN A tried to [NAME] LPN B's signature (LPN B wasn't working on [DATE]) so she went through every card for every resident to see what was missing; -She found an entry for [DATE] for Resident #2's alprazolam (which was discontinued on [DATE]) that had not been destroyed but the card was missing. She knew it had not been destroyed because she did not have the card not the inventory sheet for that card. When medications are discontinued, the card and inventory sheet are put under her door so she can make sure the card is removed from the inventory log located in front of the narcotic book binder. -The Staffing Coordinator called her and reported he/she had an uneasy feeling about LPN A sitting at the end of A-hall, so she pulled up the surveillance video on her phone and watched LPN A; -LPN A was observed sitting at the end of the hall behind the medication cart for long periods of time; -She called CMT D and told him/her to get the RN supervisor (RN E) and go count the narcotics and send LPN A home. During interviews on [DATE] at 1:34 P.M. and on [DATE] at 2:00 P.M., the DON said the following: -The signatures on the undated entry on the Medication Substance Inventory Record (showing one card of alprazolam was removed for Resident #1) were LPN A and LPN B's signatures. -Upon review of the Medication Substance Inventory Record for A-hall, it looked like LPN A tried to [NAME] LPN B's signature (LPN B wasn't working on [DATE]); -Resident #1 did not have any corresponding medication card or count sheet for the undated entry on the Medication Substance Inventory Record. She started auditing the Medication Substance Inventory Record and identified the undated entry for Resident #1 was not correct. The missing card of alprazolam belonged to Resident #2; -Resident #2's alprazolam (which was discontinued on [DATE]) had not been destroyed (and not subtracted from the inventory record) but the card was missing from the medication cart. During interview on [DATE] at 9:57 A.M. and [DATE] at 2:48 A.M., the Administrator said staff should not divert narcotics or any resident medications. He expected LPN A to do his/her job within his/her scope of practice. Based on the review of the surveillance video he felt LPN A misappropriated the residents' medications. MO2301015

Based on observations, interviews, document review, and policy review, it was determined the facility failed to ensure food was covered during delivery on two (C and D Hall) of four halls in the facility. The deficient practice had the potential to affect 24 residents who were served meals in their rooms. Findings included: A review of the facility's policy, revised 11/2020 and titled, Meal Service & Patient Meal Delivery, revealed the policy did not address covering food items during meal delivery. During an observation on 11/08/2022 at 11:53 AM, the surveyor observed Certified Nurse Aide (CNA) #1 delivering lunch meal trays on D Hall. The enclosed cart containing the meal trays was parked at the end of the hall near room D1. CNA #1 removed a food tray from the cart, poured a beverage, and placed the beverage on the cart. CNA #1 then carried the tray, with the dessert and the beverage uncovered, approximately 70 feet down the hallway, past the medication cart and the nurses' station, to room D9. CNA #1 then returned to the cart and picked up another meal tray, poured a beverage, walked down the hallway past the medication cart and the nurses' station, and delivered the tray to room D11. During an observation and concurrent interview on 11/08/2022 at 11:58 AM, the surveyor observed CNA #2 delivering meal trays on C Hall. Two meal trays were observed on an uncovered baking rack near the front end of the hallway, with the dessert items uncovered. CNA #2 carried one meal tray down the hall to a dining room at the far end of the hall, with the dessert and lemonade uncovered. CNA #2 returned to the cart and carried the second tray approximately 75 feet down the hall to room C5, with the beverage and dessert uncovered. CNA #2 stated the plastic cover on the food delivery cart was meant to keep the food insulated and kept the food items from being contaminated. CNA #2 stated that when the plastic over was removed from the cart and the tray carried with uncovered items, food items could get cold or become contaminated. According to CNA #2, the trays should remain covered during delivery to resident rooms. In an interview on 11/08/2022 at 12:03 PM, CNA #1 stated the covered cart kept the food warm. CNA #1 could not state any other reason for covering food during delivery. CNA #1 stated covering the food was the responsibility of the kitchen. In an interview on 11/08/2022 at 12:50 PM, Licensed Practical Nurse (LPN) #1 stated food was always exposed when taken out of the cart. LPN #1 stated she usually pushed the cart room to room to avoid traveling down the hall with food and drinks uncovered. In an interview on 11/08/2022 at 1:40 PM, the Dietary Manager (DM) stated the dietary department delivered the meal trays to the hallways and then nursing staff delivered the meal tray to the residents' rooms. The DM stated nursing should take the covered cart and roll it down the hall to each room, pour the beverages at the resident's door, and then take the meal tray and beverage into the room. The DM stated the purpose of the covered cart was to ensure that nothing contaminated the food during transport. The DM stated the kitchen staff did not send anything out of the kitchen unless it was covered. The DM stated she was unaware of any recent in-services on meal delivery. In an interview on 11/08/2022 at 2:03 PM, the Registered Dietitian (RD) stated dietary put the food on the covered carts and relied on nursing staff to deliver the meal trays to the residents' rooms. The RD stated the carts were covered to help maintain food temperature and to keep foreign things out of the food between the kitchen and the residents' rooms. In an interview on 11/08/2022 at 3:31 PM, the Director of Nursing (DON) stated her expectation was for staff to push the covered cart down the hall and deliver meal trays from the cart. The DON stated she was aware of the issue observed at lunch and had already talked to staff about how trays should be delivered. In an interview on 11/08/2022 at 3:35 PM, the Administrator stated the dietary department managed meal delivery. The Administrator stated the process for delivering meal trays to the residents' rooms could be improved, and the DM was his expert on dietary and would be addressing the meal delivery process. A review of a facility document with a print date of 11/08/2022 indicated 24 residents ate their meals in their room.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that assessments were completed accurately for four (Residents #15, #17, #38, and #63) of nineteen residents reviewed. Specifically, the facility failed to ensure that 1. Residents #15, #17, and #63 had a Brief Interview for Mental Status (BIMS) attempted; 2. Resident #17 had skin conditions coded correctly; and 3. Resident #38 had insulin and anti-coagulant medications coded correctly. Findings included: A review of an undated Nursing Policies document indicated, Patients are assessed initially and at regular intervals using a Federal/state specified, standardized, comprehensive resident assessment instrument to identify functional capacity and health status. 1. A review of the Centers for Medicare & Medicaid Long-Term Care Facility Resident Assessment Instrument 3.0 Manual, dated 10/2019, indicated that a BIMS should be completed if a resident was at least sometimes understood. a. A review of Resident #15's 5-day Minimum Data Set (MDS), dated [DATE], revealed the resident had clear speech, made themselves understood, and had the ability to understand others. The MDS further revealed a BIMS should not be conducted due to the resident rarely/never being understood. During an observation on 11/07/2022 at 9:42 AM, Resident #15 was observed in their room. The surveyor observed a staff member knock on Resident #15's room door and Resident #15 asked the staff for some water and ice. In an interview on 11/09/2022 at 11:11 AM, Resident #15 stated, I'm alright. How about yourself? Resident #15 confirmed he/she ate breakfast that morning and stated, It was good. b. A review of Resident #17's annual Minimum Data Set (MDS), dated [DATE], revealed the resident had clear speech, usually made themselves understood, and usually understood others. The MDS further revealed a BIMS should not be conducted due to the resident rarely/never being understood. In an interview on 11/09/2022 at 11:23 AM, Resident #17 stated their name correctly, accurately noted that breakfast had been eaten, and identified that breakfast was pretty good. c. A review of Resident #63's annual Minimum Data Set (MDS), dated [DATE], revealed the resident had clear speech, usually made themselves understood, and usually understood others. The MDS further revealed a BIMS should not be conducted due to the resident rarely/never being understood. During an observation on 11/08/2022 at 8:03 AM, Resident #63 was in the dining room and requested a bowl of a particular cereal brand with breakfast, which staff brought to the resident. In an interview on 11/09/2022 at 11:40 AM, the Social Services Director (SSD) stated the Social Worker (SW) completed the cognitive pattern section of the MDS assessments. According to the SSD, the BIMS should be attempted for all residents and if the resident was either nonverbal or refused to participate, staff should complete a Staff Assessment for Mental Status (SAMS). In an interview on 11/09/2022 at 1:37 PM, the SW stated she tried to complete a BIMS for every resident but sometimes with residents who had dementia, the resident may not be able to complete the BIMS. According to the SW, if the resident could not answer or started to get frustrated, she would mark that the resident was unable to complete the BIMS and did the SAMS instead. Per the SW, the MDS Coordinator completed the cognitive pattern section of the MDS for Residents #15 and Resident #63. The SW explained that with Resident #17, the resident was able to remember the three words, but then could not answer any more questions. In an interview on 11/10/2022 at 8:55 AM, the Director of Nursing (DON) said her expectation was for the MDS to be accurate. The DON stated that she thought every resident should have a BIMS completed. According to the DON, Resident #15, Resident #17, and Resident #63 could all converse. In an interview on 11/10/2022 at 9:14 AM, the MDS Coordinator confirmed she had completed the MDS for Residents #15 and #63 due to the SW being off. The MDS Coordinator stated she did not mean for the MDS to indicate that the residents could not communicate, because she knew the residents could since she had filled out the speech/hearing section of the MDS for the residents. In an interview on 11/10/2022 at 9:22 AM, the Administrator said he expected the MDS Coordinator to know the MDS guidelines, follow the guidelines, and, if there were questions, to reach out to a regional person for assistance. In an interview on 11/10/2022 at 11:42 AM, Certified Nurse Aide (CNA) #10 stated Resident #15, Resident #17, and Resident #63 could all communicate their needs and answered questions appropriately most of the time. In an interview on 11/10/2022 at 11:46 AM, Licensed Practical Nurse (LPN) #7 stated Resident #15, Resident #17, and Resident #63 could all communicate their needs. 2. A review of Resident #17's Wound Management report indicated a diabetic ulcer on the resident's right big toe, a rash on the left top of the foot, and an area of skin breakdown to the right shin all healed on 08/17/2022. A review of Resident #17's annual Minimum Data Set (MDS), dated [DATE], indicated Resident #17 had one unstageable pressure ulcer and two venous and arterial ulcers present. In an interview on 11/08/2022 at 2:59 PM, the Wound Care Nurse (WCN) stated Resident #17 did not have any current skin concerns. According to the WCN, Resident #17 previously had a diabetic ulcer on the toe, a rash on the foot, and excisional drainage to the shin, but all those areas had healed. In an interview on 11/08/2022 at 3:09 PM, LPN #8 stated Resident #17 currently had a skin tear to their foot that was being treated, but no other skin breakdown. In an interview on 11/10/2022 at 8:55 AM, the Director of Nursing (DON) said her expectation was for the MDS to be accurate. During an interview on 11/10/2022 at 11:08 AM, the Administrator indicated he expected the MDS to be accurate and match care that was provided. 3. A review of Resident #38's Resident Face Sheet indicated the facility admitted the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #38's quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #38 had received insulin injections and an anticoagulant medication during the last seven days. A review of Resident #38's September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #38's Order History, from 05/10/2022 through 11/10/2022, revealed no orders for insulin or an anticoagulant medication. During an interview on 11/09/2022 at 11:28 AM, the MDS Coordinator stated she completed the medication section of the MDS for Resident #38. The MDS Coordinator stated she would have obtained medication information for Resident #38 from the resident's electronic health record. According to the MDS Coordinator, Resident #38 was on [MEDICATION(S)], which she thought was an anticoagulant at the time she completed the MDS, noting she was now aware that [MEDICATION(S)] was not an anticoagulant. The MDS Coordinator stated she thought Resident #38 had been on insulin but was unable to locate any physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/10/2022 at 8:55 AM, the DON indicated her expectation was for the MDS to be accurate. During an interview on 11/10/2022 at 11:08 AM, the Administrator indicated he expected the MDS to be accurate and match the care that was provided.

Based on observations, interviews, and facility policy review, it was determined that the facility failed to ensure the medication cart was closed and locked when unattended for one (B Hall) of four medication carts in the facility. Findings included: A review of the facility's policy titled Security of Medication Cart, dated 04/2007, indicated, Medication carts must be securely locked at all times when out of the nurse's view. When the medication cart is not being used, it must be locked and parked on the hallway. During an observation on 11/08/2022 at 8:59 AM, the medication cart on the B Hall was unlocked, with the top drawer open approximately 1/4 inch. Licensed Practical Nurse (LPN) #2 was sitting in a computer area approximately seven feet away. During a concurrent observation and interview on 11/08/2022 at 9:02 AM with another surveyor present, the surveyor opened the third drawer of the medication cart and then closed it. LPN #2 was in the computer area and did not respond. When asked, LPN #2 indicated Certified Medical Technician (CMT) #1 was responsible for the B Hall medication cart but was on the D Hall presently. LPN #2 indicated the medication cart should be locked when stored. LPN #2 confirmed the medication cart was not locked but should have been. During an interview on 11/08/2022 at 9:05 AM, CMT #1 was at the D Hall medication cart and indicated she was also responsible for the B Hall medication cart. CMT #1 indicated medication carts should be locked when stored/unattended. During an interview on 11/09/2022 at 12:21 PM, the Director of Nursing (DON) indicated the medication cart should be locked if not in use. During a follow-up interview on 11/10/2022 at 10:16 AM, the DON stated her expectation was for staff to keep the medication carts locked and on the hall. The DON indicated the medication carts should be locked if unattended. During an interview on 11/10/2022 at 11:08 AM, the Administrator indicated he expected for staff to lock a medication cart before staff walked away.

Based on interview and record review, the facility failed to properly transfer one resident (Resident #1), in a review of four sampled residents, in a hoyer lift (mechanical lift) per manufacturer's guidelines. Staff placed two loops from each strap of the hoyer lift sling onto the swivel lift bar hooks which was not in accordance with manufacturer's guidelines. The sling loops came off the bar during the transfer and the resident fell to the floor, resulting in T6 and L2 vertebrae fractures requiring surgical intervention. The facility census was 77. Review of the facility undated Mechanical Lift policy showed to place hooks in the appropriate holes of the lift sheet (sling). Review of the manufacturer's Owner's Operator and Maintenance Manual, dated 2008, showed the following: -When connecting slings equipped with color coded straps to the patient lift, the shortest of the straps MUST be at the back of the patient for support; -The colors make it easy to connect both sides of the sling equally; -Attaching a Sling to the Swivel Bar; 1. Place the straps of the sling over hooks of the swivel bar. 2. Match the corresponding colors on each side of the sling for an even lift of the patient. (The diagram provided shows to place one loop from each strap on each hook.) 3. Lift the patient. -Before lifting a patient from a stationary object (wheelchair, commode, or bed), slightly raise the patient off the stationary object and check that all sling attachments are secure. If any attachment is not correct, lower the patient and correct the problem, then raise the patient and check again. 1. Review of Resident #1's care plan, dated 1/11/22, showed the following: -The resident needed assistance in performing, improving and maintaining some of his/her activities of daily living; ; -He/She transferred with the hoyer lift. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/7/22, showed the following: -He/She had moderately impaired cognitive skills; -He/She was totally dependent on one staff for transfers. Review of the resident's progress note, dated 8/30/22, showed the certified nursing assistants (CNA) reported during transfer of the resident to bed with the mechanical lift, the loop came off the hook (located on the mechanical lift swivel bar) and the resident fell to the floor. Review of an undated document titled Final Report, showed the following: -Two staff (Certified Medication Technician (CMT) A and CNA B) were transferring the resident from his/her wheelchair to bed with the hoyer lift on 8/30/22; -Both staff said all the loops of the hoyer lift sling were in the hoyer lift's hooks; -Halfway through the transfer, when the resident was almost to the bed, the two staff heard a snap and the lower right loop was not on the hook of the lift anymore; this caused the resident to slide out of the sling to the floor; -After speaking with the staff, the swivel part of the hoyer lift that the sling loops hook onto wobbles and tilts and this is what allows the loop to come off the hook. -The Director of Nursing (DON), the administrator and Director of Environmental Services all looked at the lift with CMT A. These staff did their best attempt to replay the sequence of events, while it seems rare, the process could be duplicated with the swinging and tilting action of the lift that allow the loops to reposition so they could slide off; -Based on the root cause analysis, staff have looked and determined it is more of a process and design issue and not a mechanical issue. It has been discussed and determined a consistent process for all hoyer lifts (using the same lift) would reduce the risk of accidents. This is due to the now known safety concerns regarding the hoyer sling loops coming off (not locking into place); -The resident returned to the facility on [DATE] from the hospital. He/She had T6 and L2 kyphoplasty (surgical filling of an injured or collapsed vertebra to restore the original shape and relieves pain from spinal compression) done on 9/7 during his/her hospital stay. His/Her preoperative and postoperative diagnosis for the procedure was osteoporotic compression fractures T6 and L2. Review of the resident's MRI (a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body), dated 9/1/22, showed the following: -Indication: unspecified fall and back pain; -Impression: acute vertebral fracture at T6 and L2. During interviews on 9/20/22 at 12:17 P.M. and 3:15 P.M., CMT A said the following: -On 8/30/22, he/she and CNA B were transferring the resident from chair to bed; -He/She double hooked the hoyer lift sling loops prior to transferring the resident from the chair to the bed; -He/She explained 'double hooked' as placing two loops (from each strap) on each hook of the lift; -He/She and CMT A were positioned on each side of the resident (as the resident was up in the hoyer lift sling); -The resident was moving in the sling, and the resident and lift were swinging prior to the resident's fall; -The resident was over the bed when he/she heard a pop coming from somewhere on the lift; -The resident slid out of the sling and onto the floor. During interview on 9/20/22 at 3:30 P.M., CNA B said the following: -He/She connected the loops (of the hoyer lift sling) to the bottom hooks, and CMT A connected the loops to the top hooks; -He/She checked the loops were in the correct location and position. The loop has to be positioned in the lower part of the hook prior to transfer; -Before the resident lift was moved, CMT A readjusted the loops in the hooks; -As the resident got to the bed, they had to reposition the sling and raise the bed, then he/she heard a pop; -He/She looked at the right lower loop that came off the hook and it was intact. During an interview on 9/21/22 at 1:45 P.M., a customer service representative from the hoyer lift manufacturing company said the following: -The hoyer lift swivel bar does swing, but should not be swinging like a swing set; -The loop could come off the hook if staff did not place the loop properly. During interview on 9/22/22 at 9:26 A.M., a customer service representative from the hoyer lift manufacturing company said the owner's manual for the mechanical lift directs to use one loop per hook, so putting two loops per hook would not be following their instructions nor recommendations, and the result was unknown. During interviews on 9/20/22 at 1:39 P.M. and on 9/22/22 at 10:05 A.M., the Director of Nurses (DON) said the following: -The middle section of the hoyer lift can move around, and the facility simulated this after the fall occurred and were able to duplicate the problem of the loops coming off the hooks; -The staff were not trained to put two loops on each hook; -The staff did not report two loops were put in each hook during her investigation of the resident's fall; -She expected staff to use one loop per hook per manufacturer's guidelines. During interview on 9/22/22 at 11:27 A.M., the administrator said the following: -He was unaware staff put two sling loops in the patient lift hooks; -He expected the staff to follow the manufacturer's guidelines. MO206632

Based on observation, interview, and record review, the facility failed to use appropriate infection control procedures to prevent or reduce the risk of spreading the virus SARS-CoV-2, (a coronavirus discovered in 2019), which causes COVID-19 infection, when staff failed to separate two residents (Residents #1 and #2), who tested negative for COVID-19, from their roommates (Residents #3 and #4), who tested positive for COVID-19 infection. Facility staff also failed to ensure two residents (Residents #1 and #6), did not share a bathroom with resident (Resident #3) who had tested positive for COVID-19, and failed to document assessments for signs and symptoms of COVID-19 infection. The facility identified nine residents who tested positive for COVID-19. The facility census was 73. The administrator was notified on 7/8/22 of the Immediate Jeopardy (IJ), which began on 7/5/22. The IJ was removed on 7/11/22, as confirmed by surveyor onsite verification. Review of the Centers for Disease Control and Prevention's (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 02/02/22, showed the following: -Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as SARS-CoV-2 (the pathogen that causes COVID-19 infection); -Even as nursing homes resume normal practices, they must sustain core infection prevention and control (IPC) practices and remain vigilant for SARS-CoV-2 infection among residents and health care personnel (HCP) in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death; -Actively monitor all residents at least daily for fever (temperature greater to or equal to 100 degrees Fahrenheit) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturations via pulse oximetry (a test to monitor the level of oxygen in the blood); -In response to a newly identified SARS-CoV-2 infected health care provider or resident (an outbreak), consider increasing the monitoring for all residents from daily to every shift to more rapidly detect those with new symptoms. Increase monitoring of residents with suspected or confirmed SARS-CoV-2 infection, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to identify and quickly manage serious infection. -Identify space in the facility that could be dedicated to monitor and care for residents with confirmed SARS-CoV-2 infection; -The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed SARS-CoV-2 infection. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with SARS-CoV-2 infection; -Ideally, a resident with suspected SARS-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending; -If limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location pending return of test results; -Residents should only be placed in a COVID-19 care unit if they have confirmed SARS-CoV-2 infection. -Roommates of residents with SARS-CoV-2 infection should be managed as described in Section: Manage Residents who have had Close Contact with Someone with SARS-CoV-2 Infection; -Manage Residents who had Close Contact with Someone with SARS-CoV-2 Infection: -Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). -Residents who are up to date with all recommended COVID-19 vaccine doses and residents who have recovered from SARS-CoV-2 infection in the prior 90 days who have had close contact with someone with SARS-CoV-2 infection should wear source control and be tested as described in the testing section. In general, these residents do not need to be quarantined, restricted to their room, or cared for by HCP using the full PPE recommended for the care of a resident with SARS-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with SARS-CoV-2 infection, or the facility is directed to do so by the jurisdiction's public health authority. Quarantine might also be considered if the resident is moderately to severely immunocompromised. Review of the CDC Infection Control for Nursing Homes, Recommended Infection Prevention and Control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection, updated 02/02/22, showed the following: -The IPC recommendations described below also apply to patients with symptoms of COVID-19 (even before results of diagnostic testing) and asymptomatic patients who have met the criteria for empiric Transmission-Based Precautions (quarantine) based on close contact with someone with SARS-CoV-2 infection. However, these patients should NOT be cohorted with patients with confirmed SARS-CoV-2 infection unless they are confirmed to have SARS-CoV-2 infection through testing; -Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom; -Only patients with the same respiratory pathogen should be housed in the same room; -In general, it is recommended that the door to the room remain closed to reduce transmission of SARS-CoV-2. This is especially important for residents with suspected or confirmed SARS-CoV-2 infection being cared for outside of the COVID-19 care unit. However, in some circumstances (e.g., memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway. Review of the facility's policy for Handling a Patient that Converts to Positive COVID-19 in the Center, last revised on 7/5/22, showed the following: -Patients with known or suspected COVID-19 do not need to be placed into an airborne infection isolation room, but should be ideally be placed in a private room with their own bathroom if possible (ideally they should be staying in own room to minimize the spread); -Patients with COVID-19 should, ideally, be cared for in their own unit or section of the center with dedicated health care professionals if possible; -Patients with known or suspected COVID-19 might already be exposed. It is generally not recommended to place them with another roommate until 14 days after their exposure, assuming they have not developed symptoms or had a positive test; -If patient must remain in semi-private room, keep the curtain pulled and door closed and have patient wear a mask (if tolerated), unless cohorted with another COVID-19 positive patient; -Patients with known COVID-19 should be cared for using all recommended personal protective equipment (PPE), which included use of a fit tested N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown; -Should multiple patients meet the criteria, reasonable efforts would be made to place these patients in the same area of the building. If private rooms are not available, cohorting of patients would be deployed (ideally stay in their room, on their hall and identify room with a +fish (7/5/22); -There was no documentation to guide staff on monitoring for signs and symptoms of COVID-19. 1. Review of Resident #3's undated face sheet showed his/her diagnoses included dementia without behavioral disturbances. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by facility, dated 4/27/22, showed the following: -His/Her cognition was moderately impaired; -He/She required extensive assistance of one staff with transfers and toileting. Review of the resident's COVID-19 testing documentation, dated 7/2/22, showed he/she tested positive for COVID-19. Review of resident's progress note, dated 7/3/22 at 10:15 P.M., showed the resident reported sore throat and nasal congestion. Review of the resident's medical record showed no documentation of assessments for signs and symptoms of COVID-19 completed on 7/4/22, 7/5/22, or 7/6/22. Review of the resident's progress note, dated 7/7/22 at 9:33 P.M., showed the resident had an occasional cough. 2. Review of Resident 1's undated face sheet showed his/her diagnoses included dementia, cognitive communication deficit, and chronic kidney disease (on-going kidney disease). Review of the resident's admission MDS, dated [DATE], showed his/her cognition was moderately impaired. Review of the resident's care plan, last revised on 5/28/22, showed the following: -He/She was at risk for complications because of mild dementia that could became more severe over time; -He/She required assistance with some of his/her activities of daily living (ADLs), but was overall pretty independent; -He/She was continent of bowel and bladder; -He/She was able to ambulate independently. Review of the facility's COVID-19 resident testing documentation, dated 7/2/22, showed the resident tested negative for COVID-19. (The resident's roommate, Resident #3, tested positive for COVID-19 on this date.) Review of the resident's medical record showed the following: -He/she received the first COVID-19 vaccine on 1/23/21; -He/she received the second COVID-19 vaccine on 2/20/21; -He/she received the COVID-19 booster on 10/19/21; -No documentation of a second booster. During an interview on 7/7/22 at 4:10 P.M., the Director of Nursing (DON) said on 7/2/22 the resident was moved to another room (with Resident #9 who tested negative for COVID-19 on 7/2/22) after Resident #3 tested positive for COVID-19. Review of the facility's COVID-19 resident testing documentation, dated 7/5/22, showed the resident tested negative for COVID-19. The resident's roommate (Resident #9) tested positive for COVID-19. During an interview on 7/7/22 at 4:10 P.M., the DON said the resident was moved back to his/her original room with Resident #3 on 7/5/22 when Resident #9 tested positive for COVID-19 because Resident #1 had already been exposed to COVID-19. During an interview on 7/7/22 at 1:30 P.M., the DON said staff was supposed to immediately notify the resident's family if their roommate tested positive for COVID-19. The family should be given the opportunity for the COVID-19 negative resident to move/change rooms or remain in the room (with the COVID-19 positive resident) as the residents were already exposed to COVID-19. During an interview on 7/7/22 at 3:02 P.M., the resident's representative said today (7/7/22), staff contacted him/her to make him/her aware the resident's roommate (Resident #9) tested positive for COVID-19. He/She was unaware the resident's roommate (Resident #9) tested positive (on 7/5/22) and the resident was moved back to his/her original room on 7/5/22 with Resident #3 who had tested positive on 7/2/22. He/She was not provided an option of the resident moving to another room with a resident who was not positive for COVID-19. He/She did not want the resident to contract COVID-19. Staff assured him/her precautions would be taken to protect the resident from contracting the virus, including drawing the curtain between the residents to keep them isolated. He/She would have opted to move the resident if was given an option. Review of the resident's care plan showed no updated documentation to include increased monitoring or additional precautions to protect the resident from COVID-19 infection, after staff moved the resident in with a COVID-19 positive resident on 7/5/22. Review of the resident's medical record showed no documentation staff assessed the resident for signs and symptoms of COVID-19 prior to 7/7/22. Observation on 7/7/22 at 2:00 P.M. showed the resident lay in his/her bed by the window. Resident #3 (COVID-19 positive resident) was in his/her bed by the door. The privacy curtain between the two residents was open and the residents were talking to one another. The residents were approximately four feet apart from one another and neither resident wore a face mask. There were no bedside commodes located in the room. During an interview on 7/7/22 at 2:00 P.M., Licensed Practical Nurse (LPN A) said there were no specific precautions taken to prevent Resident #1 from contracting COVID-19. Sometimes the privacy curtain (located between the two residents' beds) was pulled, but Resident #3 would become upset when he/she could not see out the window. During an interview on 7/7/22 at 2:50 P.M., the infection preventionist said the following: -She contacted the residents' families/representatives who tested positive for COVID-19 and resident's roommate's family/representative if applicable to notify them of a roommate testing positive. -She informed families of the plan of whether the COVID-19 negative resident would remain in the room (with a COVID-19 positive resident) or be moved to another room. Each situation varied. -Initially negative residents were moved out of a room when their roommate tested positive, but they noticed that after negative/exposed residents were moved to room with another negative resident, the resident who resided in the room that resident was moved to, tested positive. -Resident #1 was in a room with Resident #3 and was moved to room with Resident #9 who was also negative on 7/2/22. -Resident #9 tested positive on 7/5/22 and Resident #1 was moved back to his/her original room with Resident #3 who had tested positive on 7/2/22. -Resident #1's family was not on her list to contact. Today, the DON asked if she was aware Resident #1's family had not been contacted and asked her to contact Resident #1's family. -Resident #1's representative was notified as requested. -Resident #1's representative asked if the resident would be moved again, and she told him/her they were just going to monitor the resident. - Monitoring would include watch for overall signs and symptoms of COVID-19, staff would keep the privacy curtain pulled between the two residents, and proper PPE would be utilized. -There was no specific documentation to show where staff monitored for signs/symptoms of COVID-19 in the resident's electronic health record (EHR). 3. Review of Resident #6's face sheet showed the resident's diagnoses included sick sinus syndrome (heart condition that affects heart rate), pacemaker placement (device implanted to assist with regulating heart rate), pneumonia (infection of lungs), atrial fibrillation (irregular heart rhythm), diabetes (elevated blood sugar), and dementia. Review of the resident's care plan, last revised on 5/31/22, showed the following: -His/Her cognition was severely impaired due to diagnosis of dementia; -He/She was independent with toileting; -He/She was independent with transfers and was able to walk with a walker; -He/She was unable to tolerate face mask due to dementia; -Staff were to attempt to keep the resident six feet apart for social distancing; Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was severely impaired; -He/She was independent with transfers, ambulation, locomotion, and toileting. Review of the facility's COVID-19 resident testing documentation, dated 7/2/22, showed the resident tested negative for COVID-19. (He/She shared a bathroom with Resident #3 who tested positive for COVID-19 on 7/2/22.) Review of the facility's COVID-19 resident testing documentation, dated 7/5/22, showed the resident tested negative for COVID-19. (His/Her room was located where he/she shared a bathroom with Resident #3 who tested positive for COVID-19 on 7/2/22.) Observation on 7/7/22 at 2:06 P.M. showed the resident was located in the room next to Resident #3. He/She shared a bathroom with Resident #3 (who tested positive for COVID-19 on 7/2/22). There was no bedside commode located in his/her room. During an interview on 7/7/22 at 4:00 P.M., Certified Nurse Assistant (CNA) C said Resident #1 and #6 (both residents who tested negative for COVID-19) shared a bathroom with Resident #3 (COVID-19 positive resident). Resident #1 and #3 were incontinent, but will use the bathroom. Resident #6 was continent and used the shared bathroom. There were no bedside commodes in Resident #3's or in Resident #6's rooms. 4. Review of Resident #4's face sheet showed his/her diagnoses included Alzheimer's disease and dementia. Review of the facility's resident COVID-19 testing log, dated 7/5/22, showed the resident tested positive for COVID-19. The resident's roommate (Resident #2) tested negative for COVID-19. Review of the resident's progress notes, dated 7/5/22 at 9:53 A.M., showed the resident tested positive for COVID-19 and would remain in his/her room at this time. Review of resident's care plan, dated 7/6/22, showed the following: -He/She tested positive for COVID-19 and would be at risk for respiratory symptoms such as cough, congestion or shortness of breath, decreased appetite, weight loss, dehydration, pain, weakness which would put him/her at risk for falls, and social isolation which placed him/her at risk for depression; -Signs and symptoms would be managed by his/her care team; -Routine assessments and monitoring would be completed even if he/she felt well in attempt to catch any signs and symptoms early. Review of the resident's medical record showed no documented assessment for signs and symptoms of COVID-19 on 7/6/22. Review of resident's POS showed a new order, dated 7/7/22, to complete progress notes related to COVID-19 three times a day; 8:00 A.M. to 1:00 A.M., 3:00 P.M. to 11:00 P.M., and 11:00 P.M. to 7:00 A.M. with special instructions to sign off when note was completed. Review of resident's progress notes, dated 7/7/22 at 9:41 P.M., showed the resident continued on isolation precautions. Review showed no documentation of an assessment for signs and symptoms of COVID-19. 5. Review of Resident #2's undated face sheet showed his/her diagnoses included diabetes and chronic kidney disease. Review of the resident's quarterly MDS, dated [DATE], showed his/her cognition was moderately impaired. Review of the resident's COVID-19 test, dated 7/5/22, showed the resident tested negative for COVID-19. Review of resident's progress notes, dated 7/5/22 at 4:48 P.M., showed the resident's representative was notified the resident's roommate tested positive for COVID-19 and the resident would remain in his/her room at this time. Review of resident's medical record showed no documentation staff assessed the resident for signs and symptoms of COVID-19 on 7/5/22, 76/22, and 7/7/22. Observation on 7/7/22 at 10:57 A.M., showed the following: -Resident #2 and Resident #4 shared a room on a non-isolation hall. The hall was shared with COVID-19 negative and positive residents; -The door to the resident's room was open; -The privacy curtain located at head of the resident's bed was partially open between the two residents. Neither resident was wearing a mask. During an interview on 7/7/22 at 11:00 A.M., Licensed Practical Nurse (LPN) A said management made the decision to keep Residents #2 and #4 together after Resident #4 tested positive for COVID-19, because Resident #2 had already been exposed. He/She could see the resident's better if the door to the room was open. Resident #4 was near the window and only coughed occasionally. He/She wasn't sure if the COVID-19 virus could spread out into the hall. During an interview on 7/7/22 at 11:30 A.M., CNA C said he/she was not aware Resident #2 was negative for COVID-19. 6. During an interview on 7/7/22 at 10:30 A.M., LPN D said there were no specific assessments for staff to complete to monitor residents for signs and symptoms of COVID-19. He/She monitored residents' signs/symptoms when he/she was in resident's room, but did not describe any specific time he/she completed the assessments. During an interview on 7/7/22 at 4:10 P.M., the DON said the following: -To minimize the spread of the COVID-19 virus, the facility was keeping residents who tested positive with their roommates who tested negative because the negative residents had already been exposed; -The administrator attended a meeting and received direction from another facility that this plan had worked for their facility, so he decided to try it. The plan was recently implemented on 7/5/22 and they were still working the kinks out; -Families should have an option for COVID-19 negative residents to move to another room. Families were notified of the negative residents remaining with the COVID-19 positive residents, and neither of the resident's representative asked for the resident to go to another room; -Resident #3 should have had a bedside commode and should not share a bathroom with residents who tested negative; -There were no specific assessments for monitoring residents for signs and symptoms of COVID-19, including for Residents #1 and #2; -Staff were expected to check residents' vital signs and monitor for any signs and symptoms of COVID-19. If the residents showed any signs and symptoms of COVID-19, staff were expected to obtain the resident's temperature. She was not sure how often staff monitored residents for signs and symptoms of COVID-19. During an interview on 7/7/22 at 4:34 P.M., the administrator said the following: -He visited with another facility's administrator who said they kept resident's roommates (who tested negative for COVID-19) in the room when the resident tested positive for COVID-19. That particular administrator said it had worked for their facility, so he decided to try it. -He considered it a problem not to give families/residents (who tested negative for COVID-19) an option to move to another room. Families should be made aware they had options. -Resident #1 had been exposed to two COVID-19 positive residents for several days and he didn't think Resident #1 would contract the virus based on the resident's antigen testing. -If either of the two COVID-19 negative residents' families said they had a concern with the residents rooming with positive COVID-19 residents, they would have made adjustments. -Keeping the resident's curtains pulled would be ideal to separate the positive and negative residents from one another. In this circumstance, staff should treat both residents as if they were positive for COVID-19. -He discussed with the facility's medical director who said they could keep positive COVID-19 residents in same room with residents who were negative for COVID-19, and keep positive COVID-19 residents on the same wing/halls would be ideal. During an interview on 7/7/22 at 4:50 P.M., the facility's physician said when she was questioned regarding new policy of cohorting positive and negative COVID-19 residents, We told them not to do that (clarifies that we refers to the medical provider and medical director). She spoke with the medical director, and she and the medical director said, We do not support that, referring to putting/keeping positive and negative COVID-19 residents together. Her preference was for all positive COVID-19 residents to be placed together. She would not recommend moving a COVID-19 exposed, but negative resident, into a room with another resident who is COVID-19 negative. The facility should either move positive or negative residents, cohort/isolate positive residents and quarantine exposed residents. She understood this would be the protocol after speaking with administration on 7/6/22. During interview on 7/7/22 at 7:00 P.M., the facility's physician said if two residents had already been roomed together (established roommates) and one resident became COVID-19 positive, then the likelihood that the roommate was or would become COVID-19 positive was likely. At that point, transferring/moving certain residents such as those with dementia could become detrimental to their mental health and may require the medical provider to use additional medications to calm them that would otherwise not be required. However, the facility's medical provider stated she would not recommend putting a (new) COVID-19 positive resident in with a resident who is COVID-19 negative. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation 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 E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.)

Based on observation, interview and record review, the facility failed to ensure staff used the appropriate transfer technique for one resident (Resident #8) who was assessed as requiring a hoyer lift (mechanical transfer device used for residents who cannot bear weight) for transfers and as directed by his/her plan of care of 11 residents sampled. Certified Nurse Aide (CNA) A transferred Resident #8 manually by himself/herself using the pivot method (the person bears at least some weight on one or both legs and spins to move their body from one surface to another) without using a gait belt (belt placed around the resident's waist and provides a handle to hold onto for those who require assistance during transfers, ambulation, or repositioning). The improper transfer resulted in injury to the resident which required treatment in the emergency room where it was found the resident had fractures to both the right and left leg. The facility census was 74. On 12/9/21 at 1:50 P.M., the administrator was notified of the past non-compliance immediate jeopardy (IJ) which occurred on 11/10/21. On 11/10/21, the administrator identified Resident #8 sustained fractures from an improper transfer by CNA A. Upon discovery, facility staff were in-serviced on appropriate transfer techniques and how to identify the amount of assistance each resident required for transfers. Facility staff interviewed all other residents who required the hoyer lift for transfers to identify any additional issues or concerns. The IJ was removed and corrected on 11/12/21. Record review of the facility's policy on Safe Lifting and Movement of Residents, revised July 2017, showed the following: -In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort, and medical condition, will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Manual lifting of residents will be illuminated when feasible; -Nursing staff, in conjunction with rehabilitative staff, shall assess individual residents' needs for transfer assistance on an ongoing basis; -Staff will document resident transferring and lifting needs in the care plan; -Staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices; -Safe lifting and movement of residents is part of an overall facility employee health and safety program. 1. Record review of Resident #8's face sheet showed the following: -admitted [DATE] (latest return); -Diagnoses included [CONDITION(S)], diabetes, [CONDITION(S)], [CONDITION(S)], anxiety, dementia, and age related [CONDITION(S)] (a medical condition in which the bones become brittle and fragile from loss of tissue). Record review of the resident's Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 10/15/21, showed the following: -Cognition was severely impaired; -Required physical assist of two or more staff for transfers; -Impaired range of motion of the lower extremity on both sides. Record review of the resident's care plan, revised 10/21/21, showed the following: -The resident required assistance in performing, improving, and maintaining some activities of daily living; -Transfer with the hoyer lift and two staff (approach start date of 12/24/20). Record review of the resident's nurse's notes, dated 11/10/21, showed the following: -At 11:37 A.M. the charge nurse came to the Director of Nursing (DON) and asked the DON to assess the resident's leg. The resident's right lower leg looked bowed towards the right. The DON softly touched the resident's leg and the resident denied pain. There was no obvious swelling or bruising, but the leg appeared deformed. The physician and family were contacted and the resident was sent to the hospital; -At 9:42 P.M. the resident returned to the facility from the emergency room (ER). The resident has fractures to the right and left tibia (bone in the leg beneath the knee) as well as the right fibula (bone in the leg below the knee); -Splints and soft casts to both lower extremities (legs) in place. The primary physician was made aware of the resident's return and diagnosis. A new order was received to increase the resident's [MEDICATION(S)] (narcotic pain medication) 5/325 milligrams (mg) to every six hours. The resident had rested well with complaints only during turning and repositioning. Record review of the resident's ER provider notes, dated 11/10/21, showed the following: -At 11:54 A.M. the resident arrived at the ER from the nursing home, complaining of left lower leg pain; -Per facility staff, the resident did not fall but the nurse was called into the room by the CNA because his/her leg looked deformed; -The resident's family member said the resident does not walk and is normally in a wheelchair; -The X-ray of the right ankle showed profound osteopenia (a loss of bone mineral density and mass causing bones to become weaker). The resident had predominately transverse fractures (the break is at a right angle to the longer plane of the bone) to the distal (near the ankle) fibular and tibial shafts; -The X-ray of the left ankle showed marked osteopenia and comminuted fracture (broken in more than two pieces) of the distal tibia; -The resident reported he/she did not fall and reported pain in the right and left leg; -X-rays showed a distal tibia fracture on the left and tibial and fibula fractures on the right side; -Since the resident does not walk at baseline, suggestion to discharge the resident with splints and follow up. The resident's family was in agreement and was not interested in surgical management; -The resident was transferred back to the facility. Record review of the facility's undated investigation summary showed the following: -On 11/10/21 Licensed Practical Nurse (LPN) B had the DON look at Resident #8's leg; -The DON noted the resident's right lower leg looked bowed to the right; -When touched softly, the resident denied pain and there was no obvious swelling or bruising but the leg looked deformed; -Around 12:00 P.M. the resident was sent to the hospital; -At approximately 2:00 P.M. the hospital called the facility to report the resident had fractures. The resident has diagnoses of [CONDITION(S)] (arthritis that occurs when the protective cartilage that cushions the ends of the bones wears down over time) and [CONDITION(S)]; -The resident returned to the facility later that evening; -The investigation showed that staff from 11/9/21 noted no change from the resident's baseline; -Day shift staff on 11/10/21 stated the resident was already up in his/her wheelchair when they arrived; -Night shift CNA A assisted the resident up to the chair by himself/herself on the morning of 11/10/21; -CNA A said the resident did bear weight on the left leg and pivoted to the chair during the transfer; -The DON asked CNA A if he/she knew Resident #8 used a hoyer lift for transfer and CNA A said Yes, but I thought I could do it.; -CNA A said the resident did not hit his/her leg or bump into anything during the transfer. CNA A didn't hear anything and the resident did not complain of any pain; -CNA A said he/she was just trying to be nice and get people up for the day shift; -CNA A was suspended; -Conclusion of the investigation: The fractures had to come from the improper transfer; -The root cause was CNA A wanted to help day shift staff and get more residents up; -CNA A said he/she knew he/she was wrong for not transferring the resident the correct way. Observation on 12/8/21 at 10:50 A.M. showed the following: -The name plate on the wall outside the resident's room showed H-2 next to the resident's name (indicating the resident required the hoyer lift and two staff for transfers); -The resident lay in bed with both lower legs in soft casts wrapped with ace bandages. During an interview on 12/8/21 at 10:50 A.M., the resident said both of his/her ankles were broken when a staff member transferred the resident without the hoyer lift. Record review of the written statement from CNA A, dated 11/12/21, showed the following: -On the morning of 11/10/21, CNA A got Resident #8 up using the pivot method; -CNA A had the resident bear weight on his/her left leg and turned the resident slightly to get into the wheelchair; -The resident did not bump into anything and did not complain when the transfer was completed; -CNA A was aware Resident #8 required the hoyer lift for transfers, but CNA A was trying to hurry and get residents up to help out day shift staff; -CNA A knew that the symbols on the residents' doors was how staff knew how to transfer a resident. During an interview on 12/13/21 at 10:30 A.M., CNA A said on 11/10/21 he/she went into Resident #8's room around 5:45 A.M. CNA A transferred the resident from the bed to the wheelchair by himself/herself manually, without the hoyer lift and without a gait belt. CNA A assisted the resident to stand up by holding onto the band of the resident's pants and had the resident bear weight on his/her left leg and pivot into the wheelchair. CNA A said nothing unusual happened during the transfer. CNA A was aware the resident was supposed to be transferred with the hoyer lift but CNA A thought he/she could do it by himself/herself without the lift. There were plenty of functional hoyer lifts available to use. CNA A was trained and knew how to operate the hoyer lift. CNA A was just trying to hurry to help out day shift staff and thought he/she could transfer the resident on his/her own. Record review of a written statement by CNA C, dated 11/10/21, showed the resident was already dressed and sitting in the wheelchair when CNA C arrived to work that morning. CNA C and CNA D went to clean up Resident #8 after he/she had vomited. When the aides removed the resident's pants they found that his/her leg felt weird. CNA C went and got LPN B. Record review of a written statement by CNA D, dated 11/10/21, showed the resident was already up and in the wheelchair when CNA D arrived. CNA C and CNA D went to clean up the resident after he/she vomited. They were changing the resident's clothes when they noticed his/her leg didn't look right and they thought he/she possibly had a broken leg. Record review of the written statement from LPN B, dated 11/10/21, showed he/she was called to the resident's room at 10:45 A.M. by a CNA. The resident's right lower leg was bowing to the right and mis-shapen. The resident was seated in his/her wheelchair. LPN B had no knowledge of what happened. During an interview on 12/9/21 at 10:05 A.M., LPN B said the following: -On 11/10/21 Resident #8 was already up in his/her wheelchair when he/she arrived for work; -CNA C and CNA D came to LPN B and told him/her the resident's leg didn't look right; -LPN B assessed the resident and his/her right leg was bowed; -LPN B told the DON who also assessed the resident; -The resident's right leg was painful to touch and slightly swollen; -There was no deformity to the left leg; -LPN B called the physician and the family and received orders to transfer the resident to the hospital; -Facility staff did not transfer the resident; -The resident was transferred from his/her wheelchair to the gurney by Emergency Medical Services (EMS) when they arrived; -The resident returned to the facility later that evening with both legs in soft casts; -Staff know how residents transfer from the symbol on the name plates outside the rooms; -CNA A is the staff who transferred Resident #8 on 11/10/21 before the day shift staff arrived. During an interview on 12/9/21 at 10:35 A.M., the DON said on 11/10/21 the resident was up in his/her wheelchair. The DON noticed there was no hoyer lift pad under the resident. Later that morning LPN B asked the DON to come look at the resident's leg. The resident's right leg was bowed. The nurse contacted the physician and received orders to send the resident to the emergency room . The investigation showed the night shift aide, CNA A, transferred the resident by himself/herself by standing and pivoting the resident from the bed into the wheelchair. The resident required the hoyer lift for transfers. The DON contacted CNA A who said he/she knew the resident required the hoyer lift for transfers, but he/she thought he/she could do it by himself/herself and was trying to help out the day shift staff. CNA A said the transfer went fine and nothing unusual occurred. The DON said staff are aware of how residents transfer from their care plans and also the symbols on the nameplates outside of residents' rooms. The DON expected staff to transfer residents as directed. During an interview on 12/9/21 at 1:11 P.M., the administrator said he expected staff to transfer residents as directed by their care plan. During an interview on 12/9/21 at 1:38 P.M., the resident's physician said Resident #8 had extremely brittle bones due to [CONDITION(S)]. If twisted or moved the wrong way his/her bones could splinter. It was most likely the resident's fractures were caused from the manual transfer. The physician expected staff to transfer residents as directed by their care plans. MO 8

Based on interview and record review the facility failed to follow the facility policy and thoroughly investigate when three residents (Resident #1, #2 and #6) made allegations of sexual abuse against Certified Nurse Aide (CNA) A. The facility failed to implement safeguards to prevent further abuse after residents reported sexual abuse. The facility also failed to thoroughly investigate allegations of misappropriation of property for two residents (Resident #13 and Resident #14). The facility census was 77. The Administrator was notified on 10/5/21 at 11:40 A.M of the Immediate Jeopardy (IJ), which began on 9/6/20. The IJ was removed on 10/6/21, as confirmed by surveyor onsite verification. Review of the facility's policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, last revised 9/1/16, showed the following: -Abuse, neglect and misappropriation of patient property will not be tolerated by anyone including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors or any other individual in this center; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; -Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault; -Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation; -Prevention: The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors; -All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors; -Center will seek and accept complaints from patients, patient families and partners without reprisal; -Identification policy: Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect or misappropriation of patient property if it meets any of the following criteria; a. Any allegation or indication of possible willful infliction of injury to include unexplained bruising; b. Unreasonable confinement, to include unwanted restriction of access to all patient areas of the building; c. Any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others; d. Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental and psychological well being to include toileting issues; e. Any complaint of the use of oral, written or gestured language that will fully includes disparaging and derogatory terms to patients or families or within their hearing distance; f. Any complaint of sexual harassment, sexual coercion, sexual assault, or inappropriate touching; g. Any instances of hitting, slapping, pinching, or kicking or other potentially harmful action; h. Any behavior control strategy involving corporal punishment; i. Any complaint of humiliation, harassment, threats of punishment or deprivation; j. Any complaint regarding the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. -All events reported as possible abuse, neglect, or misappropriation will be investigated to determine whether the alleged abuse neglect or misappropriation did or did not take place; -Within 24 hours to 5 days obtain statements and conduct interviews with partners (staff), visitors, residents (involved and others with whom the alleged perpetrator had contact or may have affected); -The investigation file will include the initial report, contact and response from agencies, copy relevant nurses and social services notes, schedule or staffing sheets used, statements and interview notes, and the summary statement; -The results of all investigations will be completed within five working days of the incident. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally required assessment instrument, dated 9/11/20, showed the following: -Cognitively intact; -No hallucinations, delusions, or behaviors; -Requires physical assistance of one staff member for transfers, bed mobility, dressing, toilet use, and bathing. Review of the facility's investigation, dated 9/12/20, showed the following: -Resident #1 said on 9/5/20, CNA A had kissed him/her on the mouth; -On 9/6/20 CNA A got in the resident's bed, laid across him/her diagonally, and started trying to kiss on him/her while CNA A rubbed his/her (pointed to genital area) on his/her legs; -The resident said he/she told CNA A to get off of him/her and he/she did; -The resident said he/she did not report the first incident because he/she and CNA A had a friendship; -After CNA A got in the bed with him/her he/she could see something was not right; -It was so upsetting he/she can't remember who he/she told what; -The resident's roommate who is a little hard of hearing, said he/she believes he/she did hear something loud that night but thought the roommate had turned on an electronic device loudly, so he/she didn't think anything of it.; -The facility found the allegations unsubstantiated and instructed CNA A not to provide care for Resident #1; -The investigation did not include a statement or interview from CNA A. Review of resident's significant change in status assessment MDS dated [DATE], showed the following: -Cognitively intact; -No behaviors, hallucinations, or delusions; -Requires extensive physical assistance of one staff member for bed mobility, dressing, and toilet use. During an interview on 6/3/21 at 11:15 A.M., the resident said the following: -CNA A was his/her favorite staff member, CNA A would spoil him/her with small gifts like extra snacks or keeping him/her stocked with supplies; -One day CNA A had just made him/her laugh and then CNA A leaned down and tried to kiss him/her on the mouth. It shocked the resident and he/she thought that's nasty, I'm an old person; -CNA A tried to kiss him/her on the mouth a few times and he/she made sure CNA A knew it was inappropriate; -Then one night CNA A lay beside the resident in his/her bed and tried to kiss him/her on the mouth and then he/she stopped; -He/She didn't know what to do, so he/she did not tell anyone; -The second night CNA A got into his/her bed and tried to kiss him/her with his/her mouth open, then got on top of the resident on top of the covers; -CNA A rubbed his/her groin against the resident and he/she could feel CNA A getting sexually aroused. The resident tried to push CNA A off of him/her but he/she could not, and CNA A kept going until he/she was finished (clarified to mean climaxed) and it was humiliating; -He/She reported CNA A tried to kiss him/her and laid across him/her, but then three men came to speak to him/her about it and he/she couldn't tell them everything because he/she was embarrassed and humiliated, but he/she did tell the director of nursing (DON) everything; -He/She felt like the staff didn't believe him/her until he/she told the DON everything; -They moved CNA A's assignment so he/she would not work with the resident, but he/she would still see CNA A and could tell he/she was so angry at the resident; -He/She tried to talk to CNA A to make it okay, the resident was torn because CNA A was the resident's friend, and now CNA A was angry with him/her, but he/she did not want it to happen again and did not know what to do; it was agonizing; -He/She was so glad CNA A finally left and doesn't work at the facility any more. It was horrible, painful, awkward and confusing when CNA A still worked at the facility, it was very stressful for him/her; -Another resident had expressed to the resident that CNA A played with him/her down there. He/She could not recall the resident's last name but said he/she had discharged home; -At this point he/she wished CNA A would go to prison because he/she worries he/she will do something worse to someone else. 2. Review of Resident #2's Face sheet showed the following: -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No hallucinations, delusions, or behaviors; -Requires extensive physical assistance of one staff member for bed mobility, dressing, toilet use, hygiene, and bathing. Review of the facility investigation, dated 9/29/20, showed the following: -On 9/25/20, Resident #2 reported CNA A takes his/her bra off roughly and grabs his/her breast as he/she is doing it; -The resident said CNA A pulls his/her underwear off roughly as well; -When CNA A takes the resident's clothes off to go to bed, CNA A then stands back and surveys the resident, with his/her hands on his/her hips and looks at him/her; -He/She does not want CNA A to provide care to him/her anymore; -CNA A was noted as an exemplary employee, he/she was moved to evening shift and assigned to another hall; -The investigation did not include staff who were interviewed or their statements, or a statement or interview from CNA A. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Requires extensive assistance with bed mobility, dressing, toilet use, and personal hygiene; -Dependent on staff for transfers, and moving on and off the unit. During an interview on 6/2/21, at 2:30 P.M., the resident said the following: -He/She was a retired registered nurse; -He/She knew the difference between caring for a patient and sexual actions; -He/She felt violated by CNA A; -CNA A would undress the resident and then just stand back and look him/her over in a sexual way; -CNA A would run his/her hand across his/her breast in a sexual way; -When CNA A would wash his/her groin area he/she would wash and wash longer than it should take; -He/She would hold his/her legs together tight almost like he/she had contractures because he/she was afraid if he/she relaxed, he/she would give CNA A permission to go further, and if he/she fought CNA A would hurt him/her; -When he/she would hold his/her legs together CNA A would tell him/her he/she was not being a good subservient woman/man by not obeying him/her; -He/She felt like CNA A was grooming him/her; -When other residents and staff were around CNA A would make a point to show the resident extra attention which made the resident feel like he/she couldn't tell anyone, like they would not believe him/her; -If he/she upset CNA A, CNA A would be rough with him/her by roughly taking his/her bra off over his/her head instead of undoing the strap and taking it off properly; -He/She reported a sexual allegation against CNA A because CNA A's behaviors hurt him/her emotionally and he/she did not want it to happen to anyone else. 3. Review of the facility's investigation, dated 12/28/20, showed the following: -On 12/26/20, Resident #6 called the police to express concerns a staff member that fit the description of CNA A touched his/her pants and patted the bed; -The resident's statement in the investigation showed the resident said CNA A came in his/her room while he/she was walking by his/her bed, CNA patted the bed like a motion for me to get in bed with him/her; -The facility investigation included one staff interview. The facility did not document multiple staff that worked with CNA A were interviewed. Review of Resident #6's annual MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors. During an interview on 6/3/21, at 4:30 P.M., the resident said the following: -Back around Christmas he/she called the police because CNA A came into his/her room and started to take his/her pants down and patted the bed like he/she wanted him/her to get into bed with him/her; -He/She said it made him/her uncomfortable and intimidated, like CNA A wanted to do bad things to him/her. 4. During an interview on 6/2/21, at 12:45 P.M., the Director of Nursing (DON) said the following: -CNA A no longer worked at the facility, he/she resigned after a third allegation in December with Resident #6; -He/She told the CNA there were no halls left for him/her to work so he/she resigned; -The facility did not terminate CNA A's employment; -The allegations with Resident #1 there were some inconsistencies so the facility did not feel they could prove it happened; -The allegation with Resident #2 was shortly after the allegation with Resident #1, the residents talk, so she felt like Resident #1's allegations could have influenced Resident #2's perception; -To his/her knowledge Resident #1, #2, and #6 had not made other sexual allegations about staff; -He/She did not have a way to know or track previous allegations against individual staff members to see trends; -He/She did not have all the staff interviews recorded or a list of staff that were interviewed during the investigation. During an interview on 10/27/21, at 10:45 A.M. and 11:57 A.M., the administrator said the following: -The facility investigates all allegations of abuse or neglect; -Alleged perpetrator is suspended or removed pending the investigation; -DHSS and/or police are notified as directed in the policy; -Witnesses (if applicable) are interviewed; -Staff and resident's are interviewed for potential witnesses; -Statements and observations are reviewed; -Facility makes a conclusion based on the investigation; -If any further action is required based on the findings, will process with actions needed i.e. training, termination, etc.; -If there are credible allegations and/or see a pattern of allegations then the allegation is put into the employee's file; -The facility did not feel like the allegations against CNA A were credible, and that is why a record of the allegations made against the CNA or the investigations of the allegations were not in the employee's file; -The DON keeps all the investigations in his/her office to see if there are trends with allegations. -The facility did not see a trend with sexual allegations made against CNA A; -With CNA A, the facility moved him/her to different areas in the building because with past allegations, the facility felt like those resident's would cause more resident's to make allegations so his/her assignment was changed for his/her protection; -As time went on there were not any places in the facility for him/her to work. 5. Review of Resident #13's quarterly MDS, dated [DATE] showed the following: -His/her cognition was intact. Review of resident's complaint resolution form dated 8/9/21 showed the following: -Resident told Social Worker that he/she was missing $160 in cash that was in his/her purse inside a checkbook; -Resident could not find his/her purse; -Staff searched the resident's room and found the purse in the bathroom; -Resident looked through his/her purse and noticed money was missing; -On 8/26/21, the CNA that was suspected stopped showing up to work. Review of facility's investigative witness statement dated 8/9/21, showed the following: -Resident told Social Worker that he/she was missing $160 in cash that was in his/her purse in a checkbook; -Resident could not find his/her purse; -Staff searched the resident's room and found purse in the bathroom; -Resident looked through his/her purse and noticed money was missing from his/her checkbook. Review of resident's progress notes, dated 8/25/21 showed the following: -Resident recently reported he/she had money missing from purse; -Social worker spoke with the resident and was reported to DON. During an interview on 10/14/21 at 10:25 A.M., the resident said the following: -He/She told several people about money being missing; -Staff had told the resident that they would look at cameras in the building and let him/her know if they found anything; -Staff have not gotten back to him/her about the outcome of the situation. 6. Review of Resident #14's face sheet showed the following: -admitted on [DATE]. Review of resident's progress notes, dated 8/30/21 showed the the Admissions Director was informed by the resident's family member that the resident had $50 missing that was in the resident's purse on admission. Review of resident's admission MDS, dated [DATE] showed the following: -His/her cognition was intact; -There were no documented behaviors. Review of facility's investigative witness statement dated 9/3/21, showed the following: -The Admissions Director was informed by the resident's family member that the resident had $50 missing; -He/She searched the resident's room and purse; -He/She told the resident's family member that the facility was looking into what happened to the money. Review of a Word document provided by the DON on 10/13/21, dated 8/30/21 showed the following: -Resident #13 and Resident #14 had missing money; -The DON interviewed staff and CNA P was mentioned as a suspect; -The DON interviewed CNA P and he/she denied taking the money; -The DON moved CNA P to another hall; -CNA P stopped showing up to work; -The missing money occurred around the time that he/she started working and then stopped when he/she left the facility. During a telephone interview on 10/19/21 at 2:16 P.M., Resident #14's family member said the following: -Staff went through the resident's purse to see if they could find the money; -The Admissions Director said the facility would investigate the situation; -The facility did not get back to him/her back with a final conclusion of the situation. During a telephone interview on 10/19/21 at 2:35 P.M., the Admissions Director said the following: -He/She spoke to Resident #14's family member about the missing money; -He/She filled out a Complaint form and a Witness statement form; -He/She spoke to some staff members about the missing money; -He/She did not document who he/she spoke to and what they said; -He/She did not talk to other residents about whether money or other items were missing; -The facility did not know who had taken the resident's money; -He/She was only involved in investigations that she is asked to be a part of. During an interview on 10/13/21 at 12:59 P.M., the Social Service Director said the following: -Allegations are reported to the DON; -He/She was involved in the investigation process; -He/She wrote the Witness form and documented in the progress notes for Resident #14; -He/She was not involved with Resident #13's allegation. During an interview on 10/13/21 at 2:52 P.M., the DON said the following: -He/She did not have written statements from CNAs or other residents; -He/She did not document conversations with CNAs or other residents; -Staff do not want their names to be mentioned if they give him/her information about other CNAs who may be guilty; -He/She interviewed CNA P and he/she denied taking the money; -He/She moved CNA P onto a different hall to work; -CNA P stopped coming to work and his/her last day was 9/14/21. During an interview on 10/14/21 at 4:18 P.M., the administrator said the following: -Staff should have written statements from witnesses; -The DON was responsible for investigations; -Social Services can do interviews and help with investigations; -Investigations could be better and documentation of investigations was ideal; -He would need to follow up on whether the residents' were reimbursed the money taken. NOTE: At the time of survey, the violation was determined to be at the immediate and serious 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 address and lower the level of the 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 be taken to address Class I violation(s). MO 344

Based on interview and record review, the facility failed to ensure three residents (Resident #1, #2, and #6) were free from abuse by Certified Nurse Aide (CNA) A. The facility failed to implement safeguards to prevent further abuse after residents reported sexual abuse. The facility census was 77. The Administrator was notified on 10/5/21 at 11:40 A.M. of the Immediate Jeopardy (IJ), which began on 9/6/20. The IJ was removed on 10/6/21, as confirmed by surveyor onsite verification. Review of the facility's policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, last revised 9/1/16, showed the following: -Abuse, neglect and misappropriation of patient property will not be tolerated by anyone including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors or any other individual in this center; -Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; -Sexual abuse includes but is not limited to sexual harassment, sexual coercion, or sexual assault; -Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation; -Prevention: The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors; -All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors; -Center will seek and accept complaints from patients, patient families and partners without reprisal; -Identification policy: Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect or misappropriation of patient property if it meets any of the following criteria; a. Any allegation or indication of possible willful infliction of injury to include unexplained bruising; b. Unreasonable confinement, to include unwanted restriction of access to all patient areas of the building; c. Any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others; d. Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental and psychological well-being to include toileting issues; e. Any complaint of the use of oral, written or gestured language that will fully includes disparaging and derogatory terms to patients or families or within their hearing distance; f. Any complaint of sexual harassment, sexual coercion, sexual assault, or inappropriate touching; g. Any instances of hitting, slapping, pinching, or kicking or other potentially harmful action; h. Any behavior control strategy involving corporal punishment; i. Any complaint of humiliation, harassment, threats of punishment or deprivation; j. Any complaint regarding the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. -All events reported as possible abuse, neglect, or misappropriation will be investigated to determine whether the alleged abuse neglect or misappropriation did or did not take place; -The results of all investigations will be completed within five working days of the incident. 1. Review of Resident #1's face sheet showed the following: -admitted to the facility on [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's quarterly Minimum Data Set (MDS), a federally required assessment instrument, dated 9/11/20, showed the following: -Cognitively intact; -No hallucinations, delusions, or behaviors; -Requires physical assistance of one staff member for transfers, bed mobility, dressing, toilet use, and bathing. Review of the facility's investigation, dated 9/12/20, showed the following: -Resident #1 said on 9/5/20, CNA A had kissed him/her on the mouth; -On 9/6/20 CNA A got in the resident's bed, laid across him/her diagonally, and started trying to kiss on him/her while CNA A rubbed his/her (pointed to genital area) on his/her legs; -The resident said he/she told CNA A to get off of him/her and he/she did; -The resident said he/she did not report the first incident because he/she and CNA A had a friendship; -After CNA A got in the bed with him/her, he/she could see something was not right; -It was so upsetting he/she can't remember who he/she told what; -The resident's roommate who is a little hard of hearing, said he/she believes he/she did hear something loud that night, but thought the roommate had turned on an electronic device loudly, so he/she didn't think anything of it; -The facility found the allegations unsubstantiated and instructed CNA A not provide care for Resident #1. Review of the resident's significant change in status MDS dated [DATE], showed the following: -Cognitively intact; -No behaviors, hallucinations, or delusions; -Requires limited physical assistance of one staff member for transfers, and hygiene; -Requires extensive physical assistance of one staff member for bed mobility, dressing, and toilet use. During an interview on 6/3/21 at 11:15 A.M., the resident said the following: -CNA A was his/her favorite staff member, CNA A would spoil him/her with small gifts like extra snacks or keeping him/her stocked with supplies; -One day CNA A had just made him/her laugh and then CNA A leaned down and tried to kiss him/her on the mouth. It shocked the resident and he/she thought that's nasty, I'm an old person; -CNA A tried to kiss him/her on the mouth a few times and he/she made sure CNA A knew it was inappropriate; -Then one night CNA A lay beside the resident in his/her bed and tried to kiss him/her on the mouth and then he/she stopped; -He/She didn't know what to do, so he/she did not tell anyone; -The second night CNA A got into his/her bed and tried to kiss him/her with his/her mouth open, then got on top of the resident on top of the covers; -CNA A rubbed his/her groin against the resident and he/she could feel CNA A becoming more sexually aroused, the resident said he/she tried to push CNA A off of him/her, but he/she could not, and CNA A kept going until he/she was finished (clarified to mean climaxed) and it was humiliating; -He/She reported CNA A tried to kiss him/her and laid across him/her, but then three men came to speak to him/her about it and he/she couldn't tell them everything because he/she was embarrassed and humiliated, but he/she did tell the director of nursing (DON) everything; -He/She felt like the staff didn't believe him/her until he/she told the DON everything; -They moved CNA A's assignment so he/she would not work with the resident, but he/she would still see CNA A and could tell he/she was so angry at the resident; -He/She tried to talk to CNA A to make it okay, the resident was torn because he/she was the resident's friend, and now CNA A was angry with him/her, but he/she did not want it to happen again and did not know what to do; it was agonizing; -He/She was so glad CNA A finally left and doesn't work at the facility anymore; -It was horrible, painful, awkward and confusing when he/she was still working at the facility; -It was very stressful for him/her; -Another resident had expressed to him/her that CNA A played with him/her down there; -He/She could not recall the resident's last name, but said he/she had discharged home; -At this point he/she wished CNA A would go to prison because he/she worries he/she will do something worse to someone else. 2. Review of Resident #2's Face sheet showed the following: -admitted to the facility on [DATE]; -diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No hallucinations, delusions, or behaviors; -Requires extensive physical assistance of one staff member for bed mobility, dressing, toilet use, hygiene, and bathing; -Dependent on staff for transfers. Review of the facility investigation, dated 9/29/20, showed the following: -On 9/25/20, Resident #2 reported CNA A takes his/her bra off roughly and grabs his/her breast as he/she is doing it; -The resident said CNA A pulls his/her underwear off roughly as well; -When CNA A takes the resident's clothes off to go to bed, CNA A then stands back and surveys the resident, with his/her hands on his/her hips and looks at him/her; -He/She does not want CNA A to provide care to him/her anymore; -The facility investigation noted that CNA A was an exemplary employee, he/she was moved to the evening shift and assigned to another hall. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Requires extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. During an interview on 6/2/21, at 2:30 P.M., the resident said the following: -He/She was a retired registered nurse; -He/She knows the difference between caring for a patient and sexual actions; -He/She felt violated by CNA A from May 2020 until September 2020; -CNA A would undress the resident and then just stand back and look him/her over in a sexual way; -CNA A would run his/her hand across his/her breast in a sexual way; -When CNA A would wash the resident's groin area he/she would wash and wash longer than it should take; -He/She would hold his/her legs together tight almost like he/she had contractures because he/she was afraid if he/she relaxed, he/she would give CNA A permission to go further, and if he/she fought, CNA A would hurt him/her; -When he/she would hold his/her legs together CNA A would tell him/her he/she was not being a good subservient woman/man by not obeying him/her; -He/She felt like CNA A was grooming him/her; -When other residents and staff were around, CNA A would make a point to show the resident extra attention which made the resident feel like he/she couldn't tell anyone, like they would not believe him/her; -If he/she upset CNA A, he/she would be rough with him/her by roughly taking his/her bra off over his/her head instead of undoing the strap and taking it off properly; -He/She reported a sexual allegation against CNA A because the behaviors of CNA A hurt him/her emotionally and he/she did not want it to happen to anyone else. 3. Review of the facility's investigation, dated 12/28/20, showed the following: -On 12/26/20, Resident #6 called the police to express concerns of a staff member that fit the description of CNA A who touched his/her pants and patted the bed; -The resident's statement in the investigation showed the resident said CNA A came in his/her room while he/she was walking by his/her bed, CNA patted the bed like a motion for the resident to get in bed with him/her. Review of Resident #6's annual MDS, dated [DATE], showed the following: -Cognitively intact; -No behaviors; -Requires extensive physical assistance of one staff member for toilet use, hygiene, and bathing; -Requires extensive physical assistance of two or more staff members for bed mobility, transfers, and dressing. During an interview on 6/3/21, at 4:30 P.M., the resident said the following: -Back around Christmas he/she called the police because CNA A came into his/her room and started to take his/her pants down and patted the bed like he/she wanted him/her to get into bed with him/her; -He/She said it made him/her uncomfortable and intimidated- like CNA A wanted to do bad things to him/her. 4. Review of the Department of Health and Senior Services complaint database showed, on 6/11/17 the facility filed a self-report complaint that Resident #12 made an allegation of rape against CNA A. The self-report was not substantiated. 5. During an interview on 6/3/21, at 4:45 P.M. Licensed Practical Nurse (LPN) C said the following: -He/She was not sure what the investigations showed, but he/she knew Resident #3, Resident #1, and Resident #2 made sexual allegations about CNA A; -Resident #3 made allegations of rape in 2019 and said CNA A penetrated the resident anally and orally; -Resident #1 made allegations that CNA A climbed into bed with him/her and also kissed him/her on the mouth; -Resident #2 made allegations that CNA A touched his/her breast. During an interview on 6/3/21, at 1:00 P.M., Registered Nurse (RN) B said the following: -He/She felt like he/she needed to share his/her experience with CNA A in light of residents' (Resident #12, #3, #1, #2, and #6) allegations; -CNA A wanted to date him/her, and he/she expressed to CNA A that he/she was not interested; -CNA A would stand too close to him/her and find reasons to be close to him/her; -CNA A tried to kiss him/her despite him/her saying no, and felt like CNA A would have continued if he/she had not been stern; -CNA A propositioned him/her several times, it lasted four to six months even after him/her repeatedly telling CNA A no; -He/She found himself/herself trying to sneak in the building and go out of his/her way to avoid CNA A. During an interview on 6/2/21, at 12:45 P.M., the Director of Nursing (DON) said the following: -CNA A no longer worked at the facility, he/she resigned after a third allegation in December with Resident #6; -He/She told CNA A there were no halls left for him/her to work so he/she resigned; -The facility did not terminate CNA A's employment; -He/She did not know there were allegations of sexual abuse regarding CNA A in 2017 or 2019 and there was no any information about them in CNA A's employee file; -With the allegations regarding Resident #1 there were some inconsistencies, so the facility did not feel they could prove it happened; -The allegation with Resident #2 was shortly after the allegation with Resident #1, the residents talk, so she felt like Resident #1's allegations could have influenced Resident #2's perception; -To her knowledge Resident #1, #2, and #6 had not made other sexual allegations about staff. During an interview on 10/27/21, at 10:45 A.M. and 11:57 A.M., the administrator said the following: -The allegation with Resident #1, was heavily investigated and grew every time a staff member discussed the allegation with him/her depending on who he/she was talking to. With the inconsistencies, the facility felt like the allegation was not true. The allegation was not substantiated by the facility; -Resident #1 discussed his/her story in the hall several times, and it was determined that is what encouraged the allegations made by Resident #2 and possibly Resident #6; -Resident #6 also does not prefer to be cared for by staff of CNA A's race, and the facility felt like that is why he/she called the police and made the allegations; -Law enforcement was not contacted about the allegations for Resident #1 and Resident #2, Resident #6 called the police to make his/her allegation against CNA A; -The facility does a standard investigation, if there are credible allegations and/or see a pattern of allegations then the allegation is put into the employees file; -The facility did not feel like the allegations against CNA A were credible, and that is why the allegations were not in the employee's file; -The DON keeps all the allegations in his/her office to see if there are trends with allegations; -The DON may not have known about the allegation in 2017 because there was a different DON at the time. Resident #3 that made allegations in 2019, still makes the same allegations against CNA A and had continued to do so. Resident #3 was delusional; -The facility did not see a trend with sexual allegations made against CNA A; -With CNA A, the facility moved him/her to different areas in the building because with past allegations, the facility felt like those residents would cause more residents to make allegations so his/her assignment was changed for CNA A's protection; -As time went on there were not any places in the facility for him/her to work. NOTE: At the time of survey, the violation was determined to be at the immediate and serious 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 address and lower the level of the 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 be taken to address Class I violation(s). MO 344

Based on interview and record review, the facility failed to report the results of investigations involving abuse and misappropriation of money to the state agency within five working days of the incidents for four residents (Residents #13, #14, #16, and #17), in a review of seven sampled residents. The facility's census was 77. Review of the facility's policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, last revised 9/1/16, showed the following: -Identification policy: Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect or misappropriation of patient property if it meets any of the following criteria; a. Any allegation or indication of possible willful infliction of injury to include unexplained bruising; b. Unreasonable confinement, to include unwanted restriction of access to all patient areas of the building; c. Any patient or family complaint of physical or verbal harm, pain or mental anguish resulting from the actions of others; d. Any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental and psychological well being to include toileting issues; e. Any complaint of the use of oral, written or gestured language that will fully includes disparaging and derogatory terms to patients or families or within their hearing distance; f. Any complaint of sexual harassment, sexual coercion, sexual assault, or inappropriate touching; g. Any instances of hitting, slapping, pinching, or kicking or other potentially harmful action; h. Any behavior control strategy involving corporal punishment; i. Any complaint of humiliation, harassment, threats of punishment or deprivation; j. Any complaint regarding the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent. -All events reported as possible abuse, neglect, or misappropriation will be investigated to determine whether the alleged abuse neglect or misappropriation did or did not take place; -The results of all investigations will be completed within five working days of the incident. Review of the facility's policy showed no direction for the facility to report the results of all investigations of abuse/neglect/misappropriation investigations to the state agency within five working days of the incident. 1. Review of Resident #13's quarterly Minimum Data Set (MDS), a federally required assessment, dated 7/27/21, showed the resident's cognition was intact. Review of resident's complaint resolution form, dated 8/9/21, showed the following: -The resident told the social worker he/she was missing $160 in cash that was in his/her purse inside a checkbook; -The resident could not find his/her purse; -Staff searched the resident's room and found the purse in the bathroom; -The resident looked through his/her purse and noticed money was missing. Review of resident's progress notes, dated 8/25/21, showed the following: -The resident recently reported he/she had money missing from his/her purse; -The social worker spoke with the resident and he/she reported to the Director of Nursing (DON). 2. Review of Resident #14's face sheet showed the resident was admitted to the facility on [DATE]. Review of resident's progress notes, dated 8/30/21, showed the resident's family member informed the admissions director the resident was missing $50 that was in his/her purse on admission. Review of resident's complaint resolution form, dated 8/30/21, showed the resident stated he/she was missing $50 in cash in his/her purse in his/her beside dresser. Review of the resident's admission MDS, dated [DATE] showed the resident's cognition was intact. 3. Review of a document provided by the DON on 10/13/21, dated 8/30/21 showed the following: -Resident #13 and Resident #14 had missing money; -The DON spoke with staff and Certified Nurse Assistant (CNA) P was mentioned as a suspect; -The DON interviewed CNA P and he/she denied taking the money; -CNA P was moved to another hall; -CNA P stopped showing up to work; -The missing money occurred about the time when CNA P started at the facility and then stopped when CNA P left the facility. 4. Review of an investigation report, provided by the facility on 10/13/21 at 11:00 A.M., showed the following: -At approximately 10:30 A.M. (on 10/2/21), residents were entering the living room area to play Bingo; -Resident #17 was ambulating in their wheelchair, and Resident #16 was walking with a walker; -As Resident #16 passed #17, Resident #17 said something; -Resident #16 turned around and hit Resident #17 on top of the head with a closed hand; -Resident #17 did not incur an injury; -Activities Partner U and Licensed Practical Nurse (LPN) J immediately separated the two residents; -Interventions put in place: Nursing supervisor was notified of event. 15 minute safety checks initiated on both residents. Checks continued for two hours to ensure both residents' safety. Staff in-serviced on the need to keep the two residents separated. If seen together, staff should separate residents and notify charge nurses. Responsible parties of both residents were notified; -The investigation was completed on 10/03/21. During an interview on 10/14/21 at 8:50 A.M., the DON said the following: -He/She was notified of the altercation on 10/02/21; -The final investigation report for the incident was completed on 10/04/21; -The final investigation report was not sent to the state agency within five working days of the incident. 5. During an interview on 10/13/21 at 2:52 P.M., the DON said the following: -He/She was ultimately responsible for the investigations; -He/She knew completed investigations were to be turned into state agency within five working days; -He/She believed the type of item taken or the amount of money determined if the facility needed to notify the state agency; -He/She was not sure there was a policy on reporting to the state agency. During an interview on 10/14/21 at 4:18 P.M., the administrator said the following: -Staff notified him/her during the onsite investigation that investigation outcomes needed reported to the state agency within five working days; -He expected staff to follow the facility's policy for reporting. MO 5 MO 2

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #10) in a review of 11 residents was treated in a manner to maintain dignity and respect. The facility census was 77. Review of the facility policy, Patient Care Policies, revised 2/2020 showed the following: -We support the patient/resident's right to live in an environment which is individualized for them; -We strive to cultivate and sustain an excellent quality of life for each individual with person-centered care and services, by honoring and supporting each patient/resident's preferences, choices, values and beliefs. During interview on 6/29/21, at 2:39 P.M., the director of nursing (DON) said the facility did not have a policy pertaining to resident haircuts. Review of Resident #10's care plan, revised 3/24/01, showed the following: -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -He/She was on hospice care; -He/She was hard of hearing and usually is able to make his/her needs known and understand others; -He/She needed assistance with activities of daily living; -He/She needed assistance with combing/brushing his/her hair; -He/She required assist of one for bathing. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/22/21, showed the following: -Moderately impaired decision making ability; -Inattention and disorganized thinking; -Extensive assistance by one staff member for personal hygiene. During an interview on 6/23/21, at 1:57 P.M., the resident's family member said the following: -He/She was visiting the resident and when he/she gave the resident a hug he/she noticed the resident's hair had been cut so short in the back that the resident's scalp was visible; -He/She nor any responsible party gave permission for the resident's hair to be cut; -He/She was unsure who cut the resident's hair; -He/She reported the incident to the facility; -The resident looked so sad when asked about his/her hair being cut; -The resident wore his/her hair longer for a quite a while. Observation on 6/3/21, at 10:15 A.M., showed the resident sat in his/her wheelchair and had a clean appearance. He/She had short hair. It had been 2 1/2 months since the staff member had cut the resident's hair. The beautician had cut the resident's hair after the incident with family approval to make it look more appealing. The length of the hair was approximately 3 inches all the way around. During an interview on 6/2/21, at 2:41 P.M., Certified Nurse Aide (CNA) K said the following: -He/She thinks the resident's hair was cut because it was matted up and was easier to comb when it was shorter; -The resident had longer hair before it was cut so short. During an interview on 6/3/21, at 2:40 P.M., the social services designee said the following: -The resident's family filed a grievance related to the resident's hair cut without permission; -The family was very upset; -The facility investigated and it was determined a staff member cut the resident's hair without permission; -He/She was unsure why staff cut the resident's hair; -Haircuts typically need family approval if the resident was unable to give consent; -The facility has a beautician on staff to cut the resident's hair. During an interview on 6/2/21, at 1:25 P.M., licensed practical nurse (LPN) I said the following: -A resident's hair should not be cut without the resident or family/guardian's permission; -It was not appropriate to cut the resident's hair so short; -He/She was not working when the resident's hair was cut and was unsure who cut it. During an interview on 6/3/21 and 6/30/21, at 4:35 P.M. and 9:49 A.M., the Director of Nurses (DON) said the following: -She would expect family to be contacted to get permission for a haircut if the resident was unable to give consent for the haircut; -There would not be a reason to cut the resident's hair close to the scalp; -She could not give a reason why the resident's hair got cut so short; -Family did not give permission for the resident's hair to get cut so short; -It was reported to her that CNA L cut the resident's hair; -CNA L denied cutting the resident's hair; -CNA L no longer worked at the facility. MO 050

Based on interview and record review, the facility failed to notify one resident's (Resident #9's) family member with a change in condition in a review of 11 sampled residents. The facility census was 77. Review of the facility's policy, Policies and Procedures Regarding Change in Patient Status revised 2/2021 showed the following: -The patient or patient representative is encouraged to be involved in all decision-making regarding changes in the plan of care; -Notification of Patient Representative, the charge nurse on duty is notified immediately of any change in a patient's condition; - The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's representative; - If unable to contact the family, the patient will be transferred per doctor's orders, and efforts to reach the patient's representative will be continued and documented. Record review of Resident #9's Admission Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff), dated 9/26/20, showed the following: - The resident's cognition was severely impaired; - The resident required extensive assistance of staff for transfers and bathing; - diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] - Occasionally incontinent of bladder and bowel; - No unhealed pressure areas. Record review of the resident's care plan dated, 10/14/2020 showed the following: - The resident has two Stage II pressure ulcers (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous (covered in mucous) in texture) May also present as an intact or open/ruptured blister) on his/her bottom; - The resident was also treated for [MEDICAL RECORD OR PHYSICIAN ORDER] - The resident's ulcer will not increase in size and will not exhibit signs of infection; - Weekly body audit; - Report any signs of skin breakdown (sore, tender, red or broken areas); - Resident will not develop skin breakdown related to incontinence. Record review of the resident's progress note dated 10/28/2020 at 3:19 P.M., showed the following: - The resident's right heel has a dark colored area, blister that opened skin still intact; - New order for skin prep (a liquid film-forming dressing) in place, boot when in bed, duoderm (wound dressing) continues to be on coccyx wound (pressure ulcer of tailbone), turn and reposition every two hours; - No documentation staff contacted the resident's family member. During interview on 9/30/21 at 2:53 P.M. charge nurse Licensed Practical Nurse (LPN) M said the wound care nurse or charge nurse was responsible for notification of pressure ulcer changes to the physician or NP (nurse practitioner) and resident's family representative with documentation of notifications in the progress notes and treatment in the progress notes. The responsibility of notification and documentation would be the nurse who finds the change upon assessment. He/She did not remember contacting the family of the change in the skin assessment. During an interview on 6/22/21 at 11:39 A.M. the wound care nurse, LPN N said the following: - On 10/28/20 the resident's coccyx pressure ulcer measured 0.3 X 0.3 centimeter; - On 11/4/20, the resident's coccyx pressure ulcer measured 0.5 X 0.5 centimeter; - On 11/11/20, the resident's coccyx pressure ulcer measured 1 X 1 centimeter; - On 11/17/20, the resident's coccyx pressure ulcer measured 2.1 X 2.1 centimeters; - Tissue documented as unstageable (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be present on some parts of the wound bed. Often includes undermining and tunneling) due to slough in ulcer bed; - He/She did not contact the resident's family member of the coccyx pressure ulcer status. During an interview on 6/17/21 at 3:44 P.M., the resident's family member said the following: - The facility did not notify him/her the condition of the pressure ulcer on the resident's coccyx; - The facility did not notify him/her of the dark colored area and opened blister on the right heel. During interview on 9/30/21 at 3:15 P.M., the Director of Nursing (DON) said she would expect staff to notify the wound care nurse, physician, family member and document notification attempts in the progress notes. She not aware of problems with staff notifying the resident's family member of change in condition. Responsibility for notification fall on the charge nurse or wound care nurse when staff identify a change in condition. MO 474

Based on interview and record review, the facility failed to ensure five of five randomly selected Certified Nurse Aides (CNA) received the required annual 12 hours resident care training. This deficient practice had the potential to affect all residents. The facility census was 101. Review of the CNA individual in-service records, showed: - CNA A, hired 04/17/12, no documentation of the training hours per in-service; - CNA B, hired 10/07/02, no documentation of the training hours per in-service; - CNA C, hired 06/29/17, no documentation of the training hours per in-service; - CNA D, hired 08/06/15, no documentation of the training hours per in-service; - CNA E, hired 09/13/12, no documentation of the training hours per in-service. During an interview on 10/09/19 at 10:48 [NAME]M., the Director of Nursing (DON) said the prior DON had not been tracking each CNAs hours of in-service training. She said the in-service records listed the topic and the date but no length of time. She said she expects each CNA to receive 12 hours of in-service training. The facility did not provide a policy regarding CNA in-service training.

Based on interview and record review the facility failed to consistently implement, evaluate, and modify interventions as necessary to address prevention of falls for two residents, ( Resident #2 and Resident #3) in a sample of eight residents. Resident #2 fell sustaining a fractured humerus (upper arm bone). The facility census was 101. 1. Record review of the facility policy for fall and fall Risk dated 10/2010 showed the following: - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -The staff will identify appropriate interventions to reduce the risk of falls; -Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture; - If a medication is suspected as a possible cause of a resident's falling, the initial intervention might be to taper or stop that medication, the Pharmacist, nursing staff, and the Attending Physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period; -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant; -If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable; -In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g. hip padding or treatment of [REDACTED]. -The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling; - If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g. dizziness or weakness) has resolved; - If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. 2. Record review of Resident #2's care plan, dated 1/22/19, showed the following; -The resident's cognition was severely impaired; -The resident is at risk for falls due to dementia, poor balance, non-compliance with fall alarms, and refusal to ask for assistance; -Remind the resident to ask for assistance to get up; -Anti rollbacks in place on wheelchair; -Fall mats on the floor next to the low bed; -Keep the door to the resident's room open whenever possible; -Chair and bed alarm in place per the family request; -Fireman's pole in the bathroom; -Personal care items within reach; -Frequent visual checks. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 5/23/19 showed the following: -The resident's cognition was severely impaired. -The resident's short and long term memory were impaired; -The resident was able to transfer with supervision of staff; -The resident required extensive assistance of staff to toilet; -The resident's balance was not steady but he/she was able to stabilize without staff intervention; -The resident had two falls with no injuries since admission. Record review of the resident's undated physician's progress note showed: -The resident had repeated falls; -The resident was impulsive, had poor safety awareness, and does not wait for assistance before getting out of the bed or chair; -The staff should continue the environmental interventions and monitor the resident closely. Record review of the resident's fall report, dated 7/4/19 at 11:13 [NAME]M., showed the resident was found on the floor in the bathroom. Record review of the resident's event report dated, 7/4/19 at 11:13 [NAME]M., showed the following: -The resident was found on the floor in the bathroom; -The resident's bed and wheel chair alarm were in place; -The resident was redirected to use his/her call light when in need. Record review of the resident's care plan showed no documentation the care plan interventions were evaluated, modified or updated to prevent another fall. Record review of the resident's event report dated 7/8/19, showed the following: -The resident was found on the floor in his/her room; -The resident's bed alarm had been in place. Record review of the resident's care plan showed no documentation the care plan interventions were evaluated, modified or updated to prevent another fall. Record review of the resident's progress note dated, 7/10/19 at 10:20 P.M., showed the following: -The resident was confused, and severely agitated; -The resident was given 1:1 (one on one monitoring) care by the assistant director of nurses (ADON). Record review of the resident's progress note dated, 7/11/19 at 1:58 P.M., showed the following: -The resident was very agitated, irritated and restless; -The resident had a witnessed fall in his/her room; -The resident was found on the floor next to his/her wheelchair; -The resident has been in and out of bed and ignores the bed alarm; -The resident turned the alarm off several times. Record review of the resident's care plan showed no documentation the care plan interventions were evaluated, modified or updated to prevent another fall. Record review of the resident's progress note dated, 7/13/19 at 4:47 P.M., showed the following: -The resident attempted to transfer himself/herself to the toilet unassisted; -The Certified Nurse Aide (CNA) found the resident on the floor with his/her left arm in an awkward position; -The resident complained of pain in the left shoulder; -The resident was sent to the hospital for evaluation. Record review of the resident's hospital history and physical, dated 7/13/19 at 5:03 P.M., showed the resident had a fractured left humerus, secondary to a fall. During an interview on 7/30/19 at 11:50 [NAME]M., the resident said he/she fell and broke his/her arm. During interview on 7/30/19 at 12:50 P.M., the social services designee said the following: -The interdisciplinary team meets to see if they have other suggestions for new interventions to prevent falls; -The team couldn't think of any other interventions (for the resident's falls). During an interview on 7/30/19 at 12:35 [NAME]M., Licensed Practical Nurse (LPN) B said the following: -The resident won't wait for staff or use the call light; -The resident turns the alarms off; -The resident had a very unsteady gait; -After the resident fell , staff continued the same interventions; -Staff ask the resident to call for help and check on the resident frequently at least every 1/2 hour; -1:1 supervision would keep the resident from falling; -The resident does tell the staff he/she needs to toilet every 45 minutes and does have urgency and frequency. During an interview on 7/30/19 at 1:00 P.M., LPN C said the following: -Staff discussed the resident's falls but couldn't think of any other interventions to prevent the next fall; -Only 1:1 care would prevent the resident from falling. During an interview on 7/30/19 at 1:15 P.M., LPN D said the resident fell the last time because he/she would get up and down with out assistance and couldn't be re-directed. During interview on 7/31/19 at 6:20 [NAME]M. LPN A said the following: -The CNA found the resident on the floor on 7/13/19 at 4:00 [NAME]M.; -The resident had a left arm injury and right shoulder pain; -The resident had dementia and was not oriented; -The bed alarm was working but staff couldn't get to the resident fast enough; -LPN A saw the resident in bed a few minutes before he/she fell ; -There are no other interventions to prevent the resident from falling. During interview on 7/30/19 at 11:15 [NAME]M. the care plan coordinator said the following: -When a resident falls the nurse is responsible to document the fall; -The nurse can add an intervention; -Resident #2 fell on [DATE]; the resident's care plan was not updated with a new intervention; -The resident had a bed alarm, chair alarm, fall mat, low bed, the resident should be checked frequently; -The resident can follow instructions at times; -The resident had poor safety awareness. 3. Record review of Resident #3's care plan, dated 3/11/19, showed the following: -The resident had a history of [REDACTED].>-Give the resident verbal reminders not to transfer without help; -Keep the resident's call light within reach; -Observe the resident frequently and place the resident in a supervised area when the resident is out of bed; -Keep the resident's room free of clutter. Record review of the resident's progress note, dated 5/17/19 at 11:19 [NAME]M., showed the resident slid out of the wheelchair onto the floor in the hallway. Record review of the resident's care plan showed no documentation the care plan interventions were evaluated, modified or updated to prevent another fall. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had short and long term memory impairment; -The resident's cognition was moderately impaired; -The resident required extensive assistance of staff for most activities of daily living; -The resident's balance was not steady, and required human intervention for stabilization. Record review of the resident's progress note, dated 6/15/19 at 9:37 [NAME]M., showed the following: -The resident was found on the floor between the wheel chair and the bed; -The bed was in high position. Record review of the resident's care plan showed no documentation the care plan interventions were evaluated, modified or updated to prevent another fall. Record review of the resident's progress note, dated 6/18/19 at 3:46 P.M., showed the resident was found on the floor next to the bed on the fall mat on the left side of the bed. Record review of the resident's care plan showed no documentation the care plan interventions were evaluated, modified or updated to prevent another fall. Record review of the resident's progress note, dated 6/24/19 at 5:30 P.M., showed the following: -The resident was found sitting on the floor between the bed and the wheelchair; -The resident's roommate reported the resident transferred himself/herself to the bed and slid to the floor; -The resident had no injury; -The resident was reminded to wait for staff to help before transferring. Record review of the resident's care plan showed no documentation the care plan interventions were evaluated, modified or updated to prevent another fall. Record review of the resident's POS, dated 6/30/19-7/30/19, showed the following: -The resident's [DIAGNOSES REDACTED]. -The resident requires the assistance of two staff to get out of bed. During an interview on 7/30/19 at 10:40 [NAME]M., the resident said: -He/She fell out of the wheelchair and had bruises; -There were no changes made to his/her care after the fall. During an interview on 7/30/19 at 2:00 P.M., the Director of Nurses (DON) said the following: -Staff were expected to evaluate current interventions and update resident care plans with a new intervention after each resident fall; -This was not currently being done. During an interview on 8/1/19 at 3:30 P.M., the administrator said when there is a fall, the staff evaluate what has been done or can be done differently to prevent a fall and the care plan should be updated with a multidisciplinary approach. MO 1

Based on interview and record review the facility failed to notify two residents' (Resident #2 and #8) designated representative with a change in condition of eight sampled residents. The facility census was 101. 1. Record review of Resident #8's Admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/3/19, showed the following: -The resident was cognitively intact; -The resident required extensive assistance of staff for transfers and bathing. Record review of the resident's physician's orders [REDACTED]. Record review of the resident's progress note dated, 7/30/19 at 11:57 [NAME]M., showed the following: -The resident reported feeling bad; -The resident had a mild occasional loose cough; -The resident's temperature was 101.1 (normal range is 98.6 Fahrenheit (F) orally) temporal (forehead) (usually 0.5°F to 1°F lower than an oral temperature), pulse was 128 (normal range 60-100), blood pressure was 82/46 (normal range is less than 120/80 mmHg (millimeters of mercury; a measure of pressure) and more than 90/60 mmHg); -The resident's urine was cloudy amber in color with sediment present; -The resident requested to go to the emergency room ; -The resident was transported to the emergency room by non-emergency transportation. During an interview on 8/1/19 at 10:15 [NAME]M., the Assistant Director of Nurses (ADON) said the following: -The resident was alert and oriented; -The resident talked to the nurse and said he/she wanted to go to the hospital; -The resident was sent to the hospital at 11:00 [NAME]M.; -The nurse did not contact the resident's family member; -The family member contacted the facility at 4:00 P.M. and was upset that he/she was not contacted. During an interview on 8/1/19 at 3:00 P.M. and 8/9/19 at 3:30 P.M., the Director of Nurses (DON) said the following: -The resident wanted to go to the hospital; -The resident's vital signs were a little out of range, he/she had a low grade temp, his/her blood pressure was a little low and his/her pulse was a little high; -The resident insisted he/she go to the hospital and said he/she called his/her family member and informed the family member he/she was going; -The DON did not talk to the family member, but the family member did talk to the ADON. 2. Record review of the Resident #2's quarterly MDS, dated [DATE], showed the following: -The resident had short and long term memory impairment; -The resident was moderately cognitively impaired; -The resident required extensive assistance of staff for most activities of daily living; -The resident's balance was not steady, and he/she required human intervention for stabilization. Record review of the resident's POS, dated 7/1/19-8/1/19, showed the resident's [DIAGNOSES REDACTED]. Record review of the resident's progress note, dated 7/11/19 1:58 P.M., showed the following: -The resident was very agitated; -A new order was obtained to collect a urine specimen for urinalysis (urine test to check for infection); -The urine specimen was picked up this morning. Record review of the resident's progress note, dated 7/12/19 at 10:59 P.M., showed the resident was seen by the nurse practitioner and new orders were received. Record review of the resident's POS showed an order dated 7/12/19 for [MEDICATION NAME] (antibiotic for urinary tract infection) capsule 100 milligrams (mg) one capsule by mouth every 12 hours. Record review of the resident's medical record showed no documentation the resident's family member was notified. During an interview on 8/1/19 at 11:45 [NAME]M. the resident's family member said the facility did not let the family member know about the resident's urinary tract infection or antibiotic treatment. During an interview on 8/1/19 at 3:30 P.M., the administrator said: -The facility had no policy available for notification of family/representative when a resident had a change in condition available; -Nurses should notify the resident's family/representative when there is a change in condition. MO# 9

Based on interview and record review the facility failed to report an allegation of sexual abuse to the state agency for one resident (Resident #1) in a review of eight sampled residents. The facility census was 101. 1. Record review of the facility policy for protection and response for allegations of Abuse, Neglect, Misappropriation of Patient Property and exploitation, dated 12/11/17, showed the following: - Abuse will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual in this center. Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect, misappropriation of patient property or exploitation must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in abuse or serious bodily injury. All allegations of possible abuse, neglect, misappropriation of patient property or exploitation will be immediately assessed to determine the appropriate direction of the investigation; -It is the policy of this facility that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or 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 administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. 2. Record review of the Resident #1's 14 day Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 5/3/19, showed the following: -The resident was cognitively intact; -The resident had no documented behaviors, hallucinations or delusions; -The resident was independent with most activities of daily living. Record review of the resident's Physician's Order Sheet (POS), dated 6/14/19-7/14/19, showed the resident's [DIAGNOSES REDACTED]. Record review of the facility's investigation (no date) showed the following: -On (MONTH) 21 the admission's coordinator and Social Worker came to the Director of Nursing (DON) and reported Resident #1 was making allegations of being sexually abused by an aide. It was graphic in nature involving oral sex. The aide was to have sat resident in a chair and then straddled the resident putting his/her genitalia in the resident's mouth. When asked why the resident didn't scream out or yell the resident said the aide put something on a rag and put it over the resident's mouth in order to make the resident not able speak out so the resident couldn't scream; -After speaking to everyone the resident was eating all meals in main dining room, still participated in activities and had no change in eating or sleeping pattern. The family member was told the facility had to take all allegations seriously and err on the side of safety. The facility took the aide out of the resident's care permanently. The team believed the accusation to be unfounded at this time. During interview on 7/16/19 at 3:00 P.M., the admission's coordinator said the following: -The first time the resident made any allegation of abuse was on 6/21/19; -The resident had made other allegations since that time; -The resident went into the admission's office and made the allegation of sexual abuse; -The resident describes the staff member as skinny, described race and that the aide did not speak English; -The DON was notified; -The facility felt the resident was delusional. During interview on 7/16/19 at 3:30 P.M., the social service designee (SSD) said the following: -The admission's coordinator told the SSD about the allegation of abuse on (MONTH) 21st; -He/She told the DON; -One day last week the resident came to the SSD office with concerns about a missing phone; -The resident said a tall, bald, person sneaks in the resident's room at night and tries to have sex with the resident and wipes his/her face with a peri wipe. During an interview on 7/30/19 at 2:00 P.M., the DON said the following: -Staff report allegations of abuse to the DON or Administrator; -The DON or Administrator initiate an investigation; -Allegations of abuse are reported to the state; -This allegation was not reported to the state because the investigation showed no evidence of abuse and the resident's family member agreed. During interview on 8/1/9 at 3:30 P.M. the administrator said the following: -The administrator was aware of the resident's allegations; -The resident made multiple allegations; -When a resident makes an allegation for the first time, the facility reports to the state within two hours; -The resident had made previous allegations; -The administrator doesn't know if the resident's allegations were reported.

Based on interview and record review, the facility failed to implement one resident's current care plan interventions to prevent falls resulting in a major injury for one resident (Resident #305) in a review of 21 sampled residents, who the facility had identified at risk for falls. The facility failed to provide the resident's care needs with two staff member assistance as directed by the plan of care. The resident fell from the bed during care needs, sustained a closed head injury and expired as a result of the fall. The facility also failed to implement safety interventions to prevent injury when staff failed to safely transfer three residents (Residents #26, #35, and #36) via the resident's determined transfer method and technique, left two residents (Residents #26 and Resident #80) unattended with beds in the highest position and failed to ensure a call light was in reach for one resident (Resident #48). The facility's census was 97. 1. During an interview on [DATE] at 10:20 A.M., the Director of Nurses (DON) and Administrator said the following: -The facility had no policy mandating a care plan be updated after a resident fall, this was the standard of care the facility followed; -After a resident falls, the nurse assesses the resident and chooses an intervention immediately to put on the care plan, by looking at the resident, the resident's medications, or the resident's change in condition; -The facility fall rounds are done after a resident falls by physical therapy, the fall nurse, maintenance, nursing, which may include the DON, the Assistant Director of Nurses (ADON), the Care Plan Coordinator, the Minimum Data Set (MDS) Coordinator and activities; -During fall rounds, the staff go to the resident's room, look at the room, check for other interventions needed and update the care plan; -The staff are able to see the resident's care plan on the computer and the hand held device; -The staff are expected to look at the care plan before giving the resident care; -This is the standard the facility follows. 2. Review of the facility Plan of Care Documentation for Certified Nurse Assistant (CNA) Hand Held Devices dated 2012, showed the following: -The hand held device contained an Overview View all screen. Staff could search for any resident in the center and document on the selected resident; -CNA staff would select the appropriate Activity of Daily Living (ADL) and document; -This was a great way to find out how a resident performed ADLs if they were not their resident. Prior to helping the resident with their needs, click the view all button and select the appropriate ADL and view the cautions for that resident. This would help a CNA quickly see what level of support the resident would need for the ADL; -The example screen showed eating, toilet/bladder, toilet/bowel, personal hygiene, dressing, bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit and bathing ADL choices. 3. Review of the undated facility policy Gait Belts for Transfer showed the following: -Gait belts were provided to assist staff to safely transfer or ambulate residents; -Apply the belt around the resident's waist; -Stand as close to resident as possible, maintaining a broad base of support; -To transfer, assist the resident to a standing position by grasping belt at the waist from underneath, pivot the resident into chair or bed; -To ambulate, assist the resident to a standing position by grasping belt at the waist from underneath, standing on weaker side of resident wrap arm around the resident's waist and grasp belt from underneath, maintain a firm grasp on the belt and proceed to ambulate. 4. Review of the undated facility policy Mechanical Lift showed the following: -A mechanical lift was used appropriately to facilitate transfers of residents; -The mechanical lift was used by all nursing personnel; -At least two people were present during transferring with a lift; -Place lift sling under resident, making sure the position of the seat was close to the knees; -Set base legs to the widest position under the resident; -Keep resident centered between legs of the base and facing toward the person who was operating the mechanical lift; -Lower lift and place hooks in the appropriate holes of the lift sheet with hooks facing away from the resident; -Using lever gently raise and move the resident to the destination, lower the resident and position comfortable; -Unhook and remove sling. 5. Review of the Administrator's e-mail communication dated [DATE] showed the facility had no standard policy regarding bed safety and this was based on individual resident needs. 6. Record review of Resident #305's significant change MDS, a federally mandated assessment instrument completed by facility staff, dated [DATE] showed the resident had one fall with no injury since his/her admission. Record review of the resident's post fall initial note showed the following: -On [DATE] at 11:30 A.M. the resident was found with his/her legs on the floor and his/her head on the bed; -The resident was confused and attempting to get out of bed; -The care plan interventions in place at the time were a low bed and fall mat on the floor. Record review of the resident's quarterly fall assessment dated [DATE] showed the following: -The resident had fallen in the last ,[DATE] days; -The resident was at risk for falls. Record review of the resident's quarterly MDS dated [DATE] showed the following: -The resident had moderate cognitive impairment; -The resident's [DIAGNOSES REDACTED]. -The resident was dependent on two staff for transfers; -The resident required extensive assistance of two staff for bed mobility; -The resident had impaired range of motion, upper and lower extremity on one side; -The MDS does not indicate the resident had behaviors. Record review of the resident's care plan dated [DATE] showed the following: -The resident was at risk for bleeding related to the use of anticoagulants; -The resident will have no abnormal bleeding; -Staff should observe for abnormal bleeding; -The resident was at risk for falling; -The resident had a history of [REDACTED].>-The resident fell out of bed when attempting to walk [DATE]; -The resident should have two staff at all times to provide care related to behaviors; -The resident had a history of [REDACTED]. -The resident had limited mobility; -The resident had confusion; -The resident's personal items should be kept within reach; -Low bed with fall mat; -The resident is at risk for complications related to behaviors. Record review of the resident's post fall initial note dated [DATE] at 6:00 P.M. showed the following: -The resident rolled out of bed; -The bed was still in high position, the resident having just been fed; -The resident was lying on the floor on his/her back; -The resident hit his/her head with no injury; -The immediate intervention initiated was the bed was lowered. Review of the resident's physician's orders [REDACTED]. -Adult aspirin (blood thinner) 81 [MEDICATION NAME] coated (EC) milligrams (mg) one tablet daily; -Eliquis (blood thinner) 2.5 mg one tablet by mouth two times daily; -The resident's [DIAGNOSES REDACTED]. Record review of the resident's nurse's note dated [DATE] showed the following: -While giving morning care to the resident, the CNA observed the resident roll out of bed; -The CNA explained the resident took his/her right foot and put it over the left leg causing the resident to lose his/her balance; -The resident fell out of bed and landed on the floor; -The resident's head hit the garbage can and caused two lacerations (cuts) to the right side of his/her head; -The resident's physician was made aware of the fall; -The resident's family was made aware of the fall; -The facility was notified at 2:00 P.M. the resident was admitted to the hospital with [REDACTED]. Record review of the resident's consult report dated [DATE] showed the following: - The neurosurgeon was asked by the physician in the emergency room to evaluate the resident with a traumatic subdural hematoma; -The resident had a history of [REDACTED]. -He/she was maintained on Eliquis and aspirin (blood thinning medication); -He/she was mostly confined to a wheelchair; -Today he/she rolled out of bed and fell striking his/her head; -The resident does not believe he/she lost consciousness; -The resident was brought to the emergency room , where a Computed Tomography (CT) (x-ray image) scan showed an interhemispheric (between two hemispheres of the brain) subdural hematoma; -The resident complains of a mild-to-moderate headache; -The resident noted with persistent weakness of his/her left side, which is no worse than baseline [MEDICAL CONDITION] on the left with decreased tone; - The physician reviewed a noncontrast CT scan of the resident's brain, which showed perhaps 14 millimeter(mm) in maximal thickness interhemispheric subdural hematoma without much mass effect; -There was no midline shift; -The resident has some blood within the 4th ventricle (cavity) and a small amount of subarachnoid (the space between the membranes covering the brain) hemorrhage (bleeding)within the basilar cisterns; -He/she has a tentorial (an extension of the covering of the brain) subdural hematoma on the right side; -ASSESSMENT AND PLAN: The resident had multiple medical problems, on Eliquis, status [REDACTED]. -Believe the interhemispheric and right tentorial subdural hematomas are related to the fall likely exacerbated by the Eliquis; -No indication for emergent surgery as the risks would outweigh the potential benefits; -Will admit the resident to the intermediate care unit and follow him/her with serial neurologic exams; -The resident's prognosis for functional recovery is fairly poor; -The resident is at high risk for continued hemorrhage with neurologic decline which might necessitate craniotomy (the surgical removal of part of the bone from the skull to expose the brain) in attempt to save his/her life. Record review of the resident's Certification of Death issued on [DATE] showed the following: -The resident's date of death was [DATE]; -The underlying cause of death was closed head injury. During interview on [DATE] at 10:40 A.M., [DATE] at 2:25 P.M., and [DATE] at 8:36 A.M., CNA E said the following: -He/she was changing the resident and doing peri-care; -The bed was in high position; -The resident was on a low air loss mattress; -The resident was on his/her left side; -The resident swung his/her right leg over the left leg, and reached over to grab something; -The resident fell out of bed; -The resident hit his/her head and was bleeding; -The resident went to the hospital and passed away; -He/she had always repositioned the resident by him/herself; -He/she never asked for help to reposition the resident; -He/she did not know the resident needed to be repositioned by two staff; -He/she would have looked at the hand held device for care plan information regarding the resident; -He/she had always taken care of the resident by him/herself because the resident was cooperative with care; -He/she had looked at the resident's care plan information previously, but was unaware the care plan had been updated to say the resident required two staff for care. During interview on [DATE] at 3:00 P.M. CNA O said the following: -He/she had repositioned the resident by him/herself on many occasions; -He/she did not ask for assistance with the resident's care unless the resident needed to be pulled up in bed; -The resident had fallen when he/she wanted to get up alone; -The resident would slide out of the bed towards the window onto the fall mat and did not get hurt. During interview on [DATE] at 2:40 P.M. and [DATE] at 7:30 A.M., Licensed Practical Nurse (LPN) C said the following: -The nurse would look on the computer at the resident's care plan if the nurse was not familiar with the resident's care; -The CNA had the hand held device which has all the information regarding fall prevention, transfer information, how many staff are needed for care; -When staff repositioned the resident he/she would throw his/her right leg over hard; -The staff would reposition the resident with one staff when he/she was not having behaviors; -He/she would hold the resident close and use a draw sheet and the resident did not fall out of bed. During interview on [DATE] at 10:00 A.M., [DATE] at 1:00 P.M. and [DATE] at 2:38 P.M. and 4:00 P.M. the DON said the following: -The nurses give report to the CNA; -Staff had a hand held device that contained point of care information regarding every resident. Resident care plans were not written on paper and were accessible on the hand held devices. Staff should access the resident's care plan information on their hand held device; -The resident's fall risk is noted as well as interventions to prevent falls; -The CNA did not follow the resident's care plan of having two staff for care; -When the resident fell out of bed, the bed was in a higher position; -For residents with a low air loss bed, staff are expected to have two staff for care, the bed should be left in a low position, and the fall mat in place when care was completed. During interview on [DATE] at 11:00 A.M. the resident's physician said the following: -The resident had previous falls; -The resident was put on two staff assist for care. During interview on [DATE] at 4:10 P.M., the Administrator said the following: -Prior to the incident, CNA E should have looked at the resident's care plan and caution screen; -The CNAs are expected to have their care plan device and check the resident's care plan. 7. Review of Resident #26's significant change MDS dated [DATE] showed he/she was dependent on two or more staff for transfers. Review of the resident's care plan dated [DATE] showed he/she was at risk for falls and required the assistance of two staff and a Hoyer lift (mechanical full body lift) for transfers. Review of the resident's nursing summary dated [DATE] showed the following: -He/she required staff assistance with bed mobility, and transfers with a Hoyer lift; -He/she was disoriented to place, time and situation. Observation on [DATE] at 4:30 P.M. showed the following: -CNA A placed a Hoyer lift pad under the resident; -CNA B entered the room and told CNA A the resident was a two person transfer only and did not require the Hoyer lift; -CNA A was unable to get his/her hand held device to work correctly; -CNA A looked on CNA B's hand held device and determined the resident was a two person transfer without the Hoyer lift; -CNA A applied a gait belt and the two staff assisted the resident to the wheelchair via gait belt with minimal weight bearing assistance from the resident. During interview on [DATE] at 4:30 P.M., CNA B said he/she looked at his/her handheld plan of care device and determined that the resident did not require the use of the Hoyer lift and was a two staff physical assist. Observation of the hand held device on [DATE] at 4:40 P.M. showed the resident was to be transferred with two staff using the sling and Hoyer lift. During an interview on [DATE] at 3:46 P.M., CNA A said the following: -He/she obtained the Hoyer lift pad from the resident's wheelchair and placed it under the resident because that was how he/she normally transferred the resident; -CNA B had been working at the facility longer and he/she thought CNA B knew more about the resident and went along with what he/she said the transfer status was; -His/her hand held device with care plan information was not working properly. He/she had notified the DON, but nothing had been done to correct the problem. During interview on [DATE] at 4:45 P.M., LPN D said the resident was supposed to have assistance of two staff and use of the Hoyer lift and sling when staff transferred the resident. Observation on [DATE] at 7:25 A.M. showed the following: -CNA C placed a Hoyer lift pad under the resident with the bed in its highest position; -CNA C exited the room to obtain the Hoyer lift with the resident left unattended in his/her bed left in its high position; -There was nothing in place on either side of the bed that would have prevented the resident from rolling out of bed; -Staff left the resident unattended in the bed in the high position for approximately three minutes. During an interview on [DATE] at 10:16 A.M., CNA C said the following: -Beds should not be left in the highest position when staff leave the room; -Beds should be lowered to lowest position prior to exiting the resident's room to obtain for supplies, including the Hoyer lift. 8. Review of Resident #35's face sheet showed he/she had [DIAGNOSES REDACTED]. Review of the resident's admission MDS dated [DATE] showed the following: -His/her cognition was severely impaired; -He/she required extensive assistance of two staff with transfers. Review of the resident's care plan dated [DATE] showed the following: -He/she had limited ability to perform self-care; -Staff were to assist him/her with bed mobility, transfers, and toileting when needed; -He/she had a low air loss mattress and required assistance of two staff for performance of care while he/she was in bed (one staff member on each side of the bed); -He/she required assistance of two staff when transferring out of bed. Observation on [DATE] at 8:35 A.M. showed the following: -The resident attempted to climb out of his/her bed; -The Assistant Director of Nursing (ADON) entered the resident's room to assist the resident, but said he/she was unsure of the resident's plan of care with regards to the resident's transfer status; -The ADON assisted the resident with activities of daily living (ADL), including perineal care and dressing with no assistance from any other staff; -The ADON asked LPN D what the resident's transfer status was and LPN D responded that the resident required assistance of two staff; -CNA E told the ADON that the resident only required one staff with transfers; -CNA C entered the resident's room and told the ADON that the resident only required assistance of one staff and a gait belt for transfers; -The ADON did not look at the portable plan of care device to verify the resident's transfer status; -The ADON placed a gait belt around the resident's waist, asked him/her to hug him/her around his/her neck, and assisted the resident into a standing position by placing his/her arms around the resident and using the gait belt to assist the resident into the standing position; -The resident stood, but was unsteady and did not follow commands well; -The ADON pivoted the resident and placed him/her into the Broda chair (reclining wheelchair) with minimal participation from the resident. During an interview on [DATE] at 3:10 P.M., the ADON said the following: -Staff were to look on their plan of care devices to determine a resident's transfer status; -He/she did not have a plan of care device and only the CNAs or licensed staff working in the CNA role would have one of these devices; -He/she asked the CNAs who worked with the resident what his/her transfer status was prior to her/him transferring the resident; -He/she was told by the CNAs that the resident required assistance of one staff with transfers. 9. Review of Resident #36's quarterly MDS dated [DATE] showed the following: -His/her cognition was severely impaired for daily decision making; -He/she required extensive assistance of two or more staff with transfers; -He/she was unsteady and could only transfer with human assistance. Review of the resident's care plan last reviewed on [DATE] showed the following: -The resident required assistance with transfers; -There was no documentation to direct staff on how many staff were required for transfers; -There was documentation to show that a gait belt was to be used with transfers. Review of the resident's POS dated [DATE] showed he/she had the following Diagnoses: [REDACTED]. -[MEDICAL CONDITION]; -Repeated falls; -Difficulty walking. Observation of the resident on [DATE] at 4:30 P.M. showed the following: -CNA A transferred the resident from the bed to the wheelchair by holding onto the resident for standby assistance without the use of a gait belt; -The resident was able to stand and bear weight, but wanted to make sudden movements such as rising from the wheelchair when CNA A was not paying attention or was ready to assist him/her; -CNA A assisted the resident to the bathroom and onto the toilet without the use of a gait belt; -The resident rose up from the wheelchair, grabbed onto the assist bar and seated him/herself on the toilet with CNA A standing beside him/her; -The resident was unsteady on his/her feet and did not wait for staff assistance before attempting to get up from the toilet; -CNA A explained to the resident to wait for assistance back to the wheelchair; -CNA A assisted the resident back to the wheelchair without the use of a gait belt, and the resident sat down hard into the wheelchair, hit his/her left elbow on the armrest of the chair, and said, ouch, I hurt my arm. During an interview on [DATE] at 3:46 P.M. CNA A said the following: -He/she did not use gait belts, because he/she did not have one; -He/she would use a gait belt on residents if he/she worked with a partner who had one; -Some of the residents had a gait belt and some did not, he/she was unsure if the resident had one; -He/she was unaware that he/she had to ask for a gait belt; -Care plans located on the hand held devices guided staff on what the resident's transfer status was; -He/she had been unable to get her handheld device to work properly and he/she could not see the resident's status; -He/she had notified the DON of the device's malfunction, but nothing had been done to resolve the problem. During an interview on [DATE] at 1:00 P.M., Physical Therapy Assistant (PTA) F said he/she expected nursing staff, including CNAs to use a gait belt with transferring the resident, because he/she was so unsteady and needed extra support. During interview on [DATE] at 11:45 A.M. LPN D said the resident required the assistance of one staff with a gait belt. 10. Review of Resident #80's quarterly MDS, dated [DATE], showed the following: -Cognitively intact;-Extensive assist of one for bed mobility; -Extensive assist of two for transfers and toileting; -Always incontinent of bladder; -No falls since prior assessment. Review of the resident's fall risk assessment dated [DATE] showed the resident was high risk for falls. Review of the resident's care plan dated [DATE], showed the following: -Problem: At risk for [MEDICAL CONDITION] activity; -Goal: Resident will not sustain avoidable physical injury related to [MEDICAL CONDITION] activity; -Approach: Observe for twitching or jerking of extremities; -Problem: At risk for falls due to poor safety awareness; -Goal: Resident to continue extensive assist of one for transfers to/from bed; -Approach: Extensive assist of one for bed mobility and transfers. Review of the resident's POS, dated (MONTH) (YEAR) showed the resident's [DIAGNOSES REDACTED]. Observation of the resident on [DATE] showed the following: -At 4:45 P.M., the resident lay dressed in an elevated bed (waist level) on a pressure reducing mattress; -CNA R stood in the room waiting to transfer the resident via stand up lift. CNA R said he/she had to wait on a second staff member; -At 4:47 P.M., CNA R exited the room leaving the resident in bed at an elevated height to answer a call light next door; -At 4:52 P.M., CNA R and CNA S entered the room, lowered the bed and transferred the resident to his/her wheelchair. During interview on [DATE] at 11:25 A.M. CNA R said the following: -Beds should always be lowered to original height after providing cares and before exiting the room, especially if the resident is a fall risk and the bed is not against the wall; -Staff should not exit the room if resident in an elevated bed due to risk of significant injury if the resident fell ; -The resident was not a fall risk and does not move in bed. 11. Review of Resident 48's significant change MDS, dated [DATE] showed: -Short and long term memory impairment; -Extensive assist of one for bed mobility, transfer and toilet use; -Not steady, only able to stabilize with human assist when moving from seated to standing and surface to surface transfers; -Occasionally incontinent of bladder and bowel; -No falls since prior assessment. Review of the resident's fall risk assessment dated [DATE] showed the following: -High risk for falls; -Fall in past 30 days. Review of the resident's care plan, dated [DATE] showed: -Problem: Risk for falls related to limited mobility, confusion, incontinence, pain and medication use; -Goal: Will not sustain significant injury related to fall; -Approach: Call light in reach, remind resident to ask for help when feels weak; -Falls: [DATE] (feet slipped, fell in bathroom), [DATE] (fell in bathroom after self-transfer). Review of the resident's POS, dated (MONTH) (YEAR) showed: -[DIAGNOSES REDACTED]. -Fall precautions (enter fall precautions every shift). Observation of the resident on [DATE] showed the following: -At 8:20 A.M. the resident lay in his/her bed with his/her call light on the floor, under the bed and wrapped around the top, right bed wheel; -At 12:30 P.M., the resident lay in bed on his/her back with the call light on the floor, under the bed and wrapped around the top, right, bed wheel; -At 2:00 P.M. the resident remained in bed with the call light in the same location; -At 3:00 P.M., the resident remained on his/her back in bed with the call light in the same location. During interview on [DATE] at 12:25 P.M. and [DATE] at 11:56 A.M. CNA T said the following: -The resident was a fall risk and had falls; -Staff review their portal devices to check for residents who are at risk for falls; -Staff have access to care plans through their portal devices; -The resident was a two person transfer with a Hoyer lift; -Resident call lights should be in reach at all times; -Staff are to check to ensure lights are within residents' reach every two hours but he/she checked every hour. During interview on [DATE] at 2:40 P.M. the DON said the following: -He/she expected staff to look at their hand held devices to determine the resident's transfer status prior to transfer; -He/she expected staff to transfer the resident as directed on their plan of care; -He/she expected staff to lower a resident's bed and provide them with a call light before exiting the room at any time; -Residents should never be left unattended with their beds in the highest position; -He/she expected gait belts to be used with residents who require assistance with non-mechanical transfers; -He/she expected a resident's call light to be in reach at all times and staff should check to ensure they are in place every two hours or more frequently. NOTE: At the time of the survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. The DON identified all residents who utilized an air mattress and added bolsters to those beds. The DON and nurse manager inserviced staff in regard to the need for two staff to assist when a resident is using an air mattress and there is an open side to the bed and on the use of care plans as they relate to resident safety. Care plans and care plan devices were updated. The DON and Care Plan Coordinator were reviewing and updating all residents' care plans and checking for accuracy of appropriate transfer status and fall interventions. 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 E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). Complaint # MO 5

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, remained free from physical abuse when a staff member argued with the resident and grabbed the resident's arms causing a large skin tear and bruising on the left arm. The resident was sent to the emergency room for treatment of [REDACTED]. The facility's census was 94. 1. Review of the facility's policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, last revised 12/11/17, showed the following: -Definition Policy: Abuse and Neglect will not be tolerated by anyone, including staff. The patient has the right to be free from abuse and neglect. The center Administrator is responsible for assuring that resident safety, including from risk of abuse or neglect, holds the highest priority; -Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish; -Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm; -Identification Policy: Any resident event that is reported to any partner, resident, family, other partner of any other person will be considered an allegation of either abuse or neglect if it meets the following criteria; -Any instances of hitting, slapping, pinching, or kicking or other potentially harmful actions; -Prevention Policy: The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors; -All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors; -Residents with needs and behaviors that might lead to conflict with partners or other residents will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict; -Procedure: The interventions designed to meet the needs of such residents will include but will not be limed to the following; -Identification of residents whose personal histories render them at risk for abusing other residents or partners; -Assessment of appropriate intervention strategies to prevent occurrences; -Monitoring the resident for any changes that would trigger abusive behavior; -Reassessment of the protective strategies on a regular basis; -Dementia management program as needed. 2. Review of Certified Nurse Aide (CNA) A's employee file, Abuse Protection and Response Policy, dated 3/5/18, showed the following: -Definitions: Abuse: the willful infliction of injury, physical harm, pain or mental anguish; -Physical Abuse: includes hitting, slapping, pinching and kicking; -CNA A signed and dated the acknowledgement of the Abuse Protection and Response Policy. 3. Record review of Resident #1's quarterly Minimum Data set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/2/18, showed the following: -Understood and understands; -Moderate impaired cognition; -Feeling down, depressed or hopeless; -No behaviors; -Supervision of staff with transfers, dressing, toileting and personal hygiene; -[DIAGNOSES REDACTED]. -Height 5'6 and weight 119 pounds. Review of the resident's care plan dated 3/5/18 showed the following: -Problem: Limited ability to perform self care; -Problem: Cognition can fluctuate from being intact to having moderate cognitive loss; - Related hearing impairment; -Evidence by: able to make most of his/her needs known; -Interventions: Anticipate needs; -Ask yes/no questions; -Be alert to nonverbal communications; -Introduced self with each contact and explain what is being done; -Simplify communication as needed. Review of the resident's CNA plan of care, undated, showed the following: -Resident Caution and Diagnosis: [REDACTED]. -Person Centered Information-two people at all times with care; -Stand by to one assist with transfers; -Check on resident frequently due to high fall risk; -Wake after 8:00 A.M., eats in the main dining room; -Diagnosis: [REDACTED]. -Extensive assist of one staff with dressing, transfers, walking in room and corridor, locomotion on and off the unit. Review of the resident's nurse's note, dated 4/26/18 at 3:11 P.M., showed on 4/23/18 the Assistant Director of Nursing (ADON) overheard the resident hollering out and went to his/her room. Upon entering the room he/she noted CNA A standing across from the resident who was also standing, and CNA A had been holding and was holding the resident around the resident's wrists. The ADON asked what was going on and the CNA A and resident were both talking loudly at the same time. He/she asked CNA A to step out of the room so the resident could calm down and tell the ADON what happened. The resident said CNA A got upset because he/she wanted his/her breakfast heated. The resident had a very large skin tear involving what appeared to be fat and muscle tissue on his/her left forearm. The area was swollen and bruised. He/she was sent to the emergency room for evaluation. Review of the resident's hospital discharge instructions, dated 4/23/18 at 10:24 A.M., showed the resident's [DIAGNOSES REDACTED]. Review of the resident's physician progress notes [REDACTED]. The resident was sent to the emergency room . Review of the resident's nurse's note, dated 4/24/16 at 12:36 A.M., showed the resident complained of his/her wrist hurting. There was a bruise on his/her right wrist and he/she complained of tenderness. He/she required additional help because of his/her left wrist injury. Review of the resident's physician progress notes [REDACTED]. The resident was sent to the emergency room and steri strips were applied. The resident had extensive bruising. Subcutaneous bleeding (bruising) on left forearm and dorsum (back) of the left hand. During interview on 5/2/18 at 10:56 A.M., the resident said someone twisted his/her arm. He/she had bruises on his/her right forearm which were adjacent to the approximated skin tear (approximately 6 cm in length) and a bruise to his/her left hand. He/she didn't know why staff grabbed him/her. Staff had his/her arms up in the air shaking him/her. He/she didn't know who the staff was or why he/she did this to him/her. The staff's name had a T in it and he/she made him/her madder than hell. He/she was now a little more leery of people. The facility told him/her the staff member would not be back. He/she wanted him/her arrested. The staff member did not deserve to be around older people because they could not fight him/her off. During observation on 5/2/18 at 12:53 P.M., the resident's right forearm showed an approximated (to draw two tissue surfaces close together as in the repair of a wound) skin tear, approximately 6 cm in length. During interview on 5/2/18 at 10:11 A.M., CNA B said CNA A had come to work in a bad mood and told Licensed Practical Nurse (LPN) C he/she was tired of this[***] CNA A started passing breakfast trays and said, You know the resident (Resident #1), will want his/her tray hot and we go through this every morning and you know the food is hot because it just came off of the cart. CNA A took the food into the resident's room and it sounded like he/she dropped the plate on the table which caused CNA B to go in the resident's room and look. CNA A came back out of the resident's room and sat down. The resident came to his/her door and said, If you don't want to be here, why are you? CNA A went back into the resident's room because the resident was yelling, I don't know why people are here that don't want to be here. CNA A asked the resident if he/she wanted his/her tray and the resident said, Why don't you get out of my room. The resident stood up and said he/she was going to spit on CNA A. CNA A grabbed both of the resident's arms with both of his/her hands and when he/she let go the resident had a skin tear. CNA A had long fingernails. CNA A said to the resident, What happened to your arm? The Assistant Director of Nurses (ADON) came to the room and applied treatment. The resident did not have a skin tear prior to CNA A grabbing his/her arm. The resident was upset and crying. Review of a written statement dated 5/2/18, showed CNA B wrote CNA A came into work with an attitude and told the nurse he/she was sick of this[***]around here. Breakfast trays came up and he/she passed them. The nurse said the resident needs his/her tray reheated and CNA A said we go through this every day. The nurse told CNA A to reheat the tray. CNA A took the tray into the resident's room and slammed or dropped it on the table and that was what made CNA B look into the resident's room. CNA A came out of the resident's room and the resident said if you don't want to be here why are you here; the resident was yelling at the aide about not wanting to do his/her work. CNA B asked CNA A if he/she wanted him/her to go in the resident's room and CNA A said no, I got it and went back in the resident's room and asked the resident if he/she wanted his/her food. The resident was telling the aide to get out before he/she spit on him/her. The resident stood up, yelled at CNA A to get out repeatedly and CNA A grabbed both of the resident's arms. The resident started yelling look what you did to me and CNA B saw blood coming from the resident's right arm and was shocked. The ADON overheard the commotion and came down the hall. The resident was yelling and CNA A was yelling what happened to your arm. The ADON and the nurse removed CNA A while CNA B got a towel to stop the bleeding. The resident was very upset and crying. During interview on 5/2/18 at 10:26 A.M., Licensed Practical Nurse (LPN) C said he/she saw CNA A around 7:15 A.M. and he/she was late to work. CNA A was irritated. Resident #1 can be very trying but was weak because he/she sleeps all of the time. The staff will wake the resident up for breakfast and he/she will want his/her tray warmed up. At approximately 9:00 A.M. he/she went to give the resident his/her medication and the resident said he/she didn't get his/her breakfast. The resident said CNA A took the tray but didn't bring it back. LPN C asked CNA A if the resident got his/her breakfast and the CNA A said, He/she was tired of this[***] LPN C went to the end of the hall and he/she could hear a little yelling and started coming out another resident's room. He/she looked into Resident #1's room and the resident was yelling at CNA A to get out of his/her room. The resident did not have a skin tear prior to the incident. If staff was having issues with residents he/she would expect staff to walk away and get their charge nurse. If staff was not interacting with residents appropriately he/she would talk to staff and ask them to step away and report this to the Director of Nurses (DON). He/she didn't report CNA A or talk to him/her about his/her irritated mood that he/she had exhibited when he/she started work. Review of a written statement, received on 5/2/18, showed LPN C wrote CNA A was irritated because the resident said his/her breakfast was cold. He/she gave the resident his/her medications and he/she said his/her breakfast was taken from him/her. LPN C stepped outside the room and there was a tray sitting on the desk. He/she asked CNA A if it was the resident's food being cold and he/she said, I'm sick of this[***] LPN C thought the tray sitting there was for the resident so he/she took the lid off and felt to see if the food was warm. CNA A said Did you stick your hands on my food?! He/she explained that he/she was trying to help and that if it was warm he/she would take the tray to the resident. He/she said No, that's my food. About fifteen minutes later he/she heard someone yell his/her name and he/she made his/her way up the hall and found CNA A and the ADON in the resident's room and the resident's arm had a huge skin tear. During interview on 5/2/18 at 9:33 A.M., the ADON said he/she had heard the resident screaming and he/she went to see why he/she was screaming. When he/she walked in the resident's room CNA A had the resident's arms in his/her hands and they were both standing. The ADON asked what was going on and they both started talking loudly. He/she asked the CNA to leave the room. He/she asked the resident what happened and the resident said CNA A was upset because he/she wanted his/her breakfast heated. CNA A was upset about being at work that day and had an attitude. The ADON said CNA A did have an attitude earlier that morning. The resident had a skin tear on his/her left forearm. The ADON said he/she placed a moist wash cloth over the skin tear and the resident was very upset and crying. He/she wanted the police to come and how CNA A didn't want to be there. The skin tear was a couple of layers deep. He/she had the nurse go get the Director of Nurses (DON) who said the resident needed to go to the hospital. The ADON approximated the skin and placed an ice pack on the resident's arm because it was bruising and swelling. There was a bruise on the resident's right forearm where the CNA was holding the resident's arm. Review of a written statement received on 5/2/18, showed the ADON wrote he/she overheard a resident screaming out and went to see what was going on. When he/she walked into Resident #1's room, he/she found the resident and CNA A both standing and the CNA was holding both of the resident's arms. The resident said the CNA got upset because the resident wanted his/her breakfast heated. He/she asked the CNA to step out of the room and calmed the resident down. He/she noticed a skin tear on the resident's left forearm. He/she noted the severity of the skin tear and asked the nurse to get the DON. There was bruising and swelling as well. Review of the facility acquired written statement, showed on 4/23/18 at 11:00 A.M. the ADON wrote he/she overheard a resident screaming when he/she was sitting in his/her office. When he/she got to Resident #1's room the resident was standing beside his/her bed hollering the CNA hurt him/her and he/she wanted the police called. CNA A stood across from the resident holding the resident by the wrist. The CNA was talking at the same time the resident was and the ADON asked the CNA to leave the room. There were bruising and a large skin tear on the resident's left wrist/forearm area and a small bruise on his/her right wrist area. The resident said the CNA brought him/her a cold breakfast and he/she wanted it heated. The resident said this upset the CNA who was already in a bad mood. During interview on 5/2/18 at 9:00 A.M., the DON said when she was called to the resident's room the resident had a washcloth over his/her arm. She found a large skin tear approximately 6 centimeters (cm) x 4 cm and she could see the tendons. She went to find CNA A. CNA B said CNA A caused the skin tear. She found CNA A in another resident's room and immediately removed him/her. CNA A had long pointed sharp fingernails. Staff were not to have long fingernails because fingernails could cause injury to a resident. They had attitude issues with CNA A with nurses in the past. The resident was alert and oriented and had confusion at times. The resident didn't always have issues, only if he/she was having a bad day. The CNA resigned after asked to take a drug test. He/she did not interview other residents or staff because he/she removed CNA A. She should have interviewed other residents or staff to make sure there had been no other residents affected by CNA A. During interview on 5/2/18 at 11:52 A.M., the DON said she was never informed of CNA A's mood the morning of the incident. Staff should have pulled the employee to the side to find out what the issue was and find out what his/her issue was and if they couldn't handle it let the charge nurse know. Review of the facility acquired written statement dated 4/23/18, showed the DON wrote the following: -He/she was called into the resident's room at 9:30 A.M. on 4/23/18; -The ADON was with the resident holding a wash cloth over the resident's left arm; -When the wash cloth was lifted a large deep skin tear was seen; -The resident was asked what happened and he/she said staff did it and he/she wanted him/her arrested; -The resident said his/her food was cold and CNA A grabbed his/her arm causing a skin tear; -He/she informed the charge nurse the resident needed to go to the hospital for treatment; -The emergency medical system was called and the resident was taken to the hospital; -CNA A had very long artificial nails; -CNA A said he/she grabbed the resident's arm when the resident was trying to harm him/her. Review of the facility acquired written statement, dated 4/23/18, showed CNA A wrote he/she walked into the resident's room to give him/her a hall tray and he/she said it was cold. He/she came back into his/her room to get the plate and to warm it up and as he/she came back to his/her room the resident was standing up in front of his/her door yelling at him/her, calling me out by name. The resident dug his/her nails into the CNA's arm as he/she was telling the resident to let him/her see what happened to the resident's arm. The resident yelled and said he/she did that. The only time he/she put his/her hands on the resident was when he/she grabbed the resident's hand and said to keep calm and let him/her see what happened at 9:52 A.M. During interview on 5/9/18 at 10:04 A.M., Law Enforcement Officer D said CNA A told him/her the resident was mad. The resident got out of bed and followed CNA A out of his/her room. The resident tried to kick CNA A and CNA A followed the resident back into his/her room and that was when CNA A grabbed the resident's arm. The officer went to the hospital and saw the resident's injury to his/her wrist and it was a significant skin tear. Law Enforcement Officer D said CNA A should not have followed the resident back into his/her room because the resident was mad. He/She was confident after seeing the resident's injury to his/her arm that CNA A grabbed the resident's arm because CNA A was mad . This was serious enough that he/she was submitting his/her information to the prosecuting attorney. During a telephone interview on 5/2/18 at 9:00 A.M. and 11:52 A.M., the DON said the following: -The resident was alert and oriented with times of confusion; -The resident didn't always have issues, only if he/she was having a bad day; -The resident could be combative; -LPN C never told her of CNA A's mood issue. During telephone interview on 5/9/18 at 11:45 A.M. and 12:33 P.M., the DON said the following: -The resident's behavior could rub staff the wrong way by telling staff they were there to serve him/her; -He/she would have expected the LPN to call CNA A aside and ask him/her what was going on and let him/her vent/verbalize any issues and try to put him/her in a better place; -The resident required two people with all care. During interview on 5/2/18 at 9:00 A.M. and 5/16/18 at 9:12 A.M., the administrator said the following: -He/she viewed the camera which showed the resident came to his/her doorway and said something to the aide; -The aide went over to the resident's doorway; -That was the opportunity for the CNA to turn around and leave the resident's room; -Staff were trained on abuse and burn out and he could not predict staff would be abusive, all he could do was to continue and educate on abuse prevention. Complaint MO 8, MO 8, MO 5, MO 2

Based on interview and record review, the facility failed to provide protective oversight for one resident (Resident #1) of 10 sampled residents, who the facility allowed to smoke independently without supervision. The resident had paralysis/weakness to the left side of body from a past stroke and used a wheelchair for mobility. Staff noticed burn holes in the resident's clothing and care planned a smoke apron be utilized for the resident. Facility staff did not reassess the resident's ability to smoke independently after the resident had a decline in cognition and was found sleeping while smoking. On [DATE], facility staff failed to offer the resident the smoke apron prior to allowing the resident to smoke unsupervised outside. Facility staff found the resident in flames when staff went to get the resident for supper. The fire alarm activated. The resident was sent to the hospital with 3rd degree burns to the scalp, neck, chest, and shoulders. The resident died on [DATE]. The facility census was 100. 1. Record review of the facility's Smoking Practice for Residents policy updated [DATE], showed the following: -It is the practice of the facility that all residents are allowed to smoke independently provided they are able to meet the following smoking safe practice standards: -All residents who wish to smoke unsupervised, must be able to pass the smoking assessment as conducted by the social work and nursing departments upon admission, yearly, and again during a change of medical or mental condition; -Only upon passing the smoking assessment will the resident be able to smoke unsupervised in the designated smoking area; -Residents may keep their cigarettes/cigars in their possession; -Residents are encouraged to keep their lighters or matches with the nurses, but not required; -Smoking is allowed only on the back patio and never is it allowed inside the building or in front of the building; -When the outside temperature is colder than 10 degrees Fahrenheit and warmer than 95 degrees, independent smoking is not encouraged; -The facility recommends that no resident go outside for more than 30 minutes at a time when the temperature is too cold or too hot as outlined above. This is due to the fact that, as a facility, we must provide protective oversight to all of our residents and the above temperatures put every resident's health at risk to be outside; -When it is too hot or too cold to go outside to smoke, the resident may use an electronic cigarette as an alternative until the temperature meets the guidelines listed above; -The employees of the facility will not provide supervised smoking times to those residents who do not pass the safe smoking assessment. These residents will be allowed to smoke only with visiting family member or friends; -All smokers are expected to extinguish all cigarettes/cigars in the proper outside receptacles; -Residents are not allowed to share cigarettes with other residents. This is due to the fact that not every resident is aware of who is allowed to smoke independently or not; -Electronic cigarettes are allowed in the resident's room or the allowed smoking area only. They are not to be used in any other areas of the center. Any resident, whether they have passed the smoking assessment or not, may use an electronic cigarette in the designated area only; -Non-compliance of this practice will result in the following: First offense will result in smoking privileges being suspended for one week. The second offense will result in the loss of smoking privileges permanently. The resident will be allowed to smoke only with visiting family members and friends at that time. 2. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed staff assessed the resident as follows: -Required extensive assist of one staff for bed mobility, transfer, dressing, toileting, hygiene, and bathing; -Had functional limitation in range of motion (code for limitation that interfered with daily functions or placed the resident at risk of injury) of one side upper extremity (shoulder, elbow, wrist, hand) and one side lower extremity (hip, knee, ankle, foot); -Used a wheelchair for mobility device; -Active [DIAGNOSES REDACTED]. Record review of the resident's care plan, dated [DATE], showed the following: -Problem: The resident is a smoker; -Goal: The resident will be able to smoke as he/she wishes, while abiding by the facility smoking policy; -Interventions: Cigarettes are able to be kept in his/her room; -Nursing staff keeps lighters and furnishes on request; -Ensure the resident is aware of the facility policy; -Smoking assessment completed by nursing/social services regularly; -When the temperature is 10 degrees or colder, 100 degrees or hotter, or the heat index is above 110 degrees, the resident has been advised not to smoke outside due to health concerns; -Provided education on options of purchasing an electronic cigarette. Record review of the resident's Smoking Assessment, dated [DATE], showed the following: -Physically able to touch his/her thumb to each finger; -Physically able to grasp small objects; -Physically able to open and close index finger and middle finger in scissors motion; -Physically able to bend arm at elbow, bringing hand to mouth and down; -Physically able to hold cigarette without dropping; -The resident exhibited the physical ability to smoke independently as evidenced by demonstration of all of the assessed motor skills; -Had the cognitive ability to handle lighter/matches safely; -Had the cognitive ability to dispose of ashes and butts appropriately; -Had the cognitive ability to demonstrate safety issues; -Had the cognitive ability to understand the smoking policy; -Correctly answered questions related to appropriate places to smoke; -Correctly answered questions related to storage and use of lighters; -Had the cognitive ability to understand the consequences of non-compliance with smoking policy; -The resident exhibited the cognitive ability to smoke independently as evidenced by yes to answers to all of the assessed areas; -Based on the physical and cognitive assessment, the resident was determined appropriate for independent smoking; -Any significant change of status or non-compliance with the smoking policy will result in reassessment. Further review of the resident's care plan, showed on [DATE], the following intervention was added to the resident's care plan: -The facility has purchased a smoking apron for the resident to wear as he/she recently had some burn holes in some of his/her tops; -He/she is encouraged to wear it whenever he/she goes outside to smoke. Record review of the resident's nurse's note, dated [DATE], untied, showed: -A call was placed to psych nurse practitioner to report the resident had increased confusion; -The resident attempted to leave the facility related to increased confusion; -New orders received to discontinue Zoo (antidepressant) 100 milligram (mg) in the morning; -Discontinue Zoo 50 mg in the afternoon; -Start Zoo 50 mg every morning for 4 days then discontinue; -Change to Cymbalta (antidepressant) 60 mg twice a day. Record review showed no documentation the facility reassessed the resident for his/her ability to smoke independently after the resident had a change in his/her mental condition. Record review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Had rejection of care that was necessary to achieve the resident's goals for health and well-being (e.g., bloodworm, taking medications, activities of daily living assistance) one to three days; -Required extensive assist of one staff for bed mobility, transfer, dressing, toileting, hygiene, and bathing; -Was independent with set up help only for locomotion on and off the unit and eating; -Had functional limitation in range of motion of one side upper extremity (shoulder, elbow, wrist, hand) and one side lower extremity (hip, knee, ankle, foot); -Used a wheelchair for mobility device; -Active [DIAGNOSES REDACTED]. Record review of the resident's skilled nurse's notes, dated [DATE] at 2:58 P.M., showed the following: -Diagnoses: [REDACTED]. functioning) without behavioral disturbances, major depressive disorder (a mental disorder characterized by at least two weeks of low mood that is present across most situations), and psychosis (abnormal condition of the mind that involves a loss of contact with reality); -Modified independence with decision making ability; -Short term memory problem not of recent onset; -Left sided weakness/hemiparesis; -The resident lives at the facility for long term care related to having a stroke with left sided weakness; -Impaired vision and glasses; -Able to understand others and make his/her needs known; -Requires extensive assist with most activities of daily living; -Independent with supervision in his/her electric wheelchair; -Independent smoker; -He/she has burned holes in his/her clothes before and now is required to wear a smoking apron to protect his/her self; -Elopement risk; -Has wandered in the past and wears a undergird for safety; -Does not walk, but could potentially get somewhere unsafe related to his/her electric wheelchair. Record review of the resident's physician progress notes [REDACTED]. -The nurse requested the resident be seen due to the resident declining; -The resident is doing poorly in all aspects, he/she has had decrease in appetite and increase in confusion; -Apparently the resident has been drinking alcohol in his/her room and has fallen asleep on patio while smoking; -Review of systems-Neuro: confusion and memory loss; -Physical exam- Neuro: forgetful; -Plan: No new recommendations for his/her decline. Record review of the resident's medical record, showed the facility did not document any notes regarding the resident's alcohol use and falling asleep smoking. During an interview on [DATE] at 4:20 P.M., the Director of Nursing (DON) said the resident did have an episode when he/she was smoking and fell asleep while smoking and when investigated found the resident had been drinking alcohol. The DON was unsure where the alcohol had come from, but the resident did allow the DON to remove the airplane size containers of alcohol from his/her room. The DON thought she had documented the incident, but apparently had not. Record review showed no documentation the facility reassessed the resident for his/her ability to smoke independently after the resident had an increase in confusion. Record review of the resident's psychotherapy evaluation, dated [DATE], showed the following: -Reason for visit: depression; -Continues to have episodes of confusion; -Mini-Mental State Exam (used extensively in clinical and research settings to measure cognitive impairment. Commonly used to screen for dementia) completed with score of 18 out of 26 (mild cognitive impairment); -Diagnosis: [REDACTED]. Record review showed no documentation the facility reassessed the resident for his/her ability to smoke independently after mini-mental state examination showed the resident with mild cognitive impairment. Record review of the resident's therapy screening, dated [DATE] showed the following: -Discipline: Occupational therapy; -Screen type: Other- safety to remain in electric wheelchair; -[DIAGNOSES REDACTED]. -Results of therapy screening: The resident is no longer safe to remain in power chair (electric wheelchair) due to running into objects, making it unsafe for him/herself as well as running into other residents making it an unsafe environment for other residents; -The resident has been getting stuck in places requiring assistance of others to get him/her to safety, running into walls, and now causing a fall of another resident by running into him/her; -The resident will be fitted with an oversize wide high back manual wheelchair with lateral (outer side) support in order to maintain his/her safety and others. Record review showed no documentation the facility reassessed the resident for his/her ability to smoke independently after the change in the resident's medical condition that required a change from an electric wheelchair to a manual wheelchair. Review of the resident's nurse's notes, dated [DATE] (late entry for [DATE] at 1:53 P.M.), showed the following: -At approximately 4:00 P.M., the resident informed the CNA he/she was ready to get up from bed and get prepared for the evening meal; -The CNA proceeded to transfer the resident from his/her bed to his/her wheelchair; -The resident had told the CNA that he/she wanted to go out on the patio to have a cigarette before going to the dining room as he/she does every evening; -The CNA took the resident out onto the patio and came back into the facility to prepare the other residents for supper; -Licensed Practical Nurse (LPN) C was passing medications to the other residents that resided on the same hall as this resident; -At approximately 5:00 P.M., LPN C noticed the resident still sitting out on the patio and asked the CNA to please check on the resident and inform him/her it was time for supper and his/her medications; -No distress was noted at this time; -Within seconds, the CNA was yelling from the patio there was a fire; -LPN C responded to CNA and noted flames around the resident and the resident's wheelchair; -Called staff immediately to area on fire and contacted emergency services; -Emergency services responded and the resident was transferred to the hospital. Record review of the facility's acquired written statement dated [DATE], by Certified Medication Technician (CMT) A, showed the following: -On [DATE] at 3:45 P.M., the resident was placed in the patio area so he/she could smoke before dinner; -CMT A periodically checked on the resident through the window; -At about 4:50 P.M., CMT A went out to check on the resident and to see if he/she was ready to come in for dinner; -The resident was just lighting a cigarette at that time, so CMT A informed the resident that he/she would come back in five to ten minutes to take him/her to the dining room; -There were no signs of a fire at that time; -At about 5:,[DATE]:05 P.M., CMT A went back to check on the resident and noted the resident was on fire. Record review of the facility's second acquired written statement by CMT A, showed the following: -On [DATE] at about 5:05 P.M., CMT A and another Certified Nurse Assistant (CNA) were headed to the patio area; -The CMT noticed flames originating from the resident's chair and they both ran outside; -He/she grabbed the fire blanket after alerting his/her supervisor there was a fire; -He/she placed the fire blanket on top of the resident and attempted to put out the flames; -As soon as the flames were put out, he/she went back into the facility to make sure his/her supervisor was aware. During an interview on [DATE] at 3:00 P.M., CMT A said the following: -The resident was an independent smoker; -The resident always seemed alert and oriented to him/her; -The resident had a smoking apron and refused to wear it all the time; -On [DATE] around 3:45 P.M., CMT A and CNA B got the resident up in his/her wheelchair; -The resident was switched from an electric wheelchair to a manual wheelchair on [DATE]; -After getting the resident up, he/she pushed the resident outside to the patio area; -He/she did not offer or place the smoking apron on the resident prior to taking the resident outside, because the resident usually refused to wear the smoking apron; -The resident wore a small bag around his/her neck that held his/her cigarettes and lighters; -At around 4:45 P.M., he/she went outside to see if the resident was ready to come back in for his/her supper and the resident was lighting a cigarette at that time; -He/she told the resident he/she would be back in a bit to bring him/her inside; -At about 5:00 P.M., CMT A and CNA B were in the common area doing a look around to see who else needed to be gotten up or taken to the dining room, when LPN C asked where the resident was so he/she could give the resident his/her medications; -CMT A and CNA B headed toward the patio area when CNA B noted smoke and yelled fire, fire, fire; -CNA B and CMT A went outside and noted flames coming from the back of the resident's wheelchair or clothing toward his/her back; -CMT A grabbed the fire blanket as CNA B went over to the resident; -He/she handed the fire blanket to CNA B and both of them placed the blanket over the resident and patted the resident with the blanket to put out the flames; -The blanket put the fire out; -The nurse arrived and began assessing the resident, so CMT A went back inside to the front of the facility to wait for the ambulance and when they arrived, he/she took them to the patio; -He/she had seen burn holes in the resident's clothing prior to the fire and that was why the resident was supposed to use the smoking apron when smoking; -The resident did not have the smoking apron on at the time of the fire. Record review of the facility's acquired written statement, dated [DATE] by CNA B, showed the following: -On [DATE] at around 5:00 P.M., he/she was in the common area of the facility, turned around and looked outside toward the facility gazebo and saw a fire; -He/she told CMT A fire; -They both ran outside and when they got to the door, he/she tried to pull the fire alarm; -He/she looked up and saw the resident on fire; -CMT A yelled fire, fire, fire; -He/she ran to the resident, CMT A handed him/her a fire blanket and he/she placed the fire blanket over the resident and swept the resident on both sides; -The resident stated, I am burning alive, I am burning alive; -He/she finished putting out the flames with the fire blanket; -The other nurses came outside and began assessing the resident and took over, so he/she went back inside. During an interview on [DATE] at 2:20 P.M., CNA B said the following: -He/she helped CMT A get the resident up at about 3:45 P.M. on [DATE]; -The resident was an independent smoker and supposed to wear a smoking apron, but was non-compliant with wearing the smoking apron; -He/she did not offer or place the smoking apron on the resident prior to the resident going outside that day, because the resident would not wear the smoking apron; -The resident for the most part was alert and oriented prior to the fire; -The resident kept his/her cigarettes and lighters in a little bag around his/her neck at the time of the fire; -On [DATE], the resident was switched from an electric wheelchair to a manual wheelchair, required staff assistance to get around in his/her wheelchair and getting outside and inside facility; -At about 5:00 P.M., CNA B was in the common area getting ready to go get the resident from outside when he/she noted flames; -He/she was initially unsure where the flames were coming from; -He/she went to run outside and pulled the fire alarm on the way out the door; -CMT A ran with him/her outside, CMT A grabbed the fire blanket, placed the blanket over the resident and they both swept the resident with the blanket putting out the fire; -The fire was coming from the back of the resident's wheelchair when they arrived outside; -CMT A yelled fire, fire, fire as they were headed out the door and when the door opened and the smoke came into the building the fire alarms sounded; -The resident kept saying I am burning alive, I am burning alive; -Once CNA B and CMT A got the fire put out, the nurses were outside assessing the resident and he/she then went back inside; -He/she denied any inservice regarding supervising independent smokers since the fire. Record review of the resident's ambulance report, dated [DATE], showed the following: -Time call received: 5:14 P.M.; -Nature of call: Person on fire inside; -On scene: 5:20 P.M.; -Chief complaint: Burn patient greater than age 50 and 2nd/3rd degree (Second-degree burns are partial thickness burns and appear red, blistered, and may be swollen and painful. Third-degree burns are full thickness burns and result in white or blackened charred skin that may be numb) burns to greater than 10% of body surface area; -Cause of injury: Burn; -History: The resident was outside smoking and caught fire; -A staff member was outside with the resident and went inside for a few moments and came back outside to find the resident on fire in his/her wheelchair; -Staff placed blanket over the resident to put him/her out, placed ice and wet towels on the resident and called 911; -The resident has history of falling asleep while smoking; -Observation: The resident was found sitting in wheelchair; -Charring and melted parts to wheelchair were found on chair the resident was sitting in; -The resident was conscious, alert, and oriented times three; -The resident's airway, breathing, and circulation intact in normal range; -The resident had partial and full thickness burns to the head, both shoulders, down the front and back of both arms, the right hand, front of top of chest including both breasts and back to bottom of scapula (shoulder blade) on both sides; -The resident's hair was gone off top of his/her head; -His/her lungs had slight wheezes in the lower fields; -The resident rated pain 10 out of 10 (most severe pain the resident has ever had); -Transported from scene: 5:29 P.M.; -Arrived to emergency room : 5:45 P.M. Record review of the local fire department patient care report, dated [DATE], showed the following: -Time call received: 5:14 P.M. -Responded with ambulance for a call for a person on fire; -Upon arrival the fire was out and the fire department assisted the ambulance with getting the resident out of his/her wheelchair onto the stretcher; -The resident was taken to the ambulance where all further care was provided by the ambulance personnel. Record review of the Fire Department Investigation, dated [DATE], showed the following: -Alarm: [DATE] at 5:15 P.M.; -Arrival: [DATE] at 5:20 P.M.; -Remarks: Units responded for a burn patient (resident); -Dispatch advised the patient was smoking, caught fire and is now no longer on fire; -Fire and ambulance arrived on scene and staff stated the fire alarm is going off; -The patient was located outside and the smoke had set the alarm off; -The alarm was silenced and reset; -The ambulance personnel treated and transported the patient to the burn center. The police department on the scene and investigated; -It appears that the patient ignited clothing or the foam padding surrounding him/her. Review of the local police investigation, dated [DATE], showed the following: -Date/time reported: [DATE] at 5:13 P.M.; -On [DATE] at approximately 5:27 P.M., the police officer arrived at the nursing home in reference to a resident that was on fire; -The fire department and ambulance were already on the scene; -The victim was being loaded into the ambulance when the officer arrived; -The police officer noted the resident had what appeared to be a severe burn around his/her upper shoulders and he/she did not have any hair; -The police officer proceeded through the dining hall to a small patio just outside the door and to the rear of the building; -The concrete patio/sidewalk was covered with what appeared to be water; -There was a wheelchair that appeared to have been on fire about four feet away from a small table; -There were also two large pieces of a fabric covered foam; -The police officer initially thought this was from the wheelchair, but the nursing staff advised it was padding that had been placed between the wheelchair back and the back of the victim to keep him/her upright; -There was a blanket, described by staff members as a fire blanket, lying on top of the table; -The police officer spoke with the fire department and was informed the fire was intense enough that the wheelchair had melted to the victim's body and they had to cut some of the material away. Record review of the resident's emergency room record, dated [DATE], showed the following: -History of present illness comments: Presents status [REDACTED].M.; -Arrived to the emergency room via Emergency medical services (EMS) with ,[DATE]% 2nd to 3rd degree burns; -Burns to his/her head, neck, anterior (front) trunk, posterior (back) trunk, right upper arm, left upper arm, and left hand; -Denies experiencing trouble breathing and is primarily complaining of pain, particularly to his/her left hand; -Per EMS, the resident has a history of stroke and paralysis to his/her left side; -Severity: Serious; -Physical exam: The resident has light singeing at the entrance of nares (nostrils), no intranasal (lying within the nasal structure) or oral soot; -3rd degree burns to his/her head 4%, neck 1%, anterior trunk 3%, posterior trunk 5%, right upper arm 1%, left upper arm 2%. He/she has 2nd degree burn to left hand 0.5%; -Overall 3rd degree burns 16.5%, 2nd degree burns 0.5%; -Plan: Will be admitted to the Burn Intensive Care Unit for continued care. Record review of the resident's discharge summary from an area hospital, dated [DATE], showed the resident passed away on [DATE]. During an interview on [DATE] at 8:30 A.M. and 9:04 A.M., the Director of Nursing (DON) said the following: -The resident had a smoking apron because he/she burned holes in his/her clothes; -The resident told staff he/she had dropped his/her cigarette; -The resident was not wearing the smoking apron when the incident occurred; -The CNA did not put it on him/her; -The resident did not like to wear it, it embarrassed him/her; -On [DATE] or [DATE], the DON saw the resident outside smoking and he/she was not wearing the apron; -She talked the resident into putting it on at the time, but the resident was not happy about it; -The resident needed to have the apron and the DON talked to her about it; -It was common knowledge the resident did not like to wear the apron and the resident was very adamant about not wearing it; -The resident was going to smoke no matter what; -The DON thought the back side of the wheelchair cushion caught on fire; -The resident had a pillow behind his/her back for positioning; -At the hospital, the resident said he/she dropped his/her cigarette and felt it getting warm. During an interview on [DATE] at 4:20 P.M., the DON said the following: -She felt the resident did not warrant a new smoking assessment after the assessment on [DATE]; -She had spoken to the resident on multiple occasions regarding his/her smoking and safety, but was not sure any of those discussions were documented anywhere; -The resident did not like the smoking apron and said it was his/her right not to have to wear it; -The smoking apron was never mandated to go in place, it was just to be encouraged; -The resident knew staff was monitoring his/her smoking by looking for holes in his/her clothes, and if new holes were found, the resident wouldn't be allowed to smoke independently anymore; -Staff had discussed in morning meetings the resident and his/her smoking and nothing further had been reported to her in regards to ashes or holes being found in the resident's clothing; -She had observed the resident outside smoking on [DATE] or [DATE], and the resident smoked without any problems; -When questioned about the alcohol incident, she said the resident was found with small alcohol bottles on him/her and those were removed from the resident's room with the resident's permission; -When questioned about the documentation regarding the alcohol incident, she was not sure if it was documented anywhere; -She felt the smoking apron and the resident having to use it heightened the resident to do better and be more conscience when smoking; -She did expect staff to offer the apron each time the resident went outside to smoke, but not force the resident to wear it; -She only expected staff to monitor the resident for holes or ashes when he/she came inside from smoking and to report if noted; -She did not think the resident required a new smoking assessment after being switched from an electric wheelchair to a manual wheelchair; -Did not feel the resident needed to be supervised while in the manual wheelchair; -The resident had to be pushed out onto the patio by staff to smoke and to be brought back in after being switched to a manual wheelchair; -The resident had no way of alerting staff he/she was on fire while out on the patio. During an interview on [DATE] at 4:20 P.M., the administrator said the following: -He did not feel the resident warranted a new smoking assessment following the [DATE] assessment; -The resident was due for annual smoking assessment in May; -He did not expect staff to force the resident to wear his/her smoking apron, but he did expect staff to offer the apron every time the resident went outside to smoke; -There are no call lights or emergency pull lights out on the patio; -There is no way for a resident to let staff know they needed something while out on the patio, unless they came in and informed staff. During a telephone interview on [DATE] at 2:56 P.M., the resident's physician said the following: -Staff informed her the resident had fallen asleep while smoking on a couple of occasions; -She said over the last couple of months the resident was less alert and less aware; -She described the resident as being drowsy, tired, or sleepy on [DATE] and said that was normal for the resident; -She said the resident could answer questions about pain or smoking, but when questioned about things like what he/she had eaten that day, the resident could not answer; -The resident was forgetful; -The resident had mild dementia; -She was not aware the resident was switched to a non-motorized wheelchair on [DATE]. MO 6 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 address and lower the violation at the time. During the onsite visit, the facility began reassessing the residents who smoke to determine if they were able to smoke independently and include smoking needs in the residents' care plans. The facility planned to conduct annual smoking assessments and change of status assessments, for both resident improvement or decline. The facility changed the smoking policy and staff will supervise all resident smoking at specific smoke times. The facility began inservicing staff regarding supervised smoking and reporting c